4.2. Drugs used in psychoses and related disorders
4.2.1. Antipsychotic drugsThe initiation of antipsychotics would usually be under the guidance of a specialist who may base selection on a wide range of factors.
If haloperidol is not considered appropriate, other antipsychotics from the Total Formulary may be considered.
Preferred choice for adult patients <65 years of age. If risperidone is not considered appropriate, other atypical antipsychotics from the Total Formulary may be considered.
Use in the treatment of schizophrenia in adults is restricted to second-line therapy in patients where predominantly negative symptoms have been identified as an important feature.
Restricted to psychiatrist initiation in accordance with local protocol as an alternative treatment option in patients in whom it is important to avoid weight gain and metabolic adverse effects.
The local protocol specifies that lurasidone be:
- For first-line presentation psychosis only: use as a first-line treatment of schizophrenia where aripiprazole or olanzapine are not suitable
- For adults aged 18 years and above with an establised diagnosis of schizophrenia: use as a third-line treatment option where aripiprazole has been ineffective and weight gain and metabolic adverse effects are to be minimised.
IM chlorpromazine is not recommended for rapid tranquillisation.
Restrictions: Restricted to initiation by consultant psychiatrist. The injection is restricted to use when oral therapy is not suitable. CSM have advised that there is an increased risk of stroke in elderly patients with dementia treated with olanzapine. The long-acting injection (ZypAdhera) for maintenance treatment of schizophrenia has not been accepted for use by the SMC and is non-Formulary.
Restrictions: Consultant only. Patients must be registered with a Clozapine patient monitoring scheme.
Restrictions: Restricted to initiation by a consultant psychiatrist with the injection being further restricted to use by consultant psychiatrists only. The treatment of moderate to severe manic episodes in bipolar 1 disorder and the prevention of a new manic episode in patients who experienced predominantly manic episodes is non-Formulary. Treatment of schizophrenia in adolescents 15 years and older is restricted to the initiation and management under the supervision of a child/ adolescent psychiatrist.
Restrictions: Restricted to initiation by a consultant psychiatrist.
Restrictions: Restricted to initiation by consultant psychiatrist and the Prescribing Notes below.
Immediate-release tablets are Formulary for:
- Bipolar disorder:
- Treatment of moderate to severe manic episodes in bipolar disorder.
- Prevention of recurrence in patients with bipolar disorder, in patients whose manic episode has responded to quetiapine treatment
Indications not recommended by SMC and therefore non-Formulary are:
- Treatment of major depressive episodes in bipolar disorder.
- Prevention of recurrence in patients with bipolar disorder, in patients whose depressive episode has responded to quetiapine treatment.
- Add-on treatment of major depressive episodes in patients with Major Depressive Disorder (MDD) who have had sub-optimal response to antidepressant monotherapy (applicable to MR tablets only)
Quetiapine prolonged-release preparations are not included in the GGC Adult Formulary.
4.2.2. Antipsychotic depot injectionsWhen considering a first-line choice of long-acting injectable antipsychotic, a first-generation depot medicine should be chosen from the NHSGGC Formulary. The exception to this is where there is good evidence of effect with a specific SGA oral medication favouring its use as an LAI and where compliance, concordance, adherence or persistence with the oral medication is problematic. A second-line choice in the event of treatment failure or emergent, intolerable side-effects with the first-line choice would be an alternative first-generation depot medicine. Again, the exception to this is if there are emergent side-effects including EPSEs or Tardive Dyskinesia, where formulary SGA LAI would be considered.
Restrictions: Use for the maintenance treatment of schizophrenia in adult patients stabilised with oral aripiprazole is restricted to use under the overall supervision of a psychiatrist.
See Prescribing Notes for further details.
- The maintenance treatment of schizophrenia in adult patients stabilised with paliperidone or risperidone is restricted to use under the overall supervision of a psychiatrist. For relevant SMC advice click here
- Use of the Trevicta® brand for maintenance therapy of schizophrenia in adult patients who are clinically stable on one-monthly paliperidone palmitate injectable product.
Restrictions: Restricted to use under the overall supervision of a psychiatrist and subject to NHSGGC protocol.