Stimulants for kids with ADHD—how to proceed safely
A cardiac-focused history and physical exam are essential before you write that prescription. But what about an EKG? Should you order one—or not?
For patients already taking stimulants, we recommend monitoring BP and heart rate and ordering an EKG only if the patient exhibits cardiac symptoms or there are concerns based on follow-up history and physical examination. Should a patient develop palpitations while taking a therapeutic dose of stimulants, a detailed history of the onset and duration of symptoms is important. For example, tachycardia that has a gradual onset and occurs with exercise is suggestive of physiological sinus tachycardia. In our judgment, most patients who experience symptoms that suggest sinus tachycardia simply require downward readjustment of their medication or a switch to a nonstimulant.
However, if the patient or family history prompts you to suspect other arrhythmias such as ectopic beats or supraventricular tachycardia, immediate assessment either in an emergency department or in the physician’s office may be required, because obtaining an EKG during symptoms is crucial for the diagnosis. Similarly, unexplained exercise intolerance or the onset of chest pain associated with exercise, dizziness, syncope, seizures, or dyspnea requires immediate cardiovascular assessment.
And finally, whether your patient has just started taking medication for his or her ADHD or has been on the medication for some time, it’s important to periodically reassess the need to continue the stimulant therapy; ADHD symptoms may decrease during mid- to late adolescence and into adulthood.21
CASE › The FP completed a thorough physical exam and found no evidence of any conditions that would increase the likelihood of SCD in the young patient. There was no history of SCD in the boy’s family, either. Based on these findings, the FP opted to forgo an EKG. She prescribed lisdexamfetamine, starting with 20 mg/d (the lowest dose available) and then monitored his course by telephone. Eventually, 30 mg was found to be an effective dose. At a 6-week follow-up visit, the boy’s ADHD symptoms were substantially reduced, without any adverse effects—cardiac or otherwise.
CORRESPONDENCE
Sudhir Ken Mehta, Cleveland Clinic Children’s Hospital, 9500 Euclid Avenue, Cleveland, OH 44111; kemeht@ccf.org
