Download 1. circumstances when shared care is appropriate

Shared Care Prescribing Agreement
Lithium for Affective Disorders
Section A: To be completed by the hospital consultant initiating the treatment
GP Practice Details:
Patient Details:
Name: ………………………………………
Name: ………………………………………………
Address: ……………………………………
Address: ……………………………………………
Tel no: ………………………………………
DOB: ……/………/…………
Fax no: ……………………………………
Hospital number: …………………………………
E-mail: ……………………………
NHS number (10 digits): …………………………
Mental Health Team details:
Mental Health Team details contd:
Consultant name: ……………………………
Fax no:………………………………………
Clinic name: ………………………………….
Tel no: ………………………………………
Address:......................................................
……………………………………………….
…………………………………………………..
NHS.net e-mail: ……………………………
Diagnosis:
Drug (brand) name & dose to be prescribed by GP:
…………………………………………………………….
Licensed indication yes/no
……………………………………………………
Next hospital appointment: …………/……..…/……………..
Dear Dr:………………………………….
Your patient is prescribed ………………………………………… (Insert specific brand name and dose) for the
above diagnosis and they are stabilised on this treatment. I am requesting your agreement to sharing the care
of this patient from ……………………..…. (Insert date) in accordance with the attached Shared Care
Prescribing Guideline (Title: Lithium for Affective Disorders; Approval date:…………..). Please take particular
note of Section 2 where the areas of responsibilities for the consultant, GP and patient for this shared care
arrangement are detailed.
Patient information has been given outlining aims and potential side effects of this treatment. A lithium booklet
has been supplied and a lithium care plan has been opened. The patient has given me consent to treatment
under a shared care prescribing arrangement (with your agreement) and has agreed to comply with
instructions and follow up requirements.
Please monitor the following in accordance with the attached schedule:
 Every three months*:(*NICE recommendations): lithium blood level (sample taken 12 hours after last
dose)
 Every six months: thyroid function & eGFR
 Annually: weight, serum calcium, BP, pulse, lipids, fasting blood glucose, HbA1c and LFTs
Test
Lithium level (mmol/l)
Result
Test Date
Test
Result
Test Date
U&E (Na, Ca,
Cr & eGFR)
TFT
Weight (kg)
(or BMI)
Mental Health Team please ensure the latest blood results are attached with this agreement
Lithium level must not be above: …..………………..(mmol/l) or below:………………………………(mmol/l)
Other relevant information: ………………………………………………………………………………………..
Section B: To be completed by the GP and returned to the hospital consultant
Please sign and return your agreement to shared care within 14 days of receiving this request
Tick which applies:
□ I accept sharing care as per shared care prescribing guideline and above instructions
□ I would like further information. Please contact me on……………………………….
□ I am not willing to undertake shared care for this patient for the following reason:
…………………………………………………………………………………………………………………………..
GP name: ………………………………………….………. GMC no: ……………………………………………....
GP signature: ……………………………………………… Date: ……...…/…………../…....…..
Date original approved: February 2004
Version 201705
Date last review: June 2016
Date next review : June 2019
Working in partnership with
SHARED CARE PRESCRIBING GUIDELINE
Lithium for Affective Disorders
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
Participating Primary Care
Organisations
Kingston CCG
Dr Anthony Hughes, GP on behalf of
Medicines Management Committee
Seema Buckley, Director & Chief
Pharmacist
Richmond CCG
Dr Kate Moore, Vice Clinical Chair
Emma Richmond, Chief Pharmacist
Merton CCG
Dr Andrew Otley, Mental Health Lead
Sedina Agama, Chief Pharmacist
Wandsworth
Dr Nicola Jones, Clinical Chair
Nick Beavon, Chief Pharmacist
Sutton CCG
Dr Chris Kears, Mental Health Lead
Sarah Taylor, Chief Pharmacist
Date original approved: February 2004
Version 201705
Participating Hospital Trusts
SWL & St. George’s Mental Health NHS Trust
Helen Miller (DTC Chair & Consultant Psychiatrist)
Dianne Adams (DTC secretary & Chief Pharmacist)
Date last review: June 2016
Date next review : June 2019
2
1.
CIRCUMSTANCES WHEN SHARED CARE IS APPROPRIATE
 Prescribing responsibility will only be transferred when the consultant and the GP are in agreement
that the patient’s condition is stable or predictable.
 The patients will only be referred 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 as outlined
below.
 The hospital will provide the patient with a minimum initial supply of 2 weeks medication.
2.
AREAS OF RESPONSIBILITY
In general the various responsibilities will be shared as outlined below, but for an individual patient
there may be some variation in the detail (e.g. on who does which blood tests) but this must be clearly
agreed between the consultant and GP
Consultant
GP
 Formulate diagnosis and initiate
 Prescribe specific dosage, form and brand of lithium ensuring
treatment plan
monitoring results indicate it is safe to do so, adjusting dosage as
required. Priadel MR® 200mg and 400mg tablets are the formulary
 Follow Mental Health Trust guidelines
choice for lithium carbonate tablets. If liquid is prescribed note,
for prescribing and monitoring lithium
therapy
SWLStG uses only the high strength lithium citrate liquid
1.018g/5ml (equivalent to 400mg lithium carbonate/5ml).
 Provide verbal and written information
to the patient and answer their questions
 Measure lithium plasma levels every 3 months in accordance
about lithium
with NICE guidelines (or at any other time if signs of toxicity) and
 Establish willingness for adherence to
send a copy of the results to the CMHT.
lithium treatment (to avoid abrupt
 If monitoring results not available at the time of prescribing,
cessation of treatment)
prescribe only a limited supply (e.g. maximum 14 days) and
 Perform baseline physical health
arrange for blood tests.
checks (including body weight and ECG),
 Measure thyroid function and renal function every 6 months in
renal and thyroid function, serum calcium,
accordance with NICE guidelines and send a copy of the results to
creatinine, eGFR and sodium (recorded in
the CMHT.
the electronic care notes). FBC should be
 Update the patient’s lithium monitoring booklet with all results
done if indicated
and changes in treatment when presented by patient
 Initiate lithium treatment and establish
 Perform annual health checks including record of body weight in
desired dose / blood level
accordance with NICE guidelines (including serum calcium)
 Provide lithium treatment monitoring
 Monitor mental state
booklet and complete with relevant
 Monitor adherence to medication
details. Open lithium care plan
 Assess for adverse effects (Healthcare professionals are asked
 Provide information on the new lithium
to report suspected adverse reactions via the Yellow Card Scheme
app (NHS Health Monitor for Lithium).
at: www.mhra.gov.uk/yellowcard)
The app will: provide information on the
 Be alert for medicines that interact with lithium; if any are added,
do’s and don’ts with lithium, record blood
stopped or have their dosage changed re-check the lithium level
test results, set reminders for forthcoming
and observe for any signs of toxicity or of relapse of symptoms.
blood tests, record sleep and mood data
 Contact mental health community team or medicines
and results can be emailed the to the GP
information for advice on: dosage adjustment to maintain lithium
and Consultant.
level, management of adverse effects or patients who refuse blood
 Check on going monitoring of lithium
tests.
occurs
 Refer patient back to CMHT if concerns over mental state or
Communicate to GP:
concerns over poor compliance with treatment, refusal for
 Dosage, form & brand of lithium to be
monitoring and of physical health issues that affect dosing or
prescribed (this must be specified in all
treatment.
correspondence, prescriptions and the
patient’s lithium record)
 Current lithium plasma level
 Desirable plasma level range to be
maintained
 Frequency of follow-up appointments
with CMHT and communicate treatment
changes to the GP promptly within Trust
recommended times.
Date original approved: February 2004
Version 201705
Date last review: June 2016
Date next review : June 2019
3
N.B. results of all tests and investigations should be copied by / to both consultant and GP
Patient and Carers responsibilities
Carry lithium monitoring booklet or updated lithium app to required appointments and allow Health Care
professionals involved in their care to see the booklet/app info.
3.
COMMUNICATION AND SUPPORT
Hospital contacts:
Out of hours contacts & procedures:
(the referral letter will indicate named consultant)
ENTER CONTACT DETAILS OF YOUR
LOCAL CMHT
The on-call Psychiatrist and Pharmacist can be
contacted via the hospital switchboard on
020 3513 5000.
Tel:
Fax:
Nhs.net e-mail:
Specialist support/resources available to GP including patient information:
 Additional information on any aspect of lithium treatment is available during working hoursfrom Mental
Health Medicines Information 020 3513 6829
 Patient information leaflets & lithium monitoring booklets for patients are available from Springfield
Hospital Pharmacy 020 3513 6204.
 Information leaflets, choice of treatment for illnesses & illness leaflets (funded by SWLStG):
http://www.choiceandmedication.org/swlstg-tr/
4. CLINICAL INFORMATION
Place in therapy:
Therapeutic summary:
Dose & route of administration:
Duration of treatment:
Monitoring Requirements:
The NPSA Patient Safety Alert
states that NHS providers “should
ensure that patients prescribed
lithium are monitored in
accordance with NICE guidance”
In accordance with NICE CG 185
(Sept 2014): Healthcare
professionals in secondary care
should ensure, as part of the care
programme approach, that people
with bipolar disorder receive
physical healthcare from primary
care after responsibility for
monitoring has been transferred
from secondary care.
Date original approved: February 2004
Version 201705
One of the drugs of first choice for established recurrent illness insteadof or in addition to antipsychotics and/or antidepressants as appropriate.
Treatment and prophylaxis in mood disorders – exact mechanism of
action unknown
Dose - established for each individual patient to produce the desired
blood level (usual therapeutic range 0.4 – 1.0mmol/l but specific target
level will be individual for each patient).
Route of administration – oral (see notes on formulations in “practical
issues” section below).
For prophylaxis, likely to be for several years
General monitoring of the patient’s mental state, adherence to treatment
and for any adverse effects of their medication.



Every three months*:(*NICE recommendations)
o lithium blood level (sample taken 12 hours after last dose)
Every six months*:
o measure thyroid function
o measure renal function (eGFR)
Annually*:
o physical health check including measure of body weight,
serum calcium, BP, pulse, lipids, fasting blood glucose,
HbA1c and LFTs
In addition, measure lithium blood levels if signs of toxicity or relapse of
illness appear, or if any medication is added / removed which may affect
lithium blood levels (See interactions section)
Request on each laboratory form that a copy of all results be sent
to both consultant & GP. For those patients using the lithium app
can email the results directly to the GP and Specialist Consultant
Date last review: June 2016
Date next review : June 2019
4
4. CLINICAL INFORMATION contd.
Summary of adverse effects:
(See summary of product
characteristics (SmPC) for full list,
visit www.medicines.org.uk )
N.B. because of potential risk to
unborn child, women of childbearing age should be clearly
informed of the risks of pregnancy
and should be encouraged to
discuss with you any possible
pregnancy, plans to breastfeed (or
plans to conceive) as early as
possible.
Clinically relevant drug
interactions:
N.B. included are the “potentially
hazardous” interactions as listed
in the BNF – see latest BNF /
SmPC for more complete
information
N.B. increased lithium plasma
level/decreased lithium excretion
brings the risk of lithium toxicity
N.B. the effect of adding these
drugs to lithium treatment is
described here – the opposite
effect is likely if the drug is
withdrawn
N.B. care may also be needed if
one interacting drug is switched
for another (e.g. change in
diuretic)
Practical issues:
Adverse effect
Frequency
Management
Lithium toxicity (signs:
vomiting, diarrhoea,
polyuria, increased thirst,
coarse tremor, ataxia,
muscle pain / weakness,
drowsiness, confusion)
Unknown
(affected by
dosage, drug
interactions,
physical
illness, salt &
fluid balance)
Stop lithium,
measure lithium blood
level urgently, rehydrate,
contact CMHT, DO NOT
force diuresis, consider
A+E referral
Impaired renal function
(identified by monitoring)
Unknown
contact CMHT
Impaired thyroid function
Unknown
contact CMHT
(identified by monitoring)
 ACE inhibitors and Angiotensin-II antagonists – increased lithium
blood level (monitor lithium closely until stabilised)
 Analgesics – decreased lithium excretion by azapropazone,
diclofenac, ibuprofen, indometacin, ketorolac (avoid concomitant use),
mefenamic acid, naproxen, parecoxib, piroxicam, rofecoxib, and
probably other NSAIDs (risk of lithium toxicity-monitor lithium closely
until stabilised)
 Antidepressants – SSRIs may increase risk of CNS effects
 Antipsychotics – increased risk of EPSE / neurotoxicity with
clozapine, haloperidol, phenothiazines, sulpiride; increased risk of
ventricular arrhythmias with amisulpride, sertindole, thioridazine
 Acetazolamide – increased lithium excretion (monitor lithium closely
until stabilised)
 Diuretics – decreased lithium excretion/increased lithium blood level.
Loop diuretics safer than thiazides (monitor lithium closely until
stabilised)
 Methyldopa – neurotoxicity without increased lithium blood level
(monitor patients for sign of toxicity)
 Steroids – may alter lithium excretion and should therefore be
avoided
 Tetracyclines
Formulations of lithium
 Different brands and formulations of lithium are likely to produce
different lithium blood levels
 The brand & formulation of lithium should remain unchanged for a
patient & should be specified on each prescription, in all
correspondence and on the patient’s lithium monitoring booklet
 Take extra care when prescribing lithium in liquid form, as different
brands contain very different concentrations of lithium (e.g. Li-Liquid
(Rosemont) is available in 2 strengths)
 SWLStG only uses the high strength lithium citrate liquid
1.018g/5ml (equivalent to 400mg lithium carbonate/5ml)
If the lithium level is outside the desired range for this patient
 If level is above 1.0mmol/l contact the patient to arrange urgent
assessment and to ensure that they take no more lithium and
monitored for signs of toxicity.
Otherwise:
 Confirm correct dosage is being prescribed / taken
Date original approved: February 2004
Version 201705
Date last review: June 2016
Date next review : June 2019
5

Confirm blood sample taken 12 hours post-dose

Check for drug interactions (N.B. some over-the-counter drugs may
interact e.g. ibuprofen)
 Check hydration and salt intake or loss
 Assess physical & mental state of the patient
 Adjust the dosage if indicated and repeat level after 5-7 days
Potential risk in pregnancy
Because of the potential risk to the unborn child, women of child-bearing
age should:
 Be clearly informed of the risks of pregnancy
 Be encouraged to discuss with you any possible pregnancy as early
as possible
 Be encouraged to discuss with you any plans to conceive as early
as possible
 Contact Mental Health Medicines Information (020 3513 6829) or
the Perinatal Mental Health Service for advice.
Key references:



NPSA Patient Safety Alert NPSA 2009/PSA005
“Using lithium safely” Drug & Therapeutics Bulletin 1999, 37, 22
“Lithium for maintenance treatment of mood disorders” (Cochrane
review), Burgess S et al In: The Cochrane Library, Issue 3, 2001
 British National Formulary May 2016.
https://www.medicinescomplete.com/mc/bnf/current/whatsnew.htm#ne
ws607(accessed 7th June 2016)
 NICE clinical guideline 185 - Bipolar disorder: the assessment and
management of bipolar disorder in adults, children and young people in
primary and secondary care. September 2014, Last updated: February
2016
 SWLStG Lithium prescribing and monitoring. TWC21j.
 Stockley’s Drug Interactions:
https://www.medicinescomplete.com/mc/stockley/current/x170953.htm?q=lithium%20tetracycline&t=interactions&ss=interactions&tot
=1&p=1#_hit (accessed 7th June 2016)
Lithium App.
Download the Apple IPhone version of the Lithium App here:
https://itunes.apple.com/us/app/nhs-physical-healthmonitor/id1040946243?mt=8
Download the Android version of the Lithium App here:
https://play.google.com/store/apps/details?id=com.incentivated.nhs.Healt
hMonitor
Date first prepared: January 2004
Date reviewed: January 2013, January
2015, June 2016
Date review approved: February 2013,
February 2015, June 216
Next review date: June 2019
Date original approved: February 2004
Version 201705
Prepared by:
Carl Holvey, Principal Pharmacist SWLStG MH Trust
Reviewed by: Caroline Mollison, Pharmacist, SWLSTG MH
Trust June 2016
Approved by (Approval date):
S W London Mental Health Prescribing Forum:
S W London & St Georges Mental Health NHS Trust June
2016
Date last review: June 2016
Date next review : June 2019
6