ADHD Stimulants: Adverse Effects and Contraindications

00:01 Hi, I'm Doctor Rhonda Lawes, and in this discussion we're going to look at the adverse effects contraindications and how you should monitor for those for your patients.

00:10 You've prescribed stimulants to treat ADHD.

00:13 Now first let's go back and do a quick review of the mechanism of action.

00:16 That's going to be a strong link to remembering the adverse effects.

00:20 So stimulants block the reuptake of the neurotransmitters dopamine and norepinephrine. Now because these medications block the reuptake of these neurotransmitters, that leads to a higher concentration of dopamine and norepinephrine in the synaptic cleft.

00:35 That's a good thing because that will move the levels of dopamine and norepinephrine in critical brain regions.

00:41 You're trying to address for ADHD to help alleviate those symptoms.

00:46 Remember, the goal of treatment of ADHD is to restore normal levels or closer to normal levels of dopamine and norepinephrine.

00:54 So we reviewed the mechanism.

00:56 Now let's talk about what the problem is.

00:58 Why is there an adverse effect.

01:01 Well this increased neurotransmission in other areas of the brain and body can also lead to the adverse effects.

01:08 So let's take a look at what happens when you have extra dopamine and norepinephrine.

01:13 So the general adverse effects.

01:16 Just think about it under the category of sympathetic nervous system stimulation.

01:20 Right. You've got those extra neurotransmitters.

01:22 So you would expect tachycardia.

01:25 They're going to have a really fast heart rate.

01:27 Remember sympathetic nervous system stimulation.

01:31 They're going to have vasoconstriction.

01:33 Therefore an increased blood pressure they're going to be sweaty.

01:36 They can be a little jittery and anxious as you would be when your sympathetic nervous system is overstimulated.

01:41 And they're going to have difficulty with sleeping.

01:44 So when you're thinking about prescribing a stimulant for your client, these are the things you want to educate them to let you know about if they're experiencing them.

01:53 Now, also keep in mind another adverse effect is the increase in the dopamine levels. This is because the patient can feel this euphoria.

02:01 Now that may cause the patient to struggle with addiction.

02:05 But when these drugs, these stimulants are used as prescribed for ADHD.

02:09 It typically helps normalize the dopamine levels without producing a euphoria.

02:16 Now think about the overall effect.

02:18 Because the adverse effect we're talking about those extra dopamine and norepinephrine. You've got that extra stimulation of the sympathetic nervous system. So you have this heightened arousal and alertness which is what your sympathetic nervous system is supposed to do.

02:32 So what it does that's well for the ADHD client is it can improve their attention and their focus. If they have ADHD and they're taking stimulants, that's the therapeutic effect we're looking for.

02:44 But even in our clients with ADHD who need the medication, this can lead them to be restless and irritable and they can have difficulty in sleeping.

02:53 It's all back to those extra neurotransmitters.

02:56 Now, there are some other adverse effects we'd like you to keep in mind, but the most common ones are it really goes after appetite.

03:02 It suppresses their appetite.

03:04 Now, this is particularly problematic for children because we want to watch to make sure that it doesn't impact their growth and development and cause them to lose weight and weight and become underweight, particularly during their childhood.

03:16 It can also make people a little emotionally labile, so that's something that you really have to work with your client.

03:21 Because remember, in ADHD, emotional regulation is also a challenge.

03:26 So sometimes the symptoms of the treatment look a lot like the actual ADHD.

03:31 Also this may cause the client to want to have social withdrawal.

03:35 So you want to have a conversation with them and see how things are going in the psychosocial area.

03:41 I wanted to revisit the concept of addiction and stimulants.

03:45 Now keep in mind, as a provider, you need to be aware and help educate your clients that ADHD stimulants do not increase their risk of developing a substance use disorder if they don't already have a comorbid conduct disorder or a substance use disorder.

04:01 Now, that's why you as a clinician, you've got to remain alert to this and keep an eye on assessment.

04:06 Watch for signs of potential problem of stimulant misuse and diversion.

04:10 Okay. That's the basics.

04:12 But also if you're dealing with a child and you're dealing with parents, you want to explain to Explain to them that this is a much less common risk and how this comes to be, and that you will partner with them and to remain alert and watch for those signs together. Now, the other contraindications are going to go back to what we know about the overload of norepinephrine and dopamine.

04:34 So if a client has already has symptomatic cardiovascular disease they've got moderate to severe hypertension.

04:40 We don't want them to take a stimulant that will make those problems worse.

04:45 Same thing with hyperthyroidism.

04:46 Right. They're already there.

04:48 Sympathetic nervous system is already cranking.

04:51 So we want to be really careful with stimulant use with someone with hypothyroidism. Now obviously if we know they have some hypersensitivity or some idiosyncrasy to sympathomimetic amines, we don't want them to have a stimulant.

05:05 Anything that raises the blood pressure can also raise the pressure in the eyes.

05:09 So if the client has glaucoma that's another contraindication.

05:13 If the patient has anxiety or they have agitated states, giving them a stimulant could also make those worse.

05:20 So as you do as a provider, you have to weigh out the benefits and the risks.

05:24 And this may be an additional problem.

05:26 Why you want to look for a different type of medication to address the symptoms of ADHD.

05:31 Now, if the client has a history of drug abuse, that's like what we just talked about.

05:36 This client is at an increased risk for addiction.

05:39 This would involve a very therapeutic conversation and a thorough assessment.

05:44 Now the last one is MAOIs.

05:46 But you know the MAOIs don't play well with any other medications it seems like.

05:50 So you don't want someone taking a stimulant and an maoi at the same time.

05:55 So you want it to be at least two weeks since the last administration of an maoi before they would take a stimulant safely.

06:02 Now, how do you choose an agent? Well, here's the things you want to consider.

06:06 You want to think about the desired onset of action.

06:09 Remember, they have right away a little bit longer and then extended.

06:13 So you have to look at what the needs are.

06:15 You have to figure out how long do you want it to act.

06:18 What are we trying to treat here.

06:19 Is this just during school? What is the time frame that the patient with ADHD? Or it Or it could even be for work.

06:26 What's the time frame? They need the medication to be effective.

06:29 Also, the patient has to be able to swallow if you're going to prescribe some of these medications, as are pills or tablets.

06:36 Okay. So first thought is what are we trying to do with this medication.

06:40 When is it most important to control these symptoms.

06:43 That's your desired onset and duration.

06:46 Now you want to be sure that they're able to swallow pills.

06:48 And don't just assume that they will be able to do that.

06:51 Make sure you do an assessment for that.

06:53 Then we're next to drug palatability.

06:56 Tolerability. How does the individual patient do with it.

06:59 What are their preferences and concerns.

07:01 And that's also including the onset of action and the duration of the action.

07:06 Then this next point I'm not a fan of, but it's reality.

07:10 Insurance coverage and costs are things that you have to consider and what the patient has available to them and what they can get in their area from their pharmacy.

07:18 Unfortunately, ADHD medications can often be in short supply, so that's something that you need to be prepared for and have a backup plan for your patient.