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4. Central Nervous System

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4. Central Nervous System 1 4. Central Nervous System For further advice on mental health issues see NHS Fife website www.moodcafe.co.uk/ 4.1 - Hypnotics and anxiolytics 4.1.1 Hypnotics 1st Choice Non-drug treatment e.g.sleep hygeine 2nd Choice Drug treatment 1st Choice Zopiclone 2nd Choice Temazepam Nitrazepam Prescribing Points Before a hypnotic is prescribed, the cause of the insomnia should be established and underlying factors be addressed. Non-drug management should be considered 1st e.g. sleep hygiene, avoiding caffeine intake close to bedtime. A patient self help guide on sleep problems is available at www.moodcafe.co.uk/article/uploaded/tipsforbettersleep.pdf Prescriptions for hypnotics should only be issued for short-term relief (1- 4 weeks) of severe insomnia that is disabling or causing unacceptable patient distress. In new patients hypnotics should not be added as a repeat prescription. They should only be prescribed as ‘acutes’. Prescribers should exercise caution when starting a patient on a benzodiazepine or ‘z’ drug as these medicines have a ‘street value’. Relative durations of action are: short-acting: lorazepam, temazepam, zopiclone intermediate-acting: nitrazepam long-acting: chlordiazepoxide, diazepam Short-acting hypnotics are preferable in patients with sleep onset insomnia, when sedation the following day is undesirable or when prescribing for elderly patients. Short-acting hypnotics have a higher potential for abuse and withdrawal phenomena are more common. Long-acting hypnotics are indicated in patients with poor sleep maintenance (e.g. early morning waking), when an anxiolytic effect is needed during the day or when sedation the following day is acceptable. Longer acting hypnotics can increase the risk of falls in the elderly and may cause ataxia and confusion. Patients who have been on a benzodiazepine for many years can be switched to diazepam and the diazepam then be slowly withdrawn (See withdrawal protocol BNF section 4.1.). The sedating antihistamine promethazine is regarded as less suitable for prescribing in the BNF. However, it is sometimes used in patients for occasional insomnia when ‘z’ drugs and benzodiazepines are considered inappropriate. Chloral and Derivatives S - Chloral Hydrate H – Hospital Use Only S – Specialist Initiation or Recommendation R – Restricted Use Fife Formulary January 2013 Last amended August 2014 2 Prescribing Points Reserved for paediatric patients. Melatonin S - Melatonin 3mg tablets (Bio-melatonin ®) (Unlicensed) Prescribing Points Unlicensed, immediate release melatonin is used in treating sleep onset insomnia and also in delayed sleep phase syndrome in children in conditions such as ADHD. Treatment with melatonin in children and adolescents should be initiated and supervised by a specialist. The need for continuing melatonin therapy should be reviewed at least annually. Other formulations and strengths of unlicensed melatonin (including liquid preparations for younger children or in the presence of swallowing difficulties or the use of C/R melatonin in patients with learning difficulties) may be prescribed if Bio-Melatonin ® is considered clinically unsuitable. Circadin ® (melatonin MR 2mg tablets) has not been approved by the SMC for the treatment of insomnia and should not be prescribed routinely in NHS Fife. Circadin ® should only be prescribed if an Individual Patient Treatment Request has been approved. 4.1.2 Anxiolytics For further advice on anxiety disorders see NHS Fife website www.moodcafe.co.uk/content.asp?ArticleCode=1595 Acute anxiety 1st Choice Diazepam (long acting) 2nd Choice Lorazepam (short acting) Chlordiazepoxide(long acting) Prescribing Points Patient self help guides on anxiety problems are available at www.moodcafe.co.uk/content.asp?ArticleCode=984 Prescriptions for anxiolytics should only be issued for short-term relief (1- 4 weeks) of severe acute anxiety that is disabling or causing unacceptable patient distress. The use of benzodiazepines to treat short–term “mild” anxiety is inappropriate and unsuitable. Benzodiazepines should not be used as sole treatment for chronic anxiety. Benzodiazepines should be used at the lowest possible dose for the shortest possible time. Dependence is particularly likely in patients with a history of alcohol or drug abuse and in patients with marked personality disorders. Patients who have been on a benzodiazepine for many years can be switched to diazepam and the diazepam then be slowly withdrawn (See withdrawal protocol BNF section 4.1.). The most common use for chlordiazepoxide is for alcohol withdrawal. Lorazepam acts for a shorter period and does not accumulate with repeated doses but has greater potential for withdrawal phenomena, dependence and abuse. Lorazepam is useful in H – Hospital Use Only S – Specialist Initiation or Recommendation R – Restricted Use Fife Formulary January 2013 Last amended August 2014 3 patients with impaired liver function and in the elderly. Other drugs for acute anxiety Propranolol (standard tablets) Prescribing Points Used to relieve the physical symptoms of anxiety e.g. palpitations and tremor. Long acting propranolol preparations are more expensive than standard tablet formulations. Anxiety Disorders Also see - NICE CG 113 - Generalised Anxiety Disorder and Panic Disorder (with or without Agoraphobia), January 2011 www.nice.org.uk/nicemedia/live/13314/52601/52601.pdf NICE CG 31 - Obsessive-Compulsive Disorder, November 2005 www.nice.org.uk/nicemedia/live/10976/29945/29945.pdf NICE CG 26 - Post-Traumatic Stress Disorder, March 2005 www.nice.org.uk/nicemedia/live/10966/29771/29771.pdf 1st Choice Citalopram +/- psychological Fluoxetine therapies Sertraline 2nd Choice Clomipramine +/- psychological Venlafaxine therapies 3rd Choice Pregabalin +/ - psychological therapies Prescribing Points Psychological therapies should be considered along with pharmacological treatment in patients with anxiety disorders. Refer to NICE Clinical guidelines. The choice of agent for the treatment of anxiety disorders will depend on licensed indications, patient preference, severity of the condition and cost. Also refer to NICE Clinical guidelines. For further prescribing information on antidepressants see section 4.3. Pregabalin is approved for restricted 3 rd line use in the treatment of GAD and anxiety associated with schizophrenia. Pregabalin is restricted to specialist initiation / specialist recommendation after failure with/intolerance to at least two different formulary SSRIs/SNRIs. Treatment should be reviewed after a 12 week trial period and discontinued if found to be ineffective. Prescribers should be alert to the misuse potential of pregabalin. All strengths of pregabalin capsules are the same cost; therefore ensure the H – Hospital Use Only S – Specialist Initiation or Recommendation R – Restricted Use Fife Formulary January 2013 Last amended August 2014 4 correct strength of capsule is prescribed i.e. 300mg rather than 2x 150mg. 4.2 - Drugs used in psychoses and related disorders Also see :- Appendix 4A - Guidance on Drug Treatment of Schizophrenia in Patients 18 Years and Over www.fifeadtc.scot.nhs.uk/ NICE Clinical Guidance 82 - Schizophrenia: Core interventions in the treatment and management of schizophrenia in adults in primary and secondary care. March 2009. http://publications.nice.org.uk/schizophrenia-cg82 For prescribing in pregnancy refer to the UK Teratology Information Service http://www.uktis.org./index.html 4.2.1 Antipsychotic drugs General Prescribing Points Patients should receive antipsychotic drugs for a minimum of 6 weeks before the drug is deemed ineffective. Antipsychotics should be initiated with caution in the first episode (i.e. start with a low dose). Patients should be reviewed regularly to monitor efficacy and development of side-effects. Specialist advice should be sought before discontinuing antipsychotics due to the risk of relapse. Prescribing of more than one antipsychotic drug at the same time is not recommended. See NHS Fife Policy M1-P3-MH - Regular Prescription of more than one antipsychotic drug at the same time - http://intranet.fife.scot.nhs.uk/uploadfiles/publications/M1-P3- MH_%20%20(MH3)%20More%20than%20one%20antipsychotic%20Sep%2011. pdf Antipsychotics vary in their side effect profile and this will influence choice of therapy. See Appendix 4A - Guidance on Drug Treatment of Schizophrenia. Antipsychotics in older people with dementia In elderly patients with dementia, all antipsychotic drugs are associated with a small increased risk of mortality and an increased risk of stroke or transient ischaemic attack. Elderly patients are also particularly susceptible to postural hypotension and to hyper- and hypothermia in hot or cold weather. It is recommended that: Antipsychotic drugs should not be used in older patients to treat mild psychotic symptoms i.e. non-distressing symptoms. Initial doses of antipsychotic drugs in elderly patients should be reduced (to half the adult dose or less), taking into account factors such as the patient’s weight, co- morbidity, and concomitant medication. Doses used should be the lowest possible, titrated carefully and closely monitored. Treatment should be reviewed regularly. Patients/caregivers should be cautioned to immediately report signs and symptoms of potential cerebrovascular adverse events such as sudden weakness or numbness in the face, arms or legs, and speech or vision problems. Antipsychotics may be prescribed with caution in the management of behavioural disorders H
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