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New York Times,
2/21/06
HEART RISKS WITH STIMULANT USE? MAYBE
WORRY? FOR SOME
by Benedict Carey
Psychiatrists say they have been getting panicked phone calls from
patients worried by a government advisory panel's recommendation
this month that drugs for attention-deficit disorder carry a
prominent warning about heart risks.
The calls are coming not just from parents of children who take the
drugs but from adult users, who the panel warned might be at the
highest risk for heart problems.
"Every single adult patient I saw today, the first thing out of
their mouth was, 'Am I going to drop dead on this?' Every single one
of them," said Dr. Timothy Wilens, a psychiatrist at Massachusetts
General Hospital in Boston.
Dr. James McGough, a professor of clinical psychiatry at the
University of California, Los Angeles, said he had received several
calls from parents "who were very upset and nervous" about potential
risks.
The panel, convened to consider ways the drugs' effects on the heart
could be investigated, made its recommendation on Feb. 9 based on a
Food and Drug Administration analysis of more than 300 people who
died while they were taking stimulant medications. The agency
concluded that in 25 of the cases -- 19 children and 6 adults -- the
stimulant appeared to be strongly related to the deaths, many
apparently from heart problems.
The Food and Drug Administration will soon decide whether to accept
the advisory panel's advice and require a strong warning on the
drugs' labels.
Doctors who treat adults and children with stimulants like Ritalin
and Adderall say the risk is remote, given that an estimated 2.5
million children and 1.5 million adults are taking the medications,
and a handful of them will die suddenly each year, whether taking
drugs or not.
But psychiatrists and cardiologists say that people with high blood
pressure, heart murmurs or other cardiovascular problems should talk
to their doctors to determine whether they need to be more closely
monitored or should taper off the drugs altogether.
"Ideally, doctors should be screening patients for these things up
front, before prescribing the drugs," said Dr. James Waxmonsky, a
psychiatrist at the University at Buffalo, part of the State
University of New York.
Some panel members expressed concerns about children with structural
heart abnormalities who might be given stimulants. Perhaps the most
common abnormality is hypertrophic obstructive cardiomyopathy, a
thickening of the muscle that can cause a blockage -- and death --
when under stress.
Such problems are often not diagnosed before drug treatment begins,
but a good pediatrician who is aware a child is being considered for
stimulant treatment will often pick up a soft heart murmur that
might reflect an abnormality, said Dr. Steven Nissen, chief of
cardiology at the Cleveland Clinic and a panel member. "This
seemingly small step could save a life," he said.
Norine Eaton, 50, of Williamsville, NY, who has been on stimulants
for attention problems for six years and who has two teenage sons on
the medications, said she read about the panel's warning in a
newspaper article.
"If I had any family history of heart disease, I would absolutely
have stood up and called my doctor," she said in a telephone
interview, "but I have not noticed any heart problems in myself or
my sons."
The biggest worry for adults is high blood pressure. Stimulants
usually prompt slight increases in heart rate and raise blood
pressure, and even these changes can increase the risk of heart
problems in someone who is vulnerable, Dr. Nissen said.
Adults with hypertension who are considering the drugs should have
their blood pressure stabilized first, doctors say.
"A smoker with high cholesterol and a family history of heart
disease: that's a person I would be very concerned about taking
stimulants," Dr. Nissen said.
Lew Mills, 49, a therapist in San Francisco who takes a stimulant
for attention-deficit disorder, said he first worried about the
drugs' effect about a year and a half ago, when he was moving after
a divorce and felt overwhelmed by stress. He said he went to a
doctor and found that his blood pressure was elevated. "I was
concerned that the medicine was adding to the blood pressure
problem," he said.
But Dr. Mills said that he stayed on the stimulants and resumed
exercising, and that once the divorce was complete, his blood
pressure soon returned to normal.
Dr. Wilens of Massachusetts General has just completed a study of 13
men and women, ages 20 to 55, being treated for high blood pressure
who were also taking Adderall, a strong stimulant.
The patients spent six weeks on Adderall and two weeks off, while
doctors monitored their blood pressure.
Two of them had mild increases in blood pressure, one while taking
the stimulant and the other while not.
"It's a small study, but we found the same rate of symptoms" whether
people were on the stimulants or not, said Dr. Wilens, who consults
widely with drug makers.
Answers to just a few questions can tell a doctor a lot about a
person's risk. Are there any congenital or structural heart defects?
Are there unexplained bouts of dizziness or heart palpitations? Is
there any family history of heart disease, in particular sudden
deaths in close relatives who died young?
Doctors considering stimulant treatment should be asking all these
questions. And if the answers are not forthcoming -- many parents
have no idea if a child has an underlying heart abnormality, for
example -- at least families will be aware of possible risks and can
investigate further.
"Over all, I think some type of warning is a good idea, and it does
lead to more in-depth discussions between doctors and families," Dr.
Waxmonsky said in an e-mail message. "However, it would be helpful
to know what the exact risk is so that we could provide patients
with some meaningful numbers instead of just theoretical concerns."
William Pelham, a psychologist at the University at Buffalo who
studies psychosocial treatments for attention-deficit disorder, said
that a warning might also prompt parents to consider addressing the
problem without drugs. "As it is, most parents don't even hear about
the alternatives to medication," he said.
In a recent trial that involved 154 children, most of them on
stimulants, Dr. Pelham found that an intensive summer-long course of
behavior modification allowed most parents to reduce the level of
drugs their children were taking or wean them off the medication
altogether.
Still, many patients say they will take their chances with
stimulants even if they have heart problems in their families.
Joseph Neal, 29, a student and Web designer in Nashville, said he
had totaled two cars as a result of attention-deficit problems.
"Quite simply, it is not safe for me to operate a motor vehicle
while unmedicated," he wrote in an e-mail message.
He said he found the concerns over rare side effects "quite absurd."
"I need these medications to be a fully functional human being," Mr.
Neal said. "If there was a one-in-four chance that I'd grow a second
head, I'd take it. Besides, the second head might work better."
Copyright 2006 The New York Times Company |
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