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GUIDELINES REFERENCE NUMBER
SABP/Executive Board/0017/Guidelines 01
GUIDELINE NAME
High Dose Antipsychotic Treatment (HDAT)
BRIEF OUTLINE OF THIS GUIDELINE
This guideline aims to improve the safety of people using our services who are
treated with High Dose Antipsychotic Treatment (HDAT). This will involve outlining
responsibilities for professional staff for physical health monitoring,
acknowledgement and records of HDAT treatment and review of medication.
Version Number 5.0
Approving Committee Executive Board
Policy Category Clinical
Executive Lead Chief Pharmacist
Name of Author Deputy Chief Pharmacist
Date Approved 25th January 2019
Date Issued 18th February 2021
Review Date 25th July 2022
Target Audience All registered clinical staff
KEY PRINCIPLES ABOUT THIS POLICY
1. Prescribing High Dose Antipsychotic Treatment (HDAT).
2. Monitoring High Dose Antipsychotic Treatment (HDAT).
3. Reviewing High Dose Antipsychotic Treatment (HDAT).
This policy has been reviewed and is compliant with the most up to date
Code of Practice and NICE Guidelines
Title of Code of Practice NICE Reference Number(s)
Royal College of
Psychiatrists
Consensus statement on
high-dose antipsychotic
medication
CR190
Page 2 of 20
VERSION CONTROL LIST
Version Date Author Status Comment
1.0 October
2009
Fiona
Lockwood Live
1.1 July 2011 Simon
Whitfield Draft
Procedure formal review
date to expire in
November 11. Version 1.1
sent out for consultation.
1.2 29/09/11 Simon
Whitfield
Draft for
October
PAG
2.1 November
2015
Fiona
Lockwood Draft
3.0 January
2016
Fiona
Lockwood Approved
3.1 June 2017 Deborah
Meah Draft
3.2 January
2018 Kate Organ Draft
Appendix 3
Appendix 4
3.3 November
2018 Kate Organ Draft
Reformat into new Trust
format
4.0 January
2019 Kate Organ Approved
5.0 February
2021 Kate Organ Approved
Covid Review extension
agreed
Page 3 of 20
Summary of Changes since Version 3.0
Numbers
(Select the appropriate action)
Page Paragraph Appendix
Original/New/Amendment/Deleted –
Statement
(select the appropriate action)
1.2 A high dose of antipsychotic is defined as a total
daily dose (whether of a single antipsychotic or
more than one prescribed combination) greater
than 100% of the maximum recommended daily
dose as stated in SPC or BNF (Royal College of
Psychiatrists 2014).
Use of “Discretionary” (PRN or “as required”)
antipsychotic medication should also be taken
into account if given on a regular /semi-regular
basis. Please refer to Rapid Tranquilisation
Policy and Procedure (SABP/RISK/0019) if a
stat dose is given which causes the total dose
for that day to exceed BNF maximum.
To calculate the total antipsychotic percentage
dose for an individual, use the Antipsychotic
Dosage Ready Reckoner table to determine the
percentage of the BNF maximum for each
antipsychotic that is prescribed and then the
sum of percentages.
New
1.3 The use of high dose antipsychotics should be
an exceptional clinical practice
New
3.0 GUIDELINE
New
Page 4 of 20
4.0 Monitoring requirements
New
5.0 REFERENCES
New
8 6 Home Treatment Teams and Community
Services
To ensure the policy is implemented, complied
and reviewed within their areas of responsibility.
New
10 9.1 Amendment
Every effort to obtain valid informed consent
should be used to inform the person of the
reason for use of HDAT and the potential side
effects. For people unable to provide informed
consent, and for whom it is clinically appropriate
to treat with HDAT the reason to proceed with
treatment, and the process of reaching that
decision, specifying the legal framework used,
should be documented and recorded in the
Electronic Patient Record (EPR). The risks and
benefits of treatment, and monitoring
requirements must be documented in the EPR.
10 9.1.1 Addition – reference to CTO 11 and CTO 12
2 New
3 New
4 New
Page 5 of 20
Contents Page
Section Page
POLICY SECTION
Version Control List 2
Summary of Changes 3
1.0 Policy Purpose 6
2.0 Policy Statement 6
3.0 Related Policies 7
4.0 Glossary of Terms 7
5.0 References 7
PROCEDURE SECTION
6.0 Roles and Responsibilities 9
7.0 Procedure Flow Chart 10
8.0 Procedure Statement 11
9.0 Procedure 11
9.1 Consultant Psychiatrist Role and Responsibilities 11
9.2 Nursing Staff Roles and Responsibilities 14
9.3 Pharmacist Role and Responsibilities 14
10.0 Monitoring 15
11.0 Equality Analysis 15
12.0 Appendices 15
Appendix 1 Royal College of Psychiatrists CR190. Consensus
statement on high-dose antipsychotic medication 15
Appendix 2 POMH-UK Antipsychotic Dosage Ready Reckoner 16
Appendix 3 High Dose Antipsychotic Treatment (HDAT)
Prescribing Form 18
Appendix 4 High Dose Antipsychotic Therapy (HDAT) Monitoring
Form for Initiation 19
Page 6 of 20
POLICY SECTION
1.0 Purpose
This policy aims to outline the key responsibilities for the safe use of high dose
antipsychotic treatment (HDAT) within SABP.
2.0 Policy Statement
In November 2014, the Royal College of Psychiatrists issued a revised
‘Consensus statement on high dose antipsychotic medication’ (Appendix 1).
This document contains important recommendations in relation to the decision
to treat individuals with antipsychotic medication in excess of BNF
recommended dosages. This guideline advises on the implementation of these
recommendations in SABP.
A high dose of antipsychotic is defined as a total daily dose (whether of a
single antipsychotic or more than one prescribed in combination) greater than
100% of the maximum recommended daily dose as stated in SPC or BNF
(Royal College of Psychiatrists 2014).
Use of “Discretionary” (PRN or “as required”) antipsychotic medication should
also be taken into account if given on a regular /semi-regular basis. Please
refer to Rapid Tranquilisation Policy and Procedure (SABP/RISK/0019) if a stat
dose is given which causes the total dose for that day to exceed BNF
maximum.
To calculate the total antipsychotic percentage dose for an individual, use the
POMH-UK Antipsychotic Dosage Ready Reckoner table (appendix 2) to
determine the percentage of the BNF maximum for each antipsychotic that is
prescribed and then the sum of percentages.
The use of high dose antipsychotics (HDAT) should be an exceptional clinical
practice.
Page 7 of 20
If HDAT treatment has been initiated for, the purposes of rapid tranquilisation
please refer to the separate policy and follow its recommendations including
the physical health monitoring during the acute period.
3.0 Related SABP Policies
• The Medicines Policy
• Rapid Tranquilisation Policy
• Physical Healthcare Policy
• Unlicensed Medicines
4.0 Glossary of Terms
BNF British National Formulary
CTO11/CTO12 Forms relating to Community Treatment Orders
ECG Electrocardiogram
EPR Electronic Patient Record
GASS Glasgow Antipsychotic Side-effect Scale
GP General Practitioner
HDAT High Dose Antipsychotic Treatment
MEWS Modified Early Warning Score
MDT Multidisciplinary team
MHA Mental Health Act 1983
MI Myocardial Infarction
POMH-UK Prescribing Observatory for Mental Health
PRN When necessary
SABP Surrey & Borders Partnership NHS Foundation Trust
SPC Summary of Product Characteristics
T2/T3/S62 Statutory MHA consent to treatment forms
5.0 References
• Adapted from Southern Health Guidelines for the use of High Dose
Antipsychotics (HDAT) SHCP134 Version 3 January 2017
• Maudsley Guidelines 12th Edition 2015
• Consensus Statement – high-dose antipsychotic medication, CP190, Nov 2014
Page 8 of 20
• QT Interval and drug therapy, DTB 2016 54:33-36
• Rapid Tranquilisation Policy and Procedure (SABP/RISK/0019)
Page 9 of 20
PROCEDURE SECTION
6.0 Roles and Responsibilities
• The overarching policy for this procedure is the Medicines Policy. To view the
Executive roles and responsibilities please refer to this policy under section 6
on page13.
• Chief Pharmacist
Has responsibility to ensure the policy is regularly reviewed and
communicated to all staff
• Directors
To ensure the policy is implemented within their directorate.
• Professional Roles: to implement and comply with the responsibilities
detailed in the procedure
o Consultant Psychiatrists
o Nurses
o Pharmacists
• Ward Managers and Matrons
To ensure the policy is implemented, complied and reviewed within their
areas of responsibility.
• Home Treatment Teams and Community Services
To ensure the policy is implemented, complied and reviewed within their
areas of responsibility.
• Staff
To follow the relevant procedures outlined within the policy
Page 10 of 20
7.0 Procedure Flow Chart
Consultant Psychiatrist
• Initiates HDAT and signs form, attach to chart
• Record risks vs benefits in EPR
• Complete & record baseline monitoring
• Consent to treatment check
• Complete ongoing physical health monitoring
• Regularly review HDAT prescribing
• Review side effects and physical health of patient regularly
• Patient is informed and provided with information and
opportunity for shared decision making
Nursing Staff • Ensure HDAT is reviewed regularly
• Prompt medical staff to complete physical health monitoring
• Record observations on MEWS chart
• Ensure consent to treatment is valid
• Review side effects and physical health of patient regularly
Pharmacists • Ensure HDAT is reviewed regularly
• Prompt medical staff to complete physical health monitoring
• Ensure consent to treatment is valid
• Identify patients on HDAT
• Annotate prescription charts with HDAT stickers and % BNF
doses
Page 11 of 20
8.0 Procedure Statement
This procedure outlines the key responsibilities for clinical staffing,
monitoring and records to be made for the safe use of HDAT within SABP.
9.0 Procedure/Process
9.1 Consultant Psychiatrist Roles and Responsibilities
9.1.1 Before Starting HDAT
• Complete a medication review of current treatment to ensure sufficient
time has been allowed for response and at least two different
antipsychotics have been tried, within BNF dosing.
• Review the person using our services’ likely compliance
• Consider alternative approaches including adjuvant therapy, first and
second generation antipsychotics including clozapine have been
considered.
• The responsibility to exceed the BNF maximum doses with either a single
antipsychotic or a combination of more than one lies with the person’s
consultant psychiatrist. The decision should be discussed with the
multidisciplinary team and the individual and their carer, where possible.
• Every effort to obtain valid informed consent should be used to inform the
person of the reason for use of HDAT and the potential side effects. For
people unable to provide informed consent, and for whom it is clinically
appropriate to treat with HDAT the reason to proceed with treatment, and
the process of reaching that decision, specifying the legal framework
used, should be documented and recorded in the Electronic Patient
Record (EPR). The risks and benefits of treatment, and monitoring
requirements must be documented in the EPR.
• Check HDAT is on MHA form T2, form T3, form CTO11, form CTO12, or
form S62, if applicable.
Page 12 of 20
9.1.2 Initiation of High-Dose Antipsychotic Treatment (HDAT)
• Complete HDAT form (appendix 3)
• Records need to be made in the person’s clinical notes at initiation of
treatment and at regular treatment reviews, e.g. MDT review. These are
to include risk vs benefit analysis of person having HDAT treatment.
• Indicate in the clinical/medical notes the person’s target symptoms.
• Consider any contra-indications or risk factors such as cardiac
history(particularly MI, arrhythmias and abnormal ECG), hepatic/renal
impairment, epilepsy, diabetes, substance misuse, harmful use of
alcohol, smoking, adults over 65 years, dehydration, being overweight
and diarrhoea and vomiting.
• Consider and minimise potential drug interactions, specifically
concomitant treatment: with other drugs: diuretics, anti-arrhythmics, anti-
hypertensives, tricyclic antidepressants and drugs which may prolong QT
interval, cause electrolyte disturbances or increase antipsychotic blood
levels. Consider recent use of IM medications.
• Where possible increase the dose slowly, ideally over intervals of at least
one week.
• Allow adequate time for response between each dose increase.
Page 13 of 20
9.1.3 Monitoring Requirements
• Complete and assess risk factors.
• Complete physical health monitoring, as stated in table below, and
document on HDAT monitoring form (appendix 4)
• If HDAT is for rapid tranquilisation/ treatment of acute violence and
aggression, follow the separate policy recommendations
Baseline, before
initiation of HDAT
U&Es, FBC, LFTs, prolactin
Blood lipids (cholesterol, triglycerides) – fasting sample
Plasma glucose - fasting sample or HbA1c
ECG, BP, pulse, extra-pyramidal side-effects (EPSE)
Weight, waist circumference and BMI
Weekly for 6 weeks
ECG, BP, Pulse, EPSE, hydration status
Weight, waist circumference and BMI
At 6 weeks
ECG, BP, EPSE
Weight, waist circumference and BMI
Side effect scales e.g. GASS
At 3 months
ECG, BP , Pulse, U&Es, FBC, LFTs, prolactin
Side effect scales e.g. GASS
EPSE
Blood lipids (cholesterol, triglycerides) – fasting sample
Plasma glucose - fasting sample or HbA1c
Weight, waist circumference and BMI
6 monthly
U&Es, FBC, LFTs,
Prolactin (not required for aripiprazole, clozapine, olanzapine
<20mg/day, quetiapine, but worth measuring if symptoms arise)
Blood lipids (cholesterol, triglycerides) – fasting sample
Plasma glucose - fasting sample or HbA1c
ECG, BP, Pulse, EPSE
Weight, waist circumference and BMI
Page 14 of 20
9.1.4 Regular Review of HDAT Prescribing
• Review progress, target symptoms and side effects, at least once every 3
months. Continued use of HDAT where there is no clinical response,
should be justified in case notes. Consultants should consider seeking a
second opinion from a colleague. The review should be documented in
the patient’s notes. Recommended rating scales include the BPRS (Brief
Psychiatric Rating Scale) to assess target symptoms and GASS/GASS-C
for side effect review.
• If there are any abnormalities in the test results review treatment and
refer, where necessary.
• Where patients are discharged on HDAT the GP should be contacted and
monitoring agreed.
9.2 Nursing Staff Roles and Responsibilities
• Check for clinical signs of dehydration.
• Record monitoring on MEWS
• Document “High dose” status in progress notes.
• Assist completing the recommended physical health monitoring outlined
above
• Check the monitoring sheet is being completed and bring it to the
attention of medical staff if checks have not been completed.
• Ensure the high-dose status is discussed and recorded at review.
• Ensure that consent to treatment includes the use of HDAT, if applicable
9.3 Pharmacist Role and Responsibilities
• Identify that a patient is on high-dose antipsychotics.
• Complete HDAT form including: high-dose details and total % of BNF
maximum dose, Interacting medications
• Attach “High Dose” label to prescription card and complete total % of BNF
dose
• Endorse each antipsychotic with % of BNF maximum dose
• Check HDAT is included on consent to treatment documentation
T2/T3/CTO11/CTO12/Section 62
Page 15 of 20
10.0 MONITORING TABLE
The monitoring table for this procedure can be located in the Medicines
Policy which is the overarching policy for this document.
11.0 EQUALITY ANALYSIS
The equality analysis for this procedure can be located in the Medicines
Policy which is the overarching policy for this document
12.0 APPENDICES
Appendix One:
Royal College of Psychiatrists CR190. Consensus statement on high-dose
antipsychotic medication
Available from:
http://www.rcpsych.ac.uk/usefulresources/publications/collegereports/cr/cr19
0.aspx
Appendix Two:
POMH-UK Antipsychotic Dosage Ready Reckoner:
Page 17 of 20
http://nww.sabp.nhs.uk/services/pharmacyservices/audit/pomhuk/generalinfo/readyreckoner/view
Appendix Three
HIGH DOSE ANTIPSYCHOTIC TREATMENT (HDAT) PRESCRIBING FORM
• This form is to be completed by the person who uses services consultant psychiatrist
• Patients need to be made aware of the HDAT and associated risks
• Follow SABP HDAT Guidelines
• SABP HDAT Monitoring Form to be attached to the drug chart and completed
according to the guidelines
• Review at every opportunity the need for HDAT
• A copy of this form to be uploaded to the EPR and attached to the drug chart
CONSULTANT TO COMPLETE
Patient Name
NHS Number
Ward or Team
Rationale for HDAT, including consideration for clozapine
Total BNF dose of regular antipsychotics prescribed (oral and depot)
Total BNF dose of all antipsychotic’s including PRN
Specify drug(s) and dose(s)
Expected duration of treatment
Next review of HDAT prescribing
Date of HDAT monitoring form initiated
Information and consent gained by patient or SOAD
• I am aware of the additional risks associated with High Dose Antipsychotic Treatment
• I take responsibility for the additional physical health monitoring requirements in
accordance with Trust guidelines
• I am aware of the unlicensed use of a single medication above BNF maximum doses
• I have informed the person receiving HDAT of its use, including and risks and benefits
Name of Consultant GMC Number Signature Date
Appendix 4: High Dose Antipsychotic Therapy (HDAT) Monitoring Form for Initiation (record result values in progress notes)
Patient Name Consultant MHA consent? Rationale
NHS Number Ward Patient consent?
Co-Morbid Condition (please circle)
• Cardiovascular, hepatic/renal impairment, epilepsy, diabetes
• Substance/alcohol misuse, high-dose methadone
• Overweight, smoking status
What additional actions need to be taken?
High Dose Antipsychotic Therapy (HDAT) Monitoring Date Dose details
Specify % Drug(s) & dose(s)
Monitoring Baseline Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 At 3 mths At 6mths 6 mthly
ECG (date and QTc msec)
BP (√ & date if OK)
Pulse (√ & date if OK)
Weight
BMI
Waist circumference
EPSE (√ & date if assessed)
GASS (√ & date completed)
U&E’s (√ & date if OK)
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Monitoring Baseline Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 At 3 mths At 6mths 6 mthly
FBC (√ & date if OK)
LFTs (√ & date if OK)
Prolactin (date and value)
Fasting Lipids (√ & date if OK)
Fasting glucose or HbA1c (√ & date if OK)