Physicians, every time they initiate a medication treatment, are faced with the question of what possible positive and negative effects this medication may have on this specific individual, both in the short and long term. When it comes to ADHD medications, elevated heart rate and blood pressure are common side effects that are always part of the pre-treatment and ongoing assessment. This is because, if you live with a high heart rate and elevated blood pressure year after year, it can lead to heart problems over time.
However, we don’t know much about whether the quite moderate increases in heart rate and blood pressure associated with ADHD-medications have any negative health consequences in the long term. It’s been difficult to find the answers to questions like this because randomized controlled trials (RCTs) controlling for confounding and excluding chance spanning over many years are expensive, time-consuming, and difficult to perform. Prior to the study by Zheng et al in JAMA Psychiatry, one of the studies with the longest follow-up period, compared young people using ADHD medication with age-matched peers without treatment for 2 years. It showed a slight increase in blood pressure during the day but not at night. The researchers concluded that since the heart gets to rest all night, it probably recovers during that time.
Unfortunately, there are almost no studies that extend beyond 2 years, but Zhang et al follows individuals with ADHD aged 6 to 64 years for 14 years. The results show that individuals using ADHD medications had an increased risk of cardiovascular disease compared to those not using ADHD medication. The risk increased by 4% for each year the medication was used in the first 3 years before it stabilized. However, the absolute risk was low.
So, what does this mean in clinical practice? Should physicians stop prescribing ADHD medications to avoid harming their patients? And should patient refrain from using ADHD medications out of fear of developing heart problems?
No, certainly not! Firstly, it is important to weigh potential risks against proven benefits. Research shows, for example, that central stimulant ADHD medications are effective and reduce the risk of serious outcomes such as accidents, suicides, and criminal activities. Recommending people who use medication to stop based solely on potential cardiovascular risk does not take the broader picture into account. Clear recommendations require more research and studies that also include individuals over 65 years old.
In summary, we welcome well-conducted and large epidemiological studies that examine both risks and benefits of ADHD treatment in adults. Zhang and the research group behind this study are highly experienced and skilled researchers. There has been a lack of well-made research on adults and the long-term effects of medication, and this study is a significant contribution to the growing knowledge base.
However, it is also important to note that:
This is an observational study where it is not certain whether there is a causal relationship and in which direction it goes. The increased risk of cardiovascular disease could also be due to other medications or lifestyle factors linked to both ADHD and cardiovascular disease. ADHD itself is strongly associated to a higher risk of cardiovascular disease based on various negative consequences of untreated ADHD.
There is a long list of medications that can increase the risk of high blood pressure to a similar extent as found in this study.
These results apply at the group level, and as a patient, there is no need to be overly concerned about personal health. In clinical practice, a risk-benefit assessment is always made for each individual patient, weighing the increased risk that higher blood pressure may entail against the gains that ADHD treatment can provide. Physicians regularly follow up with their ADHD patients, focusing specifically on blood pressure and other signs and symptoms of cardiovascular disease during the course of treatment.
The increased risk in the study applied only to those with doses 1.5 times higher than the recommended daily dose. If you are within normal ranges, you likely have no increased risk at all.
We would like to emphasize the importance of precision when diagnosing, treating, and following up on psychiatric disorders. ADHD is no exception. We also believe it is crucial to highlight the importance of precision medicine and precision health, meaning always starting from an individual-specific risk-benefit analysis. This is especially true when it comes to individuals with ADHD, as it is such a heterogeneous group of people.
Reference to the original study: Zhang L, Li L, Andell P, et al. Attention-Deficit/Hyperactivity Disorder Medications and Long-Term Risk of Cardiovascular Diseases. JAMA Psychiatry. Published online November 22, 2023. doi:10.1001/jamapsychiatry.2023.4294
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