Use of Zuclopenthixol Acetate (Clopixol Accuphase) in adult inpatients (>17 years old)

Zuclopenthixol Acetate (Clopixol Accuphase©) should only be used, with caution and with the authorisation of a consultant psychiatrist, in the treatment of acute mania or psychosis if any of the following apply: 

1. The patient has required repeated injections of a short-acting antipsychotic drug (such as Olanzapine or Haloperidol), or benzodiazepines (such as Lorazepam), and at least 60 minutes have passed since last administration to assess full response 
2. Continuing to give further repeated injections of short-acting antipsychotics would be inappropriate 
3. The patient is known to have previously responded to Zuclopenthixol Acetate and tolerated it well, and the anticipated benefit of treatment with Zuclopenthixol Acetate outweighs its risk 
4. The patient has made an advance statement indicating that this is the treatment of choice in these circumstances, and they are known to have good response and tolerability to it.  

The advice and authorisation of a consultant psychiatrist MUST be obtained BEFORE Zuclopenthixol Acetate is prescribed. 

PRIOR to prescribing, the patient MUST be seen by the prescribing doctor.  

DO NOT administer against verbal, faxed, or scanned requests. 

DO NOT prescribe as a course of treatment.  

The patient MUST be fully assessed by a professional appropriately trained to carry out a mental state assessment (e.g. doctor, physician associate, advanced nurse practitioner) before each administration. 

Prescribe oral and IM procyclidine as PRN when prescribing Zuclopenthixol Acetate.  

The MDT should consider withholding other antipsychotics for the duration of action of Zuclopenthixol Acetate which is 3 days following administration.  

DO NOT USE in the following: 

1. If rapid sedation is required (onset of action is too slow) 
2. For patients who are accepting oral antipsychotic medication 
3. In an attempt to hasten the antipsychotic effect of other antipsychotic medication 
4. At the same time as other parenteral antipsychotics or benzodiazepines 
5. For patients who are naïve to antipsychotics, or have never had a trial of a potent dopamine antagonist (such as Haloperidol, Risperidone, Zuclopenthixol, Flupenthixol) 
6. For patients who are sensitive to the extra-pyramidal effects of antipsychotics 
7. For patients who have a history of Neuroleptic Malignant Syndrome 
8. For unconscious patients 
9. For patients who are pregnant or breast-feeding 
10. For patients with Parkinson’s disease or dementia with Lewy Bodies 
11. For a patient who is physically resistant (due to risk of intravasation and oil embolus) 

Use with CAUTION in the following:

1. Patients with a history of cardiovascular disease or risk factors for QTc prolongation (such as hypokalaemia, hypomagnesaemia) 
2. Patients who are known to have convulsive disorders, renal disorders, hepatic disorders or severe respiratory disease 
3. Patients with pre-existing organic brain syndrome or learning disabilities or dementia 
4. Patients who have risk factors for stroke 
5. Patients with narrow angle glaucoma, prostatic hypertrophy, hypothyroidism, hyperthyroidism, myasthenia gravis, or phaeochromocytoma 
6. Patients on concurrent prescriptions of drugs which increase Zuclopenthixol levels (such as Fluoxetine and Paroxetine) 

For administration by deep intramuscular (IM) injection only into the upper outer buttock or lateral thigh.

Reminder: Zuclopenthixol Acetate (Clopixol Accuphase©) has no place in immediate sedation as it’s onset of action is slow and not rapid.  

1. Sedative effects are usually seen 2 hours after injection and peak around 36 hours. The effects usually last up to 72 hours.  
2. Antipsychotic effects are evident 8 hours after injection. 

The lowest effective dose should be used to minimise risk of adverse reactions. 

Zuclopenthixol Acetate (Clopixol Accuphase©) should be prescribed as a “stat” dose only. If it is indicated, it should be administered immediately and not prescribed “just in case”. Prescribe Procyclidine oral and IM when required. 

1. Adults 

The dose is 50-150mg IM (1-3mls) as a single dose, repeated if necessary after 2-3 days.  

Some patients may need an additional injection between 1-2 days after the first injection. At least 24 hours must have elapsed between injections.  

The duration of treatment should not exceed TWO weeks and the cumulative dose must not exceed 400mg, with no more than 4 injections given in total.  

DO NOT prescribe as a course of injections.  

The patient should be medically assessed BEFORE each administration.  

   b. Elderly 

The dose may need to be reduced in this patient group due to reduced metabolism and elimination. Do not give more than 100mg per injection.

   c. Reduced renal or hepatic function 

Contact Pharmacy for advice on dosing. 

Adverse reactions are usually dose-dependant and are more common in patients who have not previously been exposed to Zuclopenthixol Acetate (Clopixol Accuphase©) before.  

Baseline ECG monitoring should be done as part of admission (although depending on patient distress, this may not be possible). Please ensure a further ECG is carried out following administration irrespective of whether baseline has been completed or not, and consider if further ECG monitoring is needed thereafter.