4.4 CNS stimulants and drugs for attention deficit hyperactivity disorder

Drugs used for narcolepsy not listed below:

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.

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
  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. 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
    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.

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

BrandFormulation characteristicsRelease profileDuration of action
Xenidate XL tablets21% immediate release / 79% modified releaseInitial peak at 1.35 hours; second peak after 5.30 hours12 hours
Concerta XL tablets22% immediate release / 78% modified releaseInitial peak at 1-2 hours; second peak after 6-8 hours12 hours
Medikinet XL capsules50% immediate release / 50% modified releaseInitial peak reached rapidly, second peak after 3-4 hours8 hours
Equasym XL capsules30% immediate release / 70% modified releaseInitial peak at 2 hours; second peak after 4-5 hours8 hours
Methylphenidate immediate release
  • Tablets 5mg, 10mg, 20mg (£20.38 = 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 (£64.09 = 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 (£24.73 = 28 tablets)

Indications and dose

  • Narcolepsy
    • Adults: Initially 10 mg daily in divided doses, increased in steps of 10 mg every week, maintenance dose to be given in 2–4 divided doses; maximum 60 mg per day
    • Elderly: Initiate at 5 mg daily; increase in steps of 5 mg every week
  • Refractory attention deficit hyperactivity disorder (ADHD)
    • The licensed age groups and dosing recommendations vary between dexamfetamine formulations; specialist to advise on the required dose for individual patients

Notes

  1. 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.
  2. 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
  3. Schedule 2 controlled drug – prescription requirements apply. Refer to BNF
  4. Specialist to prescribe dexamfetamine until the dose is stabilised. Ongoing prescribing may then be continued in primary care.
  5. Monitor for aggressive behaviour or hostility during initial treatment.
  6. Pulse, blood pressure, psychiatric symptoms, appetite, height (paediatric patients only), and weight will be recorded by the specialist at initiation. ECG may be performed if clinically appropriate. The BNF recommends subsequent monitoring should be performed following each dose adjustment, and at least every 6 months thereafter. Specialist and GP to agree monitoring frequency and responsibilities according to individual patient circumstances.
  7. Specialists to perform annual review to assess ongoing need for treatment.
  8. Licensing of dexamfetamine formulations differ with respect to patient age and indications. Prior to prescribing, the relevant Summary of Product Characteristics (SPC) should be checked and the patient advised if the product is to be used off-label.
Modafinil
  • Tablet 100mg, 200mg (£7.07 = 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
Guanfacine hydrochloride (Intuniv®)

The routine commissioning of guanfacine prolonged-release capsules (Intuniv®) is not accepted in Devon for the treatment of attention deficit hyperactivity disorder (ADHD) in children and adolescents aged 6-17 years (see Commissioning Policy for more details).


Last updated: 04-11-2021

 

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