Table 3 Prescribing indicators accepted in round 2 of Delphi exercise with Median and 75^th Centile Value

1

Consider adjunctive metformin, unless contraindicated, in people with SMI (Severe Mental Illness) who are prescribed clozapine or olanzapine and who have demonstrated early weight gain*

*early weight gain is defined as 5% of body weight in the first month of treatment and is a predictor of long-term weight gain (> 15% over 3 months)

1

2

2

For people with dementia who have a history of cerebrovascular disease or who have evidence on neurological examination or neuroimaging of cerebrovascular disease consider low-dose aspirin eg. 75 mg daily to prevent or lessen further cognitive decline, unless contraindicated

2

2

3

Perform VTE risk assessment for all adults with SMI admitted to the secondary care setting with reduced mobility

1

2

4

Where gastroprotection is indicated, low dose proton pump inhibitors (PPIs) are the preferred treatment choice in adults with SMI who are prescribed agents with a high anticholinergic cognitive burden (ACB). This is because H₂ receptor antagonists may increase the ACB and could increase the risk of cognitive impairment

1.5

2

5

Tobacco smoking can alter the pharmacokinetics of psychotropic medications: For people with SMI who are taking TCA’s, mirtazapine, haloperidol and benzodiazepines, do not reduce the dose of the psychotropic drug but instead, monitor for adverse effects

2

2

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

6

i.Adults over 50 years who are prescribed sodium valproate, carbamazepine, primidone, or phenytoin because these agents are associated with reduced bone mineral density, osteopenia, osteoporosis and increased risk of fractures

2

2

7

ii.Adults < 50 years old on oral steroids (prednisolone > 7.5 mg/day or equivalent for ≥ 3 months)

2

2

8

In individuals with inadequate light exposure or at risk of vitamin D deficiency (eg. nursing home residents, African, African-Caribbean and South Asian populations), supplementation with 10 µg/day of vitamin D should be considered

2

2

9

Adults who consume more than 3.5 units of alcohol per day should be advised to reduce their alcohol intake to nationally recommended levels (< 14 units/week in both men and women)

1

1.75