Psychotropic Drug Formulary MHS Lead Executive Director: Dr Caroline Allum Name of originator Dr Elizabeth Francis Author and job title: Governance Lead Pharmacist, Head of Clinical Audit & NICE Approved by: Drugs & Therapeutics Group (MHS) Edition: November 2018 Review date: February 2020 Disclaimer Every attempt has been made to ensure that the information in this Formulary is correct at the time of publication. Where there is doubt, information should be verified against relevant specialist publications DOCUMENT IS UNCONTROLLED WHEN PRINTED CONTENTS PAGE Section Document Control Sheet v 1.0 Introduction 1 2.0 Principles 4 3.0 Formulary Management 4 3.1 Formulary Implementation 4 3.2 Requests for Additions/Changes to the Formulary 5 3.3 Funding Issues 6 3.4 Forward Planning 6 3.5 Drug price ranges 8 3.6 Links to relevant Policies and Procedures 8 BNF Section Headings Central Nervous System 10 Hypnotics and Anxiolytics 10 Hypnotics 10 Anxiolytics 12 Benzodiazepines: Approximate equivalent doses to diazepam 13 Drugs used in Psychosis and related disorders 14 Antipsychotic drugs – First Generation 14 Antipsychotic drugs – Second Generation 16 Summary of the Royal College of Psychiatrists recommendation on the use of high dose antipsychotics 17 Antipsychotics: initiative to reduce prescribing to older people with dementia 19 Antipsychotics: risk of venous thromboembolic events 20 Prescribing clozapine – cautions and mandatory monitoring of FBC 22 Clozapine associated gastroinstestinal hypomotility / obstruction 22 White blood cell and Neutrophil count interpretation 24 Missed clozapine dose(s) 24 Smoking and clozapine 24 Caffeine and clozapine 24 Physical health monitoring for all patients prescribed antipsychotics 25 Antipsychotic depot injections 27 Paliperidone palmitate (Xeplion®) – reports of fatalities 28 Licensed route/site of administration for antipsychotic depot injections 29 Antimanic Drugs 30 Prescribing lithium - baseline, on-going monitoring and cautions 31 Prescribing valproate – baseline, on-going monitoring and cautions 33 Prescribing lamotrigine – baseline, on-going monitoring and cautions 34 Antidepressant Drugs 35 Tricyclic and relative antidepressant drugs 35 Monoamine oxidase inhibitors – cautions 37 Selective serotonin re- uptake inhibitors 39 Citalopram and escitalopram: QT interval prolongation – new maximum and daily dose restrictions 39 (including in elderly patients) NELFT Psychotropic Drug Formulary/Dr Elizabeth Francis/Sep 17/UNCONTROLLED WHEN PRINTED Page ii CONTENTS PAGE Other antidepressant drugs 42 CNS Stimulants and other drugs used for Attention Deficit Hyperactivity Disorder (ADHD) 43 (CAMHS use only) Differences in extended release methylphenidate for ADHD 45 Methylphenidate: immediate- and modified-release dose equivalents (mg) 45 Antiepileptics in psychiatric disorders 46 Antiepileptic drugs (AEDs): new advice on switching between different manufacturers’ products for a 47 particular drug Drugs used in Parkinsonism and related disorders 48 Antimuscarinic drugs used in parkinsonism 48 Drugs used in essential tremor, chorea, tics, and related disorders 48 Drugs used in Substance Dependence 49 Alcohol dependence 49 Wernicke’s encephalopathy 50 Nicotine dependence 52 NRT: Patches, lozenges, Inhalator, Nasal Spray – Dosing schedules 52 NICE guidance on smoking cessation 54 NICE guidance on pharmacotherapies for smoking cessation 55 Opioid dependence 56 Methadone and buprenorphine for the management of opioid dependence (TA114) 56 Drugs used in dementia (old age psychiatry only) 57 MHRA Drug Safety Update: Memantine Pump, Rivastigmine transdermal patch 57 NELFT Psychotropic Drug Formulary/Dr Elizabeth Francis/Sep 17/UNCONTROLLED WHEN PRINTED Page iii CONTENTS PAGE Appendix 1 Prescribing in Children and Adolescent Mental Health Services (CAMHS) 60 Appendix 2 2a Drugs used outside of the UK Marketing Authorisation 62 2b List of NELFT approved unlicensed medicines [Unlicensed indication] 65 2c Medicines available as a Special-order (‘Specials’) 67 Appendix 3 Clozaril Patient Monitoring Service (CPMS) Registration Forms – links 68 Appendix 4 4a Example clozapine dosing schedule for in-patients with Schizophrenia – 69 CPMS 4b Example clozapine dosing schedule for in-patients with Schizophrenia – 70 Maudsley (12th Edition, 2015) Appendix 5 Plasma Clozapine and Olanzapine Assay Request Forms – links 71 Appendix 6 Calculating total daily prescribed antipsychotic dose (Adults) 72 Appendix 7 Maximum recommended/licensed antipsychotic doses (Adults) 73 Appendix 8 Haloperidol: Oral and Intramuscular equivalent doses for rapid control of 74 Severe Acute Psychomotor Agitations associated with Psychotic Disorder or manic episodes of Bipolar 1 Disorder Appendix 9 9a Psychotropic drugs and cytochrome P450 (CYP) interactions 75 9b Major cytochrome based drug and food interactions 76 Appendix 10 Smoking and psychotropic drugs 78 Appendix 11 Caffeine and psychotropic drugs 79 Caffeine and psychotropic drug interactions Caffeine content of drinks Appendix 12 New Drug Request Form 80 Appendix 13 1-monthly Paliperidone palmitate LAI (Xeplion®): Initiation or switching from 82 other depot preparations Appendix 14 Aripiprazole LAI (Abilify Maintena®): Initiation or switching from oral or other 83 depot antipsychotic preparations Appendix 15 Blank 84 Appendix 16 Olanzapine Embonate (ZypAdhera®) Long Acting Injection cautions and 85 administration guidelines Olanzapine LAI physical health observation chart 87 Appendix 17 Controlled Drugs Schedules 89 Appendix 18 Non-formulary drugs 91 Appendix 19 NELFT NICE Technology Appraisal Guidance (TAG) Adherence Check List – 93 Mental Health Services Appendix 20 NELFT Approved Psychotropic Drugs 94 Appendix 21 List of abbreviations 95 Appendix 22 22a Potential intervention to support the implementation of the MHRA safety alert 96 on the use of valproate in women of child-bearing age 22b Required safety precautions when prescribing valproate for women of child- 97 bearing age Appendix 23 Antipsychotic Dosage Ready Reckoner [Adults] 98 NELFT Psychotropic Drug Formulary/Dr Elizabeth Francis/Sep 17/UNCONTROLLED WHEN PRINTED Page iv Document Control Sheet Date Amendment Details Amended / Updated By January 2013 First Edition Authored by Approved: 18th November 2014 – MHS DTG Dr Elizabeth Francis January 2014 Reviewed Dr Elizabeth Francis August 2014 Haloperidol* – new (lower) maximum dose for oral and intramuscular Dr Elizabeth administration (see Appendix 8) Francis (*Refer to the BNF/eBNF for children for dosing guidance in children and adolescents) Nalmefene approved for initiation by substance misuse consultant Topiramate approved for third line use in alcohol dependency, initiation by substance misuse consultant; prescribing responsibility retained within NELFT [Off-Label/unlicensed use] Quetiapine XL status changed to “Non-formulary” New legal status of: o Zaleplon – POM to Schedule 4 Part 1 Controlled Drug (CD Benz POM) o Zopiclone – POM to Schedule 4 Part 1 Controlled Drug (CD Benz POM) o Tramadol – POM to Schedule 3 Controlled Drug (CD No Register POM); but exempt from Safe Custody Regulations Aripiprazole IM Depot injection (Abilify Maintena®) – Named-patient use only Intranet links updated for new/updated NELFT Intranet website October 2014 New NICE Clinical Guideline: Psychosis and Schizophrenia in adults: Dr Elizabeth treatment and management (CG178 March 2014): Francis Monitoring and cautions for all patients prescribed antipsychotic drugs, including cautions in hepatic and renal impairment October 2014 New NICE Clinical Guideline: Bipolar disorder: the assessment and Dr Elizabeth management of bipolar disorder in adults, children and young people in Francis primary and secondary care (CG185 September 2014) & new BNF updates (electronic BNF October 2014): Lithium monitoring Valproate monitoring and cautions, including stopping valproate if there is abnormal liver function Lamotrigine monitoring and cautions November Summary table for antipsychotic physical health monitoring added Dr Elizabeth 2014 Updated NICE Technology Appraisals and Clinical Guidelines integrated Francis into relevant sections Discontinued drugs removed from document: o Clopixol Acuphase 100mg/2mL o Depixol Depot 100mg/mL, 0.5mL ampoule Forms in appendices updated – New Chair of the DTG Lisdexamfetamine (Elvanse®) included for ADHD [Schedule 2 CD POM] NELFT Psychotropic Drug Formulary/Dr Elizabeth Francis/Sep 17/UNCONTROLLED WHEN PRINTED Page v Document Control Sheet Date Amendment Details Amended / Updated By December Aripiprazole depot approved for inclusion in the formulary Dr Elizabeth 2014 Paliperidone depot (Xeplion®) Initiation/Switching Form updated (Appendix Francis 13) Aripiprazole depot (Abilify Maintena®) Initiation/Switching Form added (Appendix 14) January 2015 Updated guidance on the prescribing of high dose combination Dr Elizabeth antipsychotics (Summary of The Royal College of Psychiatrists Francis recommendations on the use of high dose antipsychotics, 2014) Paliperidone palmitate (Xeplion®) – additional safety information included for the prescribing of paliperidone depot and risk of death Citalopram and escitalopram: QT interval prolongation (p39) – new sections included: o Drug interactions o Guidance on monitoring o Link to full MHRA guidance Updated guidance reference added: Guidance on the Administration to Adults of Oil-based Depot and other Long-Acting Intramuscular Antipsychotic Injections (February 2014, 4th Edition) Appendix 6 – Calculating