ArcaMax

DEAR DR. ROACH: I am a 72-year-old woman who has been taking Adderall for attention deficit hyperactivity disorder (ADHD) for years. I recently got diagnosed with "nonobstructive coronary artery disease" by a CT angiogram. Do I need to stop taking Adderall? -- V.P.

ANSWER: The studies designed to answer this question have shown mixed results. However, after reading many studies on the subject, there probably is a small increased risk of heart attack and death from stimulants like amphetamine/dexamphetamine (Adderall).

This risk is highest when the stimulant is first started, but one study showed a 3% absolute increased risk, meaning that 1 person in 30 will have a bad heart event (within a few years), compared to a person not taking Adderall.

Nonobstructive coronary artery disease means there is plaque in the blood arteries that supply blood to the heart muscle, but the plaque isn't large enough to obstruct flow. This is better than obstructive CAD, but there are still areas of cholesterol and calcium in the coronary arteries that can possibly rupture and trigger a heart attack. A person with known blockages is at a much higher risk for a heart attack than a person without known blockages. So, in your case, the concern for Adderall is even greater.

I would be uncomfortable prescribing Adderall to an older person with known coronary disease. Your doctor needs to carefully consider continuing this medication. I recommend a nonstimulant agent, such as clonidine (often used as a blood pressure medicine) or guanfacine, which are likely to have less risks.

DEAR DR. ROACH: My wife and I both have chronically low blood sodium levels, mostly around 132, but sometimes lower. It never reaches 135. This is of concern because sodium is essential for cell maintenance. Sometimes it goes as low as 129, which concerns our doctor. No other metabolic measure is outside the normal range.

We can think of two possible culprits. My wife and I never eat fast food, and she does not use much additional salt in her cooking. But we both suffer from labile hypertension, which can cause our systolic pressure to go as high as 170 mm Hg during stressful times (like elections).

We both take clonidine, supplemented with olmesartan for one of us and losartan for the other. Clonidine is dehydrating, and we wonder if it or the other medications might be lowering our blood sodium. In your opinion, is diet or medication the most likely cause of our low sodium? -- T.D.

ANSWER: It's more likely the medicines than diet. A healthy kidney is able to regulate sodium under a very wide range of sodium and water intakes. However, clonidine and angiotensin receptor blockers (olmesartan and losartan are ARBs) sometimes cause low sodium levels. Diuretics like HCTZ and chlorthalidone are the most likely medications to reduce sodium, but the medicines you are on can also do this, likely by affecting a hormone called antidiuretic hormone or causing the kidney to lose excess sodium.

Clonidine is a bit of an unusual choice for a blood pressure medicine. It's not a first-line drug. In addition to ARBs, ACE inhibitors and diuretics, calcium blockers are the usual first-line blood pressure treatments. Your doctor may have another reason for prescribing clonidine that I don't know of.

In people who continue to have high blood pressure on these medications, a medicine to block the hormone aldosterone (spironolactone and eplerenone do this) is a frequent choice among high blood pressure experts.

========

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.

(c) 2024 North America Syndicate Inc.

All Rights Reserved