Download GP at 6 months in between specialist reviews

WORKING IN PARTNERSHIP WITH
SHARED CARE GUIDELINE FOR THE
TREATMENT OF ATTENTION DEFICIT
HYPERACTIVITY DISORDER (ADHD) IN
CHILDREN AND YOUNG PEOPLE
1
IMPORTANT: This guideline does not replace the relevant NICE guidance, the BNF or the individual drug summary of product characteristics
(SPC), which should all be read in conjunction with this guidance. Prescribers should also refer to the appropriate paragraph in the current edition of
the BNF.
West Kent CCG ADHD Shared Care Guideline Version 2.0 March 2016 Final
WORKING IN PARTNERSHIP WITH
Document Reference No.
Status
Version Number
Replacing/Superseded policy
documents
Number of Pages
Target audience/applicable to
Author
MMSCG001
Final
2.0
or
Acknowledgements
Version 1.0 October 2013
3
West Kent GPs and Specialist Paediatricians from the partnership organisations
Nirusha Govender, Lead Pharmacist for Children and Young People, KCHFT
Sameena Shakoor, Consultant Paediatrician, KCHFT
Janice Moorekite, Prescribing Advisor, West Kent CCG
Dr Sanaa SAEED, Consultant Child and Adolescent Psychiatrist,
Sussex Partnership NHS Foundation Trust
Graham Brown, Lead Children’s & Younger Peoples Mental Health Pharmacist,
Western Sussex Hospitals NHS Foundation Trust
With acknowledgement and thanks to: Cambridgeshire and Peterborough Clinical
Commissioning Group, Lancashire Medicines Management Group and Cornwall NHS
Partnership Foundation Trust whose documents were used as a basis for this guidance.
Contact Point for Queries
Date Ratified
Date of Implementation/distribution
Circulation
Review date
Copyright
Dr Sanaa SAEED, Consultant Child and Adolescent Psychiatrist,
Sussex Partnership NHS Foundation Trust (on behalf of CAMHS for West Kent
CCG)
April 2016
April 2016
Policy Leads, partnership organisations staff intranet
April 2018
West Kent Clinical Commissioning Group in Partnership with
Kent Community Health NHS Foundation Trust (KCHFT) and
Sussex Partnership NHS Foundation Trust
Governance Arrangements
Authorised/Ratified On
West Kent Clinical Commissioning Group, Medicines Optimisation
Group (MOG)
Kent Community Health NHS Foundation Trust, Medicines
Management Governance Group (MMGG)
Drug and Therapeutics Group, Sussex Partnership NHS Foundation
Trust
West Kent GPs and Specialists from the partnership organisations
West Kent Clinical Commissioning Group, Medicines Optimisation
Group (MOG)
Kent Community Health NHS Foundation Trust, Medicines
Management Governance Group (MMGG)
Drug and Therapeutics Group, Sussex Partnership NHS Foundation
Trust
April 2016
Review Date
2 years from ratification
Review criteria
This document will be reviewed prior to review date if a legislative
change or other event dictates.
Directorate or Function Governance
Group responsible for developing
document
Circulation group
Authorised/Ratified by Governance
or Function Group
Key References
1.
2.
3.
4.
5.
NICE Clinical Guideline 72, Attention deficit hyperactivity disorder: Diagnosis and Management of ADHD in
children, young people and adults. September 2008
NICE Quality Standard 39, Attention deficit hyperactivity disorder. July 2013
Access to www.medicines.org.uk/emc for individual drug SPCs for Methylphenidate, Dexamfetamine,
Lisdexamfetamine and Atomoxetine. Accessed December 2015
NICE Clinical Guideline 158, Antisocial behavior and conduct disorders in children and young people: recognition
and management. March 2013
NICE technology appraisal 98, Methylphenidate, atomoxetine and dexamfetamine for attention deficit hyperactivity
disorder (ADHD) in children and adolescents. March 2006
2
IMPORTANT: This guideline does not replace the relevant NICE guidance, the BNF or the individual drug summary of product characteristics
(SPC), which should all be read in conjunction with this guidance. Prescribers should also refer to the appropriate paragraph in the current edition of
the BNF.
West Kent CCG ADHD Shared Care Guideline Version 2.0 March 2016 Final
WORKING IN PARTNERSHIP WITH
Executive Summary
Treatment of Attention Deficit Hyperactivity Disorder (ADHD) in children and adolescents aged from 6 years up to
but not including 18 years of age.
This shared care guideline relates to patients with ADHD whose condition is stable at hand over from the ADHD
Specialist (Paediatrics/CAMHS) to primary care.
This shared care guideline is in accordance with NICE clinical guideline 72 and NICE Quality Standard 39.
The GP is expected to:

Prescribe the recommended medication after initiation and stabilisation by the specialist (also, in
exceptional clinical circumstances prescribing may be requested during a titration; the GP should do so
on these occasions providing clear guidance has been given by the Specialist).

Monitor height, weight, blood pressure, pulse and auscultation (heart rate and regularity) at six months
in between the annual specialist reviews. Email these findings to the Specialist for action.

Act in accordance with the advice in this guideline if side effects are identified.
The Specialist is expected to:

Undertake an assessment and identify people suitable for medication.

Initiate prescribing and request for transfer to shared care when stable.

Assess for efficacy and adverse effects at the start of treatment and then at least yearly, monitoring
height, weight, auscultation (heart rate and regularity), pulse and blood pressure at annual reviews.

Respond to auscultation (heart rate and regularity), blood pressure, height and weights sent in by GPs
with advice about continuing (or not) with the ADHD medication.

Offer an annual break in patients who are prescribed stimulant medication. If a treatment break is
refused by patient/carer/family the rationale should be documented in the notes (in accordance with
MHRA guidance and product SPCs)

Arrange transfer of care for young people over the age of 17.
The Parent/Carer is expected to:

Follow the Specialist advice by booking an appointment for their child’s auscultation (heart rate and
regularity), blood pressure, pulse, weight and height to be measured, attending these and specialist
appointments.

Let the Specialist know if there are any concerns.

Store the tablets safely and securely out of the reach of children and young people.
This shared care guideline excludes:

Treatment of children under 6 years

Treatment of adults aged 18 years and over
Sharing of care depends on communication between the Specialist, GP and the patient or their parent/carer. The
intention to share care should be explained to the patient and accepted by them. Patients are under regular
follow-up and this provides an opportunity to discuss drug therapy. The Doctor/Healthcare Professional who
prescribes the medication has the clinical responsibility for the drug and the consequences of its use.
3
IMPORTANT: This guideline does not replace the relevant NICE guidance, the BNF or the individual drug summary of product characteristics
(SPC), which should all be read in conjunction with this guidance. Prescribers should also refer to the appropriate paragraph in the current edition of
the BNF.
West Kent CCG ADHD Shared Care Guideline Version 2.0 March 2016 Final
WORKING IN PARTNERSHIP WITH
Scope
Children and young people (from 6 -18 years old) with a diagnosis of ADHD.
Aim
To clarify the responsibilities and roles of the Specialist and GPs in the management of drug treatment in children
and young people with ADHD.
Introduction
NICE Clinical Guideline ADHD: Diagnosis and management of ADHD in Children and Young People and Adults
(March 2013) indicates that ongoing prescribing of medication may take place in primary care.
NICE guidance states:

For a diagnosis of ADHD, symptoms of hyperactivity/impulsivity and/or inattention should:
•
meet the diagnostic criteria in DSM-IV or ICD-10 (hyperkinetic disorder) and
•
be associated with at least moderate psychological, social and/or educational or occupational
impairment based on interview and/or direct observation in multiple settings, and
•
be pervasive, occurring in two or more important settings including social, familial, educational
and/or occupational settings.

As part of the diagnostic process, include an assessment of the person's needs, coexisting conditions,
social, familial and educational or occupational circumstances and physical health. For children and
young people, there should also be an assessment of their parents' or carers' mental health.

Healthcare professionals should offer parents or carers of pre-school children with ADHD a referral to a
parent-training/education programme as the first-line treatment if the parents or carers have not already
attended such a programme or if the programme they attended has had a limited effect.

Teachers who have received training about ADHD and its management should provide advice on
behavioural support in the classroom.

If the child or young person with ADHD has moderate levels of impairment, the parents or carers should
be offered referral to a group parent-training/education programme, either on its own or together with a
group treatment programme (cognitive behavioural therapy [CBT] and/or social skills training) for the
child or young person.
In school-age children and young people with severe ADHD, drug treatment should be offered as the
first-line treatment. In that instance, parents should also be offered a group-based parenttraining/education programme.
Drug treatment for children and young people with ADHD should always form part of a comprehensive
treatment plan that includes psychological, behavioural and educational advice and interventions.
When a decision has been made to treat children or young people with ADHD with drugs, healthcare
professionals should consider:
•
Methylphenidate for ADHD without significant comorbidity
•
Methylphenidate for ADHD with comorbid conduct disorder
•
Methylphenidate or atomoxetine when tics, Tourette's syndrome, anxiety disorder, stimulant
misuse or risk of stimulant diversion are present
•
Atomoxetine if methylphenidate has been tried and has been ineffective at the
•
Maximum tolerated dose or the child or young person is intolerant to low or moderate doses of
methylphenidate.
•
Lisdexamfetamine is licensed for use as a second line agent to methylphenidate. This should
preferably be done after the use of at least two modified release preparations of
methylphenidate unless a previous adverse reaction to methylphenidate or unacceptable side
effect has ruled out further use.
If there is a choice of more than one appropriate drug, the product with the lowest cost (taking into
account the cost per dose and number of daily doses see Appendix 5) should be prescribed.
Antipsychotics are not recommended for the treatment of ADHD in children and young people.
When starting drug treatment children and young people should be monitored for side effects. In
particular, those treated with atomoxetine should be closely observed for agitation, irritability, suicidal
thinking and self-harming behaviour, and unusual changes in behaviour, particularly during the initial
months of treatment, or after a change in dose. Parents and/or carers should be warned about the
potential for suicidal thinking and self-harming behaviour with atomoxetine and asked to report these to
their healthcare professionals. Parents or carers should also be warned about the potential for liver
damage in rare cases with atomoxetine (usually presenting as abdominal pain, unexplained nausea,
malaise, darkening of the urine or jaundice).
Dexamfetamine should be considered in children and young people whose ADHD is unresponsive to a
maximum tolerated dose of methylphenidate, atomoxetine or lisdexamfetamine.
In children and young people whose ADHD is unresponsive to methylphenidate and atomoxetine then
consideration for the use of lisdexamfetamine or dexamfetamine is appropriate.
Further treatment may include the use of medication unlicensed for the treatment of ADHD (such as
bupropion, clonidine, modafinil and imipramine) or combination treatments (including psychological
treatments for the parent or carer and the child or young person). The use of medication unlicensed
for ADHD should only be considered in the context of tertiary services.









4
IMPORTANT: This guideline does not replace the relevant NICE guidance, the BNF or the individual drug summary of product characteristics
(SPC), which should all be read in conjunction with this guidance. Prescribers should also refer to the appropriate paragraph in the current edition of
the BNF.
West Kent CCG ADHD Shared Care Guideline Version 2.0 March 2016 Final
WORKING IN PARTNERSHIP WITH
Medication

Where drug treatment is considered appropriate, methylphenidate, atomoxetine and dexamfetamine
are recommended, within their licensed indications, as options for the management of ADHD in children
and adolescents. (Lisdexamfetamine is included in this guideline as an alternative medication to dexamfetamine
which has been made available since the publication of the NICE guidance).

Methylphenidate, lisdexamfetamine and dexamfetamine are all Schedule 2 Controlled Drugs.
Controlled drug prescription requirements should be followed.

The decision regarding which product to use should be based on the following:
•
the presence of comorbid conditions (for example, tic disorders, Tourette's syndrome,
epilepsy)
•
the different adverse effects of the drugs
•
specific issues regarding compliance identified for the individual child or adolescent, for
example problems created by the need to administer a mid-day treatment dose at school
•
the potential for drug diversion (where the medication is forwarded on to others for nonprescription uses) and/or misuse
•
the preferences of the child/adolescent and/or his or her parent or guardian.

When prescribing methylphenidate for the treatment of children or young people, modified-release
preparations should be considered for the following reasons:
•
convenience
•
improving adherence
•
reducing stigma (because the child or young person does not need to take medication at
school)
•
reducing problems schools have in storing and administering controlled drugs
•
their pharmacokinetic profiles. Alternatively, immediate-release preparations may be
considered if more flexible dosing regimens are required, or during initial titration to determine
correct dosing levels.

Diagnosis and initiation of treatment must be made by a Specialist in the treatment of ADHD

Stimulants used to treat ADHD work by increasing dopamine levels in the brain to improve focus and
functioning

If there is a choice of more than one appropriate drug, the product with the lowest cost (taking into
account the cost per dose and number of daily doses see Appendix 5) should be prescribed.

Following titration and dose stabilisation, prescribing and monitoring should be carried out under locally
agreed shared care arrangements with primary care.

Newly licensed medicines for ADHD that are currently not included in this guideline will be considered
for inclusion by the partnership governance mechanisms when they become available.
5
IMPORTANT: This guideline does not replace the relevant NICE guidance, the BNF or the individual drug summary of product characteristics
(SPC), which should all be read in conjunction with this guidance. Prescribers should also refer to the appropriate paragraph in the current edition of
the BNF.
West Kent CCG ADHD Shared Care Guideline Version 2.0 March 2016 Final
WORKING IN PARTNERSHIP WITH
Drug
Methylphenidate
Form and Cost
included per pack
size of 30/28 where
applicable
Atomoxetine
Tablets 5mg(£3.03),
10mg(£5.49),
20mg(£10.92)
(Medikinet®, Ritalin®,
Tranquilyn®)
(Strattera®)
Capsules 10mg(£62.46),
18mg(£62.46), 25mg(£62.46),
40mg(£62.46), 60mg(62.46),
80mg(£83.28), 100mg(£83.28)
*Note Ritalin-SR® 20mg
tablets is imported from the
USA and is a special item
(cost will be significantly
higher and vary within the
pharmacy supply chain in the
UK).
Oral Solution 4mg/ml (300ml =
£100.00)
Tablets M/R
18mg(£31.19),
27mg(£36.81), 36mg
(£42.45), 54mg(£60.48)
(Xenidate® XL, Matoride®
XL, Concerta® XL)
Dexamfetamine
Tablets
5mg(£19.89/£24.75)
(Amfexa®)
*Note Dexedrine® Spansule
(MR Capsule) 5mg, 10mg,
15mg is imported from the
USA and is a special item
(cost will be significantly
higher and vary within the
pharmacy supply chain in the
UK).
Oral Solution 5mg/5ml
(150ml = £34.35 and
500ml = £114.49)
Lisdexamfetamine
Hard capsules
30mg(£58.24),
50mg(£68.60),
70mg(£83.16)
(Elvanse®)
*Note Vyvanse® Capsules
20mg, 30mg, 40mg, 50mg,
60mg, 70mg is imported
from the USA and is a
special item (cost will be
significantly higher and vary
within the pharmacy supply
chain in the UK).
Guanfacine
Prolonged-release tablets 1mg(£56.00),
2mg(£58.52), 3mg(£65.52),4mg(£76.16)
(Intuniv®)
*Note Intuniv® PR Tablets 1mg, 2mg, 3mg, 4mg
has recently been launched in the UK (January
2016) and has been issued  status as it is subject
to additional monitoring by the MHRA which will
allow quick identification of new safety information.
Healthcare professionals are asked to report
any/ALL suspected adverse reactions via the Yellow
Card system.
Capsules M/R
10mg(£25.00),
20mg(£30.00),
30mg(£35.00) (Equasym
XL®)
Capsules M/R
5mg(£24.04),
10mg(£25.00),
20mg(£30.00),
30mg(£35.00),
40mg(£57.72),
50mg(£62.52),
60mg(£67.32) (Medikinet
XL®)
Modified Release
preparations are not
interchangeable.
Prescribe by brand.
6
IMPORTANT: This guideline does not replace the relevant NICE guidance, the BNF or the individual drug summary of product characteristics (SPC), which should all be read in conjunction with this guidance. Prescribers should
also refer to the appropriate paragraph in the current edition of the BNF.
West Kent CCG ADHD Shared Care Guideline Version 2.0 March 2016 Final
WORKING IN PARTNERSHIP WITH
Dose
(For full details see
NICE CG72, the
individual SPCs
and the BNFC)
Child aged 6-18 years:
Short acting

< 6 years –
unlicensed

> 6 years – up to
60 mg daily in
divided doses
Long acting
Concerta® XL /Matoride®
XL

< 6 years –
unlicensed

> 6 years up to
54 mg once daily
(some guidelines,
e.g., the
Canadian ones
(http://www.caddr
a.ca/practiceguidelines/downlo
ad ) recommend
up to 72 mg/day
in children < 40
kg and up to 90
mg/day in
adolescents
Equasym® XL

< 6 years –
unlicensed

>6 years up to 60
mg once daily
Medikinet® XL

< 6 years –
unlicensed

> 6 years up to
60 mg once daily
Child over 6 years bodyweight under 70kg:
Initially 500micrograms/kg daily
for 7 days, increased according
to response. Usual maintenance
1.2mg/kg daily but may be
increased to 1.8mg/kg daily
(max. 120mg daily) under the
direction of a specialist.
Child/Adolescent body-weight
over 70kg: Initially 40mg for 7
days, increased according to
response. Usual maintenance
80mg daily but may be
increased to a maximum
recommended total daily dose of
120mg under the direction of a
specialist.
Child aged 6-18 years:
Initially 2.5mg 2-3 times
daily, increased if
necessary at weekly
intervals by 5mg daily
Child over 6 years:
30mg once daily in the
morning, increasing by
20mg daily increments at
weekly intervals to a
maximum of 70mg
Usual max. 1mg/kg (up to
20mg) daily (40mg daily
has been required in some
children).
Maintenance dose given in
2-4 divided doses.
There is no proprietary
product.
Doses above 100mg daily are
not licensed but are stated in the
BNFc.
Intuniv® is indicated for the treatment of
ADHD in children and adolescents 6-27years
old for whom stimulants are not suitable, not
tolerated or have been shown to be ineffective
Intuniv® must be used as part of a
comprehensive ADHD treatment programme,
typically including psychological, educational
and social measures.
Treatment must be initiated under the
supervision of an appropriate specialist in
childhood and/or adolescent behavioural
disorders.
It is recommended that all patients, either
starting treatment for ADHD or switching from
another medication begin treatment on a dose
of 1mg/day.
The dose may be adjusted in increments of not
more than 1mg/week. The usual maximum
dose is 4mg in children and 4-7mg in
adolescents depending on weight.
Dose should be individualised according to the
patient's response and tolerability.
Depending on the patient's response and
tolerability for Intuniv® the recommended
maintenance dose range is 0.05-0.12
mg/kg/day.
See table available in the product SPC.
Missed dose:
Discontinue if no response
after one month
In the event of a missed dose, Intuniv® dosing
can resume the next day. If two or more
consecutive doses are missed, re-titration is
recommended based on the patient's
tolerability to guanfacine.
Evening dose: It effect
wears off (with rebound
hyperactivity) a dose at
bedtime may be
appropriate (establish
need with trial bedtime
dose)
When prescribing
7
IMPORTANT: This guideline does not replace the relevant NICE guidance, the BNF or the individual drug summary of product characteristics (SPC), which should all be read in conjunction with this guidance. Prescribers should
also refer to the appropriate paragraph in the current edition of the BNF.
West Kent CCG ADHD Shared Care Guideline Version 2.0 March 2016 Final
WORKING IN PARTNERSHIP WITH
methylphenidate for the
treatment of children or
young
people, modified-release
preparations should be
considered for the
following
reasons:

Convenience

improving
adherence

reducing stigma
(because the
child or young
person does not
need to take
medication at
school)

reducing
problems schools
have in storing
and administering
controlled drugs

their
pharmacokinetic
profiles.
Alternatively, immediaterelease preparations may
be considered if more
flexible dosing regimens
are required, or during
initial titration to determine
correct dosing
levels.
Note –Dosing schedules
for the individual
preparations should be
consulted.
Refer to SPCs or BNFc for
dosing schedules.
8
IMPORTANT: This guideline does not replace the relevant NICE guidance, the BNF or the individual drug summary of product characteristics (SPC), which should all be read in conjunction with this guidance. Prescribers should
also refer to the appropriate paragraph in the current edition of the BNF.
West Kent CCG ADHD Shared Care Guideline Version 2.0 March 2016 Final
WORKING IN PARTNERSHIP WITH
Administration
Common Adverse
Effects
(please refer to the
latest SPC or BNFc
for full list)
Potentially Serious
Drug Interactions
(please refer to the
latest SPC or BNFc
for full list)
Contents of Equasym XL®
capsules and Medikinet
XL® capsules, can be
sprinkled on a tablespoon
of apple sauce, and then
swallowed immediately
without chewing. Drinking
some fluids, e.g. water
should follow the intake of
sprinkles with apple sauce.
Concerta XL® - tablet
membrane can pass
through the GI tract
unchanged. Dose form not
appropriate for dysphagia
or if GI lumen is restricted.
Concerta XL® must be
swallowed whole with the
aid of liquids, and must not
be chewed, divided, or
crushed.
Decreased appetite,
weight loss, growth
retardation, insomnia,
mood changes,
headaches, dizziness,
drowsiness, tachycardia,
increased blood pressure,
cough, gastrointestinal
side-effects, rashes
delusions, hallucinations,
anxiety, panic, stimulant
related tics, sexual
dysfunction.
Adrenergic neurone
blockers: antagonism of
hypotensive effect
Coumarins: possible
increased anticoagulant
effect
MAOIs and Moclobemide:
risk hypertensive crisis
SSRIs and tricyclic
antidepressants:
Methylphenidate may
inhibit metabolism of the
antidepressants
Total daily dose may be given
either as a single dose in the
morning or in 2 divided doses
with the last dose no later than
early evening.
Tablets can be halved.
Take with or without food.
Swallow whole or opened
and dispersed in a glass
of water (take
immediately)
Intuniv® is a prolonged-release formulation to
be taken orally in the morning or evening.
The tablet should be swallowed whole, and
should not be administered with high fat meals,
to avoid increasing guanfacine exposure.
Halve the dose in moderate
hepatic impairment, quarter the
dose in severe hepatic
impairment.
Atomoxetine oral solution should
only be prescribed when
patients are unable to take
tablets.
Emergence of suicidal
behaviour, self-harm or hostility,
serious liver damage; decreased
appetite, weight loss, insomnia,
irritability, headache,
drowsiness, dizziness,
gastrointestinal side-effects,
lethargy, increased heart rate
and blood pressure,
dysmenorrhea, sexual
dysfunction, rashes.
Decreased appetite, weight
loss, growth retardation,
insomnia, mood changes,
headaches, dizziness,
drowsiness, tachycardia,
increased blood pressure,
cough, gastrointestinal
side-effects, rashes
delusions, hallucinations,
anxiety, panic, stimulant
related tics, sexual
dysfunction.
Sleep difficulties,
headache, reduced
appetite, upper
abdominal pain, reduced
weight gain or weight
loss, reduced appetite,
Tics
Somnolence, headache, fatigue, abdominal
pain upper, vomiting, diarrhea, nausea,
constipation, dry mouth sedation, weight gain,
depression, anxiety, insomnia, nightmare,
sedation, dizziness, lethargy, bradycardia,
hypotension and syncope.
Methadone, amiodarone,
disopyramide, moxifloxacin,
parenteral erythromycin,
mefloquine, antipsychotics
which prolong QTc interval,
sotalol, and hypokalaemias
secondary to diuretics:
increased risk of ventricular
arrhythmias.
Antidepressants: increased risk
of seizures.
Additionally:
SSRIs: Potential for increased
atomoxetine levels with
paroxetine and fluoxetine.
Guanethidine: antagonism
of hypotensive effect
MAOI and Moclobemide:
risk of hypertensive crisis
MAOIs: risk of
hypertensive crisis
Chlorpromazine,
haloperidol: effects of
lisdexamfetamine
possibly reduced
When Intuniv® is used concomitantly with
CYP3A4/5 inhibitors and inducers, plasma
concentrations of guanfacine may be elevated
or lowered, potentially affecting the efficacy
and safety of Intuniv®. Intuniv® can increase
plasma concentrations of concomitantly
administered medicinal products that are
metabolised via CYP3A4/5.
The pharmacodynamic effect of Intuniv® can
have an additive effect when taken with other
products known to cause sedation,
hypotension or QT prolongation.
9
IMPORTANT: This guideline does not replace the relevant NICE guidance, the BNF or the individual drug summary of product characteristics (SPC), which should all be read in conjunction with this guidance. Prescribers should
also refer to the appropriate paragraph in the current edition of the BNF.
West Kent CCG ADHD Shared Care Guideline Version 2.0 March 2016 Final
WORKING IN PARTNERSHIP WITH
Contraindications
(please refer to the
latest SPC or BNFc
for full list)
Severe depression,
suicidal ideation, anorexia
nervosa, psychosis,
uncontrolled bipolar
disorder, severe mood
disorders, mania,
schizophrenia,
psychopathic/borderline
personality disorders,
hyperthyroidism or
thyrotoxicosis,
cardiovascular disease,
structural cardiac
abnormalities,
phaeochromocytoma,
vasculitis, cerebrovascular
disorders, glaucoma
MAOIs: two week washout
period required between and
MAOI and Atomoxetine
prescriptions.
Tricyclics: increased risk of
ventricular arrhythmias.
Phaeochromocytoma, narrowangle glaucoma, severe
cardiovascular or
cerebrovascular disorders
Cardiovascular disease
including moderate to
severe hypertension,
structural cardiac
abnormalities, advanced
arteriosclerosis, hyper
excitability or agitated
states, hyperthyroidism,
glaucoma, porphyria,
history of drug or alcohol
abuse, patients with Gilles
de la Tourette syndrome or
similar dystonias
Hypersensitivity to the active substance or to
any of the excipients listed in the SPC.
Intuniv® can cause syncope, hypotension and
bradycardia. Syncope may involve risk of falls
or accidents, which could result in serious
harm. Caution is advised when treating
patients who have a history of hypotension,
heart block, bradycardia or cardiovascular
disease, or who have a history of syncope or a
condition that may predispose them to
syncope, such as hypotension, orthostatic
hypotension, bradycardia, or dehydration.
Caution is also advised when treating patients
with Intuniv® who are being treated
concomitantly with antihypertensives or other
medicinal products that can reduce blood
pressure or heart rate or increase the risk of
syncope. Patients should be advised to drink
plenty of fluid.
Caution in patients with a known history of QT
prolongation and suicidal ideation.
Children and adolescents treated with Intuniv®
may show an increase in their BMI. Therefore,
monitoring of height, weight and BMI should be
done prior to initiation of therapy and then
every 3 months for the first year, taking into
consideration clinical judgement. 6 monthly
monitoring should follow thereafter, with more
frequent monitoring following any dose
adjustment.
10
IMPORTANT: This guideline does not replace the relevant NICE guidance, the BNF or the individual drug summary of product characteristics (SPC), which should all be read in conjunction with this guidance. Prescribers should
also refer to the appropriate paragraph in the current edition of the BNF.
West Kent CCG ADHD Shared Care Guideline Version 2.0 March 2016 Final
WORKING IN PARTNERSHIP WITH
Monitoring Standards and Actions to take in the event of abnormal test results/symptoms
MONITORING
Methylphenidate, Dexamfetamine and Lisdexamfetamine, Guanfacine
Parameter
Frequency of
monitoring
Action
By whom
Weight
6monthly
Failure to gain weight appropriately – reduce the dose
or withdraw the medicine
Specialist annual review
GP at 6 months in between specialist
reviews
- Use proforma appendix 2A/2B, 3 or
4 to communicate as appropriate
GP
Full blood
count (FBC)
Blood
pressure and
pulse
Auscultation
(heart rate
and
regularity)
Growth
(weight and
height)
6 monthly
6 monthly
Have a low threshold for carrying out a FBC e.g. if
recurrent infections or purpuric rash occur. There is
no need for routine testing.
Monitor whilst taking medication to ensure within
published range e.g. for age of child – see Appendix
1. If raised repeat the measurement. The dose may
need to be reduced, or arrangements may need to be
made for 24hour blood pressure readings. The
Specialist will be able to advise.
Many children lose a small amount of weight (about a
kg) at the beginning of treatment. Weight and height
should be plotted on published Growth Charts – see
appendix 1. If weight loss continues or if child’s weight
trajectory crosses more than one centile line or if this
translates into the height trajectory being similarly
affected:

Provide supporting information to help
parents promote good diet – see Appendix 1.

Reduce dose or encourage breaks from
treatment at weekends/in school holidays.

Withdraw treatment
Specialist annual review
GP at 6 months in between specialist
reviews
- Use proforma appendix 2A/2B, 3 or
4 to communicate as appropriate
Specialist annual review
GP at 6 months in between specialist
reviews
- Use proforma appendix 2A/2B, 3 or
4 to communicate as appropriate
11
IMPORTANT: This guideline does not replace the relevant NICE guidance, the BNF or the individual drug summary of product characteristics
(SPC), which should all be read in conjunction with this guidance. Prescribers should also refer to the appropriate paragraph in the current edition of
the BNF.
West Kent CCG ADHD Shared Care Guideline Version 2.0 March 2016 Final
WORKING IN PARTNERSHIP WITH
Atomoxetine, Guanfacine
Parameter
Frequency of
monitoring
Action
By whom
Gaunfacine
*Special note
Treatment
initiation
Specialist initially as per
titration and annual review.
GP at 6 months in between
specialist reviews
- Use proforma appendix
2A/2B, 3 or 4 to
communicate as
appropriate
Appearance
of suicidal
behaviour,
self-harm or
hostility
Ongoing basis
at appointments
Monitoring during titration
During dose titration, weekly monitoring for signs and
symptoms of somnolence and sedation, hypotension and
bradycardia should be performed.
Ongoing monitoring
During the first year of treatment, the patient should be
assessed at least every 3 months for:
Signs and symptoms of:

somnolence and sedation

hypotension

bradycardia

weight increase /risk of obesity
It is recommended clinical judgement be exercised during this
period. 6 monthly monitoring should follow thereafter, with
more frequent monitoring following any dose adjustments
Patients/parents should be advised of this risk and made aware of
possible signs and symptoms to report back to the specialist
immediately if noticed.
Blood
pressure
and pulse
Auscultation
(heart rate
and
regularity)
Growth
(weight and
height)
6 monthly
Monitor whilst taking medication to ensure within published range
e.g. for age of child – see appendix 1.
6 monthly
Many children lose a small amount of weight (about a kg) at the
beginning of treatment. Weight and height should be plotted on
published Growth Charts – see appendix 1. If weight loss
continues or if child’s weight trajectory crosses more than one
centile line or if this translates into the height trajectory being
similarly affected:

Provide supporting information to help parents promote
good diet – see Appendix 1.

Reduce dose or encourage breaks from treatment at
weekends/in school holidays.

Withdraw treatment
Specialist and GP
Telephone the on-call
practitioner/on-call CAMHS
psychiatrist to
communicate in
emergency
Specialist annual review
GP at 6 months in between
specialist reviews
- Use proforma appendix
2A/2B, 3 or 4 to
communicate as
appropriate
Specialist annual review
GP at 6 months in between
specialist reviews
- Use proforma appendix
2A/2B, 3 or 4 to
communicate as
appropriate
12
IMPORTANT: This guideline does not replace the relevant NICE guidance, the BNF or the individual drug summary of product characteristics
(SPC), which should all be read in conjunction with this guidance. Prescribers should also refer to the appropriate paragraph in the current edition of
the BNF.
West Kent CCG ADHD Shared Care Guideline Version 2.0 March 2016 Final
WORKING IN PARTNERSHIP WITH
ROLES and RESPONSIBILITIES
Specialist Responsibilities
1.
2.
3.
4.
5.
Confirmation of diagnosis and identification of suitable patients following full assessment.
Request agreement of shared care with primary care prescriber.
Initiation of licensed ADHD therapy: methylphenidate, dexamfetamine, lisdexamfetamine & atomoxetine.
Discussion of risks and benefits with patients, outline possible side effects and explain their roles.
To undertake a complete history, documenting: concomitant medicines; past and present medical and psychiatric disorders
or symptoms; family history of sudden cardiac death, unexplained death, or malignant arrhythmia.
6.
7.
To undertake a physical examination for the presence of heart disease.
To assess baseline cardiovascular status, including blood pressure and auscultation (heart rate and regularity) before
prescribing and get specialist cardiac advice if appropriate.
Issuing initial prescription(s) until the patient is stabilised (minimum of one month) even if prescribing responsibility is
transferred earlier than this.
To ensure the patient/parent/carer are fully informed of the potential benefits and side effects of treatment and ensure the
person with parental responsibility (and where appropriate, the young person) consents to the treatment. Share with the GP any
information about consent that s/he needs to know.
8.
9.
10. To review the patient and monitor the following (if relevant to specific drug)at least 6 monthly act on the results
appropriately and communicate these results to the primary care prescriber:

Weight and appetite, recorded at baseline, following dosage adjustments and 6 monthly.

Auscultation (heart rate and regularity), blood pressure and pulse, recorded at baseline, following dosage adjustments and at 6
monthly reviews (please note variation to this for guanfacine monitoring requirements for treatment initiation in the first year in
the table above)

Blood and platelet counts at discretion of supervising clinician(s) (e.g. if recurrent nose bleeds, bruising or infections
occur). Baseline, then when clinically indicated.

Liver function tests if prescribing atomoxetine if clinically indicated.

To refer patients who develop symptoms such as palpitations, exertional chest pain, unexplained syncope, 13dyspnoea,
or other symptoms suggestive of heart disease for prompt specialist cardiac evaluation.

The development of new or worsening of pre-existing, psychiatric symptoms (also following dose adjustments)
and at every visit) and any comorbidity associated with ADHD.
11. When stimulant medication (methylphenidate, dexamfetamine or lisdexamfetamine) is being used, to look out for signs of
diversion (transfer of the medicine from the individual for whom it was prescribed for, to one for whom it is not prescribed),
misuse, and abuse.
12. If prescribing modified release methylphenidate this must be by ‘Brand’ to avoid the risk of the wrong formulation being
dispensed.
13. Patients prescribed stimulant medication should be offered an annual treatment break to assess continued need for
pharmacotherapy.
14. Ensure that all newly treated patients (and/or their carers) receive appropriate education and advice regarding their drug
therapy, shared care arrangements and when to seek medical advice in order to maximize compliance. This should include
written information where appropriate.
15. Providing primary care prescriber with clinic letter stating planned introduction and reviews and additional advice if appropriate.
16. Communicate promptly with the GP about any changes in treatment and respond promptly to any concerns
raised by the GP.
17. Provide outpatient reviews, monitor effectiveness/side effects
18. Notify the GP of the patient’s failure to attend for clinical review or drug monitoring and give advice on stopping the medication.
19. To liaise and advise primary care prescriber to interrupt treatment at least annually to assess ongoing need.
20. To advise and support parents and teachers, liaising where appropriate with the child’s school.
21. To use feedback and questionnaires, ideally from the child`s school as well as home, to monitor response and facilitate the
possible change of medication.
22. To take responsibility for stopping the drug and organizing medication breaks.
23. Ensure clear arrangements are in place for back up, advice and support e.g. out of hours and/or when the consultant initiating
therapy is not available.
24. Evaluate any adverse effects reported by the GP (Any adverse effects which are suspected to relate to the drug should be
reported via the Yellow Card System).
25. Refer for additional behavioural therapy (social skills, anger management or parents’ group/parenting skills) if and when
appropriate.
26. Arrange transfer to adult services if medication is to continue over the age of 17.
13
IMPORTANT: This guideline does not replace the relevant NICE guidance, the BNF or the individual drug summary of product characteristics
(SPC), which should all be read in conjunction with this guidance. Prescribers should also refer to the appropriate paragraph in the current edition of
the BNF.
West Kent CCG ADHD Shared Care Guideline Version 2.0 March 2016 Final
WORKING IN PARTNERSHIP WITH
Primary Care Prescriber (GP) Responsibilities
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
Ensure that shared care arrangements are in place before taking over prescribing/monitoring and:

That the patient/carer is clear what is being monitored and by whom.

That the patient/carer knows what significant adverse effects/events to report urgently and to whom they should report
(specialist or GP).
Confirm that proposed therapy is not contra-indicated because of concurrent therapy for other conditions the patient may be
suffering from e.g. check drug-drug and drug-disease interactions and refer to secondary care with a full history where
appropriate.
To provide repeat prescriptions of the licensed ADHD medications described above at the dose recommended once the
patient is stabilised (not before initial one month stabilisation period). A demonstrable system should be in place to ensure
that prescribing is reviewed by the primary care prescriber if there is no record of the fact that monitoring has taken place
within the agreed time scales. Prescriptions for stimulants (methylphenidate, dexamfetamine or lisdexamfetamine)
should be restricted to 30 days supply and are only valid for 28 days from the date of signature as stimulant
medications are controlled drugs subject to safe custody and specific regulations for prescribing.
Be aware of the potential of Atomoxetine to (rarely) precipitate suicidal behaviour, self-harm or hostility particularly where
there is a history of depression or suicidal behaviour. Ask specialist for an early review if needed as a matter of urgency.
To record any changes in therapy in the prescribing record on receipt of such communication from secondary care and to act
upon these.
To monitor prescribing rate of ADHD medications for individual patients.
Monitor height, weight, blood pressure, pulse and auscultation (heart rate and regularity) annually six months after the annual
specialist review or more frequently if there are specific concerns and at the request of the specialist. Check these against
standard charts (see Appendix 1) or email the observations to the Specialist Paediatrician who will be able to provide
guidance. If in doubt about effectiveness or side-effects, share this information with the specialist clinic. Seek advice from the
Specialist Paediatrician if the patient does not attend for monitoring appointments.
To contact consultant / specialist if deterioration in behavior.
Check for possible drug interactions when newly prescribing or stopping concurrent medication.
Report any suspected adverse drug reactions to the specialist who initiated therapy under the shared care agreement.
Report adverse events via the yellow card scheme.
To refer patients who develop symptoms such as palpitations, exertional chest pain, unexplained syncope,
dyspnoea or other symptoms suggestive of heart disease for prompt specialist cardiac evaluation.
Arrange appropriate investigations (FBC) if patients present with unexplained bruising; consider withdrawal of medication;
seek paediatric/haematology advice and contact the specialist team.
Arrange appropriate investigation if the patient shows signs of liver problems and discontinue the medication if the person
has jaundice or has laboratory evidence of hepatic injury. Seek paediatric/gastro-enterology advice and contact the specialist
team.
To monitor patients overall health and well-being.
Discuss potential benefits and side effects of treatment with the patient/carer to address any outstanding queries.
Liaise with consultant / specialist if any cause for concern or drug discontinued.
If requested, undertake an ECG for appropriate patients and send tracings to consultant/specialist for review.
If prescribing modified release methylphenidate this must be by ‘Brand’ to avoid the risk of the wrong formulation being
dispensed.
When prescribing stimulant medication, to look out for signs of diversion (transfer of the medicine from the individual for
whom it was prescribed to one for whom it is not prescribed), misuse, and abuse.
If care of the patient is transferred to another prescriber that the new prescriber is made aware of this information.
In appropriate patients to interrupt treatment at least annually after a discussion with the child`s parent and on the
recommendation of the specialist.
To ensure all relevant staff within the practice are aware of the shared care guidelines
Monitor compliance through rates of prescription
14
IMPORTANT: This guideline does not replace the relevant NICE guidance, the BNF or the individual drug summary of product characteristics
(SPC), which should all be read in conjunction with this guidance. Prescribers should also refer to the appropriate paragraph in the current edition of
the BNF.
West Kent CCG ADHD Shared Care Guideline Version 2.0 March 2016 Final
WORKING IN PARTNERSHIP WITH
Patient’s / Carer’s role
1.
2.
3.
4.
Ask the Specialist or GP for information, if he or she does not have a clear understanding of the treatment. Discuss
Discuss
potential
benefits
and side
effects
of treatmentwith
with the
the specialist
any
outstanding
queries.
potential
benefits
and side
effects
of treatment
specialistand
andGP,
GP,raise
raise
any
outstanding
queries. Discuss
potential
benefits
and
side
effects
of
treatment
with
the
specialist
and
GP,
raise
any
outstanding
queries
Share any concerns in relation to treatment with any medication covered by this agreement with the Specialist Paediatrician.
Provide adequate feedback to relevant Healthcare Professional and ensure that the correct person from the child`s school
provides such feedback to titrate medication effectively.
Inform the Specialist or GP of any other medication being taken, including over-the- counter products.
5.
Read the patient information leaflet included with your medication and report any side effects or concerns you
have to the consultant / specialist or primary care prescriber.
6. Report any adverse effects to their Specialist whilst child/young person is taking drug(s)
7. Attend all appointments suggested in the time frame advised so that the therapy can be properly monitored. This includes
booking appointments in primary care as suggested by the specialist. Be aware that if monitoring is not possible because
appointments are not made and attended, it may not be possible for the medication to continue.
8. Arrange blood tests as per consultant / specialist request.
9. For children who need to take medication during the school day, ensure that school have a supply of tablets in its original
packaging as supplied by the community pharmacy with a label stating clear instructions for administration of the medicine.
10. When supplying medicines to school please ensure you adhere and comply with the school’s medicine policy.
11. Please note that some of the medicines prescribed may be classified as controlled drugs and these drugs will have further special
storage or safe custody requirements when sent to school – please ensure you are familiar with these requirements at your
child’s school.
12. Store the tablets safely and securely out of the reach of children and young people keeping in mind that all medication is
dangerous if taken in over-dose.
15
IMPORTANT: This guideline does not replace the relevant NICE guidance, the BNF or the individual drug summary of product characteristics
(SPC), which should all be read in conjunction with this guidance. Prescribers should also refer to the appropriate paragraph in the current edition of
the BNF.
West Kent CCG ADHD Shared Care Guideline Version 2.0 March 2016 Final
WORKING IN PARTNERSHIP WITH
Appendix 1: Resources
Post-diagnostic advice

After diagnosis people with ADHD and their parents or carers may benefit from advice about
diet, behaviour and general care.
General advice


Following a diagnosis of ADHD, healthcare professionals should consider providing all
parents/carers self-instruction manuals, and other materials such as DVDs, based on
positive parenting and behavioural techniques.
All patients should be offered psycho-educational advice and or workshops.
Dietary advice




Healthcare professionals should stress the value of a balanced diet, good nutrition and
regular exercise.
The elimination of artificial colouring and additives from the diet is not recommended as a
generally applicable treatment.
Clinical assessment of ADHD should include asking about foods or drinks that appear to
influence their hyperactive behaviour. If there is a clear link, healthcare professionals should
advise elimination of certain food/drinks from the diet.
Dietary fatty acid supplementation is not recommended for the treatment of ADHD in
children and young people.
Growth (height and weight)

Standard growth charts are available from http://www.rcpch.ac.uk/child-health/researchprojects/uk-who-growth-charts/uk-growth-chart-resources-2-18-years/uk-2-18-years
Blood Pressure



Blood pressure can be checked against population norms such as the NIH charts which
allow readings to be checked against gender, age and height centile
http://www.nhlbi.nih.gov/files/docs/guidelines/child_tbl.pdf
Blood pressure, pulse, weight and height measurements may be emailed to the specialist
clinic using the proforma in Appendix 3.
Please indicate if you require a response from the specialist clinic. The contact details for
sending these values to the clinics are:
Contact numbers for advice and support
Name / position
Specialist /
Consultant:
West Kent
Community
Paediatricians
Hospital
Pharmacy:
Out of hours:
Team Location
Duty Consultant
(Maidstone CAMHS)
Knightrider House,
Knightrider Street,
Maidstone,
Kent,
ME15 6LU
Dr Sameena Shakoor,
Kent Community Health NHS
Consultant Paediatrician Foundation Trust
and Clinical Lead
The Homeopathic Hospital
41 Church Road
Royal Tunbridge Wells
Or Duty Paediatrician
Kent TN1 1JU
Maidstone Hospital
Hermitage Ln, Maidstone,
Kent, ME16 9QQ
Tunbridge Wells
Hospital (Pembury)
Tonbridge Road, Pembury
Tunbridge Wells
Kent, TN2 4QJ
On call physicians
N/A
Telephone
Email
01622 356930
N/A
01892 539144
N/A
01622 224313
N/A
01892 633281
N/A
N/A
16
IMPORTANT: This guideline does not replace the relevant NICE guidance, the BNF or the individual drug summary of product characteristics
(SPC), which should all be read in conjunction with this guidance. Prescribers should also refer to the appropriate paragraph in the current edition of
the BNF.
West Kent CCG ADHD Shared Care Guideline Version 2.0 March 2016 Final
WORKING IN PARTNERSHIP WITH
Appendix 2A: Specialist Paediatrician Review Letter for Primary Care
Community Paediatrics – Homeopathic Hospital, Tunbridge Wells
17
IMPORTANT: This guideline does not replace the relevant NICE guidance, the BNF or the individual drug summary of product characteristics
(SPC), which should all be read in conjunction with this guidance. Prescribers should also refer to the appropriate paragraph in the current edition of
the BNF.
West Kent CCG ADHD Shared Care Guideline Version 2.0 March 2016 Final
WORKING IN PARTNERSHIP WITH
Appendix 2B: Specialist Paediatrician Review Letter for Primary Care
Community Paediatrics – The Heathside Centre, Coxheath
18
IMPORTANT: This guideline does not replace the relevant NICE guidance, the BNF or the individual drug summary of product characteristics
(SPC), which should all be read in conjunction with this guidance. Prescribers should also refer to the appropriate paragraph in the current edition of
the BNF.
West Kent CCG ADHD Shared Care Guideline Version 2.0 March 2016 Final
WORKING IN PARTNERSHIP WITH
Appendix 3:
Brief health check for ADHD patients in primary care
Patient Name:
Date of Birth:
NHS number:
The above patient was seen in primary
care on:
Blood pressure :
Auscultation (heart rate and regularity):
Pulse rate :
Weight :
Height:
Any other comments:
Please tick if you would like the Specialist to advise about continued treatment.
(*Specialist to use Appendix 3 to provide the response)
Signature:
Name (in full) and designation:
Name of GP practice:
Thank you. Please email this record to the Specialist.
19
IMPORTANT: This guideline does not replace the relevant NICE guidance, the BNF or the individual drug summary of product characteristics
(SPC), which should all be read in conjunction with this guidance. Prescribers should also refer to the appropriate paragraph in the current edition of
the BNF.
West Kent CCG ADHD Shared Care Guideline Version 2.0 March 2016 Final
WORKING IN PARTNERSHIP WITH
Appendix 4:
Advice to Primary Care from the Specialist
Patient Name:
Date of Birth:
NHS number:
Thank you for sending in the above patient’s physical measurements.
Having seen this information and checked the patient’s record, I can advise the following:
Advice:
Date:
Signature:
Name(in full) of Healthcare Professional:
Designation of Healthcare Professional:
This advice is to be sent to the GP and copied to parents/carers.
20
IMPORTANT: This guideline does not replace the relevant NICE guidance, the BNF or the individual drug summary of product characteristics
(SPC), which should all be read in conjunction with this guidance. Prescribers should also refer to the appropriate paragraph in the current edition of
the BNF.
West Kent CCG ADHD Shared Care Guideline Version 2.0 March 2016 Final
WORKING IN PARTNERSHIP WITH
Appendix 5: Cost Analysis of Licensed ADHD Medicines
Medication
Strength
Methyphenidate
instant release
(including
Ritalin®)
Concerta® XL
Matoride® XL
Equasym® XL
Medikinet® XL
Guanfacine MR
(Intuniv®)
Atomoxetine
(Strattera®)
5mg
Cost / single
dose unit (£)
£0.10
Original pack
cost;(Pack Size)
£3.03 (30)
10mg
£0.18
£5.49 (30)
18mg
27mg
36mg
45mg**
£1.04
£1.23
£1.42
£2.27
(1x 18mg & 1x
27mg)
£2.45
£0.83
£1.13
£2.02
£0.83
£1.00
£1.17
£2.34 (2 x 30mg)
£0.80
£0.80
£0.96
£1.12
£1.93
£2.24 (2 x 30mg)
£2.00
£2.09
£2.34
£2.72
£4.43
£4.68
£5.06
£2.23 (£4.46)***
£31.19 (30)
£36.81 (30)
£42.45 (30)
£68.00 (30)
54mg
18mg
36mg
54mg
10mg
20mg
30mg
60mg
5mg
10mg
20mg
30mg
40mg
60mg
1mg
2mg
3mg
4mg
5mg (2mg & 3mg)
6mg (2 x 3mg)
7mg (3mg & 4mg)
10mg, 18mg,25mg,
40mg & 60mg
80mg & 100mg
£895.71
£302.95
£412.45
£737.30
£314.17
£365.00
£425.83
£851.66
£292.49
£292.49
£351.13
£409.53
£702.63
£819.06
£730.00
£762.85
£854.10
£992.80
£1616.95
£1708.20
£1846.90
£813.95 (1627.90)***
£1084.05
(£1898.00)***
Lisdexamfetamine
30mg
£759.20
(Elvanse®)
50mg
£894.25
70mg
£1084.05
Dexamfetamine
5mg
5mg OD is £321.20;
10mg BD is £1284.80
*Assumes drug used 365 days a year with no break at weekends or during school holidays.
** No single dose for this strength, hence made up of 2 doses combined.
*** Based on one dose being prescribed. Dosing is based on body weight, so two doses are
sometimes prescribed, this doubles the cost – indicated in brackets.
Note: Costs correct as of
www.ppa.org.uk/ppa/edt_intro.htm
£2.97 (£5.20)***
[£2.23 + £2.97)]
£2.08
£2.45
£2.97
£0.88
£73.62 (30)
£24.95 (30)
£33.96 (30)
£60.48 (30)
£25.00 (30)
£30.00 (30)
£35.00 (30)
£70.00 (30)
£24.04 (30)
£24.04 (30)
£28.86 (30)
£33.66 (30)
£57.72 (30)
£67.32 (30)
£56.00 (28)
£58.52 (28)
£65.52 (28)
£76.16 (28)
£124.04 (28)
£131.04 (28)
£141.68 (28)
£62.46 (28)
(£124.92)***
£83.28 (28)
(£145.60)***
£58.24 (28)
£68.60 (28)
£83.16 (28)
£24.75 (28)
Cost per year (365
days)*
5mg OD is £36.87;
5mg TDS is £110.61
10mg OD is £66.80;
10mg BD is £133.60
£379.48
£447.86
£516.48
£827.33
06/01/16
(Inc.
VAT).
Figures
from
21
IMPORTANT: This guideline does not replace the relevant NICE guidance, the BNF or the individual drug summary of product characteristics
(SPC), which should all be read in conjunction with this guidance. Prescribers should also refer to the appropriate paragraph in the current edition of
the BNF.
West Kent CCG ADHD Shared Care Guideline Version 2.0 March 2016 Final