Ritalin Helps…but what about the side effects?

Dealing with Stimulant Side effects

The stimulants are often used to treat AD/HD and other conditions. The most common stimulants are methylphenidate (Ritalin, Concerta, Metadate-ER, and the Daytrana patch) and amphetamine (Dexedrine, Dexedrine Spansules, Adderall and Adderall XR and Vyvanse.) We have been using these medications for years. Despite some dramatic media reports, the stimulants have a fairly good safety record.

When a medication gives you a symptom that you did not want, we call that symptom a side effect. Many individuals take stimulants with few side effects. Others experience mild problems. Some are simply unable to tolerate stimulants. Often we can treat annoying side effects so the individual can continue to take the stimulant. Too many people stop their medication instead of working with their physician to find a way to decrease side effects. On the other hand, stimulants can have the potential for real side effects. This is why it is a good idea to keep in close contact with your doctor, especially during the early stages of treatment.

Often we can treat side effects so you can continue to take your medication.

Instead of stopping your medication, work with your physician to find a way to reduce side effects.

Reduced appetite: This effect may be worse in the very young. It may improve after several weeks or months. If it continues to be problematic, one may reduce the dose; or time a short-acting stimulant to wear off before mealtimes. On the average, the methylphenidate compounds have slightly less of an appetite effect than the amphetamines. However this can vary from one individual to another.  In some cases we resign ourselves to a eating a large breakfast and supper followed by a very small lunch. A large late evening snack can also help.. I see less appetite suppression in adults. I suspect that this is because that adults may eat for different reasons than children. An adult is more likely to eat for psychological or social reasons. Many adults hope that they will shed some extra pounds while taking stimulants. Sometimes they do but other times they do not. Non-stimulant AD/HD medications may not cause as much appetite suppression

Rebound: Some people who take short acting methylphenidate or amphetamine experience irritability or depression for an hour as the stimulant wears off. Sometimes this is worse than the individual’s behavior before the medication was started. One can avoid rebound by spacing the doses closer together, giving a smaller dose after the final larger dose, or by switching to a longer acting stimulant. Recently several new long-acting stimulant preparations have been released. Although the long-acting compounds often have less rebound, the problem may still occur in susceptible individuals. Sometimes, we add a small dose of short-acting stimulant when the longer-acting stimulant wears off. This can have tradeoffs. If the stimulant reduces appetite, the extra dose of short acting stimulant may create problems with the evening meal.

Headache: If this does not improve with time, we may reduce the dose or switch to another stimulant. Sometimes caffeine restriction helps. If one is a heavy consumer of caffeine, one should taper rather than stop the caffeine. If one stops the caffeine suddenly, the result is often a caffeine withdrawal headache. If sudden caffeine cessation happens at the same time as the start of the stimulant, the caffeine withdrawal headache may be mistaken for a stimulant side effect. Many individuals with untreated AD/HD may try to self medicate with caffeine and thus have a substantial caffeine dependence.

Jittery feeling: Eliminate caffeine or other stimulant-type medications. A small dose of a beta-blocker (a type of blood pressure medication) can block tremor or jitters. Make sure that the individual is eating regular meals. Some people are especially susceptible to this side effect and simply cannot tolerate stimulants. In this case we may need to prescribe a nonstimulant AD/HD medication.

Gastrointestinal upset: Take the medication with meals or eat smaller, more frequent meals.

Sleep difficulty: It is a good idea to take a sleep history before starting a stimulant medication. Sometimes the sleep problem is due to the AD/HD, not the medication. One the average, people with AD/HD have more sleep problems than individuals without AD/HD. This is separate from any medication effect.  If the sleep problem is truly due to medication effect, we have several options. Sleep difficulty is more common when one is using a long-acting stimulant or if one is giving a short-acting stimulant late in the evening. Now that there are more long-acting stimulants on the market, one can often eliminate this problem by using one of the more intermediate-length stimulants. Clonidine or guanfacine may help decrease agitation and may also facilitate sleep. We also counsel the individual on establishing good sleep habits. Paradoxically, there are a few individuals who sleep better when they take a small dose of stimulant in the late evening. For these individuals, the stimulant helps slow racing thoughts and helps them lie still in their beds. Sometimes, a thorough sleep history will suggest a different type of sleep problem. In this case, the individual might benefit from a referral to a sleep lab for an overnight sleep evaluation.

Irritability: Sometimes irritability may be due to the AD/HD or another psychiatric disorder. The irritability may also be due to lack of sleep. It is possible to “cheat sleep” while taking a stimulant. If one sleeps less, the stimulant can mask the tired feeling. However if the individual continues the sleep deprivation for an extended time, he or she will become irritable and concentration will deteriorate.  If the irritability is truly due to the stimulant, one might reduce the stimulant dose, switch to a different stimulant, add an SSRI, (fluoxetine, sertraline) an alpha agonist (clonidine/guanfacine) or use a nonstimulant medication to treat the AD/HD.

Depression: This may occasionally be a delayed effect of stimulant medication. It may be more common with the long-acting stimulants. Screening for a history of depression, and treating co-existing depression can minimize this. If the depression truly is related to the medication, one may switch to another class of medications to treat the AD/HD. These second-line medications would include the tricyclic antidepressants, bupropion (Wellbutrin) and atomoxetine (Strattera.)

Anxiety: If an individual is anxious, the stimulants can exacerbate the symptoms. The treatment of this side effect is similar to that of depression. It may be best to treat a co-existing anxiety disorder before treating the AD/HD. However if the anxiety is mostly related to AD/DH symptoms, we may treat the AD/HD symptoms first.

Blood glucose changes: Individuals with diabetes mellitus or borderline glucose tolerance could potentially see a rise in blood sugar. On the other hand, if the stimulant cuts one’s appetite, one may use less insulin. Individuals with diabetes can often take stimulants, but  they may need closer monitoring of their diabetic control.

Increased blood pressure: Stimulants may cause increases in blood pressure or pulse. This is usually not significant at normal doses in most people. However occasionally, the blood pressure effects can be significant. Individuals on very high doses of stimulants or individuals at risk for blood pressure problems should be monitored more closely. Some adults may opt to continue the stimulant and add a blood pressure medication. A small open study suggested that adults who were well controlled on their blood pressure medications could take amphetamine without significant increases in blood pressure. Individuals with blood pressure changes need to discuss the risks and benefits with their physicians.

In the past there have been inconsistent reports as to the effects of stimulants on children’s blood pressure and heart rate. A long term follow-up of the large MTA Study suggests that children and adolescents on stimulants showed modest increase in heart rate but no significant risk for high blood pressure. During the ten year follow up, none of the children in this study reported any significant cardiovascular problems.. Because stimulants do have the potential for a change in heart rate, it is a good idea to screen individuals for underlying heart conditions early in treatment and monitor this periodically.

In late 2011 a large retrospective study of adults aged 25-64 reported that individuals who were taking amphetamine, methylphenidate or atomoxetine did not have a higher incidence of heart attack, stroke or sudden cardiac death than matched individuals who were not taking stimulants. .

Tics and stereotyped (repetitive) movements: In the past we rarely gave stimulants to individuals with tics because we believed that the stimulant would make the tics worse. Recent data seems to indicate that low to moderate doses of amphetamine or methylphenidate do not exacerbate tics. Even though group studies may not show a significant increase in  tics, specific individuals may note tic increase when starting stimulants. this may be due to the fact that tics wax and wane on their own. However there are a few individuals who clearly show worse tics in stimulants. These individuals may want to consider a nonstimulant medication. If an individual has tics, or develops them while on a stimulant, it should be discussed with the prescribing physician. The patient and physician should then carefully weigh the risks and potential benefits or medication treatment.

Psychosis or paranoia: This is a very rare side effect but it can happen. Psychosis may occur in an individual who is already predisposed to a bipolar disorder or another psychotic disorder. In a few cases, psychosis has occurred in individuals who have no previous history of bipolar disorder or psychosis. Psychosis may also occur when someone takes a stimulant overdose. Before one starts a stimulant it is important to have a thorough evaluation and to screen for other psychiatric conditions. Sometimes AD/HD can coexist with another condition such as bipolar disorder. In this case, one should first stabilize the bipolar disorder and then later treat the AD/HD.  If psychosis occurs while taking a stimulant, the individual should call his or her doctor immediately or go to an emergency room.

Seizures: Several studies have suggested that individuals whose epilepsy is well-controlled on medication can safely take stimulants. A small study suggested that asymptomatic individuals with an abnormal EEG might be at increased risk of seizures when they take stimulants. (2)

Sudden Death: There are anecdotal accounts of individuals who died suddenly died while taking stimulants. However, the incidence of these cases does not appear to exceed the incidence of individuals in the overall population who die in this manner. (3)

1) Wilens et al, An Open Label Study of the Tolerability of Mixed Amphetamine Salts in Adults with Attention Deficit/Hyperactivity Disorder and Treated Essential Hypertension, J. Clin. Psychiatry 67.5 2006

2) Hemmer s, et al Stimulant Therapy and Seizure Risk in Children with ADHD, Pediatric Neurology Vol 24 No.2; Elsevere Science Inc. 2001

3) ADHD Individual Drug Risk Studies To Be Considered By Drug Safety Committee. Press release. February 8, 2006. Available at: http://www.fdaadvisorycommittee.com/FDC/AdvisoryCommittee/ Committees/Drug Safety and Risk Mgmt/020906 ADHD/020906_ADHD-P.htm. Accessed 3/16/2006.

4) Vitiello et al Blood pressure and heart rate in the multimodal treatment of attention deficit/hyperactivity disorder study over 10 years. American Journal of Psychiatry.2011 Sep 2

5) ADHD Medications and Risk of Serious Cardiovascular Events in Young and Middle-aged Adults: Habel et al JAMA. 2011;306(24):2673-2683.

Northern County Psychiatric Associates

Our practice has experience in the treatment of Attention Deficit disorder (ADD or AD/HD), Depression, Separation Anxiety Disorder, Obsessive-Compulsive Disorder, and other psychiatric conditions.

We are located in Northern Baltimore County and serve the Baltimore County, Carroll County and Harford County areas in Maryland. Since we are near the Pennsylvania border, we also serve the York County area.

Our services include psychotherapy, psychiatric evaluations, medication management, and family therapy. We treat children, adults, and the elderly.