Attention deficit hyperactivity disorder (ADHD)
Prescribe modified release methylphenidate preparations by brand as advised by the specialist team.
Initially 5mg 2-3 times a day, dose is increased if necessary at weekly intervals according to response, increased if necessary up to 100mg daily in 2-3 divided doses, if effect wears off in evening (with rebound hyperactivity) a dose early evening may be appropriate (establish need with trial). Treatment may be started using a modified-release preparation.
Initially 5mg 2-3 times a day, dose is increased if necessary at weekly intervals according to response, increased if necessary up to 100mg daily in 2-3 divided doses, if effect wears off in evening (with rebound hyperactivity) a dose early evening may be appropriate (establish need with trial). Treatment may be started using a modified-release preparation.
Initially 5mg 2-3 times a day, dose is increased if necessary at weekly intervals according to response, increased if necessary up to 100mg daily in 2-3 divided doses, if effect wears off in evening (with rebound hyperactivity) a dose early evening may be appropriate (establish need with trial). Treatment may be started using a modified-release preparation.
Initially 18mg once daily, dose to be taken in the morning, increased in steps of 18mg every week, adjusted according to response, discontinue if no response after 1 month; maximum 54mg per day.
Initially 18mg once daily, dose to be taken in the morning, increased in steps of 18mg every week, adjusted according to response, discontinue if no response after 1 month; maximum 54mg per day.
Initially 18mg once daily, dose to be taken in the morning, increased in steps of 18mg every week, adjusted according to response, discontinue if no response after 1 month; maximum 54mg per day.
Initially 18mg once daily, dose to be taken in the morning, increased in steps of 18mg every week, adjusted according to response, discontinue if no response after 1 month; maximum 54mg per day.
Initially 10mg once daily, dose to be taken in the morning before breakfast; increased gradually at weekly intervals if necessary; maximum 100mg per day.
Initially 10mg once daily, dose to be taken in the morning before breakfast; increased gradually at weekly intervals if necessary; maximum 100mg per day.
Initially 10mg once daily, dose to be taken in the morning before breakfast; increased gradually at weekly intervals if necessary; maximum 100mg per day.
Initially 10mg once daily, dose to be taken in the morning before breakfast; increased gradually at weekly intervals if necessary; maximum 100mg per day.
Initially 10mg once daily, dose to be taken in the morning before breakfast; increased gradually at weekly intervals if necessary; maximum 100mg per day.
Initially 10mg once daily, dose to be taken in the morning before breakfast; increased gradually at weekly intervals if necessary; maximum 100mg per day.
Initially 10mg once daily, dose to be taken in the morning before breakfast; increased gradually at weekly intervals if necessary; maximum 100mg per day.
Initially 10mg once daily, dose to be taken in the morning before breakfast; increased gradually at weekly intervals if necessary; maximum 100mg per day.
Initially 10mg once daily, dose to be taken in the morning before breakfast; increased gradually at weekly intervals if necessary; maximum 100mg per day.
Body-weight up to 70kg - Initially 500micrograms/kg daily for 7 days, dose is increased according to response; maintenance 1.2mg/kg daily, total daily dose may be given either as a single dose in the morning or in 2 divided doses with last dose no later than early evening. High daily doses to be given under the direction of a specialist up to 1.8mg/kg per day; maximum 120mg per day.
Body-weight 70kg and above - Initially 40mg daily for 7 days, dose is increased according to response; maintenance 80-100mg daily, total daily dose may be given either as a single dose in the morning or in 2 divided doses with last dose no later than early evening. High daily doses to be given under the direction of a specialist; maximum 120mg per day.
Body-weight up to 70kg - Initially 500micrograms/kg daily for 7 days, dose is increased according to response; maintenance 1.2mg/kg daily, total daily dose may be given either as a single dose in the morning or in 2 divided doses with last dose no later than early evening. High daily doses to be given under the direction of a specialist up to 1.8mg/kg per day; maximum 120mg per day.
Body-weight 70kg and above - Initially 40mg daily for 7 days, dose is increased according to response; maintenance 80-100mg daily, total daily dose may be given either as a single dose in the morning or in 2 divided doses with last dose no later than early evening. High daily doses to be given under the direction of a specialist; maximum 120mg per day.
Body-weight up to 70kg - Initially 500micrograms/kg daily for 7 days, dose is increased according to response; maintenance 1.2mg/kg daily, total daily dose may be given either as a single dose in the morning or in 2 divided doses with last dose no later than early evening. High daily doses to be given under the direction of a specialist up to 1.8mg/kg per day; maximum 120mg per day.
Body-weight 70kg and above - Initially 40mg daily for 7 days, dose is increased according to response; maintenance 80-100mg daily, total daily dose may be given either as a single dose in the morning or in 2 divided doses with last dose no later than early evening. High daily doses to be given under the direction of a specialist; maximum 120mg per day.
Body-weight up to 70kg - Initially 500micrograms/kg daily for 7 days, dose is increased according to response; maintenance 1.2mg/kg daily, total daily dose may be given either as a single dose in the morning or in 2 divided doses with last dose no later than early evening. High daily doses to be given under the direction of a specialist up to 1.8mg/kg per day; maximum 120mg per day.
Body-weight 70kg and above - Initially 40mg daily for 7 days, dose is increased according to response; maintenance 80-100mg daily, total daily dose may be given either as a single dose in the morning or in 2 divided doses with last dose no later than early evening. High daily doses to be given under the direction of a specialist; maximum 120mg per day.
Body-weight up to 70kg - Initially 500micrograms/kg daily for 7 days, dose is increased according to response; maintenance 1.2mg/kg daily, total daily dose may be given either as a single dose in the morning or in 2 divided doses with last dose no later than early evening. High daily doses to be given under the direction of a specialist up to 1.8mg/kg per day; maximum 120mg per day.
Body-weight 70kg and above - Initially 40mg daily for 7 days, dose is increased according to response; maintenance 80-100mg daily, total daily dose may be given either as a single dose in the morning or in 2 divided doses with last dose no later than early evening. High daily doses to be given under the direction of a specialist; maximum 120mg per day.
Body-weight up to 70kg - Initially 500micrograms/kg daily for 7 days, dose is increased according to response; maintenance 1.2mg/kg daily, total daily dose may be given either as a single dose in the morning or in 2 divided doses with last dose no later than early evening. High daily doses to be given under the direction of a specialist up to 1.8mg/kg per day; maximum 120mg per day.
Body-weight 70kg and above - Initially 40mg daily for 7 days, dose is increased according to response; maintenance 80-100mg daily, total daily dose may be given either as a single dose in the morning or in 2 divided doses with last dose no later than early evening. High daily doses to be given under the direction of a specialist; maximum 120mg per day.
Body-weight up to 70kg - Initially 500micrograms/kg daily for 7 days, dose is increased according to response; maintenance 1.2mg/kg daily, total daily dose may be given either as a single dose in the morning or in 2 divided doses with last dose no later than early evening. High daily doses to be given under the direction of a specialist up to 1.8mg/kg per day; maximum 120mg per day.
Body-weight 70kg and above - Initially 40mg daily for 7 days, dose is increased according to response; maintenance 80-100mg daily, total daily dose may be given either as a single dose in the morning or in 2 divided doses with last dose no later than early evening. High daily doses to be given under the direction of a specialist; maximum 120mg per day.
Body-weight up to 70kg - Initially 500micrograms/kg daily for 7 days, dose is increased according to response; maintenance 1.2mg/kg daily, total daily dose may be given either as a single dose in the morning or in 2 divided doses with last dose no later than early evening. High daily doses to be given under the direction of a specialist up to 1.8mg/kg per day; maximum 120mg per day.
Body-weight 70kg and above - Initially 40mg daily for 7 days, dose is increased according to response; maintenance 80-100mg daily, total daily dose may be given either as a single dose in the morning or in 2 divided doses with last dose no later than early evening. High daily doses to be given under the direction of a specialist; maximum 120mg per day.
Initially 30mg once daily, increased in steps of 20mg every 1 week if required, dose to be taken in the morning, discontinue if response insufficient after 1 month; maximum 70mg per day.
Initially 30mg once daily, increased in steps of 20mg every 1 week if required, dose to be taken in the morning, discontinue if response insufficient after 1 month; maximum 70mg per day.
Initially 30mg once daily, increased in steps of 20mg every 1 week if required, dose to be taken in the morning, discontinue if response insufficient after 1 month; maximum 70mg per day.
Prescribing Notes:
- Prescribe modified release methylphenidate preparations by brand as advised by the specialist team. The pharmacokinetic profiles of brands differ; a specific modified release formulation will be chosen to suit the symptoms and lifestyle of the individual. The specialist team may switch from one formulation to another.
- Xaggitin XL and Concerta XL tablets are considered to be bioequivalent, additionally the tablets are similar in appearance. The preferred brand of methylphenidate modified-release tablets 18mg, 27mg 36mg, 54mg is Xaggitin XL. Higher doses of methyphenidate may be considered under the direction of a specialist.
- Immediate release methylphenidate preparations offer the advantage of flexible dosing. These products are less expensive than the modified release preparations and are used in preference when acceptable to the patient.
- Combinations of modified release and immediate release preparations may be prescribed on the advice of a specialist. For example, where the effects of the modified release preparation wear off and a “top up” dose is required in the evening.
- In some individuals the dosing regimen may include pre-planned omitted doses at the weekend, around mealtimes or in the evenings (e.g. during social activities or to avoid side effects such as appetite suppression).
- Medication is useful in some adults with ADHD as part of a comprehensive treatment programme under the care of a specialist in the treatment of ADHD.
- Several factors are considered in the selection of the most suitable medicine for the individual. Factors which are considered include: comorbidities, the side-effect profile, practicalities of taking the medication (e.g. during the working day), the risk of misuse (either by the individual or by passing on medication to others) and the individual preference of the patient and/or their carer.
- Where more than one medicine is considered appropriate, the most cost-effective one should be selected. For more detailed advice on the diagnosis and management of ADHD please consult the following clinical guidelines developed by NICE and the British Association of Psychopharmacology.
- Methylphenidate and lisdexamfetamine are controlled drugs and are therefore subject to the regulations for controlled drugs. NICE guideline NG46 provides guidance on the safe use and management of controlled drugs.
- For guidance relevant to individuals wishing to travel with a supply of controlled drugs please follow the link to the Home Office website.
- The economic case for atomoxetine has been demonstrated for a treatment duration of one year.
- Atomoxetine oral solution is restricted to use in patients who are unable to swallow capsules. It is considerably more expensive than the capsules. Atomoxetine should normally be used 2nd line in patients who do not respond to methylphenidate or 1st line when methylphenidate is contraindicated or not tolerated e.g. because of significant anxiety, tic disorders or sleep difficulties. It may be used 1st line in patients where drug diversion is a concern or if substance misuse is also an issue.
- Majority of children will persist with some degree of symptoms into adulthood (15-66% depending on the criteria used). Some individuals may be diagnosed with ADHD as adults, not having been diagnosed during childhood.
History Notes
21/11/2023
Update to prescribing notes.
27/10/2022
East Region Formulary content agreed.
Prescribe modified release methylphenidate preparations by brand as advised by the specialist team.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Guanfacine has been noted to be a drug of choice in individuals with significant tics/Tourette’s or anxiety disorder. Titration should be gradual, patients should avoid stopping suddenly due to risk of rebound hypertension.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Dose as per specialist and BNFc.
Prescribe with caution due to risk of abuse.
Dose as per specialist and BNFc.
Prescribing Notes:
Methylphenidate
- Prescribe modified release methylphenidate preparations by brand as advised by the specialist team. The pharmacokinetic profiles of brands differ; a specific modified release formulation will be chosen to suit the symptoms and lifestyle of the individual. The specialist team may switch from one formulation to another.
- Xaggitin XL and Concerta XL tablets are considered to be bioequivalent, additionally the tablets are similar in appearance. The preferred brand of methylphenidate modified-release tablets 18mg, 27mg 36mg, 54mg is Xaggitin XL. Higher doses of methyphenidate may be considered under the direction of a specialist.
- Immediate release methylphenidate preparations offer the advantage of flexible dosing. These products are less expensive than the modified release preparations and are used in preference when acceptable to the patient.
- Combinations of modified release and immediate release preparations may be prescribed on the advice of a specialist. For example, where the effects of the modified release preparation wear off and a “top up” dose is required in the evening.
Atomoxetine
- Atomoxetine oral solution is restricted to use in patients who are unable to swallow capsules. It is considerably more expensive than the capsules. Atomoxetine should normally be used 2nd line in patients who do not respond to methylphenidate or 1st line when methylphenidate is contraindicated or not tolerated e.g. because of significant anxiety, tic disorders or sleep difficulties. It may be used 1st line in patients where drug diversion is a concern or if substance misuse is also an issue.
Guanfacine
- Guanfacine modified release tablets are an alternative non-stimulant agent with a different mode of action to other licensed treatments.
- Guanfacine is a non-stimulant and can be used as an alternative to atomoxetine in children and adolescents from the age of 6 years, as part of a comprehensive ADHD treatment programme. Currently some Boards have Shared Care Agreements in place to facilitate prescribing in Primary Care.
- Guanfacine is indicated for use tic disorder in patients with coexisting ADHD.
- Patients are advised to contact the specialist service if more than one dose of guanfacine is missed.
- Seek advice from pharmacy team, or information sources such as SPS - Specialist Pharmacy Service, NEWT Guidelines or Medicines For Children if any issues with swallowing or alternative route of administration required as this may result in off-label prescribing.
Other prescribing notes
- In some individuals the dosing regimen may include pre-planned omitted doses at the weekend, around mealtimes or in the evenings (e.g. during social activities or to avoid side-effects such as appetite suppression).
- Medication is useful in some children or adolescents with ADHD as part of a comprehensive treatment programme under the care of a specialist in the treatment of ADHD.
- Several factors are considered in the selection of the most suitable medicine for the individual. Factors which are considered include: comorbidities, the side-effect profile, practicalities of taking the medication (e.g. during school hours), the risk of misuse (either by the individual or by passing on medication to others) and the individual preference of the child or adolescent and/or their family or carer. Patients with co-morbidities, including autism, may be more sensitive to side-effects and initiation doses should start low and be titrated gradually to maximise chance of tolerating the medicine.
- Where more than one medicine is considered appropriate, the most cost-effective one should be selected. For more detailed advice on the diagnosis and management of ADHD please consult the following clinical guidelines developed by NICE and the British Association of Psychopharmacology.
- Methylphenidate, dexamfetamine and lisdexamfetamine are controlled drugs and are therefore subject to the regulations for controlled drugs. NICE guideline NG46 provides guidance on the safe use and management of controlled drugs.
- For guidance relevant to individuals wishing to travel with a supply of controlled drugs please follow the link to the Home Office website.
- Shared care arrangements are available for drugs used in the treatment of ADHD to facilitate the seamless transfer of individual patient care from secondary care to general practice.
- Medication may also be prescribed for ADHD symptoms occurring in children with some neurological and neurodevelopmental disorders.
- Seek advice from pharmacy team, or information sources such as SPS - Specialist Pharmacy Service, NEWT Guidelines or Medicines For Children if any issues with swallowing or alternative route of administration required as this may result in off-label prescribing.
History Notes
15/01/2024
Full update to pathway following review of Central Nervous System paediatric chapter.
27/10/2022
East Region Formulary content agreed.