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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...
04.02.03  Expand sub section  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  Expand sub section  Benzodiazepines
04.02.03  Expand sub section  Antipsychotic drugs
04.02.03  Expand sub section  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  Expand sub section  Valproic acid to top
 note 

NICE CG185 Bipolar disorder: assessment and management April 18 update

Sodium valproate 
(Oral)
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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)
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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  Expand sub section  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
   
 ....
 Non Formulary Items
Asenapine 
(Sycrest)

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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