M235 Order Set DRAFT 6.3 for APPLY...***Diagnosis based on criteria from the Diagnostic and...

Initiation of Treatment for Early Phase Psychotic Disorders Order Set ACTION

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Submitted by: Read Back ID PRINTED NAME YYYY-MM-DD HH:MM

Practitioner: ID PRINTED NAME YYYY-MM-DD HH:MM SIGNATURE

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Document allergies on approved form and ensure medication

reconciliation has been reviewed as per organizational process

PATIENT INFORMATION

Administration

Document Purpose This order set may be used for both inpatient and outpatient care settings.

This order set is intended for patients who have had less than 3 adequate trials of antipsychotic medication.

An 'adequate trial of antipsychotic medication' for the purpose of this document considers adequacy in terms of dose (1),

duration (1) and adherence (2).

• Duration: oral antipsychotic medication trial for at least 6 weeks, or long acting injectable (LAI) antipsychotic for at least 4

injection cycles

• Estimated adherence: at least 75% of the time

Working Diagnosis ***Diagnosis based on criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)*** (3)

Select one:

Schizophrenia

Schizoaffective Disorder

Schizophreniform Disorder

Brief Psychotic Disorder

Delusional Disorder

Other (specify):

Diagnosis Specifier(s)

Comorbid Diagnoses

Employment Status Select all that apply:

Unemployed

Part-time employment Part-time student

Full-time employment Full-time student

Volunteering

Other (specify):

Education (highest level completed) Select one:

Less than high school

High school

College/vocational degree or diploma

Bachelor's degree

Master's degree

Doctoral degree

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PATIENT INFORMATION

Administration Continued…

Current Living Arrangement Select all that apply:

Living alone

Living independently With spouse With partner With family Other (specify):

Living in supported care - with (specify):

No fixed address

Treatment Capacity Assessment Capable

Further treatment capacity assessment required

Incapable

Further treatment capacity assessment required

Assessment Tools

Functioning Assessment Tools Clinical Global Impression-Severity (CGI-S) Scale:

Considering your total clinical experience with this particular population, how mentally ill is the patient at this time?

Select one:

1 = Normal

2 = Borderline mentally ill

3 = Mildly ill

4 = Moderately ill

5 = Markedly ill

6 = Severely ill

7 = Among the most extremely ill patients

Symptoms of Psychosis Assessment Tools Brief Psychiatric Rating Scale (BPRS) available at: http://www.psychiatrictimes.com/clinical-scales-

schizophrenia/clinical-scales-schizophrenia/bprs-brief-psychiatric-rating-scale

Positive and Negative Syndrome Scale (PANSS)

Movement Disorder Assessment Tools Abnormal Involuntary Movement Scale (AIMS) available at: http://www.psychiatrictimes.com/clinical-scales-movement-

disorders/clinical-scales-movement-disorders/aims-abnormal-involuntary-movement-scale

Tools for Monitoring Antipsychotic Side Effects (TMAS)

available at: http://epicanada.org/project/tool-for-monitoring-antipsychotic-side-effects/

Extrapyramidal Symptom Rating Scale (ESRS)

Other

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PATIENT INFORMATION

Vitals/Monitoring Weigh patient, measure height: Weight: (4) kg, Height: m BMI: (4) kg/m2

Waist circumference: (4) cm

T (5), HR (5), RR (5), BP (4) as per policy/procedure

Lab Investigations (if not previously obtained) Hematology

CBC (5)

Chemistry

Electrolytes (Na+, K+, Cl-, HCO3-) (5) Creatinine (5) ALT (5) Prolactin (2)

Urine β HCG Urine drug screen (5)

Additional Lab Investigations

Fasting glucose (4) A1C (4) HDL, LDL, Total Cholesterol, Triglycerides (2)

Prolactin

Diagnostics ECG (2) Reason:

MRI Reason:

CT Reason:

Reason:

Allergies and Medication Review Allergies (list allergen and reaction):

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PATIENT INFORMATION

Management of Psychosis ***It is recommended that preference be given to atypical antipsychotics in the treatment of early psychosis patients** (7)

**It is recommended that LAI (Long-Acting Injectable) antipsychotic therapy is offered during all phases of psychotic disorders, including the early phase*** (7)

***To address high rates of partial/non-adherence in early psychosis patients (relapse prevention), preference is given to medications available in a long acting formulation*** (7)

Atypical Antipsychotics Oral Medication with LAI Formulations

aripiprazole mg PO (frequency) [caution-geriatric]

paliperidone mg PO (frequency) [caution-renal]

risperidone mg PO (frequency) [caution-geriatric, renal]

LAI Antipsychotic Medication

***Tolerability with equivalent oral antipsychotic should be established prior to initiating treatment with LAI formulation*** (8)

aripiprazole monohydrate mg IM (frequency) (start date) [caution-geriatric]

paliperidone palmitate mg IM (frequency) (start date) [caution-renal]

risperidone microspheres mg IM (frequency) (start date) [caution-geriatric, renal]

OR

Alternate Atypical Antipsychotic Medication Rationale for using alternate antipsychotic therapy:

Metabolic concerns Movement dysfunction Gastrointestinal dysfunction Prolactin-related adverse events

asenapine mg PO (frequency)

lurasidone mg PO (frequency) [caution-geriatric, renal]

olanzapine mg PO (frequency) [caution-geriatric, renal]

quetiapine mg PO (frequency) [caution-geriatric]

ziprasidone mg PO (frequency) [caution-geriatric]

Alternate Antipsychotic (Typical Antipsychotic)

Adjunctive Management Anticholinergic Agents

Benzodiazepines

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PATIENT INFORMATION

Adjunctive Management Continued… Rationale for using benzodiazepine(s):

Akathisia Anxiety Insomnia Agitation Substance withdrawal

Other

Anticonvulsants:

Antidepressants:

Other:

Psychoeducation Provide psychoeducation to patient and family/caregiver. Provide information on the following topics verbally, in writing,

and electronically, as applicable: (2)

• Diagnosis and course of illness/prognosis/recovery

• Treatment options, including their potential efficacy and side effects

• Alternate treatment options, including clozapine

• Risk of relapse and recognition of warning signs and relapse prevention strategies

• Risk of suicide and monitoring for warning signs

• Impact of substance use (particularly cannabis), including interactions with treatment options as well as illness

• Importance of adherence with treatment and follow-up as well as adherence enhancement strategies

Provide education on healthy eating, physical activity, and smoking cessation (2)

Provide patient and family with contact information for local crisis supports: (2) (specify)

Referrals Concurrent disorder treatment - Reason: OT - Reason:

Psychotherapy: CBT (2) Individual Group Family (2)

SW - Reason: Reason:

Additional Orders

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PATIENT INFORMATION

Implementation Considerations ***The recommendations in this document are intended as general guidance, and do not replace clinical judgement.

Physicians must consider relative risks and benefits in each patient when applying these recommendations***

• Choice of Antipsychotics: This order set reflects the general preference toward initiation of atypical antipsychotics prior

to typical antipsychotics, according to expert consensus and review of current treatment guidelines (5; 9).

• Diagnostic Imaging: Evidence suggests that routine neuroimaging in first episode psychoses does not yield findings

which alter clinical management in a meaningful way (10). Consider selective use of neuroimaging to exclude organic

causes of psychosis where patient's symptoms, or other aspects of their presentation, suggest a higher likelihood of an

underlying organic cause (11).

• Drug-specific Reminders: Drug-specific reminders may be helpful to prompt prescribers to consider lower doses or

alternate medications for the vulnerable patient. The following caution flags are for the organization's consideration

when developing an order set:

[caution-geriatric] = the agent may be inappropriate for the older patient; consider dose adjustment, alternative

treatment, and/or increased frequency of clinical monitoring

[caution-renal] = the agent may be nephrotoxic; consider dose adjustment, alternative treatment, and/or increased

frequency of clinical monitoring

References Key References (1–11) Other References (12; 13)

All medications have been reviewed using Lexicomp and Compendium of Pharmaceuticals and Specialties (eCPS).

1. Agid, O., Arenovich, T., Sajeev, G., Zipursky, R.B., Kapur, S., Foussias, G...Remington, G. (2011). An algorithm-based

approach to first-episode schizophrenia: Response rates over 3 prospective antipsychotic trials with a retrospective data

analysis. Journal of Clinical Psychiatry, 72(11), 1439–1444. doi:10.4088/JCP.09m05785yel

2. National Institute for Health and Care Excellence. (2014). Psychosis and schizophrenia in adults: The NICE guideline on

treatment and management. National Institute of Health and Care Excellence. Retrieved October 23, 2015, from

www.nice.org.uk

3. American Psychiatric Association. (2013). Schizophrenia spectrum and other psychotic disorders. In Diagnostic and

Statistical Maual of Mental Health Disorders. DSM-5 (Ed 5th., pp. 87–122). Arlington, VA: American Psychiatric Association.

4. Robinson, D.J., Luthra, M., & Vallis, M. (2013). Clinical practice guidelines for the prevention and management of

diabetes in Canada: Diabetes and mental health. Canadian Journal of Diabetes. Retrieved October 30, 2015, from

www.guidelines.diabetes.ca

5. Canadian Psychiatric Association. (2005). Clinical practice guidelines:Treatment of schizophrenia. Canadian Journal of

Psychiatry. Retrieved October 20, 2015, from www.cpa-apc.org

6. Reus, V.I., Fochtmann, L.J., Eyler, A.E., Hilty, D.M., Horvitz-Lennon, M., Jibson, M.D...Yager, J. (2016). The American

Psychiatric Association practice guidelines on the use of antipsychotics to treat agitation or psychosis in patients with

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PATIENT INFORMATION

dementia. American Psychiatric Association. Retrieved October 13, 2016, from

www.psychiatryonline.org/doi/pdf/10.1176/appi.books.9780890426807

7. Malla, A., Tibbo, P., Chue, P., Levy, E., Manchanda, R., Teehan, M...Roy, M.-A. (2013). Long-acting injectables

antipsychotics: Recommendations for clinicians. Canadian Journal of Psychiatry, 58(5), 30S–35S.

8. Janssen Pharmaceuticals Inc. (2015). Invega Sustenna product monograph. Janssen Pharmaceuticals Inc. Retrieved

October 14, 2016, from

www.janssen.com/canada/sites/www_janssen_com_canada/files/product/pdf/invs03132015cpm_nc.pdf

9. Lehman, A.F., Lieberman, J.A., Dixon, L.B., McGlashan, T.H., Miller, A.L., Perkins, D.O...Kreyenbuhl, J. (2004). Practice

guideline for the treatment of patients with schizophrenia. American Psychiatric Association. Retrieved October 14, 2016,

from www.psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/schizophrenia.pdf

10. Choosing Wisely Canada. (2015). Thirteen things physicians and patients should questions. Choosing Wisely Canada.

Retrieved October 14, 2016, from www.choosingwiselycanada.org

11. National Institute for Health and Clinical Excellence. (2008). Technology appraisal guidance: Structural neuroimaging in

first-episode psychosis. National Institute for Health and Clinical Excellence. Retrieved from

www.nice.org.uk/guidance/ta136

12. Goulet, K., Deschamps, B., Evoy, F., & Trudel, J.-F. (2009). Use of brain imaging (computed tomography and magnetic

resonance imaging) in first-episode psychosis: Review and retrospective study. Canadian Journal of Psychiatry, 54(7), 493–

501.

13. Khandanpour, N., Hoggard, N., & Connolly, D. J. A. (2013). The role of MRI and CT of the brain in first episodes of

psychosis. Clinical Radiology, 68(3), 245–250. doi:10.1016/j.crad.2012.07.010

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M235 Order Set DRAFT 6.3 for APPLY...***Diagnosis based on criteria from the Diagnostic and...

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