ebook_ADHD2019

The World Federation of ADHD Guide 95 Titration on to methylphenidate Whilst almost all clinical guidelines stress the importance of titration when initia- ting medication treatments for ADHD, few give any advice about the practicalities of titration in a routine clinic setting. Whilst there are several approaches to titra- tion on to methylphenidate, we believe that a dose optimization titration method is the most effective. Here the child is started on a low dose of methylphenidate (e.g. 5 mg of immediate release twice or three times a day, or the equivalent of an extended-release preparation). Baseline measures are recorded as described above and the child is reviewed after 1-2 weeks (either in person or by telephone), at which time the measures are repeated. If the child has improved, and there is no room for further improvement, one option is to continue treatment at the same dose. It is however not uncommon for parents to report that symptoms have been optimised after the initial dose, because they have been surprised by how much the Box 5.1 SUMMARY OF MEDICATION ADVERSE EFFECTS Stimulant medications – methylphenidate, amphetamines, lisdexamfetamine Relatively common adverse effects include: insomnia; decreased appetite; weight loss; nervousness; agitation; anxiety; low mood; nightmares; stomach pain; nausea; vomiting; dizziness; palpitations; headache; vision problems; tachycardia; hypertension; sweating; skin rash; numbness, tingling, or cold feeling in hands or feet. Whilst some may settle after 2-3 weeks, they need to be monitored and alternative medications considered if they are getting worse. Less common side effects include: exacerbation of motor and vocal tics, aggressiveness/hostility (especially when medication is wearing off) and psychosis. Non-stimulant – atomoxetine Relatively common adverse effects include: nausea (which usually settles after a few weeks); dry mouth; appetite loss; insomnia; fatigue; constipation; dizziness; erectile dysfunction; somnolence; abdominal pain; urinary hesitation; tachycardia; hypertension; irritability; abnormal dreams; dyspepsia; ejaculation disorder; increased sweating; vomiting; hot flushes; sensation of tingling, tickling; menstrual disorder; weight loss; depression; sinus headache; dermatitis; mood swings. Uncommon but important adverse effects include suicidal ideation and liver failure. Non-stimulant – guanfacine Relatively common adverse effects include: somnolence; dizziness; dry mouth; constipation; nausea; headache; stomach pain; weight gain; irritability. If sedation and somnolence occurs, it is recommended that medication be given at night. It is important for patients to be advised to contact a health professional if they are experiencing more severe adverse effects including: severe dizziness; slow heartbeat; fainting or psychiatric symptoms or mood changes (such as depression, hallucinations, or thoughts of suicide).