Preferred Prescribing Choices of Antipsychotic Drugs (APD) in Adults for Schizophrenia and Other Psychoses

Transcription

1 Preferred Prescribing Choices of Antipsychotic Drugs (APD) in Adults for Schizophrenia and Other Psychoses HPFT Medicines Formulary lists the APDs that have been approved for use, however, it does not provide any detail on how these APDs should be selected. It is widely accepted that there is very little difference in efficacy between the approved APDs (except clozapine). However, there are notable differences in their side-effect profiles and more recently, due to patent expiries, significant variations in their cost (see graphs 1 and 2). When making prescribing decisions, clinicians are expected to take into account many factors including the cost impact an APD choice will have on the wider health economy. The algorithm below and table 1 include the important factors to be considered when selecting an APD for schizophrenia. Table 1 also lists the preferred APDs as they represent more cost-effective choices. APDs are also often used in the management of other mental health disorders and the same considerations should be applied when selecting an APD in these situations too. Clinicians should consider selecting APDs from the preferred list wherever possible, however it is recognised that the preferred APDs may not always be appropriate or meet the needs of every individual and second line alternative APD choices are therefore provided. Clinicians must ensure that there is a clear and valid rationale for selecting an alternative choice of APD and that this is documented and communicated to the relevant GPs when requesting continuation prescribing. Sufficient clinical information, including monitoring requirements must also be provided so that the GP can safely take on prescribing responsibility. See pg 6 for checklist of minimum information that must be provided to the GP. Antipsychotic Treatment Algorithm for Schizophrenia (Adapted from Maudsley Prescribing Guidelines in Psychiatry 11 th Edition) Choice of APD should be based on indication, product licensing, comorbidities, risk factors, likely benefits, side effect profile, cost, previous patient response and individual patient preference as well as other factors see table pg 2 and 3 Agree choice of APD from preferred list where possible with patient (and carer if appropriate). Include use of patient decision aids where possible. Titrate if necessary to minimum effective dose Adjust dose according to response and tolerability Assess over 2-3 weeks. Reassess partial responders at 6 to 8 weeks Effective Continue at dose established as effective. Once stable provide the GP with the necessary information to allow safe transfer of prescribing & monitoring responsibility Ineffective or not tolerated Change APD and follow above process Poor compliance Not tolerated Change APD and follow above process Effective Continue at dose established as effective. Once stable provide the GP with the necessary information to allow safe transfer of prescribing & monitoring responsibility Ineffective Consider clozapine in line with NICE CG 82 and SIGN 131 If poor adherence is related to poor tolerability, discuss with patient and change APD If poor adherence is related to other factors, consider APD depot/lai or compliance aids Page 1 of 6

2 Preferred APD choices and second line alternatives NICE CG 82 for Schizophrenia does not differentiate between choice of first and second generation antipsychotics. An oral APD should be offered first line unless patient prefers depot/lai after an acute episode, or when avoiding covert non-adherence to antipsychotic treatment is a clinical priority. HFPT Drugs and Therapeutics Committee has considered the SIGN 131 Guideline on management of schizophrenia, and concluded that the prescribing choices listed below are appropriate. First generation oral APDs are not drugs of choice ahead of second generation oral agents or first generation antipsychotic depots. Table 1 Antipsychotic Group Oral antipsychotics First generation (typical) (FGA) and Second generation (atypical) (SGA) Antipsychotic Depot (FGA) and Long Acting injections (LAI) (SGA) Preferred choices 2 nd line alternatives Prescribing Notes Haloperidol tablets (FGA), Olanzapine tablets (SGA), Quetiapine immediate release (IR) tablets (SGA), Risperidone tablets (SGA) Sulpiride tablets (FGA) Flupentixol decanoate (FGA), Fluphenazine decanoate (FGA), Haloperidol decanoate (FGA), Pipotiazine palmitate (FGA), Zuclopenthixol decanoate (FGA) All other FGAs listed in HPFT formulary Amisulpride tablets (SGA), Aripiprazole tablets (SGA), Quetiapine XL tablets (SGA), Clozapine tablets (SGA) Risperidone LAI (SGA), Paliperidone palmitate LAI (SGA) Second line alternatives should be considered when preferred choices are not appropriate. The rationale for selecting a second line preference must be valid, documented and clearly communicated to GP. All APDs should be prescribed by generic name. See side-effect table and cost comparison charts below to help guide choice of APD. Standard tablets are preferred. Orodispersible tablets and liquid formulations should only be used when clinically essential. Use cost chart to select the most cost-effective formulations. Quetiapine IR tablets must be used for all new patients. XL tablets may be used when initiating/titrating doses in acute situations however patients must be switched to IR tablets thereafter. XL tablets otherwise should only be used when IR tablets are not tolerated because of excessive sedation or non compliance with a twice daily regime. Rationale for XL must be documented and provided to GP. Clozapine to be considered for schizophrenia in those who have not responded to two APDs including a SGA. Clozapine prescribing to remain with HPFT. Olanzapine embonate LAI is not approved for use except on an individual named patient basis. Paliperidone oral is not approved for use. Paliperidone LAI is approved for use within licensed indications on a named patient basis when one or more of the following advantages of paliperidone (over risperidone) would be of significant benefit - monthly administration, quicker onset of action, 7 day flexibility to avoid missed doses, smaller administration volume, fewer drug interactions, wider dosing range and no dose adjustment required in mild to moderate hepatic impairment. Page 2 of 6 2

3 Antipsychotics relative side-effects The following table can be used by prescribers in conjunction with patients to help guide choice of APD. Alternatively the Choice and Medication website provides information for patients on medicines used in mental health. The handy chart comparing medicines used for psychosis is a more patient friendly resource which may be helpful when discussing potential benefits and harms of individual antipsychotics with patients. Please note the Choice and Medication website may include information on medicines that have not been approved in Hertfordshire. Preferred oral choices Haloperidol Olanzapine Quetiapine (IR) Risperidone Sulpiride 2nd Line alternative oral choices Amisulpride Aripiprazole Chlorpromazine Clozapine Flupentixol Promazine Trifluoperazine Zuclopenthixol Preferred Depot injections Flupenthixol Fluphenazine Haloperidol decanoate Pipotiazine Zuclopenthixol 2 nd Line Alternative Long acting injections Paliperidone Risperidone Consta marked effect moderate effect mild/ transient effect little or minimal effect no information available or little reported Reference: Stephen Bazire Psychotropic Drug Directory 2012 Page 3 of 6 3

4 Graph 1 - Antipsychotic comparative costs for 28 days treatment on maximum licensed doses. (Drug Tariff Sep 2013) (NB Doses quoted do not imply equivalence) Clozapine tabs (Denzapine ) 900mg/day Aripiprazole liquid 30mg/day Aripiprazole orodisp tabs 30mg/day Aripiprazole tabs 30mg/day Amisulpride liquid (Solian )1200mg/day Amisulpride liquid 1200mg/day Amisulpride (Solian )1200mg/day Amisulpride 1200mg/day Sulpiride liq (Sulpor ) 2400mg/day Sulpiride tabs 2400mg/day Sulpiride tabs (Dolmatil ) 2400mg/day Risperidone oral sol 16mg/day Risperidone liquid (Risperdal ) 16mg/day Risperidone orodisp (Risperdal Quicklets) 16mg/day Risperidone tabs (Risperdal ) 16mg/day Risperidone tabs 16mg/day 4.33 Quetiapine MR (Seroquel XL) tabs 800mg/day Quetiapine (Seroquel ) tabs 750mg/day Quetiapine tabs (Gen) 750mg/day Haloperidol liquid 30mg/day Haloperidol tabs 30mg/day Olanzapine velotabs (Zyprexa ) 20mg/day Olanzapine tabs (Zyprexa ) 20mg/day Olanzapine orodispersibe sugarfree (Gen) 20mg/day Olanzapine orodispersible (Gen) 20mg/day Olanzapine tabs (Gen) 20mg/day Preferred APD choice Premium priced preparations to be avoided/restricted 2nd line alternative choices 2nd line premium priced preparations to be avoided Page 4 of 6 4

5 Graph 2 - Antipsychotic depot and LAI comparative costs for 28 days treatment on ranging doses Drug Tariff Sep 2013 ( Doses quoted do not imply equivalence) Paliperidone 150mg/month Paliperidone 100mg/month Paliperidone 75mg/month Paliperidone 50mg/month Risperidone Consta 50mg/2w Risperidone Consta 37.5mg/2w Risperidone Consta 25mg/2w Pipotiazine (Piportil) 200mg/4w Pipotiazine (Piportil) 100mg/4w Pipotiazine (Piportil) 50mg/4w Fluphenazine (Modecate) 100mg/2w Zuclopenthixol (Clopixol) 600mg/1w Zuclopenthixol (Clopixol) 500mg/2w Zuclopenthixol (Clopixol) 200mg/2w Haloperidol (Haldol) 300mg/4w Haloperidol (Haldol) 50mg/4w Flupentixol (Depixol Conc) 300mg/2w Flupentixol (Depixol Conc) 50mg/4w Flupentixol (Depixol) 40mg/2w Flupentixol (Depixol) 20mg/2w Preferred APD depot 2nd line alternative APD LAI Page 5 of 6 5

6 Transfer of APD prescribing to GPs Patients must be stabilised on an APD before requesting the GP to take over prescribing responsibility. The following minimum information must be provided to enable the GP to safely take on the continued prescribing for the patient: Choice of APD: including formulation and dose. Rationale for choice of APD: if not a preferred choice, provide explanation as to why preferred choices are not appropriate and why second line alternative APD has been selected. Where relevant include details of APDs that have already been tried and why they were discontinued or not appropriate. Monitoring requirements: as per physical health policy. Date of next review Prescriber contact details: in case GP has any queries or concerns. Clinicians must ensure all the above information is included in correspondence to GPs to ensure the smooth and safe transfer of prescribing responsibility. References; NICE Clinical guideline 82 Schizophrenia 2009 SIGN 131 Management of Schizophrenia 2013 Psychotropic Drug Directory 2012, Stephen Bazire The Maudsley Prescribing Guidelines in Psychiatry 11 th Edition 2012 Drug Tariff - September 2013 Approved by HPFT DTC September 2013 Approved by HMMC September 2013 Approved by PCMMG November 2013 Review date: September 2015 or sooner if new evidence is published or if significant price changes occur. Page 6 of 6