The safety of Ritalin has been in the spotlight in recent years. Ritalin is widely used to manage the symptoms of attention deficit disorder with hyperactivity (ADHD). If you or your child use Ritalin, you might like to know that there is a growing body of scientific research showing that there is a small increase in risk for cardiac problems.
Ritalin is a psychostimulant medication and the active ingredient is methylphenidate. This blog post concerns methylphenidate. There are many drugs that containmethylphenidate, not just Ritalin. These include:
- Acerta
- Concerta
- Contramyl
- Medikinet
- Mefedinel
- Meglarat
- Methylphenidate 10 Biotech
- Methylphenidate HCl-Douglas
- Methylphenidate Unicorn
- Neucon
- Radd
The Safety of Ritalin affects Millions
Although researchers describe the cardionvascular risk associated with methyphenidate usage as “small,” the absolute numbers are concerning. It’s difficult to find current figures but I did find some numbers in an old BMJ editorial by John Jackson. Citing a paper from the journal Pediatrics, he reckoned that in 2011, 6.4 million children in the US alone received a diagnosis of attention-deficit/hyperactivity disorder (ADHD). Furthermore, 3.5 million of those children received a stimulant drug, typically methylphenidate,
Those figures blow my mind: 3.5 million kids in one year getting potent medication! And that’s just in the US, so what do the figures look like for the entire planet? Especially if the statistics were current. It is not an overstatement to observe that millions and millions of children use psychostimulant medication every year.
Amphetamine Type Stimulants
Notwithstanding that we routinely give this medication to children, a reality check is appropriate. Methylphenidate is potent medication. In terms of the Drug Master Plan developed by the South African government, Ritalin belongs in a category of drugs termed “amphetamine type stimulants.” Other drugs in this category include amphetamine, methamphetamine (“Tik”), MDMA (‘Ecstasy’), ephedrine, and pseudoephedrine.
In South Africa, methylphenidate is a schedule six drug. These are drugs that have “a moderate to high potential for abuse or for producing dependence.” Other schedule six drugs include methadone, morphine, pethidine, opium, oxycodone, opium, to name but a few of the better known substances. Let’s not fool ourselves about the safety of Ritalin.
The health concerns of methylphenidate use apply to both children and adults. CNS stimulants target the ascending reticular activating system in the brainstem and its connections to the neocortex. They work by blocking the reuptake of catecholamines like norepinephrine and dopamine. The resultant increase in catecholamines activates cardiovascular beta-1 adrenoreceptors, increasing heart rate. Stimulants also activate alpha adrenoreceptors, which triggers vasoconstriction leading to elevated blood pressure.
Given this physiology, the repeated finding of elevations in blood pressure in association with the use of methylphenidate comes as little surprise. More worryingly, research shows an increase in other cardiac problems in association with methylphenidate usage.
The Original Shin
Shin et al published the most controversial study on the safety of Ritalin in 2016. Their project was slightly different to most in that they investigated whether patients experienced an adverse cardiovascular event more frequently in the period soon after commencing using methylphenidate, than during any other period before using the drug or after discontinuation. Effectively, they were asking if methylphenidate played a role in triggering adverse cardiovascular events.
They found that arrhythmia was 61% more likely to occur within the first two months of treatment and that risk was highest within the first three days of usage. Furthermore, a risk for heart attack appeared after the first week of treatment and persisted for two months.
Predictably, an angry response from medical orthodoxy met the Shin study. There were complaints that the Shin findings were frightening parents and could lead to “ill-advised decisions not to treat children suffering with ADHD.” Fortunately, a more measured analysis of the Shin study appeared as an editorial in the same journal, concluding that there was a need to consider the option of non-stimulant treatment and, when stimulants were prescribed, to closely monitor such patients.
Additional Research on the Safety of Ritalin
A meta-analysis published in 2018 concluded that the use of methylphenidate in children increased the risk of serious adverse events, including cardiac arrhythmia and psychosis. Another meta-analysis published in 2017 investigated methylphenidate, amphetamines, and atomoxetine in children and adolescents with ADHD. They reported that increases in systolic BP were linked to all three medications.
In 2020, the Journal of the American College of Cardiology published a review of the cardiovascular effects of ADHD therapies. Incredibly, they found an association between psychostimulants like Ritalin and adverse cardiovascular events. They noted that sympathomimetic stimulants caused modest elevations in resting heart rate and blood pressure. More significantly, they found that adverse effects included cardiac arrhythmia, non-ischaemic cardiomyopathy, and even sudden death. They did caution, though, that these associations did not necessarily imply causation and pointed to the need for further research.
In contrast, a meta-analysis published in 2022 concluded that there was no association between cardiovascular disease and medications used to treat ADHD. The study included both children and adults and a range of different types of medication. Unfortunately, as the authors themselves concede, there were major methodological problems with this review.
A Danish study found the odds ratio for cardiac arrest increased by 1.78 (nearly double) in people using methylphenidate. The risk was 2.59 times higher in people that had recently (within 180 days) started using methylphenidate.
A 2024 study examined 26,710 Swedish adolescents who used methylphenidate over a five-year period. They found a 10% increase in the risk of cardiovascular events in adolescents using methylphenidate. The risk persisted for six months after commencement of methylphenidate.
To Use or Not to Use
For many children and adults with ADHD, using methylphenidate improves quality of life. A review of the chronic use of methylphenidate published in July 2024 concluded that methylphenidate improved performance in all domains of cognitive functioning. Not only does it improve attention and concentration, but there are also positive spin-offs in other areas of life. Interpersonal relationships may improve because the user is less impulsive and more predictable, which facilitates social interactions. They may be less anxious because they are more efficient and less distractible. So, there is no question that methylphenidate has benefits.
So, I’m not suggesting that there should be a prohibition on using Ritalin. Rather, I am simply pointing out that informed consent should include a discussion about the safety of methylphenidate and the associated cardiovascular risks.
Alternative Treatments
Consider alternative treatments to methylphenidate. For instance, there is research that shows that levels of polyunsaturated fats are low in people with ADHD and that taking Omega-3 may improve symptoms.
Clearly, a health supplement like Omega-3 is a soft option when compared to an amphetamine-like stimulant such as methylphenidate. Nonetheless, additional interventions, such as exercise or vagal nerve stimulation could supplement treatment with Omega-3. Treatment should be a lifestyle change, so it is not merely popping a prescription pill and thinking no further about the problem. Holistic treatment implemented as a lifestyle change may lead to long-term gains without the potential side-effects of drug usage.
