netFormulary Leicestershire Health Community NHS
Medicines Formulary  
 Search
 Formulary Chapter 4: Central nervous system - Full Chapter
Chapter Links...
 Details...
04.01  Expand sub section  Hypnotics and anxiolytics
 note  The Committee on Safety of Medicines (CSM) provides the following advice on benzodiazepine prescribing:
  • Benzodiazepines are indicated for the short-term relief (2-4 weeks only) of anxiety that is severe, disabling or subjecting the individual to unacceptable distress, occurring alone or in association with insomnia or short-term psychosomatic, organic or psychotic illness.
  • The use of benzodiazepines to treat short-term ‘mild’ anxiety is inappropriate and unsuitable.
  • Benzodiazepines should be used to treat insomnia only when it is severe, disabling or subjecting the individual to extreme distress.
    Abrupt withdrawal from benzodiazepines may produce confusion, toxic psychosis, convulsions, or a condition resembling delirium tremens. Therefore if a patient has been prescribed benzodiazepines long term withdrawal should be gradual
04.01.01  Expand sub section  Hypnotics
 note 
  • Consider non pharmacological treatments first e.g. sleep hygiene (Principles of sleep hygiene below, Leicestershire Partnership patient leaflet available here)
  • Prescribe a hypnotic only if severe insomnia is interfering with normal daily life
  • Limit to short period of time and review BNF advice.
  • If treatment with one of the recommended hypnotic medicines does not work, the doctor should not prescribe one of the others available.

Principles of sleep hygiene

  • Avoid excessive use of caffeine, alcohol or nicotine. A hot milky drink at bedtime may help promote sleep.
  • Do not stay in bed if not asleep.
  • Avoid daytime naps or periods of inactivity.
  • A warm bath or exercise a few hours before bedtime may promote sleep.
  • Avoid strenuous physical or mental activity near to bedtime.
  • Make sure the bed and bedroom are comfortable; avoid extremes of noise and temperature.
  • Rise at the same time every morning, regardless of sleep duration.

In patient use: recommendations

  • All PRN hypnotic prescriptions should be endorsed with a maximum frequency of 5 nights out of 7
  • PRN hypnotics should not be offered before 11pm
  • All regular hypnotic prescriptions should be assigned a review date of 2 weeks to ensure usage does not become long-term
  • All prescriptions for hypnotics on discharge should be queried unless the patient was a regular user of hypnotics prior to admission

Zopiclone
View adult BNF View SPC online  Track Changes
First Choice
Green
As with benzodiazepines avoid prolonged use (risk of tolerance and withdrawal symptoms). 
Zolpidem
View adult BNF View SPC online  Track Changes
Second Choice
Green

May be considered if patient experiences hangover effect with zopiclone. Zolpidem is contraindicated in people with psychosis

 
   
Temazepam
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Green
For patients who cannot tolerate other choices or who have previously responded to treatment.
The exemptions applied to Temazepam as a schedule 3 controlled drug have been removed. Temazepam should now be treated as a full CD. This includes ordering, storage, destruction and register requirements. In addtion there is a need for prescriptions to be written in words and figures and, in the hospital setting, the TTO letter should be printed and countersigned by the prescriber.  
   
Melatonin
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted

Melatonin 1mg/ml solution
There is now a licensed manufactured 1mg/1ml melatonin oral solution on the market. Please note this is contraindicated in children as it contains excipients at levels which can cause harm in children. For children please consider:
• First line crushing Circadin M/R tablets
• If a liquid is essential please prescribe a brand which is propylene glycol free and alcohol free such as Rosemont. This will need to be specified on the prescription.


For indications included in LMSG guidance. Simple amber classification only applies to doses up to 10mg daily.

Amber Simple for indications included in LMSG guidance. Simple amber classification only applies to doses up to 10mg daily.

Red  for circadian asynchrony in patients on HDU / ITU at UHL. It is also classified as RED for use for Huntington's Disease and learning disability.


 
Link  Leicestershire Guidance: Melatonin Guidelines for Children
Link  Simple Amber List
   
Melatonin M/R Tablets (Slenyto®, Circadin®)
View adult BNF View SPC online View childrens BNF  Track Changes
Formulary
Amber Simple

Please Prescribe By Brand Name

Circadin® - Approved for indications included in LMSG guidance. Simple amber classification only applies to doses up to 10mg daily. Circadin® is not supported for its licensed indication of primary insomnia in patients over 55 due to lack of evidence for effectiveness. This includes circadian asynchrony in elderly institutionalised patients.

Slenyto® - Approved for treatment of insomnia in children and adolescents aged 2-18 with Autism Spectrum Disorder (ASD) and / or Smith-Magenis syndrome, where sleep hygiene measures have been insufficient. New patients only

 
Link  Leicestershire Guidance: Melatonin Guidelines for Children
   
Promethazine
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Green
NICE recommends a sedating antihistamine is suitable for treating insomnia in patients who maybe prone to the development of tolerance and addiction 
   
Sodium Oxybate
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber Simple
High Cost Medicine
For initiation by sleep clinic at UHL only  
   
04.01.01  Expand sub section  Pitolisant
Pitolisant (Wakix®)
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber Simple

For treatment of narcolepsy.

Restricted to initiation by Specialist at Sleep Clinic.

 
   
04.01.02  Expand sub section  Anxiolytics
 note 
  • Limit to short period of time and review CSM Advice
  • Diazepam and its active metabolite have a long half life. There is a potential for accumulation especially in the very elderly.
  • Diazepam should only be given by the intramuscular route when oral and intravenous routes are not possible
  • Propranolol can often relieve the somatic symptoms of anxiety without the risks associated with benzodiazepine dependence
  • General Anxiety Disorder and Panic Disorder treatment options include antidepressant therapy
Diazepam
View adult BNF View SPC online  Track Changes
First Choice
Green
 
Lorazepam
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Green
Lorazepam is shorter-acting than diazepam and seems more likely to produce dependence. For this reason it should only be prescribed as an anxiolytic for existing users or where treatment will be for a very short time (e.g. for its amnesic effect when a course of cytotoxic chemotherapy is administered). Lorazepam may occasionally be useful in calming an acutely agitated patient if used with an antipsychotic agent such as haloperidol.

 

Link  LPT Guidance: Rapid Tranquilisation Policy
Link  UHL Guidelines: Rapid Tranquilisation of Disturbed Adult Patients
   
04.02  Expand sub section  Drugs used in psychoses and related disorders to top
 note 
  • For new onset psychosis seek specialist psychiatric advice
  • If the therapeutic goal is calming then a benzodiazepine may be more appropriate. These should only be prescribed for short periods.
  • If there is an ongoing requirement for antipsychotics seek specialist advice.
  • ECG monitoring is required before initiation of many antipsychotic drugs. Check SPC before prescribing
  • Patients on atypical antipsychotics should be monitored in line with the Leicestershire Partnership Trust Guidance on the monitoring of metabolic parameters in patients prescribed regular antipsychotics and agreed shared care agreement for prescribing of atypical antipsychotics. 
  • The Royal College of Psychiatrists has issued advice on the use of antipsychotics above their licensed dose.  Leicestershire Partnership Trust (LPT) guidance available below.
  • There is a clear increased risk of stroke and a small increased risk of death when antipsychotics (typical or atypical) are used in elderly people with dementia. Local guidance on management of behavioural problems in dementia and an antipsychotic drug prescribing care plan in dementia have been produced. 
  • Levomepromazine is also used in the treatment of nausea and vomiting associated with cytotoxic therapy.
  • Zuclopenthixol acetate (Clopixol Acuphase) is available for use only by specialists in psychiatric settings.
  • Haloperidol may be used by specialists in palliative care or ITU.  It is also an option for use in rapid tranquilisation if a parenteral form is required and appropriate.
Risperidone
View adult BNF View SPC online  Track Changes
First Choice
Amber SCA
 
Amisulpride
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber SCA

For use on the advice of a specialist in psychiatry. 

Link  SCA: Atypical Antipsychotics
   
Clozapine
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Red
For use on the advice of a specialist in psychiatry.
Treatment resistant schizophrenia. Classified RED i.e. not suitable for GP prescribing



 
   
Flupentixol
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber SCA
For use on the advice of a specialist in psychiatry for schizophrenia 
Link  SCA: Typical Antipsychotics
   
Lurasidone
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber SCA
Schizophrenia in adults aged 18 years and over.
For those who do not respond to or do not tolerate aripiprazole, or those who are not suitable for clozapine. 
   
Olanzapine
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber SCA

For use on the advice of a specialist in psychiatry. Also licensed for treatment of mania.

Long-term safety and tolerability of olanzapine:
Following long-term (>24 weeks) treatment with olanzapine, the types of metabolic changes seen in young people aged 12−18 years are similar to those seen in adults. However, the magnitude of changes in parameters such as body weight and some blood lipid levels appears to be greater in young people
 

Link  SCA: Atypical Antipsychotics
   
Promazine Hydrochloride
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Green
Short term adjunctive management of psychomotor agitation
Option for the treatment of agitation in the elderly but see also guidance on treatment of behavioural disturbance in dementia below. 
Link  Antipsychotic care plan for behavioural problems in patients with dementia
Link  Managing behavioural problems in patients with dementia
   
Quetiapine
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber SCA
Immediate release tablets only. For use on the advice of a specialist in psychiatry in line with NICE Clinical Guideline for Bipolar Disorder only. 
Link  NICE CG 185: Bipolar Disorder
Link  SCA: Atypical Antipsychotics
   
Sulpiride
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Green Conditional
If for use in schizophrenia or psychoses–to be initiated after discussion with specialist 
   
Zuclopenthixol
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber SCA
For use on the advice of a specialist in psychiatry 
Link  SCA: Typical Antipsychotics
   
Aripiprazole Oral
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber SCA
For bipolar disorder restricted to use in line with NICE TA
In Schizophrenia as an option if quetiapine causes problems with prolactin, aripiprazole is the drug of choice in these circumstances.

Date of entry of decision to Formulary:July 2013

 
Link  NICE TA 292: Aripiprazole in Bipolar Disorder (adolescents)
Link  SCA: Atypical Antipsychotics
   
Aripiprazole I.M.
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Red
Intramuscular preparation available for Rapid Tranquilisation only.
 
Link  Leicestershire Partnership (LPT) Guidance: Quick Reference Guide; Rapid Tranquilisation
Link  Leicestershire Partnership Trust (LPT) Guidance: Aripiprazole
Link  LPT Guidance: Rapid Tranquilisation, full policy
   
04.02.02  Expand sub section  Antipsychotic depot injections
Aripiprazole long-acting injection (Abilify Maintena®)
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber SCA
Specialist in Psychiatry Initiation only 
Link  SCA: Atypical Antipsychotics
   
Flupentixol Decanoate
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber SCA
Specialist in Psychiatry Initiation only 
Link  SCA: Typical Antipsychotics
   
Fluphenazine Decanoate
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber SCA
Specialist in Psychiatry Initiation only 
Link  SCA: Typical Antipsychotics
   
Haloperidol Decanoate
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber SCA
Specialist in Psychiatry Initiation only 
Link  SCA: Typical Antipsychotics
   
Risperidone (Risperdal Consta®)
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber SCA
Specialist in Psychiatry Initiation only. 
Link  Leicestershire Guidance: Risperdal Consta
Link  SCA: Atypical Antipsychotics
   
Zuclopenthixol Decanoate
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber SCA
Specialist in Psychiatry Initiation only. 
Link  SCA: Typical Antipsychotics
   
Olanzapine embonate (olanzapine pamoate) (Zypadhera®)
View adult BNF View SPC online View childrens BNF  Track Changes
Restricted Drug Restricted
Red
For use by specialists in psychiatry only  
   
04.02.03  Expand sub section  Drugs used for mania and hypomania
 note  Olanzapine is also licensed for treatment of mania
Carbamazepine
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted Specialist in Psychiatry Initiation only. 
Link  Leicestershire Guidance: Antiepileptics and Bone Mineral Density
Link  Toxicology and Therapeutic Dose Monitoring
   
Lithium
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber SCA
Specialist in Psychiatry Initiation only. BNF recommends to prescribe by brand. Priadel is the brand recommended for new patients due to cost. 
Link  Leicestershire Guidelines: Lithium in Acute and Primary Care Settings
Link  NPSA alert: Safer Lithium Therapy
Link  SCA: Lithium
Link  Toxicology and Therapeutic Dose Monitoring
   
Semisodium Valproate (Depakote®)
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber Simple
Mania in bipolar disorder. Specialist in Psychiatry Initiation only. 
Link  Drug Safety Update: Valproate medicines (Epilim▼, Depakote▼)
Link  MHRA Guidance: Valproate use by women and girls
Link  Resources to Use: Booklet for Healthcare Professionals
Link  Resources to Use: Card to give to patients
Link  Resources to Use: Consultation Checklist
Link  Resources to Use: Guide to give to patients
Link  Topiramate and Valproate Flow Chart
   
04.03  Expand sub section  Antidepressant drugs
 note 
  • Antidepressants are not recommended for the initial treatment of mild depression
  • Patients should be informed of delay in onset of action, potential side effects and the risk of withdrawal / discontinuation symptoms
  • If a patient fails to respond to the first antidepressant prescribed, check compliance and side effects before a gradual increase in dose in line with the schedule suggested by the Summary of Product Characteristics.
  • Consider switching to another antidepressant if there has been no response after a month. If there has been a partial response, a decision to switch can be postponed until 6 weeks.
  • Antidepressants should be continued for at least six months after remission of an episode of depression, because this greatly reduces the risk of relapse.
  • There is an increased risk of bleeding when SSRIs are given with NSAIDs or aspirin.  If no alternatives are appropriate NICE guidance recommends that gastroprotection is offered. 
  • Cumulative use of drugs with anticholinergic side effects have been shown to be associated with an increased risk for dementia. The long-term impact of prescribing these drugs should be considered when initiating them as the untoward effects may not be reversed by withdrawing them later down the line.
Sertraline
View adult BNF View SPC online  Track Changes
First Choice
Green
Higher cost than citalopram.
The cost of sertraline has increased significantly due to fluctuating supply problems. Consider citalopram as first line in new patients unless inappropriate e.g. patients with QT prolongation. 
Citalopram
View adult BNF View SPC online  Track Changes
First Choice
Green
Cost effective choice in patients where QT interval prolongation is not an issue (see MHRA advice below for detail) Maximum daily dose 40 mg for adults; 20 mg for patients older than 65 years; and 20 mg for those with hepatic impairment.
Also licensed for panic disorder 
Fluoxetine
View adult BNF View SPC online  Track Changes
Second Choice
Green
 
   
Mirtazapine
View adult BNF View SPC online  Track Changes
Second Choice
Green
 
   
Agomelatine
View adult BNF View SPC online  Track Changes
Formulary
Amber SCA
For depression, in line with SCA 
Link  SCA: Agomelatine for major depressive dissorder
   
Lofepramine
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Green
If a tricyclic is considered appropriate. 
   
Paroxetine
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Green
Specialist use for the treatment of OCD 
   
Venlafaxine
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Green
Third line only. Please note that venlafaxine twice daily tablets should be considered first as they have a lower cost acquisition than Sustained Release once daily preparations.
For doses >300mg traffic light status is Amber  
Link  SCA: Venlafaxine - for prescribing doses over 300mg daily.
   
Clomipramine
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber Simple
For initiation by or on the advice of a specialist in psychiatry. For OCD only in line with NICE CG 31. Not recommended as an initial choice for non specialists. 
   
Mianserin
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber Simple
As an option a)If the patient is on specific concurrent medication likely to interact with usual choices. b)In resistant depression as augmentation therapy. See NICE guidance below. For initiation by or on the advice of a specialist in psychiatry.
 
Link  NICE CG 91: Depression in patients with a chronic physical health problem
Link  SCA: Mianserin
   
Moclobemide
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber Simple
Reversible monoamine-oxidase inhibitor (RIMA)
For initiation by or on the advice of a specialist in psychiatry.
Not recommended as an initial choice for non specialists.
 
   
Phenelzine
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber Simple
For initiation by or on the advice of a specialist in psychiatry. Option in PTSD 
   
Escitalopram
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted Green Traffic Light for treatment resistant depression and generalised anxiety disorder only

Green Traffic Light All indications except treatment resistant depression and generalised anxiety disorder


The MHRA has advised that escitalopram is associated with dose-dependent QT interval prolongation and should not be used in those with: congenital long QT syndrome; known pre-existing QT interval prolongation; or in combination with other medicines that prolong the QT interval. ECG measurements should be considered for patients with cardiac disease, and electrolyte disturbances should be corrected before starting treatment.
For escitalopram, the maximum daily dose for patients older than 65 years is now reduced to 10 mg/day. 
Link  MHRA Advice: Citalopram and escitalopram: QT interval prolongation—new maximum daily dose restrictions (including in elderly patients), contraindications, and warnings
   
Vortioxetine
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber Simple
Third line only


Date of entry of decision to formulary: February 2016 
   
04.04  Expand sub section  CNS stimulants and other drugs used for attention deficit hyperactivity disorder
Methylphenidate
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber SCA
Specialist paediatric initiation only.
Prescribe methylphenidate modified release by brand; different brands have specific release characteristics which may be tailored to individual patient circumstances (Equasym XL, Medikinet XL, Concerta XL).
Methylphenidate immediate release preparations are interchangeable and can be prescribed generically.  
Atomoxetine
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber SCA
Specialist paediatric initiation only. 
   
Dexamfetamine
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber SCA
Specialist paediatric initiation only. 
   
Lisdexamfetamine mesilate
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber SCA
Lisdexamfetamine is a Schedule 2 controlled drug
For ADHD refractory to methyphenidate. Specialist initiation only.
May also be used as an alternative to a "specials" preparation in patients unable to swallow solid dosage forms. (Off-label use if not refractory to methylphenidate)
The capsule can be opened and the entire contents dissolved in a glass of water. See SPC for further detail

 
   
Guanfacine
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber SCA
Specialist paediatric initiation only 
Link  SCA: ADHD in Children and Adolescents
   
Modafinil (Provigil®)
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber SCA
For treatment of narcolepsy only. Restricted to initiation by Specialist at Sleep Clinic  
Link  MHRA advice: Modafinil restriction to narcolepsy
Link  SCA: Modafinil for narcolepsy
   
04.05  Expand sub section  Drugs used in the treatment of obesity to top
 note  Obesity

  • Obesity is a risk factor for cardiovascular disease, diabetes, gallstones and osteoarthritis. The simplest and most effective method to lose unwanted weight is to consume fewer calories than are required to maintain current body weight. If an increase in physical activity is also combined with this approach, weight loss will be accelerated.
  • Drugs to increase weight loss should only be prescribed for individuals with a BMI of 30 kg/m2 or above and in whom a 3-month program including supervised diet, exercise and behaviour modification has failed to produce a reasonable weight loss.
  • If other medical risk factors are present (e.g. coronary heart disease, diabetes hypertension or sleep apnoea) it may be appropriate to introduce drug treatment at a BMI of 28 kg/m2 or greater.
Orlistat
View adult BNF View SPC online  Track Changes
Formulary
Green
Prescribe in line with NICE guidance.
Treatment with orlistat should be discontinued after 12 weeks if less than 5% of the body weight has been lost since the start of therapy.
 
Link  MHRA Advice: Orlistat: theoretical interaction with antiretroviral HIV medicines
   
04.06  Expand sub section  Drugs used in nausea and vertigo
 note 
  • Anti-emetics should only be prescribed when the cause of nausea or vomiting is known. If an anti-emetic is indicated, the drug should be chosen according to the aetiology.
  • Metoclopramide, prochlorperazine and haloperidol may cause extrapyramidal side effects, particularly in children and young adults. Domperidone is much less likely to cause these. Acute dystonias may be treated with procyclidine injection.
  • Sickness in pregnancy is best left untreated unless severe. Specialist advice should be sought before using an antiemetic in pregnancy.
  • Dexamethasone, Lorazepam and Levomepromazine are also used in nausea and vomiting associated with cytotoxic therapy.
  • Levomepromazine tablets are available as 25mg strength and also as a 6mg (unlicensed) strength to assist administration of smaller doses. Take care when prescribing that the correct strength is specified.
  • For further information on prescribing of anti-emetics in malignancy see 'Nausea and Vomiting' section (page 18) of Leicestershire guidance.
  • Hyoscine patches are occasionally used by specialists in palliative care or neurology for treatment of hypersalivation.
  • For further information regarding the use of anti-emetics in palliative care please see the LOROS guidance on symptom management.
Metoclopramide Hydrochloride
View adult BNF View SPC online  Track Changes
First Choice
Green
For symptoms associated with gastro-duodenal, hepatic and biliary disease because it acts directly on the gastro-intestinal tract.
Can cause dystonic reactions in young adults.
The MHRA have advised that the maximum dose in adults in 24 hours is 30mg. The usual dose is 10mg up to three times a day. Treatment should be limited to a maximum of 5 days. 
Prochlorperazine
View adult BNF View SPC online  Track Changes
First Choice
Green
Nausea associated with vertigo.
Avoid in the elderly during very hot or very cold weather (risk of hyper- or hypothermia)
 
Domperidone
View adult BNF View SPC online  Track Changes
Second Choice
Green
Acts at the chemoreceptor trigger zone; used for the relief of nausea and vomiting associated with cytotoxic therapy. It is less likely to cause central effects (e.g. sedation and extrapyramidal reactions) because it does not readily cross the blood-brain barrier. It is preferred for patients with Parkinson’s disease or those with a high risk of dystonias.
Also has a place in the treatment of non-ulcer dyspepsia.
The MHRA has advised that there is a small risk of serious ventricular arrhythmia and sudden cardiac death with domperidone. See link below 
Link  MHRA Advice: Domperidone: risks of cardiac side effects— indication restricted to nausea and vomiting, new contraindications, and reduced dose and duration of use
Link  UKMI Advice: Domperidone: new restrictions in use
   
Cyclizine
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Green
If nausea or vomiting is unresponsive.
Cyclizine has antihistaminic and anticholinergic actions, which may be additive to the other agents listed. Sedative at higher doses.
 
   
Haloperidol
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Green
Nausea or vomiting induced by opioids in palliative care. There have been shortages recently of haloperidol and also of the alternatives recommended. Therefore check LMSG statement below for alternatives.

The statement does not apply to treatment of delirium on ITU at UHL. Relevant clinicians will receive appropriate guidance as required.  
Link  Leicestershire Guidance: Treatment of Nausea and Vomiting in Palliative Care
   
Cinnarizine + Dimenhydrinate  (Arlevert®)
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber Simple
For dizziness in Meniere's Disease use only when other medical therapies have failed 
Link  Leicestershire Evaluation: Arlevert® in Menieres
Link  Simple Amber List
   
Ondansetron
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Green

Green for nausea. Long term administration for chemotherapy or continuation for delayed emesis not recommended.
Melts remain restricted as they have significantly higher cost than tablets - "Films" preferred if unable to swallow tablets.
IV Monograph available through 'Injectable Medicines Guide' link on front page of INsite.
The new maximum single intravenous dose of ondansetron for the management of chemotherapy-induced nausea and vomiting (CINV) in adults is now 16 mg (infused over at least 15 minutes)- See MHRA advice via link below

 
Link  MHRA Advice: Ondansetron (Zofran): risk of QTc prolongation – important new intravenous dose restriction
   
Droperidol
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Red
Specialist anaesthetics use at UHL as a 3rd line option after cyclizine and ondansetron  
Link  Leicestershire Evaluation: Droperidol in PONV
   
04.07  Expand sub section  Analgesics
04.07.01  Expand sub section  Non-opioid analgesics and compound analgesic preparations
 note 
  • Paracetamol is usually adequate for mild pain. Regular doses are more effective than if presrcibed "when required".
  • With paracetamol, a dose reduction is necessary in adults with certain risk factors and/or low body weight.
  • Non-steroidal anti-inflammatory drugs (NSAID) such as ibuprofen are an alternative first step in the analgesic ladder.
Paracetamol
View adult BNF View SPC online  Track Changes
First Choice
Green
Soluble paracetamol tablets should only be used if essential as they have a higher cost than standard preparations. They should be used with caution in patients with hypertension due to the sodium content. 
04.07.01  Expand sub section  Compound analgesic preparations
 note 
  • Doses of codeine >30mg are associated with a significant increase in undesirable effects.
  • In patients with chronic pain, if a weak opioid is required in addition to paracetamol, prescribe separately initially so that the dose can be titrated to optimum effect.
Paracetamol and codeine (Co-codamol® 8/500)
View adult BNF View SPC online  Track Changes
First Choice
Green
Caution: Abuse potential in prisons. 
Paracetamol and codeine (Co-codamol® 30/500)
View adult BNF View SPC online  Track Changes
First Choice
Green
Soluble tablets should only be used if essential as they have a higher acquisition cost than standard preparations.
Caution: Abuse potential in prisons. 
04.07.02  Expand sub section  Opioid analgesics to top
 note 
  • Opioids need to be used carefully. There have been a number of reports to the NPSA of deaths and severe harm due to the administration of high doses (30mg or greater) of diamorphine or morphine injections to opioid naive patients. Always check and confirm previous doses before prescribing and don’t increase doses by more than 50%.
  • A closely monitored trial is recommended before deciding whether a patient is prescribed opioids for long term use in chronic non palliative pain. Long and short term adverse effects need to be taken into consideration before initiating.  
  • 80% of patients taking opioids will experience at least one adverse effect which should be treated symptomatically. Tolerance to some side effects usually occurs within the first few days of initiating treatment eg nausea, vomiting, dizziness and somnolence but pruritis and constipation tend to persist. All opioids have the potential to cause physical dependence, tolerance and addiction.
  • Naloxone injection which can reverse opioids should be available in all clinical locations where opioid injections are used in case of overdose.
  • E-learning modules on pain management are available on the MHRA website and e-UHL for UHL staff
For advice on pain control in cancer or palliative pain of cancer origin or progressive, life limiting and near death conditions contact the Palliative Care Teams LRI ext. 7512 or 5414, LGH ext. 4680, GGH ext. 3540.
These numbers are converted into direct dial lines by prefixing with (0116) 258 xxxx
LOROS (0116) 231 8415.
The LOROS guidance provides information on symptom management at the end of life, including pain control
For advice on pain control in non palliative pain where the condition is not immediately life limiting use the following options.
Contact the Leicestershire Pain Service (0116) 258 5653 for advice.
Refer UHL inpatients via ICM to inpatient pain service.
Refer Primary care patients to Chronic Outpatient Pain Service
Codeine Phosphate
View adult BNF View SPC online  Track Changes
First Choice
Green
15mg and 30mg tablets.
Caution: Abuse potential in prisons. 
Dihydrocodeine Tartrate
View adult BNF View SPC online  Track Changes
First Choice
Green
Useful for patients who don’t respond to codeine or who take medicines that prevent codeine from working.
Dihydrocodeine syrup 10mg/5ml is available but should only be used if essential as it has a higher acquisition cost than the tablets.
 
Morphine
View adult BNF View SPC online  Track Changes
First Choice
Green
Schedule 2 Controlled Drug
 
Buprenorphine patches
View adult BNF View SPC online  Track Changes
Second Choice
Green
For patients with stable palliative pain and also in patients with stable chronic non palliative pain who can’t tolerate oral morphine. 
   
Diamorphine Hydrochloride (Injection)
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Green
Alternative if necessary to give a high dose of opioid via a syringe driver as more soluble than morphine.
Schedule 2 Controlled Drug
 
   
Fentanyl (Patches)
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Green
Expensive. Lowest strength patch equivalent to large equivalent dose of oral morphine.
Initiation restricted to patients with:
Stable palliative pain.
Established renal failure in accordance with UHL guidelines.
UHL patients with stable chronic non palliative pain on advice of UHL Pain Team.
Schedule 2 Controlled Drug
 
   
Methadone
View adult BNF View SPC online  Track Changes
Formulary
Amber Simple

Chronic pain with on-going advice from specialist services on dose reduction.

 
   
Oxycodone
View adult BNF View SPC online View childrens BNF  Track Changes
Restricted Drug Restricted
Green

Schedule 2 Controlled Drug   For palliative pain and chronic non-palliative pain on advice of UHL Pain Team.


Specify either immediate release or modified release on the prescription to avoid confusion between preparations. To avoid confusion, in primary care please specify brand on prescription. Preferred brands in primary care are Shortec and Longtec, which may be different to the choices used in secondary care. 

 

 
   
Oxycodone + naloxone (Targinact®)
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber Simple
Initiation restricted to recommendation of a UHL pain consultant or palliative care consultant for patients who are significantly affected by opiod-induced constipation in whom laxatives have not worked or produced unacceptable side effects.
Schedule 2 Controlled Drug 
Link  Simple Amber Medicines
   
Pethidine Hydrochloride
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Green
For use in obstetrics only as it is associated with less respiratory depression in the neonate than morphine.
Schedule 2 Controlled Drug
 
   
Tramadol
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Green
Schedule 3 Controlled drug (exempt from Safe Custody Regulations).
In chronic non palliative pain use only if weak opioids or NSAIDS have proved problematical or pain is uncontrolled. Avoid in elderly patients.
Use of tramadol should be limited to the lowest effective dose for the shortest possible time. Also used for post-operative patients orally or parenterally. Upon discharge, review dose/use and limit supply.
For prison use: Use with caution, treated with full CD regulations in this setting. Only prescribe as 24 hour preparation. 
   
Tapentadol SR
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber Simple
Supported for use by or under the guidance of pain clinic clinicians only for chronic pain in patients requiring opiates but not responding as expected to morphine. Immediate release preparation in acute pain not supported

Also supported for use in cancer pain for the same place in therapy as above. 
Link  Leicestershire Evaluation: Tapentadol SR in Cancer Pain
Link  Simple Amber List
   
04.07.03  Expand sub section  Neuropathic pain
 note  Algorithms for treatment of neuropathic pain, trigeminal neuralgia and post-herpetic pain are included in the guidance at the link below. Drugs available for use within these pathways include tricyclics, gabapentin (generic), pregabalin (prescribe as Lyrica for this indication), duloxetine, lidocaine plasters and capsaicin cream.  
Pregabalin can be prescribed twice daily compared to three times daily for gabapentin however this should make little difference to the majority of patients.  Prescribing pregabalin three times a day is very expensive.
Professionals prescribing pregabalin and gabapentin should be aware that these drugs can lead to dependence and may be misused or diverted.
04.07.04  Expand sub section  Antimigraine drugs
04.07.04.01  Expand sub section  Treatment of the acute migraine attack
 note 
  • New NICE guidance now recommends that combination treatment for acute migraine using a triptan plus an NSAID, or a triptan plus paracetamol are the most clinically and cost effective options for treatment of acute migraine offering a more rapid and prolonged benefit.
  • Oral sumatriptan has more evidence from randomised controlled trials to support its use than any other triptan although efficacy varies amongst individuals. Therefore prescribe triptans generically and start with the one with the lowest cost. If this is consistently ineffective, try one or more alternative triptans eg naratriptan, eletriptan, rizatriptan, frovatriptan and almotriptan. QIPP detail aid: TRIPTANS – choice of agent.
  • For women and girls with predictable menstrual-related migraine that does not respond adequately to standard acute treatment, consider treatment with zolmitriptan or frovatriptan on the days migraine is expected.
  • Giving an anti-emetic a few minutes before the analgesic can improve gastric motility and enhance absorption (even in the absence of nausea and vomiting) eg metoclopramide or domperidone. Prochlorperazine or domperidone suppositories are useful if vomiting has commenced.
  • If vomiting restricts oral triptan therapy despite an anti-emetic, zolmitriptan nasal spray is the preferred option as significantly more (30%) is absorbed through the nasal mucosa than sumatriptan nasal spray which is mostly absorbed in the GI tract. Oro- dispersible tablets dissolve on the tongue and are convenient to take but are absorbed in the GI tract and not the buccal mucosa.
  • A holistic approach should be adopted when treating migraine; lifestyle and behavioural triggers should be identified that increase the frequency of attacks resulting in over use of medication. This increases the risk of adverse effects and can also cause medication overuse headache. Information on prevention of over use headache can be found here.
  • Do not offer ergots or opioids for the acute treatment of migraine.
Sumatriptan (oral)
View adult BNF View SPC online  Track Changes
First Choice
Green
Prescribe generically. In trials, oral sumatriptan 50mg and 100mg strengths showed similar onset, analgesic efficacy and tolerability but the response to the 50mg strength was less consistent.  
Zolmitriptan (oral)
View adult BNF View SPC online  Track Changes
Second Choice
Green
Prescribe generically. 
   
Rizatriptan Wafers
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Green
Dissolves on the tongue without water, which is convenient to take and rapidly absorbed.
Due to high cost, restricted preparations should be reserved for occasions where oral administration is problematic.
 
   
Sumatriptan (nasal spray and injection)
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Green
Due to high cost, restricted preparations should be reserved for occasions where oral administration is problematic.
Nasal spray is less costly than injection.
 
   
Zolmitriptan (nasal spray)
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Green
Due to high cost, restricted preparations should be reserved for occasions where oral administration is problematic.
 
   
04.07.04.02  Expand sub section  Prophylaxis of migraine
 note 
  • Prophylaxis is recommended if attacks are frequent (one or more per fortnight).
  • Review need for continuing prophylaxis at 6 month intervals.
  • Current treatment with non formulary choices for prophylaxis may be continued in patients whose migraine is well controlled.
Propranolol immediate release
View adult BNF View SPC online  Track Changes
First Choice
Green
Avoid abrupt withdrawal. 
Topiramate
View adult BNF View SPC online  Track Changes
Second Choice
Green
More expensive than propranolol. Teratogenic-avoid in women of child bearing age. 
   
Amitriptyline
View adult BNF View SPC online  Track Changes
Formulary
Green
Useful for mixed presentation headache.
Nortripyline is a less sedative alternative used by local specialists although there is no formal evidence of efficacy; it is more costly than amitriptyline.
Use with caution in the prison environment. 
   
Botulinum Toxin Type A
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Red
High Cost Medicine
Botulinum Toxin Type A in line with the NICE TA260
A request form should be completed, see link below.

Date of entry of decision to Formulary: September 2012
 
Link  Botulinum Toxin Order Form
Link  NICE TA 260: Botulinum toxin type A for the prevention of headaches in adults with chronic migraine.
   
Flunarizine (Sibelium®)
 Track Changes
Unlicensed Drug Unlicensed
Red
Unlicensed medication for prophylaxis of migraine in adults. For initiation by secondary care specialist only.
To be used once other medications have been unsuccessful  
   
04.08  Expand sub section  Antiepileptics to top
04.08.01  Expand sub section  Control of epilepsy
 note 
    • Epilepsy can be described as idiopathic (or primary) generalised epilepsy (tonic-clonic convulsions, typical absences, myoclonic and atonic seizures), or focal (partial) epilepsy with or without secondary generalisation.
    • Anti-epileptic drugs (AED) therapy should be initiated on the recommendation of a specialist once the diagnosis has been confirmed.
    • Whenever possible treatment should involve a single AED. A second drug for a single seizure type should be considered only when the first choice drug is ineffective despite adequate plasma concentrations. The first drug should then be withdrawn slowly.
    • Patients taking phenytoin, carbamazepine, phenobarbital or primidone should be stabilised on one particular brand or generic and this should be quoted on all prescriptions and correspondence. See MHRA guidance on substitution of brands of all antiepileptic drugs.
    • Therapeutic monitoring is not routinely recommended but may be useful for monitoring in special situations or in selected patients. Plasma concentration measurements for sodium valproate do not correlate well with therapeutic effect and thus may not be useful.
    • Long term use of carbamazepine, phenytoin, primidone and sodium valproate is associated with decreased bone mineral density. Monitoring is necessary see Leicestershire Guidance - Antiepileptics and Bone Mineral Density
    • Please be aware of MHRA advice on Valproate. Valproate must no longer be used in any woman or girl able to have children unless she has a pregnancy prevention programme in place. No woman or girl should stop taking valproate without first discussing it with their doctor.
    • Care should be taken when prescribing all AEDs for women and girls of reproductive age due to a possible increased risk of birth defects. Referral to a specialist is necessary if considering pregnancy. Levetiracetam and lamotrigine are considered to have a lower teratogenic risk. Folic acid 5 mg per day should be prescribed before any possibility of pregnancy.
    • Hormonal contraception may affect or be affected by AEDs.

 

Lamotrigine
View adult BNF View SPC online  Track Changes
Formulary First line for focal (partial) epilepsy and alternative to sodium valproate for idiopathic generalised epilepsy; may exacerbate myoclonic seizures.
Lamotrigine is generally well tolerated but use has been associated with serious blood disorders and skin reactions. Initiate slowly.
 
   
Sodium Valproate
View adult BNF View SPC online  Track Changes
Formulary

First line for all types of idiopathic generalised epilepsy.
Valproate must no longer be used in any woman or girl able to have children unless she has a pregnancy prevention programme in place. Please use resources below to ensure effective counselling and selection of patients. 

No woman or girl should stop taking valproate without first discussing it with their doctor.

 
Link  Drug Safety Update: Valproate medicines (Epilim▼, Depakote▼)
Link  MHRA Guidance: Valproate use by women and girls
Link  Leicestershire Guidance: Valproate Advice Following MHRA Alert 24th April 2018
Link  Resources to Use: Booklet for Healthcare Professionals
Link  Resources to Use: Card to give to patients
Link  Resources to Use: Consultation Checklist
Link  Resources to Use: Guide to give to patients
Link  Topiramate and Valproate Flow Chart
   
Levetiracetam
View adult BNF View SPC online  Track Changes
Formulary Alternative in focal partial epilepsy and idiopathic generalised epilepsy. Levetiracetam has a different mode of action to lamotrigine and carbamazepine.

Intravenous preparation is classified as Red on the Leicestershire traffic lights. 
   
Everolimus (Votubia)
View adult BNF View SPC online  Track Changes
Formulary
Red
NHS England
BlueTeq

Refractory focal onset seizures associated with tuberous sclerosis complex (ages 2 years and above) as per NHSE Clinical Commissioning Policy

Blueteq prior approval required before initiation
Implementation Date: September 2019

 
Link  NHSE Clinical Commissioning Policy: Everolimus for refractory focal onset seizures associated with tuberous sclerosis complex (ages 2 years and above)
   
Carbamazepine
View adult BNF View SPC online  Track Changes
Formulary Alternative for focal (partial) epilepsy and useful if rapid titration is required but is generally less well tolerated. 
   
Ethosuximide
View adult BNF View SPC online  Track Changes
Formulary Alternative to sodium valproate for typical absence seizures. 
   
Phenytoin
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted 3rd line drug due to long term side effects.
Also indicated in the management of seizure activity following brain injury. 
   
Clobazam
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted  
   
Clonazepam
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted  
   
Gabapentin
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted

As of 1st April 2019, gabapentin will become a schedule 3 controlled drug. Gabapentin will be subject to the prescribing requirements for CDs, but not to the safe storage and register requirements.  

 
   
Oxcarbazepine
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted  
   
Phenobarbital
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted  
Link  Leicestershire statement on the prescription of phenobarbital liquid
   
Piracetam
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted  
   
Primidone
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted  
   
Tiagabine
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted  
   
Topiramate
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted

Please ensure that female patients under 50 years of age receive the necessary counselling as per LMSG flow chart

 
Link  Simple Amber: Topiramate
Link  Topiramate and Valproate Flow Chart
   
Pregabalin
View adult BNF View SPC online  Track Changes
Formulary

As of 1st April 2019, pregabalin will become a schedule 3 controlled drug. Pregabalin will be subject to the prescribing requirements for CDs, but not to the safe storage and register requirements.

Green Traffic Light when prescribed in line with neuropathic pain guidelines.


Amber Traffic Light simple amber when used for refractory epilepsy or generalised anxiety disorder

 
Link  Leicestershire Guidance: Neuropathic pain
Link  MHRA Advice: Pregabalin, gabapentin and risk of abuse and dependence: new scheduling requirements from 1 April
   
Lacosamide
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber Simple
 
Link  Leicestershire Evaluation: Lacosamide in Epilepsy
   
Rufinamide
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber Simple
 
   
Zonisamide
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber Simple
 
   
Brivaracetam
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber Simple

Specialist initiation only. Third line alternative

 
Link  Leicestershire Evaluations: Brivaracetam in Epilepsy
   
Eslicarbazepine
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber Simple
 
Link  Leicestershire Evaluation: Eslicarbazepine in Epilepsy
   
Perampanel
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber Simple
 
Link  Leicestershire Evaluation: Perampanel in Epilepsy
   
Retigabine
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Red

Retigabine is due to be withdrawn in 2017. Existing patients to have therapy reviewed by a specialist and no new patients to start therapy with retigabine.

The MHRA have restricted retigabine to last-line use, after reports of pigment changes in ocular tissue, skin, lips or nails.

 
Link  Leicestershire Evaluation: Retigabine in Epilepsy
   
04.08.02  Expand sub section  Drugs used in status epilepticus
Phenytoin IV
View adult BNF View SPC online  Track Changes
First Choice
Red
 
Lorazepam IV
View adult BNF View SPC online  Track Changes
First Choice
Red
 
Diazepam (rectal solution)
View adult BNF View SPC online  Track Changes
Second Choice
Amber Simple
Alternative to lorazepam if there is no IV access.
Injection by intramuscular route and suppositories are unsuitable due to slow absorption and should not be used.
 
   
Midazolam
View adult BNF View SPC online  Track Changes
Second Choice
Amber Simple
IM or buccal midazolam can be given as an alternative to lorazepam if there is no IV access. This is an unlicensed indication.
A licensed product, Buccolam, is now available for treatment of prolonged, acute, convulsive seizures in infants, toddlers, children and adolescents (from 3 months to < 18 years) For infants between 3-6 months of age treatment should be in a hospital setting where monitoring is possible and resuscitation equipment is available. 
Link  Simple Amber List
   
04.09  Expand sub section  Drugs used in parkinsonism and related disorders
04.09.01  Expand sub section  Dopaminergic drugs used in Parkinsons disease
 note 
  • All for specialist recommendation or initiation based on individual circumstances, local guidance and shared care agreements (SCA) listed below.
  • Excessive daytime sleepiness and sudden onset of sleep can occur with levodopa substitutes and dopamine receptor agonists.

 

Co-beneldopa
View adult BNF View SPC online  Track Changes
First Choice
Amber Simple
Cheaper than co-careldopa and should be tried first as there is no evidence of benefit of one over the other.  
Ropinirole
View adult BNF View SPC online  Track Changes
First Choice
Amber Simple
Simple amber for treatment of Parkinson’s disease and restless leg syndrome.
Ropinirole XL is available as a generic preparation. UHL will prescribe generically, primary care may specify a brand according to price.  
Pramipexole
View adult BNF View SPC online  Track Changes
First Choice
Amber SCA
Treatment of Parkinson’s disease and restless leg syndrome.
Modified release (MR)is much more expensive than intermediate release (IR). It is restricted to initiation only on consultant recommendation after a trial with the immediate release pramipexole has not been tolerated. Treatment should then be reviewed to establish additional benefits and if none are apparent then the patient should revert to the IR. Patients established on therapy who have demonstrated benefit on MR should not be switched to IR.  
Rasagiline
View adult BNF View SPC online  Track Changes
First Choice
Amber Simple
 
Selegiline
View adult BNF View SPC online  Track Changes
First Choice
Amber Simple
 
Co-careldopa
View adult BNF View SPC online  Track Changes
Second Choice
Amber Simple
More expensive than co-beneldopa. Reserve for patients who are currently stabilised on it and for patients who don’t respond or tolerate co-beneldopa.  
   
Rotigotine
View adult BNF View SPC online  Track Changes
Second Choice
Amber SCA
For treatment of Parkinson’s disease and restless leg syndrome.

Available as a first line choice for prescribing by specialists experienced in the treatment of Parkinson's disease (Neurologists and Geriatricians)  
Link  Leicestershire Evaluation: Rotigotine in Parkinsons
Link  Leicestershire Evaluation: Rotigotine in Restless Legs
Link  SCA: Pramipexole and Rotigotine
   
Amantadine
View adult BNF View SPC online  Track Changes
Formulary
Amber Simple
 
   
Safinamide (Xadago®)
View adult BNF View SPC online  Track Changes
Formulary
Amber Simple

For treatment of Parkinson’s disease
 

 
Link  Leicestershire Evaluation: Safinamide in Parkinsons Disease
   
Apomorphine
View adult BNF View SPC online  Track Changes
Formulary
Amber SCA
High Cost Medicine
For use in Parkinson's disease in line with shared care agreement  
Link  MHRA Advice: Apomorphine with domperidone: minimising risk of cardiac side effects
Link  SCA: Apomorphine in the treatment of Parkinson’s disease
   
04.09.01  Expand sub section  Catachol-O-methyltransferase inhibitors to top
Entacapone
View adult BNF View SPC online  Track Changes
Formulary
Amber Simple

Available as individual component and as combined product.
Stalevo and Stanek both contain same quantities of carbidopa/entacapone/levodopa.
UHL currently stocks Stanek

 
   
Tolcapone
View adult BNF View SPC online  Track Changes
Formulary
Red
 
   
04.09.02  Expand sub section  Antimuscarinic drugs used in parkinsonism
 note 
  • Anticholinergic agents may sometimes be of use in reducing mild tremor but have little effect on rigidity or bradykinesia. They are no longer routinely recommended in treatment of Parkinson’s disease but may be used in selected patients under specialist advice. 
  • Anticholinergic agents can reduce the severity of drug induced parkinsonian symptoms. Akathisia does not usually respond well and tardive dyskinesias may be made worse
  • Prophylactic use with antipsychotics is not recommended. Treatment may be started if symptoms occur but should be reviewed every 3 months for continuing need.
  • Use with caution in elderly patients because they tend to cause mental confusion.
  • Cumulative anticholinergic medication use  has been shown to be associated with an increased risk for dementia. The long-term impact of prescribing these drugs should be considered when initiating them as the untoward effects may not be reversed by withdrawing them later down the line.


 

Procyclidine Hydrochloride
View adult BNF View SPC online  Track Changes
First Choice
Green
Drug induced parkinsonian symptoms.
Injection acts quickly and is effective in relieving acute dystonic reactions caused by dopamine- blocking agents including antipsychotics and metoclopramide.
 
Trihexyphenidyl (Benzhexol)
View adult BNF View SPC online  Track Changes
Second Choice
Green
 
   
04.09.03  Expand sub section  Drugs used in essential tremor, chorea, tics, and related disorders
Botulinum Toxin Type A  (Botox®/ Xeomin® )
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Red
High Cost Medicine

Supported in line with CCG Commissioning policy. Please ensure correct brand is prescribed as per CCG policy. 
Dysport® should be reserved for use in a) ophthalmology for use in extra ocular muscles b)patients already on therapy who had previously not responded to Botox®

NOT supported for chronic constipation in children

 
Link  Leicestershire Evaluation: Botulinum (Xeomin®)
Link  Leicestershire Guidance: Botulinum Toxin Commissioning Policy
   
Botulinum Toxin Type B ( Neurobloc® )
View adult BNF View SPC online View childrens BNF  Track Changes
Restricted Drug Restricted
Red
Neurology use only  
   
Riluzole (Rilutek®)
View adult BNF View SPC online  Track Changes
Formulary
Amber SCA
High Cost Medicine
 
Link  SCA: Riluzole (Rilutek®)in the treatment of Amylotrophic Lateral Sclerosis form of Motor Neurone Disease
   
04.10  Expand sub section  Drugs used in substance dependence
04.10  Expand sub section  Alcohol dependence
 note  Acamprosate or oral naltrexone may be initiated by specialists for maintenance treatment to prevent relapse after successful withdrawal from alcohol.  Both are classed as simple amber on the Leicestershire Traffic Light system so GPs can continue prescribing in primary care.  There is no requirement for a shared care agreement to be in place.
Acamprosate
View adult BNF View SPC online  Track Changes
Formulary
Amber Simple
Alcohol dependance 
   
04.10  Expand sub section  Cigarette smoking to top
 note 

Smoking Cessation- Prescribing Points

  • Smoking remains the biggest preventable cause of ill-health and premature death and the biggest driver of health inequalities particularly cancer, coronary heart disease and respiratory disease.
  • All patients, wherever they are, who wish to quit smoking can be referred to the Leicestershire NHS STOP! Smoking Service.  
  • Behavioural therapy should always be provided alongside pharmacotherapy either as direct provision or by the STOP! Smoking Service, as it significantly increases the chance of quitting successfully.
  • Most smokers need to make multiple attempts to quite before achieving long-term success.Treatment should be available for more than one episode providing patients are adequately motivated to attempt to stop smoking again.
  • Appropriate governance mechanisms should be in place to provide comprehensive advice on treatment, monitor use, agree quit dates and a plan of ongoing support at the end of treatment.
  • Smoking is not allowed on secondary care premises.
  • Smoking cessation medications should be chosen according to patient specific requirements. Consider patient preference, motivation, cigarettes smoked per day, the time to the first cigarette of the day, desired speed of nicotine delivery, ability to adjust and titrate nicotine dose, tolerance for side effects, interactions and ease of use.  In more dependent smokers a combination of short and long acting NRT should be considered to relieve craving.
  • NRT can be prescribed for in-patients over the age of 12 years for the short term management of craving and withdrawal symptoms. 
  • All in-patients who smoke should be encouraged to agree to referral to STOP! Smoking Service. In patients unwilling to be referred for smoking cessation NRT can be offered for temporary abstinence or to allow a reduction in smoking in line with NICE PH45 Tobacco: harm reduction approaches to smoking.
  • Smoking cessation can affect levels of medication and dose adjustment may be necessary e.g. clozapine.  Further information and advice can be obtained from the Medicines Information Service on 0116 258 6491.
  • The risks and benefits of NRT should be discussed with pregnant women who smoke, particularly those who do not wish to accept the offer of help from the NHS Stop Smoking Service. If a pregnant woman is unable to give up without pharmacological therapy the risks of NRT are lower than those of smoking tobacco  Pregnant women using nicotine patches should be advised to remove them before going to bed (use for 16 hours per day).
Nicotine Replacement Therapy
View adult BNF View SPC online  Track Changes
Formulary
Green
Long-Acting:
≥ 10 cigarettes per day – NiQuitin Patch 21mg/24 hours applied daily
< 10 cigarettes per day – NiQuitin Patch 14mg/24 hours applied daily
In pregnant women recommend removing for 8 hours over night

Short-Acting:
  • NiQuitin Mini Lozenge 4mg
    One lozenge dissolved in the mouth whenever there is an urge to smoke (maximum 15 lozenges per 24 hours)
  • NiQuitin Strips 2.5mg Oral Film
    One strip to be dissolved in the mouth every 1-2 hours when there is an urge to smoke (maximum 15 strips per 24 hours)
  • Nicorette Inhalator 15mg
    Use whenever there is an urge to smoke (maximum 6 cartridges per day equivalent to approximately 48 x 5 minute sessions)
    Caution may be restricted in the prison environment.
  • Nicorette Quickmist 1mg/spray Mouthspray
    Use 1-2 sprays whenever there is an urge to smoke (maximum 4 sprays per hour and 64 sprays per 24 hours)

  • Full range available through the STOP! Clinics and primary care prescribers. Also available from community pharmacists under an enhanced service agreement .
     
       
    Bupropion Hydrochloride
    View adult BNF View SPC online  Track Changes
    Formulary
    Green
    Only available in primary care and STOP clinics
    The mode of action of bupropion in smoking cessation is unclear but may involve an effect on noradrenaline and dopamine neurotransmission. It should not be used in patients with a history of seizures, acute alcohol or benzodiazepine withdrawal, hepatic cirrhosis, CNS tumour, eating disorders or bipolar disorder.
     
       
    Varenicline
    View adult BNF View SPC online  Track Changes
    Formulary
    Green
    Only available in primary care and STOP clinics.
    Varenicline is a selective nicotine receptor partial antagonist and is currently extensively monitored by the MHRA for suicidal behaviour. If suicidal thoughts, depressed mood or agitiation develop, medical advice should be sought promptly and treatment discontinued. Patients with a history of psychiatric illness should not be prescribed varenicline.
     
       
    04.10  Expand sub section  Opioid dependence
     note  Naltrexone may be initiated by specialists for maintenance treatment to help prevent relapse to opioid dependence.   This is classed as simple amber on the Leicestershire traffic light system so GPs may continue to prescribe without the need for a shared care agreement.
    04.10.01  Expand sub section  Alcohol dependence
    Disulfiram
    View adult BNF View SPC online  Track Changes
    Formulary
    Amber Simple
     
    Link  Simple Amber: Disulfiram
       
    Nalmefene
    View adult BNF View SPC online  Track Changes
    Restricted Drug Restricted
    Green
    For use in line with NICE TA 325

    Date decision added to Formulary: February 2015 
    Link  NICE TA 325: Nalmefene for reducing alcohol consumption in people with alcohol dependence
       
    04.10.02  Expand sub section  Nicotine dependence
    04.10.03  Expand sub section  Opioid dependence
    04.10.03  Expand sub section  Opioid substitution therapy to top
    04.10.03  Expand sub section  Adjunctive therapy and symptomatic treatment
    04.10.03  Expand sub section  Opioid-receptor antagonists
    04.11  Expand sub section  Drugs for dementia
     note 

    Donepezil is the first line choice.  The decision to use other cholinesterase inhibitors is based on consideration of individual patient factors.  Donepezil, rivastigmine and galantamine are recommended as options for managing mild to moderate disease in line with NICE TA 217.  Memantine is indicated for moderate disease if intolerance to or medical contraindication to AChE or severe Alzheimer's.

    Donepezil
    View adult BNF View SPC online  Track Changes
    First Choice
    Amber Simple
     
    Rivastigmine
    View adult BNF View SPC online  Track Changes
    Formulary
    Amber Simple
     
       
    Memantine
    View adult BNF View SPC online  Track Changes
    Restricted Drug Restricted
    Amber Simple
     
       
    Galantamine
    View adult BNF View SPC online  Track Changes
    Restricted Drug Restricted
    Red
    Currently supplied by LPT 
       
     ....
     Non Formulary Items
    Brexpiprazole

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Black

    LPT prescribing group have reviewed and found no significant advantages over existing formulary products

     
    Buprenorphine prolonged release injection  (Buvidal®)

    View adult BNF View SPC online Track Changes
    Non Formulary
    Black

    Not yet reviewed by TAS. Patients may be started by Turning point as part of a pilot scheme. Buvidal should not be initiated by UHL or LPT. If patients on established therapy are admitted to UHL, contact turning point for advice. 

    NICE Evidence summary

     
    Cannabis oil and cannabis extracts

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Black

    This applies to all cannabis extracts, cannabis oil and cannabinols or cannabinol derivatives. Not reviewed in Leicestershire

    Epidiolex is not currently available in LLR - pending TAS review in March/April 2019

    Link  Home Office: Drug Licensing Factsheet- Cannabis, CBD and other cannabinoids
     
    Cariprazine

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Black
     
    Dolasetron Mesilate

    View adult BNF View SPC online Track Changes
    Non Formulary
    Black
    Link  Leicestershire Evaluation: Dolasetron in PONV
     
    Dosulepin

    View adult BNF View SPC online Track Changes
    Non Formulary
     
    Erenumab  (Aimovig®)

    View adult BNF View SPC online Track Changes
    Non Formulary
    Black

    Awaiting NICE TA publication

     
    Fentanyl buccal tablets  (Effentora buccal®)

    View adult BNF View SPC online Track Changes
    Non Formulary
    Black

    Not yet reviewed

     
    Fremanezumab  (Ajovy®)

    View adult BNF View SPC online Track Changes
    Non Formulary
    Black

    Awaiting NICE TA publication

     
    Galcanezumab  (Emgality®)

    View adult BNF View SPC online Track Changes
    Non Formulary
    Black

    Awaiting NICE TA publication

     
    Granisetron

    View adult BNF View SPC online Track Changes
    Non Formulary
    Black
     
    Melatonin

    View adult BNF View SPC online Track Changes
    Non Formulary
    Black

    Indication: - Primary insomnia in adults. Circadian asynchrony in elderly institutionalised patients. This status is currently under review - May 2018

     
    Melatonin (Colonis)  (1mg/ml oral solution)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Black

    Short-term treatment of jet-lag in adults

     
    Nabilone

    View adult BNF View SPC online Track Changes
    Non Formulary
    Black
     
    Naltrexone–bupropion  (Mysimba®)

    View adult BNF View SPC online Track Changes
    Non Formulary
    Black
    Not recommended by NICE TA 494
    Link  MHRA Advice: Naltrexone/bupropion (Mysimba): risk of adverse reactions that could affect ability to drive
     
    Nefopam

    View adult BNF View SPC online Track Changes
    Non Formulary
     
    Oxycodone + naloxone  (Targinact® Post Colorectal surgery)

    View adult BNF View SPC online Track Changes
    Non Formulary
    Black
    Not supported by TAS for use in pain management post colorectal surgery due to lack of evidence for use in this way.
    Link  Leicetershire Evaluation: Targinact in Pain Colorectal
     
    Quetiapine modified release (XL)

    View adult BNF View SPC online Track Changes
    Non Formulary
    Link  SCA: Atypical Antipsychotics
     
    Sodium valproate M/R capsules  (Episenta®)

    View adult BNF View SPC online Track Changes
    Non Formulary
    Black
    Link  Leicestershire Evaluation: Sodium Valproate Episenta® in Epilepsy
     
    Sufentanil

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Black
     
    Tramadol + dexketoprofen  (Skudexa®)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Black
    Drug not reviewed in Leicestershire
     
    Trifluoperazine

    View adult BNF View SPC online Track Changes
    Non Formulary
     
    Xonvea®  (Doxylamine & pyridoxine)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Black

    Not reviewed in Leicestershire

     
      
    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 children's BNF
    click to search medicines.org.uk
    Link to SPCs
    SMC
    Scottish Medicines Consortium
    High Cost Medicine
    High Cost Medicine
    Cancer Drugs Fund
    Cancer Drugs Fund
    NHSE
    NHS England
    Homecare
    Homecare
    CCG
    CCG

    Traffic Light Status Information

    Status Description

    Black

    Drugs not recommended for use in the Leicestershire Health Community because of lack of evidence of clinical effectiveness, cost prioritization or concerns over safety. All new drugs will be black until they have been through the appropriate approval process - then they will appear as a specific entry   

    Red

    Drugs which should be prescribed only by hospital specialists (clinical review by specialist as appropriate and annually as a minimum).  

    Amber SCA

    Drugs which would initially be prescribed by a hospital specialist and then by a GP where full agreement to share the care of each specific patient has been reached under a LMSG Shared Care Agreement (SCA). Specific patient monitoring or intervention required.   

    Amber Simple

    Drugs suitable to be initiated and prescribed in primary care only after specialist assessment and recommendation. A shared care agreement is not required.  

    Green Conditional

    Drugs for which GPs are able to take full responsibility for prescribing and monitoring subject to specified conditions e.g. prescribing in line with agreed LMSG guidance or able to demonstrate suitable competence see comments under individual entries.   

    Green

    Drugs for which GPs would normally take full responsibility for prescribing and monitoring. Drugs included in this list have been specifically considered by LMSG.   

    netFormulary