Pre-treatment workup before the first stimulant dose: BP, heart rate, weight, bloods (TSH, baseline urine drug screen, LFTs if atomoxetine planned). Cardiology input is symptom- and history-driven — not a routine ECG for everyone.
Autism & learning disabilities
- Autism spectrum disorder: DSM-5-TR allows both an ASD and an ADHD diagnosis together — autism is no longer an exclusion criterion. Look for restricted/repetitive behaviours, sensory sensitivities, social reciprocity difficulties; refer to psychology for formal assessment if suspected.
- Learning disabilities: 50–60% of people with ADHD have co-occurring dyslexia, dyscalculia or dysgraphia. Medication treats attention only, not the learning disability — literacy programmes, OT and educational/workplace adjustments are separate supports.
Cardiovascular assessment
- History first: ask about exertional chest pain or breathlessness, syncope, palpitations, a heart murmur, hypertension, congenital heart disease or prior cardiac surgery, and a first-degree relative with sudden cardiac death under 40.
- Baseline vitals: document BP, heart rate and weight before the first dose — stimulants commonly raise heart rate and BP, and you need a baseline to judge any change.
- Cardiology/ECG: reserved for a positive history or symptoms above, not a routine test for every patient — current guidance is risk-based, not age-based.
Other baseline investigations
- TSH: hyperthyroidism is a contraindication; hypothyroidism mimics ADHD — check and normalise before starting.
- Urine drug screen: baseline before the first prescription; if positive for cannabis or stimulants, address substance use first.
- LFTs: only if atomoxetine is planned — baseline, repeat at 4–6 weeks, then annually; stop if ALT >3× the upper limit of normal.
- Height, weight & BMI: stimulants suppress appetite and can impair growth in children — record at every visit; reconsider dose if weight loss exceeds 10% of baseline.
Key contraindications. Moderate–severe hypertension or symptomatic cardiovascular disease; untreated/acute mania or psychosis; current substance misuse; severe depression, suicidality or anorexia nervosa; glaucoma, hyperthyroidism, or MAOI use within 14 days. Guanfacine is TGA-approved only for ADHD diagnosed before age 18 — not a general adult non-stimulant option. Confirm the complete list against the current product information at the TGA eBS or AMH before prescribing.
Safety
- Stabilise hypertension and clear symptomatic cardiac disease before starting — recheck BP and consider a non-stimulant (atomoxetine) if hypertension persists.
- Don't start a stimulant in untreated mania, psychosis, or active substance use disorder — treat the acute episode first.
- Check hepatic function before and during atomoxetine; stop if ALT rises above 3× the upper limit of normal or jaundice develops.
Red flags / refer
- Positive cardiac history or exertional symptoms → cardiology review before any stimulant.
- Suspected autism or a significant learning disability → psychology/educational assessment alongside ADHD management.
- Any absolute contraindication present → specialist review of stimulant versus non-stimulant options before initiating.
MH-01D v1.0 · Reviewed Jun 2026 · Review Jun 2027
For health-professional use. Framework: AADPA Clinical Practice Guideline; Suetani et al, Aust Prescr 2026;49:10-5. Confirm doses at amhonline.amh.net.au. Companion sheets: MH-01A Recognition; MH-01B Screening & Referral; MH-01C Diagnostic Algorithm & Comorbidity.
