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Editorials

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:i2874

Rapid Response:

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

03 June 2016
Mukesh Kripalani
Consultant Psychiatrist
Barnet Enfield and Haringey Mental health NHS Trust