Should I restart atenolol, stop risperidone, restart Caplyta (lumateperone), and stop Adderall (amphetamine and dextroamphetamine) given my history of psychiatric conditions and cardiac symptoms?

Medication Management Decision

You should stop Adderall immediately, continue atenolol (or restart if recently stopped), switch from risperidone to aripiprazole rather than Caplyta, and avoid combining multiple medications that prolong QTc interval. 1, 2

Critical Cardiovascular Concerns

Adderall Must Be Discontinued

• Amphetamines increase systolic blood pressure by 1.93 mmHg and diastolic blood pressure by 1.84 mmHg, with sustained effects even after 8 weeks of use. 3
• Amphetamines increase heart rate by 3.71 beats per minute and significantly increase risk of adverse cardiovascular events. 3
• Prolonged amphetamine-dextroamphetamine use causes cardiomyopathy through increased oxidative stress, sympathetic overactivity, and direct myocardial toxicity. 4
• Amphetamines should be avoided in patients with underlying coronary artery disease and tachyarrhythmias. 1
• The risk of withdrawals due to adverse effects is 2.69 times higher with amphetamines compared to placebo. 3

Beta-Blocker (Atenolol) Should Be Continued

• Beta-blockers like atenolol are listed among medications that promote weight gain, but this concern is outweighed by cardiovascular protection if you have cardiac symptoms. 1
• Atenolol may exacerbate depression symptoms, so monitor mood closely. 1
• If cardiac symptoms are present, continuing atenolol provides essential heart rate and blood pressure control. 1

Antipsychotic Selection Strategy

Why Risperidone Should Be Stopped

• Risperidone causes 0-5 ms mean QTc prolongation and has been associated with hypothermia, bradycardia, and cardiac arrest in rare cases. 2, 5
• Risperidone is specifically listed as a medication that promotes weight gain and should be minimized when possible. 1
• Users of atypical antipsychotics like risperidone have dose-dependent increased risk of sudden cardiac death (adjusted incidence-rate ratio 1.59 to 2.86). 1

Why Aripiprazole Is Superior to Caplyta

• Aripiprazole demonstrates 0 ms mean QTc prolongation and is recommended as the preferred antipsychotic when cardiovascular concerns exist. 2
• Aripiprazole has minimal to no effect on QTc interval and should be preferred when QTc prolongation is a concern. 2
• Aripiprazole has lower risk of weight gain, diabetes, and dyslipidemia compared to other antipsychotics. 2
• The American Academy of Pediatrics and European Heart Journal recommend aripiprazole as first-line for patients with QTc concerns. 2

Why Not Restart Caplyta (Lumateperone)

• While Caplyta may have been effective previously, aripiprazole provides superior cardiovascular safety profile with 0 ms QTc prolongation. 2
• Given your cardiac symptoms and need to stop Adderall, minimizing all cardiovascular risks is paramount. 2

Essential Monitoring Requirements

Before Starting Aripiprazole

• Obtain baseline ECG to document current QTc interval. 2
• Check and correct electrolyte abnormalities, maintaining potassium >4.5 mEq/L and normalizing magnesium. 2
• Review all other medications for QTc-prolonging effects. 2

Ongoing Monitoring

• Repeat ECG after dose titration of aripiprazole. 2
• Discontinue medication immediately if QTc exceeds 500 ms or increases >60 ms from baseline. 2
• Monitor electrolytes, particularly potassium levels, throughout treatment. 2
• Monitor blood pressure and heart rate regularly after stopping Adderall. 3

High-Risk Factors Requiring Extra Caution

• Female gender and age >65 years significantly increase risk of QTc prolongation and torsades de pointes. 2
• Concomitant use of multiple QTc-prolonging medications exponentially increases risk. 2
• Underlying cardiac disease, electrolyte abnormalities (hypokalemia, hypomagnesemia), and baseline QTc >500 ms are critical risk factors. 2

Common Pitfalls to Avoid

• Never combine multiple antipsychotics, as this exponentially increases QTc prolongation risk and torsades de pointes. 2
• Do not restart Adderall even at lower doses, as cardiovascular effects are sustained and dose-dependent. 3
• Avoid abrupt discontinuation of atenolol if you have been taking it, as sudden cessation can produce withdrawal syndrome. 1
• Do not assume weight gain from atenolol outweighs cardiovascular benefits if you have cardiac symptoms. 1