Indications And Dose
Short-term use in anxiety—not recommended ▶BY MOUTH ▶Adult: 400 mg 3–4 times a day ▶Elderly: Up to 200 mg 3–4 times a day
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Drug reference
Short-term use in anxiety—not recommended ▶BY MOUTH ▶Adult: 400 mg 3–4 times a day ▶Elderly: Up to 200 mg 3–4 times a day
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Acute porphyrias p. 1120. acute pulmonary insufficiency. respiratory depression
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Abrupt withdrawal (may precipitate convulsions). avoid prolonged use. elderly. emotionally unstable personality (if taken over long periods)— increased risk of dependence. epilepsy (may induce seizures). history of alcohol dependence. history of drug dependence. muscle weakness. respiratory disease
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MHRA/CHM ADVICE: MEPROBAMATE: LICENCE TO BE CANCELLED (APRIL 2016) Following an EU-wide review of meprobamate, the UK licence holder has ceased manufacturing and the licence is due to be cancelled by December 2016. No new stock will be released into the normal distribution chain after 31 December 2016, although existing stock placed on the market before that date is likely to be dispensed until the products approach their expiry date. Prescribers should review the treatment of any patient who is currently receiving a meprobamate-containing medicine with a view to switching them to an alternative treatment, and not start any new patients on medicines that contain meprobamate.
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→Appendix 1: meprobamate
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Agitation. agranulocytosis. anal inflammation. ataxia. blood disorder. bone marrow disorders. dizziness. drowsiness. hypersensitivity. hypotension. nausea. paraesthesia. purpura non- thrombocytopenic. skin reactions. Stevens-Johnson syndrome. stomatitis. thrombocytopenia. vomiting. withdrawal syndrome
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Avoid if possible.
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Avoid. Concentration in milk may exceed maternal plasma concentrations fourfold and may cause drowsiness in infant.
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Elimination may be prolonged in chronic impairment.
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Increased cerebral sensitivity. Dose adjustments Start with small doses in severe Nervous system impairment.
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There can be variation in the licensing of different medicines containing the same drug. Forms available from special-order manufacturers include: oral suspension, oral solution Tablet CAUTIONARY AND ADVISORY LABELS 2 ▶Meprobamate (Non-proprietary) Meprobamate 400 mg Meprobamate 400mg tablets | 84 tablet P £197.63 DT = £197.63 c 3.2 Attention deficit hyperactivity disorder Attention deficit hyperactivity disorder Description of condition Attention deficit hyperactivity disorder (ADHD) is a behavioural disorder characterised by hyperactivity, impulsivity and inattention, which can lead to functional impairment such as psychological, social, educational or occupational difficulties. While these symptoms tend to co- exist, some patients are predominantly hyperactive and impulsive, while others are principally inattentive. Symptoms typically appear in children aged 3–7 years, but may not be recognised until after 7 years of age, especially if hyperactivity is not present. ADHD is more commonly diagnosed in males than in females. ADHD is usually a persisting disorder and some children continue to have symptoms throughout adolescence and into adulthood, where inattentive symptoms tend to persist, and hyperactive-impulsive symptoms tend to recede over time. ADHD is also associated with an increased risk of disorders such as oppositional defiant disorder (ODD), conduct disorder, and possibly mood disorders such as depression, mania, and anxiety, as well as substance misuse. Aims of treatment The aims of treatment are to reduce functional impairment, severity of symptoms, and to improve quality of life. Non-drug treatment g Patients should be advised about the importance of a balanced diet, good nutrition and regular exercise. h Environmental modifications are changes made to the physical environment that can help reduce the impact of ADHD symptoms on a person’s day-to-day life. g The modifications should be specific to the person’s circumstances, and may involve changes to seating arrangements, lighting and noise, reducing distractions, optimising work or education by having shorter periods of focus with movement breaks, and reinforcing verbal requests with written instructions. These changes should form part of the discussion at the time of diagnosis of ADHD and be trialled and reviewed for effectiveness before drug treatment is started. ADHD focused psychological interventions which may involve elements of, or a complete course of cognitive behavioural therapy (CBT) may be effective in patients who have refused drug treatment, have difficulty with adherence, Nervous system are intolerant of, or unresponsive to drug treatment. In patients who have benefited from drug treatment, but whose symptoms are still causing significant impairment in at least one area of function (such as interpersonal relationships, education and occupational attainment, and risk awareness), consider a combination of non-drug treatment with drug treatment. h Drug treatment g Drug treatment should be initiated by a specialist trained in the diagnosis and management of ADHD. Following dose stabilisation, continuation and monitoring of drug treatment can be undertaken by the patient’s general practitioner under a shared care arrangement. Treatment should be started in patients with ADHD whose symptoms are still causing significant impairment in at least one area of function, despite environmental modifications. Patients with ADHD and anxiety disorder, tic disorder, or autism spectrum disorder should be offered the same treatment options as other patients with ADHD. Lisdexamfetamine mesilate p. 369 or methylphenidate hydrochloride p. 365 are recommended as first-line treatment. If symptoms have not improved following a 6-week trial of either drug, switching to the alternative first- line treatment should be considered. Dexamfetamine sulfate p. 368 [unlicensed] can be tried if the patient is having a beneficial response to lisdexamfetamine mesilate but cannot tolerate its longer duration of effect. Modified-release preparations of stimulants are preferred because of their pharmacokinetic profile, convenience, improved adherence, reduced risk of drug diversion (drugs being forwarded to others for non-prescription use or misuse), and the lack of need to be taken to work. Immediate-release preparations can be given when more flexible dosing regimens are required, or during initial dose titration. A combination of modified-release and immediate- release preparations taken at different times of the day can be used to extend the duration of effect. The magnitude, duration of effect, and side-effects of stimulants vary between patients. In patients who are intolerant to both methylphenidate hydrochloride p. 365 and lisdexamfetamine mesilate, or who have not responded to separate 6-week trials of both drugs, treatment with the non-stimulant atomoxetine below can be considered. Advice from, or referral to a tertiary specialist ADHD service should be considered if the patient is unresponsive to one or more stimulant drugs (e.g. methylphenidate hydrochloride p. 365 and lisdexamfetamine mesilate) and atomoxetine below. A specialist service should also be consulted for advice before starting treatment with guanfacine p. 370 [unlicensed], or an atypical antipsychotic in addition to stimulants in patients with ADHD and co- existing pervasive aggression, rages or irritability. If sustained orthostatic hypotension or fainting episodes occur with guanfacine p. 370 treatment, the dose should be reduced or an alternative treatment offered. h Other treatment options such as bupropion hydrochloride p. 521, modafinil p. 514, tricyclic antidepressants, and venlafaxine p. 386 [all unlicensed] have been used in the management of ADHD, but due to limited evidence their use is not recommended without specialist advice. g Patients should be monitored for effectiveness of medication and side-effects, as well as changes in sleep pattern, sexual dysfunction (associated with atomoxetine below), and stimulant diversion or misuse. If the patient develops new, or has worsening of existing seizures, review drug treatment and stop any drug that might be contributing to the seizures; treatment can be cautiously reintroduced if it is unlikely to be the cause. Monitor patients for the development of tics associated with stimulant use. If tics are stimulant related, consider a dose reduction, stopping treatment, or changing to a non-stimulant drug. If there is worsening of behaviour, consider adjusting drug treatment and reviewing the diagnosis. Treatment should be reviewed by a specialist at least once a year and trials of treatment-free periods, or dose reductions considered where appropriate. h Useful Resources Attention deficit hyperactivity disorder: diagnosis and management. National Institute for Health and Care Excellence. Clinical guideline 87. March 2018. www.nice.org.uk/guidance/ng87 CNS STIMULANTS › CENTRALLY ACTING SYMPATHOMIMETICS
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Driving and skilled tasks Drowsiness may affect performance of skilled tasks (e.g. driving); effects of alcohol enhanced. l LESS SUITABLE FOR PRESCRIBING Meprobamate is less suitable for prescribing.
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Up to 200 mg 3–4 times a day
First-line fragment. Read the complete Indications and Dose section above.
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