Table 2 Prescribing indicators accepted in round 1 of Delphi exercise with Median and 75^th Centile Value

1

Assess CV risk in all adults with SMI over 40 years using a validated cardiovascular risk assessment tool eg. SCORE, QRISK2, QRISK3 and review on a regular basis eg. annually

1

2

2

Consider statin therapy (eg. Atorvastatin 20 mg daily) for those adults who have ≥ 10% 10-year risk of developing CV disease using a validated CV risk assessment tool

2

2

3

Commence high intensity statin therapy (eg. atorvastatin 80 mg daily) in adults with existing CV disease for secondary prevention. Lower doses can be chosen if there are potential drug interactions, high risk of adverse effects or patient preference

2

2

4

Commence statin therapy (eg. atorvastatin 20 mg daily) for the primary and secondary prevention of CVD in adults with chronic kidney disease (CKD). Discuss the use of higher doses with a specialist in nephrology/cardiology if eGFR < 30 mL/min

2

2

5

If total cholesterol > 9 mmol/L, non-HDL > 7.5 mmol/L or triglycerides (TG) > 10 mmol/L refer to a metabolic specialist

2

2

6

Statins with a high degree of lipophilicity eg. simvastatin may be associated with central nervous system disturbance eg. sleep disturbance, nightmares. Consider more hydrophilic statins eg. atorvastatin, pravastatin in people with SMI

2

2

7

Commence antihypertensive therapy in adults < 80 years with a clinic blood pressure of ≥ 140 mmHg systolic and/or ≥ 90 mmHg diastolic (stage 1 hypertension) and subsequent ambulatory blood pressure monitoring (ABPM) daytime average ≥ 135/85 mmHg who have one or more of the following:

i.Target organ damage

ii.Established CV disease

iii.Renal disease

iv.Diabetes (Type 1 or 2)

v.A 10 year CVD risk of ≥ 20%

2

2

8

Commence antihypertensive therapy to adults of any age with clinic blood pressure ≥ 160/100 mmHg and ABPM ≥ 150/95 mmHg (stage 2 hypertension)

1.5

2

9

Lifestyle interventions should always be part of the first line approach to reducing BMI in overweight/obese individuals with SMI

1

2

10

Lifestyle interventions should be continued alongside additional interventions to reduce BMI in overweight/obese individuals with SMI

1

1.75

11

Offer smoking cessation advice to all people with SMI who smoke.(See section E1 for full smoking cessation intervention)

1

1

12

Commence antiplatelet therapy (aspirin or clopidogrel or prasugrel or ticagrelor) in adults with SMI with a documented history of coronary, cerebral or peripheral vascular disease

2

2

13

For people who present with catatonia, consider the impact of this on mobility when assessing VTE risk and reassess where appropriate

2

2

14

Prescribe pharmacological VTE prophylaxis with low molecular weight heparin following risk assessment according to local or national clinical guidelines

2

2

If glycosylated haemoglobin (HbA1c) 42–47 mmol/mol and fasting plasma glucose (FG) 5.5–6.9 mmol/L:

15

i.offer an intensive structured lifestyle education programme

1

2

16

ii.if ineffective, consider a trial of metformin

2

2

17

In existing diabetes, if HbA1c ≥ 48 mmol/mol or FG ≥ 7.0 mmol/L refer to an endocrine specialist for optimisation of diabetic control except in older adults where a HbA1c upper limit of 58 mmol/mol is acceptable

1

2

18

Consider thyroid supplementation with levothyroxine in adults with SMI if thyroid stimulating hormone (TSH) > 10 mU/L

2

2

19

When starting levothyroxine, 50-100mcg daily is the recommended starting dose for most adults. In adults over 65 years or adults with ischaemic heart disease lower doses of 25mcg daily can be initiated

2

2

20

TFTs should be performed 4–6 weeks after starting levothyroxine and dose adjusted according to response. TSH is the most reliable marker of adequacy of replacement of treatment and a value within the reference range 0.4–4.0mIU/L) should be considered the therapeutic target

2

2

21

Adults with subclinical hypothyroidism (ie. TSH elevated but < 10mIU/L and T4 within normal range) should have their TFTs repeated within 3–6 months to exclude transient causes of elevated TSH. The measurement of thyroid antibodies in subjects with subclinical hypothyroidism helps to establish the risk of developing overt hypothyroidism

2

2

22

Do not routinely start thyroid supplementation with levothyroxine for the management of depression in a euthyroid adult or an adult with symptoms that overlap those of hypothyroidism

2

2

23

Adults with SMI with evidence of hyperthyroidism/thyrotoxicosis on blood results should be referred to an endocrine specialist

1

1

24

Monitor baseline prolactin for all people with SMI before initiating an antipsychotic known to raise prolactin

1

2

25

Systematically assess for symptoms of hyperprolactinaemia in people with SMI who are prescribed an antipsychotic at 3 months and biannually thereafter

2

2

26

If symptoms of hyperprolactinaemia appear in a person taking an antipsychotic at any stage, measure prolactin levels

2

2

27

In symptomatic hyperprolactinaemia, where a dose reduction or a switch to an alternative antipsychotic with a lower potential to elevate prolactin is not possible, consider adjunctive aripiprazole at a dose of 5 mg daily. Repeat prolactin levels after at least 1 week to establish benefit

1

2

28

Where prolactin levels are > 3000mIU/L, refer to an endocrine specialist to rule out other causes of elevated prolactin

2

2

29

Dopamine agonists (eg. cabergoline, bromocriptine) should not be initiated in adults with SMI for the management of hyperprolactinaemia except under specialist endocrine advice due to the risk of psychosis

1

2

30

Consider the increased risk of bleed (not limited to gastrointestinal bleed) when a selective serotonin reuptake inhibitor (SSRI), serotonin noradrenaline reuptake inhibitor (SNRI) or tricyclic antidepressant (TCA) is combined with aspirin, non-steroidal anti-inflammatory drugs (NSAIDs) and direct oral anticoagulants (DOACs)

1

2

31

Identify and manage anaemia as for the general population

1

2

32

Monitor folic acid levels periodically in people who are prescribed antiepileptic drugs and correct any folic acid deficiencies

2

2

33

Always identify and correct vitamin B12 deficiency before prescribing folic acid

1

2

34

Consider folic acid 5 mg daily for women who are pregnant or planning pregnancy and who are taking antiepileptic drugs including valproate, carbamazepine and possibly lamotrigine. Note that folic acid may reduce the efficacy of lamotrigine and monitor for deterioration in mental illness

1

2

35

Do not routinely prescribe folic acid as an augmenting agent in the treatment of depression

2

2

36

Identify and manage vitamin B12 deficiency as for the general population

2

2

37

Do not routinely prescribe Omega 3 fish oils in people with SMI

2

2

38

Ask and document smoking status for all patients with SMI

1

1

39

Opportunistically offer smoking cessation advice to all people with SMI who smoke documenting this advice and current readiness to quit eg. ‘not interested in quitting’, ‘not right time’, ‘would like to but not ready’ etc. For those not ready, check-in again on future interactions

1

1

40

For those ready to make a quit attempt consider nicotine replacement therapy (NRT), varenicline or buproprion to support smoking cessation for people who smoke more than 10 cigarettes per day or who smoke within 30–60 min of waking with consideration for contraindications and comorbidities

2

2

When selecting a pharmacological intervention, consider the following:

41

i.Combinations of different forms of NRT can be used

2

2

ii.Tobacco smoking can alter the pharmacokinetics of psychotropic medications:

42

Consider a dose reduction by up to 50% in patients taking clozapine who stop smoking abruptly. Carefully monitor for adverse effects of clozapine and destabilisation of mental illness. Perform a clozapine assay 3–5 days after dose adjustment or abrupt cessation of smoking

2

2

43

Consider a dose reduction by up to 20% in patients taking olanzapine who stop smoking abruptly. Carefully monitor for adverse effects of olanzapine and destabilisation of mental illness

2

2

44

Follow the most recent NICE/SIGN/GOLD/BTS guidance for the optimisation of medicines in COPD or Asthma

2

2

45

When managing an acute exacerbation of COPD or asthma in adults with SMI consider the potential for steroid induced mania/psychosis. Current guidance recommends prednisolone 40 mg/day for 5 days. A lower dose of 30 mg/day for the shortest possible duration may be warranted in adults with a history of psychosis/mania depending on the severity of the exacerbation

2

2

46

Inform adults with SMI who are prescribed systemic corticosteroid therapy of the risk of mania/psychosis at the point of prescribing and monitor for signs of mania/psychosis

1

1.25

Carry out a fracture risk assessment using a validated tool such as QFracture or Frax to determine the need for antiosteoporosis therapy for:

47

i.Women aged ≥ 65 years and men aged ≥ 75 years

2

2

48

ii.Adults over 50 years of age with risk factors [eg. body mass index < 18.5 kg.m2, history of falls, family history of hip fracture, oral steroid use (prednisolone > 7.5 mg/day or equivalent for ≥ 3 months, secondary causes of osteoporosis, smoking, > 14 units alcohol/week (women) or > 21 units alcohol/week (men)]

2

2

49

Adults > 50 years of age with a history of vertebral fracture should be considered for antiosteoporosis therapy with an oral bisphosphonate without necessarily requiring risk assessment or DEXA scan

2

2

50

Offer access to a combined health eating and physical activity programme to aid in the prevention of weight gain to all adults with psychosis or schizophrenia

1

1

Advise all adults aged 19–64 years to aim to achieve one of the following each week:

51

i.A mixture of moderate and vigorous aerobic activity ever week and strength exercise on 2 or more days that work all of the major muscles

2

2

52

Adequate dietary calcium consumption is recommended to meet reference intake levels of 700 mg/day in adults. Calcium supplementation can be considered if targets cannot be met by dietary intake

2

2

53

Offer smoking cessation advice to all people with SMI who smoke- see section E1 for a full smoking cessation intervention

1

2