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4.4 Central nervous system stimulants and other drugs used for attention deficit hyperactivity disorder

4.4 Central nervous system stimulants and other drugs used for attention deficit hyperactivity disorder

Methylphenidate, dexamfetamine and atomoxetine should be used for Attention Deficit Hyperactivity Disorder only in 
accordance with the NICE and local shared care guidelines. These three medicines are for initiation in secondary care by specialists 
with a specific interest in ADHD. 
 
NICE guidance 
Treatment and management 
Drug treatment for children, you people and adults with attention deficit hyperactivity disorder (ADHD) should always be:
     >     Part of a comprehensive treatment plan that includes psychological, behavioural and educational or occupational needs
         initiated by a healthcare professional with expertise in ADHD following a comprehensive assessment
 
Do Not start drug treatment for ADHD in children, young people or adults in primary care.   
After dose titration and stabilisation by a specialist, GPs can continue prescribing and monitoring drug treatment under the shared
care arrangements.
If a child or young person is currently receiving drug treatment but has not been assessed in secondary care, then refer to a 
specialist in ADHD.
 
Pre-school children 
Drug treatment is NOT recommended. 
School-age children and young people with moderate ADHD and moderate impairment 
Drug treatment is NOT indicated first-line. 
Reserve drug treatment for those with: 
      moderate levels of impairment who have refused non-drug interventions
      persistent significant impairment following a parent-training/education programme or group psychological treatment
 
School-age children and young people with severe ADHD and severe impairment
First-line: drug treatment as follows: 
  >     methylphenidate for ADHD without significant co-morbidity or with co-morbid conduct disorder
  >     methylphenidate or atomoxetine in the presence of tics, Tourette's syndrome, anxiety disorder, stimulant misuse or risk
          of stimulant diversion.
 
Second-line: atomoxetine if methylphenidate is ineffective at the maximum tolerated dose or is poorly tolerated. 
 
Third-line: dexamfetamine if no response to maximum tolerated doses of methylphenidate or atomoxetine 
 
Guanfacine 
Children and adolescents 6 -17 years of age for whom stimulants are not suitable, not tolerated or have been shown to be
ineffective. Specialist initiation only. See New Medicine Guideline
 
AMBER                     Guanfacine
SHARED CARE         1mg, 2mg, 3mg, 4mg prolonged-release tablets
                                 
Adults with ADHD
First-line: methylphenidate (unlicensed). 
OR atomoxetine (unlicensed) if there are concerns about drug misuse and diversion. 
 
Second-line: atomoxetine or dexamfetamine (unlicensed) if methylphenidate is ineffective or cannot be tolerated. 
Do NOT use antipsychotics for ADHD in children, young people or adults. 
 
Monitoring 
The responsibility for carrying out routine monitoring is outlined in the shared care protocol. 
For all drugs monitor:
     >     Height (children and young people) - every 6 months.
         Weight - 3 and 6 months after the start of treatment, then every 6 months.
         Heart rate and blood pressure - before and after each dose change and every 3 months.
 
Cautions and counselling
Atomoxetine 
Warn parents/carers/adult patients about the potential for:
    >     Suicidal thinking and self harm 
        Liver damage (rare)
 
AMBER                  Atomoxetine capsules 10mg, 18mg, 25mg, 40mg, 60mg
SHARED CARE        
 
AMBER                  Dexamfetamine tablets 5mg  
SHARED CARE        
 
AMBER                  Methylphenidate tablets 5mg, 10mg, 20mg 
SHARED CARE      
 
Prolonged release methylphenidate formulations, should be considered second line and used for patients requiring
methylphenidate in the morning and afternoon when administration of a midday dose is problematic or inappropriate.  The 
pharmacokinetic profile of each brand of prolonged release formulation differs from those of other prolonged release formulation
of methylphenidate, and they cannot be considered to be interchangeable.  As such, prolonged release methylphenidate 
preparations should be prescribed by brand name. 
 
AMBER
SHARED CARE       Methylphenidate
                                 prolonged release tablets 18mg, 27mg 36mg, 54mg  (Concerta XL®) 
                                 prolonged release capsules 10mg, 20mg, 30mg (Equasym XL®)  
                                 prolonged release capsules 10mg, 20mg, 30mg, 40mg (Medikinet XL®)  
                                 prolonged release tablets  18mg, 27mg, 36mg, 54mg (Xaggitin®XL)
 
 Combined Adult and Child ADHD Shared Care Guideline is available  click here.
 
Modafinil 
The European Medicines Agency has recommended that the use of modafinil should be restricted to treat only sleepiness 
associated with narcolepsy, and that it should no longer be used for the treatment of excessive sleepiness associated with 
obstructive sleep apnoea or chronic shift work sleep disorder.
On the basis of the available data, the Agency's Committee for Medicinal Products for Human Use (CHMP) concluded that the 
benefits of this medicine only outweighed the risks in the therapeutic indication narcolepsy. For all other indications the 
Committee found that the risks outweighed the benefit shown in clinical trials. Therefore, the Committee concluded that all other
indications should be withdrawn from the marketing authorisations of these medicines.
 
AMBER                    Modafinil (initiation by consultant neurologist only)  
                                 tablets 100mg, 200mg
 
Lisdexamfetamine (young children and Young adults)
For use by ELCAS and some Consultant Paediatricians in the treatment of ADHD in children and adults 
(only in complex patients who meet two specific criteria - SEE BELOW) 
AMBER                    Lisdexamfetamine
SHARED CARE        capsules 20mg, 30mg, 40mg, 50mg, 60mg, 70mg (Elvanse®) 
 
       >   extenuating circumstances exist which mean that a patient would not reliably receive all the required doses of dexamfetamine 
            throughout the day and requires a once daily dose of lisdexamfetamine to support adherence.
       >   treatment has been agreed through the internal governance arrangements of the trust
 
Lisdexamfetamine (Adults)
For use as an option as part of a treatment programme for ADHD in adults
AMBER                   Lisdexamfetamine 
SHARED CARE       capsules 20mg, 30mg, 40mg, 50mg, 60mg, 70mg (Elvanse® Adult) 
 



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public seeking advice on medicine-related matters are advised to speak with their GP, pharmacist, nurse or contact NHS111 Service 
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