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. |
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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. |
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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. |
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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. |
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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 |
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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. |
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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 |
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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 |
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Inadequate response to treatment |
¤ Review the diagnosis. |
¤ Check adherence to antipsychotics. |
¤ Review psychological treatments. |
¤ 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. |
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. |
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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 |
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