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 Formulary Chapter 4: Central nervous system - Full Chapter
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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
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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
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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
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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
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First Choice
Amber Simple
 
Selegiline
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First Choice
Amber Simple
 
Co-careldopa
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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
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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
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Formulary
Amber Simple
 
   
Safinamide (Xadago®)
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Formulary
Amber Simple

For treatment of Parkinson’s disease
 

 
Link  Leicestershire Evaluation: Safinamide in Parkinsons Disease
   
Apomorphine
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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
Entacapone
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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
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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
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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)
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Second Choice
Green
 
   
04.09.03  Expand sub section  Drugs used in essential tremor, chorea, tics, and related disorders to top
Botulinum Toxin Type A  (Botox®/ Xeomin® )
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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® )
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Restricted Drug Restricted
Red
Neurology use only  
   
Riluzole (Rilutek®)
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Formulary
Amber SCA
High Cost Medicine
 
Link  SCA: Riluzole (Rilutek®)in the treatment of Amylotrophic Lateral Sclerosis form of Motor Neurone Disease
   
 ....
 Non Formulary Items
  
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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