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4.2 Drugs uses in psychoses and related disorders

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4.2.1 Antipsychotic Drugs

(see nausea and vomiting in terminal care section 4.6)
Chlorpromazine tablets, syrup, suppositories, injection (deep IM only)
Haloperidol capsules, tablets, elixir, injection
Promazine tablets, syrup, injection
Sulpiride tablets
Trifluoperazine tablets, MR capsules, syrup
Flupentixol tablets
Levomepromazine tablets, injection (palliative care only)
Zuclopenthixol tablets

 

Atypical Antipsychotics
Amisulpride tablets (consultant psychiatrist only)
Olanzapine tablets, injection (consultant psychiatrist only)
Risperidone tablets, liquid - first line
Quetiapine tablets, MR tablets (Consultant psychiatrist only. MR reserved for patients with compliance problems)
 
Aripiprazole tablets - see NICE TA 213: 'Aripiprazole for the treatment of schizophrenia in people aged 15 to 17 years'

Notes:

1. A baseline ECG is now recommended for all in-patients prior to receiving any antipsychotic drug. An ECG should also be performed if physical examination shows specific cardiovascular risk (e.g. high blood pressure) or there is a personal history of cardiovascular disease (NICE CG82, March 2009). It is recognised that carrying out a baseline ECG immediately prior to Rapid Tranquillisation is inappropriate. However, in settings where Rapid Tranquillisation is likely to be used, it is suggested that a baseline ECG is obtained on or soon after admission to the ward.

2. Link to Managing behaviour problems in patients with dementia:

  • Only 1 in 5 patients with dementia symptoms can be helped with antipsychotic drugs, any effect is likely to be weak.

  • Serious harms, particularly stroke and increased mortality are associated with antipsychotic use in dementia.

  • NICE and social care guidance recommends use of antipsychotics in dementia for non-cognitive symptoms only if the person is severely distressed or there is an immediate risk of self-harm or harm to others.

  • Treatment should be short term (maximum 12 weeks). A plan for dose reduction or discontinuation should be made when treatment is started and documented in the care plan.

3. Extrapyramidal symptoms may be relieved by anticholinergic drugs such as procyclidine but they should not be prescribed as routine prophylaxis.

4. Tardive dyskinesia is usually associated with long term therapy.

5. High doses of antipsychotic drugs are should be prescribed on the advice of a consultant psychiatrist only. A pre-treatment ECG should be performed in this instance.

6. Risperidone has been associated with intra-operative floppy iris syndrome in patients undergoing cataract surgery. Patients taking this drug should be identified at pre-op assessment and the surgeon informed. See DSU November 2013 

Antipsychotic use may be associated with an increased risk of venous thromboembolic events.

Prescribing for the elderly

The balance of risks and benefit should be considered before prescribing antipsychotic drugs for elderly patients. In elderly patients with dementia, antipsychotic drugs are associated with a small increased risk of mortality and an increased risk of stroke or transient ischaemic attack. Furthermore, elderly patients are particularly susceptible to postural hypotension and to hyper- and hypothermia in hot or cold weather.

It is recommended that:

  • Antipsychotic drugs should not be used in elderly patients to treat mild to moderate psychotic symptoms.

  • Initial doses of antipsychotic drugs in elderly patients should be reduced (to half the adult dose or less), taking into account factors such as the patient’s weight, co-morbidity, and concomitant medication.

  • Treatment should be reviewed regularly.

  

4.2.2 Antipsychotic depot injections

Flupenthixol decanoate injection
Haloperidol decanoate injection
Zuclopenthixol decanoate
Risperidone - consultant psychiatrist only

 

4.2.3 Antimanic Drugs

Lithium carbonate tablets
Lithium citrate liquid
Sodium valproate MR (Epilim Chrono)

Sodium valproate should not be used during pregnancy and in women of childbearing potential unless clearly necessary (high risk of neurodevelopmental delayand congenital malformations in children following maternal use). See DSU November 2013 and also DSU January 2015.

 

Notes:

1. The decision to give prophylactic lithium treatment requires specialist advice.

2. Lithium salts have a low therapeutic/toxic ratio and plasma concentrations must be regularly monitored to achieve levels of 0.4-1.0 mmol/litre.  Levels of 0.4 - 0.8 are usually adequate for maintenance and will minimise side effects. Sampling should be 12 hours post dose.

3. Changing patients from their usual brand of lithium preparation may result in altered serum concentrations of the drug.

4. 5.4mmol Lithium in 5ml is equivalent to 200mg lithium carbonate.

For link to BNF section: 4.2 Drugs used in psychoses and related disorders