Atypical antipsychotics are expected to be better tolerated than older antipsychotics because of their lower propensity to cause certain adverse effects. All atypical drugs have been shown to cause fewer acute extrapyramidal symptoms (EPS) than a standard typical agent (usually haloperidol) and some (clozapine, sertindole and quetiapine) appear to cause these effects no more often than placebo. In the longer term, clozapine, olanzapine and (less robustly) other atypical antipsychotics are thought to cause less tardive dyskinesia than typical antipsychotics. Problems caused by hyperprolactinaemia occur less often with some atypical antipsychotics than with typical drugs although risperidone and amisulpride appear to have no advantages in this respect. Other adverse effects may occur as frequently with some atypical antipsychotics as with some typical drugs. Clozapine, risperidone and quetiapine are known to cause postural hypotension; clozapine, olanzapine and quetiapine are clearly sedative; and anticholinergic effects are commonly seen with clozapine, and, much less frequently, with olanzapine. Some adverse effects are more frequent with atypical drugs. Idiosyncratic effects seem particularly troublesome with clozapine and, to a lesser extent, sertindole, olanzapine and zotepine. Bodyweight gain is probably more problematic with atypical antipsychotics than with typical drugs. Overall tolerability, as judged by withdrawals from therapy, is not clearly proven to be better with atypical drugs, although some individual trials do indicate an advantage with atypical agents. Differences in tolerability between individual atypical antipsychotics have not been clearly shown. The tolerability profile of atypical drugs certainly benefits from a lower incidence of acute EPS effects, along with less certain or less uniform benefits in symptomatic hyperprolactinaemia or tardive dyskinesia. Other, perhaps more trivial, adverse effects militate against their good tolerability, and effects such as bodyweight gain may severely reduce tolerability. Without clear advantages in tolerability in patient groups used in trials, drug choice in regard to adverse effects should continue to be on a patient to patient basis.

Brugada syndrome (BrS) presents with a characteristic electrocardiogram (ECG) and is associated with sudden cardiac death. Until now, prolongation of QTc interval and its association with Torsade de Pointe and possible fatal arrhythmia have been the focus of routine baseline ECGs before prescribing psychotropic medication. A semi-systematic literature review was conducted using PubMed. The terms ‘Brugada’, ‘Brugada Syndrome’ AND ‘psychotropic’ ‘antipsychotic’ ‘antidepressant’ ‘mood stabilisers’ ‘clozapine’ ‘Tricyclic Antidepressants’ ‘Lithium’ were searched. From a search that delivered over 200 articles, 82 articles were included. Those that included details around causative medication, doses of medication and where clear timeline on drug cause were included. Where clarification was needed, the manufacturer of the medication was contacted directly. Psychotropic medication can be associated with BrS, Brugada phenocopy or unmasking of BrS, in overdose or in normal doses. Our results include a table summarising a number of psychotropic overdoses that led to BrS unmasking. Routine screening for BrS in patients before prescribing psychotropic medication is a natural extension of the baseline ECG currently routinely done to rule out QTc prolongation. Psychiatrists need to invest in ensuring better skills in interpreting ECGs and work closer with cardiologists in interpreting ECGs.

Introduction Clozapine is a high-risk drug that is used widely in Secondary and Tertiary Centres.1 Therapeutic Drug Monitoring (TDM) advice and recommendation is readily available from distinguished authors.2,3 The rate of clozapine TDM, appropriate sample collection for TDM, appropriate actions following a clozapine level varies between services and prescribers within our organisation. Aim To establish how many current West London NHS Trust (WLT) patients had a clozapine TDM, how many plasma samples collected for TDM were done appropriately, the proportion of patients with an appropriately collected plasma sample result within the largely accepted therapeutic range, and whether there was documentation that the plasma level was reviewed and if any prescription changes were made. Methods Approval to undertake the service evaluation was given by the Trust clinical governance and audit committee as ethical review as not required. No patient identifiable details were shared or collected. All patients who had been registered on the Trusts clozapine patient monitoring service for over 8 weeks were enrolled. Anonymised patient demographic data was collected including concomitant medication. Plasma levels were sought for every patient enrolled. The appropriateness of the samples taken were scrutinised. The plasma level result was collected. Electronic patient notes were also scrutinised to assess actions following the plasma level result. Data were collected in a binary yes/no format and results calculated as a percentage. Data was stored and collected in accordance to Trust General Data Protection Regulation (GDPR). Results In total 316 patients were included. 97% of these patients had evidence of TDM levels done during the time of the audit. 88% of these patients’ samples were done correctly. Only 45% of patients had levels within the widely acceptable therapeutic range. Of those patients whose levels fell outside the therapeutic range less than half (42%) had documentation that the level was reviewed. Discussion/Conclusion It is widely accepted that clozapine TDM when done accurately can be a vital source of information to inform prescribers on the appropriate dose, concordance and toxicity of clozapine therapy. Our Trust showed evidence of routine clozapine TDM. There was some variation in the appropriate sample collection but what was most alarming is the lack of documentation that action was taken when the TDM level was outside the general acceptable range. Standardising the actions following clozapine TDM needs to be a priority for the Trust if clozapine TDM is to continue to be carried out in almost 100% of the patient population. References 1. Taylor DM, Barnes TRE, Young AH. The Maudsley Prescribing Guidelines in Psychiatry 14th Edition. Wiley Blackwell. 2. Taylor DM et al. The use of clozapine plasma levels in optimising therapy. Psych Bull 1995:19:753-755 3. Perry PJ. Therapeutic drug monitoring of antipsychotics. Psychopharmacology 200; 148:83-89

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