Ritalin Helps…but what about the side effects?

      

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Ritalin Helps….

but what about the side effects?

Carol E. Watkins, M.D.

Glenn

Brynes, Ph.D., M.D.

 

The stimulants are often used to treat AD/HD and

other conditions. The most common stimulants are methylphenidate (Ritalin,

Concerta, Metadate-ER) and amphetamine (Dexedrine, Dexedrine Spansules, Adderall

and Adderall XR.) 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. Some people find that

methylphenidate compounds have slightly less appetite suppression than

amphetamine compounds.  In some cases we resign ourselves to a eating a

large breakfast and supper followed by a very small lunch. A late evening snack

can also help. Some non-stimulant AD/HD medications do not cause the same degree

of 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, it may still occur

in susceptible individuals. Sometimes, we add a tiny dose of short-acting

stimulant when the longer-acting stimulant wears off. 

Headache: If this

does not improve with time, we may reduce the dose or switch to another

stimulant. Sometimes caffeine restriction helps. However, if an individual with

a heavy caffeine habit suddenly stops the caffeine he may get a caffeine

withdrawal headache. If the 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.

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.

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. 

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 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.

Irritability:

Sometimes irritability may be due to the AD/HD or another psychiatric disorder.

If the irritability is truly due to the stimulant, one might reduce the

stimulant dose, switch to a different stimulant, add an SSRI, (paroxetine,

sertraline) an alpha agonist (clonidine/guanfacine) or use another class of

medications 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. 

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 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.

(1)

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. 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:

These are rare side effects. They 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. It is important to screen for and treat certain other psychiatric

disorders prior to starting a stimulant. If psychosis occurs while taking a

stimulant, one should immediately stop the medication and call the prescribing

doctor.

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. 

Updated July 2006

Carol E. Watkins, M.D.

Glenn Brynes, Ph.D., M.D.

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Contact Us:

Telephone:410-329-2028

Fax: 410-343-1272

Postal address: We have two locations in Baltimore County

      Monkton Office16829 York Road/PO

Box 544/Monkton, MD 21111

      Lutherville Office: 2360 West

Joppa Road Suite 223/ Lutherville, MD

Email: [email protected]

Please use telephone for appointments or medical questions.

Carol Watkins, M.D.

Glenn Brynes, Ph.D., M.D.

Rita Preller, LCSW-C

Copyright © 2006  Northern County

Psychiatric Associates

Last modified:

August 01, 2006

 

 

 

 

 

 

 

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