Adult Neurodevelopmental Services ADHD Shared Protocol Issue 1: April 2016 1
2 Adult Neurodevelopmental Service Shared Care Protocol for Adult Attention Deficit Hyperactivity Disorder (ADHD) 1. BACKGROUND 1.1 ADHD is a neuro-developmental condition which manifests as cognitive and behavioural deficits. It is characterised by the core symptoms of hyperactivity, impulsivity and inattention. ADHD is thought to be a persistent condition and a diagnosis of adult ADHD should only be made by a specialist psychiatrist or appropriately qualified healthcare professional with training and expertise in the diagnosis of ADHD. 1.2 It is now widely recognised that in up to 78% (Faraone et al 2010) of ADHD patients the condition continues into adulthood and continues to cause impairment of functioning in a large proportion of these patients. Hence these patients need continuation of their treatment. 1.3 NICE clinical guidelines on the treatment of ADHD (2008) recognises drug treatment of ADHD as part of a comprehensive treatment programme addressing psychological, behavioural and educational or occupational needs. However, it considers drug treatment as the first line treatment unless the person prefers psychological treatment. 1.4 However a comprehensive treatment programme can only be provided by a multi-disciplinary service fully funded for this purpose. The newly developed DWMH Adult Neurodevelopmental Service has not been fully funded by the commissioners and will be provided on a spot purchase basis, therefore at this early stage the Trust will be providing only a limited service to individual named patients for whom this service has been requested and funded by commissioners. 1.5 This service will not be able to address psychological, behavioural and educational or occupational needs of these patients at this stage but initial assessment will identify those needs and Primary Care Physicians will be expected to access the required services through local authorities, IAPT or voluntary organisations. 1.6 The limited service that the Trust we currently provides includes assessment, diagnosis, recommending drug treatment, reviews for optimising the medication and annual reviews thereafter.
2 DRUG TREATMENT OF ADHD IN ADULTS 2.1 NICE; Full guideline Draft (2008) recognised that the treatment strategies for ADHD in adults was essentially similar to those used in childhood. It also very importantly stated that it remains an anomaly that many drugs that are considered to be safe and effective in children and adolescents are not licensed for use in adults. 2.2 The British Association for Psychopharmacology (BAP) 2006; Evidencebased Guidelines for Management of ADHD, addressed the issue of off-license prescribing. It observed that the BNF (Joint Formulary Committee 2005) stated; unlicensed use of medicines becomes necessary if the clinical need cannot be met by licensed medicines; such use should be supported by appropriate evidence and experience. 2.3 BAP Guidelines further state: Although controlled evidence for prescribing in adults is not extensive, this consensus statement can be considered to meet the criteria for adequate evidence and experience when prescribing standard medications to adults with ADHD, when done in the context or with support of specialist psychiatric services. 2.4 Concerta XL, Medikinet XL and lisdexamfetamine are licensed for use in adolescents whose symptoms persist into adulthood and who have shown clear benefit from treatment. Atomoxetine is licensed for initiation in adulthood. Elvanse Adult (lisdexamfetamine) has recently been given licence for treatment initiation in adults. 2.5 Prescribers should always consider any risk/potential of addiction, misuse or diversion as part of their initial assessment. 3. PATHWAYS OF RFERRAL TO ADULT NEURODEVELOPMENTAL SERVICE 3.1 All referrals should initially be sent to: 3
Dr. S H Jawed Consultant Psychiatrist, Adult Neurodevelopmental Service Dorothy Pattison Hospital Alumwell Close Walsall West Midlands WS2 9XH Dr. R Joseph Consultant Psychiatrist, Adult Neurodevelopmental Service Bushey Fields Hospital Bushey Fields Road Dudley West Midlands DY1 2LZ 3.2 Referrals will then be screened by Dr. Jawed and Dr. Joseph. 3.3 Once accepted, referral will be passed on to Commissioning Department to secure the funding approval from relevant CCGs If the referral is considered to be appropriate for the service but funding has not been agreed with the CCG, the Adult neurodevelopmental Service s admin staff will seek funding approval from the relevant CCG. 3.4 On funding approval, appointment letters will be sent out by the Adult Neurodevelopmental Service s admin staff. Letters will also be sent out to PCPs informing them of the appointments and requesting addition information (if required) and baseline physical examination and investigations that PCP should carry out prior to initiation of treatment. 3.5 The funding may be requested for one or more of these assessment pathways, as advised by Dr. Jawed/Dr. Joseph Patients never formally diagnosed Patients previously diagnosed requesting treatment Patient already on treatment, needing review Annual Reviews for patients To be completed yearly Full New patient Assessment for Diagnosis & Treatment New Patient Baseline Assessment New Patient Baseline Assessment Annual Review 4
4. RESPONSIBILITIES 4.1 Responsibilities of Adult Neurodevelopmental Service Diagnosis of ADHD based on comprehensive assessment Recording pre-treatment measurement of weight, pulse rate and blood pressure. A full history and physical examination including: o Assessment of history of exercise syncope, undue breathlessness and other cardiovascular symptoms. o Family history of cardiac disease and examination of the cardiovascular system. To advise primary care physicians (PCP) on social, psychological and behavioural interventions that may be required. Adult Neurodevelopmental Service would not be providing these interventions. To identify co-morbid mental health conditions and advise the PCP to refer the patient to the Adult Mental Health Services if required. To advise on initiating and stabilising treatment with Methylphenidate, Dexamfetamine, Lisdexamphetamine and Atomoxetine. Communicate to PCP which brand of methylphenidate long acting is prescribed, as different brands are not interchangeable. Discuss the benefits and side effects of treatment with patient (including MHRA advice for Atomoxetine in relation to hepatic disorders and suicidal ideation/ self-harming behaviour) Explain the licensing of medicines and when medicines are used off label to the service user and carer and secure their written agreement (if applicable). Also discuss misuse and diversion issues. Send a letter to the PCP requesting shared care stating the patient s diagnosis. Carry out drug optimising and annual reviews as per funding agreement and communicate promptly with the PCP when treatment is changed. Advise the PCP on when to adjust the dose, discontinue treatment, or consult with the Adult Neurodevelopmental Service Ensure that clear backup arrangements exist for PCP to obtain advice and support. 4.2 Responsibilities of Primary Care Physicians To carry out baseline physical investigations as requested by the Adult Neurodevelopmental Service and communicate back the results to them Prescribe Methylphenidate, Dexamfetamine and Atomoxetine at the dose recommended by the Adult Neurodevelopmental service 5
Adjust the dose when advised by the Adult Neurodevelopmental service Report to and seek advice from the Adult Neurodevelopmental service on any aspect of patient care that is of concern and may affect treatment. Carry out regular physical checks and investigations as recommended by the license of each medication and communicate results back to Adult Neurodevelopmental Service. Carry out regular Clinical Monitoring as recommended by the NICE Guidelines and communicate any abnormal results back to Adult Neurodevelopmental Service. Current monitoring requirements which are subject to change include the following: o Weight: Weight to be measured 3rd and 6th month after initiation and six monthly thereafter. If evidence of weight loss monitor BMI, if weight loss persists refer back to prescribing professional. o Heart rate and Blood pressure: Chart before and after each dose change and routinely every three months. Sustained resting tachycardia, arrhythmia or clinically significant high systolic blood pressure after two measurements, consider dose after two measurements consider dose reduction and refer to physician. o Sexual dysfunction: Erectile and ejaculatory dysfunction also dysmenorrhoea should be monitored as potential side effects of Atomoxetine. Refer back to the Adult Neurodevelopmental Service, if the patient s condition deteriorates for a review. Specific triggers for referral back may include: Sustained resting tachycardia, arrhythmia or a clinically significant increase in systolic blood pressure measured on two occasions (reduce dose and refer) Anxiety symptoms, including panic Stop treatment on the advice of Adult Neurodevelopmental Service or immediately if an urgent need to stop treatment arises. Report adverse events to the prescribing professional and the MHRA/ CSM via Yellow card located in BNF or online www.yellowcard.gov.uk. 4.3 Responsibilities of the Patients Report to the prescribing GP if he or she does not have a clear understanding of the treatment. Share any concerns in relation to treatment with methylphenidate, Dexamfetamine, Lisdexamhetamine and Atomoxetine. Inform prescribing GP of any other medication being taken, including overthe-counter products. 6
Report any adverse effects or warning symptoms to the prescribing GP whilst taking Methylphenidate, Dexamfetamine, Lisdexamhetamine and Atomoxetine. 4.4 Contact for support and advice Dr. S H Jawed Consultant Psychiatrist, Adult Neurodevelopmental Service Dorothy Pattison Hospital Alumwell Close Walsall West Midlands WS2 9XH Dr. R Joseph Consultant Psychiatrist, Adult Neurodevelopmental Service Bushey Fields Hospital Bushey Fields Road Dudley West Midlands DY1 2LZ 01922 607039 01384 325065 References 1. DSM IV (Diagnostic and Statistical Manual American Psychiatric Association 2000) 2. Faraone SV, Spencer T, Aleardi M et al. Meta-analysis of the efficacy of methylphenidate for treating adult attention-deficit/hyperactivity disorder. J Clin Psychopharmacol 2004;24:24-29 3. NICE Guideline Quick reference guide; http://www.nice.org.uk/nicemedia/pdf/cg72qrg.pdf 4. British Association for Psychopharmacology 2006; Evidence based guidelines for management of Attention-Deficit/hyperactivity Disorder in Adolescents in transition to Adult Services and in Adults 5. Ritalin, Concerta XL, EquasymXL, Medikinet XL,Elvanse Adult and 7
Atomoxetine Summary of Product Characteristics (accessed via www.medicines.org.uk.emc) 6. Essential Shared Care Agreement (South Staffordshire): Methylphenidate (immediate release and long acting), Dexamfetamine, and Atomoxetine for Attention Deficit Hyperactivity Disorder (ADHD) in Adults (E032 ADHD in Adults ESCA) 7. Full Shared Care Agreement for Methylphenidate, Dexamfetamine, Atomoxetine and Lisdexamfetamine for use in Attention Deficit Hyperactivity Disorder In Adults. On behalf of East Leicestershire and Rutland Clinical Commissioning Group, Leicester City Clinical Commissioning Group, West Leicestershire Clinical Commissioning Group, Leicestershire Partnership NHS Trust and University Hospitals of Leicester NHS Trust. Reviewed in February 2015 8
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