# Attention-deficit/hyperactivity disorder (ADHD referral pathway) - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: Atomoxetine 100 mg capsules SmPC sections 4.2 and 4.4 (eMC product 10337) · CONCERTA (methylphenidate HCl) extended-release tablets US prescribing information, section 2 Dosage and Administration (DailyMed SetID 1a88218c-5b18-4220-8f56-526de1a276cd); Ritalin LA US prescribing information, section 2 (DailyMed SetID effd952d-ac94-47bb-b107-589a4934dcca) · Magnus W, Anilkumar AC, Shaban K. Attention Deficit Hyperactivity Disorder. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Bookshelf ID: NBK441838. PMID: 28722868. · Intuniv 4 mg prolonged-release tablets SmPC sections 4.1 and 4.2 (eMC product 7507) - Verified date: 2026-08 ## Verified against - Atomoxetine 100 mg capsules SmPC sections 4.2 and 4.4 (eMC product 10337) - CONCERTA (methylphenidate HCl) extended-release tablets US prescribing information, section 2 Dosage and Administration (DailyMed SetID 1a88218c-5b18-4220-8f56-526de1a276cd); Ritalin LA US prescribing information, section 2 (DailyMed SetID effd952d-ac94-47bb-b107-589a4934dcca) - Magnus W, Anilkumar AC, Shaban K. Attention Deficit Hyperactivity Disorder. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Bookshelf ID: NBK441838. PMID: 28722868. - Intuniv 4 mg prolonged-release tablets SmPC sections 4.1 and 4.2 (eMC product 7507) ## Treatment metadata - Methylphenidate — 10 mg — oral.solid - Atomoxetine — 40 mg — oral.solid - Guanfacine — oral.solid ## Complete treatment card ```text ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD REFERRAL PATHWAY) Sources: Atomoxetine 100 mg capsules SmPC sections 4.2 and 4.4 (eMC product 10337) · CONCERTA (methylphenidate HCl) extended-release tablets US prescribing information, section 2 Dosage and Administration (DailyMed SetID 1a88218c-5b18-4220-8f56-526de1a276cd); Ritalin LA US prescribing information, section 2 (DailyMed SetID effd952d-ac94-47bb-b107-589a4934dcca) · Magnus W, Anilkumar AC, Shaban K. Attention Deficit Hyperactivity Disorder. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Bookshelf ID: NBK441838. PMID: 28722868. · Intuniv 4 mg prolonged-release tablets SmPC sections 4.1 and 4.2 (eMC product 7507) Review status: REVIEWED against 4 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (7) - Trouble focusing on tasks, missing details, and rushing through work [inattention] - Seems not to listen when spoken to directly and struggles to get organized [inattention · poor concentration] - Avoids or dislikes tasks needing sustained mental effort, loses things, and is forgetful [inattention · poor concentration] - Fidgety and restless, feels driven by an internal motor, and talks excessively [hyperactivity · irritability] - Interrupts others and has trouble waiting for a turn [impulsivity] - In adults, symptoms often show up as procrastination, mood swings, and low self-esteem instead of overt hyperactivity - Everyday functioning suffers - for example, a parent struggling to get children to school on time or keep the home organized SIGNS - what you find (1) - Physical exam adds little to diagnosis but helps rule out a medical cause such as a thyroid problem TESTS (5) - No lab or imaging test diagnoses the condition - it is a clinical diagnosis based on history - Neuropsychological testing lacks the sensitivity to make the diagnosis on its own - The Brown scale can help identify the disorder in adults - The Vanderbilt scale, completed by both teacher and parent, is the standard tool for children - Onset before age 12, with impairment present in more than one setting, is required for diagnosis IF NOT THIS - what else fits (4) - Depression and anxiety can be mistaken for it, since poor focus and distractibility overlap - Substance abuse disorder should be checked for, since these patients are prone to it - Hearing loss, learning disorders, and developmental disorders need to be excluded - Symptoms explained by another disorder, such as a manic or psychotic episode, rule this diagnosis out Source StatPearls "Attention Deficit Hyperactivity Disorder" - disease-level clinical article Status traced to the source above Rx: Main treatment | Non-stimulant alpha-2 agonist, prolonged-release - no Egyptian product registered MAIN TREATMENT - choose one 1. METHYLPHENIDATE [1st line] Adult 18 or 36 mg once daily, titrated weekly to a maximum of 72 mg once daily - long-term (specialist supervision) Peds 6 to 12 years: 18 mg once daily to start; range 18 to 54 mg once daily 13 to 17 years: 18 mg once daily to start; range 18 to 72 mg once daily, not to exceed 2 mg/kg/day (Pediatric patients 6 to 12 years: 18 mg once daily (range 18-54 mg once daily). Pediatric patients 13 to 17 years: 18 mg once daily (range 18-72 mg once daily, not to exceed 2 mg/kg/day).) Source CONCERTA (methylphenidate HCl) extended-release tablets US prescribing information, section 2 Dosage and Administration (DailyMed SetID 1a88218c-5b18-4220-8f56-526de1a276cd); Ritalin LA US prescribing information, section 2 (DailyMed SetID effd952d-ac94-47bb-b107-589a4934dcca) Why Requires formal specialist psychiatric diagnosis and baseline CV screen before prescribing Caution Capped at 60 mg daily. Concerta's label goes to 72 mg, but Ritalin LA states twice that a daily dose above 60 mg is not recommended, and the lower of the two is what is used here. Above 60 mg is a specialist decision. Ceiling, not a target. Concerta is the highest-licensed methylphenidate product at 72 mg once daily; Ritalin LA states that daily dosage above 60 mg is not recommended, and no product licence supports 100 mg. Titrate to effect, review cardiovascular and psychiatric symptoms at every step, and do not exceed 72 mg without a specialist saying so in writing. Baseline ECG, blood pressure, heart rate, height, and weight are mandatory before starting and every 6 months. Side effects include insomnia, appetite suppression, growth restriction, tachycardia, and hypertension. Methylphenidate is a controlled substance with high potential for abuse and diversion. Egypt CONCERTA 18MG 30 EXTENDED RELEASE TAB. ALZA CORPORATION-USA > JANSSEN CILAG 257.00 EGP -> ? strength differs CONCERTA 36MG 30 EXTENDED RELEASE TAB. ALZA CORPORATION-USA > JANSSEN CILAG 428.00 EGP -> ? strength differs 2. ATOMOXETINE [2nd line] Adult 40 mg once daily in morning for 7-14 days, then increase to target 80 mg once daily (max 100 mg daily) - long-term Peds 0.5-1.2 mg/kg/day [child max 100 mg] (6 years and over, under 70 kg: 0.5 mg/kg/day for at least 7 days, then up to a maintenance of about 1.2 mg/kg/day. Over 70 kg: 40 mg, then 80 mg. Never above 100 mg a day at any weight.) 6 years and over: Under 70 kg: 0.5 mg/kg/day for at least 7 days, then up to about 1.2 mg/kg/day. Over 70 kg: 40 mg, then 80 mg. Never above 100 mg a day at any weight. 3kg -> 1.5-3.6 mg/day 4kg -> 2-4.8 mg/day 5kg -> 2.5-6 mg/day 6kg -> 3-7.2 mg/day 7kg -> 3.5-8.4 mg/day 8kg -> 4-9.6 mg/day 9kg -> 4.5-10.8 mg/day 10kg -> 5-12 mg/day 11kg -> 5.5-13.2 mg/day 12kg -> 6-14.4 mg/day 13kg -> 6.5-15.6 mg/day 14kg -> 7-16.8 mg/day 15kg -> 7.5-18 mg/day 16kg -> 8-19.2 mg/day 17kg -> 8.5-20.4 mg/day 18kg -> 9-21.6 mg/day 19kg -> 9.5-22.8 mg/day 20kg -> 10-24 mg/day 21kg -> 10.5-25.2 mg/day 22kg -> 11-26.4 mg/day 23kg -> 11.5-27.6 mg/day 24kg -> 12-28.8 mg/day 25kg -> 12.5-30 mg/day 26kg -> 13-31.2 mg/day 27kg -> 13.5-32.4 mg/day 28kg -> 14-33.6 mg/day 29kg -> 14.5-34.8 mg/day 30kg -> 15-36 mg/day 31kg -> 15.5-37.2 mg/day 32kg -> 16-38.4 mg/day 33kg -> 16.5-39.6 mg/day 34kg -> 17-40.8 mg/day 35kg -> 17.5-42 mg/day 36kg -> 18-43.2 mg/day 37kg -> 18.5-44.4 mg/day 38kg -> 19-45.6 mg/day 39kg -> 19.5-46.8 mg/day 40kg -> 20-48 mg/day 41kg -> 20.5-49.2 mg/day 42kg -> 21-50.4 mg/day 43kg -> 21.5-51.6 mg/day 44kg -> 22-52.8 mg/day 45kg -> 22.5-54 mg/day 46kg -> 23-55.2 mg/day 47kg -> 23.5-56.4 mg/day 48kg -> 24-57.6 mg/day 49kg -> 24.5-58.8 mg/day 50kg -> 25-60 mg/day Source Atomoxetine 100 mg capsules SmPC sections 4.2 and 4.4 (eMC product 10337) Why Non-stimulant alternative for patients with active tic disorders, severe anxiety, or substance abuse history Caution There is a rare risk of severe liver injury; instruct patient to report yellow skin/eyes or dark urine immediately. Takes 2-4 weeks to demonstrate therapeutic response. Check pulse and blood pressure at the start and as you go up. Around one child in ten gets a pronounced rise in one or the other. Plot height and weight through treatment - growth needs watching, not assuming. Patients who are being treated for ADHD should be carefully monitored for the appearance or worsening of suicide-related behaviour. Egypt ATOMAFUTIX 40 MG 30 CAPS. FUTURE PHARMA... 259.50 EGP (8.65/unit) ATOMOXETINE 40MG 10 CAPS. SABAA > SOVAL... 90.00 EGP (9.00/unit) ATTENSERA 40 MG 30 CAPS. MASH PREMIERE 306.00 EGP (10.20/unit) STRATTERA 40MG 28 CAPS. ELI LILLY 530.00 EGP (18.93/unit) ATOMOXAPEX 40 MG 30 H.G. CAPS. MULTI-APEX 333.00 EGP ATOMAFUTIX 4MG/ML SYRUP 100 ML FUTURE PHARMA... 119.00 EGP -> ? strength differs, ? different route - not oral solid ATOMOXAPEX 4MG/ML SYRUP 100 ML MULTI-APEX 120.00 EGP -> ? strength differs, ? different route - not oral solid NON-STIMULANT ALPHA-2 AGONIST, PROLONGED-RELEASE - NO EGYPTIAN PRODUCT REGISTERED 3. GUANFACINE [2nd line] Adult A paediatric drug, not an adult one. SmPC verbatim: "The safety and efficacy of guanfacine in adult and the elderly with ADHD has not been established. Therefore, guanfacine should not be used in this group." The child and adolescent regimen is on the paediatric line below. - Not applicable - the licence stops at 17 years. Peds 0.05-0.12 mg/kg/day [child max 7 mg] (1 mg once daily to start, raised by no more than 1 mg a week, weight-banded. SmPC verbatim: "For all patients, the recommended starting dose is 1 mg of guanfacine, taken orally once a day." and "The dose may be adjusted in increments of not more than 1 mg per week." Target band verbatim: "the recommended maintenance dose range is 0.05-0.12 mg/kg/day." Ceilings by weight, from the SmPC's own tables - children 6 to 12 years, 25 kg and up: maximum 4 mg. Adolescents 13 to 17 years: 34-41.4 kg maximum 4 mg; 41.5-49.4 kg maximum 5 mg; 49.5-58.4 kg maximum 6 mg; 58.5 kg and above maximum 7 mg, and that top step only "after the subject has completed a minimum of 1 week of therapy on a 6 mg/day dose". "Adolescent subjects must weigh at least 34 kg.") Age restriction: 72-215 months 6 to 12 years: 1 mg once daily to start, raised by no more than 1 mg a week, to a maintenance range of 0.05 to 0.12 mg/kg/day. Maximum 4 mg daily, at 25 kg and above. 13 to 17 years: 1 mg once daily to start, raised by no more than 1 mg a week, to 0.05 to 0.12 mg/kg/day. Maximum by weight: 34 to 41.4 kg, 4 mg; 41.5 to 49.4 kg, 5 mg; 49.5 to 58.4 kg, 6 mg; 58.5 kg and above, 7 mg - and only after a minimum of 1 week on 6 mg daily. Must weigh at least 34 kg. Not for children under 25 kg 25kg -> 1.2-3 mg/day 26kg -> 1.3-3.1 mg/day 27kg -> 1.4-3.2 mg/day 28kg -> 1.4-3.4 mg/day 29kg -> 1.5-3.5 mg/day 30kg -> 1.5-3.6 mg/day 31kg -> 1.6-3.7 mg/day 32kg -> 1.6-3.8 mg/day 33kg -> 1.7-4 mg/day 34kg -> 1.7-4.1 mg/day 35kg -> 1.8-4.2 mg/day 36kg -> 1.8-4.3 mg/day 37kg -> 1.9-4.4 mg/day 38kg -> 1.9-4.6 mg/day 39kg -> 2-4.7 mg/day 40kg -> 2-4.8 mg/day 41kg -> 2.1-4.9 mg/day 42kg -> 2.1-5 mg/day 43kg -> 2.1-5.2 mg/day 44kg -> 2.2-5.3 mg/day 45kg -> 2.2-5.4 mg/day 46kg -> 2.3-5.5 mg/day 47kg -> 2.4-5.6 mg/day 48kg -> 2.4-5.8 mg/day 49kg -> 2.5-5.9 mg/day 50kg -> 2.5-6 mg/day Source Intuniv 4 mg prolonged-release tablets SmPC sections 4.1 and 4.2 (eMC product 7507) Why The disease article names it, verbatim: "Lastly, alpha agonists such as clonidine and guanfacine can be used as an effective treatment for ADHD." and it says where it fits - "They are found to be more effective in younger children than adults." The SmPC's indication section names the disease and the patient, verbatim: "Intuniv is indicated for the treatment of attention deficit hyperactivity disorder (ADHD) in children and adolescents 6-17 years old for whom stimulants are not suitable, not tolerated or have been shown to be ineffective." It sits beside atomoxetine as the second non-stimulant option. Egypt registers no guanfacine product, so no brand and no price can be shown. Caution Never stopped abruptly. SmPC verbatim: "When stopping treatment, the dose must be tapered with decrements of no more than 1 mg every 3 to 7 days, and blood pressure and pulse should be monitored in order to minimise potential withdrawal effects, in particular increases in blood pressure and heart rate". Blood pressure, pulse, height and weight before the first tablet. SmPC verbatim: the baseline evaluation "should address a patient's cardiovascular status including blood pressure and heart rate, documenting comprehensive history of concomitant medications, past and present co-morbid medical and psychiatric disorders or symptoms, family history of sudden cardiac/unexplained death and accurate recording of pre-treatment height and weight on a growth chart". Sedation and low blood pressure are dose-related and come early. SmPC verbatim: "Patients should be advised that somnolence and sedation can occur, particularly early in treatment or with dose increases. If somnolence and sedation are judged to be clinically concerning or persistent, a dose decrease or discontinuation should be considered." Weekly checks during titration - "During dose titration, weekly monitoring for signs and symptoms of somnolence and sedation, hypotension and bradycardia should be performed." Two missed doses means starting the titration again. SmPC verbatim: "If two or more consecutive doses are missed, re-titration is recommended based on the patient's tolerability to guanfacine." Prolonged-release and immediate-release are not the same milligram. SmPC verbatim: "Immediate-release guanfacine tablets should not be substituted on a mg/mg basis, because of differing pharmacokinetic profiles." The disease article's own warning about the class: it links these drugs to a range of cardiovascular effects, blood pressure falling among them, along with sedation - more with clonidine than with guanfacine - weight gain and dizziness. Egypt no Egyptian brand matched - prescribe by generic name Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)