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 Formulary Chapter 4: Central nervous system - Full Chapter
Notes:

CNS-related Prescribing Guidance

Please see our Prescribing Guidelines page for all prescribing guidance relating to this chapter.

CNS-related Shared Care Agreements

Please see our Shared Care Agreements page for all shared care agreements (SCAs) relating to this chapter.

 

 Details...
04.01  Hypnotics and anxiolytics
 note 
04.01.01  Hypnotics
Melatonin (Circadin MR 2mg ®)
(Oral)
View adult BNF View SPC online
Formulary

For short-term treatment of insomnia in ADULTS in the following circumstances:

  • Red In-patient use (maximum 3 weeks treatment) by Consultant Care of the Elderly as short-term treatment of insomnia. Not for continuation in Primary Care.
  • Amber GWH and SFT only: For epileptic adults with insomnia, who cannot have Z drugs due to effect on seizure threshold.
  • Tablets 2mg m/r
  • ONLY prescribe as the brand Circadin® 
  • Maximum licensed duration of use is 13 weeks.
  • For use in paediatrics see paediatric section (chapter 16).
  • Please note, the brand Slenyto for paediatric use is not on formulary.
 
   
04.01.01  Benzodiazepines
 note 

Benzodiazepine and Z drug deprescribing Algorithm

Not recommended.

Controlled Drug Temazepam 
(Oral)
View adult BNF View SPC online
Formulary
Green
  • Tablets 10mg, 20mg
  • Oral solutionSF 10mg in 5ml
  • Temazepam has a short duration of action and has no active metabolites.
  • Temazepam is a Schedule 3 controlled drug; a maximum of 30 days supply for all controlled drugs is the good practice advice from the Department of Health. Ref: Safer Management of Controlled Drugs, May 2007.

 

 

 
   
04.01.01  Zaleplon, Zolpidem and Zopiclone
Zopiclone 
(Tablet)
View adult BNF View SPC online
Formulary
Green
  • Tablets 3.75mg, 7.5mg
  • Treatment with zopiclone should be as short as possible. Generally the duration of treatment varies from a few days to two weeks with a maximum, including the tapering off, of four weeks.
  • Prescription valid for 28 days
 
Controlled Drug CD Benz POM
Link  NICE TA77: Zaleplon, zolpidem and zopiclone for the management of insomnia
   
04.01.01  Chloral and derivatives to top
Chloral Hydrate 
(Oral)
View adult BNF View SPC online
Formulary
Red
  • 143mg/5ml oral solution
  • GWH: Paediatric use only
  • SFT: used for pre-procedure sedation only.
  • Short-term use only. License is for severe insomnia which is interfering with normal daily life and where other therapies have failed. 
  • Not to be initiated in primary care.
 
Link  MHRA DSU Dec 2014: Chloral hydrate (Welldorm) and Triclofos
   
04.01.01  Clomethiazole (Chlormethiazole)
04.01.01  Antihistamines
Promethazine Hydrochloride
(Oral)
View adult BNF View SPC online
Formulary
Green
  • Tablets 10mg, 25mg
  • Elixir 5mg/5ml
  • Promethazine may be a useful alternative to benzodiazepines and other hypnotics for night time sedation. However, residual sedation may occur the following day and its sedative effects may diminish after a few days of continued treatment.
  • License states it should only be used short-term for insomnia in adults or for paediatric sedation.
 
   
04.01.01  Alcohol
04.01.01  Sodium oxybate
04.01.02  Anxiolytics to top
Escitalopram 
(Oral)
View adult BNF View SPC online
First Choice
Green
  • Tablets 5mg, 10mg and 20mg
  • Licensed option for Generalised Anxiety Disorder (GAD)
  • 1st line option 
 
Sertraline 
(Oral)
View adult BNF View SPC online
Formulary
Green
  • Tablets 500mg and 100mg
  • Sertraline does not have UK marketing authorisation for GAD but is recommended by NICE CG113 (off-label).
  • Sertraline should be used with caution in patients with additional risk factors for QTc prolongation such as cardiac disease, hypokalaemia or hypomagnesemia, familial history of QTc prolongation, bradycardia and concomitant use of medications which prolong QTc interval.
 
   
Venlafaxine 
(Oral)
View adult BNF View SPC online
Formulary
Green
  • 2nd line option if a SSRI is ineffective
  • Tablets 37.5mg, 75mg, 150mg, 225mg and 300mg
  • Capsules 37.5mg, 75mg, 150mg and 225mg
 
   
Pregabalin 
(Capsule)
View adult BNF View SPC online
Formulary
Green
  • Capsules 25mg, 50mg, 75mg, 100mg, 150mg, 225mg, 200mg, 300mg. NOTE pregabalin tablets are NOT included on the BSWformulary
  • If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin.
  • The SPC advises caution when used with opioids due to risk of CNS depression - this increased risk was observed at low doses of pregabalin (≤ 300 mg) and there was a trend for a greater risk at high doses of pregabalin.
 
Controlled Drug Schedule 3 CD
Link  NHSE Controlled drugs use regulations
Link  PHE and NHSE Advice for prescribers on the risk of the misuse of pregabalin and gabapentin
Link  MHRA Drug Safety Update (Apr 2019):Pregabalin (Lyrica), gabapentin (Neurontin) and risk of abuse and dependence: new scheduling requirements
   
Duloxetine 
(Capsule)
View adult BNF View SPC online
Formulary
Green
  • Capsules 30mg, 60mg
  • Useful for mixed anxiety and depression.
  • AWP guidance suggests it should not be prescribed except where other treatments are poorly tolerated or ineffective if being used for depression alone.
  • Ensure you have chosen the correct product as Duloxetine comes in different strengths and forms which have different license indications.
  • Hyponatraemia has been reported with duloxetine, and may be due to a syndrome of inappropriate anti-diuretic hormone secretion (SIADH). The majority of cases of hyponatraemia were reported in the elderly, especially when coupled with a recent history of, or condition pre-disposing to, altered fluid balance. Caution is required in patients at increased risk for hyponatraemia, such as elderly, cirrhotic, or dehydrated patients, or patients treated with diuretics.
 
   
04.01.02  Benzodiazepines
 note 

Benzodiazepine and Z drug deprescribing Algorithm

Diazepam 
(Oral,Rectal)
View adult BNF View SPC online
Formulary
Green
  • Tablets 2mg, 5mg, 10mg
  • Oral Solution 2mg in 5ml,
  • Suppositories
 
Controlled Drug CD Benz POM
   
Diazepam injection

View adult BNF View SPC online
Formulary
Red
  • Injection (emulsion - Diazemuls®) 10mg in 2ml
  • Injection 5mg/ml
 
Controlled Drug CD Benz POM
   
Lorazepam  
(injection)
View adult BNF View SPC online
Formulary
Red
  • Injection 4mg in 1ml
  • For short term use in status epilepticus or rapid tranquilisation. By intramuscular or slow intravenous injection (into a large vein). 
  • Note: Only use intramuscular route when oral and intravenous routes not possible. For intramuscular injection it should be diluted with an equal volume of water for injections or physiological saline (but only use when oral and intravenous routes not possible).
  • See NICE NG10 (link below).
  • Shorter half life and no active metabolites, but carries a greater risk of withdrawal symptoms.
  • Also used in chemotherapy antiemetic regimens
 
Controlled Drug CD Benz POM
Link  SPS memo April 2020 - Shortage of Ativan (lorazepam) Injection 4 mg in 1 ml
Link  NICE NG10 Violence and aggression: short-term management in mental health, health and community settings May 2015
   
Lorazepam 
(Tablets)
View adult BNF View SPC online
Formulary
Green
  • Tablets 1mg
  • For short term use . Shorter half life and no active metabolites, but carries a greater risk of withdrawal symptoms.

 

 
Controlled Drug CD Benz POM
   
04.01.02  Buspirone
Buspirone Hydrochloride
(Tablets)
View adult BNF View SPC online
Formulary
Amber
  • Tablets 5mg
  • No withdrawal effects but response to treatment may take up to 2 weeks
 
   
04.01.02  Beta blockers
Propranolol 
(Oral)
View adult BNF View SPC online
Formulary
Green
  • Tablets 10mg, 40mg
  • Modified Release capsules
  • Propranolol (usual dose 20-60mg per day in divided doses) is useful in situational anxiety, especially for prominent somatic symptoms such as tachycardia, sweating and tremor. Also used in endocrinology for adjunctive management of thyrotoxicosis and thyrotoxic crisis.
 
   
04.01.02  Meprobamate
04.01.03  Barbiturates to top
 note 

Not recommended.

04.02  Drugs used in psychoses and related disorders
04.02.01  Antipsychotic Drugs
 note 
  • See NICE Clinical Guideline: Schizophrenia and NICE Clinical Guideline: Bipolar disorder
  • At a population level there is little meaningful difference in efficacy between each of the antipsychotic drugs (other than clozapine). Response and tolerability to each antipsychotic drug varies significantly between individuals.
  • Choice of antipsychotic medication is influenced by the patient’s medication history, the relative side-effect profiles and consideration of individual patient factors such as risk of extrapyramidal side-effects, weight gain, impaired glucose tolerance, QT-interval prolongation etc.
  • Oral antipsychotics would usually only be initiated on the advice of a prescriber with experience in psychiatry.
  • Carefully consider risks / benefits of prescribing antipsychotics in elderly - especially in dementia
  • Patients with severe & enduring mental health problems require at least an annual health check. 
  • MHRA Drug Safety update 01 Mar 2009 Antipsychotics: use in elderly people with dementia
  • MHRA Drug Safety Update 01 Jun 2009 Antipsychotics: risk of venous thromboembolic events
  • See PrescQIPP's toolkit Reducing antipsychotic prescribing in dementia
  • Orodispersible tablets (e.g. Velotabs®) should only be used when swallowing difficulties are present or it is vital that there is a check on successful administration. 

    Acute management of psychotic illness

    Prescribing for patients presenting with acute psychosis should be commenced after seeking specialist advice. However, you may wish to prescribe without seeking specialist advice if you feel confident in prescribing such medications in specific circumstances, eg. an existing patient suffering a recurrent acute episode previously managed on antipsychotic treatment.

    For other indications (where a specialist opinion is sought)

    GP's will be asked to continue prescribing where appropriate. On discharge to primary care a date should be indicated on which the need for medication is to be reviewed.

Chlorpromazine 
(Oral)
View adult BNF View SPC online
Formulary
Amber
  • 25mg,50mg,100mg tablets
  • 25mg/5ml solution SF
  • 25mg/5ml syrup
  • 100mg/5ml solution

 

 
   
Haloperidol  
(Oral)
View adult BNF View SPC online
Formulary
Green
  • Tablets 500 micrograms, 1.5mg, 5mg, 10mg
  • Oral liquidSF 1mg in 1ml
  • Notes: Baseline ECG is recommended prior to treatment with haloperidol in all patients, especially in the elderly and patients with a positive personal or family history of cardiac disease or abnormal findings on cardiac clinical examination. 
 
   
Haloperidol  
(Injection )
View adult BNF View SPC online
Formulary
  • Green for palliative care use
  • Red  for rapid tranquillisation
  • Injection 5mg in 1ml for palliative care see guidance for BaNES CCG/RUH patients on link below
  • Injection 5mg in 1ml (Rapid traquilisation) 
  • Notes: Baseline ECG is recommended prior to treatment with haloperidol in all patients, especially in the elderly and patients with a positive personal or family history of cardiac disease or abnormal findings on cardiac clinical examination.

 

 
   
Levomepromazine 
(Tablet,injection)
View adult BNF View SPC online
Formulary
Green
  • Tablet 25mg
  • For palliative care for the management of pain, associated restlessness, distress or vomiting.
 
   
Sulpiride 
(Oral)
View adult BNF View SPC online
Formulary
Amber
  • Tablets 200mg, 400 mg
 
   
Trifluoperazine 
(Oral)
View adult BNF View SPC online
Formulary
Amber
  • Tablets 1mg, 5mg
  • Oral solutionSF 1mg in 5ml, 5mg in 5ml
 
   
Zuclopenthixol 
(Oral)
View adult BNF View SPC online
Formulary
Amber
  • Clopixol® tablets 2mg, 10mg or 25mg

 

 
   
Zuclopenthixol Acetate
(Clopixol Acuphase®)
(Injection)
View adult BNF View SPC online
Formulary
Red
  • Injection 50mg in 1ml
  • Injection 100mg in 2ml
  • For deep IM injection
  • For the initial treatment of acute psychoses including mania and exacerbation of chronic psychoses, particularly where a duration of effect of 2-3 days is desirable
  • Inpatient use only, AWP internal guideline to be followed

 

 
   
04.02.01  First-Generation Antipsychotic Drugs
04.02.01  Second-Generation Antipsychotic Drugs
Amisulpride 
(Oral)
View adult BNF View SPC online
Formulary
Amber
  • Tablets 50mg, 100mg, 200mg, 400mg
  • Oral Solution
 
   
Aripiprazole 
(Oral)
View adult BNF View SPC online
Formulary
Amber
  • Tablets 5mg, 10mg, 15mg, 30mg
  • Orodispersible tablet 10mg, 15mg
  • Oral solution 1mg/ml
 
Link  3Ts Shared Care Document
Link  NICE TA213: Aripiprazole for the treatment of schizophrenia in people aged 15 -17 years
Link  NICE TA292: Aripiprazole for treating moderate to severe manic episodes in adolescents with bipolar I disorder
   
Clozapine (Zaponex®)
(Oral)
View adult BNF View SPC online
Formulary
Red
  • Tablets 25mg, 100mg
  • Note:  Patients must be registered with the Zaponex® Treatment Access System (ZTAS). Licensed for treatment resistant schizophrenia.
  • The patient, the supervising consultant and the dispensing pharmacy must all be registered with ZTAS. In this formulary area the AWP internal pharmacy is the primary supplier for clozapine for almost all patients.
  • Regular (minimum monthly) full blood counts are required prior to and during clozapine treatment, if these are not up-to-date then medication cannot be dispensed.

See link below for AWP Procedure for the care of patients taking clozapine in primary care settings during the COVID-19 pandemic

 
Link  AWP Procedure for the care of patients taking clozapine in primary care settings during the COVID-19 pandemic
Link  MHRA Drug Safety Update October 2017: Clozapine: reminder of potentially fatal risk of intestinal obstruction, faecal impaction, and paralytic ileus
   
Olanzapine  
(Injection )
View adult BNF View SPC online
Formulary
Red
  • Injection 10mg/2ml (Rapid tranquilisation)
  • Note: Olanzapine has been associated with an increased risk of hyperglycaemia, diabetes mellitus and exacerbations of diabetes. In patients with risk factors for diabetes mellitus, appropriate clinical and blood glucose monitoring should be conducted.
 
   
Olanzapine  
(Oral)
View adult BNF View SPC online
Formulary
Amber
  • Tablets 2.5mg, 5mg, 7.5mg, 10mg, 15mg, 20mg
  • Orodispersible tablet 5mg, 10mg, 15mg, 20mg
  • Note: Olanzapine has been associated with an increased risk of hyperglycaemia, diabetes mellitus and exacerbations of diabetes. In patients with risk factors for diabetes mellitus, appropriate clinical and blood glucose monitoring should be conducted.

 
   
Quetiapine 
(Oral)
View adult BNF View SPC online
Formulary
Amber
  • Tablets 25mg, 100mg, 150mg, 200mg, 300mg
  • MR tablets 50mg, 150mg, 200mg, 300mg, 400mg
  • Can be initiated in primary care with the advice from the Primary Care Liaison Service (PCLS) (AWP) or by specialist psychiatry health care professionals.
  • Note: Quetiapine XL is ONLY recommended for use when individuals cannot tolerate immediate-release quetiapine or if concordance with a twice daily regimen is difficult.  
 
   
Risperidone 
(Oral)
View adult BNF View SPC online
Formulary
Amber
  • Tablets 500 micrograms, 1mg, 2mg, 3mg, 4mg, 6mg
  • Orodispersible tablet (Quicklets®) 500 micrograms, 1mg, 2mg, 3mg, 4mg
  • Liquid 1mg in 1ml
  • Also indicated for the short-term treatment (up to 6 weeks) of persistent aggression in patients with moderate to severe Alzheimer's dementia unresponsive to non-pharmacological approaches and when there is a risk of harm to self or others.
 
Link  MHRA DSU Risperidone and paliperidone: risk of intraoperative floppy iris syndrome in patients undergoing cataract surgery Dec 2014
   
04.02.02  Antipsychotic depot injections to top
Flupentixol Decanoate
(Depixol®)
(Injection)
View adult BNF View SPC online
Formulary
  • Red in south Wiltshire via service commissioned at Fountain Way, Salisbury.
  • Amber in rest of Wiltshire, Swindon and BaNES
  • Depixol® injection 20mg/ml - 20mg in 1ml, 40mg in 2ml
  • Depixol® injection 100mg /ml ("Concentrate") - 50mg in 0.5ml, 100mg in 1ml
  • Depixol® injection 200mg/ml ("Low-volume") - 200mg in 1ml

 

 
   
Fluphenazine Decanoate

(Injection)
View adult BNF View SPC online
Formulary
Amber
  • injection 25mg/ml - 12.5mg in 0.5ml, 25mg in 1ml, 50mg in 2ml
 
   
Fluphenazine Decanoate
(Modecate® Concentrate)
View adult BNF View SPC online
Formulary
Amber
  • injection 100mg/ml ("Concentrate") - 50mg in 0.5ml, 100mg in 1ml
 
   
Haloperidol Decanoate
(Haldol ®)
(Injection)
View adult BNF View SPC online
Formulary
  • Red in south Wiltshire via service commissioned at Fountain Way, Salisbury.
  • Amber in rest of Wiltshire, Swindon and BaNES
  • Haldol® injection 50mg in 1ml
  • Haldol®injection 100mg in 1ml

 

 
   
Paliperidone 
(Injection)
View adult BNF View SPC online
Formulary
Red
  • AWP use only
  • Xeplion® Long Acting Injection (LIA) 50mg, 75mg, 100mg, 150mg once a month after initial loading dose
  • Xeplion is not currently on 3Ts formulary- under review
  • Be aware that there is also a Trevicta® Long Acting Injection (LIA) administered once every three months which is currently non-formulary. 
 
   
Risperidone (Risperdal Consta®)
(Injection)
View adult BNF View SPC online
Formulary
Red
  • AWP use only
  • Risperdal Consta® long acting injection 25mg, 37.5mg, 50mg
  • Notes: Refrigerated storage. Given every two-weeks. Generally, not for new initialtions (use paliperidone long acting injection in preference) but patients currently stable should be continued
 
   
Zuclopenthixol Decanoate
(Clopixol®)
(Injection)
View adult BNF View SPC online
Formulary
  • Red in south Wiltshire via service commissioned at Fountain Way, Salisbury.
  • Amber in rest of Wiltshire, Swindon and BaNEs
  • Clopixol® injection 200mg in 1ml
  • Clopixol® injection 500mg in 1ml ("Concentrate")

 

 
   
04.02.03  Drugs used for mania and hypomania
 note 

Antipsychotic drugs – In an acute manic episode treatment with an antipsychotic drug may be required .Some atypical antipsychotics are also licensed as mood stabilisers (see BNF4.2.1)

Lamotrigine 
(Tablet)
View adult BNF View SPC online
Formulary
Amber
  • Tablet 25mg, 50mg, 100mg, 200mg 
  • Dispersible tablet 2mg, 5mg, 25mg, 100mg  
  • Prevention of depressive episodes in patients with bipolar I disorder who experience predominantly depressive episodes

 

 
Link  3Ts Lamotrigine- Prevention of depressive episodes in patients with bipolar disorder who experience predominantly depressive episodes.Shared Care
   
04.02.03  Benzodiazepines
04.02.03  Antipsychotic drugs
04.02.03  Carbamazepine
 note 

NICE CG185 Bipolar disorder: assessment and management April 18 update

Carbamazepine 
(Oral, Rectal)
View adult BNF View SPC online
Formulary
Amber
  • Tablet 100mg, 200mg, 400mg
  • Tegretol® m/r tablet 200mg, 400mg.  Prescribe M/R tablet by brand
  • LiquidSF 100mg/ml
  • Suppository 125mg, 250mg
  • Prescribe generically for non epilepsy indications.
  • Carbamazepine may be used for the prophylaxis of bipolar disorder in patients unresponsive to lithium; it seems to be particularly more effective in patients with rapid cycling manic-depressive illness (4 or more episodes per year).
 
   
04.02.03  Valproic acid to top
 note 

NICE CG185 Bipolar disorder: assessment and management April 18 update

Sodium valproate 
(Oral)
View adult BNF View SPC online
Formulary
Amber
  • Crushable tablet 100mg
  • E/C tablets 200mg, 500mg
  • m/r tablet 200mg, 300mg, 500mg (Category 2 MHRA)
  • m/r capsules 150mg, 300mg
  • LiquidSF 200mg/5ml 
  • Valproate must not be used in any woman or girl able to have children unless there is a pregnancy prevention programme (PPP) in place (see MHRA link).
  • Both semi‑sodium and sodium valproate are metabolised to valproic acid (also known as valproate), which is the pharmacologically active component.
  • Any of the available valproate preparations may be used as a mood stabliser in bipolar disorder (off label, but NICE recommended).

COVID-19 MHRA have issued guidance- see link below.

 

 

 
Link  MHRA Valproate Pregnancy Prevention Programme: temporary advice for management during coronavirus (COVID-19) May 2020
Link  MHRA April 2019: Valproate medicines and serious harms in pregnancy: new Annual Risk Acknowledgement Form and clinical guidance from professional bodies to support compliance with the Pregnancy Prevention Programme
   
Valproic Acid (Depakote®)
(Oral)
View adult BNF View SPC online
Formulary
Amber
  • Depakote® tablets 250mg, 500mg
  • Prescribe by brand name
  • May 2020: There are stock shortages of Depakote currently. AWP are using the brand syonell instead. There is also a different brand available called Belvo which can also be used. AWP have confirmed that this is a like for like switch and that primary care can switch patients from Depakote to an alternative brand during the shortages. Patients should be advised that the packaging and colour of the tablets are different, but the medicine is exactly the same.
  • Valproic acid – The semisodium salt (Depakote®) is licensed for the treatment of manic episodes associated with bipolar disorder.
  • Any of the available forms of valproate may be used off-label as a mood stabiliser.
  • Valproate must not be used in any woman or girl able to have children unless there is a pregnancy prevention programme (PPP) in place (see MHRA link)

COVID-19 MHRA have issued guidance- see link below. 

 
Link  MHRA Valproate Pregnancy Prevention Programme: temporary advice for management during coronavirus (COVID-19) May 2020
Link  3Ts Valproic Acid for the treatment of manic episode in bipolar disorder when lithium is contraindicated or not tolerated.
Link  MHRA April 2019: Valproate medicines and serious harms in pregnancy: new Annual Risk Acknowledgement Form and clinical guidance from professional bodies to support compliance with the Pregnancy Prevention Programme
   
04.02.03  Lithium
 note 

AWP guidance for managing lithium during COVID outbreak

SPS ARCHIVED NPSA Alert – Safer lithium therapy 2009

Lithium Carbonate (Priadel®)
(Tablet)
View adult BNF View SPC online
Formulary
Amber with Shared Care
  • Priadel® M/R tablet 200mg,
  • Priadel® M/R tablet 400mg
  • Prescribed by brand name.
  • Monitor lithium levels. Samples should be taken 12 hours after the preceding dose. Refer to shared care information on links below. Note the SCAs are old and an updated and aligned version for BSW is expected to be published by Autumn 2020.

  • 9th September 2020: BSWCCG Meds Op team statement: We have received a number of queries related to the CAS alert 21st August 2020 - Supply Disruption Alert for Priadel® (lithium carbonate) 200mg and 400mg MR tablets which are being discontinued in the UK. Remaining supplies of both strengths are expected to be exhausted by April 2021. 


    Specialists at AWP are working alongside mental health colleagues nationally to look at the switching process for existing patients and will provide information and updates in due course. 

    Clinical guidance advises that patients must be maintained on the same brand of lithium to ensure that a consistent serum lithium level is maintained. The switching of brands necessitated by the discontinuation of Priadel® tablets will require individualised determination of dose, close monitoring of serum lithium levels and vigilance for relapse and tolerability in all cases.

    Due to the timeframes outlined in the CAS alert, we do not anticipate any urgent switches required but please be reassured that we are liaising with specialists at AWP who are also working alongside mental health colleagues nationally to look at the switching process for existing patients and will provide information and updates in due course. In the meantime, they have requested people refrain from switching brands until local guidance is agreed and to ONLY contact them with patient specific urgent clinical queries.

    There is also a statement from Royal College of Psychiatrists - https://www.rcpsych.ac.uk/news-and-features/latest-news/detail/2020/08/03/statement-on-lithium-carbonate-priadel

    Stock information-

    We have had queries relating to local early and unexpected shortages - Essential Pharma have been contacted and they have assured us that there is currently plenty of stock available. 

    • Essential Pharma have put in place monthly wholesaler quotas for Priadel in order to protect supplies from stockpiling
    • New quota for September has been ordered by wholesalers and will be available for pharmacies to order by the end of this week or early next week(w/c 8th September)
    • Urgent orders can be placed by pharmacies using Movianto (if the pharmacy has an account with them)- there may be additional costs for such urgent orders.

    Lastly Priadel Liquid is not being discontinued but should be reserved for those patient who have a clinical requirement for a liquid preparation to avoid shortages of this preparation.

 

 
Link  3Ts Lithium Shared Care Document
Link  3Ts Lithium signature sheet
Link  BCAP Lithium Shared Care Document
Link  SFT Lithium Shared Care Document
   
Lithium Carbonate (Camcolit ® 400mg/ Essential Pharma 250mg)
(Tablet)
View adult BNF View SPC online
Formulary
Amber with Shared Care
  • 250mg
  • 400mg MR
  • Prescribed by brand name.
  • Monitor lithium levels. Samples should be taken 12 hours after the preceding dose.
  • The proprietary (brand) name of “Camcolit 250mg tablets” has changed to “Lithium Carbonate Essential Pharma 250 mg film-coated tablets”, effective from 1st October 2015. The product strength and formulation have not changed, only the name has changed.
  • This name change only applies to Camcolit 250mg. Please note, the product name for “Camcolit 400mg prolonged release Lithium carbonate film-coated tablet” is not affected.
  • Refer to shared care information on links below. Note the SCAs are old and an updated and aligned version for BSW is expected to be published by Autumn 2020.
 
Link  3Ts Lithium Shared Care Document
Link  3Ts Lithium signature sheet
Link  BCAP Lithium Shared Care Document
Link  SFT Lithium Shared Care Document
   
Lithium Carbonate (Liskonum®)
(Tablet)
View adult BNF View SPC online
Formulary
Amber with Shared Care
  • 450mg MR
  • Prescribed by brand name.
  • Monitor lithium levels. Samples should be taken 12 hours after the preceding dose.
  • Refer to shared care information on links below. Note the SCAs are old and an updated and aligned version for BSW is expected to be published by Autumn 2020.
 
Link  3Ts Lithium Shared Care Document
Link  3Ts Lithium signature sheet
Link  BCAP Lithium Shared Care Document
Link  SFT Lithium Shared Care Document
   
Lithium Citrate Liquid
(Priadel®)
View adult BNF View SPC online
Formulary
Amber with Shared Care
  • Priadel® SF syrup 520mg (equivalent to 5.4mmol Li+) in 5ml
  • Li-Liquid® (5ml ≡ 200mg lithium carbonate MR tablets)
  • Prescribed by brand name.
  • See the National Patient Safety Agency safer lithium therapy alert link below. 
  • Monitor lithium levels. Samples should be taken 12 hours after the preceding dose.
  • Refer to shared care information on links below. Note the SCAs are old and an updated and aligned version for BSW is expected to be published by Autumn 2020.
 
Link  3Ts Lithium Shared Care Document
Link  3Ts Lithium signature sheet
Link  BCAP Lithium Shared Care Document
Link  SFT Lithium Shared Care Document
   
04.03  Antidepressant drugs
 note 

See NICE Clinical Guideline 23: Depression in adults:recognition and management April 2016 update

04.03.01  Tricyclic and related antidepressant drugs
 note 
  • SPS UKMI How do you switch between tricyclic, SSRI and related antidepressants? Oct 2019
  • Due to the risk of toxicity in overdose, consider limiting the quantity prescribed on each prescription. Lofepramine is associated with fewer anticholinergic side effects, is less sedating and is considered to be safer in overdose. Amitriptyline, imipramine and clomipramine should be avoided where there is a suicide risk.
  • Dosulepin has been excluded from this formulary. It is more toxic than other tricyclic antidepressants particularly due to its pro-convulsive and cardiac arrhythmic effects and it is very dangerous in overdose.
  • When initiating therapy, start low and increase to a therapeutic dose over 1–3 weeks.
  • Weight gain can be significant with tricyclic antidepressants.
  • If the patient drives, always counsel the patient about sedation and slower reaction times. (The latter may occur even if patient doesn’t feel drowsy.)
  • Arrhythmias and heart block - occasionally follow the use of tricyclic antidepressants, particularly amitriptyline, and may be a factor in the sudden death of patients with cardiac disease.
  • Renal impairment – Tricyclic antidepressants are excreted by kidneys, therefore, start with low doses and increase slowly. Accumulation may occur causing adverse drug reactions. Dividing total daily dose into 2-3 doses may be helpful.
  • Myocardial infarction – Avoid tricyclic antidepressants if previous MI. Trazodone or Sertraline (see below) may be used but try to avoid any antidepressant therapy for first two months post MI if possible.
  • Elderly and dementia – AVOID tricyclic antidepressants in dementia or where significant cognitive impairment is present.
04.03.01  Tricyclic antidepressants
Amitriptyline 
(Oral)
View adult BNF View SPC online
Formulary
Green
  • Tablets 10mg, 25mg, 50mg
  • Oral solution 25mg in 5ml
  • Not recommended for the treatment of depression – see BNF. A sedating TCA with a high incidence of side-effects and can be fatal in overdose.  Low dose useful for neuropathic pain.
 
   
Clomipramine 
(Capsule)
View adult BNF View SPC online
Formulary
Green
  • Capsule 10mg, 25mg, 50mg
  • Note: Also used in phobic and obsessional states
 
   
Imipramine 
(Oral)
View adult BNF View SPC online
Formulary
Green
  • Tablets 10mg
  • Liquid SF   25mg/5ml
 
   
Lofepramine 
(Oral)
View adult BNF View SPC online
Formulary
Green
  • Tablets 70mg
  • Oral suspension 70mg in 5ml
  • Probably the safest TCA in overdose
 
   
04.03.01  Related antidepressants to top
Trazodone 
(Oral)
View adult BNF View SPC online
Formulary
Green
  • Capsules 50mg, 100mg
  • Tablets 150mg
  • LiquidSF 50mg in 5ml
  • Sedative antidepressant related to the TCAs, may be less toxic in overdose.
  • Used off-label for behavioural symptoms of dementia.
 
   
04.03.02  Monoamine-oxidase inhibitors
 note 
  • Specialist initiation only.
  • Third line drugs for atypical depression.
  • All irreversible monoamine-oxidase inhibitors are considered less suitable for prescribing. Isocarboxacid and tranylcypromine have not been included in this formulary. Hypertensive crisis can occur following ingestion of tyramine or other pressor amines in foods or medication.
  • Consider phenelzine for patients who have failed to respond to alternative antidepressants and who are prepared to tolerate the side effects and dietary restrictions associated with its use. Consider its toxicity in overdose when prescribing for patients at high-risk of suicide.

 

Phenelzine 
(Tablet)
View adult BNF View SPC online
Formulary
Amber
  • Tablets 15mg 
  • Patients should avoid consuming large amounts of tyramine-rich food (such as mature cheddar, yeast extracts, red wine and fermented soya bean products) and sympathomimetics (such as ephedrine, pseudoephedrine and phenylpropanolamine).
  • Patients should be advised to take last dose before 3pm in order to minimise sleep disturbance / insomnia.
  • Refer the patient to the patient information leaflet (PIL) supplied with the product for dietary restrictions or go to https://patient.info/health/depression-leaflet/antidepressants for a full list.
 
Link  Oct 2019 - Information on shortages of phenelzine
   
04.03.02  Reverible MAOIs
Moclobemide 
(Tablet)
View adult BNF View SPC online
Formulary
Amber
  • Tablets 150mg, 300mg 
  • Patients should avoid consuming large amounts of tyramine-rich food (such as mature cheddar, yeast extracts, red wine and fermented soya bean products) and sympathomimetics (such as ephedrine, pseudoephedrine and phenylpropanolamine).
  • Patients should be advised to take last dose before 3pm in order to minimise sleep disturbance / insomnia.
  • Refer the patient to the patient information leaflet (PIL) supplied with the product for dietary restrictions or go to https://patient.info/health/depression-leaflet/antidepressants for a full list.
 
   
04.03.03  Selective serotonin re-uptake inhibitors
 note 
  • SPS UKMI How do you switch between tricyclic, SSRI and related antidepressants? Oct 2019
  • SSRIs may initially increase anxiety levels and it may be necessary to ‘cover’ their initiation with a brief course of a benzodiazepine in order to encourage compliance.
  • Abrupt withdrawal of SSRIs should be avoided (associated with headache, nausea, paraesthesia, dizziness and anxiety). All patients prescribed antidepressants should be counselled on the risk of discontinuation symptoms.
  • Consider the risks of relapse before changing antidepressant therapy in a patient who is stable.
  • MHRA guidance is that no SSRI should be used for treating depression in the under 18s, but where necessary fluoxetine is first choice.
  • BCAP/AWP depression pathway Jan 2017 
Sertraline 
(Tablet)
View adult BNF View SPC online
First Choice
Green
  • Tablets 50mg, 100mg
  • Sertraline should be used with caution in patients with additional risk factors for QTc prolongation such as cardiac disease, hypokalaemia or hypomagnesemia, familial history of QTc prolongation, bradycardia and concomitant use of medications which prolong QTc interval.
 
Escitalopram 
(Oral)
View adult BNF View SPC online
First Choice
Green
  • Tablets 5mg, 10mg
  • Drops 20mg/ml
  • 20 mg for adults;
  • 10 mg for patients older than 65 years;
  • 10 mg for those with hepatic impairment
 
Fluoxetine 
(Oral)
View adult BNF View SPC online
Second Choice
Green
  • Capsules 20mg, 30mg, 40mg, 60mg
  • Liquid 20mg in 5ml
  • 10mg tablets and 10mg capsules are available but are prohibitively expensive.
  • Note: Long half life, least likely SSRI to cause withdrawal reactions. 
 
   
Citalopram 
(Oral)
View adult BNF View SPC online
Formulary
Green
  • Tablets 10mg, 20mg, 40mg
  • Oral dropsSF 40mg in 1ml–8mg (4 drops may be considered equivalent to 10mg tablet)
  • Note: Fewer drug interactions than fluoxetine or paroxetine. 
  • For citalopram, new restrictions on the maximum daily doses now apply:
    • 40 mg for adults;
    • 20 mg for patients older than 65 years;
    • 20 mg for those with hepatic impairment.
 
Link  MHRA DSU December 2014: Citalopram and escitalopram: QT interval prolongation
Link  MHRA DSU July 2016: Citalopram: suspected drug interaction with cocaine; prescribers should consider enquiring about illicit drug use
   
Paroxetine 
(Oral)
View adult BNF View SPC online
Formulary
Amber
  • Tablets 10mg, 20mg, 30mg
  • Oral Suspension 10mg/5ml 150ml
  • Paroxetine has a place in therapy for anxiety disorder.  Caution when stopping, higher risk of withdrawal reactions
 
   
Vortioxetine 
(Tablet)
View adult BNF View SPC online
Formulary
Amber
  • Tablets 5mg, 10mg, 20mg 
  • To be used 3rd line where SSRIs, SNRIs or mirtazapine have been ineffective or poorly tolerated in accordance with NICE TA (link below)
 
Link  NICE TA367 - Vortioxetine for treating major depressive episodes
   
04.03.04  Other antidepressant drugs
 note 
  • There is little evidence to suggest these agents are superior in terms of efficacy but they differ in side-effect profile and this may influence choice of agent. Drugs from different classes are sometimes used in combination for resistant depression.
  • Use of mirtazapine and venlafaxine are reserved for those patients that have found a SSRI ineffective or where a SSRI is contraindicated or poorly tolerated
Duloxetine 
(Capsules)
View adult BNF View SPC online
Formulary
Amber
  • Capsules 20mg, 30mg, 40mg and 60mg
  • The starting and recommended maintenance dose is 60 mg once daily with or without food. 
  • Ensure you have chosen the correct product as Duloxetine comes in different strengths and forms which have different license indications.
  • Hyponatraemia has been reported with duloxetine, and may be due to a syndrome of inappropriate anti-diuretic hormone secretion (SIADH). The majority of cases of hyponatraemia were reported in the elderly, especially when coupled with a recent history of, or condition pre-disposing to, altered fluid balance. Caution is required in patients at increased risk for hyponatraemia, such as elderly, cirrhotic, or dehydrated patients, or patients treated with diuretics.
 
   
Mirtazapine 
(Oral)
View adult BNF View SPC online
Formulary
Green
  • Tablets 15mg, 30mg, 45mg
  • Orodispersible tablets 15mg, 30mg, 45mg
  • Oral solution 15mg/ml
  • Mirtazapine soluble tablets are more expensive than standard formulation. They should be reserved for patients with swallowing difficulties only.
  • Mirtazepine oral solution is only for use via enteral feeding tubes.
  • Mirtazapine appears to be safe in overdose and is thought to cause less insomnia, anxiety and agitation.
  • Sexual dysfunction is rare and the likelihood of drug interactions is low. Weight gain may be significant.
 
   
Venlafaxine 
(Oral)
View adult BNF View SPC online
Formulary
Green
  • Tablets 37.5mg, 75mg, 150mg, 225mg
  • Treatment and prevention of major depressive episodes
  • Immediate-release venlafaxine (BD dosage) is considerably less expensive than once daily (XL). The XL formulation should only be used if the immediate-release formulation is not tolerated or if concordance with a twice daily regimen is difficult.
  • Elevation of blood pressure may occur at higher doses and the manufacturer recommends BP monitoring at daily doses >200mg.
  • Updated prescribing advice for venlafaxine: NICE has recommended the following with regard to venlafaxine:
    • Compared with other equally effective antidepressants recommended for routine use in primary care, venlafaxine is associated with a greater risk of death from overdose .
    • The increased likelihood of the person stopping treatment because of side effects (and the consequent need to increase the dose gradually) with venlafaxine.
    • The potential for higher doses of venlafaxine to exacerbate cardiac arrhythmias and the need to monitor the person’s blood pressure
    • The possible exacerbation of hypertension with venlafaxine
 
   
04.04  CNS stimulants and other drugs used for attention deficit hyperactivity disorder to top
 note 

NICE Guideline NG87 (covers adults and children): NICE NG87 March 2018 Attention deficit hyperactivity disorder: diagnosis and management

Controlled Drug Methylphenidate Hydrochloride MR

(Oral)
View adult BNF View SPC online
First Choice
Amber with Shared Care
  • Xaggitin® XL  Modified release tablet 18mg, 27mg, 36mg, 54mg - First line for new patients as the most cost-effective formulary choice locally
  • Concerta® XL Modified release tablet 18mg, 27mg, 36mg: existing patients only.
  • Equasym® XL Modified release capsule 10mg, 20mg, 30mg

Note: SCA for Adults link below. SCA for Paeds see Chapter 16

 
Controlled Drug Lisdexamfetamine 
(Capsule)
View adult BNF View SPC online
Second Choice
Amber with Shared Care
  • Capsules 20mg, 30mg, 40mg, 50mg, 60mg, 70mg 
  • Once daily dosing.

 Note: SCA for Adults link below. SCA for Paeds see Chapter 16

 
Link  BSW SCA For ADHD in adults with no other serious mental health co-morbidities.
   
Atomoxetine 
(Capsule)
View adult BNF View SPC online
Third Choice
Amber with Shared Care
  • Capsules 10mg, 18mg, 25mg, 40mg, 60mg, 80mg, 100mg 

 Note: SCA for Adults link below. SCA for Paeds see Chapter 16

 
Link  BSW SCA For ADHD in adults with no other serious mental health co-morbidities.
   
Modafinil 
(Tablet)
View adult BNF View SPC online
Formulary
Amber
  • Tablet 100mg, 200mg
  • Narcolepsy should be diagnosed and treatment initiated by a specialist physician.

 

 

 
Link  Feb 2020 Letter sent to HCPs - Modafinil: potential risk of congenital malformations during pregnancy
Link  MHRA DSU December 2014: Modafinil (Provigil): now restricted to narcolepsy
   
04.04  Cocaine
04.05  Drugs used in the treatment of obesity
 note 

These drugs should be initiated in primary care or under appropriate specialist guidance.

Weight loss services/referrals:

Tier 1 & 2 services: Wiltshire Weight Management Pathway:

https://prescribing.wiltshireccg.nhs.uk/?wpdmdl=1680

NHS Wiltshire CCG: Tier 3 and 4 services:

https://www.nbt.nhs.uk/sites/default/files/North%20Bristol%20Centre%20for%20Weight%20Loss,%20Metabolic%20&%20Bariatric%20Surgery%20-%20Information%20for%20GPs%20(November%202014).pdf

NHS Wiltshire CCG Weight Management on referral - Eligibility & Referral Guidance:

https://prescribing.wiltshireccg.nhs.uk/?wpdmdl=1681

Wiltshire Council Health Improvement Services: https://prescribing.wiltshireccg.nhs.uk/?wpdmdl=1682

NHS BaNES CCG: Passport to Health programme, Health Improvement Services, The Bungalow, 11 Park Road, Keynsham. Tel 01225 831852

04.05.01  Anti-obesity drugs acting on the gastro-intestinal tract
Orlistat 
(Capsule)
View adult BNF View SPC online
Formulary
Green
  • Capsules 120mg
 
   
04.05.02  Centrally acting appetite suppressants
04.06  Drugs used in nausea and vertigo to top
 note 
  • Haloperidol and levomepromazine (section 4.2.1) are also used for the relief of nausea.
  • Treat the underlying cause of nausea before starting an anti-emetic wherever possible.
  • Both metoclopramide and prochlorperazine may precipitate extrapyramidal effects especially in the young and the elderly.
  • Ondansetron is less sedating and suitable for use in day case.

 Pregnancy: Please see the SPS Q&A: How can nausea and vomiting be treated during pregnancy? (Updated November 2019)

04.06  Vomiting during pregnancy
04.06  Postoperative nausea and vomiting
04.06  Motion sickness
04.06  Other vestibular disorders
04.06  Cytotoxic chemotherapy to top
04.06  Palliative care
04.06  Migraine
04.06  Antihistamines
Cinnarizine 
(Tablet)
View adult BNF View SPC online
Formulary
Green
  • Tablet 15mg 
 
   
Cyclizine 
(Tablet,injection)
View adult BNF View SPC online
Formulary
Green
  • Tablet 50mg
  • Injection 50mg in 1ml
 
   
Promethazine Hydrochloride

(Oral,injection)
View adult BNF View SPC online
Formulary
Green
  • Tablets 10mg, 25mg
  • Elixir 5mg/5ml
  • Injection 25mg/ml
 
   
04.06  Phenothiazines and related drugs
Droperidol 
(Injection)
View adult BNF View SPC online
Formulary
Red
  • GWH only for short-term peri-operative use on the advice of a consultant anaesthetist
 
   
Prochlorperazine 
(Oral,injection)
View adult BNF View SPC online
Formulary
Green
  • Tablet 5mg
  • Syrup 5mg in 5ml
  • Intramuscular injection 12.5mg in 1ml
  • Buccal tablet 3mg (as an alternative to injection in Primary Care)
  • Notes: Severe reactions to prochlorperazine should be treated with procyclidine injection, Prochlorperazine should not be prescribed for patients with Parkinson's & should be used with caution in the elderly.
 
   
04.06  Domperidone and metoclopramide to top
 note 

Domperidone guidance May 2017

Domperidone 
(Oral,rectal)
View adult BNF View SPC online
Formulary
  • Green for short-term use/ 1 week
  • Amber for long-term use (off-label)
  • Tablet 10mg
  • Suspension 5mg in 5ml
  • Suppository 30mg (only available as unlicensed import)
  • Domperidone is the antiemetic of choice in Parkinsons Disease
  • Domperidone should be used at the lowest effective dose for the shortest possible duration (max. treatment duration should not normally exceed 1 week);

 

 
Link  MHRA Drug Safety Update (Dec 2019): Domperidone for nausea and vomiting: lack of efficacy in children; reminder of contraindications in adults and adolescents
Link  MHRA Drug Safety Update Dec 2014: Domperidone: risks of cardiac side effects
   
Metoclopramide 
(Oral, injection)
View adult BNF View SPC online
Formulary
  • Green for short-term use (maximum 5 days)
  • Amber for long-term use (off-label)
  • Tablet 10mg
  • Syrup 5mg in 5ml
  • Injection 10mg in 2ml
  • Metoclopramide and prochlorperazine are associated with a high risk of dystonias and oculogyric crises particularly in children, young adults and the elderly. 
  • Severe reactions to metoclopramide should be treated with procyclidine injection
  • Metoclopramide should not be prescribed for patients with Parkinson's disease.
 
Link  MHRA DSU Dec 2014 Metoclopramide: risk of neurological adverse effects
   
04.06  5HT3 antagonists
Ondansetron 
(Oral,injection)
View adult BNF View SPC online
Formulary
Amber
  • Tablet 4mg, 8mg
  • SyrupSF 4mg in 5ml
  • Injection 4mg in 2ml, 8mg in 4ml
  • Long term treatment is rarely justified or necessary. 
  • Ondansetron is used for the following groups of patients:
    • For the prevention of PONV: in patients classified as ‘high risk’.
    • In the treatment of PONV: for patients requiring rescue medicine.
    • In general patients: those with protracted nausea and vomiting who have failed to respond to two conventional anti-emetics at full dose. If the symptoms are severe, ondansetron may be prescribed after trying only one conventional anti-emetic.
  • See MHRA safety update link below: Recent epidemiological studies suggest exposure to ondansetron during the first trimester of pregnancy is associated with a small increased risk of the baby having a cleft lip and/or cleft palate. 
 
Link  MHRA Drug Safety update 27th Jan 2020: Ondansetron: small increased risk of oral clefts following use in the first 12 weeks of pregnancy
   
04.06  Neurokinin receptor antagonist
Aprepitant 
(Capsule)
View adult BNF View SPC online
Formulary
Red
  • Capsules 80mg, 125mg
  • As an adjunct to dexamethasone and a 5HT3 antagonist in preventing nausea and vomiting associated with moderately and highly emetogenic chemotherapy
 
   
04.06  Cannabinoid
04.06  Hyoscine
Hyoscine Hydrobromide

(tablets/patches)
View adult BNF View SPC online
Formulary
Green
  • 150mcg ,300mcg tablet
  • Scopoderm® TTS Patch 1mg/ 72hrs
 
   
Hyoscine Hydrobromide

(Injection)
View adult BNF View SPC online
Formulary
  • Red 400mcg per ml injection
  • Green for palliative care
 
   
04.06  Other drugs for Ménière's disease to top
 note 

Vertigo and nausea associated with Ménière’s syndrome and middle ear surgery may be difficult to treat. Hyoscine, antihistamines, and phenothiazines (such as prochlorperazine) are effective in the prophylaxis and treatment of such conditions. In an acute attack prochlorperazine may be given rectally or by IM injection or cyclizine may be given by IM injection.

Betahistine Dihydrochloride
(Tablet)
View adult BNF View SPC online
Formulary
Green
  • Tablet 8mg, 16mg
 
   
04.07  Analgesics
 note 

NB Co-proxamol is NOT included in the BSW formulary and is a unlicensed drug.

Co-proxamol is also included in the NHSE Low Value Medicines guidance;

https://www.england.nhs.uk/wp-content/uploads/2017/11/items-which-should-not-be-routinely-precscribed-in-pc-ccg-guidance-v2.pdf

Since 1985 advice aimed at the reduction of co-proxamol toxicity and fatal overdose has been provided, but this was not effective and resulted in withdrawal of co-proxamol by the MHRA. Since the withdrawal, further safety concerns have been raised which have resulted in co-proxamol being withdrawn in other countries. Due to significant safety concerns, co-proxamol was included in the NHSE guidance.

 

Methoxyflurane (Penthrox®)
View adult BNF View SPC online
Formulary
Red
  • 3 ml inhalation vapour, liquid

RUH ONLY - for emergency relief of moderate to severe pain and to facilitate the treatment of fractures and joint dislocations, in conscious adult patients who have suffered a traumatic injury.

Not on formulary at SFT or GWH

 
Link  Risk Minimisation Materials including Patient Alert Card and HCP Administration Checklist
   
04.07.01  Non-opioid analgesics and compound analgesic preparations
 note 
04.07.01  Compound analgesic preparations
Paracetamol  
(Oral,rectal)
View adult BNF View SPC online
First Choice
Self
  • Tablet 500mg    
  • Dispersible tablet 500mg
  • Oral SuspensionSF 120mg/5ml, 250mg/5ml     
  • Suppository 60mg, 120mg, 240mg, 500mg, 1g
  • Avoid expensive paracetamol capsules, use tablets. If difficulty in taking tablets consider ‘caplets’ before soluble tablets.

Inform patients about the dangers of paracetamol overdose to prevent inappropriate self-medication. Some patients are considered high risk for hepatotoxicity with paracetamol. There is no clear consensus on dose adjustments which must be guided by clinical judgement. Consider dose reduction for patients with one or more of the following risk factors;

  • Low body weight (less than 50kg)
  • Likely glutathione depleted, i.e. Starvation / cachexia / chronic malnutrition / eating disorders
  • Hepatic impairment
  • Regular excess alcohol (ethanol) consumption
  • Taking enzyme inducing medication (including; carbamazepine, phenobarbital, phenytoin, primidone, rifampicin, St John's Wort).
 
Paracetamol and codeine
(Co-codamol® 8/500)
(Tablets)
View adult BNF View SPC online
Formulary
Self
  • Tablets 8/500     
  • Effervescent tablets 8/500
  • Effervescent analgesics not generally recommended due to cost and high sodium content. Restricted to patients unable to swallow tablets.
  • Low dose weak opioid combinations with paracetamol are not recommended because they offer little additional pain relief compared with regular full dose paracetamol.
 
   
Aspirin 
(Tablets)
View adult BNF View SPC online
Formulary
Green
  • Tablets 300mg
  • Included on formulary for the relief of headache and migraine
  • 1-2 tablets (300-600mg) every 3-4 hours as required, to a maximum of 12 tablets (3.6g) daily in divided doses.
 
   
Paracetamol and codeine
(Co-codamol® 30/500)
(Tablet)
View adult BNF View SPC online
Formulary
Green
  • Tablets 30/500     
  • Effervescent tablets 30/500
  • Effervescent analgesics not generally recommended due to cost and high sodium content. Restricted to patients unable to swallow tablets.
  • Combination analgesics are not recommended.
 
   
Paracetamol and dihydrocodeine
(Co-dydramol®)
(Tablets)
View adult BNF View SPC online
Formulary
Green
  • Previously co-dydramol (dihydrocodeine/paracetamol) was available only in the ratio 1:50 (co-dydramol 10/500 mg). Two additional products are now available with a higher strength of dihydrocodeine (codydramol 20/500 mg and 30/500 mg tablets). It is therefore important that co-dydramol products are prescribed and dispensed by strength to minimise dispensing errors and the risk of accidental opioid overdose.
  • Low dose weak opioid combinations with paracetamol are not recommended because they offer little additional pain relief compared with regular full dose paracetamol.
 
   
Paracetamol  
(Injection )
View adult BNF View SPC online
Formulary
Red
  • Intravenous infusion 1000mg/100ml, 500mg/50ml (Perfalgan)
  • Vigilance is advised when prescribing and administering Intravenous Paracetamol 10mg/mL solution for infusion, to ensure that the correct, weight-adjusted dose is ALWAYS given.
 
Link  MHRA DSU: Intravenous paracetamol (Perfalgan): risk of accidental overdose Dec 2014
   
04.07.02  Opioid analgesics
 note 
Controlled Drug Morphine Sulphate M/R
(Zomorph®)
(Capsule)
View adult BNF View SPC online
First Choice
Green
  • m/r capsule 10mg, 30mg, 60mg, 100mg, 200mg
  • 12 hourly dosing
  • Zomorph can be opened and the contents administered in semi-solid food for patients with swallowing difficulties.
  • Zomorph is also licensed for use via gastric or gastronomy tubes (diameter >16F.G.).
  • There is no evidence of superior clinical analgesic effect of other opioids over morphine.
  • Prescribe by brand name.
 
Controlled Drug Morphine Sulphate (Sevredol®)
(immediate release tablets)
View adult BNF View SPC online
First Choice
Green
  • 10mg,20mg,50mg immediate release tablets
  • Sevredol® tablet - 4 hourly dosing
 
Controlled Drug Morphine Sulphate 5mg
(MST Continus)
(prolonged-release tablets)
View adult BNF View SPC online
First Choice
Green
  • 5mg prolonged-release tablets ONLY on formulary to allow dose titration 
 
Controlled Drug Morphine Sulphate solution 10mg/5ml
(Oramorph®)
View adult BNF View SPC online
First Choice
Green
  • 10mg/5ml   Schedule 5 (CD Inv)
  • 4 hourly dosing PRN
  • Oramorph Oral Solution contains ethanol (alcohol). Each 10 ml dose contains contains up to 810 mg of alcohol, which is equivalent to 81 mg/ml (10%v/v). The amount of alcohol in 10 ml of this medicine is equivalent to 20 ml beer or 8 ml wine. To be taken into account in pregnant or breast-feeding women, children and and those addicted to alcohol. 
  • This product contains 3 g sucrose in each 10 ml dose. This product also contains 1 g corn syrup, which contains glucose, in each 10 ml dose. This should be taken into account in patients with diabetes mellitus. May be harmful to the teeth. Patients with rare hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucrose-isomaltase insufficiency should not take this medicine.

 

 
Controlled Drug Oxycodone 
(Modified Release tablets)
View adult BNF View SPC online
Second Choice
  • Amber  for non cancer patients and for all other indications for BaNES/West Wilts. (TLS under review feb 2020).
  • Amber Swindon for patients with non-cancer pain. (TLS under review Feb 2020).
  • Red GWH for use as a 1st line opiate analgesic as part of post-operative, enhanced recovery programmes following protocol. Patients will not be discharged on oxycodone, unless on advice of pain management specialist.
  • M/R Tablets 5mg, 10mg, 20mg, 40mg, 60mg, 80mg 
  • Oxycodone may be initiated in preference to morphine for the management of pain by a specialist GP with an interest in pain or with pain team advice when: Dose escalation with morphine is not possible due to opioid toxicity eg. hallucinations, myoclonic jerks and confusion.
  • For use in palliative care see chapter 21.
 
   
Controlled Drug Oxycodone (immediate release)
(Oral)
View adult BNF View SPC online
Second Choice
Amber
  • For cancer patients for break through pain 
  • Tablets 5mg, 10mg, 20mg.
  • Oral solution 5mg/5ml, or concentrate 10mg/ml
  • Oxycodone may be initiated in preference to morphine for the management of pain by a GP with experience in palliative care or on the advice of the palliative care team or pain team. 

 

 
   
Controlled Drug Buprenorphine 
(4 day patch)
View adult BNF View SPC online
Formulary
Green
  • Patch 35 microgram/ hour, for 4 days
  • Patch 52.5 microgram/ hour, for 4 days
  • Patch 70 microgram/ hour, for 4 days
  • Only to be used in patients with cognitive deficit or swallowing difficulties, after a trial of soluble/liquid medication. Zomorph capsules can be opened for ease of swallowing.
  • Buprenorphine patches are not suitable for management of acute / intermittent pain.
  • Patients and/or their carers need to be aware that these patches need to be applied at appropriate 96 hour intervals (or 4 days). Remember to remove the old patch before application of new patch. Avoid use of multiple patches.
 
   
Controlled Drug Buprenorphine 
(7 day patch)
View adult BNF View SPC online
Formulary
Green
  • Patch 5 microgram/hour for 7 days 
  • Patch 10 microgram/hour for 7 days
  • Patch 15 micrograms/hour for 7 days
  • Patch 20 microgram/hour for 7 days
  • Only to be used in patients with cognitive deficit or swallowing difficulties, after a trial of soluble/liquid medication. Zomorph capsules can be opened up for ease of swallowing.
  • Buprenorphine patches are NOT suitable, or licensed, for management of acute / intermittent pain.
  • Patients and/or their carers neeed to be aware that these patches need to be applied at appropriate seven-day intervals. Remember to remove the old patch before application of new patch. Avoid use of multiple patches.
 
   
Codeine Phosphate 
(Oral)
View adult BNF View SPC online
Formulary
Green
  • Tablet 15mg, 30mg, 60mg
  • Oral solution 25mg in 5ml
  • Useful for the relief of mild to moderate pain but is too constipating for long-term use
 
   
Controlled Drug Diamorphine  
(injection)
View adult BNF View SPC online
Formulary
Green
  • Injection 5mg, 10mg, 30mg, 100mg, 500mg 
  • For use in Palliative Care see chapter 20
 
Link  Advice on the use of morphine instead of diamorphine
Link  Diamorphine injection 5mg and 10mg ampoules - Supply Disruption Alert 25/03/2020
   
Dihydrocodeine 
(Oral)
View adult BNF View SPC online
Formulary
Green
  • Tablets 30mg
  • Oral solution 10mg/5ml
  • The efficacy of dihydrocodeine does not increase above a certain dose, but the risks of side effects and dependence increase. Do not prescribe more than a 30mg per dose.
  • For post-operative analgesia on discharge.
  • Short-term use only.   
 
   
Controlled Drug Fentanyl  
(sublingual tablets)
View adult BNF View SPC online
Formulary
Amber
  • 100mcg, 200mcg, 300mcg, 400mcg, 600mcg, 800mcg sublingual tablet
  • Palliative care or pain specialist initiation only
  • Patients must be assessed by the palliative care or pain team before commencing treatment. They should be used in the minority of patients with breakthrough pain that fail immediate release morphine or oxycodone. Review weekly.

 

 
   
Controlled Drug Fentanyl 
(3 day Patch)
View adult BNF View SPC online
Formulary
Green
  • Patch 12 microgram/hour, for 3 days
  • Patch 25 microgram/hour, for 3 days
  • Patch 50 microgram/hour, for 3 days
  • Patch 75 microgram/hour, for 3 days
  • Patch 100 microgram/hour, for 3 days
  • Fentanyl patches are only licensed for chronic intractable pain. For palliative care use.
  • Fentanyl patches are not suitable for use in the management of acute / intermittent pain.
  • Oral morphine 90mg over 24 hours is equivalent to one ’25 micrograms/hour’ patch.  
  • Only to be used in patients who require equivalent dose of at least 60mg morphine daily
  • Fentanyl is available both as a reservoir patch and a matrix patch (do not cut either)
  • Patients and/or their carers need to be aware that fentanyl patches need to be applied at appropriate 72-hour (three-day) intervals. Remember to remove the old patch before application of new patch
 
Link  •MHRA Drug Safety Update Oct 2018 | Transdermal fentanyl “patches”: reminder of potential for life-threatening harm from accidental exposure, particularly in children
   
Controlled Drug Fentanyl  (Actiq ®)
(lozenges)
View adult BNF View SPC online
Formulary
Amber
  • 200mcg,400mcg,600mcg,800mcg,1.2mg,1.6mg
  • lozenges with integral oromucosal applicator
  • Patients must be assessed by the palliative care or pain team before commencing treatment.
  • They should be used in the minority of patients with breakthrough pain that fail immediate release morphine or oxycodone. Review weekly.
  • For peri-operative analgesia (including fentanyl and alfentanil) see section 15.1.4     
  • Prescribe by brand name to ensure that the correct product is dispensed.

 

 
   
Controlled Drug Methadone 
(Oral)
View adult BNF View SPC online
Formulary
Amber
  • Tablets 5mg 
  • Oral Solution 1mg/ml
  • For treatment of substance misuse see section 4.10.3
 
   
Controlled Drug Morphine Sulphate 
(Injection/Infusion)
View adult BNF View SPC online
Formulary
Green
  • Injection 10mg/1ml, 30mg/1ml
 
   
Controlled Drug Oxycodone 
(Injection)
View adult BNF View SPC online
Formulary
Amber
  • For palliative care use, specialist initiation
  •  Injection 20mg/2ml, 50mg/1ml

 

 
   
Controlled Drug Pethidine 
(Injection)
View adult BNF View SPC online
Formulary
Red
  • 50mg/ml and 100mg/2ml
  • Hospital use only: (GWH and RUH) NOT for primary care prescribing.
 
   
Controlled Drug Tramadol 
(Oral,injection)
View adult BNF View SPC online
Formulary
Green
  • Capsules 50mg
  • Soluble tablets 50mg
  • Modified release MR capsules and tablets [Immediate release should be used where possible as tramadol MR preparations can be extremely expensive. Primary care prescribers should follow prescribing messages on OptimiseRX etc for preferred cost-effective choice] 
  • Injection 50mg/ml
  • Schedule 3 CD with exemption from safe custody requirements
 
Link  SPS May 2018: What is the risk of developing Serotonin Syndrome following concomitant use of tramadol with selective serotonin reuptake inhibitors (SSRIs)?
   
04.07.03  Neuropathic pain to top
 note 
Amitriptyline 
(Tablet)
View adult BNF View SPC online
First Choice
Green
  •  Tablet 10mg, 25mg, 50mg
  • 'Off label' use for pain

 

 

 
Imipramine 
(Oral)
View adult BNF View SPC online
Formulary
Green
  • Not licensed for neuropathic pain but a widely accepted treatment (off-label).
 
   
Nortriptyline 
(Tablets)
View adult BNF View SPC online
Formulary
Amber
  • Tablets 10mg, 25mg
  • 'Off label' use for neuropathic pain
  • Specialist initiation
  • Should only be used if amitriptyline isn't tolerated or is contra indicated
  • More expensive than amitriptyline. NB 1x25mg significantly more cost effective than 3 x 10mg tablets
 
   
Duloxetine 
(Capsule)
View adult BNF View SPC online
Formulary
Green
  • Capsules 30mg, 60mg
  • For the treatment of diabetic peripheral neuropathic pain
  • Discontinue if inadequate response after 2 months, review treatment every 3 months.
  • Ensure you have chosen the correct product as Duloxetine comes in different strengths and forms which have different license indications.
  • Hyponatraemia has been reported with duloxetine, and may be due to a syndrome of inappropriate anti-diuretic hormone secretion (SIADH). The majority of cases of hyponatraemia were reported in the elderly, especially when coupled with a recent history of, or condition pre-disposing to, altered fluid balance. Caution is required in patients at increased risk for hyponatraemia, such as elderly, cirrhotic, or dehydrated patients, or patients treated with diuretics.
 
   
Gabapentin 
(Capsule)
View adult BNF View SPC online
Formulary
Green
  • Capsules 100mg, 300mg, 400mg
  • Elderly patients require the lowest possible initial dose of gabapentin.

 

 
Controlled Drug Schedule 3 CD
Link  Controlled drugs use regulations
Link  PHE and NHSE Advice for prescribers on the risk of the misuse of pregabalin and gabapentin
Link  MHRA Drug Safety Update (Apr 2019): Pregabalin (Lyrica), gabapentin (Neurontin) and risk of abuse and dependence: new scheduling requirements
   
Lidocaine  
(plaster 5%)
View adult BNF View SPC online
Formulary
  • Red to be used in patients with multiple rib fractures in acute trusts on the advice of Pain Consultant only.
  • Amber for the following indications:
    • Post-Herpetic Neuralgia (licensed indication) 
    • Focal neuropathic pain with allodynia, as advised by a pain specialist (off-label). Locally agreed indication (August 2019).
    • Also can be used as per Palliative Care specialist recommendation (off-label). Locally agreed indication (August 2019).
  • NHS England guidance “Items which should not routinely be prescribed in primary care” recommends lidocaine 5% plasters should not be initiated by prescribers in primary care due to its low clinical effectiveness and lack of robust evidence (see link below).

  • Medicated plasters lidocaine 5%. Prescribe by the brand name: Ralvo®
 
Link  BSW Lidocaine Plaster guidance
Link  Items which should not routinely be prescribed in primary care guidance for CCGs
   
Pregabalin 
(Capsule)
View adult BNF View SPC online
Formulary
Green
  • Capsules 25mg, 50mg, 75mg, 100mg, 150mg, 225mg, 200mg, 300mg
  • NOTE pregabalin tablets are NOT included on the BSWformulary
  • Pregabalin is also indicated for the treatment of Generalised Anxiety Disorder (GAD) in adults. 
  • The SPC advises caution when used with opioids due to risk of CNS depression - this increased risk was observed at low doses of pregabalin (≤ 300 mg) and there was a trend for a greater risk at high doses of pregabalin.

 

 
Controlled Drug Schedule 3 CD
Link  Controlled drugs use regulations
Link  PHE and NHSE Advice for prescribers on the risk of the misuse of pregabalin and gabapentin Dec 2014
Link  MHRA Drug Safety Update (Apr 2019): Pregabalin (Lyrica), gabapentin (Neurontin) and risk of abuse and dependence: new scheduling requirements
   
04.07.03  Trigeminal neuralgia
Carbamazepine 
(Tablets)
View adult BNF View SPC online
Formulary
Green
  • Tablets 100mg, 200mg, 400mg
 
   
04.07.03  Postherpetic neuralgia
Capsaicin 
(Cream)
View adult BNF View SPC online
Formulary
Green
  • Cream containing 0.075% capsaicin (Axsain®)   
  • For the treatment of post herpetic neuralgia (after lesions have healed) & painful diabetic peripheral neuropathy sparingly up to 3-4 times a day.
  • The recommended duration of use in the first instance is 8 weeks, since there is no clinical trial evidence of efficacy for treatment of more than 8 weeks duration. After this time, it is recommended that the patient's condition should be fully clinically assessed prior to continuation of treatment, and regularly re-evaluated thereafter, by the supervising consultant.

 

 
Link  Sep 2019 - Shortage of capsaicin cream
   
04.07.03  Chronic facial pain
04.07.04  Antimigraine drugs
 note 

First Choice Combination Therapy

Oral triptan (sumatriptan or zolmitriptan) (for young people aged 12-17years consider nasal triptan) AND an NSAID (ibuprofen or naproxen) OR paracetamol (tabs or suppositories) Oral powder: Aspirin 900mg plus metoclopramide 10mg (MigraMax®)

First choice Monotherapy

Oral triptan (sumatriptan or zolmitriptan) (for young people aged 12-17 years consider nasal triptan) OR NSAID (ibuprofen or naproxen) OR OR aspirin 900mg (not in children less than 16 years or paracetamol consider adding in antiemetic even the absence of nausea vomiting where non oral preparation nasal are ineffective not tolerated:non metoclopramide prochlorperazine and NSAID triptan eg injection

Pregnancy

First line paracetamol, second line consider triptan or NSAID. DO NOT give NSAIDS in third trimester.  (Limited experience of use of triptans in pregnancy, manufacturers recommend avoiding unless potential benefit outweighs the risk).

5HT1 agonists

Notes:

  • If one 5HT1 agonist is ineffective patients may respond to another. Choose the cheapest one from each group as a first line.
  • 5HT1 agonists should not be used for prophylaxis and they are contraindicated in ischaemic heart disease, previous MI, coronary vasospasm (including Prinzmetal’s angina) & uncontrolled hypertension.
  • Advise people with migraine that riboflavin 400mg once a day may reduce migraine frequency and intensity (Riboflavin is not a licensed medicine and patients should be advised to purchase OTC)
04.07.04.01  Treatment of the acute migraine attack to top
04.07.04.01  Analgesics
 note 

Treatment of a migraine attack should be guided by response to previous treatment and the severity of the attacks. A simple analgesic such as paracetamol (preferably in a soluble or dispersible form) or an NSAID, usually ibuprofen (aspirin can be used as an alternative), is often effective; concomitant antiemetic treatment may be required. If treatment with an analgesic is inadequate, an attack may be treated with a specific antimigraine compound such as the 5HT1- receptor agonist sumatriptan. Ergot alkaloids are associated with many side-effects and should be avoided.

Excessive use of acute treatments for migraine (opioid and non-opioid analgesics, 5HT1-receptor agonists, and ergotamine) is associated with medication-overuse headache (analgesic-induced headache); therefore, increasing consumption of these medicines needs careful management.

04.07.04.01  5HT1 agonists
Almotriptan 
View adult BNF View SPC online
Formulary
Green
  • Swindon only
  • Tablets 12.5mg
  • The maximum recommended dose is two doses in 24 hours.
 
   
Sumatriptan 
(Oral, injection, nasal)
View adult BNF View SPC online
Formulary
Green
  • Tablet 50mg, 100mg
  • Injection 6mg/0.5ml syringe
  • Nasal spray 10mg/0.1ml actuation, 20mg/0.1ml actuation
  • Do not prescribe as film coated tablets.
 
   
Zolmitriptan 
(Oral, nasal)
View adult BNF View SPC online
Formulary
Green
  • Tablets 2.5mg/5mg and orodispersible tablets 2.5mg/5mg
  • Nasal spray 5mg/0.1ml actuation
  • Also used for menstrual migraine 2.5mg twice to three times a day on days when migraine expected (off-label).
 
   
Frovatriptan 
(Oral)
View adult BNF View SPC online
Formulary
Green
  • 2.5mg tablets
  • Current evidence base supports the use of Frovatriptan as a first-line acute treatment for Menstrual Migraine and for perimenstrual prophylaxis. No triptan is specifically licensed for this indication (off-label).
  • For the treatment of menstrual migraine only when other triptans (sumatriptan / zolmitriptan) have proven ineffective. Give 2.5mg twice daily on days when migraine expected.
  • Frovatriptan is distinctive from other triptans due to its long elimination half-life of 26 hours, which confers a longer duration of action.
 
   
04.07.04.01  Ergot alkaloids
04.07.04.01  Anti-emetics
04.07.04.01  Other drugs for migrane to top
04.07.04.02  Prophylaxis of migraine
 note 
  • BSW Chronic Migraine Pathway for Adults
  • Review the need for continuing migraine prophylaxis 6 months after the start of prophylactic treatment if effective.

  • Women should not get pregnant whilst taking the antiepileptic class of migraine prophylaxis, and should take 5mg folic acid in case of contraceptive failure (thought to minimise teratogenic effects). Issues regarding antiepileptic treatments and contraception, pregnancy/teratogenicity are more fully outlined in the epilepsy section 4.8.1.
Amitriptyline 
(Tablets)
View adult BNF View SPC online
Formulary
Green
  • Tablet 10mg, 25mg, 50mg
  • Notes: Initial dose 10mg nocte gradually increasing up to 75mg nocte if necessary (max 150mg nocte).
  • Amitriptyline is not included in NICE CG150, but local neurologists recommend considering as a first line option if migraine co-exists with depression, disturbed sleep, chronic pain condition or troublesome tension-type headache. However, amitriptyline is highly anticholinergic. Avoid if >65 years or frail and inform patient of  risk of serious side effects including cognitive impairment
  • Trial at maximum tolerated dose for 6-8 weeks. Review/stop if not effective.
 
   
Atenolol 
(Oral)
View adult BNF View SPC online
Formulary
Green
  • Tablets 25mg, 50mg, 100mg
  • SyrupSF 25mg/5ml
  • Note: Atenolol 25mg once daily increasing to 50mg once daily (unlicensed for this indication, atenolol may be better tolerated than propranolol. Not included in NICE CG150)
 
   
Propranolol LA 
(Modified release capsule)
View adult BNF View SPC online
Formulary
Green
  • Capsules M/R 80mg, 160mg
  • Note: Propranolol LA 80 mg od -160mg twice daily (unlicensed for this indication and not included in NICE CG150)
 
   
Topiramate (migraine)
(Tablets)
View adult BNF View SPC online
Formulary
Green
  • Tablet 25mg, 50mg, 100mg
  • Note: Licensed dose: Initially 25mg ON for 1/52 then increase by 25mg/ wk; usual dose 50-100mg daily in 2 divided doses; max 200mg od. Local consultants advise to start at low doses (e.g. 15mg od) & titrate slowly (due to side effects being common) to maintenance of 50mg bd.
  • Before the initiation of treatment with topiramate in a woman of childbearing potential, pregnancy testing should be performed and a highly effective contraceptive method advised. The patient should be fully informed of the risks related to the use of topiramate during pregnancy.
  • Contra-indicated for this indication if highly effective contraception is not used.
 
Link  DSU Medicines with teratogenic potential: what is effective contraception and how often is pregnancy testing needed? March 2019
   
Candesartan 
(Tablet)
View adult BNF View SPC online
Formulary
Amber
  • Tablets 2mg, 4mg, 8mg, 16mg, 32mg 

Candesartan has been approved for prophylaxis of chronic migraine (unlicensed indication) only when recommended by a specialist. Recommended dose 2mg daily increased by 2mg weekly if needed to max 8mg BD. Patient information leaflet here. See BSW migraine pathway below.

 
Link  BSW Chronic Migraine Pathway for Adults
   
Sodium valproate 
(Oral)
View adult BNF View SPC online
Formulary
Amber
  • Crushable tablet 100mg
  • E/C tablets 200mg, 500mg
  • m/r tablet 200mg, 300mg, 500mg (Category 2 MHRA)
  • m/r capsules 150mg, 300mg
  • LiquidSF 200mg/5ml 

Sodium valproate has been approved for  the prophylaxis of chronic migraine (unlicensed indication) only when recommended by a specialist (AMBER TLS) and local recommendations are for use only where the patient is NOT a female of child bearing age. Recommended dose 200 mg BD incr. if needed to 1.2–1.5 g daily in divided doses. See BSW migraine pathway below. 

 

 

 

 
Link  BSW Chronic Migraine Pathway for Adults
   
Botulinum A toxin (botox®)
(Injection (migraine))
View adult BNF View SPC online
Formulary
Red
High Cost Medicine
  • Powder for reconstitution 50 unit vial, 100 unit vial, 200 unit vial
  • If effective repeat 12 weekly, if ineffective discontinue after 2 cycles.
  • See BSW policy and prior approval form for chronic migraine below.
 
Link  
Link  BSW CCG Botulinum toxin – chronic migraine policy
Link  BSW CCG Botulinum toxin – chronic migraine prior approval form
Link  NICE TA 260 Botulinum toxin type A for the prevention of headaches in adults with chronic migraine June 2012
   
Fremanezumab (Ajovy®)
(Injection )
View adult BNF View SPC online
Formulary
Red
High Cost Medicine
BlueTeq
  • 225 mg solution for injection in pre-filled syringe or pre-filled pen
  • For use in line with NICE TA631 and BSW migraine pathway below
  • Fremanezumab is recommended as an option for preventing migraine in adults, only if:
    • the migraine is chronic, that is, 15 or more headache days a month for more than 3 months with at least 8 of those having features of migraine
    • at least 3 preventive drug treatments have failed and
    • the company provides it according to the commercial arrangement.
  • Stop fremanezumab if the migraine frequency does not reduce by at least 30% after 12 weeks of treatment.
 
Link  
Link  BSW Chronic Migraine Pathway for Adults
Link  NICE TA631 Fremanezumab for preventing migraine
   
Flunarazine 
(Capsule)
View adult BNF View SPC online
Unlicensed Drug Unlicensed
Red
  • 5mg capsules (unlicensed)
  • RUH for named patients only. Not on formulary at SFT or GWH.
 
   
04.07.04.03  Cluster headache
 note 
04.08  Antiepileptics
04.08.01  Control of epilepsy
 note 
  • NICE Clinical Guideline CG 137 updated February 2020. The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care.
  • MHRA Drug Safety Update Dec 2014 | Antiepileptic drugs: new advice on switching between different manufacturers’ products for a particular drug
  • Category 1: For these drugs, doctors are advised to ensure their patient is maintained on a specific brand.
  • Category 2: For these drugs, the need for continues supply of a particular manufacturer's product should be based on clinical judgement and consultation with the patient and / or carer, taking into account factors such as seizure frequency and treatment history.
  • Category 3: For these drugs, it is usually unnecessary to ensure that patients are maintained on a specific manufacturers product unless there are specific reasons such as patient anxiety and risk of confusion or dosing errors. Can be prescribed generically.
  • When used for pain syndromes, generic medicines are appropriate to use.
  • Abrupt withdrawal of anti-epileptics, particularly barbiturates and benzodiazepines, should be avoided as this may precipitate severe rebound seizures.
Brivaracetam 
(Oral,injection)
View adult BNF View SPC online
Formulary
Amber
  • Tablets 10mg, 25mg, 50mg, 75mg, 100mg
  • Liquid 10mg/1ml
  • IV 10mg/1ml 5ml ampoule
  • Brivaracetam recommended as an adjunctive AED treatment for adult patients (≥16 years) with focal-onset seizures.
  • Only to be used when first or second line treatments have failed. 
 
   
04.08.01  Partial seizures with or without secondary generalisation to top
04.08.01  Generalised seizures
04.08.01  Carbamazepine and Oxcarbazepine
Carbamazepine 
(Oral,rectal)
View adult BNF View SPC online
Formulary
Amber
  • Tablet 100mg, 200mg, 400mg
  • Tegretol® m/r tablet 200mg, 400mg.  Prescribe M/R tablet by brand (Category 1 MHRA)
  • LiquidSF 100mg/ml
  • Suppository 125mg, 250mg
  • Prescribe generically for non epilepsy indications.
 
   
Eslicarbazepine 
(Tablet)
View adult BNF View SPC online
Formulary
Amber with Shared Care
  • 200mg, 800mg
  • Adjunctive therapy in adolescents and adults Only to be used if other treatments have been ineffective or not tolerated.
  • Not approved for monotherapy use.
 
Link  3Ts Eslicarbazepine Shared Care Document
Link  BCAP Eslicarbazepine Shared Care Document
   
Oxcarbazepine 
(Oral)
View adult BNF View SPC online
Formulary
Amber
  • 150mg,300mg ,600mg tablets
  • 60mg/ml oral suspension
 
   
04.08.01  Ethosuximide
Ethosuximide 
(Oral)
View adult BNF View SPC online
Formulary
Amber
  • 250mg capsules
  • 250 mg/5 ml oral solution
  • Used as per NICE CG137 for absence seizures
 
   
04.08.01  Gabapentin and pregabalin
Gabapentin 
(Oral)
View adult BNF View SPC online
Formulary
Amber
  • Capsule 100mg, 300mg, 400mg (Category 3 MHRA)
  • Tablets 600mg, 800mg
  • Schedule 3 CD, exempted from safe custody requirements.
  • Oral solution 50mg/ml is available but is expensive. Use only if no other option is suitable and there are significant swallowing problems.

     

 
Controlled Drug Schedule 3 CD
Link  Controlled drugs use regulations
Link  PHE and NHSE Advice for prescribers on the risk of the misuse of pregabalin and gabapentin Dec 2014
Link  MHRA Drug Safety Update (Apr 2019): Pregabalin (Lyrica), gabapentin (Neurontin) and risk of abuse and dependence: new scheduling requirements
   
Pregabalin 
(Oral)
View adult BNF View SPC online
Formulary
Amber
  • Capsules 25mg, 50mg, 75mg, 100mg, 150mg, 225mg, 200mg, 300mg (Category 3 MHRA)
  • Oral solution 20mg/ml. Oral solution is expensive and only included for people with swallowing difficulties.
  • NOTE pregabalin tablets are NOT included on the BSWformulary
  • Schedule 3 CD, exempted from safe custody requirements.
  • The SPC advises caution when used with opioids due to risk of CNS depression - this increased risk was observed at low doses of pregabalin (≤ 300 mg) and there was a trend for a greater risk at high doses of pregabalin.
  • Most cost-effective to prescribe the least number of capsules to form the required dose twice daily instead of three times daily.
  • Pregabalin as an adjunctive treatment of partial seizures with or without secondary generalisation.
  • Pregabalin is also indicated for the treatment of Generalised Anxiety Disorder (GAD) in adults. 

 

 
Controlled Drug Schedule 3 CD
Link  Controlled drugs use regulations
Link  PHE and NHSE Advice for prescribers on the risk of the misuse of pregabalin and gabapentin Dec 2014
Link  MHRA Drug Safety Update (Apr 2019): Pregabalin (Lyrica), gabapentin (Neurontin) and risk of abuse and dependence: new scheduling requirements
   
04.08.01  Lacosamide to top
Lacosamide  
(Tablet)
View adult BNF View SPC online
Formulary
Amber
  • Tablets 50mg, 100mg, 150mg, 200mg (Category 3 MHRA)
  • For the adjunctive treatment of partial seizures with or without secondary generalisation
 
   
04.08.01  Lamotrigine
Lamotrigine 
(Tablet)
View adult BNF View SPC online
Formulary
Amber
  • Tablet 25mg, 50mg, 100mg, 200mg (Category 2 MHRA)
  • Dispersible tablet 2mg, 5mg, 25mg, 100mg  
 
   
04.08.01  Levetiracetam
Levetiracetam 
(Oral)
View adult BNF View SPC online
Formulary
Amber
  • Tablets 250mg, 500mg, 750mg, 1g (Category 3 MHRA)
  • Oral solutionSF 100mg/ml
  • Granules in sachets, 250mg, 500mg and 1000mg Desitrend (second line use only)
 
   
Levetiracetam 
(IV)
View adult BNF View SPC online
Formulary
Red
  • Concentrate for I/V infusion 100mg/ml 5ml vial (Category 3 MHRA)
 
   
04.08.01  Perampanel
04.08.01  Phenobarbital and other barbiturates
Controlled Drug Phenobarbital 
(Tablet)
View adult BNF View SPC online
Formulary
Amber
  • Tablets 15mg, 30mg, 60mg (Category 1 MHRA)
  • For existing patients ONLY - maintain patients on existing brands.
 
   
Primidone 
(Tablet)
View adult BNF View SPC online
Formulary
Amber
  •  50mg, 250mg Serb brand - prescribe by brand (Category 1 MHRA)
  • Note: SERB brand of Primidone are now packaged and marketed by TEVA. Prescribe by brand (category 1 MHRA)

 
   
04.08.01  Phenytoin to top
Phenytoin 
(Oral)
View adult BNF View SPC online
Formulary
Amber
  • Capsule 25mg, 50mg, 100mg, 300mg Flynn brand.
  • Prescribe by brand (Category 1 MHRA)
  • Suspension 30mg in 5ml Epanutin brand (15ml of suspension approx. equal to one 100mg phenytoin sodium capsule).
 
Link  Feb 2020 - Epanutin (phenytoin) 30mg/5ml Oral Suspension - Supply Disruption Alert
   
04.08.01  Retigaine
04.08.01  Rufinamide
Rufinamide 
(Oral)
View adult BNF View SPC online
Formulary
Amber
  • Use as per NICE CG137, for initiation by tertiary specialist as an adjunct for Lennox-Gastaut syndrome.
  • Also recommended by NICE CG137 for tertiary specialist initiation for off-label use as an adjunct for tonic or atonic seizures
  • 100mg/200mg/400mg tablets or 40mg/ml oral suspension
 
   
04.08.01  Rufinamide
04.08.01  Tiagabine
04.08.01  Topiramate to top
Topiramate 
(Oral)
View adult BNF View SPC online
Formulary
Amber
  • Tablet 25mg, 50mg, 100mg, 200mg (Category 2 MHRA)
  • Sprinkle capsules 15mg, 25mg, 50mg
  • Before the initiation of treatment with topiramate in a woman of childbearing potential, pregnancy testing should be performed and a highly effective contraceptive method advised. The patient should be fully informed of the risks related to the use of topiramate during pregnancy.
 
Link  DSU Medicines with teratogenic potential: what is effective contraception and how often is pregnancy testing needed? March 2019
   
04.08.01  Valproate
Sodium Valproate 
(Oral)
View adult BNF View SPC online
Formulary
Amber
  • Crushable tablet 100mg
  • E/C tablets 200mg, 500mg
  • m/r tablet 200mg, 300mg, 500mg (Category 2 MHRA)
  • m/r capsules 150mg, 300mg
  • LiquidSF 200mg/5ml

COVID-19 MHRA have issued guidance: see link below

 
Link  MHRA Valproate Pregnancy Prevention Programme: temporary advice for management during coronavirus (COVID-19) May 2020
Link  MHRA April 2019: Valproate medicines and serious harms in pregnancy: new Annual Risk Acknowledgement Form and clinical guidance from professional bodies to support compliance with the Pregnancy Prevention Programme
   
Sodium Valproate 
(IV)
View adult BNF View SPC online
Formulary
Red
  • Intravenous injection 400mg 

COVID-19 MHRA have issued guidance: see link below

 
Link  MHRA Valproate Pregnancy Prevention Programme: temporary advice for management during coronavirus (COVID-19) May 2020
Link  MHRA April 2019: Valproate medicines and serious harms in pregnancy: new Annual Risk Acknowledgement Form and clinical guidance from professional bodies to support compliance with the Pregnancy Prevention Programme
   
04.08.01  Vigabatrin
Vigabatrin 
(Oral)
View adult BNF View SPC online
Formulary
Red
  • Tablet 500mg (Category 3 MHRA)
  • PowderSF 500mg
 
   
04.08.01  Zonisamide
Zonisamide 
(Capsule)
View adult BNF View SPC online
Formulary
Amber
  • Capsules 25mg, 50mg, 100mg (Category 2 MHRA)
  • As an adjunctive treatment for refractory partial seizures with or without secondary generalisation.
 
   
04.08.01  Benzodiazepines
Clobazam 
(Oral)
View adult BNF View SPC online
Formulary
Amber
  • 10mg (Category 2 MHRA)
  • Endorse SLS when used for epilepsy.
  • Clobazam oral suspension 5mg or 10mg/5ml is available but is expensive. Use only if no other option is suitable and there are significant swallowing problems.

     

 
   
Clonazepam 
(Tablet)
View adult BNF View SPC online
Formulary
Amber
  • Tablet 500 microgram, 2mg (Category 2 MHRA)
  • For injection see 4.8.2 
 
   
04.08.01  Other Drugs to top
Perampanel 
(Oral)
View adult BNF View SPC online
Formulary
Amber
  • Tablets 2mg, 4mg, 6mg, 8mg, 10mg, 12mg (Category 2 MHRA)
  • Initiated by a specialist for the adjunctive treatment of partial-onset seizures with or without secondarily generalised seizures in patients with epilepsy aged 12 years and older who have failed on treatment with all first and second line agents.
  • Perampanel oral suspension 500mcg/ml is available but is expensive. Use only if no other option is suitable and there are significant swallowing problems.

 

 
Link  BCAP For the adjunctive therapy in the treatment of partial-onset seizures in patients with epilepsy aged 12 years and older Shared Care
Link  NICE CG137: The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care
   
04.08.02  Drugs used in status epilepticus
 note 

Major status epilepticus should be treated initially with IV lorazepam. IV diazepam may also be used. Lorazepam has a longer duration of action.

Diazepam  
(rectal solution)
View adult BNF View SPC online
Formulary
Green
  • 2.5mg, 5mg, 10mg
 
   
Diazepam (Diazemuls® )
( injection )
View adult BNF View SPC online
Formulary
Red
  • 5mg/ml Intravenous injection (emulsion) (Diazemuls®)
 
   
Lorazepam  
(injection)
View adult BNF View SPC online
Formulary
Red
  •  4mg in 1ml
  • By slow intravenous injection (into large vein) 
 
Link  SPS memo April 2020 - Shortage of Ativan (lorazepam) Injection 4 mg in 1 ml
   
Controlled Drug Midazolam Maleate  (Epistatus®)
(Buccal)
View adult BNF View SPC online
Formulary
Amber with Shared Care
  • Epistatus® Oromucosal solution prefilled single syringe 10mg/1ml  (licensed in adolescents from 10 years to less than 18 years
  • Epistatus® Oromucosal solution 10mg/ml prefilled syringes: 2.5mg/0.25ml, 5mg/0.5ml, 7.5mg/0.75ml, (unlicensed).  Individually wrapped in a pack of 4.
  • Do not prescribe Oromucosal solution 10mg/ml multidose 5ml bottle. In primary care, all patients should use the pre-filled syringe format as this is what the specialist primary care nursing team can provide training on for carers/schools/nurseries/after-school clubs etc.
  • Prescribe by BRAND (NB Buccolam brand is a different salt, STRENGTH and volume) 

 

 
Link  3Ts Oromucosal Midazolam Under 10s Shared Care Document
Link  3Ts Oromucosal Midazolam Over 10s Shared Care Document
Link  BCAP Oromucosal Midazolam Over 10s Shared Care Document
Link  BCAP Oromucosal Midazolam Under 10s Shared Care Document
Link  SFT Oromucosal Midazolam Over 10s Shared Care Document
Link  SFT Oromucosal Midazolam Under 10s Shared Care Document
Link  SFT Oromucosal Midazolam adults and children: Shared Care Document
   
Controlled Drug Phenobarbital  
(injection)
View adult BNF View SPC online
Formulary
Red
  • 30mg/1ml,60mg/1ml,200mg/1ml
 
   
Phenytoin 
(IV)
View adult BNF View SPC online
Formulary
Red
  • Intravenous injection 250mg/5ml
 
   
Clonazepam  
(injection )
View adult BNF View SPC online
Unlicensed Drug Unlicensed
Red
  • 1mg/ml or infusion of 1mg 
  • Discontinued in the UK however an unlicensed import is used by acute trusts. 
 
   
Paraldehyde 
(Rectal Enema)
View adult BNF View SPC online
Unlicensed Drug Unlicensed
Red
  • Consultant neurologist recommendation only
 
   
04.08.03  Febrile convulsions
04.09  Drugs used in parkinsonism and related disorders
04.09.01  Dopaminergic drugs used in Parkinsons disease
 note 

Dopamine receptor agonists

Restless Legs

All other possible causes of symptoms should be excluded before prescribing for restless leg syndrome.  In patients with a serum ferritin of less than 50mcg/l, prescribing oral iron supplements resolves symptoms in approx. 50% of cases.

Where all other causes have been excluded, plain ropinirole may be considered for moderate to severe idiopathic RLS. Where plain ropinirole is prescribed, the patient should be reviewed after 3 months and ropinirole discontinued if no effect has been seen.

A CCG Individual Funding Request should be made prior to initiation of any other treatment for RLS e.g. pramipexole or rotigotine.

Useful further information: BMJ Feb 2017 New concepts in the management of restless legs syndrome

04.09.01  Dopamine receptor agonists to top
Ropinirole 
(Tablet)
View adult BNF View SPC online
First Choice
  • Amber for use in parkinson's diease
  • Green PLAIN ropinirole only for use in restless legs
  • Tablet 0.25mg, 0.5mg, 1mg, 2mg, 5mg (generic)
  • Tablets m/r 2mg, 3mg (new strength) 4mg, 6mg (new strength) 8mg.  
  • Prescribe by brand name for most cost effective prescribing.
  • Ipinnia XL preferred brand to use in primary care.

 

 
Pramipexole 
(Tablet)
View adult BNF View SPC online
Second Choice
Amber
  • Tablets 88 micrograms, 180 micrograms, 350 micrograms, 700 micrograms (generic)
  • Tablets m/r 260 micrograms, 520 micrograms, 1.05mg, 1.57mg, 2.1mg, 2.62mg, 3.15mg
  • Abrupt discontinuation of dopaminergic therapy can lead to the development of a neuroleptic malignant syndrome or a dopamine agonist withdrawal syndrome. The Pramipexole should be tapered off as per advice in the SPC. Dopamine agonist withdrawal syndrome could still appear while tapering and a temporary increase of the dose could be necessary before resuming tapering.
  • Prescribe by brand name for most cost effective prescribing.

 

 
   
Rotigotine  
(patches)
View adult BNF View SPC online
Third Choice
Amber
  • 2mg/24 hours, 4mg/24 hours, 6mg/24 hours, 8mg/24 hours
  • Note: Third line agent where ropinirole and pramipexole are ineffective or not tolerated.
  • May be considered as first line for patients with severe swallowing difficulties.  
 
Link  BCAP- Rotigotine for the treatment of Parkinson’s disease
   
Apomorphine 
(Injection)
View adult BNF View SPC online
Formulary
Red
  • Injection 20mg/2ml, 50mg/5ml
  • APO-go® pen 10mg/ml 3ml pen injector
  • APO-go® PFS 5mg/ml 10ml prefilled syringe
  • Supply of Neria lines and ancillaries available via homecare (contact RUH pharmacy homecare team) for BaNES patients.  Neria lines via FP10 from GP for all other CCGs.
  • Note: Apomorphine is sometimes helpful in stabilising patients experiencing unpredictable "off" periods with levodopa treatment. It is essential to stabilise patients on domperidone for at least 2 days before starting treatment with apomorphine.
 
Link  MHRA DSU: Apomorphine with domperidone: minimising risk of cardiac side effects April 2016
   
04.09.01  Levodopa
Co-Beneldopa 
(Oral)
View adult BNF View SPC online
Formulary
Amber
  • Capsule 62.5mg, 125mg, 250mg
  • Dispersible tablet 62.5mg, 125mg
  • M/R capsule 125mg.
 
   
Co-Careldopa 
(Tablet)
View adult BNF View SPC online
Formulary
Amber
  • Sinemet-62.5,  Sinemet 110 (10/100) Sinemet Plus (25/100), Sinemet-275 tablet
  • Half Sinemet CR m/r tablet 25/100
  • Sinemet CR m/r tablet 50/200.
 
   
Co-Careldopa and Entacapone
(Sastravi®)
(Tablet)
View adult BNF View SPC online
Formulary
Amber
  • Prescribe as Sastravi® brand (Bioequivalent and more cost effective). Sastravi exactly the same strengths as Stalevo - see below:
    • Tablets 50mg levodopa, 12.5mg carbidopa, 200mg entacapone
    • Tablets 75mg levodopa, 18.75mg carbidopa, 200mg entacapone
    • Tablets 100mg levodopa, 25mg carbidopa, 200mg entacapone
    • Tablets 125mg levodopa, 31.25mg carbidopa, 200mg entacapone
    • Tablets 150mg levodopa, 37.5mg carbidopa, 200mg entacapone
    • Tablets 175mg levodopa, 43.75mg carbidopa, 200mg entacapone
    • Tablets 200mg levodopa, 50mg carbidopa, 200mg entacapone
 
   
04.09.01  Monoamine-oxidase-B inhibitors
Rasagiline 
(Tablet)
View adult BNF View SPC online
Formulary
Amber
  • Tablets 1mg
  • First Line monoamine oxidase B inhibitor licensed as monotherapy or in combination with levo-dopa for ‘end of dose’ fluctuations’. Adjunct therapy in later disease – In patients who cannot tolerate starting or increasing a dopamine agonist.
  • Rasagiline first line in cognitively frail PD patients and in other older and / or more advanced patients.
 
   
Selegiline Hydrochloride

(Tablet)
View adult BNF View SPC online
Formulary
Amber
  •  5mg, 10mg.
 
   
Safinamide 
View adult BNF View SPC online
Formulary
Red
  • 50mg, 100mg film-coated tablets
  • RUH only. Not included on formulary at SFT or GWH
 
   
04.09.01  Catachol-O-methyltransferase inhibitors
Entacapone 
(Tablet)
View adult BNF View SPC online
First Choice
Amber
  •  200mg
  • Notes: Entacapone is licensed for use as an adjunct to co-beneldopa or co-careldopa for patients with Parkinson’s disease who experience ‘end-of-dose’ deterioration and cannot be stabilized on these combinations. It is important thtn Entacapone and co-beneldopa or co-careldopa are taken together at the same time of day.
 
Opicapone 
View adult BNF View SPC online
Second Choice
Amber
  • Capsules 50mg
  • Notes: Opicapone is significantly more expensive than entacapone. Opicapone is included in the formulary as a second line COMT inhibitor for the treatment of Parkinson's disease in patients who have been unable to tolerate a trial of a reasonable duration of entacapone (typically experiencing intolerable GI disturbances or unmanageable isues relating to stained secretions).
 
   
04.09.01  Amantadine
Amantadine 
(Oral)
View adult BNF View SPC online
Formulary
Amber
  • Capsules 100mg
  • Syrup 50mg in 5ml
  • For Parkinsons Disease
  • 'Off label' for the treatment of fatigue in Multiple Sclerosis according to NICE CG186 Oct14 
 
Link  NICE CG186 Multiple sclerosis in adults: management (Nov 19 update)
   
04.09.02  Antimuscarinic drugs used in parkinsonism to top
Orphenadrine 
(solution)
View adult BNF View SPC online
Formulary
Amber
  • Orphenadrine 50mg/5ml oral solution sugar free
 
   
Procyclidine 
(Oral,injection)
View adult BNF View SPC online
Formulary
Green
  • Tablet 5mg
  • Syrup 2.5mg/5ml, 5mg/5ml
  • Injection 10mg in 2ml - Note: See SPS November 2019 stock shortages link below
 
Link  SPS Shortage of procyclidine (Kemadrin) 5mg/ml injection (May 2020 update)
   
Trihexyphenidyl 
(Oral)
View adult BNF View SPC online
Formulary
Amber
  • Tablet 2mg, 5mg
  • Syrup 5mg /5ml 

 

 
   
04.09.03  Drugs used in essential tremor, chorea, tics, and related disorders
 note 

Tics etc

Notes: Haloperidol may be useful in improving motor tics and symptoms of Gilles de la Tourette syndrome and related choreas. Chlorpromazine and haloperidol (section 4.2.1) are used to relieve intractable hiccups.

Botulinum A toxin 
(Injection)
View adult BNF View SPC online
Formulary
Red
High Cost Medicine
NHS England
CCG
  • Dysport® injection 300 or 500 unit vial
  • Botox® Injection powder for reconstitution 50 unit vial, 100 unit vial, 200 unit vial
  • Xeomin® Injection powder for reconstitution 50 unit vial, 100 unit vial, 200 unit vial.
  • See BSW CCG Botulinum commissioning policy for approved indications on the link below.
  • Botox can also be used for migraine in accordance with recommendations of NICE TA 260.
  • Xeomin® may be used for chronic sialorrhoea associated with chronic neurological conditions in line with licences and with NICE TA605
  • Preparations are not interchangeable and should be used under specialist supervision.
  • Commissioned by NHS England for use in focal spasticity in children according to set criteria.

 

 
Link  BSW botulinum toxin policies
Link  NICE TA260 Botulinum toxin type A for the prevention of headaches in adults with chronic migraine June 2012
Link  NICE TA605 Xeomin (botulinum neurotoxin type A) for treating chronic sialorrhoea October 2019
   
Riluzole 
(Tablet)
View adult BNF View SPC online
Formulary
Amber
  • Tablets 50mg
  • Notes: Riluzole is used to extend life or the time to mechanical ventilation in patients with motor neurone disease (MND) who have amyotrophic lateral sclerosis (ALS).
  • NICE recommend Riluzole for treating the amyotrophic lateral sclerosis (ALS) form of motor neurone disease (MND). See link below.
  • There is no formal Shared Care Agreement for Riluzole from GWH or RUH hospitals. See below for the SFT SCA.
 
Link  NICE TA20: Motor neurone disease - riluzole
Link  SFT Shared care guidelines for the management of patients prescribed riluzole in the management of Motor Neurone Disease
   
Tetrabenazine 
(Tablet)
View adult BNF View SPC online
Formulary
Amber
  • Tablets 25mg
  • Notes: Tetrabenazine has a useful action for movement disorders
  • Tetrabenazine may cause depression and excessive sedation. It may also precipitate extrapyramidal side effects. It is therefore important to initiate treatment on the minimum effective dose and increase dosage no more frequently than on a weekly basis.
 
   
04.09.03  Torsion dystonias and other involuntary movements
04.10  Drugs used in substance dependence
 note 

Drug and Alcohol Service: All drugs below should be prescribed in conjunction with a recovery programme. BANES CCG commissions this from AWP SDAS. For information including contact details etc click here.  Wiltshire CCG commissions this from Turning Point.

04.10  Alcohol dependence
04.10  Cigarette smoking to top
04.10  Opioid dependence
04.10.01  Alcohol dependence
Acamprosate 
(Tablet)
View adult BNF View SPC online
Formulary
Amber
  • Tablets e/c 333mg
  • Use only in the context of supervised withdrawal regime with psychosocial recovery programme. For maintenance of abstinence in alcohol dependent patients.
  • See shared care guidelines below for maintenance of abstinence.
  • Acamprosate is supported by NICE (CG115) following assisted withdrawal or for harmful drinkers and people with mild alcohol dependence who have requested a pharmacological intervention in combination with an individual psychological intervention.
 
Link  3Ts Acamprosate Shared Care document
Link  BCAP Acamprosate Shared Care document
   
Chlordiazepoxide 
(Capsule)
View adult BNF View SPC online
Formulary
Green
  • Capsule 5mg, 10mg
  • Use only in the context of supervised withdrawal regime over a period of 5-10 days, with psychosocial recovery programme.
 
   
Disulfiram 
(Tablet)
View adult BNF View SPC online
Formulary
Amber
  • Tablets 200mg
 
   
Nalmefene 
(Tablet)
View adult BNF View SPC online
Formulary
  • Red BaNES due to commissioned service
  •  Green Wiltshire and Swindon
  • Tablets 18mg
  • NICE recommended for reducing alcohol consumption in people with alcohol dependance- see link below
  • Notes: Prescribing should be an adjunct to psychological therapy. Detoxification from alcohol should not take place in isolation and be supported with a post detoxification care plan. 
 
Link  BaNES CCG Treatment pathway for Increasing and Higher Risk drinkers
Link  Nalmefene information for GPs in Wiltshire CCG
Link  NICE TA325 Nov 2014: Nalmefene for reducing alcohol consumption in people with alcohol dependence
   
Naltrexone 
(Tablet)
View adult BNF View SPC online
Formulary
Amber
  • Tablets 50mg (generic) for AWP / CDAS
  • For abstinence from alcohol for people who have already undergone detoxification within the treatment pathway 
  • Naltrexone is supported by NICE CG115 following assisted withdrawal or for harmful drinkers and people with mild alcohol dependence who have requested a pharmacological intervention in combination with an individual psychological intervention.
 
Link  3Ts Naltrexone Hydrochloride tablets for Shared Care Document
Link  3Ts Naltrexone signature sheet
Link  BCAP Specialist Drug and Alcohol Service Shared Care Document
Link  NICE CG115 Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence Feb 2011
   
04.10.02  Nicotine dependence
Bupropion Hydrochloride

(Tablet)
View adult BNF View SPC online
Formulary
Green
  • Tablets m/r, f/c 150mg
  • CSM advice: Bupropion is contra-indicated in patients with a history of seizures or of eating disorders, a CNS tumour, or who are experiencing acute symptoms of alcohol or benzodiazepine withdrawal.

June 2020 - Out of stock until end November 2020. See MHRA Supply Disruption Alert

 
Link  BSW Stop smoking community quick guide 2020
   
Nicotine 
(Oral,Nasal,Patch)
View adult BNF View SPC online
Formulary
Green
  • 16 hour transdermal patch 5mg, 10mg, 15mg, 25mg
  • 24 hour transdermal patch TTS 10 (7mg), TTS 20 (14mg), TTS 30 (21mg)
  • Inhalator 15mg cartridge
  • Chewing gum 2mg, 4mg, 6mg
  • Lozenge 1mg, 1.5mg, 2mg, 4mg
  • Sublingual microtab 2mg
  • Nasal spray 10mg/ml, 0.5mg/dose
  • Oromucosal spray 1mg per dose
 
Link  BSW Stop smoking community quick guide 2020
   
Varenicline 
(Tablets)
View adult BNF View SPC online
Formulary
Green
  • Tablets 500 micrograms, 1mg
  • Notes: Smoking cessation. Varenicline should only be prescribed on advice from smoking cessation advisor.  
 
Link  BSW Stop smoking community quick guide 2020
Link  December 2014 MHRA DSU: Varenicline and suicidal behaviour: cohort study provides some reassurance
Link  NICE TA123: Varenicline
   
04.10.03  Opioid dependence
 note 
04.10.03  Opioid substitution therapy to top
Controlled Drug Buprenorphine  
(sublingual tablets)
View adult BNF View SPC online
Formulary
  • Amber with Shared Care BaNES
  • Amber Swindon/North Wilts: Under review
  • Sublingual Tablets 400micrograms, 2mg, 8mg
  • For treatment of substance misuse 
  • See BaNES CCG shared care for substance misuse on link above
  • The recommended criteria for generalist prescribers to prescribe in the field of opioid dependence is that they have completed the RCGP Certificate in the Management of Drug Misuse (part one) and be part of the Local Enhanced Service (LES) for substance misuse
  • GPs with Specialist Interest (GPwSI) in substance misuse and specialist prescribers in the field of substance misuse (not LES prescribers) are "secondary care prescribers" for the purpose of these guidelines.
  • Supervised Consumption through an accredited pharmacy should be undertaken for a minimum of twelve weeks at the start of methadone and buprenorphine treatment in line with DOH and NICE

 

 
   
Controlled Drug Methadone  
(Solution)
View adult BNF View SPC online
Formulary
Amber
  • Oral solution 1mg/1ml
  • Oral solutionSF 1mg/1ml
 
   
Controlled Drug Methadone  
(Injection )
View adult BNF View SPC online
Formulary
Red
  • Injection 10mg/1ml, 20mg/2ml, 50mg/1ml
 
   
04.10.03  Adjunctive therapy and symptomatic treatment
Naloxone 
(Antidote,injection)
View adult BNF View SPC online
Formulary
Amber
  • 400 micrograms in 1ml amp
  • Reversal of CNS/Respiratory Depression
 
Link  Patient safety alert – risk of distress and death from inappropriate doses of naloxone in patients on long-term opioid or opiate treatment
   
04.10.03  Opioid-receptor antagonists
Naltrexone 
(Tablets)
View adult BNF View SPC online
Formulary
Amber with Shared Care
  • BaNES and Swindon only
  • Tablets 50mg (generic) for AWP / CDAS
  • Notes: Naltrexone should be initiated by a specialist in the field of substance misuse. However, it may be prescribed on an on-going basis by a primary care prescriber for the maintenance of abstinence from opioids (or alcohol or for mild alcohol dependence) following advice from a specialist practitioner.
 
Link  3Ts Naltrexone Hydrochloride tablets for Shared Care Document
Link  3Ts Naltrexone signature sheet
Link  BCAP Specialist Drug and Alcohol Service Shared Care Document
Link  NICE TA115: Drug misuse - naltrexone
   
04.11  Drugs for dementia
 note 
  • NICE TA217 Donepezil, galantamine, rivastigmine, memantine for Alzheimer’s disease updated May 2016
  • Note: Behavioural and psychological symptoms can be part of the dementing process, but it is important to exclude any intercurrent illness. Behavioural and psychological approaches are important and the use of medication has a lower profile. If medication is used, the rule of start low, go slow, monitor effects frequently applies. It is important to review any drug at regular intervals and assess whether it can be stopped as the treatment symptoms may have remitted.
  • Dementia Services are commissioned differently in Swindon CCG, Wiltshire CCG (AWP) and BaNES CCG (RICE and AWP) - hence the difference in traffic light status of the drugs below.
Donepezil 
(Tablet)
View adult BNF View SPC online
First Choice
  • Amber with Shared Care  BaNES
  • Red  Swindon
  • Green  Wiltshire
  • Tablet 5mg, 10mg
 
Galantamine 
(Oral)
View adult BNF View SPC online
Formulary
  • Amber with Shared Care BaNES and Wiltshire
  • Red Swindon
  • Capsules MR 8mg, 16mg, 24mg
  • Tablet 8mg, 12mg

 

 
Link  BCAP Shared Care Document
Link  SFT Shared Care Document
   
Memantine 
(Tablet)
View adult BNF View SPC online
Formulary
  • Amber with Shared Care BaNES
  • Red Swindon and Wiltshire

  • Tablet 10mg, 20mg

 

 
Link  BCAP Memantine Shared Care Document
   
Rivastigmine 
(Capsule,Patch)
View adult BNF View SPC online
Formulary
  • Amber with Shared Care BaNES and Wiltshire 
  • Red Swindon
  • Capsule 1.5mg, 3mg, 4.5mg, 6mg
  • Patches 4.6mg/24 hours, 9.5mg/24 hours (only for patients who cannot take oral therapy). 

 

 

 
Link  3Ts Shared Care Document
Link  BCAP Shared Care Document
Link  MHRA DSU Dec 2014: Rivastigmine (Exelon) transdermal patch: risk of medication errors
Link  SFT Shared Care Document
   
 ....
 Non Formulary Items
Acetazolamide 

View adult BNF View SPC online
Non Formulary
 
Agomelatine (Valdoxan®)

View adult BNF View SPC online
Non Formulary
 
Controlled Drug  Alfentanyl Sublingual Spray 5 mg in 5mL


View adult BNF View SPC online
Non Formulary
 
Alprazolam 

View adult BNF View SPC online
Non Formulary
 
Amantadine (Lysovir®)
(Influenza)

View adult BNF View SPC online
Non Formulary
 
Amitriptyline and perphenazine
(Triptafen®)

View adult BNF View SPC online
Non Formulary
 
Amitriptyline and perphenazine
(Triptafen-M®)

View adult BNF View SPC online
Non Formulary
 
Controlled Drug  Amobarbital (amylobarbitone) and secobarbital (quinalbarbitone)
(Tuinal®)

View adult BNF View SPC online
Non Formulary
 
Controlled Drug  Amobarbital (amylobrbitone)
(Sodium Amytal®)

View adult BNF View SPC online
Non Formulary
 
Aripiprazole (Abilify Maintena®)

View adult BNF View SPC online
Non Formulary
 
Asenapine 
(Sycrest)

View adult BNF View SPC online
Non Formulary
 
Aspirin + Codeine (Co-codaprin®)

View adult BNF View SPC online
Non Formulary
 
Aspirin + Metoclopramide
(MigraMax®)

View adult BNF View SPC online
Non Formulary
 
Aspirin + Papaveretum
(Aspav®)

View adult BNF View SPC online
Non Formulary
 
Benperidol (Anquil®)

View adult BNF View SPC online
Non Formulary
 
Benzatropine 

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Non Formulary
 
Botulinum A toxin (Azzalure®)

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Non Formulary
 
Botulinum A toxin (Vistabel®)

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Non Formulary
 
Botulinum B toxin (NeuroBloc®)

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Non Formulary
 
Controlled Drug  Buprenorphine and Naloxone
(Suboxone®)

View adult BNF View SPC online
Non Formulary
 
Controlled Drug  Butobarbital (butobarbitone)
(Soneryl®)

View adult BNF View SPC online
Non Formulary
 
Cabergoline 

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Non Formulary
 
Cabergoline (Cabaser®)

View adult BNF View SPC online
Non Formulary
 
Cannabidiol (Epidyolex®)

View adult BNF View SPC online
Non Formulary

BSW cannabis-based medicinal products - interim position statement 
in response to publication of NICE guideline that covers prescribing of cannabis-based medicinal products for people with intractable nausea and vomiting, chronic pain, spasticity and severe treatment-resistant epilepsy.  

NICE is developing a Technology Appraisal on CBD for adjuvant treatment of seizures associated with Lennox-Gastaut syndrome and Dravet syndrome expected December 2019. 

Epidyolex remains non-formulary and is not funded by BSW. This will be reviewed on publication of NICE TA.

 

 
Chloral Betaine (Welldorm®)

View adult BNF View SPC online
Non Formulary
 
Cinnarizine and Dimenhydrinate
(Arlevert®)

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Non Formulary
 
Clomethiazole (Heminevrin®)

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Non Formulary
 
Clomipramine 

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Non Formulary
 
Clomipramine Hydrochloride
(Anafranil®)

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Non Formulary
 
Clonidine Hydrochloride


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Non Formulary

January 2020 - Clonidine is NOT included on the BSWformulary for migraine.  Clonidine for migraine prophylaxis has been superseded by other agents; NICE guidance on the menopause advises against routine use of clonidine as first-line treatment for vasomotor symptoms alone. There is currently a national shortage of clonidine 25mcg tablets. This SPS memo offers advice on alternatives formulations  but note these may be expensive and should be reserved ONLY for patients where no other therapeutic option is suitable.

 
Clozapine (Denzapine®)

View adult BNF View SPC online
Non Formulary
 
Co-Careldopa Intestinal Gel
(Duodopa®)

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Non Formulary
Red Specialist Centre
High Cost Medicine
NHS England
BlueTeq
  • NON Formulary Except following individual patient funding approval from NHSE
  • NHSE Commissioned for PD but not routinely.
  • Duodopa Intestinal gel co-careldopa 5/20 (carbidopa 5 mg as monohydrate, levodopa 20 mg)/mL, 100ml
  • Co-careldopa for use with enteral tube (Duodopa)
Link  NHSE Clinical Commissioning Policy: Levodopa-Carbidopa Intestinal Gel (LCIG) July 2015
 
Co-proxamol 

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Non Formulary
  • NB Co-proxamol is NOT included in the BSW formulary and is a unlicensed drug.

    Co-proxamol is also included in the NHSE Low Value Medicines guidance (link below);

    Since 1985 advice aimed at the reduction of co-proxamol toxicity and fatal overdose has been provided, but this was not effective and resulted in withdrawal of co-proxamol by the MHRA. Since the withdrawal, further safety concerns have been raised which have resulted in co-proxamol being withdrawn in other countries. Due to significant safety concerns, co-proxamol was included in the NHSE guidance.

Link  NHSE Items which should not routinely be prescribed in primary care: Guidance for CCGs (June 2019)
 
Controlled Drug  Dexamfetamine 
(Adult ADHD)

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Non Formulary

Dexafetamine is not licensed for use in adults with ADHD. The safety and efficacy of dexamfetamine in adults have not been established.

 
Controlled Drug  Dextromoramide 

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Non Formulary
 
Dihydrocodeine Tartrate
(DF 118 Forte®)

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Non Formulary

Controlled Drug Injection Only
 
Dihydrocodeine Tartrate
(DHC Continus®)

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Non Formulary

Controlled Drug Injection Only
 
Controlled Drug  Dipipanone (Diconal®)

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Non Formulary
 
Dolasetron Mesilate
(Anzemet®)

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Non Formulary
 
Dosulepin 

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Non Formulary

NOT RECOMMENDED for the treatment of depression

 
Dosulepin Hydrochloride
(Prothiaden®)

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Non Formulary
 
Doxepin 

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Non Formulary
 
Eletriptan (Relpax®)

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Non Formulary
 
Ergotamine Tartrate
(Cafergot®)

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Non Formulary
 
Ergotamine Tartrate
(Migril®)

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Non Formulary
 
Controlled Drug  Fentanyl Buccal Film
(Breakyl)

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Non Formulary
 
Flupentixol (Fluanxol®)

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Non Formulary
 
Fluphenazine Hydrochloride
(Moditen®)

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Non Formulary
 
Flurazepam (Dalmane®)

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Non Formulary
 
Fluvoxamine Maleate
(Faverin®)

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Non Formulary
 
Fluvoxamine Maleate
(Fluvoxamine®)

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Non Formulary
 
Fosaprepitant (Ivemend®)

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Non Formulary
 
Fosphenytoin Sodium
(Pro-Epanutin®)

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Non Formulary
 
Granisetron 

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Non Formulary
 
Granisetron transdermal patch
(Sancuso®)
(3.1mg/24hrs)

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Non Formulary
 
Haloperidol (Dozic®)

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Non Formulary
 
Haloperidol (Serenace®)

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Non Formulary
 
Controlled Drug  Hydromorphone (Palladone®)

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Non Formulary
 
Controlled Drug  Hydromorphone Hydrochloride
(Palladone® SR)

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Non Formulary
 
Isocarboxazid 

View adult BNF View SPC online
Non Formulary
 
Isometheptene Mucate
(Midrid®)

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Non Formulary
 
Controlled Drug  Ketamine oral solution


Non Formulary
 
Levodopa + carbidopa ER
(Numient®)

View adult BNF View SPC online
Non Formulary
 
Liraglutide (Saxenda®)

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Non Formulary

Advisory summary on novel obesity drugs

 
Lisuride 

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Non Formulary
 
Lofexidine (BritLofex®)

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Non Formulary
 
Loprazolam 

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Non Formulary
 
Lurasidone (Latuda®)

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Non Formulary
 
Controlled Drug  Meprobamate 

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Non Formulary
 
Meptazinol (Meptid®)

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Non Formulary
 
Controlled Drug  Methadone Hydrochloride
(Methadose®)

View adult BNF View SPC online
Non Formulary
 
Methysergide (Deseril®)

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Non Formulary
 
Mianserin 

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Non Formulary
 
Midazolam (Buccolam®)

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Non Formulary
 
Controlled Drug  Midazolam (Buccolam®)

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Non Formulary
 
Migraleve®


View adult BNF View SPC online
Non Formulary
 
Controlled Drug  Morphine and cyclizine
(Cyclimorph®)

View adult BNF View SPC online
Non Formulary
 
Morphine Sulphate (MST Continus Suspension)

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Non Formulary
 
Controlled Drug  Morphine Sulphate M/R capsules


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Non Formulary
 
Controlled Drug  Morphine suppositories


View adult BNF View SPC online
Non Formulary
 
Nabilone 

View adult BNF View SPC online
Non Formulary

BSW cannabis-based medicinal products - interim position statement 
in response to publication of NICE guideline that covers prescribing of cannabis-based medicinal products for people with intractable nausea and vomiting, chronic pain, spasticity and severe treatment-resistant epilepsy.  

 
Naltrexone Hydrochloride
(Opizone®)

View adult BNF View SPC online
Non Formulary
 
Naltrexone/ bupropion
(Mysimba®)

View adult BNF View SPC online
Non Formulary
Link  Nice TA494: Naltrexone–bupropion for managing overweight and obesity
 
Naratriptan (Naramig®)

View adult BNF View SPC online
Non Formulary
 
Nefopam 

View adult BNF View SPC online
Non Formulary
 
Nefopam (Acupan®)

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Non Formulary
 
Netupitant and Palonosetron
(Akynzeo®)

View adult BNF View SPC online
Non Formulary
 
Nicotine (Voke®)
(Inhaler)

View adult BNF View SPC online
Non Formulary
 
Nitrazepam 

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Non Formulary
 
Nortriptyline 

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Non Formulary
 
Oxazepam 

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Non Formulary
 
Paliperidone (Invega®)

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Non Formulary
 
Palonosetron (Aloxi®)

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Non Formulary
 
Controlled Drug  Papaveretum 

View adult BNF View SPC online
Non Formulary
 
Controlled Drug  Papaveretum 
(Papaveretum with hyoscine injection)

View adult BNF View SPC online
Non Formulary
 
Paracetamol (Panadol OA®)

View adult BNF View SPC online
Non Formulary
 
Paracetamol and codeine
(Co-codamol ®15/500)

View adult BNF View SPC online
Non Formulary
 
Paracetamol and dihydrocodeine
(Remedeine®)

View adult BNF View SPC online
Non Formulary
 
Paracetamol and methionine
(Pardote®)

View adult BNF View SPC online
Non Formulary
 
Paracetamol and metoclopramide
(Paramax®)

View adult BNF View SPC online
Non Formulary
 
Controlled Drug  Pentazocine 

View adult BNF View SPC online
Non Formulary
 
Pergolide 

View adult BNF View SPC online
Non Formulary
 
Pergolide (Celance®)

View adult BNF View SPC online
Non Formulary
 
Pericyazine (Neilactil®)

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Non Formulary
 
Perphenazine 

View adult BNF View SPC online
Non Formulary
 
Perphenazine (Fentazin®)

View adult BNF View SPC online
Non Formulary
 
Controlled Drug  Pethidine Hydrochloride and promethazine
(Pamergan® P100)

View adult BNF View SPC online
Non Formulary
 
Phenytoin 
(Neuropathic pain)

View adult BNF View SPC online
Non Formulary
 
Phenytoin Sodium (Epanutin® Ready Mixed Parenteral)

View adult BNF View SPC online
Non Formulary
 
Pimozide (Orap®)

View adult BNF View SPC online
Non Formulary
 
Pipotiazine Palmitate
(Piportil® Depot)
(Injection)

View adult BNF View SPC online
Non Formulary
  • Discontinued in UK
 
Piracetam (Nootropil®)

View adult BNF View SPC online
Non Formulary
 
Pitolisant (Wakix®)

View adult BNF View SPC online
Non Formulary
 
Pizotifen 

View adult BNF View SPC online
Non Formulary
 
Primidone 
(essential tremor)

View adult BNF View SPC online
Non Formulary
 
Promazine Hydrochloride
(Promazine®)

View adult BNF View SPC online
Non Formulary
 
Reboxetine (Edronex®)

View adult BNF View SPC online
Non Formulary
 
Retigabine 

View adult BNF View SPC online
Non Formulary
  • Retigabine was withdrawn with effect from June 2017
 
Rimonabant (Acomplia®)

View adult BNF View SPC online
Non Formulary
 
Rizatriptan (Maxalt®)

View adult BNF View SPC online
Non Formulary
 
Controlled Drug  Secobarbital (quinalbarbitone)
(Seconal Sodium® )

View adult BNF View SPC online
Non Formulary
 
Sertindole (Serdolect®)

View adult BNF View SPC online
Non Formulary
 
Sibutramine Hydrochloride
(Reductil®)

View adult BNF View SPC online
Non Formulary
 
Controlled Drug  Sodium Oxybate (Xyrem®)

View adult BNF View SPC online
Non Formulary
High Cost Medicine
NHS England
  • NON Formulary except when used in accordance with NHSE policy Sodium Oxybate for symptom control of narcolepsy with cataplexy (children).
Link  NHSE Clinical Commissioning Policy: Sodium oxybate for symptom control of narcolepsy with cataplexy (children) 2016
 
Sufentanil (Zalviso®)

View adult BNF View SPC online
Non Formulary
 
Sumatriptan (Imigran® Radis)

View adult BNF View SPC online
Non Formulary
 
Controlled Drug  Tapentadol (Palexia®)

View adult BNF View SPC online
Non Formulary
 
Controlled Drug  Targinact (Oxycodone/Naloxone)
(Targinact®)
(Pain)

View adult BNF View SPC online
Non Formulary

NOT RECOMMENDED as an opioid analgesic

 
Controlled Drug  Targinact (Oxycodone/Naloxone)
(Targinact®)
(Restless legs)

View adult BNF View SPC online
Non Formulary

NOT RECOMMENDED as an opioid analgesic

 
Tasimelteon (Hetlioz®)

View adult BNF View SPC online
Non Formulary
 
Tiagabine (Gabitril®)

View adult BNF View SPC online
Non Formulary
 
Tolcapone (Tasmar®)

View adult BNF View SPC online
Non Formulary
 
Tolfenamic Acid (Clotam®)

View adult BNF View SPC online
Non Formulary
 
Controlled Drug  Tramadol Hydrochloride and paracetamol
(Tramacet®)

View adult BNF View SPC online
Non Formulary
 
Controlled Drug  Tramadol oral drops


View adult BNF View SPC online
Non Formulary
 
Tranylcypromine 

View adult BNF View SPC online
Non Formulary
 
Triclofos Sodium (Triclofos® oral Solution BP (Triclofos Elixir))

View adult BNF View SPC online
Non Formulary
 
Trimipramine 

View adult BNF View SPC online
Non Formulary

NOT RECOMMENDED for the treatment for depression

 
Tropisetron (Navoban®)

View adult BNF View SPC online
Non Formulary
 
Tryptophan 

View adult BNF View SPC online
Non Formulary
 
Trytophan (Optimax®)

View adult BNF View SPC online
Non Formulary
 
Valproic acid (Convulex®)

View adult BNF View SPC online
Non Formulary
 
Zaleplon (Sonata®)

View adult BNF View SPC online
Non Formulary
 
Ziprasidone (Zeldox®)

View adult BNF View SPC online
Non Formulary
 
Zolpidem 
(Oral)

View adult BNF View SPC online
Non Formulary
Link  NICE TA77: Zaleplon, zolpidem and zopiclone for the management of insomnia
 
Zotepine (Zoleptil®)

View adult BNF View SPC online
Non Formulary
 
  
Key
note Notes
Section Title Section Title (top level)
Section Title Section Title (sub level)
First Choice Item First Choice item
Non Formulary Item Non Formulary section
Restricted Drug
Restricted Drug
Unlicensed Drug
Unlicensed
Track Changes
Display tracking information
click to search medicines.org.uk
Link to adult BNF
click to search medicines.org.uk
Link to SPCs
SMC
Scottish Medicines Consortium
Cytotoxic Drug
Cytotoxic Drug
CD
Controlled Drug
High Cost Medicine
High Cost Medicine
Cancer Drugs Fund
Cancer Drugs Fund
NHSE
NHS England
Homecare
Homecare
CCG
CCG
Blueteq
High Cost Drug Approval System

Traffic Light Status Information

Status Description

Red

RED - Hospital only – to be prescribed by a specialist and supplied from secondary care ONLY throughout treatment.  

Amber

Amber medicines are considered suitable for GP prescribing following specialist initiation or recommendation.  

Amber with Shared Care

Shared Care - these medicines require specialist initiation and stabilisation. Ongoing division of responsibility for drug and disease monitoring between specialist and GP by a Shared Care Guideline (SCG). If no SCG in place status reverts to red.  

Green

These medicines are appropriate for initiation in both primary and secondary care. Prescribing is appropriate within licensed or local recommendations.  

Self

Suitable for patient to be directed to buy themselves  

Grey

Not currently used. We intend to include this TLS in future to highlight where a decision to use this medicine is under review.   

Black

Not currently used. We intend to include this TLS in future to highlight where a decision has been made by either or both the local or national NHS not to routinely commission this preparation for its licensed indications. Do not prescribe.  

Red Specialist Centre

Not currently used. We intend to include this TLS in future to highlight where this medicine and indication is ONLY available through a Specialist Centre according to a NICE Highly Specialised Technology or NHSE Specialised Commission Circular / Policy.  

netFormulary