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POLICY DOCUMENT

Document Title Antipsychotic Long-Acting Injections Guidance

Reference Number CG/Antipsychotic LAI/03/15

Policy Type Medicines Policy


Electronic
N:\Pharmacy\Intranet
File/Location
http://intranep/TeamCentre/pharm/PublishedDocuments/nepft-
Intranet Location
antipsychotic-long-acting-injections-guidance-120306-2.doc

Status FINAL

Version 2 / March 2015


Version No./Date
Version 1 / March 2012
Author(s)
Responsible for Medicines Information and Research Pharmacist
Writing and Associate Director for Pharmacy
Monitoring
Medicines Procedures Group Feb 2015
Approved By
Medicines Management Group Mar 2015

Approval Date March 2015


Implementation
March 2015
Date
Review Date March 2018

© North Essex Partnership University NHS Foundation Trust


Copyright (2015). All rights reserved. Not to be reproduced in whole or
in part without the permission of the copyright owner.
All matters or concerns regarding fraud or corruption should be reported to: Chris
Rising, Senior Manager (Chris.Rising@bakertilly.co.uk 07768 873701), Hannah
Wenlock, LCFS Lead (Hannah.Wenlock@bakertilly.co.uk 07972 004257) Mark
Trevallion, LCFS Lead (Mark.Trevallion@bakertilly.co.uk 07800 718680) OR the
National Fraud and Corruption Line 0800 028 40 60
https://www.reportnhsfraud.nhs.uk/

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CG/Antipsychotic LAI/03/15 Implementation Date: March 2015 Review Date: March 2018
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CONTENTS

Section Subject Page


Number Number
1 Introduction 3
2 Aim 3
3 Scope 3
4 References To Other Standards, Policies Or Procedures 3
5 Guidance 3
6 References and Bibliography 7
7 Summary of Changes 7

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CG/Antipsychotic LAI/03/15 Implementation Date: March 2015 Review Date: March 2018
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Guidance For The Use Of Antipsychotic Long-Acting
Injections In North Essex
1. Introduction
Long-acting or depot antipsychotic injections can be a useful form of administering
antipsychotics. The introduction of atypical injections has produced an increased
pressure on the drug budget, which may be justified if it can be shown to save
hospital admissions, length of stay and show an improved quality of life compared
with the alternatives available.

2. Aim
This guidance is to provide information about the choice of antipsychotic long-acting
injections available.

3. Scope
All practitioners within the North Essex Partnership University NHS Foundation Trust
(NEP) and the associated primary care areas of Mid, West and North East Essex.

4. References To Other Standards, Policies Or Procedures


NEP Medicines Management Policy. Available on the Intranet at:
http://intranep/TeamCentre/pharm/PublishedDocuments/Forms/PolicyTabs.aspx

5. Guidance

5.1 Advantages of long-acting injections


Assured compliance
Steady plasma levels compared to oral medication
Reduction in relapses, rehospitalisation and severity of the relapse
Bioavailability problems may be less (less first-pass metabolism for some
people)
Stable therapeutic effects
Better downward titration to minimise side-effects
Less brain tissue loss and deterioration (CATIE)

5.2 Disadvantages
Once it has been administered it cannot be removed if side-effects develop
(dystonia, EPSE, NMS)
Perception by the patient of being controlled, losing control over their
treatment, or possibly being a punishment.
Pain at the site of injection, lasting possibly 10 days
Tissue necrosis. Over time hard plaques may form, which will reduce the
ease of administration and the efficacy of the injection as well as causing
discomfort.
Loss of dignity with the gluteal route

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CG/Antipsychotic LAI/03/15 Implementation Date: March 2015 Review Date: March 2018
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5.3 Choice of injection (when oral medication has already been considered)

Oily depot injection (alternatives have different


efficacies and side effects), use anticholinergics
as necessary to help with side effects

Unacceptable side effects


at effective dose or lack of
efficacy

st
Paliperidone LAI –(1 Choice) or
nd
Risperidone Consta LAI (2 Choice)

Unacceptable side effects at effective


dose or lack of efficacy at therapeutic
doses

Aripiprazole Maintena (by Form B application to MMG) or


Olanzapine LAI (after agreement of clinic, adequate training and by
Form B application to MMG)

If there are no mitigating factors the oily depot injections should be first choice (most
cost-effective). The efficacy for the treatment of schizophrenia is similar, but the side
effects profile is different for each one. Risperidone Consta and Paliperidone are less
effective for people with treatment-resistant illness. They are both much more
expensive than the oily depot injections, which should be considered first.
For comparisons, please see www.choiceandmedication.org.uk/nepft for more
information, or “Psychotropic Directory” Steve Bazire. A brief table to compare the
properties of these injections has been devised below.

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Injection Route Dose for Duration Peak Time to Comment
adults of action (days) steady
under 65 (weeks) state
(weeks)
Aripiprazole Gluteal or 400mg Data not 5-7 16 By Form B
deltoid monthly, available. application to
Maintena
continue oral May MMG only
aripiprazole depend on
10-20mg for route and
14 days after dose
injection
Flupentixol GlutealLateral Test 20mg 3-4 7-10 10-12 C/I if circulatory
thigh Maintenance collapse or loss of
decanoate 50mg 4- consciousness.
weekly to May cause
300mg 2- aggression/agitatio
weekly n or mood
Max.400mg elevation
weekly
Fluphenazine Gluteal Test 12.5mg 1-3 ¼-2 6-12 Less sedating,
decanoate Maintenance less hypotensive,
12.5-100mg more EPSE
2-5-weekly
Max. 50mg
weekly.

Haloperidol Gluteal 50mg 4- 6 3-9 10-12 Monthly injection


weekly, usually. Reserve
decanoate
increasing by for chronic
50mg relapsing clients
increments to with schizophrenia
max.300mg who have
Elderly 12.5- responded well to
25mg 4/52 haloperidol
Olanzapine NON-FORMULARY IN NEP. Requires high level of monitoring in inpatient conditions. See
Olanzapine guidance for more information.
pamoate
Gluteal Starting dose 6 4 12 By Form B
of depot application to
depends on MMG only after
oral dose, agreement of clinic
see NEP
guidance or
SPC. Inject 2
or 4 weekly.
Paliperidone Deltoid 50-150mg Depends 3-10 2-3 Same active
initially, then monthly* on route moiety as
palmitate
deltoid/ gluteal Risperidone. May
have less side
effects and may
improve
concordance
Risperidone Deltoid or Oral test dose 5-6 weeks 28-42 6-8 Injection requires
gluteal 25-75mg 2- BUT will refrigeration and
Consta
weekly not start reconstitution.
until 3-4 Initial lag period
weeks after means oral/IM
administrati supplementation is
on required.
Zuclopenthixol Gluteal Test dose 2-4 weeks 4-9 10-12 High doses have
decanoate 100mg been used for
200-500mg aggression (out of
every 1-4 licence)
weeks
MAX 600mg
weekly
Note: Do not confuse with Zuclopenthixol acetate injection THIS IS ACUPHASE – NOT A
DEPOT INJECTION. DO NOT USE AS A DEPOT. SEE Tab 9 RAPID TRANQUILLISATION
PROCEDURE FOR MORE INFORMATION.

5.4 Reduction of local reaction and necrosis


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Use the lowest practical volume
Warm the injection before use, up to a maximum 37°C (body temperature).
This lowers viscosity, making it easier to inject, and reduces shock to the
muscle tissue.
Use alternate buttocks or arms (rotate injection sites) to allow time to heal
Use the Z-tracking technique to avoid extravasation
Use a needle of the right size for the patient (longer for people with a higher
BMI)
Inject less frequently if possible to prevent hard plaques of tissue forming.
See the Medicines Policy tab 8 Injection preparation and Administration

5.5 Monitoring
All antipsychotics should be monitored for efficacy and side effects including
metabolic side-effects. They should be done more frequently initially, at changes, and
if the patient is unwell.

Investigation Frequency Investigation Frequency


BMI 6/12 Prolactin Annual
Hip/waist ratio 6/12 Blood pressure 6/12
Blood sugars 6/12 Full blood count 6/12
Liver function tests 6/12 U and Es 6/12
ECG Annual Blood lipids Annual
Adverse side effects using standard tool (West Wales, 6/12
Lunsers, GASS)

For side-effects scales refer to Medicines Policy tab 6

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CG/Antipsychotic LAI/03/15 Implementation Date: March 2015 Review Date: March 2018
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5.6 Prescribing high cost injections
Risperidone consta injection and Paliperidone injection are both high-cost medicines.
They must be initiated by a consultant in mental health, and will continue to be
prescribed and monitored by NEP until the dose is stabilised (about 3 months)
It is recommended that Paliperidone be used in preference to Risperidone consta
because it has a number of practical advantages. The cost is slightly higher, but this
is outweighed by increased concordance and decreased requirement for nursing
input. Details are included in appendix 1 and 2.
Both preparations are NOT recommended for treatment-resistant schizophrenia as
they have been found to be ineffective for many of those patients.
Aripiprazole Maintena and Olanzapine LAIare both non-formulary at NEP and if a
client requires these treatments, there must be prior approval from the MMG via the
Form B Process.

6 References and Bibliography


www.choiceandmedication.org.uk/nepft for patient leaflets and comparisons
Manufacturer’s patient information leaflet (PILs) and Summary of Product
Characteristics (SPCs) www.medicines.org.uk
BNF (current) https://www.medicinescomplete.com/mc/bnf/current/
Royal College of Psychiatry www.rcpsych.nhs.uk
Taylor D et al. The Maudsley Prescribing Guidelines in Psychiatry 11th Ed.
2012 Wiley-Blackwell
Bazire S. Psychotropic Drug Directory 2014. Lloyd-Reinhold Communications

7 SUMMARY OF CHANGES
Section
Date Summary of Changes
Number(s)
Formatting, grammatical changes. Links updated and
throughout
added in where appropriate. Logos updated.
Information on Aripiprazole Maintena and Olanzapine
5.3, 5.6 Depot added in. Piportil removed as discontinued. Flow
chart modified to include olanzapine and aripiprazole
February
Appendix 3
2015 Removed as costing information goes out of date quickly
and
and can be easily found elsewhere if required.
section 5
Appendix 1
To be reviewed – useful or just refer to SPC?
&2
6 References and bibliography updated.

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