What baseline assessments and ongoing monitoring are recommended when initiating ADHD pharmacotherapy (stimulants or non‑stimulants) in patients?

ADHD Medication Monitoring: Baseline Assessments and Ongoing Surveillance

Before initiating any ADHD medication—stimulant or non-stimulant—screen for cardiovascular risk factors, substance use history (especially in adolescents), and bipolar disorder risk, then monitor blood pressure, pulse, height, weight, and symptom response at every visit during titration and at regular intervals during maintenance. 1

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Baseline Assessments Before Initiating Pharmacotherapy

Cardiovascular Screening (All Patients)

• Measure baseline blood pressure and heart rate in all patients before starting any ADHD medication, as stimulants increase blood pressure by 1–4 mm Hg and heart rate by 1–2 beats per minute. 1
• Obtain a detailed personal and family cardiac history, specifically screening for sudden death in first-degree relatives, symptomatic cardiovascular disease, Wolff-Parkinson-White syndrome, hypertrophic cardiomyopathy, long QT syndrome, and arrhythmias. 1
• If any cardiac risk factors are identified, obtain an ECG and consider cardiology consultation before initiating treatment. 1
• Stimulants are contraindicated in patients with symptomatic heart disease, uncontrolled hypertension, or pheochromocytoma. 1, 2

Substance Use Assessment (Adolescents and Adults)

• Screen all adolescents for current or past substance use before starting medication, as active substance use requires referral to a subspecialist for consultative support and guidance. 3
• Assess for risk of medication diversion in adolescents, as diversion to parents, classmates, or acquaintances is a special concern; consider prescribing non-stimulant medications (atomoxetine, extended-release guanfacine, or extended-release clonidine) to minimize abuse potential. 3
• Active substance use disorder is a relative contraindication to stimulants, requiring close supervision or use of non-stimulant alternatives. 1

Psychiatric Screening (All Patients)

• Screen for personal or family history of bipolar disorder, mania, or hypomania before initiating atomoxetine or any ADHD medication, as treatment-emergent psychotic or manic symptoms can occur. 2
• Conduct a detailed psychiatric history, including family history of suicide, bipolar disorder, and depression, to determine if the patient is at risk for bipolar disorder. 2
• Assess severity of ADHD dysfunction across multiple settings (home, school/work, social environments) to confirm that pharmacotherapy is warranted. 3

Additional Baseline Measures

• Record baseline height and weight in children and adolescents, as stimulants and atomoxetine can affect growth trajectories. 4
• For atomoxetine specifically, assess for hepatic insufficiency and adjust dosing accordingly (50% reduction for moderate hepatic impairment, 25% reduction for severe impairment). 2
• Screen for narrow-angle glaucoma, as atomoxetine is contraindicated due to risk of mydriasis. 2

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Ongoing Monitoring During Titration (First 4–6 Weeks)

Weekly Assessments

• Measure blood pressure and pulse at every dose adjustment, as cardiovascular effects are dose-dependent and require close monitoring during titration. 1, 4
• Use standardized ADHD rating scales (parent- and teacher-rated for children; self- and collateral-rated for adults) to objectively measure symptom improvement at each visit. 1
• Assess for common adverse effects, including appetite suppression, sleep disturbances, gastrointestinal symptoms, irritability, and mood changes. 1, 4
• Titrate stimulant doses by 5–10 mg increments weekly (methylphenidate) or 5 mg increments weekly (amphetamines) based on response and tolerability, allowing adequate time between adjustments to evaluate efficacy. 1

Special Monitoring for Adolescents

• Monitor prescription refill requests and symptom patterns for signs of misuse or diversion, including requests for early refills or inconsistent symptom reports. 3
• Utilize prescription drug monitoring programs to identify and prevent diversion activities. 3

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Maintenance Monitoring (After Symptom Stabilization)

Monthly Visits Until Stable

• Schedule monthly follow-up visits until symptoms stabilize and optimal dosing is achieved. 1
• Continue to assess therapeutic response and adverse effects using standardized rating scales at each visit. 1

Ongoing Long-Term Monitoring

• Measure height and weight at every visit in children and adolescents, as stimulants and atomoxetine can slow growth velocity during the first 9–12 months of treatment. 4
• Monitor blood pressure and heart rate at each visit during stable long-term treatment to detect cardiovascular effects. 1, 4
• Assess functional improvement across multiple domains, including academic/occupational performance, social relationships, and home functioning. 1
• Evaluate sleep quality and appetite at each visit, as these are common adverse effects requiring intervention. 1
• Screen for treatment-emergent psychiatric symptoms, including mood changes, irritability, aggression, psychotic symptoms, or manic symptoms. 2

Periodic Reassessment

• Implement medication-free periods at regular intervals (e.g., annually) to determine whether continued treatment remains necessary and beneficial. 5
• Periodically reevaluate the long-term usefulness of medication for the individual patient, as the need for treatment may change over time. 2

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Special Monitoring Considerations by Medication Class

Stimulants (Methylphenidate and Amphetamines)

• Monitor for rebound symptoms in the late afternoon/evening, which may require addition of a short-acting dose or switch to a longer-acting formulation. 1
• Assess driving safety in adolescents, as ADHD increases crash risk; ensure medication coverage extends through driving hours with longer-acting or late-afternoon doses. 3

Atomoxetine

• Allow 6–12 weeks for full therapeutic effect, with median time to response of 3.7 weeks; do not prematurely discontinue due to delayed onset. 1
• Monitor for urinary retention or hesitation, which occurs in 1.7% and 5.6% of adult patients, respectively. 2
• Screen for suicidal ideation, particularly in the first few months of treatment. 2
• Monitor liver function if hepatic symptoms develop (jaundice, dark urine, upper-right-quadrant tenderness). 2

Alpha-2 Agonists (Guanfacine and Clonidine)

• Monitor for sedation and fatigue, which are common adverse effects, particularly during dose titration. 1
• Assess blood pressure and heart rate, as these medications decrease both parameters. 1
• Never discontinue abruptly, as rebound hypertension can occur; taper gradually if discontinuation is needed. 1

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Critical Pitfalls to Avoid

• Do not start stimulants at excessively high doses, as this increases adverse effects and reduces adherence; begin conservatively and titrate systematically. 1
• Do not assume adequate trial without proper titration; for example, 18 mg Concerta is subtherapeutic for most patients and requires titration to 36–54 mg. 1
• Do not delay ADHD treatment due to comorbid anxiety or mood symptoms, as untreated ADHD worsens functional impairment and can amplify psychiatric comorbidities. 1
• Do not prescribe immediate-release stimulants for "as-needed" use, as ADHD requires consistent daily symptom control; this approach lacks evidence and creates erratic symptom control. 1
• Do not discontinue effective treatment solely due to concerns about "taking medication forever", as untreated ADHD is associated with increased risk of accidents, substance abuse, and functional impairment. 1
• Do not combine bupropion with stimulants, as safety data are insufficient. 1