Methylphenidate. Plain – Ritalin® and Medikinet®: Child 4-5 years old (unlicensed), initially 2.5 mg twice daily, increased in steps of 2.5 mg daily if required, at weekly intervals For Children over 6 years initially 5mg once, or twice daily with or after breakfast and lunch, increasing if necessary in weekly intervals of 5-10mg in 2 to 3 divided doses. The maximum licensed dose for methylphenidate is 60mg daily, with 90mg daily used in some specialist centres, which is supported by NICE (NICE NG 87 March 2018). In some children rebound hyperactivity may occur if the effect of the drug wears off in the evening. An additional dose later in the day may eliminate this difficulty but may disturb sleep. Equasym XL®: Child 6* years or over, initially 10mg once daily (in the morning before breakfast), increasing if necessary in weekly intervals to a maximum of 60mg daily. For children 4-5 years 10mg daily (in the morning with breakfast) could be considered but this is unlicensed. Medikinet XL®: Child 6* years or over, initially 10mg once daily (in the morning with breakfast), adjusted according to response at weekly intervals to a maximum of 60mg daily. For children 4-5 years old Medikinet XL 5mg once daily (in the morning before breakfast) could be considered, with this being unlicensed Concerta XL®, Xaggitin XL Matoride XL® & Xenidate XL®: Child 6* years or over initially 18mg once daily (in the morning), increasing if necessary in weekly increments of 18mg up to a maximum licensed dose of 54mg once daily. For children 4-5 years 18mg daily (in the morning with breakfast) could be considered but this is unlicensed. Branded Concerta XL Generics – all are considered by MHRA as being bioequivalent to Concerta XL preparations Branded Generic Doses Available Xaggitin XL 18mg, 27mg, 36mg & 54mg Delmosart XL 18mg, 27mg, 36mg & 54mg Matoride XL 18mg, 36mg & 54mg Xenidate XL 18mg, 27mg, 36mg & 54mg Note: SPfT endorses Xaggitin XL as a suitable 12 hour MPH option for new patients and for switching appropriate existing Concerta XL patients due to its cost effectiveness (50% reduction in acquisition costs), same doses available and pilot studies suggesting ease of switching.
Methylphenidate. Generic prescribing of MR Methylphenidate is not recommended due to cost implications and impact of monitoring of patient response to treatment as a result of increased variability in different brands being supplied to the young person. There is also the added factor that modified release preparations have varying release profiles and generic prescribing can lead to the supply of an inappropriate MR formulation product which does not treat meet the clinical needs of the young person. However, where the clinician (CAMHS/ Paediatricians) has assessed a young person would benefit from a modified release profile, the following is recommended: • To prescribe by brands and not generically as different versions of modified-release preparations may not have the same clinical effect • To prescribe a cheaper bio-equivalent brand as agreed between ELFT, CAMHS, Paediatricians and the CCGs • Any switch in bioequivalent MR Methylphenidate brand must be agreed with the clinician (CAMHS/ Paediatricians), GP, parent/ carer and where appropriate, the young person. • Written medication information must be provided on the brand where a bioequivalent switch has been agreed ADVERSE EFFECTS Where the young person is under the care of the Paediatrician and/ or CAMHS team, the GP can seek advice from the relevant specialist with regards to making any changes and/ or discontinuation of medication Adverse effect1 Symptoms/ signs Occurs with MPH, ATMX, DEX, LDE or GUA? Frequency* Suggested actions Gastro-intestinal symptoms Stomach ache MPH, LDEX, GUA Very common Usually transient may occur on starting treatment but these go after a few days. Possibly helped by taking the medication after food. Decreased appetite/ anorexia MPH, DEX, ATMX Common Usually transient. Take medication with food rather than before meals. For MPH, DEX: additional meals or snacks taking early in the morning or in the late evening when the 1 For a full list of adverse effects, please consult the most recent version of the BNFC, or the manufacturers Summary of Product Characteristics (SPC). stimulant effects of the drugs have worn off may help. Dry mouth MPH, DEX, LDEX, GUA Common Usually transient. Encourage fluid intake, chewing of sugar-free gum or sucking sugar-free boiled sweets. Abdominal pain, nausea and vomiting MPH, DEX, ATMX, GUA Common Usually at beginning of treatment & may be helped by taking with food. Constipation ATMX, GUA Common Maintain a good fluid intake, a fibrous diet and exercise regularl...
Methylphenidate. Plain – Ritalin® and Medikinet®: Child over 6 years initially 5mg once or twice daily e.g. with or after breakfast and lunch, increasing if necessary in weekly intervals of 5-10mg in 2 to 3 divided doses. The maximum licensed dose for methylphenidate is 60mg daily, with 90mg daily used in some specialist centres, which is supported by NICE (NICE CG 72 September 2008). In some children rebound hyperactivity may occur if the effect of the drug wears off in the evening. An additional dose later in the day may eliminate this difficulty but may disturb sleep.
Methylphenidate. Diagnosis or history of severe depression, anorexia nervosa or anorexic disorders, suicidal tendencies, psychotic symptoms, mania, schizophrenia, severe mood disorders, or psychopathic or borderline personality disorder, vasculitis or stroke. Lisdexamfetamine▼ - Advanced arteriosclerosis, agitated states, hyperexcitability, hyperthyroidism, moderate hypertension, severe hypertension, symptomatic cardiovascular disease. Dexamfetamine - History of drug abuse or alcohol abuse - Pregnancy and lactation. Atomoxetine Not be used in combination with monoamine oxidase inhibitors (MAOIs), narrow angle glaucoma, pheochromocytoma, severe cardiovascular and cerebrovascular disorders. Monitoring Requirements: o Blood pressure & pulse every 6 months o Height and weight every 6 months and plotted on a growth chart o If the patient has a change in height or weight that crosses two percentile lines, then this suggests an aberrant growth trajectory and should be reffered to the specialist. o If growth is significantly affected by drug treatment (that is, the child or young person has not met the height expected for their age), the option of a planned break in treatment over school holidays should be considered to allow 'catch-up' growth to occur o Strategies to manage decreased weight gain in children, include: o taking medication either with or after food, rather than before meals o taking additional meals or snacks early in the morning or late in the evening when the stimulant effects of the drug have worn off o obtaining dietary advice o consuming high-calorie foods of good nutritional value o No routine measurement of LFTs / FBC, but measure if signs of liver impairment (seen with atomoxetine) o In line with other shared care documents, see ‘areas of responsibility’
