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4.2 Drugs used in psychoses and related disorders

4.2 Drugs used in psychoses and related disorders

Schizophrenia NICE Clinical Guidelines 2009

These guidelines relate to adults (18 years and older). For information on early detection and intervention, and for 
recommendations on psychological and psycho-social interventions, see the full guidance.

Treatment and management

First and acute episodes of schizophrenia  
          ¤   Urgently refer anyone presenting with psychotic symptoms in primary care to and appropriate specialist team.
          ¤   If a GP needs to start antipsychotics they should they should have experience in treating and managing schizophrenia.
          ¤   Use an oral antipsychotic for people with newly diagnosed schizophrenia
          ¤   Decide which drug to use together with the patient, and carer if appropriate*
          ¤   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
* NB - This guidance replaces NICE TA43 which recommended atypical antipsychotics first-line;  this recommendation no 
            longer stands.
          > 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)
          > Do NOT use a loading dose of an antipsychotic
          > Carry out a trial at the optimum dose for 4-6 weeks
          > Do NOT prescribe regular combined antipsychotics, except for short periods (e.g. when changing medication).
          > Review prn antipsychotics regularly e.g. weekly, and check whether the dose taken has increased above the maximum in
             the BNF/SPC. 
Maintenance treatment  
Do NOT use intermittent dosing strategies unless the patient will not accept continuous maintenance treatment or if it is 
Depot/long-acting injectable antipsychotics  
       ¤     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.
       ¤     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
Link to Suggested Monitoring Requirements of High Risk Drugs

An electrocardiogram (ECG) is needed if:  
       ¤   specified in the SPC
       ¤   there is a personal history of cardiovascular disease,
       ¤   cardiovascular risk is identified e.g. hypertension,
       ¤   the person is admitted as an inpatient.
During treatment 
       ¤   Record the indications, expected benefits and risks, and expected time-frame for a change in symptoms and for side effects 
            to occur.
       ¤   Justify and record reasons for doses outside the range specified in the BNF/SPC.
       ¤   Monitor and record the following regularly throughout treatment, but especially during titration:
                   >  efficacy, including changes in symptoms and behaviour,
                   >  side effects,
                   >  adherence,
                   >  physical health.
        ¤  Record the rationale for continuing, changing or stopping medication and the effects of such changes

Cautions and counselling 

Discuss the following with the patient:
       ¤     any non-prescribed treatments including complementary therapies,
       ¤     prescription and non-prescription medicines,
       ¤    use of alcohol, tobacco and illicit drugs
Inadequate response to treatment 
       ¤   Review the diagnosis.
       ¤   Check adherence to antipsychotics.
       ¤   Review psychological treatments.
       ¤   Consider other causes of non-response.
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.


       >    Inform the patient of the high risk of relapse if medication is stopped within 1-2 years.
       >    If withdrawing antipsychotic medication do so gradually.
       >    Regularly monitor for signs and symptoms of relapse for at least 2 years after withdrawal. 

All material in this section is aimed at health care professionals, but is information currently held in the public domain, members of the  
public seeking advice on medicine-related matters are advised to speak with their GP, pharmacist, nurse or contact NHS111 Service 
 Email: info.elmmb@nhs.net
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