Is it safe to refill Adderall IR (amphetamine and dextroamphetamine) 30 mg twice daily for a patient with uncontrolled hypertension and ADHD who requested a 28-day refill?

Do Not Refill Adderall IR in This Patient with Uncontrolled Hypertension

You should not refill Adderall IR 30 mg twice daily for this patient until their hypertension is controlled to a target of <130/80 mmHg. The 2017 ACC/AHA guidelines explicitly recommend discontinuing or decreasing the dose of amphetamines when blood pressure is elevated, and to avoid use in patients with severe or uncontrolled hypertension 1.

Immediate Management Steps

Hold the Adderall refill entirely until blood pressure control is achieved 2. The patient's request for a 28-day refill instead of 30 days does not change the fundamental safety concern—amphetamines cause elevated blood pressure and should be avoided in uncontrolled hypertension 1.

Why This Matters

• Amphetamines increase systolic blood pressure by approximately 1.93 mmHg and diastolic blood pressure by 1.84 mmHg on average, with some individuals experiencing substantially larger increases 3
• At the high dose of 30 mg twice daily (60 mg total daily), cardiovascular effects are more pronounced 4, 5
• The immediate-release formulation creates rapid peaks in blood pressure that are particularly problematic in hypertensive patients, causing more pronounced cardiovascular stress 2
• 10% of patients on amphetamines develop new-onset hypertension (BP ≥140/90 mmHg) 4

Blood Pressure Control Algorithm

Step 1: Initiate or Intensify Antihypertensive Therapy

Start appropriate antihypertensive medication immediately, as uncontrolled hypertension requires treatment independent of Adderall use 1:

• First-line options: ACE inhibitors (e.g., lisinopril 10-40 mg daily), ARBs (e.g., losartan 50-100 mg daily), or calcium channel blockers (e.g., amlodipine 5-10 mg daily) 2
• Target blood pressure: <130/80 mmHg before restarting any ADHD medication 2

Step 2: Confirm Blood Pressure Readings

• Obtain repeat measurements to rule out white coat hypertension 2
• Consider ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) for accurate assessment 2
• Recheck blood pressure after at least 2 weeks of antihypertensive treatment 2

Step 3: Consider Alternative ADHD Treatment

While blood pressure is being controlled, implement behavioral therapies for ADHD as recommended by ACC/AHA guidelines 1:

• Behavioral interventions can be effective as monotherapy or adjunct treatment 1
• This provides symptom management during the period when stimulants are contraindicated 2

If Blood Pressure Control Is Achieved

Only after achieving target BP <130/80 mmHg, consider these safer alternatives rather than resuming Adderall IR:

Option 1: Switch to Non-Stimulant Medication (Preferred)

• Atomoxetine is the first-choice option for patients with hypertension, as it has minimal impact on blood pressure compared to stimulants 2, 6
• Extended-release guanfacine or clonidine may actually help lower blood pressure while treating ADHD 2, 6
• These provide 24-hour symptom control without the cardiovascular peaks of stimulants 2, 6

Option 2: Switch to Long-Acting Stimulant (If Non-Stimulants Fail)

If non-stimulants are ineffective and blood pressure remains well-controlled, consider switching from Adderall IR to a long-acting formulation 2:

• Long-acting stimulants provide smoother cardiovascular effects with more stable blood pressure profiles throughout the day 2
• They avoid the rapid peaks and troughs that exacerbate hypertension 2
• Start at a lower total daily dose than the current 60 mg (e.g., 20-30 mg of long-acting formulation) 2
• Implement more frequent blood pressure monitoring (weekly initially, then monthly) 2, 6

Option 3: Resume Adderall IR at Reduced Dose (Last Resort)

Only if blood pressure is controlled AND non-stimulants have failed AND long-acting stimulants are not tolerated:

• Reduce dose substantially (e.g., from 30 mg twice daily to 10-15 mg twice daily) 1
• Monitor blood pressure weekly for the first month, then monthly 2, 6
• If blood pressure rises above target, immediately reduce dose or discontinue 2

Critical Monitoring Requirements

If any ADHD medication is restarted after blood pressure control:

• Check blood pressure and heart rate at each dose adjustment 2
• Monitor quarterly in adults during maintenance treatment 2
• Amphetamines also increase heart rate by approximately 3.71 beats per minute 3
• 5-15% of patients experience more substantial cardiovascular increases requiring intervention 2, 6

Common Pitfalls to Avoid

Do not simply reduce the refill from 30 to 28 days and consider this adequate risk mitigation—the daily dose and formulation remain unsafe in uncontrolled hypertension 1.

Do not restart Adderall IR even if blood pressure improves slightly but remains above target—wait for BP <130/80 mmHg 2.

Do not use immediate-release formulations as first-line when restarting stimulants in hypertensive patients—the rapid onset creates cardiovascular instability 2.

Do not combine multiple antihypertensive agents from the same class (e.g., two ACE inhibitors) when optimizing blood pressure control 2.