Methylphenidate

How it works

It blocks the reuptake of dopamine and noradrenaline at the presynaptic transporter, increasing synaptic concentrations of these monoamines in the prefrontal cortex and other regions involved in attention and impulse control.

Prescribing in practice

• Assess cardiovascular history and screen for significant cardiac disease before starting, as methylphenidate raises heart rate and blood pressure and is contraindicated in certain cardiac and psychiatric conditions.
• Monitor height and weight, as growth may be suppressed during treatment, and review the continued need for therapy periodically including planned treatment-free reviews.
• Initiation should be under a specialist in ADHD; titrate according to response and tolerability using a children's formulary and the SPC.

Monitoring

Monitor heart rate, blood pressure, height, weight, appetite, sleep and mental state (including emergence of tics, anxiety or psychiatric symptoms) at baseline and regularly during treatment.

Counselling the patient

• Explain that the medicine helps with concentration and impulsivity but works alongside behavioural and educational support.
• Report palpitations, chest pain, fainting, marked mood changes or new involuntary movements.
• Appetite suppression and difficulty sleeping are common; giving doses earlier in the day and with or after food can help.

Evidence & guidelines

NICE recommends methylphenidate as a first-line medication for ADHD in children and young people when medication is indicated, supported by extensive randomised trial evidence including the MTA study.