| 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 |
| |
| * 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. |
| |
| 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 |
| |
| Monitoring |
| Link to Suggested Monitoring Requirements of High Risk Drugs |
| |
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. |
| |
| 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.
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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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| back to main chapter |
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