How long should Adderall (amphetamine and dextroamphetamine) be discontinued before elective surgery in a patient with Attention Deficit Hyperactivity Disorder (ADHD)?

Perioperative Management of Adderall (Amphetamine/Dextroamphetamine)

Adderall does not need to be discontinued before elective surgery and can be safely continued through the perioperative period.

Evidence-Based Recommendation

The available evidence strongly supports continuing amphetamine therapy perioperatively rather than discontinuing it 1. A case series of 8 patients taking chronic prescription amphetamines (prescribed for 2-10 years) who underwent general anesthesia demonstrated safe intraoperative courses with no significant cardiovascular instability 1. These patients underwent procedures ranging from 30 minutes to 4.25 hours, with 6 of 8 requiring tracheal intubation, and all had stable outcomes 1.

Rationale for Continuation

Cardiovascular Safety Profile

• Historical concerns about catecholamine depletion and blunted response to hypotension have not materialized in clinical practice 1
• The theoretical risk of intraoperative hypotension due to chronic amphetamine use causing catecholamine depletion was not observed in actual surgical patients 1
• No significant increase in hypotension or arrhythmias occurred in patients continuing their amphetamine therapy 1

Risks of Discontinuation

• Discontinuing chronic medications before surgery generally carries more risk than benefit, particularly for agents where withdrawal syndromes exist 2
• Abrupt cessation of amphetamines can lead to rebound ADHD symptoms, fatigue, depression, and cognitive impairment that may complicate postoperative recovery 3
• The principle of continuing chronic psychiatric medications perioperatively is well-established, as demonstrated with antidepressants where discontinuation increased delirium and confusion (30% vs 13%) without reducing anesthetic complications 4

Anesthetic Considerations

Intraoperative Management

• Anesthesiologists should be informed that the patient is taking amphetamines to allow appropriate monitoring and medication selection 1
• Direct-acting vasopressors (phenylephrine, epinephrine) should be used preferentially over indirect-acting agents if hemodynamic support is needed 2
• Standard anesthetic techniques are appropriate; no special "amphetamine-safe" protocols are required 1

Monitoring Requirements

• Routine cardiovascular monitoring is sufficient 1
• No additional specialized monitoring is required beyond standard ASA guidelines 1

Comparison with Similar Medications

This recommendation differs significantly from phentermine, another sympathomimetic medication used for weight loss, which requires discontinuation at least 4 days before procedures requiring anesthesia due to risks of hyperadrenergic effects and paradoxical refractory hypotension 5. The key distinction is that therapeutic amphetamines for ADHD at prescribed doses have a different risk profile than appetite suppressants like phentermine 5, 1.

Common Pitfalls to Avoid

• Do not confuse prescription amphetamines for ADHD with illicit amphetamine abuse - the perioperative management differs significantly 1
• Do not automatically discontinue all sympathomimetic medications - each class has distinct perioperative considerations 5, 1
• Avoid indirect-acting vasopressors (ephedrine) if possible, as amphetamines may alter their effectiveness 2

Practical Implementation

• Continue the patient's usual morning dose of Adderall on the day of surgery 1
• Document amphetamine use clearly in the anesthetic record 1
• Ensure adequate postoperative pain control, as amphetamines do not interfere with opioid analgesia 1
• Resume normal dosing schedule immediately postoperatively once oral intake is tolerated 1