Drug management

There is evidence that drug treatment, in addition to having beneficial effects on the features of hyperkinetic disorder (HKD) and Attention Deficit/ Hyperactivity Disorder (ADHD), has positive effects on academic activity, productivity and relationships with family and peers.

All medication for ADHD should only be initiated by a healthcare professional with training and expertise in diagnosing and managing ADHD.

Healthcare professionals initiating medication for ADHD should:

• be familiar with the pharmacokinetic profiles of all the short- and long-acting preparations available for ADHD
• ensure that treatment is tailored effectively to the individual needs of the child, young person or adult
• take account of variations in bioavailability or pharmacokinetic profiles of different preparations to avoid reduced effect or excessive adverse effects

Baseline assessment

• NICE state that before starting medication for ADHD, people with ADHD should have a full assessment, which should include:
  • a review to confirm they continue to meet the criteria for ADHD and need treatment
  • a review of mental health and social circumstances, including:
    • presence of coexisting mental health and neurodevelopmental conditions
    • current educational or employment circumstances
    • risk assessment for substance misuse and drug diversion
    • care needs
  • a review of physical health, including:
    • a medical history, taking into account conditions that may be contraindications for specific medicines
    • current medication height and weight (measured and recorded against the normal range for age, height and sex)
    • baseline pulse and blood pressure (measured with an appropriately sized cuff and compared with the normal range for age)
    • a cardiovascular assessment an electrocardiogram (ECG)
      • is not needed before starting stimulants, atomoxetine or guanfacine, unless the person has any of the features in criteria for referral for specialist opinion (below), or a co-existing condition that is being treated with a medicine that may pose an increased cardiac risk (1)
    • if the treatment may affect the QT interval
      
      
  • referral for specialist opinion before commencing medication:
    • cardiology opinion before starting medication for ADHD if any of the following apply:
      • history of congenital heart disease or previous cardiac surgery
      • history of sudden death in a first-degree relative under 40 years suggesting a cardiac disease
      • shortness of breath on exertion compared with peers
      • fainting on exertion or in response to fright or noise
      • palpitations that are rapid, regular and start and stop suddenly (fleeting occasional bumps are usually ectopic and do not need investigation)
      • chest pain suggesting cardiac origin
      • signs of heart failure a murmur heard on cardiac examination
      • blood pressure that is classified as hypertensive for adults
    • paediatric hypertension specialist before starting medication for ADHD if blood pressure is consistently above the 95th centile for age and height for children and young people

Drug treatment choice - children aged 5 years and over and young people

• methylphenidate (either short or long acting) as the first line pharmacological treatment
• switching to lisdexamfetamine should be considered if a 6-week trial of methylphenidate at an adequate dose and not derived enough benefit in terms of reduced ADHD symptoms and associated impairment
• dexamfetamine should be considered if ADHD symptoms are responding to lisdexamfetamine but who cannot tolerate the longer effect profile
• atomoxetine or guanfacine should be offered if:
  • they cannot tolerate methylphenidate or lisdexamfetamine or
  • their symptoms have not responded to separate 6-week trials of lisdexamfetamine and methylphenidate, having considered alternative preparations and adequate doses

Drug treatment choice - adults

• lisdexamfetamine or methylphenidate are options as first-line pharmacological treatment for adults with ADHD
  • switching to lisdexamfetamine should be considered for adults who have had a 6-week trial of methylphenidate at an adequate dose but have not derived enough benefit in terms of reduced ADHD symptoms and associated impairment
  • switching to methylphenidate should be considered for adults who have had a 6-week trial of lisdexamfetamine at an adequate dose but have not derived enough benefit in terms of reduced ADHD symptoms and associated impairment
  • dexamfetamine should be considered for adults whose ADHD symptoms are responding to lisdexamfetamine but who cannot tolerate the longer effect profile
• atomoxetine should be offered to adults if:
  • they cannot tolerate lisdexamfetamine or methylphenidate or
  • their symptoms have not responded to separate 6-week trials of lisdexamfetamine and methylphenidate, having considered alternative preparations and adequate doses

For details then consult the full guideline (1).

Monitoring is detailed in the full guideline (1).

Reference:

• NICE (September 2019).Attention defificit hyperactivity disorder: diagnosis and management