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1 Title Document Details Shared Care Agreement: Antipsychotics (Risperidone, Olanzapine, Quetiapine, Aripiprazole, Amisulpride or Asenapine) Trust Ref No Local Ref (optional) Main points the document Requirements of shared care covers Who is the document Prison healthcare staff aimed at? Author Adopted from SSSFT Approval Process Approved by Quality and Safety Delivery Group (Committee/Director) Approval Date 6 th December 2017 Initial Equality Impact no Screening Full Equality Impact no Assessment Lead Director Director of Quality and Nursing Category Policy Sub Category Guideline Review date 31 st October 2019 Distribution Who the policy will be Prison healthcare distributed to Method Notification to healthcare manager of availability on website Document Links Required by CQC Yes Required by NHSLA no Other Amendments History No Date Datix Ref:

2 Essential Shared Care Agreement: Antipsychotics (Risperidone, Olanzapine, Quetiapine, Aripiprazole, Amisulpride or Asenapine) Reference number SH/ESC: Antipsychotic Version 1 Author Ratification / Issue date October 2017 Reviewed date October 2019 Please complete the following details: Patient Name: Datix Ref:

3 NHS Number: Patient s Address: Patient s Date of Birth: As of this date: Please add to repeat prescription Medication prescribed: Dose: Note: Guidelines will only be written when it has been agreed that shared care is or maybe an appropriate option in individual cases, and will include a statement of Specialist Unit /GP responsibilities. Shared Care Guidelines will ensure that all GPs have sufficient information to enable them to undertake responsibility for specialist therapies and other therapies which may affect/interact with specialist therapies. It is not the intention to insist that GPs prescribe such a therapy and any doctor who does not wish to undertake the clinical and legal responsibility for a Shared Care Drug is not so obliged. Acceptance of the Shared Care Guidelines will be endorsed by the Quality Assurance process within Shropshire Community Health NHS Trust and South Staffordshire and Shropshire Foundation NHS Trust. The information contained in this guideline is issued on the understanding that it is the best available from the resources at our disposal at the time of issue. For further information please refer to the relevant Summary of Product Characteristics and NICE guidance or contact your local Specialist or Drug Information Centre. Further copies of this guideline may be obtained from: South Staffordshire & Shropshire Healthcare Foundation NHS Trust website Shropshire Community Health NHS Trust website Produced: October 2017 Review Date: October 2019 Datix Ref:

4 SHARED CARE GUIDELINES FOR ANTIPSYCHOTICS Referral Criteria In some cases, prescribing will have been initiated in the community by a GP and in these cases, shared care is not appropriate, and prescribing responsibility remains with the GP. An initial assessment, risk assessment and review of previous information and treatment history will be completed by Shropshire Community Health primary mental health clinicians and appropriate interventions provided in primary care. Referral to the SSSFT secondary mental health team (Inreach) should be made based on the patient needs requiring secondary care mental health team input. The SSSFT secondary care mental health team will be referred to as the Inreach Team from here on in this document. When initiation is by the Inreach team; the visiting consultant will prescribe on SystmOne and the prescription will be dispensed via the normal mechanism for the establishment. The potential trigger for shared care is when the patient appears stable since the last review, i.e. no change in mental state, no significant changes in medication An individual care programme approach care plan will be defined for them and a copy of the care plan will be available in the patient s medical records on system one for the GP to review. Specialist Services Responsibilities Assess the patient, establish a diagnosis and determine a management strategy to include the establishment of a Care Programme Approach where appropriate and involvement of care co-ordinator from the Inreach team. Baseline tests will be requested by the Inreach team care co-ordinator and tests will be undertaken by primary care. Results will be reviewed in system one initially by the GP prior to being filed in the patient s record (according to local arrangements). The GP will complete any priority actions associated with abnormal results and advise the Inclusion integrated team via task. The Inreach team care co-ordinator will highlight the results to the visiting psychiatrist for review before transfer to shared care. Results of baseline (or other) tests will be recorded in the system one record and accessible to all healthcare staff. Ensure that the Inreach team care co-ordinator has drawn up a plan of care involving the GP. The specialist should ensure that the patient s condition and antipsychotic dose is stable before the GP is asked to participate in shared care. Send a letter to the GP suggesting that the patient s condition now seems appropriate for a shared care approach, and that shared care is assumed to be formally agreed for this patient, unless the practice responds differently within 2 weeks. Datix Ref:

5 Communicate to the GP, monitoring results to date, and what needs to be monitored next and when (see Appendix 1). If the indication or use is off label for the product, the GP will be informed and this will be documented on the clinical system. The visiting psychiatrist will prescribe two weeks supply of antipsychotic dispensed by the normal mechanism for the establishment) after the date of the letter Specialist services will review the patient as clinically appropriate and will ensure the GP understands what the plan for review timings is. Alteration of (or advice about) antipsychotic dosage according to clinical parameters should be provided by the specialist. Evaluation of adverse events reported by the GP, and identification of any specific monitoring required. Restarting antipsychotic therapy should this be necessary. GP Responsibilities Reply to the request for shared care as soon as practicable by sending a task to the Inreach team once the agreement in Appendix 2 has been signed and attached to the patient record. Monitoring the patient s overall health and well-being Specific monitoring agreed with the specialist; see Appendix 1. Prescribing antipsychotic in line with recommendations by the specialist Adverse drug reaction/interaction monitoring Immediate referral to hospital is required if patients develop signs of Neuroleptic Malignant Syndrome (see under Adverse Effects for symptoms) Note: Neuroleptic Malignant Syndrome is an extremely rare adverse effect of all antipsychotics. Keeping the care co-ordinator and the Inreach team informed of progress Inform specialist of all relevant medical information regarding the patient and any changes to the patient s medication irrespective of indication. Appendix 1 Monitoring of patients taking antipsychotics Atypical antipsychotics differ in their potential to cause the metabolic syndrome & diabetes: high risk antipsychotics include e.g. Olanzapine & Clozapine; 80% of patients developing Datix Ref:

6 Diabetes will do so in the first year of treatment. The following represents minimum recommended monitoring requirements, clinicians may monitor more frequently if clinically indicated (and NICE recommends weekly monitoring of weight for the first 6 weeks). Time Period Antipsychotic Drug/ Class All: Weight (should be done weekly for the first 6 weeks and NICE recommend plotting on a chart) and BMI Waist circumference Pulse & BP f- Glucose, HbA1c f- Lipid (total cholesterol, HDL-cholesterol, LDL-cholesterol, triglycerides), U&Es, serum creatinine, LFTs, FBC Prolactin ECG (if personal history of CV disease or high risk) Prior to initiation = baseline Assessment of any movement disorders, nutritional status, diet and level of activity Clozapine, ECG required Clozapine: for monitoring during initiation, refer to Clozapine Policy & Procedures All: BMI Clozapine & Olanzapine: f- glucose, HbA1c, pulse and BP 1 month 3 months All: f-lipid, BMI and weight, pulse and BP, f-glucose, HbA1c, 12 months All: f-glucose, HbA1c f-lipids, BP, BMI, waist circumference All: f-glucose, HbA1c f-lipids, pulse & BP, BMI and weight, U+Es, FBC, LFTs After first year Waist circumference Annually (after first year) All: f-glucose, HbA1c f-lipids, pulse & BP, BMI and weight, U+Es, FBC, LFTs Waist circumference In addition to annual testing requirement Quetiapine: additionally TFTs All- in children & adolescents: BMI 6-monthly Clozapine & Olanzapine: f- glucose & HbA1c every 6 months Clozapine: U+Es, LFTs The following paraclinical tests may be indicated: Prolactin HbA1c Haemoglobin Clotting studies If patient has galactorhoea, menstrual abnormalities, increased breast growth, and/or changed libido. Routinely in children & adolescents at baseline before starting any medication If patient has clinically manifest Diabetes Mellitus see NICE Guideline 28 for schedules If patients show excessive bruising Datix Ref:

7 S-levels, U-drug If clinically indicated screen, X-rays, EEG, MRI, CT, SPECT etc. All tests mentioned above need to be taken more often if a deterioration either clinically or biochemically is noted. Please refer to BNF for further information. Adverse Effects Common adverse effects include sedation, movement problems, weight gain, anticholinergic side effects, blurred vision and sexual problems. For full details, see Summary of Product Characteristics for the individual drug. Neuroleptic malignant syndrome (NMS) hyperthermia, muscle rigidity, bradycardia, tachycardia, elevated or labile blood pressure, autonomic instability, altered consciousness, incontinence, sweating and elevated CPK levels - is an extremely rare adverse effect of all antipsychotics. Should a patient develop signs suggestive of neuroleptic malignant syndrome immediate referral to hospital is required and all antipsychotics should be discontinued immediately. Side Effects Action Tardive Dyskinesia and other movement disorders Refer to consultant A reduction in dose, discontinuation or change to an alternative (atypical) antipsychotic may be required GP to consider treated with anticholinergic medications or Extrapyramidal benzodiazepines symptoms(tremor, rigidity, bradykinesia, Acute dystonia may require treatment with intramuscular akathisia, acute procyclidine. dystonia) Referral back to the consultant See above Discontinue antipsychotic(s) Immediate referral to hospital (NMS is a medical Neuroleptic malignant emergency) syndrome (NMS) Refer immediately to consultant Restrict dose to night time only or try to give a smaller dose Somnolence/Drowsiness in the morning Patients should be advised not to drive or operate machinery Constipation Recommend a high fibre diet and to drink plenty of fluids Consider adding a bulk-forming and/or stimulant laxative Dry mouth Suck on sugar free boiled sweets Hypotension/dizziness Advise patient to take time to get up. Measure BP periodically in patients over 65 years Weight Gain Encourage a healthy balanced diet and regular exercise Datix Ref:

8 Increase in prolactin levels (transient) If Symptoms of hyperprolactinaemia occur (rare), a reduction in dose may be required. Refer to Consultant. Ask about side effects at every consultation. Appendix 2: Shared Care Agreement for Atypical Antipsychotics (Oral) Shared Care Agreement for Atypical Antipsychotics (Oral) Name of Prescriber: Specialist Area: Telephone Number: Fax Number: Signature: Date: Patient s Name: Address: Drug and dose: Name of GP: Signature: Date: Practice Address Datix Ref:

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