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NICE rules out antipsychotic drugs for ADHD patients

By Lilian Anekwe

NICE has ruled out use of antipsychotic drugs in patients with attention-deficit hyperactivity disorder, after evidence linking them with stroke, diabetes and parkinsonism.

Instead, it recommends, patients should be treated with methylphenidate, atomoxetine and dexamfetamine.

GPs managing patients with ADHD under shared-care arrangements should ‘determine severity of behavioural or attention problems suggestive of ADHD', and then either employ watchful waiting for up to 10 weeks, or refer to secondary care, it adds.

It is the first guidance of its kind in the area, with GPs having been plagued by a lack of information on how to manage patients with ADHD, autistic spectrum disorders and other behavioural conditions.

The lack of clarity was exposed by new research, presented at a Royal College of Psychiatrists' conference in Liverpool last week.

An analysis of the prescribing rates of 369 practices in the UK general practice research database found the overall prevalence of use of antipsychotics increased by 76% from 1992 to 2004.

Prescriptions for atypical antipsychotics – which have been linked with an increased risk of stroke, diabetes and parkinsonism in adults – rose from 0.01 per 1,000 patient years in 1994 to 0.55 in 2004. Prescriptions for typical antipsychotics fell from 0.46 in 2000 to 0.25 in 2004.

Study leader Professor Ian Wong, professor of paediatric medicines research at The School of Pharmacy University of London, told delegates the bulk of the prescribing was for children and adolescents with ADHD and autism spectrum disorders.

But Professor Wong, who is also a member of the NICE ADHD guideline development group, said: ‘I don't think we will see a huge change when the guidance is published, because historically GPs have been not been given much guidance at all and they are still willing to consider it as a treatment option.'

Dr Caroline Donelly, a GPSI in psychiatry in Chelmsford, Essex, said: ‘There's a massive lack of young people and adolescent services, so even if you are prescribing under shared care arrangements, there's a shortage of specialists to give you advice. It leaves GPs in the lurch a little bit.

‘I don't think GPs feel comfortable prescribing these things but sometimes we have our backs against the wall with parents who are desperate and have kids facing expulsion from school.'

NICE guidance on ADHD

- Determine the severity of behavioural and/or attention problems suggestive of ADHD and how they affect the child and their parents
- Consider watchful waiting for up to 10 weeks, or offering referral for a formal diagnosis of ADHD
- If the problems persist refer to a paediatrician, child psychiatrist or specialist child and mental health services
- Consider prescribing methylphenyidate, atomoxetine and dexamfetamine as drug treatment under shared care arrangements only
- Do not use antipsychotics for patients with ADHD

NICE clinical guideline 72: Diagnosis and management of ADHD in children, young people and adults

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