Medication and side effects

Webinar Transcript

Introduction and Clinical Panel Overview

Lisa Mangle: Welcome everyone. My name is Lisa Mangle, Clinical Director at ADHD 360 and one of the company’s founders. My role involves overseeing clinicians, leading training for new staff, and managing preceptorships. We train our clinical team on crucial topics such as ADHD treatments and side effect management. While we frequently discuss treatment benefits, we must also address how to manage side effects effectively.

Today, we do not have formal slides or a rigid agenda; we will address your direct questions regarding ADHD medication and side effect management. Joining me today are Karina and Rebecca. Karina, could you introduce yourself and explain your role?

Karina Matthews: Hello, I’m Karina Matthews, a response nurse at head office. I handle daily clinical calls from patients. Many patients call with similar questions regarding physical side effects, anxiety, and medication adjustments. We organized this session to address these recurring themes and provide clear guidance.

Rebecca Whelan: Good evening, everyone. I am Rebecca Whelan, an adult clinician and Deputy Clinical Director at ADHD 360. In addition to assessing and treating adult patients, I work alongside Lisa to manage clinical standards and ensure high-quality care across our teams.

Managing Appetite Suppression and Nutritional Strategies

Lisa Mangle: One of the most common topics raised by patients is appetite suppression, which is a primary side effect of stimulant medications. Once taken, stimulants often reduce hunger.

To manage this, I recommend eating a substantial breakfast before taking your medication. Rather than a quick slice of toast, aim for a hearty meal—such as cereal combined with toast, yogurt, or fruit. For lunch, set a timer as a reminder to eat, as you may not feel hungry. For children, inform teachers that they might not feel hungry at lunchtime, and avoid forcing food. Instead, offer a main meal in the evening as the medication wears off, followed by a nutritious supper if needed.

When working with dietitians, we focus on small, calorie-dense foods for individuals with reduced appetite. For instance, small cheese crackers, full-fat milk, or milkshakes blended with fruit provide essential calories in manageable portions without feeling overwhelming.

Rebecca Whelan: Binge eating is also commonly associated with ADHD as a symptom of impulsivity and dopamine-seeking behavior. When starting medication, patients may experience weight reduction for two reasons: initial appetite suppression or a decrease in binge eating as dopamine levels stabilize. As dopamine regulates, patients often report making healthier food choices, experiencing fewer impulsive cravings, and having the mental bandwidth to plan and prepare meals. Clinicians evaluate weight changes individually to differentiate between side effects and positive therapeutic outcomes.

Balancing Dosage Optimization and Cardiovascular Effects

Lisa Mangle: Our objective is to optimize medication so symptoms are significantly reduced while keeping side effects tolerable. Increasing to a maximum dose is unhelpful if it causes intolerable side effects such as insomnia, severe appetite loss, or an excessively high heart rate. When heart rate increases, the body’s sympathetic nervous system may trigger an adrenaline release, leading to feelings of anxiety. If a patient experiences elevated heart rate or anxiety on a specific stimulant (such as Lisdexamfetamine/Elvanse), switching to a different stimulant class (such as Methylphenidate) or a non-stimulant may resolve the issue.

Addressing Co-occurring Anxiety and Co-prescribing

Karina Matthews: We receive many questions regarding whether anti-anxiety medications can be taken alongside ADHD treatments.

Lisa Mangle: Yes, anti-anxiety medications can be co-prescribed. ADHD, anxiety, and low mood can exist as co-occurring conditions. If anxiety persists despite optimized ADHD treatment, medications such as SSRIs or beta-blockers (e.g., Propranolol) may be considered in coordination with a GP. When combining SSRIs with ADHD medications, clinicians monitor for rare conditions such as Serotonin Syndrome. Patients are advised to track their blood pressure and heart rate regularly and report any sudden changes.

Rebecca Whelan: Co-occurring anxiety is very common. While Serotonin Syndrome is extremely rare, clinicians assess all potential interactions carefully to ensure co-treatment is safe and effective.

Long-Term Safety and Non-Stimulant Options: Atomoxetine

Lisa Mangle: Patients often ask about long-term side effects of non-stimulants like Atomoxetine. Atomoxetine has been prescribed and studied for over two decades. While rare side effects such as hepatic (liver) stress can occur, clinical data shows that liver function normalizes if the medication is discontinued.

Rebecca Whelan: Patients experiencing liver-related issues would typically present with abdominal pain before any jaundice appears. Severe abdominal discomfort should always be evaluated by a clinician.

Dosing Timing, Nausea, and Dietary Interactions

Lisa Mangle: Stimulant medications typically take 30 to 40 minutes to begin working. Adults may choose to take medication shortly before eating, provided they reliably consume a meal afterward. For children, consuming breakfast prior to administration is strongly recommended. Regarding dietary interactions: grapefruit and grapefruit juice can alter medication absorption and should be avoided around dosing times. Similarly, high doses of Vitamin C taken simultaneously with certain stimulants may affect absorption, so taking medication with water rather than fruit juice is advised. Additionally, jaw clenching or teeth grinding (bruxism) can occur if a dose is slightly higher than required. If bruxism occurs, consult your clinician to evaluate whether a minor dose adjustment or a protective mouthguard is appropriate.

Risk Assessment, Tics, and Caffeine Intake

Lisa Mangle: All medications carry potential side effects, but common initial side effects—such as mild headaches, dry mouth, or minor gastrointestinal upset—often resolve within 3 to 5 days. Clinicians continuously weigh therapeutic benefits against potential risks. Regarding tics and involuntary movements: ADHD medications do not cause tics, but enhanced focus can make pre-existing tics more noticeable. If tics become painful or disruptive, switching to a non-stimulant such as Guanfacine (Intuniv) or Clonidine may be beneficial. Concerning caffeine: we strongly advise eliminating caffeine (coffee, tea, energy drinks) during medication titration. Because caffeine is a stimulant, combining it with ADHD medication can cause heart rate spikes, jitteriness, and increased anxiety. Once medication levels are fully stabilized, minor caffeine intake may be re-introduced cautiously under clinician guidance.

Mood Changes, Dose Titration, and Hormonal Considerations

Rebecca Whelan: Mood changes—including severe irritability, low mood, or emotional blunting—warrant immediate clinical evaluation. If a medication negatively impacts mood or emotional well-being, clinicians will explore alternative doses or medication classes.

Lisa Mangle: Dose titration involves gradually increasing dosage under clinical supervision until optimal symptom control is achieved without intrusive side effects. Hormonal fluctuations during the menstrual cycle—specifically drops in estrogen during the luteal phase (the week prior to menstruation)—can temporarily reduce ADHD medication effectiveness. In some cases, clinicians may prescribe a minor dose adjustment during that specific week to maintain symptom control.

Thyroid Health, Alcohol, and Non-Stimulant Guidelines

Lisa Mangle: Patients with hypothyroidism (underactive thyroid) taking replacement therapy (e.g., Levothyroxine) can safely take ADHD medications, provided thyroid levels are monitored annually via routine blood tests. Untreated hyperthyroidism (overactive thyroid) remains a contraindication due to baseline cardiovascular impacts. Regarding alcohol: alcohol acts as a depressant and dehydrating agent. When combined with stimulants, the effects of alcohol can feel more intense and unpredictable. Patients are advised to exercise caution, stay well-hydrated, and avoid alcohol during active medication hours. For non-stimulant medications: Atomoxetine nausea is a primary side effect, and taking it with meals or consulting a GP for anti-nausea management can help. Guanfacine (Intuniv) lowers blood pressure and heart rate, and can cause drowsiness or fatigue. Patients should ensure adequate fluid intake. Females of childbearing potential taking Guanfacine must use effective contraception as a safety standard.

Closing Remarks

Lisa Mangle: Managing ADHD medication is a personalized process requiring ongoing collaboration between patient and clinician. We appreciate all your questions and will collate unanswered topics for future resource guides. Thank you for attending, and have a good evening.