Title Document Type Issue no Shared care guidelines in the Treatment of Attention Deficit/ Hyperactivity Disorders Shared Care Guidelines and Information for GPs Clinical Governance Support Team Use Issue date September 2010 (Reviewed October 2013) Review date October 2016 Distribution Prepared by Developed by Equality & Diversity Impact Assessed Posted on NHS Borders intranet Clinicians from Andrew Lang Centre, Mental Health Specialist Pharmacist & Formulary Pharmacist Clinicians from Andrew Lang Centre, Mental Health Specialist Pharmacist & Formulary Pharmcist By development group
Shared Care Guidelines and Information for G.P.s Drugs used in the Treatment of Attention Deficit/Hyperactivity Disorders INTRODUCTION Attention Deficit Hyperactivity Disorder (ADHD) is diagnosed if the three main clinical features of inattention, over-activity and impulsivity have been present from an early age, persist in more than one situation (eg at home and at school) and impair function. UK prevalence is 2 to 5% of school age children. The diagnosis is made following a comprehensive assessment by an appropriately trained Child and Adolescent Psychiatrist and/or Paediatrician with a special interest and training in the field. ADHD is often associated with learning difficulties, social difficulties and other medical and psychiatric disorders. Management includes close liaison with other agencies involved as well as behaviour and educational intervention. DRUG TREATMENT Drug treatment will be initiated by the Psychiatrist/Paediatrician following full discussion and agreement with parents or carers and child. (Patient information leaflets given.) The clinical efficacy of drugs used in the treatment of ADHD is very well evidenced and guidelines for their use have been set out in SIGN 112 (Oct 2009) and by NICE 72 (Sep 2008). DRUGS USED Methylphenidate Hydrochloride (drug of first choice) In form of: Methylphenidate (generic)- Available as 5mg, 10mg tablet Equasym XL - A once daily long-acting form. Available in 10mg, 20mg and 30mg capsules Concerta XL - A once daily long acting from. Available in 18mg, 27mg, 36mg capsules Medikinet XL - A once daily long acting form. Available as 5mg, 10mg, 20mg, 30mg, 40 mg capsules Recommended Dosage Dose usually starts at 5mg once or twice daily (or the lowest dose of the long acting preparation advised by the ADHD clinician) and is incrementally increased to achieve maximum response. If no response is achieved within four weeks, the drug is discontinued. Withdrawal should be gradual especially after long term use. A usual maintenance dose is 10-60mg per day depending on age and response. Maximum recommended dose is 2.1mg per kg per day. Total daily dose of 15mg of standard release formulation is considered equivalent to Concerta XL18mg once daily. Effects Dopaminergic effect on the central nervous system, improves concentration and memory. Rapid onset (20-30 minutes), short duration (3-4 hours). Long acting
preparations have a slower onset (up to 1 hour) and are effective for up to 8 hours (Equasym XL & Medikinet XL) and 12 hours (Concerta XL). Adverse Effects Precautions and Contra-indications Drug Interactions Controlled Drug Therefore subject to requirements for safe custody and hand written prescriptions stating the quantity to be dispensed in words and figures. It is recommended that 28 days only be prescribed and dispensed. May be a drug of misuse. Not Licensed for use in Children Aged 6 years and under or adults but BNF for children gives a dose for 4-6 years for non MR preparations and used routinely in 5 and 6 year olds. Dexamphetamine Sulphate No longer included in NHS Borders formulary for new starts patients currently stable on dexamfetamine do not require to have their choice of medication changed. Lisdexamfetamine dimesylate Lisdexamfetamine dimesylate is indicated in children aged 6 years of age and over when response to previous methylphenidate treatment is considered clinically inadequate. Effects Lisdexamfetamine dimesylate is a pharmacologically inactive prodrug which is rapidly absorbed from the gastrointestinal tract and hydrolysed primarily by red blood cells to dexamfetamine. Recommended Dosage The starting dose for all patients is 30mg once daily in the morning. This may be increased at approximately weekly intervals by 20mg increments, to a maximum of 70mg once daily. The lowest effective dose should be administered. Treatment should be stopped if the symptoms do not improve after 1 month at an appropriate dose. Adverse Effects Precautions and Contra-indications Drug Interactions Schedule 2 controlled drug.
Therefore subject to requirements for safe custody and hand written prescriptions stating the quantity to be dispensed in words and figures. It is recommended that 28 days only be prescribed and dispensed. The SmPC gives details of abuse liability studies which showed that lisdexamfetamine dimesylate has less potential for abuse than dexamfetamine. Atomoxetine Restricted to use in patients who do not respond to stimulants or in whom stimulants are not tolerated or are not clinically appropriate. Effects A selective noradrenaline re-uptake inhibitor. Particularly useful in children with anxiety, tic disorders and Tourettes. Recommended dosage Child over six years and adolescent with body weight up to 70kg, initially 500micrograms/kg daily for seven days, then increased according to response to usual maintenance dose 1.2mg/kg daily. Maximum 1.8mg/kg daily (Max 120mg daily). Child and adolescent with body weight over 70kg, initially 40mg daily for seven days then increased according to response to usual maintenance dose 80mg daily; maximum dose of 120mg daily under specialist direction.. Total daily dose may be given either as a single dose in the morning or in two divided doses with the last dose given no later than early evening. Adverse Effects Precautions and Contra-indications Drug Interactions License for Use For 6-18 year olds only (UK) Atomoxetine is not a stimulant drug (not a controlled drug) and is less likely to be mis-used. Course of ADHD and Arrangements for Transition to Adult Services Approximately 2/3 of young people grow out of the symptoms especially hyperactivity. However, around 1/3 may continue with significant symptoms and are at higher risk of substance mis-use, offending behaviour and emotional and social problems. Most patients will require to continue treatment throughout secondary schooling. At age 18 discussion should take place about the need for continued treatment. If the patient is to continue on treatment they will be referred on to the adult Community Mental Health Team for further management.
Shared Care Aspects Psychiatrist/Paediatrician/Prescribing Psychiatric Nurse Responsible for: Assessment and diagnosis of children with ADHD Initial baseline measurement of height, weight, blood pressure and pulse before initiating a trial of medication, and referral on to a paediatrician for medical assessment if previous history or family history of cardiac disease. Decisions on initiating and discontinuing treatment, altering doses and communicating any such changes to GP Monitoring response to treatment, including measuring height, weight and blood pressure (minimum annual review for established cases) Communicating with Primary Care, School Nurse and other involved Services Communicating with GP/Paediatrician about any complications of treatment School Nurse responsible for: Arranging for extra monitoring of weight and height at request of ADHD clinician, if concern about growth. Alert psychiatrist/paediatrician if any concern. General Practitioner Responsible for: Prescribing drug treatment as recommended by Specialist Communicate any new findings or concerns with ADHD clinician. Contact Points 1. Child and Adolescent Mental Health Services Dr Anne-Marie McGhee and Dr Sarah Glen Child and Adolescent Psychiatrists The Andrew Lang Unit Viewfield Lane Selkirk TD7 4LJ Tel: 01750 23715 3. Borders General Hospital Pharmacy Shirley Watson, Clinical Pharmacist Pharmacy Department Borders General Hospital Melrose TD6 9BS Tel: 01896 826783 2. Primary Care Prescribing Team Ros Anderson Senior Pharmacist Medicines Management Pharmacy Department Borders General Hospital Melrose TD6 9BS Tel: 01896 827708 4. Dr Diana Leaver Community Paediatrician Dept of Child Health Borders General Hospital Melrose TD6 9BS Tel: 01896 826686
Appendix 1 Diagnostic criteria for ADHD to assist with referral by General Practitioners (see SIGN Guideline No 112 Oct 2009) The core symptoms of ADHD and HKD (hyperkinetic disorder) comprise developmentally inappropriate levels of: Inattention (difficulty in concentrating) Hyperactivity (disorganised, excessive levels of activity) Impulsive behaviour In order to meet diagnostic criteria it is essential that symptoms: Have their onset before the age of seven years (ADHD) or six years (HKD) Have persisted for at least six months Must be pervasive (present in more than one setting, e.g. at home, at school, socially) Have caused significant functional impairment Are not better accounted for by other mental disorders (e.g. pervasive developmental disorder, schizophrenia, other psychotic disorders, depression or anxiety) Associated morbidity includes educational under-achievement, antisocial behaviour, delinquency and an increased risk of road traffic accidents in adolescence. In addition, there can be a dramatic effect on family life. The diagnostic criteria for ADHD and HKD have changed with each revision of the Diagnostic and Statistical Manual (DSM) and International Classification of Diseases (ICD) respectively. It is likely that there will be further revision of the criteria to address outstanding issues such as subtypes of disorder, age of onset and the applicability of the criteria across the life span. Current DSM-IV and ICD-10 diagnostic criteria are similar, with differences relating primarily to symptom severity and pervasiveness. DSM identifies three subtypes of ADHD: Predominantly inattentive type (which features inattention but not hyperactivity/impulsivity) Predominantly hyperactive-impulse type (which features hyperactivity/impulsivity but not inattention Combined type (which features signs of inattention and hyperactivity/impulsivity). HKD characterises more severe disturbance with significant hyperactivity included as a criterion for diagnosis. DSM and ICD are categorical models and minimum thresholds of presenting symptoms must be present to achieve diagnosis. Children and young people failing to meet the defined criteria of ADHD/HKD may nevertheless be experiencing significant difficulties in day to day life. Despite the immense literature describing the investigation of ADHD and HKD, their precise definitions continue to be debated and their validity as disorders questioned. This has been addressed in a number of ways and there is substantial evidence in support of the above definitions of ADHD, its subtypes and HKD. Evidence for the
validity of diagnostic criteria for younger children is beginning to emerge, although the applicability of diagnostic criteria across the age range requires further investigation.
Appendix 2 Hypertension in Children (provided by Dr A Duncan) 1. Proper Measurement Ensure paediatric cuffs are available in practices Bladder of cuffs is 2/3 lengths of the upper arm and encircles the arm Korktkoff phases: o K1 is systolic BP o K4 (muffling) is diastolic BP in children 12 years and younger o K5 (disappearance) is diastolic BP in children older than 12 years Children should sit; infants should be supine Right arm at level of heart Inflate 20mmHg above point where the radial pulse disappears Circadium rhythm; nadir of BP early morning hours and peak in the afternoon 2. Definition of Hypertension Significant Hypertension Age Systolic Diastolic 0-7 days >95 8-30 days >103 Infant (<2yr) >111 >73 3-5 yrs >115 >75 6-9 yrs >121 >77 10-12 yrs >125 >81 13-15 yrs >135 >85 16-18 yrs >141 >91 An unacceptable drug-induced rise in blood pressure would be a 20% or greater increase above baseline. Adapted from the Task Force on Blood Pressure Control in Children Report of the Second Task Force on Blood Pressure Control in Children Paediatrics 79:1-25 (1987) Revised: October 2013 For Review: October 2016. Lead clinician ADHD (CAMHS).