Is it advisable to change the medication for an adult patient with attention‑deficit/hyperactivity disorder who is stable on lisdexamfetamine (Vyvanse) 50 mg daily and now has stage 1 hypertension with diastolic blood pressure ≥90 mm Hg?

Management of Stage 1 Hypertension in a Patient Stable on Vyvanse

You should not discontinue Vyvanse at this time, but you must initiate antihypertensive therapy immediately while continuing the current ADHD medication. 1

Blood Pressure Classification and Treatment Threshold

Your patient has stage 1 hypertension with diastolic readings of 92-93 mmHg (stage 1 is defined as 130-139/80-89 mmHg). 1 The elevated diastolic component is particularly concerning and requires prompt intervention regardless of the Vyvanse use. 2

Why Continuing Vyvanse is Appropriate

• Amphetamines are a recognized cause of elevated blood pressure, but the ACC/AHA guidelines recommend either discontinuing/decreasing the dose OR managing the hypertension with antihypertensive therapy—not automatically stopping the medication. 1

• The patient is clinically stable on their current ADHD regimen, which is a critical consideration for quality of life and functional outcomes. 2

• The blood pressure elevation is modest (stage 1, not stage 2), and amphetamines typically cause average increases of only 1-4 mmHg in systolic and diastolic blood pressure. 2, 3 Your patient's readings suggest the hypertension may have multifactorial causes beyond just the Vyvanse.

• Research demonstrates that stimulants cause minor, clinically manageable cardiovascular changes in most patients, with the benefits of treating ADHD outweighing cardiovascular risks when properly monitored. 4, 5

Immediate Management Steps

1. Confirm the Diagnosis

• Obtain repeat blood pressure measurements using home blood pressure monitoring (HBPM) or ambulatory blood pressure monitoring (ABPM) to rule out white coat hypertension before initiating pharmacotherapy. 1
• The target blood pressure should be <130/80 mmHg. 1, 2

2. Initiate Antihypertensive Therapy

Start a first-line antihypertensive agent immediately:

• Preferred options include ACE inhibitors (e.g., lisinopril), ARBs (e.g., losartan), calcium channel blockers (e.g., amlodipine), or thiazide diuretics. 1, 2
• For stage 1 hypertension with ASCVD risk ≥10%, combination therapy with nonpharmacological interventions is recommended. 1
• Recheck blood pressure within 1 month after initiating antihypertensive therapy. 1

3. Implement Lifestyle Modifications

• Nonpharmacological therapy should be used in addition to pharmacological therapy, including dietary sodium reduction, weight management if indicated, increased physical activity, and alcohol limitation. 1

4. Enhanced Monitoring Protocol

• Monitor blood pressure and heart rate at each follow-up visit while the patient remains on Vyvanse. 2
• If blood pressure rises above target (<130/80 mmHg) despite initial antihypertensive therapy, intensify the antihypertensive regimen by adding a second agent rather than immediately discontinuing Vyvanse. 2

When to Consider Changing ADHD Medication

Only consider switching from Vyvanse if:

• Blood pressure remains ≥140/90 mmHg despite optimal antihypertensive therapy with 2-3 agents. 2
• The patient develops stage 2 hypertension (≥140/90 mmHg) that is clearly medication-induced. 1
• Cardiovascular risk factors accumulate or target organ damage develops. 1

Alternative ADHD Medications if Switching Becomes Necessary

• Atomoxetine (non-stimulant) is the preferred first-choice alternative, as it has minimal impact on blood pressure compared to stimulants. 2
• Alpha-2 adrenergic agonists (extended-release guanfacine or clonidine) may actually help lower blood pressure due to their hypotensive effects. 2
• If continuing with stimulants, long-acting formulations provide smoother cardiovascular effects compared to immediate-release preparations. 2

Critical Pitfalls to Avoid

• Do not abruptly discontinue effective ADHD treatment without attempting blood pressure management first—this prioritizes a modifiable cardiovascular risk factor over the patient's functional status and quality of life. 2
• Do not delay antihypertensive therapy while attempting lifestyle modifications alone in a patient with confirmed stage 1 hypertension and likely ASCVD risk ≥10%. 1
• Do not assume the blood pressure elevation is solely due to Vyvanse—evaluate for other secondary causes of hypertension and cardiovascular risk factors. 1
• Avoid combining two RAS blockers (e.g., ACE inhibitor + ARB) if intensifying therapy. 2

Follow-Up Timeline

• Recheck blood pressure in 1 month after initiating antihypertensive therapy. 1
• If blood pressure is controlled (<130/80 mmHg), continue current regimen with quarterly blood pressure monitoring. 2
• If blood pressure remains elevated, intensify antihypertensive therapy before considering ADHD medication changes. 2