How to titrate Adderall (amphetamine and dextroamphetamine) in a patient with a history of myocardial infarction (MI) who is currently taking Wellbutrin (bupropion) 200mg sustained release (SR) twice daily (BID) and Celexa (citalopram) 40mg?

Adderall Titration in Post-MI Patient on Wellbutrin and Celexa

Do not restart Adderall in this patient—the FDA explicitly contraindicates stimulant use in adults with recent myocardial infarction, and the risk of recurrent MI, sudden death, or ventricular arrhythmia far outweighs any benefit for ADHD management. 1

Primary Contraindication

The FDA drug label for amphetamine products states that stimulants "should also generally not be treated" in adults with serious structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities, coronary artery disease, or other serious cardiac problems 1. Adults taking stimulants at usual ADHD doses have experienced sudden deaths, stroke, and myocardial infarction 1.

History of MI is a specific high-risk condition where stimulants may place patients at "increased vulnerability to the sympathomimetic effects" of these drugs 1. The mechanism involves:

• Modest increases in blood pressure (2-4 mmHg) and heart rate (3-6 bpm) on average, with some individuals experiencing much larger increases 1
• Direct sympathomimetic effects causing coronary vasoconstriction and increased myocardial oxygen demand 2, 3, 4
• Risk of coronary vasospasm even in patients with normal coronary arteries 5

Evidence of Cardiovascular Risk

Multiple case reports document acute MI in young patients without traditional cardiovascular risk factors after taking prescribed doses of Adderall 2, 3. One case involved an adolescent who took only the total prescribed daily dose one time and developed acute MI 2. Another young man developed acute MI after taking two 15-mg tablets of Adderall XR 3. A 28-year-old healthy male developed ST-elevation MI, ventricular fibrillation, and cardiac arrest associated with amphetamine use 4.

Prolonged amphetamine use has been documented to cause cardiomyopathy through increased oxidative stress, sympathetic overactivity, and direct myocardial toxicity 6. This creates additional risk in a patient with already compromised cardiac function post-MI.

Drug Interaction Concerns

The combination of Wellbutrin (bupropion) 200mg SR BID with Adderall creates additional risk:

• Amphetamines enhance the activity of sympathomimetic agents, and cardiovascular effects can be potentiated 1
• Both drugs increase norepinephrine activity, creating additive sympathomimetic burden on the cardiovascular system 1

The concurrent use of Celexa (citalopram) 40mg does not directly potentiate amphetamine effects but does not mitigate cardiovascular risk 1.

Alternative Management Strategy

Instead of restarting Adderall, optimize non-stimulant ADHD management:

• The patient is already on bupropion 400mg total daily (200mg BID), which has FDA approval for ADHD in some formulations and provides noradrenergic activity for ADHD symptoms
• Consider adding atomoxetine (Strattera), a selective norepinephrine reuptake inhibitor without the direct sympathomimetic effects of stimulants
• Implement behavioral interventions and cognitive-behavioral therapy for ADHD symptom management
• Reassess ADHD symptom severity versus cardiovascular risk—the mortality risk from recurrent MI outweighs functional impairment from untreated ADHD

If Stimulant Use Is Absolutely Necessary (Against Recommendation)

Only consider this approach if the patient has undergone comprehensive cardiac evaluation showing:

• Normal left ventricular ejection fraction (>50%) 7
• No evidence of ongoing ischemia on stress testing 7
• Stable on optimal post-MI medical therapy including beta-blocker, ACE inhibitor/ARB, and statin 7, 8
• At least 3 months post-MI with complete recovery 7
• Cardiology clearance with documented discussion of risks

If proceeding (which is strongly discouraged):

1. Start with the lowest possible dose: 5mg immediate-release once daily in the morning 1
2. Monitor blood pressure and heart rate before each dose escalation—hold if systolic BP >140 mmHg, diastolic BP >90 mmHg, or heart rate >100 bpm 1
3. Increase by 5mg increments no more frequently than weekly, only if cardiovascular parameters remain stable 1
4. Maximum dose should not exceed 20mg daily (far below typical ADHD dosing) 1
5. Obtain ECG before initiation and after reaching maintenance dose to assess for arrhythmias or ischemic changes 1
6. Instruct patient to immediately report any exertional chest pain, unexplained syncope, palpitations, or dyspnea and undergo prompt cardiac evaluation 1

Critical Monitoring Parameters

If stimulant therapy proceeds despite contraindication:

• Weekly blood pressure and heart rate checks for first month 1
• Monthly cardiovascular assessments thereafter 1
• Immediate discontinuation if any cardiac symptoms develop 1
• Consider repeat stress testing at 3-6 months to assess for silent ischemia 7

The safest recommendation remains complete avoidance of stimulant therapy in this patient population, as the FDA warnings are based on reports of sudden death and MI in adults with cardiac disease taking usual ADHD doses 1.