The cardiovascular safety of methylphenidate
BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2874 (Published 31 May 2016) Cite this as: BMJ 2016;353:i2874All rapid responses
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Energy drinks are also being taken with prescribed as well as unsubscribed doses of Ritalin. This is quite well documented on forums on the web where people are advising each other on using the combination of drugs. I first came across this when a young builder who was finding his job too exhausting described how he was asdvised to use them by his friends. I also hear that energy drinks are described as just placebos and only act like a strong cup of coffee. I have tried them but the taste is disgusting - so a proper trial was impossible for me although older people are commonly taking them as well according to the shop keeper...
Competing interests: No competing interests
Dear editor,
The study in this edition of the BMJ shows a possible cardiovascular risk of methylphenidate. The authors of the Korean study state that the potential absolute risk is relatively low. The actual risks may be higher.
The Korean study focused on cardiovascular incidents in relatively young patients. In these patients the baseline cardiovacular risk will be low. Thus the absolute increase in cardiovascular risk will also be low. Moreover patients were included with at least one prescription. Given the high incidence of early discontinuation of treatment, the risk will be diluted by patients who did not have substantial exposure. On the long term a cumulative dose dependent increased cardiovascular risk is to be expected.
Given the enormous rise in the exposure to methylphenidate and similar amfetamine derivatives (dexamfetamine) in the past decennia we are facing a growing population with long term exposure to these stimulants. Moreover increasingly older patients are diagnosed with ADHD and treated accordingly, often on a chronic basis. Many of these patients also use antidepressants that may add to the stimulant effects. Finally we see a rise in the recreational use of MDMA and other stimulants.
In the nineties of the previous century several amphetamine-like appetite suppressants were withdrawn from the market for their cardiovascular adverse effects, in particular pulmonary arterial hypertension and cardiac valve disease. We may be at tha start of a new pandemie of cardiovascular problems caused by stimulants.
Case reports of methylphenidate and pulmonary hypertension or heart valve disease are still relatively rare. As for now the risk appears to be low, but more epidemiological studies are needed, especially among long-term users.
Competing interests: No competing interests
What about cardiovascular risk with stimulants in adults?
Dear Editor
John Jackson’s editorial on cardiovascular safety on methylphenidate is laudable but I feel the discussion was rather limited.
I would like to point out that the traditional concept of ADHD/ADD onset in childhood and been challenged by 2 seminal cohort studies. With 2 large longitudinal studies from the United Kingdom (1) and Brazil (2) have suggested the onset in adulthood. Prior to those studies, meta-analysis has been an age related decline in impairing symptomatology (3) but the Brazilian study suggested an adult onset symptom group could be as high as 10.3%. This in contrast to individuals who have persistent symptoms at the age of 18-19, was only 17.2%
Hence we should not be limiting our cohorts to individuals below the age of 17 as adults become increasingly relevant. The risk could be higher for arrhythmia due to increasing co-prescribing often seen in this age group due to higher incidence of anxiety and depression and age related cardiovascular risk factors.
I expect scenario to change significantly in the next few years, as ADHD/ADD becomes a more mainstream diagnosis. Current NICE guidelines on treatment and management of ADHD suggest an electrocardiogram (ECG) if there is past medical or family history of serious cardiac disease, a history of sudden death in young family members or abnormal findings on cardiac examination (https://www.nice.org.uk/guidance/cg72/resources/attention-deficit-hypera...).
Would John suggest a routine ECG for all individuals who haven’t been diagnosed with a congenital heart disease, prior to initiation of stimulant treatment? I suspect we would need more evidence, especially in adulthood, to alter recommended practise.
References:
1. Angew-Blais JC, Polanczyk GV, Danese A, et al. Evaluation of the persistence, remission and emergence of attention-deficit/hyperactivity disorder in young adulthood. JAMA Psychiatry. Doi: 10.1001/jamapsychiatry.2016.0465
2. Caye A, Rocha TB-M, Anselmi L et al. Attention deficit/hyperactivity disorder trajectories from childhood to young adulthood: evidence from a birth cohort supporting late-onset syndrome. JAMA Psychiatry. Doi: 10.1001/jamapsychiatry.2016.0383
3. Faraone SV, Biederman J, Mick E. The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow up studies. Psychol Med.2006;36(2):159-165
Competing interests: No competing interests