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Antipsychotics Prescribing Guidelines for Schizophrenia

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Antipsychotics Prescribing Guidelines for Schizophrenia Document Title Antipsychotics Prescribing Guidelines for Schizophrenia Document Description Document Type Prescribing Guidance Service Application Medicines Management Version 1.4 Policy Reference no. POL 249 Lead Author(s) Name Job Title Linda Geddes Senior Pharmacist (DGNFT) Andrew Campbell Chief Pharmacist Amandeep Dhillon Locality Pharmacist (DWMH) Change History – Version Control Version Date Comments 1.0 14/11/2012 New guidelines issued agreed by Policies and Procedures Focus Group 25/10/2012 and formally ratified by Governance and Quality Committee 14/11/2012 1.1 04/09/2014 Policy updated and formally ratified by Policies and Procedures Focus Group 1.2 21/09/2015 Updated antipsychotic dosage ready reckoner – version 6, page 12 1.3 02/02/2017 Planned policy update and review. Policy formally ratified by Policies and Procedures Group 1.4 18/12/2017 Updated antipsychotic dosage ready reckoner – version 7, page 12 Link with National Standards National Health Service Litigation Authority Care Quality Commission National Institute for Health and Care Excellence (NICE) Guidance National Patient Safety Agency West Midlands Quality Review Essence of Care Aims Standards IG Toolkit Key Dates Day Month Year Ratification Date 18 12 2017 Review Date 18 12 2019 1 Executive Summary Sheet Document Title: Antipsychotics Prescribing Guidelines for Schizophrenia Please tick () This is a new document within the Trust as appropriate This is a revised document within the Trust What is the purpose of this document? To provide guidance on the pharmacological treatment available for schizophrenia with Dudley and Walsall Mental Health Partnership NHS Trust (DWMHPT). Guidance to be audited annually (see appendix 1). What key issues does this document explore? Drug choice and Monitoring recommendations for Schizophrenia Who is this document aimed at? All DWMHT clinic service leads, all clinicians including medical, non medical prescribers and Pharmacists Business Administration Managers General Practitioners Dudley CCG Walsall CCG What other policies, guidance and directives should this document be read in conjunction with? Medicines Management Policy Physical Health Monitoring Policy How and when will this document be reviewed? Every 2 years via the Medicines Management Committee 2 Document Index Pg No 1. Introduction 4 2. Scope 4 3. Recommended Procedure for Antipsychotic Use 4 3.13 Antipsychotics use in Schizophrenia Algorithm 6 Selecting Antipsychotics for Schizophrenia & Prescribing 4. 7 Formulary 4.1 Antipsychotic Selection Table 8 4.2 Relative Adverse Effects Profile of Antipsychotic Drugs 9 5. Dosages 10 5.7 Prescribing High Dose Antipsychotics 10 5.20 Equivalent doses of Antipsychotics 12 6. Monitoring Requirementts 13 7. Antipsychotics in Specials Groups 13 7.2 Elderly patients including those with Dementia 13 7.3 Pregnancy & Breast Feeding 13 Appendices Pg no Data collection tool for Compliance with Antipsychotics in 1 14 ‘Schizophrenia’ Formulary / Guidelines 2 Schizophrenia Quick Reference Guide 17 3 1 Introduction 1.1 Schizophrenia is usually accompanied by other co-morbid illnesses such as anxiety, substance misuse and depression. Antipsychotics should only be prescribed by a specialist psychiatrist. There is no first line antipsychotic drug which is suitable for all patients. 1.2 This document reflects current NICE guidelines on Schizophrenia. It is strongly advised that the use of these recommendations should be balanced with consideration of the patient’s clinical circumstances, their preferences and attitudes. 1.3 Prescribing audits will be undertaken to check standards and compliance with this prescribing guideline 2 Scope 2.1 The guideline covers antipsychotic use in the management and treatment of schizophrenia across the various stages of the illness, including prodromal presentations, first-episode, relapse prevention and treatment-resistance. 2.2 It is beyond the scope of this guideline to include a recommended approach to treatment in pregnancy states, breast feeding patients and rapid tranquillization, which are not specific to schizophrenia. 2.3 Target Population: 18 – 65 years of age diagnosed with schizophrenia. 3 Recommended Procedure for Antipsychotic Use 3.1 Initiation of antipsychotic treatment for schizophrenia should be by specialist psychiatrist. 3.2 ECG and other necessary investigations should be checked before antipsychotics are prescribed in accordance with NICE guidelines, the Summary Product Characteristics (SPC) and the Trust standards for Physical Healthcare Policy. 3.3 Oral antipsychotics should be offered first. 3.4 Patient and carers should be duly provided appropriate information to enable jointly made decisions to improve patient experience and concordance with therapy (see Choice and Medication website). A decision about which medicine is prescribed should be made jointly with the individual based on an informed discussion of the relative benefits and side effects of medicines which includes the following: Metabolic (including weight gain and diabetes) Extrapyramidal (includes akathisia, dyskinesia and dystonia) Cardiovascular (Includes prolonging the QT interval) Hormonal (includes increasing prolactin levels) 4 3.5 Adequate documentation (clinical rating scale information, response to treatment, full details of medications used, and the rationale for changing medication) should be completed for each treatment choice. Record the indications and expected benefits and risk of oral medication and expected time for change in symptoms and appearance of side effects. 3.6 All antipsychotic prescribing should be prescribed by their generic names with appropriate formulations stipulated to avoid ambiguities and related errors. 3.7 Where a choice exists between brand, generic, or different formulations (e.g. slow release) of a recommended antipsychotic, initiate treatment with a form that is likely to be best tolerated to enhance adherence with treatment. 3.8 The antipsychotic should be initiated at a low dose and slowly titrate to the optimum effective dose, or the maximum manufacturers recommended dose or BNF recommendations. Evaluate response from two weeks, and ensure optimum duration of four to six weeks before switching unless adverse effects occur. 3.9 Where there is no/insufficient response after maintaining the maximum tolerated dose for at least four weeks the antipsychotic should be withdrawn gradually, whilst introducing an alternative antipsychotic. Record the rationale for continuing, changing or stopping the medication and the effects of such changes. 3.10 Sedatives may be required for short term behavioural control if needed. 3.11 If any steps of treatment differ from the recommendation, the rationale should be adequately documented. 3.12 Recommendations are illustrated in the following algorithm - 3.13. 5 3.13 Antipsychotics use in Schizophrenia Algorithm Choice of antipsychotic (AP) should be guided by considering the clinical characteristics of the patient and the efficacy and side effect profiles of the medication. Stages may be skipped depending on the clinical picture or history of antipsychotic failures. Returning to an earlier stage may be justified by history of past response Stage 1 First Episode Schizophrenia. Early trial of FGAPartial or SGAor Non as- singleresponse antipsychotic in conjunction with psychological interventions (family interventions and individual CBT). First episode patients usually require lower antipsychotic dosing and should be closely monitored due to greater sensitivity to medication side effects. Duration of therapy: 1–2 years. If intolerant or non-adherent, offer Long Acting Injectable antipsychotic. Inadequate adherence to PartialStage or 2Non -response oral medication at any Trial of a single SGA or FGA different to one tried in stage 1 for up to 4wks stage, may call for a long acting antipsychotic preparation (Initially use Partial or Non-response a small test dose as set Stage 3 out in the BNF or SPC). CLOZAPINE Partial or Non-response Stage 4 CLOZAPINE + FGA or SGA (An adequate trial of such an augmentation may need to be up to 8-10 A treatment weeks) refractory Partial or Non-response evaluation Stage 5 should be Trial of a single agent considered at FGA or SGA (not tried in stage 1 or 2) stage 4 -6 Non-response Stage 6 Time limited combination therapy e.g. SGA + FGA, combination of SGAs (FGA or SGA) & other non antipsychotic agents FGA: First Generation antipsychotic SGA: Second Generation Antipsychotic If chlorpromazine is prescribed warn of its potential to cause skin photosensitivity. Advise using sunscreen if necessary. 6 4 Selecting Antipsychotics for Schizophrenia & Prescribing Formulary In Dudley and Walsall Mental Health Partnership NHS Trust preferred choice of antipsychotics are based on current available evidence with the following criteria: Consideration of patients’ medical history or other co-morbidities e.g. substance abuse, smoking (impact on metabolism on drugs particularly clozapine and olanzapine) and medication history. The relative importance of side effect profile of the antipsychotic to the patients. Acquisition costs of different available therapies: Consideration should always be given to medication acquisition cost. If all other things are equal (i.e. efficacy, safety, tolerability), then less expensive antipsychotic relevant to the clinical situation should be the first choice Longer term clinical and economic outcomes Formulation of antipsychotics Prescribers are advised to refer to the latest edition
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