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4.2 Drugs used in psychoses and related disorders

       Schizophrenia NICE Clinical Guidelines [NICE CG178 prevention and management]
         These guidelines relate to adults (18 years and older). For information on early detection and intervention, and for
         recommendations on psychological and psychosocial interventions, see the full guidance.
         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
              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
         * NB - This guidance replaces NICE TA43 which recommended atypical antipsychotics first-line; 
                     this recommendation no longer stands

               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. 
          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
             Link to Suggested Monitoring Requirements of High Risk Drugs
             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.  
         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
              Inadequate response to treatment
                  º  Review the diagnosis.
                  º Check adherence to antipsychotics.
                  º  Review psychological treatments.
                  º  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.
                  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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