What is the best blood pressure medication for an ADHD patient on 70mg Vyvanse (lisdexamfetamine) and dextroamphetamine (Dex)?

Blood Pressure Management in ADHD Patients on High-Dose Stimulants

For an ADHD patient on 70mg Vyvanse and dextroamphetamine requiring antihypertensive therapy, alpha-2 adrenergic agonists (extended-release guanfacine or clonidine) are the optimal first choice, as they simultaneously treat ADHD symptoms while lowering blood pressure, directly counteracting the cardiovascular effects of the stimulants. 1

Primary Recommendation: Alpha-2 Agonists

Alpha-2 adrenergic agonists offer dual benefits in this clinical scenario:

• Guanfacine-XR or clonidine-XR actively lower blood pressure through their hypotensive effects, making them uniquely suited for hypertensive ADHD patients 1, 2
• These medications provide additional ADHD symptom control, potentially allowing reduction of stimulant doses 1
• Studies demonstrate small decreases in systolic BP, diastolic BP, and heart rate when administered alone or combined with psychostimulants 2
• Common side effects include somnolence, dry mouth, dizziness, bradycardia, and hypotension rather than hypertension 1

Critical precaution: Never abruptly discontinue alpha-2 agonists, as this causes rebound hypertension 1

Alternative Antihypertensive Options

If alpha-2 agonists are contraindicated or ineffective, standard antihypertensives should be initiated:

First-Line Agents

• ACE inhibitors (lisinopril) are recommended as first-line therapy 1
• ARBs (losartan) serve as alternatives to ACE inhibitors 1
• Calcium channel blockers (amlodipine) are also appropriate first-line options 1

Important: Avoid combining two RAS blockers (e.g., ACE inhibitor plus ARB) 1

Cardiovascular Monitoring Protocol

Before initiating any treatment changes:

• Confirm hypertension with repeat measurements using ambulatory BP monitoring (ABPM) or home BP monitoring to exclude white coat hypertension 1
• Establish baseline cardiovascular parameters including BP and heart rate 1
• Target BP should be <130/80 mmHg before continuing high-dose stimulants 1

Ongoing monitoring requirements:

• More frequent BP and pulse monitoring is necessary when continuing stimulants in hypertensive patients 1
• Recheck BP after at least 2 weeks of antihypertensive treatment 1
• Monitor at each dose adjustment of ADHD medications 3

Stimulant Effects on Blood Pressure

Understanding the cardiovascular impact of current regimen:

• Both lisdexamfetamine (Vyvanse) and dextroamphetamine cause statistically significant increases in BP and heart rate 2, 4
• Average increases are 1-4 mmHg for systolic and diastolic BP, and 1-2 bpm for heart rate 1
• Amphetamines specifically show mean increases of +5.4 mmHg systolic BP and +7.3 bpm heart rate 4
• Long-term studies of lisdexamfetamine show mean increases at 2 years of +3.4 mmHg SBP and +3.2 mmHg DBP 5

Management Algorithm

Step 1: Assess BP control

• If BP ≥140/90 mmHg, this requires treatment independent of stimulant use 1
• Consider holding next stimulant dose until BP reassessed if severely elevated 1

Step 2: Initiate antihypertensive therapy

• First choice: Extended-release guanfacine or clonidine for dual ADHD/BP benefit 1, 2
• Second choice: ACE inhibitor, ARB, or calcium channel blocker if alpha-2 agonists contraindicated 1

Step 3: Optimize and monitor

• Achieve BP <130/80 mmHg before continuing full stimulant doses 1
• If BP remains elevated despite treatment, consider reducing stimulant dose or switching ADHD medication 1
• Implement more frequent BP monitoring schedule 1

Step 4: Consider ADHD medication adjustments if needed

• Reduce lisdexamfetamine dose (e.g., from 70mg to 50mg or 30mg) 1
• Consider switching to atomoxetine, which has minimal BP impact compared to stimulants, though it still causes minor increases 1, 2
• Atomoxetine provides 24-hour symptom control as a selective norepinephrine reuptake inhibitor 1

Common Pitfalls to Avoid

• Do not abruptly discontinue alpha-2 agonists without tapering due to rebound hypertension risk 1
• Do not combine two RAS blockers (ACE inhibitor + ARB) 1
• Do not ignore the need for antihypertensive treatment even if stimulants are discontinued, as BP ≥140/90 requires treatment regardless 1
• Do not use thiazide diuretics as monotherapy without considering other first-line agents in this population 1
• Recognize that new-onset hypertension occurs in approximately 10% of adults on stimulant medications 4

Risk-Benefit Considerations

• The cardiovascular risk of stimulants at therapeutic doses is extremely low, with no increased risk of sudden cardiac death after 2-3 years of treatment 1, 2
• Benefits of treating ADHD outweigh cardiovascular risks when BP is adequately controlled 2
• Great caution is advised when prescribing stimulants to patients with known cardiovascular risk factors 2