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Psychopharmacology tip #12. This one is a thread because I'm talking about a pet peeve - Clopixol-Acuphase - how does it work, when should it be used and.... I'm going full caps here... IT'S NOT RAPID TRANQ (1/14)
Clopixol-Acuphase refers to the drug, zuclopenthixol acetate. It's a typical or first generation antipsychotic that potently binds and blocks the D2 receptors everywhere it can find. (2/14)
Zuclopenthixol comes in several forms, but its usually given orally or as the depot form, zuclopenthixol decanoate that is a very effective maintenance treatment in schizophrenia. (3/14)
It's a effective antipsychotic. A bit like clozapine, zuclopenthixol may also have some anti-aggression effects that are independent of its antipsychotic effect but the evidence is small-scale and often conflicting. (4/14)
If rapid tranq is needed for aggression, we usually turn to short acting benzo's like lorazepam, sedating antihistamines such as promethazine, or more rarely, rapid acting IM olanzapine or haloperidol. The latter are sensible if the aggression is driven by psychosis. (5/14)
There seems to be this perception that Acuphase is a more efficacious antipsychotic and that its a more powerful form of rapid tranq. It's not. (6/14)
There is no evidence that is more sedating than the others. There's no evidence that it is a more efficacious antipsychotic than olanzapine or haloperidol (clozapine is the only one with greater efficacy than these). (7/14)
Acuphase is not the meropenem of rapid tranquilisation. Plasma levels don't peak for 24-36 hours after administration. That's hardly rapid. (8/14)
The advantage of Acuphase is its duration of action. It has efficacy for 2-3 days. If you have a patient who is requiring repeated doses of IM antipsychotics over several days then Acuphase may then reduce the number of injections required. That benefits everyone. (9/14)
Clinical scenarios I have repeatedly on more than one occasion where I don't think Acuphase is appropriate.
1. Severely distressed patients who are already taking oral antipsychotics. No! This is a recipe for causing neuroleptic malignant syndrome. (10/14)
1. Severely distressed patients who are already taking oral antipsychotics. No! This is a recipe for causing neuroleptic malignant syndrome. (10/14)
2. Patients who "aren't improving quickly enough". It's the same drug as the oral and depot formulations. It's the pharmacokinetics and dosing frequency that differ. (11/14)
3. Those who need a one-off dose of rapid tranq but people think the exisiting and recommended rapid tranq options "aren't strong enough". (12/14)
Acuphase should be reserved for patients with severe acute psychosis, where oral treatment is not possible and giving one IM injection every 2-3 days is preferable to giving multiple doses of other rapid onset IM antipsychotics. (13/14)
Be mindful of the risk of neuroleptic malignant syndrome too. Once you give it, you can't take it back. (14/14)
