Pre-existing cardiovascular conditions and pharmacological treatment of adult ADHD
ABSTRACT Stimulants and atomoxetine should generally not be used or used only with caution in adults with pre-existing cardiovascular conditions. The extent to which pre-existing cardiovascular conditions influence initiation of these ADHD medications in adults is not known.
We performed a retrospective cohort study of privately insured adults with new ADHD treatment episodes. Pre-existing cardiovascular conditions were assessed by the presence of ICD-9-CM codes for congenital abnormalities, atherosclerosis, cardiac disease, and cerebrovascular disease in the 12 months before the index ADHD diagnosis. The primary outcome was new initiation of a stimulant or atomoxetine in the 3 months after the index date. Multivariate logistic regression was used to predict the likelihood of treatment initiation with stimulants or atomoxetine based on pre-existing cardiovascular conditions, patient demographic characteristics, clinical mental disorder comorbidities, other psychotropic drug use, and provider type.
Of 8752 patients with a new ADHD treatment episode, 917 (10.5%) had evidence of >or=1 pre-existing cardiovascular condition. Stimulants were started by 40.8% of patients with and 53.0% of patients without pre-existing cardiovascular conditions (Adjusted Odds Ratio, AOR 0.71; 95%CI 0.61-0.82). Pre-existing cardiovascular conditions reduced the likelihood of initiating stimulant treatment in younger but not in older patients (p-value for age x cardiovascular condition interaction = 0.0002). Initiation of atomoxetine treatment was not affected by pre-existing cardiovascular conditions (AOR 1.19, 95%CI 0.94-1.50).
Pre-existing cardiovascular conditions reduce the likelihood of stimulant therapy but not atomoxetine treatment in adult ADHD patients. However, many adult ADHD patients with pre-existing cardiovascular conditions initiate stimulant therapy.
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ABSTRACT: Introduction: This drug safety review provides an update on the long-term cardiovascular risks of therapeutic stimulant class medication for children and adults with attention-deficit/hyperactivity disorder (ADHD). Areas covered: Relevant literature on the long-term (defined as ≥ 12 months) cardiovascular effects of stimulant class medications for ADHD was sought using PubMed searches for clinical literature, epidemiological reports, as well as reviews of post-marketing data and clinical guidelines/consensus statements. Comparison was made to the non-stimulant atomoxetine. Expert opinion: Long-term cardiovascular risks of stimulants for healthy children and adults with ADHD are limited to minor mean elevations in blood pressure (≤ 7 mmHg) and heart rate (≤ 10 bpm). In a sizeable minority of individuals these elevations are greater and/or reach a clinical threshold. Subjective complaints may also be anticipated during long-term treatment, yet without an increase in serious cardiac outcomes above background rates per age. Future research is needed on possible latent or cumulative cardiovascular risks in healthy individuals, as well as the longer-term cardiovascular safety in vulnerable populations.Expert Opinion on Drug Safety 02/2015; 14(4):1-9. DOI:10.1517/14740338.2015.1011620 · 2.74 Impact Factor
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ABSTRACT: Most major psychiatric disorders have an onset in childhood or adolescence in a sizeable proportion of patients, and earlier onset disorders often have a severe and chronic course that can seriously disrupt sensitive developmental periods, with lifelong adverse consequences. Accordingly, psychopharmacologic treatments have been increasingly utilized in severely ill youth. However, the increased use of psychopharmacologic treatments in pediatric patients has also raised concerns regarding a potential overdiagnosis and overtreatment of youth, without adequate data regarding the pediatric efficacy and safety of psychotropic agents. Over the past decade, a remarkable number of pediatric randomized controlled trials have been completed, especially with psychostimulants, antidepressants, and antipsychotics. For these frequently used agents, effect sizes against placebo have typically been at least moderate, with most numbers-needed-to-treat well below 10 for response, indicating clinical significance as well. Nevertheless, data also point to a greater and/or different profile of susceptibility to adverse effects in pediatric compared to adult patients, as well as to a role for nonpharmacologic treatments, given alone or combined with pharmacotherapy, for many of the youth. Taken together, these results highlight the need for a careful assessment of the risk-benefit relationship of psychopharmacologic treatments in patients who cannot be managed sufficiently with nonpharmacologic interventions and for routine, proactive adverse effect monitoring and management. Although considerable progress has been made, there is still enormous need for additional data and funding of pediatric psychopharmacology trials. It is hoped that the field will acquire the necessary resources to propel pediatric clinical psychopharmacology to new levels of insight by linking it with, but not replacing it by, pharmacoepidemiologic and biomarker approaches and advances.The Journal of Clinical Psychiatry 05/2011; 72(5):655-70. DOI:10.4088/JCP.11r07064 · 5.14 Impact Factor
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ABSTRACT: Compared to children, adults with ADHD are at greater risk for developing adverse cardiovascular related outcomes and, if treated, may be likely to carry a greater burden of exposure to stimulant medications. The goal of this report is to critically review the available literature relevant to the cardiovascular safety of CNS stimulants for adult ADHD (aADHD). Twenty potential clinical trials of a CNS stimulant for aADHD have been published between 1979 and 2012. Of these, ten presented sufficient data to estimate the relative change in various cardiovascular parameters associated with ADHD treatment modalities. These trials were predominantly focused on long-acting stimulant preparations for acute symptom reduction (median duration=6 weeks, range: 4-24 weeks) and enrolled relatively young subjects (median age=36 years, range: 22-40). Using random effects meta-analysis, we found that subjects randomized to CNS stimulant treatment demonstrated a statistically significant increased resting heart rate [+5.7bpm (3.6, 7.8), p<0.001] and systolic blood pressure findings [+2.0mmHg (0.8, 3.2), p=0.005] compared with subjects randomized to placebo. There was a statistically significant increased risk for a resting heart rate >90bpm [4.2% (n=50) vs. 1.7% (n=8), OR=2.75 (1.3, 6.7), p=0.006] associated with CNS stimulant treatment. In light of prognostic value of resting heart rate with regard to cardiovascular morbidity in epidemiological studies, future research of adults with ADHD should focus on the potential clinical impact of the increase in heart rate observed in this meta-analysis.European neuropsychopharmacology: the journal of the European College of Neuropsychopharmacology 07/2012; 23(6). DOI:10.1016/j.euroneuro.2012.06.011 · 5.40 Impact Factor