4.4 CNS stimulant and drugs for attention deficit hyperactivity disorder

NICE TA98 - Attention deficit hyperactivity disorder (ADHD) - methylphenidate, atomoxetine and dexamfetamine (March 2006)

NICE CG72- Attention deficit hyperactivity disorder (ADHD) (Sept 2008)

Please refer to the Shared Care Guidance for methylphenidate, lisdexamfetamine and also atomoxetine

Atomoxetine
  • Capsules 10mg, 18mg, 25mg, 40mg, 60mg, 80mg, 100mg (£106.18 = 80mg daily)

Indications

  • Attention deficit hyperactivity disorder (under specialist supervision)

Dose

  • Adult over 18 years, body-weight over 70kg, initially 40mg daily for 7 days, increased according to response; usual maintenance 80–100mg daily, but may be increased to maximum 120mg daily [unlicensed dose] under the direction of a specialist
  • Child 6–18 years, body-weight over 70kg, initially 40mg daily for 7 days, increased according to response; usual maintenance 80mg daily, but may be increased to maximum 120mg daily [unlicensed] under the direction of a specialist
  • Adult and child over 6 years, body-weight under 70kg, initially 500 micrograms/kg daily for 7 days, increased according to response; usual maintenance 1.2mg/kg daily, but may be increased to 1.8mg/kg daily (maximum 120mg daily) [unlicensed] under the direction of a specialist
Lisdexamfetamine
  • Capsules 20mg, 30mg, 40mg, 50mg, 60mg, 70mg (£75.18 = 60mg daily)

Indications

  • ADHD when response to previous drug treatment, including methylphenidate, is inadequate.

Notes

  1. The routine commissioning of lisdexamfetamine has been accepted in Devon for the management of attention deficit hyperactivity disorder in children and adolescents (see Commissioning Policy for more details).
Methylphenidate immediate release
  • Tablets 5mg, 10mg, 20mg (£10.92 = 30 x 20mg)

Indications

  • Attention deficit hyperactivity disorder (under specialist supervision)

Dose

  • Standard release, adult over 18 years [unlicensed use], 5mg 2–3 times daily increased if necessary at weekly intervals according to response, maximum 100mg daily in 2–3 divided doses
    • Child 6–18 years, initially 5mg 1–2 times daily, increased if necessary at weekly intervals by 5–10mg daily; usual maximum 60mg daily in 2–3 divided doses but may be increased to 2.1mg/kg daily in 2–3 divided doses (maximum 90mg daily) under the direction of a specialist, discontinue if no response after 1 month
    • Child 4–6 years see BNF for Children
Methylphenidate modified release
  • Xenidate® XL tablets 18mg, 36mg, 54mg (£27.59 = 30 x 36mg)
  • Concerta® XL tablets 27mg (£36.81 = 30 x 27mg)
  • Equasym XL® capsules 10mg, 20mg, 30mg (£35.00 = 30 x 30mg)
  • Medikinet XL® capsules 5mg, 10mg, 20mg, 30mg, 40mg (£57.72 = 30 x 40mg)

Indications

  • Attention deficit hyperactivity disorder (under specialist supervision)

Dose

  • Xenidate® XL or Concerta® XL, adult over 18 years [initiation unlicensed], initially 18mg once daily in the morning, adjusted at weekly intervals according to response, maximum 108mg daily
    • Child 6–18 years, initially 18mg once daily (in the morning), increased if necessary at weekly intervals by 18mg according to response, usual maximum 54mg once daily, but may be increased to 2.1mg/kg daily (maximum 108mg daily) [unlicensed] under the direction of a specialist; discontinue if no response after 1 month
  • Equasym® XL and Medikinet® XL, adult over 18 years [unlicensed use], initially 10mg once daily in the morning, increased gradually at weekly intervals if necessary, maximum 100mg daily
    • Child 6–18 years, initially 10mg once daily in the morning, increased gradually at weekly intervals if necessary, usual maximum 60mg daily but may be increased to 2.1mg/kg daily (maximum 90mg daily) [unlicensed] under the direction of a specialist; discontinue if no response after 1 month
Modafinil
  • Tablet 100mg, 200mg (£15.11 = 200mg daily)

Indications

  • Excessive sleepiness associated with narcolepsy with or without cataplexy

Dose

  • Narcolepsy 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. Modafinil should be used only in patients who have had a complete evaluation of their excessive sleepiness, and in whom a diagnosis of narcolepsy has been made by a specialist physician
  2. Treatment should only be initiated by a specialist physician. A baseline electrocardiogram should be done before treatment initiation; patients with abnormal findings should be further evaluated by specialists before modafinil treatment can be initiated
  3. Blood pressure and heart rate should be monitored in patients receiving modafinil as follows:
    1. In patients with no previous history of hypertension/heart disease – three monthly for 6 months, then six monthly
    2. In patients with existing hypertension/heart disease – two weeks from start of treatment, then after 1 month, then 3 monthly for six months, then six monthly
  4. Modafinil should be discontinued in patients who develop arrhythmia or moderate to severe hypertension, and should not be restarted until the condition has been adequately evaluated and treated
  5. Modafinil should be used with caution in patients with a history of psychosis, depression, or mania; abuse of alcohol, drugs, or illicit substances. Such patients should be monitored closely and advised to report any suspected adverse behaviours or thoughts - patients should be assessed immediately and treatment stopped if appropriate
  6. Modafinil should be discontinued and not restarted in cases of serious skin or hypersensitivity reactions or psychiatric disorders such as suicidal ideation
  7. MHRA Drug Safety Alert (August 2010): 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.
Guanfacine hydrochloride (Intuniv®)

The routine commissioning of guanfacine is not accepted in Devon for the treatment of attention deficit hyperactivity disorder (ADHD) in children and adolescents (see Commissioning policy for more information).

 

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