ADHD Drugs: Is Cardiac Screening Needed for All Patients?

ADDitude interviews Steven E. Nissen, M.D., on the FDA's new label advising cardiac screening for those on ADHD medications.

Cardiovascular Risks, Part 2

What can someone who is considering taking a stimulant medication or giving it to a child do to minimize the risk?
Before taking any medication for ADD, make sure the diagnosis is well-established, and that it has been documented by a psychiatrist or a mental-health professional. I advise trying treatments, such as behavioral therapy, before turning to medication.

If medication is needed to manage the impulsivity, distractibility, and hyperactivity of ADHD, the patient should first undergo a thorough examination, including being checked for cardiovascular disease. At a minimum, the doctor should listen to the heart and lungs, and take a complete history. If the prescribing physician detects a heart murmur or high blood pressure, this finding should be investigated before starting an ADD drug.

Once therapy is started, the clinical response—improved attention—should be monitored and dosage adjusted to achieve the desired effect with the smallest possible dosage. You should monitor for elevated blood pressure and other side effects. I also think it's a good idea to periodically try going off the medication.

What about people who are already taking a stimulant and who don't seem to have any problems? Should they take any precautions?
Yes. The effects of increased blood pressure and heart rate are cumulative. The longer you have been taking these medications, the more important it is to be screened periodically.

Are certain individuals who use stimulants more vulnerable to cardiovascular problems?
Yes. Several of the children who experienced sudden death had an underlying disorder known as hypertrophic obstructive cardiomyopathy. This is a heritable disorder that causes increased thickness of the heart muscle. Most patients with this condition have a heart murmur.

Are there diagnostic tests that can predict cardiac risks before they occur?
It's difficult to justify the cost of such tests for millions of ADHD patients. If a heart murmur is detected, an echocardiogram may be recommended. If an abnormal heart rhythm is found during examination, an EKG might be sensible.

I will say that, the older the adult, the more thorough the evaluation should be. This might include an exercise stress test, but without good data, I can't recommend that for everyone, either.

What research is needed?
Large, long-term clinical trials. The defense of stimlant medication for treating ADHD is based on studies that involved a few hundred kids.

Are you advising that the FDA ban stimulants?
Of course not. A 12-year-old who is not able to focus at school should certainly be able to get medication that helps him. It's a matter of balancing risks and benefits. If a medication is potentially risky, we should restrict its use to those for whom it is essential.

I want doctors to think carefully each time they pick up their pen to write a prescription for a stimulant.

This article comes from the October/November 2006 issue of ADDitude.

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TAGS: Ritalin, Concerta, Adderall, Strattera, ADHD Stimulant Medications, Side Effects of ADHD Meds

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