4.4 CNS stimulants 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

  • 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 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
  • 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. Refer to individual shared care guidelines for use in children and adolescents and adults
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
  • 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)
Methylphenidate immediate release
  • Tablets 5mg, 10mg, 20mg (£10.92 = 30 x 20mg)

Indications

  • Attention deficit hyperactivity disorder (under specialist supervision)

Dose

  • Child 4–6 years see BNF for Children
  • 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
  • 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

Notes

  1. Refer to individual shared care guidelines for use in children and adolescents and adults
Methylphenidate modified release
  • Xenidate® XL Modified release tablets 18mg, 27mg, 36mg, 54mg (£21.21 = 30 x 36mg)
  • Concerta® XL Modified release tablets 18mg, 27mg, 36mg (£42.45 = 30 x 36mg)
  • Equasym® XL Modified release capsules 10mg, 20mg, 30mg (£35.00 = 30 x 30mg)
  • Medikinet® XL Modified release 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:
    • 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
    • Adult over 18 years (initiation unlicensed), initially 18mg once daily in the morning, adjusted at weekly intervals according to response, maximum 108mg daily
  • Equasym® XL and Medikinet® XL:
    • 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
    • Adult over 18 years (unlicensed use), initially 10mg once daily in the morning, increased gradually at weekly intervals if necessary, maximum 100mg daily

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. Refer to individual shared care guidelines for use in children and adolescents and adults

Narcolepsy

Drugs used for narcolepsy not listed below:

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. 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:
      • modafinil should not be used during pregnancy due to the increased risk to the fetus
      • effective contraception is needed during treatment with modafinil and for 2 months after stopping modafinil treatment
      • 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)

 

Home > Formulary > Chapters > 4. Central Nervous System > 4.4 CNS stimulants and drugs for attention deficit hyperactivity disorder

 

  • First line
  • Second line
  • Specialist
  • Hospital