COVID-19: Providing medication

Our guidance on providing medication includes information for clinicians on prescribing medication including benzodiazepines, lithium and clozapine. 

Continued treatment with commonly prescribed psychotropic drugs

Careful consideration should be given to whether now is the best the time to withdraw or change patients from antidepressant, anxiolytic or antipsychotic medication. In some circumstances this may be unavoidable due to clinical need but the clinical rationale should be carefully documented and arrangements for monitoring put in place.

For many patients it is likely that advice will be given to continue on regular medication until this can be reviewed in a face-to-face setting and the patient can be involved in shared decision making with their usual doctor or healthcare provider. This should take account of the fact that anxiety and depressive and psychotic symptoms are all likely to worsen during extreme stress and social disruption. Patients will be at increased risk of relapse or recurrence of affective and psychotic illness.

Advise patients to continue their current dosage until the changes in health care provision necessary during the COVID-19 outbreak have been reversed, and only then consider whether dosage reductions or withdrawal might be appropriate, in discussion with their usual doctors.

Benzodiazepines and/or rapid tranquilisation

Patients taking benzodiazepines and/or rapid tranquilisation should have increased physical health monitoring and this should be reflected in the patient’s individualised care plan.

Treatment with lithium in febrile patients

Febrile patients may become dehydrated and lithium levels may rise, putting patients at greater risk of toxicity. Look for signs of potential toxicity such as coarse tremor. If these are present obtain an urgent lithium level.

If there is any delay in obtaining a lithium level, pause treatment and obtain a lithium level as soon as possible.Ongoing treatment, and the dose used, should be governed by blood levels.Be aware that sudden discontinuation of lithium can be associated with a rapid relapse of symptoms, particularly mania.Use caution until the patient has regained physical health, with increased frequency of monitoring of lithium levels and renal function.

Clozapine treatment

It is highly unlikely that during this period it will be possible to start patients on clozapine treatment safely unless normal haematological monitoring can be assured. There may be some rare clinical situations in inpatient settings where this is the right thing to do, supported by advice from the relevant clozapine patient monitoring service.

• Patients who are already established on clozapine should continue with regular blood monitoring whenever possible. Wear PPE and follow IPC procedures if a patient has symptoms suggestive of COVID-19 infection.
• If a patient describes symptoms suggestive of COVID-19, be aware that similar symptoms can arise from incidental (non-COVID-19) infections associated with neutropenia.
• Centralised monitoring of leucocyte and neutrophil counts for patients taking clozapine is mandatory. The frequency of blood testing and duration for which a blood test is ‘valid’, is based on the risk of clozapine-induced neutropenia and agranulocytosis. Dispensing or administering clozapine outside these durations (i.e. without a valid full blood count, FBC) is unlicensed.
• Normal monitoring of FBC for clozapine-treated patients may be unavoidably disrupted during the pandemic. Clinicians can request permission to extend blood test validity for individual patients in circumstances where clozapine might normally be withheld pending the results of a FBC. A local expert in clozapine use will review the request and respond with 48 hours. Local services must identify the local expert with responsibility for reviewing requests. Clozapine Prescribing Variation Test
• The decision to supply clozapine outside the licensed duration of a valid blood test may be taken to meet the needs of a specific patient. The reasons for recommending and supplying clozapine so should be fully explained to the patient and documented in the patient notes.
• The three companies who supply clozapine have issued guidance about their brand of clozapine and Covid-19 virus. This information has been sent directly from each company to those pharmacies who supply their respective brand of clozapine. More details are available from info@ztas.co.uk ( zaponex), Denzapine@britannia-pharm.com ( denzapine) and CPMS@mylan.co.uk Cloraril).

Key resources on clozapine:

Clozapine and blood dyscrasias in patients with coronavirus (COVID-19)

Clozapine - emergency protocol for patients on monthly monitoring

COVID-19 and psychotropics

Patients with cognitive impairment

It is likely that people with underlying cognitive impairment will be at increased risk of delirium if suffering from COVID-19 related illness. It will be important when deciding on the best management plan (both non pharmacological and pharmacological) to consider all the relevant factors including risk to self and to others.

In this situation in the best interest of avoiding risk of further transmission of infection to others you may have to consider earlier pharmacological intervention if the situation warrants but be mindful of the need for physical health monitoring. Risk reduction strategies should be considered early on including careful review of any exacerbating factors such as anticholinergic side effects of psychotropic medication.

Depots

• If the patient describes COVID-19 symptoms, and is due to have their depot/LAI administered, consult the prescriber and consider an alternative short term treatment plan, such as deferring treatment for 2 weeks (if currently psychologically well and risk of rapid relapse is considered low) or switching to oral formulations (refer to guidance about dosage equivalence).
• If the decision is made to defer depot/LAI, ensure a clear plan/risk assessment is agreed and documented regards follow up with continued monitoring of mental and physical health, with the agreed date of when to review and next administer depot/LAI.
• If the patient describes COVID-19 symptoms but it is essential to administer depot/LAI, do so wearing PPE and follow IPC procedures.
• In all circumstances, ensure a clear plan is agreed and documented with patient/carer, care coordinator and the consultant responsible for the patient’s care (or their deputy) regarding follow up after depot administration and monitoring of physical and mental health symptoms. Ensure that colleagues in primary care are made aware of any changes to pharmacological treatment.

Further guidance on managing depots during COVID-19

• North East London Foundation Trust guidance on managing depots during COVID-19 pandemic
• Oxford Precision Psychiatry Lab guidance on managing patients on long-acting injectable (LAI, or depot) antipsychotics during the COVID-19 pandemic

Other medication: Ibuprofen

While there is currently no strong evidence that ibuprofen can make COVID-19 worse, patients should be advised to take paracetamol to treat their symptoms, unless they have been advised paracetamol is not suitable for them.

Ibuprofen or other non-steroidal anti-inflammatory (NSAID) may interact with some mental health medicines  so clinicians should advise as to whether it is safe for patients to take to one of these drugs take alongside their existing medication.

If they are already taking ibuprofen or another NSAID on the advice of their doctor, they should not stop taking it without checking first.

Administration of medication to detained patients

For guidance on the administration of medication to detained patients, please refer to the section on Emergency legislation and the Mental Health Act.

Providing Attention deficit hyperactivity disorder (ADHD) medication

Clinicians should make decisions in relation to individual patient need about undertaking ADHD assessments either remotely or in person during the COVID-19 pandemic.

• During the COVID-19 virus crisis, evidence-based strategies routinely recommended in parent-focused ADHD interventions can and should be implemented remotely. Clinicians should discuss with parents the evidence base underpinning any online programme of interest.
  

• Expert opinion, based on knowledge of other situations where CYP with ADHD have their usual structures disrupted, e.g. during holidays, suggests that access to pharmacological treatment may reduce health risks leading to COVID-19 virus infection, as behaviour related to ADHD may become more disorganised and poorly controlled at this time, impacting on the ability to maintain physical distancing.
  

• Where the use of medication is deemed desirable, strategies for remote prescribing and monitoring should be implemented. The availability of electronic prescribing varies across services. For services with access to EMIS/TPP electronic transfer of prescriptions has now been enabled. Flexibility in relation to the prescribing of controlled drugs is currently being considered and likely to change. Prescribers should do whatever they can to initiate and maintain prescribing in accordance with local and national guidelines and legislation, as well as their assessments of the patient’s needs.
  

• Whenever possible, parents/carers should be asked to assist with home physical monitoring to avoid unnecessary infection risks, namely, weight, height and blood pressure with age adjusted cuff, and communicate results to clinicians who will assess them against age adjusted norms. There is a risk that measurements provided by parents may not be accurate and clinicians will need to assess whether they make sense. A face-to-face physical examination may be deemed necessary depending on individual risk appraisals.

The European ADHD Guidelines Group has produced guidance on starting ADHD medications during the COVID-19 pandemic:recommendations. The EAGG deems it appropriate, in terms of the risk–benefit ratio, to remotely start a pharmacological treatment if the three following conditions are satisfied:

1. First, the individual with ADHD should not have a personal history of shortness of breath on exertion compared with peers; fainting on exertion or in response to fright or noise; excessive palpitations, breathlessness or syncope (at rest or after exercise) or palpitations that are rapid, regular, and start and stop suddenly (fleeting occasional bumps are usually ectopic and do not need investigation); chest pain suggesting cardiac origin; or any previously documented hypertension, congenital heart abnormality, previous cardiac surgery, or underlying condition that increases the risk of having a structural cardiac disorder (eg, genetic conditions or multisystemic disorders).
2. The second condition is that the individual with ADHD does not have a family history of early (<40 years) sudden death in a firstdegree relative suggesting cardiac disease.
3. Finally, the patient must have baseline monitoring before initiation; blood pressure and heart rate can be measured by a family member or another person remotely (with telephonic assistance, if needed) on three separate occasions.

If the first or second conditions are not satisfied, a referral to a cardiologist should be made before starting the pharmacological treatment. If only the third condition (baseline monitoring) is not satisfied, the prescriber will need to evaluate the risks and benefits of a faceto-face assessment in the context of the severity of ADHD symptoms, and the impact on the patient and the family

Further resources relevant to ADHD medication:

• ADHD management during the COVID-19 pandemic: guidance from the European ADHD Guidelines Group
• Minded.org.uk

Prescribing valporate

•  This temporary advice will ensure the PPP requirements can continue to be met safely. Valproate is harmful if used in pregnancy, and children exposed to valproate in utero have a very high risk for congenital malformations (10% risk) and neurodevelopmental disorders (30–40% risk).
• Initiation of valproate requires a face-to-face consultation (which may be undertaken with appropriate social distancing) but remote consultations could be considered based on the clinician’s risk assessment.
• Even during the pandemic, the required annual review of existing female patients should not be delayed. Arrangements can be made for virtual video consultation or telephone consultation in line with the process laid out in the guidance.
• No patient should stop taking valproate without talking to their doctor.
• Where face-to-face consultation is not possible and pregnancy testing is required, home pregnancy testing may be acceptable provided the guidance’s minimum criteria are met.

Psychotropic prescribing for children and adolescents: starting, continuing and monitoring treatment during the COVID 19 pandemic

This guidance focusses on what to consider when starting and/or continuing psychotropic medication in children and adolescents whilst working remotely during the COVID-19 pandemic.

When prescribing medication for ADHD, antidepressants, antipsychotics or mood stabilisers in children and adolescents, it is important to consider the following factors:

1. Individual circumstances of the case: diagnoses (including the presence of mental and physical disorder comorbidity), clinical severity, and risks
   
2. Degree of impairment associated with the disorder(s), including consideration of educational achievement and social interactions
   
3. Evidence base for treatment (including pharmacological and psychological) options
   
4. Potential benefits and potential risks of starting or maintaining treatment, and the potential consequences or such treatment being either postponed or withheld
   
5. Possible adverse effects associated with pharmacological and non-pharmacological treatments, and how these can be mitigated, monitored, and where necessary managed
   
6. Practical constraints in requesting, supplying and continuing prescriptions (as examples, prescriptions for controlled medications; ability of parent to collect prescription)
   
7. Practical arrangements for monitoring specific medications: for example, blood pressure assessment, blood tests, ECG assessments
   
8. Mechanisms for effective communication with involved colleagues in general practice and mental health services
   

These factors should be discussed with the competent young person and/or person holding parental responsibility to allow them to arrive at an evidence-informed and practicable decision.