Practical advice for the system in response to the NatPSA for Attention Deficit Hyperactivity Disorder (ADHD) medicines.

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Responsibilities

In addition to the actions stated in the National Patient Safety Alert (NatPSA) on supply disruptions affecting various strengths of medications for attention deficit hyperactivity disorder (ADHD), the following information has been provided to support systems and healthcare professionals with further management.

Service provision across the system

Establish an all age multidisciplinary cross sector oversight team to review local action to date against this national patient safety alert:

  • co-ordinate and support sharing of information within and across systems for any areas having difficulty implementing the alert
  • establish system level communication to support clinicians and patients affected by the shortage
  • highlight any additional support or resources that may be available

Networking and communication

Work across the system to minimise the adverse impact on patients/parents:

  • ensure the skills of any healthcare professional with specialist knowledge of ADHD medication are utilised to best effect across the local community
  • establish system-wide networks in order to share information and intelligence about stock availability and any specific local supply issues
  • support systems to enable rapid and timely communication with patients about stock availability

Shared decision making

Support shared decision making alongside any local decisions/protocols which prioritise alternative ADHD medication in the event of non-availability.

Support from ADHD specialists

Specialist teams should offer rapid response to primary care teams seeking urgent advice/opinion for the management of patients. This includes those known to be at a higher risk as a consequence of these shortages. For example, those with complex presentations including co-morbid autism, mental health or substance misuse needs.

Prescribing

Adjust the clinical management plan for patients affected by the supply disruption of ADHD medicine.

New patients

Do not start new patients with medicines affected by the shortage unless the patient is prescribed this medication as part of the SATURN or SNAPPER clinical trial program.

Existing patients

If clinically appropriate, prescribe an alternative product or formulation if competent to do so (with specialist support if necessary). For example, alternative bio-equivalent formulations of methylphenidate.

Clinicians should check the Medicines Supply tool to ensure there is sufficient stock of the alternative medicine before prescribing.

Continue on-going prescribing of those ADHD medicines NOT affected by shortages in line with the patient’s treatment plan together with any relevant locally agreed protocols and NICE guideline NG87.

Prescribe any ADHD medicines affected by the supply disruption on a separate prescription (FP10). If an electronic prescription, do not send to the nominated pharmacy unless the medicine is confirmed to be in stock. Note that patients can use their NHS number or prescription “token” to obtain their prescribed medicine from any community pharmacy.

Do not prescribe more than one month’s supply at a time of the affected medicine. Ensure a system is in place to safeguard against stockpiling or overordering.

Do not prescribe antipsychotics or benzodiazepines as alternatives to ADHD medicines.

Take account of NICE(NG87) if considering discontinuation or short term treatment breaks (previously called drug holidays).

Guanfacine

Ensure patients who are prescribed guanfacine do not suddenly discontinue their medication:

  • identify and inform patients who have been prescribed guanfacine that their medication may be in short supply/unavailable and plans are in place to manage this
  • in collaboration with specialists, clinicians can prescribe unlicensed guanfacine
  • endorse prescriptions with “Special Order” to enable pharmacy to import through specialist wholesalers if possible

Intuniv SPC and risk materials provides further information if dose tapering and subsequent monitoring is needed.

Considerations when prescribing guanfacine contains further information on the clinical management.

Understanding unlicensed medicines contains general information on unlicensed medicines.

Lisdexamfetamine

In discussion with the patient, clinicians can prescribe unlicensed lisdexamfetamine. Understanding unlicensed medicines contains general information on unlicensed medicines.

Do not switch from lisdexamfetamine to dexamfetamine without close consideration of the risks of diversion or misuse. Specialist advice should be sought.

Manufacturers of dexamfetamine have advised that they are unable to support an uplift in supplies to accommodate a switch from lisdexamfetamine to dexamfetamine.

Methylphenidate

In discussion with the patient, prescribers can make adjustments to certain methylphenidate brands in short supply, without the need for additional specialist advice. This may be by making a short-term switch to an alternative bio-equivalent brand or formulation, or generic prescription for a methylphenidate modified-release product.

Considerations when prescribing modified-release methylphenidate contains further information.

Ordering and supply

Collaborate to ensure that medicines affected by the supply disruption are available for patients who are in urgent need, or to avoid an unintended treatment break:

  • share knowledge of medicine availability and local usage patterns within the system
  • ensure timely communication with patients about stock availability
  • collaborate to prevent over ordering or stockpiling, which may lead to diversion or misuse
  • do not give more than one month’s supply at a time of the affected medicine
  • prescribers and pharmacists must discuss any potential change to brand or formulation with the patient or carer

Make arrangements to enable ordering of medicines from alternative wholesalers if the usual wholesaler is unable to supply, including importation of unlicensed products where appropriate.

Return undispensed prescriptions

Local services or prescribers should implement a system to manage prescriptions that have not been dispensed against. This is to reduce the risk of diversion, misuse or overdose (intentional or unintentional). For example, prescribers should always request the return of any undispensed prescriptions before issuing a new prescription for an alternative product.

Check bioequivalence

Methylphenidate

In the event of a generic prescription for methylphenidate modified-release, the pharmacist must ensure the product they are dispensing is bioequivalent to the brand the patient is usually on.

Prescribing available medicines to treat ADHD contains an overview of the supply picture and indicates which methylphenidate modified-release brands are bioequivalent to each other.

Considerations when prescribing modified-release methylphenidate contains a summary of the pharmacokinetic profiles for methylphenidate brands currently licensed in the UK. This can be used to support product selection.

Unlicensed medicines

When prescribing a product that is not licensed in the UK due to a supply issue with the licensed alternative, prescribers must indicate on the FP10 prescription that an unlicensed product is required. This is so the community pharmacy can order the correct medicine, and can be done in one of the following two ways.

Electronic prescriptions

If the required unlicensed product is shown on the electronic prescribing system, prescribers should select “xxxx (imported)”

Paper prescriptions

Where the unlicensed product is not shown on electronic prescribing systems, prescribers should use a paper prescription and annotate with the words “special order”.

Keeping up-to-date

The following resources can support activity: