Below is a chronological summary of minor updates to the Saudi ADHD CPG as reviewed and approved by the Medical and Psychological Committee.
Note:
- Updates 2022-1a,2022-1b,2022-2,2022-3a,2022-3b,2022-4a,2022-4b,2022-4c are based upon minor updates to the source CPG published by NICE.
- Additional updates to the source CPG (1.5.x) affected the NICE discussion section (rationale and impact) on the NICE website only.
Update 2022-1a
It is now recommended [“should”] to perform a cardiovascular assessment even in the absence of family history or risk factors.
Before:
7.3 Before starting medication for ADHD, people with ADHD should have a full assessment, which should include:
- […]
- a review of physical health, including:
- […]
- a cardiovascular assessment if there is family history or other risk factors
After:
7.3 Before starting medication for ADHD, people with ADHD should have a full assessment, which should include:
- […]
- a review of physical health, including:
- […]
- a cardiovascular assessment
Update 2022-1b
ECG was previously recommended if it “may affect QT interval”, but is now recommended in the presence of [7.4]: “history of congenital heart disease or previous cardiac surgery, history of sudden death in a first-degree relative under 40 years suggesting a cardiac disease, shortness of breath on exertion compared with peers, fainting on exertion or in response to fright or noise, palpitations that are rapid, regular and start and stop suddenly (fleeting occasional bumps are usually ectopic and do not need investigation), chest pain suggesting cardiac origin, signs of heart failure, a murmur heard on cardiac examination, blood pressure that is classified as hypertensive for adults”
Before:
7.3 Before starting medication for ADHD, people with ADHD should have a full assessment, which should include:
- […]
- a review of physical health, including:
- […]
- an electrocardiogram (ECG) if the treatment may affect the QT interval
After:
7.3 Before starting medication for ADHD, people with ADHD should have a full assessment, which should include:
- […]
An electrocardiogram (ECG) is not needed before starting stimulants, atomoxetine or guanfacine, unless the person has any of the features in recommendation 7.4, or a co-existing condition that is being treated with a medicine that may pose an increased cardiac risk.
Update 2022-2
Added note that MPH for children aged 5 years is considered off-label.
Before:
7.6 Offer methylphenidate (either short or long acting) as the first line pharmacological treatment for children aged 5 years and over and young people with ADHD.
After:
7.6 Offer methylphenidate (either short or long acting) as the first line pharmacological treatment for children aged 5 years and over and young people with ADHD, taking into consideration that this is an off-label use for children aged between 5 and 6 years.
Update 2022-3a
Added note that LDX is considered off-label for “adults with no ADHD symptoms in childhood”.While this change adopted from NICE may seem to imply so-called “adult-onset ADHD”, for which there is insufficient evidence, the medical and psychological committee members agreed that it actually refers to adult-diagnosed ADHD with an absence of evidence for childhood-onset, such as when an adult cannot remember (“absence of evidence is not evidence of absence”).
Before:
7.10 Offer lisdexamfetamine or methylphenidate as first-line pharmacological treatment for adults with ADHD.
After:
7.10 Offer lisdexamfetamine or methylphenidate as first-line pharmacological treatment for adults with ADHD. This is an off-label use of lisdexamfetamine for adults with no ADHD symptoms in childhood.
Update 2022-3b
Added note that some preparations of MPH are not licenced for ADHD in adults.
Before:
7.10 Offer lisdexamfetamine or methylphenidate as first-line pharmacological treatment for adults with ADHD.
After:
7.10 Offer lisdexamfetamine or methylphenidate as first-line pharmacological treatment for adults with ADHD. This is an off-label use of lisdexamfetamine for adults with no ADHD symptoms in childhood.
Update 2022-4a
Added note that ATX is off label for “adults with no ADHD symptoms in childhood”.
Before:
8.14 If tics are stimulant related, reduce the stimulant dose, or consider changing to guanfacine (in children aged 5 years and over and young people only), atomoxetine, clonidine, or stopping medication.
After:
8.14 If tics are stimulant related, reduce the stimulant dose, or consider changing to guanfacine (in children aged 5 years and over and young people only), atomoxetine (off-label use for adults with no ADHD symptoms in childhood), clonidine, or stopping medication.
Update 2022-4b
Added note that clonidine is “off-label use for children”.
Before:
8.14 If tics are stimulant related, reduce the stimulant dose, or consider changing to guanfacine (in children aged 5 years and over and young people only), atomoxetine (off-label use for adults with no ADHD symptoms in childhood), clonidine, or stopping medication.
After:
8.14 If tics are stimulant related, reduce the stimulant dose, or consider changing to guanfacine (in children aged 5 years and over and young people only), atomoxetine (off-label use for adults with no ADHD symptoms in childhood), clonidine (off-label use for children), or stopping medication.
Update 2022-4c
Added restriction on clonidine use in primary and secondary care.
Before:
8.14 If tics are stimulant related, reduce the stimulant dose, or consider changing to guanfacine (in children aged 5 years and over and young people only), atomoxetine (off-label use for adults with no ADHD symptoms in childhood), clonidine (off-label use for children), or stopping medication.
After:
8.14 If tics are stimulant related, reduce the stimulant dose, or consider changing to guanfacine (in children aged 5 years and over and young people only), atomoxetine (off-label use for adults with no ADHD symptoms in childhood), clonidine (off-label use for children), or stopping medication. Clonidine should only be considered for people under 18 years after advice from a tertiary ADHD service.
Update 2022-5
Added cross-reference to related Saudi guidelines to add value for guideline users.
Before:
2.1 Be aware that people in the following groups may have increased prevalence of ADHD compared with the general population:
- […]
- people with neurodevelopmental disorders (for example, autism spectrum disorder, tic disorders, intellectual disability and specific learning difficulties).
After:
2.1 Be aware that people in the following groups may have increased prevalence of ADHD compared with the general population:
- […]
- people with neurodevelopmental disorders (for example, autism spectrum disorder, tic disorders, intellectual disability and specific learning difficulties). See p24, Early Recognition and Diagnosis, Evidence-Based CPG for Management of Children with ASD (Saudi Health Council, 2022).
Update 2022-6
Added cross-reference to related Saudi guidelines to add value for guideline users.
Before:
7.17 Offer the same medication choices to people with ADHD and anxiety disorder, tic disorder or autism spectrum disorder as other people with ADHD.
After:
7.17 Offer the same medication choices to people with ADHD and anxiety disorder, tic disorder or autism spectrum disorder as other people with ADHD. See p52, Pharmacological Interventions, Evidence-Based CPG for Management of Children with ASD (Saudi Health Council, 2022).
Update 2023-1
A change of wording to clarify that recommendation 7.21 only covers preparations of methylphenidate
Before:
7.21 Think about using immediate- and modified-release preparations of stimulants to optimise effect (for example, a modified-release preparation of methylphenidate in the morning and an immediate-release preparation of methylphenidate at another time of the day to extend the duration of effect).
After:
7.21 Think about using a modified-release preparation of methylphenidate in the morning and an immediate-release preparation of methylphenidate at another time of the day to extend the duration of effect.
Update 2023-2
A change of wording because ADHD is recognised as a neurodevelopmental disorder
Before:
- 2.1 Be aware that people in the following groups may have increased prevalence of ADHD compared with the general population:
- […]
- people with neurodevelopmental disorders (for example, autism spectrum disorder, tic disorders, intellectual disability and specific learning difficulties). See p24, Early Recognition and Diagnosis, Evidence-Based CPG for Management of Children with ASD (Saudi Health Council, 2022).
- […]
After:
- 2.1 Be aware that people in the following groups may have increased prevalence of ADHD compared with the general population:
- […]
- people with other neurodevelopmental disorders (for example, autism spectrum disorder, tic disorders, intellectual disability and specific learning difficulties). See p24, Early Recognition and Diagnosis, Evidence-Based CPG for Management of Children with ASD (Saudi Health Council, 2022).
- […]
Update 2023-3
Addition of a brief note about transcutaneous electrical stimulation of the trigeminal nerve for ADHD.
Before:
(None)
After:
- 5.19 Evidence on the safety and efficacy of transcutaneous electrical stimulation of the trigeminal nerve for attention deficit hyperactivity disorder (ADHD) is inadequate in quality and quantity. Therefore, this procedure should only be used in the context of research.