When should a patient with attention deficit hyperactivity disorder (ADHD) stop taking Adderall (amphetamine and dextroamphetamine) before undergoing a cholecystectomy?

Preoperative Management of Adderall Before Cholecystectomy

Hold Adderall (amphetamine/dextroamphetamine) on the morning of surgery to minimize cardiovascular complications and drug interactions with anesthetic agents.

Timing of Discontinuation

The 2021 Mayo Clinic Proceedings consensus statement on perioperative analgesic management specifically addresses amphetamines in the context of drug-drug interactions, noting that concomitant use of amphetamines with certain analgesics (particularly butorphanol or nalbuphine) may result in increased risk of serotonin syndrome 1. While this guideline does not provide an explicit timeline for amphetamine cessation, the cardiovascular stimulant properties and potential for intraoperative hemodynamic instability warrant careful consideration.

Recommended Approach

• Hold Adderall on the day of surgery (morning dose should be skipped) to reduce risk of:

  • Intraoperative hypertension and tachycardia during laryngoscopy and pneumoperitoneum 1
  • Potentiation of vasopressor effects with anesthetic agents 1
  • Increased risk of serotonin syndrome when combined with perioperative analgesics 1

• For elective cholecystectomy, consider holding for 24 hours preoperatively if the patient has cardiovascular comorbidities or poorly controlled hypertension, as amphetamines cause sustained sympathetic stimulation 1

Key Perioperative Considerations

Cardiovascular monitoring is essential because:

• Laparoscopic cholecystectomy involves pneumoperitoneum creation, which increases systemic vascular resistance and can exacerbate amphetamine-induced hypertension 2
• The combination of residual amphetamine effects and surgical stress may produce significant hemodynamic instability 2, 3

Avoid specific drug combinations:

• Do not use butorphanol or nalbuphine for perioperative analgesia in patients taking amphetamines due to serotonin syndrome risk 1
• Exercise caution with other serotonergic agents including fentanyl, tramadol, and ondansetron 1

Postoperative Resumption

• Resume Adderall on postoperative day 1 once the patient is hemodynamically stable, tolerating oral intake, and no longer requiring parenteral opioids 4
• Multimodal analgesia with acetaminophen 1g every 6 hours and NSAIDs (ibuprofen 400mg three times daily) should be prioritized to minimize opioid requirements and drug interactions 4, 5

Common Pitfalls to Avoid

• Do not abruptly discontinue Adderall for extended periods (>48 hours) without discussing with the patient's prescribing physician, as this may cause significant ADHD symptom rebound and affect postoperative recovery
• Do not assume all stimulants behave identically—this recommendation is specific to amphetamine-based medications 1
• Monitor for withdrawal symptoms including fatigue and depression if held longer than 24-48 hours, though these are generally mild with short-term discontinuation
• Communicate clearly with anesthesia about the patient's Adderall use and timing of last dose to guide intraoperative medication selection 1