Drugs used for narcolepsy not listed below:

• Pitolisant and sodium oxybate (See 4.1.1 Hypnotics)

The notes below reflect the place in the treatment pathway for ADHD medicines. This is broadly in line with the treatment pathway described in NICE guideline NG87 (Attention deficit hyperactivity disorder: diagnosis and management), but has been refined by local commissioning policies.

Devon Referral Support Services (DRSS) has produced an ADHD and Autism FAQ which includes information on Right to Choose referrals.

National Patient Safety Alert (27 September 2023): Shortage of methylphenidate prolonged-release capsules and tablets, lisdexamfetamine capsules, and guanfacine prolonged-release tablets

ADHD Medicines Shortage: local providers have worked together to produce guidance to support primary care (click here)

SPS - Prescribing available medicines for ADHD: up-to-date information on national supply

Methylphenidate modified-release

• Xenidate XL tablets 18mg, 27mg, 36mg, 54mg (£34.34 = 54mg daily)
• Concerta XL tablets 18mg, 27mg, 36mg, 54mg (£68.71 = 54mg daily)
• Medikinet XL capsules 5mg, 10mg, 20mg, 30mg, 40mg, 50mg, 60mg (£62.83 = 60mg daily)
• Equasym XL capsules 10mg, 20mg, 30mg (£65.33 = 60mg daily)

Indications

• Attention deficit hyperactivity disorder (ADHD)

Notes

1. Prescribe by brand. Methylphenidate modified-release preparations contain both immediate-release (IR) and modified-release (MR) methylphenidate. The proportion of IR and MR methylphenidate differs between brands; different preparations may not have the same clinical effect. See table below and note 8.
2. Due to its lower acquisition cost, Xenidate XL is the preferred option for new initiations and those who have not tolerated other formulations.
3. The use of Concerta XL should be limited to existing patients already prescribed it, or those who are unable to tolerate Xenidate XL.
4. Refer to individual shared care guidelines for use in children and adolescents and adults.
5. Methylphenidate is recommended as the first line option for the treatment of ADHD.
6. Schedule 2 controlled drug – prescription requirements apply. Refer to BNF.
7. Licensing differs between brands:
   1. Xenidate XL: Licensed for use in children aged 6 years of age and over and adolescents. In adolescents whose symptoms persist into adulthood and who have shown clear benefit from treatment, it may be appropriate to continue treatment into adulthood. Treatment initiation in adults is unlicensed
   2. Concerta XL: Licensed for use in children aged 6 years of age and over and adults when remedial measures alone prove insufficient
   3. Medikinet XL: Licensed for use in children aged 6 years of age and over and adults
   4. Equasym XL: Licensed for use in children aged 6 years of age and over. Not licensed for use in adults.
8. MHRA Drug Safety Update (September 2022): Methylphenidate long-acting (modified-release) preparations: caution if switching between products due to differences in formulations.

The following table shows the various different formulation characteristics and release profiles of modified-release methylphenidate:

Methylphenidate immediate-release

• Tablets 5mg, 10mg, 20mg (£30.58 = 3 x 20mg daily)

Indications

• Attention deficit hyperactivity disorder (ADHD)

Notes

1. Refer to individual shared care guidelines for use in children and adolescents and adults
2. Methylphenidate is recommended as the first line option for the treatment of ADHD
3. Schedule 2 controlled drug – prescription requirements apply. Refer to BNF
4. Not licensed for use in children under 6 years and adults.
5. Consult individual brands for pharmacokinetic profiles, broadly categorised as:
   1. Maximum plasma concentration reached 1-2 hours after administration
   2. Duration of action 1-4 hours.

Lisdexamfetamine

• Elvanse capsules 20mg, 30mg, 40mg, 50mg, 60mg, 70mg (£83.16 = 70mg daily)
• Elvanse Adult capsules 30mg, 50mg, 70mg (£83.16 = 70mg daily)

Indications

• Attention deficit hyperactivity disorder (ADHD) in patients who cannot tolerate, or have not adequately responded to, methylphenidate

Notes

1. Refer to individual shared care guidelines for use in children and adolescents and adults
2. Lisdexamfetamine is more expensive than methylphenidate, and has not been shown to be more effective or better tolerated, it is therefore recommended to treat ADHD only in patients who cannot tolerate, or have not responded to, methylphenidate
3. Schedule 2 controlled drug – prescription requirements apply. Refer to BNF
4. Licensing differs between products, refer to SPCs.
5. Children and adolescents: The routine commissioning of lisdexamfetamine is accepted in Devon for the management of attention deficit hyperactivity disorder (ADHD) in children aged 6 years of age and over for whom previous drug treatment for ADHD, including methylphenidate, has been unsatisfactory (see Commissioning Policy for more details)
6. Adults: The routine commissioning of lisdexamfetamine is accepted in Devon for the treatment of attention deficit hyperactivity disorder (ADHD) in adults who have failed to gain an adequate response to, or tolerate, methylphenidate (see Commissioning Policy for more details)

Atomoxetine

• Capsules 10mg, 18mg, 25mg, 40mg, 60mg, 80mg, 100mg (£72.57 = 80mg daily)

Indications

• Attention deficit hyperactivity disorder (ADHD)

Notes

1. Refer to individual shared care guidelines for use in children and adolescents and adults
2. Atomoxetine is only recommended to treat ADHD in patients who cannot tolerate, or have not responded to, methylphenidate or lisdexamfetamine
3. Not licensed for use children under 6 years.

Dexamfetamine sulphate

• Tablets 5mg, 10mg, 20mg (£74.26 = 20mg daily)
• Oral solution sugar free 5mg/5ml (£170.00 = 150ml) (see note 5)

Indications

• Narcolepsy
• Refractory attention deficit hyperactivity disorder (ADHD)

Notes

1. Refer to individual shared care guidelines for use in children and young people and adults
2. Narcolepsy: dexamfetamine is reserved for second line use if modafinil is not tolerated or is ineffective despite maximum dose, or if significant adverse effects occur.
3. ADHD: dexamfetamine use has largely been replaced by lisdexamfetamine, however treatment may be continued for established patients. New initiations should be limited to patients whose ADHD symptoms are responding to lisdexamfetamine but who cannot tolerate the longer effect profile
4. Licensing of dexamfetamine formulations differ with respect to patient age and indications. Prior to prescribing, the relevant Summary of Product Characteristics (SmPC) should be checked and the patient advised if the product is to be used off-label.
5. Due to its higher acquisition cost, the oral solution sugar free should be reserved for patients who are unable to use tablets.
6. Schedule 2 controlled drug – prescription requirements apply. Refer to BNF

Guanfacine

• Prolonged-release tablets 1mg, 2mg, 3mg, 4mg (£76.16 = 4mg daily)

Indications

• Attention deficit hyperactivity disorder (ADHD) in children and adolescents aged 6 to 17 years, where previous treatment with stimulants and previous treatment with atomoxetine, is ineffective, or not tolerated, or these treatments are not suitable

Notes

1. Refer to shared care guideline for use in children and adolescents
2. Guanfacine is more expensive than stimulants and atomoxetine and has not been shown to be more effective or better tolerated; it is therefore recommended to treat ADHD only in children and young people who have not responded to or cannot use these treatments.
3. Not licensed for use children under 6 years.
4. Children being treated with guanfacine should normally have this withdrawn prior to transition to adult services unless an individual request has been submitted and approved by the relevant adult specialist service provider Drug and Therapeutics Committee (or equivalent) for continuation within a secondary care setting.
5. The routine commissioning of guanfacine is accepted in Devon for the management of attention deficit hyperactivity disorder (ADHD) in children and adolescents aged 6 to 17 years, where previous treatment with stimulants and previous treatment with atomoxetine, is ineffective, or not tolerated, or these treatments are not suitable (see Commissioning Policy for more details)

Modafinil

• Tablet 100mg, 200mg (£6.94 = 200mg daily)

Indications

• Excessive sleepiness associated with narcolepsy with or without cataplexy

Dose

• Adult over 18 years: initially 200mg daily, either in 2 divided doses (morning and at noon) or as a single dose in the morning, dose adjusted according to response to 200–400mg daily in 2 divided doses or as a single dose
• Elderly: initiate at 100mg daily

Notes

1. Narcolepsy should be diagnosed and treatment initiated by a specialist physician
2. Refer to individual shared care guidelines
3. MHRA Drug Safety Update (March 2011): Modafinil (Provigil) now restricted to narcolepsy. The European Medicines Agency has recommended that the use of modafinil should be restricted to treat only sleepiness associated with narcolepsy, and that it should no longer be used for the treatment of excessive sleepiness associated with obstructive sleep apnoea or chronic shift work sleep disorder.
4. MHRA Drug Safety Update (November 2020): Modafinil (Provigil): increased risk of congenital malformations if used during pregnancy
   1. Modafinil potentially increases the risk of congenital malformations (including congenital heart defects, hypospadias and orofacial clefts); modafinil should not be used in pregnancy and alternative treatment options for narcolepsy should be considered
   2. women of childbearing potential must use effective contraception during treatment and for 2 months after stopping modafinil
   3. modafinil may reduce the effectiveness of steroidal contraceptives, including oral contraceptives, therefore alternative or concomitant methods of contraception are required – see Advice on contraception use
   4. ensure all female patients of childbearing potential taking modafinil are informed and fully understand that:
      1. modafinil should not be used during pregnancy due to the increased risk to the foetus
      2. effective contraception is needed during treatment with modafinil and for 2 months after stopping modafinil treatment
      3. they should discuss plans for pregnancy early with their doctor and continue contraception for 2 months after stopping modafinil

Solriamfetol

• Tablet 150mg, 75mg (£248.64 = 150mg once daily)

Indications

• Excessive daytime sleepiness associated with narcolepsy (with or without cataplexy)

Dose

• Adult over 18 years: 75mg once daily; dose increased according to response after at least 3 days up to 150mg once daily. In patients with severe symptoms, a starting dose of 150 mg once daily may be considered. Dose to be taken upon awakening and not within 9 hours of bedtime as this may affect night time sleep.
• Elderly: Consideration should be given to the use of lower doses and close monitoring in this population particularly renal function.

Notes

1. Narcolepsy should be diagnosed and treatment initiated by a specialist physician.
2. Refer to individual shared care guidelines
3. NICE TA758: Solriamfetol (Sunosi) is recommended as an option for treating excessive daytime sleepiness in adults with narcolepsy with or without cataplexy (January 2022)
   1. This is only if modafinil and either dexamfetamine or methylphenidate have not worked well enough or are not suitable
4. NICE TA777: Solriamfetol (Sunosi) is not recommended, within its marketing authorisation, to improve wakefulness and reduce excessive daytime sleepiness in adults with obstructive sleep apnoea whose sleepiness has not been satisfactorily treated by primary obstructive sleep apnoea therapy, such as continuous positive airway pressure (CPAP) (March 2022)