Today, we’re speaking to Dr Sara Noden, a GP with an extended role in ADHD, and Dr Nishi Yarger, Consultant Psychiatrist in adult ADHD services.

Title of paper: A guide for primary care clinicians managing ADHD medication side effects

Available at: https://doi.org/10.3399/bjgp25X742653

Transcript

This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.

Speaker A

00:00:00 .320 - 00:00:55 .720

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 Noden, a GP with an extended role in ADHD, and Dr. Nishi Yarger, 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?

Speaker B

00:00:56 .620 - 00:01:39 .320

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.

Speaker A

00:01:39 .560 - 00:01:54 .040

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.

Speaker B

00:01:54 .320 - 00:02:58 .810

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.

Speaker A

00:02:59 .050 - 00:03:14 .570

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.

Speaker C

00:03:14 .650 - 00:04:27 .649

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.

Speaker A

00:04:27 .969 - 00:05:05 .980

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?

Speaker B

00:05:06 .300 - 00:06:14 .360

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.

Speaker A

00:06:14 .840 - 00:06:26 .840

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?

Speaker B

00:06:27 .880 - 00:07:16 .120

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.

Speaker A

00:07:16 .280 - 00:07:18 .520

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

Speaker C

00:07:18 .680 - 00:09:38 .930

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 res