ADHD medication prescribing in the UK is at record levels and still rising. Adult diagnoses have multiplied, Right to Choose has opened the pathway to independent providers, and the shared care arrangements meant to return stable patients to their GP are under strain. For psychiatrists, GPs, and nurse and pharmacist prescribers, that makes competent ADHD prescribing both more in demand and more closely scrutinised than it has ever been. This article summarises what NICE guideline NG87 expects, how titration and monitoring work in practice, and where prescribers most often get into difficulty.
ADHD medication options for adults
The licensed medications fall into two groups. Stimulants — methylphenidate in its immediate- and modified-release forms, lisdexamfetamine and dexamfetamine — are the most effective and act within the hour. Non-stimulants — atomoxetine and, in some circumstances, guanfacine — take weeks to reach full effect but carry no diversion potential and suit patients for whom stimulants are unsuitable or not tolerated. Stimulants are Schedule 2 controlled drugs, with the prescription-writing and supply rules that follow.
What NICE NG87 says about first-line treatment
NG87 recommends lisdexamfetamine or methylphenidate as first-line pharmacological treatment for adults, switching to the other if the first gives inadequate benefit after an adequate trial at an adequate dose. Dexamfetamine is an option for those responding to lisdexamfetamine but not tolerating its duration. Atomoxetine is recommended where stimulants are not tolerated or ineffective. Medication should be offered only after environmental modifications have been considered, as part of a treatment plan that includes psychoeducation and, where appropriate, psychological or coaching support — and only by a prescriber with training and expertise in ADHD.
Before prescribing: the checks that cannot be skipped
The pre-treatment assessment protects the patient and the prescriber. It includes a cardiovascular history — palpitations, syncope, exertional chest pain, and a family history of sudden cardiac death under 40 — with baseline blood pressure and heart rate and an ECG where indicated; weight, and height in anyone still growing; a psychiatric history with attention to psychosis, mania, tics and suicidality; a substance use history; a medication review for interactions, particularly with MAOIs, serotonergic drugs and antihypertensives; and, in women of reproductive age, pregnancy status and contraception. Document each of these. A GP asked to take on shared care will look for them, and their absence is the commonest reason a request is declined.
Titration in practice
Titration starts low and rises stepwise to the dose that gives the best balance of benefit and tolerability, reviewed at each step. For methylphenidate and lisdexamfetamine that typically means increases at weekly or fortnightly intervals over four to eight weeks, with the patient reporting effect and side effects — appetite, sleep, headache, anxiety, mood, heart rate and blood pressure — between reviews. Watch particularly for emotional dysregulation, irritability or mood elevation that might reveal an unrecognised bipolar vulnerability, and for a pattern of 'wearing off' in the afternoon that a change of formulation rather than dose would fix. Titration is complete when the dose is stable and the patient is functioning better on it, not when the maximum dose is reached.
Monitoring ADHD medication
Once stable, NG87 expects heart rate and blood pressure to be checked before and after each dose change and at least every six months, weight monitored at least six-monthly in adults, and a review of effectiveness, adverse effects, adherence and continued need at least annually. The patient should know what to report between reviews. Sustained tachycardia or hypertension, chest pain, new psychiatric symptoms, tics, significant weight loss or any concern about diversion warrant prompt specialist review.
Shared care and the GP
When the dose is stable the intention under NG87 is for ongoing prescribing to transfer to the GP under a shared care agreement, with the specialist providing periodic review. Shared care is voluntary for the GP, and in the current climate many practices decline requests that arrive on a provider's own form, before titration is complete or without baseline data. Prescribers who use the local ICB protocol, transfer only stable patients and stay reachable get their patients onto shared care; those who do not leave patients paying privately for repeat prescriptions or, worse, on medication with no monitoring at all.
Medication and ADHD coaching
Medication changes the conditions for attention and self-control; it does not undo the habits, avoidance and self-belief built over years of unmanaged ADHD. Patients who combine medication with psychoeducation and ADHD coaching report the best outcomes, and prescribers who know the coaches in their area and refer to them proactively see it in their reviews.
Training to prescribe in ADHD
Prescribers without a formal grounding in ADHD are increasingly choosing structured CPD over learning under pressure. Mind Companion Institute's Prescribing in ADHD course, awarding 22 CPD hours, covers the full pathway — assessment for treatment, medication choice, titration, monitoring, shared care and diversion risk — for prescribers in psychiatry, primary care and independent practice.