ebook_ADHD2019

The World Federation of ADHD Guide 93 where available, a psychostimulant will generally be the first-choice medication and we would agree with this position. There are circumstances where a clinician may feel it appropriate to start with a non-stimulant medication (atomoxetine, guanfacine or where these are not available clonidine), such as: a current or past history of substance misuse; the presence of tics or anxiety or where there is a strong preference within the family to avoid stimulants. These are relative prefe- rences rather than absolute contraindications to stimulants, and the presence of any one of these conditions should not preclude the use of a stimulant medication. Amphetamines and methylphenidate appear to be equally effective and have similar adverse event profiles 14 and both are available in many countries as im- mediate release short acting and extended-release preparations. Where cost is important, and a stimulant is being thought of, the cheaper and more flexible im- mediate-release preparation will often be the first choice. 5 In low-middle income countries, this might be the only option for primary care physicians. In some cou- ntries such as Australia, the government has mandated that a short-acting medica- tion has to be tried first, and that this may only be changed to the intermediate-ac- ting or longer-acting medications if it the short acting does determines significant side effects and the child requires a longer cover during the day. Thus, it is very important to be familiarized with pharmacodynamics and pharmacokinetics pro- perties of this presentation. However, an extended-release methylphenidate pre- paration or the long acting amphetamine prodrug lisdexamfetamine are also often considered as first-line treatments where: financial constraints are less important; in circumstances where it is deemed important to reduce stigma and increase pri- vacy as is often the case for adolescents; where poor compliance needs to be ad- dressed or when it is particularly important to reduce the chance of diversion. In practice, many clinicians now start with an extended-release preparation and those that still initiate treatment with immediate-release methylphenidate will usually switch most patients to an extended release preparation after titration when the dose is stabilized. Which extended-release or long acting preparation is chosen will depend first on what is available locally and also on the desired profile of action required across the day. In Europe, regulatory issues restrict the use of lisdexamfetamine to pa- tients who have failed to have an optimal response to methylphenidate. In other countries, it can be considered as a potential first line treatment. Titrating on to ADHD medications – general principles Treating ADHD is easy, treating ADHD well takes a lot more skill and effort. There is strong evidence that ADHD medications are very effective at reducing core ADHD symptoms and that, in many cases, both symptoms and functional impairments can be reduced such that and residual impairment is minimal. 5 For