Fasting total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides (if fasting levels are not already available) *

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1 Antipsychotic Shared Care and Physical Health Monitoring Recommendations Version 5 INDICATION - All patients on antipsychotics for chronic psychiatric illness Consultant/Specialist Care Services will initiate antipsychotic treatment RESPONSIBILITIES OF THE SECONDARY CARE SPECIALIST Perform mental health assessment prior to starting any antipsychotics Discuss with the patient and carer the benefits and side-effects of different antipsychotic drugs, and agree on a mutually acceptable treatment regime Ideally perform baseline physical health monitoring tests before starting medication, however in acute presentations and based on clinical judgement, the initiation of treatment which should not be delayed with the tests being carried out as soon as is practical. These may include: (i) BMI or other Obesity Measure (weight and waist circumference) (ii) HbA1c, fasting blood glucose, random blood glucose * (iii) (iv) (v) Fasting total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides (if fasting levels are not already available) * Blood Pressure and Pulse. ECG, if indicated e.g. on drugs that could prolong QT interval, pre-existing cardiac disease, high dose antipsychotics (i.e. >100% BNF maximum) (vi) Full Blood Count * (vii) Liver function tests * (viii) Prolactin * (Appendix 3 Management of hyperprolactinaemia) (ix) Thyroid Function Test if Quetiapine is to be used * (x0 Smoking habits - offer help on smoking cessation (*The following results will be accessible to all clinicians and practitioners via ICE) Notify GPs of any base line tests which are found to be outside the normal range (See Appendix 2 for summary of normal ranges) Initiate antipsychotic treatment, including titration of dosage until a stable mental state is achieved, usually but not exceptionally, a period of 3 months. Page 1

2 To monitor for side effects e.g. movements disorders such as Parkinson s Disease, Tardive Dyskinesia, Akathisia, Dystonia, Sexual Dysfunction (less likely with lower therapeutic doses To re-do physical health monitoring tests at 3 months and (at least annually if still stabilising treatment) and notify GPs of any tests are found to be outside the normal range. Arrange for the completion and actioning of an annual self- assessment of side effects using the Glasgow Antipsychotic Side-effect Scale (GASS) Appendix 1 To inform the GP of the patients response to medication and general progress, including the records of physical health monitoring. To inform the GP of any change in medication or if the medication is to be stopped. Patients where further dose adjustments are made to treatment or when antipsychotics are switched should remain or be brought back under Secondary Care until stabilised. inform the GP if Clozapine is being prescribed. In such patients secondary care will be responsible for the annual health check. The same will apply to all patients where secondary care continues to provide the regular prescription for any other antipsychotic including depots and those on High Dose Antipsychotics. RESPONSIBILITIES OF THE GENERAL PRACTITIONER To provide regular prescriptions for antipsychotics as per guidance from specialist services/secondary care, except Clozapine. To be aware of the increased risk of Diabetes, Cardiovascular Disease and Hyperlipidaemia in patients who have schizophrenia and/or are receiving regular antipsychotics. To re-do the physical health monitoring tests at least annually in stabilised patients. To provide ANNUAL health checks including: (i) (ii) (iii) (iv) (v) (vi) (vii) (viii) (ix) (x) BMI or other Obesity Measure (weight and waist circumference) HBA1c,, fasting blood glucose, random blood glucose Fasting total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides (if fasting lipids not already available) Blood pressure and pulse ECG, if indicated e.g. on drugs that could prolong QT interval, Cardiac Disease. Full Blood Count Liver function tests Prolactin (Appendix 3 Management of hyperprolactinaemia) Thyroid Function Test if on Quetiapine Smoking habits - offer help on smoking cessation This data populates the Annual Health Check template on SystmOne. Page 2

3 To inform the specialist services of any physical health problems at the earliest opportunity. If the patient suffers any adverse reaction, the GP should liaise with secondary care/specialist services. To perform blood count if unexplained infection or fever. These drugs rarely cause Neutropenia. To be aware of Neuroleptic Malignant Syndrome. Symptoms include: Labile blood pressure Rigidity Autonomic dysfunction High temperature Extra pyramidal side effects Confusion This is a rare side effect but the patient needs to be referred to Accident and Emergency immediately for supportive therapy. Additional resources The Choice and Medication site provides information on medication groups, advice on many mental health conditions, tables comparing the main treatments used, and user-friendly guidance on how the drugs are thought to work and on their common side-effects For a synopsis of the most up to date, comprehensive, regulated prescribing information refer to the electronic Medicines Compendium (emc) BDCT Drugs and Therapeutics Group V5 May 2015 Review date May 2017 Page 3

4 Appendix 1 Glasgow Antipsychotic Side-effect Scale (GASS) Name: Age: Sex: M / F Please list current medication and total daily doses below: This questionnaire is about how you have been recently. It is being used to determine if you are suffering from excessive side effects from your antipsychotic medication. Please place a tick in the column which best indicates the degree to which you have experienced the following side effects. Also tick the end or last box if you found that the side effect was distressing for you. Waddell & Taylor, 2007 Over the past week: Never Once A few times 1. I felt sleepy during the day 2. I felt drugged or like a zombie 3. I felt dizzy when I stood up and/or have fainted 4. I have felt my heart beating irregularly or unusually fast 5. My muscles have been tense or jerky 6. My hands or arms have been shaky 7. My legs have felt restless and/or I couldn t sit still 8. I have been drooling 9. My movements or walking have been slower than usual 10. I have had uncontrollable movements of my face or body 11. My vision has been blurry 12. My mouth has been dry 13. I have had difficulty passing urine 14. I have felt like I am going to be sick or have vomited 15. I have wet the bed 16. I have been very thirsty and/or passing urine frequently 17. The areas around my nipples have been sore and swollen 18. I have noticed fluid coming from my nipples 19. I have had problems enjoying sex 20. Men only: I have had problems getting an erection Every day Tick this box if distressing Tick yes or no for the last three months No Yes Tick this box if distressing 21. Women only: I have noticed a change in my periods 22. Men and women: I have been gaining weight Page 4

5 Staff Information 1. Allow the patient to fill in the questionnaire themselves. All questions relate to the previous week. 2. Scoring For questions 1-20 award 1 point for the answer once, 2 points for the answer a few times and 3 points for the answer everyday. Please note zero points are awarded for an answer of never. For questions 21 and 22 award 3 points for a yes answer and 0 points for a no. Total for all questions= 3. For male and female patients a score of: 0-21 absent/mild side effects moderate side effects severe side effects 4. Side effects covered include: 1-2 sedation and CNS side effects 3-4 cardiovascular side effects 5-10 extra pyramidal side effects anticholinergic side effects 14 gastro-intestinal side effects 15 genitourinary side effects 16 screening question for diabetes mellitus prolactinaemic side effects 22 weight gain The column relating to the distress experienced with a particular side effect is not scored, but is intended to inform the clinician of the service user s views and condition. Page 5

6 Appendix 2 Normal ranges- reference guide BMI Categories: Underweight = <18.5 Normal weight = Overweight = Obesity = BMI of 30 or greater HbAlc mmol/mol reference range (males) Blood glucose mmol/l Fasting <6.0, Random <11.0 Cholesterol (total) mmol/l (males) Cholesterol (HDL) mmol/l >1.5 (target range) Cholesterol (LDL) mmol/l <3.0 Triglycerides (fasting) mmol/l <1.7 Blood Pressure mm/hg Normotensive 140/90 Pulse beats per minute (95% of general population) QT interval Msec <440 (men) <470 (women) For further information on QTc the following American website is useful FBC Haemoglobin g/dl (male) (female) WBC 10 9 /L Platelets 10 9 /L Neutrophil count 10 9 /L Lymphocyte count 10 9 /L Monocyte count 10 9 /L Eosinophil count 10 9 /L Basophil count 10 9 /L <0.10 Mean cell volume MCV fl Packed cell volume PCV (males) (females) Red cell count RBC /L (males) (females) Mean corpusc Hb MCH Pg RBC dist. width U&E Estimated GFR ml/min/1.73m 2 Over 90 is normal (Stage 1 CKD) Sodium mmol/l Potassium mmol/l Creatinine umol/l Urea mmol/l LFTs Alk phos iu/l ALT iu/l <40 Bilirubin umol/l 5 21 Albumin g/l Gamma- GT (not on routine profile) iu/l <90 (male), <50 (females) Prolactin Mu/L <550 (male) <600 (female) TFTs Thyroxine (ft4) pmol/l Tri-iodothyronine (T3) nmol/l Thyroid stimulating Hormone (TSH) mlu/l Page 6

7 Appendix 3 Management of hyperprolactinaemia. Hyperprolactinaemia is probably unavoidable in practice and even when not symptomatic may grossly affect hypothalamic function. It is more common in bipolar disorder and schizophrenia and is linked to longer term clinical consequences such as osteoporosis, hip fractures and possibly breast cancer. Long term use of prolactin elevating drugs should probably be avoided in young women given these risks. Prolactin Mu/L <550 (male) <600 (female) Symptoms of raised prolactin :- Sexual dysfunction Menstrual disturbances Galactorrhoea Gynaecomastia. Reduced libido and infertility are usually seen with prolactin levels Mu/L with galactorrhoea and amenorrhoea occurring when levels exceed 2012Mu/L. Levels should be taken at baseline, 3 months and annually unless symptoms arise. Normal prolactin or asymptomatic raised prolactin Do not increase frequency of routine monitoring unless patient developments symptoms of raised prolactin. Increased prolactin or symptomatic 1. Check clinical relevance. Consider other causes pregnancy, lactation, stress, pathological causes e.g. pituitary tumour, hypothyroidism, chronic renal insufficiency, liver disease polycystic ovarian syndrome. 2. Reduce dose or switch to a prolactin sparing antipsychotic antipsychotic eg aripiprazole, quetiapine, olanzapine, lurasidone, clozapine (secondary care responsibility). 3. To ensure that the hyperprolactinemia is due to medication and not to a structural lesion in the hypothalamic/pituitary area, temporarily stop the antipsychotic to determine whether prolactin levels return to normal. Levels will typically normalise within a few days to a week for oral medications but will be a number of weeks in the cases of depot or long acting injections due to the prolonged half lives of these preparations. Dopamine agonists (cabergoline, bromocriptine, amantandine) should generally be avoided as they may precipitate psychosis, but with careful monitoring and dose adjustment may be successful where other strategies have failed. If changing the antipsychotic or reducing dose of the antipsychotic is not possible or there are signs suggestive of a pathological cause seek endocrinology advice and consider performing magnetic resonance imaging or computed tomography of the hypothalamic/pituitary area. References Psychotropic Drug Directory 2014 S Bazire Maudsley Prescribing Guidelines in Psychiatry 12 th Ed D Taylor, C Paton, S Kapur Medication-Induced Hyperprolactinemia Molitch,Mayo Clin Proc 2005:80: Pharmacological Causes of hyperprolactinaemia Ther Clin Risk Manag 2007 Oct: 3(5) Page 7