BNF for Children 2011-2012

190 4.4 CNS stimulants and other drugs for ADHD BNFC 2011–20124 Central nervous systemabnormalities; phaeochromocytoma; vasculitis; cerebrovasculardisordersPregnancy limited experience—avoid unless potentialbenefit outweighs riskBreast-feeding limited information available—avoidSide-effects abdominal pain, nausea, vomiting, diarrhoea,dyspepsia, dry mouth, anorexia, reduced weightgain; tachycardia, palpitation, arrhythmias, changes inblood pressure; tics (very rarely Tourette syndrome),insomnia, nervousness, asthenia, depression, irritability,aggression, headache, drowsiness, dizziness,movement disorders; fever, arthralgia; rash, pruritus,alopecia; growth restriction; less commonly constipation,abnormal dreams, confusion, suicidal ideation,urinary frequency, haematuria, muscle cramps, epistaxis;rarely sweating and visual disturbances; veryrarely hepatic dysfunction, cerebral arteritis, psychosis,seizures, neuroleptic malignant syndrome, toleranceand dependence, blood disorders includingleucopenia and thrombocytopenia, exfoliativedermatitis, and erythema multiforme; supraventriculartachycardia, bradycardia, and convulsions alsoreportedLicensed use not licensed for use in children under 6years; doses over 60 mg daily not licensed; doses ofConcerta c XL over 54 mg daily not licensedIndication and doseAttention deficit hyperactivity disorder initiatedby specialist. By mouthChild 4–6 years 2.5 mg twice daily increased ifnecessary at weekly intervals by 2.5 mg daily tomax. 1.4 mg/kg daily in 2–3 divided doses; discontinueif no response after 1 monthChild 6–18 years initially 5 mg 1–2 times daily,increased if necessary at weekly intervals by 5–10 mg daily; licensed max. 60 mg daily in 2–3divided doses but may be increased to 2.1 mg/kgdaily in 2–3 divided doses (max. 90 mg daily) underthe direction of a specialist; discontinue if noresponse after 1 monthEvening dose If effect wears off in evening (withrebound hyperactivity) a dose at bedtime may beappropriate (establish need with trial bedtime dose)Note Treatment may be started using a modified-releasepreparationAdministration Ritalin c tablets may be halved; contentsof Equasym XL c capsules, and Medikinet XL ccapsules, can be sprinkled on a tablespoon of applesauce, then swallowed immediately without chewingMethylphenidate Hydrochloride (Non-proprietary)2Tablets, methylphenidate hydrochloride 5 mg, netprice 30-tab pack = £2.67; 10 mg, 30-tab pack = £6.74;20 mg, 30-tab pack = £9.59Brands include Medikinet c30-tab pack = £36.81; 36 mg (white), 30-tab pack =£42.45. Label: 25Counselling Tablet membrane may pass through gastrointestinaltract unchangedCautions dose form not appropriate for use in dysphagia or ifgastro-intestinal lumen restrictedDoseAttention deficit hyperactivity disorder. By mouthChild 6–18 years initially 18 mg once daily (in themorning), increased if necessary at weekly intervals by18 mg according to response; licensed max. 54 mg oncedaily, but may be increased to 2.1 mg/kg daily (max.108 mg daily) under the direction of a specialist; discontinueif no response after 1 monthNote Total daily dose of 15 mg of standard-release formulationis considered equivalent to Concerta c XL18 mg once dailyNote Concerta c XL tablets consist of an immediatereleasecomponent (22% of the dose) and a modifiedreleasecomponent (78% of the dose)Equasym XL c (Shire) 2Capsules, m/r, methylphenidate hydrochloride 10 mg(white/green), net price 30-cap pack = £25.00; 20 mg(white/blue), 30-cap pack = £30.00; 30 mg (white/brown), 30-cap pack = £35.00. Label: 25DoseAttention deficit hyperactivity disorder. By mouthChild 6–18 years initially 10 mg once daily in themorning before breakfast, increased gradually at weeklyintervals if necessary; licensed max. 60 mg daily, but maybe increased to 2.1 mg/kg daily (max. 90 mg daily) underthe direction of a specialist; discontinue if no responseafter 1 monthNote Contents of capsule can be sprinkled on a tablespoonof apple sauce (then swallowed immediatelywithout chewing)Note Equasym XL c capsules consist of an immediatereleasecomponent (30% of the dose) and a modifiedreleasecomponent (70% of the dose)Medikinet XL c (Flynn) 2Capsules, m/r, methylphenidate hydrochloride 10 mg(lilac/white), net price 28-cap pack = £20.18; 20 mg(lilac), 28-cap pack = £26.91; 30 mg (purple/lightgrey), 28-cap pack = £31.39; 40 mg (purple/grey), 28-cap pack = £43.20. Label: 25DoseAttention deficit hyperactivity disorder. By mouthChild 6–18 years 10 mg once daily in the morning withbreakfast, adjusted at weekly intervals according toresponse; licensed max. 60 mg daily, but may beincreased to 2.1 mg/kg daily (max. 90 mg daily) underthe direction of a specialist; discontinue if no responseafter 1 monthNote Contents of capsule can be sprinkled on a tablespoonof apple sauce (then swallowed immediatelywithout chewing)Note Medikinet XL c capsules consist of an immediatereleasecomponent (50% of the dose) and a modifiedreleasecomponent (50% of the dose)Ritalin c (Novartis) 2Tablets, scored, methylphenidate hydrochloride10 mg, net price 30-tab pack = £5.57Modified releaseConcerta c XL (Janssen) 2Tablets, m/r, methylphenidate hydrochloride 18 mg(yellow), net price 30-tab pack = £31.19; 27 mg (grey),MODAFINILCautions monitor blood pressure and heart rate inhypertension (see Contra-indications); ECG requiredbefore initiation; possibility of dependence; bipolardisorder or history of psychiatric disorders; alcohol ordrug abuse; interactions: Appendix 1 (modafinil)Contra-indications moderate to severe uncontrolledhypertension, arrhythmia; history of left ventricular