The Maudsley Prescribing Guidelines in Psychiatry

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3 The Maudsley Prescribing Guidelines in Psychiatry

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5 The Maudsley Prescribing Guidelines in Psychiatry 12th Edition David Taylor Director of Pharmacy and Pathology South London and Maudsley NHS Foundation Trust Professor of Psychopharmacology King s College London, London, UK Carol Paton Chief Pharmacist Oxleas NHS Foundation Trust Joint Head of the Prescribing Observatory for Mental Health Honorary Research Fellow, Imperial College London, London, UK Shitij Kapur Professor of Schizophrenia, Imaging and Therapeutics Executive Dean and Head of Faculty, Institute of Psychiatry, Psychology and Neuroscience (IoPPN) Deputy Vice Principal (Health Schools) King s College London, London, UK

6 This edition first published by David Taylor, Carol Paton and Shitij Kapur Eleventh edition published by David Taylor, Carol Paton and Shitij Kapur Registered Office John Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial Offices 9600 Garsington Road, Oxford, OX4 2DQ, UK The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK 111 River Street, Hoboken, NJ , USA For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at blackwell The right of the author to be identified as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by health science practitioners for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom. Library of Congress Cataloging in Publication Data Taylor, David, 1946, author. The Maudsley prescribing guidelines in psychiatry / David Taylor, Carol Paton, Shitij Kapur. 12th edition. p. ; cm. Prescribing guidelines in psychiatry Includes bibliographical references and index. ISBN (pbk.) I. Paton, Carol, author. II. Kapur, Shitij, author. III. South London and Maudsley NHS Trust, issuing body. IV. Title. V. Title: Prescribing guidelines in psychiatry. [DNLM: 1. Mental Disorders drug therapy Great Britain. 2. Psychopharmacology methods Great Britain. 3. Psychotropic Drugs administration & dosage Great Britain. 4. Psychotropic Drugs therapeutic use Great Britain. WM 402] RC dc A catalogue record for this book is available from the British Library. Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. Set in 10/12pt Sabon by SPi Publisher Services, Pondicherry, India

7 Contents Preface Acknowledgements Notes on using The Maudsley Prescribing Guidelines List of abbreviations xi xii xiii xv Chapter 1 Plasma level monitoring of psychotropic drugs 1 Interpreting sample results 2 Acting on clozapine plasma concentration results 11 Interpreting post-mortem blood concentrations 13 Chapter 2 Schizophrenia 15 Antipsychotic drugs 15 General introduction 15 general principles of prescribing 20 Minimum effective doses 22 Quick reference for licensed maximum doses 24 Equivalent doses 26 high dose antipsychotics: prescribing and monitoring 28 Antipsychotic prophylaxis 31 combined antipsychotics 37 Negative symptoms 41 Monitoring 45 relative adverse effects a rough guide 48 treatment algorithms for schizophrenia 49 First generation antipsychotics place in therapy 52 omega 3 fatty acid (fish oils) in schizophrenia 54 New and developing drugs to treat schizophrenia 56 NICE guidelines for the treatment of schizophrenia 59 Antipsychotic response to increase the dose, to switch, to add or just wait what is the right move? 61 Antipsychotic long acting injections 66 depot antipsychotics pharmacokinetics 70

8 vi Contents Management of patients on long term depots 72 Aripiprazole LAI 74 olanzapine LAI 75 Paliperidone palmitate LAI 77 risperidone LAI 80 ANTIPSYCHOTICS ADVERSE EFFEcts 84 Extrapyramidal side effects 84 Akathisia 88 Weight gain 90 treatment of drug induced weight gain 92 tardive dyskinesia 97 Neuroleptic malignant syndrome 102 Catatonia 105 QT prolongation 110 Dyslipidaemia 117 diabetes and impaired glucose tolerance 121 Hypertension 128 Hyponatraemia 130 Hyperprolactinaemia 133 sexual dysfunction 137 Pneumonia 143 switching antipsychotics 144 refractory SCHIZOPHRENIA AND CLOZAPINE 147 clozapine dosing regimen 147 optimising clozapine treatment 149 Alternatives to clozapine 153 re starting clozapine after a break in treatment 159 Initiation of clozapine for community based patients 160 clozapine ADVERSE EFFEcts 165 common adverse effects 165 clozapine: uncommon or unusual adverse effects 168 clozapine: serious haematological and cardiovascular adverse effects 170 clozapine induced hypersalivation 174 clozapine induced gastrointestinal hypomotility (CIGH) 177 clozapine, neutropenia and lithium 181 clozapine and chemotherapy 186 Chapter 3 Bipolar affective disorder 189 Lithium 189 Valproate 197 Carbamazepine 203 Antipsychotics in bipolar disorder 208 treatment of acute mania or hypomania 211 Bipolar depression 216 rapid cycling bipolar affective disorder 223

9 Contents vii Prophylaxis in bipolar affective disorder 225 Physical monitoring for people with bipolar affective disorder 228 Chapter 4 Depression and anxiety 231 Introduction 231 Basic principles of prescribing in depression 231 official guidance on the treatment of depression 232 Antidepressants: general overview 233 st John s wort 246 recognised minimum effective doses of antidepressants 250 drug treatment of depression 252 treatment of refractory depression 255 Psychotic depression 266 Electroconvulsive therapy and psychotropic drugs 269 Psychostimulants in depression 272 Post stroke depression 276 treatment of depression in the elderly 279 Antidepressant discontinuation symptoms 283 Antidepressant prophylaxis 287 Antidepressants: alternative routes of administration 290 Antidepressants: swapping and stopping 296 drug interactions with antidepressants 303 cardiac effects of antidepressants 307 Antidepressant induced arrhythmia 312 Antidepressant induced hyponatraemia 316 Antidepressants and hyperprolactinaemia 319 Antidepressants and diabetes mellitus 321 Antidepressants and sexual dysfunction 324 ssris and bleeding 328 Antidepressants: relative adverse effects a rough guide 332 Anxiety spectrum disorders 334 Benzodiazepines in the treatment of psychiatric disorders 343 Benzodiazepines: dependence and detoxification 346 Benzodiazepines and disinhibition 350 Chapter 5 Children and adolescents 353 Principles of prescribing practice in childhood and adolescence 353 depression in children and adolescents 355 Bipolar illness in children and adolescents 362 Psychosis in children and adolescents 367 Anxiety disorders in children and adolescents 369 obsessive compulsive disorder in children and adolescents 374 Post-traumatic stress disorder in children and adolescents 379 Attention deficit hyperactivity disorder 384 Autism spectrum disorders 390

10 viii Contents tics and Tourette s syndrome 397 Melatonin in the treatment of insomnia in children and adolescents 402 rapid tranquillisation in children and adolescents 405 doses of commonly used psychotropic drugs in children and adolescents 408 Chapter 6 Substance misuse 409 Introduction 409 Alcohol dependence 411 opioid misuse and dependence 429 Nicotine and smoking cessation 456 Pharmacological treatment of dependence on stimulants 463 Benzodiazepine misuse 466 gbl and GHB dependence 467 drugs of misuse: a summary 469 Interactions between street drugs and prescribed psychotropic drugs 472 Chapter 7 Use of psychotropic drugs in special patient groups 477 the elderly 477 Dementia 487 safer prescribing of physical health medicines in dementia 507 Management of non-cognitive symptoms of dementia 517 Parkinson s disease 529 Multiple sclerosis 533 huntington s disease 538 Pregnancy 541 Breastfeeding 559 renal impairment 576 hepatic impairment 590 hiv infection 598 Eating disorders 607 Acutely disturbed or violent behaviour 611 Borderline personality disorder 618 Learning disabilities 621 Delirium 625 Epilepsy 632 Surgery 637 Velo-cardio-facial syndrome 643 cytochrome (CYP) function 646 Psychiatric side-effects of non-psychotropic drugs 650 Atrial fibrillation 656 Chapter 8 Miscellaneous conditions and substances 659 Psychotropic drugs in overdose 659 Biochemical and haematological effects of psychotropics 665 Prescribing drugs outside their licensed indications ( off-label prescribing) 673 observations on the placebo effect in mental illness 676

11 Contents ix drug interactions with alcohol 679 Nicotine 684 smoking and psychotropic drugs 688 Caffeine 690 complementary therapies 695 Enhancing medication adherence 700 driving and psychotropic medicines 706 covert administration of medicines within food and drink 714 Index 717

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13 Preface This 12th edition of The Maudsley Prescribing Guidelines in Psychiatry marks its 20th year in continuous production. Readers who have owned or used previous editions will find this edition no different in style from previous incarnations. This is deliberate the feedback we receive suggests the organisation and structure are well liked. Each section of The Guidelines is a densely referenced but succinct review of the literature, set alongside some fairly broad recommendations for practice. Each of these sections has been updated and revised, and some new ones added (for example, interpreting clozapine plasma levels, post mortem plasma levels, summary of depot pharmacokinetics). Much of the guidance provided in this edition has changed as a result of more recent research; some of it to a small extent, some of it to an extent amounting to a reversal of prior guidance (for example, on the use of fish oils in psychosis). These changes reflect the very nature of the scientific method that hypotheses come and go as evidence mounts or is countered. This edition of The Guidelines has a particularly international flavour. This is because the 11th edition sold more copies outside the UK than in it, and because there are, we think, at least ten translations of The Guidelines in existence. Although The Guidelines are still essentially our local guide to prescribing, we have made a special effort to widen, geographically speaking, its utility. This is most noticeable in the inclusion of drugs not licensed in the UK (e.g. ziprasidone, iloperidone, desvenlafaxine), but widely used in other countries. Readers should, therefore, not assume that every drug mentioned in The Guidelines is available in their own country. The reader should also be aware that no guideline could take account of every psychotropic drug used around the world, so omissions are inevitable. As with previous editions, very special thanks are due to Maria O Hagan who manages the writing and structuring of The Guidelines; an increasingly complex process given the size, complexity and heavily referenced nature of the current edition. Thanks are also due to the many expert contributors to The Guidelines who are listed overleaf, and to Adam Gilbert, our editor at Wiley. David Taylor

14 Acknowledgements We thank the following people for contributing their time and expertise to this 12th edition of The Maudsley Prescribing Guidelines in Psychiatry. Adam Winstock Adelaida Naumann Sinden Adrian Treloar Allan Young Andrea Danese Anne Connolly Argyris Stringaris Ayesha Ali Bimpe Idowu Carmine Pariante Celia Feetam Cheryl Kipping Daniel Harwood Daniel Hayes Dave Branford David R. Coghill Delia Bishara Emily Finch Eromona Whiskey Faith Borgan Fiona Gaughran Flora Coker Francis Keaney Gay Sutherland Georgina Boon Gordana Milavic Ifeoma Okonkwo Irene Guerrini James Bell Jane Marshall Jenny Bearn Kalliopi Vallianatou Katie Beck Louise Howard Marco Lyons Marinos Kyriakopoulos Maxine Patel Michael Kelleher Nada Zahreddine Oliver Howes Olubanke Olofinjana Paul Gringras Petrina Douglas Hall Rob McCutcheon Robert Flanagan Robert Howard Robin Murray Russell Foster Sally Porter Sarah Elliott Seema Varma Shubhra Mace Siobhan Gee Thomas Barnes Tiago Marques Tom Walker Tilley Tony Cleare Vivienne Curtis

15 Notes on using The Maudsley Prescribing Guidelines The main aim of The Guidelines is to provide clinicians with practical and useful advice on the prescribing of psychotropic agents in commonly encountered clinical situations. The advice contained in this handbook is based on a combination of literature review, clinical experience and expert contribution. We do not claim that this advice is necessarily correct or that it deserves greater prominence than guidance provided by other professional bodies or special interest groups. We hope, however, to have provided guidance that helps to assure the safe, effective and economic use of medicines in psychiatry. We hope also to have made clear precisely the sources of information used to inform the guidance given. Please note that many of the recommendations provided here go beyond the licensed or labelled indications of many drugs, both in the UK and elsewhere. Note also that, while we have endeavoured to make sure all quoted doses are correct, clinicians should always consult statutory texts before prescribing. Users of The Guidelines should also bear in mind that the contents of this handbook are based on information available to us in December Much of the advice contained here will become out dated as more research is conducted and published. No liability is accepted for any injury, loss or damage, however caused. Notes on inclusion of drugs The Guidelines are used in many other countries outside the UK. With this in mind, we have included in this edition those drugs in widespread use throughout the western world in December Thus, we have included, for example, ziprasidone and iloperidone, even though these drugs are not marketed in the UK at this time. Their inclusion gives The Guidelines relevance in those countries where ziprasidone and iloperidone are marketed, and may also be of benefit to UK readers, since many unlicensed drugs can be obtained through formal pharmaceutical importers. We have also tried to include information on drugs likely to be introduced into practice in the next two years. Many older drugs, or those not widely available (methotrimeprazine, pericyazine, maprotiline, zotepine, loxapine etc.), are either only briefly mentioned or not included on the basis that these drugs are not in widespread use at the time of writing.