NICE guidance - the use of newer (atypical) antipsychotic drugs for the treatment of schizophrenia

NICE in 2002 (1) stated that atypical antipsychotic medication should be used in preference over typical antipsychotics but no longer make that assertion (2)

• using oral antipsychotic medication (2)
  • oral antipsychotic medication should be offered to people with newly diagnosed schizophrenia
  • information should be provided on the benefits and side effects of each antipsychotic and discuss these with the service use
  • the decision on which antipsychotic to use should be done in partnership with the service user, and carer if appropriate.
    • when deciding on the most suitable medication, consider the relative potential of individual antipsychotics to cause extrapyramidal side effects (such as akathisia), metabolic side effects (such as weight gain), and other side effects (including unpleasant subjective experiences)
    • regular combined antipsychotic medication should not be started, except for short periods (for example, when changing medication)
  • before starting antipsychotics an electrocardiogram (ECG) should be offered if:
    • specified in the summary of product characteristics (SPC)
    • physical examination shows specific cardiovascular risk (such as diagnosis of high blood pressure)
    • there is personal history of cardiovascular disease, or
    • the service user is being admitted as an inpatient
  • when using antipsychotic medication then consider treatment with antipsychotic medication as an individual therapeutic trial:
    • record the indications, expected benefits and risks, and expected time for a change in symptoms and for side effects to occur
    • start with a dose at the lower end of the licensed range and titrate upwards slowly within the dose range in the British National Formulary (BNF) or SPC
    • justify and record reasons for dosages outside the range specified in the BNF or SPC
    • monitor and record the following regularly and systematically throughout treatment, but especially during titration:
      • efficacy, including changes in symptoms and behaviour
      • side effects of treatment, taking into account overlap with some of the clinical features of schizophrenia
      • adherence
      • physical health
    • the rationale for continuing, changing or stopping medication and the effects of such changes should be recorded
    • carry out a trial of the medication at optimum dosage for 4-6 weeks
  • also the clinician should discuss with the service user, and carer if appropriate:
    • any non-prescribed therapies (including complementary therapies) the service user wishes to use
    • alcohol, tobacco, prescription and non-prescription medication and illicit drugs. Discuss their possible interference with the effects of prescribed medication and psychological treatments. Discuss the safety and efficacy of non-prescribed therapies
  • NICE recommend that a clinician should not use a loading dose of antipsychotic medication ('rapid neuroleptisation')
  • the service user should be warned of a potential photosensitive skin response with chlorpromazine and advise using sunscreen if necessary

Notes:

• depot/long-acting injectable antipsychotic medication
  • depot/long-acting injectable antipsychotics should be considered when:
    • service users would prefer this after an acute episode
    • avoiding covert non-adherence to medication is a clinical priority

Reference:

• 1. NICE (May 2002). Guidance on the use of newer (atypical) antipsychotic drugs for the treatment of schizophrenia
• 2. NICE (March 2009). Schizophrenia Core interventions in the treatment and management of schizophrenia in adults in primary and secondary care