Mania & Hypomania

Stop antidepressant treatment in all patients

If not on any bipolar medication follow formulary below

If taking lithium, check level, if it is < 1.0 mmol/L increase dose. If the level is adequate follow formulary below

If taking another mood stabiliser, ensure dose is optimal then follow the formulary below

Can be combined with lithium or valproate if response to adequate dose of monotherapy is ineffective

Baseline ECG required before treatment - assess need for further ECGs during treatment on an individual basis

Pack Price
30 capsule £1.18
Pack Price
100 tablet
1000 tablet
28 tablet £11.20
30 tablet
Pack Price
100 tablet
250 tablet
28 tablet £12.34
30 tablet
Pack Price
28 tablet £22.05
Pack Price
100 tablet
20 tablet
28 tablet £21.86
30 tablet
50 tablet
Pack Price
100 ml £7.10
500 ml

Can be combined with lithium or valproate if response to adequate dose of monotherapy is ineffective

Plasma level reduced by up to 50% by cigarette smoke

Recommended dose initially 10mg adjusted as necessary to 5 - 20mg 
  
Plasma concentration monitoring form ONLY for diagnosis of acute poisoning  

Pack Price
28 tablet £6.91
Pack Price
28 tablet £15.00
Pack Price
28 tablet £12.10
56 tablet
Pack Price
28 tablet £35.87
56 tablet
Pack Price
28 tablet £26.35
Pack Price
28 tablet £46.50
Pack Price
28 tablet £20.18
Pack Price
28 tablet £34.83
Pack Price
28 tablet £34.81
Pack Price
28 tablet £49.74
Pack Price
28 tablet £37.24
Pack Price
28 tablet £66.76
Pack Price
28 tablet £58.01
Pack Price
28 tablet £96.14

Can be combined with lithium or valproate if response to adequate dose of monotherapy is ineffective

Patients can be initiated on modified release formulation but all patients should be considered for a switched to immediate release once an optimal dose is established (see policy below)

Immediate release formulation should be used even though only the modified release formulation is licensed for this indication

If XL is needed for clinical reasons then prescribe by branded generic: Biquelle® XL, Zaluron® XL, Sondate® XL and Mintreleq® XL have the lowest cost. N.B In East Kent GPs are being advised to switch to Sondate® XL 

Cost effective use of quetiapine

Plasma concentration monitoring form ONLY for diagnosis of acute poisoning

Pack Price
30 tablet
6 tablet
60 tablet £13.84
Pack Price
2 tablet
60 tablet £52.22
Pack Price
2 tablet
60 tablet £61.75
Pack Price
60 tablet £51.30
Pack Price
60 tablet £73.45
Pack Price
60 tablet £67.66
Pack Price
60 tablet £113.10
Pack Price
60 tablet £113.10
Pack Price
60 tablet £170.00
Pack Price
60 tablet £226.20

Can be combined with lithium or valproate if response to adequate dose of monotherapy is ineffective

Pack Price
20 tablet £0.59
Pack Price
20 tablet £0.61
6 tablet
60 tablet
Pack Price
60 tablet £1.28
Pack Price
20 tablet
60 tablet £1.55
Pack Price
20 tablet
60 tablet £1.72
Pack Price
28 tablet £3.04
30 tablet
60 tablet
Pack Price
100 ml £4.10
Pack Price
28 tablet £23.86
Pack Price
28 tablet £24.02
Pack Price
28 tablet £44.43
Pack Price
28 tablet £43.49
Pack Price
28 tablet £50.35

Can be combined with lithium or valproate if response to adequate dose of monotherapy is ineffective

Plasma concentration monitoring form ONLY for diagnosis of acute poisoning

Pack Price
28 tablet £1.12
Pack Price
28 tablet £1.18
Pack Price
28 tablet £1.29
Pack Price
28 tablet £11.09
Pack Price
28 tablet £78.06
Pack Price
28 tablet £78.06
Pack Price
150 ml £100.72

Aim for plasma level of 1.0 mmol/L to treat acute episode

Can be combined with an antipsychotic if response to adequate dose of monotherapy is ineffective

Usually takes at least a week to achieve therapeutic response

Lithium level must be measured weekly until stable, then 3 monthly for the first year and a minimum of six monthly thereafter

Calcium, thyroid and renal function must be monitored every 6 months.

Ensure patient has a Lithium information record card

KMPT lithium policy

NPSA Safer lithium therapy 

Shared Care Guidelines for Lithium

NB There is a shortage of liquid Priadel which is expected to last until at least mid August 2018.  For information on alternatives please see the SPS advice

Pack Price
100 tablet £2.76
Pack Price
100 tablet £4.02

Lithium citrate tetrahydrate 509mg = 200mg lithium carbonate

This is a twice daily preparation

Aim for plasma level of 1.0 mmol/L to treat acute episode

Can be combined with an antipsychotic if response to adequate dose of monotherapy is ineffective

Usually takes at least a week to achieve therapeutic response

Ensure patient has a Lithium information record card

Lithium level must be measured weekly until stable, then 3 monthly for the first year and a minimum of six monthly thereafter

Calcium, thyroid and renal function must be monitored every 6 months.

KMPT lithium policy

NPSA Safer lithium therapy 

Shared Care Guidelines for Lithium

Pack Price
150 ml £6.73

Not licensed for this indication but can be used if liquid or modified release (once daily) formulation is required, otherwise use valproic acid

Can be combined with an antipsychotic if response to adequate dose of monotherapy is ineffective

Recommended dose initially 500mg modified release daily, increasing according to tolerability and response

Do not offer valproate to girls or young women of childbearing potential. If use cannot be avoided discuss risks and ensure that adequate contraception is being used.

Valproate medicines (Epilim▼, Depakote▼) are contraindicated in women and girls of childbearing potential unless conditions of Pregnancy Prevention Programme are met. Use materials provided by MHRA (see link above)
   
KMPT Protocol for using valproate in women of childbearing potential           
Medicines related to valproate: risk of abnormal pregnancy outcomes

Valproate annual risk acknowledgement form

Pack Price
100 tablet £5.60
Pack Price
100 tablet £4.21
Pack Price
100 tablet £7.29
Pack Price
100 capsule
Pack Price
100 tablet £11.65
Pack Price
100 tablet £17.47
Pack Price
100 capsule £13.00
Pack Price
100 tablet £29.10
Pack Price
300 ml £9.33
Pack Price
300 ml £4.16
Pack Price
30 sachet £30.00
Pack Price
30 sachet
Pack Price
30 sachet £30.00
Pack Price
100 sachet £21.00
30 sachet £30.00
Pack Price
30 sachet £30.00
Pack Price
100 sachet £41.00
30 sachet £30.00

Can be combined with an antipsychotic if response to adequate dose of monotherapy is ineffective

Do not offer valproate to girls or young women of childbearing potential. If use cannot be avoided discuss risks and ensure that adequate contraception is being used.

Valproate medicines (Epilim▼, Depakote▼) are contraindicated in women and girls of childbearing potential unless conditions of Pregnancy Prevention Programme are met. Use materials provided by MHRA (see link above)


KMPT Protocol for using valproate in women of childbearing potential                  
Medicines related to valproate: risk of abnormal pregnancy outcomes 

Valproate annual risk acknowledgement form

Pack Price
100 capsule
Pack Price
100 capsule
Pack Price
100 capsule
Pack Price
90 tablet £17.08
Pack Price
90 tablet £34.11

Not licensed for this indication but recommended by The Maudsley Prescribing Guidelines in Psychiatry (12th edition)

Up to 8mg/day

Can be used short term in combination with antipsychotic and / or valproate or lithium

Pack Price
100 tablet £30.74
60 tablet
Pack Price
100 tablet £28.39
150 tablet
60 tablet
Pack Price
1 ml
150 ml

Up to 4mg/day

Can be used short term in combination with antipsychotic and / or valproate or lithium

Short duration of action

May be preferred in patients with hepatic impairment

Risk of withdrawal symptoms is greater than with longer acting benzodiazepines

Not widely used in the community

 

 

Pack Price
100 tablet
1000 tablet
28 tablet £3.74
30 tablet
50 tablet
Pack Price
28 tablet £8.82
30 tablet

Anaphylactic reactions reported even on first dose, medical assistance must be available when first dose given

Can be combined with lithium or valproate if response to adequate dose of monotherapy is ineffective 

Guideline and named patient form for asenapine maleate  

Pack Price
60 tablet £102.60
Pack Price
60 tablet £102.60

Restricted to initiation by specialists

Not licensed for this indication but recommended by The Maudsley Prescribing Guidelines in Psychiatry (12th edition)

No longer endorsed by NICE

Use MR formulation to reduce the risk of side effects

Pack Price
30 tablet
50 tablet
56 tablet £5.20
60 tablet
Pack Price
30 tablet
50 tablet
56 tablet £10.24
60 tablet

Restricted to initiation by specialist consultants only

Not licensed for this indication but recommended by The Maudsley Prescribing Guidelines in Psychiatry (12th edition) for refractory mania / bipolar disorder

Smoking reduces plasma levels by up to 50%

Please check the Summary of Product Characteristics (SPC) for information on monitoring and side effects

Always follow the trust policy for initiation in hospital or in the community (links below) 

KMPT clozapine policy

Clozapine outpatient prescription

Clozapine community initiation policy

Nicotine Replacement Therapy Guidance with advice on clozapine dose changes with changes in smoking status  
Plasma concentration assay request form  

Pack Price
100 tablet
28 tablet
500 tablet
84 tablet
Pack Price
100 tablet
28 tablet
500 tablet
84 tablet