NHS Grampian

Westholme Woodend Hospital Queens Road ABERDEEN AB15 6LS

Date 22nd April 2021 Our Ref : FA/MH_AntiPDepots/MGPG1088 Enquiries to MGPG Extension 56334 Direct Line 01224 556334 Email [email protected]

Dear Colleague

This letter authorises the extended use of the following guidance until 1st April 2022:

Managing Depots Or Long-Acting Injections During The COVID-19 Pandemic, Version 1

This guidance remains clinically accurate and relevant.

If you have any queries regarding this please do not hesitate to contact the Pharmacy and Medicines Directorate.

Yours sincerely

Lesley Coyle Chair of Medicines Guidelines and Policies Group

This controlled document shall not be copied in part or whole without the express permission of the author or the author’s representative.

Title: Managing Antipsychotic Depots Or Long-Acting Injections During The COVID-19 Pandemic

Unique Identifier: NHSG/COVID19_MH/AntiPDepots/GADTC1088

Replaces: N/A – New Document

Lead Author/Co-ordinator: Principal Pharmacist, Cornhill

Subject (as per document Prescribing and Prescription registration categories):

Key word(s): COVID19 Decanoate Decanoate Decanoate Palmitate Xeplion Trevicta Abilify Maintena

Process Document: Policy, Guideline Protocol, Procedure or Guideline

Document application: NHS Grampian

Purpose/description: Managing Antipsychotic Depots Or Long-Acting Injections During The COVID-19 Pandemic.

Group/Individual Principal Pharmacist, Cornhill responsible for this document:

Policy statement: It is the responsibility of all staff to ensure that they are working to the most up to date and relevant policies, protocols procedures.

Responsibilities for ensuring registration of this document on the NHS Grampian Information/ Document Silo:

Lead Author/Co-ordinator: Principal Pharmacist, Cornhill

Physical location of the Royal Cornhill Hospital original of this document:

Job title of creator of this Principal Pharmacist, Cornhill document:

Job/group title of those who Mental Health Operational Medicines Management Group have control over this document:

UNCONTROLLED WHEN PRINTED Review Date: April 2021 NHSG/COVID19_MH/AntiPDepots/GADTC1088 i Managing Antipsychotic Depots Or Long-Acting Injections During The COVID-19 Pandemic – Version 1

Responsibilities for disseminating document as per distribution list:

Lead Author/Co-ordinator: Mental Health Operational Medicines Management Group

Responsibilities for implementation:

Organisational: Operational Management Team and Chief Executive Sector General Managers, Medical Leads and Nursing Leads Departmental: Clinical Leads Area: Line Manager

Review frequency and This policy will be reviewed in one year or sooner if current date of next review: treatment recommendations change.

Responsibilities for review of this document:

Lead Author/Co-ordinator: Principal Pharmacist, Cornhill

Revision History: Summary of Changes Changes Marked* Revision Previous (Descriptive summary of the (Identify page numbers Date Revision Date changes made) and section heading ) N/A – New Document

* Changes marked should detail the section(s) of the document that have been amended, i.e. page number and section heading.

UNCONTROLLED WHEN PRINTED Review Date: April 2021 NHSG/COVID19_MH/AntiPDepots/GADTC1088 ii Managing Antipsychotic Depots Or Long-Acting Injections During The COVID-19 Pandemic – Version 1

Managing Antipsychotic Depots Or Long-Acting Injections During The COVID-19 Pandemic

It is essential that the administration of antipsychotic depots or long-acting injections is maintained during the current COVID-19 pandemic to minimise the risk of relapse.

To support patients who are self-isolating and to reduce the pressure on staff over the next few weeks and months it may be appropriate to consider adjusting the timing of administration or extending the interval between depots/long-acting injections for patients on a case-by-case basis. If this isn’t possible and it is necessary to give a COVID-19 confirmed or suspected patient a depot/long acting injection at home it should be given by a healthcare professional following up-to-date personal protective equipment (PPE) guidance.

The following information provides advice on extending the interval between depots/long- acting injections.

Medicine Dosing Maximum dose per Potential options interval single injection First-generation antipsychotic depots Flupentixol 400mg If appropriate consider 1 – 4 weekly Decanoate (max volume = 3mL) extending the interval between Haloperidol 300mg doses and adjusting the dose 4 weekly Decanoate (max volume = 3mL) accordingly: Zuclopenthixol e.g. flupentixol decanoate 600mg Decanoate 1 – 4 weekly 200mg/week – change to (max volume = 3mL) 400mg/fortnight. Second-generation antipsychotic long-acting injections If necessary the dose can be Aripiprazole given up to 6 weeks after last (Abilify® monthly* 400mg dose before reverting to Maintena) monthly1 If necessary the dose can be Paliperidone given up to 6 weeks after last Palmitate monthly* 150mg dose before reverting to (Xeplion®) monthly2 If necessary the dose can be Paliperidone given 3 months + 2 weeks after Palmitate 3-monthly 525mg last dose before reverting to (Trevicta®) 3-monthly3 Consider switching to Risperidone fortnightly 50mg paliperidone palmitate (Xeplion®)

*monthly = one injection per calendar month

UNCONTROLLED WHEN PRINTED Review Date: April 2021 NHSG/COVID19_MH/AntiPDepots/GADTC1088 - 1 - Managing Antipsychotic Depots Or Long-Acting Injections During The COVID-19 Pandemic – Version 1

NB: A change in frequency of administration may not be appropriate in the following situations:

• Where the patient has not previously tolerated a higher dose due to side-effects. • Where changing the frequency results in the dose of the injection exceeding the maximum licensed dose for a single injection.

If the patient’s treatment is altered (i.e. dose increased and interval frequency extended) then the patient should be reviewed (electronically if patient is self-isolating or shielding) and monitored for increased incidence of side-effects or emerging issues. The patient should be advised to contact their Mental Health Team should any problems occur.

Switching from risperidone long-acting injection to paliperidone palmitate (Xeplion®) long-acting injection2

Paliperidone is the active metabolite of risperidone and switching from risperidone long- acting injection to an equivalent dose of paliperidone palmitate (Xeplion®) long-acting injection is straightforward. When switching patients from risperidone long-acting injection, initiate paliperidone therapy in place of the next scheduled injection. Paliperidone should be continued at monthly intervals. The one-week initiation dosing regimen including the intramuscular injections (day 1 and 8, respectively) is not required. Patients previously stabilised on different doses of risperidone long-acting injection can attain similar paliperidone steady state exposure during maintenance treatment with paliperidone monthly doses according to the following:

Doses of risperidone long-acting injection and paliperidone needed to attain similar paliperidone exposure at steady state Previous risperidone long-acting Paliperidone palmitate (Xeplion®) long- injection dose acting injection dose 25mg every 2 weeks 50mg monthly 37.5mg every 2 weeks 75mg monthly 50mg every 2 weeks 100mg monthly

NB: Paliperidone palmitate should not be used in individuals with a creatinine clearance <50mL/min.

Paliperidone long-acting injection is a high cost medicine and community pharmacies will not routinely keep in stock. These will need to be ordered, so if switching is planned liaise with the community pharmacy regarding the likely timescale for availability.

Switching from paliperidone 1-monthly (Xeplion®) long-acting injection to paliperidone 3-monthly (Trevicta®) long-acting injection3

Patients who are adequately treated with 1-monthly paliperidone palmitate injection (i.e. for four months or more) and do not require dose adjustment may be switched to 3-monthly paliperidone injection. Trevicta® should be initiated in place of the next scheduled dose of 1-monthly paliperidone palmitate (+/- 7 days). The Trevicta® dose should be based on the previous 1-monthly paliperidone palmitate injectable dose using a 3.5 fold higher dose shown in the following table:

UNCONTROLLED WHEN PRINTED Review Date: April 2021 NHSG/COVID19_MH/AntiPDepots/GADTC1088 - 2 - Managing Antipsychotic Depots Or Long-Acting Injections During The COVID-19 Pandemic – Version 1

Trevicta® doses for patients adequately treated with Xeplion® injection Dose of 1-monthly paliperidone palmitate Equivalent dose of Trevicta® 3-monthly (Xeplion®) long-acting injection paliperidone palmitate long-acting injection 50mg 175mg 75mg 263mg 100mg 350mg 150mg 525mg

References:

1. Abilify® Maintena 400mg powder and solvent for prolonged-release suspension for injection Summary of Product Characteristics https://www.medicines.org.uk/emc/product/7962/smpc; last updated on eMC 14 May 2019; accessed 10/04/2020

2. Xeplion® prolonged release suspension for injection Summary of Product Characteristics https://www.medicines.org.uk/emc/product/7653/smpc, last updated on eMC 24 Oct 2018, accessed 10/04/2020

3. Trevicta® prolonged release suspension for injection Summary of Product Characteristics https://www.medicines.org.uk/emc/product/7230, last updated on eMC 20 Nov 2019, accessed 1/04/2020

UNCONTROLLED WHEN PRINTED Review Date: April 2021 NHSG/COVID19_MH/AntiPDepots/GADTC1088 - 3 - Managing Antipsychotic Depots Or Long-Acting Injections During The COVID-19 Pandemic – Version 1