An ADHD assessment happens once. Titration runs for weeks or months. The dose goes up step by step, side effects come and go, pulse and blood pressure need checking at every change, rating scales come back from the patient and often a parent or teacher, and a controlled drug prescription has to reach the pharmacy every month.
In a clinic, most of that happens in one room. In an online service, the patient is at home, readings come from their own monitor, questionnaires arrive by link, and the prescription goes by post. The clinical decisions don't change. What changes is how everything reaches the clinician, and whether it's all in one place when they need it.
This guide covers how to run titration online in line with the National Institute for Health and Care Excellence (NICE) guideline on ADHD, NG87. It's about running the service, not a dosing guide: the doses themselves follow the British National Formulary (BNF) and your own protocols.
Key takeaways
- 01Monitoring is where online ADHD services get caught out: the CQC still has concerns about the ongoing monitoring of patients prescribed ADHD medicines.
- 02Check before the first prescription: NICE expects height, weight, pulse, blood pressure, and a cardiovascular assessment recorded before medication starts.
- 03Plan how readings are taken at home: a validated monitor, the right cuff, and a set technique, recorded with the date and who took them.
- 04Review more often than you prescribe: dose steps usually come weekly, while each controlled drug prescription covers up to 30 days, so add weekly check-ins between review appointments.
- 05Store readings as data: pulse, blood pressure, and weight charted against each dose change show what a written note can't.
- 06Plan for the GP saying no: shared care is voluntary, so build the service as if you'll keep prescribing after titration.
Why is monitoring where online ADHD services get caught out?
Because it's the part that happens between appointments. In its July 2026 report on controlled drugs, the Care Quality Commission (CQC) said there are "still concerns about the effectiveness of care processes", in particular "ongoing monitoring of patients who are prescribed medicines for ADHD". It also raised concerns about how information is shared between private services and the NHS.
The same report warned about scope. NICE expects ADHD medicine to be started by a healthcare professional with training and expertise in diagnosing and managing ADHD, and the CQC has seen nurse and pharmacist independent prescribers diagnose ADHD and "wrongly interpret this as meeting NICE guidance". Before you design the process, make sure everybody in it is working within their scope of practice. Pharmacist prescribers face a further question about registration, covered in do pharmacist prescribers need CQC registration.
A titration process that holds up has 3 things: the right checks before the first prescription, a regular rhythm of contact while the dose changes, and every reading and decision recorded where the next clinician can see it.
What does titration look like from start to finish?
Titration has a clear shape, and each stage leaves something on the record.
| Stage | What happens | What's recorded |
|---|---|---|
| Baseline | A prescribing assessment before the first dose | History, current medicines, height, weight, pulse, blood pressure, cardiovascular assessment, and rating scales |
| Starting | The first prescription | The decision, the prescription, and the plan |
| Titration | The dose adjusted step by step | Symptoms, impairment, and side effects at each change, with pulse and blood pressure |
| Optimised dose | Symptoms reduced, side effects tolerable | The agreed dose, and the plan for maintenance |
| Maintenance | Regular prescriptions and monitoring | Pulse and blood pressure every 6 months, weight on schedule, and an annual review |
| After titration | The GP takes on prescribing, or you continue | The letter to the GP, and who does what |
What should you check before the first prescription?
NICE sets out a full assessment before anybody starts ADHD medication. It includes:
- Mental health and social circumstances, including coexisting conditions and a "risk assessment for substance misuse and drug diversion".
- A medical history, looking for conditions that may be contraindications, and current medicines.
- Height and weight, "measured and recorded against the normal range for age, height and sex".
- Baseline pulse and blood pressure, "measured with an appropriately sized cuff and compared with the normal range for age".
- A cardiovascular assessment.
An electrocardiogram (ECG) isn't needed unless the person has one of the features NICE lists, or a coexisting condition treated with a medicine that may increase cardiac risk. NICE recommends a cardiology opinion before starting if there's:
- congenital heart disease or previous cardiac surgery
- sudden death in a first-degree relative under 40 suggesting heart disease
- shortness of breath on exertion compared with peers
- fainting on exertion or in response to fright or noise
- palpitations that are rapid, regular, and start and stop suddenly
- chest pain suggesting a cardiac cause
- signs of heart failure, or a murmur heard on examination
- blood pressure classified as hypertensive for adults
Get the GP record before you prescribe
For a remote service, the medical history can't rest on what the patient remembers. The General Medical Council's (GMC) prescribing guidance says that without access to relevant information from the patient's records, you mustn't prescribe controlled drugs or medicines liable to misuse, apart from in limited circumstances. Ask for the GP summary record and consent to contact the GP at the start, not when the first prescription is due.
Put the baseline on its own form
Make the baseline a form of its own, a baseline prescribing assessment completed before the first prescription and kept on the record. If a reading is missing, the prescription should wait. A blank field noticed at the next review is too late.
How do you get readings when the patient is at home?
NICE asks for pulse and blood pressure measured with the right cuff, and height and weight measured and recorded. An online service has to decide where each reading comes from.
| Route | Works well for | Watch out for |
|---|---|---|
| The patient's own validated monitor | Pulse and blood pressure at every dose change | The monitor must be validated, the cuff must fit, and the patient needs a set technique |
| A pharmacy or GP practice | An independent baseline reading, or confirming a high one | Availability and cost vary, and the free NHS pharmacy check is only for adults aged 40 and over without high blood pressure |
| A face-to-face appointment | Children, physical examination, or readings that don't add up | It needs somewhere near the patient |
| Home scales and a height measure | Adult weight every 6 months | Children's growth needs careful, consistent measurement, so decide who measures and how |
Teach the technique
NICE's guideline on blood pressure, NG136, says monitors should be properly validated, maintained, and recalibrated, and points to the British and Irish Hypertension Society's list of validated devices. Readings should be taken with the person quiet and seated, their arm outstretched and supported, and the right cuff size. For home readings, it describes 2 measurements at least 1 minute apart, with the person seated. Automated monitors may not be accurate if the pulse is irregular, so an irregular pulse needs checking another way.
Send the patient the technique with the first request for a reading, not after a strange one comes back.
Record where each reading came from
The General Pharmaceutical Council's (GPhC) guidance for pharmacies providing services at a distance says "Some monitoring can be 'self-reported', for example, checks on blood pressure. But there may be clinical reasons for considering whether readings should be independently verified."
Record each reading with the date, the time, and who took it, whether that's the patient, a pharmacy, or your clinic. When a number changes, you'll know whether the patient changed or the method did. A photo of the monitor's display, uploaded with the reading, is a simple extra check.
How often should you review during titration?
More often than you prescribe. Two rhythms run side by side:
- Dose changes come about weekly. The product information for the most commonly used medicines, such as lisdexamfetamine and long-acting methylphenidate, allows dose increases at roughly weekly intervals.
- Prescriptions come about monthly. NICE's guideline on controlled drugs, NG46, says to prescribe no more than 30 days' supply of a controlled drug, unless you document why.
NICE's ADHD guideline asks for progress during titration to be "reviewed regularly (for example, by weekly telephone contact) with a specialist". It also asks for titration to be slower, and monitoring more frequent, for people with coexisting conditions, such as autism, tics, a learning disability, anxiety, depression, epilepsy, or heart disease.
A 4-weekly review appointment on its own matches the prescription, but not the pace of titration. So build both:
| Contact | How often during titration | What it's for |
|---|---|---|
| Weekly check-in | Every week, or at each dose step | How the dose feels, side effects, and pulse and blood pressure from home |
| Review appointment | About every 4 weeks | Rating scales, a month of readings, the dose decision, and the next prescription |
| Unscheduled contact | Whenever it's needed | A reading over your threshold, or side effects that can't wait |
The weekly check-in can be a short form in the patient's portal, with a call when the answers need one, so the clinician stays informed between appointments without a full consultation every week.
What should every titration review record?
Give the review appointment its own short form, so every review captures the same things and the whole titration reads as one history.
| Field | Why it matters |
|---|---|
| Current medicine and dose | So every other reading can be matched to a dose |
| Rating scale scores | NICE asks for symptoms, impairment, and side effects on standard scales at each dose change |
| Side effects | Sleep, appetite, and mood, with a sleep diary if sleep has changed |
| Pulse and blood pressure | NICE asks for these before and after each dose change |
| Weight | A reduced appetite shows up in weight, and children's height and weight go on a growth chart |
| Misuse or diversion concerns | NICE asks for changes in the potential for stimulant misuse and diversion to be monitored |
| The plan | The next dose, the next review, and anything to check before then |
Flag readings when they arrive
NICE says that if someone has sustained resting tachycardia (more than 120 beats per minute), an arrhythmia, or systolic blood pressure above the 95th percentile, or a clinically significant increase, measured on 2 occasions, the dose should be reduced and they should be referred to a paediatric hypertension specialist or adult physician.
A reading like that shouldn't sit in a form until the next review. Set your thresholds in the system so a reading outside them alerts the clinician the day it's submitted.
Chart readings against the dose
Store pulse, blood pressure, and weight as data, not as text inside notes. Then you can see them over time against each dose change, and a slow climb in blood pressure, invisible across 5 separate notes, is obvious on one chart. Our guide to tracking what matters to patients covers how the same data can be shown back to the patient.
How do rating scales fit in?
NICE asks for symptoms, impairment, and side effects to be recorded "at baseline and at each dose change on standard scales by parents and teachers". For an online service, that means getting questionnaires to people who aren't the patient and won't have an account.
- Send them by private link. A parent, partner, or teacher gets a link that opens straight into their questionnaire, with no account to create.
- Keep the answers with the clinician. The responses come back to the patient's record and are seen by the clinical team.
- Show who's still to reply. A list of which questionnaires are back and which are waiting saves a lot of chasing.
- Use the same scale every time, so the scores can be compared from one dose to the next.
Check the licence for every published scale before you build it into software. Some are free to use, some need permission, and some are sold per use. The wording of a published scale should be locked in your system, because its scoring depends on the exact questions. Your own forms can stay editable.
How do private controlled drug prescriptions work?
The main stimulants used for ADHD, methylphenidate, lisdexamfetamine, and dexamfetamine, are Schedule 2 controlled drugs. Atomoxetine and guanfacine aren't controlled drugs, though they're still prescription-only medicines.
In England, a private prescription for a Schedule 2 controlled drug has to meet extra legal requirements:
- The FP10PCD form. It must be written on the standard private prescription form, the FP10PCD.
- A private prescriber identification number. Each prescriber applies for one through their NHS England Controlled Drugs Accountable Officer (CDAO) team, and it goes on every private controlled drug prescription.
- Paper, in practice. The law only allows these prescriptions to be electronic through the NHS Electronic Prescription Service, so private ones are still on paper.
- The original first. The pharmacy can't supply until the original prescription reaches it, so post it in good time, by tracked post.
- 28 days. The prescription can't be dispensed more than 28 days after the date on it.
- Up to 30 days' supply, in line with NG46.
Scotland, Wales, and Northern Ireland have their own private forms: the PPCD(1), the WP10PCD, and the PCD1.
Small mistakes here show up at inspection. In 2023, a CQC inspection of one online ADHD provider, rated requires improvement, found prescriptions that "were not signed or dated, this is a legal requirement". Issue each prescription from the patient's record, with the prescriber's details, PIN, and signature, and follow it through a status trail from issued to posted, received, and dispensed.
The dispensing pharmacy will have its own checks. The GPhC's guidance lists stimulants among the medicines that need extra safeguards when prescribed remotely, and says a prescriber shouldn't base prescribing decisions on a questionnaire alone. A pharmacy that sees a baseline assessment, readings, and reviews on every patient will be much easier to work with.
What happens once the dose is right?
Titration ends when the dose is optimised. Monitoring doesn't.
| Check | How often (NICE NG87) |
|---|---|
| Heart rate and blood pressure | Before and after each dose change, and every 6 months |
| Weight, adults | Every 6 months |
| Height, children and young people | Every 6 months |
| Weight, children 10 and under | Every 3 months |
| Weight, over-10s and young people | At 3 and 6 months after starting, then every 6 months |
| Medication review | At least once a year, by someone with training and expertise in managing ADHD |
NICE also suggests considering trial periods of stopping or reducing the medicine, and says routine blood tests and ECGs aren't needed unless there's a clinical reason.
Automated reminders for each of these turn a schedule into something that actually happens. The recall message that brings patients back covers how to word them.
Plan for the GP saying no to shared care
NICE expects that after titration and dose stabilisation, prescribing and monitoring "should be carried out under Shared Care Protocol arrangements with primary care". In practice, that often doesn't happen with private providers.
- It's voluntary. The British Medical Association (BMA) says shared care can be declined by the GP practice for any reason.
- It's not recommended with private providers. The BMA's guidance on private healthcare says shared care with private providers is not recommended.
- It's become less likely. As part of its collective action since 1 July 2026, the BMA has asked practices in England to decline new shared care arrangements that aren't supported by a locally commissioned agreement.
If the GP declines, prescribing and monitoring stay with you. So price and staff the service as if you'll keep prescribing after titration, with a monthly prescription, 6-monthly checks, and an annual review, and treat shared care as a bonus when it happens.
Keep the GP informed either way
Whether or not the GP takes on prescribing, keep them informed. NG46 asks prescribers outside general practice to tell the GP when they prescribe a controlled drug, and the GMC asks remote prescribers to share relevant information with the GP. Send a letter from the record when medication starts, when titration ends, and whenever the medicine or dose changes. The CQC's concern about information sharing between private services and the NHS is exactly this gap.
If you're still setting up the service, our guide to launching and marketing a new ADHD clinic covers the pathway and the marketing, and which regulator an online clinic registers with covers registration.
Run ADHD titration on Clinic Pro
Clinic Pro builds the system titration runs on, with every reading, form, and prescription on one record.
- A baseline prescribing assessment, its own form, held on the record before the first prescription.
- A titration review appointment type with its own short form covering dose, response, side effects, observations, and the plan, each saved to one history.
- Readings held as data, charted against dose changes, with readings outside your thresholds flagged when they arrive.
- Rating scales sent through the patient portal, or by private link to a parent, partner, or teacher.
- Prescribing from the record with your PIN and signature, a status trail, and printing built in.
- Letters to the GP produced from the record, and reminders for reviews and 6-monthly checks.
- An introduction to our dispensing partner, who already handles ADHD medicines.
Running ADHD care online, or planning to? See how a virtual clinic launches on Clinic Pro, or read how clinical admin keeps assessment, titration, and monitoring on one record.
Titration is a process, so run it as one
Titration isn't a series of separate appointments. It's one process over weeks and months, and it's only as safe as the information flowing through it between appointments.
Check everything before the first prescription, decide how readings are taken at home, review weekly while the dose changes, record the same things every time, and plan to keep prescribing if the GP says no. Then a patient at home gets the same care as one sitting in your clinic.
