41 - Monitoring

Monitoring

40 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 1 Monitoring Table 1.6 summarises suggested monitoring for those receiving antipsychotic medication.1 Monitoring of people taking antipsychotics is very poor in most countries.2–5 The guidance given here is strongly recommended to ensure safer use of these drugs. Other sections in this chapter provide further background information and relevant references. This table is a summary; see the individual sections for details and discussion. Table 1.6  Suggested monitoring for people receiving antipsychotic medication. Parameter/test Suggested frequency Action to be taken if results outside reference range Medications with special precautions Medications for which monitoring is not required Urea and electrolytes (including creatinine or eGFR) Baseline, then yearly as part of a routine physical health check Investigate all abnormalities detected Amisulpride and sulpiride renally excreted – consider reducing dose if eGFR reduced None Full blood count6–8 Baseline, then yearly as part of a routine physical health check and to detect chronic bone marrow suppression (small risk associated with some antipsychotic medications) Stop suspect medication if neutrophils fall below 1.5×109/L (unless diagnosed with BEN). Refer to specialist medical care if neutrophils below 0.5×109/L. Clozapine FBC weekly for 18 weeks, then 2-­weekly up to 1 year, then monthly (schedule varies from country to country) None Blood lipids9,10 (cholesterol, triglycerides; fasting sample, if possible) Baseline, at 3 months, then yearly to detect antipsychotic-­ induced changes and to generally monitor physical health Offer lifestyle advice. Consider changing antipsychotic medication and/or initiating statin therapy. Clozapine, olanzapine: 3-­monthly for first year, then yearly Some antipsychotic medications (e.g. aripiprazole, brexpiprazole cariprazine,11 lurasidone) not clearly associated with dyslipidaemia but prevalence is high in this patient group12–14 so all patients should be monitored Weight9,10,14 (include waist size and BMI, if possible) Baseline, frequently for 3 months, then yearly to detect antipsychotic-­ induced changes and generally monitor physical health Offer lifestyle advice. Consider changing antipsychotic medication and/or dietary/ pharmacological intervention. Clozapine, olanzapine – frequently for 3 months then 3-­monthly for first year, then yearly Aripiprazole, ziprasidone, brexpiprazole, cariprazine and lurasidone not clearly associated with weight gain but monitoring strongly recommended Plasma glucose (fasting sample, if possible) Baseline, at 4–6 months, then yearly to detect antipsychotic-­induced changes and generally monitor physical health Offer lifestyle advice. Obtain fasting sample or non-­fasting and HbA1C. Refer to GP or specialist. Clozapine, olanzapine, chlorpromazine – test at baseline, one month, then 4–6 monthly Some antipsychotic medications not clearly associated with IFG but prevalence is high,15,16 so all patients should be monitored (Continued)

CHAPTER 1 Table 1.6  (Continued) Parameter/test Suggested frequency Action to be taken if results outside reference range Medications with special precautions Medications for which monitoring is not required ECG17,18 Baseline, when the target dose is reached (ECG changes are rare in practice),19 on admission to hospital, if there are cardiac symptoms, or when medication is changed (e.g. to high-­dose or combined antipsychotic medications)17 Discuss with/refer to cardiologist if abnormality detected Haloperidol, pimozide, sertindole – ECG mandatory Risk of sudden cardiac death increased with most antipsychotic medications.20 Ideally, all patients should be offered an ECG at least yearly. Ziprasidone – ECG mandatory in some situations Pimavanserin – ECG strongly recommended Blood pressure Baseline and then frequently during dose titration and after dosage changes If severe hypotension or hypertension (clozapine) observed, slow rate of titration. Consider switching to another antipsychotic if symptomatic postural hypotension. Treat hypertension in line with national guidelines. Clozapine, chlorpromazine and quetiapine most likely to be associated with postural hypotension Amisulpride, aripiprazole, brexpiprazole, cariprazine, lumateperone, lurasidone, trifluoperazine, sulpiride Prolactin Baseline, at 6 months, then yearly Switch medications if hyperprolactinaemia confirmed and symptomatic. Consider tests of bone mineral density (e.g. DEXA) for those with chronically raised prolactin. Amisulpride, sulpiride, risperidone and paliperidone particularly associated with hyperprolactinaemia Asenapine, aripiprazole, brexpiprazole, cariprazine, clozapine, lumateperone, lurasidone, quetiapine, olanzapine (low dose), xanomeline and ziprasidone do not usually elevate plasma prolactin, but measure if symptoms arise Liver function tests21–23 Baseline, then yearly as part of a routine physical health check Stop suspect medication if LFTs indicate hepatitis (transaminases × 3 normal) or functional damage (PT/albumin change) Clozapine and chlorpromazine associated with hepatic failure Amisulpride, sulpiride Creatinine phosphokinase Baseline, then if NMS suspected See section on NMS in this chapter NMS most likely with high-­potency FGAs but can occur with any dopamine antagonist or partial agonist None Other tests Patients on clozapine may benefit from an EEG24,25 as this may help determine the need for antiseizure treatment (although interpretation is obviously complex). Those on quetiapine should have thyroid function tests yearly, although the risk of abnormality is very small.26,27 BEN, benign ethnic neutropenia; BMI, body mass index; DEXA, dual-­energy x-­ray absorptiometry; eGFR, estimated glomerular filtration rate; FGA, first-­generation antipsychotic; HbA1c, glycated haemoglobin; IFG, impaired fasting glucose; NMS, neuroleptic malignant syndrome; PT, prothrombin time.