Medications for Attention Deficit Hyperactivity Disorder (ADHD):

Focus on Drug Information

B.C. Provincial Academic Detailing (PAD) Service October 2022

Brand Name Generic Name

Participants in this PAD session will have the opportunity to:
methylphenidate
Ritalin®
immediate release
1. Discuss how the efficacy of medications for ADHD is measured in
Ritalin SR® methylphenidate
clinical trials. Concerta® extended release
Biphentin® methylphenidate
2. Review clinical considerations which support treatment decisions, Foquest® controlled release
including: basic pharmacology, onset of effect, adverse events, dextroamphetamine
Dexedrine®
dosing, cost and drug interactions. immediate release
dextroamphetamine
Dexedrine Spansule®
3. Consider the clinical relevance of pharmacokinetic differences sustained release
between available methylphenidate and amphetamine amphetamine mixed
Adderall XR®
formulations. salts extended release
Vyvanse® lisdexamfetamine
This education session will focus on ADHD drug information relevant to people
aged 6 years and older. The diagnosis of ADHD (including over-diagnosis, Strattera® atomoxetine
under-diagnosis) and the management of stimulant use disorder are beyond guanfacine
the scope of this session. Intuniv XR®
extended release

BC’s Provincial Academic Detailing (PAD) Service is offered free of charge to health care professionals. The service is provided by health authorities and supported by the Ministry
of Health. Relevant topics are identified in consultation with various groups. All written materials are externally reviewed by clinicians and experts in critical appraisal.
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ADHD Medications: Basic pharmacology & clinical considerations

Basic pharmacology Clinical considerations

methylphenidate sympathomimetics: ↑ blood pressure insomnia psychosis ↓ appetite non-medical use
Ritalin, Concerta, inhibit norepinephrine ↑ heart rate mania ↓ growth dependence
Biphentin, Foquest anxiety
reuptake & inhibit
amphetamines dopamine reuptake or
Dexedrine, Adderall XR, increase dopamine
Vyvanse release

atomoxetine sympathomimetic: ↑ blood pressure pediatrics: suicidal ideation ↓ appetite urinary retention
Strattera inhibits norepinephrine ↑ heart rate somnolence >> psychosis ↓ growth sexual dysfunction
reuptake insomnia mania
first developed as an CYP2D6:
antidepressant but marketing adults: drug interactions
shifted to ADHD
insomnia >> genetic metabolic
somnolence variability

guanfacine alpha2A-adrenergic ↓ blood pressure somnolence irritability upon CYP3A4:

Intuniv XR receptor agonist ↓ heart rate sedation affective lability discontinuation: drug interactions
also approved as an nightmares ↑ blood pressure
antihypertensive in
other countries ↑ heart rate
sympathomimetics: mimic or stimulate the sympathetic nervous system (e.g., increase peripheral vascular resistance, blood pressure, heart rate); epinephrine is considered prototypical
alpha2A-adrenergic receptor agonist: opposes sympathetic nervous system activity (e.g., decreases peripheral vascular resistance, blood pressure, heart rate); similar to clonidine
non-medical use: use of a prescription stimulant without a prescription or in a way other than prescribed
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ADHD Medications: Evidence for practice

Adverse events can be Consider patient and caregiver

Pre-specify treatment goals.
anticipated from similarities preferences, onset and duration
It is reasonable to assess within
and differences in basic of medication effect, and cost
12 weeks (or earlier).
pharmacology. when choosing a formulation.

▪ Most ADHD medication clinical trials are ▪ Methylphenidate, amphetamines and ▪ Pharmacokinetics (time to maximum
≤ 12 weeks in length and are designed to atomoxetine stimulate the sympathetic concentration, duration of effect) are
measure a statistical change in core ADHD nervous system leading to shared adverse estimated from small sample sizes and
symptoms (inattention, hyperactivity, events: increase in heart rate and blood can show substantial variability between
impulsivity).1-4 pressure, insomnia and appetite patients.2,6
▪ Measured in this way, methylphenidate suppression.2-4 ▪ Systematic reviews do not firmly identify
and amphetamines have an onset of effect ▪ Guanfacine has an opposing effect on the differences in efficacy or common and
within hours, atomoxetine within 1-4 sympathetic nervous system leading to: serious adverse events between the
weeks and guanfacine within 1-2 weeks.2-4 reductions in heart rate and blood various formulations of methylphenidate
pressure, syncope and somnolence.2-4 and amphetamines but few direct
▪ Guidelines and narrative reviews often
comparisons exist.1,7,8
report on a selection of observational ▪ Non-medical use and dependence is
studies indicating potential longer-term attributed to methylphenidate and
benefits but the literature is lacking a amphetamines, which inhibit dopamine
comprehensive and systematic overview reuptake or increase dopamine release.2,4
of these studies.5

1CORTESE CIPRIANI Lancet Psychiatry 2018:5:727-38; 2Health Canada Drug Product Database; 3Health Canada Drug Health Product Register; 4US FDA Approved Drugs; 5WONG Lancet Psychiatry 2019:6:528-37; 6COGHILL BMC
Psychiatry 2013:13:237; 7Cochrane Database Systematic Reviews CD007813, CD009996, CD012857, CD013011; 8CATALA-LOPEZ PLoS One 2017:e0180355
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ADHD Medications: Translating efficacy from clinical trials

Factors to consider when translating

Systematic Review & Network Meta-Analysis (Lancet Psychiatry 2018)6,7
efficacy from ADHD medication clinical
trials to clinical practice:1-6 133 trials; 14,346 children & adolescent participants; 10,296 adult participants

▪ The objective of drug-approval trials submitted to Outcomes: efficacy & Medications* statistically-significantly better than placebo
Health Canada & the US Food and Drug acceptability at 12 weeks Children & Adolescents Adults
Administration (FDA) is to show a statistically-
significant reduction in core ADHD symptoms versus methylphenidate
placebo (inattention, hyperactivity, impulsivity). ADHD core symptoms: methylphenidate
amphetamines
reduction in symptoms rated amphetamines
▪ Most trials are short-term (i.e., ≤ 12 weeks); there atomoxetine
by clinicians atomoxetine
is insufficient data to assess outcomes at 26 & 52 guanfacine
weeks.
Acceptability: discontinuation
▪ The symptom scales used in these trials can vary; for any reason, encompasses methylphenidate amphetamines
this makes meta-analyses difficult to translate efficacy & tolerability
clinically (e.g., the statistical difference is reported
but not the absolute benefit). Clinician impression of
methylphenidate: 65%
improvement: proportion of
▪ There is no consensus definition for a clinically- placebo: amphetamines: 72% placebo: methylphenidate: 51%
participants much or very
important difference or of ‘responder’ which could 25% atomoxetine: 43% 25% amphetamines: 62%
much improved from
inform the calculation of a number-needed-to-treat guanfacine: 55%
baseline**
(NNT).
* Medications approved by Health Canada for ADHD
▪ In a 2018 network meta-analysis with 101
**Clinical Global Impression-Improvement (CGI-I) 7-point scale: very much improved, much improved, minimally improved, no
comparisons (drug versus placebo & drug versus change, minimally worse, much worse or very much worse relative to baseline state; does not indicate the degree of
drug), the certainty of evidence was assessed as participants’ clinical severity at the end of the trial; proportion of participants ‘much or very much improved’ was estimated by
high quality for one comparison, moderate for 12, converting the reported odds ratio to a risk ratio which was then applied to the placebo response rate (25%)
low for 38, and very low for 50.

1Health
Canada Drug Product Database; 2Health Canada Drug Health Product Register; 3US FDA Approved Drugs; 4WONG Lancet Psychiatry 2019:6:528-37; 5Cochrane Database Systematic Reviews CD007813, CD009885,
CD009996, CD012857, CD013011; 6CORTESE CIPRIANI Lancet Psychiatry 2018:5:727-38 & 871-73; 7FARAONE CORTESE Molecular Psychiatry 2022:27:212-19
 5
ADHD Medications: Comparing formulations
▪ The US Food and Drug Administration (FDA) indicates that for methylphenidate and amphetamines, drug blood concentration relates to
efficacy and adverse events; modification to a drug’s pharmacokinetics may impact the onset and duration of these effects.1
▪ There are differences in the pharmacokinetics between formulations but they are measured in small sample sizes and can show substantial
variability between patients, making comparisons between formulations difficult.2 This table provides our best estimates.
▪ Formulations that combine immediate and sustained-release features (e.g., extended/delayed/controlled release) are principally designed to
minimize the need for a dose at school or work.2,3,4

Formulation Tmax1 Tmax2 Duration of effect

Methylphenidate Drug release features
Ritalin tablets2,3 immediate release (IR) only 2 hours not expected not reported (drug half-life 2-3 hours)
Ritalin SR tablets2,3 sustained release (SR) only 4 hours not expected 8 hours
Concerta tablets2,3 biphasic: 22% IR, 78% SR 1 hour 6-10 hours 12 hours
Biphentin capsules2,4,5 biphasic: 40% IR, 60% SR 1-3 hours 6-7 hours 12 hours
Foquest capsules2 biphasic: 20% IR, 80% SR 1-2.5 hours 8.5-16 hours 16 hours
Amphetamines
Dexedrine tablets2,6,7 immediate release (IR) only 3 hours not expected not reported (drug half-life 8-12 hours)
Dexedrine Spansule capsules2,6,8 biphasic: 40% IR, 60% SR 8 hours 10-12 hours
not reported
Adderall XR capsules2,3 biphasic: 50% IR, 50% SR 5-8 hours 12 hours
Vyvanse capsules2,6 prodrug of dextroamphetamine 3.5-4.5 hours not expected 12-14 hours
Principal source of information: regulatory reviews and prescribing information from Health Canada and the US FDA
Tmax1: time to first maximum concentration (peak); Tmax2: time to second maximum concentration (peak); duration of effect: time period for which a change in ADHD symptoms was
statistically different from placebo; prodrug: Vyvanse (lisdexamfetamine) is the parent drug which is converted to dextroamphetamine in vivo

1USFDA 2019 Attention Deficit Hyperactivity Disorder Guidance; 2Health Canada Drug Product Database; 3US FDA Clinical Pharmacology Biopharmaceutics Reviews; 4COGHILL BMC Psychiatry 2013:13:237; 5CORTESE CNS Drugs
2017:31:149-60; 6US FDA Approved Drugs; 7DOLDER Front Pharmacol 2017:8:617; 8Paladin Correspondence
 6
ADHD Medications: Comparing cost

Formulation Generic: cost/30 days1 Brand: cost/30 days1 BC PharmaCare Coverage2

Methylphenidate

Ritalin, Ritalin SR $10 - $30 Regular Benefit

Concerta* $20 - $30 $95 - $150 Limited Coverage
Biphentin $30 - $175 Non-Benefit
Foquest $95 - $160 Non-Benefit
Amphetamines

Dexedrine* $10 - $135 $15 - $205 Regular Benefit

Dexedrine Spansule* $30 - $115 $40 - $150 Regular Benefit
Adderall XR† $20 - $30 $70 - $120 Limited Coverage
Vyvanse** $90 - $160 Limited Coverage
Atomoxetine

Strattera† $20 - $45 $105 - $195 Limited Coverage

Guanfacine

Intuniv XR $85 - $260 $100 - $310 Non-Benefit

Cost per 30 days: does not include mark-up or professional fee; provided as a range which includes approximate cost for initial to maximum doses
* Concerta and Dexedrine brand formulations reimbursed up to the cost of generic formulations
** Vyvanse capsules are Limited Coverage, chewable tablets are a Non-Benefit
† Adderall XR and Strattera brand formulations are Non-Benefits

1Calculated from McKesson Canada August 17, 2022; 2BC PharmaCare Formulary
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ADHD Medications: BC PharmaCare coverage

Regular Benefit Drug

minimum 1 week trial at adequate dose

methylphenidate dextroamphetamine
immediate or sustained release immediate or sustained release
Ritalin IR generics§, Ritalin SR generics§ Dexedrine*, Dexedrine Spansules*, generics

If unsatisfactory trial or intolerance to EITHER class above and patient requires Unsatisfactory trial or intolerance
12 hours of continuous medication coverage, defined as no demonstrated
can apply for Special Authority for a long-acting stimulant effectiveness for symptoms of ADHD
or functional impairment secondary
to ADHD after a minimum 1 week
methylphenidate amphetamine mixed salts trial at adequate dose(s)
lisdexamfetamine
extended release extended release
Vyvanse**
Concerta*, generics Adderall XR generics†

If unsatisfactory trial or intolerance to BOTH a methylphenidate AND an

atomoxetine
amphetamine above (at least one extended release or long acting),
can apply for Special Authority for atomoxetine Strattera generics†

§Ritalin brand name no longer marketed in Canada

*Concerta and Dexedrine brand formulations reimbursed up to the cost of generic formulations
BC PharmaCare Medication Coverage ADHD Medication Coverage **Vyvanse capsules are Limited Coverage, chewable tablets are a Non-Benefit
†Adderall XR and Strattera brand formulations are Non-Benefits
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Methylphenidate, Amphetamines: Clinical considerations
Select adverse events - not intended to reproduce a product monograph; see separate reference list
▪ Medical history: recommended to assess for cardiovascular symptoms & family history before treatment with ADHD medications ■ ECG: not
recommended if no specific indication from personal or family history or physical exam (Canadian Paediatric, Cardiovascular, Psychiatry joint
position statement & Canadian ADHD Guideline)
▪ Health Canada contraindications: symptomatic cardiovascular disorders, moderate to severe hypertension ■ caution where increases in heart
rate & blood pressure may compromise cardiovascular status ■ rare serious cardiovascular events have been reported during ADHD medication
Cardiovascular use ■ large cohort studies have not confirmed increased cardiovascular risk in general pediatric or adult populations
1-27 ▪ Blood pressure & heart rate: monitor after each dose change & every 6 months (UK NICE) ■ mean increases: BP 2-4 mmHg, HR 3-6 bpm
▪ Congenital Long QT: avoid use → CredibleMeds®
▪ Peripheral vasculopathy including Raynaud’s disease: reduce dose or discontinue
▪ Priapism (children, adolescents, adults): rare cases associated with methylphenidate, atomoxetine ■ case reports with amphetamines when in
combination with other priapism-causing medications ■ seek medical attention if painful or long lasting
▪ Insomnia: reported by up to 25% of trial participants ■ review non-pharmacologic strategies, reduce dose, change formulation or timing
▪ Agitation-type adverse events: if agitation, psychosis, mania, aggressive behaviour emerge or are accompanied by suicidal thoughts, consider
possible causal role of medication (Health Canada)
Neuropsychiatric ▪ Anxiety, depression: address most impairing disorder first (Canadian ADHD Guideline)
2,4-19,28-34 ▪ Bipolar: ensure mood stabilized prior to initiating ADHD medication ■ increase vigilance for manic episodes (Canadian ADHD Guideline)
▪ Tics (motor, verbal): may be improved or exacerbated ■ meta-analyses do not show an increase in new onset or worsening of tic disorders in
most patients ■ monitor at each visit & after dose changes (Health Canada)
▪ Appetite (decrease or loss): dose related ■ reported by up to 1/3 of trial participants ■ strategies: take medication with or after meals, time
meals or snacks for when stimulant effects are reduced ■ review for possible dose reduction
Appetite, ▪ Height (pediatrics): suppression by 1-4 cm with early childhood medication exposure or persistent use through adolescence, dependent on
Growth cumulative drug exposure ■ limiting lifetime exposure associated with greater adult height
3-19,35-41 ▪ Monitoring (pediatrics): measure weight every 3 months, measure height every 6 months (UK NICE Guideline)
▪ Planned medication breaks: consider if height or weight concerns ■ optimal duration of break unknown

▪ All formulations have Health Canada & US FDA warnings for the potential for non-medical use (NMU) & dependence
▪ Available evidence does not associate pediatric medical use of methylphenidate or amphetamines for ADHD with later development of
substance use disorders ■ evidence does not consistently suggest a protective effect
Non-Medical Use
▪ Data on NMU is limited to self reports, surveys & emergency centre reporting, with highly variable estimates & definitions ■ oral is the most
5-19,42-44
frequently self-reported NMU route by post-secondary students ■ other routes are associated with increased risk of serious adverse outcomes
▪ British Columbia Centre on Substance Use provides a 2022 Practice Update for the management of Illicit Stimulant Use Disorder
 9
Atomoxetine (Strattera): Clinical considerations
Select adverse events - not intended to reproduce a product monograph; see separate reference list
▪ Medical history: recommended to assess for cardiovascular symptoms & family history before treatment with ADHD medications ■ ECG: not
recommended if no specific indication from personal or family history or physical exam (Canadian ADHD & American Academy of Paediatrics
Guidelines)
▪ Health Canada contraindications: symptomatic cardiovascular disorders, moderate to severe hypertension, conditions where heart rate & blood
pressure increases may compromise cardiovascular status ■ rare serious cardiovascular events have been reported during ADHD medication
Cardiovascular use ■ large cohort studies have not confirmed increased cardiovascular risk in general pediatric or adult populations
1-11
▪ Blood pressure & heart rate: monitor after each dose change & every 6 months (UK NICE Guideline) ■ 5-10% of participants experienced
increases in HR (≥ 20 bpm) or BP (≥ 15-20 mmHg) in ADHD trials (all ages) ■ orthostatic hypotension, syncope
▪ QTc prolongation: Congenital Long QT: avoid use → CredibleMeds® ■ caution with CYP2D6 inhibitors, genetic phenotype poor metabolizers
▪ Peripheral vasculopathy including Raynaud’s disease: reduce dose or discontinue

▪ Pediatric trials: somnolence (~10% of trial participants), more common than insomnia ■ lower incidence of somnolence & fatigue with dose
divided twice daily (but ↑ cost) compared to once a day dosing ■ rapid dose escalations associated with increased rates of somnolence
▪ Adult trials: insomnia (~15% of trial participants), more common than somnolence
Neuropsychiatric
▪ Agitation-type adverse events: suicidal ideation reported in pediatric trials, post-marketing reports in all ages ■ monitor for emergence &
2,5,6
behaviour changes (e.g., agitation, aggression, anxiety, panic attacks, hostility, mania, psychosis) on initiation & dose changes (Health Canada)
▪ Bipolar: ensure mood stabilized prior to initiating ADHD medication & increase vigilance for manic episodes (Canadian ADHD Guideline)

▪ Appetite (decrease or loss): reported by 10-25% trial participants ■ children, adolescent trials: lower incidence of decreased appetite & nausea
with twice daily (but ↑ cost) compared to once a day dosing ■ rapid dose escalations associated with increased rates of digestive complaints
Appetite,
▪ Growth: associated with a lag in height & weight over initial 9-12 months of treatment, normalizing at 3 years on average
Growth ▪ Monitoring (pediatrics): measure weight every 3 months, measure height every 6 months (UK NICE Guideline)
3,5,6,12
▪ Planned medication breaks or dose reduction: consider if height or weight concerns ■ optimal duration of break unknown

▪ Priapism (children, adolescents, adults): rare cases associated with methylphenidate, atomoxetine ■ case reports with amphetamines when
combined with other priapism-causing medications ■ seek medical attention if painful or long lasting
Genitourinary ▪ Sexual dysfunction (female & male): decreased libido, abnormal orgasm, erectile dysfunction, impotence, dysmenorrhea
5,6,14-16
▪ Urinary hesitancy, retention, dysuria: up to 8% in adult trials, post-marketing reports in children

▪ CYP2D6 inhibitor medications (see drug interaction table on page 11) & genetic phenotype poor metabolizers (populations affected: White 7%,
CYP2D6 metabolic
Black 2%, Asian <1%): up to 5 fold higher peak concentration & 10 fold higher exposure to atomoxetine
variability ▪ Pharmacogenetic testing: routine testing not recommended (Canadian ADHD Guideline)
2,5,6,13
▪ Use lowest effective dose, titrate slowly, only increase dose if ADHD symptoms are not improved & if previous dose well tolerated
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Guanfacine (Intuniv XR): Clinical considerations
Select adverse events - not intended to reproduce a product monograph; see separate reference list

▪ Medical history: recommended to assess for cardiovascular symptoms & family history before treatment with ADHD medications ■ ECG: not
recommended if no specific indication from personal or family history or physical exam (Canadian ADHD & American Academy of Pediatrics
Guidelines)
▪ Caution: history of hypotension, syncope, heart block, bradycardia ■ avoid dehydration
Cardiovascular ▪ Blood pressure & heart rate: reductions are dose related ■ mean decreases: BP 3-8 mmHg, HR 3-9 bpm ■ orthostatic hypotension or syncope
1-6 ▪ Monitor blood pressure & heart rate: at baseline, after dose increases or decreases, every 6 months, during taper & after discontinuation
(Health Canada)
▪ QTc prolongation: mean increase from baseline of approximately 5 msec ■ consider if known history of QT prolongation, risk factors for
Torsades de Pointes or on concomitant QT prolonging or heart rate lowering medications (Health Canada)

▪ Rebound hypertension, increased heart rate: possible if guanfacine stopped without tapering or if multiple doses missed (for example, during
acute gastrointestinal illness)
▪ Caution: when prescribing other medications that can elevate blood pressure & heart rate immediately following guanfacine discontinuation,
Tapering including methylphenidate, amphetamines, atomoxetine
2-4 ▪ Taper: total daily dose by no more than 1 mg every 3 to 7 days & monitor blood pressure & heart rate during taper
▪ Missed doses: if multiple doses are missed (2 or more consecutive), re-titration based on tolerability recommended
▪ Planned medication breaks: require tapering

▪ Occurs in up to 54% of participants in monotherapy studies & 18% of participants when combined with a stimulant
Somnolence, ▪ Common reason for drug discontinuation
Sedation ▪ Dose related: more pronounced early in treatment & as dose increases (28% of participants on 2 mg to 51% on 4 mg)
3,4,6,7 ▪ Morning & evening dosing resulted in similar incidence of somnolence ■ drug elimination half-life is 18 hours

▪ Most common psychiatric adverse effects in trials: irritability, affective lability, nightmares
Neuropsychiatric ▪ Agitation-type adverse events: if agitation, psychosis, mania, aggressive behaviour emerge or are accompanied by suicidal thoughts, consider
3 possible causal role of medication (Health Canada)
 11
ADHD Medications: Drug interaction overview
Not intended as an exhaustive drug interaction list; for complete information, consult a drug interaction resource.

Avoid Caution / Monitor Dose modification recommended

Pharmacokinetic interactions methylphenidate amphetamines atomoxetine guanfacine
begin with a 50% dose
Cytochrome 3A4 inhibitors (e.g., clarithromycin, ketoconazole, ritonavir) - - - reduction of guanfacine
a dose increase of
Cytochrome 3A4 inducers (e.g., carbamazepine, phenytoin) - - - guanfacine may be needed
low amphetamine
Cytochrome 2D6 inhibitors (e.g., bupropion, fluoxetine, paroxetine, slow atomoxetine dose
- doses to start; slow -
mirabegron) or Cytochrome 2D6 poor metabolizers (genetic phenotype) dose titration
titration

monitor for: increased

Alkalinizing agents (e.g., sodium bicarbonate, acetazolamide) - amphetamine effect - -

monitor for: valproic acid

Valproic acid and derivatives - - - toxicity

Pharmacodynamic interactions
MAOIs (e.g., linezolid, selegiline, moclobemide) contraindicated within 14 days -
Serotonergic drugs (e.g., SSRIs, serotonergic antidepressants) monitor for: serotonin toxicity - -
Antihypertensives caution: hypotension
caution: opposing effects on blood pressure and heart rate
Heart rate lowering drugs (e.g., beta blockers, clonidine, diltiazem, verapamil) avoid: bradycardia

Sympathomimetics (e.g., pseudoephedrine, caffeine, cocaine, modafinil) caution: synergistic increases in blood pressure and heart rate -
monitor for: decreased stimulant effect, caution: potential additive
Antipsychotics extrapyramidal symptoms
- sedation
caution: potential additive
CNS depressants (e.g., benzodiazepines, sedative hypnotics) - - - sedation
Health Canada Drug Product Database; US FDA Approved Drugs; Lexicomp Interactions; Indiana University Cytochrome P450 Drug Interaction Table
 Medications for Attention Deficit Hyperactivity Disorder (ADHD):
Focus on Drug Information
B.C. Provincial Academic Detailing (PAD) Service October 2022

Adverse events can be Consider patient and caregiver

Pre-specify treatment goals.
anticipated from similarities preferences, onset and duration
It is reasonable to assess within
and differences in basic of medication effect, and cost
12 weeks (or earlier).
pharmacology. when choosing a formulation.

Reference list is available upon request.

Materials are designed to be used in conjunction with an academic detailing session provided by a PAD pharmacist.
For more information, or to schedule an academic detailing session, please contact:

BC Provincial Academic Detailing Service

Email: [email protected] Web: www.bcpad.ca

This document has been compiled for the British Columbia Ministry of Health’s Pharmaceutical, Laboratory and Blood Services Division. The information contained in this document is intended for educational
purposes only, and is not intended as a substitute for the advice or professional judgment of a health care professional. The information in this document is provided without any express or implied warranty
regarding its content, and no party involved with the preparation of this document is responsible for any errors or omissions that may be contained herein, nor is any party involved with the preparation of this
document responsible for the result obtained from the use of information in this document. Any use of this document, or the accompanying academic detailing session, will imply acknowledgement of this disclaimer
and release the Province of British Columbia, its employees, agents and any party involved in the preparation of this document from any and all liability.
v. Oct 13, 2022
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