Who decides whether medication is suitable
Suitability is a clinical decision, made by your prescriber with you. At NeuroFX that is Tina, an independent prescriber, and you see the same clinician throughout.
The decision is made at your onboarding appointment, before anything is prescribed. It follows NICE guideline NG87 and the British National Formulary (BNF), the reference prescribers use for each medicine's cautions and limits.
Nothing on this page is individual medical advice. It is here so that you know what we will ask and why, before you book.
What we check before prescribing
NICE asks for a full baseline assessment before ADHD medication starts.1 At NeuroFX that covers:
- that you still meet the criteria for ADHD and that treatment is needed
- your mental health, and any other conditions alongside ADHD
- your medical history, especially your heart, blood pressure, liver, thyroid, any seizures and any tics
- any heart conditions in your close family
- every medicine and supplement you take, so we can check for interactions
- your pulse, blood pressure and weight, and height for children
- your use of alcohol and other drugs
An ECG, a tracing of the heart's rhythm, is not routine. NICE says one is not needed before starting unless you have one of the heart-related features listed further down this page, or you take another medicine that may raise cardiac risk.1 For some people we ask for an ECG or blood tests because of something in their own or their family's history.
When starting is usually straightforward
Most of these checks are there to rule things out. Starting medication is usually straightforward when all of the following are true:
- your pulse and blood pressure are in the normal range
- you have no history of heart problems, and no parent, brother, sister or child who died suddenly before the age of 40
- your mental health is stable
- you are not pregnant or breastfeeding
- you do not take a medicine that interacts with ADHD medication
Even then, we start with a low dose and adjust it gradually, with reviews every 3 to 4 weeks until the dose is right.
When we take extra care
Some conditions do not rule medication out, but they change how we go about it. NICE asks for slower dose changes and more frequent monitoring when any of these are present:1
- another neurodevelopmental condition, such as autism, a tic disorder or a learning disability
- a mental health condition, such as an anxiety disorder (including obsessive-compulsive disorder), depression, bipolar disorder, schizophrenia, a personality disorder, an eating disorder, post-traumatic stress disorder or substance misuse
- a physical health condition, such as heart disease, epilepsy or an acquired brain injury
The BNF adds cautions for individual medicines. They include tics or a family history of Tourette syndrome, a history of alcohol or drug dependence, and a susceptibility to angle-closure glaucoma, which is a type of glaucoma.2
In practice, extra care means a lower starting dose, smaller steps, more time between changes, and sometimes a different choice of medicine.
When we ask for a specialist's opinion first
NICE lists the situations in which a cardiologist's opinion is needed before ADHD medication starts:1
- congenital heart disease, or previous heart surgery
- the sudden death of a parent, brother, sister or child before the age of 40 that suggests heart disease
- shortness of breath on exertion compared with other people your age
- fainting on exertion, or in response to fright or noise
- palpitations that are rapid and regular, and that start and stop suddenly
- chest pain that suggests a heart problem
- signs of heart failure
- a heart murmur
- blood pressure in the hypertensive range for an adult
For a child or young person whose blood pressure is consistently above the 95th centile for their age and height, NICE asks for referral to a paediatric hypertension specialist first.1
If any of these applies to you, we will not start medication until that opinion is in, and we will talk you through how to arrange it. This delays the start. It does not mean medication is ruled out.
Pregnancy and breastfeeding
Tell us if you are pregnant, planning a pregnancy or breastfeeding. The BNF advises that these medicines are avoided in pregnancy, or used only where the potential benefit outweighs the risk, and that they are avoided while breastfeeding.2 If you already take ADHD medication, please do not stop it suddenly. Speak to your prescriber first.
During an episode of psychosis or mania
NICE says ADHD medication should be stopped during an acute psychotic or manic episode. It can be considered again once the episode has resolved, weighing the risks and benefits for that person.1
When a medicine is ruled out
Every medicine has a list of conditions it must not be used with, called contra-indications. The lists differ from one medicine to the next, so a condition that rules out one does not always rule out the others. These are the BNF's lists for the four medicines we prescribe.2
Methylphenidate
Not used with: anorexia nervosa; an abnormal heart rhythm (arrhythmia); disease of the heart muscle (cardiomyopathy); cardiovascular disease; a structural abnormality of the heart; heart failure; severe high blood pressure; disorders of the blood vessels in the brain (cerebrovascular disorders); inflammation of the blood vessels (vasculitis); an overactive thyroid (hyperthyroidism); phaeochromocytoma, a rare tumour of the adrenal gland; psychosis; mania; uncontrolled bipolar disorder; severe depression; suicidal tendencies.
Lisdexamfetamine
Not used with: symptomatic cardiovascular disease; moderate or severe high blood pressure; advanced hardening of the arteries (arteriosclerosis); an overactive thyroid (hyperthyroidism); agitated states.
Atomoxetine
Not used with: severe cardiovascular disease; severe cerebrovascular disease; phaeochromocytoma.
Guanfacine
The BNF lists no contra-indications for guanfacine. It asks for caution with a slow heart rate, heart block, a history of cardiovascular disease, a history of QT-interval prolongation (a change in the heart's electrical rhythm) or low potassium.
Words such as severe, uncontrolled and symptomatic matter here. Whether a past or well-controlled condition counts is a clinical judgement, which is why we look at each person individually.
ADHD medication if you are also autistic
Being autistic does not rule out ADHD medication. NICE recommends offering autistic people with ADHD the same medication choices as anyone else with ADHD.1
What differs is how often it works and how carefully it needs to be introduced. In the largest controlled trial of methylphenidate in autistic children with hyperactivity, 49% responded and 18% stopped because of side effects.3 In children with ADHD alone, more than 70% respond to methylphenidate.4 So medication can help, but in these trials it helped fewer autistic children, and side effects were more common.
Those trials were in children. We take the same careful approach with autistic adults.
Because of this, NICE asks for slower dose titration and more frequent monitoring where autism is present.1 For us that means:
- a lower starting dose and smaller steps
- more time between dose changes
- a written baseline of sleep, appetite, mood and sensory experience before the first dose, so that any change can be measured
- structured tracking at every review, because side effects can be harder to notice or describe
- a low threshold for pausing, stepping back or trying a different medicine
Medication treats the symptoms of ADHD: inattention, hyperactivity and impulsivity. It does not treat autism, and a Cochrane review found no evidence that methylphenidate changes the core features of autism in either direction.5
For more detail, read ADHD medication in autistic children and ADHD and autism together. If autism has not yet been assessed, our autism assessment page explains how that works.
If medication is not suitable, or not suitable yet
Sometimes the answer is not yet. Blood pressure may need treating first, or we may be waiting for a specialist's opinion. Once that is resolved, we look again.
If we find a clinical reason during onboarding why medication is not appropriate or safe, we will explain it to you and may decline to start. Under our terms, the medication package fee is then refunded in full.
A decision not to prescribe changes nothing about your diagnosis or your report. Medication is one part of ADHD treatment, and NICE recommends non-medication treatment for adults who choose not to take medication, cannot tolerate it or find that it does not help.1 Our guides cover the options, for adults and for children.
What to tell us before you start
Please tell us about any of the following, even if it was a long time ago:
- any heart condition or heart surgery, including in childhood
- a parent, brother, sister or child who died suddenly before the age of 40
- fainting, chest pain, palpitations or unusual breathlessness when you exercise
- high blood pressure
- seizures or epilepsy
- tics or Tourette syndrome, in you or your family
- glaucoma
- thyroid, liver or kidney problems
- your mental health history, including psychosis, mania or bipolar disorder, depression and eating disorders
- your use of alcohol and other drugs
- pregnancy, plans for a pregnancy, or breastfeeding
- every medicine and supplement you take, including anything bought over the counter
If you are not sure whether something matters, mention it anyway.
