Complications
Stimulants should be stopped if mania occurs. Once the manic episode has resolved, consideration should be given to restarting or starting a new attention deficit hyperactivity disorder medication, depending on the risk:benefit analysis as guided by the individual circumstances.[80]
A Swedish national register study of over 2.5 million people found attention deficit hyperactivity disorder (ADHD) patients had a threefold greater risk of obesity relative to their non-ADHD siblings and cousins. A meta-analysis found that compared with typically developing people, adults with unmedicated ADHD almost 50% more likely to be overweight or obese (9 studies, over 45,000 participants).[32]
Type 2 diabetes mellitus has been found to be more common in adults with attention deficit hyperactivity disorder compared with age- and sex-matched controls.[32]
Insomnia and general sleep disorders are 50% to 60% higher than the general population, with self-reported increased difficulty in falling asleep and frequency of night awakenings, moderately worse sleep quality, greater daytime sleepiness, and feeling less rested at wake up.[147]
Dose should be minimized and patient should be assessed for eating disorder. Weight loss often occurs in clinical practice, and under such circumstances high protein/energy drinks can be helpful (care should be taken as certain energy drinks contain caffeine, which may exacerbate issues with blood pressure, pulse, palpitations, or tremor), otherwise medication may have to be stopped. It is a potentially serious complication, although likelihood is not high.
Possible management may include the following: dose of stimulants should be minimized or alternative formulation prescribed; hypnotics can be prescribed; and patient can be switched to a shorter-acting agent or take the medication earlier in the day. Can switch to atomoxetine or alternative therapy. Melatonin, alpha-agonists, or sedative antidepressants may also be used in addition to regular therapy.
People with attention deficit hyperactivity disorder (ADHD) are around twice as likely to develop a drug or alcohol use disorder than those without ADHD.[32]
Adolescents and young adults are more than three times more likely to develop sexually transmitted infections compared with age- and sex-matched controls.[32]
People with attention deficit hyperactivity disorder have been found to be at greater risk of accidental injury including road traffic accidents and minor traumatic brain injury.[32]
Stimulant medications have a high potential for abuse and misuse, which can lead to the development of a substance use disorder (including addiction). Misuse and abuse can result in overdose and death. The risk is increased with higher doses and unapproved administration methods (e.g., snorting, injection). Assess the patient’s risk for abuse, misuse, and addiction before prescribing these medications, and monitor for signs and symptoms of abuse, misuse, and addiction during treatment.
Stimulant medication can be used with caution in patients with existing substance use disorder, depending on the individual risk:benefit analysis.[81][128] If stimulants are needed, an extended-release formulation is recommended.[81] Immediate-release stimulants should be avoided in patients with ADHD and substance use disorders.[3] Close monitoring and anticipatory discussion with the patient is paramount.[81][127] Atomoxetine and bupropion have low/no misuse potential, and, depending on the individual risk: benefit analysis, may be considered as alternative treatments for ADHD in people with coexisting stimulant use disorder; however, they are likely to be less effective against symptoms of ADHD than long-acting stimulant medication.[127]
Stimulants should be stopped if arrhythmia occurs. A careful cardiac history (including family history of sudden death or arrhythmia, symptoms including syncope, dyspnea with exertion) should be obtained. In cases where there are symptoms of concern or a history of such symptoms, ECG/cardiology consultation should be obtained prior to starting a stimulant.[80]
Cardiovascular effects of long-term extended-release mixed amphetamine salts (≤60 mg/day) are not expected in otherwise healthy adults with attention deficit hyperactivity disorder.
Approximately 6% to12% of adults and children experience clinically relevant changes in heart rate (20 bpm or greater) and blood pressure (15-20 mmHg or greater). It is recommended that heart rate and blood pressure are measured and recorded on a centile chart before treatment is started and, during treatment, after each adjustment of dose; and then at least every 6 months to detect possible clinically important increases.[80]
Attention deficit hyperactivity disorder is associated with an increase in suicidal attempts (OR 2.37, 95% CI 1.64 to 3.43), suicidal ideations (OR 3.53, 95% CI 2.94 to 4.25), suicidal plans (OR 4.54, 95% CI 2.46 to 8.37), and completed suicide (OR 6.69, 95% CI 3.24 to 17.39).[148]
Mostly due to accidental death or suicide.[32]
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