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The Royal College of Psychiatrists Improving the lives of people with mental illness

CR138. Consensus statement on high-dose antipsychotic medication

Price: £7.50

Approved: Oct 2005

Published: May 2006

Status: under review

Number of pages: 52

Review by: 2008

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This report replaces Consensus statement on the use of high-dose antipsychotic medication (CR26 from 1993) and The association between antipsychotic drugs and sudden death (CR57 from 1997).
This revised statement reflects the consensus opinion of the members of the Working Group. It addresses the use of high-dose antipsychotic medication only in adult mental health services, and not other psychiatric services such as child and adolescent, elderly, and learning difficulties. Recommendations are made in respect of clinical practice for those involved professionally, as part of a multidisciplinary team or individually, with people receiving antipsychotic medications. Guidance on implementing these recommendations is provided. The issue of compatibility between the proposed recommendations and current relevant treatment guidelines, including the National Institute for Clinical Excellence (NICE) Schizophrenia Guideline (National Institute for Clinical Excellence, 2002) are discussed.
Recent prevalence studies reveal that up to a quarter of psychiatric in-patients are prescribed a high dose of antipsychotic medication, with the highest prevalence figures being found in psychiatric intensive care units, rehabilitation wards and forensic units. There are only limited data on the frequency of prescription of high-dose antipsychotics in psychiatric patients receiving care in the community.
The results of the published trials of high-dose antipsychotic medication for treatment-resistant schizophrenia provide no evidence to support such a strategy. On the basis of current evidence, high-dose prescribing, either with a single agent or combined antipsychotics, should rarely be used and then only for a time-limited trial in treatment-resistant schizophrenia after all evidence-based approaches have been shown to be unsuccessful or inappropriate.
Antipsychotic drugs are commonly prescribed in combination for those with a psychotic illness who have shown a lack of a satisfactory response to a single antipsychotic. While the limited research conducted fails to demonstrate convincing benefits for such a strategy, there is evidence that combined antipsychotics are associated with an increased risk of adverse effects and pharmacokinetic interactions. However, there is some support for the addition of a second antipsychotic to clozapine in people with treatmentresistant schizophrenia for whom clozapine alone has proved insufficiently effective.
High-doses of antipsychotic medication are sometimes used for rapid tranquillisation, persistent aggression and to reduce the risk of relapse. However, there is a paucity of research evidence specifically examining the efficacy and safety of high doses for rapid tranquillisation. There is no convincing evidence base for the use of high-dose antipsychotic medication in the management of persistent aggression associated with psychosis, or for relapse prevention in psychosis. Relapse prevention studies have tended not to study high-dosage regimens, but rather have examined standard-dose regimens, and low-dose and intermittent, targeted treatment strategies.
A possible link has been postulated between antipsychotic drugs and ventricular tachycardia and sudden death but no consensus has been achieved on the frequency of these events, the contribution of high dosage, or even whether a true causal association exists. To reduce the risk of arrhythmia, all patients should be assessed (including electrocardiography) for cardiovascular disease prior to the institution of antipsychotic drug therapy. Periodic monitoring of the electrocardiogram (ECG), and electrolytes during therapy is advocated when high-dose antipsychotic drug treatment is used.
The Consensus Working Group makes 22 recommendations, including some under the areas of aggression with psychosis and that of rapid tranquillisation and treatment-resistant psychosis.
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