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 Formulary Chapter 4: Central nervous system - Full Chapter
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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
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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
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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
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Second Choice
Green
 
   
Mirtazapine
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Second Choice
Green
 
   
Agomelatine
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Formulary
Amber SCA
For depression, in line with SCA 
Link  SCA: Agomelatine for major depressive dissorder
   
Lofepramine
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Restricted Drug Restricted
Green
If a tricyclic is considered appropriate. 
   
Paroxetine
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Restricted Drug Restricted
Green
Specialist use for the treatment of OCD 
   
Venlafaxine
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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
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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
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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
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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
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Restricted Drug Restricted
Amber Simple
For initiation by or on the advice of a specialist in psychiatry. Option in PTSD 
   
Escitalopram
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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
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Restricted Drug Restricted
Amber Simple
Third line only


Date of entry of decision to formulary: February 2016 
   
 ....
 Non Formulary Items
Dosulepin

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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 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.   

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