Medicines Guideline: High-dose antipsychotic prescribing (MG01)

Medicines Guideline: High-dose antipsychotic prescribing (MG01) Document author Assured by Review cycle Ben Browning, Locality Lead Pharmacist (Secure Services) MOG sub-group (04.05.16) Review every two years or sooner if guidance changes. Next review March 2018 This document is version controlled. The master copy is on Ourspace. Once printed, this document could become out of date. Check Ourspace for the latest version. This guidance should be read in conjunction with the following Trust documents: 1. Enabling policy for ward pharmacists and Medicine Management Technicians 2. Procedure for Prescribing Medicines 3. Policy for the use of Medication to Manage Disturbed (Violent) Behaviour on Mental Health Units (Rapid Tranquilisation) 1. Introduction Antipsychotic medication has long been established and proven as an effective intervention in the treatment of severe mental illness. Clinical guidelines and recommendations produced by NICE and the Royal College of Psychiatrists recommend that, with a few exceptions, patients should only be prescribed one antipsychotic at a time. It is estimated that up to 25% of psychiatric inpatients are prescribed High-Dose antipsychotic medication either as monotherapy or as a result of poly-prescribing. The majority of these service-users are under the care of forensic services or psychiatric intensive care units (PICU). Research carried out by the Prescribing Observatory for Mental Health has identified that when required ( PRN ) antipsychotic prescriptions also contribute significantly to the prevalence of high-dose antipsychotic prescriptions within Mental Health Services nationally. The participation of AWP in the POMH-UK audit yielded results consistent with these national findings, with particular focus being placed on considering clinical practice within our own PICU wards. The British National Formulary (BNF) provides recommended dose ranges for antipsychotics licensed for the treatment of illnesses such as schizophrenia and bipolar disorder; this information can also be found in the Summary of Product Characteristics (SPC) for most antipsychotics at www.medicines.org.uk The prescribing of high dose antipsychotics is a complex area of clinical practice with multiple aetiological and cultural factors. In reviewing current practice, it is important to consider relevant factors such as adherence to existing policies (e.g. Rapid Tranquilisation), availability of deescalation and seclusion, training competencies, admission procedures and ward staffing compliment. There are sometimes legitimate reasons for high dose prescribing and it will remain Guideline: High-dose antipsychotic prescribing Review date: 30/03/2018 Page 1 of 16

an inevitable part of routine practice. The purpose of this guidance is to ensure robust procedures for physical monitoring and recording when using high doses, such that this is a considered and informed clinical decision. This addresses the relevant quality issues, ensuring safe, effective prescribing and consideration of the patient experience. 2. Evidence base and safety considerations The evidence base for high-dose antipsychotic prescribing in schizophrenia is sparse the effectiveness and side-effect burden associated with these approaches have not been exclusively studied in clinical trials. However, the evidence that does exist suggests that patients prescribed high doses (in particular, combinations of) antipsychotics are more likely to suffer from side-effects and spend longer in hospital with no greater likelihood of remission of symptoms. The only exception to this may be that a second antipsychotic can be modestly beneficial in schizophrenia partially responsive to clozapine. In 2006 the Medicines Healthcare Regulatory Authority (MHRA) conducted a review of the cardiac safety of all antipsychotics available in the UK, which led to a recommendation that the wording avoid concomitant neuroleptics be added to the SPC of every antipsychotic. The risks and problems associated with high dose prescribing (including combinations of antipsychotics) 1. Side effects There may be an increased incidence of side effects such as tachycardia, postural hypotension, sedation, seizures, hyperprolactinaemia, extrapyramidal side effects (EPSE), akathisia and tardive dyskinesia. 2. Interactions Higher doses or additional antipsychotics may increase the likelihood of, and risks from drug-drug interactions. Antipsychotic plus: antidepressants may antipsychotic plasma concentrations tricyclic antidepressants antipsychotics plasma concentrations and therefore risk of arrhythmias diuretics risk of electrolyte abnormalities antihypertensives risk of postural hypotension antiarrhythmics - cardiac risks 3. Safety concerns and increased mortality Increased risk of metabolic and/or cardiovascular disease (e.g. QTc prolongation, which may contribute to sudden death). See tables 1 and 2 for further details. Combinations of antipsychotics may increase the risk of the development of Neuroleptic Malignant Syndrome. 4. Non-adherence Making drug regimes more complicated, or the development of side effects can lead to a reduction in adherence. 5. Increased cost Cost issues of using one medication at high-dose, or two medications in combination. 6. Difficulty with determining cause and effect Which medication is helping? 7. Lack of supporting evidence Guideline: High-dose antipsychotic prescribing Review date: 30/03/2018 Page 2 of 16

Evidence base for high-dose or combination prescribing is limited. Although liability would rest solely with the prescriber, the nursing and pharmacy teams must be aware of the risks associated with high-dose antipsychotic treatment and be prepared to highlight these risks, in line with their own professional responsibilities. Knowledge of the proposed rationale for high-dose antipsychotic treatment would also be expected of the nursing and pharmacy teams. Definition of a High-Dose Antipsychotic Prescription High-dose applies to a prescription where either: 1) The total daily dose of a single antipsychotic exceeds the upper limit (100%) of the BNF maximum licensed dose for that drug. 2) Where more than one antipsychotic is prescribed the sum of all the percentages added together exceeds 100%. See worked example below: Percentage method for determining a High-Dose antipsychotic prescription e.g.: A prescription for olanzapine 20mg per day + haloperidol 5mg BD PRN Olanzapine maximum oral BNF dose = 20mg per day = 100% Haloperidol maximum oral BNF dose = 20mg per day = 100% Olanzapine 20mg O.N. + haloperidol 5mg B.D. PRN = 150% = HIGH DOSE There are some situations where high-dose /combination prescribing may be justified. In these cases, the decision to prescribe high-dose or combination antipsychotics will be the sole responsibility of the Responsible Clinician (R.C.) and the treatment plan should be clearly documented in the patient s care notes. Where possible, informed consent should be obtained from the patient and clearly documented (see Appendix 1.4). 1. For people with treatment-resistant schizophrenia who have shown a poor or only partial response to an optimised clozapine prescription; the addition of a first- or second-generation antipsychotic is a commonly accepted strategy, even though the evidence base is modest. 2. An acute exacerbation of illness during treatment with a long-acting or depot antipsychotic may justify the temporary prescription of an additional oral or IM antipsychotic. 3. When transferring a patient from one antipsychotic medication to another, the clinician may wish to cross-taper from the first medication to the second. This is an acceptable method of transfer and may reduce the risk of relapse during this period. 3. High-Dose Antipsychotic Prescriptions: Key Recommendations 1. High-Dose Antipsychotic prescribing should only be considered when clozapine is not (or is no longer) a viable treatment option in the management of treatment-resistant schizophrenia. When a clozapine prescription has been optimised and adherence to treatment has been demonstrated, but the patient has shown limited response to this, the addition of a second oral antipsychotic may be considered based on published supporting evidence. 2. Regular combined / high dose antipsychotic treatment should not be routinely prescribed. 3. Where there is high dose prescribing, where possible patients should give their consent to treatment and be given a copy of the Patient information letter to sign (See Appendix 1.4). Once complete this letter must also be uploaded to RiO. Guideline: High-dose antipsychotic prescribing Review date: 30/03/2018 Page 3 of 16

4. Patients prescribed high dose antipsychotics must be regularly reviewed (at least once a week) by the multidisciplinary team and at CPA meetings. Progress and outcomes of high-dose treatment should be discussed and documented on RiO. 5. The high dose antipsychotic prescription should only be continued for the shortest time necessary. 6. Registered practitioners should ensure that the patient is monitored for response to treatment, including symptom rating scales, side effects and physical health monitoring (e.g. ECG and relevant blood tests). 7. Where high dose antipsychotics are prescribed, the initiating doctor must complete the highdose/combination antipsychotic monitoring form and document reason(s) for prescribing at high dose. See appendix 1.3. A record must also be kept in the patients notes on Rio. 8. If a second antipsychotic is added to clozapine as an augmentation strategy, the choice of second drug should not compound the side-effects of clozapine. 9. PRN antipsychotic prescriptions should be reviewed regularly and cancelled if the serviceuser has not required these within the past 2 weeks. Please see the Enabling policy for ward pharmacists and Medicine Management Technicians and the Procedure for Prescribing Medicines 10. Authority for the prescription of High Dose Antipsychotic rests with the patient s consultant psychiatrist or his/her nominated deputy. Non-medical prescribers should not prescribe Highdose antipsychotic medication, unless the consultant psychiatrist has authorised this. 4. Responsibilities of the Consultant Psychiatrist The consultant must document on RiO when and why high dose antipsychotic(s) have been prescribed. To discuss the rationale for high-dose antipsychotic treatment with the patient and document their consent (where agreed and where possible) on Rio. To work collaboratively with the patient about their choice of medication; monitoring response to treatment and any side effects, and to make use of rating scales (listed under specialist assessments on RiO). To complete the high-dose antipsychotic medication monitoring form and attach it to the patient s drug chart. (It can be kept filed with the corresponding drug chart after use). To check that any advanced decision previously made by the patient is clearly documented in the patients notes on RiO. To ensure any high-dose antipsychotic treatment is covered by the relevant Mental Health Act paperwork - forms T2, T3, s62 or s64 where relevant. To ensure informal patients who can give their informed consent to treatment are given a copy of the Patient information letter to sign (See Appendix 1.4). This must also be uploaded onto RiO. The decision to use high-dose antipsychotic treatment and on-going monitoring is the responsibility of the consultant psychiatrist. 5. Responsibilities of the Deputy to Consultant Psychiatrist To ensure a physical health check is offered to the patient, including relevant blood tests and ECG, as per the high-dose/combination medication form as soon as possible. This is Guideline: High-dose antipsychotic prescribing Review date: 30/03/2018 Page 4 of 16

especially relevant when the BNF maximum licensed dose has been exceeded. If the physical health check is refused then the consultant must be contacted and a discussion with the MDT regarding best interests and risk mitigation should be arranged. To complete the High-dose / combination antipsychotic medication monitoring form. See appendix 1.3 To check that the patient has signed (where possible) the patient information letter (see Appendix 1.4 of the High-dose /combination antipsychotic medication monitoring form To work collaboratively with the patient about their choice of medication; monitoring response to treatment and any side effects, and to make use of rating scales (listed under specialist assessments on Rio). To ensure on discharge that the receiving care team are informed of Highdose/combination antipsychotic medication prescribing and the associated monitoring required. 6. Responsibilities of Nursing Staff To monitor physical observations as per the NEWS chart in accordance with the NEWS procedure. To work collaboratively with the patient about their choice of medication; monitoring response to treatment and any side effects, and to make use of rating scales (listed under specialist assessments on Rio). To be aware of the High-dose/combination antipsychotic medication monitoring form and its application in practice. To check if an advanced decision has been made by the patient and is documented in the service users notes on Rio. To check that high-dose antipsychotics are covered on Forms T2, T3, s62 or s64 where relevant, before medication is administered. To ensure that high-dose prescribing is discussed at reviews including CPA meetings. 7. Responsibility of Locality Clinical Pharmacist To identify patients who are prescribed high-dose antipsychotic treatment and highlight this to the medical and nursing team where necessary. When calculating the dose which exceeds the BNF maximum licensed dose, the pharmacist must endorse the drug chart to indicate that the patient is prescribed a highdose antipsychotic and to request that the consultant psychiatrist completes a Highdose/combination antipsychotic medication monitoring form. To check where possible, that the prescribed medication is covered by consent to treatment paper work where relevant. To check that physical health monitoring and any relevant blood tests are being done as per the High-dose/ combination antipsychotic medication form. To check for any drug interactions. To work collaboratively with the MDT and patient about their choice of medication; and to give advice as necessary. To work collaboratively with the nurse in charge and the prescriber with particular focus on those patients who are prescribed high-dose antipsychotics. Guideline: High-dose antipsychotic prescribing Review date: 30/03/2018 Page 5 of 16

8. Risk factors to consider when prescribing high doses Table 1: Risk factors for QTc prolongation and arrhythmias: Cardiac Metabolic Others Factor Symptoms Long QT syndrome Bradycardia Ischaemic heart disease Myocarditis Myocardial infarction Left ventricular hypertrophy Hypokalaemia Hypomagnesaemia Hypocalcaemia Extreme physical exertion Stress / shock Anorexia Extremes of age elderly more susceptible Female gender Table 2: Management of QT prolongation in patients receiving antipsychotics (adapted from Maudsley Prescribing Guidelines 12 th edition) QTc Action Refer to cardiologist <440 msec (men) or None unless abnormal T Consider if in doubt <470 msec (women) wave morphology. >440 msec (men) >470 msec (women) but <500 msec Consider reducing dose; repeat ECG. Consider >500 msec Stop suspected causative Immediately drug(s). Refer. Abnormal T wave morphology Review treatment. Refer Immediately Prescribers should also be aware of non-psychotropic drugs which are associated with QT prolongation. Some examples include: Amiodarone, ampicillin, chloroquine clarithromycin co-trimoxazole diphenhydramine domperidone, erythromycin, mefloquine, methadone mirabegron, some quinolones, quinidine, quinine, sotalol, tamoxifen, (see www.medicines.org for full prescribing information). DRUG-DRUG INTERACTIONS Drug interactions must also be considered some of the most common interactions are listed on Appendix 1.3. For further guidance, please refer to the SPC for the individual drugs (www.medicines.org.uk) or contact a member of the pharmacy team (details on Ourspace). NEUROLEPTIC MALIGNANT SYNDROME: If Neuroleptic malignant syndrome (NMS) is suspected call for an ambulance immediately symptoms include fever, sweating, rigidity, confusion, fluctuating blood pressure, tachycardia. Do not give any further doses of antipsychotic. Guideline: High-dose antipsychotic prescribing Review date: 30/03/2018 Page 6 of 16

9. Appendix 1.1: Antipsychotic percentage dose conversion table (NB: For doses not listed in the tables below a manual conversion will be required) Percentage of BNF maximum adult ORAL daily dose Antipsychotic Form 25% 33% 40% 50% 67% 75% 80% 100% of BNF max Amisulpride oral 400mg 600mg 800mg 1200mg Aripiprazole oral 5mg 15mg 20mg 30mg (inc any IM doses given) Asenapine oral 5mg 10mg 15mg 20mg Benperidol oral 0.5mg 0.75mg 1.0mg 1.5mg Chlorpromazine oral 250mg 400mg 500mg 750mg 800mg 1000mg Clozapine oral 225mg 300mg 450mg 600mg 675mg 900mg Flupentixol oral 6mg 9mg 12mg 18mg Haloperidol oral 5mg 10mg 15mg 20mg Levomepromazine oral 250mg 500mg 750mg 1000mg Lurasidone oral 37mg 74mg 111mg 148mg Olanzapine oral 5mg 10mg 15mg 20mg (inc any IM doses given) Paliperidone oral 3mg 4mg 6mg 8mg 9mg 12mg Pericyazine oral 75mg 100mg 150mg 200mg 225mg 300mg Perphenazine oral 6mg 8mg 12mg 16mg 18mg 24mg Pimozide oral 5mg 10mg 15mg 20mg Promazine oral 200mg 400mg 600mg 800mg Quetiapine oral 200mg 400mg 600mg 800mg Risperidone oral 4mg 8mg 12mg 16mg Sulpiride oral 600mg 800mg 1200mg 1800mg 2400mg Zuclopentixol oral 50mg 60mg 75mg 100mg 120mg 150mg Guideline: High-dose antipsychotic prescribing Review date: 30/03/2018 Page 7 of 16

Percentage of BNF maximum adult INTRAMUSCULAR (IM) dose Antipsychotic Form 25% 33% 50% 67% 75% 100% of BNF max Aripiprazole (7.5mg/ml injection) Shortacting IM 7.5mg per day 15mg per day 30mg per day (inc any oral doses given) Haloperidol Shortacting IM 3mg per day 4mg per day 6mg per day 8mg per day 9mg per day 12mg per day Olanzapine Shortacting IM 10mg per day 20mg per day Zuclopenthixol Acetate (Clopixol Acuphase) 50mg every 2 days 75mg every 2 days 100mg every 2 days 150mg every 2 days NB: Max 400mg of Clopixol Acuphase over a 14 day period. After the first two doses (which may have a gap of 24hrs between them), any further doses should be at least 48hrs apart. Aripiprazole LAI Depot 200mg every month 300mg every month 400mg every month Flupentixol decanoate Depot 100mg per week 200mg per week 300mg per week 400mg per week Fluphenazine decanoate Depot 37.5mg every 2 weeks 50mg every 2 weeks 75mg every 2 weeks 100mg every 2 weeks Haloperidol decanoate Depot 100mg every 4weeks 150mg every 4 weeks 200mg every 4 weeks 300mg every 4 weeks Olanzapine embonate LAI Depot 150mg every 2 weeks / 300mg every 4 weeks 210mg every 2 weeks / 405mg every 4 weeks 300mg every 2 weeks Paliperidone LAI Depot 50mg every month 75mg every month 100mg every month 150mg every month Risperidone LAI Depot 25mg every 2 weeks 37.5mg every 2 weeks 50mg every 2 weeks Zuclopenthixol decanoate Depot 200mg per week 300mg per week 400mg per week 600mg per week Guideline: High-dose antipsychotic prescribing Review date: 30/03/2018 Page 8 of 16

10. Appendix 1.2 Common interactions with antipsychotics (not all are listed) For full prescribing guidance, please refer to the SPC for the individual drugs www.medicines.org.uk, current BNF or Stockleys drug interactions source book. The Pharmacy team can also be contacted (details on ourspace). Analgesics e.g. opioid analgesics Increased risk of ventricular arrhythmias when antipsychotics that prolong the QT interval given with analgesics Increased risk of convulsions when antipsychotics given with tramadol Enhanced hypotensive and sedative effects when antipsychotics given with opioid analgesics. Anti-arrhythmic drugs e.g. amiodarone, disopyramide, flecainide, Increased risk of ventricular arrhythmias when antipsychotics that prolong the QT interval are given with anti-arrhythmic drugs. Antibacterials e.g. clarithromycin, erythromycin, moxifloxacin, rifampicin, Plasma levels with clarithromycin, erythromycin, moxifloxacin (enzyme inhibitors) Increased risk of ventricular arrhythmias Reduced levels with rifampicin (enzyme inducer) Increased risk of agranulocytosis with sulfonamides e.g. trimethoprim Antidepressants e.g. SSRIs (Fluoxetine, Paroxetine) Tricyclics Plasma levels possibly by SSRIs e.g. fluoxetine, fluvoxamine, & paroxetine Risk of ventricular arrhythmias with tricyclics & SSRIs (variable - check interaction potential) Levels by St Johns Wort Antiepileptics e.g. carbamazepine, valproate Anticonvulsant effect convulsive threshold is lowered. Plasma levels by carbamazepine (enzyme inducer) Plasma levels possibly increased or decreased by valproate (enzyme inhibitor) Antifungals e.g. Ketoconazole, itraconazole, imidazoles Plasma levels with triazoles Antimalarials e.g. mefloquine, quinine, chloroquine, hydroxychloroquine Increased risk of ventricular arrhythmias when haloperidol, given with mefloquine or quinine Guideline: High-dose antipsychotic prescribing Review date: 30/03/2018 Page 9 of 16

Antipsychotics ALL Increased risk of ventricular arrhythmias / QTc prolongation when some are given concomitantly. Antivirals e.g. indinavir, ritonavir etc Plasma levels with antivirals (enzyme inhibitor) Anxiolytics and hypnotics Sedative effects. Plasma level of haloperidol with buspirone. Atomoxetine Risk of ventricular arrhythmias when antipsychotics that prolong the QT interval given with atomoxetine. Beta blockers e.g. propranolol and sotalol Enhanced hypotensive effect with phenothiazines Increased risk of ventricular arrhythmias when amisulpride, phenothiazines, pimozide or sulpiride given with sotalol Diuretics Hypokalaemia Increases risk of ventricular arrhythmias Enhanced hypotensive effect (with phenothiazines) Grapefruit juice Plasma levels of quetiapine Guideline: High-dose antipsychotic prescribing Review date: 30/03/2018 Page 10 of 16

11. Appendix 1.3 High-dose Antipsychotic Monitoring Form The information on this form should be completed as soon as treatment with high-dose antipsychotics is initiated, and then retained as an on-going monitoring record. It is acknowledged that it will not always be routinely possible to complete the chart in acute settings prior to administration of high dose antipsychotics. This form should be kept with the patients drug chart and reviewed and updated at ward round. If the patient is discharged on high-dose antipsychotic treatment, the community team should be advised on the need for continued monitoring and sent a copy of the monitoring form. Authority for prescribing high-dose treatment rests with the service users Consultant Psychiatrist or their deputy. Non-medical prescribers should not prescribe highdose/combination antipsychotic medication without the agreement of the responsible clinician. Please refer to the relevant section of the guideline above for assistance in converting doses of IM & oral antipsychotic medication to %BNF max dose: Patient name: Consultant: Date of birth: NHS number: Ward: RiO number: High dose Antipsychotic details. To be completed by the Prescriber (or Pharmacist) Drug Route Total daily dose Regular or PRN? Start date Anticipated stop date % of BNF maximum licensed dose Total % cumulative BNF maximum dose Total % cumulative BNF maximum dose Are there any contraindications / special warnings to treatment with high-dose / combination antipsychotics? If the patient is subject to consent to treatment requirements (under the MHA), has high-dose monotherapy or combination treatment been documented on the T2, T3, 62 or 64 forms? For Informal patients have they given consent to treatment with high-dose/combination antipsychotics AND a copy of the Patient information letter (see Appendix 1.4) uploaded in Rio? Y Y Y N N N Guideline: High-dose antipsychotic prescribing Review date: 30/03/2018 Page 11 of 16

Has the GASS tool been completed? Y N Reason(s) for prescribing high-dose / combination antipsychotics: This section MUST be completed by the initiating doctor. Physical Health checklist for high-dose/combination antipsychotics: If any of the risk factors in red italics are present, the team MUST discuss these with the consultant psychiatrist in ward review. Table 2 Cardiac function / risks of cardiac disease (see NICE CG 127) Please circle Comments History of cardiac disorder e.g. MI, arrhythmias, Y N Family history of cardiac disorder or sudden death Y N History of ECG abnormalities / QTc interval prolongation Y N Hypertension (>140/90mmHg) (on individual basis) Y N Abnormal pulse e.g. irregular Y N Hyperlipidaemia Y N Obesity Y N Smoker Y N Over 40 Y N Guideline: High-dose antipsychotic prescribing Review date: 30/03/2018 Page 12 of 16

Previous episode of Neuroleptic Malignant Syndrome? Y N Renal function (U&Es) Result Sodium Potassium egfr Liver function (LFTs) Result Aspartate transaminase (AST) Alkaline phosphatase (ALP) Gamma glutamyl transpeptidase (GGT) Full blood count Result Haemoglobin Neutrophils Platelets White Cell Count Other Result Temperature Name and Signature of the doctor completing the check list: Name (PRINT): Signature: Date: Name and Signature of the Consultant Psychiatrist: Name (PRINT): Signature: Date: Guideline: High-dose antipsychotic prescribing Review date: 30/03/2018 Page 13 of 16

12. Appendix 1.4 Patient Information Letter (Intended for those patients who are asked to take high dose antipsychotics as part of their treatment, and are considered to have capacity to give informed consent for this). Dear (patient name) NOT for retrospective use You have been prescribed an antipsychotic / combination of antipsychotics, the total dose of which exceeds 100% of a BNF maximum. Name of antipsychotic Dose Frequency Reason for high dose / high dose combination: Please complete the following section, and if you are happy to accept treatment please sign and hand to one of the nurses or doctors, so that it can be uploaded in to your electronic record. If you would like a copy of this letter, please ask a member of staff and they will photocopy it for you. My doctor has fully explained the reasons why I am prescribed high dose / combination antipsychotics AND in a way that I understand. Y / N Monitoring requirements have been fully explained to me Y/ N The risks associated with taking high dose / combination antipsychotics has been explained to me Y / N My concerns / questions have been fully answered Y /N Guideline: High-dose antipsychotic prescribing Review date: 30/03/2018 Page 14 of 16

If you have any further questions you would like to ask your doctor / nurse please state them below and a member of staff will ensure they are addressed: 1) 2) 3) 4) Thank you for your assistance Yours sincerely Name and signature of Consultant Psychiatrist: Name and signature of Patient: Date: Date: Guideline: High-dose antipsychotic prescribing Review date: 30/03/2018 Page 15 of 16

13. References and further reading 1. Royal College of Psychiatrists. Consensus Statement on High-dose antipsychotic medication. Council Report CR138. May 2006 2. Violence and aggression: short-term management in mental health, health and community settings NICE guideline. May 2015 www.nice.org.uk/guidance/ng10 3. Psychotropic Drug Directory 2014. Stephen Bazire. Lloyd-Rheinhold Communications LLP 4. POMH UK Audit May 2013 Prescribing high-dose and combination antipsychotics: Acute/PICU, rehabilitation/complex needs and forensic psychiatric services. Supplementary audit (Topic 1f and 3c) 5. Schizophrenia. NICE CG178. Psychosis and schizophrenia in adults: prevention and management. Feb 2014 www.nice.org.uk/guidance/cg178 6. High dose and combination antipsychotic prescribing, MI Bulletin. Oxfordshire and Buckinghamshire Mental Health Partnership NHS Trust March 2006.Vol 5 No1 7. Enabling policy for ward pharmacists and Medicine Management Technicians 8. Procedure for Prescribing Medicines 9. Policy for the use of Medication to Manage Disturbed (Violent) Behaviour on Mental Health Units (Rapid Tranquilisation) in AWP 10. Guidelines on monitoring Physical Health and Treatment with Medication. Bethan Shepherd. March 2009 www.awp.nhs.uk 11. Medicines Information Bulletin, Oxford & Buckinghamshire Mental Health Partnership NHS Trust, High dose and Combination Antipsychotic prescribing March 2006. 12. www.medicines.org.uk 13. The Maudsley Prescribing Guidelines in Psychiatry. 12 th edition. 2015 14. BNF online, accessed Feb 2016. www.evidence.nhs.uk/formulary/bnf/current Version History Version Date Revision description Editor Status 3.1 11.06.2014 Legacy document: High-dose and combination antipsychotic prescribing: Guidance for prescribers and registered practitioners Interim update 11.6.14 to reflect Haloperidol dose changes. Bethan Shepherd Approved 4 April 2016 Review and re-format Ben Browning Draft 4 04.05.2016 Approved MOG sub-group S. Jones Approved Guideline: High-dose antipsychotic prescribing Review date: 30/03/2018 Page 16 of 16