Do I say yes or no to this? HDAT (With Poll)

So no idea if this is a UK thing or not, but my pdoc wants me to agree to the below (With out a face to face consultation) and after reading the below I think I made the right decision to say no, ‘I need the doctor to explain his rationale.’ I was nice about it. Just said a phone call or an email will be fine.

After reading the below, it kinda sucks that we got to this point.

Not sure whether the benefit is worth it, as we have exhausted a lot of meds, and this HDAT thing when I already have a borderline QTC level is not something I think appropriate

If I deny this treatment, I will have to keep my symptoms to myself, otherwise if they decide that I need it and I am not making the right decision, then I don’t know what might happen

Anyways, please read below, or vote your thought’s in the poll anyway if you know more about this stuff? Please also share any experiences with doctors approving above ‘safe’ regulator limits at discretion of the pdoc?

  • Do HDAT
  • Do Not fo HDAT
  • Unsure
  • Other: Please comment

0 voters

  • High dose antipsychotic therapy (HDAT): an antipsychotic drug prescribed at a daily dose above the maximum recommended limit in the BNF or Summary of Product Characteristics (SPC), with respect to the age of the patient and the indication being treated OR more than one antipsychotic prescribed concurrently where the sum of each antipsychotic ‘percentage of BNF maximum’ is greater than 100%

Antipsychotics are sometimes prescribed alone or in combination, which can result in cumulative daily doses above recommended limits (HDAT). The use of HDAT has been linked with cardiovascular toxicity and sudden death, thus the aim of this policy is to reduce the risk of adverse events for individuals who require HDAT.

Staff are encouraged to read the whole policy but I (the Author) have chosen three key messages from the document to share

  1. The use of HDAT should be exceptional clinical practice and only employed when an adequate trial of standard treatments, including clozapine, have failed and the responsibility to exceed the licensed dose of a single antipsychotic, or a combination of more than one, lies with the service user’s Consultant Psychiatrist.
  2. High dose antipsychotic treatment regime should be as a limited therapeutic trial with doses returned to standard dosage of the BNF or SPC after a period of 3 months, unless the clinical benefit outweighs the risks.
  3. Documentation of target symptoms, response and side effects, ideally using validated rating scales, should be standard practice so that there is on-going consideration of the risk-benefit ratio for the patient. Close physical monitoring is essential.

7.1. Prescribing high dose antipsychotics

  •  The responsibility to exceed the licensed dose of a single antipsychotic, or a combination of more than one, lies with the service user’s Consultant Psychiatrist. The decision should be discussed with the multidisciplinary team, the service user and/or carer and valid consent obtained. For those service users who are detained and lack capacity, the Mental Health Act 2007 and The Mental Health Capacity Act 2005 should be adhered to.Details of the decision making process should be recorded in the service user’s electronic patient record (EPR) including the clinical indication for the use of HDAT and whether or not the service user has been informed. A reason must be specified if the service user has not been informed.A care plan must be developed to cover appropriate monitoring.

7.2. Risks of high dose antipsychotics

  •  The majority of antipsychotic adverse effects are dose-related. High dose treatment increases the incidence and severity of such adverse effects: extra- pyramidal side effects (EPSE), tachycardia, postural hypotension, sedation, hyperprolactinaemia and risk of seizures.
  •  The risk of QTc prolongation and associated arrhythmias is also significantly increased with high dose antipsychotics. Case reports of arrhythmias and sudden death highlight the risk of high dose prescribing and rapid dose escalation. The difficulties in obtaining a pre-treatment ECG are not underestimated; however an ECG should be performed at the earliest opportunity. Adequate cardiac and ECG monitoring is advised during initiation and continuation of high dose treatment. Additional biochemical/ECG monitoring is advised if drugs that are known to cause electrolyte disturbances or QTc prolongation are subsequently co-prescribed and/or cardiac symptoms are present e.g. chest pain, irregular pulse etc.
  •  High dose antipsychotics can worsen cognitive function.
  •  Although neuroleptic malignant syndrome (NMS) is not clearly dose-dependent, the use of high dose antipsychotics may be a risk factor. If symptoms of NMS are suspected, creatinine phosphokinase should be measured.
  •  The speed of drug delivery should also follow normal dosing recommendations as rapid titration can often increase the risk of adverse effects.
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Man that´s dangerous… I wouldn´t do it, but doctors know better.

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Have you tried Clozapine?

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Yea I tried it earlier in the year

I had tachycardia before I started, and it stayed high. Also messed the bed a couple of times, and was constipated for a fair amount of time

Plus it was sedating as ■■■■

Didn’t get on with it at all

But I am aware it would be the answer to the riddle (Maybe), but I don’t want to wear nappies to bed and I like to be able to have a ■■■■

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I thought the same. When they told me this over the phone my immediate reaction was no thanks

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I don’t think they can get me on this as I am working

If it were me, I’d ask them to measure the plasma concentrations of the antipsychotics I’m already taking. If they’re ok, I definitely wouldn’t do it. If they’re very low, then I’d consider it for me.

But if I had qtc issues like you, then I wouldn’t do it.

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It’s hard for me to tell you what I think you should do…but I will say if it were me, I would do it. You and I have both had a rough time getting stable on meds. I’ve seen you deeply struggling for a long while now too.

I would try it for their three month period, especially if they say they would follow up with ECG testing. And maybe it would help you with the diazepam as a rescue med.

I didn’t want to be on an old first generation med either, but Trilafon is the best of the six APs I’ve been on. And I didn’t really want to take a fourth psych med but Buspar is helping me significantly (I also take Trilafon, Lamictal, and Prozac). I’ll do whatever I need to do to get stable.

At least strongly consider both sides before making a final decision. No one can force you, but it may be the right choice too.

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Is that a simple blood test?

Thanks @Shmookitty - it’s a tough decision, and I don’t really think the severity of what’s not treated warrants the risk in my view

What I can’t understand is why the doctor got a support worker to tell me this reading off an email

Seems like a pretty significant thing to be doing

But I guess since Covid they must be adept in making these decisions remotely, and without a consultation with the patient

Or are they just pushing my buttons?

I have no idea

Yes, I believe so…

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I agree with you. I wouldn’t do it if you’re that scared of risk, but I also think they need to properly address all your concerns, not just send emails. That part is definitely not fair.

As for the plasma levels, I think those are simple blood tests in the lab. That is an excellent idea as part of the decision making process, and one I would definitely address with the professionals.

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I wouldn’t do it either especially with your heart issues

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@Shmookitty & @everhopeful I will ask for this blood test. Thank you. Did not know such a thing existed

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Jfc that is a horrifying waiver to sign. I agree with you about refusing. You have a mouth on you when you’re agitated, but as far as I know you have never actually assaulted anyone (and definitely not since getting sober). This seems like a last ditch effort for someone who would be an extreme danger to others. You are sometimes a danger to yourself, but trading risk of death by suicide for a risk of death by heart failure doesn’t seem like a step up.

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No way.

As @ninjastar pointed out, you can get mouthy, but that in no way should lead to such a thing.

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That is horrific, plain and simple.

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No way would I do this.

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I am not giving consent to this

Have been checking online, and I am pretty sure that I can say no without consequences but we’ll see.

To clarify, I have not used my mouth to offend people from the mental health team since we talked about this a while back. I am being calm with them, and my mother is on every call with me as a mod

It’s going quite well with the mental health team, but this did catch me off guard

Since getting sober when I was 18 - which was 2005 I think, I have not laid a finger on anyone, or broken the law.

Since I have been working with instead of against, I might have overshared what’s going on in my head, as part of the deal from them was honesty in that I am not to hide things from them - this is now under review on my part

When I was 17, my psychosis was a 10. When I was 23, it was a 10.

I said to my mother yesterday that I don’t understand why this is on the table, as if we benchmark me now at age 35 to 17 & 23 this is probably a 2 on the scale

We are having a meeting with them soon face to face, as I want to understand why we keep messing with meds

Honestly, I do not think we can get things much better. My illness seems to have become less acute waves and more a continuous chronic interference in my brain.

We don’t have the massive brain explosions anymore, and I think that’s thanks to the meds

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I have never heard of this in Belgium. I don’t think they can prescribe more than what the manufacturer states based on their clinical trials.

Personally, I wouldn’t do it. Seems like this is treatment in the dark without scientific backing.

Feels like going back to the Middle Ages.

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