What laboratory tests or studies should be conducted before initiating Adderall (amphetamine and dextroamphetamine) or Ritalin (methylphenidate) therapy to clear a patient for treatment?

From the Guidelines

Before starting Adderall or Ritalin, a comprehensive evaluation including cardiovascular assessment, basic blood work, psychiatric evaluation, substance abuse screening, and baseline height, weight, and BMI measurement should be completed to minimize potential risks and side effects. When considering the initiation of these medications, it is crucial to assess the patient's overall health to ensure safe and effective use. The evaluation should include:

• A comprehensive cardiovascular assessment, including blood pressure, heart rate, and ECG to screen for underlying cardiac conditions, as these medications can increase heart rate and blood pressure 1.
• Basic blood work, such as a complete blood count, comprehensive metabolic panel to assess liver and kidney function, and thyroid function tests to rule out conditions that might mimic ADHD symptoms.
• A thorough psychiatric evaluation to confirm ADHD diagnosis and identify any co-existing mental health conditions.
• Substance abuse screening, as stimulants have abuse potential.
• For patients with relevant risk factors, consider screening for glaucoma and assessing for a history of seizures or tics.
• A baseline height, weight, and BMI measurement should be documented, particularly in children and adolescents, as these medications can affect growth and appetite 1. These evaluations are essential to ensure the medications can be used safely and effectively while minimizing potential risks and side effects.

From the FDA Drug Label

Prior to treating patients with methylphenidate hydrochloride oral solution, assess: for the presence of cardiac disease (i.e., perform a careful history, family history of sudden death or ventricular arrhythmia, and physical exam) the family history and clinically evaluate patients for motor or verbal tics or Tourette’s syndrome

The patient should be assessed for the presence of cardiac disease and Tourette's syndrome or tics before starting methylphenidate.

• A careful history and family history of sudden death or ventricular arrhythmia should be performed.
• A physical exam should also be conducted. 2

From the Research

Pre-Treatment Labs and Studies for Adderall/Ritalin

Before starting Adderall or Ritalin, several labs and studies should be considered to ensure safe treatment. These include:

• Cardiac safety evaluations, as stimulants can have adverse cardiac effects 3
• Blood pressure monitoring, as stimulants can cause increases in blood pressure 4, 5
• Electrocardiogram (ECG) parameters, to assess the risk of sudden death or corrected QT interval (QTc) prolongation 5
• Assessment of preexisting cardiac risk factors, to inform treatment decisions 3, 5

Key Findings

Key findings from relevant studies include:

• Methylphenidate and amphetamine salts have similar risks for cardiac events 3
• Stimulants can cause elevations in hemodynamic parameters, including blood pressure and heart rate 4
• The risk of sudden death is extremely rare and not clearly attributed to methylphenidate or amphetamines 5
• Atomoxetine may increase blood pressure and heart rate, but its effects on QTc are uncertain 5

Treatment Strategies

When selecting a treatment strategy for ADHD, consider the following:

• Individualized features of the patient, such as medical history and treatment goals 6
• Proposed mechanisms of action of established pharmacologic and non-pharmacologic treatments 6
• Targets of novel treatments and the most relevant evidence supporting efficacy and safety 6
• Guidance for optimizing initiation of treatment and follow-up of patients in clinical settings 6