When should mixed amphetamine salts (Adderall) be discontinued in a patient?

Reasons to Discontinue Adderall (Mixed Amphetamine Salts)

Adderall should be discontinued immediately if the patient develops absolute contraindications including symptomatic cardiovascular disease, uncontrolled hypertension (particularly Stage 2: ≥140/90 mmHg), active psychotic disorder, glaucoma, hyperthyroidism, concomitant MAO inhibitor use, or active stimulant abuse. 1, 2

Absolute Contraindications Requiring Immediate Discontinuation

Cardiovascular Conditions

• Symptomatic cardiovascular disease including uncontrolled hypertension, underlying coronary artery disease, or tachyarrhythmias requires immediate cessation 1
• Stage 2 hypertension (≥140/90 mmHg) that develops or worsens on Adderall mandates discontinuation or dose reduction, as amphetamines are explicitly listed as medications that impair blood pressure control 2
• New-onset chest pain, palpitations, syncope, or arrhythmias during treatment necessitates stopping the medication 1

Ophthalmologic Contraindications

• Glaucoma (particularly intractable glaucoma) is an absolute contraindication because sympathomimetic effects can elevate intraocular pressure and precipitate irreversible vision loss 1, 2

Psychiatric Contraindications

• Active psychotic disorder requires immediate discontinuation, as stimulants can exacerbate psychosis 1
• New-onset psychosis, confusion, or severe agitation during treatment mandates stopping the medication 1

Metabolic and Endocrine Contraindications

• Hyperthyroidism is a contraindication due to additive sympathomimetic effects 1

Drug Interactions

• Concomitant MAO inhibitor use is absolutely contraindicated 1

Substance Use Disorders

• Active illicit use or abuse of stimulants requires discontinuation unless the patient is in a highly controlled treatment setting with close supervision 1

Relative Indications for Discontinuation

Lack of Therapeutic Efficacy

• Perceived inadequate medication effectiveness is a common reason for discontinuation and should prompt reassessment 3
• If ADHD symptoms fail to improve after adequate dose titration and duration of trial, consider switching to alternative agents 4

Adverse Effects

Psychological Side Effects:

• Severe agitation, insomnia, anxiety, or mood changes are common reasons for discontinuation 1, 3
• Psychological side effects are strongly associated with medication discontinuation in multivariate analyses 3

Cardiovascular Side Effects:

• Persistent hypertension or tachycardia despite dose adjustment warrants discontinuation or switching to non-stimulant alternatives 1, 2
• While average increases are modest (1-4 mmHg BP, 1-2 bpm HR), 5-15% of patients experience substantial increases requiring intervention 2

Other Common Side Effects:

• Rare but serious effects including severe headache, tremor, or signs of impending overdose (confusion, sedation, slurred speech) require immediate cessation 1

Patient-Specific Factors

Pregnancy and Breastfeeding:

• Discontinuation should be strongly considered during pregnancy due to potential neonatal effects, though this must be weighed against maternal functional impairment 5

Household Substance Abuse Risk:

• If a household member has a history of stimulant abuse and the medication cannot be secured, discontinuation may be necessary 1

Clinical Monitoring to Identify Need for Discontinuation

Baseline and Ongoing Assessments

• Blood pressure and pulse must be checked at baseline, with each dose adjustment, and at least quarterly in adults 1, 2
• Height and weight should be monitored to detect growth suppression in children 1
• Cardiovascular symptoms (chest pain, palpitations, syncope) should be assessed at each visit 2

Red Flags Requiring Immediate Evaluation

• Blood pressure ≥140/90 mmHg on repeated measurements 2
• Heart rate persistently >100 bpm at rest 2
• New cardiac symptoms or arrhythmias 2
• Emergence of psychotic symptoms 1
• Acute angle-closure glaucoma symptoms 2

Important Clinical Pitfalls

Do not abruptly discontinue after prolonged use at high doses without considering a gradual taper, as this may cause withdrawal symptoms including fatigue and depression 5

Do not assume that controlled hypertension on antihypertensive therapy permits continued Adderall use if blood pressure rises above target (<130/80 mmHg); the stimulant should be reduced or stopped first before intensifying antihypertensive therapy 2

Do not continue Adderall in patients with inadequate symptom control without reassessing the diagnosis, optimizing the dose, or considering alternative treatments 3

Do not overlook the need for comprehensive cardiovascular screening (personal and family history of sudden death, structural heart disease, arrhythmias) before initiating therapy, as this identifies patients at higher risk who may require earlier discontinuation 2