Second generation (atypical) antipsychotics (Formulary)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Atypical antipsychotics may be better tolerated than typical antipsychotics and cause fewer extrapyramidal side-effects. Advise patients on possible weight gain; refer to Handy fact sheet - antipsychotics and weight gain or request a copy from Pharmacy Department, New Craigs, tel: 01463 704000 (Raigmore Hospital switchboard).

Note: Only use orodispersible tablets where there is swallowing difficulty or where consumption can be supervised. Place the orodispersible tablet in the mouth, where it will rapidly disperse with saliva and can be easily swallowed. Removal of intact orodispersible tablets from the mouth is difficult. As the orodispersible tablet is fragile administer immediately on opening the blister. Alternatively, disperse in a full glass of water or other suitable beverage (orange juice, apple juice, milk or coffee) immediately before administration.

MHRA advice: Atypical (second generation) antipsychotics: reminder to monitor and manage weight, glucose, and lipid levels (December 2014) (www.gov.uk).

AMISULPRIDE

Therapy notes

MHRA advice: Clozapine and other antipsychotics: monitoring blood concentrations for toxicity (August 2020) (www.gov.uk).

Formulation and dosage details

Formulation:

Tablets 50mg, 100mg, 200mg, 400mg

Dosage:

Acute psychotic episode, 400 to 800mg daily in 2 divided doses, adjusted according to response; maximum 1200mg daily.

Predominantly negative symptoms, 50 to 300mg daily.

Formulation and dosage details

Formulation:

Oral solution 100mg/mL

Dosage:

Acute psychotic episode, 400 to 800mg daily in 2 divided doses, adjusted according to response; maximum 1200mg daily.

Predominantly negative symptoms, 50 to 300mg daily.

ARIPIPRAZOLE

Therapy notes

MHRA advice: Aripiprazole (Abilify and generic brands): risk of pathological gambling (December 2023) (www.gov.uk).
MHRA advice: Clozapine and other antipsychotics: monitoring blood concentrations for toxicity (August 2020) (www.gov.uk).

Formulation and dosage details

Formulation:

Tablets 5mg, 10mg, 15mg, 30mg

Dosage:

For schizophrenia, 10 to 15mg once daily, usual maintenance 15mg once daily, maximum 30mg once daily
For mania, 15mg once daily, increased if necessary, maximum 30mg once daily.

Formulation and dosage details

Formulation:

Orodispersible tablets 10mg, 15mg

Dosage:

For schizophrenia, 10 to 15mg once daily, usual maintenance 15mg once daily, maximum 30mg once daily.
For mania, 15mg once daily, increased if necessary, maximum 30mg once daily.

Formulation and dosage details

Formulation:

Oral solution 5mg/5mL

Dosage:

For schizophrenia, 10 to 15mg once daily, usual maintenance 15mg once daily, maximum 30mg once daily.
For mania, 15mg once daily, increased if necessary, maximum 30mg once daily.

Formulation and dosage details

Formulation:

Solution for injection vials 7·5mg/mL

Dosage:

By intramuscular injection, for rapid control of agitation and disturbed behaviours in patients with schizophrenia when oral therapy is not appropriate, initially 5·25 to 15mg for 1 dose, alternatively usual dose 9·75mg for 1 dose, followed by 5·25 to 15mg after 2 hours if required, maximum 3 injections daily, maximum daily combined oral and parenteral dose 30mg.

CLOZAPINE

Therapy notes

MHRA advice: Clozapine and other antipsychotics: monitoring blood concentrations for toxicity (August 2020) (www.gov.uk)
MHRA advice: Clozapine: reminder of potentially fatal risk of intestinal obstruction, faecal impaction, and paralytic ileus (October 2017) (www.gov.uk).
MHRA advice: Smoking and smoking cessation: clinically significant interactions with commonly used medicines (December 2014) (www.gov.uk).

  • Clozapine is indicated in treatment-resistant schizophrenia and in patients who have severe, untreatable neurological adverse reactions to other antipsychotic agents, including atypical antipsychotics. Treatment resistance is defined as a lack of satisfactory clinical improvement despite the use of adequate doses of at least two different antipsychotic agents, including an atypical antipsychotic agent, prescribed for adequate duration.
  • Clozapine is also indicated in psychotic disorders occurring during the course of Parkinson's disease, in cases where standard treatment has failed.
  • Clozapine can cause agranulocytosis. The manufacturer’s mandatory protocol for monitoring FBC must be followed. See SmPCs clozapine.

TAM guideline: Clozapine initiation and re-titration

Formulation and dosage details

Formulation:

Tablets 25mg, 100mg (specialist use only)

Dosage:

Clozapine is initiated by secondary care and restricted to patients registered with a clozapine patient monitoring service. For further information contact Pharmacy Department, New Craigs, tel: 01463 704000 (Raigmore Hospital switchboard).

Formulation and dosage details

Formulation:

Orodisperisible tablets 25mg, 100mg (specialist use only)

Dosage:

Clozapine is initiated by secondary care and restricted to patients registered with a clozapine patient monitoring service. For further information contact Pharmacy Department, New Craigs, tel: 01463 704000 (Raigmore Hospital switchboard).

LURASIDONE

Therapy notes

 SPC

Formulation and dosage details

Formulation:

Film-coated tablets 18.5mg, 37mg, 74mg (Restricted: Specialist recommendation only)

Dosage:

  • As per SMC994/14: Treatment of schizophrenia in adults aged 18 years and over as an alternative treatment option in patients in whom it is important to avoid weight gain and metabolic adverse effects.
  • Bipolar affective disorder depression (off-label indication).

OLANZAPINE

Therapy notes

MHRA advice: Clozapine and other antipsychotics: monitoring blood concentrations for toxicity (August 2020) (www.gov.uk).
MHRA advice: Smoking and smoking cessation: clinically significant interactions with commonly used medicines (December 2014) (www.gov.uk)

  • When one or more factors are present that might result in slower metabolism of olanzapine (eg female, older person, non-smoker) consider lower initial dose and more gradual dose increase.

Formulation and dosage details

Formulation:

Tablets 2·5mg, 5mg, 7·5mg, 10mg, 15mg, 20mg

Dosage:

Schizophrenia, combination therapy for mania, preventing recurrence in bipolar disorder, 10mg daily adjusted to usual range of 5 to 20mg daily; doses greater than 10mg daily only after reassessment; maximum 20mg daily.
Monotherapy for mania, 15mg daily adjusted to usual range of 5 to 20mg daily; doses greater than 15mg only after reassessment; maximum 20mg daily.

Formulation and dosage details

Formulation:

Orodispersible tablets 5mg, 10mg, 15mg, 20mg

Dosage:

Schizophrenia, combination therapy for mania, preventing recurrence in bipolar disorder, 10mg daily adjusted to usual range of 5 to 20mg daily; doses greater than 10mg daily only after reassessment; maximum 20mg daily.
Monotherapy for mania, 15mg daily adjusted to usual range of 5 to 20mg daily; doses greater than 15mg only after reassessment; maximum 20mg daily.

QUETIAPINE

Therapy notes

MHRA advice: Clozapine and other antipsychotics: monitoring blood concentrations for toxicity (August 2020) (www.gov.uk).

Risk minimisation materials

  • Where possible use the immediate-release tablets. Only use the higher cost modified-release (modified release) tablets where there is a particular clinical advantage.

Formulation and dosage details

Formulation:

Tablets 25mg, 100mg, 150mg, 200mg, 300mg

Dosage:

Schizophrenia, 25mg twice daily on day 1, 50mg twice daily on day 2, 100mg twice daily on day 3, 150mg twice daily on day 4, then adjusted according to response, usual range 300 to 450mg daily in 2 divided doses; maximum 750mg daily.
Older people, initially 25mg daily as a single dose, increased in steps of 25 to 50mg daily in 2 divided doses.

Mania, 50mg twice daily on day 1, 100mg twice daily on day 2, 150mg twice daily on day 3, 200mg twice daily on day 4, then adjusted according to response in steps of up to 200mg daily to maximum 800mg daily; usual range 400 to 800mg daily in 2 divided doses.
Older people, initially 25mg daily as a single dose, increased in steps of 25 to 50mg daily in 2 divided doses.

Treatment of depression in bipolar disorder, 50mg daily on day 1, 100mg daily on day 2, 200mg daily on day 3, 300mg daily on day 4, then adjusted according to response, usual dose 300mg daily, maximum 600mg daily; licensed for once daily administration for this indication however local experience suggests a lesser risk of hypotension with a twice daily split dose, or use of the m/r tablets.

Prevention of mania and depression in bipolar disorder, continue at the dose effective for treatment of bipolar disorder and adjust to lowest effective dose, usual range 300 to 800mg daily in 2 divided doses.

Formulation and dosage details

Formulation:

Modified release tablets 50mg, 150mg, 200mg, 300mg, 400mg

Dosage:

Schizophrenia, 25mg twice daily on day 1, 50mg twice daily on day 2, 100mg twice daily on day 3, 150mg twice daily on day 4, then adjusted according to response, usual range 300 to 450mg daily in 2 divided doses; maximum 750mg daily.
Older people, initially 25mg daily as a single dose, increased in steps of 25 to 50mg daily in 2 divided doses.

Mania, 50mg twice daily on day 1, 100mg twice daily on day 2, 150mg twice daily on day 3, 200mg twice daily on day 4, then adjusted according to response in steps of up to 200mg daily to maximum 800mg daily; usual range 400 to 800mg daily in 2 divided doses.
Older people, initially 25mg daily as a single dose, increased in steps of 25 to 50mg daily in 2 divided doses.

Treatment of depression in bipolar disorder, 50mg daily on day 1, 100mg daily on day 2, 200mg daily on day 3, 300mg daily on day 4, then adjusted according to response, usual dose 300mg daily, maximum 600mg daily; licensed for once daily administration for this indication however local experience suggests a lesser risk of hypotension with a twice daily split dose, or use of the m/r tablets.

Prevention of mania and depression in bipolar disorder, continue at the dose effective for treatment of bipolar disorder and adjust to lowest effective dose, usual range 300 to 800mg daily in 2 divided doses.

RISPERIDONE

Therapy notes

MHRA advice: Clozapine and other antipsychotics: monitoring blood concentrations for toxicity (August 2020) (www.gov.uk).
MHRA advice: Drug-name confusion: reminder to be vigilant for potential errors (January 2018) (www.gov.uk).
MHRA advice: Risperidone and paliperidone: risk of intraoperative floppy iris syndrome in patients undergoing cataract surgery (December 2014) (www.gov.uk).

Formulation and dosage details

Formulation:

Tablets 500 micrograms, 1mg, 2mg, 3mg, 4mg, 6mg

Dosage:

Psychoses, 2mg in 1 to 2 divided doses on first day then 4mg in 1 to 2 divided doses on second day (slower titration appropriate in some patients); usual dose range 4 to 6mg daily; doses above 10mg daily only if benefit considered to outweigh risk (maximum 16mg daily). Older people, or in hepatic or renal impairment, initially 500 micrograms twice daily increased in steps of 500 micrograms twice daily to 1 to 2mg twice daily.

Mania, initially 2mg once daily, increased if necessary in steps of 1mg daily; usual dose range 1 to 6mg daily.
Older people, initially 500 micrograms twice daily increased in steps of 500 micrograms twice daily to 1 to 2mg twice daily.

Formulation and dosage details

Formulation:

Orodispersible tablets 500 micrograms, 1mg, 2mg, 3mg, 4mg

Dosage:

Psychoses, 2mg in 1 to 2 divided doses on first day then 4mg in 1 to 2 divided doses on second day (slower titration appropriate in some patients); usual dose range 4 to 6mg daily; doses above 10mg daily only if benefit considered to outweigh risk (maximum 16mg daily). Older people, or in hepatic or renal impairment, initially 500 micrograms twice daily increased in steps of 500 micrograms twice daily to 1 to 2mg twice daily.

Mania, initially 2mg once daily, increased if necessary in steps of 1mg daily; usual dose range 1 to 6mg daily.
Older people, initially 500 micrograms twice daily increased in steps of 500 micrograms twice daily to 1 to 2mg twice daily.

Formulation and dosage details

Formulation:

Liquid 1mg/mL

Dosage:

Psychoses, 2mg in 1 to 2 divided doses on first day then 4mg in 1 to 2 divided doses on second day (slower titration appropriate in some patients); usual dose range 4 to 6mg daily; doses above 10mg daily only if benefit considered to outweigh risk (maximum 16mg daily). Older people, or in hepatic or renal impairment, initially 500 micrograms twice daily increased in steps of 500 micrograms twice daily to 1 to 2mg twice daily.

Mania, initially 2mg once daily, increased if necessary in steps of 1mg daily; usual dose range 1 to 6mg daily.
Older people, initially 500 micrograms twice daily increased in steps of 500 micrograms twice daily to 1 to 2mg twice daily.

Editorial Information

Document Id: F101