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)

prolonged release tablets 16mg, 27mg, 36mg, 54mg (Delmosart®XL) * cost-effective brand, for use in paediatrics

prolonged release tablets 18mg, 27mg, 36mg, 54mg (Xenidate 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

RED Solriamfetol (Sunosi) ICS/CCG Commissioned Blueteq required

NICE TA758 Solriamfetol is recommended as an option for treating excessive daytime sleepiness in adults with narcolepsy with or

without cataplexy. This is only if modafinil and either dexamfetamine or methylphenidate have not worked well

enough or are not suitable.

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)

All material in this section is aimed at health care professionals, but is information currently held in the public domain, members of the

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

Email: info.elmmb@nhs.net