4: Central Nervous System

Before a hypnotic is prescribed the underlying cause should be identified and addressed, and realistic sleep requirements should be discussed with the patient.

All hypnotics should be used for the minimum length of time due to the risks of dependence.

Patients who require short term treatment for insomnia during their hospital admission should not routinely be prescribed a hypnotic to continue following discharge.

Benzodiazepines should be prescribed at the lowest possible dose for the shortest possible time due to the risk of dependence.

Diazepam should be used with caution in the elderly. Lorazepam is preferred in these patients.

Some antidepressants are licensed for anxiety: see section 4.3

The choice of drug should be made by the patient/client and healthcare professional together, considering the relative potential of individual antipsychotic drugs to cause extrapyramidal side effects (including akathisia), metabolic side effects (including weight gain) and other side effects (including unpleasant subjective experiences). Provide information and discuss the likely benefits and possible side effects of each drug, including:

• metabolic (including weight gain and diabetes)
• extrapyramidal (including akathisia, dyskinesia and dystonia)
• cardiovascular (including prolonging the QT interval)
• hormonal (including increasing plasma prolactin)
• other (including unpleasant subjective experiences)

Indications:

Licensed: schizophrenia and related psychoses; bipolar disorder; short term use for aggression in Alzheimers

Unlicensed: a range of indications including – but not limited to – aggression in dementia; emotional dysregulation; personality disorder; augmentation for depressive disorder without psychosis

• These preparations may only be initiated on the advice of senior medical staff working in psychiatry.
• Prescribing will usually be undertaken by the mental health team but, with agreement from primary care, may be transferred to the patient's GP.
• Primary care prescribers should include medicines prescribed and supplied by secondary care in the patient's SCR in order to maintain a full medicine list.

First-line options for the treatment of acute mania include atypical antipsychotics (particularly olanzepine) or valproate compounds. Occasionally, benzodiazepines are added for short-term use.

In general, SSRIs are the first-line choice for the treatment of depression.

Tricyclics should not be used to treat depression in patients over 75 years old.

In general, SSRIs are the first-line choice for the treatment of depression.

Meta-analysis of comparative efficacy of 12 antidepressants – Bandolier comment

Where there is mixed depression and anxiety, citalopram may be considered first line.

SSRIs may initially increase anxiety levels and it may be necessary to ‘cover’ their initiation with a brief course of a benzodiazepine in order to encourage compliance.

Abrupt withdrawal of SSRIs should be avoided (associated with headache, nausea, paraesthesia, dizziness and anxiety).

Withdrawal syndrome is reported to the CSM more commonly with paroxetine than with other SSRIs.

Venlafaxine may be considered if a patient fails on another antidepressant or in severe depression.

BP monitoring is advisable for doses of venlafaxine above 200mg daily.

Mirtazapine may be useful for treating depression in patients with reduced appetite.

GHNHSFT: Refer to ChemoCare electronic prescribing system

Paracetamol and codeine should be prescribed separately and the dose titrated according to pain. Co-codamol may be prescribed in palliative care to reduce tablet burden.

Low dose weak opioid combinations with paracetamol (e.g. co-proxamol, co-codamol 8/500) offer little additional pain relief compared with regular full dose paracetamol and are not recommended.

Effervescent analgesics are not generally recommended because they are expensive and contain large amounts of sodium. Use is restricted to patients unable to swallow tablets or in the treatment of migraine attacks (see section 4.7.4.1).

In general, the use of more than one opioid should be avoided.

Opioid Equivalence Chart

Caution: Some opioids accumulate in renal impairment resulting in increased and prolonged effect.

Regular paracetamol (1g qds) may have an 'opioid-sparing' effect, thus enabling a lower opioid dose.

The choice of antiepileptic agent will depend on the type of epilepsy

Prescribing of Antiepileptic Drugs (AEDs):

Prescribers should consider the MHRA guidance (summarised below) regarding the generic prescribing of AEDs.

MHRA Summary:

Category 1 – Phenytoin, carbamazepine, phenobarbital, primidone

For these drugs, prescribers are advised to ensure that their patient is maintained on a specific manufacturer’s product (i.e. prescribe by brand or by using the generic drug name and name of the manufacturer / marketing authorisation holder).

Category 2 – Valproate, lamotrigine, perampanel, rufinamide, clobazam, clonazepam, oxcarbazepine, eslicarbazepine, zonisamide, topiramate

For these drugs the need for continued supply of a particular manufacturer’s product should be based on clinical judgement and consultation with patient and/or carer taking into account factors such as seizure frequency and treatment history.

Category 3 - Levetiracetam, lacosamide, tiagabine, gabapentin, pregabalin, ethosuximide, vigabatrin

For these drugs it is usually unnecessary to ensure that patients are maintained on a specific manufacturer’s product unless there are specific concerns such as patient anxiety, and risk of confusion or dosing errors.

Antimuscarinics can be of help with tremor, but use is limited by side effects of confusion, prostatism, dry eyes, and dry mouth especially in the elderly.

In alcohol withdrawal Pabrinex® and/or thiamine may be required.
Facilities for treating anaphylaxis should be available when administering Pabrinex®.

Contact Gloucestershire Smoking Advice Service (GSAS) for advice or referrals (0300 422 0040)

• Anxiety should be tolerated to some extent and, wherever possible, be managed by non-pharmaceutical means
• Medication is associated with a high frequency of unwanted and sometimes serious side effects.
• There is a clear increased risk of stroke and a small increased risk of death when antipsychotics (typical or atypical) are used in elderly people with dementia (Read more for MHRA advice)
• Depression and additional pathologies should be specifically sought.
• Sedation, parkinsonism and non-specific decline should be watched for.
• Benzodiazepine use in elderly patients is associated with falls and cognitive impairment.