What are the contraindications for Adderall (amphetamine and dextroamphetamine)?

Adderall Contraindications

Adderall is absolutely contraindicated in patients with previous hypersensitivity to stimulants, glaucoma, symptomatic cardiovascular disease, hyperthyroidism, hypertension, concomitant MAO inhibitor use, active psychotic disorders, and in patients with recent history of stimulant abuse unless in a controlled/supervised setting. 1

Absolute Contraindications

The American Academy of Child and Adolescent Psychiatry identifies the following as firm contraindications in clinical practice:

Cardiovascular Conditions

• Symptomatic cardiovascular disease - Amphetamines increase blood pressure, heart rate, and peripheral vascular resistance through α- and β-adrenergic stimulation 1, 2
• Hypertension - Contraindicated due to risk of further blood pressure elevation 1
• Glaucoma - Sympathomimetic effects may increase intraocular pressure 1

Endocrine Disorders

• Hyperthyroidism - Amphetamines potentiate sympathetic activity in already hypermetabolic states 1

Psychiatric Conditions

• Active psychotic disorders - Stimulants are psychotomimetic and should not be used in patients with schizophrenia, psychosis NOS, or manic episodes with psychosis 1, 3
• The FDA label notes that chronic amphetamine intoxication can cause psychosis "often clinically indistinguishable from schizophrenia" 3

Drug Interactions

• Concomitant MAO inhibitor use - This combination causes severe hypertension with risk of cerebrovascular accident and is absolutely contraindicated 1
• MAO inhibitors must be discontinued at least 14 days before starting amphetamines 1

Hypersensitivity

• Previous sensitivity to stimulant medications - Any prior allergic or hypersensitivity reaction is a contraindication 1

Relative Contraindications Requiring Extreme Caution

Substance Abuse History

• History of stimulant abuse or dependence - While the FDA includes a "black box" warning, the American Academy of Child and Adolescent Psychiatry notes this may not be an absolute contraindication if the patient is in a controlled setting with close supervision 1, 4
• Extended-release formulations (Adderall XR) are preferred over immediate-release when diversion risk exists 4
• Household members with substance abuse history require additional safeguards to prevent medication diversion 4

Bipolar Disorder

• Stimulants may precipitate manic episodes or destabilize mood in patients with comorbid bipolar disorder 5
• Mood stabilization must precede ADHD treatment in these patients 5

FDA Package Insert Contraindications NOT Supported by Recent Evidence

The following are listed in FDA labeling but have been contradicted by controlled trials:

Motor Tics and Tourette's Syndrome

• FDA labeling lists these as contraindications, but controlled studies show methylphenidate does not worsen motor tics in Tourette's syndrome 1
• Amphetamine may worsen tics more than methylphenidate, so caution is warranted even though not an absolute contraindication 1

Marked Anxiety

• Listed in FDA labeling, but children with comorbid anxiety disorder actually improve on stimulants 1

Seizure Disorders

• Package inserts warn against use, but epileptic patients stabilized on anticonvulsants do not show increased seizure frequency when stimulants are added 1
• Stabilize seizures with anticonvulsants before initiating stimulant treatment 1

Critical Safety Monitoring

Even when not contraindicated, monitor for:

• Cardiovascular toxicity - Chronic amphetamine use has been associated with cardiomyopathy through oxidative stress, sympathetic overactivity, and direct myocardial toxicity 6, 7
• Blood pressure and heart rate - Must be monitored regularly in all patients 4
• Signs of abuse or diversion - Particularly in adolescents and college students 4, 7
• Serotonin syndrome - When combining with other serotonergic medications 1