Piportil Depot (pipotiazine palmitate) injection was globally withdrawn in March 2015 because of a shortage of the active ingredient. There are no generic versions available and pipotiazine is not available in an oral formulation. Therefore, clinicians will need to switch to another antipsychotic as existing stocks run out. In Scotland alone, about 410 patients ¹ are currently prescribed Piportil Depot, which translates to roughly 5000 recipients UK-wide (if that figure is generalisable). We present our suggestions for managing the antipsychotic switch.

1. 1 Treatment decisions should be made on an individual basis, in discussion with the patient, their carers (if the patient agrees) and the treating team.

2. 2 An early decision is whether a long-acting injection (LAI) or depot is still required or whether a switch to oral medication should be considered. This decision should take account of the patient’s views, the risk and likely consequences of a relapse and the risk of covert nonadherence with oral treatment. The main advantage of LAIs is that adherence is transparent. The patient’s psychiatric history will be informative in making this decision.

3. 3 With the exception of clozapine, there are no major differences in efficacy between individual antipsychotics, although they vary markedly in their risk of side-effects. ^{Reference Leucht, Cipriani, Spineli, Mavridis, Örey and Richter2} Consequently, the patient’s past experience of antipsychotics, and their views on potential adverse effects, will be important considerations guiding the choice of a new antipsychotic.

4. 4 If it is decided to switch to another LAI, then appropriate guidance, including that in the summary of product characteristics of the new LAI, should be followed regarding the details of the switch. If the patient has not previously received the new antipsychotic then a test dose is required before starting the LAI. In the case of first-generation antipsychotic LAIs, this takes the form of a low dose of the LAI, but with second-generation antipsychotic LAIs, it takes the form of a few days’ treatment with the oral form of the same antipsychotic.

5. 5 Acquisition costs vary considerably between first- and second-generation antipsychotic LAIs, but this should be only one of a range of factors considered in the selection of the new antipsychotic.

6. 6 The long half-life of Piportil Depot makes withdrawal effects unlikely. Illness relapse is likely to be the most common clinical concern after switching. We advise clinicians to be vigilant regarding relapse for at least 12 months after the switch, and the patient’s specific relapse signature should be discussed and borne in mind. Further details on the kinetics and switching of LAIs are given elsewhere. ^{Reference Taylor, Paton and Kapur3,Reference Haddad, Fleischhacker, Haddad, Lambert and Lauriello4}

The long half-life means that any existing adverse effects, for example extrapyramidal symptoms or hyperprolactinaemia, are likely to persist for some months after the switch. If an anticholinergic agent has been necessary to treat extrapyramidal symptoms during Piportil Depot treatment, it may be necessary to continue it for several months after the switch, before gradually withdrawing it. Similarly, hyperprolactinaemia may continue for up to 6 months after stopping Piportil Depot, even if the new antipsychotic is not associated with raised prolactin levels. Carry-over effects need to be considered when evaluating the tolerability of any replacement antipsychotic. ^{Reference Haddad, Fleischhacker, Haddad, Lambert and Lauriello4}