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BNSSG Shared Care Guidance Amber One Month

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BNSSG Shared Care Guidance Amber One Month NHS Bristol North Bristol NHS Trust NHS North Somerset University Hospitals Bristol NHS Foundation Trust NHS South Gloucestershire Weston Area Health NHS Trust BNSSG Shared Care Guidance Amber One Month Section 1: Heading Avon & Wiltshire Mental Health Partnership NHS Trust Trust(s) Speciality / Department Mental Health Typical depot antipsychotics: Flupentixol decanoate (Depixol®, Depixol conc.® and Depixol Low Volume® ) Fluphenazine decanoate (Modecate®, Modecate Drug Concentrate®, generic also available) Haloperidol decanoate (Haldol Decanoate®) Pipotiazine palmitate (Piportil®,), Zuclopenthixol decanoate (Clopixol® and Clopixol Conc®). The maintenance treatment of schizophrenia and paranoid psychoses. Indication Please see SPC for individual depots as slight variations exist www.medicines.org.uk Section 2: Treatment Schedule Given by deep intramuscular injection. Dose as per SPC for individual drug Flupenthixol: 2-4 weekly Usual dose and frequency of Zuclopenthixol: 2-4 weekly administration Haloperidol: 4 weekly Fluphenazine: 2-5 weekly Pipotiazine: 4 weekly Deep intramuscular oily injection. Route and formulation Please note that some of the preparations contain sesame oil - please check allergy status. Duration of treatment Long term Section 3: Monitoring Please give details of any tests that are required before or during treatment, including frequency, responsibilities (please state whether they will be undertaken in primary or secondary care), cause for adjustment and when it is required to refer back to the specialist. Page 1 of 8 Approved BNSSG D&TC November 2012 BNSSG Shared Care Guidance Baseline tests By AWP Specialist Team 1. *ECG, BP and pulse 2. Creatinine phosphokinase, fasting blood glucose, fasting lipid profile (HDL & triglycerides) 3. LFTs, U&Es, TSH, FBC, prolactin 4. Waist circumference, weight & BMI 5. VTE risk assessment including e.g. reduced mobility. *Cardiovascular screen: ECG - patients with schizophrenia are at higher risk of heart disease and depot antipsychotics may cause QTc prolongation and induce arrhythmias Subsequent tests When stable dose has been reached and after 3 months of starting or switching depot. Primary care to organsie: 1. Fasting blood glucose, fasting lipid profile (HDL & triglycerides) 2. Prolactin - irrespective of symptoms 3. Waist circumference, weight & BMI 4. If possible, assess patient for VTE risk and consider preventative measures. Routine at 12 months and annually after first year. 1. BP and pulse, 2. Creatinine phosphokinase, fasting blood glucose, fasting lipid profile (HDL & triglycerides), 3. LFTs, U&Es, TSH, FBC, prolactin 4. Waist circumference, weight & BMI 5. *ECG if indicated 6. If possible, assess patient for VTE risk and consider preventative measures. *Cardiovascular screen: ECG - Schizophrenic patients are at higher risk of heart disease and depot antipsychotics may cause QTc prolongation and induce arrhythmias. Results and when to refer: 1. Raised prolactin (above threshold) - If symptoms arise e.g. in women: amenorrhoea, menstrual disorders, galactorrhoea and reduced libido and in men: reduced libido, impotence & gynaecomstia. The longer the patient is exposed to hyperprolactinaemia, the greater the risk of reduced bone density and hypogonadism. Action: Reduce dose or alternative oral antipsychotic may be necessary. Refer to specialist team for advice. Treatment with calcium and vitamin D should be considered and started by the GP. 2. Significant weight gain - > 5% over baseline Antipsychotics are associated with weight gain especially in first 6 to 9 months of treatment (average 2 to 10lb or ~0.9Kg to 4.5Kg). Action: Encourage healthy balanced diet and regular exercise. Recommend annual follow-up by GP. 3. Abnormal ECG / Cardiac disorders: QTc prolongation and arrhythmias. See below when to refer to cardiologist. Also seek advice from AWP Specialist. GPs should also be aware of non-psychotropic drugs which are associated with QT prolongation. Some examples include: Erythromycin, clarithromycin, ampicillin, co-trimoxazole, some quinolones Quinidine, amiodarone, sotalol, Chloroquine, mefloquine, Quinine Methadone, tamoxifen, diphenhydramine. Page 2 of 8 Approved BNSSG D&TC November 2012 BNSSG Shared Care Guidance Section 4: Side Effects Please list the most common side effects and management. Please provide guidance on when the GP should refer back to the specialist. Pain may occur at injection site and occasionally erythema, swelling and nodules. Minor side effects include drowsiness, especially at the start of treatment, nasal stuffiness, dry mouth, insomnia, agitation and weight gain Extrapyramidal symptoms (tremor, rigidity, hypersalivation, bradykinesia, akathisia, acute dystonia) Depot antipsychotics generally do not produce acute movement disorders at the time of administration; this may take hours to days. Neuroleptic malignant syndrome (extremely rare adverse effect of all antipsychotics). Venous thromboembolism, including cases of pulmonary embolism and cases of deep vein thrombosis have been reported with antipsychotic drugs – frequency unknown. Since patients treated with antipsychotics often present with acquired risk factors for VTE, all possible risk factors for VTE (including e.g. reduced mobility, post surgery -refer to NICE CG92 and MHRA). At present there are insufficient data available to determine any difference in risk between atypical and conventional antipsychotics, or between individual drugs. All possible risk factors for VTE should be identified before and during antipsychotic treatment and preventative measures Side effects and management taken. Please see below for management and individual SPCs www.medicines.org.uk 1. Tardive dyskinesia - A wide variety of movements can occur such as: lip smacking or chewing, tongue protusion (fly catching), choreiform hand movements, pelvic thrusting. Can lead to difficulty speaking, eating or breathing. Can be worse under stress. Action: A reduction in dose, discontinuation or change to an alternative e.g. atypical LAI or atypical oral if appropriate. Seek advice from AWP specialist. 1b. Extrapyramidal side effects e.g. pseudo parkinisonism (e.g. tremor) An anticholinergic may be prescribed e.g. procyclidine 5mg tds prn but must be reviewed at least every 3 months (can cause euphoria). May seek advice from AWP specialist. 2. Suspected neuroleptic malignant syndrome (NMS) Signs and symptoms include: hyperthermia, fever, sweating, muscle rigidity, autonomic instability, altered consciousness, confusion, fluctuating blood pressure, tachycardia, raised CPK Page 3 of 8 Approved BNSSG D&TC November 2012 BNSSG Shared Care Guidance & altered LFTs. Action: Discontinue antipsychotic. Contact specialist immediately. Call for ambulance. Repeat CPK. 3. Somnolence / drowsiness Action: Advise patient not to drive or operate machinery. Consider specialist for advice. 4. Insomnia - refer to specialist if becomes an issue 5. Constipation : Action: Recommend a high fibre diet. Consider adding a bulk- forming and / or stimulant laxative. 6. Dry mouth Action: Suggest sugar-free gum, artificial saliva or occassional boiled sweets. 7. Hypotension / dizziness - advise patient to take time when getting up. Persistent side effects unresolved by reducing dose or which Referral back to specialist are intolerable to the service user or of concern. Section 5: Drug Interactions Please list clinically significant drug interactions (eMC link please click here) 1. Enhanced response to alcohol, effects of barbiturates and other CNS depressants. 2. Enhanced anticholinergic effects with anticholinergic drugs. 3. Increased risk of ventricular arrhythmias when depot antipsychotics co-administered with other drugs known to significantly increase the QT interval. Co-administration should be avoided. Relevant classes include: • class Ia and III antiarrhythmics (e.g. quinidine, amiodarone, sotalol, dofetilide) • some antipsychotics (e.g. thioridazine) • some macrolides (e.g. erythromycin) • some antihistamines • some quinolone antibiotics (e.g. moxifloxacin) Significant Drug Interactions Tricyclic antidepressants Lithium Cisapride 4. Drugs known to cause electrolyte disturbances such as thiazide diuretics (hypokalaemia) and drugs known to increase the plasma concentration of the antipsychotic should also be used with caution as they may increase the risk of QT prolongation and malignant arrythmias. 5. Impair the anti-parkinsonian effect of L-dopa, effect of anti- convulsants, metabolism of tricyclic antidepressants and the control of diabetes. 6. Increase the effect of anticoagulants and antidepressants Page 4 of 8 Approved BNSSG D&TC November 2012 BNSSG Shared Care Guidance 7. Drugs known to cause electrolyte disturbances such as thiazide diuretics (hypokalaemia) and drugs known to increase the plasma concentration of the antipsychotic should also be used with caution as they may increase the risk of QT prolongation and malignant arrythmias. 8. Concomitant use of drugs such as metoclopramide, piperazine or antiparkinson drugs may increase the risk of extrapyramidal effects such as tardive dyskinesia These interactions are not exhaustive. The practitioner should refer to the individual drugs SPC for the full list of interactions: www.medicines.org.uk Reminder to ask patient about Development of any side effects which may be attributable to specific problems the depot including pain or nodule formation at injection site. Section 6: Contra-indications, Cautions and Special Recommendations Please list 1. Hypersensitivity
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