DEPOT ANTIPSYCHOTIC MEDICATION:

GUIDELINES FOR PRESCRIBING

AND ADMINISTERING

FEBRUARY 2020

This policy supersedes all previous policies

Policy title Depot Antipsychotic Medication: Guidelines for Prescribing and Administration
Policy PHA04
reference
Policy category Clinical
Relevant to All Clinical staff
Date published 2019
Implementation February 2020
date
Date last December 2016
reviewed
Next review February 2023
date
Policy lead Lucy Reeves, Chief Pharmacist

Contact details Email:lucy.reeves@candi.nhs.uk

Accountable Dr Vincent Kirchner, Medical Director
director
Approved by Drugs and Therapeutic Committee
(Group):
February 2020
Approved by Quality Committee
(Committee):
Document Date Version Summary of amendments
history
March 2009 3 Routine review
April 2010 4 Routine review
March 2012 5 Routine review
Nov 2014 6 Routine review
Route of aripiprazole depot updated to include
deltoid. Paliperidone three monthly depot is added.
Dec 2016 7
Olanzapine depot monitoring advice updated.
Administration of depots under restraint added.
Feb 2020 8 High dose antipsychotic monitoring form removed
Membership of
the policy Dr Julian Summerfield (Consultant Psychiatrist, Lead Pharmacists, Modern Matrons,
development/ Consultant Nurse for Physical Health
review team

Consultation
Drug and Therapeutic Committee members

DO NOT AMEND THIS DOCUMENT

Further copies of this document can be found on the Foundation Trust intranet.

I DEPOT ANTIPSYCHOTIC MEDICATION GUIDELINES_PRESCRIBING_ADMINSTRATION_PHA04_FEB 2020

 Contents Page
1 Introduction 1

2 Aims and objectives 1

3 Scope of the policy 1

4 Prior to initiation of depot treatment 1

5 Advice on prescribing depot antipsychotics 1

6 Use of unlicensed doses 16

7 Administration of depot antipsychotic medication 16

8 Use of alternative sites or sites which are off-label 18

9 Depots/LAIs administered under restraint 19

10 Generic names/Brand names 19

11 Management of patients on long term depot antipsychotics in relapse 19

prevention
12 Intramuscular anticholinergic medication 21

13 Primary care involvement 22

14 Zuclopenthixol acetate (Clopixol acuphase) 22

15 Related policies 22

16 Dissemination and implementation arrangements 22

17 Training requirements 22

18 Monitoring and audit arrangements 22

19 Review of the policy 23

20 References 24

Appendix 1: Equivalent doses of antipsychotics 28

Appendix 2: Sites Of Administration 29

Appendix 3: Equality Impact Assessment Form 30

II DEPOT ANTIPSYCHOTIC MEDICATION GUIDELINES_PRESCRIBING_ADMINSTRATION_PHA04_FEB 2020

1 Introduction

1.1.1 Antipsychotic depot / long acting injections (LAI) preparations are used for
maintenance therapy in the treatment of schizophrenia, especially when
adherence with oral treatment is unreliable.

2 Aims and objectives

2.1.1 To provide guidance on prescribing antipsychotic depot/long-acting injections

(LAIs).

3 Scope of the policy

3.1.1 This policy is aimed at all clinical staff who are directly involved in the
management of patients who are prescribed depot/LAI antipsychotic
preparations.

4 Prior to initiation of depot treatment

4.1.1 Depot preparations should be a treatment option where a service user

expresses a preference for such treatment after an acute episode because of
its convenience, or as part of a treatment plan in which the avoidance of covert
non-adherence (intentional or unintentional) with antipsychotic medication is a
clinical priority1.

4.1.2 Following full discussion between the responsible clinician and the service
user, the decision to initiate depot antipsychotic injections must 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) related to the delivery of regular intramuscular injections1.

4.1.3 As with oral antipsychotics, service users receiving depots must be

maintained under regular clinical review, particularly in relation to the risks
and benefits of the medication regimen.

5 Advice on prescribing depot antipsychotics

5.1 Choice of depot antipsychotic

5.1.1 The choice of depot medication is determined by the needs of the individual
service user. There are few differences between individual older long-acting
antipsychotics. Fluphenazine may be associated with relatively more
extrapyramidal side effects but perhaps less weight gain. Flupenthixol,
halopepridol and fluphenazine are considered equally effective. Zuclopenthixol
may be more effective in preventing relapses than others, although this may be
at the expense at the increased burden of side effects. Flupenthixol decanoate
can be given in very much higher “neuroleptic equivalent” doses than the other
depot antipsychotics and still remain “within BNF limits”, although it is doubtful
that this confers any real therapeutic advantag e 2 . The typical depot
antipsychotics should be considered first-line.

1
5.1.2 These medicines are long-acting preparations. Therefore service users should
be exposed to the oral form of the medicine (or a test dose of the injection)
prior to their first full dose of the injection to minimise the possibility of a long-
lasting idiosyncratic reaction. Patients must be offered a patient information
leaflet from the Choice and Medication website located on the intranet.

5.2 Dosages - First generation long-acting antipsychotic injections

5.2.1 For first generation long-acting antipsychotics, a test dose must be given. This is
a test of the sensitivity or extrapyramidal side effects and any sensitivity of the
base oil2. The allergy status for the medicines and base oil (e.g. sesame oil,
vegetable oil derived from coconuts) or excipients e.g. benzyl alcohol must be
checked and documented in Electronic patient record (Carenotes).

5.2.2 Begin with the lowest therapeutic dose. There is some information that low
doses are at least as effective as higher doses. Low doses are likely to be better
tolerated2.

5.2.3 See table 1 for when the next dose should be administered.

5.2.4 Oral antipsychotics may also be prescribed initially. These should be gradually
reduced and stopped once therapeutic maintenance dose has been established.
If the total dosage exceeds BNF limits, the trust High Dose Antipsychotic
Therapy guidelines must be implemented (see appendix 1).

5.2.5 The depot should be administered at the longest possible licensed interval,
bearing in mind the maximum recommended single dose. There is no evidence
to suggest that shortening the dose interval improves efficacy. Injections are
painful, so less frequent administration is desirable2.

5.2.6 The observation that some patients deteriorate in the days before the next dose
is due is not supported by fact. For some hours to days (with some
preparations), plasma levels of antipsychotics continue to fall, albeit slowly after
the next injection. Thus patients are most at risk of deterioration immediately
after a long-acting injection and not before it. In most trials, relapse occurs only
three to six month after withdrawing therapy. This is roughly the time to clear
steady state long-acting medicines from the blood2.

5.2.7 Doses should be adjusted after an adequate period of assessment. Attainment

of peak plasma levels, therapeutic effect and steady-state plasma levels are
delayed with the long-acting injections1. Attainment of steady state usually takes
three months for first-generation antipsychotic depots3. Doses may be reduced
if adverse effects occur, but should only be increased after careful assessment
over at least one month, preferably longer1.

5.2.8 When swapping from one first generation antipsychotic depot to another first
generation antipsychotic depot, a direct exchange from one depot to another
can usually be made3. If the person has not previously had the new depot,
ensure tolerability is checked first with a test dose.

5.2.9 When swapping from a combination of oral antipsychotics plus depot to a depot
alone, relapses are more likely in the first three to four months. If the risk of
2
 relapse is high, consider increasing the depot dose and then reduce the oral
doses later3.

5.2.10 When swapping from a first generation antipsychotic depot to another

antipsychotic, stop the depot and introduce the new antipsychotic when the next
depot date is due, remembering that a slow decay of depot plasma levels may
occur. So be aware of adding the new medicine too quickly3.

Table 14-12:
Medicine Test dose Dose range Interval
First generation long-acting antipsychotics
Fluphenazine in 12.5mg (6.25mg in patients 12.5-100mg every Reasonable steady state
sesame oil over 60 years) two to five weeks is achieved at intervals of
two to four weeks
Flupenthixol in thin 20mg (consider 5- 10mg in 50 every four Weekly to four weekly
vegetable oil elderly patients) weeks -
(derived from 400mg/week
coconuts)
Haloperidol in 50mg every four weeks (12.5 50-300mg every Four weekly
sesame oil – 25mg every four weeks in four weeks
elderly patients)
Zuclopenthixol in 100mg (consider 25-50mg in 200-600mg every Weekly to four weekly
thin vegetable oil elderly patients) one to four weeks.
(derived from Maximum: 600mg
coconuts) every week.
Second generation long-acting antipsychotics
Aripiprazole (powder None. Response & tolerability 300-400mg/month Four weekly
and solvent for to oral aripiprazole must be
prolonged release checked prior to initiating the
suspension) depot.
Olanzapine (powder None. Tolerability to oral 150mg every two Two to four weekly
and solvent for olanzapine must be checked weeks to 405mg
prolonged release prior to initiating the depot. every month
suspension)
Paliperidone LA None. Response and 25-150mg/month Four weekly
(prolonged release tolerability to oral risperidone
suspension) must be checked prior to
initiating the depot.
Paliperidone three None. Stabilisation with 175-525mg/ three Three monthly
monthly (prolonged paliperidone monthly depot months
release suspension) for at least four months must
(Trevicta) have preceded initiation
Risperidone (powder None. Response and 25-50mg/2weeks Two weekly
and solvent for tolerability to oral risperidone
prolonged release must be checked prior to
suspension) initiating the depot.

3
5.3 Dosages - second generation long-acting antipsychotic injection

5.3.1 Second generation long-acting antipsychotic injections have a relatively lower

propensity for extrapyramidal side effects2.

5.3.2 Second-generation long-acting antipsychotic injections do not require test

doses2. Patients to be prescribed risperidone injection or paliperidone monthly
depot must be prescribed oral risperidone first to check for tolerability and
response to treatment. Patients prescribed paliperidone three monthly depot
must be preceded by paliperidone monthly preparation. Patients prescribed
aripiprazole or olanzapine depot must be prescribed the respective oral
formulation first to check tolerability and response to treatment4.

5.4 Risperidone long acting injection

5.4.1 A test dose is not required, however response and tolerability to oral
risperidone must be confirmed before starting the depot formulation. See
table 2.

5.4.2 The recommended dose is 25 mg intramuscularly every two weeks. For those
patients on a fixed dose of oral risperidone for two weeks or more, the following
conversion scheme should be considered. Patients treated with a dosage of 4
mg or less oral risperidone should receive 25 mg, while patients treated with
higher oral doses should be considered for the higher dose of 37.5 mg.
Sufficient antipsychotic coverage should be ensured during the three-week lag
period following the first injection. Where patients are not currently taking oral
risperidone, the recommended dose is risperidone injection 25mg every two
weeks.

5.4.3 In the elderly, no dose adjustment is required from the recommendation in 5.4.2.
However there have been anecdotal cases of reduced mobility.

5.4.4 Deltoid and gluteal intramuscular injections at the same doses are bioequivalent
and, therefore, interchangeable12.

5.4.5 After a single intramuscular injection with risperidone injection, the release
profile consists of a small initial release of risperidone (<1% of the dose),
followed by a lag time of 3 weeks. The main release of risperidone starts from
Week 3 onwards, is maintained from 4 to 6 weeks, and subsides by Week 7.
Oral antipsychotic coverage should therefore be given during the first 3 weeks
of treatment. Oral antipsychotic supplementation on a reducing titration is
sometimes required for longer (6-8 weeks)2,12.

5.4.6 The depot must be administered every two weeks as the pharmacokinetic
profile does not allow for longer intervals.

5.4.7 Opinions on the dose equivalence vary depending on the reference used.
Doses of 25-50mg every 2 weeks m a y equate to oral doses of 1-
4mg/day2,3.

5.4.8 It must be stored in the fridge.

4
5.4.9 Risperidone injection must be administered every two weeks by deep
intramuscular deltoid or gluteal injection. Only needles supplied with the packs
should be used. For deltoid administration, use the 1-inch needle alternating
injections between the two arms. For gluteal administration, use the 2-inch
needle alternating injections between the two buttocks.

5.4.10 Switching to risperidone long-acting injection

Table 2: Switching to or from risperidone long-acting injection2, 3, 12

Switching Recommended method of switching Comments
from

No treatment Start risperidone oral at 2mg/day and Use oral risperidone before
(new patient titrate to effective dose. If tolerated, giving injection to assure good
or recently prescribe equivalent dose of risperidone tolerability. Those stabilised on
non- long-acting injection. Oral risperidone 2mg/day should be started on
adherent). should be continued for at least three 25mg every two weeks. Those
Starting weeks, then taper over one to two weeks. on higher doses, start on 37.5mg
risperidone Be prepared to continue oral risperidone every 2 weeks. Be prepared to
injection for longer. use 50mg every 2 weeks.
Oral For those patients on a fixed dose of oral See above.
risperidone to risperidone for two weeks or more, the
risperidone following conversion scheme should be
injection considered. Patients treated with a dosage
of 4 mg or less oral risperidone should
receive 25 mg risperidone injection, while
patients treated with higher oral doses
should be considered for the higher dose of
37.5 mg. Where patients are not currently
taking oral risperidone, the oral pre-
treatment dosage should be considered
when choosing the i.m. starting dose.
Oral Either:- Broadly speaking for those of low
antipsychotics doses, start at 25mg every two
Switch to oral risperidone and titrate to
(not weeks, then adjust as necessary.
effective dose. If tolerated, prescribe
risperidone) to If the patient was previously
equivalent dose of risperidone long-acting
risperidone maintained on doses of middle or
injection. Oral risperidone should be
injection upper range of licensed doses,
continued for at least three weeks, then
start at 37.5mg or 50mg every
taper over one to two weeks. Be prepared
two weeks. The continued needs
to continue oral risperidone for longer.
for oral antipsychotics after three
Or:- to four weeks may indicate
Check tolerability and response to oral higher doses or risperidone long-
risperidone if possible. Give risperidone acting injection are required.
long-acting injection, then the oral
antipsychotics should be slowly tapered
three to four weeks later. Be prepared to
continue oral antipsychotics for longer.
Depot Check tolerability to oral risperidone first For those of low doses, start at
antipsychotic with one dose if possible. Risperidone 25mg every two weeks, then
to risperidone long-acting injection should be given one adjust as necessary. If the
injection week before the last dose of the previous patient was previously
5
 depot injection2. Consider
supplementation with an oral medicine if
the risk of relapse is high3.
Or
Check tolerability to oral risperidone first
with one dose if possible. Switch on the
depot due date, supplementing with oral
risperidone for three to four weeks3.
Antipsychotic Check tolerability to oral risperidone first
polypharmacy with one dose if possible. Risperidone
with depot to long-acting injection should be given one
risperidone week before the last dose of the previous
injection depot injection. The oral antipsychotics
should be slowly tapered three to four
weeks later. Be prepared to continue oral
antipsychotics for longer.
maintained on doses of middle or
upper range of licensed doses,
start at 37.5mg every two weeks.
Be prepared to increase to 50mg
every two weeks.
Aim to treat the patient with
risperidone long-acting injection
as the sole antipsychotic. The
dose should be dictated as far as
possible by the total dose or oral
and injectable antipsychotic.

Risperidone The last dose of risperidone injection will

injection to finally stop releasing risperidone about six
others weeks later, so wait until then and
introduce the new antipsychotic gradually
from day 423.

Table 3: Approximate dose equivalence of risperidone to paliperidone2

Risperidone oral Paliperidone oral Risperidone LAI Paliperidone LAI
(mg/day) (mg/day) (mg/two weeks) (mg/month)
2 4 25 50
3 6 37.5 75
4 9 50 100
6 12 - 150

5.5 Paliperidone long acting injection

5.5.1 Paliperidone LAI is restricted to consultant initiation only within the Trust. A non-
formulary form must be completed for the specific patient by the consultant
before starting treatment (see the trust formulary). Pharmacy will monitor
prescribing to ensure it is appropriate and within the Trust formulary
specifications.

5.5.2 Tolerability and response to risperidone must be established (oral or LAI)

before considering prescribing paliperidone LAI.

5.5.3 There are two methods of initiating paliperidone LAI, depending on if the patient
is prescribed risperidone tablets or injection. See Table 4 and 5. It has a
6
 nanocrystal technology formulation allowing both an early and sustained
release3.

5.5.4 Paliperidone LAI should be administered every calender month. Only needles
supplied with the pack should be used. It is stored at room temperature 4.

5.5.5
Table 411: Switch from oral risperidone
Days Dose
Day 1 150mg (deltoid muscle)
Day 8 100mg (deltoid muscle)
Day 36 75mg which may be adjusted thereafter between 25-150mg
once every calender month). (deltoid or gluteal muscles).

Table 511: Switch from risperidone injection

Dose of Risperidone LAI Dose of Paliperidone LAI
25mg every two weeks 50mg every month
37.5mg every two weeks 75mg every month
50mg every two weeks 100mg every month

Table 6: Switching to and from paliperidone palmitate2

Switching Recommended method of Comments
from switching
No treatment, Check tolerability and response to The lowest most effective
starting oral risperidone first. Give the two maintenance dose should be used.
paliperidone initiation doses, 150mg IM deltoid on The manufacturer recommends a
LAI day 1, 100mg IM deltoid on day 8. dose of 75mg monthly for the
Maintenance dose starts one month general adult population. This is
later (Day 36). approximately equivalent to
3mg/day oral risperidone (see table
5).Maintenance dose adjustments
should be made monthly. The full
effect of the dose adjustment may
not be apparent for several months.
Paliperidone Give the two initiation doses, followed Oral paliperidone/risperidone
/Risperidone by the maintenance dose (see table 3 supplementation during initiation is
to and prescribe equivalent dose). not necessary.
paliperidone
LAI
Oral Check tolerability to oral risperidone
antipsychotics first with one dose if possible.
to Reduce the dose of the oral
paliperidone antipsychotic over one to two weeks,
LAI following the first injection of
paliperidone. Give the two initiation
doses followed by the maintenance
dose.
Depot Check tolerability to oral risperidone The manufacturer recommends a
antipsychotic first with one dose if possible. Start dose of 75mg monthly for the
paliperidone LAI (at the maintenance general adult population. If
dose) when the next injection is due. switching from risperidone injection,
No initiation doses are required2. Go see table 5 and prescribe the
7
 straight to monthly3.
Antipsychotic Check tolerability to oral risperidone
polypharmacy first with one dose if possible. Start
with depot paliperidone LAI (at the maintenance
dose) when the next injection is due.
No initation doses are required.
Reduce the dose of the oral
antipsychotic cover over one to two
weeks, following the first injection of
paliperidone.
Paliperidone Start the oral antipsychotic when the
LAI to oral next injection is due, but titrate slowly
antipsychotic as paliperidone levels can persist for
six months.
equivalent dose. .Maintenance dose
adjustments should be made
monthly. The full effect of the dose
adjustment may not be apparent for
several months.
Aim to treat the patient with
paliperidone long-acting injection as
the sole antipsychotic. The
maintenance dose should be
dictated as far as possible by the
total dose or oral and injectable
antipsychotic

Paliperidone Start risperidone injection when the

LAI to next depot dose is due3.
risperidone
LAI
Paliperidone Start the new depot slowly to avoid
LAI to another additive ADRs and NMS as
depot paliperidone levels can persist for up
to six months3.
Others to Oral antipsychotics can be stopped
paliperidone over one week except olanzapine,
LAI quetiapine and clozapine which need
to be stopped over four weeks to
minimise insomnia and cholinergic
rebound3.

5.5.6 Elderly population

Efficacy and safety in elderly > 65 years have not been established. In general,
recommended dosing of paliperidone LAI for elderly patients with normal renal
function is the same as for younger adult patients with normal renal function.
However, because elderly patients may have diminished renal function, dose
adjustment may be necessary.

5.5.7 Renal impairment

Paliperidone LAI has not been systematically studied in patients with renal
impairment. For patients with mild renal impairment (creatinine clearance ≥ 50
to < 80 ml/min), recommended initiation of paliperidone LAI is with a dose of
100 mg on treatment day 1 and 75 mg one week later, both administered in the
deltoid muscle. The recommended monthly maintenance dose is 50 mg with a
range of 25 to 100 mg based on patient tolerability and/or efficacy. Paliperidone
8
 LAI is not recommended in patients with moderate or severe renal impairment
(creatinine clearance < 50 ml/min).

5.5.8 Avoiding missed doses

It is recommended that the second initiation dose of paliperidone LAI be given

one week after the first dose. To avoid a missed dose, patients may be given
the second dose 4 days before or after the one-week (day 8) time point.
Similarly, the third and subsequent injections after the initiation regimen are
recommended to be given monthly. To avoid a missed monthly dose, patients
may be given the injection up to 7 days before or after the monthly time point. If
the target date for the second injection (day 8 ± 4 days) is missed, the
recommended reinitiation depends on the length of time which has elapsed
since the patient's first injection.

5.5.9 Missed second initiation dose (< 4 weeks from first injection)

If less than 4 weeks have elapsed since the first injection, then the patient
should be administered the second injection of 100 mg in the deltoid muscle as
soon as possible. A third injection of 75 mg in either the deltoid or gluteal
muscles should be administered 5 weeks after the first injection (regardless of
the timing of the second injection). The normal monthly cycle of injections in
either the deltoid or gluteal muscle of 25 mg to 150 mg based on individual
patient tolerability and/or efficacy should be followed thereafter.

5.5.10 Missed second initiation dose (4-7 weeks from first injection)

If 4 to 7 weeks have elapsed since the first injection, resume dosing with two
injections of 100 mg in the following manner:

 a deltoid injection as soon as possible,

 another deltoid injection one week later,

 resumption of the normal monthly cycle of injections in either the deltoid

or gluteal muscle of 25 mg to 150 mg based on individual patient
tolerability and/or efficacy.

5.5.11 Missed second initiation dose (> 7 weeks from first injection)

If more than 7 weeks have elapsed since the first injection, initiate dosing as
described for the initial recommended initiation of paliperidone LAI above.

5.5.12 Missed monthly maintenance dose (1 month to 6 weeks)

After initiation, the recommended injection cycle of paliperidone depot is

monthly. If less than 6 weeks have elapsed since the last injection, then the
previously stabilised dose should be administered as soon as possible, followed
by injections at monthly intervals.

5.5.13 Missed monthly maintenance dose (> 6 weeks to 6 months)

9
 If more than 6 weeks have elapsed since the last injection of paliperidone LAI,
the recommendation is as follows:

For patients stabilised with doses of 25 to 100 mg:

 a deltoid injection as soon as possible at the same dose the patient was
previously stabilised on

 another deltoid injection (same dose) one week later (day 8)

 resumption of the normal monthly cycle of injections in either the deltoid

or gluteal muscle of 25 mg to 150 mg based on individual patient
tolerability and/or efficacy

For patients stabilised with 150 mg:

 a deltoid injection as soon as possible at the 100 mg dose

 another deltoid injection one week later (day 8) at the 100 mg dose

 resumption of the normal monthly cycle of injections in either the deltoid

or gluteal muscle of 25 mg to 150 mg based on individual patient
tolerability and/or efficacy

5.5.14 Missed monthly maintenance dose (> 6 months). If more than 6 months have
elapsed since the last injection of paliepridone depot, initiate dosing as
described for the initial recommended initiation of paliperidone LAI.

5.5.15Sites of administration
Deltoid muscle administration
The recommended needle size for initial and maintenance administration of the
depot into the deltoid muscle is determined by the patient's weight. For those ≥
90 kg, the 1½ inch, 22 gauge needle (38.1 mm x 0.72 mm) is recommended.
For those < 90 kg, the 1-inch, 23 gauge needle (25.4 mm x 0.64 mm) is
recommended. Deltoid injections should be alternated between the two deltoid
muscles.

Gluteal muscle administration

The recommended needle size for maintenance administration of the depot into
the gluteal muscle is the 1½-inch, 22 gauge needle (38.1 mm x 0.72 mm).
Administration should be made into the upper-outer quadrant of the gluteal area.
Gluteal injections should be alternated between the two gluteal muscles.

5.6 Paliperidone three monthly long-acting injection (Trevicta)14

5.6.1 Paliperidone three monthly depot, is indicated for the maintenance treatment of
schizophrenia in adults who are clinically stable on one monthly paliperidone LAI.
Patients who are adequately treated for four months or more and do not require dose
adjustment may be switched to paliperidone three monthly depot. It is restricted in the
formulary, to be requested via the non-formulary route, and should be reserved for

10
service users that are non-compliant with monthly administration and susceptible to
relapse.

5.6.2 Paliperidone three monthly depot must be initiated in place of the next scheduled
dose of 1-monthly paliperidone LAI (± 7 days). The dose equivalence is per table 7.

Table 7: Paliperidone three monthly depot doses for patients adequately treated with one
monthly paliperidone palmitate depot
Last dose of one monthly paliperidone Initiate paliperidone three monthly depot at
palmitate depot the following dose
50 mg 175 mg
75 mg 263 mg
100 mg 350 mg
150 mg 525 mg
There is no equivalent dose for the 25 mg dose of paliperidone montlhy depot.

5.6.3 Paliperidone three monthly depot must be administered by intramuscular

injection once every 3 months (± 2 weeks). If needed, dose adjustment can be made
every 3 months in increments within the licensed range, but onset of action may take
several months.
5.6.4 If paliperidone three monthly depot is discontinued, its prolonged activity must
be considered.

Table 8: Doses of one monthly paliperidone palmitate injectable for patients switching
from paliperidone three monthly depot
If the last dose of paliperidone Initiate 1-monthly paliperidone palmitate injectable 3
palmitate is months later at the following dose
175 mg 50 mg
263 mg 75 mg
350 mg 100 mg
525 mg 150 mg

5.6.5 To avoid a missed dose of the depot, patients may be given the injection up to 2
weeks before or after the 3-month time point.
Table 9: Missed doses
If scheduled dose is missed and Action
the time since last injection is
> 3½ months up to 4 months The injection should be administered as soon as possible
and then resume the 3-monthly injection schedule.
4 months to 9 months See table 10.
> 9 months Re-initiate treatment with the monthly paliperidone LAI. The
three monthly depot can then be resumed after the patient
has been adequately treated with 1-monthly paliperidone
palmitate depot for at least four months.

11
Table 10: Recommended re-initiation regimen after missing 4 months to 9 months of
paliperidone palmitate three monthly depot
If the last dose of Administer 1-monthly paliperidone palmitate Then administer 3-
paliperidone three injectable, two doses one week apart (into monthly paliperidone
monthly depot was deltoid muscle) LAI
Day 1 Day 8 1 month after day 8
175 mg 50 mg 50 mg 175 mg
263 mg 75 mg 75 mg 263 mg
350 mg 100 mg 100 mg 350 mg
525 mg 100 mg 100 mg 525 mg

5.6.6 In general, recommended dosing of paliperidone three monthly depot for elderly
patients with normal renal function is the same as for younger adult patients with
normal renal function.

5.6.7 For patients with mild renal impairment (creatinine clearance ≥ 50 to < 80
ml/min), dose should be adjusted and the patient stabilised using the monthly
paliperidone depot, and then changed to the three monthly depot. It is not
recommended in patients with moderate or severe renal impairment (creatinine
clearance < 50 ml/min).

5.6.8 No dose adjustment is required in patients with mild or moderate hepatic

impairment. Caution is recommended in such patients with severe hepatic impairment.

5.6.9 Paliperidone three montlhy depot must be administered using only the thin wall
needles that are provided in the pack. Needles from the monthly paliperidone LAI pack
or other needles must not be used.

5.6.10 Sites of administration

Deltoid muscle administration

• For those ≥ 90 kg, the thin wall 1½ inch, 22 gauge (0.72 mm x 38.1 mm) needle must
be used.
• For those < 90 kg, the thin wall 1 inch, 22 gauge (0.72 mm x 25.4 mm) needle must
be used.
It should be administered into the centre of the deltoid muscle. Deltoid injections must
be alternated between the two deltoid muscles.

Gluteal muscle administration

The needle to be used for administration into the gluteal muscle is the thin wall 1½
inch, 22 gauge (0.72 mm x 38.1 mm) needle regardless of body weight. It must be
administered into the upper-outer quadrant of the gluteal muscle. Gluteal injections
must be alternated between the two gluteal muscles.

5.7 Aripiprazole long acting injection

5.7.1 For patients who have never taken aripiprazole, tolerability and response with
oral aripiprazole must occur prior to initiating treatment with aripiprazole depot.
The recommended starting and maintenance dose is 400 mg. Titration is not
12
 required. It should be administered once monthly as a single injection (no
sooner than twenty-six days after the previous injection). After the first injection,
treatment with 10 mg to 20 mg oral aripiprazole should be continued for fourteen
consecutive days to maintain therapeutic aripiprazole concentrations during
initiation of therapy (after which it should be stopped). If there are adverse
reactions with the 400 mg dosage, reduction of the dose to 300 mg once
monthly should be considered9.

5.7.2 Aripiprazole depot is restricted in the formulary and can be requested via the
non-formulary route (see the trust formulary).

5.7.3 Aripiprazole depot should administered in the gluteal or deltoid muscle.

5.7.4 The safety and efficacy of aripiprazole depot in the treatment of schizophrenia in
patients 65 years of age or older has not been established.

5.7.5 Missed doses

Table 119: Missed doses

If 2nd or 3rd dose is missed and Action
time since last injection is:
> 4 weeks and < 5 weeks The injection should be administered as soon as
possible and then resume monthly injection schedule.
> 5 weeks Concomitant oral aripiprazole should be restarted for 14
days with next administered injection and then resume
monthly injection schedule.
th
If 4 or later doses are missed Action
& time since last injection is:
> 4 weeks and < 6 weeks The injection should be administered as soon as
possible and then resume monthly injection schedule.
> 6 weeks Concomitant oral aripiprazole should be restarted for 14
days with next administered injection and then resume
monthly injection schedule.

5.7.6 Dose adjustments of aripiprazole depot in patients who are taking concomitant
strong CYP2D6 inhibitors, strong CYP3A4 inhibitors, and/or CYP3A4 inducers
for more than fourteen days.

Table 12: Dose adjustments9

Adjusted dose
Patients taking 400 mg of aripiprazole depot
Strong CYP2D6 or strong CYP3A4 inhibitors 300 mg
Strong CYP2D6 and strong CYP3A4 inhibitors 200 mg
CYP3A4 inducers Avoid use
Patients taking 300 mg of aripiprazole depot
Strong CYP2D6 or strong CYP3A4 inhibitors 200 mg
Strong CYP2D6 and strong CYP3A4 inhibitors 160 mg
CYP3A4 inducers Avoid use

13
 Table 13: Examples of interacting medicines9:
Strong CYP2D6 Strong CYP3A4 inhibitors Strong CYP3A4 inducers
inhibitors
Quinidine Ketoconazole Carbamazepine
Fluoxetine Itraconazole Rifampicin
Paroxetine HIV protease inhibitors Rifabutin
Phenytoin
Phenobarbital
Primidone
Efvirenz
Nevirapine
St John‟s Wort

5.7.7 Sites of administration

Gluteal muscle administration

The recommended needle for gluteal administration is a 38 mm (1.5 inch), 22
gauge hypodermic safety needle; for obese patients (Body mass index > 28
kg/m2), a 50 mm (2 inch), 21 gauge hypodermic safety needle must be used.
Gluteal injections must be alternated between the two gluteal muscles.

Deltoid muscle administration

The recommended needle for deltoid administration is a 25 mm (1 inch), 23
gauge hypodermic safety needle; for obese patients, a 38 mm (1.5 inch), 22
gauge hypodermic safety needle must be used. Deltoid injections must be
alternated between the two deltoid muscles.

5.8 Olanzapine long acting injection

5.8.1 Olanzapine LAI is non-formulary due to its adverse safety profile and
subsequent monitoring requirements. Its use in exceptional cases must
be approved via the non-formulary process. Appropriate arrangements
must be in place for continued administration and monitoring in the
community before the non-formulary request will be approved. Where use
has been approved, the sections 5.8.3 & 5.8.4 must be adhered to:

5.8.2 Trust staff may also be required to take over prescribing and administration for
patients currently established on olanzapine LAI after transfer from another
Trust. Likewise a non-formulary form must be completed and arrangements in
place for administration and monitoring. Consideration should also be given to
switching the patient to an alternative antipsychotic LAI.

5.8.3 Before prescribing or administering olanzapine LAI, staff must undertake an

e- learning package produced by the pharmaceutical company
(https://www.zypadhera.co.uk/SignIn.aspx). Certificates must be retained by
ward/team manager.

5.8.4 After each injection, patients m u s t be observed in a ward or community team

base by appropriately qualified staff for at least three hours for signs and
symptoms consistent with olanzapine overdose9. The ward or team base must
have resuscitation equipment available. The member of staff undertaking the
14
 observation, does not have to be a doctor or nurse, but he/she must report any
concerns immediately to a nurse or doctor. At the end of the observation, a
nurse must confirm that the patient is alert, oriented, and does not have any
signs and symptoms of overdose.

For the remainder of the day after the injection, patients should be advised to be
vigilant for signs and symptoms of an overdose secondary to post-injection
adverse reactions, be able to obtain assistance if needed, and should not drive
or operate machinery10.

If d u rin g t he ob se rva t io n , an overdose is suspected, close medical

supervision and monitoring should be initiated and 999 must contacted.
Supervision and monitoring must continue until examination indicates that
signs and symptoms have resolved or an ambulance team is present.

5.8.5 Service users must initially be treated with oral olanzapine before
administering the depot to establish tolerability and response. In line with trial
studies, the introduction of long-acting IM olanzapine should be made without
recourse of cross-tapering of oral medication5,10.

5.8.6 If oral olanzapine supplementation is clinically indicated, then the combined total
dose of olanzapine from both formulations should not exceed the corresponding
maximum oral olanzapine dose of 20 mg/day. See table 4.

5.8.7 Olanzapine pamoate releases olanzapine slowly, over six to eight weeks after
each injection. The time to steady state is three months3.

5.8.8 Olanzapine pamoate salt provides a slow continuous release of olanzapine that
is complete approximately six to eight months after the last injection. Therefore
supervision by a clinician, especially during the first 2 months after
discontinuation of olanzapine LAI, is needed when switching to another
antipsychotic product10.

5.8.9 Olanzapine LAI must be administered in the gluteal muscle only10. It is not
licensed for administration in the deltoid muscle.

5.8.10 Olanzapine LAI has not been systematically studied in elderly patients (> 65
years). Olanzapine LAI is not recommended for treatment in the elderly
population unless a well-tolerated and effective dose regimen using oral
olanzapine has been established. A lower starting dose (150 mg/4 weeks) is not
routinely indicated, but should be considered for those 65 and over when clinical
factors warrant. Olanzapine depot is not recommended to be started in patients
>75 years.

15
 Table 14: Recommended Dose Regimen
Oral Olanzapine Recommended starting dose of Maintenance Dose after 2
Olanzapine Depot months
10mg/day 210mg/2 weeks or 405mg/4 weeks 150mg/2 weeks or 300mg/4
weeks
15mg/day 300mg/2 weeks 210mg/2 weeks or 405mg/4
weeks
20mg/day 300mg/2 weeks 300mg/2 weeks

6 Use of Unlicensed Doses

6.1.1 If for therapeutic reasons clinicians consider a dose of depot medication above
the BNF limit is advisable, a full discussion must take place involving the
patient, consultant psychiatrist, the prescriber (if the not the consultant) and
the nurse who will administer the depot injection. This discussion and its
conclusion must be recorded in full in the service user‟s electronic records.

6.1.2 For service users detained under the Mental Health Act, and requiring a
second opinion, reference must be made on the T2 or T3 forms specifying the
dose prescribed and is above maximum licensed dose.

6.1.3 If the prescribed dose of risperidone injection is above the maximum licensed
dose (50mg every two weeks), consideration should be given to prescribing
paliperidone LAI as the maximum dose is 150mg every month (see table 3).

7 Administration of depot antipsychotic medication

7.1.1 There is a procedure for the s afer use of injectable medicines which is
available on the Trust intranet.

7.1.2 Check the depot is licensed for administration into the preferred muscle site.

7.1.3 The table below details the sites for administration of depot medication.
Appendix 3 contains diagrams of the various injection sites referred to below.

Table 154
Depot Licensed Site of Injection Practice Points
Flupenthixol decanoate Upper outer quadrant Maximum volume into a
(Depixol injection, (dorsogluteal region) or single site must not
depixol conc. Injection, lateral thigh (vastus exceed 2ml.
depixol low volume) lateralis)
Fluphenazine decanoate Gluteal region Maximum volume into a
(Modecate injection, single site is not specified
Modecate conc in the SPC.
injection)
Haloperidol decanoate Gluteal region Maximum volume into a
(Haldol decanoate) single site must not
exceed 3ml.

16
 Zuclopenthixol Upper outer quadrant Maximum volume into a
decanoate (Clopixol, (dorsogluteal region) or single site must not
clopixol conc injection lateral thigh (vastus exceed 2ml.
lateralis)
Risperidone Gluteal region/deltoid Fractions of a dose may not
muscle be administered.
Paliperidone m ont hly Gluteal region/deltoid Fractions of a dose must
depot (restricted in the muscle not be administered.
formulary and obtained
via a non-formulary form)

Paliperidone t hr ee Gluteal region/deltoid Fractions of a dose must

m ont hly depot
( T r e vi ct a) (restricted in
the formulary and
obtained via a non-
formulary form)
Aripiprazole depot
(restricted in the
formulary and obtained
via a non-formulary form)
Olanzapine depot (non-
formulary)
muscle not be administered.
Gluteal region/deltoid The suspension must be
muscle injected slowly as a single
injection (doses must not be
divided) into the gluteal
muscle.
Gluteal region Fractions of a dose must
not be administered

17
7.1.4 The gluteal region consists of the dorsogluteal muscle and ventrogluteal muscle.
The ventrogluteal muscle has been approved by the Trust to be used as an
alternative site to the dorsogluteal, where the BNF states gluteal site. It is
acknowledged that this will be administering via an off-label route.

7.1.5 The dorsogluteal site (upper outer quadrant) is perhaps the most popular site. It
is close to the sciatic nerve and gluteal artery and is covered by abundant
adipose tissue in most people13. This may result in the medicine not reaching
the target muscle. This may result in reduced medicine uptake and tissue
irritation.

7.1.6 The ventrogluteal site has few major nerves and blood vessels. The muscle is
well defined and large. There can be significant differences in fat depth in obese
people. Some authors have argued this is the best site because of notably fewer
complications, specifically injuries to the sciatic nerve. Additionally, it can be
almost guaranteed that a standard 3cm or 4cm needle will penetrate the
muscle. In practice mental health nurses are reluctant to use this area because
of problems locating the site and a perceived risk of needle stick injury when
injection between the „V‟ of the index and middle fingers13.

7.1.7 The deltoid muscle is rarely used because of the weak evidence it causes more
discomfort. Only small volumes (less than 2ml) are recommended at this site.
With the exception of risperidone injection, paliperidone monthly depot,
paliperidone three monthly depot and aripiprazole monthly depot which are
licensed for administration via this route, the deltoid muscle is not routinely used
as a site of administration. There is also a risk of injury to the radial nerve and
brachial artery13. There is no research in regards to other depots.

7.1.8 The lateral thigh is rarely used. This site is easily accessible, but may result in
considerable discomfort14. However it is licensed for administration of
flupenthixol and zuclopenthixol depot6,8. It could potentially be used for self-
administration under supervision13.

7.1.9 The front of the thigh is not a licensed site of administration. This site may also
result in considerable discomfort.

8 Use of alternative sites or sites which are off -label

8.1.1 If there is a good clinical reason for using an off-label site e.g. the amount of
subcutaneous (fatty tissue) is too great for the needle to deposit the medication
into the muscle or the patient chooses not to have the injection in the clinically
preferred site, a full discussion including a risk assessment must take place.
The discussion should involve the consultant psychiatrist, the prescriber (if not
the consultant) and the administering nurse and patient. This discussion and its
conclusion must then be fully recorded in the patient‟s Electronic patient record
(Carenotes). The member of staff must have completed the relevant training
and supervised practice to equip them to administer in the alternative site safely
e.g. the deltoid site. However there is little evidence for other sites in terms of
risks and safety.

18
9 Depots/LAIs administered under restraint

9.1.1 Occasionally depot antipsychotic medication may be administered under

planned restraint. In keeping with the trust policy, depot antipsychotic
medication should be administered with the patient in a prone position.

9.1.2 When considering which depot antipsychotic medication to use, consideration

should be given to the licensed site of injection (see table 15) for example
flupenthixol decanote and zuclopenthixol decanoate can be administered in the
lateral thigh (a licensed site) in a prone restraint rather than in the gluteal region.
9.1.3 If an unlicensed site is considered, the advice of pharmacy must be sought. A
discussion involving the consultant, prescriber and nurse must be recorded in
the patient‟s electronic patient record (Carenotes) prior to administration.

10 Generic names/Brand names.

10.1.1 Depot / LAI must always be prescribed generically, however paliperidone LAIs
must be clearly annotated to distinguish between the different formulations
(monthly or three monthly).

Table 16
GENERIC NAME BRAND NAME
Flupenthixol Decanoate Depixol
Zuclopenthixol Decanoate Clopixol
Fluphenazine decanoate Modecate
Haloperidol Decanoate Haldol Decanoate
Haloperidol injection Haldol
Aripiprazole long acting injection Abilify Maintena
Risperidone injection Risperdal Consta
Paliperidone monthly depot Xeplion
Paliperidone three monthly depot Trevicta
Olanzapine depot Zypadhera

11 Management of patients on long term depot antipsychotics in relapse

prevention

11.1.1 Patients should be reviewed prior to the next injection including an assessment
of the previous injection site checking for signs of swelling, pain, inflammation,
infection or tissue damage4.

11.1.2 Clinical reviews should be undertaken every six months and should include a
shared understanding of relapse plans and any concerns about treatment 4.

11.1.3 If a dose reduction is considered, a risk versus benefit analysis should be done
taking in the following point2s:

o Is the patient symptom free and if so for how long? Longstanding, non-
distressing symptoms, which have previously not responded to
medication, may be excluded.

19
 o What is the severity of side effects? (GASS tool)

o What is the previous pattern of illness?

o Has dosage reduction been attempted before? If so, what was the
outcome?

o What are the current social circumstances?

o What is the potential cost of relapse (e.g. hospital admission,

employment)?

11.1.4 If after consideration of the points raised, a decision to reduce medication is

made:

 Oral antipsychotics should be discontinued first, if concurrently

prescribed

 The interval between the injections should be increased gradually

within licensed limits.

 If possible, reduce the dose by no more than a third at a time.

 Reduction in dosage should be made no more frequently than every 3

months if possible, preferably every six months.

 If the patient becomes symptomatic, this should not be seen as a

failure, but as an important step in determining the minimum
effective dose that the patient requires.

12 Intramuscular anti-cholinergic medication

12.1.1 Some service users may require anti-cholinergic medication to alleviate

the side effects of depot medication. Depot preparations do not produce acute
extra pyramidal side effects (EPSEs) at the time of administration. If they do
occur this may take hours or days. The administration of i.m. procyclidine
with each depot is illogical as its anticholinergic effects will have worn off by
the time the depot plasma level peaks2. An anticholinergic is usually
prescribed v i a t h e oral or intramuscular routes on an „as required‟ basis.

21
13 Primary Care Involvement

13.1.1 Some service users may have depot medication prescribed and administered
at their GP practice. This must always be with prior agreement and after
clear communication and liaison between the consultant psychiatrist and the
GP. Information such as when to review the medication and how to
effectively communicate information or any other information between
secondary and primary care should be included in the transfer of care.

14 Zuclopenthixol acetate (Clopixol acuphase)

14.1.1 There is a separate document for Clopixol Acuphase - Guidance for the use
of Clopixol Acuphase (zuclopenthixol acetate) in Adult Mental Health
Inpatient Settings. Although an oily based preparation, it is not intended as a
long-acting depot. Clopixol acuphase must not be used as a test dose for
zuclopenthixol decanoate injection.

15 Related policies

 Antipsychotic Prescribing Guidelines.

 Safer Use of Injectable Medicines procedure.
 Medicines Management Policy.

16 Dissemination and implementation arrangements

This document will be circulated to all managers who will be required to

cascade the information to members of their teams. It will be available to all
staff via the Trust intranet. Managers will ensure that all staff are briefed on its
contents and on what it means for them.

17 Training requirements

Staff administering depot/LAI must be suitably qualified and competent to

administer depot injections. Supplementary training for specific LAI
preparation must be completed where applicable. For further training
requirements please refer to the Trust‟s Mandatory Training Policy and
Learning and Development Guide.

18 Monitoring and audit arrangements

22
 Elements to Lead How trust Frequency Reporting Acting on Change in
be will monitor arrangemen ts recommendatio practice and
monitored compliance ns and Lead(s) lessons to be
shared

Process for Chief Clinical ongoing Divisional Leads Required actions will Required changes
prescribing Pharmacist pharmacy review be identified and to practice will be
medicines (CP) of medicine DTC completed in a identified and
charts. specified time frame. actioned within a
specific time
frame. A lead
member of the
team will be
identified to take
Process for Nursing ongoing DTC each change
medicine Director
forward where
administration
appropriate.
Lessons will be
learned with all
relevant
stakeholders

19 Review of the policy

The next review date for this policy is February 2023.

23
20 References

1 National Institute for Health and Clinical Excellence (2014). Psychosis and schizophrenia in
adults. Treatment and management. NICE Clinical Guidance 178.

2 Taylor D. Paton C., Kapur S. The South London and Maudsley NHS Foundation Trust.
Oxleas NHS Foundation Trust. Prescribing Guidelines. 13th Edition. London. Informa
Healthcare. 2018.

3 Bazire S. Psychotropic drug directory. The professionals‟ pocket handbook and aide
memoire. 2018.

4 Guidance on the Administration to Adults of Oil-based Depot and Other Long-acting

Intramuscular Antipsychotic Injections. Fourth edition. PHGB/NPR/1113/0021 February 2014.

5 Sanofi. The specification of product characteristics. Modecate concentrate 100mg per ml (21
March 2015) (online). Available: https://www.medicines.org.uk/emc/medicine/6955 (accessed
February 2020).

6 Lundbeck Ltd. The specification of product characteristics . Depixol injection and conc.
Injection (February 2017). (online). Available:
https://www.medicines.org.uk/emc/medicine/1074 (accessed February 2020)

7 Janseen Cilag Ltd. The specification of product characteristics. Haldol decanoate. (March
2019). (online). Available: https://www.medicines.org.uk/emc/medicine/904 (accessed
February 2020)

8 Lundbeck Ltd. The specification of product characteristics. Depixol injection and conc.
Injection (December 2016). (online). Available:
https://www.medicines.org.uk/emc/medicine/21319(accessed February 2020)

9 Otsuka Pharmaceuticals. The specification of product characteristics. Abilify maintena (April

2019). (online). Available: https://www.medicines.org.uk/emc/medicine/28494. (accessed
February 2020)

10 Eli Lilly and Company Ltd. The specification of product characteristics. Zypadhera powder
and solvent for prolonged release suspension for injection (November 2018). (online).
Available: https://www.medicines.org.uk/emc/medicine/21361 (accessed February 2020)

11 Janseen Cilag Ltd. The specification of product characteristics. Xeplion 50 mg, 75 mg, 100
mg and 150 mg prolonged release suspension for injection. (September 2018). (online).
Available: https://www.medicines.org.uk/emc/medicine/24403 (accessed February 2020)

12 Janseen Cilag Ltd. The specification of product characteristics. Risperdal Consta 25, 37.5 and
50 mg powder and solvent for prolonged-release suspension for intramuscular injection.
(September 2018). (online). Available: https://www.medicines.org.uk/emc/medicine/9939
(accessed February 2020)

13 Gray R. et al (2009). Antipsychotic long-acting injections in clinical practice: medication

management and patient choice. Br. J. of Psych. 195, s51 – s56.

14. Janseen Cilag Ltd. The specification of product characteristics. Trevicta prolonged-release
suspension for intramuscular injection. (November 2019). (online).
Availablehttps://www.medicines.org.uk/emc/medicine/32050 (accessed February 2020).

24
Appendix 1

Table 10: Equivalent doses of antipsychotics2,3

Antipsychotic Equivalent dose Range of values in
(consensus) literature
Amisulpride 100mg per day 40-150mg per day
Benperidol 2mg per day
Chlorpromazine 100mg per day -
Clozapine 100mg per day 30-150mg per day
Flupenthixol 2-3mg per day 2-3mg per day
Flupenthixol depot 10mg per week 10-20mg per week
Fluphenazine 2mg per day 2-5mg per day
Fluphenazine depot 5mg per week 1-12.5mg per week
Haloperidol 2-3mg per day 1.5-5mg per day
Haloperidol depot 15mg per week 5-25mg per week
Paliperidone LAI 12.5mg every week or 50mg
every month
Pericyazine 24mg
Perphenazine 10mg per day 10mg per day
Pimozide 2mg per day 2mg per day
Pipothiazine depot 10mg per week 10-12.5mg per week
Promazine 100mg 50-200mg per day
Risperideone 500micrograms – 1mg per 500micrograms –3mg per
day day
Risperidone long- 12.5mg per week or25mg
acting injection every two weeks
Sulpiride 200mg per day 200-270mg per day
Trifluoperazine 5mg per day 2.5-5mg per day
Zuclopenthixol 25mg per day 25-60mg per day
Zuclopenthixol depot 100mg per week 40-100mg per week
NB: Check the maximum licensed dose for each preparation when using this table.

28
Appendix 2

Buttock (Gluteus Medius) Site for IM Injection Leg (Vastus Lateralis) Site
For IM Injection

Hip (Ventrogluteal) Site for IM Injection Arm (Deltoid) Site for IM

Injection

29
 Appendix 3

Equality Impact Assessment Tool

Yes/No Comments

Does the policy/guidance affect one group less

1 or more favourably than another on the basis of:

Race No

Ethnic origins (including gypsies and travellers) No

Nationality No

Gender No

Culture No

Religion or belief No

Sexual Orientation including lesbian, gay and bisexual No

people

Age No

Disability- learning disability, physical disability, sensory No

impairment and mental health problems

2 Is there any evidence that some groups are No

affected differently?

3 If you have identified potential discrimination, are N/A

any exceptions valid, legal and/or justifiable?

4 Is the impact of the policy/guidance likely to be No

negative?

5 If so can the impact be avoided? N/A

6 What alternatives are there to achieving the N/A

policy/guidance without the impact?

7 Can we reduce the impact by taking different N/A

action?

30