Antipsychotic Medicine - Prescribing and Monitoring (Dr J Lawton) Flashcards
What are some of the components of Mental Health Services across Nottingham?
Primary care - GP, mental health nurses Specialist MH Services Early Intervention in Psychosis Teams Crisis and Home Treatment Teams Community MH Teams Assertive Outreach Teams (some patients don't engage with primary care) In-Patient Care - acute, residential
Who may be involved in MDT for Adult Mental Health Services?
GP, psychiatrist, nurses, junior docs, pharmacists, healthcare assistants, occupational therapists, psychologists, non-medical prescribers, social workers.
What extra services may be offered to the public aside form the Adult Mental Health services?
MH Services for Older People (65+) Child and Adolescent MH Services Intellectual Disability Services Forensic Psychiatry Drug and Alcohol Services Dual Diagnosis Services (i.e. substance misuse and MH) Perinatal Psychiatry Services Offender Health Services
What are the roles of a pharmacist in MH care?
Explain medicine, provide information
Support adherence, review treatment plans - simplify regimens and review PRN use
Interactions, polypharmacy, high doses, monitor side effects and also general physical health.
Drug histories, TDM result interpretations
Sign post to services- links to MH services
Promote evidence based treatments
Break the stigma
Support carers
Healthy choices / Health promotion
Smoking cessation (smoking, cP450 1A2 induction and clozapine
What is GASS?
Glasgow Anti-Psychotic Side Effect Scale
What is an MHA Second Opinion Consultee?
After 3 months being detained and treated under the Mental Health Act; before release, experts are consulted
What is the rate of relapse like in chronic schizophrenia?
60-70% with chronic will relapse within 1 year of stopping medication VS
10-30% who remain on treatment
How long should medication be continued for after an acute episode of schizophrenia?
1-2 years following recovery
Do not stop medicine abruptly
Monitor for signs/symptoms of relapse for 2 years after stopping medication.
What formulations are used that are modified for anti-psychotic target use?
Olazapine, aripiprazole and risperidone are available as oro-dispersible tablets;
Freeze dried wafer
Disperses in saliva
Difficult to conceal
Short acting injections used for tranquilisation
Long acting depot injections - may improve medication adherence
What is Rapid Tranquilisation?
Use of medicine to control extreme agitation, aggression or potentially violent behaviour that put the individual or those around them at risk of physical harm.
The aim is to sedate the person to minimise the risk without the person losing consciousness.
What medication is no longer recommended for rapid tranquilisation and why?
Clopixol-Acuphase
Peak concentration in plasma after 24h
What are the risks associated with anti-psychotic use in rapid tranquilisation?
Excessive sedation
Loss of consciousness
Respiratory depression –> arrest
Cardiovascular complications or collapse
Seizures Akathisia Dystonia Dyskinesia NMS
What are the risks associated with using benzodiazepines in rapid tranquilisation?
Excessive sedation
Loss of consciousness
Respiratory depression –> arrest
Cardiovascular collapse
What should be monitored in a patient that has been sedated by rapid tranquilisation?
Blood pressure, respiration, pulse, temperature, level of consciousness
Give some examples of monthly depot injections?
Paliperidone palmitate Xepilion
Risperidone Consta
Aripiprazole Maintena
Olazapine ZypAdhera
Where are long acting depot injections of anti-psychotics administered?
Deltoid or gluteal
What is NMS?
Neuroleptic malignant syndrome (NMS) is a life-threatening neurological disorder most often caused by an adverse reaction to neuroleptic or antipsychotic drugs.
What is Akathisia?
Akathisia is a movement disorder characterized by a feeling of inner restlessness and a compelling need to be in constant motion, as well as by actions such as rocking while standing or sitting.
What drugs are oil based depot injections?
Normally contain palmitate or decanoate
Old fashioned oil based formulations
What is treatment resistant schizophrenia?
Failure to respond to two different antipsychotics (one of which is atypical) each prescribed for atleast 6-8 weeks in recommended doses.
What ‘other’ reasons could be the cause of treatment resistant schizophrenia?
Not taking the medicines
Alcohol or illicit substance use
What should be tried in patients that have treatment resistant schizophrenia?
Clozapine is the drug of choice and should be introduced at the earliest opportunity.
What service encomapases patients taking Clozapine?
The UK Registered Clozapine Patient Monitoring Services
What is monitored in patients taking Clozapine?
Full blood count needed
Weekly bloods needed for first 18 weeks
Fortnightly bloods up to a year
Then monthly bloods
What happens when a patients monitoring on Clozapine comes up with a Red Alert Result?
Stop clozapine immediately
What kind of drugs are contraindicated in patients taking Clozapine?
Patients taking other drugs that cause bone marrow suppression
What is Clozapine metabolised by?
c1A2 and c2D6
When is a patient most at risk when taking Clozapine?
In the first 18 weeks
What are the side effects of Clozapine?
Drowsiness Hypertension or hypotension and dizziness Increased HR Raised body temperature Hypersalivation Constipation (can be severe) Nausea (domperidone) Weight gain Nocturnal enuresis Lowers the seizure threshold (use prophylactic sodium valproate when clozapine given >600mg/day) Raised blood glucose and lipid levels Cardiomyopathy / myocarditis
What is nocturnal enuresis?
Nocturnal enuresis is involuntary urination that happens at night while sleeping, after the age when a person should be able to control his or her bladder.
How can Clozapine induced nausea be treated?
Domperidone
How can the lowering of the seizure threshold be counterbalanced in patients taking >600mg/day Clozapine?
Sodium valproate prophylaxis
What is necessary if 48hr without a Clozapine dose?
Patient must re-titrate the dose due to a loss of tolerance
What are the signs of cardiomyopathy / myocarditis?
Persistent tachycardia with fever, hypotension or chest pain
Rare but can be fatal
What can be done is Clozapine does not work?
Assess response over atleast 6 months
Gradually increase the dose
Monitor plasma concentrations of clozapine
Augment with a 2nd anti-psychotic for a trial period.
How is the choice made for a specific anti-psychotic?
Decision should be made with HCP and service user taking into account the views of the carer if the service user agrees
Provide information and discuss the likely benefits and possible side effects of each drug including; metabolic, extrapyramidal, cardiovascular, hormonal, other
What are the side effects considered when discussing anti-psychotics?
Metabolic Extrapyramidal Cardiovascular Hormonal Others
How do we facilitate patient choice?
Informed discussion
Decision aids
Choice and medication
What baseline investigations are completed before a patient is started on an anti-psychotic?
Physical examination Weight, BMI, waist circumference Pulse and BP Fasting glucose and HbA1c Fasting blood lipids Prolactin levels ECG if specified CV risk Any movement disorders Nutritional status, diet and level of physical activity Smoking status
What are routinely monitored in patients taking anti-psychotic medication?
Response (change in symptoms and behaviour) Side effects and impact on functioning Weight, weekly for first 6 wks, then at 3 months then annually Waist circ, annually Pulse/ BP at 3 months then annually Adherence checks Overall physical health Shared care with GP
What steps outline good prescribing of anti-psychotics?
Record indication, benefits/risks and expected response time
Start at lower end of the dose range, slowly titrate upwards keeping within the BNF limits
Consider a therapeutic trial as 4-6 weeks at optimum dose
Justify and record reasons for Rx doses above BNF limits
Record rationale for changes or continuation medication and the reasoning
Avoid polypharmacy except for short periods e.g. when switching antipsychotics
