Download Psychotropics shared care - South West London and St George`s

SHARED CARE PRESCRIBING AGREEMENT
SHARED CARE PRESCRIBING AGREEMENT of psychotropics
(which are approved for transfer to GPs and are not included in other shared care agreements)
Medicines approved for transfer to GPs are found in the formulary policy and licensed indications of
medicines in the formulary: http://www.swlstg-tr.nhs.uk/for-health-professionals/
Current shared care (not in all CCGs): ADHD, Adult ADHD, melatonin, dementia medicines & lithium
NOTES to the GP
The expectation is that these guidelines should provide sufficient information to enable GPs to be
confident to take clinical and legal responsibility for prescribing this drug.
The questions below will help you confirm this:
 Is the patient’s condition predictable or stable?
 Do you have the relevant knowledge, skills and access to equipment to allow you to monitor
treatment as indicated in this shared care prescribing guideline?
 Have you been provided with relevant clinical details including monitoring data?
If you can answer YES to all these questions (after reading this shared care guideline), then it is
appropriate for you to accept prescribing responsibility.
If the answer is NO to any of these questions, you should not accept prescribing responsibility. You
should write to the consultant within 14 days, outlining your reasons for NOT prescribing. If you do not
have the confidence to prescribe, we suggest you discuss this with your local Trust/specialist service,
who will be willing to provide training and support. If you still lack the confidence to accept clinical
responsibility, you still have the right to decline. Your CCG pharmacist will assist you in making
decisions about shared care.
It would not normally be expected that a GP would decline to share prescribing on the basis of cost.
The patient’s best interests are always paramount
Date Prepared: 201502
Date approved by:
South West London & St Georges NHS Trust
Mental Health Interface Prescribing Forum
Sutton CCG
Merton CCG
Richmond CCG
Wandsworth CCG
Kingston CCG
Next Review: 201702
Prepared by:
Carl Holvey (Lead Clinical & Deputy Chief
Pharmacist)
Participating Primary Care Organisations
Kingston CCG
Dr Anthony Hughes, GP on behalf of Medicines
Management Committee
Seema Buckley, Director & Chief Pharmacist
Richmond CCG
Dr Stavroula Lees, lead GP for Mental health
Emma Richmond, Head of Medicines
Management
Merton CCG
Dr Andrew Otley, Mental Health Lead
Sedina Agama, Chief Pharmacist
Wandsworth CCG
Dr Gillian Ostrowsky, Associate Medical Director
Nick Beavon, Chief Pharmacist
Sutton CCG
Dr Chris Keers, Mental Health Lead
Sarah Taylor, Chief Pharmacist
Participating Provider Organisations
SWL & St. George’s Mental Health Trust
Dr Helen Miller, DTC Chair & National Deaf
Service in patient Psychiatrist
Dianne Adams, Chief Pharmacist
Psychotropics
Date approved: 201502
Review date: 201702
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SHARED CARE PRESCRIBING AGREEMENT
(which are approved for transfer to GPs and are not included in other shared care agreements)
1.
CIRCUMSTANCES WHEN SHARED CARE IS APPROPRIATE
 Prescribing responsibility will only be transferred when the Specialist and the GP are in agreement
that the patient’s condition is stable or predictable and in accordance with NICE guidance.
 Patients will only be referred back to the GP once the GP has agreed in each individual case and the
hospital will continue to provide prescriptions until successful transfer of responsibilities is completed,
as outlined below.
 The hospital will provide the patient with a minimum initial supply of 12 weeks of medication on
initiation.
2.
AREAS OF RESPONSIBILITY
Mental Health Service
GP
1 To assess the patient and establish a diagnosis; to determine a management 1. Monitor the patient’s
strategy and communicate this to the patient & GP. The diagnosis must
overall health, well-being
clearly be demonstrated through a detailed report. These must meet the
and compliance.
diagnostic criteria of the DSM-IV or the ICD-10 (where appropriate).
2. Review the patient in
2 Consider and discuss with the patient and/or carer (where applicable)
accordance with specialist
medicines treatment options laid-down in applicable: NICE, national and
advice
Local recommendations. This should include consideration of contra3. Prescribe the treatment
indications, interactions and cautions, a discussion of the reasons for
once the treatment has
treatment, the possible adverse effects and the lack of information in relation
been established, the
to longer-term outcomes including effectiveness and adverse effects.
patient stabilised on a
3 Discuss any unlicensed prescribing of medication with the patient and/or
particular dose and brand
carer and obtain consent. ‘Off-label’ or unlicensed formulations will only be
of medication, and the
transferred when the medicine is stable and is included in the approved list of
care of the patient has
indications/formulations (see Formulary policy).
been transferred and
4 Ensure relevant baseline investigations are performed, documenting weight,
accepted.
blood pressure, pulse and any additional relevant investigations (See
4. Monitor the physical health
SWLStG physical monitoring of Psychotropic medicines). Facilitate physical
in line with SWLStG
health investigations required for on-going monitoring of psychotropic
recommendations for
medicines by the GP where the patient needs reminding or they are difficult to
monitoring of
engage.
psychotropics:
5 Initiate treatment in line with approved treatment protocols. Supply standard
http://www.swlstgquantities of medicines recommended by the Trust: normally 14 days on
tr.nhs.uk/for-healthdischarge or for an outpatient treatment. Longer (usually a month) for off-label
professionals/
medicines, dementia medicines, ADHD medicines and abstinence medicines. 5. Check that the patient is
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Provide the GP with appropriate clinical information and individual patient
attending arranged
information in a timely manner (24hr on discharge and 7 days from an
specialist appointments (at
outpatient appointment):
least annually).
I.e. working diagnosis, mental state, medicines, dosages and intended
6. Re-refer the patient or
dosage ranges, significant medical history, reason for referral, ongoing
seek specialist advice from
support given (e.g. talking therapies), allergies, details of medicines tried and
the psychiatrist if there is
deemed unsuitable, reasons for stopping/swapping and requested monitoring
deterioration in
(clinical monitoring, frequency of tests, tolerability, investigations undertaken,
symptomatology,
compliance [including details of compliance aids], advice should
behaviour, poor
abnormalities be identified). Routine outpatient psychiatric review letter to
compliance or adverse
GPs should include prescribing advice for GPs even if no change is required,
effects of medication.
to assure the GP a review of the medicine has occurred.
7. Alert the specialist to
7 Be available to give advice to GP if the patient’s condition changes and to
previous misuse of drugs
ensure that procedures are in place for prompt specialist review.
by the patient if such
8 Ensure issues related to capacity and consent to treatment have been
information is known. This
considered and communicated to the GP. To accept referrals of patients
is particularly important
prescribed psychotropic medicines whom become pregnant and need still
where controlled drugs are
need specialist review i.e. they are at high risk of relapse or still need on
prescribed.
going treatment for their mental health.
8. To report any adverse
9 Prescribe at least 14 days of treatment for any medicine changes or upon
drug reactions to the
discharge from hospital or on changing ‘routine’ medicines
Medicines and Healthcare
10 Trust teams should provide any specific training which may be needed by GPs, eg disease
Products
management,
Regulatory administration o
11 Continue prescribing for certain patients:
Authority (MHRA) as part
11.1
Patient is not registered with a GP.
of the yellow card scheme.
11.2
The GP has made a specific request not to be involved in shared
9. Refer back to consultant if
Date approved: 201502
Review date: 201702
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SHARED CARE PRESCRIBING AGREEMENT
prescribing for a particular patient.
patient becomes pregnant.
Where the GP has a poor or no relationship with the patient
10. The GP will commence
Patient is taking clozapine
prescribing 14 days after
The Community team has made a decision that they will continue
inpatient discharge or
prescribing for a particular patient, because the medication regimen
community, unless the
is unstable and needs frequent changes.
community retain
11.6
There are major risk concerns associated with non-compliance that
prescribing responsibility
cannot be managed by the GP.
(see section 11 in the
11.7
Where the medicine is not approved to be transferred as per the
Mental Health Service
South West London Mental health formulary.
responsibility).
12 Community teams may transfer depot antipsychotics on ensuring that the GP 11. Adverse effects should be
practice has sufficient time to: establish the arrangements for prescribing,
communicated to the
dispensing, administration of the injection, systems for calling the patient to
mental health or substance
appointments and a process should the patient fail to attend.
misuse team. Refer the
13 Initiate methods of improving compliance (which may include request
back to the specialist for
compliance aids such as dosetts and blister packs from GPs and community
advice where needed (or
pharmacy) following approved guidance.
see below).
14 The keyworkers/ care co-ordinators will take appropriate steps to monitor and 12. Here a patient receives a
improve compliance with medication after discharge from hospital, eg:
medicine supplied by the
assessing and monitoring side effects of medication and discuss medication
Specialist the GP should
with the patient to aid recovery.
make a note on their
15 Advise the patient to keep medicines safe and that they are for personal use
prescribing system. The
only.
procedure to do this can
16 Advise patients prescribed controlled drugs about the need to store correctly
obtained from the MHT or
and the risks of driving while taking sedatives.
CCG Pharmacist.
17 Mental Health Teams must use Trust approved template to communicate
medicines advice to GPs. These templates have been ratified (by CQRG) to
ensure they include the relevant headings about medicines required by GPs.
Patient’s role
1. Attend follow up appointments with Consultant (at least annually)
2. Attend for tests and follow up appointments with GP (as per the Trust recommendations) & report side effects.
11.3
11.4
11.5
3.
COMMUNICATION AND SUPPORT
Hospital contacts:
(the referral letter will indicate named consultant)
Enter the contact details of your Service
Out of hours contacts & procedures:
The on-call Psychiatrist and Pharmacist can be
contacted via SWLStG’s switchboard: 020 3513 5000.
Tel:
Fax:
Email:
Specialist support/resources available to GP including patient information:
1. Contact the relevant community team or inpatient team.
Kingston
Wandsworth
Merton OP CMHT
Merton assessment (18-75)
Merton CAMHs Sutton & Merton CMH & ID
Sutton OP CMHT
Sutton assessment (18-75)
Sutton CAMHs Richmond Royal
2. Medicines Information Website www.choiceandmedication.org/swlstg-tr
3. Mental Health Medicines Information Helpline (for patients and GPs)- 020 3513 6829
4. Information in the British National Formulary (BNF) www.bnf.org
5. Summary of Product Characteristics www.emc.medicines.org.uk
6. SWLStG Prescribing information: http://www.swlstg-tr.nhs.uk/for-health-professionals/
4.
Indication(s)
CLINICAL INFORMATION
Approved off label indications and formulations that may be transferred to GPs are listed
in the SWLStG Mental health formulary and licensed indications as per SPCs
Specific shared care between the Trust and CCGs exists for:
Lithium
Melatonin (Circadin® only)
ADHD medicines (children)
ADHD medicines (adults) –Richmond & Merton with SWLStG, Kingston with
Yourhealthcare
Date approved: 201502
Review date: 201702
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SHARED CARE PRESCRIBING AGREEMENT
Antidementia medicines
Place in therapy
Therapeutic
summary
Duration of treatment
Dose and Route of
Administration
Unapproved medicines & specials for the treatment of mental illness or substance misuse
that are non-formulary are not included.
The Mental Health formulary has short guidance on 1st line medicines used in South West
London
BNF
http://www.swlstg-tr.nhs.uk/for-health-professionals/
See the Maudsley Guidelines free via myilibrary (using an NHS Athens password)
Determined on individual basis, ongoing may be required, it will be communicated to GPs
in the referral letter.
Formulations available in South West London may be found in the Psychotropic formulary:
http://www.swlstg-tr.nhs.uk/for-health-professionals/
Off label and high doses of antipsychotics or antidepressants should follow local guidance,
see the SWLStG formulary policy for further advice:
http://www.swlstg-tr.nhs.uk/for-health-professionals/
Summary of adverse
effects
Antidepressants
Adverse effect
Hyponatraemia
This table is not
exhaustive, see
individual SmPCs for
incidences of adverse
effects
*Refer back to the
specialist for
review/advice if the
medicine(s) need a
dose reduction, to be
stopped or side effects
are severe or
intolerable.
Bleeding or bruising
Alteration of glycaemic
control
Weight change.
Hypotension
QTc elongation
Heart rate
Arrhythmias
Myocardial Infarction
Sexual dysfunction
Hyperprolactinaemia
Discontinuation
symptoms
Sedation
Nausea and vomiting
Antipsychotics
Anxiety/agitation
BP changes
Date approved: 201502
Review date: 201702
Management considerations
Try restricting fluid if possible, withdraw and reintroduce slowly.
Stopping the antidepressant may be the only option. Unlikely
with MAOIs.
Stop if combined with other medicines that cause bleeding.
Mirtazapine medicine of choice.
Consider switch to mirtazapine or venlafaxine if on SSRI.
Relationship between weight change and depression
complicated. SSRI and SNRIs can cause loss and gain.
Mirtazapine and TCAs can cause weight gain. Management
will depend on severity and nature of weight change.
Offer nutritional advice. The medicine may need to be stopped,
switched or augmented.
More common with TCAs. SNRIs, reduce dose or switch to
SSRI.
Occurs with all SSRIs, SNRIs and TCAs. Mirtazapine may be
indicated.* Combining QTc prolonging medicines i.e.
antipsychotics and antidepressants may be unavoidable.
Increased with SNRIs and TCAs and decreased by SSRIs and
MAOIs. The medicine may need to be stopped or switched.
Most commonly associated with BBB or QTc prolongation
(torsades). May require the medicine to be stopped. Refer
back
Confirmed increased risk of MI within 3 months of initiation of
TCAs. Other Antidepressants have been shown to be a safer
option.
All antidepressants are associated with sexual dysfunction.
Reboxetine may cause spontaneous ejaculation. Medicine
may need to be stopped or switched.*
Consider switch to mirtazapine.*
Reduce the dose more slowly. Add analgesics. Switch to a
longer acting medicine of the same class.*
May wear off, take the dose at night, switch to a less sedating
antidepressant (e.g. sertraline).
Take with or after food or at night. There is a paucity of
evidence to support the use of ondansetron or ganisetron in
problematic cases.
Usually diminishes in weeks. Relaxation techniques may be
helpful.
Dose reductions may be helpful.
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SHARED CARE PRESCRIBING AGREEMENT
Blurred vision
Blood changes or
agranuolocytosis
Dizziness
Dry mouth
Dyspnoea
Elevated lipids &
glucose
Hyperprolactinaemia
Insomnia
Injection site pain
LFT changes
Sexual dysfunction
Somolence
Tachycardia
Akathisia
Tremor, rigidity,
stiffness, hypokinesia,
hypersalivation,
dyskinesia
TFT change
Weight gain
Neuroleptic Malignant
Syndrome
Constipation
Benzodiazepines &
Z-drugs
Lamotrigine
Agitation, aggression or
oversedation
Confusion or amnesia
Hypotension or
dizziness
Headache
Rash
Insomnia
Dizziness
Rash
Valproate
Bone marrow
suppression
Seizures
Oedema (of the legs,
face or lips)
Nausea
Increase appetite and
weight gain
Gastric irritation &
nausea
Date approved: 201502
Review date: 201702
Dose reductions may be helpful
Increase frequency of FBC monitoring, stop medicine if severe.
May be postural, check BP, advise avoiding standing up
quickly or driving.
Sugar-free citrus sweets or chewing gum or artificial saliva.
Review cardiac signs observations & ECG
Assess relevance and treat accordingly.
Reduce dose or switch.* Not expected with aripiprazole.
Specialist may consider augmenting with aripiprazole.
Usually diminishes in weeks. Switch dose to morning.*
Rotate site, ensure correct length of needle, check technique,
use local anaesthetic cream prior to injection
Increase frequency of monitoring, consider reducing the dose
for twice the upper limit and stopping the medicines for three
times the upper limit (excludes amisulpiride, supliride and
paliperidione).
Assess for hyperprolactinaemia, medicine may need to be
stopped or switched.*
Advise avoid operating machinery and driving, switch to night
time or evening.
May be benign, treat with beta blocker if persistent.
May increase the risk of suicide, treat with propranolol
Dose reduction may be helpful, procyclidine for short periods
only.
May occur with Quetiapine only, assess relevance and treat
accordingly.
See the Trust obesity pathway. Much less with aripiprazole.
Specialist may consider augmenting with metformin or
aripiprazole if switch is not an option.*
Stop medicine, urgent referral to physician.
Severe faecal impaction may occur with clozapine. Investigate
thoroughly and treat.*
Reduce the dose or stop medicine. Avoid abrupt withdrawal
where the patient has been taking it for more than two weeks
Reduce the dose or stop the medicine
Avoid standing quickly, avoid driving.
Simple analgesia.
Stop (if acutely prescribed) or switch the medicine.*
Try adjusting the timings of the dose, avoid driving or operating
machinery.
Avoid standing quickly, avoid driving. Lowering the dose may
help (check serum level)
Urticaria and a macopapular rash can occur.
SJS or TEN –stop immediately.*
Stop lamotrigine and monitor for sign of fever or infection
closely.*
Reduce dose or stop.*
Consider stopping medicine and switching to an alternative,
refer back.
Slow down titration.
Dietary advice, following obesity care pathway where
applicable.
Slow titration, use modified release taken at night or take with
the largest meal of the day. May be less with semi-sodium
valproate.
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SHARED CARE PRESCRIBING AGREEMENT
Confusion, lethargy,
ataxia & tremor
Liver impairment
Thrombocytopenia/ rash
Blurred vision
Dry mouth
Constipation
Nausea and vomiting
Antimuscarinics
Confusion or dizziness
Urinary retention.
Bradycardia,
dysrhythmias
Diarrhoea
Constipation
Sleep disturbance
Urinary retention
Seizures
Headache
Nausea or vomiting
Headache
Nausea or vomiting
Hallucinations or
confusion
Abnormal gain,
dizziness
Acetylcholine
esterase inhibitors
(AChEIs)
Memantine
Check serum valproate and ammonia level, dose may need to
be reduced.
Stop if patient is <20years old. Monitor more closely with two
times the upper limit and consider reducing the dose (check
levels and side-effects). Stop if three times the upper limit.*
Stop.*
Reduce dose, advise on not driving or operating machinery.
Sugar-free citrus sweets or chewing gum or artificial saliva.
Advise on fluids, diet and exercise. Mild laxative may be helpful
Take with food, usually abates after a week.
Reduce dose, care on standing. Advise on not driving or
operating machinery. Stop if marked.
Stop, and consider introducing at a much lower dose.
If severe or persistent consider switch to memantine for a trial.*
Usually abates quickly on initiation.
Usually mild, advise on diet, exercise and use of mild laxative.
Take earlier in the day, slow the titration, try reducing the dose.
Stop.*
Stop.*
Slow titration, reducing the dose and paracetamol may all help.
Seen on initiation or dose changes. Take with food.
Slow titration, reducing the dose and paracetamol may all help.
Seen on initiation or dose changes. Take with food.
Refer back to specialist.
Advise on avoiding standing quickly and steadying self, try
reducing the dose or stop.
Seen with memantine, reduce dose, stop if severe or
Somnolence/tiredness
persistent.*
Incidences of adverse effects may vary between medicines, consult Summary of Product Characteristics (SmPC) or
BNF for a full list of adverse effects for individual medicines.
*Refer back to the specialist for review/advice if the medicine(s) need a dose reduction, to be stopped or side
effects are severe or intolerable.
Monitoring
Requirements
Please see the SWLStG list of recommended physical monitoring (including side-effects)
for psychotropics: http://www.swlstg-tr.nhs.uk/for-health-professionals/
Clinically relevant
drug interactions
Practical issues
Consult Summary of Product Characteristics (SmPC) or BNF for a full lists of drug
interactions
Generic prescribing is preferred for most mental health medicines, Brands are
occasionally prescribed for those with autism or fixed beliefs over their medicines.
Lithium MUST be prescribed by brand.
Guidance on stopping psychotropics is being developed and will be available in due
course.
Key references
BNF
SPC
Meyler’s, Adverse Drug reactions 8th Edition. Elsivier 2006.
Further guidance for health care professional is available on the SWLStG website via
http://www.swlstg-tr.nhs.uk/for-health-professionals/
Date approved: 201502
Review date: 201702
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