Adderall Discontinuation Before CABG
Adderall does not need to be discontinued before CABG surgery. There is no guideline recommendation or high-quality evidence requiring preoperative discontinuation of prescription amphetamines for cardiac surgery, and available data suggest these medications can be safely continued through the perioperative period.
Evidence-Based Rationale
No Guideline Requirement for Discontinuation
The comprehensive ACC/AHA CABG guidelines 1 provide explicit recommendations for discontinuing multiple medication classes before surgery, including:
- Antiplatelet agents: Clopidogrel/ticagrelor (5 days), prasugrel (7 days) 1
- Anticoagulants: Enoxaparin (12-24 hours), fondaparinux (24 hours), bivalirudin (3 hours) 1
- GP IIb/IIIa inhibitors: Eptifibatide/tirofiban (2-4 hours), abciximab (12 hours) 1
Notably absent from these guidelines is any recommendation to discontinue amphetamines or stimulant medications 1, 2. This omission is significant given the comprehensive nature of these perioperative medication management guidelines.
Supporting Clinical Evidence
A prospective case series of 8 patients on chronic prescription amphetamines (used for 2-10 years) who underwent general anesthesia demonstrated safe perioperative outcomes 3. All patients maintained cardiovascular stability during anesthesia, with operating times ranging from 30 minutes to 4.25 hours 3. The authors concluded that amphetamine use need not be stopped before surgery and anesthesia 3.
Theoretical Concerns Are Not Supported
Historical concerns about catecholamine depletion and blunted hemodynamic responses in chronic amphetamine users have not materialized in clinical practice 3. The available evidence contradicts the theoretical risk of intraoperative hypotension in these patients 3.
Clinical Approach
Continue Adderall through the day of surgery without interruption, as there is no evidence-based reason for discontinuation and potential harm from abrupt cessation in patients with ADHD or narcolepsy 3.
Key Considerations
- Hemodynamic monitoring: Standard intraoperative blood pressure management is sufficient; no special precautions are required beyond routine CABG monitoring 3
- Avoid confusion with other medications: Do not mistakenly discontinue Adderall based on protocols for antiplatelet or anticoagulant agents, which have entirely different perioperative bleeding risks 2
- Disease control: Abrupt discontinuation may worsen underlying ADHD or narcolepsy symptoms during the stressful perioperative period without providing any surgical benefit 3, 4
Common Pitfall to Avoid
Do not extrapolate discontinuation recommendations from other cardiovascular medications (such as ACE inhibitors, where evidence is mixed 5, 6) to amphetamines, as these drug classes have completely different mechanisms and perioperative risk profiles 3, 4.