Update on ADHD medication shortage in the UK

We are providing an important update on the ongoing ADHD medication shortages affecting the UK. This situation impacts several medications commonly used to treat Attention Deficit Hyperactivity Disorder (ADHD), leading to significant disruptions for patients. We acknowledge the challenges this shortage presents and are committed to providing support to our clinicians and patients.

Current Supply Disruptions

The Department of Health and Social Care (DHSC) has issued multiple alerts and notifications regarding these shortages:

• National Patient Safety Alert (NatPSA) : Issued on 27 September 2023, highlighting shortages of methylphenidate prolonged-release capsules and tablets, lisdexamfetamine capsules, and guanfacine prolonged-release tablets.
• Medicine Supply Notifications (MSNs) :
• Lisdexamfetamine (Elvanse) capsules on 13 February 2024.
• Guanfacine (Intuniv) prolonged-release tablets on 28 March 2024.

These notifications have superseded the earlier NatPSA and provide detailed updates on the supply situation. Prescribing advice is available from the following key resources listed in the NatPSA:

• NICE guideline [NG87]. Attention deficit hyperactivity disorder: diagnosis and management
• MHRA (2022). Methylphenidate long-acting (modified-release) preparations: caution if switching between products due to differences in formulations 

If you are taking any of these medications, please contact your ADHD medicine prescriber using the numbers below for advice about the most appropriate option for you.

The disruption is due to a combination of manufacturing issues and increased global demand. Supply of the above products are not expected to be restored until various times between October and December 2024. Other strengths are not expected to be able to support excessive increased demand. This may have an impact upon several of the young people in your care. The following information will help you support young people and their families while they wait for the medication disruption to be resolved

Please do not share your medication with anyone else.

If your needs are very complex, for example you have mental health problems, or your ADHD symptoms causes you severe difficulty, you can discuss this with your GP, and they may recommend a specialist consultant review. 

Anyone who is currently waiting to be started on ADHD medication will not receive a prescription until stocks are available. 

Anticipated re-supply dates (correct on date of distribution)

Methylphenidate Modified-Release bioequivalent alternatives. NB: Modified-release methylphenidate preparations MUST be prescribed by brand due to differences in bioavailability
Medicines affected	Anticipated re-supply date	Bioequivalent Alternatives
Xenidate XL 18mg tablets	17th January 2025	Matoride XL 18mg tablets Affenid XL 18mg tablets Xaggitin XL 18mg tablets
Xenidate XL 27mg tablets (Viatris UK Healthcare Ltd)	22nd November 2024	Concerta XL 27mg tablets
Xenidate XL 36mg tablets (Viatris UK Healthcare Ltd)	22nd November 2024	Delmosart 36mg XL tablets
Xenidate XL 54mg tablets (Viatris UK Healthcare Ltd)	22nd November 2024	Delmosart 54mg modified-release tablets Matoride XL 54mg tablets
Xaggitin XL 27mg tablets (Ethypharm UK Ltd)	18th October 2024	Concerta XL 27mg tablets
Xaggitin XL 36mg tablets (Ethypharm UK Ltd)	25th October 2024	Delmosart 36mg XL tablets
Xaggitin XL 54mg tablets (Ethypharm UK Ltd)	15th November 2024	Delmosart 54mg modified-release tablets  Matoride XL 54mg tablets
Delmosart 18mg modified-release tablets (Accord-UK Ltd)	Unavailable	Matoride XL 18mg tablets  Affenid XL 18mg tablets Xaggitin XL 18mg tablets
Delmosart 27mg modified-release tablets (Accord-UK Ltd)	Unavailable	Concerta XL 27mg tablets
Affenid XL 27mg tablets (Zentiva Pharma UK Ltd)	31st October 2024	Concerta XL 27mg tablets
Affenid XL 36mg tablets (Zentiva Pharma UK Ltd)	31st October 2024	Delmosart 36mg XL tablets
Affenid XL 54mg tablets (Zentiva Pharma UK Ltd)	31st October 2024	Delmosart 54mg modified-release tablets
Concerta XL 18mg tablets (Janssen-Cilag Ltd)	18th October 2024	Matoride XL 18mg tablets Affenid XL 18mg tablets Xaggitin XL 18mg tablets
Concerta 36mg tablets (Janssen-Cilag Ltd)	15th November 2024	Delmosart 36mg XL tablets
Concerta XL 54mg tablets (Janssen-Cilag Ltd)	25th October 2024	Delmosart 54mg modified-release tablets Matoride XL 54mg tablets
Matoride XL 36mg tablets (Sandoz Ltd)	31st October 2024	Delmosart 36mg XL tablets
NB: Matoride XL is not available in 27mg strength

Most patients will be able to switch between their currently prescribed 12-HOUR duration brand/branded generic to another 12-HOUR duration brand/branded generic without concern. Switches can take place in primary care.

However, due to the relatively wide confidence limits allowed, it is possible that a minority of patients could experience a change in symptom control or tolerability following a switch.

For patients who have switched between 12-hour formulations before and previously experienced a change in symptom control or tolerability, and are prescribed Concerta XL for this reason, refer to the specialist.

The specialist may consider the following: if there were problems with:

• symptom control - consider if this change in symptom control might be acceptable for a short period of time, until the shortage of the brand they take resolves, or whether an alternative medication would be more appropriate.
• tolerability – establish what the tolerability issues were and consider whether it would be appropriate to temporarily prescribe a lower dose of their currently unavailable brand (assuming that strength is available) or to switch to a lower dose of the previously less-well tolerated brand. Decisions should be made on an individual case-by-case basis and if lower doses are used, this should consider the potential for a reduction in efficacy.
• The shortages are likely to extend to strengths that are not listed in the National Patient safety Alert, do not newly initiate any ADHD medication listed above – this includes ongoing prescribing for those patients who have had a private assessment.
• Maintain 28-day prescribing - Prescribers should avoid increasing quantities for existing patients on ADHD medication as this will add further pressures to the current stock disruption situation.
• The stock availability is currently variable across pharmacies – it is vital you establish how much supply the patient has remaining and consider the risk before referring to specialist services. 
• Methylphenidate modified release preparations can be switched to an alternative in primary care (see table under ‘Anticipated Supply dates’).
  • Community pharmacies will use different wholesalers, therefore contact the local pharmacies to understand the stock availability as recommended in the NatPSA alert.
  • Community pharmacies will ONLY be able to dispense what is written on the prescription, therefore new prescriptions will be needed for changes to the drug/dose/strength. 
  • The table below will support you to manage patients impacted by the shortage accordingly, the specialist teams are aware of the situation and will support where needed – see contact details at the end of this document.
  • NICE guidelines recommend having regular treatment breaks from ADHD medications. It is not unusual to stop taking medication over the weekend or during school holidays.
  • Clonidine is not licenced for ADHD and is NOT included in Kent and Medway Shared care guidance.

Methylphenidate Modified-Release bioequivalent alternatives. NB: Modified-release methylphenidate preparations MUST be prescribed by brand due to differences in bioavailability   Patients can be switched to a bioequivalent alternative in primary care, if more information needed refer to specialists Excipients may vary between bioequivalent products. Specialist advice may be needed to support switching between IR and MR methylphenidate.
Reference product	Bioequivalent Alternatives
Concerta XL tablets	Affenid XL tablets Delmosart tablets Matoride XL tablets Xaggitin XL tablets Xenidate XL tablets
Switching between IR and MR Concerta XL 18mg once daily is equivalent to a total daily dose of 15mg IR methylphenidate.
Equasym XL capsules	There are no products bioequivalent to Equasym XL. Seek specialist advice if switching is required.
Switching between IR and MR Equasym XL 10mg once daily is equivalent to a total daily dose of 10mg IR methylphenidate.
Medikinet XL capsules	There is no bioequivalent product for Medikinet XL, however other products with similar IR/MR ratio are available for example, Metyrol XL and Meflynate XL.
Switching between IR and MR Medikinet XL 10mg once daily is equivalent to a total daily dose of 10mg IR methylphenidate.
Metyrol XL / Meflynate XL capsules	Metryrol XL and Meflynate XL are both bioequivalent to Ritalin XL (not marketed in the UK). If there is a need to switch, these products offer similar IR/MR ratio and pharmacokinetics. Other products with a similar IR/MR ratio are available for example, Medikinet XL.
Switching between IR and MR Metyrol XL 10mg once daily is equivalent to a total daily dose of 10mg IR methylphenidate.

 

 

 

 

Lisdexamfetamine
Medicines affected	Anticipated re-supply date as per Takeda/SPS	Alternatives
Elvanse 20mg, 30mg, 40mg, 50mg, 60mg and 70mg capsules (Takeda UK Ltd)	Currently available	Refer to ‘Clinical Advice’ section below    NB: Information from Takeda RE: Elvanse Adult vs Elvanse: The physical attributes of Elvanse® (lisdexamfetamine dimesylate) and Elvanse Adult® (lisdexamfetamine dimesylate) are exactly the same, the only difference between the two medications is the indication population (licensing) where Elvanse is only indicated for paediatric patients (6 years and older), whereas Elvanse Adult is indicated for adults. Elvanse Adult and Elvanse can be used interchangeably off label – this would be at the prescribers clinical discretion
Elvanse Adult 20mg, 30mg, 40mg, 50mg, 60mg and 70mg capsules (Takeda UK Ltd)	Currently available

 

 

 

 

 

 

 

 

 

 

 

 

 

Guanfacine
Medicines affected	Anticipated re-supply date as per Takeda	Alternatives
Intuniv 1mg modified-release tablets (Takeda UK Ltd)	Currently available	Refer to ‘Clinical Advice’ section below
Intuniv 2mg modified-release tablets (Takeda UK Ltd)	Currently available
Intuniv 3mg modified-release tablets (Takeda UK Ltd)	Currently available
Intuniv 4mg modified-release tablets (Takeda UK Ltd)	Currently available

 

 

 

 

 

 

 

 

 

 

 

Atomoxetine
Medicines affected	Anticipated re-supply date	Alternatives
Atomoxetine 25mg capsules	Currently available	Refer to ‘Clinical Advice’ section below
Atomoxetine (Strattera) 4mg/ml oral solution (Eli Lilly)	31st October 2024
NB:  Atomoxetine 10, 18, 40, 60, 80 and 100mg capsules are back in stock as of 06/11/23 Atomoxetine 25mg capsules are back in stock as of 6/12/23, Glenmark brand available via Phoenix Healthcare Distribution Ltd, Lexon UK Ltd, Alliance Healthcare Distribution, Bestway Pharmacy, Trident Pharmaceuticals, Sigma Pharmaceuticals. NB:  Several manufacturers have discontinued.

 

 

 

 

 

 

 

 

 

 

Methylphenidate Modified-release preparations	Lisdexamfetamine	Guanfacine	Atomoxetine
·         We recommend that a risk-based approach to referral to specialist team is taken to manage demand. ·         Consider whether there is pre-existing evidence that stopping ADHD medication was associated with a rapid relapse of high-risk behaviour (e.g. serious self-harm, severe aggression leading to injuries or the Police being called, school exclusion etc). These individuals should, if possible, be prioritised for referral for alternate medication. ·         In general, it would be hoped that should medication be stopped that no significant adverse events will occur, however should significant issues arise contacting the specialist teams directly for support may be required.
Can be switched in primary care
In the first instance, we would suggest offering reassurance to patients on stimulant medication of the following: o   The simplest initial intervention would be to consider ONLY using their current supply of medication on days they most need o   Reducing the dose (where formulation allows this) may be helpful to allow current supply to last longer o   We recognise that this is a worrying situation, but a temporary pause in medication is not physically harmful despite it being impactful in other ways o   Switch to a bioequivalent alternative o   Refer to specialist if further information needed.	In the first instance, we would suggest offering reassurance to patients on stimulant medication of the following: o   The simplest initial intervention would be to consider ONLY using their current supply of medication on days they most need o   Reducing the dose (where formulation allows this) may be helpful to allow current supply to last longer o   We recognise that this is a worrying situation, but a temporary pause in medication is not physically harmful despite it being impactful in other ways Refer to specialist for further advice Please see MSN for further info	Patients on guanfacine should NOT stop this suddenly (due to possibility of rebound hypertension) and will need to be reviewed by their specialist ADHD team if patient unable to get supply of medication. (If it is not possible to reduce slowly, monitor BP and HR on stopping. The hypotensive effect of guanfacine may take about 2 – 4 days to resolve. This is usually asymptomatic and clinically insignificant. Monitor BP and HR at day 2, and again at day 4. If blood pressure is raised at day 4, measure again at weekly intervals until normal. If there are signs of clinically significant rebound hypertension, seek advice from specialist. Acknowledging South London and Maudsley) Please see MSN for further info	Patients on Atomoxetine could reduce their dose or take it on alternate days in the short term. Refer to specialist for further advice

 

Clinical advice

High risk patients requiring switching of medication/prioritisation (list is not exhaustive)

• Children/adults with complex needs (mental and physical co-morbid conditions).
• Children/adults with co-morbid neurodevelopmental conditions e.g. ASD/ADHD and intellectual disability.
• Children/adults with the above and challenging behaviours.
• Children/adults on polypharmacy e.g. antipsychotic + stimulant + other medication/ psychotropic.
• Children/adults in special needs provision/ school.
• Reports of child/adult showing increased risk e.g. physical aggression/ self-injurious behaviours/ breakdown of placement or school provision etc.

Advice to specialist teams/ services

• Continue to review those on maintenance doses as per clinically appropriate.
• Advised to provide 28 days or maximum 30 days (for controlled drug) prescriptions for stable and repeat prescriptions of ADHD medicines. Do not issue more than 30 day supply as this may exacerbate supply shortages.
• When changing the dose and/ or issuing prescriptions, please check supply with the pharmacy used by the patient/ family.
• For those on maintenance dose, please adjust dose based on product availability.
• Where the dose has been adjusted due to product availability, it is the responsibility of the clinician to agree with the patient/ family when the next review needs to take place.
• To advise GPs/ primary care on dose adjustments (if needed) for patients under primary care maintained on ADHD medicines. Advice should take into consideration product availability, as well as agreement with the GP who should review the patient post dose change in needed.
• To advice GPs/Primary care on patients suitable for a treatment break, based on specialist’s clinical judgement.

Advice to primary care services

• Practices are advised to identify patients who are currently on ADHD medications and add alert to clinical record of supply issues. A patient information leaflet and ‘easy to read leaflet’ are available to support conversations with patients.
• Provide 28 days or maximum 30 days (for controlled drug) prescriptions for stable and repeat prescriptions of ADHD medicines. Do not issue more than 30 day supply as this may exacerbate supply shortages.
• GPs are advised to contact the appropriate specialist service at the earliest opportunity if there are on-going issues in obtaining medication for advice on dose adjustments OR if patient is identified as ‘high risk/ high needs’- Contacts are provided at the end of this memo.
• Liaise with local and nominated pharmacies for patients with electronic prescriptions to ensure pharmacies are pre-emptively keeping adequate stocks and are informed where a dose/ formulation has changed.

Advice to community pharmacies

• Identify patients who have repeat prescriptions of ADHD medicines.
• To have a system in place to ensure adequate stocks for those families/patients who have a designated pharmacies for repeat supply.
• Where community pharmacies are part of a chain, the adviCe is to liaise with other branches in your locality to have an indication of local stock availability of ADHD medicines.
• Where another branch in your locality has stock, please liaise and transfer, required stock, to your branch and/or liaise with the branch and send prescription to them to be completed (if practical for families/ patients). 

Advice to schools

• Identify children and young people within their care who may be affected by changes to their ADHD medication. 
• For schools who administer ADHD medication, the advice would be to share the medication supply parents have at home and have a system in place to take and handover the medication at the end of the school day. Due to the current shortages, it will not be possible to provide a separate supply for school and another supply for home. 
• Ensure contingency plans are put in place for children with EP/EHCP/health care plans to help manage ADHD and related behaviours if they are off ADHD medication for more than ONE week. 
• Ensure reasonable adjustments are made to accommodate continued access to learning for children with ADHD as per the Kent Mainstream Core Standards, Medway Ordinarily Available Provision in Mainstream Schools, and the Equalities Act 2010 

Further advice/ support

The situation with regards to product availability is fluid at present. If services are unsure about the supply of a certain strength and/ or product, please contact your local pharmacy team for further advice. 

Patient education/counselling

• Services to agree what information should be shared with patients/families re: shortages. A patient information leaflet and ‘easy to read leaflet’ are available to support conversations with patients.
• Patients should be provided age/cognitively appropriate verbal and written medication on medication. This should include any specific additional monitoring which may be needed for specific patients.
• Patients should avoid abrupt withdrawal of medication.
• Patients can be signposted to the information on ADHD in adults available from the Royal College of Psychiatrists (adults) and to Medicines in Children leaflets (children/ parents/carers)

If you have any worries or concerns, please contact your GP surgery or specialist team for help/ advice.

London CAMHS

Kent and Medway CYPMHS

Essex (SET CAMHS) 

(Last updated 17 October 2024)