B-QuiCK: Pharmacological management of ADHD in adults and children

B-QuiCK: Pharmacological management of ADHD in adults and children

• Methylphenidate, lisdexamfetamine or dexamfetamine are all first-line treatment options for adults with ADHD who have symptoms that significantly impact their daily lives
• Prescribe the most appropriate formulation based on the clinical situation, patient preference and medicine availability

Pre-treatment screening and investigations

• Review medical history and prescribed medicines to identify cautions and rule out any contraindications (Click here for contraindications and cautions)
• Record weight, check heart rate and blood pressure (CVD assessment)
• Consider ECG, cardiologist opinion or referral in the following situations:
  • Prescribed concurrent medicines that “may pose an increased cardiac risk”
    • Discuss with cardiologist if patient is prescribed any cardiac medicine
    • Arrange an ECG (at minimum) if taking any medicines with potential cardiovascular adverse effects, e.g. tricyclic antidepressants.
  • Hypertension - do a baseline ECG
  • A history of congenital heart disease, cardiac surgery or sudden cardiac-related death in a first-degree relative aged < 40 years
  • Shortness of breath or fainting on exertion
  • Heart palpitations
  • Suspected cardiac chest pain
  • Heart murmur on examination

Establish symptom and function baseline

• Provides a baseline for dose titration and measuring treatment response
• Can use a validated symptom questionnaire, e.g. Adult ADHD Self-Report Scale
• Identify areas in which symptoms have the most significant impact on life and collaboratively set treatment goals

Identifying and addressing co-morbidities is critical

• Assess for (and manage) co-morbid mental health conditions before initiating psychostimulant medicines, e.g. schizophrenia, bipolar disorder, suicidal ideation or substance misuse
• If previously diagnosed with a mental health condition, re-evaluate current treatment plan (for that condition) and check for medicine interactions

Psychostimulant medicines and eating disorders

Psychostimulant medicines during pregnancy and breast-feeding

Choosing a medicine – immediate- or modified-release?

Prescribe a formulation based on the clinical situation, desired duration of effect, patient preference and medicine availability (Click here for an overview of funded psychostimulant medicines).

Immediate-release formulations: Ritalin, Rubifen, Dexamfetamine (Noumed)

• Allows for simple dose titration
• Fast onset and short duration of action, therefore several doses throughout the day may be required
  • May lead to poor treatment adherence, dosing errors and adverse effects due to fluctuations in blood concentrations or rebound ADHD symptoms at the end of the medicines’ duration of action (rapid “weaning off” effect)
• Prescribe immediate-release methylphenidate generically where appropriate (to allow brand change depending on supply)

Modified-release formulations: Rubifen SR, Ritalin LA, Concerta, Methylphenidate ER-Teva, Methylphenidate Sandoz XR, Vyvanse (lisdexamfetamine)

• Single-daily dosing is often more convenient and can improve adherence
• Lessens or avoids sharp blood concentration spikes and drop-offs, reducing the potential for adverse effects and rebound ADHD symptoms when the treatment wears off
• Modified-release formulations, e.g. Concerta, and lisdexamfetamine are less likely to be misused or abused because of the smaller immediate-release component and the delivery technology prevents tampering/makes other delivery methods ineffective
• Prescribe modified-release methylphenidate preparations by brand

Initiate psychostimulant medicines at a lower dose and titrate up; this is a trial and error process (Click here for initial dosing regimens).

Initial monitoring during dose titration

• Frequent monitoring is necessary during initial titration
• Check-ins can be via phone/virtual but an in-person clinical review is needed within two to four weeks of starting psychostimulant medicines
• Use standard scales to assess symptom improvement and measure treatment response, including personal treatment goals
• Consider slower dose titration, more frequent in-person monitoring or discussion with a psychiatrist for patients with other neurodevelopmental disorders, concomitant mental health conditions or any other condition that may be worsened while taking psychostimulant medicines, e.g. cardiovascular disease (including hypertension), epilepsy

Finding the right daily dosing regimen

• The optimal dose reduces core ADHD symptoms and improves functional outcomes with minimal adverse effects
• A treatment response is typically expected at doses of 0.5 – 1 mg/kg for methylphenidate (expert opinion)

At every follow-up, review:

1. Are core ADHD symptoms well controlled, i.e. low scores on symptom scales?
2. Does symptom control vary throughout the day (or from day to day) and does this variation present challenges?
3. Is the duration of action correct for the individual needs of that patient?
4. Are there any adverse effects that warrant a dose reduction?

Increase or decrease the dose of psychostimulant based on the responses to these questions

Switching to a modified-release formulation

• Patients initiated on immediate-release formulations of methylphenidate can be switched to the equivalent total dose (in milligrams) of a modified-release formulation, if appropriate
• Start patients initiated on dexamfetamine (who want to switch to lisdexamfetamine, and vice versa), on the lowest dose and titrate up again as amfetamines are not dose equivalent

Tailoring the psychostimulant regimen over time once the appropriate formulation and optimal dose have been established

• Immediate-release methylphenidate doses can be added to provide symptom control:
  • Before the effects of a modified-release formulation become apparent
  • When the effects of the modified-release formulation have decreased
• Doses may not need to be taken every day, e.g. medicine-free periods during the weekends or reduced doses on certain days to avoid adverse effects. N.B. Psychostimulant medicines should be taken consistently (i.e. every day) during titration to observe effects on all areas of the patient’s life, before tailoring the regimen.

Monitoring and follow-up once stabilised on psychostimulant medicines

• Arrange regular follow-up to assess treatment response and monitor for adverse effects:
  • Six-monthly is reasonable if symptoms are mild to moderate and well controlled
  • More frequent review if severe symptoms, co-morbidities or other concerns
• Every review should include:
  • Evaluation of ongoing improvement in ADHD symptoms; use standard scales
  • Measurement of weight, heart rate and blood pressure. ECG or laboratory investigations only required if there is a clinical indication.
  • Assessment for, and addressing, any adverse effects, e.g. sleep disturbances, mood changes, changes in appetite or weight loss, increases in blood pressure or heart rate, tics, seizures, deteriorating mental health

Trial a different psychostimulant if treatment response is insufficient

• If insufficient (or no) improvement in ADHD symptoms after a six-week trial of a psychostimulant at an appropriate dose (e.g. 0.5 – 1 mg/kg) switch to another formulation or medicine
• Before switching:
  • Determine that the medicine is being taken as prescribed
  • Confirm that the agreed upon treatment goals are realistic and align with the expected effects of psychostimulant medicines
  • Assess whether the most appropriate ADHD symptoms are being measured to evaluate treatment response
  • Identify co-morbidities or other modifiable factors that may impact treatment goals, e.g. psychiatric co-morbidities, family or social circumstances. Address these where possible.
  • Reconsider if the ADHD diagnosis is correct

General principles for switching psychostimulant formulations

• Establish a baseline for symptoms and daily functioning to guide dose titration. Re-evaluation for substance misuse or diversion may also be appropriate.
• Previously trialled brands of methylphenidate, or amfetamines, that resulted in a good treatment response and were well tolerated should be the first choice
• Ideally, select another brand that is most similar to the current medicine. However, be aware that some patients may not respond/experience the same effect even with a similar brand.
• Theoretically, all brands of methylphenidate have daily dose equivalence but start the new brand at a reduced dose, to evaluate treatment response before titrating back up
  • If switching from a modified-release (or prodrug) formulation to divided doses of an immediate-release formulation, warn patients that they may experience variations in symptom control because of peaks and troughs in plasma levels
• Methylphenidate and amfetamines are not considered dose equivalent; if switching between these, start at the lowest dose and slowly increase based on treatment response and adverse effects (Click here for initial dosing regimens)
  • Dexamfetamine doses are typically half of methylphenidate doses (expert opinion)
• Close monitoring is required; evaluate treatment response and adverse effects one to two weeks after any change in formulation or dose
• Consider dosing adjustments before switching again. Confirm that any new adverse effects are not related to the duration of action.
• Trial a second alternative within the same class before switching to a different medicine, e.g. trial two brands of methylphenidate before switching to an amfetamine, or trial both types of amfetamine before switching to a methylphenidate formulation

Regularly revisit the need for treatment

• Continue treatment as long as the patient is experiencing benefit; this may be life-long in some cases
• Regularly discuss preferences for continuing or stopping treatment, including:
  • Confirmation that a clinical indication remains
  • The patient’s (or caregiver’s) opinion on whether they are still experiencing a therapeutic benefit
  • The development of any new adverse effects
  • The impact of missed doses or dose reductions on the patient’s day-to-day life
• A treatment holiday or a period of treatment at a reduced psychostimulant dose can be helpful to assess ongoing need

Stopping psychostimulant treatment for ADHD

• Psychostimulant medicines can generally be stopped abruptly without adverse effects
• Consider a gradual taper if the patient is stabilised on a high dose, or has previously reported discontinuation symptoms during a treatment holiday
• Discuss factors that may prompt restarting psychostimulant medicines in the future

Clinician resources

Patient and family/whānau resources