Introduction to Stimulants

Stimulants (prescription, not recreational) are a class of medications commonly used to treat attention-deficit hyperactivity disorder (ADHD) and narcolepsy. Class effects include increased alertness, attention, and energy.

Stimulants are either in the amphetamine or methylphenidate class.

All stimulants regardless of class will start working within 30-60 mins.

  • Height
    • If family is exceedingly concerned about height loss, then stimulant may not be the best option.
  • Sudden Death
    • “Before prescribing an ADHD drug, it is important to be aware of whether the patient: has a family history of sudden death or death related to cardiac problems; participates in strenuous exercise; or takes other sympathomimetic drugs; as these are thought to be additional risk factors. In patients with relevant risk factors, and based on the physician’s judgement, further evaluation of the cardiovascular system may be considered before starting on the drug.”
  • Cardiac Assessment Checklist
    • Discuss with families the issue of very rare cases of sudden death in individuals taking stimulants
    • Ask in detail about the child’s cardiac history
    • Take a careful family history of cardiac disease and sudden unexplained death
    • Ask about other medications, especially sympathomimetics
    • Ask about “strenuous exercise”
    • Ensure that a physical examination (either by yourself or another physician) has been performed, including a careful cardiac examination
    • Measure baseline HR & BP
    • For patients with cardiac risk factors, pursue further evaluation or consultation (ideally with a pediatric cardiologist) before starting a stimulant
    • See also: Cardiac Risk Assessment Before the Use of Stimulant Medications in Children and Youth, A Joint Position Statement by the CPS, CCS, and CACAP (Bélanger et al., 2009)
  • Baseline ECGs in children without cardiac risk factors are generally considered unnecessary (AAP, AACAP, CPS, CACAP, CCS)
  • However, a history and physical exam has low sensitivity, and it is often not useful in identifying cardiac pathology. As a result, an ECG may be a more cost-effective solution than a history and physical.
  • Significant cardiac problems
  • Hyperthyroidism
  • Glaucoma
  • Psychosis
  • Hypersensitivity to the drug
  • Pregnancy
  • Stimulants are not contraindicated in individuals with seizure disorders, autism spectrum disorder, or Tourette syndrome, but their use should be cautious in these populations.

  • Sympathomimetics
    • Stimulants potentiate other sympathomimetics (e.g., Beta2-agonists)
  • Benzodiazepines and antihistamines
    • Stimulants may counteract sedative effects
  • Lithium
    • Stimulatory effects of amphetamines may be inhibited
  • Tricyclic antidepressants
    • The combination may enhance the effects of both the TCA and the stimulant
  • Phenytoin and phenobarbital
    • AMPH may act synergistically to increase anticonvulsant activity
  • MAOIs
    • Hypertensive crisis
  • St. John’s Wort
    • Has some MAOI activity