ADHD Medication Side Effects: Which Pass, Which Need Adjusting

Two separate mistakes get made about medication side effects. The first is ignoring all of them: "your sleep gets a bit disturbed, you get used to it." The second is dropping everything at the first side effect.

Both come from not knowing the same piece of information: some side effects are temporary, some can be adjusted, and a small part really are a stop sign. This article separates those three. Decisions about dose, medication and duration are things to be made with your doctor.

The common ones

These are the topics most often reported in guidelines and consensus statements:

• Reduced appetite. Especially in the hours when the effect is at its strongest. It can lead to skipped meals and, over time, weight loss.
• Delayed sleep onset. More time spent in bed; shorter sleep duration.
• Dry mouth.
• Headache. Usually in the first days.
• Stomach upset, nausea. More noticeable when taken on an empty stomach.
• A slight rise in blood pressure and pulse. Small in most people, but a topic that needs to be followed.
• Restlessness, tension, increased anxiety. Dose-dependent in some people.
• Symptoms coming back as the effect wears off. What is called rebound.

The network meta-analysis by Cortese and colleagues (2018), which pooled 133 randomized studies, evaluates both the efficacy and the tolerability of stimulants together. The picture there is this: side effects are common, and being severe enough to lead to stopping treatment is rarer.

Which ones pass with time

Some side effects lessen noticeably within the first week or two. Headache, nausea and mild restlessness are usually in this group.

This does not mean "grit your teeth." There is a difference between waiting out a period knowingly and enduring without knowing what is going on. Knowing whether something is temporary makes that first week bearable.

The real problem here is taking what happens in the first days to be the final picture. The state at the start of a medication adjustment is not the final state of the medication.

Which ones need adjusting

Some do not pass on their own but improve with an adjustment. The adjustment can be one of three things: the dose itself, the time of the dose or the form of the medication.

• Sleep disturbance is often about the time of the dose. In a long-acting form, the time of the morning dose directly affects the evening.
• Loss of appetite is something talked through with the meal plan and, again, with the dose timing.
• Ups and downs during the day are common in short-acting forms; a change of form can come onto the agenda. I explained the difference between them in the article on Ritalin and Medikinet.
• A feeling of emotional flattening is generally a sign of a high dose; I wrote about this part in the article on whether medication changes your personality.

The shared emphasis of the guidelines is this: a side effect is a reason for adjustment before it is a reason to end treatment.

You do not have to carry the side effect. Most of the picture can be adjusted; and to be able to ask for the adjustment, you have to mention the side effect.

The ones to report without delay

A small group of side effects is not in the "I will mention it at the check-up" category. NICE (NG87) and the European consensus statement (Kooij et al., 2019) recommend prompt assessment for these:

• Chest pain, palpitations, shortness of breath, fainting or feeling as if you are about to faint.
• A marked change in mood, newly started intense anxiety or low mood.
• Changes in visual or auditory perception.
• Uncontrolled movements, newly started tics.
• Marked and rapid weight loss.

This list is not to frighten; it is to know the limit. Knowing the limit lets you carry everything else more comfortably.

What is looked at in follow-up

The check-ups after the medication is started are not a formality. What is generally looked at:

• Blood pressure and pulse.
• The course of weight and appetite.
• Sleep duration and time taken to fall asleep.
• Mood and anxiety.
• Change in symptoms: what has improved, what has stayed the same.

In children, following height and weight is especially important; I wrote about that part in the article on height in children.

A practical way to describe side effects

Saying "it was fine, I think" at the follow-up appointment is throwing away the information you hold. Trusting memory does not work in this picture anyway.

What works is keeping three lines a day for two weeks:

1. What time I took the dose.
2. At what hour of the day work got harder, at what hour it was easier.
3. What time I managed to fall asleep at night, how my appetite was.

These three lines are almost everything the doctor needs for adjusting the dose and its timing. I also explained how to keep a follow-up log in a separate article.

Non-stimulant options

If the side effect picture with stimulants cannot be carried, non-stimulant medications come onto the agenda. Their effect starts more slowly and their side effect profile is different.

This is not a "plan B"; in some pictures it can be the first option. The decision is the doctor's.

What I am left with

Reading lists of side effects itself creates anxiety, I know that. But not knowing the list costs more: something you do not know the nature of leads you to quietly stop the medication.

The framework that seems most useful to me is this: side effects are items on the bargaining table. If sleep is disturbed, the timing is discussed; if appetite switches off, the meal plan is discussed; if the middle of the day collapses, the form is discussed. Getting up from the table is the last option.

No item of the decision is made here. This article is so that you do not go to that table empty-handed.