Patient Case #2: Dealing With Comorbidities in Adult ADHD


Drs Stephen Faraone, Theresa Cerulli, Craig Chepke, and Andrew J. Cutler discuss how to deal with other comorbidities when treating an adult with ADHD.

Stephen Faraone, PhD: Craig, this patient has anxiety, they also have hypertension, how might those comorbidities influence the choice of a medication for ADHD?

Craig Chepke, MD, FAPA: We have to think about more tailoring treatments, in terms of her cardiovascular risk factors, then something like a stimulant would be riskier for her, especially at the young age, where she's already having these problems with hypertension and diabetes because as we know, this is cumulative over time. And even a small amount of additional burden there could be substantial by the time this woman is in her 50s or 60s. That would play heavily in and start to tilt me away from stimulants. More importantly, I'd say, I'm sitting and listening to Theresa and Andy talk about is it start with depression, start with ADHD, why not have our cake, and eat it too? Theresa you were starting to go there with the non-stimulant that had benefit in depression. I would say something like an extended release viloxazine would be a perfect fit here, FDA indicated for ADHD in the United States, has a long, rich, history of decades of use as an antidepressant in Europe, we have efficacy there for both. It's not indicated in the States for MDD as we know, but we do have that evidence both in terms of tolerability and the cardiovascular risk factors. That would be a nice way to put a bow on this one, if there is a nice way. But that would be a great way to address both problems, that, I'm not neglecting either of these problems, we're looking at both simultaneously.

Andrew J. Cutler, MD: I like that. And I also do want to give a caveat and that is I have plenty of adults with hypertension that I treat with stimulants.

Craig Chepke, MD, FAPA: Of course.

Andrew J. Cutler, MD: We all do. If the blood pressure is being managed and well-controlled and I think we would all agree with that. But I like your thought process, if you can kill 2 birds, or 3 birds, with one stone, why not?

Theresa Cerulli, MD: And remember this patient is taking buspirone for anxiety, a standing dose, and then also a benzodiazepine as needed. When I mentioned treatment with a non-stimulant if we were going to go that route, it may address mood symptomatology potentially, or at least not worsen mood symptomatology while we're treating the ADHD. I'm also thinking, I'm not a big fan of combining anti-anxiety medications and stimulants as the risk with stimulants of worsening some anxiety symptoms in somebody already prone to anxiety. Depending on the patient and the situation, I'm just more careful before I go that route. You were more specific Craig, with which non-stimulant than I was, but that is the reason I was thinking along those lines as well.

Andrew J. Cutler, MD: You know, it's interesting, sometimes you must tease out the chicken and the egg if you can. I have many patients, as I'm sure you do too, who I treat the ADHD and the anxiety gets better because a lot of the anxiety and that overwhelmed feeling we talked about is because they can't keep track of things, they're always worrying, "What did I forget? What am I going to lose? What kind of mess did I make out of things?" You have to carefully tease things out.

Transcript edited for clarity

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