Antipsychotic Long-Acting Injections Guidance

POLICY DOCUMENT

Document Title Antipsychotic Long-Acting Injections Guidance

Reference Number CG/Antipsychotic LAI/03/15

Policy Type Medicines Policy Electronic N:\Pharmacy\Intranet File/Location http://intranep/TeamCentre/pharm/PublishedDocuments/nepft- Intranet Location antipsychotic-long-acting-injections-guidance-120306-2.doc

Status FINAL

Version 2 / March 2015 Version No./Date Version 1 / March 2012 Author(s) Responsible for Medicines Information and Research Pharmacist Writing and Associate Director for Pharmacy Monitoring Medicines Procedures Group Feb 2015 Approved By Medicines Management Group Mar 2015

Approval Date March 2015 Implementation March 2015 Date Review Date March 2018

© North Essex Partnership University NHS Foundation Trust Copyright (2015). All rights reserved. Not to be reproduced in whole or in part without the permission of the copyright owner. All matters or concerns regarding fraud or corruption should be reported to: Chris Rising, Senior Manager ([email protected] 07768 873701), Hannah Wenlock, LCFS Lead ([email protected] 07972 004257) Mark Trevallion, LCFS Lead ([email protected] 07800 718680) OR the National Fraud and Corruption Line 0800 028 40 60 https://www.reportnhsfraud.nhs.uk/

http://intranep/TeamCentre/pharm/PublishedDocuments/nepft-antipsychotic-long-acting-injections-guidance-120306-2.doc CG/Antipsychotic LAI/03/15 Implementation Date: March 2015 Review Date: March 2018 Page 1 of 7

CONTENTS

Section Subject Page Number Number 1 Introduction 3 2 Aim 3 3 Scope 3 4 References To Other Standards, Policies Or Procedures 3 5 Guidance 3 6 References and Bibliography 7 7 Summary of Changes 7

Guidance For The Use Of Antipsychotic Long-Acting Injections In North Essex

1. Introduction Long-acting or depot antipsychotic injections can be a useful form of administering antipsychotics. The introduction of atypical injections has produced an increased pressure on the drug budget, which may be justified if it can be shown to save hospital admissions, length of stay and show an improved quality of life compared with the alternatives available.

2. Aim This guidance is to provide information about the choice of antipsychotic long-acting injections available.

3. Scope All practitioners within the North Essex Partnership University NHS Foundation Trust (NEP) and the associated primary care areas of Mid, West and North East Essex.

4. References To Other Standards, Policies Or Procedures NEP Medicines Management Policy. Available on the Intranet at: http://intranep/TeamCentre/pharm/PublishedDocuments/Forms/PolicyTabs.aspx

5. Guidance

5.1 Advantages of long-acting injections Assured compliance Steady plasma levels compared to oral medication Reduction in relapses, rehospitalisation and severity of the relapse Bioavailability problems may be less (less first-pass metabolism for some people) Stable therapeutic effects Better downward titration to minimise side-effects Less brain tissue loss and deterioration (CATIE)

5.2 Disadvantages Once it has been administered it cannot be removed if side-effects develop (dystonia, EPSE, NMS) Perception by the patient of being controlled, losing control over their treatment, or possibly being a punishment. Pain at the site of injection, lasting possibly 10 days Tissue necrosis. Over time hard plaques may form, which will reduce the ease of administration and the efficacy of the injection as well as causing discomfort. Loss of dignity with the gluteal route

5.3 Choice of injection (when oral medication has already been considered)

Oily depot injection (alternatives have different efficacies and side effects), use anticholinergics as necessary to help with side effects

Unacceptable side effects at effective dose or lack of efficacy

st Paliperidone LAI –(1 Choice) or Risperidone Consta LAI (2nd Choice)

Unacceptable side effects at effective dose or lack of efficacy at therapeutic doses

Aripiprazole Maintena (by Form B application to MMG) or Olanzapine LAI (after agreement of clinic, adequate training and by Form B application to MMG)

If there are no mitigating factors the oily depot injections should be first choice (most cost-effective). The efficacy for the treatment of schizophrenia is similar, but the side effects profile is different for each one. Risperidone Consta and Paliperidone are less effective for people with treatment-resistant illness. They are both much more expensive than the oily depot injections, which should be considered first. For comparisons, please see www.choiceandmedication.org.uk/nepft for more information, or “Psychotropic Directory” Steve Bazire. A brief table to compare the properties of these injections has been devised below.

Injection Route Dose for Duration Peak Time to Comment adults of action (days) steady under 65 (weeks) state (weeks) Aripiprazole Gluteal or 400mg Data not 5-7 16 By Form B Maintena deltoid monthly, available. application to continue oral May MMG only aripiprazole depend on 10-20mg for route and 14 days after dose injection Flupentixol GlutealLateral Test 20mg 3-4 7-10 10-12 C/I if circulatory decanoate thigh Maintenance collapse or loss of 50mg 4- consciousness. weekly to May cause 300mg 2- aggression/agitatio weekly n or mood Max.400mg elevation weekly Fluphenazine Gluteal Test 12.5mg 1-3 ¼-2 6-12 Less sedating, decanoate Maintenance less hypotensive, 12.5-100mg more EPSE 2-5-weekly Max. 50mg weekly.

Haloperidol Gluteal 50mg 4- 6 3-9 10-12 Monthly injection decanoate weekly, usually. Reserve increasing by for chronic 50mg relapsing clients increments to with schizophrenia max.300mg who have Elderly 12.5- responded well to 25mg 4/52 haloperidol Olanzapine NON-FORMULARY IN NEP. Requires high level of monitoring in inpatient conditions. See pamoate Olanzapine guidance for more information. Gluteal Starting dose 6 4 12 By Form B of depot application to depends on MMG only after oral dose, agreement of clinic see NEP guidance or SPC. Inject 2 or 4 weekly. Paliperidone Deltoid 50-150mg Depends 3-10 2-3 Same active palmitate initially, then monthly* on route moiety as deltoid/ gluteal Risperidone. May have less side effects and may improve concordance Risperidone Deltoid or Oral test dose 5-6 weeks 28-42 6-8 Injection requires Consta gluteal 25-75mg 2- BUT will refrigeration and weekly not start reconstitution. until 3-4 Initial lag period weeks after means oral/IM administrati supplementation is on required. Zuclopenthixol Gluteal Test dose 2-4 weeks 4-9 10-12 High doses have decanoate 100mg been used for 200-500mg aggression (out of every 1-4 licence) weeks MAX 600mg weekly Note: Do not confuse with Zuclopenthixol acetate injection THIS IS ACUPHASE – NOT A DEPOT INJECTION. DO NOT USE AS A DEPOT. SEE Tab 9 RAPID TRANQUILLISATION PROCEDURE FOR MORE INFORMATION.

5.4 Reduction of local reaction and necrosis http://intranep/TeamCentre/pharm/PublishedDocuments/nepft-antipsychotic-long-acting-injections-guidance-120306-2.doc CG/Antipsychotic LAI/03/15 Implementation Date: March 2015 Review Date: March 2018 Page 5 of 7

Use the lowest practical volume Warm the injection before use, up to a maximum 37°C (body temperature). This lowers viscosity, making it easier to inject, and reduces shock to the muscle tissue. Use alternate buttocks or arms (rotate injection sites) to allow time to heal Use the Z-tracking technique to avoid extravasation Use a needle of the right size for the patient (longer for people with a higher BMI) Inject less frequently if possible to prevent hard plaques of tissue forming. See the Medicines Policy tab 8 Injection preparation and Administration

5.5 Monitoring All antipsychotics should be monitored for efficacy and side effects including metabolic side-effects. They should be done more frequently initially, at changes, and if the patient is unwell.

Investigation Frequency Investigation Frequency BMI 6/12 Prolactin Annual Hip/waist ratio 6/12 Blood pressure 6/12 Blood sugars 6/12 Full blood count 6/12 Liver function tests 6/12 U and Es 6/12 ECG Annual Blood lipids Annual Adverse side effects using standard tool (West Wales, 6/12 Lunsers, GASS)

For side-effects scales refer to Medicines Policy tab 6

5.6 Prescribing high cost injections Risperidone consta injection and Paliperidone injection are both high-cost medicines. They must be initiated by a consultant in mental health, and will continue to be prescribed and monitored by NEP until the dose is stabilised (about 3 months) It is recommended that Paliperidone be used in preference to Risperidone consta because it has a number of practical advantages. The cost is slightly higher, but this is outweighed by increased concordance and decreased requirement for nursing input. Details are included in appendix 1 and 2. Both preparations are NOT recommended for treatment-resistant schizophrenia as they have been found to be ineffective for many of those patients. Aripiprazole Maintena and Olanzapine LAIare both non-formulary at NEP and if a client requires these treatments, there must be prior approval from the MMG via the Form B Process.

6 References and Bibliography www.choiceandmedication.org.uk/nepft for patient leaflets and comparisons Manufacturer’s patient information leaflet (PILs) and Summary of Product Characteristics (SPCs) www.medicines.org.uk BNF (current) https://www.medicinescomplete.com/mc/bnf/current/ Royal College of Psychiatry www.rcpsych.nhs.uk Taylor D et al. The Maudsley Prescribing Guidelines in Psychiatry 11th Ed. 2012 Wiley-Blackwell Bazire S. Psychotropic Drug Directory 2014. Lloyd-Reinhold Communications

7 SUMMARY OF CHANGES Section Date Summary of Changes Number(s) Formatting, grammatical changes. Links updated and throughout added in where appropriate. Logos updated. Information on Aripiprazole Maintena and Olanzapine 5.3, 5.6 Depot added in. Piportil removed as discontinued. Flow chart modified to include olanzapine and aripiprazole February Appendix 3 2015 Removed as costing information goes out of date quickly and and can be easily found elsewhere if required. section 5 Appendix 1 To be reviewed – useful or just refer to SPC? & 2 6 References and bibliography updated.