What is the impact of Vyvanse (lisdexamfetamine), amitriptyline, and sertraline on Blood Pressure?

Impact of Vyvanse, Amitriptyline, and Sertraline on Blood Pressure

Vyvanse (Lisdexamfetamine) - Increases Blood Pressure

Vyvanse consistently raises blood pressure and heart rate, with mean increases of 2-4 mmHg in blood pressure and 3-6 bpm in heart rate, though some patients experience larger elevations. 1

• The FDA label explicitly warns that CNS stimulants like lisdexamfetamine cause increased blood pressure and heart rate, requiring monitoring for potential tachycardia and hypertension in all treated patients 1
• Vyvanse is contraindicated in patients with serious cardiac disease, structural cardiac abnormalities, cardiomyopathy, serious arrhythmias, or coronary artery disease due to cardiovascular risks 1
• The American College of Cardiology recognizes stimulants like methylphenidate (similar mechanism to Vyvanse) as causes of elevated blood pressure 2
• All patients on Vyvanse require regular blood pressure monitoring regardless of baseline cardiovascular status 1

Amitriptyline - Variable Effects, Can Increase Blood Pressure

Amitriptyline can cause hypertension even at therapeutic doses, though it may also cause orthostatic hypotension, making blood pressure monitoring essential. 3

• A case report documented amitriptyline-induced hypertension in a young patient at standard prophylactic doses for migraine, with blood pressure normalizing after discontinuation and re-elevating upon rechallenge 3
• Amitriptyline increased mean arterial blood pressure in healthy volunteers after 6 days of treatment 4
• Among tricyclic antidepressants, amitriptyline carries the greatest risk for weight gain, which can secondarily affect blood pressure 5
• The International Society of Hypertension notes that tricyclic antidepressants can increase blood pressure with an increased odds ratio of 3.19 for hypertension 5
• Regular blood pressure monitoring is recommended for all patients on amitriptyline regardless of dose 3

Important caveat: Amitriptyline can also cause orthostatic hypotension, particularly when combined with MAOIs, resulting in dizziness and postural blood pressure drops 6

Sertraline - Weight-Neutral to Weight-Loss, Minimal BP Impact

Sertraline is associated with weight loss in short-term use and weight neutrality long-term, with minimal direct blood pressure effects, making it the preferred choice among these three medications for patients with hypertension concerns. 5

• Among SSRIs, sertraline demonstrates weight loss with short-term use and weight neutrality with long-term use 5
• The International Society of Hypertension guidelines indicate that SSRIs (including sertraline) do not increase blood pressure 5
• The American College of Cardiology recommends SSRIs as alternatives to SNRIs when blood pressure is a concern 2
• One case report documented orthostatic hypotension upon sertraline withdrawal (not during active treatment), which resolved with extended titration 7

Clinical Management Algorithm

For patients requiring these medications:

1. Baseline assessment: Measure blood pressure before initiating any of these agents 1, 3

2. Monitoring frequency:

   • Vyvanse: Monitor blood pressure at every visit, especially during dose titration 1
   • Amitriptyline: Regular monitoring regardless of dose, particularly in first 6 months 3
   • Sertraline: Standard monitoring; increased vigilance only during discontinuation 7

3. If hypertension develops:

   • Consider dose reduction or discontinuation of the offending agent 3
   • Optimize antihypertensive therapy with ACE inhibitors, ARBs, or calcium channel blockers as first-line agents 5
   • For patients requiring continued treatment, target blood pressure to 120-129 mmHg systolic if tolerated 5

4. Medication selection priority for patients with existing hypertension:

   • First choice: Sertraline (minimal BP impact) 5
   • Avoid or use with caution: Vyvanse and amitriptyline (both can elevate BP) 1, 3
   • Consider switching from amitriptyline to sertraline if depression/anxiety is the indication 2