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 Formulary Chapter 4: Central nervous system - Full Chapter
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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
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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)
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First Choice
Green
Caution: Abuse potential in prisons. 
Paracetamol and codeine (Co-codamol® 30/500)
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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
 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
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First Choice
Green
15mg and 30mg tablets.
Caution: Abuse potential in prisons. 
Dihydrocodeine Tartrate
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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
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First Choice
Green
Schedule 2 Controlled Drug
 
Buprenorphine patches
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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)
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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)
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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
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Formulary
Amber Simple

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

 
   
Oxycodone
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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®)
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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
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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
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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
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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 to top
 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)
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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)
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Second Choice
Green
Prescribe generically. 
   
Rizatriptan Wafers
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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)
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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)
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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
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First Choice
Green
Avoid abrupt withdrawal. 
Topiramate
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Second Choice
Green
More expensive than propranolol. Teratogenic-avoid in women of child bearing age. 
   
Amitriptyline
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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
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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  
   
 ....
 Non Formulary Items
Buprenorphine prolonged release injection  (Buvidal®)

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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

 
Erenumab  (Aimovig®)

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Non Formulary
Black

Awaiting NICE TA publication

 
Fentanyl buccal tablets  (Effentora buccal®)

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Non Formulary
Black

Not yet reviewed

 
Fremanezumab  (Ajovy®)

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Non Formulary
Black

Awaiting NICE TA publication

 
Galcanezumab  (Emgality®)

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Non Formulary
Black

Awaiting NICE TA publication

 
Nefopam

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Non Formulary
 
Oxycodone + naloxone  (Targinact® Post Colorectal surgery)

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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
 
Sufentanil

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Non Formulary
Black
 
Tramadol + dexketoprofen  (Skudexa®)

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Non Formulary
Black
Drug 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.   

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