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Certain ADHD meds linked to elevated heart rate, systolic BP

Roshini Claire Anthony
17 Oct 2018

Individuals with attention-deficit hyperactivity disorder (ADHD) who are treated with atomoxetine or methylphenidate may have a risk for elevated heart rate and systolic blood pressure (BP), according to a meta-analysis.

Based on 11 studies, patients who were treated with methylphenidate experienced an increase in heart rate compared with those who were treated with placebo, with similar findings observed in both children and adolescents (pooled standardized mean difference [SMD] with random-effects model, 1.56, 95 percent confidence interval [CI], 0.71–2.41; p<0.001) and adults (pooled SMD with random-effects model, 2.04, 95 percent CI, 0.92–3.15; p<0.001), with no significant difference between the two age groups (p=0.5). [Int J Environ Res Public Health 2018;doi:10.3390/ijerph15081789]

Analysis of 10 studies also showed an increase in systolic BP following methylphenidate treatment compared with placebo in children and adolescents (pooled SMD with random-effects model, 1.61, 95 percent CI, 0.81–2.41; p<0.001) and adults (pooled SMD with random-effects model, 1.40, 95 percent CI, 0.62–2.18; p<0.001), also with no significant difference between the two age groups (p=0.71).

Children and adolescents treated with atomoxetine experienced a greater increase in heart rate compared with those treated with methylphenidate (four studies; pooled SMD with random-effects model, 0.86, 95 percent CI, 0.11–1.62; p=0.025) as well as a greater increase in systolic BP (three studies; pooled SMD with random-effects model, 0.366, 95 percent CI, 0.23–051; p<0.001).

Despite these findings, incidence of adverse cardiac events was comparable between adults receiving methylphenidate and placebo (three studies; odds ratio [OR], 2.33; p=0.18) and between children or adolescents receiving methylphenidate and atomoxetine (five studies; OR, 0.88; p=0.64).

The results were based on a meta-analysis of 22 studies comprising 46,107 patients which compared the cardiovascular safety of methylphenidate with placebo or atomoxetine when used as ADHD treatment. Of these patients, 39,996 were treated with methylphenidate, 5,274 with atomoxetine, and 837 with placebo. The primary outcome was proportion of patients who experienced changes in heart rate and systolic BP post- vs pre-treatment with the ADHD drugs.

“There is substantial concern from clinicians, patients, parents, and the public about the cardiovascular safety of ADHD medications,” said the authors led by Dr Edwin Liang from the Department of Psychological Medicine, Yong Loo Lin School of Medicine, Singapore.

However, previous studies on the impact of these drugs have produced varying results, with some showing increases in heart rate and systolic BP associated with atomoxetine use in children and adolescents and others showing an impact of methylphenidate on systolic BP only. [CNS Drugs 2017;31:199-215]

“This meta-analysis can potentially inform both clinicians and patients about the cardiovascular side effects associated with atomoxetine and methylphenidate to make an informed decision about its potential risks to increase heart rate and systolic BP,” said Liang and co-authors, recommending that neither drug be used in patients with severe cardiovascular or cerebrovascular problems.

They advised that prior to treatment, a thorough history and medical examination be conducted in patients who are being considered for treatment with either atomoxetine or methylphenidate. Regular monitoring of cardiovascular health should be done before and during treatment particularly with regard to heart rate and systolic BP, and patients who develop tachycardia or hypertension while on atomoxetine or methylphenidate should undergo cardiac evaluation, they said.

The authors also suggested further research into assessing the long-term effects of atomoxetine on heart rate and systolic BP and whether antihypertensives or beta-blockers could prevent increases in heart rate and systolic BP in patients on methylphenidate.

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