High dose antipsychotic treatment monitoring audit

AimsTo quantify how many patients were prescribed high dose antipsychotic treatment (HDAT) and establish whether guidance for monitoring HDAT was being followed in an Assertive Outreach Team.BackgroundSevere mental health disorders are associated with significant premature mortality, predominantly due to physical health conditions. Antipsychotic medications are associated with side effects, including metabolic syndrome and QT prolongation, which increase the risk of serious physical illness. HDAT is defined as when the total dose of antipsychotics prescribed exceeds 100% of the maximum BNF dose, if each dose is expressed a percentage of its maximum dose. There is limited evidence of clinical benefit with HDAT but an increased risk of side effects. Patients prescribed HDAT should therefore be monitored for side effects and clinical benefit. Sussex Partnership NHS Foundation Trust developed a form specifically for this purpose, to be completed in addition to a physical health assessment.MethodAll patients on caseload were audited using the electronic notes. Current inpatients were excluded, as inpatient HDAT monitoring forms are attached to paper drug charts and therefore were not available for review.ResultA total of 61 patients were audited. Nine were excluded due to being inpatients. 16 were on community treatment orders and 26 were prescribed a long-acting antipsychotic injection. 10 were prescribed clozapine. The median number of medications prescribed was one. Four patients were prescribed HDAT ranging from 117-150% of the maximum BNF dose. Of these four, one had a HDAT form but this was out of date. 39 of 52 (75%) patients audited had had a physical health assessment in the past 12 months. Two of the 13 missing a physical health assessment were on HDAT.ConclusionPhysical health monitoring should be carried out for all patients on antipsychotics, but is particularly important for patients on HDAT. This audit identified a problem in both general physical health checks and HDAT monitoring. On discussion with the multi-disciplinary team a number of barriers to appropriate physical health monitoring were identified. There was a lack of awareness within the multi-disciplinary team that patients were receiving HDAT and regarding the implications for side effects. A reliable system to highlight the need for physical health checks was also missing and the team did not have sufficient equipment to perform the necessary checks. Identifying these barriers should enable improvements in physical health and HDAT monitoring which can be re-audited.

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Reducing the use of high dose antipsychotic medication in acute adult inpatient psychiatric units

BJPsych Open ◽

10.1192/bjo.2021.893 ◽

2021 ◽

Vol 7 (S1) ◽

pp. S341-S341

Author(s):

Shay-Anne Pantall ◽

Sarah Warwicker ◽

Lisa Brownell

Keyword(s):

Antipsychotic Medication ◽

Psychiatric Inpatient ◽

Electronic Prescribing ◽

Antipsychotic Treatment ◽

High Dose ◽

Junior Doctors ◽

List Type ◽

Increased Risk ◽

Adult Inpatient ◽

Inpatient Units

AimsTo evaluate the use of antipsychotics, and high dose antipsychotic treatment (HDAT) in psychiatric inpatient unitsBackgroundThe Royal College of Psychiatrists published a consensus statement on high dose antipsychotic medication in October 1993. Such treatment carries an increased risk of adverse effects including towards ventricular tachycardia and sudden death.MethodA retrospective case note review of all male patients on acute adult inpatient units in a psychiatric hospital in South Birmingham on a date in June 2018 (n = 45) including review of electronic patient records and prescriptions. This was compared with the results of an earlier study, with identical methods, undertaken in June 2015.Result•In both 2015 and 2018, only a minority of patients (20% and 11% respectively) were informal.•In both 2015 and 2018, the majority of inpatients had a diagnosis of schizophrenia (54% and 67%)•In both 2015 and 2018, 93% inpatients were prescribed antipsychotic medication.•In 2015, 56% patients were prescribed HDAT. This reduced in 2018 to 16%.•This reduction in use of HDAT was almost entirely due to a reduction in the prescription of PRN antipsychotic medication.•In terms of regularly prescribed antipsychotic medication, in both years, the most commonly prescribed drug was flupentixol, with a range of other second generation oral and long acting medications being prescribed, usually at doses within BNF limits.Between the two years, there was a substantial change in the prescribing of PRN antipsychotics. In 2015, 59% individuals were prescribed at least one PRN antipsychotic (27% were prescribed two). In 2018, this reduced to 40% prescribed at least one, and only 2% being prescribed 2 PRN antipsychotics. In both years, oral quetiapine was a common choice (39% patients in 2015 prescribed oral quetiapine, and 34% in 2018). In 2015, 39% patients were prescribed oral or intramuscular aripiprazole, while this reduced to 7% in 2018.ConclusionThe vast majority of psychiatric inpatients were being prescribed antipsychotic medication. Prescription of high dose antipsychotic medication was common in 2015, and this was largely attributable to high levels of prescribing of PRN antipsychotics. Following an educational programme for junior doctors and ward nurses, and the introduction of electronic prescribing, we achieved a significant change in practice, particularly in the prescribing of PRN antipsychotics, which has reduced our patients’ risk of receiving high dose antipsychotic medication.

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Off-label prescribing of quetiapine in south locality crisis teams

BJPsych Open ◽

10.1192/bjo.2021.267 ◽

2021 ◽

Vol 7 (S1) ◽

pp. S87-S87

Author(s):

Mamta Kumari ◽

Arun Kumar Gupta ◽

Peter Clarke

Keyword(s):

Side Effects ◽

Physical Health ◽

Health Monitoring ◽

Treatment Options ◽

General Medical Council ◽

Evidence Base ◽

Medical Council ◽

Team Members ◽

Off Label ◽

Psychotropic Medicines

AimsThe audit was carried out to determine the frequency of off label prescribing of quetiapine and compliance with standards within Trust Policy (UHM PGN 02 PPT PGN 08) – Physical Health Monitoring of Patients Prescribed Antipsychotics and other Psychotropic Medicines, NICE CG178, General Medical Council Ethical Standards and Royal College of Psychiatrists – College Report CR210.The main objectives of the audit were to determine if:Patients have been appropriately informed of off-label status and consent recorded.Alternative licensed treatment first used/ruled out.Appropriate communication on transfer of care.Appropriate physical health monitoring completed.BackgroundQuetiapine is associated with various physical side effects. Patients should be fully informed of the expected risks and benefits of treatment, and the limited evidence base for off-label prescribing.There are additional issues around the transfer of prescribing to primary care.MethodThe sample consisted of 50 consecutive patients selected from the crisis team caseload in the month of December 2018.Data reviewed in this audit were taken from six months period.Records audited were obtained from RiO (electronic records) and prescription charts.Data collection was started in January 2019 and completed in March 2019The audit tool was a dichotomous scale questionnaire based on NICE guidelines.Result4 patients from the sample (8%) were prescribed off-label quetiapine.100% had physical health monitoring completed as per Trust policy.100% off-label indication been clearly documented in notes.100% Consent to treatment was documented.100% had medication reviewed in the previous 6 months.75% had licensed medication used or ruled out before considering off-label quetiapine use25% risks/benefits of treatment were documented as part of a patient discussion.25% had documented evidence that alternative treatment options were discussed.25% had documented evidence of Community consultant/GP consent/agreement was obtained before transfer of prescribing75% had a documented plan for review of quetiapine for treatment efficacy and side effects50% had a documented plan in place for ongoing physical health monitoringConclusionSuggested a wider audit may be required with greater patient numbers and which specifically filters for patients prescribed quetiapine.Audit result has been shared with Crisis team members, Medicines Optimisation Committee and South Locality Quality Standards Committee in the trust.

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Audit of ADHD medication prescription and monitoring in intellectual disability services, Greater Glasgow & Clyde

BJPsych Open ◽

10.1192/bjo.2021.218 ◽

2021 ◽

Vol 7 (S1) ◽

pp. S66-S66

Author(s):

Neha Bansal ◽

Muzammil Hayat

Keyword(s):

Intellectual Disability ◽

Side Effects ◽

Physical Health ◽

Health Monitoring ◽

Symptom Severity ◽

Adhd Medication ◽

Audit Tool ◽

Medication Prescription ◽

Ongoing Treatment ◽

Medication Dosage

AimsStudies have shown that people with intellectual disability (ID) show a greater severity of attention deficit hyperactivity disorder (ADHD) symptoms and atypical presentation, as well as having a greater risk of developing comorbidities, such as challenging behaviour, anxiety, tic disorders and sleep problems. It is estimated that 1.5% of patients with ID will have a clinical diagnosis of ADHD.The aim of this audit was to find whether individuals with ID and ADHD, who are prescribed medication for ADHD are adequately monitored and reviewed in accordance with the ADHD medication prescription guidance by NICE and the Royal College of Psychiatrists (RCPsych).MethodThis audit looked at ADHD medication prescription for the ID population within Greater Glasgow & Clyde NHS. This is the 6th audit cycle where electronic records (EMIS) were analysed between 28/9/19 to 09/10/20. (The 5th cycle data collection period ended on 28/9/19). We collected data on all patients aged over 18 years.An audit tool was developed to find whether the following were documented; patient demographics, physical health monitoring, symptom severity, medication dosage, side effects, need for ongoing treatment and frequency of review. 100% of patients should have all components on the ADHD audit tool documented, as per NICE/ RCPsych prescription guidance.Result32 patients were identified as being diagnosed with ADHD prescribed medication. One patient was impacted by the COVID-19 pandemic which meant that the required monitoring was not fully carried out. The age ranged from 18 to 56 years. 75% had mild intellectual disability, 19% had moderate and 6% had severe, with no cases of profound intellectual disability. Blood Pressure/pulse was recorded in 84% of patients. Height/weight/ BMI was recorded in 81% of patients. 97% of patients had ADHD symptom severity, medication dosage, side effects, need for ongoing treatment and frequency of review recorded.ConclusionThere is further scope for improvement in the monitoring and documentation of physical health observations, however there was a significant improvement compared to the previous cycle of the audit. Other aspects of monitoring and documentation appear to be recorded in almost 100% of patients. This finding emphasises the challenges of physical health monitoring and compliance in psychiatry as a whole. We need to continue to encourage awareness and education around the physical health risks to our patients, not only due to their comorbidities but also as a result of the psychotropic medications we prescribe them.

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Intramuscular maintenance treatment with ultra-high-dose long-acting injectable aripiprazole in an elderly patient suffering from chronic refractory schizophrenia: A case report

European Psychiatry ◽

10.1016/j.eurpsy.2016.01.2120 ◽

2016 ◽

Vol 33 (S1) ◽

pp. S573-S573 ◽

Cited By ~ 1

Author(s):

L. Bartova ◽

M. Dold ◽

N. Praschak-Rieder ◽

A. Naderi-Heiden ◽

S. Kasper

Keyword(s):

Side Effects ◽

Maintenance Treatment ◽

Rating Scale ◽

Antipsychotic Treatment ◽

High Dose ◽

Symptom Scale ◽

Meaningful Improvement ◽

Plasma Level Monitoring ◽

Competing Interest ◽

Long Acting

Long-acting injectable (LAI) aripiprazole is increasingly appreciated in the course of a maintenance treatment of schizophrenia due to efficacy in delaying – and decreasing relapse, and low rates of feared side effects. In line with the prescribing information, the maximal starting – as well as maintenance dose was restricted to 400 mg following a 26-day interval between the single doses.We present a 72-year-old female inpatient (66 kg) with an acute exacerbation of chronic refractory schizophrenia, exhibiting primarily positive symptoms including excessive persecutory delusions, self-care deficit, poor insight and insufficient adherence to continuous intake of oral medication. Since she developed a post-injection syndrome after an accidental intravascular administration of olanzapine LAI 405 mg, the antipsychotic treatment was switched to aripiprazole LAI 300 mg once monthly. Due to insufficient clinical response, aripiprazole LAI was gradually increased up to 1200 mg per month under continuous plasma level monitoring. Here, 2 single injections of aripiprazole LAI 300 mg were delivered into both gluteal muscles concurrently, every 14 days.Consequently, we observed a clinically meaningful improvement (a total-score reduction from 111 to 75 on the Positive and Negative Syndrome Scale), as well as no objectifiable side effects, assessed by “The Dosage Record Treatment Emergent Symptom Scale” and “The Barnes Akathisia Rating Scale”, despite multi-morbidity and rather advanced age of the patient.Our safe experience with applying the almost threefold higher monthly dose over 12 weeks may encourage researchers to further investigate the efficacy, tolerability as well as handling of highly dosed aripiprazole LAI in refractory schizophrenia.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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Antipsychotic monitoring in dementia: quality of completion of antipsychotic monitoring forms in an older adult mental health service

BJPsych Bulletin ◽

10.1192/bjb.2021.70 ◽

2021 ◽

pp. 1-7

Author(s):

Helen Anderson ◽

Anna Kolliakou ◽

Daniel Harwood ◽

Nicola Funnell ◽

Robert Stewart ◽

...

Keyword(s):

Mental Health ◽

Physical Health ◽

Health Monitoring ◽

Psychological Symptoms ◽

Antipsychotic Treatment ◽

Pharmacological Interventions ◽

Health Records ◽

People With Dementia ◽

Adult Mental Health Service

Aims and method To support safe prescribing of antipsychotics in dementia, antipsychotic monitoring forms were embedded into our electronic health records. We present a review of the data collected on these forms to assess prescribing and identify areas for improvement in our practice and processes. Data were extracted from the structured fields of antipsychotic initiation and review forms completed between 1 January 2018 and 31 January 2020. Results We identified gaps in practice where improvements could be made, mainly with regard to physical health monitoring (and particularly electrocardiograms, performed in only 50% of patients) and the low (less than 50%) recorded use of non-pharmacological interventions for behavioural and psychological symptoms of dementia. In addition, antipsychotic treatment was continued despite lack of benefit in almost 10% of reviews. Clinical implications We advocate for recommendations on physical health monitoring of people with dementia taking antipsychotics to be added to the National Institute for Health and Care Excellence guidance on dementia and the Prescribing Observatory for Mental Health (POMH-UK) national audit.

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Establishing a physical health monitoring service for patients on depot antipsychotic medication

European Psychiatry ◽

10.1016/j.eurpsy.2016.01.2089 ◽

2016 ◽

Vol 33 (S1) ◽

pp. S564-S564

Author(s):

M. Gill ◽

M. McCauley

Keyword(s):

Side Effects ◽

Physical Health ◽

Antipsychotic Medication ◽

Health Monitoring ◽

Side Effect ◽

Blood Test ◽

Best Practice ◽

Self Report ◽

Physical Parameters ◽

Depot Antipsychotic

IntroductionPatients with major mental illness are recognised to be at risk of premature death for a multitude of reasons. Those with schizophrenia and bipolar disorder are at highest risk.ObjectivesInternational best practice recommends monitoring of blood tests, physical parameters such as weight, BMI, waist circumference and blood pressure, and side effects of patients prescribed antipsychotic medication. A clinic was established to target these interventions.AimsThis initiative aimed to improve the physical health monitoring of patients prescribed depot antipsychotic medication in a catchment area of approximately 36,000 in Ireland.MethodsA twice-yearly, multidisciplinary monitoring clinic was established. A protocol was drawn up, following a literature review and inspection of current international guidelines, and a proforma assisted as an aide-mémoire. A self-report questionnaire, the Glasgow Antipsychotic Side Effect Scale, was used to enquire about side effects.ResultsEvaluation took place in descriptive form with audit used to examine outcomes. Full blood test monitoring improved from 9% of patients to 61% in one year, with 78% of patients having had at least one blood test recorded. Prior to the clinic's establishment, only one patient had had any physical parameters recorded, but this improved to 96% recorded after the clinics were run. Side effect documentation also improved.ConclusionsThe clinic was well-received and led to improved teamwork. Future recommendations include organising the clinic so as to include simultaneous blood testing. A similar project is being planned to target all patients attending who are prescribed antipsychotic medication.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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The Association between Use of ICS and Psychiatric Symptoms in Patients with COPD—A Nationwide Cohort Study of 49,500 Patients

Biomedicines ◽

10.3390/biomedicines9101492 ◽

2021 ◽

Vol 9 (10) ◽

pp. 1492

Author(s):

Alexander Jordan ◽

Pradeesh Sivapalan ◽

Josefin Eklöf ◽

Jakob B. Vestergaard ◽

Howraman Meteran ◽

...

Keyword(s):

Cohort Study ◽

Side Effects ◽

Psychiatric Symptoms ◽

Psychiatric Hospitals ◽

High Dose ◽

Moderate Increase ◽

High Exposure ◽

Increased Risk ◽

Antidepressant Use ◽

Psychiatric Side Effects

Psychiatric side effects are well known from treatment with systemic corticosteroids. It is, however, unclear whether inhaled corticosteroids (ICS) have psychiatric side effects in patients with COPD. We conducted a nationwide cohort study in all Danish COPD outpatients who had respiratory medicine specialist-verified COPD, age ≥40 years, and no previous cancer. Prescription fillings of antidepressants and risk of admissions to psychiatric hospitals with either depression, anxiety or bipolar disorder were assessed by Cox proportional hazards models. We observed a dose-dependent increase in the risk of antidepressant-use with ICS cumulated dose (HR 1.05, 95% CI 1.03–1.07, p = 0.0472 with low ICS exposure, HR 1.10, 95% CI 1.08–1.12, p < 0.0001 with medium exposure, HR 1.15, 95% CI 1.11–1.15, p < 0.0001 with high exposure) as compared to no ICS exposure. We found a discrete increased risk of admission to psychiatric hospitals in the medium and high dose group (HR 1.00, 95% CI 0.98–1.03, p = 0.77 with low ICS exposure, HR 1.07, 95% CI 1.05–1.10, p < 0.0001 with medium exposure, HR 1.13, 95% CI 1.10–1.15, p < 0.0001 with high exposure). The association persisted when stratifying for prior antidepressant use. Thus, exposure to ICS was associated with a small to moderate increase in antidepressant-use and psychiatric admissions.

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Testing a computerised tool to improve physical health monitoring in a medium secure forensic setting

BJPsych Open ◽

10.1192/bjo.2021.593 ◽

2021 ◽

Vol 7 (S1) ◽

pp. S222-S223

Author(s):

Mike Smith ◽

Mustafa Abbas

Keyword(s):

Physical Examination ◽

Physical Health ◽

Health Monitoring ◽

Mental Health Problems ◽

Relevant Information ◽

Substantial Improvement ◽

Due Date ◽

Blood Tests ◽

The Past ◽

Health Checks

AimsThis project aimed to improve adherence to regular monitoring of the physical health of inpatients within a medium secure forensic psychiatric unit. A computerised tool to remind doctors to do checks was created, which was proposed would improve adherence.BackgroundThe physical health of people with mental health problems is of some concern, with higher rates of physical comorbidity and mortality compared to the general population.The forensic inpatient population has a high burden of both severe mental illness and physical ill health, and a high medication burden with potential adverse effects on physical health.To support the health of patients in our medium secure unit, each should routinely have three physical health checks done at least every six months. These are 1) an electrocardiogram (ECG), 2) a set of blood tests and 3) a full physical examination.MethodPatient records for 26 patients across two medium secure psychiatric wards were checked for 1) an ECG, 2) a full set of blood tests and 3) a full general physical examination within the past 6 months.A tool was created that automatically calculated the next due date for each check and colour coded which were overdue (red) or within 30 days of the due date (yellow). This tool was given to the core trainees working on these wards to help them keep track of which checks needed to be done.The records for patients on the same two wards were rechecked four months later and the adherence rates compared.ResultOn both wards, for each of the three physical health checks, a substantial improvement was seen in the proportion completed within the past 6 months.ConclusionThe tool created was a useful means of presenting, in one place, relevant information needed by doctors working in medium secure forensic wards regarding physical health checks, and drawing their attention to tasks that needed to be done. This led to an improvement in the adherence to physical health monitoring in these wards. An area for future improvement was identified regarding the unit's capacity to perform ECGs in a timely manner.

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Application of polymeric nanoparticles in oral delivery of recombinant human erythropoietin: A review

Journal of Drug Delivery and Therapeutics ◽

10.22270/jddt.v9i1-s.2336 ◽

2019 ◽

Vol 9 (1-s) ◽

pp. 403-407

Author(s):

Pankaj Rajendra Dhapake ◽

Jasmine G Avari

Keyword(s):

Side Effects ◽

Drug Release ◽

Oral Delivery ◽

Recombinant Human Erythropoietin ◽

Dosage Form ◽

The Body ◽

High Dose ◽

Risk Of Death ◽

Human Erythropoietin ◽

Increased Risk

Recombinant Human Erythropoietin drugs are known as erythropoietin stimulating agents which stimulate the bone marrow to produce more red blood cells in the body. It is used an antianemic in the treatment of renal anemia and chemotherapy induced anemia. It also use in treatment of HIV, cerebral malaria and neurological disease like schizophrenia. The recombinant human erythropoietin dosage form currently available in the market is parenteral dosage form that is ready for injection liquid vial (syringe), which is usually administered 2-3 times weekly. To achieve a therapeutic effect of parenterally administered EPO, cumulative doses are required that significantly exceed levels of endogenous EPO. These high serum levels result in prolonged circulation times of EPO and unspecific binding to non-targeted tissue, which may lead to severe undesired side effects i.e. growth of tumor and also increased risk of death. By using the nanotechnology, side effects and toxicity related to high dose of erythropoietin should be reduces and prolong drug release. this will achieve by reducing administration frequency and lowering dosage of erythropoietin. Keywords: Recombinant Human Erythropoietin, Nanoparticle, Prolong drug release, Anemia

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High-dose antipsychotics: addressing patients' resistance to physical health monitoring

BJPsych Advances ◽

10.1192/apt.bp.113.011833 ◽

2015 ◽

Vol 21 (2) ◽

pp. 88-97

Author(s):

Paula Marie Murphy ◽

Andrew Iles ◽

Suja Sreedharan

Keyword(s):

Decision Making ◽

Clinical Practice ◽

Physical Health ◽

Health Monitoring ◽

Flow Diagram ◽

High Dose ◽

Strict Adherence ◽

Legal Implications ◽

Case Vignettes

SummaryHigh-dose antipsychotics are sometimes used in clinical practice when patients fail to respond to treatment at standard doses. Owing to the potential physical complications associated with this, strict adherence to physical health monitoring is essential. Challenges arise for clinicians when patients refuse to cooperate with this monitoring. We discuss different interventions to overcome this problem, many of which are coercive in nature, and consider their professional, ethical and legal implications. We include a flow diagram to assist clinicians in their documentation and decision-making in these circumstances as well as case vignettes showing when monitoring under restraint is and is not justifiable.

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