The decision to prescribe stimulant medication for Attention-Deficit/Hyperactivity Disorder (ADHD) is never as simple as writing a script. Medications like methylphenidate, amphetamines, and lisdexamfetamine are effective, but they come with nuances that require careful assessment, monitoring, and ongoing clinical judgment.

The Maudsley Prescribing Guidelines—one of the most respected psychopharmacology references—provide a clear framework for managing these risks. In this article, we’ll unpack the special precautions clinicians should keep in mind when starting and maintaining ADHD medications.

1. Cardiovascular Safety Comes First

Stimulants increase catecholamine activity, which means they can raise blood pressure and heart rate. For most healthy individuals, these changes are modest. But in patients with underlying heart disease, they may tip the balance toward danger.

Precautions:

• Always take a thorough cardiovascular history (personal and family).

• Red flags include structural heart disease, arrhythmias, unexplained syncope, or a family history of sudden cardiac death.

• Physical exam should include pulse and blood pressure at baseline.

• An ECG is not mandatory for all, but it is recommended if risk factors are present.

• Cardiology consultation may be needed in borderline cases.

2. Start Low, Go Slow

The temptation is often to chase symptom control quickly. The Maudsley cautions against this. Rapid dose escalation increases side effects like insomnia, irritability, and hypertension.

Precautions:

• Begin with the lowest dose of the chosen stimulant.

• Increase only in small increments, with intervals long enough to assess tolerability.

• Avoid aggressive titration, especially in children and adolescents.

3. Monitor Vital Signs and Growth

Children and adolescents are particularly vulnerable to the growth-suppressing effects of stimulants. Adults too may experience sustained increases in heart rate and blood pressure.

Precautions:

• Record weight, height, pulse, and blood pressure at baseline.

• Recheck regularly—every few weeks during titration, then every 3–6 months once stable.

• Watch for plateauing of growth curves in children.

4. Psychiatric Red Flags

ADHD medications don’t exist in a vacuum—they interact with the brain’s broader psychiatric landscape.

Precautions:

• Psychosis: Stimulants may worsen hallucinations or delusions; avoid if active psychosis is present.

• Mania: In bipolar disorder, stimulants can trigger manic switches. Stabilize mood before prescribing.

• Anxiety: Stimulants may aggravate anxiety symptoms; careful titration is key.

• Tics: Stimulants may exacerbate tics in some patients. Atomoxetine or guanfacine may be safer alternatives.

5. Misuse and Diversion Risks

Stimulants have well-known abuse potential. This is a clinical reality that requires thoughtful handling.

Precautions:

• Screen for substance use disorders before prescribing.

• Prefer long-acting formulations or prodrugs (e.g. lisdexamfetamine) in patients at higher risk, as they are harder to misuse.

• Educate patients and families about secure storage and the dangers of diversion.

• If substance misuse is ongoing, coordinate with addiction services before initiating stimulants.

6. Drug Interactions

Stimulants are not pharmacologically lonely—they interact.

Precautions:

• Watch for CYP450 interactions (especially with amphetamines).

• Avoid co-prescribing with other strong sympathomimetics (e.g. decongestants, some antidepressants).

• Caffeine, nicotine, and energy drinks may amplify side effects.

7. Long-Term Vigilance

ADHD is often lifelong, but medication strategies should evolve. The Maudsley emphasizes periodic re-evaluation.

Precautions:

• Reassess the continued need for medication every 6–12 months.

• Consider a “drug holiday” in children during school breaks to evaluate growth and functioning.

• Document benefits and side effects at each review to guide future care.

8. Informed Consent and Documentation

Safe prescribing is also about communication and clarity.

Precautions:

• Explain the rationale, expected benefits, and possible risks to patients (and parents, when applicable).

• Encourage questions, and provide written information if possible.

• Document consent, monitoring plans, and clinical decisions thoroughly.

Conclusion

ADHD medications are among the most effective interventions in psychiatry, but they require a careful balance of efficacy, safety, and vigilance. The Maudsley guidelines remind us that the art of prescribing lies not in simply starting medication, but in choosing wisely, monitoring diligently, and adjusting thoughtfully.

Done well, stimulant prescribing can be life-changing—helping patients not just survive, but thrive.

✦ About the Author
I’m Dr. Srinivas Rajkumar T, MD (AIIMS, New Delhi), Consultant Psychiatrist in Chennai. At my Mind and Memory Clinic (Apollo Clinic, Velachery, Opp. Phoenix Mall), I specialize in ADHD management through a holistic model that integrates medication, behavioral therapy, lifestyle guidance, and advanced neuromodulation (rTMS, tDCS, neurofeedback, ketamine therapy).

📍 Mind and Memory Clinic, Apollo Clinic, Velachery, Chennai (Opp. Phoenix Mall)
📞 +91 85951 55808