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National supply shortage of medicines for ADHD - Update September 2024
Update on ADHD medication shortage in the UK
We are providing an important update on the ongoing ADHD medication shortages affecting the UK. This situation impacts several medications commonly used to treat Attention Deficit Hyperactivity Disorder (ADHD), leading to significant disruptions for patients. We acknowledge the challenges this shortage presents and are committed to providing support to our clinicians and patients.
Current Supply Disruptions
The Department of Health and Social Care (DHSC) has issued multiple alerts and notifications regarding these shortages:
- National Patient Safety Alert (NatPSA) : Issued on 27 September 2023, highlighting shortages of methylphenidate prolonged-release capsules and tablets, lisdexamfetamine capsules, and guanfacine prolonged-release tablets.
- Medicine Supply Notifications (MSNs) :
- Lisdexamfetamine (Elvanse) capsules on 13 February 2024.
- Guanfacine (Intuniv) prolonged-release tablets on 28 March 2024.
These notifications have superseded the earlier NatPSA and provide detailed updates on the supply situation. Prescribing advice is available from the following key resources listed in the NatPSA:
- NICE guideline [NG87]. Attention deficit hyperactivity disorder: diagnosis and management
- MHRA (2022). Methylphenidate long-acting (modified-release) preparations: caution if switching between products due to differences in formulations
If you are taking any of these medications, please contact your ADHD medicine prescriber using the numbers below for advice about the most appropriate option for you.
The supply disruption of these products is caused by a combination of manufacturing issues and an increased global demand.
Please do not share your medication with anyone else.
If your needs are very complex, for example you have mental health problems, or your ADHD symptoms causes you severe difficulty, you can discuss this with your GP, and they may recommend a specialist consultant review.
Anyone who is currently waiting to be started on ADHD medication will not receive a prescription until stocks are available.
Prescribing advice: Products in red below are in short supply.
Note: GPs are advised to contact specialist teams for advice if needed with regards to changing products/switches.
|
Category of medication |
DHSC and NHS England Medicines stock status |
Live update: 1st September 2024 |
Action needed |
|
Stimulant |
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Methylphenidate: Biphasic release profile of 22% immediate: 78% modified Bioequivalent products- Available in strengths- 18mg/ 27mg/ 36mg/ 54mg Concerta® XL tablets Delmosart® prolonged-release tablets Matoride® XL tablets Xaggitin® XL tablets Xenidate® XL tablets Affenid® XL tablets |
All Brands are in limited supply – supply disruptions are expected to continue until October 2024. Affenid® XL tablets- 27mg/ 36mg/ 54mg- projected resupply dates: October 2024 Delmosart® PR tablets- 18mg/27mg/36mg- no projected date Matoride® XL - 36mg – no projected supply date Xaggitin® XL tablets- 18mg/ 27mg/ 36mg/ 54mg- projected dates: October 2024 Xenidate® XL tablets- 18mg/27mg/ 36mg/ 54mg- projected date November 2024 Concerta® XL – 54mg – no projected date |
All currently out of stock |
DHSC/ NHS advice to primary care Prescribe alternate available brands Prescribe on separate FP10 and do not send as electronic prescription to nominated pharmacy unless supply has been confirmed Seek advice from specialist service. DHSC/ NHS advice to specialist teams Defer starting any new patients on the affected brands until the supply disruptions are resolved. Offer rapid response to primary care teams seeking urgent advice/opinion for the management of patients with ADHD, narcolepsy and idiopathic hypersomnia. This includes those known to be at a higher risk of adverse impact because of these supply disruptions. For example, those with complex presentations including co-morbid autism, mental health or substance misuse needs. To prescribe generically (Except Kent CAMHS) and pharmacy can supply product available e.g. ‘Methylphenidate modified release 18mg tablets’ Additional advice See sub-sections under table |
|
Methylphenidate: Biphasic release profile of 30% immediate: 70% modified
No bio-equivalent product Equasym XL 10mg/ 20mg/ 30mg capsules |
Remains available, but supply disruptions are expected as they cannot support increased demand. |
Currently available, but supply is expected to remain inconsistent. |
Do not start any new patients Aim to keep on Equasym XL (stable patients) Check product availability before prescribing Consider using lower dose with top up of immediate release Consider switching to Medikinet XL (50:50), and add immediate top up if clinically appropriate Consider switching to longer acting biphasic above (22:78) if patient would benefit from being on a longer acting stimulant |
|
Methylphenidate: Biphasic release profile of 50% immediate: 50% modified
Medikinet XL capsules 5mg, 10mg, 20mg, 30mg, 40mg, 50mg, 60mg
Metyrol XL capsules 10mg, 20mg, 30mg, 40mg, 50mg |
Available |
Limited stock currently available |
These products are bioequivalent in terms of release profile To continue to prescribe by brand
|
|
Category of medication |
DHSC and NHS England Medicines stock status |
Live update: 1st September 2024 |
Action needed |
|
Stimulant |
|
|
|
|
Methylphenidate immediate release Methylphenidate tablets 5mg, 10mg, 15mg Requires up to three times a day dosing |
Available |
All strengths available |
Can be prescribed instead of modified release if appropriate for those on lower doses or requiring short acting product Can be prescribed as a top up to modified release if appropriate Prescribe generic (Except Kent CAMHS) |
|
Lisdexamfetamine Elvanse 20mg, 30mg, 40mg, 50mg, 60mg and 70 mg capsules. Elvanse ADULT caspules 30mg, 50mg, 70mg |
Available |
All strengths available |
No bioequivalent product Elvanse and Elvanse ADULT contain the same active ingredient: Lisdexamfetamine DHSC/ NHS advice primary care Prescribe on separate FP10 and do not send as escript to nominated pharmacy unless supply has been confirmed Seek advice from specialist service DHSC/ NHS advice specialist teams Use clinical judgment when initiating patients who may require titration at 10mg increments Take into account that Elvanse 40mg, Elvanse Adult 40mg and Elvanse 60mg doses may be unavailable at times, which will limit titration options. Offer advice to primary care teams seeking advice/opinion on the management of individual patients. This includes those known to be at a higher risk of adverse impact of these shortages. For example, those with co-morbidity autism, mental health or substance misuse Additional advice: Defer low risk new initiations if clinically appropriate Aim to keep on the same product/ dose where possible (stable patients) Check product availability before prescribing Adjust dose based on product availability Prescribe generic as Lisdexamfetamine and pharmacy can supply product which is available e.g. ‘Lisdexamfetamine 20mg capsules’ Alternatives if clinically appropriate Long acting biphasic methylphenidate 22:78 with immediate release top up Non stimulant Dexamfetamine immediate release as below: |
|
Category of medicine |
Stock status |
Action needed |
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Stimulant |
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Dexamfetamine - BLACK TRIANGLE DRUG Dexamfetamine tablets 5mg and 10mg Dexamfetamine capsules 5mg/ 10mg/ 15mg Dexamfetamine 5mg/ 5ml oral solution sugar free |
No projected issues with product availability |
Specialist service initiation only |
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Can be considered as a potential alternative to Lisdexamfetamine in special cases/ circumstances Risk of abuse/ diversion should be considered as part of the prescribing decision 20 mg capsule lisdexamfetamine dimesylate is approximately equivalent to 5.9 mg of dexamfetamine. |
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Suggested equivalence as follows (South London and Maudsley NHS): LISDEX 20mg = 5mg Dexamfetamine in divided doses LISDEX 30mg= 7.5mg Dexamfetamine in divided doses LISDEX 40mg= 10mg Dexamfetamine in divided doses LISDEX 50mg= 15mg Dexamfetamine in divided doses LISDEX 60mg= 17.5mg Dexamfetamine in divided doses LISDEX 70mg= 20mg Dexamfetamine in divided doses (MAX 20mg/24hrs for children/ adolescents) |
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Dosing as per BNF Requires between twice to four times a day dosing |
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Non-stimulants |
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Atomoxetine |
Limited stock of capsules currently available |
No bio-equivalent products |
|
Capsules 10mg/ 18mg/ 25mg/ 40mg/ 60mg/ 80mg/ 100mg
|
Oral solution 4mg/ml- out of stock |
Stable patients: Advise to maintain dose/ product where possible Adjust dose based on product availability |
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Oral solution 4mg/ml
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uanfacine prolonged release Tablets: 1mg, 2mg, 3mg, 4mg
|
All strengths available |
No bio-equivalent products Stable patients: Advise to maintain dose/ product where possible Adjust dose based on product availability |
Clinical advice
High risk patients requiring switching of medication/prioritisation (list is not exhaustive)
- Children/adults with complex needs (mental and physical co-morbid conditions).
- Children/adults with co-morbid neurodevelopmental conditions e.g. ASD/ADHD and intellectual disability.
- Children/adults with the above and challenging behaviours.
- Children/adults on polypharmacy e.g. antipsychotic + stimulant + other medication/ psychotropic.
- Children/adults in special needs provision/ school.
- Reports of child/adult showing increased risk e.g. physical aggression/ self-injurious behaviours/ breakdown of placement or school provision etc.
Advice to specialist teams/ services
- Continue to review those on maintenance doses as per clinically appropriate.
- Advised to provide 28 days or maximum 30 days (for controlled drug) prescriptions for stable and repeat prescriptions of ADHD medicines. Do not issue more than 30 day supply as this may exacerbate supply shortages.
- When changing the dose and/ or issuing prescriptions, please check supply with the pharmacy used by the patient/ family.
- For those on maintenance dose, please adjust dose based on product availability.
- Where the dose has been adjusted due to product availability, it is the responsibility of the clinician to agree with the patient/ family when the next review needs to take place.
- To advise GPs/ primary care on dose adjustments (if needed) for patients under primary care maintained on ADHD ADHD medicines. Advice should take into consideration product availability, as well as agreement with the GP who should review the patient post dose change in needed.
- To advice GPs/Primary care on patients suitable for a treatment break, based on specialist’s clinical judgement.
Advice to primary care services
- Practices are advised to identify patients who are currently on ADHD medications and add alert to clinical record of supply issues. A patient information leaflet and ‘easy to read leaflet’ are available to support conversations with patients.
- Provide 28 days or maximum 30 days (for controlled drug) prescriptions for stable and repeat prescriptions of ADHD medicines. Do not issue more than 30 day supply as this may exacerbate supply shortages.
- GPs are advised to contact the appropriate specialist service at the earliest opportunity if there are on-going issues in obtaining medication for advice on dose adjustments OR if patient is identified as ‘high risk/ high needs’- Contacts are provided at the end of this memo.
- Liaise with local and nominated pharmacies for patients with electronic prescriptions to ensure pharmacies are pre-emptively keeping adequate stocks and are informed where a dose/ formulation has changed.
Advice to community pharmacies
- Identify patients who have repeat prescriptions of ADHD medicines.
- To have a system in place to ensure adequate stocks for those families/patients who have a designated pharmacies for repeat supply.
- Where community pharmacies are part of a chain, the adviCe is to liaise with other branches in your locality to have an indication of local stock availability of ADHD medicines.
- Where another branch in your locality has stock, please liaise and transfer, required stock, to your branch and/or liaise with the branch and send prescription to them to be completed (if practical for families/ patients).
Further advice/ support
The situation with regards to product availability is fluid at present. If services are unsure about the supply of a certain strength and/ or product, please contact your local pharmacy team for further advice.
Patient education/counselling
- Services to agree what information should be shared with patients/families re: shortages. A patient information leaflet and ‘easy to read leaflet’ are available to support conversations with patients.
- Patients should be provided age/cognitively appropriate verbal and written medication on medication. This should include any specific additional monitoring which may be needed for specific patients.
- Patients should avoid abrupt withdrawal of medication.
- Patients can be signposted to the information on ADHD in adults available from the Royal College of Psychiatrists (adults) and to Medicines in Children leaflets (children/ parents/carers)
Information for patients and families
Introduction
Attention Deficit Hyperactivity Disorder (ADHD) can be managed by changes in lifestyle, diet, having social/ family relationships for support, as well as attending peer support or for children parenting groups. For a proportion of children and adults in addition to this, they may need ADHD medication to help with attention, concentration or feeling less physically or mentally ‘on the go.’
What is the current situation?
Currently, there are problems with the availability and supply of a range of a type of medication used to treat ADHD, called stimulants. These include Concerta XL®, Delmosart XL®, Xaggitin XL®, Xenidate XL®, Affenid XL®, and Matoride XL®.
There are supplies of this stimulant medication coming in, but this is changing every day.
Why is this happening?
There is no one reason why there are shortages in the stimulant medication supply. There has been an increase in demand for medication to manage ADHD. There has also been a change in the companies who produce and supply the medication. Some have stopped making certain strengths and others have stopped making certain products. All this combined has led to difficulties in meeting the supply needs of patients.
How long is this likely to be the case?
There are supplies coming in of the ADHD medication. Supply of most stimulant medication is expected to return to normal between September 2024 and January 2025.
Which medicines are affected?
The main medication affected are some of the stimulant medications. There are various brands and strengths coming into pharmacies, but they are in short supply and at times also showing as ‘not available’.
What should I do as a patient/ parent/ carer?
For now, please continue with the medication you/ or your child has been prescribed.
Please order repeat medication from your GP with at least between 7-14 days supply left of medication.
Check with your usual pharmacy if they have the medication or they can order it in when you give the prescription.
Check with nearby pharmacies to see if they have and/or able to order in the medication.
If you are not sure what to do, or if the medication is not available, then please contact your GP or specialist team at the earliest opportunity for advice and help.
What will happen if the medication I/ my child’s is taking is not available?
Please contact your GP at the earliest opportunity if your medication is a regular repeat from the GP surgery.
Please contact your specialist service, if you are open to secondary care for prescribing and/ or you/ your child has only recently started ADHD medication.
Specialist team refers to for example, adult ADHD service, Child development centre, children services or child and adolescent mental health team. If you are with a specialist team, their contact details will be on your appointment letter.
Where the medication or a particular strength of a medication is not available, your GP/ member of the specialist team will talk to you about other medication strengths or options available.
Information for parents/ carers: Medication at school
If your child is having medication administered at school by staff, it is important to let the school special needs (SEN) team know about the shortages in ADHD medication.
The advice would be to agree a plan with the school SEN team and class teacher to help support your child whilst they are at school- in the event your child attends school and has not taken their ADHD medication.
Schools like to keep an ‘original pack’ labelled for the child at school. Due to the current shortages, it may not be possible to provide a separate supply for home and school. The advice would be to share the medication between home and school and agree with the school who the medication should be handed to at the start of the school day and who will hand it back to the parent at the end of the school day.
In cases, where the ADHD medication is needing to be shared between home and school, please request the next prescription when you have 14 days of medication left. This should allow enough time for the prescription to come from GP/ specialist team and for the pharmacy to source the medication.
If you or the SEN team would like advice and support, please contact your child’s CAMHS team. (Links below.)
If you are open to social care- please let your social worker/ family support worker know of the shortages.
Please be patient with services as there will be delays in getting changed prescriptions and medication across areas. Specialist services, GPs and community pharmacies are working together to ensure the disruption to the supply of ADHD medication effects patients as little as possible.
If you have any worries or concerns, please contact your GP surgery or specialist team for help/ advice.
(Last updated 18 September 2024)