What foods, drinks, and medications should be avoided when taking stimulants for Attention Deficit Hyperactivity Disorder (ADHD)?

Foods, Drinks, and Medications to Avoid with ADHD Stimulants

The primary concern when taking stimulants for ADHD is avoiding MAO inhibitors (which are absolutely contraindicated) and using caution with other medications that increase blood pressure or heart rate, while food and drink interactions are generally minimal and do not require strict avoidance. 1

Absolute Medication Contraindications

Monoamine oxidase (MAO) inhibitors are absolutely contraindicated with stimulant medications due to the risk of hypertensive crisis. 1 This includes medications like:

• Phenelzine
• Tranylcypromine
• Selegiline (at higher doses)
• Isocarboxazid

Patients must wait at least 14 days after discontinuing an MAO inhibitor before starting stimulant therapy. 1

Medications Requiring Caution

Cardiovascular Medications

• Vasopressors and sympathomimetics (epinephrine, norepinephrine, dopamine, dobutamine) should be used with caution as stimulants can potentiate their blood pressure effects. 2
• Albuterol and other beta-2 agonists: When administered systemically (oral or intravenous), these can have potentiated cardiovascular effects with stimulants, resulting in increased heart rate and blood pressure. 2 However, inhaled albuterol at standard doses (200-800 mcg) has not shown significant interactions. 2

Antihypertensive Medications

• Stimulants may reduce the effectiveness of antihypertensive medications due to their blood pressure-elevating effects. 1 Patients with symptomatic cardiovascular disease or hypertension should not receive stimulants. 1

Other Medications

• Tricyclic antidepressants: While sometimes used together under careful monitoring, this combination requires caution due to potential cardiovascular effects. 1
• Drugs that increase seizure risk: Stimulants may lower the seizure threshold, so caution is needed with other medications that affect seizure threshold. 1

Food and Drink Considerations

Acidic Foods and Beverages

Contrary to common misconceptions, there is no strong evidence in the provided guidelines requiring strict avoidance of acidic foods or citrus juices with stimulant medications. The guidelines do not mention specific food restrictions for methylphenidate or amphetamine-based stimulants. 1

Timing with Meals

• For appetite loss management, stimulants can be given with meals, and patients can consume high-calorie drinks or snacks late in the evening when stimulant effects have worn off. 1
• Gastric pH modifiers (magnesium hydroxide/aluminum hydroxide, omeprazole) do not affect atomoxetine bioavailability, suggesting that food pH is not a major concern. 2

Alcohol

• Alcohol consumption with atomoxetine does not change the intoxicating effects of ethanol, though this does not mean combining them is recommended. 2
• For stimulants, alcohol should be avoided due to potential masking of intoxication effects and increased cardiovascular strain, though specific contraindications are not detailed in the guidelines. 3

Caffeine

While not explicitly addressed in the guidelines, caffeine is a stimulant that can additively increase heart rate, blood pressure, and anxiety when combined with ADHD stimulants. Clinical judgment suggests moderation is prudent.

Medical Conditions Requiring Avoidance

Stimulants are contraindicated in patients with:

• Previous sensitivity to stimulant medications 1
• Glaucoma 1
• Symptomatic cardiovascular disease 1
• Hyperthyroidism 1
• Hypertension 1
• Active psychotic disorder 1
• History of stimulant abuse (unless in controlled setting with close supervision) 1

Special Monitoring Situations

Substance Use History

• Patients with substance use history require careful screening before prescribing stimulants, with consideration of non-stimulant alternatives like atomoxetine as first-line treatment. 1, 4
• Monthly follow-up visits with urine drug screening are recommended to monitor for relapse and medication diversion. 4

Seizure Disorders

• Stimulants should be initiated only after seizure control is established with anticonvulsants, as they may lower the seizure threshold. 1
• However, published studies show that epileptic patients on anticonvulsants do not show increased seizure frequency when methylphenidate is added. 1

Common Pitfalls to Avoid

• Do not assume all long-acting formulations are interchangeable: Newer preparations like Concerta have abuse-deterrent properties making them preferable for at-risk populations. 1, 5
• Do not overlook cardiovascular screening: Baseline blood pressure, pulse, height, and weight should be obtained before starting stimulants. 1
• Do not ignore signs of diversion: Adolescents are at particular risk for selling or sharing medications, necessitating monitoring of prescription refill patterns. 1
• Do not combine with MAO inhibitors under any circumstances due to severe hypertensive crisis risk. 1, 4