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. |
| |
Prescribing
|
| > 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
|
contraindicated.
|
| |
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 |
| |
Monitoring |
Link to Suggested Monitoring Requirements of High Risk Drugs
Pre-treatment
|
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.
|
Withdrawal |
| > 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 |
| Copyright© 2019 East Lancashire Medicines Management Board. |
| All rights reserved. Disclaimer/Terms and conditions |
| |
|
| |
| |
