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NHS Bath and North East Somerset, Swindon and Wiltshire CCG
Royal United Hospitals Bath NHS Foundation Trust
Great Western Hospitals NHS Foundation Trust
Salisbury NHS Foundation Trust
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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...
04.02.01  Expand sub section  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.

04.02.01  Expand sub section  First-Generation Antipsychotic Drugs
04.02.01  Expand sub section  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)
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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 )
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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 (Velotab®) 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
   
 ....
 Non Formulary Items
Lurasidone (Latuda)

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

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

View adult BNF View SPC online
Non Formulary
 
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.  

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