Psychotropic Medication Monitoring

Overview

People with mental illness have a higher risk of physical illness such as cardiovascular disease and type 2 diabetes. This can result in a reduced life expectancy compared to the general population. This is not entirely due to lifestyle factors such as higher smoking rates, poor diet and substance misuse. These factors can be compounded by the medicines used to treat mental illness. Many of these can cause weight gain and adversely affect lipid profiles. Many have other serious side effects affecting the liver and kidneys (1).

Most physical health monitoring is best performed in primary care. NICE Clinical Guideline 178: Psychosis and schizophrenia in adults: prevention and management, recommends monitoring of physical health by secondary care for the first year of treatment, or until medicines are stabilised. Local agreements and the treatment setting, in-patient or community, will determine the best arrangement for physical health monitoring.

One exception is Clozapine which is an atypical anti-psychotic and has enhanced monitoring requirements and this is managed by secondary care - see Clozapine section below.

See the document below for advice on monitoring schedules for psychotropic medication from AWP:

• (1) Procedure for Monitoring Psychotropic Medication – a guide to essential tests and investigations (Med37)

Prolactin and Antipsychotics

Notes on Antipsychotics and prolactin (2)

Antipsychotic medicines are probably the most common cause of raised prolactin levels. All antipsychotics have the potential to raise prolactin, although to varying degrees.

 All first generation (typical) antipsychotics and some second generation (atypical) antipsychotics, e.g. risperidone, paliperidone, amisulpride, are most commonly associated with hyperprolactinaemia. The degree of prolactin elevation appears to be dose related, and the dose threshold for this adverse effect is often the same threshold required for a therapeutic response.

Some antipsychotics do not normally increase prolactin above the normal range. These include aripiprazole, clozapine, olanzapine, quetiapine, lurasidone. Aripiprazole may actually decrease and normalise prolactin levels.

Prolactin levels significantly start to fall within 3 days, and return to normal within 3 weeks after stopping an oral antipsychotic. For a long acting/depot antipsychotic, levels may not return to normal for many months. Although prolactin levels rise and fall quickly, their associated symptoms can take much longer to present and also longer to subside once levels return to normal.

Advice from local psychiatrists on Prolactin monitoring

Ongoing or annual monitoring of prolactin is not recommended unless symptoms arise. The serum prolactin should be checked before starting all antipsychotics (this can be done at the same time as other baseline blood tests).  Prolactin only needs to be monitored in females under 50 and males under 65 years old.

Please find attached the following guideline from AWP for further details and flow charts:

• (2) Medicines Guideline: Antipsychotic-induced hyperprolactinaemia: identification, monitoring and management (MG12) - open the medicines information for health care professionals tab to find this guideline.

Clozapine

Clozapine was the first of the atypical antipsychotics to be developed and has been found to be the most effective antipsychotic drug for treatment-resistant schizophrenia (TRS), but its use has been limited because of the risk of serious side-effects. In order to reduce the risk of these side-effects causing serious harm, The Medicine and Healthcare Products Regulatory Authority (MHRA) has placed restrictions on its prescribing and dispensing, including extensive monitoring.(3)

Clozapine is a red drug on the BNSSG formulary and should only be prescribed by as specialist. Initial screening checks and ongoing monitoring of patients is also managed by secondary care. Clozapine should be added to the patient’s GP record as a hospital only medicine. See the document (Med42)  on the AWP website for details:

• (3) Procedure for the care of patients taking clozapine in primary care settings (Med42)

All patients on Clozapine are registered with ZTAS  - Zaponex (Clozapine) Treatment Access System - a secure, comprehensive web-accessed patient database which can be accessed by registered healthcare professionals. A warning system will alert the prescriber (specialist) of any abnormal or concerning results (due to relatively high risk of neutropenia or agranulocytosis). Patients who have other abnormalities picked up that are not due to Clozapine may need to be investigated by their GP as appropriate.

Whilst the prescribing and monitoring of Clozapine is managed by AWP, there are adverse effects that may first present in primary care. It is important that staff in primary care are aware of these adverse effects so that need for prompt referral is recognised. A full list of adverse effects can be reviewed in the Summary of Product characteristics. As well as blood dyscrasias, other serious adverse effects of clozapine requiring urgent attention include:

• Severe constipation sometimes leading to impaction and obstruction
• Myocarditis and cardiomyopathy
• Disturbed glucose control and diabetes
• Seizures
• An increased risk of developing pneumonia

Resources

Pharmacy service :: Avon and Wiltshire Mental Health Partnership NHS Trust (awp.nhs.uk) - links to medication information for professionals produced by AWP

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.