DEPOT ANTIPSYCHOTIC MEDICATION: GUIDELINES FOR PRESCRIBING AND ADMINISTERING FEBRUARY 2020 This policy supersedes all previous policies Policy title Depot Antipsychotic Medication: Guidelines for Prescribing and Administration Policy PHA04 reference Policy category Clinical Relevant to All Clinical staff Date published 2019 Implementation February 2020 date Date last December 2016 reviewed Next review February 2023 date Policy lead Lucy Reeves, Chief Pharmacist Contact details Email:[email protected] Accountable Dr Vincent Kirchner, Medical Director director Approved by Drugs and Therapeutic Committee (Group): February 2020 Approved by Quality Committee (Committee): Document Date Version Summary of amendments history March 2009 3 Routine review April 2010 4 Routine review March 2012 5 Routine review Nov 2014 6 Routine review Route of aripiprazole depot updated to include deltoid. Paliperidone three monthly depot is added. Dec 2016 7 Olanzapine depot monitoring advice updated. Administration of depots under restraint added. Feb 2020 8 High dose antipsychotic monitoring form removed Membership of the policy Dr Julian Summerfield (Consultant Psychiatrist, Lead Pharmacists, Modern Matrons, development/ Consultant Nurse for Physical Health review team Consultation Drug and Therapeutic Committee members DO NOT AMEND THIS DOCUMENT Further copies of this document can be found on the Foundation Trust intranet. I DEPOT ANTIPSYCHOTIC MEDICATION GUIDELINES_PRESCRIBING_ADMINSTRATION_PHA04_FEB 2020 Contents Page 1 Introduction 1 2 Aims and objectives 1 3 Scope of the policy 1 4 Prior to initiation of depot treatment 1 5 Advice on prescribing depot antipsychotics 1 6 Use of unlicensed doses 16 7 Administration of depot antipsychotic medication 16 8 Use of alternative sites or sites which are off-label 18 9 Depots/LAIs administered under restraint 19 10 Generic names/Brand names 19 11 Management of patients on long term depot antipsychotics in relapse 19 prevention 12 Intramuscular anticholinergic medication 21 13 Primary care involvement 22 14 Zuclopenthixol acetate (Clopixol acuphase) 22 15 Related policies 22 16 Dissemination and implementation arrangements 22 17 Training requirements 22 18 Monitoring and audit arrangements 22 19 Review of the policy 23 20 References 24 Appendix 1: Equivalent doses of antipsychotics 28 Appendix 2: Sites Of Administration 29 Appendix 3: Equality Impact Assessment Form 30 II DEPOT ANTIPSYCHOTIC MEDICATION GUIDELINES_PRESCRIBING_ADMINSTRATION_PHA04_FEB 2020 1 Introduction 1.1.1 Antipsychotic depot / long acting injections (LAI) preparations are used for maintenance therapy in the treatment of schizophrenia, especially when adherence with oral treatment is unreliable. 2 Aims and objectives 2.1.1 To provide guidance on prescribing antipsychotic depot/long-acting injections (LAIs). 3 Scope of the policy 3.1.1 This policy is aimed at all clinical staff who are directly involved in the management of patients who are prescribed depot/LAI antipsychotic preparations. 4 Prior to initiation of depot treatment 4.1.1 Depot preparations should be a treatment option where a service user expresses a preference for such treatment after an acute episode because of its convenience, or as part of a treatment plan in which the avoidance of covert non-adherence (intentional or unintentional) with antipsychotic medication is a clinical priority1. 4.1.2 Following full discussion between the responsible clinician and the service user, the decision to initiate depot antipsychotic injections must take into account the preferences and attitudes of the service user towards the mode of administration and organisational procedures (for example; home visits and location of clinics) related to the delivery of regular intramuscular injections1. 4.1.3 As with oral antipsychotics, service users receiving depots must be maintained under regular clinical review, particularly in relation to the risks and benefits of the medication regimen. 5 Advice on prescribing depot antipsychotics 5.1 Choice of depot antipsychotic 5.1.1 The choice of depot medication is determined by the needs of the individual service user. There are few differences between individual older long-acting antipsychotics. Fluphenazine may be associated with relatively more extrapyramidal side effects but perhaps less weight gain. Flupenthixol, halopepridol and fluphenazine are considered equally effective. Zuclopenthixol may be more effective in preventing relapses than others, although this may be at the expense at the increased burden of side effects. Flupenthixol decanoate can be given in very much higher “neuroleptic equivalent” doses than the other depot antipsychotics and still remain “within BNF limits”, although it is doubtful that this confers any real therapeutic advantage 2 . The typical depot antipsychotics should be considered first-line. 1 5.1.2 These medicines are long-acting preparations. Therefore service users should be exposed to the oral form of the medicine (or a test dose of the injection) prior to their first full dose of the injection to minimise the possibility of a long- lasting idiosyncratic reaction. Patients must be offered a patient information leaflet from the Choice and Medication website located on the intranet. 5.2 Dosages - First generation long-acting antipsychotic injections 5.2.1 For first generation long-acting antipsychotics, a test dose must be given. This is a test of the sensitivity or extrapyramidal side effects and any sensitivity of the base oil2. The allergy status for the medicines and base oil (e.g. sesame oil, vegetable oil derived from coconuts) or excipients e.g. benzyl alcohol must be checked and documented in Electronic patient record (Carenotes). 5.2.2 Begin with the lowest therapeutic dose. There is some information that low doses are at least as effective as higher doses. Low doses are likely to be better tolerated2. 5.2.3 See table 1 for when the next dose should be administered. 5.2.4 Oral antipsychotics may also be prescribed initially. These should be gradually reduced and stopped once therapeutic maintenance dose has been established. If the total dosage exceeds BNF limits, the trust High Dose Antipsychotic Therapy guidelines must be implemented (see appendix 1). 5.2.5 The depot should be administered at the longest possible licensed interval, bearing in mind the maximum recommended single dose. There is no evidence to suggest that shortening the dose interval improves efficacy. Injections are painful, so less frequent administration is desirable2. 5.2.6 The observation that some patients deteriorate in the days before the next dose is due is not supported by fact. For some hours to days (with some preparations), plasma levels of antipsychotics continue to fall, albeit slowly after the next injection. Thus patients are most at risk of deterioration immediately after a long-acting injection and not before it. In most trials, relapse occurs only three to six month after withdrawing therapy. This is roughly the time to clear steady state long-acting medicines from the blood2. 5.2.7 Doses should be adjusted after an adequate period of assessment. Attainment of peak plasma levels, therapeutic effect and steady-state plasma levels are delayed with the long-acting injections1. Attainment of steady state usually takes three months for first-generation antipsychotic depots3. Doses may be reduced if adverse effects occur, but should only be increased after careful assessment over at least one month, preferably longer1. 5.2.8 When swapping from one first generation antipsychotic depot to another first generation antipsychotic depot, a direct exchange from one depot to another can usually be made3. If the person has not previously had the new depot, ensure tolerability is checked first with a test dose. 5.2.9 When swapping from a combination of oral antipsychotics plus depot to a depot alone, relapses are more likely in the first three to four months. If the risk of 2 relapse is high, consider increasing the depot dose and then reduce the oral doses later3. 5.2.10 When swapping from a first generation antipsychotic depot to another antipsychotic, stop the depot and introduce the new antipsychotic when the next depot date is due, remembering that a slow decay of depot plasma levels may occur. So be aware of adding the new medicine too quickly3. Table 14-12: Medicine Test dose Dose range Interval First generation long-acting antipsychotics Fluphenazine in 12.5mg (6.25mg in patients 12.5-100mg every Reasonable steady state sesame oil over 60 years) two to five weeks is achieved at intervals of two to four weeks Flupenthixol in thin 20mg (consider 5- 10mg in 50 every four Weekly to four weekly vegetable oil elderly patients) weeks - (derived from 400mg/week coconuts) Haloperidol in 50mg every four weeks (12.5 50-300mg every Four weekly sesame oil – 25mg every four weeks in four weeks elderly patients) Zuclopenthixol in 100mg (consider 25-50mg in 200-600mg every Weekly to four weekly thin vegetable oil elderly patients) one to four weeks. (derived from Maximum: 600mg coconuts) every week. Second generation long-acting antipsychotics Aripiprazole (powder None. Response & tolerability 300-400mg/month Four weekly and solvent for to oral aripiprazole must be prolonged release checked prior to initiating the suspension) depot. Olanzapine (powder None. Tolerability to oral 150mg every two Two to four weekly and solvent for olanzapine must be checked weeks to 405mg prolonged release prior to initiating the depot. every month