Episode 7: Managing ADHD Medicines in Real Life | Practical Counselling for Clinicians

What happens if a patient forgets their ADHD medicine?

Should they take weekends off?

Can they exercise? Drive? What about pregnancy, university, shift work, appetite, weight loss or the ongoing medicine shortages?

In this practical episode of Prescribe or Pass: The PoP Pod, we move beyond pharmacology and into the real-world questions pharmacists, doctors and other clinicians are asked every day.

We discuss:

• What to do after a missed dose
• Drug holidays: when they may (and may not) be appropriate
• Managing appetite suppression and weight loss
• Sleep and exercise
• Nutrition and growth in children
• Shift work and university life
• Pregnancy and shared decision-making
• Driving and roadside drug testing
• PBS restrictions and ADHD medicine shortages
• When treatment should be reviewed, and why growing bigger doesn’t automatically mean needing a higher stimulant dose

This episode is designed for pharmacists, pharmacy students and other health professionals wanting a practical, evidence-based understanding of ADHD medicines that extends well beyond the Product Information.

Whether you’re counselling a patient collecting their first prescription or supporting someone who’s been taking these medicines for years, this episode is packed with practical clinical pearls you can use in everyday practice.

Learning objectives

By the end of this episode, you should be able to:

• Counsel patients on the practical management of ADHD medicines in everyday life.
• Discuss common issues including missed doses, appetite, sleep, exercise and driving.
• Recognise situations where treatment review or referral may be appropriate.
• Provide evidence-based advice on common questions encountered in pharmacy practice.

Prescribe or Pass: The PoP Pod is a clinician education podcast created by pharmacist Kate Thomas, providing evidence-based learning for continuing professional development (CPD) in medicines and therapeutics. Whether you’re a pharmacist, pharmacy student, doctor, nurse practitioner or other prescribing clinician, join us as we explore the science behind medicines, and the practical conversations that improve patient care.

Transcript

SPEAKER_00 0:00

I'd like to acknowledge the traditional custodians of the land on which I'm recording today and pay my respects to elders past and present. I'm Kate. I'm an Australian pharmacist with more than 25 years of experience working across hospital pharmacy, community pharmacy, palliative care, aged care, and now voluntary assistant dying. Welcome to Pop Pod, the clinician edition of Prescribe All Commons. Look for me on Instagram, TikTok, Facebook, and YouTube at Prescribe Orcons. Every episode explores one medicine, one condition, or one clinical concept, explaining not just what we do, but why we do it. Whether you're a pharmacy student, pharmacist, or any clinician who works with medicines, welcome to the Pop Pod. This is episode 7 in our ADHD Medicines series. Over the past six episodes, we've explored what ADHD is, how stimulant and non-stimulant medicines work, why different people receive different medicines, and the important differences between methylphenidate, dexamphetamine, lizdexamphetamine, and the non-stimulant options. This episode is a little different. Rather than focusing on pharmacology, we're going to focus on real life. These are the questions pharmacists answer every single day. What happens if someone forgets a dose? Should they stop taking it on the weekends? Can they exercise? Will it stop them eating? Can they drive? What happens if there's another medicine shortage? And when should treatment actually be reviewed? If you're using this podcast as part of your continuing professional development, listen for the practical counseling points throughout this episode. And as always, we'll finish with some reflective questions to consolidate your learning. Let's start with probably the most common question. I forgot to take my medicine this morning. The answer depends on which medicine we're talking about and what time of day it is. For stimulant medicines, taking the dose too late in the day can significantly interfere with sleep. If someone normally takes vive ans at 7 a.m. but remembers it at 3 p.m., taking it then probably isn't helpful. They may still have clinically significant effects well into the evening. Likewise with long-acting methylphenidate preparations. The general advice is take it when remembered if it's still early enough in the day. If it's already late afternoon, skip the dose and resume normal schedule the following morning. Patients shouldn't double dose the next day to compensate. Atomoxetine is slightly different. Because it works continuously rather than providing an immediate effect, timing is a little bit more flexible. However, people should still follow the advice provided by their prescriber and the consumer medicines information. As pharmacists, one of the most useful counseling points is reminding patients that perfection isn't required. Missing one dose doesn't mean treatment has failed. Drug holidays. Another common question is whether people should take breaks. Historically, many children stopped stimulant medicines during school holidays, and the thinking was simple. If they weren't sitting in a classroom, perhaps they didn't need the medication. But today we take a much more individual approach. Some people genuinely function well without medicine on weekends. Others discover that ADHD affects much more than school or work, driving, relationships, household organization, parenting, emotional regulation, financial management, remembering appointments. These don't suddenly disappear because it's Saturday. Some children also benefit socially during school holidays. They're still attending sports, camps, and family events. For others, appetite and growth may improve during breaks. There isn't one universally right answer. Drug holidays should be a planned decision made with a treating clinician rather than something parents simply start and stop themselves. Appetite and weight loss. Reduced appetite is probably the most recognized side effect of stimulant medicines. The important point is that the medicine usually isn't making someone feel nauseated, instead, it's suppressing the normal sensation of hunger. People simply forget to eat. Then suddenly, when the medicine wears off in the evening, they realize they're starving. This creates an obvious counseling opportunity. Rather than waiting until lunchtime to eat, many people do much better by eating a substantial breakfast before their morning dose. Planning snacks can also help. Some people find liquid nutrition easier than large meals. Smoothies, milk-based drinks, yogurt, high protein snacks. For children, monitoring growth becomes particularly important. Most children continue to grow normally, but regular monitoring of heightened weight forms part of good clinical practice. Significant or persistent weight loss deserves review. Sometimes adjusting timing, changing formulation, or modifying the dose can help. Sleep. People often assume ADHD medicines automatically cause insomnia. Reality is more complicated. Untreated ADHD itself frequently causes sleep problems. Many people struggle to settle because their thoughts race. Some actually sleep better once symptoms are controlled. Others experience insomnia, particularly if doses are too high or taken too late. This is where understanding each formulation becomes significantly useful. Long acting preparations obviously remain active longer. Counseling should include basic sleep hygiene, regular bedtime, limiting caffeine later in the day, reducing bright screen exposure before bed. If persistent insomnia develops after starting a medication, it shouldn't simply be ignored. It deserves review. Exercise. Another question pharmacists hear all the time is, can I still exercise? And for most people, absolutely. Regular physical activity remains strongly recommended. However, stimulant medicines can slightly increase heart rate and blood pressure. Most healthy people tolerate this perfectly well. But patients should remain hydrated, particularly during hot Australian summers. And there's another practical issue that's worth thinking about, particularly in children and adolescents. Exercise increases energy requirements. At the same time, stimulant medicines can reduce appetite, meaning some children simply aren't eating enough to meet those increased needs. If a child is very active, playing competitive sports several times a week, for example, but they're regularly skipping lunch because they're just not hungry, that combination can contribute to inadequate energy intake and over time may affect weight gain and potential growth. That doesn't mean children taking ADHD medicines shouldn't exercise, quite the opposite. Physical activity has enormous physical and mental health benefits and should continue to be encouraged. Instead, it means we need to think about nutrition as well as exercise. Encouraging a substantial breakfast before the morning dose, planning energy dense snacks when the medicine begins to wear off, and monitoring growth over time all become important parts of good ADHD care. They should also be encouraged to seek medical review if they experience symptoms such as chest pain, collapse, severe dizziness or palpitations during exercise. Elite athletes may have additional anti-doping considerations depending on the sport. That's a specialized area requiring appropriate documentation and approvals. Shift workers. Shift work creates unique challenges. Many ADHD medicines are designed around a typical daytime schedule. What happens if someone works permanent night shift or rotating shifts? There isn't one universal answer. Some people adjust timing to match their waking hours. Others require different formulations. Some people even require different strategies on work days versus off. This is definitely an area where pharmacists should avoid giving rigid rules. Instead, encouraging review with the prescribing clinician. Treatment should fit the patient's life, not the other way around. University students. University often exposes weaknesses in executive functioning. Students suddenly lose the external structure provided by school. Nobody reminds them about lectures, assignments, laundry, food, bills. Everything depends on self-management. And this is often when ADHD symptoms become much more obvious. From a medication perspective, students commonly ask whether they should take stimulants only on exam days. The answer is no, these medicines aren't intended as cognitive enhancers for occasional use. They're treating an underlying neurodevelopmental condition. If someone genuinely has ADHD, the medication often helps with day-to-day studying, organization, and planning, not simply exam performance. Pregnancy. Pregnancy is understandably one of the most anxiety-provoking situations, and there is no simple yes or no answer. Some women choose to stop stimulant medicines before or during pregnancy. Others continue treatment because untreated ADHD creates substantial risks. For example, driving accidents, severe functional impairment, occupational risks, mental health deterioration. Treatment decisions involve balancing potential benefits and risks. Ideally, pregnancy planning occurs before conception wherever possible. This allows discussion with the treating psychiatrist, GP, and obstetric team. As pharmacists, our role isn't to make those decisions independently. It's to facilitate informed discussions and ensure patients don't suddenly cease treatment without appropriate advice. Driving. Can people drive while taking ADHD medicines? Yes. In fact, appropriately treated ADHD is generally associated with safer driving than untreated ADHD. Untreated ADHD has been associated with increased crash risk, inattention, and impulsive driving. People often assume stimulant medicines impair driving because they control drugs. In reality, for appropriately diagnosed patients taking prescribed doses, the opposite is true. Another question pharmacists are increasingly asked is whether ADHD medicines can affect roadside drug testing. The answer is they can. Medicines containing amphetamines, such as dexamphetamine and lizdexamphetamine, which is converted into dexamphetamine in the body, may be detected on some drug tests. However, a positive test does not automatically mean someone has committed an offense. In Australia, people who are taking these medicines exactly as prescribed have a legitimate medical explanation. The specific laws and processes vary between states and territories, including how confirmatory laboratory testing and medical review are handled. This is another reason it's important for patients to take medicines only as prescribed and to keep evidence of their prescription readily available, particularly if they are driving regularly or traveling interstate. Of course, if someone experiences significant side effects such as dizziness or excessive insomnia, they shouldn't drive until those issues have been assessed. Pharmacists should also remind patients to carry evidence of their prescription when traveling, particularly interstate or internationally. PBS and medicine shortages. Over the past few years, ADHD medicine shortages have become frustratingly common. Patients have often visited multiple pharmacies trying to locate stock. This creates anxiety and occasionally leads people to ration medicines by skipping doses. As pharmacists, communication becomes incredibly important. If a shortage exists, explain what is actually happening. Check whether another strength or brand is available. Liaise with the prescriber where necessary. Importantly, don't assume formulations are automatically interchangeable. Some patients have different release mechanisms, different pharmacokinetics, and different approved substitution arrangements. Sometimes changing products is appropriate, sometimes it isn't. The decision should be made carefully. Patients also benefit from practical advice. Ordering repeats a little earlier where appropriate, keeping enough medicine to avoid last minute panic, using the same pharmacy where possible, allowing stock to be monitored more effectively. When should treatment be reviewed? Finally, let's talk about review. One of the biggest misconceptions is that once someone finds the right ADHD medicine, the treatment never changes. In reality, ADHD management is dynamic. Children grow. As an aside though, one misconception worth mentioning is that most ADHD medicines aren't dosed according to body weight. Parents often assume that because their child has grown, they automatically need a higher dose. But for most stimulant medicines, that's not how prescribing works. Instead, clinicians gradually titrate the dose until they find the best balance between symptom control and side effects. Some children need surprisingly small doses, while others need much larger ones despite weighing the same. The main exception is adomoxetine, where dosing in children under 70 kilograms is initially based on body weight. University starts, people change jobs, become parents, entermenopause, retire, body weight changes, other medical conditions develop, other medicines are started, life changes. Treatment needs to change with it. Review is also appropriate if someone develops troublesome side effects, if symptom control declines, if medicine is no longer lasting as long as expected, if blood pressure changes significantly, or if people simply aren't achieving the goals they hoped treatment would help them achieve. Good ADHD care isn't just writing another prescription every six months. It's an ongoing conversation. Key practice points. Let's summarize this episode's key learning. Missing a single dose isn't an emergency, but doubling doses should be avoided. Drug holidays should be individualized rather than routine. Appetite suppression can often be managed with thoughtful meal timing. Sleep problems deserve assessment rather than simply being accepted. Exercise remains encouraged for most patients. Shift workers often require individualized medication timing. University students benefit from treating everyday executive function, not just exams. Pregnancy decisions require shared decision making. Appropriately treated ADHD generally improves rather than worsens driving safety. Medicine shortages require clear communication and careful substitution decisions. And finally, ADHD treatment should evolve as patients' lives evolve. If you're completing CPD, here are a few questions to consider. Think about the last patient who asked you about missed doses or side effects. Did your counseling address the practical realities of living with ADHD medication or mainly focus on the product information? How confident are you in counseling patients about drug holidays, pregnancy, driving, and medicine shortages? Which of these areas would benefit from further learning? When a patient tells you their medicine isn't working anymore, what factors would you now consider before assuming the medicine itself has failed? Thank you for joining me for episode 7 of Prescribe or Pass the Pop Pod, our ADHD series. Over the past seven episodes, we've explored what ADHD is, how the medicines work, why different medicines are chosen, and now how to manage those medicines in everyday life? But before we finish this series, there's one more thing we need to tackle. Some of the biggest challenges people with ADHD face don't come from the medicines themselves, they come from the myths. Is ADHD overdiagnosed? Does everyone have a little bit of ADHD? Do stimulant medicines cause addiction or change someone's personality? Can adults really have ADHD? And does sugar or even smartphones or social media actually cause it? In our final episode, we'll unpack some of the most common misconceptions clinicians still hear. Separate the evidence from the folklore, and then ask one final question. What have we learned over the last eight episodes? I'll see you then.