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Prescribing Guideline
Pharmacological Management of
Attention Deficit Hyperactivity Disorder
(ADHD) in Adults
PG17
PG17 – Pharmacological Management of ADHD
Approved by Drugs and Therapeutics Committee: October 2016
Review date: October 2020
Page 1 of 10
Document Control
Version
1.0
Date Issued
May 2014
2.0
October 2016
Target audience/ staff groups:
Ratifying Group:
Date ratified:
Implementation date:
Review date:
Document History
Version
Start
date
0.1
Apr 2011
0.2
Dec 2011
End date
Author(s) Name / Job Title / Email:
Amanda Gulbranson, Clinical Effectiveness Lead
[email protected]
James Lee, Senior Clinical Pharmacist
[email protected]
Clinical staff responsible for the prescribing of pharmacological treatment
for the management of ADHD in adults
Drug and Therapeutics Committee
October 2016
October 2016
October 2020
Author
History
AG
AG
First draft of new Prescribing Guideline
Revised draft to include feedback from ADHD Focus meeting and
LMC ADHD working group (Nov 2011). Guidelines for children,
adolescents and adults merged.
Incorporation of feedback from Trust Clinical Lead for ADHD/ ASC
service, area prescribing and joint formulary groups, including
specific guidance on monitoring and treatment review (and
decisions on continuing/ stopping treatment).
Final amendments agreed following discussions at DTC Dec 2012
Appendix 1 & 2 added. Adult & CAMHS guidance split. Reference &
link to PG18 included
Document ratified at DTC
0.3
Oct 2012
AG
0.4
0.5
Dec 2012
Mar 2014
AG
AG
1.0
1.1
2.0
Sep 2016
Oct 2016
May14
KS
Mark Jay/JL
JBS
Document ratified at DTC and signed off
PG17 – Pharmacological Management of ADHD
Approved by Drugs and Therapeutics Committee: October 2016
Review date: October 2020
Page 2 of 10
Pharmacological Management of
Attention Deficit Hyperactivity Disorder
Introduction
The purpose of these guidelines is to outline the pharmacological treatment of Attention Deficit
Hyperactivity Disorder (ADHD) in adults (>18 years old).
The aim of is to promote safe and effective prescribing that is concordant with:
• NICE CG 72: Attention deficit hyperactivity disorder. Diagnosis and management of ADHD
in children, young people and adults
• NICE TAG 98: Methylphenidate, atomoxetine and dexamfetamine for attention deficit
hyperactivity disorder (ADHD) in children and adolescents
• British Association for Psychopharmacology: Evidence-based guidelines for management
of attention-deficit/ hyperactivity disorder in adolescents in transition to adults services
and in adults (2014)
• NICE Quality standard QS39
The guidelines are not intended to replace prescribing information contained in the BNF, BNF for
Children, or Summary of Product Characteristics.
Refer to PG16 for prescribing guidance in children (≤11yrs) and young people (12-18 years).
Referrals and treatment pathways
Referrals are accepted from GP practices in Devon (excluding Plymouth, but including Wembury),
and DPT Professionals. Referral forms are available on DAISY:http://daisy.exe.nhs.uk/directorates/specialist-services/devon-autism-and-adhd-service-(dana).aspx
and the DPT external website.
If accepted, referrals are placed into one of the four pathways described below. The usual
prescribing role of the ADHD service is described, where the client is diagnosed with ADHD,
chooses to receive pharmacological treatment, and there are no contraindications to treatment.
1 Assessment of possible diagnosis of ADHD
Usual role of DPT specialist service: Initiation of anti-ADHD medication, titration to a stable
dose, transfer of this to GP, then responsive treatment advice and annual reviews to support GP.
2 Review of a previous diagnosis of ADHD, for someone not currently on anti-ADHD
medication
Usual role of DPT specialist service: Initiation of anti-ADHD medication, titration to a stable
dose, transfer of this to GP, then responsive treatment advice and annual reviews to support GP.
3 Review of ADHD treatment options, for someone already receiving anti-ADHD medication
from GP
Usual role of DPT specialist service: Review of medication, with suggestions for optimising
treatment as necessary. Occasional temporary transfer of treatment from GP to specialist service
to change or optimise treatment; responsive treatment advice and annual reviews to support GP
thereafter.
PG17 – Pharmacological Management of ADHD
Approved by Drugs and Therapeutics Committee: October 2016
Review date: October 2020
Page 3 of 10
4 Transfer of treatment initiated by Paediatricians or CAMHS (from age 17½)
Usual role of DPT specialist service: Review of medication, with suggestions for optimising
treatment as necessary. Occasional temporary transfer of treatment from GP to specialist service
to change or optimise treatment, responsive treatment advice and annual reviews to support GP
thereafter.
Medication Choice
Stimulant Medication
The usual first line treatment is methylphenidate.
Modified release preparations are usually preferred, as a once daily dosing schedule improves
concordance, and minimises the discomfort of peaks and troughs of blood levels of the drug.
However patient choice may mean that instant release is the first choice form.
The usual form of modified release methylphenidate is Concerta XL.
Xenidate XL is marketed as a different formulation with the equivalent modified release envelope
as Concerta.
Equasym XL and Medikinet XL have a slightly shorter action (see Appendix 1)which may be
useful if Concerta XL interferes with sleep.
GP’s may choose to make adjustments using differently branded equivalent preparations for
reasons of cost-saving.
If an individual is unresponsive or intolerant to an adequate trial of a methylphenidate preparation
(usually about 6 weeks), then either an alternative stimulant or atomoxetine should be considered.
The second line stimulant is dexamfetamine.
The third line stimulant is lisdexamfetamine. Primary Care are often reluctant to take over
prescriptions of this drug, there should be liaison with the patient’s GP about its acceptability to
them before initiating unless the service feels it can if necessary continue repeat prescribing.
Non-stimulant Medication
Atomoxetine is the usual second line treatment where stimulant drugs are ineffective or not
tolerated. It is the first line treatment where stimulants are contra-indicated, or if non-stimulant
medication is preferred by the patient.
Treatment re-initiation in patients referred who have a previous diagnosis of ADHD
In these cases, care must be taken to ensure that the diagnosis of ADHD is still valid, and that all
the usual assessments that would be taken when initiating medication are thoroughly undertaken.
Before prescribing
Drug treatment should not be initiated if the diagnosis is uncertain or benefit unlikely. Drug
treatment should not be used to test an uncertain diagnosis.
Choice of treatment should be a joint decision between clinician and patient, and if appropriate
their friends and family, using the principles of shared decision making.
Prior to initiating drug treatment, the following areas should be assessed and discussed with the
patient:
PG17 – Pharmacological Management of ADHD
Approved by Drugs and Therapeutics Committee: October 2016
Review date: October 2020
Page 4 of 10
1
Full history and physical examination to include:
 Assessment for the presence of known cardiac disease; history of exercise syncope; undue
breathlessness and other cardiovascular symptoms; presence of major risk factors such as
smoking and obesity; family history of cardiac disease.
 Heart rate and blood pressure;
 Weight and Body Mass Index (BMI)
 In the case of initiating Atomoxetine, the following should be requested from the GP: (i) An
ECG to rule out QT interval prolongation and other cardiac abnormalities; (ii) Baseline Liver
Function Tests.
In view of the likely effects of stimulants on cardiac work, and the potential risk of pathological QTc
prolongation associated with atomoxetine, where findings suggest a history or presence of cardiac
disease or significant cardiac risk, individuals should be referred back to their GP for a cardiac
evaluation and possible specialist cardiology opinion prior to initiating drug treatment.
If blood pressure is 160/100 mmHg or higher then individuals should be referred back to their GP
for further assessment and possible treatment.
If blood pressure is over 140/90 mmHg but under 160/100 mmHg, then anti-ADHD medication can
be initiated in the absence of other risk factors, at the prescribing clinician’s discretion, provided
that arrangements are made to follow up with subsequent readings.
Where BMI is below 18.5, the patient should be referred back to the GP for advice on weight gain
before considering treatment with stimulant drugs.
2
Assessment of the risk of precipitating psychosis. If the patient has a history of any
psychosis, atomoxetine is the usual first-line treatment. If this is contra-indicated or not tolerated,
then caution must be used if considering stimulant medication. Concurrent treatment with an antipsychotic may be useful, and where possible should be done in close working partnership with
primary care and relevant mental health clinicians.
3
Assessment of the risk of misuse or diversion of stimulant medication. This should
take the form of history of any illegal or non-prescribed drug use, including novel psychoactive
substances. There should be an account of whether any drug use is recreational, regular, harmful
and/or dependent; the route of administration; whether drugs were ever bought and sold; and the
details of any sequelae of use. If the clinician, on the basis of this history, feels there is a lack of
patient clarity about safe, responsible and legal handling of prescribed drugs then consider nonstimulant drug treatment. Shorter acting stimulants are of higher desirability for misuse and have a
higher dependence forming potential, and so should be avoided if possible where a risk of misuse
is identified.
4
Before initiating treatment for women of child-bearing potential it is essential to
consider and discuss contraception and/ or the risks of pregnancy (including relapse, risk to the
foetus and risks associated with stopping or changing medication). Refer to Trust prescribing
guidance PG18: Pharmacological Management of Perinatal Mental Health Conditions for additional
information. If there is any possibility that the individual may be pregnant it is important to confirm
this prior to starting treatment.
5
BNF advice is to avoid both stimulant drugs and atomoxetine when breast feeding.
Where a mother wishes to receive anti-ADHD medication when nursing, and the prescribing
clinician judges that on balance of risks this would be appropriate, then short acting instant release
methylphenidate can be considered if the mother is able to judge doses around feeding, and is
able to judge if their baby is affected adversely.
PG17 – Pharmacological Management of ADHD
Approved by Drugs and Therapeutics Committee: October 2016
Review date: October 2020
Page 5 of 10
6
Assessment of the risk of suicidality. Patients should be briefed about the potential for
suicidal thoughts and behaviour as a possible side-effect of atomoxetine, their informed consent
obtained, and told to report the emergence or worsening of suicidal thoughts or behaviour
immediately, and to stop taking the drug if in doubt.
Drug treatment is the first-line treatment for adults with ADHD but should always form part of a
comprehensive treatment programme that addresses psychological, behavioural and educational
or occupational needs.
Pharmacological treatment should be initiated by an appropriately qualified prescriber specialising
in ADHD, with training in the diagnosis and management of ADHD.
Licencing
The only anti-ADHD drugs referred to here with a licence for initiation in adults are Atomoxetine
(up to 100mg) and Lisdexamfetamine.
Concerta XL® is licensed for continuation of treatment over the age of 18 where the drug was
initiated in childhood between the ages of 12 and 18.
All other prescribing is ‘off-licence’, but supported by NICE guidance as first line treatment (unless
the individual would prefer psychological treatment). Informed consent to be treated with an offlicence drug should be obtained and documented.
Titration
Stimulant medication
After initiation, doses can be gradually increased – at a minimum interval of 7 days – and the
patient reviewed at each dose increment to check:
 Therapeutic effects and the impact on impairment
 Blood Pressure
 Pulse
 Weight as BMI
 Uncomfortable autonomic arousal
 Anxiety or agitation
 Insomnia
 Tics
 Psychotic thoughts
 Mood
 Changes in affect, anger or personality
 Concordance
If any of these falls outside normal or tolerable parameters, titration can be halted, the dose
reduced, or the medication stopped. Treatment adjustment should be guided by changes in
symptoms and impairment as well as rating scales.
If a drug is not tolerated another drug may be tried as appropriate.
If no anti-ADHD drugs are tolerated, then the patient should be offered psycho-social advice on
managing their ADHD.
Titration can continue until the prescriber and client feel that an optimal balance is reached
between clinical improvement in impairment and discomfort from any side effects.
PG17 – Pharmacological Management of ADHD
Approved by Drugs and Therapeutics Committee: October 2016
Review date: October 2020
Page 6 of 10
Typical titration schedules (doses are per day)
Drug
Starting Dose
Concerta XL
18mg
Equasym XL
10mg
Medikinet XL
10-15mg
Methylphenidate HC
10-15mg
Dexamfetamine
10mg
Lisdexamfetamine
30mg
Dose Increments
18mg
10mg
10-15mg
10-15mg
10mg
20mg
Maximum Dose
108mg
100mg
100mg
100mg
60mg
70mg
Atomoxetine
Body weight up to 70kg:
Initial dose 500 micrograms/kg daily
Increase after 1 week to 1mg/kg daily
Assess response 6 weeks after initiation
Increase dose thereafter according to response, to a maximum of 1.8mg/kg daily or 120mg daily
whichever is lower
Body 70kg and above:
Initial dose 40mg daily
Increase after 1 week to 80mg daily
Assess response 6 weeks after initiation
Increase dose thereafter according to response, to a maximum of 120mg daily
BNF limit is 100mg/day, doses between 100mg-120mg are off-licence, but permitted under
direction of a specialist prescriber in ADHD.
After initiation, the patient should be monitored as follows until an effective well tolerated dose is
found:
 Therapeutic effects and the impact on impairment
 Blood Pressure
 Pulse
 Weight as BMI
 Uncomfortable adrenergic side-effects
 Anxiety, agitation, irritability
 Mood and suicidality
 Changes in affect, anger or personality
 Concordance
GP Shared Care and Annual Reviews
If a stable, tolerated dose giving an adequate treatment response is found, then the patient’s GP
should be approached requesting that the prescription be taken over by primary care. Whilst there
is no Shared Care Agreement for ADHD in Devon, most GP’s to date have agreed to this.
GP’s should be advised to check BP, pulse and BMI at 3 months and then every 6 months.
Drug treatment for ADHD should be reviewed annually by the specialist service, and continued
prescribing should be contingent on this review.
In most cases, after successful titration, anti-ADHD medication is well tolerated and doses remain
stable, and the patient can choose to continue for as long as it continues to be safe and effective.
However the GP can ask for advice on ongoing management from the specialist service, or can
ask for the patient’s specialist review to be brought forward at any time.
PG17 – Pharmacological Management of ADHD
Approved by Drugs and Therapeutics Committee: October 2016
Review date: October 2020
Page 7 of 10
Specialist annual reviews are an opportunity for the patient to discuss their ongoing treatment
choices, and have the safety and effectiveness of their current treatment checked.
If it is agreed by clinician and patient that current treatment regimen should continue unchanged,
then the GP will be given a summary of the review.
If the specialist clinician, as a result of the review, agrees with the patient that there are relatively
straightforward improvements to treatment that the GP can make, then these should be included,
with a rationale, in the summary of the review sent to the GP.
If the specialist clinician, as a result of the review, agrees with the patient that there needs to be
significant changes to treatment that need to be managed in the specialist clinic, then these should
be included, with a rationale, in the summary of the review sent to the GP, and arrangements
made to take over prescribing from the GP. If stability is the reached, transfer back to Primary Care
should be requested.
If the patient does not respond to requests from the specialist service to attend an Annual Review,
then the GP should be informed, and advised that any continued prescribing is without specialist
support or supervision.
Should a GP decline to take over prescribing, then then the specialist clinic will review its ability to
continue to prescribe dependent on capacity.
General notes to support prescribing
Methylphenidate, dexamfetamine and lisdexamfetamine are Schedule 2 controlled drugs.
Prescriptions must comply with Misuse of Drugs Regulations 2001.
When switching from a stimulant to atomoxetine, the stimulant can be continued for first 4 weeks of
treatment (as the onset of action from atomoxetine is ≃ 4-6 weeks)
User-friendly resources
A patient decision aid (which includes information on relative side effects but also some nonformulary treatments) is available from:
http://www.choiceandmedication.org/silo/documents/handychartadhd.pdf
Information available from the Royal College of Psychiatrists:
About ADHD:
http://www.rcpsych.ac.uk/mentalhealthinfo/mentalhealthandgrowingup/adhdhyperkineticdisorder.as
px?theme=print
About treatment for ADHD (with CNS stimulant medication):
http://www.rcpsych.ac.uk/mentalhealthinfo/mentalhealthandgrowingup/stimulantmedication.aspx?t
heme=print
PG17 – Pharmacological Management of ADHD
Approved by Drugs and Therapeutics Committee: October 2016
Review date: October 2020
Page 8 of 10
Appendix 1
Methylphenidate formulations- plasma profiles
IR= Immediate release
ER= Extended release
From: Bazire,S. (2014) Psychotropic Drug Directory.
PG17 – Pharmacological Management of ADHD
Approved by Drugs and Therapeutics Committee: October 2016
Review date: October 2020
Page 9 of 10
Appendix 2
Formulations
METHYLPHENIDATE HC CD2
5mg
10mg
20mg
Tablets
18mg
27mg
36mg
EQUASYM XL CD2
10mg
20mg
30mg
MEDIKINET XL CD2
5mg 10mg 20m 30mg 40mg 50mg 60mg
Capsules
DEXAMFETAMINE SULFATE CD2
5mg
Tablets
LISDEXAMFETAMINE MESILATE CD2
30mg
50mg
70mg
ATOMOXETINE PoM
10mg
18mg
25mg
(nb Ritalin® only as 10mg)
CONCERTA XL
CD2
54mg
Tablets
Capsules
Capsules
40mg
80mg
100mg
PG17 – Pharmacological Management of ADHD
Approved by Drugs and Therapeutics Committee: October 2016
Review date: October 2020
Page 10 of 10