Is methylphenidate (Ritalina or Concerta) contraindicated for a patient who previously had a stroke

Fråga: Is methylphenidate (Ritalina or Concerta) contraindicated for a patient who previously had a stroke?

Sammanfattning: It is well known that methylphenidate and other central stimulants may cause hypertension and hemorrhagic stroke, which is why these conditions are contraindications for methylphenidate treatment. Data concerning attempts to treat stroke patients with methylphenidate are scarce but new stroke as an adverse reaction to such treatment has not been reported. In the current case, where the patient seems to have had a hemorrhagic stroke due to severe hypertension, we cannot recommend methylphenidate treatment.

Svar: Methylphenidate (Ritalina /Concerta) is a type of central stimulant used to treat children with ADHD (1). Among the contraindications listed in the SPC are severe hypertension, existing cerebrovascular disorders, and vascular disorders including stroke (1). Previous reviews of the effects of amphetamine on hypertension have shown a clear association between methylphenidate therapy and increased blood pressure (2,3). Raynauds syndrome, vasoconstriction and stroke have also been observed in patients on methylphenidate treatment has been observed, most probably caused by the sympathomimetic effects of methylphenidate (4-6). In the Swedish adverse reaction register (SWEDIS) there are 37 reports of circulatory adverse events considered related to methylphenidate. None of these are strokes and most of them are arrhythmias and blood pressure effects (7).

The literature regarding stroke and methylphenidate includes publications that can be divided into two main groups: (i) stroke due to methylphenidate treatment, and (ii) methylphenidate treatment of stroke or brain injury:

(i) Stroke due to methylphenidate treatment: Several case reports describe patients who have had either cerebral vasculitis or stroke during treatment with methylphenidate. This is well known for other central stimulants, where vasculitis with subsequent stroke, mainly hemorrhagic stroke, has been observed in amphetamine abuse (8-10).

(ii) Methylphenidate in the treatment of attention deficit after stroke: On the other hand, several central stimulants have been tested in the treatment of attention deficit after stroke and traumatic brain injury. A review of studies on this showed some improvement during treatment with methylphenidate following traumatic brain injury, but not after stroke. Treatment time was only 4-6 weeks and no side effects such as cardiovascular events were described (11). However, the review did not specify whether the stroke treated was ischemic or hemorrhagic. Concerta. SPC Janssen. (cited 2012-12-07)

Reda no 8668 (year 2007)
Drugline no 21019 (year 2004)
Drugline no 23868 (year 2009)
Drugline no 23586 (year 2008)
Drugline no 23612 (year 2008)
Swedis metylfenidat access. (cited 2012-12-20)

Schteinschnaider A, Plaghos LL, Garbugino S, Riveros D, Lazarowski A, Intruvini S et al. Cerebral arteritis following methylphenidate use. J Child Neurol 2000;15(4):265-267 Thomalla G, Kucinski T, Weiller C, Rother J. Cerebral vasculitis following oral methylphenidate intake in an adult: a case report. World J Biol Psychiatry 2006;7(1):56-58 Sadeghian H. Lacunar stroke associated with methylphenidate abuse. Can J Neurol Sci 2004;31(1):109-111 Sivan M, Neumann V, Kent R, Stroud A, Bhakta BB. Pharmacotherapy for treatment of attention deficits after non-progressive acquired brain injury. A systematic review. Clin Rehabil 2010;24(2):110-121