ebook_ADHD2019

102 Rohde, Buitelaar, Gerlach & Faraone are still significant gaps in the literature, although this scenario is improving. 25 The effect on growth is often a reason for worries for parents and the most recent data does suggest that long term stimulant medication is associated with a mo- dest reduction in adult height of around 2.5 cm. 21 A summary of adverse effects for stimulant and non-stimulant medication is shown in Box 5.1. Non-stimulants have less effect on appetite but can result in somnolence rather than the insomnia that is more common with stimulants. Indeed, somnolence is the most frequently reported adverse effect for guanfacine and clonidine. The safety of the stimulants and atomoxetine have been comprehensively reviewed. 26,27 Atomoxetine has a bla- ck box warning for suicidal ideation. Whilst the association between suicidality and atomoxetine is unclear and occurrence is rare, it is important to monitor du- ring treatment. It is our policy to ask about suicidality, which is more common in ADHD, at every visit irrespective of what treatment is being prescribed. Atomo- xetine can rarely cause reversible liver damage (1 in a million), which most typi- cally presents as jaundice. If this occurs, medication should be discontinued, and patient reviewed urgently. It is also important to continue to monitor and chart growth, weight, heart rate and blood pressure throughout treatment and to make appropriate accommoda- tions and referrals should these deviate significantly from expected age and sex ad- justed norms. The issue of switching medications as a consequence of adverse ef- fects is discussed in section “Adjusting and switching treatment” below. For further suggestions about the management of adverse effects see Graham et al. 6 e Cortese et al. 8 The risk of serious cardiovascular adverse effects secondary to ADHD me- dications is low 28 especially where an efficient cardiac screen has been conducted prior to starting treatment. It is also advised that patients are asked about car- diac symptoms (excessive breathlessness or chest pain on exertion and frequent syncope) at each follow up visit. 7 There are however still valid concerns for the psychostimulants and atomoxetine about increases in pulse and blood pressure. For most, these increases are moderate, however a minority do develop iatrogenic hypertension. Whilst this can be managed by reducing or stopping the ADHD medication, this will often result in problematic return of symptoms. Following a full clinical evaluation and investigation of hypertension, another option is to add in or switch to guanfacine or clonidine (which lower blood pressure) or to treat the hypertension. 7 Of course, this cannot happen unless the problem is identified. It is therefore essential that pulse and blood pressure is taken at each follow-up visit and the results should compared to age, sex and height standardised charts. 9 ADJUSTING AND SWITCHING TREATMENT Where there is a failure to respond to a particular treatment or when a patient is unable to tolerate a particular treatment due to adverse effects, it is necessary to