Hello and welcome to BJGP Interviews.

I'm Nada Khan and I'm one of the associate editors at the bjgp.

Thanks for listening to this podcast today.

In today's episode, we're speaking to Dr.

Sara Nhodin, a GP with an extended role in ADHD, and Dr.

Nishi Yagur, consultant psychiatrist in Adult ADHD Services.

We're talking about the recent Clinical Practice article here in the BJGP titled A Guide for Primary Care Clinicians Managing ADHD Medication Side Effects.

So, thanks.

It's great to meet you both Sara and Nishi.

This is a really topical area to highlight in the journal, and not least because it seems that every week there seems to be a new article in the media about the increasing diagnosis of adhd.

So it's a really topical area to look at, but I guess, Sar, I just really wanted to start with what prompted you to write this article and why now?

Yeah, so I think coming from a GP perspective, before I specialized in adhd, I think these medications did create a bit of anxiety, especially as they're controlled drugs, their stimulants, their specialist medications, and there was a lot that I didn't know about them as I since developed a special interest and it sort of demystified some of these medications.

And I just.

I think we wanted to pass on to primary care clinicians some of that knowledge that we've learned, some really basic things that they can look out for that may or may not be related to medications and some common things that they can advise and to know when to escalate secondary care and how to manage these patients, essentially.

Yeah.

And Saura, I wonder if you could just tell us a bit more about your role as a GP with an extended role in adhd.

So you must be very much in demand at the moment, but talk us through what led you to sort of take that role and what your typical week is like.

Yeah, So I think my interest in ADHD stemmed during my training years and I currently am working as a salary GP, but also working at CNWL under Dr.

Jaga.

I'm doing diagnosis and medication titrations.

And I think my interest stemmed because of how prevalent ADHD is becoming.

I was seeing such an increase in patients presenting to gp, suspecting they have ADHD and requesting referral, and reading about this treatment and what we can offer, I was really taken aback by not only how ADHD can impact a patient in terms of their symptoms and concentration of focus, but also the lifelong issues that can arise sometimes with adhd, like all the Research showing that it increases rates of depression, underachievement at school, even early death and accidental injuries.

So I feel it's a really important, important condition for us to be able to pick up, to be able to refer promptly and start treatment.

And that's where the interest started.

And, Nishi, from your perspective, what's it like having a GP working with your team?

And from a secondary care perspective, I wonder if you could just tell us a bit more about your impression on how secondary care and general practice communicate around ADHD and people living with it.

It's been great having Sara in the team for many reasons.

So I guess primarily we're very aware that we need to work more closely with primary care.

There's so much back and forth with emails and us trying to be helpful to primary care primary care, having concerns and needing our input, that the idea of actually training primary care keeps coming up for us as a service, like, how much can we involve them, how much can we train them?

It's such a huge area of work.

We know more and more patients are coming forward and we know very much that it can't just stay a specialist service.

So as a service, we're very keen to have involvement from primary care.

So we have Sara and we also have a GP trainee, which is great from more selfish point of view.

It's been great to have a GP in the team because ADHD patients often have a lot of medical comorbidity and it's been great for us to be able to discuss that with a GP instead of needing to contact a cardiologist or go to another specialist.

We know that probably this is, you know, within the remit of a gp, so it works well both ways.

Great.

And I think, as you mentioned, you know, I don't think any specialty or general practice practitioner would feel that less collaboration is a good thing.

So I think the more the better.

And I guess I'd recommend people listening to go and read the full article here and take a close look at it.

But I wanted to specifically focus on Table 1, which lists some common ADHD medication and then some key practical advice around prescribing it.

But I wonder if you could just summarize some of the common areas we should be considering in general practice amongst patients who are being prescribed ADHD medication.

What are your top tips?

I think some of the most common symptoms and side effects that we see with patients taking medications are things like appetite suppression and weight loss.

And there are some basic advice that can be offered to a patient who might be Experiencing these, such as having a big breakfast, taking the medication with or just before.

Sorry, just after food.

And if this is still a persistent issue, then we would encourage the GP to refer back to secondary care.

Another common issue is sleep disturbance.

And again, some advice the GP can give can be taking medication.

Medication at different times of the day, such as taking it earlier.

Often a lot of these things would have been worked out with the specialist when they're being titrated, and often by the time the patient gets to the gp, these symptoms would be stabilised and the patient would be stable.

However, things can change and I think what the GP needs to look out for is any new symptoms or any new side effects that weren't present before and be able to identify what's normal, what's acceptable, what would be sufficient for simple advice and what needs to be flagged back up to the psychiatrist.

And I guess that touches on the next thing, which is shared care agreements in ADHD prescribing.

And I guess, where do you think the GP role lies here in terms of monitoring and assessing side effects of treatment for adhd?

I think it's a really complex question, actually, and quite controversial because the NICE guidelines do say that the annual review should be done by someone with expertise in adhd, but often we know that that can fall on the gp.

And I know there are lots of discussions in various areas across the country of how to best manage this and create a more uniform shared care agreement, which is really clear on who's doing the reviews.

And I think essentially, if the GP is feeling confident and competent to do the reviews and they have a good pathway back to secondary care and a good support system to raise any red flags to, then that could be something that gps might be comfortable and can consider.

But there are funding implications for that and I think that it's probably a wider issue that needs to be addressed.

Absolutely.

Nishi, do you have any thoughts about that at all?

It's a very hot topic, really, because of the number of patients that are being diagnosed and that are taking treatment.

For any service to manage annual reviews for thousands of people is not feasible.

So I think, and I agree with Sara, that you know, where there is a level of confidence, and I think our hope with this article was to give gps confidence and to enable them to almost realize that they probably are able to do this.

They.

They manage such severe illness, they manage all kinds of medications, they.

They do have the knowledge.

So I guess we wanted to share that it's not that specialist an area for most patients can be managed.

But we do appreciate that there are the more complex patients, there are the ones that do need to be seen in secondary care.

And we would just really like a much smoother collaborative working where it's easy for the GP to ask and it's easy for us to see the person that would be the ideal.

With shared care, the GP always knows I have someone I can speak to, I can send a quick email, I can get a response without the really hard kind of boundary of you have to do this and you have to do that.

And I think within shared care, the fact that the GP is prescribing every month, there is a level of, you know, that's a huge responsibility to actually, you know, prescribe something and to know what you're prescribing and what the problems may be.

And I guess there'll be situations where a patient might have been seen by someone in the GP practice saying, you know, I'm worried, I'm losing weight, and then the next prescription is due and the GP prescribes, but just knowing that, ah, that came up.

Let me just think about that.

Is that a problem here?

And be able to respond confidently Or I need to speak to someone, I need to ask a question.

So I think shared care is a big.

Is kind of a big topic.

But as Sara and I have discussed, GPs are, you know, are really top of their game and we think it is.

I feel very much that the shared knowledge and the reassurance and the being this kind of incredibly supportive backup service would really help if we could.

If we could achieve that.

And the kind of systems that you're putting in place, having GPs with extended roles and trainees in your service, I think will only help upskill people going forward.

So that might be a nice template for other, other areas to take on as well.

Let's hope.

Yeah.

Yeah, brilliant.

And it's really useful in the article as well.

You have a list of typical medications and their typical and common side effects and some key practical advice around it.

So I think that's really helpful for people to go back and take a look at as well.

So for anyone listening, again, if you've got people on these medications and you're wondering about what the common side effects are and practical advice, I think that's a really helpful place to look for that.

And I guess really my next question is about.

Sorry, you touched on this and do you have any advice on when people should be referred back to secondary care for review?

What are your thoughts on this?

Yeah, it's A good question.

So I think from the GP perspective, things to look out for, the red flags that would definitely prompt you to want secondary care input would be any patient presenting with manic or psychotic symptoms would absolutely need immediate psychiatry input and advice relating to their medication.

And secondly, any time you're suspecting misuse or diversion that would prompt a secondary care referral.

Any patient who's got new cardiac symptoms or high blood pressure and you need advice regarding the medication, whether stop or start, that would be a good time to get secondary care input.

Any patient who's had weight loss, especially more than 5% weight loss, and you've excluded any of the physical health conditions you'd normally exclude with weight loss.

These are the ones that come to mind.

Nishi, do you have any other.

I guess the only other ones are, and we do get this quite often is the patients that don't sleep, but partly, maybe linked to their medication, but often part of their ADHD or neurodiversity that often comes back to us as something to think about.

And when the medications don't seem to work anymore, I guess that's the only other time.

And again, there's a, often there's a very simple reason for it and hopefully gps can think about that.

But it happens, you know, not, not often, but it does happen.

Someone's life situation changes and actually their ADHD is more of a problem, the demands on them are greater and the medication doesn't seem as effective and that would be a very reasonable time to send someone back.

And Sara, I know that you've really upskilled in this area and have got a lot of specialist knowledge about ADHD medication and management, but do you have any tips or advice just for regular jobbing GPs who might not have that expertise?

Do you have anything that you want to tell them about, sort of maybe to boost their confidence or any tips that you want to sort of pass on to them?

I think I've learned that it's not as complicated as it looks on the outside.

I think, like I said at the beginning, a lot of gps feel a lot of anxiety about ADHD medications and I don't think they need to.

There's not many ADHD medications and they all have very similar side effect profiles and things to look out for.

So it's not like, like antipsychotics where there's lots of different things to think about for every individual medication.

I think if I could give a take home message for gps, it's really to know what is normal with these medications and what needs escalating.

And there are a lot of side effects that are normal and not to worry about immediately with these medications.

So I'm hoping that in the Table 1, GPS can refer to that and feel more comfortable knowing, okay, this is something that we can expect and know when to escalate.

And I guess from a general practice perspective, knowing our patients quite well over a long period of time helps us to sort of work out what's new or what's different and what may be down to the ADHD and what we need to be concerned about, really.

Yeah, absolutely.

I think in gp, we're in a unique position where we really know our patients.

And like Nishi said, life circumstances do change.

And although patients tend to be discharged when they're stabilized, anything in a patient's life can cause their medication to not work quite the same or a new side effect.

And as gps, we're in a really good position to know what's normal for our patients and what's beyond our remit.

Great.

Anything that either of you want to add?

I wanted to add something in terms of kind of simple things to reassure gps.

I think the risk of misuse and diversion is a real fear for gps, understandably.

But I think it would be good for them to know that the only medication out of the ones that we prescribe that really can be misused is dexamphetamine, and we don't prescribe it very much.

So the other medications have been formulated such that they can't really be misused, they don't give that hit.

And the rush that, you know, amphetamines would.

Would give for people that do misuse them.

So, you know, we tend to avoid prescribing dexamphetamine.

We would only prescribe as someone who is a very low risk of misuse, you know, who does not have a history or very low risk.

And the one that we prescribe more is lisdexamphetamine.

So the kind of modified release formulation which can't be misused.

So, you know, it's.

It's formulated in that way.

So I think this.

This fear of diversion is.

Is not as great as it needs to be.

It did become a little bit of an issue when we had supply problems with lisdexamphetamine.

We were needing to prescribe more dexamphetamine, but we were very aware that we don't want loads of dexamphetamine out there in the community, and it was only really prescribed when it should be, when it needed to be.

So I think this idea of Lots of people misusing their medication isn't quite the case.

And we know that people with ADHD are at greater risk of developing a substance misuse problem.

We know that if their ADHD is treated, that risk is hugely reduced.

They're a lot less likely to misuse drugs if they have ADHD treatment.

They don't have the desire or the need to do that.

So.

And that often becomes a problem.

Like someone say, oh, this person has misused in the past, they've had substance use problems in the past.

We shouldn't be prescribing this.

These medications for them.

It's quite the opposite.

Prescribe these medications for them and help them not fall back into that problem.

So I think that should be.

I hope it's reassuring.

Thank you.

Anything that you want to add, Sara?

No, just for really gps to be aware of ADHD and feel a bit more comfortable with adhd, both in terms of picking up patients who are undiagnosed historically under diagnosed cohorts like women who have more internalized symptoms and to be comfortable referring and to be more comfortable in the shared care agreements and familiar with these medications that I think will be more commonly prescribed in the future.

Thank you.

Yeah.

And as you point out, yes.

As these medications and the prevalence of people taking them or increasing, it is an important area that we need to consider in general practice, especially as we take on prescribing.

So thanks very much and I think that's been a really interesting chat around this area and a very topical and very practical article that you've both written.

So thanks very much for your time.

Thank you.

Thank you.

And thank you all very much for your time here and for listening to this BJGP podcast.

The original clinical practice article written by Sara and her colleagues can be found on bjgp.org and the show notes and podcast audio can be found@bjgplive.com I hope you'll take the opportunity to go back and read the paper in depth just for some tips as we discussed about how to manage ADHD medication and its side effects in practice.

Thanks again and bye.