Standard operating procedure

Titration & Medication Initiation Procedure

The step-by-step procedure for confirming the decision to start ADHD medication, completing baseline checks, choosing first-line treatment in line with NICE, titrating safely against response and tolerability, managing adverse effects, and moving to maintenance and shared care.

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What's inside

This standard operating procedure is fully drafted and structured, ready to brand and complete for your service. It covers:

  • 1. Purpose
  • 2. Scope
  • 3. Definitions and abbreviations
  • 4. Responsibilities
  • 5. Procedure
  • 6. Documentation and records
  • 7. Monitoring and review of this procedure
  • 8. Related documents
  • 9. Review and version control
  • 10. Disclaimer

Legislation & standards it maps to

  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 12 (Safe care and treatment)
  • National Institute for Health and Care Excellence, Attention deficit hyperactivity disorder: diagnosis and management, NICE guideline NG87 (2018, updated 2019)
  • British National Formulary (BNF) and British National Formulary for Children (BNFC), current edition
  • The relevant Summary of Product Characteristics (SmPC) for each medicine prescribed
  • Misuse of Drugs Act 1971, the Misuse of Drugs Regulations 2001 and the Misuse of Drugs (Safe Custody) Regulations 1973
  • General Medical Council, Good practice in prescribing and managing medicines and devices (2021)
  • Mental Capacity Act 2005

Who it applies to

All prescribers (consultant psychiatrists, specialist doctors, non-medical prescribers and any locum or sessional prescriber), specialist ADHD nurses, pharmacists, clinical and administrative staff who support titration and the registered manager or [Insert Job Title] at [Organisation Name] who diagnose, prescribe for, titrate or monitor patients started on medication for attention deficit hyperactivity disorder.

Glossary

Plain-English explanations of the technical terms and legislation used in this document.

Adverse drug reaction
An unwanted or harmful response to a medicine taken at a normal dose.
Adverse event
Any unexpected or unwanted occurrence linked to a treatment that harms, or could harm, a patient.
Atomoxetine
A non-stimulant medicine used to treat ADHD when a stimulant is unsuitable, not tolerated or has not worked.
Attention deficit hyperactivity disorder (ADHD)
A condition affecting how the brain develops, causing lasting inattention, restlessness or impulsiveness that gets in the way of daily life.
Baseline checks
The physical measurements and history taken before the first dose so that later changes and side effects can be compared against a known starting point.
Body mass index (BMI)
A measure of whether a person is a healthy weight for their height.
British National Formulary (BNF) and British National Formulary for Children (BNFC)
The standard United Kingdom reference books that tell prescribers how to use medicines safely in adults and in children.
Care Quality Commission (CQC)
The independent regulator of health and social care services in England.
Centile
A way of showing how a child's height or weight compares with other children of the same age and sex.
Clinical governance
The system through which an organisation monitors and improves the quality and safety of the care it provides.
Comorbidity
Another health condition that a person has at the same time as the one being treated.
Contemporaneous record
A note written at the time of, or very soon after, the event it describes.
Contraindication
A reason why a particular medicine or treatment should not be used in a particular person.
Controlled drug (CD)
A medicine whose supply, storage and records are tightly restricted by law because of its potential for misuse.
Dexamfetamine
A stimulant medicine, and a controlled drug, used to treat ADHD.
Diversion
When a medicine is passed on to, or used by, someone other than the patient it was prescribed for.
Duty of candour
The legal duty to be open and honest with a person and their family when something goes wrong with their care.
Formulation
The particular form a medicine comes in, such as an immediate-release or a modified-release (slow-release) tablet or capsule.
Fundamental standards
The minimum standards of safety and quality below which care must never fall.
General Medical Council (GMC)
The body that registers doctors in the United Kingdom and sets the standards they must meet.
General practitioner (GP)
A family doctor who provides everyday medical care in the community.
Glaucoma
An eye condition involving raised pressure inside the eye that can damage sight.
Guanfacine
A non-stimulant medicine used to treat ADHD in children and young people when a stimulant is unsuitable or has not worked.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The regulations that set out the fundamental standards providers must meet to deliver care, including Regulation 12 on safe care and treatment.
Hepatic impairment
Reduced liver function, which can affect how some medicines are handled by the body.
Immediate-release
A form of medicine that releases its full dose quickly after it is taken.
Indication
The medical reason for using a particular treatment.
Informed consent
Agreement to treatment given freely after the risks, benefits and alternatives have been clearly explained.
Lisdexamfetamine
A stimulant medicine, and a controlled drug, used to treat ADHD.
Maintenance
The stage of treatment once a stable, effective dose has been reached and the focus shifts to keeping the patient well.
Medicines and Healthcare products Regulatory Agency (MHRA)
The United Kingdom body that regulates medicines and medical devices and runs the Yellow Card Scheme for reporting problems.
Mental capacity
Whether a person can understand and make a particular decision for themselves at the time it needs to be made.
Mental Capacity Act 2005
The law that protects and supports people who may be unable to make particular decisions for themselves.
Methylphenidate
A stimulant medicine, and a controlled drug, that is the usual first-choice treatment for ADHD.
Misuse of Drugs Act 1971
The main law controlling dangerous or harmful drugs and how they may be possessed and supplied.
Misuse of Drugs Regulations 2001
The regulations that set out how controlled drugs may lawfully be prescribed, supplied, stored and recorded.
Modified-release
A form of medicine designed to release its dose slowly so its effect lasts longer.
Monoamine oxidase inhibitor
A type of medicine, usually for depression, that can interact dangerously with ADHD stimulants.
National Institute for Health and Care Excellence (NICE)
The body that produces evidence-based guidance on treatments and care for use across health and social care.
Near miss
An event that could have caused harm but did not, by chance or because it was caught in time.
Neurodevelopmental condition
A condition linked to how the brain grows and develops, often present from childhood.
NICE guideline NG87
The national guidance on diagnosing and managing attention deficit hyperactivity disorder.
Non-medical prescriber
A trained nurse, pharmacist or other health professional who is qualified to prescribe medicines without being a doctor.
Non-stimulant
An ADHD medicine, such as atomoxetine or guanfacine, that is not a controlled stimulant.
Optimisation
Fine-tuning the dose to the point where the medicine gives the most benefit with the fewest side effects.
Parental responsibility
The legal rights and duties a parent or guardian has to make decisions for a child.
Pharmacist
A health professional who is an expert in medicines and how they are used safely.
Red flag
A warning sign that calls for the medicine to be held or stopped and the patient reviewed urgently.
Registered Manager
The person registered with the regulator as responsible for the day-to-day running of a service.
Regulated activity
A type of care or treatment the law requires a provider to register with the regulator to deliver.
Regulation 12 (Safe care and treatment)
The legal requirement that care and treatment must be provided in a safe way for patients.
Schedule 2 controlled drug
A higher-risk class of controlled drug, including ADHD stimulants, with the strictest prescribing, storage and record rules.
Shared care
An arrangement where a specialist starts and stabilises treatment and the patient's family doctor then takes over prescribing and routine monitoring under an agreed plan.
Standard Operating Procedure (SOP)
A written, step-by-step instruction for carrying out a task consistently and safely.
Stimulant
A class of ADHD medicine, controlled by law, that increases activity in parts of the brain to improve attention and reduce impulsiveness.
Summary of Product Characteristics (SmPC)
The official document for each medicine setting out how it may be used, its doses, cautions and side effects.
Syncope
Fainting or a brief loss of consciousness.
Titration
Starting a medicine at a low dose and adjusting it in steps until the best balance of benefit and side effects is reached.
Tolerability
How well a patient is able to cope with a medicine's side effects.
Tourette's syndrome
A condition causing involuntary movements and sounds known as tics.
Yellow Card Scheme
The United Kingdom system for reporting suspected side effects of medicines and problems with medical devices to the regulator.

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Related documents

PolicyADHD Assessment Policy£54.99
PolicyMedication Management Policy£54.99
PolicySafeguarding Children Policy£54.99
PolicyConsent & Capacity Policy£54.99

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