ebook_ADHD2019

The World Federation of ADHD Guide 103 consider either adjusting or switching treatment. In general, whilst the problems may have been recognized within primary care, such alterations to the treatment plan should usually be carried out by specialists within child and mental health services or paediatrics. This is particularly true when non-response is expected as there are several general considerations that need to be addressed before a decision can be made about the most appropriate clinical response. These include reviewing dosage (always ensure an adequate dose has been applied before swi- tching treatment), addressing compliance issues (motivational interviewing may help compliance and if on an immediate-release preparation try an extended-rele- ase one), and diagnosis. It is also important to ensure that apparent non-response is not actually due to a co-existing disorder or problem that is not currently being treated. These and other questions that should be considered before switching treatments are described in Box 5.2. For stimulants the general rule is that 70% of patients have a strong clinical response to methylphenidate and 70% to an amphetamine with between 90 and 95% responding well to one or the other (of course not all of those with a good clinical response can tolerate that medication). Whilst it is sometimes the case that a patient who has adverse effects to one stimulant will have similar problems with the other, this is by no means always the case. When a patient has failed to respond or has had intolerable adverse effects to their first stimulant, it is usually ok to con- sider switching to the other class (i.e. from methylphenidate to an amphetamine or from an amphetamine to methylphenidate). Of course, some patients, particularly those with adverse effects, will be uncomfortable about such a switch and their wishes should always be taken into account. For those who have failed to respond to both stimulants classes a switch to one of the non-stimulants (atomoxetine or extended release guanfacine [or extended release clonidine in the US]) will often be the most appropriate choice. As there Box 5.2 QUESTIONS YOU SHOULD ASK BEFORE CHANGING TO ANOTHER DRUG y y Have I titrated properly? y y Is the patient at the maximum dose? y y Is this drug/preparation working well at any times during the day? y y Have I got good enough information from school? y y Are parents and school in agreement about the effects of the drug? y y Am I targeting the right symptoms? y y Is there a behavioural explanation for the drug “wearing off”? y y What else is going on in patient’s life / family life? y y Is the medication working but effects limited by side effects? y y Have I missed any comorbidity? y y Is the diagnosis right?