NEL Adult ADHD GP resources
North East London Adult ADHD GP resources
Welcome to the North East London Adult ADHD GP advice and guidance space.
Here you will find advice and guidance to support you with your requests. All guidance supports shared care arrangements and should be used alongside local shared care guidance and clinical judgement.
ADHD Treatment In-Patients With A History Of Substance Misuse Quick Clinical Guide
This guidance supports shared care arrangements and should be used alongside local shared care guidance and clinical judgement.
Can ADHD medication be prescribed in patients with a history of substance misuse?
A history of substance misuse is not a complete contraindication to using stimulants. Sometimes people with ADHD will have “self-medicated” with illicit substances in the past and receiving treatment for with prescribed stimulants removes the need for illicit versions.
⚠ Active uncontrolled substance misuse requires specialist assessment before prescribing.
What should I monitor during shared care in patients with a history of substance misuse?
- Ask about current alcohol intake, smoking/vaping, illicit drug use and changes in substance use at routine reviews.
- Assess adherence, symptom control and adverse effects.
- Check prescription request patterns for early requests, reports of lost medication, or repeated missed appointments.
- Encourage engagement with local substance misuse services where appropriate.
What if substance misuse develops or worsens?
- Discuss concerns with the patient
- Identify what substances have been used, how often, for how long and document findings
- ⚠ Hold further prescriptions
- ⚠ Refer back to the specialist ADHD service, if there is new or escalating alcohol dependence, illicit drug use, or concerns that substance misuse is affecting safe treatment.
- ⚠ Refer to drug and alcohol services if patient is willing to engage in them.
What if diversion or misuse of ADHD medication is suspected?
- Discuss concerns openly with the patient and document the outcome.
- Review prescribing history and available information. Some signs of possible diversion/misuse of stimulants may be:
- Repeated requests for early prescriptions
- Frequent reports of lost or stolen medication
- Evidence of dose escalation without specialist advice
- Concerns raised by carers, family members or healthcare professionals
- ⚠ Contact the specialist ADHD service for urgent advice regarding ongoing prescribing.
Does it need escalation?
SEEK URGENT SPECIALIST REVIEW OR EMERGENCY ASSESSMENT IF ANY OF THE FOLLOWING OCCUR:
- Suspected overdose
- Acute intoxication with prescribed ADHD medication
- Severe behavioural disturbance, psychosis or mania
- Significant safeguarding concerns
- Serious risk to the patient or others
- Evidence of diversion of controlled medication
In the event of any of these, hold further supply.
ADHD Treatment, Hypertension & Tachycardia - A Quick Clinical Guide
This guidance supports shared care arrangements and should be used alongside local shared care guidance and clinical judgement.
Can stimulants be given to patients with hypertension?
Yes, if hypertension is well controlled.
⚠ Do not start stimulants in patients with moderate to severe hypertension.
How should blood pressure rises be managed whilst on a stimulant?
- Record a baseline blood pressure and monitor every 6 months, and before and after each dose change.
- Any rises in blood pressure should be contextualized against the patient’s baseline measurements.
- Small increases in blood pressure and pulse are recognised during stimulant treatment
- Persistent and clinically significant increases in blood pressure from baseline should the following:
- Optimise hypertension management if pre-existing hypertension is present and continue monitoring
- Dose reduction and ongoing monitoring, (ambulatory/24 hour blood pressure monitoring may be appropriate
- ⚠ In more severe cases, consider pausing treatment and refer to specialist
- ⚠ Consider cardiology referral if appropriate.
How do I manage tachycardia?
- Record a baseline pulse before treatment.
- Small increases in blood pressure and pulse are recognised during stimulant treatment.
- Check for other stimulants such as caffeine or nicotine, which may worsen tachycardia.
- Any tachycardia should be contextualized against the patient’s baseline measure.
- Persistent resting tachycardia or a clinically significant increase from baseline should prompt dose reduction, monitoring and/or specialist review.
- ⚠ In more severe cases, pause therapy and refer back to specialist
- ⚠ Consider cardiology review if appropriate.
Does it need escalation?
REFER TO EMERGENCY SERVICES IMMEDIATELY IF ANY OF THE FOLLOWING OCCUR:
- Chest pain
- Persistent or regular palpitations
- Arrhythmias
- Shortness of breath (not explained by another condition)
- Syncope (fainting)
Restarting ADHD medication and advice for missed doses - A Quick Clinical Guide
This guidance supports shared care arrangements and should be used alongside local shared care guidance and clinical judgement.
Patient stopped medication for up to 1 week
Usually no re-titration is required, provided if:
- The previous dose was well tolerated
- No new cardiovascular concerns
- No significant changes in mental health
- No contraindicated medicines have been started
Action:
May resume the previous stable dose if there are no new cardiovascular, psychiatric, or medication-related concerns.
Continue routine monitoring.
Patient stopped medication for 1–8 weeks without prior plan in place – Assess for interval changes
Many patients may require cautious dose re-titration, particularly if:
- Previous adverse effects occurred
- Higher stimulant doses were used
- Significant clinical changes have occurred
Also consider if anything has changed since treatment stopped such as:
- Blood pressure
- Pulse
- Weight
- New diagnoses
- Pregnancy
- Mental health deterioration
- New medicines
- Cardiovascular symptoms
Action:
Primary care should contact the specialist service for individualized advice. A reduced restart dose and re-titration may be appropriate depending on the previous dose and clinical changes.
Patient stopped medication for more than 8 weeks – prolonged interruption
- Specialist review required
- Reassessment of ADHD symptoms
- Review of physical health
- Re-titration plan
Action:
Do not routinely restart the previous dose. Refer to the specialist service for review and re-titration plan.
Patients who have restarted medication themselves without specialist instruction
Steps to take:
- Identify duration of the treatment break
Risks
- Increased blood pressure
- Tachycardia
- Adverse psychiatric effects
- Incorrect dosing
- Reduced monitoring
Recommendation
Arrange review before continuing prescribing.
Perform appropriate safety checks.
Unknown duration of missed treatment
Treat as prolonged interruption until time of missed doses clarified.
When should primary care contact the specialist service in the case of a treatment break?
- Treatment interruption is more than 8 weeks.
- The patient was discharged from specialist follow-up.
- There is new cardiovascular disease.
- There is new psychosis, bipolar disorder, or significant mental health deterioration.
- The patient is pregnant or planning pregnancy.
- The medication was stopped because of adverse effects.
- The patient has self-restarted treatment.
- There is any uncertainty regarding safe restart or dose selection.
Managing Medication Shortage - A Quick Clinical Guide
This guidance supports shared care arrangements and should be used alongside local shared care guidance and clinical judgement.
Advice and Guidance - Managing Medication Shortage - A quick clinical guide[docx] 57KB
My patient has informed me that their pharmacy do not have my medication in stock and are unable to order it for me- What should I do?
Please check if there is an official shortage of the medication required via Specialist Pharmacy Service website (Medication shortage Tool - log in is required).
If there is no official shortage, ppatients should be encouraged to contact other local pharmacies to locate stock
My patient is on a medication in which there is an official medication shortage- What should I do?
If a specific strength is unavailable and the dose can be made using other strengths, this should be considered first.
If a specific brand is unavailable, there are certain brands which are considered interchangeable. Generic prescribing can be considered at this point. Please note that switching between MR preparations should only occur where bioequivalence has been established The follows are considered interchange:
Methylphenidate Modified Release Tablets:
- Affenid XL tablets
- Atenza XL tablets
- Concerta XL tablets
- Delmosart tablets
- Matoride XL tablets
- Xaggitin XL tablets
- Xenidate XL tablets
Methylphenidate Modified Release Capsule:
- Focusim XL capsules
- Metyrol XL capsules
- Meflynate XL capsules
- Ritalin XL capsules
Please note that Medikinet XL is not considered completely bioavailable to the above preparations. If switches to/from Medikinet XL are made, this should be done with additional care.
Switching from Methylphenidate modified release (MR) to instant release (IR)
Equivalence between of MR products and IR products is as follows:
- Concerta XL 18mg once daily is equivalent to a total daily dose of 15mg IR methylphenidate
- Medikinet XL 10mg once daily is equivalent to a total daily dose of 10mg IR methylphenidate
Switching from Lisdexamfetamine to Dexamfetamine
| Elvanse daily dose | Suggested starting dose for switches – monitor and increase if necessary/ tolerated to the full equivalent dose. | Full equivalent dose - may be necessary for symptom control, if tolerated. |
| 20mg | 5mg in divided doses | 7.5mg in divided doses |
| 30mg | 7.5mg in divided doses | 12.5mg in divided doses |
| 40mg | 10mg in divided doses | 15mg in divided doses |
| 50mg | 15mg in divided doses | 20mg in divided doses |
| 60mg | 17.5mg in divided doses | 25mg in divided doses |
| 70mg | 20mg in divided doses | 30mg in divided doses |
If the patient is on a combination of Lisdexafetamine and Dexamfetamine, please contact the specialist service for an individualized dosing regimen.
Please contact the specialist service if a switch from one pharmacological agent to another is required.
Controlled Drugs Governance
This guidance supports shared care arrangements and should be used alongside local shared care guidance and clinical judgement.
Advice and Guidance - Controlled Drugs (CD) Governance[docx] 36KB
Lost prescriptions / lost medication
Controlled drugs (e.g. methylphenidate, lisdexamfetamine, dexamphetamine) are subject to strict governance and are not routinely replaced early. Prescribers should assess circumstances (first episode vs repeated losses, timing in prescription cycle, safeguarding concerns, previous pattern). Consider checking the patient's prescribing history (including the NHS Spine where appropriate) before issuing replacement prescriptions. Genuine isolated loss may occasionally justify replacement supply, but only with clear rationale. Repeated loss should raise concern for misuse, diversion, or unstable use, requiring documentation and specialist review.
Early medication requests (including “running out early”)
Early supplies are not routine. Review adherence, prescribing history, and clinical need. Document the rationale for any exception and refer for specialist review if requests are recurrent.
Overseas travel requests
CDs may be supplied for travel. Requests should be assessed for duration, destination regulations, and risk of over-supply or diversion. Supply should be limited to a reasonable period aligned with clinical need. Patients should be advised to carry medication in original packaging with prescription label and check destination legal requirements. Large or extended supplies require specialist input or governance review.
Suspected diversion / misuse
Suspected diversion is a patient safety and medicines governance issue. Indicators include repeated early/lost requests, inconsistent histories, multiple prescribers, dose escalation without review, or concerning behaviour patterns. Do not escalate dose. Consider withholding supply pending review, document concerns clearly, and escalate for specialist ADHD assessment and/or MDT discussion. Safeguarding concerns may require additional escalation pathways.
Pregnancy and breastfeeding
This guidance supports shared care arrangements and should be used alongside local shared care guidance and clinical judgement.
Advice and Guidance - Pregnancy and breastfeeding - A GP guide[docx] 36KB
How to support patients on ADHD treatment that are planning to become pregnant.
Assess plans for conception.
Review ADHD treatment needs; Consider symptom severity, previous relapse, and risks of untreated ADHD.
Avoid stopping medication abruptly without discussion. Refer to specialist for further advice.
What to do if a patient discovers pregnant whilst on medication
Advise the patient not to stop suddenly.
Arrange prompt review. Refer to specialist to undertake an individual risk-benefit assessment.
Risk of untreated ADHD versus risk of treatment should be established and review.
What is the best option for ADHD treatment if pregnant.
Current evidence does not demonstrate a major increase in congenital malformations for most ADHD medications; however, data remain limited for some outcomes. Individual risk-benefit assessment by the specialist team is recommended.
There is insufficient evidence to recommend switching treatment solely because of pregnancy. Decisions should be specialist-led.
What if the patient wants to stop treatment during pregnancy?
Abrupt discontinuation may worsen ADHD symptoms. Consider gradual reduction if appropriate and after specialist advice.
What are non-pharmacological options?
Discuss behavioural strategies, psychological support, occupational adjustments and environmental modifications where appropriate.
Refer patients to local ADHD support organisations and maternity services for further support.
What to do if medications are stopped during pregnancy and symptoms become unmanageable?
Consider urgent specialist review if symptoms significantly affect functioning.
When to restart ADHD meds if stopped during pregnancy and who should restart?
Consider specialist referral to review for future treatment need.
Insomnia in Patients taking Stimulant medication for ADHD
This guidance supports shared care arrangements and should be used alongside local shared care guidance and clinical judgement.
Advice and Guidance - Insomnia in Patients taking Stimulant medication for ADHD[docx] 36KB
Can stimulant medication cause insomnia?
Yes. Difficulty falling asleep, reduced sleep duration and poor sleep quality are recognised adverse effects of stimulant medication.
However, ADHD symptoms themselves, anxiety, caffeine use and poor sleep hygiene may also contribute to sleep disturbance. Some patients have reported improved sleep when taking stimulant medication as their hyperactivity symptoms are better controlled.
Insomnia is often most noticeable when treatment is initiated or following dose increases.
What steps should I take if the patient present with insomnia?
- Establish whether sleep problems were present before ADHD treatment was started.
- Ask about sleep onset, night-time waking and early morning waking.
- Review stimulant dosing schedule and timing of the last dose.
- Assess for other contributors including caffeine, nicotine, alcohol, recreational drug use, anxiety, depression and physical health conditions.
- Encourage use of a sleep diary to aid diagnosis
- Encourage good sleep hygiene measures
- Consider behavioural sleep interventions or CBT-I where available
- If clinically appropriate, consider adjusting the timing of the dose to earlier in the day, or if still unresolved consider a dose reduction and monitor response.
- Continue treatment if ADHD symptoms remain controlled and sleep disturbance is mild and manageable.
What should I prescribe for the insomnia?
- Follow local prescribing guidance.
- Address underlying causes before considering additional medication.
- ⚠ Do not initiate sleep medication solely to manage stimulant-related insomnia unless recommended within local guidance or by the specialist service.
- Seek specialist advice if ongoing pharmacological treatment for insomnia is being considered.
Does it need escalation?
SEEK URGENT REVIEW IF ANY OF THE FOLLOWING OCCUR:
- ⚠ Severe insomnia causing significant deterioration in mental state or functioning.
- ⚠ New psychotic symptoms, mania or severe behavioural disturbance.
- ⚠ Suicidal ideation or significant mental health deterioration.
- ⚠ Concerns regarding medication misuse or inappropriate dose escalation.
ADHD Frequently asked medication queries: A Quick Clinical Guide
This guidance supports shared care arrangements and should be used alongside local shared care guidance and clinical judgement.
Advice and Guidance - ADHD FAQs Medication queries - A quick clinical guide[docx] 49KB
Patient reports medication wearing off too early – what are the options?
Patients may report that their medication is effective initially but symptoms return later in the day.
Possible causes include:
- Medication duration is shorter than expected.
- Dose may no longer be optimal.
- Increased work, education or lifestyle demands.
- Poor adherence or inconsistent dosing.
GP action
- Confirm adherence, dose timing and whether medication is being taken as prescribed.
- Exclude other causes of worsening symptoms (e.g. poor sleep, anxiety, substance use or physical health problems).
- Continue the current prescription if it remains safe to do so. Refer the patient to the specialist ADHD service for medication review.
Do not adjust doses or add afternoon "top-up" doses under shared care unless specifically advised by the specialist service.
Patient requesting a dose increase
Patients may request higher doses because symptoms have returned or life demands have changed.
GP action
- Explore the reason for the request.
- Confirm adherence to the current regimen.
- Exclude other contributing factors (e.g. stress, sleep disturbance or mental health difficulties).
- Continue prescribing the current dose if clinically appropriate.
If you would like further advice regarding increasing the dose, seek specialist recommendation.
Patient wants to switch from methylphenidate to lisdexamfetamine
Patients may request an alternative medication because of:
- Reduced effectiveness
- Side effects.
- Convenience or duration of action.
GP action
- Continue the current medication if it remains safe.
- Refer to the specialist ADHD service.
Medication switches require clinical assessment, dose conversion and re-titration, and should only be undertaken by the specialist service.
Patient has stopped medication and wishes to restart
Before restarting treatment, it is important to establish:
- Why medication was stopped.
- How long treatment has been interrupted.
- Whether there have been any changes to physical or mental health.
GP action
- Do not routinely restart ADHD medication after a prolonged interruption without specialist advice. Please refer to our missed doses leaflet.
- Ensure up-to-date physical observations are available.
- Refer the patient to the specialist ADHD service for assessment before restarting where required.
- Patients who have had only a brief interruption (e.g. a few missed days) may not require full reassessment; however, longer treatment breaks generally require specialist review.
Shared care medication no longer appears effective
Reduced effectiveness may be due to:
- Poor adherence.
- Lifestyle changes.
- Co-existing mental or physical health conditions.
- Medication tolerance (less commonly).
GP action
- Confirm adherence and administration.
- Assess for new physical or mental health concerns.
- Continue prescribing if clinically appropriate.
- Refer the patient for specialist review.
- Do not increase doses or change medication without specialist advice.
Pharmacy Advice – Clarity before escalating
Consider the following before referring:
- Is the medication being taken consistently?
- Has the patient changed when or how they take it?
- Have there been significant lifestyle changes?
- Are side effects limiting adherence?
- Are routine monitoring observations up to date?
- Are there any new physical or mental health concerns?