2nd April 2009
NICE has updated its clinical guideline on the management of schizophrenia. With regard to choice of antipsychotic, NICE does not recommend use of any particular drug or group of drugs. NICE recommends that choice should be made between service user (and carer if appropriate) and healthcare professional after considering side-effect profiles. In this respect, the patient decision aid on the schizophrenia section of NPC may be helpful.
The quick reference guide should be read by all those involved in the care of people with mental health problems. Specialist staff will no doubt continue to base their management of people with schizophrenia on this national guideline, and be familiar with the contents of the whole guideline.
The guideline includes important recommendations for the management of schizophrenia. Key implementation priorities include:
- GPs and primary care healthcare professionals should monitor the physical health of people with schizophrenia at least once a year (people with schizophrenia are at higher risk of cardiovascular disease than the general population).
- Offer cognitive behavioural therapy to all people with schizophrenia, and offer family intervention to all families of people with schizophrenia who live with or are in close contact with the service user.
- Offer people with newly diagnosed schizophrenia oral antipsychotic medication. Provide information on the benefits and side-effect profiles. A joint decision should be made between the healthcare professional and the service user (and carer if the service user agrees).
- In choosing an antipsychotic, consider the relative potential of the individual antipsychotic drugs to cause extrapyramidal side effects (including akathisia), metabolic side effects (including weight gain) and other side effects (including unpleasant subjective experiences).
- Do not prescribe regular combined antipsychotics except for short periods (e.g. when changing medication).
- For people who do not respond adequately to pharmacological or psychological treatment:
- review diagnosis
- consider non-adherence to medication regimen, prescribed at an adequate dose for correct duration
- review engagement with and use of psychological treatments, consider family intervention or CBT if not already undertaken
- consider other reasons, such as comorbid substance misuse
- Offer clozapine to people with schizophrenia whose illness has not responded adequately to treatment despite sequential use of adequate doses of at least two antipsychotic drugs, at least one of which is a non-clozapine second-generation antipsychotic.
Other recommendations for drug treatment include:
- Offer people an electrocardiogram if specified in the SPC, or a physical examination has identified specific cardiovascular risk (such as high blood pressure), or there is a personal history of cardiovascular disease, or the service user is being admitted as an inpatient.
- Treatment with antipsychotics should be considered as an explicit individual therapeutic trial, which includes four- to six-week treatment at optimal dosage; the guideline details the monitoring required and the records that need to be kept. “As required” prescriptions of antipsychotics can be used in certain circumstances.
- Discuss use of alcohol and tobacco, prescribed/non-prescribed treatments, and complementary therapies that the service user may wish to use, taking into account safety, efficacy and interference with prescribed treatments.
- Do not use a loading dose of antipsychotic medications.
- If prescribing chlorpromazine, warn of the potential to cause skin photosensitivity and advise using sunscreens if necessary.
- Consider offering depot/long-acting injectable antipsychotics for people who prefer such treatment after an acute episode, or to avoid covert non-adherence to antipsychotic medication.
Reasons behind NICE recommendations for antipsychotic choice
The NICE full guideline should be referred to for more details on the clinical trial and health economic evidence review that was undertaken in the preparation of the guideline.
In the previous NICE guideline on schizophrenia (2002), second-generation (atypical) antipsychotics were recommended as first-line treatment in some situations, primarily because they were thought to carry a lower potential for extrapyramidal side effects. However, systematic reviews of the evidence from clinical trials and new evidence from pragmatic effectiveness trials (CATIE and CuTLASS) suggest that choosing the most appropriate antipsychotic for an individual may be more important than the drug group. (Also see our rapid review on a recent meta-analysis of RCTs).
Considering the lack of evidence to distinguish antipsychotics on efficacy grounds, and the uncertainty of health economic evidence, NICE were unable to make a recommendation for a preference of one antipsychotic over another. The exception is clozapine, for which there was robust evidence supporting the recommendations for its use in people who do not respond adequately to other antipsychotics.
Although there was evidence on relative side effect profiles of antipsychotics from 138 evaluations, most trials were of short duration, and were not designed to prospectively examine side effects. The trials were considered to offer little insight into the longer-term adverse effects of treatment or whether or not there are any significant differences between antipsychotic drugs. Although recognising that the metabolic and neurologic side effects are not inconsistent with the SPCs for each drug, the guideline provides no information on side-effect profiles of individual antipsychotics to assist in deciding the most appropriate drug for an individual in this respect.
Further information on the management of schizophrenia can be found on the schizophrenia section of NPC. On this floor there is a patient decision aid, which includes a chart comparing the side effect profiles of individual antipsychotics, which may be helpful when considering choice of antipsychotics for an individual patient in accordance with the NICE guideline.