| Formulary Chapter 4: Central nervous system - Full Chapter
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| 04.02.01 |
Antipsychotic Drugs |
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- All antipsychotics should be employed at the minimum effective doses possible, higher doses will increase the likelihood of side effects. An alternative antipsychotic should be considered rather than resorting to the use of higher than standard doses
- For new onset psychosis seek specialist psychiatric advice.
- Atypical and typical antipsychotics should not be prescribed concurrently except when switching from one to another
- For the treatment of antipsychotic induced extra-pyramidal side effects, refer to Section 4.9.2
- Oro-dispersible tablets and oral solutions are more expensive therefore reserved for poorly compliant patients or those with swallowing difficulties.
- Antipsychotics should not routinely be prescribed to elderly patients with dementia to treat mild to moderate psychotic symptoms, because they are associated with a small increased risk of mortality and increased risk of stroke or transient ischaemic attack.
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First-Generation Antipsychotic Drugs |
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Second-Generation Antipsychotic Drugs |
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Amisulpride
(Tablet, oral solution)
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 Restricted
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- Requires specialist initiation by mental health team
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Aripiprazole
(Tablets, orodispersible tablets, short acting injection, liquid)
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Restricted
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- Requires specialist initiation by mental health team
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 CPFT Guideline for the pharmacological management of acute behavioural disturbance in in-patient wards
NICE TA213: Aripiprazole for the treatment of schizophrenia in people aged 15 -17 years
NICE TA292: Aripiprazole for treating moderate to severe manic episodes in adolescents with bipolar I disorder
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Clozapine (Denzapine®, Clozaril®, Zaponex®)
(Tablet, oral suspension)
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Restricted
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- Initiation by consultant psychiatrist only.
- Patients should receive the brand specific to the monitoring service with which they are registered.
- CPFT brand of choice is DENZAPINE®
- All patients must be registered with the Fulbourn Pharmacy or the Cavell Centre Pharmacy.
- WARNING: Missed doses are particularly significant in someone taking Clozapine. Please contact your local CPFT pharmacy department (including the out of hours service if applicable) and the patient’s psychiatrist if you are aware of a patient that has missed doses of Clozapine.
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CPFT clozapine information webpage
CPFT Clozapine Initiation and Prescribing Guidelines
 Drug-induced hypersalivation – what treatment options are available? (UKMI Q&A)
MHRA Drug Safety Update October 2017: Clozapine - impairment of intestinal peristalsis
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Olanzapine
(Tablet, Orodispersible tablet)
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Restricted
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- For mental health conditions - requires specialist initiation by mental health team
- CUHFT: use in line with Trust guidelines on delirium and dementia in older patients.
- RPH: For management of delirium in critical care.
- NWAFT: Restricted to use in palliative care
NeLM in-Focus review: metabolic adverse effects with atypical antipsychotics. Bottom line: Emerging data suggest that the risks of adverse metabolic effects, including hyperglycaemia, diabetes, weight gain and dyslipidaemia, are greater with olanzapine than other atypical antipsychotics (with the exception of clozapine).
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CPFT Guideline for the pharmacological management of acute behavioural disturbance in in-patient wards
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Quetiapine
(Immediate release (IR) tablet, modified release (MR) tablet, oral suspension)
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Restricted
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- For mental health conditions - requires specialist initiation by mental health team
- Immediate release (IR) tablets should be prescribed where possible
- Modified release tablets are significantly more expensive and are restricted to where a patient experiences excessive sedation and/or hypotension on quetiapine IR, OR if patient compliance is improved compared to twice daily dosing with quetiapine IR.
- If a patient is discharged on a modified release preparation then the rationale for this should be communicated to the GP. NB Only the modified release tablets are licensed for the adjunctive treatment of major depression
- In primary care Biquelle® XL is the preferred choices of quetiapine XL if clinically required.
- CUHFT: Neurologist/DME consultants for management of drug induced psychoses in Parkinson's Disease patients (off-label).
- NWAFT: Restricted to use in palliative care
- RPH: Restricted to the management of delirium when haloperidol is contra-indicated
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CPJPG Recommendations for Quetiapine XL
NICE Evidence summary ESUOM12 : Quetiapine for generalised anxiety disorder
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Risperidone
(Tablet, orodispersible tablet, oral solution)
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Restricted
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- For mental health conditions - Requires specialist initiation by mental health team, with the exception of low dose risperidone which can be initiated in primary care
- CUHFT: Restricted to use in line with Trust guidelines on delirium and dementia in older patients
- NWAFT: Restricted to use in palliative care
- RPH: Restricted to the continuation of treatment initiated external to the Trust
- Doses above 8-10mg daily may not increase therapeutic benefit but may result in extrapyramidal side effects.
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CPFT Guideline for the pharmacological management of acute behavioural disturbance in in-patient wards
 CUHFT: Prevention, diagnosis and management of delirium and dementia in older patients
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Lurasidone (Latuda®)
(Tablet)
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Restricted
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- CPFT: Formulary
- Non-formulary at all other Trusts and in Primary Care
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NICE Evidence summary ESNM48: Schizophrenia - Lurasidone
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Olanzapine
(Injection)
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Restricted
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- CPFT:
 unlicensed Short acting IM injection available for rapid tranquillisation.
- Olanzapine IM injection must not be given within 1 hour of any parenteral benzodiazepine (including lorazepam IM injection and midazolam IM injection)
- Non-formulary at all other Trusts and in Primary Care
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CPFT Guideline for the pharmacological management of acute behavioural disturbance in in-patient wards
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| Non Formulary Items |
Cariprazine (Reagila®)
(Capsule)
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Non Formulary
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Clozapine (Zaponex®)
(Tablet)
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Non Formulary
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- Initiation by consultant psychiatrist only.
- Patients should receive the brand specific to the monitoring service with which they are registered.
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Paliperidone
(MR tablets)
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Non Formulary
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- MR tablets are non-formulary
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MHRA: Risk of intraoperative floppy iris syndrome in people undergoing cataract surgery (Oct 13)
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Key |
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Cytotoxic Drug
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Controlled Drug
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High Cost Medicine
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Cancer Drugs Fund
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NHS England |
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Homecare |
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CCG |
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Traffic Light Status Information
| Status |
Description |
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Available Over the Counter. Consider Self Care |
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Formulary - Can be prescribed in both secondary and primary care. |
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Formulary - Specialist Advice, secondary care advice provided for primary care initiation. |
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Formulary - Specialist initiation without shared care guidance. |
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Formulary - Specialist initiation with shared care guidance. |
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Restricted - Hospital only, not to be prescribed in primary care. |
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Not recommended for prescribing. Switch to alternative cost-effective option. |
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Not recommended for prescribing in primary or secondary care. |
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Not recommended as no formal application made for addition to the formulary. Contact relevant pharmacy team for further information.
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Non-Formulary (category under review). |
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