Get urgent medical help if you take an ADHD medicine and have chest pain, fainting, shortness of breath or a racing or irregular heartbeat; hallucinations, paranoia or manic symptoms; a painful erection lasting a long time; or thoughts of suicide. After taking too much, or a dose not taken as prescribed (for example snorted or injected), call your local emergency number.
Key points
- ADHD is a neurodevelopmental condition with inattention, hyperactivity and impulsivity. Symptoms start in childhood and usually continue into adulthood, and NICE advises considering ADHD at any age.
- Diagnosis needs a full specialist assessment, not just a questionnaire. Symptoms must be frequent, occur in 2 or more settings (such as work, home and social life) and cause real impairment.
- For adults, NICE recommends lisdexamfetamine or methylphenidate first, then atomoxetine if stimulants are not tolerated or do not work. Psychological support helps alongside or instead of medicines.
- All prescription stimulants carry an FDA boxed warning, updated across the class in 2023, about abuse, misuse, addiction and overdose. Never share your medicine and store it securely.
- Check blood pressure and heart rate before starting, after each dose change and every 6 months. Never combine stimulants or atomoxetine with an MAOI.
What adult ADHD looks like
The US National Institute of Mental Health (NIMH) describes 3 groups of symptoms:
- Inattention: difficulty paying attention, staying on task or staying organised.
- Hyperactivity: restlessness, moving around at inappropriate times or talking excessively.
- Impulsivity: interrupting, intruding on others or having trouble waiting.
Everyone has these behaviours sometimes. In ADHD they are frequent, occur across several situations and interfere with daily life. NIMH notes that teens and adults with ADHD are more likely to take risks such as substance use and unsafe sex, and are at increased risk of poor job performance and financial problems. ADHD often occurs alongside anxiety, depression, sleep problems and learning disorders, which can make diagnosis harder.
How it is diagnosed
NICE NG87 advises that ADHD should be diagnosed only by a specialist psychiatrist or another professional trained in ADHD. The diagnosis is based on:
- a full clinical and psychosocial assessment, including behaviour and symptoms in different parts of everyday life;
- a full developmental and psychiatric history, observer reports (for example from a partner or family member) and a mental state assessment;
- symptoms that meet DSM-5 or ICD-11 criteria, cause at least moderate psychological, social, educational or work impairment, and occur in 2 or more important settings.
Rating scales are helpful extra tools, but NICE says they should not be the only basis for diagnosis. The assessment should also cover coexisting conditions, work and family circumstances and physical health.
Treatment
Non-drug support
NICE advises first making changes to the person's environment, for example at work. Medicines are offered if symptoms still cause significant impairment in at least one area of life. For adults who choose not to take medicine, cannot take it or find it does not work, NICE recommends at least a structured supportive psychological intervention focused on ADHD, with regular follow-up. This may include cognitive behavioural therapy (CBT). It can also be combined with medicine when symptoms persist.
Medicines
Medicines should be started only by a professional with ADHD expertise. NICE's sequence for adults:
- First line: lisdexamfetamine or methylphenidate. If one does not help enough after a 6-week trial at an adequate dose, switch to the other.
- Dexamfetamine: can be considered if lisdexamfetamine works but its long effect is not tolerated.
- Atomoxetine (a non-stimulant): offered if stimulants are not tolerated or 6-week trials of both lisdexamfetamine and methylphenidate have not worked.
- Specialist advice: get a second opinion if symptoms have not responded to one or more stimulants and one non-stimulant. Guanfacine in adults should only be used on advice from a tertiary ADHD service.
Medicine availability and licensing differ by country. In the US, lisdexamfetamine is FDA-approved for ADHD in adults and children 6 years and older, and extended-release methylphenidate (Concerta) for ages 6 to 65. Viloxazine (Qelbree), a non-stimulant not covered by the NICE sequence above, is FDA-approved for ADHD in adults and children 6 years and older. In adults it starts at 200 mg once daily, with a maximum of 600 mg. It carries a boxed warning for suicidal thoughts and behaviours, and it must not be combined with an MAOI or with certain medicines broken down by the liver enzyme CYP1A2.
Dosing principles
- Doses are adjusted step by step against symptoms and side effects until there is a good balance.
- Lisdexamfetamine: 30 mg each morning, increased by 10 or 20 mg weekly. The usual range is 30 to 70 mg a day, and 70 mg is the maximum. Lower maximums apply in severe kidney impairment (50 mg) and end-stage kidney disease (30 mg).
- Methylphenidate extended release (Concerta): adults start with 18 or 36 mg once each morning, increased weekly by 18 mg up to 72 mg. Swallow whole; do not chew, split or crush.
- Atomoxetine: adults start with 40 mg a day, increased after at least 3 days to about 80 mg, with a maximum of 100 mg. Doses are lower in moderate (50%) or severe (25%) liver impairment and with strong CYP2D6 inhibitors such as fluoxetine or paroxetine.
NICE advises reviewing medicine at least once a year to decide whether it is still needed. Trial breaks or dose reductions can be considered.
The FDA warning on misuse and diversion
On 11 May 2023, the FDA required an updated boxed warning for all prescription stimulants so that the risks of misuse, abuse, addiction and overdose are described the same way across the class. The FDA noted that most people who misuse prescription stimulants get them from family members or peers, and that sharing them can lead to addiction in the person who receives them. Current labels advise:
- assessing each person's risk of misuse before prescribing and reassessing it throughout treatment;
- storing the medicine in a safe place, preferably locked, and disposing of unused tablets properly;
- never giving the medicine to anyone else;
- knowing that the risk of overdose and death rises with higher doses or with snorting or injecting.
NICE also advises against immediate-release stimulants, or modified-release forms that are easy to inject or snort, when there is a risk of misuse or diversion.
Safety: what to check
- Before starting: medical history and current medicines; pulse and blood pressure; a cardiovascular assessment; weight; risk of substance misuse and diversion; personal or family history of bipolar disorder, depression or suicide; and tics. NICE advises an ECG or cardiology referral only if there are specific warning features, such as fainting or breathlessness on exertion, chest pain, palpitations, a heart murmur, a family history of sudden cardiac death under 40, or hypertension.
- Heart and blood pressure: stimulants raise blood pressure by about 2 to 4 mmHg and heart rate by 3 to 6 beats per minute on average, and some people have larger increases. Avoid stimulants in serious heart disease, such as structural abnormalities, cardiomyopathy, serious arrhythmia or coronary artery disease. NICE advises checking heart rate and blood pressure before and after each dose change and every 6 months.
- Contraindications and interactions: never use with an MAOI, including linezolid or intravenous methylene blue, or within 14 days of stopping one, because of the risk of a hypertensive crisis. Amphetamines combined with SSRIs, SNRIs or triptans raise serotonin syndrome risk. Atomoxetine is contraindicated in narrow-angle glaucoma, phaeochromocytoma and severe cardiovascular disease.
- Mental health: stimulants can trigger psychosis or mania, especially with a pre-existing psychotic or bipolar disorder. Atomoxetine carries a boxed warning for suicidal thoughts in children and adolescents, and its label warns of severe liver injury: stop it and do not restart if jaundice or liver injury occurs.
- Other monitoring: weight every 6 months in adults; sleep; new or worsening tics; seizures; Raynaud's-type changes in fingers and toes; and eye pressure with methylphenidate if there is glaucoma risk. NICE does not recommend routine blood tests or ECGs without a clinical reason.
- Pregnancy: data are limited. Amphetamines narrow blood vessels and may reduce blood flow to the placenta and increase the risk of premature birth. Babies born to mothers taking amphetamines should be watched for withdrawal signs. Methylphenidate studies show inconsistent findings. Discuss plans with the prescriber before stopping or continuing.
- Breastfeeding: breastfeeding is not recommended with lisdexamfetamine. Methylphenidate passes into milk in small amounts with no reported harm to infants, so the benefits and risks should be weighed.
- Older adults and kidneys: Concerta is not established above 65 years. For lisdexamfetamine, start older adults at the low end of the dose range and follow the kidney dose limits.
Frequently asked questions
Can ADHD be diagnosed for the first time in adulthood?
Yes. NICE advises considering ADHD at all ages, with symptom criteria adjusted for age. Symptoms begin in childhood, so the assessment looks back at early history, often with reports from family members.
Can I become dependent on stimulants?
Stimulants carry a risk of misuse and addiction, even when prescribed for ADHD, which is why the FDA boxed warning asks prescribers to assess and reassess this risk. Take the medicine only as prescribed and tell your prescriber about any history of substance use. Atomoxetine is a non-stimulant option.
Do I need an ECG before starting?
Not routinely. NICE advises an ECG only if there are warning features such as fainting on exertion, chest pain, a heart murmur, a family history of sudden cardiac death under 40, or a medicine that adds cardiac risk. Pulse and blood pressure are always checked.
Sources
- NICE. Attention deficit hyperactivity disorder: diagnosis and management (NG87), 2018, with later updates. nice.org.uk/guidance/ng87
- US National Institute of Mental Health. Attention-deficit/hyperactivity disorder (ADHD). nimh.nih.gov
- US FDA. Drug Safety Communication: FDA updating warnings to improve safe use of prescription stimulants used to treat ADHD and other conditions, 11 May 2023. fda.gov
- US FDA-approved labeling, lisdexamfetamine (Vyvanse). DailyMed
- US FDA-approved labeling, methylphenidate extended-release (Concerta). DailyMed
- US FDA-approved labeling, viloxazine extended-release capsules (Qelbree). DailyMed
- US FDA-approved labeling, atomoxetine capsules. DailyMed
This article is for education and does not replace advice from a doctor or pharmacist who knows the person's history and other medicines.
