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December 2014
Discontinuation of Piportil (pipotiazine palmitate) Depot Injection
Dear Colleagues
Many of you will have received a letter from Sanofi-Aventis Ltd about the global withdrawal of Piportil depot
injection from the end of March 2015. This is due to a shortage of the active pharmaceutical ingredient
pipotiazine palmitate. Unfortunately there is no generic or other branded product of pipotiazine palmitate
depot injection available. Therefore all patients currently receiving pipotiazine palmitate depot injection will
need to be reviewed and switched to an alternative antipsychotic before the end of March 2015. No new
patients should be initiated on pipotiazine palmitate.
The choice of alternative will be a clinical decision by the prescriber in conjunction with the patient. In many
cases a referral to the local mental health team may be appropriate. This may take the form of a telephone
conservation or face to face referral.
Please consider the following steps if switching to another antipsychotic depot injection.
Full drug history
Reviewing previously trialled antipsychotics and considering their response and tolerability can greatly assist
decision making.
Dose interval and patient adherence
The pharmacokinetics of the various antipsychotic depot preparation influences its dose interval.
Pipotiazine Palmitate and Haloperidol Decanoate are 4 weekly
Flupentixol Decanoate varies from 2 – 4 weekly, but can be weekly
Fluphenazine Decanoate varies from 14 – 35 days
Zuclopenthixol Decanoate varies from 1 – 4 weekly
Patient compliance may need to be considered.
Is a test dose required?
If the individual has not been exposed to the new first generation antipsychotic depot being consider a small
test dose is required first. It is usually tested at least 5 – 7days prior to the first dose of the antipsychotic
depot injection, please refer the BNF1 for more details. Please note the oil base in pipotiazine is palmitate
whereas those in other suggested alternative preparations is Decanoate. Test doses should be given in
clinics where adrenaline is available in the event of an anaphylactic reaction occurring. There is no
injectable test dose for the second generation antipsychotic depots but patients are expected to have been
exposed to the appropriate oral preparation before prescribing.
Stephen Bleakley, Acting Chief Pharmacist, Southern Health Foundation Trust and Caroline Bowyer, Chief Pharmacist, Solent NHS Trust
Approved by the Southern Health Medicines Management Committee December 2014
December 2014
Doses of depot antipsychotics1,2
Antipsychotic drug
Test dose
Equivalent dose
(mg) per week
First generation (typical) antipsychotic depots
Flupentixol Decanoate
20mg
Fluphenazine Decanoate
12.5mg
Haloperidol (as Decanoate)
25mg
Pipotiazine Palmitate
n/a
Zuclopenthixol Decanoate
100mg
Second generation (atypical) antipsychotic long acting injections (LAIM)
Aripiprazole Maintena
Stabilise on oral Aripiprazole before using the LAIM
Paliperidone Palmitate
Stabilise on oral Risperidone before using the LAIM
Risperdone Contra (for Solent Trust only)
Stabilise on oral Risperidone before using the LAIM
10mg / week
5mg / week
15mg / week
10mg / week
100mg / week
Unknown
Unknown
Unknown
Maximum weekly
dose
400mg
50mg
75mg
50mg
600mg
400mg per month
150mg per month
50 mg per month
Please note: These equivalences are intended only as an approximate guide; individual dosage instructions should also be checked; patients should
be carefully monitored after any change in medication These equivalences must not be extrapolated beyond the maximum dose for the drug.
Relative adverse effects of depot antipsychotic drugs2,3
Antipsychotic drug
Sedation
Weight
Gain
Diabetes EPSE
First generation (typical) antipsychotic depots
Flupentixol Decanoate
+
++
+
Fluphenazine Decanoate
+
+
+
Haloperidol (as Decanoate)
+
+
+/Pipotiazine Palmitate
++
++
+
Zuclopenthixol Decanoate
++
++
+
Second generation (atypical) antipsychotic long acting injections (LAIM)
Aripiprazole Maintena
+/Paliperidone Palmitate
+
++
+
Risperdone Contra (for Solent Trust only)
+
++
+
+++ high incidence, ++ moderate, + low, - very low, ? unknown
Anticholinergic
Prolactin
elevation
Potential for
QT
prolongation
Cost per year
++
+++
+++
++
++
++
++
+
++
++
+++
+++
+++
+++
+++
+
+
++
?
?
£66
£59
£99
n/a
£82
+/+
+
+
+
+++
+++
+
£2,600
£2,200 to £4,700
£1,900 to £3,400
Stephen Bleakley, Acting Chief Pharmacist, Southern Health Foundation Trust and Caroline Bowyer, Chief Pharmacist, Solent NHS Trust
Approved by the Southern Health Medicines Management Committee December 2014
December 2014
Choice of typical antipsychotics depot2
There are few differences between individual first generation antipsychotics depots. However,
Zuclopenthixol Decanoate may be more effective in prevention relapses although this may be at the
expense of increased burden of side-effect. Flupenthixol Decanoate can be dosed in very much higher
“neuroleptic equivalent” doses and still remain within BNF limits. It is doubtful if this gives any real
therapeutic advantage but will certainly increase the side-effect burden. The second generation
antipsychotic long-acting injections are considerably more expensive than first generation depots but have
lower rates of movement disorders.
How to switch
The general consensus for switching first generation antipsychotic depot injections is to initiate the new /
switched depot on the day that the previous depot injection is due. This allows for a smooth switch over and
helps minimise the risk of overlapping the two drugs involved. However, please note the test dose will need
to be administered at least 5 -7 days prior to the initiation, please refer to the BNF1. Switching to a second
generation long acting injection requires stabilisation on the oral preparation first. Please refer to the local
mental health team for advice.
Monitor mental state and side effects closely during and after switching
It is important to monitor the patient closely for any signs of relapse or potential drug related side-effects
during and after the switching period, so that the dose and dosage interval of the switched antipsychotic
depot injection can be reviewed according to response.
Second generation antipsychotic LAIM
Please note these drugs are considered red drugs across the Hampshire health economy. They are
requested to be prescribed by consultant psychiatrists only. In Southern Health Aripiprazole Maintena
requires approval via an application to the chief pharmacist or medical director before prescribing.
Please do not hesitate to call one of the Medicines Management Team if you have any questions.
Medicines Management Team Southern Health Foundation Trust Tel: 02380 874023
Medicines Management Team Solent Trust Tel: 023080 698408
References:
1.
2.
3.
British Medical Association and The Royal Pharmaceutical Society. British National Formulary (BNF) 68th Edition (Section 4.2.2) London:
2014
Taylor et al. The South London and Maudsley NHS Foundation Trust Prescribing Guidelines in Psychiatry 11 th edition. Wiley-Blackwell
London: 2012.
Steve Bazire. Psychotropic Drug Directory 2014. Lloyd-Reinhold Communications Warwickshire: 2014
Stephen Bleakley, Acting Chief Pharmacist, Southern Health Foundation Trust and Caroline Bowyer, Chief Pharmacist, Solent NHS Trust
Approved by the Southern Health Medicines Management Committee December 2014