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March 2018 saw the update of the guidelines for the diagnosis and management of ADHD published by the National Institute for Health and Care Excellence (NICE), with new and updated recommendations made throughout the guidance document building on the guidelines originally released 10 years previously in 2008. While this summary provides a brief overview of some of the updated recommendations in the 2018 revision of the NICE guidelines on the diagnosis and management of ADHD, this is not exhaustive of all recommendations and should not be used for the diagnosis or treatment of patients. Healthcare professionals should consult the full NICE guideline document, which is available on the NICE website.

The first section on service organisation and training includes updated guidance on the services provided and departments involved, as well as updated cross-referencing with other NICE guidelines on transitioning children to adult services. Similarly, the guidance regarding identification and referral of suspected ADHD cases has been updated to include cross-referencing to NICE guidelines on antisocial behaviour and conduct disorders in children and young people, along with clarification specifying that parental support/training should be group-based and ADHD-focused. This section has also been updated with new guidance making physicians aware of patient groups that may have increased prevalence of ADHD.

Guidance on the diagnosis of ADHD has been updated and now states that diagnosis should be made according to the ICD-10 or DSM-5TM. A new guidance section has also been included that outlines available information and support across all aspects of life for the patients themselves, their families/carers and educational establishments, and for other relevant healthcare professionals (when co-existing conditions exist).

To optimise management of ADHD, it is important that a treatment plan is developed. To ensure that patients and their families/carers are fully involved and have an understanding of the plan in place, the guidelines include an updated overview of treatment planning to introduce ADHD management. The update recommends that patients have a comprehensive, holistic, shared treatment plan that takes into account multiple factors, including the severity of the disorder and the patients’ goals of treatment. To ensure that the treatment plan is tailored to the individual needs of the patient, physicians should discuss with the patient and their family/carer the potential benefits and negative effects of all available treatments, the potential benefits of a healthy lifestyle, patient preferences and the importance of adherence to treatment.

Updated management recommendations were included for all age groups, covering non-pharmacological and pharmacological therapies along with an expansion of information on baseline assessments prior to pharmacological treatment initiation. As noted previously, the summary of treatment recommendations below is an overview of some of the updated treatment recommendations in the revised NICE guidelines. This overview is not exhaustive of all treatment recommendations and should not be used as the basis to treat patients. Please refer to the complete NICE guideline document available on the NICE website. Key changes to recommendations for treatment include:

  • Children aged <5 years:
    • Parents/carers of children under 5 years of age with ADHD should be offered an ADHD-focused group training programme as first-line treatment.
    • If ADHD symptoms still cause significant impairment in the child after group parental training and environmental modifications, a specialist ADHD service with expertise in managing ADHD in young children should be approached.
    • Although medication should not be offered without a secondary specialist opinion from an ADHD service with expertise in managing ADHD in young children, treatment with medication is now noted as a possibility in certain circumstances.
  • Children aged ≥5 years and young people:
    • Group-based education and support with environmental modification should be used as first-line therapy for all patients in this age group (irrespective of severity of the disorder).
      • Medication should only be considered in those patients where ADHD symptoms continue to cause significant impairment.
    • Treatment recommendations are no longer split between moderate and severe disorder groups within this age range.
    • Methylphenidate (either short- or long-acting) is recommended as first-line pharmacological therapy.
      • Consider switching to lisdexamfetamine in patients who have had a 6-week trial of methylphenidate at an adequate dose with an inadequate response.
      • Consider dexamfetamine in patients whose symptoms are responding to lisdexamfetamine but who cannot tolerate the longer effect profile.
      • Offer atomoxetine or guanfacine if patients cannot tolerate methylphenidate or lisdexamfetamine, or if their symptoms have not responded to separate 6-week trials of methylphenidate and lisdexamfetamine, having considered alternative preparations and adequate dose.
  • Adults:
    • First-line pharmacological therapy can be initiated with either lisdexamfetamine or methylphenidate.
      • Consider switching to lisdexamfetamine or methylphenidate in patients who have had a 6-week trial of lisdexamfetamine or methylphenidate at an adequate dose with an inadequate response.
      • Consider dexamfetamine in patients whose symptoms are responding to lisdexamfetamine but who cannot tolerate the longer effect profile.
      • Offer atomoxetine if patients cannot tolerate lisdexamfetamine or methylphenidate, or if their symptoms have not responded to separate 6-week trials of lisdexamfetamine and methylphenidate, having considered alternative preparations and adequate doses.

The updated guidelines for treatment in patients with co-existing conditions recommend that people with ADHD and anxiety disorder, tic disorder or autism spectrum disorder should be offered the same medication choices as other people with ADHD. It is also recommended that in children aged ≥5 years, young people and adults with ADHD who experience an acute psychotic or manic episode, all ADHD medication should be stopped; re-initiation of medication should be considered after the episode has resolved.

Finalising recommendations for treatment, the NICE guidelines now include updated advice on medication choices beyond the first- and second-line pharmacotherapies if required, key considerations when prescribing ADHD medication (such as consideration of factors related to modified-release once-daily preparations, variance of effect size and duration of stimulants, and risks of stimulant misuse or diversion) and dose titration (including recommendations that titration should be against symptoms and adverse effects in line with the British National Formulary [BNF]/BNF for Children, and that titration should be slower in those with specific co-existing conditions). Once treatment dose has been stabilised, prescribing and monitoring of ADHD medication should be carried out under Shared Care Protocol arrangements with primary care.

Refreshed guidance also expanded on maintenance and monitoring recommendations (including monitoring height, weight, cardiovascular parameters, tics, seizures, sleep and behaviour), and on methods to improve adherence to treatment across both non-pharmacological and pharmacological therapies (including benefit/risk education). Guidance changes for the management of ADHD conclude with an update to recommendations regarding medication review and patient/carer discussions to determine whether treatment should be continued.

The 2018 update to the NICE guidelines emphasises the importance of individual patient preferences and needs. These new guidelines are now structured around services that assist physicians to provide a more holistic approach to the treatment of ADHD across the lifespan. These guidelines are the result of detailed review of available evidence, and while the application of these guidelines is not obligatory, healthcare professionals are recommended to take these guidelines into account alongside consideration of the needs, preferences and values of the patient.

NICE guideline 2018. Attention deficit hyperactivity disorder: diagnosis and management. Available at: https://www.nice.org.uk/guidance/ng87. Last accessed May 2018.

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