MJB ADHD · Static reading view · Interactive version
Status: drafted · Content checked 2026-10-06
Re-titrating cautiously is usually reasonable. Changing to a medicine that has already been tried and found inadequate is a different decision, and needs reasons.
Two separate questions get mixed up when treatment restarts:
Why might a new prescriber prefer a long-acting first-line medicine? Reasonable answers include: national guidance places lisdexamfetamine and methylphenidate first; long-acting products are taken once a day; lisdexamfetamine's prodrug design is associated with lower misuse potential; and a new provider may not yet have the previous service's records.
NICE recommends offering lisdexamfetamine or methylphenidate first in adults, considering a switch after a six-week trial at an adequate dose without enough benefit, and considering dexamfetamine for adults responding to lisdexamfetamine who cannot tolerate its longer effect profile.
W1Read carefully, that sequence also means: after an inadequate lisdexamfetamine trial, the next step NICE describes is a switch, most often to methylphenidate — not another lisdexamfetamine trial.
Ask for the restart plan in writing, with reasons. Useful wording:
Please set out the proposed medicine, starting dose and titration steps; the reason for choosing it over the alternatives, including the medicine I responded to previously; what will be monitored; how long the trial will last; and what result would lead to a change.
Lisdexamfetamine is converted to the same active drug as dexamfetamine, but more gradually; the different exposure curve means tolerability and benefit can differ between them in the same person.
R10Shared active ingredient does not prove equal safety or equal effect, in either direction. Current blood pressure, pulse, heart history, mental health and other medicines all need assessing at restart.
The dexamfetamine licence lists psychiatric and cardiovascular contraindications and cautions that a prescriber must assess for the individual.
W4A previous consultant's plan deserves weight — it records clinical reasoning made with more history than a new provider has. It does not bind every future decision. The fair test is whether the new decision engages with the old one and gives reasons.
Evidence comparing restart strategies after a gap in adults is thin. Individual history matters more than population averages here.