4.4 CNS stimulants and other drugs used for ADHD
PAEDIATRIC NOTES - CENTRAL NERVOUS SYSTEM STIMULANTS AND DRUGS USED FOR ADHD
General Practitioners will be requested to issue both initial and continuing prescriptions for ADHD medication following assessment and diagnosis by specialists. Prescribing of CNS stimulants etc for ADHD for children and adolescents between the ages of 6 and 18 years assessed and diagnosed as having ADHD by a specialist in either Child and Adolescent Psychiatry or Paediatrics (prescribing guidance).
Initial management usually involves a trial of immediate-release methylphenidate with early review and stabilisation of dosage to achieve maximum reduction of main symptoms of poor concentration, distractibility and impulsiveness with minimal side effects.
Relative or absolute contra-indications for use of immediate-release methylphenidate may be an indication for use of second-line pharmacological treatments, including:
- long acting methylphenidate preparations - Concerta® XL, Equasym XL®, Medikinet XL® - Note: These XL preparations have different release characteristics and are therefore not interchangeable. They should be prescribed by brand name,
- dexamfetamine tablets or
- atomoxetine capsules (non stimulant).
On occasion off-label use of tricyclic antidepressants or clonidine may also be considered in specific circumstances.
Atomoxetine can affect heart rate and blood pressure, patients should have a careful history and physical exam to assess for the presence of cardiac disease, and receive further specialist cardiac evaluation if initial findings suggest history or disease. Heart rate and blood pressure should be recorded on a centile chart, before and during treatment, and after each dose adjustment, and then at least every 6 months.
Atomoxetine should be used with caution in children and adolescents with a personal or family history of QT interval prolongation on ECG, seizures or liver disease. Further investigations including ECG maybe indicated (see prescribing guidance).
Stimulant medication requires ongoing review with minimum six monthly specialist review once established. Height, weight, blood pressure and pulse require to be monitored at each visit. Feedback to relevant professionals must be undertaken following review.