Psychotropic Monitoring Inpatient Guidelines Baseline pregnancy test in females before starting psychotropic medication & as clinically indicated.

Atypical Antipsychotics Baseline Tests Ongoing Tests • aripiprazole (Abilify®, Abilify • CBC (clozapine, cariprazine) • CBC as indicated by manufacturer and as clinically Maintena™, Aristada®) • Waist circumference and BMI (weight indicated (clozapine only), cariprazine as clinically • asenapine (Saphris®) in lbs x 703)/height2 in inches indicated • brexpiprazole (Result®) • FPG or HbgA1c • BMI and waist circumference monthly for 6 months • cariprazine (Vraylar®) • Fasting lipid profile within 30 days of then quarterly when dose is stable • clozapine (Clozaril®, initiation if not done within last year • FPG or HbgA1c every 6 months Fazaclo®, Versacloz®) • EPS evaluation (exam for rigidity, • Fasting lipid panel at least every year if lipid levels • iloperidone (Fanapt®) tremor, akathisia) are in normal range • lumateperone (Caplyta®) • TD assessment • Fasting lipid panel every 6 months if LDL is > 130 • lurasidone (Latuda®) • EKG for clozapine and iloperidone, mg/dL • olanzapine (Zyprexa®, ziprasidone only if risk factors present • Inquiry for symptomatic prolactin elevation yearly Zyprexa Relprevv®) for QT prolongation (e.g. known heart (quarterly during 1st year for antipsychotics • paliperidone (Invega®, disease, history of syncope, FH early associated with increased prolactin) Invega Sustenna®, Invega sudden death) • Prolactin level yearly if symptoms of prolactin Trinza®) • Serum potassium and magnesium for elevation (e.g. gynecomastia, amenorrhea) • quetiapine (Seroquel®) iloperidone if at risk for electrolyte • EPS evaluation weekly after initiation & dose • risperidone (Risperdal®, disturbance increases, continue 2 weeks after last increase Risperdal Consta®, Perseris™) • Troponin and C-reactive protein • TD assessment every 3 months and as clinically • ziprasidone (Geodon®) (clozapine) indicated • Vision questionnaire and ocular evaluation yearly, ocular eval. every 2 years if ≤ 40 years old • EKG annually for clozapine and as clinically indicated; ziprasidone if patient has symptoms of QT prolongation (e.g. syncope) • Troponin and C-reactive protein weekly for 4 weeks for clozapine and as clinically indicated for suspected myocarditis • BNP as clinically indicated based on cardiac risk factors (clozapine) • Serum potassium and magnesium periodically for iloperidone if at risk for electrolyte disturbance • Olanzapine palmitate injection requires continuous observation for at least 3 hrs after injection

Updated 07/2021 Adapted from HHSC PEFC MUE Audit Criteria Typical Antipsychotics Baseline Tests Ongoing Tests • chlorpromazine (Thorazine®) • Waist circumference and BMI (weight • BMI and waist circumference monthly for 6 months • fluphenazine (Prolixin®, in lbs x 703)/height2 in inches then quarterly when dose is stable Prolixin Decanoate®) • FPG or HbgA1c • FPG or HbgA1c repeat 3-4 months after starting • haloperidol (Haldol®, Haldol • Fasting lipid profile within 30 days of then at least annually Decanoate®) initiation if not done within last year • Fasting lipid panel 3-4 months after initiating a • loxapine (Loxitane®) • EPS evaluation (exam for rigidity, new antipsychotic and at least annually if lipid levels • perphenazine (Trilafon®) tremor, akathisia) are in normal range; repeat every 6 months if LDL is • thiothixene (Navane®) • TD assessment > 130 mg/dL • thioridazine (Mellaril®) • EKG prior to initiation of thioridazine • EPS evaluation weekly after initiation & dose • trifluoperazine (Stelazine®) • Magnesium prior to initiating increases, continue 2 weeks after last increase thioridazine • TD assessment every 3 months and as clinically • CMP indicated • CBC • EKG for thioridazine 7-14 days after dose change or change of med impairing metabolism or cardiac effects of thioridazine, every 6 months thereafter and as clinically indicated • Thioridazine- Serum potassium every 6 months and as clinically indicated and magnesium as clinically indicated (especially if potassium level is low) • CMP, CBC as clinically indicated • Inquiry for symptomatic prolactin elevation yearly (quarterly during 1st year for antipsychotics associated with increased prolactin) • Prolactin level yearly if symptoms of prolactin elevation (e.g. gynecomastia, amenorrhea) • Vision questionnaire and ocular evaluation yearly, ocular eval. every 2 years if ≤ 40 years old • Determine if metabolic syndrome criteria (3 of the 5 criteria) are met 3-4 months after initiating a new antipsychotic medication and at least annually thereafter

Antihypertensives for Baseline Tests Ongoing Tests Psychotropic Use • Beta-Blockers • EKG (age 45 and over) • Blood pressure and pulse rate prior to each dose o atenolol (Tenormin®) • Blood pressure and pulse rate increase and quarterly and as clinically indicated o metoprolol (Lopressor®) • EKG (age 45 and over) as clinically indicated o propranolol (Inderal®) • When discontinued, gradually reduce dosage over a period of 1-2 weeks.

Sedative/Hypnotics Baseline Tests Ongoing Tests • benzodiazepines • Pregnancy test • Pregnancy test as clinically indicated • buspirone (BuSpar®) • sedating antihistamines o diphenhydramine Benadryl®) o hydroxyzine (Atarax®) • non-benzodiazepines o eszopiclone (Lunesta®) o zolpidem (Ambien®)

Anticonvulsant Mood Baseline Tests Ongoing Tests Stabilizers Monitor all treated with anticonvulsants periodically for emergence of suicidal ideation or behavior • carbamazepine (Tegretol®) • CBC with differential • CBC with differential 1 to 2 weeks after each dose • oxcarbazepine (Trileptal®) • Hepatic function increase, annually and as clinically indicated • Electrolytes • Electrolytes 1 to 2 weeks after each dose increase, • HLA-B*1502 test prior to initiation for annually and as clinically indicated those of Asian descent (includes South • Hepatic function monthly for the first 3 months Asians) (carbamazepine), annually and as clinically indicated • Consider HLA-A*3101 if high risk • Carbamazepine level 1 week after start, 3-4 weeks (Asian, Native Am, European, Latin Am) after dose change and as clinically indicated (carbamazepine) (carbamazepine) • gabapentin (Neurontin®) • Renal function • Renal function as clinically indicated • Signs or symptoms of respiratory depression and sedation • lamotrigine (Lamictal®) • Renal function • Monitor for rash, especially during the first 2 • Hepatic function months of therapy • CBC • Renal function, Hepatic function, and CBC as clinically indicated

Updated 07/2021 Adapted from HHSC PEFC MUE Audit Criteria Anticonvulsant Mood Baseline Tests Ongoing Tests Stabilizers Monitor all treated with anticonvulsants periodically for emergence of suicidal ideation or behavior • topiramate (Topamax®) • CMP (evaluate renal function, hepatic • CMP at 3 months, annually and as clinically function, and serum bicarbonate) indicated • Eye exam • Eye exam annually • Weight if topiramate is being used for • Weight every 3 months and as clinically indicated if weight loss used for weight loss • valproic acid (Depakene®), • CBC with differential and platelet count • CBC with differential and platelet count 1-2 weeks Divalproex Sodium • CMP (evaluate hepatic function, serum after each dose increase, every 3 months for the (Depakote®, Depakote ER®) creatinine, BUN and electrolytes) first year of treatment, annually and as clinically • Weight indicated • CMP every 3 months for the first year, annually and as clinically indicated • VPA level 1-2 weeks after initiation, after each dosage change & as clinically indicated • Weight every 3 months for the first year of treatment, then annually and as clinically indicated

Miscellaneous Mood Baseline Tests Ongoing Tests Stabilizers • lithium (Eskalith®, Lithobid®, • EKG • EKG yearly and as clinically indicated Eskalith CR®) • CBC • CBC yearly and as clinically indicated • Thyroid studies • TSH every 6 months and as clinically indicated • CMP (evaluate BUN, creatinine, • CMP at 3 months, annually and as clinically glucose, calcium and electrolytes) indicated • UA • Lithium level 5 to 7 days after initiation or dose • Weight change, 3 months after initiation and every 6 months during maintenance treatment and as clinically indicated • Weight every 6 months and as clinically indicated • UA as clinically indicated

Updated 07/2021 Adapted from HHSC PEFC MUE Audit Criteria Antidepressants Baseline Tests Ongoing Tests Monitor all treated with antidepressants periodically for emergence of suicidal ideation or behavior amoxapine (Asendin®) • EKG • TD assessment every 3 months and as clinically • TD assessment indicated • EPS evaluation (exam for rigidity, • EPS evaluation weekly after initiation & dose tremor, akathisia) increases, continue 2 weeks after last increase • Sodium level (high risk patients) • Sodium level (high risk patients) at 4 weeks and as clinically indicated • EKG as clinically indicated • Prolactin level if symptoms of prolactin elevation (e.g. gynecomastia, amenorrhea, menstrual disturbance, erectile/ejaculatory disturbances) bupropion (Wellbutrin®, • Blood pressure • Neuropsychiatric reactions (smoking cessation) Budeprion®, Zyban®) • CBC • CBC, blood pressure, EKG, hepatic function panel, • Hepatic and renal function panels renal function as clinically indicated esketamine (Spravato®) • Blood pressure prior to each dose • Blood pressure 40 minutes post-dose administration • MADRS weekly • Montgomery-Asberg Depression Rating • Sedation & dissociation at least for 2 hours post Scale (MADRS) dose • Blood pressure as clinically indicated for 2 hours post-dose mirtazapine (Remeron®) • CBC • Blood pressure during titration (children & • Fasting lipid profile within 30 days of adolescents) and as clinically indicated initiation if not done within last year • Height & weight (children & adolescents) monthly (children & adolescents) and as clinically indicated • Height & weight (children & • Sodium level (high risk patients) at 4 weeks and as adolescents) clinically indicated • Sodium level (high risk patients) • CBC as clinically indicated and • Fasting lipid profile (children & adolescents) as clinically indicated Monoamine Oxidase Inhibitors • Hepatic function panel • Hepatic and renal function panels yearly and as • phenelzine (Nardil®) • Renal function clinically indicated • tranylcypromine (Parnate®) • Blood pressure • Blood pressure during dosage adjustments and as • Sodium level (high risk patients) clinically indicated • Sodium level (high risk patients) at 4 weeks and as clinically indicated • nefazodone (Serzone®) • ALT, AST • ALT, AST – 1, 2, 4, 6, 12 months, then annually • EKG and as clinically indicated. Stop drug if 3 X upper normal limit • EKG as clinically indicated SNRIs • Blood pressure (duloxetine) • Blood pressure during dose titration (venlafaxine) • duloxetine (Cymbalta®) • Hepatic function • Height & weight (children & adolescents) monthly Venlafaxine (Effexor®, Effexor • Height & weight (children & • Sodium level (high risk patients) at 4 weeks XR®) adolescents) • Fasting lipid panel at least every year if lipid levels • Sodium level (high risk patients) are in normal range (venlafaxine) • Fasting lipid profile within 30 days of • Fasting lipid panel every 6 months if LDL is > 130 initiation if not done within last year mg/dL (venlafaxine) (venlafaxine) Optional ongoing tests if clinically indicated • Blood pressure • Hepatic function • Height & weight (children & adolescents) • Sodium level (high risk patients) SSRIs • EKG (citalopram, escitalopram) • Electrolytes (high risk patients) at 4 weeks • citalopram (Celexa®) • Electrolytes (high risk patients) • Height & weight (children & adolescents) monthly • escitalopram (Lexapro®) • Height & weight (children & Optional ongoing test if clinically indicated: Fluoxetine (Prozac®) adolescents) • EKG (citalopram, escitalopram, fluoxetine, • paroxetine (Paxil®) sertraline) • sertraline (Zoloft®) • Electrolytes (high risk patients) • Height & weight (children & adolescents) Tricyclic Antidepressants • CBC (children & adolescents) • Blood pressure during titration • amitriptyline (Elavil®) (clomipramine) • Height & weight (children & adolescents) monthly • clomipramine (Anafranil®) • EKG (clomipramine) • desipramine (Norpramin®, • Height & weight (children & • Sodium level (high risk patients) at 4 weeks Pertofrane®) adolescents) (clomipramine) Optional ongoing tests if clinically indicated: • doxepin (Sinequan®) • Hepatic function panel (clomipramine) • CBC (children & adolescents) (clomipramine) • imipramine (Tofranil®) • Sodium level (high risk patients) • EKG • maprotiline (Ludiomil®) • Blood levels (not clomipramine) • nortriptyline (Pamelor®, • Blood pressure Aventyl®) • Height & weight (children & adolescents) • protriptyline (Vivactil®) (clomipramine) • trimipramine (Surmontil®) • Hepatic function panel (clomipramine) • Sodium level (high risk patients) • trazodone (Desyrel®) • CBC • CBC and EKG as clinically indicated

Updated 07/2021 Adapted from HHSC PEFC MUE Audit Criteria

Substance Use Treatment Baseline Tests Ongoing Tests • acamprosate (Campral®) • CMP (renal) • Eye exam annually • Eye exam • Monitor for worsening depression, suicidal ideation, or suicidal behavior • CMP as clinically indicated • buprenorphine (Subutex®), • Liver function • Respiratory status buprenorphine/naloxone • CNS depression/mental status (Suboxone®) • Blood pressure • Withdrawal symptoms • Signs of addiction, abuse, or misuse • Signs or symptoms of hypogonadism or hypoadrenalism • Signs or symptoms of toxicity or overdose (especially with hepatic impairment) Optional ongoing tests if clinically indicated: • Liver function (periodically, and as clinically indicated) • disulfiram (Antabuse®) • CMP (hepatic function, serum • CMP within 2 weeks of initiation chemistries) Optional ongoing tests if clinically indicated • CBC • CBC, CMP, Eye Exam • naltrexone (ReVia®, • Liver function • Opioid withdrawal Vivitrol®) • Depression and suicidal thinking • Injection site reactions (Vivitrol®) • Liver function (periodically and as clinically indicated) • topiramate (Topamax®) See Anticonvulsants

ADHD/ADD Treatment Baseline Tests Ongoing Tests • dextroamphetamine • Height and Weight (children) • Height and Weight (children) as clinically (Dexedrine®) indicated • methylphenidate (Ritalin®, • EKG, based in risk factors, as clinically indicated Concerta®, Metadate CD®) • Blood pressure monthly for 3 months then every dextroamphetamine/amphetamine 6 months (Adderall®, Adderall XR®) • atomoxetine (Strattera®) • Height and Weight (children) • Blood pressure monthly for 3 months then every 6 months • Height and Weight (children) as clinically indicated • Monitor all treated with antidepressants periodically for emergence of suicidal ideation or behavior • clonidine (Catapres®) • Blood pressure and heart rate • Blood pressure and heart rate daily x4 days • guanfacine (Tenex®, Intuniv®) • EKG (known heart disease, history of after initiation or dose increase and as clinically syncope, family history of sudden death indicated at under 40 years of age)

Updated 07/2021 Adapted from HHSC PEFC MUE Audit Criteria