Pre-Stimulant Workup
Before starting psychostimulants, obtain a comprehensive cardiac history, family cardiac history, physical examination with vital signs (blood pressure, heart rate, height, and weight), document contraindications (active psychosis, MAO inhibitor use, glaucoma, symptomatic cardiovascular disease), and review current medications—no routine laboratory tests are required for methylphenidate or amphetamines. 1
Mandatory Cardiac Assessment
Cardiac history and physical examination with vital signs are required before initiating any stimulant medication. 1
Cardiac History Must Include:
- Family history of sudden cardiac death, particularly in young relatives 1
- Family history of Wolff-Parkinson-White syndrome, hypertrophic cardiomyopathy, long QT syndrome, or ventricular arrhythmias 1
- Personal history of symptomatic cardiovascular disease, including uncontrolled hypertension, coronary artery disease, or tachyarrhythmias 2
- Symptoms suggesting cardiac disease: chest pain, syncope, palpitations, or exercise intolerance 1
Physical Examination Requirements:
- Blood pressure measurement 1
- Heart rate and pulse 1
- Height and weight to establish growth baseline 1
- Cardiac auscultation during physical examination 1
When to Order ECG or Cardiology Referral:
ECG or cardiology consultation is indicated only if positive findings emerge from history or physical examination—it is not routinely required. 1 This represents a critical distinction from universal screening approaches, as the guidelines prioritize targeted evaluation based on risk factors rather than blanket testing.
Absolute Contraindications to Document
Psychiatric Contraindications:
- Active psychotic disorder (schizophrenia, psychosis NOS, or manic episodes with psychosis)—stimulants are psychotomimetic and absolutely contraindicated 2, 1
- Current use of MAO inhibitors—will cause severe hypertension and risk of cerebrovascular accident 2, 1
Medical Contraindications:
- Glaucoma—sympathomimetics may increase intraocular pressure 2, 1
- Hyperthyroidism 2, 1
- Symptomatic cardiovascular disease 2, 1
- For pemoline specifically (now withdrawn): preexisting liver disease or abnormal liver function tests due to documented hepatotoxicity 2
Medication and Substance Use History
Document all current medications, including over-the-counter drugs and supplements, to identify potential interactions. 1
Substance Use Assessment:
- History of recent stimulant abuse or dependence—represents a relative contraindication requiring close monitoring in controlled settings 2, 1
- History of other substance use (alcohol, opiates, benzodiazepines, cigarettes) does not preclude stimulant use but requires enhanced monitoring 2
The guidelines make an important nuanced distinction here: while recent stimulant abuse is a strong contraindication, abuse of other substances or even remote stimulant abuse may not be absolute contraindications if close supervision is possible. 2
Tic and Movement Disorder History
Document personal and family history of tics or Tourette's syndrome. 1 Notably, this is listed in FDA package inserts as a contraindication, but controlled studies have not found that methylphenidate worsens motor tics in Tourette's syndrome or increases tics in children with ADHD without Tourette's. 2 This represents an area where clinical evidence contradicts older FDA labeling.
Laboratory Testing: What Is NOT Required
No routine laboratory tests are required before starting methylphenidate or amphetamines. 1 This is a critical point that distinguishes evidence-based practice from unnecessary testing.
Exception for Pemoline (Historical):
If pemoline were being considered (now withdrawn from U.S. market), baseline liver function tests would be mandatory due to risk of hepatic failure occurring 17 times more frequently than spontaneous rate. 1, 2
Documentation of Prior Treatments
Before initiating stimulants, document adequate assessment, previous psychosocial treatments, and previous psychotropic medication trials, including medication names, dosages, duration, response, side effects, and compliance. 2 This ensures stimulants are being used appropriately in the treatment algorithm rather than as first-line therapy without adequate diagnostic evaluation.
Common Pitfalls to Avoid
- Do not order routine ECGs, echocardiograms, or extensive cardiac workup in asymptomatic patients with negative cardiac history—this represents overtreatment not supported by guidelines 1
- Do not order routine laboratory panels (CBC, CMP, thyroid function) unless clinically indicated by history or physical examination—these are not required 1
- Do not automatically exclude patients with tic disorders based on old FDA labeling—recent evidence shows stimulants may be safely used 2
- Do not miss documenting active psychosis, which remains an absolute contraindication despite being omitted from some FDA package inserts 2
Post-Initiation Monitoring Plan
Establish a monitoring schedule before starting medication: vital signs checked annually during routine physical examination for children, and blood pressure and pulse checked quarterly for adults. 1 Cardiovascular effects are generally modest (average increases of 1-2 beats per minute for heart rate and 1-4 mmHg for blood pressure), though 5-15% of individuals may experience larger increases requiring closer monitoring. 1