Haloperidol

• for management of delirium - start with low dose lorazepam or haloperidol and increase dose and frequency slowly if needed
• if no improvement over 4 days, review diagnosis Continue to treat underlying medical condition(s) Continue to address common causes of delirium, e.g. constipation, dehydration, urinary tract infection, pain, medication side effects
• can be given subcutaneously during palliative care
• high risk of QTc elongation (avoid with some antimicrobials and antiarrythmics)
• license:
  • Schizophrenia and schizoaffective disorder
  • Moderate to severe manic episodes associated with bipolar I disorder
  • Acute psychomotor agitation associated with psychotic disorder or manic episodes of bipolar I disorder
  • Persistent aggression and psychotic symptoms in moderate to severe Alzheimer's dementia and vascular dementia [when non-pharmacological treatments ineffective and there is a risk of harm to self or others]
  • Rapid control of severe acute psychomotor agitation associated with psychotic disorder or manic episodes of bipolar I disorder [when oral therapy is not appropriate]
  • Acute delirium 

Lithium

Monitoring

Tests prior to starting treatment Renal function and U&Es (DTB recommends particular attention to Na and creatinine, NICE recommend particular attention to calcium)1,3,4,7 TFTs1,3,4,7 Cardiac function (ECG recommended for patients with risk factors for, or existing CVD)1,7 FBC 7 Baseline measurement of weight (and height)/ BMI is desirable1,7 Lithium level if switching from another brand/ preparation3 Additionally, as part an annual review of physical health, NICE recommend that patients with bipolar disorder have baseline CV status assessment including pulse and BP, lipid profile, fasting blood glucose levels, liver function and HbA1c7 Monitoring until patient is stabilised Plasma levels NICE and BNF recommend levels checked one week after starting and one week after every dose change. NICE advice is to maintain level between 0.6 and 0.8mmol/L (a level of between 0.8 and 1.0mmol/L may be appropriate in patients who have relapsed previously or who have sub-threshold symptoms with functional impairment7). Levels should be monitored weekly until stable. BNF state that a target serum-lithium concentration of 0.8–1 mmol/litre is recommended for acute episodes of mania, and for patients who have previously relapsed or have sub-syndromal symptoms but levels at the lower end of the range 0.4-1.0mmol/L may be acceptable in maintenance therapy and in elderly patients SLAM also recommend measurement of plasma drug levels after 7 days, then 7 days after every dose change until the desired level is reached, 0.4mmol/L may be effective in unipolar depression, 0.6-1.0 mmol/L in bipolar illness, slightly higher levels in difficult-to-treat mania1 Ongoing Monitoring Thyroid monitoring NICE and BNF recommend TFTs every 6 months,2, 7 (more often if there is evidence of impaired thyroid function or an increase in mood symptoms that might be related to impaired thyroid function ) 43 Plasma levels NICE and BNF recommend monitoring levels every 3 months. The BNF states that drug level monitoring should be continued every 3 months but NICE state that after 12 months monitoring can be decreased to every 6 months unless patients are elderly, taking drugs that interact with lithium, have impaired renal function, have impaired thyroid function, raised calcium levels, poor symptom control, poor adherence, or their most recent lithium level was >/= to 0.8mmol/L. NICE also recommend that levels should be monitored more frequently if urea levels and creatinine levels become elevated, or eGFR falls over 2 or more tests SLAM recommend levels should be monitored every 6 months unless patient is being prescribed interacting medicines, is elderly, has established renal impairment or other relevant physical illness when more frequent monitoring is advised1. DTB recommends checking every 1-2 months for the first 6 months and then every 3- 6 months if levels are stable and adherence is good4. Priadel SPC states that the period between subsequent measurements can be increased gradually following stabilisation, but should not normally exceed 2-3 months3. BNF recommends additional measurements be made if a patient develops significant intercurrent disease or if there is a significant change in their sodium or fluid intake2. Priadel SPC also recommends additional monitoring when there are signs of manic or depressive relapse, or lithium toxicity3. Other monitoring NICE and DTB recommends annual calcium checks4,7. Additionally NICE recommend that all patients with bipolar disorder should have annual physical health reviews at least annually which includes7 • weight or BMI, diet, nutritional status and level of physical activity • cardiovascular status, including pulse and blood pressure • metabolic status, including fasting blood glucose, glycosylated haemoglobin (HbA1c) and blood lipid profile • liver function Action required if abnormal results Plasma levels NICE/BNF states serum lithium levels should be maintained between 0.6 and 1.0 mmol/l Serum lithium level range depends on whether taken once or twice daily and whether level measured at 12 or 24 hours3 44 Toxic effects reliably occur at levels >1.5mmol/L1. If signs of toxicity are present, stop treatment, check plasma levels, and take steps to reverse the toxicity. A concentration of >2mmol/L requires urgent treatment2. More frequent testing should be undertaken if there is evidence of clinical deterioration, abnormal results, a change in sodium intake, or symptoms suggesting abnormal renal or thyroid function (e.g. unexplained fatigue) or other risk factors (e.g. patient starting interacting medication)7 If urea and creatinine levels become elevated, initiate closer monitoring of dose and blood levels and assess the rate of renal function deterioration7. The NPSA alert supporting information states that the management of subclinical hypothyroidism remains controversial, but the following approach has been suggested. If the serum TSH is confirmed to be above twice the ‘normal’ limit, for example a laboratory may report this situation with TSH test results above 10 mU/L, then there is a high risk of progression to overt hypothyroidism and levothyroxine should be prescribed. If the value is between 5 and 10 mU/L more frequent monitoring is indicated and a trial of levothyroxine may be appropriate particularly if the patient is symptomatic.9 Additional notes Stopping lithium: NICE recommend that when stopping lithium the dose should be reduced gradually over at least 4 weeks, and preferably up to 3 months, even if the person has started taking another antimanic drug. During dose reduction and for 3 months after lithium treatment is stopped, monitor the person closely for early signs of mania and depression7. SLAM recommend that incremental reductions in plasma levels of >0.2mmol/L should be avoided1 A lithium treatment pack should be given to all patients on initiation of therapy and they should receive appropriate ongoing verbal and written information. The record book should be used to track blood levels.2, 9 Prescribers and pharmacists should check blood levels are monitored regularly and that it is safe to issue a repeat prescription and/or dispense the prescribed item9. Systems to identify and deal with medicines that might adversely interact with lithium therapy should be in place9. Ideally blood samples for plasma lithium level estimations should be taken 12 hours post-dose in patients prescribed a single daily dose of a prolonged-release preparation1. In practice an interval of 10-14 hours is acceptable as long as the interval is the same at each measurement and the delay after the dose noted4 NICE recommend that patients should be advised that erratic compliance or rapid discontinuation may increase the risk of manic relapse. Monitor older adults carefully for symptoms of lithium toxicity because they may develop high serum levels of lithium at doses in the normal range, and lithium toxicity is possible at moderate serum levels.7 Patients should be advised to: • avoid dietary changes which reduce or increase sodium intake2 • seek medical attention if they develop diarrhoea and/or vomiting7 45 • report the signs and symptoms of lithium toxicity, hypothyroidism, renal dysfunction and benign intracranial hypertension.2 • ensure they maintain their fluid intake, particularly after sweating (for example, after exercise, in hot climates or if they have a fever), if they are immobile for long periods or if they develop a chest infection or pneumonia7 • Patients taking lithium should be warned not to take OTC NSAIDs7 NICE recommend that patients are monitored for signs of neurotoxicity (including paraesthesia, ataxia, tremor and cognitive impairment) which can occur at therapeutic levels7 SLAM state that there is no clinically significant difference in the pharmacokinetics of Priadel and Camcolit. Other preparations should not be assumed to be bioequivalent and should be prescribed by brand.1 SLAM also note that lithium citrate liquid is available in two strengths (equivalent to 200mg and 400mg lithium carbonate in 5ml) and that care is needed when prescribing and dispensing to ensure that patient receives the intended dose. The following measures are QOF indicators for 2016/175: • percentage of patients on lithium with a record of serum TSH in the preceding 9 months • percentage of patients on lithium with a record of serum creatinine in the preceding 9 months • percentage of patients with a record of lithium levels in the therapeutic range in the preceding 4 months • The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of blood pressure in the preceding 12 months

Olanzapine

• atypical antipsychotics
• calms and sedates
• peak levels are reached 1.5 hours following a dose of immediate-release tablets or 6 hours following a dose of extended-release tablets
• License:
  • Schizophrenia
  • Treatment of mania in bipolar disorder
  • Treatment of depression in bipolar disorder
  • Prevention of mania and depression in bipolar disorder
• Add the letters IR after quetiapine to make sure you do not get XL if prescribing it once a day

Risperidone

• the only atypical antipsychotic officially indicated for Behavioural and psychological symptoms of dementia (BPSD)
• Risperidone orodispensible, oral solution and oral tablets are bio-equivalent
• Peak plasma concentration occurs in 1 to 2 hours
• Quicklets disintegrate on the tongue and can be swallowed with or without water - do not cut or divide
• The active antipsychotic fraction has a half life of 24 hours.
• Side effects: fatigue, insomnia, agitation, anxiety, headache, seizures, dystonias, neuroleptic malignant syndrome
• Monitoring required for: Type I and II diabetes, lipid changes, blood dyscrasias, cardiac arrythmias, prolonged QT interval if given with other drugs with this effect, elevated prolactin, weight gain
• Acute withdrawal syndrome – gradual withdrawal is advisable
• license:
  • Acute and chronic psychosis
  • Mania

  • Short-term treatment (up to 6 weeks) of persistent aggression in patients with moderate to severe Alzheimer's dementia unresponsive to non-pharmacological interventions and when there is a risk of harm to self or others

Risperidone Long-Acting Injection (Risperadl Consta)

• RLAI should not be prescribed for patients who have shown little or no response to oral risperidone.
• As it is not possible to give a test dose of RLAI, patients must be prescribed oral risperidone for several days before RLAI is initiated to assess tolerability (to rule out hypotension and extra-pyramidal side-effects)
• RLAI releases only small amounts of drug during the first three weeks. The main release starts in week four and peaks in weeks five to six.)
• Oral risperidone (or other current oral antipsychotic) must be continued at the same dose for at least four to six weeks following the first injection, and then tapered off over the next two weeks.