WARNINGS
Serious Cardiovascular Events
Sudden Death and Pre-Existing Structural Cardiac Abnormalities or Other Serious Heart Problems
Children And Adolescents
Sudden death has been reported in association with CNS stimulant treatment at usual doses in children
and adolescents with structural cardiac abnormalities or other serious heart problems. Although some
serious heart problems alone carry an increased risk of sudden death, stimulant products generally
should not be used in children or adolescents with known serious structural cardiac abnormalities,
cardiomyopathy, serious heart rhythm abnormalities, or other serious cardiac problems that may place
them at increased vulnerability to the sympathomimetic effects of a stimulant drug (see CONTRAINDICATIONS).
Adults
Sudden deaths, stroke, and myocardial infarction have been reported in adults taking stimulant drugs at
usual doses for ADHD. Although the role of stimulants in these adult cases is also unknown, adults
have a greater likelihood than children of having serious structural cardiac abnormalities,
cardiomyopathy, serious heart rhythm abnormalities, coronary artery disease, or other serious cardiac
problems. Adults with such abnormalities should also generally not be treated with stimulant drugs (see CONTRAINDICATIONS).
Hypertension and other Cardiovascular Conditions
Stimulant medications cause a modest increase in average blood pressure (about 2 to 4 mmHg) and
average heart rate (about 3 to 6 bpm), and individuals may have larger increases. While the mean
changes alone would not be expected to have short-term consequences, all patients should be monitored
for larger changes in heart rate and blood pressure. Caution is indicated in treating patients whose
underlying medical conditions might be compromised by increases in blood pressure or heart rate, e.g.,
those with pre-existing hypertension, heart failure, recent myocardial infarction, or ventricular
arrhythmia (see CONTRAINDICATIONS).
Assessing Cardiovascular Status in Patients being Treated with Stimulant Medications
Children, adolescents, or adults who are being considered for treatment with stimulant medications
should have a careful history (including assessment for a family history of sudden death or ventricular
arrhythmia) and physical exam to assess for the presence of cardiac disease, and should receive further
cardiac evaluation if findings suggest such disease (e.g., electrocardiogram and echocardiogram).
Patients who develop symptoms such as exertional chest pain, unexplained syncope, or other symptoms
suggestive of cardiac disease during stimulant treatment should undergo a prompt cardiac evaluation.
Psychiatric Adverse Events
Pre-Existing Psychosis
Administration of stimulants may exacerbate symptoms of behavior disturbance and thought disorder in
patients with a pre-existing psychotic disorder.
Bipolar Illness
Particular care should be taken in using stimulants to treat ADHD in patients with comorbid bipolar
disorder because of concern for possible induction of a mixed/manic episode in such patients. Prior to
initiating treatment with a stimulant, patients with comorbid depressive symptoms should be adequately
screened to determine if they are at risk for bipolar disorder; such screening should include a detailed
psychiatric history, including a family history of suicide, bipolar disorder, and depression.
Emergence Of New Psychotic Or Manic Symptoms
Treatment emergent psychotic or manic symptoms, e.g., hallucinations, delusional thinking, or mania in
children and adolescents without a prior history of psychotic illness or mania can be caused by
stimulants at usual doses. If such symptoms occur, consideration should be given to a possible causal
role of the stimulant, and discontinuation of treatment may be appropriate. In a pooled analysis of
multiple short-term, placebo-controlled studies, such symptoms occurred in about 0.1% ( 4 patients with
events out of 3482 exposed to methylphenidate or amphetamine for several weeks at usual doses) of
stimulant-treated patients compared to 0 in placebo-treated patients.
Aggression
Aggressive behavior or hostility is often observed in children and adolescents with ADHD, and has
been reported in clinical trials and the postmarketing experience of some medications indicated for the
treatment of ADHD. Although there is no systematic evidence that stimulants cause aggressive behavior
or hostility, patients beginning treatment for ADHD should be monitored for the appearance of or
worsening of aggressive behavior or hostility.
Long-Term Suppression Of Growth
Careful follow-up of weight and height in children ages 7 to 10 years who were randomized to either
methylphenidate or non-medication treatment groups over 14 months, as well as in naturalistic
subgroups of newly methylphenidate-treated and non-medication treated children over 36 months (to the
ages of 10 to 13 years), suggests that consistently medicated children (i.e., treatment for 7 days per
week throughout the year) have a temporary slowing in growth rate (on average, a total of about 2 cm
less growth in height and 2.7 kg less growth in weight over 3 years), without evidence of growth
rebound during this period of development. Published data are inadequate to determine whether chronic
use of amphetamines may cause a similar suppression of growth, however, it is anticipated that they
likely have this effect as well. Therefore, growth should be monitored during treatment with stimulants,
and patients who are not growing or gaining height or weight as expected may need to have their
treatment interrupted.
Seizures
There is some clinical evidence that stimulants may lower the convulsive threshold in patients with
prior history of seizures, in patients with prior EEG abnormalities in absence of seizures, and, very
rarely, in patients without a history of seizures and no prior EEG evidence of seizures. In the presence
of seizures, the drug should be discontinued.
Peripheral Vasculopathy, Including Raynaud's Phenomenon
Stimulants, including Evekeo, used to treat ADHD are associated with peripheral vasculopathy,
including Raynaud's phenomenon. Signs and symptoms are usually intermittent and mild; however, very
rare sequelae include digital ulceration and/or soft tissue breakdown. Effects of peripheral
vasculopathy, including Raynaud's phenomenon, were observed in post-marketing reports at different
times and at therapeutic doses in all age groups throughout the course of treatment. Signs and symptoms
generally improve after reduction in dose or discontinuation of drug. Careful observation for digital
changes is necessary during treatment with ADHD stimulants. Further clinical evaluation (e.g.,
rheumatology referral) may be appropriate for certain patients.
Serotonin Syndrome
Serotonin syndrome, a potentially life-threatening reaction, may occur when amphetamines are used in
combination with other drugs that affect the serotonergic neurotransmitter systems such as monoamine
oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine
reuptake inhibitors (SNRIs), triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan,
buspirone, and St. John's Wort (see DRUG INTERACTIONS). Amphetamines and amphetamine
derivatives are known to be metabolized, to some degree, by cytochrome P450 2D6 (CYP2D6) and
display minor inhibition of CYP2D6 metabolism (see CLINICAL PHARMACOLOGY). The potential
for a pharmacokinetic interaction exists with the co-administration of CYP2D6 inhibitors which may
increase the risk with increased exposure to Evekeo. In these situations, consider an alternative nonserotonergic
drug or an alternative drug that does not inhibit CYP2D6 (see DRUG INTERACTIONS).
Serotonin syndrome symptoms may include mental status changes (e.g., agitation, hallucinations,
delirium, and coma), autonomic instability (e.g., tachycardia, labile blood pressure, dizziness,
diaphoresis, flushing, hyperthermia), neuromuscular symptoms (e.g., tremor, rigidity, myoclonus,
hyperreflexia, incoordination), seizures, and/or gastrointestinal symptoms (e.g., nausea, vomiting,
diarrhea).
Concomitant Use Of Evekeo With MAOI Drugs Is Contraindicated (see CONTRAINDICATIONS).
Discontinue treatment with Evekeo and any concomitant serotonergic agents immediately if the above
symptoms occur, and initiate supportive symptomatic treatment. If concomitant use of Evekeo with other
serotonergic drugs or CYP2D6 inhibitors is clinically warranted, initiate Evekeo with lower doses,
monitor patients for the emergence of serotonin syndrome during drug initiation or titration, and inform
patients of the increased risk for serotonin syndrome.
Visual Disturbance
Difficulties with accommodation and blurring of vision have been reported with stimulant treatment.