Treatment and Management |
First and acute episodes of schizophrenia |
º Urgently refer anyone presenting with psychotic symptoms in primary care to and appropriate specialist team. |
º If a GP needs to start antipsychotics they should they should have experience in treating and managing |
schizophrenia. |
º Use an oral antipsychotic for people with newly diagnosed schizophrenia |
º Decide which drug to use together with the patient, and carer if appropriate* |
º Consider the benefits and risks of each antipsychotic including the relative potential of each to cause side effects, |
such as: |
> Extrapyramidal effects e.g. akathisia, |
> metabolic effects e.g. weight gain |
> unpleasant subjective experience |
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* NB - This guidance replaces NICE TA43 which recommended atypical antipsychotics first-line; |
this recommendation no longer stands |
Prescribing |
º Start with a dose at the lower end of the licensed range and titrate upwards slowly within the dose range in the |
BNF or Summary of Products Characteristics (SPC) |
º Do NOT use a loading dose of an antipsychotic |
º Carry out a trial at the optimum dose for 4-6 weeks |
º Do NOT prescribe regular combined antipsychotics, except for short periods (e.g. when changing medication). |
º Review prn antipsychotics regularly e.g. weekly, and check whether the dose taken has increased above the maximum in |
the BNF/SPC. |
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Maintenance treatment |
Do NOT use intermittent dosing strategies unless the patient will not accept continuous maintenance treatment |
or if it is contraindicated. |
Depot/long-acting injectable antipsychotics |
º Use depot/long-acting injectable antipsychotics when; |
> the patient would prefer this after an acute episode, |
> avoiding covert non-adherence to medication is a clinical priority. |
º When starting treatment: |
> consider the preferences and attitudes of the patient towards regular intramuscular injections and their |
delivery (e.g. home visits, location of clinics) |
> consider the benefits and risk of each antipsychotic, |
> initially use a small test dose as in the BNF/SPC |
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Monitoring |
Link to Suggested Monitoring Requirements of High Risk Drugs |
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Pre-treatment |
An electrocardiogram (ECG) is needed if: |
º specified in the SPC |
º there is a personal history of cardiovascular disease, |
º cardiovascular risk is identified e.g. hypertension, |
º the person is admitted as an inpatient. |
During treatment |
º Record the indications, expected benefits and risks, and expected time-frame for a change in symptoms and for |
side effects to occur. |
º Justify and record reasons for doses outside the range specified in the BNF/SPC. |
º Monitor and record the following regularly throughout treatment, but especially during titration: |
º efficacy, including changes in symptoms and behaviour, |
º side effects, |
º adherence, |
º physical health |
º Record the rationale for continuing, changing or stopping medication and the effects of such changes. |
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Cautions and counselling |
Discuss the following with the patient: |
º any non-prescribed treatments including complementary therapies, |
º prescription and non-prescription medicines, |
º use of alcohol, tobacco and illicit drugs |
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Inadequate response to treatment |
º Review the diagnosis. |
º Check adherence to antipsychotics. |
º Review psychological treatments. |
º Consider other causes of non-response. |
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Use clozapine if symptoms have not responded adequately despite sequential use of at least two different antipsychotics, |
including a non-clozapine second-generation antipsychotic. |
If there is inadequate response to clozapine, follow the steps above then check clozapine levels before adding a second |
antipsychotic to augment clozapine. Choosing a drug that does not compound the side effects of clozapine. An adequate |
trial of augmentation may need to be up to 8 to 10 weeks. |
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Withdrawal |
º Inform the patient of the high risk of relapse if medication is stopped within 1-2 years. |
º If withdrawing antipsychotic medication do so gradually. |
º Regularly monitor for signs and symptoms of relapse for at least 2 years after withdrawal. |
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