Schizophrenia (Referral and Shared Care)

Refer all patients with suspected first-episode psychosis or acute psychotic relapse urgently to secondary care mental health services (Early Intervention in Psychosis / Crisis Team). Antipsychotic treatment should be initiated by a specialist psychiatrist after baseline metabolic, cardiovascular, and neurological assessment. - Immediate urgent referral

Children and adolescents <18 years with suspected psychosis require emergency referral to child and adolescent mental health services (CAMHS).

NICE CG178 Psychosis and schizophrenia in adults: prevention and management, 2014 (updated 2014)

NICE CG178 1.3.2.1 is a bar, not a preference: antipsychotic medication must not be started in primary care at a first presentation of psychotic symptoms that have been sustained, unless the decision is taken in consultation with a consultant psychiatrist. NG181 covers rehabilitation for complex psychosis and contains no such rule; the row's own dose_source already named CG178.

5-10 mg once daily at bedtime initially, titrate in steps of 5 mg daily at intervals of at least 1 week to target 10-20 mg once daily (max 20 mg daily) under shared-care protocol - long-term (specialist supervision)

Specialist child and adolescent psychiatry initiation only.

Olanzapine 10 mg tablets SmPC section 4.2 (eMC product 3070)

First-line atypical antipsychotic for maintenance therapy in shared care following specialist initiation.

2 mg daily in 1-2 divided doses initially, increase on day 2 to 4 mg daily; usual maintenance dose 4-6 mg daily (max 16 mg daily) under shared-care protocol - long-term (specialist supervision)

Specialist child psychiatry initiation only.

Risperidone 2 mg Tablets SmPC section 4.2 (eMC product 11872)

Alternative second-generation antipsychotic for shared-care maintenance.

10 mg or 15 mg once daily to start; recommended maintenance 15 mg once daily; effective range 10-30 mg daily, maximum 30 mg daily - Long-term under psychiatric shared care

(Adolescents 15 years and over with schizophrenia: 2 mg (as oral solution) for 2 days, then 5 mg for 2 days, then the 10 mg/day target. Not recommended below 15 years for schizophrenia. Fixed milligram titration, not weight-based.)

Alternatives, all second-generation antipsychotics in shared care. Aripiprazole has the least metabolic burden of the three and 46 Egyptian products stock it.

eMC SmPC, Abilify 10 mg tablets (Otsuka), sections 4.1 and 4.2

46 live products - the second most prescribed atypical antipsychotic on the Egyptian market after olanzapine. Distinctly less weight gain and metabolic disturbance than the olanzapine already listed, and less hyperprolactinaemia than the risperidone, which is why patients get switched onto it.

Started tiny and climbed slowly. SmPC verbatim: "12.5 mg once or twice on the first day, followed by 25 mg once or twice on the second day. If well tolerated, the daily dose may then be increased slowly in increments of 25 to 50 mg in order to achieve a dose level of up to 300 mg/day within 2 to 3 weeks. Thereafter, if required, the daily dose may be further increased in increments of 50 to 100 mg at half-weekly or, preferably, weekly intervals." Therapeutic range verbatim: "In most patients, antipsychotic efficacy can be expected with 200 to 450 mg/day given in divided doses." Ceiling verbatim: increments "not exceeding 100 mg" are permissible "up to 900 mg/day", with "the possibility of increased adverse reactions (in particular seizures) occurring at doses over 450 mg/day" borne in mind. Nothing is started unless the count allows it: the SmPC restricts initiation to patients whose white cell count is at least 3,500 per cubic millimetre and whose absolute neutrophil count is at least 2,000 per cubic millimetre, both within normal limits. - Six months at least, then reviewed downward. SmPC verbatim: "Treatment should be maintained for at least 6 months." Stopping is gradual - "a gradual reduction in dose over a 1 to 2-week period is recommended."

Not a paediatric prescription. SmPC verbatim: "The safety and efficacy of Clozaril in children and adolescents under the age of 16 years have not yet been established. It should not be used in this group until further data become available."

Clozaril 25 mg Tablets SmPC sections 4.1, 4.2 and 4.4 (eMC product 4411)

The disease article states the indication twice, verbatim: "For these patients, clozapine is the recommended treatment option, with about 40% of those with treatment-resistant schizophrenia responding." and "Clozapine is also recommended for patients with schizophrenia with persistent, substantial risks of suicide or aggression despite other treatments." The SmPC's indication section names the same patient, verbatim: "Clozaril is indicated in treatment-resistant schizophrenic patients and in schizophrenia patients who have severe, untreatable neurological adverse reactions to other antipsychotic agents, including atypical antipsychotics." It sits at line 3 because resistance is defined by what came before it, the article's own definition being persistent symptoms "despite 2 or more trials of antipsychotic medications at adequate doses and durations, with documented adherence." Fourteen Egyptian products are registered, ZACLO 100 mg at 19.20 EGP through LEPONEX; the blood monitoring, not the price, is what limits its use.