Maudsley Prescribing Guidelines Research Articles

Hyperprolactinemia in patients taking antipsychotics: the importance of a shared approach between psychiatry and endocrinology

IntroductionHyperprolactinemia is a commonly encountered adverse effect of antipsychotic medication. Short and long-term repercussions of high prolactin, such as amenorrhea, sexual dysfunction, osteopenia and increased cardiovascular risk carry significant burden and may compromise therapeutic adherence. Despite its serious practical implications, hyperprolactinemia is still underscreened and its management neglected.ObjectivesTo review current clinical guidelines regarding the management of hyperprolactinemia associated with the use of antipsychotics, reflecting upon the importance and need to share the management of this risk with an endocrinology expert.MethodsWe performed a literature review to identify clinical guidelines containing specific recommendations for antipsychotic-induced hyperprolactinemia (British Association of Psychopharmacology [BAP], NICE, Maudsley Prescribing Guidelines, Royal Australian and New Zealand College of Psychiatrists), published over the last ten years, with a particular focus on its physical risks.ResultsMost guidelines do not recommend routine monitoring of prolactin levels in asymptomatic patients. NICE and BAP guidelines have suggested measuring the baseline prolactin level, but have not specified follow-up monitoring, while Maudsley guidelines have. Management strategies depend on factors such as sex, age, as well as the clinical manifestations that ensue. Different treatment strategies have been described, such as decreasing the dose of the antipsychotic, switching antipsychotics, adding aripiprazole or adding dopaminergic agonists. Referral to an endocrinology specialist should be made if the aetiology is unclear, prolactin levels continue to rise despite some intervention, the hyperprolactinaemia is severe (>3000 mIU/L) or there is suspected/confirmed pituitary adenoma. Further physical implications of having hyperprolactin are to be dressed by the endocrinology expert, namely those on bone metabolism, gonodal function and cancer risk.ConclusionsGiven the widespread use of antipsychotics and the need to have psychotic patients stabilized (sometimes with a lack of effective alternative), early detection and shared management of hyperprolactinemia are instrumental towards assisting both clinician’s and patients’ decision-making, be it towards lowering prolactin levels or managing its risk without compromising the antipsychotic’s efficacy.Disclosure of InterestNone Declared

402 - An audit of Lithium Prescribing Practices in an Old Age PsychiatryService highlighting renal impairment in this cohort

AbstractAims:To compare Lithium prescribing practices in a Psychiatry of Old Age (POA) Service in the North-West ofIreland among adults aged 65 years and over with best practice guidelines.Methods:Review of the literature informed development of audit standards for Lithium prescribing. These included National Institute for Clinical Excellent (NICE) 2014 guidelines, The British National Formulary(2019) and Maudsley Prescribing Guidelines (2018). Data was collected retrospectively, using an audit-specific data collection tool, from clinical files of POA team caseload, aged 65 years or more and prescribed Lithium over the past year.Results:At the time of audit in February 2020, 18 patients were prescribed lithium, 67% female, average age 74.6 years. Of those prescribed Lithium; 50% (n=9) had depression, 44% (n=8) had bipolar affective disorder (BPAD) and 6% (n=1) schizoaffective disorder.78% (n= 14) of patients met the NICE standard of 3-monthly lithium level. Lithium levels were checkedon average 4.5 times in past year, average lithium level was 0.61mmol/L across the group and 39% (n=7) had lithium level within recommended therapeutic range (0.6-0.8mmol/L).83% of patients (n=15) met the NICE standards of 3 monthly renal tests. Taking into consideration mostrecent blood test results, 100% (n=18) had abnormal renal function.Half (n=9) were initiated on lithium by POA service and of these, 56% (n=5) had documented renal impairment prior to initiation. Of patients on long term lithium at time of referral (n=9), almost half (n=4) had a documented history of lithium toxicity.Conclusions:The results of this audit highlight room for improvement in lithium monitoring of older adults attending POA service. Furthermore, all patients prescribed lithium had impaired renal function. This is an important finding given the associations between those admitted to hospital with COVID-19 and co- morbid kidney disease and increased risk of inpatient death.Our findings highlight the need for three monthly renal function monitoring in elderly prescribed lithiumgiven the additive adverse effects of increasing age and lithium on the kidney. Close working with specialised renal services to provide timely advice on renal management for those with renal impairment prescribed lithium is important to minimise adverse patient outcomes.

An audit of lithium prescribing practices in an old age psychiatry service highlighting renal impairment in this cohort

AimsTo compare Lithium prescribing practices in a Psychiatry of Old Age (POA) Service in the North-West of Ireland among adults aged 65 years and over with best practice guidelines.MethodReview of the literature informed development of audit standards for Lithium prescribing. These included National Institute for Clinical Excellent (NICE) 2014 guidelines, The British National Formulary (2019) and Maudsley Prescribing Guidelines (2018). Data were collected retrospectively, using an audit-specific data collection tool, from clinical files of POA team caseload, aged 65 years or more and prescribed Lithium over the past one year.ResultAt the time of the audit in February 2020, 18 patients were prescribed lithium, 67% female, average age 74.6 years. Of those prescribed Lithium; 50% (n = 9) had a depression diagnosis, 44% (n = 8) had bipolar affective disorder (BPAD) and 6% (n = 1) had schizoaffective disorder.78% (n = 14) of patients were on track to meet, or had already met, the NICE standard of 3-monthly serum lithium level. Lithium levels were checked on average 4.5 times in past one year, average lithium level was 0.61mmol/L across the group and 39% (n = 7) had lithium level within recommended therapeutic range (0.6-0.8mmol/L).83% (n = 15) of patients met the NICE standards of 3 monthly renal tests, thyroid function test was performed in 89% (n = 16) and at least one serum calcium level was documented in 63% (n = 15). Taking into consideration most recent blood test results, 100% (n = 18) had abnormal renal function, 78% (n = 7) had abnormal thyroid function and 60% (n = 9) had abnormal serum calcium.Half (n = 9) were initiated on lithium by POA service and of these, 56% (n = 5) had documented renal impairment prior to initiation. Of patients on long term lithium therapy at time of referral (n = 9), almost half (n = 4) had a documented history of lithium toxicity.ConclusionThe results of this audit highlight room for improvement in lithium monitoring of older adults attending POA service. Furthermore, all patients prescribed lithium had impaired renal function, half had abnormal calcium and two fifths had abnormal thyroid function. This is an important finding given the associations between those admitted to hospital with COVID-19 and comorbid kidney disease and increased risk of inpatient death.Our findings highlight the need for three monthly renal function monitoring in older adults prescribed lithium given the additive adverse effects of increasing age and lithium on the kidney. Close working with specialised renal services to provide timely advice on renal management for those with renal impairment prescribed lithium is important to minimise adverse patient outcomes.

QI project: Improving the discharge advice from functional old age psychiatry wards for the monitoring of lithium and antipsychotic medication in the community

AimsNICE guidelines and Maudsley prescribing guidelines both stipulate that patients over the age of 65 prescribed lithium or antipsychotic medication should have their bloods and physical parameters monitored regularly. There is currently no provision from the community mental health teams in Edinburgh to provide this monitoring, which falls to the patients GP. Following an initial data collection, it was found that there was no monitoring advice being provided on immediate discharge letters (IDLs) for patients discharged from two functional old age psychiatry inpatient wards at the Royal Edinburgh Hospital. This patient group often have comorbid medical conditions and therefore monitoring of their psychotropic medication is especially important. The aim of the QI project was for 100% of patients discharged from thesewards on lithium or antipsychotic medication to have appropriate advice documented on their immediate discharge letter (IDL) with regards to medication monitoring.MethodData were collected monthly by reviewing the notes of all discharged patients to determine the frequency at which medication monitoring advice was documented on IDLs from the two wards. A proposed new template for discharge letters which included advice on medication monitoring was discussed and agreed with the old age psychiatry team in Edinburgh. This was disseminated to the appropriate medical staff members and was included in induction packs for junior doctors. Following this a new “canned text” template was implemented to automatically populate the discharge letter with advice depending on whether they were antipsychotics/lithium/neither.ResultIDLs for 91 patients discharged between May 2020 and February 2021 were reviewed. Baseline data showed that 0% of patients (n = 15) had appropriate monitoring advice documented on their IDL. Following initial introduction of monitoring advice to the induction pack for junior doctors, the mean frequency of completed advice on IDLs was 50.9% across 6 months. Following implementation of the canned text, the frequency of completed advice on discharge letters for February 2021 was 100% (n = 7).ConclusionThis QI project has been successful in improving the rate of appropriate advice for antipsychotic and lithium monitoring being provided on immediate discharge letters. It is hoped that this will help reduce adverse effects associated with antipsychotics and lithium in older psychiatric patients. Further work could be done on determining the frequency that the advised monitoring is being carried out.

Monitoring side-effects of antipsychotics using the glasgow antipsychotic side-effect scale

AimsAntipsychotic drugs frequently produce side-effects which represent common reasons for noncompliance. National guidelines, published by the National Institute of Care and Health Excellence, the Royal College of Psychiatrists, and the Maudsley Prescribing Guidelines in Psychiatry, stipulate that patients prescribed antipsychotic drugs should be reviewed for side-effects on a weekly basis. This completed audit cycle, conducted on a mixed acute general adult psychiatric ward, examined whether patients were being assessed for side-effects of antipsychotic drugs using a standardised, self-reporting scale – the Glasgow Antipsychotic Side-effect Scale (GASS) – as per national guidelines. As identification of side-effects is important in tailoring treatment to improve compliance, auditing monitoring practice was important in realising these outcomes.MethodRetrospectively, 26 inpatients were identified over a two-month period who were prescribed antipsychotic drugs. Their notes were reviewed for documented weekly GASS scores for the duration of antipsychotic treatment. Initial data demonstrated 0% compliance with guidelines, as no patients completed a weekly GASS. The intervention to improve compliance was a training session for ward staff on implementing the GASS. Data were subsequently collected prospectively over three weeks for 15 patients.ResultSeven patients completed the GASS weekly over three weeks, representing 47% compliance. Two patients (13%) completed two forms, three (20%) completed one form, and three (20%) completed no forms. There was a positive correlation between being offered the GASS and completing it – only one patient declined to complete it and was not offered it during the third week. Of the remaining 14 patients, if the GASS was offered there was 100% rate of completion. Staff did not offer the GASS to every patient each week, which accounted for most cases of non-completion. Some patients with pre-existing symptoms of physical illnesses included these on the GASS, which complicated interpretation. Future interventions could include further staff education, and involving a ward pharmacist to review results during medication reviews to optimise treatment compliance, as no medication changes resulted directly from patients completing the GASS.ConclusionCompliance with completing the GASS weekly improved following staff education, identifying the main factor affecting compliance as staff not offering the GASS to patients. Patients generally engaged well with side-effect monitoring, as most completed the GASS when offered. Further staff education may produce even greater compliance with guidelines, and involving pharmacy staff to review GASS scores and inform medication choices may lead to use of the GASS resulting in more tolerable and effective treatment plans.

An audit into the physical health monitoring of patients who are prescribed antipsychotics in HMP Birmingham

AimsTo assess the compliance of physical health monitoring with NICE and Maudsley prescribing guidelines for those patients prescribed antipsychotics in HMP Birmingham. To assess secondary objectives including who prescribed the antipsychotics (GP vs psychiatrist), the indication and diagnosis they are prescribed for (licensed or otherwise) and which antipsychotics were usually prescribed.BackgroundPatients with psychosis or schizophrenia have a reduced life expectancy of 15-20 years when compared to the general population. The physical health effects of the medication prescribed for these conditions play a large role in this. Physical health monitoring and appropriate intervention is vital to reduce the discrepancy in life expectancy and improve the quality of life of these patients.MethodNotes of 105 patients in total at HMP Birmingham were reviewed to assess whether the primary outcomes of weight, waist circumference, physical observations, blood tests, medical systems review and education/lifestyle advice were done at the correct times. Secondary objectives of which antipsychotics were prescribed, the profession of the prescriber and the indication for the medications (or diagnosis) were also audited.ResultAntipsychotics were initiated by both GP's and psychiatrists. Appropriately, there were no prescriptions for clozapine. Olanzapine and quetiapine were the most common antipsychotics prescribed. Not all medications were prescribed for licensed indications and some lacked documentation of both a mental health diagnosis and indications in terms of symptoms. Average BMI of patients was overweight, with BMI ranging as high as 45. The pre-prescription, 12 weekly and annual physical health checks had poor compliance. Those that were completed in line with NICE and Maudsley guidelines were done so by coincidence at the time of diabetic reviews.ConclusionThe physical health monitoring of patients on antipsychotics in HMP Birmingham is not currently compliant with clinical guidelines. There needs to be improved systems in place for the monitoring of physical health both before prescriptions are initiated and after at the NICE recommended intervals. Amongst other actions, improved computer reminders and training of existing and new team members will be done. The monitoring requirements will be re-audited in 6 months following immediate implementation of the recommendations outlined below.

Management of psychomotor agitation: audit of clinical practice

Background: Psychomotor agitation (PMA) is encountered in different psychiatric settings, with prevalence ranging between 4.3 and 10%. According to The Maudsley Prescribing Guidelines in Psychiatry, stepwise management of PMA starts with behavioral intervention, followed by parenteral rapid tranquillization and physical restraint as last resorts. Our primary aim is to determine whether we follow the stepwise management of PMA. Our secondary aims are to assess the type and frequency of different psychotropics used to manage PMA, and the rate antipsychotic combination. Methods: We enlisted all patients who were prescribed psychotropics, ordered as “PRN for Agitation”, both in the emergency department and psychiatry inpatient units, between January the 7th and March the 4th of 2018, and retrospectively analyzed their electronic medical records for documentation of PMA and behavioral interventions implemented. In addition, we assessed the type and frequency of different psychotropics used for chemical restraint. Results: 76 patients met our criteria. PMA was documented in 32.4 % of the cases, with five presenting with severe agitation. 21 instances of PMA occurred while patients were in the emergency department (ED), pending admission to psychiatry inpatient units. Behavioral intervention was only documented in 9.5% of the cases in the ED, compared to 48% in the inpatient units. The most frequently prescribed regimen for managing PMA was the combination of Intramuscular (IM) Haloperidol and Diphenhydramine, at a rate of 66%, followed by IM Haloperidol and Lorazepam (19.12%) and IM Haloperidol and Promethazine (8.82%). Compliance with the route of administration was only observed in 26% of cases, and the rate of neuroleptic co-administration was 68%. Conclusion: In managing PMA, there is insufficient documentation of behavioral intervention. Compliance with psychotropic route of administration for chemical restraint was poor, as parenteral tranquillizers were the preferred agents, without initially resorting to oral psychotropics. In addition, most of our patients were prescribed more than one antipsychotic. Through a multidisciplinary approach, our goal is to improve compliance with the proposed guidelines in managing PMA, and minimize the rate of neuroleptic co-administration

British Heart Rhythm Society Clinical Practice Guidelines on the Management of Patients Developing QT Prolongation on Antipsychotic Medication.

The British Heart Rhythm Society’s Clinical Practice Guidelines on the Management of Patients Developing QT Prolongation on Antipsychotic Medication are written for heart rhythm consultants, primary care physicians, specialist registrars, nurses and physiologists who may be requested to review ECGs or advise on cases where antipsychotic-induced QT prolongation is suspected or proven. The guidance is adapted from the latest Maudsley Prescribing Guidelines in Psychiatry, published in 2018.

Limiting psychotropic medication prescription on discharge from psychiatric inpatient care: a possible suicide intervention?

Restricting access to lethal means is an effective suicide prevention strategy. However, there is little discussion in the literature about the potential contribution of prescribing practices on discharge from inpatient psychiatric care (which has been established as a high-risk period for suicide) to suicide deaths by overdose of prescribed medication. This study aimed to assess the quantity, toxicity and potential lethality of psychotropic medication being prescribed on discharge from psychiatric care to those with and without indices of suicidality. Patient demographic, clinical and prescription data were collected from 50 randomly selected charts following discharge from inpatient psychiatric care. Psychotropic medications (dose × duration) on discharge were converted to their equivalent doses of neuroleptics, antidepressants and anxiolytics to rate toxicity and potential lethality, using the Maudsley Prescribing Guidelines. Mood stabilizing medications were also documented. 39% of prescriptions analysed contained toxic and potentially fatal doses of either neuroleptic or antidepressant equivalent medication. Patient discharge from inpatient psychiatric care presents a golden opportunity to moderate access to potentially fatal psychotropic medication. Iatrogenic provision of lethal means for suicide during a period of increased risk and in a group at increased suicide risk may impact suicide prevention efforts and requires further in-depth research. Current prescribing practices may be a missed opportunity to intervene in this regard.

Prevalence and patterns of anti-epileptic medication prescribing in the treatment of epilepsy in older adults with intellectual disabilities.

The prevalence of epilepsy is higher in people with intellectual disability (ID) and increases with the degree of ID. Although life expectancy for people with ID is increasing, people with ID coexisting with epilepsy have a higher mortality rate, particularly those who had recent seizures. There have been few observational studies of the prevalence and patterns of anti-epileptic prescribing among older people with ID and epilepsy. The aim of this study was to investigate prevalence and patterns of anti-epileptic prescribing in the treatment of epilepsy in a representative population of older people with ID and epilepsy. This was an observational cross-sectional study from wave 1 (2009/2010) of Intellectual Disability Supplement to the Irish Longitudinal Study on Aging, a nationally representative sample of 753 persons with ID aged between 41 and 90years. Participants and/or proxies recorded medicines used on a regular basis and reported doctor's diagnosis of epilepsy; medication data were available for 736 (98%). Prescribing of anti-epileptic drugs (AEDs) for epilepsy in those with a doctor's diagnosis of epilepsy (N=205) was the primary exposure of interest for this study. Participant exposure to these AEDs was then categorised into AED monotherapy and polytherapy. Participants/carers reported seizure frequency, when epilepsy was last reviewed and which practitioner reviewed epilepsy. In addition, medications that may lower the seizure threshold that were listed in the Maudsley prescribing guidelines in psychiatry were examined. Of the 736 participants with reported medicines use, 38.9% (n=287) were exposed to AEDs, and 30.6% (225) had a doctor's diagnosis of epilepsy. Of those with epilepsy (n=225), 90.9% (n=205) reported concurrent use of AEDs and epilepsy. Of these 205 participants, 50.3% (n=103) were exposed to AED polytherapy, and 63 different polytherapy regimes were reported. The most frequently reported AEDs were valproic acid (n=100, 48.7%), carbamazepine (n=89, 46.3%) and lamotrigine (n=57, 27.8%). In total, 13.7% had a concurrent psychotropic, which should be avoided in epilepsy, and 32.6% had a psychotropic where caution is required. Antipsychotics with potential epileptogenic potential accounted for 80% of these medications. Of those with AED polytherapy (n=103), 29.5% (28) reported being seizure free for the previous 2years. Prevalence of epilepsy was high among older people with ID, and half were exposed to two or more AEDs. Despite the use of AED therapy, over half had seizures in the previous 2years. As the primary goals of optimal AED treatment are to achieve seizure freedom without unacceptable adverse effects, this was not achievable for many older patients with ID and epilepsy. Our findings indicated that people with ID and epilepsy were often exposed to psychotropic medications that may lower the seizure threshold. Regular review of epilepsy and medicines (including medicines that may interact with AEDs or lower the seizure threshold) by multidisciplinary teams working to agreed standards may improve quality of prescribing. Improved exchange of information and coordination of care between specialists and primary care practitioners in line with expert consensus recommendations could bring substantial benefit.

Standards of Lithium Treatment Monitoring In a Teaching Hospital in South India among Bipolar Affective Disorder

Background: Lithium is a commonly used drug with a narrow therapeutic index, it has significant adverse effects on kidney and thyroid, and is life threatening during intoxication. Maudsley guidelines on managing bipolar affective disorder patients (BPAD) with lithium recommends checking weight at baseline and every 3rd month, serum lithium after 7th day thereafter 3 months once, renal function test and serum thyroid stimulating hormone (TSH) at baseline and 6 months once. Aim: To evaluate whether Pre-Lithium workup and monitoring is done in Bipolar affective disorder (BPAD) patients initiated on Lithium as per Maudsley prescribing guidelines in psychiatry. Method: Retrospective audit conducted in a tertiary care hospital on lithium monitoring in BPAD patients treated with lithium atleast for six months compared against Maudsley prescribing guidelines. Results: Among medical records of 114 bipolar patients fulfilling study criteria, weight and serum lithium at baseline was checked in 100% of patients; serum creatinine and TSH at baseline along with lithium at 3rd month was done in 83.3%, 78.9% and 68.4% of patients respectively. Maudsley guidelines for serum creatinine, TSH and lithium level at 6th month were met only in 43.8%, 43.8% and 72.8% of patients respectively. Conclusion: The quality of lithium monitoring in bipolar patients falls well short of accepted standards; Hence addressing the issues in monitoring and following a standard protocol can improve the effectiveness of treatment and quality of life of patients.

Using junior doctors to improve patient care: Creating a clinic to monitor the physical health of patients prescribed clozapine

IntroductionIn the United Kingdom, compliance with guidelines on physical health monitoring of patients prescribed clozapine is poor. Our community team established a ‘clozapine clinic’, led by junior doctors, to monitor the physical health of this population.AimsThe aims of this audit were:– to ascertain levels of compliance with guidelines on the physical health monitoring of patients taking clozapine;– to compare the current level of compliance with that prior to the establishment of the clinic.MethodsEleven standards were drawn from National Institute for Health and Care Excellence guidelines and the Maudsley Prescribing Guidelines in Psychiatry.Three audit cycles were conducted: two prior to the establishment of the clinic and one after. In each cycle, searches of patient records were conducted and blood results were reviewed. This was supplemented by telephone calls to general practitioners to ensure a complete data set.Analysis was conducted in Microsoft Excel™ and changes between the cycles were analysed using a two-tailed Z-score.ResultsEach audit cycle included 28–30 patients. In the current cycle compliance levels varied between 66% (annual ECG recording) and 100% (monthly full blood count). The average compliance level was 73% across all standards. This represents an overall improvement on previous audit cycles. Since the clinic was established there has been a statistically significant improvement in compliance with annual monitoring of weight (P = 0.147), body mass index (P = 0.0178), and ECG monitoring (P = 0.0244).ConclusionsImprovements in the care of a vulnerable population may be achieved through setting clear standards, regular audit, and harnessing the leadership and enthusiasm of junior doctors.Disclosure of interestThe authors have not supplied their declaration of competing interest.

The Maudsley Prescribing Guidelines in Psychiatry, 12th ed

The Maudsley Prescribing Guidelines in Psychiatry, 12th ed

Monitoring of physical health parameters for inpatients on a child and adolescent mental health unit receiving regular antipsychotic therapy.

Physical health monitoring of patients receiving antipsychotics is vital. Overall it is estimated that individuals suffering with conditions like schizophrenia have a 20% shorter life expectancy than the average population, moreover antipsychotic use has been linked to a number of conditions including diabetes, obesity, and cardiovascular disease.[1–4]The severity of possible adverse effects to antipsychotics in adults has raised awareness of the importance of monitoring physical health in this population. However, there is little literature available as to the adverse effects of these medications in the child and adolescent community, which make physical health monitoring in this predominantly antipsychotic naïve population even more important.An expert group meeting in the UK has laid down recommendations in regards to screening and management of adult patients receiving antipsychotics, however no specific guidelines have been put in place for the child and adolescent age group.[5]The aim of this audit was to establish whether in-patients receiving antipsychotics had the following investigations pre-treatment and 12 weeks after treatment initiation: body mass index, hip-waist circumference, blood pressure, ECG, urea and electrolytes, full blood count, lipid profile, random glucose level, liver function test, and prolactin. This is in addition to a pre-treatment VTE risk assessment. These standards were derived from local trust guidelines, NICE guidelines on schizophrenia [6] and The Maudsley Prescribing Guidelines.[7]We retrospectively reviewed 39 electronic case notes in total, of which 24 cases were post intervention. Intervention included the use of a prompting tool. This tool was filed in the physical health files of all patients receiving antipsychotics which was intended as a reminder to doctors regarding their patient's need for physical health monitoring. Professionals involved in the monitoring of such parameters were educated in the importance and purpose of its use. Following this intervention re-audit occurred after 6 and 16 months of the initial audit to establish whether the use of the prompting tool caused any significant change in clinical practice.Overall performance in monitoring physical health parameters was initially poor, however we were able to demonstrate that with the help of a single prompt sheet there was a significant improvement following post intervention audit for the majority of parameters being monitored.

1403 – Hyperprolactinemia and antipsychotic use in psychiatric patients

Hyperprolactinemia is a common, but neglected, adverse effect of conventional and some atypical antipshycotics, such as risperidone, paliperidone, amisulpride and zotepine, usually known as “prolactin-raising” antipshycotics. It occurs in almost 42% of men and in 75% of women with schizophrenia taking risperidone and involves prolactin levels greater than 210-420 mUI/L and 210-520 mUI/L, respectively. Atypical antipsychotics such as clozapine, quetiapine, olanzapine, aripiprazole and ziprazidone have a minimal or no significant effect in prolactin levels, being known as “prolactin-sparing” antipsychotics. This work aims to review the recent literature data concerning the management of the antipsychotic taking patients with hyperprolactinemia, regarding the clinical evaluation, differential diagnosis, therapeutic strategies and international recommendations. With the exception of the “Maudsley Prescribing Guidelines” and the “National Collaborating Centre for Mental Health”, none of the current international psychiatric guidelines recommend a routine baseline prolactin determination, neither periodic prolactin levels without the presence of any hyperprolactinemia symptoms. These symptoms include gynaecomastia, galactorrhoea, menstrual irregularities, infertility, sexual dysfunction, acne and hirsutism. Antipsychotic treatment is the most common cause of hyperprolactinemia in psychiatric patients, although it may also occur during the use of tricyclic and tetracyclic antidepressants, selective serotonin reuptake inhibitors and monoaminoxidase inhibitors, and in the presence of hyphotalamic and pituitary neoplasic disease. Antipsychotic-induced hyperprolactinemia therapeutic strategies may include antipsychotic dosage reduction, switching to a “prolactin-sparing” antipsychotic or using a dopamine receptor agonist (bromocriptine, cabergoline or amantadine). Given the osteopenic/ osteoporosis risk, combined oral contraceptives must be considered in women in fertile age with amenorrhoea for a year.

921 – Physical health monitoring of patients taking antipsychotic medication in primary and secondary care: a complete audit

Mortality due to physical illness is greater in schizophrenia than in the general population. Antipsychotics have been linked with weight gain, diabetes and hyperlipidaemia. UK guidelines recommend annual health screens in primary care, and secondary care ensure patients receive this and document results in notes. To establish whether patients taking antipsychotics received annual monitoring of U&E, FBC, Lipids, Glucose, LFT, weight and blood pressure. Standards for the audit were derived from the Maudsley Prescribing Guidelines and NICE Guidelines on Schizophrenia. To improve physical health monitoring for our patients. We retrospectively reviewed 82 case notes. Intervention following initial audit included education of professionals involved in monitoring and inclusion of a Prescribed Medication Monitoring Form in case notes. Re-audit occurred 12 months after initial audit. Statistical analysis used χ 2 -test with Yates’ Continuity Correction. Following intervention recommendation of physical health monitoring to primary care increased from 40.2% to 76.8% (P < 0.0001), as did monitoring frequency: Weight (7.3% to 54.3%), BP (7.3% to 49.4%), U&E (64.6% to 82.5%), FBC (61.0% to 78.5%,) Lipids (47.6% to 72.2%), Glucose (59.8% to 79.7%) and LFT (61.0% to 81.3%) (P < 0.05 for all parameters). Documentation of blood results in secondary care notes was also increased (P < 0.05). Monitoring of physical health comorbidity in patients with serious mental illness was poor in the initial audit. This can be improved in both primary and secondary care by relatively simple measures and by increasing clinicians' understanding of the importance of monitoring.

Risks associated with antipsychotic drugs

Nursing and Residential CareVol. 14, No. 8 Clinical ReviewRisks associated with antipsychotic drugsSangita PandyaSangita PandyaSearch for more papers by this authorSangita PandyaPublished Online:16 Aug 2013https://doi.org/10.12968/nrec.2012.14.8.400AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Alzheimer's Society (2011) Antipsychotic drugs. http://bit.ly/HS7IRn (accessed 5 July 2012) Google ScholarAlzheimer's Society (2012a) Focused Intervention Training and Support (FITS) http://alzheimers.org.uk/FITS (accessed 3 July 2012) Google ScholarAlzheimer's Society (2012b) Care home training programme aims to reduce antipsychotic prescriptions. http://alzheimers.org.uk/site/scripts/news_article.php?newsID=1238 (accessed 3 July 2012) Google ScholarBanerjee S (2009) The Use of Antipsychotic Medication for People with Dementia: Time for Action. The Stationary Office, London Google ScholarCooper JE (1994) Pocket Guide to the ICD-10 Classification of Mental and Behavioural Disorders with Glossary and Diagnostic Criteria for Research. Elsevier Health Sciences, Philadelphia Google ScholarGelder M, Mayou R, Cowen P (2001) Shorter Oxford Textbook of Psychiatry. 4th edn, Oxford University Press, Oxford Google ScholarJoint Formulary Committee (2010) British National Formulary 59. BMA and RPS Publishing, London Google ScholarJoint Formulary Committee (2012) British National Formulary 63. BMA and RPS Publishing, London Google ScholarNational Collaborating Centre for Mental Health (2007) A NICE-SCIE Guideline on supporting people with dementia and their carers in health and social care National Clinical Practice Guideline Number 42. http://www.nice.org.uk/nicemedia/live/10998/30320/30320.pdf (accessed 5 July 2012) Google ScholarNational Institute for Health and Clinical Excellence (2006) Bipolar disorder The management of bipolar disorder in adults, children and adolescents, in primary and secondary care. Clinical guideline 38. http://bit.ly/MQm0Yr (accessed 3 July 2012) Google ScholarNHS Institute for Innovation and Improvement (2011) An economic evaluation of alternatives to antipsychotic drugs for individuals living with dementia. NHS Institute for Innovation and Improvement, Coventry Google ScholarRang HP, Dale MM, Ritter JM, Moore PK (2003) Pharmacology. 5th edn. Churchill Livingstone, Edinburgh Google ScholarSoanes C (2006) Compact Oxford English Dictionary for Students. Oxford University Press, Oxford Google ScholarTaylor D, Paton C, Kerwin R (2007) The Maudsley Prescribing Guidelines. 9th edn. Informa Healthcare, London Google ScholarWalker R, Whittlesea C (2007) Clinical Pharmacy and Therapeutics. 4th edn. Churchill Livingstone, Edinburgh Google ScholarWalker K (2009) Metabolic Syndrome and Antipsy-chotics. Graylands Hospital Drug Bulletin. 16(2): 1–4 Google ScholarWestbury JL (2009) How community pharmacists can help reduce antipsychotic use in care homes. Pharmaceutical Journal 283(7582): 653–4 Google Scholar FiguresReferencesRelatedDetails 1 August 2012Volume 14Issue 8ISSN (print): 1465-9301ISSN (online): 2052-2932 Metrics History Published online 16 August 2013 Published in print 1 August 2012 Information© MA Healthcare LimitedThe author would like to acknowledge the help of Dr Peter Rivers and Dr Stephen Bennett, Senior Lecturers, DeMontfort University.PDF download

Hiperprolactinémia em doentes psiquiátricos.

Hyperprolactinemia is a common, but neglected, adverse effect of conventional antipschycotics and of some of the atypical antipshycotics. It occurs in almost 42% of men and in 75% of women with schizophrenia who are treated with prolactin-raising antipshycotics, even though it has aroused minimal interest within the scientific community when compared with extra-pyramidal effects. Conventional antipsychotics and some of the atypical antipsychotics, such as risperidone, paliperidone, amisulpride and zotepine, are frequently associated with the raise in prolactin plasma levels. Because of this increment in prolactin secretion, they are usually known as prolactin-raising antipshycotics. On the contrary, some of the atypical antipsychotics, such as clozapine, quetiapine, olanzapine, aripiprazole and ziprazidone, have a minimal or no significant effect in prolactin levels, being known as prolactin-sparing antipsychotics. Hyperprolactinemia clinical symptoms include gynaecomastia, galactorrhoea, menstrual irregularities, infertility, sexual dysfunction, acne and hirsutism. Some of these symptoms are due to the prolactin direct action in body tissues, while a couple of them can be due to a hypothalamic-pituitary-gonadal axis dysregulation mediated by the elevation of prolactin. Some studies seem to point the evidence of an association between hyperprolactinemia and long-term consequences, such as bone mineral density decrement and breast cancer. However, these results must be confirmed through further studies. Antipsychotic treatment is the most common cause of hyperprolactinemia in psychiatric patients. However, the evidence of a prolactin increased plasma level demands the differential diagnosis with other pathologies, such as hyphotalamic and pituitary neoplasic disease. The management of a patient with antipsychotic-induced hyperprolactinemia must be adapted to each patient and it may include a reduction in the dosage of the offending antipsychotic, switching to a prolactin-sparing antipsychotic or the use of a dopamine receptor agonist, such as bromocriptine, cabergoline and amantadine. Given the osteopenic and osteoporosis risk, combined oral contraceptives must be considered in female patients in fertile age which have amenorrhoea for at least a one year period. With the exception of the Maudsley Prescribing Guidelines and the National Collaborating Centre for Mental Health, none of the current international psychiatric guidelines recommend a routine baseline prolactin determination, neither periodic prolactin levels without the presence of any hyperprolactinemia symptoms.

Jam today: the law and ethics of covert medication

Covert administration of medication has always been controversial and has not always been specified in care plans, it should be limited to incapacitated patients where the treatment is necessary and in best interests, or else authorised by mental health legislation or an appropriate court declaration. A lot of nursing and HCA practice that involves putting medication in food or drink may not actually be disguising it from the patient at all. The NMC guidelines do not refer to the Mental Capacity Act and are due for review, meanwhile the Maudsley Prescribing Guidelines are recommended. It is vital that HCAs and APs who administer or assist with medication understand their legal and ethical authority for hiding it, and reviewing the reasons with the wider team.

Questions for pharmacist providers in clozapine clinics: Ott and Williams

HOW LONG HAVE YOU BEEN PRACTICING IN YOUR CLINIC? WAS IT YOUR IDEA, OR SOMEONE ELSE'S? Dr. Ott: My clinic has been in operation since May 2009. I was invited by the attending psychiatrists to be a part of the launch, as well as a continuing team member for the clinic with a collaborative practice agreement. My role continues to grow as our research program expands, studies often include me as a co-investigator with similar study responsibilities to our physicians, including research and clinical visits and rating scales.