PROCEDURE REFERENCE NUMBER

SABP/EXECUTIVE BOARD/0017/PROCEDURE 28

PROCEDURE NAME
Medicines Procedure 28: Long Acting Antipsychotic Injections

BRIEF OUTLINE OF THIS PROCEDURE

This procedure describes the steps required for the prescribing, ordering, and
administration of long acting antipsychotic injections.

Version Number 1.0

Approving Committee Executive Board
Procedure Category Clinical
Executive Lead Chief Medical Officer
Name of Author Medicines Optimisation Committee

Date Approved 21st July 2021

Date Issued 23rd July 2021
All staff involved in ordering, prescribing, and
Target Audience
administering long acting antipsychotic injections

KEY PRINCIPLES ABOUT THIS PROCEDURE

To set out the steps needed when ordering, prescribing, and administering
1.
long acting antipsychotic injections
2. To reduce the risk of incorrect use of long acting antipsychotic injections

This Procedure has been reviewed and is compliant with the most up to date
Code of Practice and NICE Guidelines
Title of Code of Practice NICE Reference Number(s)
The Royal Marsden Manual of Clinical Clinical guideline [CG178] Psychosis and
Nursing Procedures 10th Edition, schizophrenia in adults: prevention and
available online management
 VERSION CONTROL LIST

Version Date Author Status Comment

0.1 November 2020 Alison Marshall Draft

Updated with comments

0.2 December 2020 Alison Marshall Draft from Depot working
group

Updated with comments

from liaison psychiatry
0.3 February 2021 Alison Marshall Draft
and Physical Health
lead

Updated with further

0.4 March 2021 Alison Marshall Draft
comments

0.5 May 2021 Alison Marshall Draft Consultation Document

Updated following
0.6 July 2021 Alison Marshall Draft
consultation.

1.0 July 2021 Alison Marshall Approved

Summary of Changes since Version

Numbers
(Select the appropriate action)
Original/New/Amendment/Deleted –
Page Paragraph Appendix Statement
(select the appropriate action)
This is a new procedure.
The Medicines Policy is the overarching SABP
policy

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Page 3 of 33
 Contents Page
Section Page
Version Control List 2
Summary of Changes 2
PROCEDURE SECTION
1.0 Roles and Responsibilities 4
2.0 Procedure Statement 4
3.0 Related SABP Policies 5
4.0 Glossary 5
5.0 References 5
6.0 Procedure 6
7.0 Information and Consent 7
8.0 Approval for use of LAI 8
9.0 The Prescription 9
10.0 Test doses prior to administration 13
11.0 Choosing an appropriate site 13
12.0 Preparation and Procedure 18
13.0 Contraindications and monitoring of side effects 21
14.0 Handling of LAI by Members of The Community Team 22
Administration at A Site Other Than A Person’s Home or SABP
15.0 22
Property
16.0 Ordering Supplies of LAI Medication 24
17.0 Stopping Treatment 24
18.0 Monitoring Table 24
19.0 Equality Analysis 25
Appendix 1 Atypical LAI Named patient request form 26
Appendix 2 Community Long Acting Intramuscular Injection Prescription 27
Appendix 3 Inpatient Prescription Chart – Regular LAI prescribing 29
Appendix 4 Summary of permitted adjustments to depot antipsychotic due dates 30
Appendix 5 LAI usual routes of administration and doses 30

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 PROCEDURE SECTION

1.0 ROLES AND RESPONSIBILITIES

1.1 The overarching policy for this procedure is the Medicines Policy, to view the
Executive roles and responsibilities please refer to this policy under section
six on page 13.

1.2 Prescribers are responsible for identifying which people who use our
services are appropriate for treatment with a long acting antipsychotic
injection, obtaining the required approval, prescribing clearly and legibly on
a Trust long acting antipsychotic injection prescription card, and monitoring
the ongoing effectiveness and appropriateness of the medication.

1.3 Nursing Staff are responsible for requesting the supply of medication to the
ward or team base, and, when having undertaken the required training,
administering the long acting antipsychotic injection on the date due. They
should additionally highlight to the MDT if an individual has missed their
scheduled long acting antipsychotic injection.

1.4 Pharmacy Staff are responsible for clinically screening prescriptions for
long acting antipsychotic injections and ensuring supply to the ward or team
base is made prior to the scheduled date for administration.

2.0 PROCEDURE STATEMENT

2.1 Long acting antipsychotic injections (LAIs) (also referred to as “depots”) are
indicated for the maintenance treatment in the treatment of schizophrenia,
mania, and other psychoses. They consist of both oil-based injections, e.g.
fluphenazine, and aqueous based injections, e.g. aripiprazole or
paliperidone LAIs. Across our Trust we have a number of clinics and wards
where LAIs are administered, and for some of our people who use our
services’ administration of these medicines will take place in their own
home.

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2.2 In order to ensure that people who use our services receive the best
possible standards of care, we need to maintain best evidence-based
practice and continually review our practices, skills and techniques of our
nurses. These guidelines offer clear guidance to practitioners about the
appropriate techniques, which are endorsed by the Trust. It also sets out
clear guidance about legal requirements, and guidance on dosage for LAI
preparations.

3.0 RELATED SABP POLICIES

The Medicines Policy
Infection Prevention and Control Policy
Information Governance Policy
Managing Medical Emergencies including Resuscitation and Anaphylaxis
Policy
Medicines Policy
Medicines Procedure 02 Allergy Recording
Medicines Procedure: Community Teams
Mental Capacity and Best Interests Policy
Non-medical Prescribing Policy
Records Management Policy
Waste Management Policy and Procedure
High Dose Antipsychotic Treatment (HDAT) Guidelines

4.0 GLOSSARY
BNF British National Formulary
CPN Community Psychiatric Nurse
LAI Long Acting Antipsychotic Injection
PAD Prescribing Advisory Database
SPC Summary of Product Characteristics

5.0 REFERENCES
Sussex Partnership NHS Foundation Trust Guidelines for the Administration
of Long Acting Antipsychotic Injections in Adults (Version 5 – January 2018)

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6.0 PROCEDURE
6.1 INTRODUCTION
6.1.1 Long acting antipsychotic injections (LAIs) are prescribed, according to their
licensed indications, for the maintenance treatment in the treatment of
schizophrenia, mania and other psychoses. They are usually prescribed
when the person who uses our services elects to have treatment
administered in this way out of convenience, or where adherence to oral
treatment has been unreliable or complicated in some way in the past. As
with other antipsychotic medications, however, they may give rise to
extrapyramidal and anticholinergic side effects, raised prolactin levels and
other symptoms such as sedation. Many adverse events will be dependent
on the dose, frequency, and the individual’s tolerance.

6.1.2 As with oral antipsychotics, people who use our services receiving LAIs
should be maintained under regular clinical review, particularly in relation to
the risks and benefits of the drug regimen. Whilst in secondary care the
clinician responsible will be a consultant psychiatrist or other nominated
prescriber. If the person who uses our services is discharged to their GP,
they should take on this role, referring the person who uses our services
back to secondary care if there are concerns. Shared care documents are
available via the Surrey PAD (https://surreyccg.res-systems.net/PAD/).

6.2 In accordance with NICE clinical guidelines for psychosis and schizophrenia
(2014):

6.2.1 A risk assessment should be performed by the clinician responsible for

treatment and the multidisciplinary team regarding concordance with
medication, and depot [LAI] preparations should be prescribed when
appropriate.

6.2.2 Depot [LAI] preparations should be a treatment option where a person who
uses our services expresses a preference for such treatment because of its

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 convenience, or as part of a treatment plan in which the avoidance of covert
non-adherence with antipsychotic drugs is a clinical priority.

6.2.3 For optimum effectiveness in preventing relapse, LAI preparations should be

prescribed within the standard recommended dosage and interval range.

6.2.4 Following full discussion between the responsible clinician and the person
who uses our services, the decision to initiate a long acting antipsychotic
injection should take into account the preferences and attitudes of the
service user towards the mode of administration and organisational
procedures. (For example, home visits and location of clinics)

6.2.5 Test doses should normally be used as set out in the BNF (see also Section
10, page 12) and full licensed prescribing information on injectable
antipsychotics is available from the Summary of Product Characteristics,
which can be found in the electronic medicines compendium
(www.medicines.org.uk ). (See also appendix 5 - Long acting antipsychotic
injection administration guide)
NOTE - test doses are not used for olanzapine, risperidone, paliperidone or
aripiprazole long acting injection. Where a person who uses our services is
neuroleptic naïve or has not previously been prescribed the active ingredient
(orally or IM), a trial of oral aripiprazole, olanzapine, or risperidone (for
risperidone and paliperidone) is recommended.

7.0 INFORMATION AND CONSENT

7.1 People who use our services and their family or carer must be offered clear
and accessible information in a suitable format regarding the use and
possible side effects of any injection being considered, to assist in ensuring
that full consent has been obtained before commencing treatment. A record
should be made in the person’s electronic patient record of any information
provided and in what format, and of any information offered but refused.

7.2 In seeking to inform the person who uses our services about their proposed
treatment consideration should be given to any communication barriers such

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 as the person who uses our services’ first spoken language, any sensory
loss, or learning disability. Where necessary the desired interpreting or
advocacy services should be sought prior to the appointment to ensure that
informed consent can be obtained. This must be documented in the
person’s electronic patient record.

7.3 For cultural, religious or personal reasons, some people who use our
services may be sensitive to the site used for administration and/or the
gender of the person administering the injection. Special arrangements will
need to be discussed and agreed and these special arrangements
documented in the person’s electronic patient record and on the
prescription.

7.4 Where a person who uses our services is assessed as lacking capacity the
decision to prescribe a LAI must be part of a “Best Interests” decision under
the Mental Capacity Act 2005. Full details of the decision made must be
documented in the person’s electronic patient record.

7.5 Information leaflets are available from the “Choice and Medication” website:
http://www.choiceandmedication.org/sabp/. Information is available on this
site in a variety of styles and languages. In addition, there is information
available under the heading “Handy Fact Sheets” to assist individuals in
deciding whether a LAI formulation is appropriate for them.

7.6 Additional information resources and other web links are also available from
the Royal College of Psychiatrists website https://www.rcpsych.ac.uk.

8.0 APPROVAL FOR USE OF LAI

8.1 In addition to a review of the clinical appropriateness of the prescription
when reviewed by a pharmacist, an approval process must be followed
when initiating aripiprazole, olanzapine, or paliperidone LAIs. Note that
risperidone is not generally recommended for use by SABP prescribers; the
LAI containing paliperidone, its active metabolite, is preferred.

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8.2 The Approval form (Appendix 1, and also to be found via our Trust Toolkit)
should be completed and submitted to the Chief Pharmacist, the senior
pharmacist at Farnham Road Hospital, or to a consultant member of our
Trust Medicines Optimisation Committee.

8.3 When authorisation is granted, the requestor will be informed, and an entry
will be made in the person’s electronic patient record.

8.4 Authorisation is also required if treatment is to be switched between one of

the above-named LAI, or if treatment is to be switched from the one-monthly
formulation of paliperidone to the 3-monthly formulation.

9.0 THE PRESCRIPTION

9.1 In the community, LAIs must be prescribed and their administration recorded
on the Community Long Acting Injection Prescription Chart. For inpatient
units the LAI must be prescribed on the Drug Prescription and
Administration Chart. (See Appendices 2 and 3)

9.2 The prescription must be legally written and signed by a doctor or non-
medical prescriber before the LAI can be administered to the person who
uses our services.

9.3 Where possible the prescription should be generated via the Management of
Medicines Springboard on SystmOne (the Electronic Patient Record used
by our Trust) and printed on card. This method will auto populate the
prescription with the person’s demographic details.

9.4 All aspects of the prescription should be completed by a doctor or non-

medical prescriber. The only exception to this would be any fields which
are automatically populated when a prescription form is generated via the
person’s electronic patient record as described above.

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9.5 In an emergency where no appropriate prescriber is available, and a person
who uses our services has arrived at a clinic for the administration of a LAI
and the prescription appears to be out of date, or there is no longer any
room to sign that medication has been given on the current prescription
chart, a verbal instruction to administer the medicine may be issued, as
described in the current version of our Trust Medicines Policy.

9.6 Prescription details on the Community Long Acting Injection Prescription

Chart must include:
• The person who uses our services’ full name, not an assumed name
• The person who uses our services’ address
• The person who uses our services’ NHS number
• The people who use our services’ date of birth.
• Any known allergies or sensitivities, including sensitivities to
dressings/ plasters. If none, then ‘no known drug allergies’ must be
written. THIS SECTION MUST NOT BE LEFT BLANK. See also our
Trust Medicines Procedure 02 Allergy Recording
• Special notes, (i.e. only accepts the injection lying down, prefers a
particular site)
• The drug name, dosage, strength, and frequency of administration
• The date that the last injection was administered unless this is the
first dose of any LAI.
• Details of their GP, next of kin, and side effect monitoring are
considered desirable information to have available on the
prescription card.
• The prescriber’s signature.

9.7 Prescriptions are only legal for six months and therefore must be reviewed
by the responsible prescriber at least every six months.

9.8 The nurse’s signature must then be added in the relevant section of the
prescription / administration chart when the medication has been given,

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 along with details of the site where the medication has been given (see also
Section 11, page 13), indicating
• Ven R = Ventrogluteal - right
• Ven L = Ventrogluteal - left
• Dor R = Dorsogluteal – right
• Dor L = Dorsogluteal - left
• Del R = Deltoid – right
• Del L = Deltoid - left
• Oth R = Route not recommended first line - right. Record in the
person’s electronic patient record the route and the reason why
selected.
• Oth L = Route not recommended first line - left. Record in the
person’s electronic patient record the route and the reason why
selected.

9.9 On no account may a nurse make alterations to the prescription for LAIs,
with regard to type or dosage, unless they are a qualified supplementary
prescriber acting within an agreed clinical management plan, or an
independent prescriber authorised by our Trust to prescribe in this area of
practice.

9.10 In circumstances where a person who uses our services is unwilling to

accept the prescribed dose, the nurse must then liaise with the prescriber at
the earliest opportunity to establish what action to take. If the person who
uses our services indicates that they would be willing to accept a lower dose
and the prescriber agrees then a new prescription is required. If the
prescriber is not on site, then an email should be used to confirm the change
in dose; the dose must be countersigned by the prescriber within one
working day (see the Trust Medicines Policy). The new dose must be either
written onto a new Community Long Acting Injection Prescription and the
dose reviewed by the prescriber responsible for the care of that person who
uses our services, or if an inpatient the dose must be recorded in the ‘Once
only prescriptions’ section of the Drug Prescription and Administration Chart

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 and the dose reviewed by the prescriber responsible for the care of the
person who uses our services. A record of the discussion and decision
made must be made in the person who uses our services’ electronic patient
record.

9.11 It is preferred that people who use our services only attend for their LAI
medication on the next due date but in reality, this does not always happen
and occasionally people attend clinics slightly earlier or later, out of greater
convenience. Where people who use our services attend for their injection
slightly earlier or later than the next due date, it is considered acceptable for
nursing staff to use their discretion as to whether to give the medication
slightly out of prescribed schedule, or ask the person who uses our services
to return on the date the LAI is actually due. (See appendix 4 for guidance).

9.12 Detailed information can also be found in the Summary of Product

Characteristics (SPC) www.medicines.org.uk, or sought from the pharmacy
team on how early or late administration can be carried out. Any
administration outside of the window specified by the manufacturer will be
classified as off-label use.

9.13 In some cases, a dose adjustment may be required, or additional oral

medication may be required in order to achieve therapeutic plasma levels
rapidly. See manufacturer’s guidance for details. Such dose adjustments or
oral treatment should be prescribed accordingly. Care must be taken to
ensure that the person using our services is aware of the short-term nature
of such oral supplementation. The prescriber should ensure that all those
involved in the care of the individual (eg primary care, other secondary care
specialists) are advised of the nature of any dose adjustment or additional
oral treatment.

9.14 Any change to the scheduled administration date or dose must be

documented in the person’s electronic patient record.

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9.15 Where an individual does not attend for their scheduled appointment every
possible opportunity should be used to ascertain the reason for this. Every
attempt to contact the person must be documented in their electronic patient
record. The consultant should be advised of the person’s nonattendance at
the earliest opportunity and a plan for further attempts to administer the
medicine, and any treatment adjustments to be made must be documented.

10.0 TEST DOSES PRIOR TO ADMINISTRATION

10.1 LAIs are long-acting medications that take a long period to fully wash out of
the body. Therefore, adverse effects, which result from injection, are likely to
be long-lived. With the exception of olanzapine, risperidone, paliperidone
and aripiprazole long acting injections, it is recommended that people who
use our services are given a small test dose before the onset of the
therapeutic dose for treatment, to avoid severe and prolonged adverse
effects. (NB the test doses are to ensure there is no reaction to oil-based
carrier).

10.2 A table of LAI suggested doses and frequencies, as provided within the
Maudsley Prescribing Guidelines in Psychiatry, which includes details of test
doses can be found in Appendix 5 of this guidance.

11.0 CHOOSING AN APPROPRIATE SITE

11.1 Most LAI are administered by deep intramuscular injection. Although other
intra- muscular sites are considered possible, the Trust primarily endorses
use of the ventrogluteal muscle, which is shown in the figures 1 and 2
below. This is based upon recent literature, which supports the fact that this
is a lower risk site in terms of potential harm to the person who uses our
services, and facilitates the LAI being effectively given into the muscle,
rather than inadvertently into the sub-cutaneous (fatty) tissues from which
absorption of the drug will be significantly delayed. Delayed absorption could
have a number of consequences, e.g. the dose may be inappropriately
increased as the anticipated response is not seen. Some medications, such
as zuclopenthixol decanoate, are only licensed for administration in the
dorsogluteal site so in these circumstances’ practitioners should follow the

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 dorsogluteal site guidance below. Details of the licensed sites are found in
Appendix 5.

11.2 Because historically nurses have predominantly used the dorsogluteal route,
this route is still approved for use until training in how to administer using the
ventrogluteal route has been proved for individuals. It is also recognised that
some people who use our services are less likely to be receptive to changes
to their injection site, and person who uses our services preference must
also be considered when selecting a site for injection.

11.3 Several LAIs are licensed for deltoid use. In the case of paliperidone LAI the
deltoid route is the licensed method for the loading dose as the
pharmacokinetics are more favourable.

11.4 Ventrogluteal site - research indicates that the ventrogluteal site is a safer
site for administration of deep intramuscular injections than other sites. This
is because it is well land-marked, allowing the nurse to easily locate it, and it
is relatively free of major blood vessels and nerves, thus reducing the risk
associated with damaging the sciatic nerve and superior gluteal artery,
which are both closely located to the dorsogluteal site. In some
circumstances, for example where the person who uses our services
chooses not to have the injection into this site, another site can be
considered for use where licensing permits; this would usually be either the
dorsogluteal muscle or lateral thigh.

11.4.1 Women tend to carry more sub-cutaneous (fatty) tissue at the ventrogluteal
site than men, so this should be considered when choosing the length of
needle to use. Greater consideration should be given to using a 50 mm
needle as this is preferential in terms of ensuring the medication is delivered
into the muscle, unless the person who uses our services is underweight.

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Figure 1 - Ventrogluteal site (NB for illustrative purposes only – consider risk of
needlestick injury when positioning hands)

Figure 2 Ventrogluteal muscle

11.5 Dorsogluteal site - research suggests that for clients receiving deep
intramuscular injections into the dorsogluteal site, who have a BMI of in
excess of 30, or where visual assessment of the site indicates, a needle of
at least 40mm should be used to ensure that medication is delivered into the
muscle and not the subcutaneous (fatty) tissue between the muscle and
skin.

11.5.1 Women tend to also carry thicker layers of subcutaneous (fatty) tissue in the
dorsogluteal area and this should be considered when choosing the site for
administration of deep intramuscular injection and choosing needle length.

Figure 3 - Dorsogluteal Site (NB for illustrative purposes only – consider risk
of needlestick injury when positioning hands)

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 Figure 4 Dorsogluteal muscle

11.6 Deltoid muscle - The Royal Marsden Guidelines state that the maximum
limit for administration into this site is 2mls. Where a needle is provided with
the product this must be used for administration.

Figure 5 Deltoid site (NB for illustrative purposes only – consider risk of
needlestick injury when positioning hands)

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 Figure 6 Deltoid muscle
11.7 Note: As a general rule, not more than 2–3 mL of oily injection should be
administered at any one site (BNF); always refer to the manufacturer’s
information.

11.8 Slow administration can result in a larger volume being tolerated. Hence it is
recommended that injections are administered no faster than 1mL over 10
seconds.

11.9 Tissue Viability - in circumstances where medication given as a deep

intramuscular injection is inadvertently deposited into the subcutaneous
(fatty) tissue, there is an increased risk of granuloma, sterile abscess,
redness and swelling at injection site, ulceration of tissue and ultimately fat
necrosis.

11.10 Use of alternative sites to those recommended first-line or sites that are “off
label” - in instances where it appears that the amount of subcutaneous
(fatty) tissue is too great for the needle to deposit the medication into the
muscle, or where the person who uses our services chooses not to have the
injection in the clinically preferred site, a full discussion should take place
involving the consultant psychiatrist, the prescriber (if not the consultant),
the pharmacist and the designated nurse. This discussion and its conclusion
should then be fully recorded in the person’s electronic patient record. The
nurse/doctor should be given the relevant training and supervised practice to

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 equip them to administer into an alternative site safely, and without
compromise to person who uses our services’ care or safety.

11.11 In such circumstances the person’s electronic patient record should

demonstrate their involvement in the decision.

12.0 PREPARATION AND PROCEDURE

12.1 The nurse administering the injection will need:
• 2 - 5ml syringe
• Green 21 gauge 38mm or 50mm needle (Note - the majority of LAI
will be provided with an appropriate sized needle by the
manufacturer)
• Needle for drawing up injection – Pink 18 gauge 40mm needle
• Gloves
• Alcohol swab
• Non-woven gauze swab (in case of seepage from injection site)
• Small plaster (optional)
• Prescribed medication
• Prescription chart (community or inpatient)
• Sharps container
• Appropriate tray or space for preparation

12.2 Confirm that the injection is due for the identified person who uses our
services or has not already been administered before assembling the
equipment by checking the prescription, the administration record and
whenever possible with the person who uses our services. See also the
Medicines Policy for the principles around administration of medicines.

12.3 Explain to the person who uses our services the procedure and which site
you will be using. Seek confirmation of person who uses our services’
consent. If there are problems with communication offer information in
another format or consider advocacy or interpreter services documenting
what action has been taken in the person who uses our services’ electronic

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 patient record. If the person who uses our services does not consent to this
site, consider another site, being aware of potential licensing implications.

12.4 Record in the person who uses our services’ electronic patient record that
verbal consent has been obtained and if an interpreter was used or
information was provided in another format, this should also be recorded in
the person’s electronic patient record.

12.5 Prior to preparation of medication, it is vital to identify an area where the

qualified nurse will not be disturbed, that provides confidentiality for the
person who uses our services and where there is appropriate facility for the
disposal of sharps - either a sharps box within a clinical area or a portable
sharps container for use in the community. See also section 15, page 22 for
guidance on administration at a location other than a trust site.

12.6 The qualified nurse should wash their hands before preparing the person
who uses our services and the medication to be administered.

12.7 Draw up the prescribed dose of medication immediately prior to the

injection, using an appropriate sized needle. Where a needle is provided
with the product this must be used for the preparation or administration as
per the manufacturer’s guidance.

12.8 Some of the LAIs require vigorous shaking prior to administration which can
be for as much as 30 seconds. Other products may have specific handling
requirements prior to administration. Full details are included in the package
insert, or available via the summary of product characteristics
(www.medicines.org.uk).

12.9 Change needle according to the product instructions and use the relevant
gauge and length needle to administer, ensuring people who use our
services who have a higher BMI have the correct length needle.

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12.10 Choose a site for the injection. In general not more than 3mLs of oily
injection should be administered at any one time in a gluteal site, and no
more than 2 mLs at the deltoid site.

12.11 Ask the person who uses our services to expose thigh, buttock or arm for
injection, using the opposite side to that of the one injected previously.

12.12 The guidance provided in the Royal Marsden Manual of Clinical Nursing
Procedures should be followed regarding skin preparation prior to
administration.

12.13 Examine site for evidence of lesions and establish that the site is pain free.
Seek clarification again that the person who uses our services is happy to
have medication given at this site. If the site is not intact or the person who
uses our services is not happy with another of the clinically preferred sites
indicated in this guidance, further discussion with the multi-disciplinary care
team should be initiated.

12.14 Administer the long-acting antipsychotic injection using the Z-track

technique as shown below.

12.15 Z-Tracking technique

12.15.1 Stretch/displace the skin by pulling it laterally away from the intended point
of injection.

12.15.2 Insert the needle into the site at a 90˚ angle. When using the dorsogluteal
site, aspirate by pulling back on the plunger for 5 seconds, allowing time for
any blood to travel from a penetrated vessel up the bore of the needle. If
blood is aspirated withdraw the needle, seal the wound and repeat the
procedure at another site with new equipment and medication. If no blood is
aspirated administer the injection at a rate no faster than 1mL over 10
seconds.

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12.15.3 Wait 10 seconds then withdraw the needle and release the skin allowing the
displaced tissue to seal the needle track

Figure 4 – Z- tracking technique

12.15.4 Dispose of sharps and equipment at the point of use in accordance with the
Waste Management Policy and Procedure.

12.15.5 Do not massage the site after the injection as this can promote dispersal into
the subcutaneous fatty tissue. Wipe the site with gauze if any medication or
blood oozes from it, and if the person who uses our services is not allergic to
them, apply a plaster (optional).

12.16 Immediately record the administration on the community long acting

intramuscular injection prescription chart, or the inpatient drug prescription
and administration chart, and in the person who uses our services’
electronic patient record.

12.17 Calculate the next due date for administration. This should be discussed with
the person who uses our services, and recorded on the prescription card,
and according to local procedure to ensure other members of the team are
aware of the due date.

13.0 CONTRAINDICATIONS AND MONITORING OF SIDE EFFECTS

13.1 Throughout treatment, contraindications to the prescribed medication must
be considered. Any concerns must be discussed with the prescriber and
documented in the person who uses our services’ electronic patient record.

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13.2 People receiving treatment with olanzapine LAI require a 3-hour period of
monitoring after administration of the injection. See our Trust Prescribing
Guidance – Olanzapine LAI available via Trustweb Toolkit.

13.3 As a benchmark and to establish the impact of side effects, all people who
use our services will be offered the opportunity to complete either a Glasgow
Antipsychotic Side-effects Scale (GASS) if receiving treatment with
aripiprazole, olanzapine, paliperidone or risperidone, or other appropriate
validated scale to measure the impact of the side effects of their LAI. This
should be offered routinely at least every 6 months, prior to the
prescription’s six-monthly review and approximately six weeks after initiation
of a LAI or when there has been dosage alteration.

13.4 Completion of the GASS (found on Trustweb Toolkit) or other validated side
effect rating scale can be carried out either in the depot clinics, by the care
coordinator or on the ward.

13.5 If the dose needs to be reduced to alleviate side effects, it is important to

recognise that the plasma-drug concentration may not fall for some time
after reducing the dose. It may take a month or longer before side effects
subside. Side effects should be reassessed by repeating GASS or other
appropriate side effect rating scale approximately 6 weeks after the dose
alteration.

13.6 Additional recommended monitoring for people who receive antipsychotic

medication is available within the Trust Best Practice Guidelines for
Psychotropic Monitoring (found on Trustweb Toolkit).

14.0 HANDLING OF LAI BY MEMBERS OF THE COMMUNITY TEAM

14.1 See the Medicines Procedure: Community Teams for details of all aspects
of medicines management within the community team, with particular
reference to record keeping and transportation.

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15.0 ADMINISTRATION AT A SITE OTHER THAN A PERSON’S HOME OR
SABP PROPERTY
15.1 If people who use our services who receive long-acting antipsychotic
injections are admitted to a general hospital ward and their dose is due, it is
vital that the Trust team and the acute hospital team liaise closely with
regard to the action to be taken.

15.2 The Community Psychiatric Nurse (CPN) may need to liaise with the
psychiatry consultant in charge in the community (who has overall
responsibility for the prescription) to ensure that they are happy for the
injection to be given, in light of their physical co-morbidities.

15.3 Whilst it is permissible for a Community Psychiatric Nurse (CPN) to visit the
ward to administer the LAI, this must only occur following consultation with
the ward medical team, in order to establish the physical well-being of the
person who uses our services and the assessed appropriateness of
administering the injection on the date it is due. Once it is agreed that the
injection should proceed, the CPN may attend the ward with the medication,
(and must also take a copy of the valid prescription). In addition:

15.4 Before administration, the LAI must be prescribed on the acute trust drug
chart or e-prescribing system by a prescriber authorised to do so.

15.5 Before administration, the LAI preparation must be examined and confirmed
by the nurse in charge of the ward or by the ward doctor.

15.6 Administration must be checked / witnessed by a qualified member of the

ward nursing team and the administration recorded on the ward drug chart
or e-prescribing system by that nurse.

15.7 Following administration, the CPN must ensure that a full record of
administration is also made on the Trust LAI prescription / administration
chart and must ensure that an appropriate entry is made in the person’s

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 electronic patient record, as well as the records held by the acute hospital
trust.

15.8 Note that it is vitally important that early planning and liaison occur (where
possible) with the acute hospital team in order to ensure that the LAI is
prescribed on their chart / system on or before the CPN’s arrival on the
ward. If the LAI is not prescribed on the acute trust chart or e-prescribing
system, then administration cannot take place.

16.0 ORDERING SUPPLIES OF LAI MEDICATION

16.1 LAI are obtained via a number of different routes in order to maximise
efficiency and minimise the financial cost of these medications.

16.2 The table below shows the preferred source of medications for community
teams
Aripiprazole Ordered for individual Order via an FP10 prescription from local
patients community pharmacy
Flupentixol Normally held as stock Order from SABP pharmacy as “stock”
Decanoate by community teams
Haloperidol Normally held as stock Order from SABP pharmacy as “stock”
decanoate by community teams
Olanzapine Ordered for individual Order via an FP10 prescription from local
pamoate patients community pharmacy
Paliperidone Ordered for individual Order via community pharmacy or registered
palmitate patients delivery service.
Risperidone Ordered for individual Order via community pharmacy or registered
patients delivery service as above
Zuclopenthixol Normally held as stock Order from SABP pharmacy as “stock”
Decanoate by community teams

17.0 STOPPING TREATMENT

17.1 When treatment is to be stopped any outstanding prescriptions held with a
community pharmacy, the SABP pharmacy, or registered delivery service
must be immediately cancelled by the team to avoid wastage.

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17.2 The person’s GP must be contacted by the team to advise that the treatment
has been stopped or altered. They should be asked to update the person’s
Summary Care Record accordingly.

18.0 MONITORING TABLE

The monitoring table for this procedure can be located in the Medicines
Policy which is the overarching policy for this document.

19.0 EQUALITY ANALYSIS

The equality analysis for this procedure can be located in the Medicines
Policy which is the overarching policy for this document

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 APPENDIX 1

Atypical LAI Named Patient Request Form

Patient initials:

Is this person detained under the Mental Health Act?

Date of Birth:

NHS number:

Treatment Requested:

Requesting Consultant:

Care setting:

If inpatient, is the request supported by the inheriting community consultant?

Name of ‘inheriting community’ consultant:

Give specific reasons for the request including details of the previous treatment, length of
previous treatments, and response to previous treatments in terms of both efficacy and side
effects.

Please indicate whether the patient has been admitted to acute care services in the last two
years and if admitted, state the length of the admission in days.

Describe how you will measure the benefit of treatment and frequency of review

Signature of Consultant………………………………………. Date

Date Received by Chief Pharmacist

Outcome of Review

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 PHOTOGRAPH

CHECK for consent

to take and store
photograph

CHECK photograph Appendix 2

is up to date
COMMUNITY LONG ACTING INTRAMUSCULAR INJECTION PRESCRIPTION
Title Surname Forenames Cons Team Name Team Base
ultant

DoB Other names used Address

NHS number Patient’s phone no. G.P. Contact person (relative or

carer)

Care Coordinator or CPN Known allergies/sensitivities Contact person’s phone

no.

Drug, dose and date of last injection given prior to this card (if applicable):
For a list of injection site codes - see overleaf

Special instructions (PTO if necessary)

Date last GASS2 completed: ……………………………
Date next GASS2 due: ……………………………
Date Drug (approved name) Date Drug (approved name)

Dose Injection site Frequency1 Valid Dose Injection Frequency1 Valid

until site until

Prescriber’s signature Prescriber’s name Prescriber’s signature Prescriber’s name

IMPORTANT – Each prescription can only be IMPORTANT – Each prescription can only
valid for a maximum of six months4 be valid for a maximum of six months4
Date Administered Site – Date of next Pharm. Date Administered Site – Date of Pharm.
given3 by (signature) Left or dose given3 by (signature) Left or next dose
Right Right

1. Be precise in describing the required frequency. “2 weekly” and
“monthly” are ambiguous. Write “Every 2 Weeks” and “Every calendar
month”. If ‘Every calendar month’ put the day of the month in the
special instruction box, e.g. ’The second Tuesday of every month.’
2. GASS = Glasgow Antipsychotic Side-effect Scale.
3. Seek advice from pharmacy if the injection needs to be given earlier
or later than the prescribed date.
4. The patient must be reviewed at a minimum of six monthly by
the prescriber using the multidisciplinary team notes.
5. If admitted, review this card and write a new one on
discharge for the community team.
6. Once no longer valid this prescription card must be scanned
and filed in the patient’s notes.
Ensure medications which are stopped are clearly crossed
through to avoid inadvertent administration

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 Injection site codes
Ven = Ventrogluteal right/left
Dor = Dorsogluteal right/left
Del = Deltoid right/left
Oth = Route not recommended first line - right/left.
Record in the notes the route and the reason why selected.

Special instructions continued:

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 Appendix 3

INPATIENT PRESCRIPTION CHART – SECTION FOR REGULAR LAI

PRECSRIBING

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 Appendix 4
Summary of permitted adjustments to depot antipsychotic due
dates
Drug name Frequency Earliest this depot Latest this depot can be given
can be given without adjustment (maintenance)
(maintenance)
Monthly 26 days after the
Aripiprazole 2 weeks after due dose.
(after 4th dose) previous dose.

Weekly 2 days before due date 2 days

Flupentixol 1 week, then give fortnightly from that

2 weekly 2 days before due date
decanoate date

3 or 4 weekly 2 days before due date 1 week, then carry on as before

(may need anticholinergic)

2 weekly 2 days before due date 6 days after due dose

Haloperidol 1 week after due dose and resume

3 weekly 2 days before due date
decanoate previous routine
2 weeks after due dose and resume
4 weekly 2 days before due date
previous routine
12 days after the
2 weekly 1 week after due dose
Olanzapine previous dose.
pamoate 24 days after the
4 weekly 2 weeks after due dose
previous dose
Up to and including 6 weeks after the
1 week before due
Monthly previous dose. Next dose given after 1
Paliperidone date.
month
palmitate
2 weeks before due 4 weeks after due dose then resume 3-
3 monthly
date monthly schedule

Weekly 2 days before due date 2 days

Zuclopenthixol 1 week, then give fortnightly from that

2 weekly 2 days before due date
decanoate date

3 or 4 weekly 2 days before due date 1 week, then carry on as before

(may need anticholinergic)

References
1. Bazire Stephen, Psychotropic Drug Directory. 2018 ed Lloyd-Reinhold Publications;216-225
2. Taylor, David et al. The Maudsley Prescribing Guidelines in Psychiatry.13th ed Wiley Blackwell;66-77
3. Summary of Product Characteristics. www.Medicines.org.uk
4. British Medical Association, Royal Pharmaceutical Society. British National Formulary. Psychosis and
Schizophrenia. 75th ed Pharmaceutical Press, BMJ Group; Sept 2018-March 2019:387-400
5. Eli Lilly and Company Limited,ukmedinfo@lilly.com
6. Janssen-Cilag Ltd,medinfo@janssen-cilag.co.uk

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Appendix 5 Taken from Taylor DM, Barnes TRE, Young AH. The Maudsley Prescribing Guidelines in Psychiatry, 13th Edition, 2018

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