What is the optimal treatment strategy for a 62‑year‑old woman with ovarian cancer receiving hormone‑suppressive therapy who has adult attention‑deficit/hyperactivity disorder?

Treatment of Adult ADHD in a 62-Year-Old Woman with Ovarian Cancer on Hormone Suppressants

Primary Recommendation

Initiate a long-acting stimulant medication—specifically methylphenidate extended-release (Concerta) or lisdexamfetamine (Vyvanse)—as first-line treatment for this patient's ADHD, as stimulants achieve 70-80% response rates and have no known contraindications related to ovarian cancer or hormone-suppressive therapy. 1, 2

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Treatment Algorithm

Step 1: Baseline Assessment Before Initiating Stimulants

Before prescribing any ADHD medication, obtain the following specific assessments:

• Cardiovascular screening: Measure blood pressure and pulse in both seated and standing positions; obtain a detailed cardiac history including syncope, chest pain, palpitations, exercise intolerance, and family history of premature cardiovascular death, arrhythmias, or structural heart disease 1, 3
• Substance use screening: Assess for any history of substance abuse, as this influences formulation choice (long-acting formulations preferred if positive history) 1
• Current medications review: Confirm she is not taking MAO inhibitors (absolute contraindication) and document all hormone-suppressive agents 4
• Baseline vital signs: Record height, weight, blood pressure, and pulse for ongoing monitoring 1, 4

Step 2: First-Line Pharmacologic Treatment

Stimulant Selection and Dosing:

• Methylphenidate extended-release (Concerta): Start at 18 mg once daily in the morning, increase by 18 mg weekly based on symptom response and tolerability, with a maximum of 54-72 mg daily 5, 6

  • Rationale: OROS delivery system provides 12-hour coverage with ascending plasma levels, minimizing peak-trough fluctuations and reducing abuse potential 1

• Alternative: Lisdexamfetamine (Vyvanse): Start at 20-30 mg once daily in the morning, increase by 10 mg weekly, maximum 70 mg daily 1

  • Rationale: Prodrug formulation reduces abuse potential; amphetamine-based stimulants show superior efficacy in adults (effect size -0.79 vs -0.49 for methylphenidate) 1, 2

Why stimulants are safe in this patient:

• No evidence of drug interactions between stimulants and hormone-suppressive therapies for ovarian cancer 1
• Stimulants work within days, allowing rapid assessment of efficacy 1
• Long-acting formulations improve adherence and reduce rebound effects 1, 5

Step 3: Monitoring During Titration

At each dose adjustment (weekly during titration):

• Measure blood pressure and pulse 1, 4, 7
• Assess ADHD symptom response using standardized rating scales 1
• Monitor for common adverse effects: appetite suppression, insomnia, headache 1, 4
• Track functional improvement across multiple settings (home, work, social) 1

Step 4: If Stimulants Are Contraindicated or Not Tolerated

Second-line option: Atomoxetine

• Start at 40 mg daily, titrate every 7-14 days to 60 mg, then 80 mg daily; maximum 100 mg/day or 1.4 mg/kg/day, whichever is lower 1
• Requires 6-12 weeks for full therapeutic effect (vs. days for stimulants) 1, 6
• Medium-range effect size (0.7 vs. 1.0 for stimulants) 1
• Advantage: No abuse potential, 24-hour coverage, non-controlled substance 1
• Disadvantage: Carries FDA black-box warning for suicidal ideation; requires close monitoring 1

Alternative second-line: Extended-release guanfacine

• Start at 1 mg once daily in the evening, increase by 1 mg weekly; target 0.05-0.12 mg/kg/day, maximum 7 mg/day 1
• Effect size around 0.7; particularly useful if sleep disturbances or anxiety are present 1, 5
• Advantage: Actually decreases blood pressure and heart rate (beneficial if cardiovascular concerns exist) 5
• Disadvantage: Requires 2-4 weeks for full effect; sedation is common 1

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Critical Safety Considerations Specific to This Patient

Cardiovascular Monitoring

• Stimulants cause average increases of only 1-2 beats/min in heart rate and 1-4 mm Hg in blood pressure 3, 7
• Studies in adults have not shown disproportionately high risk of major adverse cardiovascular events, including sudden death 3, 8
• Monitor blood pressure and pulse at baseline, each dose adjustment, and quarterly during maintenance 1, 7
• If hypertension develops (BP ≥140/90), consider switching to atomoxetine or guanfacine, which have more favorable cardiovascular profiles 5, 3

Cancer Treatment Considerations

• No known drug interactions between stimulants and hormone-suppressive therapies for ovarian cancer 1
• Untreated ADHD is associated with increased risk of accidents, substance abuse, and functional impairment—risks that may be particularly detrimental during cancer treatment 1
• Stimulant-related appetite suppression may be problematic if the patient is already experiencing cancer-related weight loss; monitor weight at each visit 1, 4

Absolute Contraindications to Stimulants

• Concurrent MAO inhibitor use or within 14 days of discontinuation 1, 4
• Known hypersensitivity to methylphenidate or amphetamines 4
• Symptomatic cardiovascular disease or uncontrolled hypertension 1, 4
• Active psychosis or mania 1

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Integrating Psychotherapy

Cognitive Behavioral Therapy (CBT) should be initiated concurrently with medication, as combination therapy yields superior outcomes compared to medication alone. 1, 2

• CBT targets executive functioning skills: time management, organization, planning, emotional self-regulation, stress management, and impulse control 2
• CBT is the most extensively studied and effective psychotherapy for adult ADHD 1, 2
• Mindfulness-based interventions (MBIs) also show promise for managing inattention symptoms, emotion regulation, and quality of life 1

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Common Pitfalls to Avoid

• Do not delay treatment due to concerns about "taking medication during cancer treatment"—untreated ADHD significantly impairs quality of life and functional capacity, which are critical during cancer therapy 1, 2
• Do not underdose stimulants: 70-80% of patients respond when properly titrated; many patients require 40-50 mg daily of amphetamine salts or 54-72 mg of methylphenidate 1, 5
• Do not assume appetite suppression is prohibitive: This side effect can often be managed by adjusting dosing times or switching formulations 1
• Do not prescribe immediate-release formulations when long-acting options are available—long-acting formulations improve adherence, reduce abuse potential, and provide more consistent symptom control 1, 5
• Do not use weight-based dosing for methylphenidate in adults; instead, use systematic weekly titration to achieve symptom control 5

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Long-Term Management

• Continue treatment as long as functional impairment persists: ADHD is a chronic condition requiring ongoing management 1, 5
• Quarterly monitoring during maintenance: Blood pressure, pulse, weight, and functional assessment 1
• Reassess need for treatment periodically: A 7-week randomized discontinuation study showed that patients on methylphenidate for >2 years experienced significant symptom worsening when medication was stopped, supporting long-term treatment in responders 5
• Address comorbid conditions: If mood or anxiety symptoms emerge or persist despite ADHD treatment, consider adding an SSRI (no significant drug interactions with stimulants) 1

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Evidence Quality Summary

The recommendation to use stimulants as first-line treatment is based on:

• Level A evidence from over 161 randomized controlled trials demonstrating 70-80% response rates 1
• Recent meta-analyses (2024-2026) showing amphetamine-based stimulants have superior efficacy in adults 1, 2
• FDA approval for methylphenidate and amphetamines in adult ADHD 4
• Guideline consensus from the American Academy of Child and Adolescent Psychiatry, American College of Obstetricians and Gynecologists, and American Academy of Pediatrics 1, 2, 5

The absence of contraindications related to ovarian cancer or hormone-suppressive therapy, combined with the high efficacy and rapid onset of stimulants, makes them the clear first-line choice for this patient. 1, 2