Medicines Management - NICE Guidance

NICE Guidance – Schizophrenia Core interventions in the treatment and management of schizophrenia in primary and secondary care - Clinical Guideline 1 - December 2002

1.3.2 Pharmacological interventions

During an acute episode, antipsychotic drugs are necessary.

Wherever possible, service users should make an informed choice as to the antipsychotic they prefer. If a service user is unable to make his or her preference known, an atypical should be prescribed. It is best to use a single drug, using doses within the British NationalFormulary (BNF) dose range and not to use high or loading doses.

Clinical response and side effects should be monitored routinely and regularly. If, with conventional antipsychotics, side effects are troublesome or symptom control is inadequate, an atypical should be offered. During an acute episode, some service users become behaviourally disturbed and may need rapid tranquillisation.

The recommendations for this can be found in subsection 1.5.

1.3.2.1 The choice of antipsychotic drug should be made jointly by the individual and the clinician responsible for treatment based on an informed discussion of the relative benefits of the drugs and their side-effect profiles. The individual’s advocate or carer should be consulted where appropriate.

1.3.2.2 Antipsychotic therapy should be initiated as part of a comprehensive package of care that addresses the individual's clinical, emotional and social needs. The clinician responsible for treatment and key worker should monitor both therapeutic progress and tolerability of the drug on an ongoing basis. Monitoring is particularly important when individuals have just changed from one antipsychotic to another.

1.3.2.3 The dosage of conventional antipsychotic medication for an acute episode should be in the range of 300–1000 mg chlorpromazine equivalents per day for a minimum of 6 weeks. Reasons for dosage outside this range should be justified and documented. The minimum effective dose should be used.

1.3.2.4 In the treatment of the acute episode for people with schizophrenia, massive loading doses of antipsychotic medication, referred to as ‘rapid neuroleptization’, should not be used.

1.3.2.5 The oral atypical antipsychotic drugs (amisulpride, olanzapine, quetiapine, risperidone, zotepine) should be considered as treatment options for individuals currently receiving conventional antipsychotic drugs who, despite adequate symptom control, are experiencing unacceptable side effects, and for those in relapse who have previously experienced unsatisfactory management or unacceptable side effects with conventional antipsychotic drugs. The decision as to what are unacceptable side effects should be taken following discussion between the patient and the clinician responsible for treatment.

1.3.2.6 When full discussion between the clinician responsible for treatment and the individual concerned is not possible, in particular in the management of an acute schizophrenic episode, the oral atypical drugs should be considered as the treatment options of choice because of the lower potential risk of extrapyramidal symptoms (EPS). In these circumstances, the individual’s carer or advocate should be consulted where possible and appropriate. Although there are limitations with advance directives regarding the choice of treatment for individuals with schizophrenia, it is recommended that they are developed and documented in individuals’ care programmes whenever possible.

1.3.2.7 It is not recommended that, in routine clinical practice, individuals change to one of the oral atypical antipsychotic drugs if they are currently achieving good control of their condition without unacceptable side effects with conventional antipsychotic drugs.

1.3.2.8 Antipsychotic drugs, atypical or conventional, should not be prescribed concurrently, except for short periods to cover changeover.

1.3.2.9 When prescribed chlorpromazine, individuals should be warned of a potential photosensitive skin response as this is an easily preventable side effect.

1.3.2.10 Where a potential to cause weight gain or diabetes has been identified (and/or included in the Summary of Product Characteristics) for the atypical antipsychotic being prescribed, there should be routine monitoring in respect of these potential risks.

1.3.3 Early post-acute period

Towards the end of an acute episode of schizophrenia, service users should be offered help to better understand the period of illness, and given the opportunity to write their account in their notes. Carers may also need help in understanding the experience.

Assessment for further help to minimise disability, reduce risk and improve quality of life should be routinely undertaken during recovery from the acute phase. In particular, psychological and family help, contingency planning and identifying local resources/services are important. Advice about drug treatments to maintain recovery is also important.

Service user focus

1.3.3.1 Consideration should be given, where practicable, to encouraging service users to write their account of their illness in their notes.

1.3.3.2 Psychoanalytic and psychodynamic principles may be considered to help health professionals to understand the experience of individual service users and their interpersonal relationships.