NHS Borders Shared Care Agreement
Antipsychotic Medication Shared Care Protocols facilitate the sharing of care and transfer of prescribing for medications that have previously been used in Secondary Care to Primary Care. The goal of this agreement is to provide consistency in the monitoring of these medications and to provide a peer-reviewed framework to allow them to be safely prescribed in the community by Primary Care. This would usually take place once the patient’s condition is stable; the patient is demonstrably benefiting from the treatment and is free from significant side effects. Unfortunately the nature of antipsychotic medication means that most prescriptions will be initiated by Primary Care under the direct request or supervision of the Community Mental Health Care teams. GPs should only take on the prescribing when confident in the use of the drug in the context of the agreement. It is hoped that within the context of this, GPs will feel confident in prescribing and subsequently monitoring for potential adverse effects of antipsychotic medications. Contingency plans however will be in place to enable the patient to receive the recommended treatment without delay, should the GP decline to prescribe. Rationale for treatment People with significant mental health problems tend to find it harder to access services and participate in social and community activities. They may require assistance in accessing and getting the right level of physical health care, at the right time with the right service. They are at a considerably higher risk of developing significant health problems than the general population; such as diabetes and coronary heart disease, and this is associated with the impact of the long term mental health conditions and the medications used to treat the symptoms of mental disorder on the general health and wellbeing of the person. These individuals have a potentially shorter lifespan up to 15 years less than the general public, which can be influenced by the impact of poorly managed physical care and potentially preventable health problems.
Antipsychotics are indicated for the treatment of psychosis (including schizophrenia), bipolar disorder and augmentation of antidepressants in treatment resistant depression. Antipsychotics are frequently also prescribed off license in the treatment of other psychiatric disorders such as the anxiety disorders. The use of antipsychotic medication brings with it the possibility of drug-related adverse physical effects which require to be monitored and their impact minimised if considered to be intolerable. It is recognised that the monitoring of such potential adverse effects of antipsychotic medication requires being both consistent and coordinated. Dose and Administration
Summary of Licensed Indications, Formulations and Dosage (from BNF March 2013)
Second Generation Oral Antipsychotic Drugs
1 Drug Indication Dosage Range Formulation
(consult BNF for further details about initial doses and titration) Amisulpiride Schizophrenia Predominantly Tablets 3rd Choice In negative symptoms: 50-300mg daily Borders Formulary Solution Acute psychotic episode: 400mg- 800mg daily in 2 divided doses Max 1.2g daily Aripiprazole Schizophrenia 10mg-30mg daily Tablets 3rd Choice In 15-30mg daily Borders Formulary Treatment and Oral solution prevention of recurrence of mania Orodispersible tabs Clozapine Treatment resistant 200-450mg daily. Tablets Alternative schizophrenia Max 900mg daily. Note titration preparation in Oral suspension requirements, & Borders Formulary need for re-titration after more than Psychosis in 48hrs treatment Parkinson’s disease break. 25-37.5mg at bedtime. Max 100mg daily. Olanzapine Schizophrenia, 10mg daily, adjusted Orodispersible 2nd Choice in combination therapy for to tablets 5-20mg daily. Borders Formulary mania, preventing recurrence in bipolar Max 20mg daily. Tablets disorder. 15mg daily adjusted Prolonged release Mania(monotherapy) to injection 5-20mg daily. Max 20mg daily. Palperidone Schizophrenia 3-12mg daily MR tabs 3rd Choice Depot in Depot: 25-150mg Borders Formulary Psychotic or manic Prolonged release monthly. injection symptoms of Maintenance dose schizoaffective disorder 75mg Quetiapine Schizophrenia Tablets 3rd Choice on Mania Varies according to indication & whether Borders Formulary Depression in bipolar XL Tablets the normal or MR (modified release disorder tablets prescribed – for once daily Prevention of relapse please see current in bipolar disorder BNF dosing) Adjunctive treatment of major depressive 150-300mg daily disorder (XL only) Risperidone Acute and Chronic Varies according to Liquid psychoses 1st Choice on indication-please consult the current Borders Formulary Mania BNF for dosing Orodispersible Oral formulation details Short term treatment (up to 6 Tablets weeks) of persistent aggression in patients with moderate to severe Alzheimer’s dementia Tablets
2 unresponsive to non- 3rd Choice Depot pharmacological interventions and when there Preparation is risk of self harm. Long acting Borders Formulary Injection Short term treatment (up to 6 weeks) of persistent aggression in conduct disorder (under specialist supervision)
First Generation Depot Antipsychotic Drugs
Drug Indication Dosage Range Formulation
(consult BNF for further details about initial doses and titration) Flupentixol Maintenance of 50-300mg every 2-4 Long acting injection decanoate schizophrenia weeks (Depixol) and other 1st Choice Borders psychoses Formulary Fluphenazine Maintenance of 12.5-100mg every 14- Long acting injection decanoate schizophrenia 35 days (Modecate) and other psychoses Haloperidol Maintenance of 50-300mg every 4 Long acting injection (Haldol schizophrenia weeks decanoate) and other psychoses Pipotiazine Maintenance of 50-100mg (max Long acting injection palmitate schizophrenia 200mg) every 4 weeks (Piportil) and other 2nd Choice Borders psychoses Formulary Zuclopentixol Maintenance of 200-500mg 1-4 weeks Long acting injection decanoate schizophrenia (Clopixol) and other 1st choice Borders psychoses Formulary Consultant / Specialist Services responsibilities 1. Perform mental health assessment prior to starting antipsychotics 2. Request that GP initiate antipsychotic prescribing after baseline investigations have been completed.(1) 3. Monitor for side effects of the medication and inform all concerned if these occur, taking appropriate action 4. To inform GP of patients response to medication and general progress. 5. To inform GP of any change in the medication dose or if it is to be stopped 6. To send a copy of the shared care protocol. 7. to advise on how to manage any abnormal results from ongoing monitoring of the medication 8. to arrange a prescription for the medication should the GP decline to prescribe
3 (1) In clinical practice, especially when the patient is acutely unwell, it may be difficult to adhere to recommendations at that time. Clinicians need to carefully weigh the risks and benefits of expedient decisions and record reasons for not performing baseline investigations. GP responsibilities: 1. Initially, to refer the patient for specialist advice, following where possible appropriate physical investigation. 2. Review the patient and if need be seek specialist advice from the psychiatrist or CMHT in accordance with their care plan. 3. Arrange via the Ambulatory Care Clinic (formerly Treatment Room) service (2) the initial investigations within a reasonable timescale to establish a baseline. 4. Inform the psychiatry team should the patient decline the initial investigations. (3) 5. Initiate and prescribe the medication in line with the recommendations from the CMHT. 6. If the practitioner decides NOT to prescribe the medication, to ask a colleague if they are willing to prescribe instead. If the Practice is unwilling to prescribe the medication then to email the CMHT at the contact below, informing them of this decision at the soonest opportunity. 7. Arrange via the Ambulatory Care Clinic (formerly Treatment Room) service (2) the ongoing investigations as per this agreement. 8. Advise CMHT of any abnormalities arising from the ongoing investigations if appropriate to do so, or any change in the clinical status of the patient. 9. For those patients who are stable on their antipsychotic medication and have been discharged by the CMHT from regular follow up; to continue to monitor according to the schedule below, referring back to CMHT in the event of any changes in their condition. If Practices are claiming for the monitoring of these drugs through the DMARDs LES then bloods and the subsequent claim should be matched i.e. if the practice staff are taking the bloods it will be a level 4 payment. However as these are drugs and investigations suggested by Secondary Care, they fall into items of service which the Ambulatory Care Clinic (formerly Treatment Room) service can be asked to perform. In this situation, they will only attract a level 3 DMARDs payment. A patient declining the initial investigations should not delay their commencement of treatment. The CMHT should be advised of this but would most often recommend starting medication and obtaining the baseline measures once the clinical situation stabilises.
(2) Monitoring required in Primary care
AMISULPIRIDE, RISPERIDONE, PALPERIDONE and ALL DEPOT INJECTIONS ARIPIPRAZOLE, QUETIAPINE, OLANZAPINE, HALOPERIDOL Baseline BMI. Fasting Lipids, Fasting Glucose. U&E’s, LFT’s, FBC, Thyroid Function, Prolactin*, Pulse & BP, ECG(4) 1 month BMI, LFTs, Glucose 3 months BMI, Lipids 6 months Glucose (TFT for Quetiapine) Annually BMI, fasting Lipids, Fasting glucose, U&Es,
4 LFTs. FBC, Prolactin*, Pulse & BP, ECG(4) Additional testing None
CLOZAPINE Baseline BMI. Fasting Lipids, Fasting Glucose. U&E’s, LFT’s, FBC, Thyroid Function, Prolactin*, Pulse & BP, ECG(4) Weekly (for 18 weeks) FBC is WEEKLY for 18 weeks, then fortnightly up to 1 year, 4 weekly thereafter. 1 month BMI, LFTs, Glucose 3 months BMI, Lipids, ECG(4), Pulse, BP 6 months BMI, Lipids, Glucose, ECG(4),Pulse, BP Annually BMI, fasting Lipids, Fasting glucose, U&Es, LFTs. FBC, Prolactin*, Pulse & BP, ECG(4)
Additional testing Weight, BMI, Lipids, Glucose, ECG(4), BP and Pulse are every 3 months.
(4)ECG interpretation is available via Cardiology in case of doubt.
* Prolactin levels may be moderately raised by antipsychotics. If the patient is asymptomatic; there is no galactorrhoea, no cycle change and the Prolactin is <1000 mu/l then no further action is required. In men, if the Prolactin is >1000 mu/l a testosterone level should be checked additionally.
Side effects and adverse effects
5 (3) Contact Details
Requests for prescriptions should be preferably via generic inbox email. This is usually a 48 hour (2 working days) turn around service Urgent requests (i.e. patients who require starting immediately ) should be given a prescription by the CMHT If the CMHT are unable to provide a prescription the surgery should be emailed together with a phone call advising them it is being sent as per the “urgent” guidelines in the document “email guidance for secondary care” Abnormal results or queries should be sent to the appropriate office for the area CMHT, NOT to the personal inbox of the psychiatrist. [email protected] [email protected] [email protected]
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