11 ADHD drugs UK review

This post aims to review the most commonly prescribed ADHD drugs in the UK. Drugs will be listed according to prescribing information in England which is available at OpenPrescribing.net. ADHD drugs UK summary:

Note on prescribing statistics

Although prescribing numbers for drugs are extracted precisely, overall, some reservation needs to be taken when looking at the list of ADHD drugs. Drugs for the treatment of ADHD can be prescribed in a generic form (chemical name of the drug) or as branded medicines, for example, a Medikinet is a branded name of methylphenidate (chemical name of the drug). When a generic form of the drug is prescribed, a pharmacy can dispense a generic drug (if one exists) or a branded drug. This limits the available prescribing information. I will therefore provide information on both generic prescribing and branded drugs.

What drugs are recommended for the treatment of ADHD in the UK?

This short review on the treatment of ADHD does not include the non-pharmacological treatment of ADHD. Recommendations on pharmacological (drug) treatment differ for children and adults.
NICE guideline, Attention deficit hyperactivity disorder: diagnosis and management recommends the following drug treatment for children aged 5 years of age and over (NICE, 2019):
As first-line treatment methylphenidate is offered (either short or long-acting)
If after 6 week trial with methylphenidate no substantial benefit is achieved, patients can be switched to lisdexamfetamine
As a third-line treatment, dexamfetamine can be offered to children who respond to lisdexamfetamine but a long mechanism of action is not suitable
Atomoxetine or guanfacine is recommended to children who cannot tolerate methylphenidate or lisdexamfetamine or to whom either of the drugs did not produce satisfactory results.

Treatment of ADHD with drugs for adults differs slightly (ibid):

• lisdexamfetamine or methylphenidate can be offered as first-line treatment of ADHD in adults
• patients can be offered lisdexamfetamine or methylphenidate after a six-week trial if either of them did not provide sufficient benefit
• dexamfetamine is offered as a third-line treatment to patients whole ADHD symptoms are controlled but the long mechanism of action is not suitable
• Atomoxetine is recommended to adults who cannot tolerate methylphenidate or lisdexamfetamine or to whom either of the drugs did not produce satisfactory results.

Legal classification of ADHD drugs UK classification

Almost all drugs recommended in the treatment of ADHD are classified as prescription-only medicines (POM). Additionally, most ADHD drugs are classified as controlled drugs (CDs) schedule 2, the highest schedule prescribed in the community. With this certain legal restrictions apply, for example, prescription has additional requirements in terms of how it is written. CD2 prescriptions expire 28 days from the date on prescription as opposed to 6 months for prescriptions, which do contain controlled drugs.
Atomoxetine (less popular ADHD medication) is classified as a prescription-only medication and is not classified as a controlled drug.

Can you choose a brand of ADHD medication prescribed or dispensed?

Patients may have some influence on the selection of prescribed drugs if for example a better response to treatment is achieved with a particular brand of medication, which mainly relates to the form in which the drug comes in, for example, immediate release or modified-release formulations. Most prescriptions for ADHD drugs require a supply of a specific brand of drug. When a prescription calls for a specific drug, a pharmacy can only supply that drug. When prescription calls for a generic drug pharmacy supplies either a generic form of the drug or a branded drug. This decision is usually driven by the cost of the drug. Patients may ask to get a specific brand of medication, however, the request may be denied.

How do ADHD drugs help with ADHD?

ADHD is characterised by impulsivity, hyperactivity and lack of attention. The exact cause of ADHD is not known, but many studies suggest an imbalance of neurotransmitters in the brain such as dopamine. Neurotransmitters are chemicals which are used in the body to send ‘messages’ to produce a different response in the body. Dopamine plays role in reinforcement and motivation. ADHD patients may produce a different response in reinforcement which produces symptoms of ADHD (Tripp & Wickens, 2009).
The most popular drugs used in the treatment of ADHD are classified as ‘stimulants’. In simple terms, methylphenidate increases (prolongs) the action of two neurotransmitters, dopamine and norepinephrine.
Lisdexamfetamine, also classified as a stimulant has the same mechanism of action.
Atomoxetine is not classified as a stimulant. Atomoxetine affects norepinephrine only and does not have much effect on the prolongation of other neurotransmitters such as dopamine. Although more effective than a placebo (a dummy pill), atomoxetine is significantly less effective than methylphenidate (Garnock-Jones & Keating, 2009).

ADHD drugs UK the most common drugs

Methylphenidate is classified as a CNS stimulant. By far, methylphenidate is the most commonly prescribed drug in the UK for the treatment of ADHD. The overall trend clearly indicates an increased number of prescriptions issued for ADHD medicines with most prescriptions issued in 2021. The table below list the number of prescriptions issued for each drug, which is included in NICE’s guidelines on the management of ADHD.

*number of prescriptions issued in 2021, OpenPrescribing.net (2022)

Which ADHD drugs is most popular in the UK?

The ranking below is based on the number of prescriptions issued for each ADHD drug in the UK in 2021 (Openprescribing.net, 2022).

1. Generic methylphenidate tablets

Generic methylphenidate tables were the most commonly prescribed medication for the treatment of ADHD. Generic methylphenidate tablets come as:
• Methylphenidate 5mg tablets
• Methylphenidate 10mg tablets
• Methylphenidate 20mg tablets
It is not surprising that methylphenidate tablets are most commonly prescribed among ADHD medicines. As per guidelines (see relevant paragraph above) methylphenidate is offered as a first-line treatment to manage ADHD. Secondly, the popularity of generic methylphenidate tablets is related to the cost of the drug. Generic methylphenidate tables cost up to 10x less than the cost of methylphenidate capsules or tablets which come as modified-release formulations.

2. Concerta XL: most popular branded ADHD drug

Number of items prescribed: 278,304
Most commonly prescribed brands of methylphenidate is Concerta XL. Concerta XL range of tablets include:

• Concerta XL 18mg tablets
• Concerta XL 27mg tablets
• Concerta XL 36mg tablets
• Concerta XL 54mg tablets

XL symbol in the name of the drug indicates that Concerta XL tablets are modified-release formulations, also known as prolonged-release or extended-release. Modified-release forms of methylphenidate produce an extended mechanism of action, which requires taking a single dose of medication each day.

3. Elvanse capsules

Numer of items prescribed: 264,016

At this moment Elvanse is the only brand of lisdexamfetamine prescribed in the UK. Elvanse popularity is on increase. Over the next 12 months, one would expect Elvanse to become a more popular prescribed ADHD medication than Concerta XL.
Elvanse capsules come as:

• Elvanse 20
• Elvanse 30
• Elvanse Adult 30mg capsules
• Elvanse 40
• Elvanse 50
• Elvanse Adult 50mg capsules
• Elvanse 60
• Elvanse 70
• Elvanse Adult 70mg capsules

Elvanse vs Elvanse Adult: what is the difference?

There is no difference between Elvanse and the equivalent strength of Elvanse Adult capsules. Each Elvanse Adult and equivalent strength of Elvanse capsules contain the same amount of the active ingredient (lisdexamfetamine) and the same non-active ingredients. As the name suggests Elvanse Adult are more likely to be prescribed in the adult population, although in practice and as evident from prescribing data, Elvanse Adults is not commonly prescribed as compared to Elvanse capsules.

4. Medikinet XL capsules

Number of items prescribed: 204,957
Medikinet XL capsules are modified-release preparation of methylphenidate. Medikinet XL capsules come in a variety of strengths including:

• Medikinet XL 10 capsules
• Medikinet XL 20 capsules
• Medikinet XL 30 capsules
• Medikinet XL 40 capsules
• Medikinet XL 50 capsules
• Medikinet XL 5 capsules

5. Equasym XL capsules

Number of items prescribed: 174,017
Almost equally as popular as Medikinet XL capsules, Equasym is another option for the treatment of ADHD which come in form of modified release capsules. Equasym XL capsules come as:

• Equasym XL 10mg capsules
• Equasym XL 20mg capsules
• Equasym XL 30mg capsules

6. Atomoxetine

Number of items prescribed: 130,437

Atomoxetine is reserved for patients who cannot tolerate methylphenidate or lisdexamfetamine. It did not stop atomoxetine to rank somewhere in the middle of the most popular ADHD drugs in the UK.

7. Xaggitin XL tablets

Number of items prescribed: 95,414

Xaggitin XL tablets are equivalent to Concerta XL tablets in the availability of different strengths of methylphenidate. In other terms, Xaggitin tablets come as modified-release tablets in the following strengths (same as Concerta XL tablets):

• Xaggitin XL 18mg tablets
• Xaggitin XL 27mg tablets
• Xaggitin XL 36mg tablets
• Xaggitin XL 54mg tablets

Xaggitin XL tablets cost half the price of Concerta XL tablets. Much lower cost will drive the popularity of Xaggitin tablets over Concerta Xl.

8. Xenidate XL

Number of items prescribed: 68,860

Slightly less popular, Xenidate XL tablets come in the same strength as previously discussed Concerta XL and Xaggitin XL tablets. One would expect Xenidate XL tablets to become more popular since the lower cost than Concerta Xl tablets.

9. Ritalin tablets

Number of items prescribed: 10,210

Ritalin is a brand of tablets which contain methylphenidate. Ritalin tablets come only in one strength – 10mg tablets. One formulation and slightly higher price as compared to generic methylphenidate tablets make Ritalin tablets less popular.

10. Ritalin XL capsules

Ritalin XL capsules contain methylphenidate and all come as modified release formulations. Ritalin XL capsules are rarely prescribed in England.

11. Tranquilyn tablets

Tranquilyn tablets which contain either 5g, 10mg, or 20mg of methylphenidate are rarely prescribed in England.

References:
NICE (2019). Attention deficit hyperactivity disorder: diagnosis and management. Available at; https://www.nice.org.uk/guidance/conditions-and-diseases/mental-health-and-behavioural-conditions/attention-deficit-disorder Accessed on 09/03/2022
Garnock-Jones KP, Keating GM. Atomoxetine: a review of its use in attention-deficit hyperactivity disorder in children and adolescents. Paediatr Drugs. 2009;11(3):203-26. doi: 10.2165/00148581-200911030-00005. PMID: 19445548. Available at: https://doi.org/10.2165/00148581-200911030-00005 Accessed on 20/03/2020
OpenPrescribing.net (2022). The DataLab, University of Oxford. Available at: https://openprescribing.net/ Accessed on 09/03/2022
Tripp G, Wickens JR. Neurobiology of ADHD. Neuropharmacology. 2009 Dec;57(7-8):579-89. doi: 10.1016/j.neuropharm.2009.07.026. Epub 2009 Jul 21. PMID: 19627998. Available at: https://doi.org/10.1016/j.neuropharm.2009.07.026 Accessed on 20/03/2022