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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...
04.06  Expand sub section  Drugs used in nausea and vertigo
 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  Expand sub section  Vomiting during pregnancy
04.06  Expand sub section  Postoperative nausea and vomiting
04.06  Expand sub section  Motion sickness
04.06  Expand sub section  Other vestibular disorders to top
04.06  Expand sub section  Cytotoxic chemotherapy
04.06  Expand sub section  Palliative care
04.06  Expand sub section  Migraine
04.06  Expand sub section  Antihistamines
Cinnarizine 
(Tablet)
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Formulary
Green
  • Tablet 15mg 
 
   
Cyclizine 
(Tablet,injection)
View adult BNF View SPC online
Formulary
Green
  • Tablet 50mg
  • Injection 50mg in 1ml
 
Link  Anticholinergic medicines (information leaflet for patients)
   
Promethazine Hydrochloride

(Oral,injection)
View adult BNF View SPC online
Formulary
Green
  • Tablets 10mg, 25mg
  • Elixir 5mg/5ml
  • Injection 25mg/ml
 
   
04.06  Expand sub section  Phenothiazines and related drugs to top
Droperidol 
(Injection)
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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  Expand sub section  Domperidone and metoclopramide
Domperidone 
(Oral)
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Formulary
  • Green when used within licensed indication which is SHORT –TERM relief of symptoms of nausea and vomiting in adults and adolescents over 12 years and weighing more than 35 kg. For use in GI pain in palliative care see Chapter 21
  • Amber for longer-term or off-label use
  • Tablet 10mg
  • Suspension 5mg in 5ml
  • Prescribe in line with MHRA advice and BSW domperidone guidance (links below)

 

 
Link  BSW Domperidone Guidance
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)
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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  Expand sub section  5HT3 antagonists
Ondansetron 
(Oral,injection)
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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  Expand sub section  Neurokinin receptor antagonist
Aprepitant 
(Capsule)
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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  Expand sub section  Cannabinoid
04.06  Expand sub section  Hyoscine to top
Hyoscine Hydrobromide

(tablets/patches)
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Formulary
Green
  • 150mcg ,300mcg tablet
  • Scopoderm® TTS Patch 1mg/ 72hrs
 
Link  Anticholinergic medicines (information for patients)
   
Hyoscine Hydrobromide

(Injection)
View adult BNF View SPC online
Formulary
  • Red 400mcg per ml injection
  • Green for palliative care
 
   
04.06  Expand sub section  Other drugs for Ménière's disease
 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
 
   
 ....
 Non Formulary Items
Cinnarizine and Dimenhydrinate
(Arlevert®)

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Non Formulary
 
Dolasetron Mesilate
(Anzemet®)

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Non Formulary
 
Fosaprepitant (Ivemend®)

View adult BNF View SPC online
Non Formulary
 
Granisetron 

View adult BNF View SPC online
Non Formulary
 
Granisetron transdermal patch
(Sancuso®)
(3.1mg/24hrs)

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.  

 
Netupitant and Palonosetron
(Akynzeo®)

View adult BNF View SPC online
Non Formulary
 
Palonosetron (Aloxi®)

View adult BNF View SPC online
Non Formulary
 
Perphenazine 

View adult BNF View SPC online
Non Formulary
 
Tropisetron (Navoban®)

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

(In use from Oct 2020) Used where a decision has been made by the BSW APC 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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