guidelines

adhd

detailed summary of nice ng87: shared care protocols, methylphenidate/lisdexamfetamine titration, and monitoring.

last reviewed: 2026-02-13
based on: NICE NG87 (last reviewed 07 May 2025)
reviewer: Dr Kola Tytler MBBS CertHE MBA MRCGP
view official NICE source

Executive summary

  • Diagnosis: Specialist Only. (DIVA interview + collateral). Primary care role is screening (ASRS) and referral.
  • Treatment: Stimulants are first line. Prescribing is usually via Shared Care Agreement (SCG) after titration.
  • Monitoring: Essential every 6 months. BP, Pulse, Weight. (ECG only if cardiac history/symptoms).

Medication Hierarchy (Adults)

  • 1st Line: Lisdexamfetamine (Elvanse) or Methylphenidate (Concerta/Medikinet)
    • Lisdexamfetamine: Start 30mg -> Max 70mg. (Prodrug, lower abuse potential).
    • Methylphenidate (XL): Start 18mg -> Max 108mg (Concerta) or equiv.
    • Switch: If one stimulant ineffective after 6 weeks, switch to the other.
  • 2nd Line: Atomoxetine (Non-stimulant)
    • Indicated if stimulants contraindicated (e.g., active substance misuse, severe anxiety, cardiac risk) or not tolerated.
    • Dosing: Weight based. Risk of liver toxicity (rare) and suicidal ideation.

Shared Care "Must Dos"

  • Do NOT accept SCG if: Patient is unstable, dose is not finalised, or monitoring requirements are unclear.
  • Stop/Review if:
    • Heart Rate: >100 bpm persistently.
    • Blood Pressure: Systolic >140mmHg (guide).
    • Weight: Significant unplanned loss.
    • Psychosis/Mania: Emergence of new symptoms -> Urgent Specialist Review.

Transparency

This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.