Beyond the basics management of complex ADHD patients. When GPs should decline shared care.

Dr. Vicki Nahamkes presents a guide for General Practitioners on managing complex ADHD patients, emphasizing that while treatment is rewarding, it requires rigorous monitoring and boundary setting. She introduces a "3C Rule" for patient reviews, assessing **Mental Clarity** (organized thinking), **Calm** (mood regulation), and **Consistency** (sleep, diet, and exercise).

Cardiovascular safety is a primary concern, particularly for older patients. Dr. Nahamkes advises a cardiovascular risk assessment before starting stimulants, aiming for a risk score below 5%. Regular blood pressure checks are mandatory, as stimulants can increase pressure by 2–4 mmHg; hypertension must be managed or the stimulant withdrawn.

A significant portion of the talk addresses special populations and comorbidities:

* **Women’s Health:** Hormonal fluctuations during menopause can severely destabilize ADHD control. Dr. Nahamkes shares a case where a patient required increased stimulant dosage and Hormone Replacement Therapy to regain stability.

* **Binge Eating Disorder:** She notes that Vyvanse is the only stimulant evidence-based for this comorbidity.

* **Bipolar Disorder:** There is a risk of stimulants unmasking mania. A detailed case study describes a patient who developed hypersexuality and reckless behavior upon starting stimulants, eventually requiring a transition to mood stabilizers like Lamotrigine instead of ADHD medication.

Dr. Nahamkes concludes with clinical pearls, noting that successful treatment often results in *decreased* steps on fitness trackers, indicating less chaotic movement and better organization. Finally, she empowers GPs to decline "shared care" for patients with complex presentations—such as those with Cluster B personality traits or unstable bipolar disorder—stating these cases often require psychiatrist-led management.

This podcast was recorded live at the ADHD, Binge and Other Eating Disorders Symposium in Melbourne hosted by ADHD-BED Integrated. adhd-bed.events

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