What additional assessments should be conducted before starting medication?
Blood pressure should be measured using an appropriately sized cuff. It is usual to measure it sitting down after around 10 minutes of rest, with three further repetitions. For children, the mean blood pressure should be compared with age and height-based percentiles. The Royal Children’s Hospital guideline for hypertension in children includes a link to the American Academy of Paediatrics online calculator that can be used for this purpose. It provides clinical information about what to do if blood pressure increases.
Off-Label Prescribing
The RANZCP has produced guidance for off label prescribing in psychiatry and we recommend that professionals prescribing for ADHD, including non-psychiatrists make themselves familiar with this guidance before prescribing off-label. Download the RANZCP Professional Practice Guideline 4: ‘Off-label’ Prescribing in Psychiatry here.
In their guidance for off-label prescribing the RANZCP outline important clinical and ethical issues. These include the need to be particularly careful when obtaining consent and ensuring that off-label prescribing is reserved for those people for whom standard treatments have not improved sufficiently. They also highlight that consent must be obtained and documented citing Principle 5 of the RANZCP Code of Ethics which is available to view here.
What are the maximum doses of the stimulants?
Currently within Australia there are variations between the states and territories as to the maximum dose allowed for both children and adults. These have been catalogued by AADPA here.
Titration protocols – extended release guanfacine
Guanfacine extended-release tablets use a controlled release mechanism that facilitates the extended duration of action (guanfacine is the only genuinely 24-hour ADHD medication). As detailed in the Consumer Medicine Information, which is available to view here, the tablets should not be crushed, chewed, divided, or compounded before swallowing because this increases the rate of guanfacine release and is likely to lead to significant adverse effects including severe hypotension.
What rating scales are recommended for monitoring core ADHD symptoms?
The International Consortium for Harmonising Outcome Measures (ICHOM) was set up to improve harmonisation of measurement internationally. The (ICHOM) Neurodevelopmental Disorders Group project used a combination of systematic review and a Delphi process to identify key outcomes for DSM-5 defined neurodevelopmental disorders (excluding autism for which a core set already exists).
This process led to the recommendation that the DSM symptom scales are the most appropriate outcome measures for core ADHD symptoms in children and adolescents. These scales include:
- Swanson, Nolan, and Pelham Rating Scale (SNAP-IV), free to use
- ADHD Rating Scale-5 (ADHD-RS-5) must be purchased for use.
- ADHD Diagnostic Rating Scale (VADRS), the VADRS is free to use
AADPA incorporated the SNAP-IV into their ADHD Tracker app along with the SKAMP a 10-item rating scale designedfor use in a school setting to monitor ADHD symptoms.
There are other freely available rating scales such as the IOWA Conners that is another 10 item scale which can be completed by parents and teachers.
Should you use medication holidays?
While there is no strong evidence to support the routine use of formal medication holidays these may be beneficial for some people. See NICE guideline 87 for a review of the evidence here (Withdrawal from pharmacological treatment and drug holidays).
Outcome measures for adults
While the same rating scales used in children and adolescents (SNAP-IV, ADHD-RS-5, and the Vanderbilt) can be used in adults, their use in this population is less well validated and may cause issues as the wording of the questions is still slanted towards younger people.
An alternative is the Adult ADHD Self-Report Scale (ASRS-v1.1).
What are the best ways to monitor adverse effects?
An alternative form update of this scale is available as a part of clinical documentation developed by Coghill, Lim, Gomez-Flores & Seth, 2015
FAQ #4. What are the Pharmaceutical Benefits Scheme (PBS) Listings for ADHD Medications?
Current PBS and approximate non-PBS cost/month can be found here on the PBS website.
FAQ #23. Are there particular issues regarding treatment of ADHD in Aboriginal and Torres Strait Islander Peoples?
This information is taken from the AADPA Factsheet on ADHD in Aboriginal and Torres Strait Islander Peoples.
FAQ #9. Is there an association between Substance Use Disorder and ADHD and what are the recommendations?
Download the AADPA Factsheet where this topic is also covered here.
FAQ #6. Can Lisdexamfetamine (Vyvanse) be Dissolved and Diluted and if so, what is the Stability?
Instructions for dissolution can be found in the Vyvanse Product Information here and Consumer Medicines Information sheets available here.
FAQ #20. What are the Career and Occupational Considerations?
For aviation, specific guidelines and constraints are outlined by the Civil Aviation Safety Authority (CASA) here.
