884 Effect of COVID-19 pandemic on the blood pressure of children and adolescents with ADHD: implications for clinical practice

Abstract

<h3>Background</h3> ADHD is one of the commonest reasons for prescribing psychotropic medications for children and young people (CYP), and the efficacy is up to 70%. Three of the four medications licensed for ADHD in the UK (Methylphenidate, Dexamfetamine/Lisdexamfetamine, and Atomoxetine) are sympathomimetic amines that exert their beneficial effect by increasing levels of dopamine and or noradrenaline in the prefrontal cortex. These sympathomimetic amines also stimulate adrenergic receptors in the heart and blood vessels; hence are associated with small but statistically significant increases in Blood Pressure (BP). Thus, while medications for ADHD are effective and generally well tolerated and safe, patients need to be monitored for cardiovascular and other side effects. Clinical guidelines recommend that if children and young people (CYP) taking medication for ADHD experience raised BP above cut-off for hypertension, dose reduction and cardiology referral should be made. However, guidelines do not specify the need to consider contextual factors. <h3>Objectives</h3> We aimed to test the hypothesis that the most plausible explanation for elevated BP among CYP with ADHD during the Covid-19 lockdown was related to Covid-linked stress and the additional anxiety about coming to the clinic during the pandemic. <h3>Methods</h3> We carried out a prospective cardiovascular assessment of a cohort of 41 CYP (88% males) attending routine medical reviews for ADHD treatment in the Borough district of Halton in North West England within the first 6 weeks of the UK-wide Covid-19 lockdown in March-May 2020. Mean age was 12 years (range 5–18 years), and 92.5% were on psycho-stimulants while 7.5% were on non-stimulants. All the medications were within the lower range of normally approved doses. Their Blood Pressures were measured with regularly calibrated electronic sphygmomanometers based on standard clinical procedures and compared to BP recorded within the previous one year. Definition of Hypertension (HT) or Pre-HT was based on the British reference charts for CYP. The CYP were followed up with non-clinic-based BP monitoring at home or by GP. <h3>Results</h3> We identified 32 CYP seen within the first 6 weeks of the UK-wide Covid-19 lockdown who had BP above cut-off for prehypertension (44%) or hypertension (37%) (figure 1), all of whom previously had their BP in the normal range. Their medication types and doses had not changed. Their medical histories and anthropometric centiles were stable. By August 2020 when the lockdown had eased, their BP were back in the normal range without any further investigations or interventions. <h3>Conclusions</h3> This audit highlights the point that clinical evaluation of changes in BP among CYP taking medications for ADHD should take the socio-ecological context into account and not automatically translate into making major clinical changes to treatment such as dose reduction or referral for cardiology review. A conservative approach of non-clinic-based monitoring may be in the best interest of such young people, who, otherwise, may lose treatment efficacy following dose reduction. This conservative approach could also prevent the affected CYP being exposed to the inconvenience and risks associated with unnecessary medical investigations. There could also be additional efficacy gains for the wider health economy.