Drugs Used for Attention Deficit Hyperactivity Disorder (ADHD)

NHSL Medicines Guidance
NHS Lanarkshire

General Notes

Attention Deficit Hyperactivity Disorder (ADHD)/hyperkinetic disorder is a neurodevelopmental disorder with core symptoms of hyperactivity, inattention and impulsivity evident from childhood which have associated psychological, social and/or educational or occupational impairment. Within the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) diagnoses of ADHD there are sub-types of ADHD, in which not all core symptoms are required for diagnosis. There is increasing evidence that ADHD can be a persistent diagnosis and that symptoms can continue to cause functional impairment into adulthood.

Co-morbidity is common with increased incidence of other neurodevelopmental disorders such as Autism Spectrum Disorder and Tourette’s syndrome as well as affective disorders, anxiety, learning disability, learning difficulties, oppositional and conduct disordered behaviour and attachment disorders. ADHD is also associated with a higher incidence of social difficulties such as educational underachievement, antisocial behaviour, substance misuse and unemployment.

Local guidelines have been developed for pharmacological ADHD treatment - Prescribing for Treatment of Attention Deficit Hyperactivity Disorder (ADHD) for Children Young People and Adults. Medication is not recommended for all patients with ADHD and is dependent upon the severity of the disorder and age (in children). Parent training advice for parents of children with ADHD is recommended along with adaptations to the school environment. There can also be a role for psychological interventions such as Cognitive Behaviour Therapy (CBT). Choice of medication can be affected by factors such as a patient or family cardiac history or tics. Side effects experienced and the effectiveness of the medication for the individual will also play a role in medication choice. The presence of compliance issues or a diversion risk will help determine if the long acting form of stimulant medication is required.

A baseline physical examination is recommended with weight, blood pressure and heart rate monitored on a minimum of a six monthly basis whilst pharmacological ADHD treatment is prescribed (see Prescribing for Treatment of Attention Deficit Hyperactivity Disorder (ADHD) for Children Young People and Adults). It is also recommended that height be monitored in children at the same frequency. For some patients a baseline ECG is recommended. If symptoms of liver failure develop in patients prescribed atomoxetine liver function tests would be recommended. Liver function tests are not however required at baseline.

Useful links

NHSL (2020) Prescribing for Treatment of Attention Deficit Hyperactivity Disorder (ADHD) for Children Young People and Adults.

NICE (2019) Attention Deficit Hyperactivity Disorder: Diagnosis and Management [NG87].

BAP (2014) Evidence-Based Guidelines for the Pharmacological Management of Attention Deficit Hyperactivity Disorder: Update on Recommendations From the British Association for Psychopharmacology.

Drugs Used for Attention Deficit Hyperactivity Disorder (ADHD)

Specialist initiation (S1)

METHYLPHENIDATE immediate release

  • Licensed 6 to 18 years.
  • First line option for ADHD.

METHYLPHENIDATE modified release

  • Licensed 6 to 18 years.
  • Xenidate XL® is licensed for continuation treatment in adults.
  • First line option for ADHD.
  • METHYLPHENIDATE modified release preparations contain an immediate release (IR) component and a sustained release (SR) component. Care should be taken to ensure the intended product is prescribed by brand name.
Brand

Immediate release (IR) vs sustained release (SR) component
Xenidate XL®

IR 22% : SR 78%
Equasym XL®

IR 30% : SR 70%
Medikinet XL®

IR 50% : SR 50%

MHRA Drug Safety Update September 2022: Methylphenidate long-acting (modified-release) preparations: caution if switching between products due to differences in formulations

LISDEXAMFETAMINE MESILATE

  • Licensed in children (from 6 years) and adults.
  • Second line option for ADHD.

DEXAMFETAMINE SULFATE

  • Licensed 6 to 18 years.
  • Second line option for ADHD.

ATOMOXETINE

  • Restriction: Atomoxetine oral solution is restricted to patients unable to swallow capsules (SMC advice).
  • Licensed 6 to 18 years and over.
  • Third line option for ADHD.

GUANFACINE

  • For children and adolescents 6 to 17 years old for whom stimulants are not suitable, not tolerated or have been shown to be ineffective. Treatment must be used as part of a comprehensive ADHD treatment programme, typically including psychological, educational and social measures (SMC advice).
  • Licensed 6 to 17 years.
  • Third line option for ADHD.

Prescribing Notes:

  • No preferred or total formulary option as prescribers should seek specialist advice before commencing treatment. Treatment may be initiated in primary care following specialist advice or referring to the local guidelines - Prescribing for Treatment of Attention Deficit Hyperactivity Disorder (ADHD) for Children Young People and Adults and national guidelines such as NICE Guideline [NG87].

  • Although off-label in adults, METHYLPHENIDATE is first line treatment of ADHD in all age groups in accordance with local and national guidance.

  • Immediate release METHYLPHENIDATE is often used during titration after which patients are often changed to a modified release (MR) preparation to optimize effect within the context of the working/school day. MR may also be used where there is a risk of diversion. Occasionally small doses of the immediate release may be used in conjunction with MR.

  • Some of the MR METHYLPHENIDATE formulations are licensed to be opened and the contents taken in specified soft foods. Medikinet XL® capsule contents may be sprinkled on yogurt or apple sauce. Equasym XL® capsule contents may be sprinkled on apple sauce. This may be an option for patients unable to swallow tablets or capsules.

  • LISDEXAMFETAMINE is a further option for patients unable to swallow capsules or tablets as the LISDEXAMFETAMINE license includes swallowing the capsules whole or the contents being dissolved in water, yoghurt or orange juice.

  • ATOMOXETINE and stimulant medication may occasionally be used in combination and is noted as a treatment option in the British Association of Psychopharmacology (BAP) guidelines for patients with a poor clinical response to monotherapy. The guidelines describe the evidence for the efficacy and safety of this combination as limited.

  • CLONIDINE is sometimes used for treatment of ADHD, most commonly in patients with learning disability. It is not licensed for treatment of ADHD but is noted as a treatment option in the NICE Guidelines [NG87].

NHSL Joint Adult Formulary Key

To indicate the category of a formulary medicine, updated sections adopt the following key:

Preferred list (P): First-line formulary choices.

Total list (T): Alternative choices when preferred list options not effective/not tolerated, or not indicated.

Specialist initiation (S1): Specialist initiation, or on the advice of a Consultant or Specialist Practitioner in this therapeutic area. Continuation in primary care is acceptable.

Specialist use only (S2): Supply via hospital, Homecare Service or a hospital based prescription (HBP) for dispensing by community pharmacy. Not prescribed in primary care setting.

Editorial Information

Last reviewed: 31/01/2022

Next review date: 31/01/2025

Author(s): NHSL.

Version: Please refer to the introduction section for an explanation of the review dates above.

Approved By: ADTC

Reviewer name(s): ADTC.