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APPENDIX 6: National Health Service National Institute for Clinical Excellence guidance on the use of newer (atypical) antipsychotic drugs for the treatment of schizophrenia

(1)The choice of antipsychotic drug should be made jointly by the individual and the clinician responsible for treatment based on an informed discussion of the relative benefits of the drugs and their side effect profiles. The individual's advocate or carer should be consulted where appropriate.

(2)It is recommended that the oral atypical antipsychotic drugs amisulpride, olanzapine, quetiapine, risperidone and zotepine are considered in the choice of first-line treatments for individuals with newly diagnosed schizophrenia.

(3)The oral atypical antipsychotic drugs listed in Section 3.3 should be considered as treatment options for individuals currently receiving typical antipsychotic drugs who, despite adequate symptom control, are experiencing unacceptable side-effects, and for those in relapse who have previously experienced unsatisfactory management or unacceptable side-effects with typical antipsychotic drugs. The decision as to what are unacceptable side-effects should be taken following discussion between the patient and the clinician responsible for treatment.

(4)It is not recommended that, in routine clinical practice, individuals change to one of the oral atypical antipsychotic drugs if they are currently achieving good control of their condition without unacceptable side-effects with typical antipsychotic drugs.

(5)In individuals with evidence of treatment-resistant schizophrenia (TRS), clozapine should be introduced at the earliest opportunity. TRS is suggested by a lack of satisfactory clinical improvement despite the sequential use of the recommended doses for 6 to 8 weeks of at least two antipsychotics, at least one of which should be an atypical.

(6)A risk assessment should be performed by the clinician responsible for treatment and the multidisciplinary team regarding concordance with medication, and depot preparations should be prescribed when appropriate.

(7)Where more than one atypical antipsychotic drug is considered appropriate, the drug with the lowest purchase cost (taking into account daily required dose and product price per dose) should be prescribed.

(8)When full discussion between the clinician responsible for treatment and the individual concerned is not possible, in particular in the management of an acute schizophrenic episode, the oral atypical drugs should be considered as the treatment options of choice because of the lower potential risk of extrapyramidal symptoms (EPS). In these circumstances, the individual's

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