8.6 CNS Stimulants

Methylphenidate is an example of a CNS stimulant that is often used to treat ADHD. CNS stimulants are Schedule II controlled substances and have a high potential for abuse and dependence.

Mechanism of Action: Methylphenidate stimulates the brain and acts similar to amphetamines. Methylphenidate is thought to block the reuptake of norepinephrine and dopamine into the presynaptic neuron.

Indications: Methylphenidate is used for ADHD.

Nursing Considerations: Methylphenidate is typically prescribed to clients over the age of 6. It should be avoided in clients with known structural cardiac abnormalities, cardiomyopathy, serious heart rhythm arrhythmias, or coronary artery disease. Blood pressure and heart rate should be monitored in all clients.

CNS stimulants have been associated with weight loss and slowing of growth rate in pediatric clients. It increases the risk of peripheral vasculopathy, such as Raynaud’s phenomenon, with signs and symptoms of fingers or toes feeling numb, cool, painful, and/or changing color from pale, to blue, to red.

Methylphenidate is contraindicated in clients using a monoamine oxidase inhibitor (MAOI), or use of an MAOI within the preceding 14 days. If paradoxical worsening of symptoms or other adverse reactions occur, the dosage should be reduced, or if necessary, discontinued.

Administer methylphenidate hydrochloride extended-release capsules orally once daily in the morning. Extended-release capsules should not be crushed, chewed, or divided. Monitor for signs of abuse and dependence while on therapy.

Side Effects/Adverse Effects: Serious cardiovascular events have occurred with sudden death reported in association with CNS-stimulant treatment in pediatric clients with structural cardiac abnormalities or other serious heart problems. Sudden death, stroke, and myocardial infarction have also been reported in adults with CNS-stimulant treatment at recommended doses. Methylphenidate may cause increased blood pressure and increased heart rate. Use of stimulants may cause psychotic or manic symptoms in clients with no prior history and may cause priapism (painful or prolonged penile erections). The most common adverse reactions (greater than 5% incidence) were headache, insomnia, upper abdominal pain, decreased appetite, and anorexia. Alcohol should be avoided because it may cause a rapid release of the drug in extended-release formulations.

If overdose occurs, consult with a Certified Poison Control Center (1-800-222-1222) or go to www.poisonhelp.org/help for the latest recommendations.

Health Teaching & Health Promotion: There are several important topics to provide clients and/or parents of minor children. Each topic is outlined in more detail below.

Controlled Substance Status/High Potential for Abuse and Dependence: Advise clients that methylphenidate is a controlled substance, and it can be abused and lead to dependence. Instruct clients that they should not give methylphenidate to anyone else. Advise clients to store methylphenidate in a safe place, preferably locked, to prevent abuse. Advise clients to comply with laws and regulations on drug disposal. Advise clients to dispose of remaining, unused, or expired methylphenidate by a medicine take-back program if available.

Serious Cardiovascular Risks: Advise clients that there is a potential serious cardiovascular risk, including sudden death, myocardial infarction, stroke, and hypertension. Instruct clients to contact a health care provider immediately if they develop symptoms such as exertional chest pain or unexplained syncope.

Blood Pressure and Heart Rate Increases: Instruct clients that methylphenidate hydrochloride extended-release capsules can cause elevations of their blood pressure and pulse rate. Teach clients, especially those with a history of hypertension, to avoid OTC cold and allergy products containing phenylephrine and pseudoephedrine.

Psychiatric Risks: Advise clients that methylphenidate can cause psychotic or manic symptoms, even in clients without prior history of psychotic symptoms or mania.

Priapism: Advise clients of the possibility of painful or prolonged penile erections and to seek immediate medical attention if this occurs.

Circulation Problems in Fingers and Toes: Instruct clients beginning treatment with methylphenidate about the risk of peripheral vasculopathy and associated signs and symptoms: fingers or toes may feel numb, cool, painful, and/or may change color from pale, to blue, to red. Instruct clients to report to their provider any new numbness, pain, skin color change, or sensitivity to temperature in fingers or toes or any signs of unexplained wounds appearing on fingers or toes.

Suppression of Growth: Advise parents that methylphenidate may cause slowing of growth and weight loss.

Alcohol Effect: Advise clients to avoid alcohol while taking extended-release capsules.^[1]

Now let’s take a closer look at the medication grid for methylphenidate in Table 8.6.^[2]

Table 8.6 Methylphenidate Medication Grid