Related guidance:
Antipsychotics information leaflet (Royal College of Psychiatrists)
- Early intervention in psychosis services should be accessible to all people with a first episode or first presentation of psychosis, irrespective of the person’s age or the duration of untreated psychosis.
- People presenting to early intervention in psychosis services should be assessed without delay. If the service cannot provide urgent intervention for people in a crisis, refer the person to a crisis resolution and home treatment team (with support from early intervention in psychosis services). Referral may be from primary or secondary care (including other community services) or a self- or carer-referral.
- Early intervention in psychosis services should aim to provide a full range of pharmacological, psychological, social, occupational and educational interventions for people with psychosis.
- Consider extending the availability of early intervention in psychosis services beyond 3 years if the person has not made a stable recovery from psychosis or schizophrenia.
- Do not start antipsychotic medication for a first presentation of sustained psychotic symptoms in primary care unless it is done in consultation with a consultant psychiatrist.
- Carry out a comprehensive multidisciplinary assessment of people with psychotic symptoms in secondary care. This should include assessment by a psychiatrist, a psychologist or a professional with expertise in the psychological treatment of people with psychosis or schizophrenia. The assessment should address the following domains:
• psychiatric (mental health problems, risk of harm to self or others, alcohol consumption and prescribed and non-prescribed drug history)
• medical, including medical history and full physical examination to identify physical illness (including organic brain disorders) and prescribed drug treatments that may result in psychosis
• physical health and wellbeing (including weight, smoking, nutrition, physical activity and sexual health)
• psychological and psychosocial, including social networks, relationships and history of trauma
• developmental (social, cognitive and motor development and skills, including coexisting neurodevelopmental conditions)
• social (accommodation, culture and ethnicity, leisure activities and recreation, and responsibilities for children or as a carer)
• occupational and educational (attendance at college, educational attainment, employment and activities of daily living)
• quality of life
• economic status. - Assess for post-traumatic stress disorder and other reactions to trauma because people with psychosis or schizophrenia are likely to have experienced previous adverse events or trauma associated with the development of the psychosis or as a result of the psychosis itself. For people who show signs of post-traumatic stress, follow the recommendations in the NICE guideline on post-traumatic stress disorder.
- Routinely monitor for other coexisting conditions, including depression, anxiety and substance misuse particularly in the early phases of treatment.
- Write a care plan in collaboration with the service user as soon as possible following assessment, based on a psychiatric and psychological formulation, and a full assessment of their physical health. Send a copy of the care plan to the primary healthcare professional who made the referral and the service user.
- For people who are unable to attend mainstream education, training or work, facilitate alternative educational or occupational activities according to their individual needs and capacity to engage with such activities, with an ultimate goal of returning to mainstream education, training or employment.
- For people with first episode psychosis offer:
• oral antipsychotic medication in conjunction with
• psychological interventions (family intervention and individual CBT) - Advise people who want to try psychological interventions alone that these are more effective when delivered in conjunction with antipsychotic medication. If the person still wants to try psychological interventions alone:
• offer family intervention and CBT
• agree a time (1 month or less) to review treatment options, including introducing antipsychotic medication
• continue to monitor symptoms, distress, impairment and level of functioning (including education, training and employment) regularly. - If the person’s symptoms and behaviour suggest an affective psychosis or disorder, including bipolar disorder and unipolar psychotic depression, follow the recommendations in the NICE guidelines on bipolar disorder or depression.
See NHS Somerset Formulary Bipolar disorder and mania.
- The choice of antipsychotic medication should be made by the service user and healthcare professional together, taking into account the views of the carer if the service user agrees. Provide information and discuss the likely benefits and possible side effects of each drug, including:
• metabolic (including weight gain and diabetes)
• extrapyramidal (including akathisia, dyskinesia and dystonia)
• cardiovascular (including prolonging the QT interval)
• hormonal (including increasing plasma prolactin)
• other (including unpleasant subjective experiences). - Before starting antipsychotic medication, undertake and record the following baseline investigations:
• weight (plotted on a chart)
• waist circumference
• pulse and blood pressure
• fasting blood glucose or glycosylated haemoglobin (HbA1c)
• blood lipid profile and prolactin levels
• assessment of any movement disorders
• assessment of nutritional status, diet and level of physical activity. - Before starting antipsychotic medication, offer the person with psychosis or schizophrenia an electrocardiogram (ECG) if:
• specified in the summary of product characteristics (SPC)
• a physical examination has identified specific cardiovascular risk (such as diagnosis of high blood pressure)
• there is a personal history of cardiovascular disease or
• the service user is being admitted as an inpatient. - Treatment with antipsychotic medication should be considered an explicit individual therapeutic trial. Include the following:
• Discuss and record the side effects that the person is most willing to tolerate.
• Record the indications and expected benefits and risks of oral antipsychotic medication, and the expected time for a change in symptoms and appearance of side effects. - At the start of treatment give a dose at the lower end of the licensed range and slowly titrate upwards within the dose range given in the British national formulary (BNF) or SPC.
• Justify and record reasons for dosages outside the range given in the BNF or SPC.
• Record the rationale for continuing, changing or stopping medication, and the effects of such changes.
• Carry out a trial of the medication at optimum dosage for 4 to 6 weeks. - Monitor and record the following regularly and systematically throughout treatment, but especially during titration:
• response to treatment, including changes in symptoms and behaviour
• side effects of treatment, taking into account overlap between certain side effects and clinical features of schizophrenia (for example, the overlap between akathisia and agitation or anxiety) and impact on functioning
• the emergence of movement disorders
• weight, weekly for the first 6 weeks, then at 12 weeks, at 1 year and then annually (plotted on a chart)
• waist circumference annually (plotted on a chart)
• pulse and blood pressure at 12 weeks, at 1 year and then annually
• fasting blood glucose or HbA1c, and blood lipid levels at 12 weeks, at 1 year and then annually
• adherence
• overall physical health. - The secondary care team should maintain responsibility for monitoring service users’ physical health and the effects of antipsychotic medication for at least the first 12 months or until the person’s condition has stabilised, whichever is longer. Thereafter, the responsibility for this monitoring may be transferred to primary care under shared care arrangements.
NHS Somerset Antipsychotic medication Shared Care Protocol
- Discuss any non-prescribed therapies the service user wishes to use (including complementary therapies) with the service user, and carer if appropriate. Discuss the safety and efficacy of the therapies, and possible interference with the therapeutic effects of prescribed medication and psychological treatments.
- Discuss the use of alcohol, tobacco, prescription and non-prescription medication and illicit drugs with the service user, and carer if appropriate. Discuss their possible interference with the therapeutic effects of prescribed medication and psychological treatments.
See NHS Somerset Formulary Substance Dependence.
- Review clinical indications, frequency of administration, therapeutic benefits and side effects of when required prescriptions each week or as appropriate and check whether ‘p.r.n.’ prescriptions have led to a dosage above the maximum specified in the BNF or SPC.
- Do not use a loading dose of antipsychotic medication (often referred to as ‘rapid neuroleptisation’).
- Do not initiate regular combined antipsychotic medication, except for short periods (for example, when changing medication).
- If prescribing chlorpromazine, warn of its potential to cause skin photosensitivity. Advise using sunscreen if necessary.
Monitoring physical health in primary care
- Develop and use practice case registers to monitor the physical and mental health of people with psychosis or schizophrenia in primary care.
- GPs and other primary healthcare professionals should monitor the physical health of people with psychosis or schizophrenia when responsibility for monitoring is transferred from secondary care, and then at least annually. The health check should be comprehensive, focusing on physical health problems that are common in people with psychosis and schizophrenia. Include (see below) and refer to relevant NICE guidance on monitoring for cardiovascular disease, diabetes, obesity and respiratory disease. A copy of the results should be sent to the care coordinator and psychiatrist, and put in the secondary care notes.
• weight (plotted on a chart)
• waist circumference
• pulse and blood pressure
• fasting blood glucose or glycosylated haemoglobin (HbA1c)
• blood lipid profile and prolactin levels
• assessment of any movement disorders
• assessment of nutritional status, diet and level of physical activity. - Identify people with psychosis or schizophrenia who have high blood pressure, have abnormal lipid levels, are obese or at risk of obesity, have diabetes or are at risk of diabetes (as indicated by abnormal blood glucose levels), or are physically inactive, at the earliest opportunity following relevant NICE guidelines on cardiovascular disease: risk assessment and reduction, including lipid modification, preventing type 2 diabetes, obesity, hypertension, prevention of cardiovascular disease and physical activity.
- Treat people with psychosis or schizophrenia who have diabetes and/or cardiovascular disease in primary care according to the appropriate NICE guidance (for example, see the NICE guidelines on lipid modification, type 1 diabetes and type 2 diabetes).
- Healthcare professionals in secondary care should ensure, as part of the care programme approach, that people with psychosis or schizophrenia receive physical healthcare from primary care as described in Psychosis and schizophrenia in adults: prevention and management (CG178).
Antipsychotic medicines (MHRA August 2005)
Increased risk of stroke
- In 2004, the Committee on Safety of Medicines advised of a clear increase in the risk of stroke with the use of the antipsychotics risperidone or olanzapine in elderly people with dementia. (The risk was approximately three-fold increased risk compared with the placebo). The committee advised that the magnitude of risk outweighed any likely benefit of treating dementia-related behavioural problems with these drugs. This increased risk is also a cause for concern in any patient with a high baseline risk of stroke. A year later, a Europe-wide review of the risk of cerebrovascular accidents (CVA), in particular when used in dementia patients concluded that this risk could not be excluded for other antipsychotics (atypical or typical).
Increased mortality
- In 2005, an analysis of 17 placebo-controlled trials found that newer antipsychotics are associated with increased mortality when used in elderly people with dementia (about 1-2% increased risk compared with no treatment). For risperidone, there is an additional increase in the risk when co-prescribed with furosemide. In November 2008, a European assessment of published observation data concluded that a similar increased risk of death could not be excluded for the older antipsychotics.
See NHS Somerset Formulary Dementia.
| Therapeutic Area | Formulary Choices | Cost for 28 (unless otherwise stated) | Rationale for decision / comments |
|---|---|---|---|
| Antipsychotics | |||
| Second-generation | Risperidone | 1mg tablet: £0.97 (20) | NHS Somerset classify as an Amber drug for psychosis, schizophrenia, bipolar disorder and challenging behaviour as per traffic light guidance and shared care protocol. For acute and chronic psychosis. Adult: 2mg daily in 1-2 divided doses for day 1, then 4mg daily in 1-2 divided doses for day 2, slower titration is appropriate in some patients, usual dose 4-6mg daily, doses above 10mg daily only if benefit considered to outweigh risk; maximum 16mg per day. Elderly: Initially 500mcg twice daily, then increased in steps of 500mcg twice daily, increased to 1-2mg twice daily. For mania. Adult: 2mg once daily, then increased in steps of 1mg daily if required; usual dose 1-6mg daily. Elderly: Initially 500mcg twice daily, then increased in steps of 500mcg twice daily, increased to 1-2mg twice daily. For short term treatment (up to 6 weeks) of persistent aggression in patients with moderate to severe Alzheimer's dementia unresponsive to non-pharmacological interventions and where there is a risk of harm to self or others. Adult: Initially 250mcg twice daily, then increased in steps of 250mcg twice a day on alternate days, adjusted according to response; usual dose 500mcg twice daily (max. per dose 1mg twice daily). |
| 2mg tablet: £1.72 (60) | |||
| 3mg tablet: £1.93 (60) | |||
| 4mg tablet: £2.03 (60) | |||
| 1mg/ml oral solution sugar free: £2.93 (100ml) | |||
| 25mg powder and solvent for suspension for injection vial: £79.69 (1) | For Schizophrenia and other psychoses in patients tolerant to risperidone by mouth and taking oral risperidone up to 4mg daily. Adult: Initially 25mg every 2 weeks, to be administered by deep intramuscular injection, into the deltoid or gluteal muscle, adjusted in steps of 12.5mg (max. per dose 50mg every 2 weeks) at intervals of at least 4 weeks, during intiation risperidone by mouth may need to be continued for 4-6 weeks; risperidone by mouth may also be used during dose adjustment of depot injection. For Schizophrenia and other psychoses in patients tolerant to risperidone by mouth and taking oral risperidone over 4mg daily. Adult: Initially 37.5mg every 2 weeks, adjusted in steps of 12.5mg (max. per dose 50mg every 2 weeks) at intervals of at least 4 weeks, during intiation risperidone by mouth may need to be continued for 4-6 weeks; risperidone by mouth may also be used during dose adjustment of depot injection. |
||
| 37.5mg powder and solvent for suspension for injection vial: £111.32 (1) | |||
| 50mg powder and solvent for suspension for injection vial: £142.76 (1) | |||
| Paliperidone as Xeplion® | 50mg/0.5ml prolonged-release suspension for injection pre-filled syringe: £183.92 (1) | NHS Somerset classify as an Amber drug for maintenance in schizophrenia in patients previously responsive to risperidone, as per traffic light guidance and shared care protocol. Paliperidone is a metabolite of risperidone. Adult: 150mg for 1 dose on day 1, then 100mg for 1 dose on day 8, to be injected by deep intramuscular injection into the deltoid muscle, dose subsequently adjusted at monthly intervals according to response; maintenance 75mg once a month, alternatively maintenance 25-150mg once a month, following the second dose, monthly maintenance doses can be administered into either the deltoid or gluteal muscle. |
|
| 75mg/0.75ml prolonged-release suspension for injection pre-filled syringe: £244.90 (1) | |||
| 100mg/1ml prolonged-release suspension for injection pre-filled syringe: £314.07 (1) | |||
| 150mg/1.5ml prolonged-release suspension for injection pre-filled syringe: £392.59 (1) | |||
| Olanzapine | 2.5mg tablet: £0.83 | NHS Somerset classify as an Amber drug for schizophrenia, mania and bipolar as per traffic light guidance and shared care protocol. For schizophrenia/combination therapy for mania and preventing recurrence in bipolar disorder. Adult: 10mg daily, adjusted according to response, usual dose 5-20mg daily, doses greater than 10mg daily only after reassessment, when one or more factors present that might result in slower metabolism (e.g. female gender, elderly, non-smoker) consider lower initial dose and more gradual increase; maximum 20mg per day. For monotherapy for mania. Adult: 15mg daily, adjusted according to response, usual dose 5-20mg daily, doses greater than 15mg daily only after reassessment, when one or more factors present that might result in slower metabolism (e.g. female gender, elderly, non-smoker) consider lower initial dose and more gradual increase; maximum 20mg per day. |
|
| 5mg tablet: £0.83 | |||
| 7.5mg tablet: £1.10 | |||
| 10mg tablet: £0.98 | |||
| 15mg tablet: £1.16 | |||
| 20mg tablet: £1.41 | |||
| 5mg orodispersible tablets sugar free: £11.62 | |||
| 10mg orodispersible tablet sugar free: £19.85 | |||
| 15mg orodispersible tablet sugar free: £20.19 | |||
| 20mg orodispersible tablet sugar free: £20.62 | |||
| NHS Somerset classify Olanzapine injection as Red (specialist prescribing only) as per Traffic light guidance. | |||
| Healthcare professionals prescribing aripiprazole are reminded to be alert to the risk of addictive gambling and other impulse control disorders. Healthcare professionals should advise patients, their families and friends to be alert to these risks. See MHRA (December 2023) for Aripiprazole (Abilify and generic brands): risk of pathological gambling. | |||
| Aripiprazole | 5mg tablet: £12.60 | NHS Somerset classify as an Amber drug for schizophrenia and mania as per traffic light guidance and shared care protocol. For schizophrenia. Adult: 10-15mg once daily; usual dose 15mg once (max. per dose 30mg once daily). For treatment and prevention of mania. Adult: 15mg once daily; usual dose 15mg once (max. per dose 30mg once daily). |
|
| 10mg tablet: £10.35 |
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| 15mg tablet: £9.96 | |||
| 30mg tablet: £30.28 |
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| 10mg orodispersible tablet sugar free: £73.87 | |||
| 15mg orodispersible tablet sugar free: £72.41 | |||
| 400mg powder and solvent for suspension for injection pre-filled syringe: £220.41 (1) | For maintenance of schizophrenia in patients stabilised with oral aripiprazole. Adult: 400mg every month, to be injected by deep intramuscular injection into the gluteal or deltoid muscle, minimum of 26 days between injections, treatment with 10-20mg oral aripiprazole daily should be continued for 14 consecutive days after the first injection. For CYP2D6 poor metabolisers. Adult: 300mg every month and as above. |
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| Quetiapine | 25mg tablet: £1.23 (60) | NHS Somerset classify as an Amber drug for schizophrenia and bipolar disorder as per traffic light guidance and shared care protocol. For schizophrenia. Adult: 25mg twice daily for day 1, then 50mg twice daily for day 2, then 100mg twice daily for day 3, then 150mg twice daily for day 4, then adjusted according to response, usual dose 300-450mg daily in 2 divided doses, the rate of dose titration may need to be slower and the daily dose lower in elderly patients; maximum 750mg per day. For treatment of mania in bipolar. Adult: 50mg twice daily for day 1, then 100mg twice daily for day 2, then 150mg twice daily for day 3, then 200mg twice daily for day 4, then adjusted adjusted in steps of up to 200mg daily, adjusted according to response, usual dose 400-800mg daily in 2 divided doses, the rate of dose titration may need to be slower and the daily dose lower in elderly patients; maximum 800mg per day. |
|
| 100mg tablet: £2.07 (60) | |||
| 150mg tablet: £7.31 (60) | |||
| 200mg tablet: £2.31 (60) | |||
| 300mg tablet: £3.86 (60) |
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| 20mg/ml oral suspension sugar free: £181.00 (150ml) | |||
| as Brancico XL® | 50mg modified-release tablet: £8.99 (60) | For schizophrenia. Adult: 300mg once daily for day 1, then 600mg once daily for day 2, then, adjusted according to response, usual dose 600mg once daily, maximum dose under specialist supervision; 800mg per day. Elderly: Initially 50mg once daily, adjusted according to response, adjusted in steps of 50mg daily. For treatment of mania in bipolar. Adult: 300mg once daily for day 1, then 600mg once daily for day 2, then, adjusted according to response, usual dose 400-800mg once daily. Elderly: Initially 50mg once daily, adjusted according to response, adjusted in steps of 50mg daily. |
|
| 150mg modified-release tablet: £19.49 (60) | |||
| 200mg modified-release tablet: £19.49 (60) | |||
| 300mg modified-release tablet: £33.74 (60) | |||
| 400mg modified-release tablet: £44.99 (60) | |||
| as Sondate XL® | 50mg modified-release tablet: £11.99 (60) | ||
| 150mg modified-release tablet: £25.99 (60) | |||
| 200mg modified-release tablet: £25.99 (60) | |||
| 300mg modified-release tablet: £44.99 (60) | |||
| 400mg modified-release tablet: £59.99 (60) | |||
| as Zaluron XL® | 50mg modified-release tablet: £27.96 (60) | ||
| 150mg modified-release tablet: £46.96 (60) | |||
| 200mg modified-release tablet: £46.96 (60) | |||
| 300mg modified-release tablet: £70.71 (60) | |||
| 400mg modified-release tablet: £94.98 (60) | |||
| as Biquelle XL® | 50mg modified-release tablet: £29.45 (60) | ||
| 150mg modified-release tablet: £49.45 (60) | |||
| 200mg modified-release tablet: £49.45 (60) | |||
| 300mg modified-release tablet: £74.45 (60) | |||
| 400mg modified-release tablet: £98.95 (60) | |||
| 600mg modified-release tablet: £70.73 (30) | |||
| NHS Somerset classify Seroquel XL as Black (not recommended) as per Traffic light guidance. | |||
| Lurasidone as Latuda® | 18.5mg tablet: £37.50 | NHS Somerset classify as an Amber drug for patients with schizophrenia who have responded to antipsychotics but have experienced metabolic side effects, provided there has been a trial of aripiprazole as per traffic light guidance and shared care protocol. For schizophrenia. Adult: Initially 37mg once daily, increased if necessary up to 148mg once daily. For schizophrenia when given with concomitant moderate CYP3A4 inhibitors (e.g. diltiazem, erythromycin, fluconazole, and verapamil). Adult: Initially 18.5mg once daily (max. per dose 74mg once daily). |
|
| 37mg tablet: £37.50 | |||
| 74mg tablet: £37.50 | |||
| Amisulpride | 50mg tablet: £13.00 (60) | NHS Somerset classify as an Amber drug for schizophrenia as per traffic light guidance and shared care protocol. For acute psychotic episode in schizophrenia. Adult: 400-800mg daily in 2 divided doses, adjusted according to response; maximum 1.2g per day. For schizophrenia with predominantly negative symptoms. Adult: 50-300mg daily. |
|
| 100mg tablet: £15.79 (60) | |||
| 200mg tablet: £29.66 (60) | |||
| 100mg/ml oral solution sugar free: £109.57 (60ml) | |||
| NHS Somerset classify Clozapine as Red (specialist prescribing only) as per Traffic light guidance. | |||
| Monitoring blood concentrations of clozapine (Clozaril, Denzapine, Zaponex) for toxicity is now advised in certain clinical situations. Blood level monitoring of other antipsychotics for toxicity may also be helpful in certain circumstances, where testing and reference values are available. See MHRA (August 2020) for Clozapine and other antipsychotics: monitoring blood concentrations for toxicity. | |||
| First-generation | Haloperidol | 1.5mg tablet: £1.94 (28) | NHS Somerset classify as an Amber drug for schizophrenia and bipolar as per shared care protocol. For schizophrenia. Adult: 2-10mg daily in 1-2 divided doses; usual dose 2-4mg daily, in first-episode schizophrenia, up to 10mg daily, in multiple-episode schizophrenia, dose adjusted according to response at intervals of 1-7 days. Individual benefit-risk should be assessed when considering doses above 10mg daily; maximum 20mg per day. Elderly: Initially, use half the lowest dose, then adjust gradually according to response up to maximum 5mg daily, doses above 5mg daily should only be considered in patients who have tolerated higher doses and after reassessment of the individual benefit-risk. Moderate to severe manic episodes associated with bipolar I disorder. Adult: 2-10mg daily in 1-2 divided doses, dose adjusted according to response at intervals of 1-3 days. Individual benefit-risk should be assessed when considering doses above 10mg daily; continued use should be evaluated early in treatment; maximum 15mg per day. Elderly: Initially, use half the lowest dose, then adjust gradually according to response up to maximum 5mg daily, doses above 5mg daily should only be considered in patients who have tolerated higher doses and after reassessment of the individual benefit-risk; continued use should be evaluated early in treatment. |
| 5mg tablet: £5.89 (28) | |||
| 5mg/5ml oral solution sugar free: £7.31 (100ml) | |||
| 10mg/5ml oral solution sugar free: £7.59 (100ml) | |||
| Flupentixol decanoate | 20mg/1ml solution for injection ampoule: £15.17 (10) | NHS Somerset classify as an Amber drug for schizophrenia and other psychoses as per traffic light guidance and shared care protocol. Adult: Test dose 20mg, dose to be injected by deep intramuscular injection into the upper outer buttock or lateral thigh, then 20-40mg after at least 7 days, then 20-40mg every 2-4 weeks, adjusted according to response, usual maintenance dose 50mg every 4 weeks to 300mg every 2 weeks; maximum 400mg per week. Elderly: Dose is usually quarter to half adult dose. |
|
| 100mg/1ml solution for injection ampoule: £62.51 (10) | |||
| 200mg/1ml solution for injection ampoule: £97.59 (5) | |||
| Zuclopenthixol decanoate as Clopixol® | 200mg/1ml solution for injection ampoule: £31.51 (10) | NHS Somerset classify as an Amber drug for maintenance treatment of schizophrenia and paranoid psychoses as per traffic light guidance and shared care protocol. Adult: Test dose 100mg, dose to be administered by deep intramuscular injection into the upper outer buttock or lateral thigh, followed by 200-500mg after at least 7 days, then 200-500mg every 1-4 weeks, adjusted according to response, higher doses of more than 500mg can be used; do not exceed 600mg weekly. Elderly: A quarter to half usual starting dose to be used. Do not confuse with zuclopenthixol acetate. |
|
| as Clopixol-Conc® | 500mg/1ml solution for injection ampoule: £37.18 (5) | ||
| NHS Somerset classify Zuclopenthixol acetate as Red (specialist prescribing only) as per Traffic light guidance. | |||