Antipsychotic Long-Acting Injection (Depot) Choice Pathway
Stage 1
•
•
Diagnosis of psychotic condition requiring treatment with antipsychotic medicine
Antipsychotic choice made collaboratively between prescriber and patient (and relative/carer if the
patient agrees). Where the patient lacks capacity to make decisions about treatment with
medicines refer to the Mental Capacity Act 2005 Policy.
•
•
•
Consider: nature/presentation of the condition, licensed indication of the medicine and local
approval/guidelines, contra-indications, likely side-effects, concomitant medicines, medical history,
family medical history/risks, lifestyle factors.
Discussion, patient views and treatment decisions must be documented.
Side-effect profile differs with each antipsychotic medicine and dose used. Refer to a pharmacist for
advice; comparison charts are available at
the Choice and Medication Website:
www.choiceandmedication.org.uk/worcestershire
Stage 2
Antipsychotic depot/long-acting injection (LAI) required to improve adherence to therapy due to
covert non-adherence or lifestyle factors
Stage 3
Antipsychotic Depot/LAI Selection:
Maintain antipsychotic drug choice where possible. Not all antipsychotics available as depot/LAI or oral
Clinical response to and tolerates oral antipsychotic:
Clozapine
Olanzapine
Clozapine
not available
as depot/LAI
Olanzapine LAI
not approved
Risperidone
Aripiprazole
Other antipsychotic not
named at Stage 3
Aripiprazole LAI
Seek guidance on
options
Seek guidance on
options
NO
Swift onset required (<4 weeks)
due to acutely psychotic
presentation and poor adherence
with oral therapy
Risperidone LAI
YES
•
•
Dose is above BNF Max: >50mg
2/52
Patient is experiencing problems
with regimen that negatively
affect treatment or are likely to
lead to disengagement
Known/predicted response
to typical antipsychotics
contraindicate their use
NO
YES
Typical/first
generation
antipsychotic depot
Seek guidance on options
where a switch is required
Paliperidone LAI
Author:
Responsible Committee:
Andrew J Down
Date Ratified:
Medicines Management and Safety Sub-Committee
24 June 2014
Antipsychotic Long-Acting Injection (Depot) Choice Pathway
It is desirable to maintain the same drug when switching from oral to depot, eg zuclopethixol tablet to
zuclopethixol decanoate depot. This is for three key reasons:
1. Known effectiveness of the drug. If a drug has been effective for a patient in oral form, but they
require a depot/long acting injection (LAI), then it makes good sense to continue with the same
drug. Equally, if a drug is not effective there is no point in attempting to treat using the same
drug but in a different formulation and whilst an ineffective drug given orally will take days to
clear from the body a depot will take weeks.
2. Known tolerance to the drug. Most adverse reactions and allergies to medicines are due to the
active drug rather than any other ingredients. The recommended initiation regimens of many
depots include a ‘test dose’ – small dose of the depot, the response to which is assessed prior to
administration of any larger treatment doses, but this is not possible for some products and
tolerance must be ensured with oral therapy. An oral dose will take days to clear from the body
rather than a depot, which will take weeks; so, it is preferable to ensure that a drug can be
tolerated through oral therapy before attempting depot/LAI formulations.
3. Smoother switch over. Switching from oral therapy to depot/LAI will cause disruption to
treatment and to the patient; if the same drug can be maintained there will be fewer changes, eg
the side-effect profile will remain broadly similar etc.
Not all oral antipsychotics are available as depot/LAI. The following antipsychotics are NOT available as
depot/LAI:
• Amisulpride
• Benperidol
• Chlorpromazine
• Clozapine
• Levomepromazine
• Pericyazine
• Perphenazine
• Pimozide
• Prochlorperazine
• Promazine
• Quetiapine
• Sulpiride
• Trifluoperazine
• Olanzapine pamoate LAI (ZypAdhera®) is not approved for use in Worcestershire.
• Pipotiazine is not available in oral formulation. The recommended initiation regimen includes a ‘test dose’.
• Paliperidone oral formulation is not approved for use in Worcestershire. Paliperidone is a metabolite of
risperidone, so therapeutic response to and tolerance of paliperidone can be inferred from treatment with
risperidone: if risperidone is not effective then paliperidone will not be effective.
• Clozapine is not available as depot/LAI – maintain on oral therapy; consider switch or augmentation – see
Clozapine Guidelines.
• Paliperidone LAI (Xeplion®) and aripiprazole LAI (Abilify Maintena®) are only licensed for maintenance
treatment of schizophrenia – not licensed for the management of other psychotic conditions
• Zuclopenthixol acetate (Clopixol Acuphase®) is not a depot antipsychotic and must not be used to regular
treatment. The appropriate zuclopenthixol depot is zuclopenthixol decanoate. The different drug salts
persist in the body for very different amounts of time and have different licensed indications.
Where there is no clear switch from an oral formulation to a depot/LAI formulation of an individual
antipsychotic, seek guidance from WHCT Department of Pharmacy and Medicines Management.
If treatment with the chosen depot/LAI fails and an alternative depot/LAI is required it is preferable to return
to Stage 1, to select a new option on the basis of treatment aims and requirements and patient views, and
test response/tolerance to oral drug, rather than switching direct to a new depot/LAI. If this is not possible
contact WHCT Department of Pharmacy and Medicines Management for advice on switching options.