Schizophrenia 45

Monitoring
Table 2.6 summarises suggested monitoring for those receiving antipsychotics. More
detail and background is provided in specific sections in this chapter.

Table 2.6 Monitoring of metabolic parameters for patients receiving antipsychotic drugs

Action to be taken Drugs for which

CHAPTER 2
Parameter/ Suggested ifresults outside Drugs with special monitoring
test frequency reference range precautions is not required

Urea and Baseline and yearly Investigate all Amisulpride and None
electrolytes as part of aroutine abnormalities detected sulpiride renally
(including physical health check excreted consider
creatinine or reducing dose if
estimated GFR) GFR reduced

Full blood count Baseline and yearly Stop suspect drug if Clozapine FBC None
(FBC)16 as part of aroutine neutrophils fallbelow weekly for
physical health check 1.5 109/L 18weeks, then
and to detect Refer to specialist fortnightly up to
chronic bone medical care ifneutro- one year, then
marrow suppression phils below 0.5 109/L monthly (schedule
(small riskassociated Note high frequency of varies from country
with some benign ethnicneutro- to country)
antipsychotics) penia in certain ethnic
groups
Blood lipids7,8 Baseline, at 3 Offer lifestyle advice Clozapine, Some antipsychotics
(cholesterol; months then yearly Consider changing olanzapine, (e.g. aripiprazole) not
triglycerides) to detect antipsychotic and/or quetiapine, clearly associated
Fasting sample, if antipsychotic initiating statin therapy phenothiazines with dyslipidaemia
possible induced changes, 3monthly for first but prevalence is
and generally year, thenyearly high inthis patient
monitor physical group911 so all
health patients should be
monitored

Weight7,8,11 Baseline, frequently Offer lifestyle advice Clozapine, Aripiprazole,

(include waist for 3 months then Consider changing olanzapine 3 ziprasidone and
size and BMI, if yearly to detect antipsychotic and/or monthly for first lurasidone not
possible) antipsychotic dietary/pharmacological year, thenyearly clearly associated
induced changes, intervention with weight gain
and generally but monitoring
monitor physical recommended
health nonetheless obesity
prevalence high in
thispatient group

Plasma glucose Baseline, at 46 Offer lifestyle advice Clozapine, Some antipsychotics

(fasting sample, months, then Obtain fasting sample olanzapine, not clearly associated
ifpossible) yearlyto detect or nonfasting and chlorpromazine with IFG but
antipsychoticinduced HbA1C test atbaseline, prevalence is high in
changes, and Refer to GP or specialist onemonth, then this patient group12,13
generally monitor 46 monthly so all patients should
physical health be monitored

Continued
 46 The Maudsley Prescribing Guidelines in Psychiatry

Table 2.6 (Continued)

Action to be taken Drugs for which

Parameter/ Suggested ifresults outside Drugs with special monitoring
test frequency reference range precautions is not required

ECG Baseline and after Discuss with/refer to Haloperidol, Risk of sudden

dose increases cardiologist if pimozide, cardiac death
CHAPTER 2

(ECGchanges rare abnormality detected sertindole ECG increased with most

inpractice14) on mandatory antipsychotics15
admission to hospital Ziprasidone ECG Ideally, all patients
and before discharge mandatory in some should be offered an
if drug regimen situations ECG at least yearly
changed
If an antipsychotic
associated with
moderatehigh risk
of QTc prolongation
is prescribed

Blood pressure Baseline; frequently If severe hypotension Clozapine, Amisulpride,

during dose orhypertension chlorpromazine and aripiprazole,
titrationto detect (clozapine) observed, quetiapine most lurasidone,
antipsychotic slow rate of titration likely to be trifluoperazine,
induced changes, Consider switching to associated with sulpiride
and generally another antipsychotic if postural
monitor physical symptomatic postural hypotension
health hypotension
Treat hypertension in
line withNICE guidelines

Prolactin Baseline, then at 6 Switch drugs if Amisulpride, Asenapine,

months, then yearly hyperprolactinaemia risperidone and aripiprazole,
to detect confirmed and paliperidone clozapine, lurasidone,
antipsychotic symptomatic particularly quetiapine,
induced changes Consider tests of bone associated with olanzapine (<20 mg),
mineral density (e.g. hyperprolactinaemia ziprasidone usually do
DEXA scanning) for not elevate prolactin,
those with chronically but worth measuring
raisedprolactin. ifsymptoms arise

Liver function Baseline, then yearly Stop suspect drug if Clozapine and Amisulpride, sulpiride
tests (LFTs)1618 as part of aroutine LFTs indicate hepatitis chlorpromazine
physical health check (transaminases 3 associated with
and to detect chronic normal) orfunctional hepatic failure
antipsychoticinduced damage (PT/albumin
changes (rare) change)

Creatine Baseline, then See section on NMS more likely None

phosphokinase ifneuroleptic Neuroleptic malignant with first-generation
(CPK) malignant syndrome syndrome antipsychotics
(NMS) suspected

Other tests:
Patients on clozapine may benefit from an EEG19,20 as this may help determine the need for valproate (although
interpretation is obviously complex). Those on quetiapine should have thyroid function tests yearly although the
risk of abnormality is very small.21,22

BMI, body mass index; DEXA, dualenergy Xray absorptiometry; ECG, electrocardiogram; EEG, electrocephalogram;
GFR, glomerular filtration rate; IFG, impaired fasting glucose; PT, prothrombin time.
 48 The Maudsley Prescribing Guidelines in Psychiatry

Relative adverse effects a rough guide

A rough guide to the relative adverse effects of antipsychotic drugs is shown in Table2.7.
The table is made up of approximate estimates of relative incidence and/or severity,
based on clinical experience, manufacturers literature and published research. See
individual sections for more precise information.
Other sideeffects not mentioned in this table do occur. Please see dedicated sections
CHAPTER 2

on other sideeffects included in this book for more information.

Table 2.7 Relative adverse effects of antipsychotic drugs

Weight Anti Prolactin

Drug Sedation gain Akathisia Parkinsonism cholinergic Hypotension elevation

Amisulpride + + + +++

Aripiprazole +

Asenapine + + + +

Benperidol + + + +++ + + +++

Chlorpromazine +++ ++ + ++ ++ +++ +++

Clozapine +++ +++ +++ +++

Flupentixol + ++ ++ ++ ++ + +++

Fluphenazine + + ++ +++ ++ + +++

Haloperidol + + +++ +++ + + ++

Iloperidone ++ + + +

Loxapine ++ + + +++ + ++ +++

Lurasidone + + + +

Olanzapine ++ +++ + + + +

Paliperidone + ++ + + + ++ +++

Perphenazine + + ++ +++ + + +++

Pimozide + + + + + + +++

Pipothiazine ++ ++ + ++ ++ ++ +++

Promazine +++ ++ + + ++ ++ ++

Quetiapine ++ ++ + ++

Risperidone + ++ + + + ++ +++

Sertindole + +++

Sulpiride + + + +++

Trifluoperazine + + + +++ + + +++

Ziprasidone + + + +

Zuclopenthixol ++ ++ ++ ++ ++ + +++

+++ high incidence/severity, ++ moderate, + low, very low.

 Schizophrenia 49

Treatment algorithms for schizophrenia

Either:
Agree choice of antipsychotic with patient and/or carer
Or, if not possible:
Start second-generation antipsychotic

CHAPTER 2
Titrate, if necessary, to minimum effective dose
(See section on Minimum effective dose in this chapter)

Adjust dose according to response and tolerability

Assess over 23 weeks*

Effective Not effective Not tolerated or

poor compliance

Continue at dose established as effective
Change drug and follow above
process. Consider use of either a
SGA or a FGA
If poor compliance related to poor tolerability,
discuss with patient and change drug
If poor compliance related to other factors,
consider early use of depot

Not effective

Clozapine**

* Any improvement is likely to be apparent within 23 weeks of receiving an effective dose. Most improvement occurs during this period.1
If no effect at 23 weeks, change dose or drug. If some response detected, continue for a total of at least 4 weeks before
abandoning treatment.
** Early use of clozapine much more likely than anything else to be successful.2

Figure 2.1 Treatment of firstepisode schizophrenia.

 Investigate social or psychological precipitants
Provide appropriate support and/or therapy
Continue usual drug treatment

Acute drug treatment required

CHAPTER 2

Add short-term sedative

or
Switch to a different, acceptable antipsychotic if appropriate
Discuss choice with patient and/or carer
Assess over at least 6 weeks

Treatment ineffective

Switch to clozapine

Figure 2.2 Treatment of relapse or acute exacerbation of schizophrenia (full adherence to medication confirmed).

Simplify drug regimen

Investigate reasons for Confused or Reduce anticholinergic load
poor adherence Consider compliance aids*
disorganised
Consider depot

Lack of insight
or support Poorly tolerated treatment

Discuss with patient Discuss with patient

consider depot antipsychotics switch to acceptable drug

*Compliance aids (e.g. Medidose system in the UK) are not a substitute for patient
education. The ultimate aim should be to promote independent living, perhaps with
patients filling their own compliance aid, having first been given support and training.
Note that such compliance aids are of little use unless the patient is clearly motivated
to adhere to prescribed treatment. Note also that some medicines are not suitable for
storage in compliance aids

Figure 2.3 Treatment of relapse or acute exacerbation of schizophrenia (adherence doubtful or known to be poor).