06 - Chapter 1 Schizophrenia and related psychoses

ANTIPSYCHOTIC DRUGS

General introduction

Classification of antipsychotics The Maudsley® Prescribing Guidelines in Psychiatry, Fifteenth Ed...

Choosing an antipsychotic 2 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 very low...

Relative efficacy Schizophrenia and related psychoses CHAPTER 1 Antipsychotics are effective in b...

References Schizophrenia and related psychoses CHAPTER 1 References Zohar J, et al. Neuroscience...

General principles of prescribing Schizophrenia and related psychoses CHAPTER 1 General principle...

Antipsychotics – minimum effective doses 8 The Maudsley® Prescribing Guidelines in Psychiatry CHA...

References Schizophrenia and related psychoses CHAPTER 1 References Dudley K, et al. Chlorpromaz...

Quick reference for licensed maximum doses Schizophrenia and related psychoses CHAPTER 1 Quick re...

Clinical effectiveness

Adverse effects

Summary 106 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Penfluridol weekly Backg...

References Schizophrenia and related psychoses CHAPTER 1 In practice, penfluridol is usually star...

Electroconvulsive therapy and psychosis

Treatment-refractory schizophrenia 108 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER...

Adverse effects

Summary Schizophrenia and related psychoses CHAPTER 1 maintained their symptomatic improvement or...

References 110 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 References Grover S,...

Omega-3 fatty acid (fish oils) in schizophrenia

References Schizophrenia and related psychoses CHAPTER 1 References Electronic Medicines Compend...

Treatment

Prevention Schizophrenia and related psychoses CHAPTER 1 Omega-­3 fatty acid (fish oils) in schiz...

Overall

Summary recommendations – fish oils (PUFAs)

References 112 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 reduction in transiti...

Alternative routes of administration Schizophrenia and related psychoses CHAPTER 1 Alternative ro...

Inhaled

Intranasal 116 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Inhaled Loxapine is t...

Intravenous

Sublingual

Equivalent doses 14 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Equivalent doses...

Buccal

Transdermal Schizophrenia and related psychoses CHAPTER 1 ­haloperidol had a shorter time to peak...

Rectal

References 118 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Rectal Chlorpromazine...

Stopping antipsychotics

Withdrawal effects of antipsychotics Schizophrenia and related psychoses CHAPTER 1 Stopping antip...

Neurobiology of withdrawal 120 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Neuro...

Pattern of tapering Schizophrenia and related psychoses CHAPTER 1 Pattern of tapering Positron em...

Tapering in practice 122 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Exponential...

When to attempt discontinuation Schizophrenia and related psychoses CHAPTER 1 When to attempt dis...

References 16 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 References Foster P. ...

References 124 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 References Leucht S,...

ANTIPSYCHOTIC ADVERSE EFFECTS

Extrapyramidal symptoms 126 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 ANTIPSYC...

References Schizophrenia and related psychoses CHAPTER 1 References Owens DGC. A Guide to the Ex...

Akathisia Schizophrenia and related psychoses CHAPTER 1 Akathisia Akathisia is a fairly common ad...

References Schizophrenia and related psychoses CHAPTER 1 Notes ■ ■Akathisia can be difficult to d...

Treatment of tardive dyskinesia

Treatment – first steps Schizophrenia and related psychoses CHAPTER 1 Treatment of tardive dyskin...

Treatment – additional agents

Treatment – other possible options 136 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER...

High-dose antipsychotic medication: prescribing and monitoring

References Schizophrenia and related psychoses CHAPTER 1 Table 1.30  Other options for the treatm...

Antipsychotic-induced weight gain Schizophrenia and related psychoses CHAPTER 1 Antipsychotic-­in...

Time course

Dose–response 142 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Time course Antips...

References Schizophrenia and related psychoses CHAPTER 1 References Barton BB, et al. Update on ...

Treatment of antipsychotic-induced weight gain

Monitoring

Treatment and prevention 144 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Treatme...

References Schizophrenia and related psychoses CHAPTER 1 References Pillinger T, et al. Comparat...

Neuroleptic malignant syndrome 150 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 N...

Efficacy Schizophrenia and related psychoses CHAPTER 1 High-­dose antipsychotic medication: presc...

References Schizophrenia and related psychoses CHAPTER 1 Risk factors for developing NMS include ...

Catatonia 154 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Catatonia Catatonia is...

References 158 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 References Rogers JP...

ECG changes – QT prolongation

Introduction

QT prolongation Schizophrenia and related psychoses CHAPTER 1 ECG changes – QT prolongation Intro...

Other ECG changes

Quantifying risk 162 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 ■ ■There is som...

Other risk factors 164 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Aripiprazole ...

ECG monitoring

Adverse effects 18 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 A small number of...

Metabolic inhibition Schizophrenia and related psychoses CHAPTER 1 Table 1.37  Non-­psychotropics...

Other cardiovascular risk factors

Summary

References 166 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Other cardiovascular ...

Effects of antipsychotic medications on plasma lipids

Effect of antipsychotic medications on lipids

Olanzapine Schizophrenia and related psychoses CHAPTER 1 Effects of antipsychotic medications on ...

Clozapine

Screening and monitoring

Clinical management of dyslipidaemia 170 The Maudsley® Prescribing Guidelines in Psychiatry CHAPT...

Recommendations

Summary of monitoring

References Schizophrenia and related psychoses CHAPTER 1 recommended by NICE for secondary preven...

Diabetes and impaired glucose tolerance

Schizophrenia

Antipsychotic medications

First-generation antipsychotic medications

Second-generation antipsychotic medications 174 The Maudsley® Prescribing Guidelines in Psychiatr...

Predicting antipsychotic-related diabetes

Monitoring 176 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 ­glucose homeostasis....

Treatment of antipsychotic-related diabetes

Prescribing high-dose antipsychotic medication Schizophrenia and related psychoses CHAPTER 1 ■ ■T...

Summary: antipsychotic medications – risk of diabetes and impaired glucose tolerance Schizophreni...

References 178 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 References Schimmelb...

Blood pressure changes with antipsychotics

Orthostatic hypotension 182 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Blood pr...

Hypertension Schizophrenia and related psychoses CHAPTER 1 Antipsychotics with a high affinity fo...

References 184 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 dopamine receptor ant...

Antipsychotic-associated hyponatraemia 186 The Maudsley® Prescribing Guidelines in Psychiatry CHA...

References 188 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 References de Leon J...

Hyperprolactinaemia 190 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Hyperprolact...

Contraindications

References 20 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 References Royal Coll...

Management

Summary of management Schizophrenia and related psychoses CHAPTER 1 Contraindications Prolactin-­...

References Schizophrenia and related psychoses CHAPTER 1 References Suzuki Y, et al. Differences...

Sexual dysfunction and antipsychotics

The human sexual response

Effects of psychosis Schizophrenia and related psychoses CHAPTER 1 Sexual dysfunction and antipsy...

Effects of antipsychotic drugs 196 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 P...

Treatment of sexual dysfunction 198 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 ...

References 200 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 The evidence base sup...

Pneumonia

Combined antipsychotics (antipsychotic polypharmacy)

Background 204 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Pneumonia Background ...

Mechanisms

Summary Schizophrenia and related psychoses CHAPTER 1 ■ ■Assume that the use of all antipsychotic...

References 206 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 References Dzahini O...

Switching antipsychotics Schizophrenia and related psychoses CHAPTER 1 Switching antipsychotics T...

References 208 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Lumateperone and pima...

Venous thromboembolism

Evidence of an association Schizophrenia and related psychoses CHAPTER 1 Venous thromboembolism E...

Mechanisms

Outcomes 212 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Mechanisms Several mech...

Poor response to antipsychotic monotherapy

Summary

Practice points

References Schizophrenia and related psychoses CHAPTER 1 Summary Antipsychotics are almost certai...

REFRACTORY SCHIZOPHRENIA AND CLOZaPINE

Clozapine initiation schedules

Clozapine dosing regimen 214 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Table 1...

Faster titrations Schizophrenia and related psychoses CHAPTER 1 Alternatively, an attempt can be ...

References 218 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Male smoker – target ...

Intramuscular clozapine

References Schizophrenia and related psychoses CHAPTER 1 Intramuscular clozapine Intramuscular cl...

Long-term antipsychotic treatment 22 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1...

Optimising clozapine treatment

Using clozapine alone

Clozapine augmentation 220 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Optimisin...

References 222 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Other options include...

Alternatives to clozapine 226 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Altern...

Summary of alternatives to clozapine Schizophrenia and related psychoses CHAPTER 1 Summary of alt...

References 230 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 References Millgate ...

Restarting clozapine after a break in treatment 234 The Maudsley® Prescribing Guidelines in Psych...

References Schizophrenia and related psychoses CHAPTER 1 References John AP, et al. Rates and re...

Initiation of clozapine in the community

Adverse effects Schizophrenia and related psychoses CHAPTER 1 monotherapy.24 Although the interpr...

Relative contraindications to community initiation

Essential criteria for suitability for community initiation

Initial work-up 236 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Initiation of cl...

Mandatory blood monitoring and registration

Dosing Schizophrenia and related psychoses CHAPTER 1 ■ ■Echocardiogram if clinically indicated. ■...

Adverse effects

Recommended additional monitoring

Switching from other antipsychotics Schizophrenia and related psychoses CHAPTER 1 Adverse effects...

Serious cardiac adverse effects

References 240 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Serious cardiac adver...

The use of combined antipsychotic medications in clinical practice

CLOZAPINE ADVERSE EFFECTS

Clozapine: common adverse effects Schizophrenia and related psychoses CHAPTER 1 CLOZAPINE ADVERSE...

References Schizophrenia and related psychoses CHAPTER 1 References Palmer SE, et  al. Life-­thr...

Clozapine: uncommon or unusual adverse effects Schizophrenia and related psychoses CHAPTER 1 Cloz...

References Schizophrenia and related psychoses CHAPTER 1 References Thompson A, et al. Late onse...

Clozapine: serious haematological adverse effects

Agranulocytosis

Summary Schizophrenia and related psychoses CHAPTER 1 Clozapine: serious haematological adverse e...

References 252 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 References Vermeulen...

Clozapine: serious cardiovascular adverse effects

Conclusion

Thromboembolism

Myocarditis Schizophrenia and related psychoses CHAPTER 1 Clozapine: serious cardiovascular adver...

Cardiomyopathy 254 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 4 days until a da...

References 256 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 References Paciullo ...

Clozapine-induced hypersalivation 258 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER ...

References 260 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 References Man WH, e...

Clozapine-induced gastrointestinal hypomotility Schizophrenia and related psychoses CHAPTER 1 Clo...

Prevention and simple management of CIGH

Management of suspected acute CIGH 264 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER...

Clozapine rechallenge following severe constipation

Summary 24 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Given the association bet...

Key message

References Schizophrenia and related psychoses CHAPTER 1 Clozapine rechallenge following severe c...

Clozapine, neutropenia and lithium

Mild neutropenia

Severe neutropenia or agranulocytosis Schizophrenia and related psychoses CHAPTER 1 Clozapine, ne...

Benign ethnic neutropenia 268 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Risk f...

Concurrent medications

Management options

Lithium Schizophrenia and related psychoses CHAPTER 1 Concurrent medications Different classes of...

Granulocyte colony-stimulating factor 270 The Maudsley® Prescribing Guidelines in Psychiatry CHAP...

References Schizophrenia and related psychoses CHAPTER 1 ■ ■Combined antipsychotic medications ar...

References Schizophrenia and related psychoses CHAPTER 1 G-­CSF in the face of a low or declining...

Clozapine and chemotherapy

Summary Schizophrenia and related psychoses CHAPTER 1 Clozapine and chemotherapy The use of cloza...

References 274 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 ■ ■The likelihood of ...

Genetic testing for clozapine treatment

Response

Agranulocytosis Schizophrenia and related psychoses CHAPTER 1 Genetic testing for clozapine treat...

Benign ethnic neutropenia

Metabolism 276 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 HLA-­B59:01 Presence ...

Other adverse effects

Antipsychotic prophylaxis

References Schizophrenia and related psychoses CHAPTER 1 NFIB rs28379954 T>C CT carriers have muc...

First episode of psychosis 28 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Antips...

Multi-episode schizophrenia

Summary Schizophrenia and related psychoses CHAPTER 1 a first admission for schizophrenia, clozap...

Adherence to antipsychotic treatment

Dose for prophylaxis

How and when to stop55 30 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 A large me...

Alternative views Schizophrenia and related psychoses CHAPTER 1 at least 3 weeks for oral antipsy...

References 32 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 References Karson C, ...

Negative symptoms

Pharmacological treatment of negative symptoms 34 The Maudsley® Prescribing Guidelines in Psychia...

Summary and recommendations 36 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 RCTs ...

References Schizophrenia and related psychoses CHAPTER 1 References Messinger JW, et al. Avoliti...

Monitoring 40 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Monitoring Table 1.6 s...

References 42 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 References National I...

Relative adverse effects – a rough guide Schizophrenia and related psychoses CHAPTER 1 Relative a...

Treatment algorithms for schizophrenia

First-episode schizophrenia Schizophrenia and related psychoses CHAPTER 1 Either: Agree the choic...

Relapse or acute exacerbation of schizophrenia 46 The Maudsley® Prescribing Guidelines in Psychia...

Relapse or acute exacerbation of schizophrenia Schizophrenia and related psychoses CHAPTER 1 Rela...

References 48 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 References Robinson D...

First-generation antipsychotics – place in therapy

Nomenclature

Role of older antipsychotics Schizophrenia and related psychoses CHAPTER 1 First-­generation anti...

References 50 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 alternative to SGAs wh...

NICE guidelines for the treatment of schizophrenia1

NICE guidelines – a summary 52 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 NICE ...

References 54 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 allow the use of long-...

Antipsychotic response – to increase the dose, to switch, to add or just wait – what is the right...

Optimal dosage

High dosage Schizophrenia and related psychoses CHAPTER 1 Antipsychotic response – to increase th...

Plasma level variations 56 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 ­network ...

Treatment options for schizophrenia that is poorly responsive to standard antipsychotic treatment...

Summary Schizophrenia and related psychoses CHAPTER 1 When treatment fails ■ ■If the dose of anti...

References 60 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 References Samara MT,...

Acutely disturbed or violent behaviour

Oral/inhaled treatment

Parenteral treatment 62 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Acutely dist...

Practical measures Schizophrenia and related psychoses CHAPTER 1 positive or negative effects and...

Zuclopenthixol acetate 66 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Zuclopenth...

References Schizophrenia and related psychoses CHAPTER 1 References Patel MX, et al. Joint BAP N...

Antipsychotic depots/long-acting injections 74 The Maudsley® Prescribing Guidelines in Psychiatry...

Advice on prescribing LAIs Schizophrenia and related psychoses CHAPTER 1 understanding of these f...

Differences between LAIs 76 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 ■ ■Adjus...

References Schizophrenia and related psychoses CHAPTER 1 References Tiihonen J, et al. Real-­wor...

Depot antipsychotics – summary of pharmacokinetics Schizophrenia and related psychoses CHAPTER 1 ...

References 82 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 References Mallikaarj...

Management of patients on long-term treatment with long-acting injectable antipsychotic medicatio...

References 84 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 ■ ■Discontinuation of ...

Aripiprazole long-acting injection

Aripiprazole 1-monthly

One-injection start

Two-injection start Schizophrenia and related psychoses CHAPTER 1 Aripiprazole long-­acting injec...

Aripiprazole 2-monthly8,9 Schizophrenia and related psychoses CHAPTER 1 Aripiprazole 2-­monthly8,...

Other LAI aripiprazole brands 88 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Oth...

References Schizophrenia and related psychoses CHAPTER 1 References Shirley M, et al. Aripiprazo...

Olanzapine long-acting injection

Switching

Stopping 90 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Olanzapine long-­acting ...

Post-injection delirium sedation syndrome Schizophrenia and related psychoses CHAPTER 1 Post-­inj...

References 92 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 References Heres S, e...

Paliperidone palmitate long-acting injection

Paliperidone long-acting injection 1-monthly Schizophrenia and related psychoses CHAPTER 1 Palipe...

Paliperidone long-acting injection 3-monthly Schizophrenia and related psychoses CHAPTER 1 Palipe...

Paliperidone LAI 6-monthly (PP6M) 96 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1...

References Schizophrenia and related psychoses CHAPTER 1 Dose adjustments should not be needed bu...

Risperidone long-acting injection

Risperidone intramuscular long-acting injections Schizophrenia and related psychoses CHAPTER 1 Ri...

Risperidone subcutaneous long-acting injections Schizophrenia and related psychoses CHAPTER 1 Ris...

References 104 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 References Knox ED, ...

Penfluridol weekly

Background