Anticholinergic (Antimuscarinic) Guidelines. Treatment of Antipsychotic Induced Extra Pyramidal Side Effects (EPSE)

Transcription

1 Berkshire West Integrated Care System Representing Berkshire West Clinical Commisioning Group Royal Berkshire NHS Foundation Trust Berkshire West Primary Care Alliance Anticholinergic (Antimuscarinic) Guidelines Treatment of Antipsychotic Induced Extra Pyramidal Side Effects (EPSE) [APC ClinDoc 036] For the latest information on interactions and adverse effects, always consult the latest version of the Summary of Product Characteristics (SPC), which can be found at: Approval and Authorisation Approved by Job Title Date Area Prescribing Committee APC Chair September 2015 Change History Version Date Author Reason v /10/2018 unknown Updated APC Category This prescribing guideline remains open to review considering any new evidence This guideline should only be viewed online and will no longer be valid if printed off or saved locally Author Unknown Date of production: Sept 2015 Job Title Unknown Review Date unknown Protocol Lead Unknown Version v.1.0

2 ANTICHOLINERGIC (ANTIMUSCARINIC) GUIDELINES TREAMENT OF ANTIPSYCHOTIC INDUCED EXTRA PYRAMIDAL (EPSE) SIDE EFFECTS Authors (Original Contributor) Ms Diane Booth Mrs Kiran Hewitt Mrs Katie Sims former Chief Pharmacist, BHFT Lead Clinical Pharmacist, BHFT Senior Clinical Pharmacist, BHFT Version 7.0 Reviewed 09/2015 Document History 6.0 updated in line with recent references Date of Next Review 09/2017 (or sooner if there are changes to national guidelines) Approved by Drug and Therapeutics Committee, BHFT 13/11/2015 Tel: , Monday Friday 9am 5pm Page 1 of 8

3 Acknowledgements: The authors would like to thank the members of the pharmacy department, Prospect Park Hospital and the Drug & Therapeutics Committee representatives of Berkshire Healthcare NHS Foundation Trust who provided help, advice and constructive feed back during the compilation of these guidelines and for future revisions. Any enquiries regarding these guidelines or other medication related queries should be forwarded to the MIS (Medicines Information Service), pharmacy department, Prospect Park Hospital, on , or your ward/locality pharmacist. Page 2 of 8

4 CONTENTS ANTICHOLINERGIC (ANTIMUSCARINIC) GUIDELINES TREAMENT OF ANTIPSYCHOTIC INDUCED EXTRA PYRAMIDAL (EPSE) SIDE EFFECTS Page Treatment Choices 4 General Treatment Principles 4 Side Effects 5 Movement Disorders 5 Toxicity 5 Discontinuation 6 Prescribing Information 6 Treatment of Special Patient Populations 7 References 8 Page 3 of 8

5 ANTICHOLINERGIC FORMULARY FIRST LINE TREATMENT CHOICE Procyclidine ALTERNATIVE Trihexyphenidyl (formerly benzhexol) If no improvement after a routine adequate trial of medication, Refer to secondary care General Treatment Principles Procyclidine has been chosen as first line treatment choice based on cost and usage within. There is no clear evidence that one anticholinergic is more efficacious than another; individual patients may respond better to, or tolerate one drug over another. 1 Anticholinergics should only be prescribed if other measures for reducing extrapyramidal side effects are not possible, such as lowering the dose of the antipsychotic, or changing to a lower risk antipsychotic e.g. an atypical agent. 2,3 Anticholinergics interact with and therefore should not be routinely used in combination with other drugs with anticholinergic/antimuscarinic properties (eg antihistamines, TCAs, MAOIs), clozapine) due to an increased risk of side effects and anticholinergic burden The lowest effective dose should be used where possible. Do not prescribe these agents prophylactically in anticipation of EPSE. Not all patients develop these side effects. Prescribe on a PRN basis if possible. The recommended dosage of procyclidine is 5mg up to three times a day. Older patients should be prescribed 2.5mg up to twice daily, initially. Most patients do not require anticholinergics on a regular basis. If regular treatment is necessary, use at the lowest effective dose. Attempts should be made to withdraw anticholinergics after three months of therapy and restarted only if symptoms re-emerge. Treatment is rarely needed long term. 4 Page 4 of 8

6 Abuse potential warning: Abuse of anticholinergics, particularly procyclidine and trihexyphenidyl is possible, and all these drugs have a potential street value. Alleged effects with relatively low doses include euphoria, reduced anxiety and psychotic effects. 5 Hence it is important that all anticholinergic consumption and prescribing is carefully monitored. Side Effects Adverse effects are related to the ability of anticholinergic agents to block acetylcholine at muscarinic receptors (and some possible dopamine agonistic activity). All anticholinergics can produce the following effects to varying degrees: 6,7,8 Gastro-intestinal: constipation, dry mouth, nausea and vomiting Ophthalmologic: blurred vision, increased intra-ocular pressure in angle closure glaucoma Cardiovascular: tachycardia, dizziness Genito-urinary: urinary retention, delayed micturition, sexual dysfunction Allergic: hypersensitivity, rash Central Effects: memory and cognitive impairment, nervousness, confusion, drowsiness, sedation, insomnia, euphoria, anxiety, agitation, paranoid delusions, hallucinations Movement disorders It is unclear whether anticholinergic use increases the risk of tardive dyskinesia (TD); much of the literature is conflicting. However, use of these drugs in patients with existing TD can exacerbate the movement disorder and may unmask any latent TD. 9,10 Toxicity It is important to consider a patient s total anticholinergic load from other drugs with an intrinsic anticholinergic activity, for example antipsychotics and tricyclic antidepressants. Page 5 of 8

7 Some evidence suggests that orphenadrine may be more toxic in overdose than the other agents (with trihexyphenidyl possibly the safest and least toxic). 11 The manufacturers of orphenadrine (Disipal ) will be discontinuing it in December 2015 because of manufacturing issues. It will no longer be available as a treatment choice within BHFT. Discontinuation If withdrawn abruptly, anticholinergic agents can cause a discontinuation syndrome, characterised by rebound EPSE, cholinergic rebound, myalgia, depression, anxiety, insomnia, headaches, gastric intestinal distress, nausea, vomiting and malaise. Withdrawal should be slow and gradual, over 1-2 weeks. High doses of medication should be withdrawn even more gradually over a period of weeks. 12 Prescribing Information Drug Form Strength Equivalent Dosages Av. Daily Dose procyclidine tablets 5mg 2mg 5mg up injection 5mg per 1ml to three times a liquid 2.5mg per 5ml day 10mg per 5ml trihexyphenidyl tablets 2mg, 5mg 2mg 1-2mg liquid 5mg per 5ml up to three times day * BNF Max. Daily Dose 30mg (60mg in exceptional circumstances) 20mg 4,13 * 1mg daily initially (5-15mg per day to be given in three to four divided doses). 6 Page 6 of 8

8 Treatment of Special Patient Populations Condition/ Population Pregnancy Lactation Cardio-vascular Disease Glaucoma Liver Disease Renal Impairment Old Age Considerations Information is extremely limited. Use near term has been associated with neonatal withdrawal symptoms. Consult MIS for advice ( ) No information readily available (may inhibit lactation) Consult MIS for advice Use with caution due to potential tachycardia Contra-indicated in angle closure glaucoma Manufacturers advise caution Manufacturers advise caution Use with great care due to anticholinergic burden. Side effects are common and problematic, e.g. confusion. Use cautiously in patients with prostatic hypertrophy. Start with a low dose and stop treatment if/when ineffective or no benefit seen and as part of routine medication rationalisation. Procyclidine can be given twice daily as clearance is reduced. Page 7 of 8

9 References 1. Raja M. Managing antipsychotic induced acute and tardive dystonia. Drug Safety 1998; 19(1): Holloman L, Marder S. Management of acute extrapyramidal effects induced by antipsychotic drugs. Am J Health Syst. Pharm 1997, 1;54(21): Kalish S et al. Antipsychotic prescribing patterns and the treatment of extrapyramidal symptoms in older people. J Am Geriatr Soc 1995; 43(9): Bazire S. Psychotropic Drug Directory 2014, Lloyd-Rheinhold Communications LLP, Dorsington, Warwickshire, UK. 5. Dose M, Tempel HD. Abuse potential of anticholinergics. Pharmacopsychiatry 2000; 33(suppl 1): SPC for trihexyphenidyl (Last Updated on emc 03-Feb-2015, Genus Pharmaceuticals 7. SPC for procyclidine (Kemadrin ) Last Updated on emc 06-Nov-2014, Aspen SPC for orphenadrine (Disipal ). Discontinued 01/12/ Awouters F et al. Tardive dyskinesia: etiology and therapeutic aspects. Pharmacopsych 1990; 23(1): Alphs L, Davis JM. Non catecholaminergic treatments of tardive dyskinesia. J Clin Psychopharmacol 1982; 2(6): Slordan L, Gjerden P. Orphenadrine. Br J Psych 1999;174: Marken PA et al. Anticholinergic drug abuse and misuse: Epidemiology and therapeutic implications. CNS Drugs 1996;5(3): Monthly Index of Medical Specialities, March 2004 edition. Haymarket Medical Publications LTD., London, UK Page 8 of 8