What are the risk factors to watch out for before prescribing Attention Deficit Hyperactivity Disorder (ADHD) medications, such as Ritalin (methylphenidate) or Adderall (amphetamine)?

Risk Factors Before Prescribing ADHD Medications

Before prescribing ADHD medications, you must obtain a detailed personal and family cardiac history, screen for psychiatric conditions (especially psychosis, bipolar disorder, and substance use), and assess for comorbid conditions that may complicate treatment. 1

Cardiovascular Risk Assessment

Cardiac screening is mandatory before initiating any ADHD medication due to the risk of sudden cardiac death in patients with underlying structural heart disease, though this risk remains extremely rare. 1, 2

Personal Cardiac History to Obtain:

• History of specific cardiac symptoms (chest pain, syncope, palpitations) 1
• Known structural cardiac abnormalities 2
• Cardiomyopathy 1, 2
• Serious cardiac arrhythmias 2
• Coronary artery disease 2

Family History Red Flags:

• Sudden death (especially in young family members) 1
• Wolff-Parkinson-White syndrome 1
• Hypertrophic cardiomyopathy 1
• Long QT syndrome 1

If any of these cardiac risk factors are present, obtain an ECG and consider cardiology referral before prescribing. 1 This applies to both stimulants and nonstimulants, as atomoxetine can increase heart rate and blood pressure, while guanfacine and clonidine can decrease them. 1

Baseline Vital Signs:

• Measure and document baseline blood pressure and heart rate 1
• Stimulants typically increase heart rate by 1-2 beats per minute and blood pressure by 1-4 mmHg on average, but 5-15% of patients experience more substantial increases 1
• Plan for ongoing monitoring throughout treatment 1

Psychiatric Risk Assessment

Screen all patients for psychiatric conditions before prescribing, as stimulants can exacerbate or unmask serious psychiatric symptoms. 2

Pre-existing Psychotic Disorders:

• Avoid stimulants in patients with active psychosis, as CNS stimulants may exacerbate symptoms of behavioral disturbance and thought disorder 2
• Even in patients without prior psychotic illness, stimulants can cause new-onset hallucinations, delusional thinking, or mania in approximately 0.1% of treated patients 2

Bipolar Disorder Risk:

• Screen for risk factors for mania before initiating treatment: comorbid or history of depressive symptoms, family history of suicide, bipolar disorder, or depression 2
• Stimulants may induce a manic or mixed mood episode in susceptible patients 2

Substance Use Disorders:

• In adolescents with newly diagnosed ADHD, assess for symptoms of substance use before starting medication 1
• If active substance use is identified, refer to a subspecialist for guidance before prescribing 1
• Monitor for signs of medication diversion, particularly in adolescents, as ADHD medications have abuse potential 1, 2

Suicidality:

• Atomoxetine carries an FDA black box warning for increased suicidal thoughts, though this occurs uncommonly 1
• Screen for depression and suicidal ideation before prescribing atomoxetine 1

Comorbid Medical Conditions

Screen for comorbid conditions that may affect treatment selection or require additional monitoring. 1

Physical Conditions to Assess:

• Tics or Tourette's syndrome: Obtain family history and clinically evaluate patients before prescribing 2
• Sleep apnea: May worsen with stimulants or improve with alpha-2 agonists 1
• Glaucoma: Avoid methylphenidate in patients with acute angle closure glaucoma risk; use cautiously in open-angle glaucoma with close monitoring 2
• Hepatic disease: Atomoxetine has been rarely associated with hepatitis 1

Developmental and Behavioral Comorbidities:

• Anxiety disorders 1
• Depression 1
• Oppositional defiant disorder 1
• Conduct disorders 1
• Learning and language disorders 1
• Autism spectrum disorders 1

Identifying these comorbidities is essential for developing the most appropriate treatment plan, as they may influence medication selection and require concurrent behavioral interventions. 1

Abuse and Diversion Risk Assessment

Before prescribing, assess each patient's risk for abuse, misuse, and addiction. 2

High-Risk Populations:

• Adolescents and young adults (higher diversion rates) 1
• Personal or family history of substance use disorders 2
• Environments with high medication diversion risk 1

Consider nonstimulant medications (atomoxetine, extended-release guanfacine, or extended-release clonidine) in patients at high risk for abuse or diversion, as these have minimal abuse potential. 1

Age-Specific Considerations

Preschool-Aged Children (4-5 years):

• Behavioral interventions should be first-line treatment 1
• Only consider methylphenidate if behavioral interventions fail and there is moderate-to-severe dysfunction 1
• Start with lower doses due to slower metabolism in this age group 1
• Weigh risks of early medication initiation against harm of delaying treatment 1

Adolescents:

• Assess for substance use before prescribing 1
• Monitor for medication diversion 1
• Consider longer-acting formulations for symptom control while driving, as adolescents with ADHD have increased crash risk 1

Growth Monitoring Requirements

Plan for ongoing height and weight monitoring in pediatric patients, as both stimulants and atomoxetine can suppress growth. 1

• Stimulants may decrease predicted adult height by 1-2 cm, particularly with higher, consistently administered doses 1
• Effects are dose-related and similar for methylphenidate and amphetamines 1
• Atomoxetine causes growth delays in the first 1-2 years with return to expected measurements after 2-3 years 1
• Patients not growing or gaining weight as expected may need treatment interruption 2

Common Pitfalls to Avoid

• Do not skip cardiac screening: Even though sudden death is extremely rare, identifying at-risk patients prevents potentially catastrophic outcomes 1, 2
• Do not abruptly discontinue guanfacine or clonidine: Taper these medications to avoid rebound hypertension 1
• Do not prescribe stimulants concurrently with MAOIs or within 14 days of MAOI discontinuation: Risk of hypertensive crisis 2
• Do not ignore psychiatric screening: New-onset psychosis or mania, while rare, requires immediate medication discontinuation 2