4.4 CNS stimulant and drugs for attention deficit hyperactivity disorder

Atomoxetine
  • Capsules 10mg, 18mg, 25mg, 40mg, 60mg, 80mg, 100mg (£70.79 = 80mg daily)

Indications

  • Attention deficit hyperactivity disorder (initiated by a specialist physician experienced in managing the condition)

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

Notes

  1. West and South Devon: refer to individual shared care guidelines for use in Central Nervous System conditions
Dexamfetamine Sulphate
  • Tablets 5mg (£24.62 = 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 (under specialist supervision)
    • The licensed age groups and dosing recommendations vary between dexamfetamine formulations; specialist to advise on the required dose for individual patients

Notes

  1. Specialist to prescribe dexamfetamine until the dose is stabilised. Ongoing prescribing may then be continued in primary care.
  2. Monitor for aggressive behaviour or hostility during initial treatment. Pulse, blood pressure, psychiatric symptoms, appetite, height (paediatric patients only), and weight will be recorded 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 General Practice to agree monitoring frequency according to individual patient circumstances.
  3. Specialists to perform annual review to assess ongoing need for treatment.
  4. When prescribed for the management of 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.
  5. Licensing of dexamfetamine formulations differ. 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.
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. West and South Devon: refer to individual shared care guidelines for use in Central Nervous System conditions
  2. 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
  • Tablet 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

Notes

  1. West and South Devon: refer to individual shared care guidelines for use in Central Nervous System conditions
Methylphenidate modified release
  • Xenidate® XL Modified release tablet 18mg, 27mg, 36mg, 54mg (£21.21 = 30 x 36mg)
  • Concerta® XL Modified release tablet 18mg, 27mg, 36mg (£42.45 = 30 x 36mg)
  • Equasym® XL Modified release capsule 10mg, 20mg, 30mg (£35.00 = 30 x 30mg)
  • Medikinet® XL Modified release capsule 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

Notes

  1. West and South Devon: refer to individual shared care guidelines for use in Central Nervous System conditions
  2. Different versions of modified-release preparations may not have the same clinical effect. To avoid confusion between these different formulations of methylphenidate, prescribers should specify the brand to be dispensed.
Modafinil
  • Tablet 100mg, 200mg (£6.86 = 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. West Devon: refer to individual shared care guidelines for use in Central Nervous System conditions
  2. Narcolepsy should be diagnosed and treatment initiated by a specialist physician
  3. MHRA Drug Safety Update (March 2011): 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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