Local shortages of ADHD medicines posing serious challenges to sufferers

Psychiatrists have voiced “serious concerns” about the limited availability and choice of ADHD medication in Malta, in the context of a global shortage of these essential treatments. 

Psychiatrist Rosemarie Sacco, president of the Association for Child and Adolescent Mental Health (ACAMH), said this shortfall was adversely affecting the treatment and well-being of individuals with ADHD, both children and adults. 

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder typically diagnosed in childhood but that persists into adulthood. It is characterised by difficulties with sustaining attention, emotion regulation, excessive activity, and impulse control. Medication often plays a crucial role in managing these symptoms effectively.

In Malta, around five per cent of children have a diagnosis of ADHD. However, at present, the country’s government formulary offers a narrow range of treatment options.

The main medications available locally are methylphenidate-based stimulants and atomoxetine, but both are in short supply. The government formulary includes only a 10mg preparation for immediate-release methylphenidate.

Additionally, for prolonged-release methylphenidate, the formulary offers only a limited selection of dosages – specifically 18mg, 27mg, and 36mg – each available only under specific circumstances.

The problem of limited options is compounded by the current global shortage of these same medications, making it even more challenging for psychiatrists to find the right medication and dosage for individuals with ADHD, she explained.

Variety of medication needed

“Having access to a variety of medication types allows for a more personalised approach to treatment, which is essential for effective management of ADHD,” Sacco said.

But, up till now, several essential medications like guanfacine, Adderall, dexedrine, and lisdexamfetamine are completely unavailable. 

These medications are crucial for treating ADHD because they provide different mechanisms of action and benefits, which can be better suited to meet individual patient needs. The lack of diverse treatment options can make it difficult to find effective management strategies for individuals living with ADHD.

Having access to a variety of medication types allows for a more personalised approach to treatment

Moreover, “alternatives to the currently available preparations of methylphenidate are critical”, added psychiatrist Daniel Vella Fondacaro.

For instance, short-acting medications like Ritalin typically require administration during school hours, as their effects only last for about four hours. This can pose challenges for children who need to take medication at school.

In contrast, longer-acting options may help children manage their ADHD symptoms throughout the school day without needing to take medication while there.

This flexibility allows treatment plans that better align with each child’s unique lifestyle and daily schedule, ultimately improving their behaviour and ability to focus during school. 

Generics don’t always work

Concerta is a long-acting methylphenidate that starts working about an hour after you take it and can help manage symptoms for up to 12 hours. However, in Malta, Concerta is not widely available through the government formulary system, which tends to focus on generic versions of medications. 

Before the current shortage of methylphenidate, Concerta was only accessible to a limited number of individuals who had it prescribed before 2021.

Since then, “newly diagnosed patients have not been automatically entitled to receive Concerta, meaning they would have to pay a significant amount out of pocket for it”, said Nigel Camilleri, the psychiatrist founder of ACAMH-Malta, who was also sharing his personal experience as a parent. 

Concerta, a long-acting medication that can help manage symptoms for up to 12 hours, is not widely available through the government formulary system. Photo: Shuttestock.com

“While generics can be good alternatives in some situations, they aren’t always exactly the same as the brand-name drugs,” Andrea Saliba, also a psychiatrist, emphasised. 

Concerta has a special release mechanism that is protected by a patent, meaning generics can’t copy how it works. Because of this, it’s important to look at not just how well a medication can be absorbed in the body but also how effective it is in treating ADHD, as differences in how drugs are made can lead to different outcomes for patients.

Additionally, there are other forms of methylphenidate medications, such as Medikinet XL and Equasym XL, which provide additional options to accommodate different lifestyles. 

Medikinet XL contains both an immediate-release component (50 per cent of the dose) and a prolonged-release component (50 per cent of the dose), while Equasym XL has a similar set-up with 30 per cent immediate-release and 70 per cent prolonged-release components. 

Children and adolescents with ADHD deserve the same standard of care as their peers across Europe

The design of these medications allows an immediate effect, while the prolonged-release portion would maintain symptom control throughout the afternoon, eliminating the need for a midday dose during school hours. 

This means that individuals can benefit from consistent therapeutic effects for about eight hours. This allows the medication to wear off just in time for evening meals and better-quality night sleep, keeping in mind that common side effects include reduced appetite and sleep disturbance. 

Increasing treatment options can be particularly advantageous for individuals balancing school, work and personal activities.

The association called for immediate action to address these shortages, expand the formulary and ensure that Maltese patients have access to the full spectrum of evidence-based treatments available in other countries. 

“Children and adolescents with ADHD deserve the same standard of care as their peers across Europe,” Sacco concluded.