What are the implications of a blood pressure reading of 138/80 in an adult patient taking Vyvanse (lisdexamfetamine) for Attention Deficit Hyperactivity Disorder (ADHD)?

Blood Pressure 138/80 on Vyvanse: Assessment and Management

A blood pressure of 138/80 mmHg in an adult taking Vyvanse (lisdexamfetamine) represents Stage 1 hypertension by ACC/AHA criteria and requires intervention, though this elevation is an expected cardiovascular effect of amphetamine therapy that occurs in most patients. 1, 2, 3

Understanding the Blood Pressure Reading

• This BP reading (138/80 mmHg) meets the ACC/AHA definition of Stage 1 hypertension (130-139/80-89 mmHg), which carries a 2-fold increased cardiovascular disease risk compared to normal BP (<120/80 mmHg). 2

• The European guidelines would classify this as "high normal" rather than hypertension (their threshold is ≥140/90 mmHg), but the cardiovascular risk remains elevated regardless of terminology. 2

• Confirm this diagnosis with out-of-office monitoring (home BP monitoring target <135/85 mmHg or 24-hour ambulatory monitoring target <130/80 mmHg) to exclude white coat hypertension before making treatment decisions. 2, 4

Expected Cardiovascular Effects of Vyvanse

• Amphetamines, including lisdexamfetamine (Vyvanse), predictably increase blood pressure by approximately 2 mmHg systolic and 2 mmHg diastolic, with heart rate increases of approximately 4 beats per minute. 3

• These cardiovascular effects are sustained with chronic use (≥8 weeks) and do not diminish over time. 3

• The FDA drug label explicitly warns that lisdexamfetamine causes blood pressure and heart rate elevations that require monitoring. 5

• Small mean increases in BP and pulse are documented across all age groups taking lisdexamfetamine in clinical trials. 6

Risk Stratification and Treatment Decision

The decision to treat this BP pharmacologically depends on the patient's 10-year ASCVD risk and presence of comorbidities:

• If the patient has known CVD, diabetes, chronic kidney disease, or 10-year ASCVD risk ≥10%, initiate antihypertensive medication immediately with a target BP <130/80 mmHg. 1

• If the patient has no additional cardiovascular risk factors and ASCVD risk <10%, lifestyle modifications are the initial approach, with medication reserved if BP remains elevated after 3-6 months. 1, 2

• Most adults with Stage 1 hypertension do not require immediate medication unless they have high cardiovascular risk or target organ damage. 2

Management Algorithm

Step 1: Optimize ADHD Medication Strategy

• Consider behavioral therapies for ADHD as an adjunct or alternative to reduce reliance on stimulant medication. 1

• Evaluate whether the current Vyvanse dose is the minimum effective dose for ADHD symptom control—dose reductions may lower BP without compromising efficacy. 1

• Do not abruptly discontinue Vyvanse, as this can worsen ADHD symptoms and quality of life; any medication changes should be gradual and coordinated with the prescribing psychiatrist. 1

• Alternative ADHD medications with potentially lower cardiovascular effects (such as atomoxetine or guanfacine) could be considered if BP remains uncontrolled, though this requires psychiatric consultation. 1

Step 2: Implement Lifestyle Modifications (All Patients)

• Sodium restriction to <1500 mg/day, increased dietary potassium to 3500-5000 mg/day, DASH diet adherence, 150 minutes/week of aerobic exercise, weight loss if overweight, and alcohol limitation to ≤1 drink daily for women or ≤2 drinks daily for men. 1, 4

• Limit caffeine intake to <300 mg/day, as coffee causes acute BP increases in hypertensive patients. 1

Step 3: Initiate Antihypertensive Therapy (If Indicated)

For high-risk patients (CVD, diabetes, CKD, or ASCVD risk ≥10%):

• Start with a single first-line agent: ACE inhibitor, ARB, thiazide/thiazide-like diuretic, or calcium channel blocker. 1

• If BP is >20/10 mmHg above target (i.e., >150/90 mmHg), initiate two first-line agents from different classes simultaneously. 1

• Target BP is <130/80 mmHg for high-risk patients. 1

For lower-risk patients:

• Continue lifestyle modifications for 3-6 months with monthly BP monitoring. 2

• Initiate medication if BP remains ≥130/80 mmHg despite lifestyle changes, targeting <130/80 mmHg. 1, 2

Step 4: Monitoring and Follow-Up

• Reassess BP and medication adherence monthly until target BP is achieved, then every 3-6 months once controlled. 1

• Use home BP monitoring or 24-hour ambulatory monitoring to confirm control and detect white coat effect or masked hypertension. 2, 4

• Monitor for adverse effects of both Vyvanse and any antihypertensive medications, including orthostatic hypotension, electrolyte abnormalities, and renal function changes. 1, 4

Critical Caveats

• Patients with uncontrolled hypertension (≥160/100 mmHg) should not initiate or continue stimulant medications until BP is controlled, as the cardiovascular risks outweigh ADHD treatment benefits. 1

• The current BP of 138/80 mmHg does not meet criteria for immediate Vyvanse discontinuation, but requires close monitoring and intervention. 1, 5

• Amphetamines increase withdrawal rates due to adverse effects by 2.69-fold compared to placebo, with an absolute risk increase of 4.3% over one month. 3

• Proper BP measurement technique is essential: 5 minutes of rest, seated position, empty bladder, correct cuff size on bare arm, arm supported at heart level, legs uncrossed with feet flat, back supported, and no talking during measurement. 2