Starting ADHD medications during the COVID-19 pandemic: recommendations from the European ADHD Guidelines Group

This addendum to our previous Comment¹ provides additional guidance from the European ADHD Guidelines Group (EAGG) on starting attention-deficit hyperactivity disorder (ADHD) medications (specifically psychostimulants and atomoxetine), during the coronavirus disease 2019 (COVID-19) pandemic, for patients who did not have a baseline, face-to-face cardiovascular assessment before the crisis began.

The EAGG deems it appropriate, in terms of the risk–benefit ratio, to remotely start a pharmacological treatment if the three following conditions are satisfied. First, the individual with ADHD should not have a personal history of shortness of breath on exertion compared with peers; fainting on exertion or in response to fright or noise; excessive palpitations, breathlessness or syncope (at rest or after exercise) or palpitations that are rapid, regular, and start and stop suddenly (fleeting occasional bumps are usually ectopic and do not need investigation); chest pain suggesting cardiac origin; or any previously documented hypertension, congenital heart abnormality, previous cardiac surgery, or underlying condition that increases the risk of having a structural cardiac disorder (eg, genetic conditions or multisystemic disorders).²

The second condition is that the individual with ADHD does not have a family history of early (<40 years) sudden death in a first-degree relative suggesting cardiac disease. Finally, the patient must have baseline monitoring before initiation; blood pressure and heart rate can be measured by a family member or another person remotely (with telephonic assistance, if needed) on three separate occasions (details are provided in the appendix of our previous Comment¹).

If the first or second conditions are not satisfied, a referral to a cardiologist should be made before starting the pharmacological treatment. If only the third condition (baseline monitoring) is not satisfied, the prescriber will need to evaluate the risks and benefits of a face-to-face assessment in the context of the severity of ADHD symptoms, and the impact on the patient and the family.

As detailed in our previous 2013 guidance,³ if persistent tachycardia or a history suggestive of arrhythmia or familial risk is identified, it is appropriate to request a 24-h electrocardiogram (ECG), rather than a standard, 12-lead ECG.

The EAGG considers that, given the current circumstances, in the absence of risk factors described in the first and second conditions, a cardiac auscultation should not be mandatory before starting a medication for ADHD.