Reference document for monitoring the physical health of service users taking psychotropic medication

Document name:

Reference document for monitoring the physical health of service users taking psychotropic medication

Version 4

Portfolio

Medicines Management

Document type:

Prescribing Guidance

Staff group to whom it applies:

All prescribers and clinical staff within the Trust

Distribution:

The whole of the Trust

How to access:

Intranet

Issue date:

February 2016

Next review:

January 2019

Approved by:

Drug and Therapeutics Subcommittee

Developed by:

Kate Dewhirst, Deputy Chief Pharmacist Diane McGowan, Principal Pharmacist

Director leads:

Medical Director

Contact for advice:

Kate Dewhirst, Deputy Chief Pharmacist

ii

CONTENTS Summary

1. Introduction ......................................................................................................... 1

Table 1.1 Schedule of monitoring or antipsychotics excluding Clozapine ............... 2

Table 1.2 Schedule of monitoring for clozapine ...................................................... 3

Table 1.3 Schedule of monitoring for mood stabilisers ............................................ 4

Suggested monitoring for antidepressants ............................................................. 5

Suggested monitoring for antidementia medicines ................................................. 5

2. Monitoring of Physical Health – Background information ................................ 6

2.1 Full blood count (FBC) .................................................................................. 6

2.2 Renal Function ............................................................................................. 6

2.3 Liver Function Tests (LFTs) ......................................................................... 7

2.4 Thyroid Function Tests (TFTs) ...................................................................... 7

2.5 ECG .............................................................................................................. 7

2.6 Extrapyramidal side-effects (EPSEs) ............................................................ 8

2.7 Prolactin ........................................................................................................ 8

2.8 Hyponatraemia ............................................................................................. 9

2.9 Blood Pressure and Pulse ............................................................................ 9

2.10 Investigations for Diabetes Mellitus ............................................................... 9

2.11 Hyperlipidaemia ............................................................................................ 10

2.12 Weight and BMI ............................................................................................. 10

3. References ........................................................................................................... 11

4. Appendices .......................................................................................................... 12

4.1 Sample recording template for antipsychotics ................................................... 12

4.2 Sample recording template for mood stabilisers. .............................................. 13

4.3 Clozapine monitoring checklist.......................................................................... 14

4.4 Example Wellbeing checklist ............................................................................ 15

4.5 Lester tool…………………………………………………………………… ............. 16

iii

Summary of key physical health risks and recommendations

Don’t just screen, intervene. Full blood count

Most antipsychotics and mood stabilisers have been associated with varying incidences of haematological disorders such as neutropenia, leucopenia and thrombocytopenia

FBC should be checked as baseline and annually (as a minimum) for all those on antipsychotics and mood stabilisers

On starting carbamazepine FBC should be carried out as a baseline and then 2 months, then after 3 to 6 months. Valproate requires baseline and 6 monthly checks.

Clozapine has regulated mandatory monitoring requirements. U&Es including Renal function (eGFR) and hyponatraemia

Baseline urea, electrolytes and serum creatinine should be carried out for all patients

An annual level as part of a routine physical health check for urea, electrolytes and serum creatinine should be carried out for all patients but a minimum of 6 monthly checks are required for patients on antidepressants, lithium and valproate

Amisulpride and sulpiride are excreted via the kidneys, dosage adjustments may be required

Hyponatraemia can be caused by many medicines and can lead to fatigue and confusion.

Hypokalaemia and hyperkalaemia, although not caused by psychotropics can increase the risk of serious arrhythmias.

A rising creatinine and a falling eGFR suggest renal problems, any marked changes should be followed up.

Liver Function

All patients should have baseline LFTs performed and checked for abnormalities

The frequency of retesting varies from drug to drug but it is normally annually for antipsychotics and 3 to 6 monthly for clozapine, olanzapine, valproate and carbamazepine. Additional monitoring is required if signs and symptoms of hepatic dysfunction are present.

Liver function tests are required at prior to initiation of agomelatine or dose increase, then at three weeks, six weeks, twelve weeks and twenty-four weeks of treatment. Subsequently these should be performed only as clinically indicated.

Thyroid function

Baseline and annual checks are recommended as part of a routine health check.

Lithium requires 6 monthly measurements

Quetiapine may affect thyroid function ECG

Antipsychotics may lead to prolongation of the QTc interval, which can pre-dispose to the potentially fatal arrhythmia Torsade De Pointes

Check at baseline and repeat annually or after significant dose changes

More frequently for high dose antipsychotics and those with additional risk factors or antipsychotics with a moderate to high risk.

It is good practice to carry out an ECG on admission to hospital in anticipation of medicines regimen changes.

iv

Blood glucose (fasting if possible)

Many psychotropic drugs affect glucose metabolism.

There is also an association between severe mental illness and impaired glucose metabolism.

Monitoring should be baseline and annually for all, with additional monitoring for most antipsychotics at 3 to 6 months in the first year.

Monthly monitoring is required for clozapine and olanzapine in the first year.

Lipid profile (fasting if possible)

Hyperlipidaemia is an established risk factor for cardiovascular disease and has been associated with some antipsychotics.

Baseline, 3 months, then yearly monitoring is recommended, as part of routine health check, for most antipsychotics (except clozapine, olanzapine, quetiapine, phenothiazines – test every 3 months for first year).

Some drugs such as mood stabilisers are not associated with lipid change but due to high incidence in this group monitoring is recommended.

Offer lifestyle advice, dietary intervention or consider change of drug. Blood pressure and Pulse

High BP is an established risk factor for CVD

Tachycardia may be a symptom of cardiomegaly (see also clozapine guidelines).

BP and pulse should be checked at baseline, during titration and annually

Postural (orthostatic) hypotension can occur during initiation. The elderly may be are particularly at risk.

Prolactin

Many antipsychotics can produce hyperprolactinaemia

Hyperprolactinaemia causes galactorrhoea, gynaecomastia, hypogonadism, sexual dysfunction and, in the long term, osteoporosis and possibly breast cancer

Monitoring is recommended for antipsychotics at baseline, 6 months and yearly (not required for aripiprazole, clozapine, quetiapine or olanzapine unless clinically suspected).

Weight, including BMI and waist measurement if possible

Being overweight and especially abdominal obesity is a risk factor for cardiovascular and cerebrovascular disease.

Excess weight has also been associated with hypertension, diabetes, osteoarthritis, pregnancy risks and infertility, gallstones and cancers.

It can have a major effect on adherence with prescribed medicines.

Baseline then frequently (at least monthly) for the first 3 months and then yearly (clozapine and olanzapine 3 monthly for first year).

v

Abbreviations used in this document BMI Body mass index BP Blood pressure CPK Creatinine phosphokinase CVD Cardiovascular disease ECG Electrocardiogram eGFR Estimated glomerular filtration rate EPSEs Extrapyramidal side-effects FBC Full blood count FPG Fasting plasma glucose GMS General medical services contract GP General Practitioner HbA1c Glycosylated haemoglobin LFTs Liver function tests LUNSERS Liverpool University neuroleptic side effect raring scale NHS National Health Service NMS Neuroleptic malignant syndrome NICE National Institute for Health and Clinical Excellence OGTT Oral glucose tolerance test QTc Corrected QT interval RPG Random plasma glucose SPC Summary of Product characteristics TFTs Thyroid function tests U&Es Urea and electrolyte

1

1. Introduction People with mental illness have a higher risk of physical illness such as cardiovascular and respiratory disease or 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 medicines used to treat the mental illness. Many of these can cause weight gain and adversely affect lipid profiles. Many have other serious side effects affecting the major organs such as the liver and kidney. The aims of monitoring physical health and adverse effects of medication are to improve adherence and concordance leading to improved mental health, reduced side effect load and improved well-being. If actions are taken on abnormal results, there should be reduced morbidity and mortality by reducing risk factors for long-term health problems such as diabetes, cardiovascular and cerebrovascular disease. These guidelines contain the recommended physical health monitoring that is required for someone taking psychotropic medication They do not cover the general health monitoring that is required for people with mental health problems, monitoring of other side effects not associated with physical health or medication effectiveness. A sample checklist for this is however included as an appendix 4.4. Monitoring for specific medicines is included in the relevant Trust guidelines. These include clozapine, lithium and high dose antipsychotics. Suggested frequencies for monitoring within the schedules are taken from an occasional paper by the Royal College of Psychiatrists, The Maudsley guidelines and the Summary of Product Characteristics. The practicalities of the treatment setting (including equipment availability) and frequency of contact may also determine appropriate intervals for monitoring. The Royal College of Psychiatrists recommend as a good-practice guideline, weight and/or waist circumference, fasting or non-fasting glucose, lipids (including cholesterol, HDL and LDL cholesterol) and triglycerides should be monitored at: baseline, 10–16 weeks, 6 months, then annually for those commenced on antipsychotics. A baseline electrocardiogram is desirable. The current prescriber, in conjunction with the care co-ordinator, should ensure that the regular physical health checks required are being carried out and recorded. This should form part of the care plan. The care plan should include who is carrying out the monitoring and who will follow up to ensure the agreed monitoring has been carried out. The care plan should be shared with the service user and primary care where appropriate. Most practitioners agree that 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 (for instance in-patient or community) will determine the best arrangement for physical health monitoring after prescribing. Sample record forms are included as appendices. Cardiometabolic assessments should be recorded on RiO. If a test or examination is not undertaken the reasons for this should be documented. This may include if a test has recently been undertaken in another setting or the service user refuses. Abnormal or high risk results must be acted upon, screen and intervene (see Lester tool appendix 4.5).This may involve referral to GPs or specialists, provision of healthcare advice, adjusting or changing medication treatment

2

regimens or initiation of treatment. These schedules include recommendations for individual medicines and those checks required to monitor the physical well being of patients with severe or long-term mental illness. The schedule relates to adults. Children and adolescents or those over 65 years may require increased monitoring or frequency of monitoring.

3

Table 1.1 Antipsychotics (excluding clozapine)

Test or Measurement Baseline Initiation 10 to 16 weeks

6 months 12 months Ongoing Comments

Full blood count Annually

U&Es including Renal function (eGFR) and hyponatraemia

Annually Amisulpride and sulpiride are renally excreted and require dose reductions in renal impairment

Liver Function Olanzapine Olanzapine Annually

Thyroid function Annually Quetiapine may affect levels of thyroid hormones

ECG Ideally at least annually. Consider after dose changes, if cardiac risk factors present or clinically indicated

Mandatory requirements exist for pimozide and haloperidol

EPSE Typicals Annually

Prolactin (except aripiprazole, quetiapine and olanzapine)

(except aripiprazole, quetiapine and olanzapine)

Annually (except aripiprazole, quetiapine and olanzapine)

Blood pressure and Pulse Annually

Fasting plasma glucose or HbA1c

Olanzapine Olanzapine Annually

Lipid profile Olanzapine, quetiapine and phenothiazines

Annually Olanzapine and quetiapine also test at 9 months

Weight, + BMI Olanzapine Annually + BMI

Height

CPK If NMS suspected

4

Table 1.2 Clozapine

Test or Measurement Baseline Initiation 10 to 16 weeks

6 months 12 months Ongoing

Full blood count According to clozapine monitoring service schedule Monthly

U&Es including Renal function (eGFR) and hyponatraemia

Annually

Liver Function Annually

Thyroid function Annually

ECG After significant dose changes, if cardiac risk factors present or clinically indicated . Ideally at least annually.

EPSE Not generally required due to extremely low incidence.

Prolactin Not generally required due to extremely low incidence.

Blood pressure and Pulse

daily for two weeks then

weekly

monthly

See Trust guidelines – minimum 3 monthly

Fasting plasma glucose or HbA1c

at one month

Annually

Lipid profile Annually

Weight, including BMI Annually

EEG if history

of seizures

CPK If NMS suspected

Height

(These tests are usually co-ordinated and carried out by clozapine clinics).

5

Table 1.3 Mood stabilisers (carbamazepine, lithium, valproate)

Test or measurement Baseline Initiation 10 to 16 weeks

6 months 12 months Ongoing

Liver function tests Carbamazepine Annually for lithium Every six months for valproate and carbamazepine

Clotting Screen If LFTs are abnormal

Full blood count Valproate and carbamazepine (at two months)

Carbamazepine and valproate

Carbamazepine and valproate

Annually for lithium Every six months for valproate and carbamazepine

U&Es including Renal function (eGFR), sodium and calcium

Every 6 months for lithium and valproate

Thyroid function Lithium Annually for carbamazepine and valproate Every six months for lithium

Blood glucose (fasting if possible)

Annually

Lipids profile Annually for over 40s

Blood pressure Annually

Pulse Annually

Height

Weight, including BMI Annually

Serum levels Lithium -see lithium guidelines

Lithium- see lithium guidelines

Lithium- see lithium guidelines

Lithium- see lithium guidelines

Minimum 6 monthly for lithium, (Over age of 65 years or other risk factors 3 monthly)

ECG If clinically indicated for lithium Annually

Lamotrigine, baseline LTFs, U&Es and FBC no specific ongoing monitoring required except routine annual health check

6

Antidepressants

Baseline measurements of

Ongoing requirement

Renal function Thyroid function Hepatic function Plasma sodium levels Blood pressure and pulse Blood glucose Weight Height

Annual physical health check Consider 6 monthly U&Es to identify hyponatraemia in those at higher risk Consider 6 monthly blood pressure monitoring except venlafaxine where the SPC recommends monitoring after initiation, after dose changes and periodically. Liver function tests are required at prior to initiation of agomelatine or dose increase, then at three weeks, six weeks, twelve weeks and twenty-four weeks of treatment. Subsequently these should be performed only as clinically indicated.

Antidementia medicines Acetylcholinesterase inhibitors (Donepezil, galantamine and rivastigmine) Memantine No mandatory monitoring is required for these medicines. Based on side effects, cautions and contra-indications, the following may be appropriate Baseline ECG Liver function Urea and electrolytes including renal function Blood pressure and pulse Ongoing These may be repeated annually unless more frequent monitoring is clinically indicated. In addition, it is recommended that body weight be monitored for those on rivastigmine.

7

2. Monitoring of Physical Health - Background Information 2.1 Full blood count (FBC)

Most antipsychotics and mood stabilisers have been associated with varying incidences of haematological disorders such as neutropenia, leucopoenia and thrombocytopenia

FBC should be checked annually (as a minimum) for all those on antipsychotics and mood stabilisers

On starting carbamazepine FBC should be carried out as a baseline and then 2 months, then after 3 to 6 months. Valproate requires baseline and 6 monthly checks.

Caution: combination of olanzapine and valproate increases the risk of neutropenia

FBC is mandatory for Clozapine as per the SPC.

The Maudsley Prescribing Guidelines recommend the medication is discontinued if the neutrophil count falls below 1.5 x 109/l and refer for specialist medical care if the count falls below 0.5 x 109/l

2.2 Renal Function

Baseline urea, electrolytes and serum creatinine should be carried out for all patients

An annual level for urea, electrolytes and serum creatinine should be carried out for all patients but a minimum of 6 monthly checks are required for patients on antidepressants, lithium and valproate

Renal impairment can be mild, moderate or severe (see table below). In renal impairment avoid anti-cholinergic and nephrotoxic drugs, use renally cleared drugs cautiously and always start mood stabilisers at low dose and increase slowly.

Make dose adjustments or medication changes as appropriate when there are abnormalities and refer to GP for investigation.

Table 2.1 - Renal Function

Renal Function

Grade of impairment eGFR ml/min/1.73m2

Mild – Stage 2 60-89

Moderate - Stage 3 30-59

Severe - Stage 4 15-29

Established renal failure Less than 15

Renal function is reported locally as estimated GFR (eGFR) normalised to a body surface area of 1.73m2 .An individual’s absolute GFR can be calculated from the eGFR as follows: GFRabsolute = eGFR x (individual’s body surface area/1.73)

8

2.3 Liver Function Tests (LFTs)

All patients should have baseline LFTs performed and checked for abnormalities

The frequency of retesting varies from drug to drug but it is normally 3 to 6 monthly.

Transient rises may be seen with some antipsychotics eg olanzapine.

Investigate all abnormalities, making dose adjustments or medication changes as appropriate.

2.4 Thyroid Function Tests (TFTs)

Patients with compromised thyroid function should have baseline and 6 monthly TFTs so that significant changes can be identified and treated

It is important that the TFTs are checked before a service user starts lithium.

2.5 ECG

Many psychotropic drugs affect the QTc interval of the cardiac muscle: o Psychotropic Drugs with high effect (prolong QTc by >20ms)

Any intravenous antipsychotic Haloperidol Methadone Thioridazine Pimozide Sertindole Drug or combination of drugs used exceeding

recommended maximum dose

o Psychotropic Drugs with moderate effect (prolong QTc by >10ms)

Chlorpromazine Quetiapine Tricyclic antidepressants

o Non psychotropic drugs associated with QTc prolongation Anticholinergic drugs Antibiotics e.g. erythromycin, clarithromycin Antiemetic - domperidone Antimalarials e.g. chloroquine, mefloquine Antiarrhythmics e.g. sotalol, amiodarone Others include tamoxifen, cyclosporine, hydroxyzine

ECG changes associated with an increase in length of the cardiac QTc interval can lead to ventricular arrhythmias and even death.

Many physiological conditions necessitate close cardiac monitoring regardless of the drugs prescribed.

9

Drugs which have a moderate or high effect on the QTc interval (see table 2.2 below) must be very carefully monitored especially if given to patients with physiological risk factors

Risks are additive when combining medicines known to prolong the QTc interval.

Carry out ECG prior to starting treatment with: o Haloperidol o Lithium o Clozapine

Carry out an ECG if the dose is about or at the top of the maximum range for antipsychotics

Other risk factors which present a much greater risk to patient mortality than the uncertain outcome of QT changes are smoking, obesity and impaired glucose tolerance.

Other risk factors for QTc prolongation include, established cardiovascular disorder, hypokalaemia, hypomagnesaemia, hypocalcaemia, anorexia nervosa, age (children and older people), genetic predisposition, extreme physical excertion and shock

Table 2.2 - QTc Ranges

Interval Men

Women Action to be taken

QTc <440ms Normal limits

<470 ms Normal limits

QTc >440ms but <500ms

>470ms but <500ms

Consider reducing dose or switch to drug of lower effect, redo ECG (consider referral to cardiologist)

QTc >500ms >500ms Stop suspected drug immediately, repeat ECG, refer to cardiologist immediately and switch to drug of lower effect.

Abnormal T-Wave

Review treatment, consider switch to drug of lower effect, refer to cardiologist immediately

2.6 Extrapyramidal side-effects (EPSEs)

Many antipsychotics produce EPSEs

Consider use of the LUNSERS rating scale or Glasgow antipsychotic side-effect scale.

Baseline then at 3 months and 12 months and then annually. 2.7 Prolactin

Many antipsychotics can produce hyperprolactinaemia

10

Hyperprolactinaemia causes galactorrhoea, gynaecomastia, hypogonadism, sexual dysfunction and, in the long term, osteoporosis and possibly breast cancer

If prolactin is excessively raised, and the cause is unclear, stopping the antipsychotic for one to two days should bring about a reduction in the prolactin level, and so prevent unnecessary CT scans.

2.8 Hyponatraemia

All patients taking antidepressants should be observed for signs of hyponatraemia (dizziness, nausea, lethargy, confusion, cramps or seizures).

Patients at high risk of hyponatraemia on antidepressants should have their sodium monitored at baseline, at 2 and 4 weeks then 3 monthly.

High risk factors are being over 80 years old, history of hyponatraemia, co-prescription of other medicines known to cause hyponatraemia, reduced renal function and medical co-morbidity (eg hypothyroidism, diabetes etc.).

2.9 Blood Pressure and Pulse

High BP is an established risk factor for CVD

BP and pulse should be checked on admission to a ward, at first out-patient appointment and at the annual check if there are no other risk factors

Postural (orthostatic) hypotension can occur during initiation of clozapine, olanzapine, quetiapine, risperidone, aripiprazole, typical antipsychotics and depots. Clozapine (see appendix 4.3), quetiapine and risperidone must be titrated up from a low dose

The elderly are particularly at risk if prescribed phenothiazines which include chlorpromazine, thioridazine (now withdrawn from the UK), pipotiazine, fluphenazine and trifluoperazine.

Tachycardia may be a symptom of cardiomegaly (see also clozapine guidelines).

2.10 Investigations for Diabetes Mellitus

Many psychotropic drugs affect glucose metabolism. There is also an association between severe mental illness and impaired glucose metabolism.

Baseline monitoring o Ideally fasting plasma glucose (FPG) test and HbA1c should be

carried out for all patients on antipsychotics annually or within 5 days of admission to hospital.

Continued monitoring o FPG should be obtained at 3 and 6 months. If there are no changes

in fasting glucose, and the individual lacks any risk factors, ongoing monitoring can be 6 or 12 monthly

o For those with risk factors or on olanzapine or clozapine, FPG should be carried out monthly for the first 3 months, then 3 monthly thereafter for the first year. This can be reduced to 6 monthly in the second year.

11

o If the patient is uncooperative and it is not possible to do an FPG then a HbA1c or RPG may be used or even a urine glucose.

o At least two abnormal plasma glucose tests are required for the definitive diagnosis of diabetes in an asymptomatic individual.

Educate service users about the symptoms of diabetes: fatigue, thirst, polyuria, weight loss, blurred vision, general itching or frequent episodes of thrush.

The units of reporting of HbA1c have recently changed from a percentage value to mmol per mol of haemoglobin (mmol/mol).

Table 2.3 - Methods for testing for blood glucose

Methods for testing blood sugar glucose

Screening Test Description

RPG Taken randomly independent of food intake

FPG Take about 8 – 12 hours after food intake

Glycosylated Haemoglobin (HbA1c)

Measures the average blood glucose level over a 60 to 90 day period and does not show current values. It should only be used for screening in conjunction with a glucose test. Treatment targets are an HbA1c of 48 to 58 mmol/mol (equivalent to 6.5 to 7.5%).

OGTT

Take 2 hour samples after a 75g glucose load in a fasting patient

Confirmation of the diagnosis requires a LABORATORY plasma glucose measurement. Fingerprick samples should not be used to diagnose diabetes. Always check for ketones – the presence of significant ketonuria or ketonaemia indicates insulin deficiency and the need for more urgent intervention. Diabetes may be diagnosed using any of the following criteria (WHO 2006, John 2012)

Test Diabetes ‘Impaired’ or ‘Pre-diabetes’

Normal

HbA1c ≥ 48 mmol/mol 42-47 mmol/mol ≤ 41 mmol/mol

Fasting glucose ≥ 7.0 mmol/L 6.1-6.9 mmol/L ≤ 6.0 mmol/L

2-hr OGTT glucose

≥ 11.1 mmol/L 7.8-11.0 mmol/L ≤ 7.7 mmol/L

Random glucose ≥ 11.1 mmol/L

A repeat confirmatory test is necessary in most cases (see below)

Most cases can be confirmed with two fasting (preferably) or random glucose measurements OR an HbA1c. If glucose and HbA1c disagree, WHO advises diagnosing diabetes if either is high. An OGTT is very rarely necessary except in pregnancy (follow the NICE guidance). 2.11 Hyperlipidaemia

Hyperlipidaemia is an established risk factor for cardiovascular disease and has been associated with some antipsychotics.

A fasting full lipid panel with fractionation of cholesterol should be performed annually as part routine monitoring for all patients with severe mental illness and more frequently for those on some antipsychotics.

12

If dyslipidaemia is discovered discuss lifestyle changes, consider changing medicines and or treat with statins.

2.12 Weight and Body Mass Index Being overweight and especially abdominal obesity is a risk factor for cardiovascular and cerebrovascular disease. Excess weight has also been associated with hypertension, diabetes, osteoarthritis, pregnancy risks and infertility, gallstones and cancers. It can have a major effect on compliance with prescribed medicines. 3. References and recommended reading 1) The NHS Plan. Published by the Department of Health HMSO 2000

http://www.dh.gov.uk 2) NICE CG178: Psychosis and Schizophrenia. February 2014

http://www.nice.org.uk/ 3) NICE CG185:Bipolar disorder, assessment and management. September 2014

http://www.nice.org.uk/ 4) Running on Empty Report

http://www.sane.org.uk/public_html/News/pdfs/RoE_Report_FINAL.pdf 5) NICE CG181: Cardiovascular disease: risk assessment and reduction including

lipid modification. July 2014 http://www.nice.org.uk 6) Cohen A, et al. The Primary Care Guide to Managing Severe Mental Illness. The

Sainsbury Centre for Mental Health. http://www.scmh.org.uk

7) NICE Guidance PH38: Type 2 diabetes: prevention in people at high risk. July 2012

8) The Royal College of Psychiatrists consensus statement on the use of High dose

Antipsychotic medication. November 2014 http://www.rcpsych.ac.uk/ 9) David Taylor, et al. The Maudsley Prescribing Guidelines, 12th Edition. 2015

10) The Royal College of Psychiatrists Occasional Paper OP66. Physical health in

mental health. Jan 2009

11) www.medicines.org.uk

12) www.bnf.org

13

Appendix 4.1 Antipsychotic Monitoring Recording Template * Record if fasting or random # Note guidance for specific drugs

Test / Date

Recommendation Baseline Initiation 10 to 16 weeks 6 months 12 months

Due Completed Due Completed Due Completed Due Completed Due Completed Due Completed

U&E Baseline & yearly

eGFR Baseline & yearly

FBC Baseline & yearly #

TFT Baseline & yearly

LFT Baseline & yearly

Glucose* Baseline, 4-6/12 & yearly #

Lipids* Baseline, 3/12ly for 1 year & yearly #

Prolactin Baseline & if on high dose

BP

Baseline, after dose change & yearly #

Pulse Baseline & yearly

ECG Baseline & after dose change

Height Baseline

Weight and BMI

Baseline, 1/12, 2/12, 3/12 & yearly #

EPSE Baseline & at each assessment

Alcohol Baseline & at each assessment

Smoking Baseline & at each assessment

CPK Baseline

14

Appendix 4.2 Mood Stabilizer Monitoring RecordingTemplate

Test Recommendation Baseline initiation 10 to 16 weeks 6 months 12 months

Due Completed Due completed Due completed Due completed Due completed Due completed

LFT Baseline, 1/12, 2/12, 4/12, 6/12 and yearly

Clotting Screen

If LFTs abnormal

Serum level

If compliance questioned / check dosing

FBC Baseline (every 2/52 for 2/12), 6/12 and yearly

U&Es Baseline, then every 6/12

TFT Baseline, then yearly

Glucose Baseline, then yearly

Lipids Baseline, then yearly

BP Baseline, then yearly

Pulse Baseline, then yearly

Height Baseline

Weight and BMI

Baseline, 1/12, 2/12, 6/12 and yearly

Alcohol Baseline & at each assessment

Smoking Baseline & at each assessment

15

Appendix 4.3 (CLOZ 9) Clozapine Physical Health Assessment Checklist

Service User Consultant

Date of Birth RiO Number

CPMS/DMS/ZTAS Number Height

To be completed at each patient visit

Date

BP

Pulse

Temp

Weight

BMI

Smoker? (Y/N) If yes, how many a day?

Caffeine intake (T=tea, C=coffee, E= energy drinks and how many a day?)

Alcohol consumption? (how many units per week)

Any medication changes since last appointment? Please specify

Tests to be completed 3, 6 or 12 monthly as per clozapine policy or as otherwise instructed

Lipids

TFT

U & E’s

LFT

FBC

Prolactin

eGFR

Glucose & HB A1c

Serum Assay

Bowel Assessment

GASS

ECG

Other

16

Appendix4.4 Sample General Health Checklist (North Kirklees Treatment Team) Well-Being Assessment Date Assessment Completed: Update of previous assessment; Y/N RIO number: First name: Surname: D.O.B: Address: Postcode: Tel no: GP: Consultant Psychiatrist: Care Co-ordinator: Outcome of assessment/ referrals made/advice given; Assessment completed by:

17

Pre-existing Medical Conditions; Medication – Prescribed Dose/Route/Frequency Length of time taken Medication – over the counter Dose/Route/Frequency Length time taken Known allergies including drug allergies. Glasgow Antipsychotic Side-effect Scale; Assessment Score: List of most problematic side-effects: Physical Examinations: Test Result Normal Range Temperature 36-37.5 C Pulse rate per/min 60-100 Blood Pressure mmHg High BP = > 140/84 Random Blood Glucose 4-7mmol/L Weight kgs Height meters BMI Between 18-30 Waist circumference (cm) Risk: F>32” M>37” Prolactin level Are you incontinent by day or night? Do you have any problems with opening your bowels? Comments: Recent check-ups When did you last see a dentist? When did you last have an eye examination? Do they need a check up? Sexual health Document any sexual health concerns: Women: Cervical smear in last 3 years Yes/No Breast examination/mammography Yes/No (every 3 years 50-70yrs old) Men: Testicular self-examination Yes/No Lifestyle Risks:

18

Smoking Quantity/day (includes roll-ups, pipes) - Is there a desire to stop? (if any children are in the house advise on risks) Alcohol Do you consume alcohol? Do you feel your alcohol consumption is a problem? If YES is there a desire to stop? Illicit substances Do you use illicit drugs or other substances? Is there a desire to stop? Healthy Eating Describe a typical day’s diet How much caffeine do you drink? Exercise and Activity including sleep Do you do any structured activity? How much/how often? Do you want to be more active? (consider a referral) What’s your sleep pattern on a typical night? Social life/leisure activities/hobbies – What social support do you have? Do you have any caring responsibility? Any children in the house?

19

Appendix 4.5

20

21

Appendix D - Version Control Sheet

This sheet should provide a history of previous versions of the policy and changes made

Version Date Author Status Comment / changes

1 November

2008

2 November

2010

3 March

2012

4 February

2016

Kate Dewhirst,

Deputy Chief

Pharmacist

Minor changes to monitoring schedules.

Addition of monitoring requirements for

agomelatine, addition of baseline CK for all

antipsychotics, addition of Lester positive

cardiometabolic health resource.

Amendments in line with NICE guidance

relating to secondary and primary care

responsibilities. Updated further reading

5

6

7

8