Shared care agreement - ADHD to 18 years - SWLSTG



|Shared Care Guideline: Prescribing Agreement |

|Methylphenidate, Lisdexamfetamine▼, Dexamfetamine and Atomoxetine for |

|Attention Deficit Hyperactivity Disorder in patients 6-18 years of age |

|Section A: To be completed by the hospital consultant initiating the treatment |

|GP Practice Details: |Patient Details: |

|Name: ……………………………………… |Name: ……………………………………………… |

|Address: …………………………………… |Address: …………………………………………… |

|Tel no: ……………………………………… |DOB: ……/………/………… |

| e-mail: …………………………… |Hospital (IAPTus/RiO) No: ……………………… |

| |NHS number (10 digits): ………………………… |

|Consultant & Clinic name: ………………………… |

|Address: ................................................................................. |

|Tel no: ……………………………………… e-mail: …………………………… |

|Diagnosis: |Drug name & dose to be prescribed by GP: |

| | |

|Next hospital appointment: |Date of appointment: |

|Dear Dr. …………………….., |

|Your patient was seen on the date above and I have started the medicine above for the above diagnosis. I am requesting your agreement to |

|sharing the care of this patient two weeks from the date of this letter in accordance with the attached Shared Care Prescribing. Please take |

|particular note of Section 2 where the areas of responsibilities for the GP and patient are detailed. |

| |

|Patient information has been given outlining potential aims and side effects of this treatment. |

|Please monitor: |

|Height, weight and blood pressure and pulse six monthly. |

|For signs of liver toxicity with atomoxetine. |

|For diversion of lisexamfetamin, dexamfeatmaine or methylphenidate. |

|For deterioration in behaviour or adverse effects (refer back to specialist). |

|Report all adverse effect of lisdexamfetamine to the MHRA via the yellow card system. |

| |

|The following investigations have been performed on the date below are acceptable for shared care. |

|Test |

|Result |

|Date |

|Test |

|Result |

|Date |

| |

|Blood pressure |

| |

| |

|Weight (incl centiles) |

| |

| |

| |

|Pulse |

| |

| |

|Height (incl centiles) |

| |

| |

| |

|Mental Health Team please ensure the latest blood results are attached with this agreement |

|Other relevant information: ……………………………………………………………………………………….. |

|……………………………………………………………………………………………………………………….. |

|Section B: To be completed by the GP and returned to the hospital consultant as detailed in Section A above |

|Please sign and return your agreement to shared care within 14 days of receiving this request |

|Tick which applies: |

|□ I accept sharing care as per shared care prescribing guideline and above instructions |

|□ I would like further information. Please contact me on:………………………. |

|□ I am not willing to undertake shared care for this patient for the following reason: |

|………………………………………………………………………………………………………………. |

|GP name: ………………………………………….………. |

|GP signature: ………………………………………………Date: …/…/….. |

|Working in partnership with |

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|SHARED CARE PRESCRIBING GUIDELINE |

|Methylphenidate, Lisdexamfetamine▼, Dexamfetamine and Atomoxetine for |

|Attention Deficit Hyperactivity Disorder in patients 6-18 years of age |

|NOTES to the GP |

|The expectation is that these guidelines should provide sufficient information to enable GPs to be confident to take clinical and legal responsibility |

|for prescribing this drug. |

| |

|The questions below will help you confirm this: |

|Is the patient’s condition predictable or stable? |

|Do you have the relevant knowledge, skills and access to equipment to allow you to monitor treatment as indicated in this shared care prescribing |

|guideline? |

|Have you been provided with relevant clinical details including monitoring data? |

| |

|If you can answer YES to all these questions (after reading this shared care guideline), then it is appropriate for you to accept prescribing |

|responsibility. Prescribe only 28 days at a time with a review date of every 6 months. |

| |

|If the answer is NO to any of these questions, you should not accept prescribing responsibility. You should write to the consultant within 14 days, |

|outlining your reasons for NOT prescribing. If you do not have the confidence to prescribe, we suggest you discuss this with your local |

|Trust/specialist service, who will be willing to provide training and support. If you still lack the confidence to accept clinical responsibility, you |

|still have the right to decline. Your CCG pharmacist will assist you in making decisions about shared care. |

| |

|It would not normally be expected that a GP would decline to share prescribing on the basis of cost. |

|The patient’s best interests are always paramount |

| |

|Reviewed: October 2015 |Review date: Sept 2017 |

|Approved by (date approved): | |

|SWLStG Drug & Therapeutic Committee | |

|Mental Health Interface Prescribing Forum | |

| |

|Participating Clinical Commissioning Groups (CCG) |Participating Hospital Trusts |

|Kingston CCG |SWL & St. George’s Mental Health Trust |

|Dr Anthony Hughes, GP on behalf of Medicines Management Committee |Dr M Zwi (CAMHS Consultant) |

|Seema Buckley, Chief Pharmacist |Dianne Adams (Chief Pharmacist) |

|Richmond CCG | |

|Dr Stavroula Lees, Lead GP for Mental Health | |

|Emma Richmond, Head of Medicines Management | |

|Merton CCG | |

|Dr Andrew Otley, Mental Health Lead | |

|Sedina Agama, Chief Pharmacist | |

|NHS Wandsworth | |

|Dr Gillian Ostrowsky, Associate Medical Director | |

|Nick Beavon, Chief Pharmacist | |

|Sutton CCG | |

|Dr Chris Kears, Mental Health Lead | |

|Sarah Taylor, Chief Pharmacist | |

|Methylphenidate, Lisdexamfetamine▼, Dexamfetamine and Atomoxetine in under 6-18yrs |

CIRCUMSTANCES WHEN SHARED CARE IS APPROPRIATE

Prescribing responsibility will only be transferred when the Child and Adolescent Mental Health Service (CAMHS) and the GP are in agreement that the patient’s condition is stable or predictable and in accordance with NICE guidance.

The patients will only be referred back to the GP once the GP has agreed in each individual case and the hospital will continue to provide prescriptions until successful transfer of responsibilities as outlined below

The hospital will provide the patient with a minimum initial supply of 4 weeks of medication

Areas of responsibility

|CAMHS |GP |

|To assess the patient and establish a diagnosis of attention-deficit hyperactivity |Monitor patient’s overall health and well being. |

|disorder; to determine a management strategy and communicate this to the family & GP. The |Prescribe methylphenidate, lisdexamfetamine, dexamfetamine|

|diagnosis must clearly be demonstrated through a detailed report outlining the current |or atomoxetine once the treatment has been established, |

|problems, developmental history and presence of “core signs” of ADHD. These must meet the |the patient stabilised on a particular dose and brand of |

|diagnostic criteria of the DSM-IV or the ICD-10 (hyperkinetic disorder). |medication and the care of patient has been transferred |

|Consider and discuss ADHD drug treatment options with the parents / responsible adult for |and accepted. |

|the children who meet the criteria laid-down in NICE guidelines of September 2008. This |Monitor height, weight and blood pressure and pulse six |

|should include consideration of contra-indications, interactions and cautions (inc |monthly. Notify the specialist if the patients growth is |

|driving), a discussion of the reasons for treatment, the possible adverse effects and the |lower than that exected, taking in to consideration the |

|lack of information in relation to longer-term outcomes including effectiveness and adverse|physical stature or the biological family. |

|effects. |Advise the patient to attend specialist appointments (at |

|Ensure relevant baseline investigations are performed, documenting height, weight and blood|least annually). |

|pressure and pulse and additional relevant investigations (e.g. ECG if family history of |Re-refer the patient or seek specialist advice from the |

|arrhythmias or sudden death). |psychiatrist or paediatrician if there is deterioration in|

|Initiate treatment with methylphenidate, lisdexamfetamine, dexamfetamine or atomoxetine |ADHD symptomatology, behaviour, or adverse effects of |

|and prescribe medication until the dose has been stabilised. During this time monitor the |medication. |

|patient as required for symptom control and side effects. Discontinue if no improvement of|Although misuse of methylphenidate, lisdexamfetamine and |

|symptoms. |dexamfetamine is rare, the GP should alert the Specialist |

|Provide the GP with appropriate clinical information and individual patient information. |to previous misuse of drugs by the young person or family |

|This may need to be more comprehensive with atomoxetine as GPs have much less experience |members if such information is known. This is particularly|

|and familiarity with this medicine. |important because methylphenidate, lisdexamfetamine and |

|Be available to give advice to GP if the patient’s condition changes and to ensure that |dexamfetamine are controlled drugs. |

|procedures are in place for prompt specialist review. |Observe for potential liver toxicity with atomoxetine, |

|Once ADHD symptoms have been reduced and the medication has been stabilised (see 4 above), |signs include abdominal pain,unexplained nausea, and |

|the patient will then be reviewed at least annually. The review should include an |malaise, darkening of urine or jaundice. |

|assessment of symptoms, benefit of treatment and review of possible side effects. |To report any adverse drug reactions to the Medicines and |

|Discontinue treatment periodically (usually annually) and advise the GP accordingly. |Healthcare Products Regulatory Authority (MHRA) as part of|

|Provide supervision and assessment of the child during these periods. |the yellow card scheme. |

|Liaise with the patient’s school and suggest appropriate extra educational provision where |Refer back to consultant if patient becomes pregnant. |

|necessary. | |

|Where the drug is to be continued beyond the age of 18, the consultant will advise about | |

|the options for ongoing care within adult services for each patient’s particular needs. | |

|Patient/ carer’s role |

|Attend follow up appointments with Consultant (at least annually) |

|Attend for tests and follow up appointments with GP (at least 6 monthly) |

|Keep medication safe and for personal use only |

COMMUNICATION AND SUPPORT

|Hospital contacts: |Out of hours contacts & procedures: |

|(the referral letter will indicate named consultant) | |

|Enter the contact details of your local | |

|CAMHS |Psychiatrist & Pharmacist available via the |

| |SWLStG Switchboard 020 3513 5000 |

|Clinic/Hospital name | |

|Consultant names | |

|Tel: | |

|Fax: | |

|E-mail: | |

| |

|Contact with CAMHS |

|BMJ patient information found by at besthealth. |

|2. Medicines Information Website swlstg-tr |

|Information in the British National Formulary for Children (BNFc) |

|Summary of Product Characteristics emc..uk |

|NICE Guidelines – QS 39 ADHD (July 2013) and CG 72 (Sept 08) .uk |

|ADHD support groups e.g. or (both of whom receive sponsorship from the pharmaceutical industry) |

|SWLSTG Psychiatric Medicines Information 020 3513 6829. |

|CLINICAL INFORMATION | | |

|Indication(s) |Attention-deficit hyperactivity disorder (which is broadly similar to hyperkinetic disorder) is defined by core signs |

| |of an excess of inattention, hyperactivity and impulsiveness. |

| |These are normal personality traits, so is important to establish that they are present to a greater extent than |

| |expected in children of a developmental stage, that they cause impairment (commonly in social or academic domains) and|

| |that they are pervasive across a range of situations. |

| |Affected children often have co-morbid conditions including conduct disorder, oppositional defiant disorder, |

| |depression, anxiety, tic disorders and other developmental disorders. |

|Place in therapy |Methylphenidate (CD Sch 2) (instant release and long acting – Xenidate XL® (Concerta XL® for 27 mg dose), Equasym XL®,|

| |and Medikinet XL®). |

| |First line for the management of Attention Deficit/Hyperactivity Disorder (ADHD) in children aged 6 years and over and|

| |in adolescents. |

| |Lisdexamfetamine (CD Sch 2) ▼ |

| |Second line for attention Deficit/Hyperactivity Disorder refractory to methylphenidate unless there are substance |

| |misuse issues or anxiety issues in which case atomoxetine should be used as the second line choice. This includes |

| |where there is a risk of the diversion of a controlled drug. |

| |Dexamfetamine (CD Sch 2) |

| |Refractory hyperkinetic states, or if methylphenidate fails. |

| |Atomoxetine |

| |First or second line management of Attention Deficit/Hyperactivity Disorder (ADHD) in children aged 6 years and over |

| |and in adolescents especially where there are substance misuse issues or anxiety issues. This includes where there is |

| |a risk of the diversion of a controlled drug. |

| | |

| |Please note: Methylphenidate is the usual preferred drug of choice, however some patients may require an alternative |

| |drug according to individual need. |

|Therapeutic summary |Methylphenidate, lisdexamfetamine, dexamfetamine and atomoxetine reduce the ADHD “core symptoms”: excessive |

| |inattention, hyperactivity and impulsivity. |

|Duration of treatment |Determined on an individual basis. Discontinue treatment periodically (usually annually), or if no improvement. |

| |Transition to adult psychiatric services to be managed on an individual case basis as currently the numbers are very |

| |few, but increasing. |

|Dose and Route of |All preparations are for oral administration. |

|Administration |Dosage and timing will depend upon the patient and the form of the medicine: |

| |Methylphenidate |

| |Standard / Immediate release preparations |

| |Ritalin® 10mg tablets & Medikinet® 5mg, 10mg, 20mg |

| |Initiate at 5mg OD or BD; increase dosage if necessary weekly, by increments of 5-10mg per day |

| |Usual maximum dosage 60mg per day in divided doses (usually at intervals of 3-4 hours) |

| | |

| |Modified release preparations |

| |1st line -Xenidate-XL® 18mg, 36mg MR tablets |

| |Initiate at 18mg daily; increase dose gradually according to needs and response of the patient. |

| |Usually up to 54mg per day (max 108mg daily unlicensed). |

| |Concerta-XL® is available for the 27mg strength |

| |Equasym XL® 10mg, 20mg, 30mg MR capsules – consists of an immediate-realease component (30% of the dose) and a |

| |modified-release component (70% of the dose) |

| |Initiate at 10 mg once daily in the morning before breakfast, increased gradually if necessary |

| |Usually up to 60 mg daily. |

| |Medikinet XL® 10mg, 20mg, 30mg, 40mg MR capsule – consists of an immediate-realease component (50% of the dose) and a |

| |modified-release component (50% of the dose) |

| |Initiate at 10 mg once daily in the morning before breakfast, increased gradually if necessary |

| |Usually up to 60 mg daily. |

| | |

| |Dosage equivalence (immediate release (IR) vs. modified release (MR)): |

| |5mg TDS (IR) = 18mg OD Xenidate-XL® |

| |10mg TDS (IR) = 36mg OD Xenidate-XL® |

| |15mg TDS (IR) = 54mg OD Xenidate-XL® |

| | |

| |5mg BD (IR) = 10mg Equasym XL® |

| |10mg BD (IR) = 20mg Equasym XL® |

| |15mg BD (IR) = 30mg Equasym XL® |

| | |

| |2nd line Lisdexamfetamine▼ |

| |Elavanse® 30mg, 50mg 70mg tablets |

| |Starting dose 30mg given each morning |

| |Increase to 50mg after one week if no response |

| |Increase up to 70mg after a further week if required |

| |Maximum dose 70mg |

| | |

| |Dexamfetamine (Schedule 2 controlled drug) |

| |Dexamfetamine sulphate 5mg tablets (standard release) |

| |Initiate at 5–10 mg daily for children over 6yrs. |

| |Increase dose to a usual maximum of 20 mg per day as necessary (in divided doses usually 2-3 times daily). May |

| |require 40 mg or more daily in older children / adolescents. |

| |Black Triangle Drug ▲(MHRA encourages the reporting of all suspected reactions). |

| | |

| |Atomoxetine |

| |Strattera® 10mg, 18mg, 25mg, 40mg, 60mg, 80mg capsules |

| |patients up to 70 kg body weight: initiate at a total daily dose of approximately 0.5mg/kg. Increase the dose |

| |gradually as required to recommended maintenance dose of approx. 1.2mg/kg/day. |

| |patients over 70 kg body weight: initiate at a total daily dose of 40mg. Increase the dose gradually as required to |

| |recommended maintenance dose of 80mg. |

|Summary of adverse effects |Adverse effect |Frequency |Management |

|Consult Summary of Product | | | |

|Characteristics (SmPC) for a| | | |

|full list. | | | |

|Methylphenidate |Nervousness and insomnia |>10% |Review dose and/or omit afternoon or evening dose if|

| | | |using three times daily |

| |Abdominal pain, nausea and vomiting |1-10% |Administer with food |

| |Athralgia, nasopharyngitis, cough or |1-10% |Review is persistent or troublesome. |

| |pharyngolaryngeal pain. | | |

| |Moderately reduced weight and slight growth |0.01-0.1% |Discontinue if significant weight loss or growth |

| |retardation during prolonged use | |retardation (see monitoring requirements below). |

| |Increased pulse and blood pressure |1-10% |Use with caution in patients with underlying |

| | | |cardiovascular medical. |

| | | |Discontinue if significant hypertension. |

| |Headache |1-10% |Refer back to psychiatric team if persistent or |

| | | |troublesome. |

| |Drowsiness/dizziness |1-10% |Refer back to psychiatric team if persistent or |

| | | |troublesome. |

| |Tachycardia /palpitations/arrythmias |1-10% |Discontinue if significant |

| |Decreased appetite |1-10% |Usually transient |

| |Dry mouth |1-10% |Refer back to psychiatric team if persistent or |

| | | |troublesome. |

| |Rash, pruritis |1-10% |Refer back to psychiatric team if persistent or |

| | | |troublesome. |

| |Leucopenia, thrombocytopenia, anaemia | ................
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