| Formulary Chapter 4: Central nervous system - Full Chapter
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| 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.
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Antipsychotic Drugs |
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- 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 11 Dec 2014 Antipsychotics: initiative to reduce prescribing to older people with dementia
- MHRA Drug Safety Update 11 Dec 2014 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.
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First-Generation Antipsychotic Drugs |
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Second-Generation Antipsychotic Drugs |
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Amisulpride
(Oral)
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Formulary
 
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- Tablets 50mg, 100mg, 200mg, 400mg
- Oral Solution
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Aripiprazole
(Oral)
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Formulary
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- Tablets 5mg, 10mg, 15mg, 30mg
- Orodispersible tablet 10mg, 15mg
- Oral solution 1mg/ml
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 3Ts Shared Care Document
NICE TA213: Aripiprazole for the treatment of schizophrenia in people aged 15 -17 years
NICE TA292: Aripiprazole for treating moderate to severe manic episodes in adolescents with bipolar I disorder
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Clozapine
(Zaponex®)
(Oral)
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Formulary
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- 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
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AWP Procedure for the care of patients taking clozapine in primary care settings during the COVID-19 pandemic
MHRA Drug Safety Update October 2017: Clozapine: reminder of potentially fatal risk of intestinal obstruction, faecal impaction, and paralytic ileus
NHS BSW Anticholineric medicines (leaflet for patients)
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Olanzapine
(Injection )
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Formulary
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- 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.
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Olanzapine
(Oral)
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Formulary
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- Tablets 2.5mg, 5mg, 7.5mg, 10mg, 15mg, 20mg
- Orodispersible tablet 5mg, 10mg, 15mg, 20mg
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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.
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NHS BSW Anticholinergic medicines (information leaflet for patients)
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Quetiapine
(Oral)
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Formulary
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- 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.
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Primary Care - see BSW Prescribe Well Spend Less
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Risperidone
(Oral)
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Formulary
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- 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.
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MHRA DSU Risperidone and paliperidone: risk of intraoperative floppy iris syndrome in patients undergoing cataract surgery Dec 2014
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| Non Formulary Items |
Lurasidone
(Latuda®)
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Non Formulary
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Sertindole
(Serdolect®)
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Non Formulary
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Ziprasidone
(Zeldox®)
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Non Formulary
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Zotepine
(Zoleptil®)
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Non Formulary
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Key |
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Cytotoxic Drug
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Controlled Drug
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High Cost Medicine
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Cancer Drugs Fund
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NHS England |
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Homecare |
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CCG |
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High Cost Drug Approval System |
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Traffic Light Status Information
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