Preferred Prescribing Choices of Antipsychotic Drugs (APD) in Adults

for Schizophrenia and Other Psychoses

HPFT Medicines Formulary lists the APDs that have been approved for use, however, it does not provide
any detail on how these APDs should be selected.
It is widely accepted that there is very little difference in efficacy between the approved APDs (except
clozapine). However, there are notable differences in their side-effect profiles and more recently, due to
patent expiries, significant variations in their cost (see graphs 1 and 2).
When making prescribing decisions, clinicians are expected to take into account many factors including the
cost impact an APD choice will have on the wider health economy. The algorithm below and table 1 include
the important factors to be considered when selecting an APD for schizophrenia. Table 1 also lists the
preferred APDs as they represent more cost-effective choices.
APDs are also often used in the management of other mental health disorders and the same considerations
should be applied when selecting an APD in these situations too.
Clinicians should consider selecting APDs from the preferred list wherever possible, however it is recognised
that the preferred APDs may not always be appropriate or meet the needs of every individual and second
line alternative APD choices are therefore provided.
Clinicians must ensure that there is a clear and valid rationale for selecting an alternative choice of APD and
that this is documented and communicated to the relevant GPs when requesting continuation prescribing.
Sufficient clinical information, including monitoring requirements must also be provided so that the GP can
safely take on prescribing responsibility. See pg 6 for checklist of minimum information that must be
provided to the GP.

Antipsychotic Treatment Algorithm for Schizophrenia

(Adapted from Maudsley Prescribing Guidelines in Psychiatry 11th Edition)

ChoiceofAPDshouldbebasedonindication,productlicensing,co
morbidities,riskfactors,likelybenefits,sideeffectprofile,cost,previous Continueatdose
patientresponseandindividualpatientpreferenceaswellasotherfactors establishedaseffective.
seetablepg2and3 Effective OncestableprovidetheGP
AgreechoiceofAPDfrompreferredlistwherepossiblewithpatient(and withthenecessary
carerifappropriate).Includeuseofpatientdecisionaidswherepossible. informationtoallowsafe
Titrateifnecessarytominimumeffectivedose transferofprescribing&
Adjustdoseaccordingtoresponseandtolerability monitoringresponsibility
Assessover23weeks.Reassesspartialrespondersat6to8weeks

Ineffectiveor
nottolerated
Poorcompliance
ChangeAPDandfollowabove
process

Nottolerated Effective Ineffective Ifpooradherenceisrelatedtopoor

tolerability,discusswithpatientand
Continueatdose changeAPD
ChangeAPDandfollow establishedaseffective. Considerclozapinein Ifpooradherenceisrelatedtoother
aboveprocess Oncestableprovidethe linewithNICECG178 factors,considerAPDdepot/LAIor
GPwiththenecessary andSIGN131 complianceaids
informationtoallowsafe
transferofprescribing&
monitoringresponsibility

HPFT Preferred Prescribing choices of antipsychotic drugs in adults for schizophrenia and other psychoses.
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 Preferred APD choices and second line alternatives

NICE CG 178 for psychosis and schizophrenia does not differentiate between choice of first and second generation antipsychotics. An oral APD should be offered first line
unless patient prefers depot/LAI after an acute episode, or when avoiding covert non-adherence (either intentional or non-intentional) to antipsychotic treatment is a clinical
priority within the treatment plan.
HFPT Drugs and Therapeutics Committee has considered the SIGN 131 Guideline on management of schizophrenia, and concluded that the prescribing choices listed
below are appropriate.
First generation oral APDs are not drugs of choice ahead of second generation oral agents or first generation antipsychotic depots.
Table 1
Antipsychotic Preferredchoices 2ndlinealternatives PrescribingNotes

Group
Oralantipsychotics Haloperidoltablets(FGA), AllotherFGAslistedinHPFT Secondlinealternativesshouldbeconsideredwhenpreferredchoicesarenot
formulary appropriate.Therationaleforselectingasecondlinepreferencemustbevalid,
Olanzapinetablets(SGA),
Firstgeneration documentedandclearlycommunicatedtoGP.
Quetiapineimmediaterelease Amisulpridetablets(SGA),
(typical)(FGA)and AllAPDsshouldbeprescribedbygenericname.
Secondgeneration (IR)tablets(SGA), Aripiprazoletablets(SGA),
SeesideeffecttableandcostcomparisonchartsbelowtohelpguidechoiceofAPD.
(atypical)(SGA) Risperidonetablets(SGA) QuetiapineXLtablets(SGA),
Standardtabletsarepreferred.Orodispersibletabletsandliquidformulationsshould
Sulpiridetablets(FGA) onlybeusedwhenclinicallyessential.Usecostcharttoselectthemostcosteffective
Clozapinetablets(SGA) formulations.
QuetiapineIRtabletsmustbeusedforallnewpatients.XLtabletsmaybeused
Antipsychotic Flupentixoldecanoate(FGA), RisperidoneLAI(SGA), wheninitiating/titratingdosesinacutesituationshoweverpatientsmustbeswitched
Depot(FGA)and toIRtabletsthereafter.XLtabletsotherwiseshouldonlybeusedwhenIRtabletsare
Fluphenazinedecanoate(FGA), *PaliperidonepalmitateLAI
LongActing nottoleratedbecauseofexcessivesedationornoncompliancewithatwicedaily
Haloperidoldecanoate(FGA), (SGA)
injections(LAI) regime.RationaleforXLmustbedocumentedandprovidedtoGP.
Pipotiazinepalmitate(FGA), *AripiprazoleLAI(SGA)
(SGA) Donotinitiateregularcombinedantipsychoticmedication,exceptforshortperiods
Zuclopenthixoldecanoate(FGA) (forexample,whenchangingmedication).
Clozapinetobeconsideredforschizophreniainthosewhohavenotrespondedtotwo
APDsincludingaSGA.ClozapineprescribingtoremainwithHPFT.
PaliperidoneoralandolanzapineembonateLAIarenotapprovedforuse.
PaliperidoneLAIisapprovedforusewithinlicensedindicationsonanamedpatient
basiswhenoneormoreofthefollowingadvantagesofpaliperidone(over
risperidone) wouldbeofsignificantbenefitmonthlyadministration,quickeronset
ofaction,7dayflexibilitytoavoidmisseddoses,smalleradministrationvolume,
fewerdruginteractions,widerdosingrangeandnodoseadjustmentrequiredinmild
tomoderatehepaticimpairment.
AripiprazoleLAIapprovedforusewithinlicensedindicationsonanamedpatient

basis.Patientsmustbestabilisedwithoralaripiprazoleortolerabilitywithoral
*Namedpatient aripiprazolemustoccurpriortoinitiatingtreatment.

HPFT Preferred Prescribing choices of antipsychotic drugs in adults for schizophrenia and other psychoses.
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 Antipsychotics relative side-effects

The following table can be used by prescribers in conjunction with patients to help guide choice of APD. Alternatively the Choice and Medication website provides
information for patients on medicines used in mental health. The handy chart comparing medicines used for psychosis is a more patient friendly resource which may
be helpful when discussing potential benefits and harms of individual antipsychotics with patients. Please note the Choice and Medication website may include
information on medicines that have not been approved in Hertfordshire.

Preferredoral Anticholinergic Prolactin

choices effects Cardiac EPSE Hypotension Sedation Weightgain elevation Proconvulsant
Haloperidol ?
Olanzapine
Quetiapine(IR)
Risperidone ?

Sulpiride ?

2ndLinealternative Anticholinergic Prolactin

oralchoices effects Cardiac EPSE Hypotension Sedation Weightgain elevation Proconvulsant
Amisulpride ?
Aripiprazole
Chlorpromazine ?
Clozapine
Flupentixol ? ?
Promazine ? ? ?
Trifluoperazine ? ?

Zuclopenthixol ? ? ?

PreferredDepot Anticholinergic Prolactin

injections effects Cardiac EPSE Hypotension Sedation Weightgain elevation Proconvulsant
Flupenthixol ? ?
?
Fluphenazine ?
Haloperidol
Pipotiazine ? ? ?
Zuclopenthixol ? ? ?
2ndLineAlternative
Longacting Anticholinergic Prolactin

injections effects Cardiac EPSE Hypotension Sedation Weightgain elevation Proconvulsant

Aripiprazole
Paliperidone
RisperidoneConsta ?

markedeffectmoderateeffectmild/transienteffect littleorminimaleffect ? noinformationavailableorlittlereported
Reference:StephenBazirePsychotropicDrugDirectory2014
HPFT Preferred Prescribing choices of antipsychotic drugs in adults for schizophrenia and other psychoses.
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 Graph 1 - Antipsychotic comparative costs for 28 days treatment on maximum licensed doses.
(Drug Tariff Sep 2014) (NB Doses quoted do not imply equivalence)

Clozapine tabs (Denzapine) 900mg/day 200

Aripiprazole liquid 30mg/day 617

Aripiprazole orodisp tabs 30mg/day 192

Aripiprazole tabs 30mg/day 192

Amisulpride liquid (Solian)1200mg/day 189

Amisulpride liquid 1200mg/day 191

Amisulpride (Solian)1200mg/day 165

Amisulpride 1200mg/day 53

Sulpiride liq (Sulpor) 2400mg/day 284

Sulpiride tabs 2400mg/day 105

Sulpiride tabs (Dolmatil) 2400mg/day 32

Risperidone oral sol 16mg/day 168

Risperidone liquid (Risperdal) 16mg/day 166

Risperidone orodisp (Risperdal Quicklets) 16mg/day 149

Risperidone tabs (Risperdal) 16mg/day 134

Risperidone tabs 16mg/day 4

Quetiapine MR (Seroquel XL) tabs 800mg/day 226

Quetiapine (Seroquel) tabs 750mg/day 211

Quetiapine tabs (Gen) 750mg/day 6

Haloperidol liquid 20mg/day 20

Haloperidol tabs 20mg/day 21

Olanzapine velotabs (Zyprexa) 20mg/day 175

Olanzapine tabs (Zyprexa) 20mg/day 159

Olanzapine orodispersibe sugarfree (Gen) 20mg/day 11

Olanzapine orodispersible (Gen) 20mg/day 5

Olanzapine tabs (Gen) 20mg/day 2

0 100 200 300 400 500 600 700

Preferred APD choice Premium priced preparations to be 2nd line alternative choices 2nd line premium priced preparations to be avoided

HPFT Preferred Prescribing choices of antipsychotic drugs in adults for schizophrenia and other psychoses.
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 Graph 2 - Antipsychotic depot and LAI comparative costs for 28 days treatment on ranging doses
Drug Tariff Sep 2014 ( Doses quoted do not imply equivalence)

Aripiprazole (Abilify Maintena) 400mg/month 220

Paliperidone (Xeplion) 150mg/month 393

Paliperidone (Xeplion) 100mg/month 314

Paliperidone (Xeplion) 75mg/month 245

Paliperidone (Xeplion) 50mg/month 184

Risperidone (Consta) 50mg/2w 286

Risperidone (Consta) 37.5mg/2w 223

Risperidone (Consta) 25mg/2w 159

Pipotiazine (Piportil) 200mg/4w 53

Pipotiazine (Piportil) 100mg/4w 27

Pipotiazine (Piportil) 50mg/4w 16

Fluphenazine (Modecate) 100mg/2w 18

Zuclopenthixol (Clopixol) 600mg/1w 60

Zuclopenthixol (Clopixol) 500mg/2w 15

Zuclopenthixol (Clopixol) 200mg/2w 6

Haloperidol (Haldol) 300mg/4w 15

Haloperidol (Haldol) 50mg/4w 4

Flupentixol (Depixol Conc) 300mg/2w 38

Flupentixol (Depixol Conc) 50mg/4w 6

Flupentixol (Depixol) 40mg/2w 5

Flupentixol (Depixol) 20mg/2w 3

0 50 100 150 200 250 300 350 400 450

Preferred APD depot 2nd line alternative APD LAI

HPFT Preferred Prescribing choices of antipsychotic drugs in adults for schizophrenia and other psychoses.
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 Transfer of APD prescribing to GPs

Patients must be stabilised on an APD before requesting the GP to take over prescribing responsibility.
The following minimum information must be provided to enable the GP to safely take on the continued
prescribing for the patient:

Choice of APD: including formulation and dose.

Rationale for choice of APD: if not a preferred choice, provide explanation as to why preferred
choices are not appropriate and why second line alternative APD has been selected. Where relevant
include details of APDs that have already been tried and why they were discontinued or not
appropriate.

Monitoring requirements: as per physical health policy.

Date of next review

Prescriber contact details: in case GP has any queries or concerns.

Clinicians must ensure all the above information is included in correspondence to GPs to ensure the
smooth and safe transfer of prescribing responsibility.

References;

NICE CG178 Psychosis and schizophrenia in adults Feb 2014

SIGN 131 Management of Schizophrenia 2013

Psychotropic Drug Directory 2014, Stephen Bazire

The Maudsley Prescribing Guidelines in Psychiatry 11th Edition 2012

Drug Tariff - September 2014

Approved by HPFT DTC September 2013

Approved by HMMC September 2013

Approved by PCMMG November 2013

Updated September 2014

Review date: September 2015 or sooner if new evidence is published or if significant price changes
occur.

HPFT Preferred Prescribing choices of antipsychotic drugs in adults for schizophrenia and other psychoses.
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