There is evidence that drug treatment, in addition to having beneficial effects on the features of hyperkinetic disorder (HKD) and Attention Deficit/ Hyperactivity Disorder (ADHD), has positive effects on academic activity, productivity and relationships with family and peers.
All medication for ADHD should only be initiated by a healthcare professional with training and expertise in diagnosing and managing ADHD.
Healthcare professionals initiating medication for ADHD should:
- be familiar with the pharmacokinetic profiles of all the short- and long-acting preparations available for ADHD
- ensure that treatment is tailored effectively to the individual needs of the child, young person or adult
- take account of variations in bioavailability or pharmacokinetic profiles of different preparations to avoid reduced effect or excessive adverse effects
Baseline assessment
- NICE state that before starting medication for ADHD, people with ADHD should have a full assessment, which should include:
- a review to confirm they continue to meet the criteria for ADHD and need treatment
- a review of mental health and social circumstances, including:
- presence of coexisting mental health and neurodevelopmental conditions
- current educational or employment circumstances
- risk assessment for substance misuse and drug diversion
- care needs
- a review of physical health, including:
- a medical history, taking into account conditions that may be contraindications for specific medicines
- current medication height and weight (measured and recorded against the normal range for age, height and sex)
- baseline pulse and blood pressure (measured with an appropriately sized cuff and compared with the normal range for age)
- a cardiovascular assessment an electrocardiogram (ECG)
- is not needed before starting stimulants, atomoxetine or guanfacine, unless the person has any of the features in criteria for referral for specialist opinion (below), or a co-existing condition that is being treated with a medicine that may pose an increased cardiac risk (1)
- if the treatment may affect the QT interval
- referral for specialist opinion before commencing medication:
- cardiology opinion before starting medication for ADHD if any of the following apply:
- history of congenital heart disease or previous cardiac surgery
- history of sudden death in a first-degree relative under 40 years suggesting a cardiac disease
- shortness of breath on exertion compared with peers
- fainting on exertion or in response to fright or noise
- palpitations that are rapid, regular and start and stop suddenly (fleeting occasional bumps are usually ectopic and do not need investigation)
- chest pain suggesting cardiac origin
- signs of heart failure a murmur heard on cardiac examination
- blood pressure that is classified as hypertensive for adults
- paediatric hypertension specialist before starting medication for ADHD if blood pressure is consistently above the 95th centile for age and height for children and young people
Drug treatment choice - children aged 5 years and over and young people
- methylphenidate (either short or long acting) as the first line pharmacological treatment
- switching to lisdexamfetamine should be considered if a 6-week trial of methylphenidate at an adequate dose and not derived enough benefit in terms of reduced ADHD symptoms and associated impairment
- dexamfetamine should be considered if ADHD symptoms are responding to lisdexamfetamine but who cannot tolerate the longer effect profile
- atomoxetine or guanfacine should be offered if:
- they cannot tolerate methylphenidate or lisdexamfetamine or
- their symptoms have not responded to separate 6-week trials of lisdexamfetamine and methylphenidate, having considered alternative preparations and adequate doses
Drug treatment choice - adults
- lisdexamfetamine or methylphenidate are options as first-line pharmacological treatment for adults with ADHD
- switching to lisdexamfetamine should be considered for adults who have had a 6-week trial of methylphenidate at an adequate dose but have not derived enough benefit in terms of reduced ADHD symptoms and associated impairment
- switching to methylphenidate should be considered for adults who have had a 6-week trial of lisdexamfetamine at an adequate dose but have not derived enough benefit in terms of reduced ADHD symptoms and associated impairment
- dexamfetamine should be considered for adults whose ADHD symptoms are responding to lisdexamfetamine but who cannot tolerate the longer effect profile
- atomoxetine should be offered to adults if:
- they cannot tolerate lisdexamfetamine or methylphenidate or
- their symptoms have not responded to separate 6-week trials of lisdexamfetamine and methylphenidate, having considered alternative preparations and adequate doses
For details then consult the full guideline (1).
Monitoring is detailed in the full guideline (1).
Reference: