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The Use of Ritalin and Clonidine in Combination
In July 1995, National Public Radio aired a news piece about three deaths in children being treated with a combination of methylphenidate (Ritalin) and clonidine (Catapres). It is estimated that currently 100,000 school-aged children are being treated with this combination of medications. Despite the steady increase in the number of children being treated with methylphenidate and clonidine, there is surprisingly little research evidence to support the use of this combination. Nonetheless, many clinicians who treat children with Tourette Syndrome and Attention Deficit Hyperactivity Disorder have found this combination to be helpful in some cases.
TSA Medical Advisory Board member, Dr. John Walkup, reviewed these three cases after obtaining information from the US Food and Drug Administration (FDA). This review and a prior review at the FDA indicate that neither methylphenidate nor clonidine taken alone or in combination played a role in the tragic deaths of these three children. In one case, there was a pre-existing heart disease. In the second, the child was on four medications and may have taken an overdose. In the third case, the child died from an unknown cause without a trace of either medication in her system. Two other authorities - Dr. Robert Fenichel of the FDA and Dr. Charles Popper - have reviewed these cases in the Journal of Child and Adolescent Psychopharmacology and they too have concluded that none of the circumstances in these fatalities provides evidence to support a conclusion that this combination played a role.
The members of the TSA Medical Advisory Board have pooled their experience in treating children with clonidine and methylphenidate. In our collective experience, we have treated many children safely with this combination. However, given the steady number of children being treated with clonidine and methylphenidate in combination, there may be some children who encounter undesirable side effects. Of particular concern are effects on blood pressure and heart rate. Thus, all children being treated with clonidine should have their blood pressure and pulse monitored. This is especially important early in treatment and when other medications, such as methylphenidate, are added. A child with a pre-existing cardiac condition and those with a family history of sudden unexpected death should have an electrocardiogram before and during treatment with clonidine. Finally, when taking a combination of methylphenidate and clonidine, skipping doses of either drug may cause fluctuations in the blood pressure. Therefore, parents may need additional education concerning the importance of adhering to the dose schedule. Clonidine should always be discontinued slowly to avoid rebound hypertension.
In summary, the TSA Medical Advisory Board agrees with the FDA that there is no reason to believe that there is any relationship between these tragic deaths and the use of these medications in combination. However, children who are treated with this combination should be monitored closely by a physician or a clinical team with experience in the use of these medications.
View the current members of the TSA Medical Advisory Board
©2007 Tourette Syndrome Association, Inc. 42-40 Bell Boulevard / Bayside NY 11361 / 718-224-2999