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 Formulary Chapter 4: Central nervous system - Full Chapter
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04.01  Hypnotics and anxiolytics
 note 
  • 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 
  • Benzodiazepines have the potential to cause tolerance, dependence and withdrawal symptoms, and are liable to abuse


Prescribing in the elderly 
Hypnotics and anxiolytics (especially those with a long half life) should be avoided in the elderly due to the fact that they may cause drowsiness, confusion and ataxia leading to falls and fractures  

04.01.01  Hypnotics
 note 

First line options include non-pharmacological approaches including introducing 'sleep hygiene' measures and advice on relaxation techniques.

 

 

Melatonin  (Circadin®)
(M/R tablets)
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Restricted Drug Restricted
Amber SCG
  • CPFT / CCS / Primary Care: Restricted to initiation by Childrens Services only for continuation in Primary Care in line with the Shared Care Guideline. 
    • 'Off label' use of a licensed medicine. 
    • For patients who require an immediate release formulation Circadin 2mg MR tablets may be crushed and dispersed in water or milk or added to soft food like yoghurt (off-label). 
    • All other formulations are not routinely recommended. However, if a liquid preparation is required, and crushed Circadin 2mg MR tablets are not clinically acceptable, please see the LINK or contact the Medicines Optimisation Team for further support.
  • Prescribing for adult patients for any indication is not currently recommended in Primary Care. 
  • CUHFT: Restricted to short-term treatment of primary insomnia in paediatrics (HOSPITAL ONLY). 
  • NWAFT: Restricted to use in Medicine for Older People whilst in hospital or on TTO prescription (HOSPITAL ONLY). 
  • RPH: Restricted to Sleep Consultants for the management of Circadian Rhythm Insomnia (HOSPITAL ONLY). 

 

 
Melatonin (Slenyto®)
(Prolonged-Release Tablets )
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Restricted Drug Restricted
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  • Slenyto® is licensed only for children with the specific indication of Autism Spectrum Disorder or Smith-Magenis syndrome and this is the only cohort of patients that Slenyto® should be prescribed for. 
  • Prescribing for adult patients for any indication is not currently recommended in Primary Care. 
 
Link  Melatonin prescribing for Paediatric Patients (Formulation Choice)
   
04.01.01  Benzodiazepines
Controlled Drug Temazepam
(Tablet, Elixir,)
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First Choice
Green

  • Benzodiazepines initiated in hospital should be stopped on discharge unless clear documentation as to reason for continued need

  • Prescribe at the lowest effective dose for the shortest possible time

  • Within hospital setting: CD prescription and storage requirements apply for ALL temazepam products.

  • CPFT: 2nd line formulary choice after zopiclone or zolpidem

  • CUHFT: Do NOT issue zopiclone, other Z drugs or temazepam from Inpatient Pharmacy for individual inpatients.

    • At discharge, do NOT only issue zopiclone, z drugs or temazepam for individual patients unless one of the following applies:-
      1. admitted on zopiclone, other Z drugs or temazepam or
      2. on either Liaison Psychiatry or the substance misuse team recommendations or
      3. clear documented advice from DME consultant/registrar
      4. Multiople sclerosis patients on Campath therapy

      If 1,2,3 or 4 do not apply then liaise with prescriber with intention that discharge request for zopiclone, other Z drugs or temazepam is cancelled.

      Where any of 1, 2, 3 or 4 apply then issue at discharge with a maximum duration of 7 days.



 
Nitrazepam
(Tablet, Oral suspension)
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  • CPFT and CUHFT only: 3rd line on the advice of mental health team only. Long-acting so risk of accumulation. Avoid use in the elderly.

  • Non formulary at all other Trusts.

 
   
04.01.01  Zaleplon, Zolpidem and Zopiclone
Zopiclone
(Tablets)
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First Choice
Green

  • Has potential to cause tolerance, dependence and withdrawal symptoms, and is liable to abuse

  • Licensed for short-term use only (4 weeks).

  • Maximum daily dose (adults) is 7.5mg at night.

  • CPFT: First line for continuous sleep disturbance

  • CUHFT:Do NOT issue zopiclone, other Z drugs or temazepam from Inpatient Pharmacy for individual inpatients.

    • At discharge, do NOT only issue zopiclone, z drugs or temazepam for individual patients unless one of the following applies:-
      1. admitted on zopiclone, other Z drugs or temazepam or
      2. on either Liaison Psychiatry or the substance misuse team recommendations or
      3. clear documented advice from DME consultant/registrar
      4. Multiople sclerosis patients on Campath therapy

      If 1,2,3 or 4 do not apply then liaise with prescriber with intention that discharge request for zopiclone, other Z drugs or temazepam is cancelled.

      Where any of 1, 2, 3 or 4 apply then issue at discharge with a maximum duration of 7 days.



 
Zolpidem
(Tablet)
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Restricted Drug Restricted
Advice

  • CPFT only: First line for sleep onset insomnia

  • Has potential to cause tolerance, dependence and withdrawal symptoms and is liable to abuse

  • Licensed for short term use only (4 weeks)

  • Maximum daily dose (adults) is 10mg

  • Non-formulary at all other Trusts

 
Link  MHRA Drug Safety Update: Zolpidem - Risk of drowsiness and reduced driving ability
Link  MHRA: Drugs and Driving
Link  NICE TA77 : Zaleplon, zolpidem and zopiclone for the management of insomnia
   
04.01.01  Chloral and derivatives to top
Chloral Hydrate
(Solution, Suppositories View adult BNF View SPC online View childrens BNF  Track Changes
Restricted Drug Restricted
Red Hospital

 

  • CUHFT and NWAFT: Specialist initiation for paediatric use only.
  • Non-formulary at all other Trusts and in Primary Care.
  • Where a liquid preparation is clinically required for paediatric patients, Chloral Hydrate 500mg/5mL is the standardised liquid strength which should be prescribed in children (unlicensed unlicensed):
    • Using standardised strengths of unlicensed liquid medicines in children, will reduce the risk of errors being made in the doses given to children and prevent hospitalisation from accidental under and overdoses
    • See link below for further information.
 
Link  RCPCH and NPPG Position Statement 18-01: Using Standardised Strengths of Unlicensed Liquid Medicines in Children (April 2020)
   
04.01.01  Clomethiazole (Chlormethiazole)
04.01.01  Sodium oxybate
Controlled Drug Sodium Oxybate (Xyrem®)
(Oral solution)
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Restricted Drug Restricted
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High Cost Medicine

 




    • RPH: Specialist initiation by a Consultant Sleep Physician only in line with Shared Care Guideline for treatment of narcolepsy with cataplexy (adults

    • Non-formulary at all other Trusts

    • (NHS England commissioned for paeditarics in-line with Clinical Commissioning Policy)



 

 
Link  RPH SCG: Sodium Oxybate for narcolepsy with cataplexy
Link  Clinical Commissioning Policy: Sodium oxybate for symptom control of narcolepsy with cataplexy (children)
   
04.01.01  Pitolisant
Pitolisant (Wakix®)
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Restricted Drug Restricted
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  • RPH only: Restricted to initiation by a Consultant Sleep Physician in line with the Shared Care Guideline for patients (adults) with narcolepsy with or without cataplexy

  • Non-formulary at all other Trusts

 
Link  RPH SCG: Pitolisant - Narcolepsy with or without cataplexy
Link  NICE Evidence summary [ES8]: Pitolisant - Narcolepsy with or without cataplexy in adults
   
04.01.02  Anxiolytics
 note  Management of acute anxiety generally involves the use of a benzodiazepine. For chronic anxiety (of longer than 4 weeks duration) it may be appropriate to use antidepressants.

Acute anxiety state
  • Treatment with benzodiazepines should be limited to the use of the lowest possible dose for the shortest possible time
  • Beta blockers (propranolol) may be helpful in reducing palpitations and tremor in patients who suffer with predominantly somatic symptoms of anxiety
  • 04.01.02  Benzodiazepines to top
    Diazepam
    (Tablet, oral solution, oral suspension, rectal solution, injection, emulsion injection)
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    Formulary
    Green

     

    • Diazepam injection comes in two forms - solution (IM or IV) and emulsion Diazemuls® (IV only). Emulsion is preferred for IV as it is less irritant to the vein.
    • CPFT: lorazepam IM injection is used for rapid tranquillisation, as diazepam injection (both formulations) is non-formulary.
    • Injection formulations are hospital only.

     



     

     
    Link  CUHFT: Rapid tranquillisation in adults with disturbed or psychotic behaviour
    Link  Diazemuls emulsion SPC
    Link  Diazepam injection solution SPC
       
    Lorazepam
    (Tablet, Injection.)
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    Formulary
    Green

     

    • Tablets disperse in water if needed
    • Several brands of lorazepam tablets can be administered sublingually (unlicensed) - check with pharmacy for further information.
    • Store injection in fridge.
    • Dilute Ativan® UK brand with an equal volume of WFI or 0.9% NaCl before IM injection. Hospira and Baxter brands (unlicensed imports from US) should NOT be diluted before IM administration - see individual box leaflets.
    • NWAFT: Tablets are restricted to use in Palliative Care only.
    • RPH: 2nd line formulary option for the management of delerium (haloperidol is 1st line formulary choice)
    • CPFT: When used for rapid tranquillisation, lorazepam IM injection must not be given within 1 hour of unlicensed olanzapine IM injection

    October 2020 - Supply disruption of Lorazepam (Ativan®) 4mg/ml Solution for injection

    • Ativan® (lorazepam) 4mg/ml solution for injection will be out of stock from w/c 27th April until early December 2020.
    • The US product, lorazepam injection 2mg/ml, supplied in Carpuject™ single dose cartridges will be available to Trusts from early May 2020 on an ‘unlicensed’ basis.
    • CarpujectTM single dose cartridges can be considered bioequivalent to the UK brand Ativan® (lorazepam) 4mg/ml solution for injection and no dosing adjustments should be required, however there is a difference in concentration of lorazepam between the two presentations so care must be taken when calculating doses.
    • Carpuject™ cartridges must be used in combination with the Carpuject™ holder provided. Injection in cartridge is diluted with an equal volume of compatible solution for IV administration (IM injection is administered undiluted).
    • Ativan® (lorazepam) 4mg/ml solution for injection supplies will remain available for primary care customers throughout this period. 
    • See Supply Disruption Alert below for further information. 

     

     
    Link  CPFT Guideline for the pharmacological management of acute behavioural disturbance in in-patient wards
    Link  June 2020: Supply Disruption Alert - Lorazepam (Atrivan) 4mg/ml solution for injection (issued 28th April 2020)
    Link  Letters sent to healthcare professionals March 2020: Ativan 4mg/ml Solution for Injection (Lorazepam) - interim supply of Irish stock to mitigate supply disruption
       
    Oxazepam
    (Tablet)
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    Restricted Drug Restricted
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    • CPFT and CUHFT: For short term management of anxiety

    • Non- formulary at all other Trusts


     

     
       
    Chlordiazepoxide
    (Capsule)
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    Restricted Drug Restricted
    Amber No SCG

    • For use in alcohol withdrawal only


     

     
    Link  CPFT Alcohol Detoxification (Inpatient) Prescribing Guidelines
    Link  CUHFT Acute alcohol withdrawal
    Link  CUHFT Alcohol and substance misuse policy
    Link  CUHFT Care of the woman who misuses drugs and alcohol in pregnancy
    Link  NICE CG115: Alcohol-use disorders - diagnosis, assessment and management of harmful drinking and alcohol dependence
       
    Controlled Drug Midazolam
    (Injection)
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    Restricted Drug Restricted
    Red Hospital
    • CPFT only: Alternative injection for rapid tranquillisation if IM lorazepam unavailable. ‘Off-label’ use

     

     
    Link  CPFT Guideline for the pharmacological management of acute behavioural disturbance in in-patient wards
       
    04.01.02  Buspirone
    Buspirone Hydrochloride
    (Tablet)
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    Restricted Drug Restricted
    Amber No SCG

    • CPFT and CUHFT: For short term management of anxiety

    • Non-formulary at all other Trusts


     

     
       
    04.01.02  Meprobamate
    04.01.03  Barbiturates
    04.02  Drugs used in psychoses and related disorders
     note  A baseline electrocardiogram (ECG) is now recommended for all in-patients prior to receiving any antipsychotic drug (NICE CG82, March 2009) and is specified in the Summary of Product Characteristics for all haloperidol preparations.  An ECG should also be offered if physical examination shows specific cardiovascular risk (e.g. high blood pressure) or there is a personal history of cardiovascular disease (NICE CG82, March 2009).  It is recognised that carrying out a baseline ECG immediately prior to Rapid Tranquillisation is inappropriate, however, in settings where Rapid Tranquillisation is likely to be used, it is suggested that a baseline ECG is obtained on or soon after admission to the ward.
    04.02.01  Antipsychotic Drugs to top
     note 
    • All antipsychotics should be employed at the minimum effective doses possible, higher doses will increase the likelihood of side effects. An alternative antipsychotic should be considered rather than resorting to the use of higher than standard doses
    • For new onset psychosis seek specialist psychiatric advice.
    • Atypical and typical antipsychotics should not be prescribed concurrently except when switching from one to another  
    • For the treatment of antipsychotic induced extra-pyramidal side effects, refer to Section 4.9.2 
    • Oro-dispersible tablets and oral solutions are more expensive therefore reserved for poorly compliant patients or those with swallowing difficulties.
    • Antipsychotics should not routinely be prescribed to elderly patients with dementia to treat mild to moderate psychotic symptoms, because they are associated with a small increased risk of mortality and increased risk of stroke or transient ischaemic attack.
     
    Chlorpromazine
    (Tablet, Oral solution, Injection)
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    Restricted Drug Restricted
    Amber No SCG

     



    • Requires specialist initiation by mental health team

    • Use of intramuscular chlorpromazine is not recommended - can cause marked postural hypotension.

    • NWAFT and CUHFT: Tablets are on formulary for intractable hiccup  


     

     
       
    Flupentixol (Depixol®)
    (Tablet)
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    Restricted Drug Restricted
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    • Requires specialist initiation by mental health team

     
       
    Haloperidol
    (Capsule, tablet, oral liquid, injection)
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    Restricted Drug Restricted
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    • For mental health conditions - requires specialist initiation by mental health team
    • CPFT:

      • Baseline ECG is recommended prior to treatment with haloperidol (oral or IM) in all patients, especially the elderly and patients with a positive personal or family history of cardiac disease or abnormal findings on cardiac clinical examination.
      • Haloperidol may still be administered in an emergency situation, without a baseline ECG, if a member of medical staff decides that the benefit of administering the medicine outweighs the cardiac risk in an individual patient.
      • The need for further ECGs during treatment should be assessed on an individual basis
    • Injection : Now only licensed for IM administration. IV administration is unlicensed.
    • All Trusts and Primary Care: Can be used in palliative care (can be initiated in primary care)
    • RPH: 1st line treatment for delirium (Hospital only)

    November 2020: Supply issues with Haloperidol 5ml/5ml oral solution sugar free

    • Haloperidol 5mg/5ml oral solution sugar free is out of stock until March 2021.
    • Haloperidol (Haldol) 2 mg/ml oral solution and Haloperidol 500microgram, 1.5mg, 5mg and 10mg tablets remain available.
    • If no other licensed Haloperidol product is clinically acceptable, specialist importers can source unlicensed haloperidol 5mg/5ml sugar free oral solution. Lead times may vary.
    • See Medicine Supply Notification below (issued 28/10/2020) for further actions to be taken in relation to this shortage. 

    March 2020 - Discontinuation of Haloperidol (Serenace) 500 microgram capsules 

     

     
    Link  Haloperidol 5mg/5ml oral solution sugar free – Supply difficulties (DHSC)
    Link  CPFT Guideline for the pharmacological management of acute behavioural disturbance in in-patient wards
    Link  CUHFT Rapid tranquilisation guidelines in adults
       
    Levomepromazine (Nozinan®)
    (Tablet, Injection)
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    Restricted Drug Restricted
    Amber No SCG

     

    • For mental health conditions - requires specialist initiation by mental health team.
    • All Trusts and Primary Care: Can be used in palliative care (can be initiated in primary care).






     

     
       
    Sulpiride
    (Tablets, oral solution)
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    Restricted Drug Restricted
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    • Requires specialist initiation by mental health team.
    • Prescribe generically.

     

     
       
    Trifluoperazine
    (Tablet, Oral solution)
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    Restricted Drug Restricted
    Amber No SCG

     

    • Requires specialist initiation by mental health team.

     

    November 2020 - Supply issues with Trifluoperazine 1mg/5ml syrup

    • Trifluoperazine 1mg/5ml syrup is out of stock until April 2021.
    • Where patients have insufficient supplies, clinicians should review the ongoing need of patients and prescribe an alternative formulation in line with the Medicine Supply Notification (link below). 
     
    Link  Trifluoperazine 1mg/5ml syrup - Medicine Supply Notification (issued on the 10/11/2020)
       
    Zuclopenthixol (Clopixol®)
    (Tablet)
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    Restricted Drug Restricted
    Amber No SCG

    • For mental health indications - requires specialist initiation by mental health team

    • CUHFT: Formulary for Gauchers Disease (off-label) - Hospital Only


     

     
       
    Zuclopenthixol Acetate (Clopixol Acuphase®)
    (Injection)
    View adult BNF View SPC online  Track Changes
    Restricted Drug Restricted
    Red Hospital

    Do not confuse with zuclopenthixol decanoate the long-acting depot injection preparation.



    • Not for neuroleptic naive patients.

    • On advice from Mental Health/psychiatry only


     

     
       
    04.02.01  First-Generation Antipsychotic Drugs
    04.02.01  Second-Generation Antipsychotic Drugs
    Amisulpride
    (Tablet, oral solution)
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    Restricted Drug Restricted
    Amber No SCG

    • Requires specialist initiation by mental health team

     
       
    Aripiprazole
    (Tablets, orodispersible tablets, short acting injection, liquid)
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    Restricted Drug Restricted
    Amber No SCG

    • Requires specialist initiation by mental health team

     
    Link  CPFT Guideline for the pharmacological management of acute behavioural disturbance in in-patient wards
    Link  NICE TA213: Aripiprazole for the treatment of schizophrenia in people aged 15 -17 years
    Link  NICE TA292: Aripiprazole for treating moderate to severe manic episodes in adolescents with bipolar I disorder
       
    Olanzapine
    (Tablet, Orodispersible tablet)
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    Restricted Drug Restricted
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    • For mental health conditions - requires specialist initiation by mental health team
    • CUHFT: use in line with Trust guidelines on delirium and dementia in older patients.
    • RPH: For management of delirium in critical care.
    • NWAFT: Restricted to use in palliative care

    NeLM in-Focus review: metabolic adverse effects with atypical antipsychotics. Bottom line: Emerging data suggest that the risks of adverse metabolic effects, including hyperglycaemia, diabetes, weight gain and dyslipidaemia, are greater with olanzapine than other atypical antipsychotics (with the exception of clozapine).

     
    Link  CPFT Guideline for the pharmacological management of acute behavioural disturbance in in-patient wards
       
    Quetiapine
    (Immediate release (IR) tablet, modified release (MR) tablet, oral suspension)
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    Restricted Drug Restricted
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    • For mental health conditions - requires specialist initiation by mental health team

    • Immediate release (IR) tablets should be prescribed where possible

    • Modified release tablets are significantly more expensive and are restricted to where a patient experiences excessive sedation and/or hypotension on quetiapine IR,  OR if patient compliance is improved compared to twice daily dosing with quetiapine IR.

    • If a patient is discharged on a modified release preparation then the rationale for this should be communicated to the GP. NB Only the modified release tablets are licensed for the adjunctive treatment of major depression

    • In primary care Biquelle® XL is the preferred choices of quetiapine XL if clinically required.

    • CUHFT: Neurologist/DME consultants for management of drug induced psychoses in Parkinson's Disease patients (off-label).

    • NWAFT: Restricted to use in palliative care

    • RPH: Restricted to the management of delirium when haloperidol is contra-indicated

     
    Link  CPJPG Recommendations for Quetiapine XL
    Link  NICE Evidence summary ESUOM12 : Quetiapine for generalised anxiety disorder
       
    Risperidone
    (Tablet, orodispersible tablet, oral solution)
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    Restricted Drug Restricted
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      • For mental health conditions - Requires specialist initiation by mental health team, with the exception of low dose risperidone which can be initiated in primary care

     

      • CUHFT: Restricted to use in line with Trust guidelines on delirium and dementia in older patients

     

      • NWAFT: Restricted to use in palliative care

     

      • RPH: Restricted to the continuation of treatment initiated external to the Trust

     

      • Doses above 8-10mg daily may not increase therapeutic benefit but may result in extrapyramidal side effects.


    September 2020 - Discontinuation of Risperdal tablets 

    Janssen-Cilag are discontinuing all strengths of Risperdal film-coated tablets and oral solution from the UK market in September 2020.

    Risperidone tablets and oral solution remains available from a number of other generic suppliers.

     
    Link  CPFT Guideline for the pharmacological management of acute behavioural disturbance in in-patient wards
    Link  CUHFT: Prevention, diagnosis and management of delirium and dementia in older patients
       
    Clozapine (Denzapine®, Clozaril®, Zaponex®)
    (Tablet, oral suspension)
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    Restricted Drug Restricted
    Red Hospital

     

    • Initiation by consultant psychiatrist only.
    • Patients should receive the brand specific to the monitoring service with which they are registered.
    • CPFT brand of choice is DENZAPINE®
    • All patients must be registered with the Fulbourn Pharmacy or the Cavell Centre Pharmacy.
    • WARNING: Missed doses are particularly significant in someone taking Clozapine. Please contact your local CPFT pharmacy department (including the out of hours service if applicable) and the patient’s psychiatrist if you are aware of a patient that has missed doses of Clozapine.

     

     
    Link  MHRA drug safety update August 2020: Clozapine and other antipsychotics: monitoring blood concentrations for toxicity
    Link  CPFT clozapine information webpage
    Link  CPFT Clozapine Initiation and Prescribing Guidelines
    Link  Drug-induced hypersalivation – what treatment options are available? (UKMI Q&A)
    Link  MHRA Drug Safety Update October 2017: Clozapine - impairment of intestinal peristalsis
       
    Lurasidone (Latuda®)
    (Tablet)
    View adult BNF View SPC online  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CPFT: Formulary

    • Non-formulary at all other Trusts and in Primary Care


     

     
    Link  NICE Evidence summary ESNM48: Schizophrenia - Lurasidone
       
    Olanzapine
    (Injection)
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    Restricted Drug Restricted
    Red Hospital

    • CPFT: unlicensed unlicensed Short acting IM injection available for rapid tranquillisation.

    • Olanzapine IM injection must not be given within 1 hour of any parenteral benzodiazepine (including lorazepam IM injection and midazolam IM injection)

    • Non-formulary at all other Trusts and in Primary Care

     
    Link  CPFT Guideline for the pharmacological management of acute behavioural disturbance in in-patient wards
       
    04.02.02  Antipsychotic depot injections
    Aripiprazole (Abilify Maintena® )
    (Depot injection)
    View adult BNF View SPC online  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • Requires specialist initiation by mental health team

     
       
    Flupentixol Decanoate
    (Depot injection)
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    Restricted Drug Restricted
    Amber No SCG

    • Requires specialist initiation by mental health team


     

     
       
    Flupentixol Decanoate
    (Low volume depot injection)
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    Restricted Drug Restricted
    Amber No SCG

    • Requires specialist initiation by mental health team

    • 200mg/ml low volume injection is more expensive so reserve for higher dose prescriptions (>250mg).

     
       
    Fluphenazine Decanoate (Modecate®)
    (Depot injection)
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    Restricted Drug Restricted
    Amber No SCG

    Discontinuation of Fluphenazine decanoate (Modecate) injection (Sanofi)

    • Being discontinued by the end of 2018, therefore, not for initiation.
    • Prescribers should complete arrangements to transfer patients on Modecate to therapeutic alternatives under medical supervision. 



     

     
       
    Haloperidol (Haldol Decanoate®)
    (Depot injection)
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    Restricted Drug Restricted
    Amber No SCG

    • Requires specialist initiation by mental health team


     

     
       
    Paliperidone (Trevicta®)
    (Depot injection)
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    Restricted Drug Restricted
    Amber No SCG

    • Requires specialist initiation by mental health team

    • 3 monthly injection. Can be considered if the dose of Xeplion® is the same for at least 4 consecutive months.

     
       
    Paliperidone (Xeplion®)
    (Depot injection)
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    Restricted Drug Restricted
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    • Requires specialist initiation by mental health team

    • Xeplion® is a once monthly depot injection

    • Trevicta® 3 monthly injection available, if the dose of Xeplion® is the same for at least 4 consecutive months


     

     
       
    Risperidone (Risperdal Consta®)
    (Depot injection)
    View adult BNF View SPC online  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • Requires specialist initiation by mental health team

    • Store in a fridge.


     


     

     
       
    Zuclopenthixol Decanoate (Clopixol®)
    (Depot injection)
    View adult BNF View SPC online  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    Do not confuse with zuclopenthixol acetate (Clopixol Acuphase®). Packaging is very similar



    • Requires specialist initiation by mental health team

     
       
    04.02.03  Drugs used for mania and hypomania
     note 

    Aripiprazole, olanzapine, quetiapine and risperidone are licensed for acute mania. Aripiprazole, olanzapine and quetiapine are licensed for the prevention of recurrence of mania. Quetiapine is also licensed for bipolar depression and the modified release formulation as an add-on treatment of major depressive episodes in patients with Major Depressive Disorder (MDD) who have had sub-optimal response to antidepressant monotherapy. 

    Lamotrigine
    ((Bipolar disorder) (Tablets, Dispersible tablets)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • Requires specialist initiation by mental health team.

    • Licensed for the prevention of depressive episodes associated with bipolar disorder


     

     
    Link  CPFT Medicines Monitoring Guidelines
    Link  UKMI Q&A: Lamotrigine – is it safe to take while breastfeeding?
       
    Pregabalin
    (Anxiety (capsule, oral solution))
    View adult BNF View SPC online  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • Requires specialist initiation for mental health conditions: Restricted to second or third line use in GAD when SSRIs/SNRIs not tolerated or not effective.



    • Prescribe generically.



    • Prescribe twice daily (three times daily is also licensed but more expensive).


     


     


     

     
    Controlled Drug Schedule 3
    Link  MHRA Drug Safety Update April 2019: Pregabalin (Lyrica), gabapentin (Neurontin) and risk of abuse and dependence - new scheduling requirements from 1 April
    Link  NICE CG113: Generalised anxiety disorder and panic disorder in adults - management
    Link  PHE - Advice for prescribers on the risk of the misuse of pregabalin and gabapentin
       
    04.02.03  Benzodiazepines to top
    04.02.03  Carbamazepine
    Carbamazepine
    (Bipolar disorder) (Immediate release (IR) tablet, modified release (MR) tablet, oral suspension)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • Requires specialist initiation by mental health team

    • For prophylaxis of bipolar disorder unresponsive to lithium. Not recommended for acute mania.

    • Consider drug interactions.

    • Modified release (MR) tablets may help reduce incidence of dose-related side-effects.


     

     
    Link  CPFT Medicines Monitoring Guidelines
       
    04.02.03  Valproic acid
     note 

    Valproate should not be prescribed routinely for women of child-bearing potential.  If there is no alternative ensure the woman is using a robust method of contraception. 

    The equivalent amount of valproic acid in a Depakote 500mg and a sodium valproate 500mg tablet are 500mg and 433mg respectively.

    Sodium valproate
    (Mania) (EC tablet, MR tablet, crushable tablet, oral solution)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • Requires specialist initiation by mental health team

    • For this indication the preferred brand for sodium valproate MR is Episenta®

    • MHRA/CHM advice: Valproate is contraindicated in women and girls of childbearing potential unless conditions of the Pregnancy Prevention Programme are met 



     

     
    Link  March 2019: Stock availability of Valproate-containing products (Sanofi)
    Link  MHRA Drug Safety Update September 2018: Valproate Pregnancy Prevention Programme - actions required now from GPs, specialists, and dispensers
    Link  CPFT Medicines Monitoring Guidelines
    Link  MHRA Drug Safety Update April 2019: Valproate medicines and serious harms in pregnancy - new Annual Risk Acknowledgement Form and clinical guidance from professional bodies to support compliance with the Pregnancy Prevention Programme
    Link  MHRA Drug Safety Update February 2020: Valproate (Epilim▼, Depakote▼) pregnancy prevention programme - updated educational materials
    Link  MHRA Drug Safety Update May 2018: Valproate medicines (Epilim▼, Depakote▼) - Pregnancy Prevention Programme
    Link  Valproate Risk Materials
       
    Valproic Acid (Depakote®)
    (EC tablet)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

     

    • Requires specialist initiation by mental health team.
    • MHRA/CHM advice: Valproate is contraindicated in women and girls of childbearing potential unless conditions of the Pregnancy Prevention Programme are met. 
    • Licensed for the treatment of manic episodes associated with bipolar disorder.
    • Prescribe as “Depakote” to avoid confusion with sodium valproate.

    June 2020 - Supply issue with Depakote (valproate semisodium) 250mg g/r tablets

    • Depakote:
      • 250mg GR tablets are unavailable with further supplies expected w/c 6th July 2020. 
      • 500mg are available to order through AAH and Phoenix.  
    • Syonell (valproate semisodium) tablets:
      • 250mg GR tabs – Available via AAH, Alliance Healthcare and Phoenix.
      • 500mg GR tabs - Avaialble via AAH, Alliance Healthcare and Phoenix.
    • Belvo (valproate semisodium) tablets:
      • No stock available of either strength, their next delivery is due w/c 22nd June and stock should be available with wholesalers by the end of month (particularly the 250mg strength).
    • For actions to deal with this shortage see Medicine Supply Notification link below - only applies to the licensed use of valproate semisodium i.e. treatment of manic episode in bipolar disorder when lithium is contraindicated or not tolerated.
    • There is also a shortage of Convulex (valproic acid) which is the only licensed valproic acid treatment of generalised, partial or other eplepsy in children and adults. Patients who are prescribed Depakote for off-license use in epilepsy indications, advice should be sought from their epilepsy specialist responsible for their care. 

     

     
    Link  March 2019: Stock availability of Valproate-containing products (Sanofi)
    Link  MHRA Drug Safety Update September 2018: Valproate Pregnancy Prevention Programme - actions required now from GPs, specialists, and dispensers
    Link  April 2020: Medicine Supply Notification - Depakote 250mg and 500mg tablets (issued 28/02/2020)
    Link  CPFT Medicines Monitoring Guidelines
    Link  MHRA Drug Safety Update April 2019: Valproate medicines and serious harms in pregnancy - new Annual Risk Acknowledgement Form and clinical guidance from professional bodies to support compliance with the Pregnancy Prevention Programme
    Link  MHRA Drug Safety Update February 2020: Valproate (Epilim▼, Depakote▼) pregnancy prevention programme - updated educational materials
    Link  MHRA Drug Safety Update May 2018: Valproate medicines (Epilim▼, Depakote▼) - Pregnancy Prevention Programme
    Link  Valproate Risk Materials
       
    04.02.03  Lithium
     note 

    Please ensure prescribed by BRAND as brands are not interchangeable


    Lithium has a narrow therapeutic range (0.4-1.0mmol/l based on a blood sample taken 12 hours after the last dose).  Regular monitoring of lithium levels is essential.  Levels should initially be checked 5-7 days after starting lithium or after a change in dose or formulation and then weekly until stable.  Thereafter levels should be monitored at three monthly intervals.

    Follow Therapeutic Drug Monitoring guidelines.

    Check eGFR and thyroid function (TSH) at baseline and then 6-monthly.  An ECG is recommended before initiating lithium if there are risk factors for or existing cardiovascular disease.  Ensure patient is given a purple NPSA Lithium Therapy Information Pack.  For further information refer to Local Services Safer Lithium Therapy Policy and Procedures and Primary/Secondary Care Lithium Prescribing and Monitoring Guideline.

    Lithium Carbonate (Priadel®)
    (Modified release (MR) tablet)
    View adult BNF View SPC online View childrens BNF  Track Changes
    First Choice
    Amber SCG
    •  200mg MR tablet (5.4mmol Li+) + 400mg MR tablet (10.8mmol Li+)


    October 2020: Priadel stock availability

    • Essential Pharma has confirmed that the monthly quotas in place at AAH, Alliance & Phoenix will remain to ensure continued supply. The quotas refresh at the start of each month. 
    • If emergency stock above these quotas are required before quotas are refreshed (on the 1st of each month), pharmacies and dispensing practices are requested to contact their wholesalers’ customer services first. If wholesalers are out of stock pharmacies / dispensing practices can place emergency orders directly with Movianto UK:
    • SKU’s to quote when ordering:
      • Priadel 200mg Tablets – PRI200TUK
      • Priadel 400mg Tablets – PRI400TUK
      • Priadel Liquid - PRI150L
     
    Lithium Citrate (Li-Liquid®)
    (Oral solution)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

     

      • Requires specialist initiation by mental health team
      • A purple NPSA Lithium Therapy Information Pack should be given to patients on initiation of lithium treatment.
      • Oral solution 509mg (5.4mmol Li+) in 5ml and 1018mg (10.8mmol Li+) in 5ml.
      • Prescribe the liquid formulation as a twice daily dose to minimise peak plasma levels.
      • Due to the differences in bioavailability, contact either your pharmacy department or the CCG Medicines Optimisation Team for support if switching between oral formulations is required.



     

     
    Link  CPFT - Guidelines for the prescribing and monitoring of lithium treatment
    Link  Patient Safety Alert - Safer lithium therapy
    Link  Primary Care: Lithium Prescribing Support in Affective disorders in Adults
       
    Lithium Citrate (Priadel®)
    (Oral solution)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

     

      • Requires specialist initiation by mental health team
      • A purple NPSA Lithium Therapy Information Pack should be given to patients on initiation of lithium treatment.
      • Liquid 520mg (approx 5.4mmol Li+) in 5ml.
      • Prescribe the  liquid formulation as a twice daily dose to minimise peak plasma levels.
      • Due to the differences in bioavailability, contact either your pharmacy department or the CCG Medicines Optimisation Team for support if switching between oral formulations is required.

     

     
    Link  CPFT - Guidelines for the prescribing and monitoring of lithium treatment
    Link  Patient Safety Alert - Safer lithium therapy
    Link  Primary Care: Lithium Prescribing Support in Affective disorders in Adults
       
    04.03  Antidepressant drugs
     note  First line options are sertraline, citalopram and fluoxetine

    Discontinuation reactions (e.g. gastrointestinal symptoms, paraesthesia, sleep disturbances, giddiness, headache) can occur if antidepressants are stopped or withdrawn abruptly.  All antidepressants should be tapered over at least a four week period before stopping.  Fluoxetine may be stopped more quickly due to its long half-life.
    04.03.01  Tricyclic and related antidepressant drugs to top
     note  An ECG is recommended before prescribing an older TCAD (amitriptyline, clomipramine, imipramine) to patients at significant risk of cardiovascular disease.  
    04.03.01  Tricyclic antidepressants
    Lofepramine
    (Tablet, Oral suspension)
    View adult BNF View SPC online  Track Changes
    Formulary
    Advice

    • Not recommended first-line for depression (use SSRI instead)

    • Lofepramine is less dangerous in overdose and less cardiotoxic than the older tricyclic antidepressants


     

     
    Link  BNF advice about antidepressants and the risk of hyponatraemia (especially in the elderly)
    Link  BNF advice about antidepressants and the risk of suicidal thoughts and behaviour (especially in young people)
    Link  Management of depression in breastfeeding mothers – are tricyclic antidepressants safe? (UKMI Q&A)
       
    Amitriptyline
    (Tablet, Oral solution)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Advice
     
    Link  BNF advice about antidepressants and the risk of hyponatraemia (especially in the elderly)
    Link  BNF advice about antidepressants and the risk of suicidal thoughts and behaviour (especially in young people)
    Link  Management of depression in breastfeeding mothers – are tricyclic antidepressants safe? (UKMI Q&A)
       
    Clomipramine
    (Capsule)
    View adult BNF View SPC online  Track Changes
    Restricted Drug Restricted
    Advice

     

    • Not recommended for first line use (mental health indications)

     

    • May be considered as an alternative to SSRIs in obsessive-compulsive disorder (OCD).

     

    • NWAFT: Non-formulary

     

    • CUHFT and CPFT: Formulary

     

    • RPH: Restricted to initiation by Sleep Consultants for cataplexy (Amber no SCG)

     



     

     
    Link  Management of depression in breastfeeding mothers – are tricyclic antidepressants safe? (UKMI Q&A)
    Link  BNF advice about antidepressants and the risk of suicidal thoughts and behaviour (especially in young people)
    Link  BNF advice about antidepressants and the risk of hyponatraemia (especially in the elderly)
       
    Imipramine
    (Tablet, oral solution)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Advice

     

    • Use as an antidepressant - not recommended for first line use
    • NWAFT and RPH: Non-formulary.

     



     

     
    Link  BNF advice about antidepressants and the risk of hyponatraemia (especially in the elderly)
    Link  BNF advice about antidepressants and the risk of suicidal thoughts and behaviour (especially in young people)
    Link  Management of depression in breastfeeding mothers – are tricyclic antidepressants safe? (UKMI Q&A)
       
    Nortriptyline
    (Tablet)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Advice

    • Use as an antidepressant - not recommended for first line use

    • If recommended for prescribing, 50mg tablets in primary care are more expensive than prescribing in combinations of 10mg and 25mg tablets.

    • NWAFT and RPH: Non-formulary

    • CUHFT: Restricted to psychiatry initiated only


     

     
    Link  BNF advice about antidepressants and the risk of hyponatraemia (especially in the elderly)
    Link  BNF advice about antidepressants and the risk of suicidal thoughts and behaviour (especially in young people)
    Link  Management of depression in breastfeeding mothers – are tricyclic antidepressants safe? (UKMI Q&A)
       
    04.03.01  Related antidepressants
    Trazodone
    (Capsule, tablet, oral solution)
    View adult BNF View SPC online  Track Changes
    Restricted Drug Restricted
    Advice

    • Not recommended for first line use

    • NWAFT and RPH: Non-formulary

    • Prescribe generically


     

     
    Link  BNF advice about antidepressants and the risk of hyponatraemia (especially in the elderly)
    Link  BNF advice about antidepressants and the risk of suicidal thoughts and behaviour (especially in young people)
    Link  Management of depression in breastfeeding mothers – are tricyclic antidepressants safe? (UKMI Q&A)
       
    04.03.02  Monoamine-oxidase inhibitors
    Phenelzine (Nardil®)
    (Tablet)
    View adult BNF View SPC online  Track Changes
    Restricted Drug Restricted
    Amber No SCG

     

    • Requires specialist initiation by mental health team.
    • Note dietary restrictions and toxicity in overdose.

    October 2020 - Shortage of Phenelzine (Nardil®) 15mg tablets

    • Nardil has been out of stock since August 2019 
    • In September 2020, Kyowa Kirin advised Nardil has been divested to Neon Healthcare. Resupply date is to be confirmed
    • Please see the shortage alert memo below for further information on how to deal with this shortage.
    • Please see Supply Disruption Alert below, issued as a CAS alert by the DHSC on the 3rd July 2020 for further information. 
     
    Link  BNF advice about antidepressants and the risk of hyponatraemia (especially in the elderly)
    Link  BNF advice about antidepressants and the risk of suicidal thoughts and behaviour (especially in young people)
    Link  July 2020: Shortage of Phenelzine (Nardil®) 15mg tablets (published 10th June 2020)
    Link  Supply Disruption Alert: Phenelzine 15mg tablets (published 3rd July 2020)
       
    Tranylcypromine
    (Tablet)
    View adult BNF View SPC online  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • Requires specialist initiation by mental health team

    • Note dietary restrictions and toxicity in overdose.


     

     
    Link  BNF advice about antidepressants and the risk of hyponatraemia (especially in the elderly)
    Link  BNF advice about antidepressants and the risk of suicidal thoughts and behaviour (especially in young people)
       
    04.03.02  Reverible MAOIs
    Moclobemide
    (Tablet)
    View adult BNF View SPC online  Track Changes
    Restricted Drug Restricted
    Amber No SCG

     

    • Requires specialist initiation by mental health team.
    • Note dietary restrictions.

    October 2020 - Shortage of Moclobemide 150mg and 300mg tablets

    • Mylan (Manerix) 150mg and 300mg tablets now available. 
    • Sandoz is currently out of stock and expects resupply for the 150mg in July 2021 and the 300mg in March 2021.
    • See shortage memo below for further advice relating to this shortage. 

     

     
    Link  BNF advice about antidepressants and the risk of hyponatraemia (especially in the elderly)
    Link  BNF advice about antidepressants and the risk of suicidal thoughts and behaviour (especially in young people)
    Link  May 2020: Shortage of Moclobemide 150mg and 300mg tablets
       
    04.03.03  Selective serotonin re-uptake inhibitors to top
     note 

    Generic first line options are citalopram and sertraline. SSRIs are considered first-line agents for the drug treatment of depression and some anxiety disorders (e.g. panic disorder, OCD, generalised anxiety disorder (GAD)).

    Citalopram
    (Tablet, Oral drops)
    View adult BNF View SPC online View childrens BNF  Track Changes
    First Choice
    Green

    • First line choice antidepressant

    • 8mg (4 drops) of citalopram 40mg/ml oral drops is equivalent in therapeutic effect to one 10mg citalopram tablet

    • Please note MHRA safety advice below relating to maximum doses


     

     
    Sertraline
    (Tablet)
    View adult BNF View SPC online View childrens BNF  Track Changes
    First Choice
    Green

     

    • First line choice antidepressant, however Sertraline is currently subject to a price consession in Primary Care making it considerably more expernsive than citalopram
    • 'Off label' when used to treat generalised anxiety disorder.
    • Use in children should be under the direction of a mental health specialist.  Where a liquid preparation is clinically require in paediatric patients, Sertraline 50mg/5mL is the standardised liquid strength which should be prescribed in children (unlicensed unlicensed):
      • Using standardised strengths of unlicensed liquid medicines in children, will reduce the risk of errors being made in the doses given to children and prevent hospitalisation from accidental under and overdoses.
      • See link below for further information.

    June 2020 - Availability of Sertraline 50mg and 100mg tablets

    • For further information on potential management options for where local supplies of sertraline 50mg and 100mg are not available, see shortage memo below.  

     

     

     
    Fluoxetine
    (Capsule, dispersible tablet, oral solution)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Green

     

    • Long half-life- caution when making dose adjustments and switching to other antidepressants.
    • Specialist initiation for children and adolescents aged 8 years and above (Amber no SCG).
    • 10mg oral formulations (tablets / capsules) are expensive. Consider prescribing 20mg dispersible tablets (e.g. Olena brand) which can be halved if required or 20mg/5ml oral solution (not sugar free version as more expensive).

    October 2020 - Serious shortage protocol (SSP) for Fluoxetine 40mg capsules has now expired

    • Sufficient stock of Fluoxetine 40mg capsules is now available to supply normal demand; as a result the SSP06 for Fluoxetine 40mg capsules expired at 23.55pm Friday 2nd October 2020. Any prescriptions for Fluoxetine 40mg capsules after this date must be dispensed in accordance with the prescription, as the SSP will no longer be valid for use.

    October 2020 - Serious shortage protocol (SSP) in place for Fluoxetine 10mg tablets

    • Endo Ventures are out of stock of fluoxetine 10mg tablets until March 2021.
    • Fluoxetine 10mg capsules and fluoxetine 20mg/5ml oral solution remain available.
    • For further information see Medicine Supply Notification and SSP link below. 

    October 2020 - Serious shortage protocol (SSP) in place for  Fluoxetine 30mg capsules

    • Advanz, sole supplier is out of stock until mid-December 2020.
    • Fluoxetine 10mg and 20mg capsules remain available.
    • For further information see Medicine Supply Notification and SSP link below. 

     

     

     
    Link  June 2020: Medicine Supply Notification - Fluoxetine 10mg tablets (published 12th March 2020)
    Link  October 2020: Fluoxetine 30mg capsules - Medicine Supply Notification (issued on the 21st October 2020)
    Link  Q&A SSP007 October 2020 - Fluoxetine 30mg capsules - valid until 22 December 2020
    Link  Q&A SSP05 October 2020: Fluoxetine 10mg tablets - valid until 31 March 2021
    Link  SSP007 October 2020: Fluoxetine 30mg capsules - valid until 22 December 2020
    Link  SSP05 October 2020: Fluoxetine 10mg tablets - valid until 31 March 2021
    Link  Triptans and SSRI or SNRI antidepressants – is there an interaction? (UKMI Q&A)
    Link  BNF advice about antidepressants and the risk of hyponatraemia (especially in the elderly)
    Link  BNF advice about antidepressants and the risk of suicidal thoughts and behaviour (especially in young people)
    Link  Management of depression in breastfeeding mothers – are selective serotonin reuptake inhibitors (SSRIs) safe? (UKMI Q&A)
    Link  MHRA 2010 - caution on use in pregnancy
    Link  NICE evidence summary: Fluoxetine for hypersexuality
       
    Paroxetine
    (Tablet, oral suspension)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Advice

     

    • Not recommended for first line use.
    • Withdraw slowly to minimise discontinuation reactions. 
    • Non-formulary at NWAFT and RPH.

     

     

     
    Link  BNF advice about antidepressants and the risk of hyponatraemia (especially in the elderly)
    Link  BNF advice about antidepressants and the risk of suicidal thoughts and behaviour (especially in young people)
    Link  Management of depression in breastfeeding mothers – are selective serotonin reuptake inhibitors (SSRIs) safe? (UKMI Q&A)
    Link  Triptans and SSRI or SNRI antidepressants – is there an interaction? (UKMI Q&A)
       
    Vortioxetine
    View adult BNF View SPC online  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • Requires specialist initiation by mental health team in line with NICE TA367 - as an option for treating major depressive episodes in adults whose condition has responded inadequately to 2 antidepressants within the current episode.

     
    Link  BNF advice about antidepressants and the risk of hyponatraemia (especially in the elderly)
    Link  BNF advice about antidepressants and the risk of suicidal thoughts and behaviour (especially in young people)
    Link  Vortioxetine for treating major depressive episodes (NICE TA367)
       
    Escitalopram (Cipralex®)
    (Tablet, oral drops)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Advice

    • Requires specialist recommendation by mental health team - second/third line ONLY

    • Please note MHRA safety advice below

    • All prescribing should be generically

    • NWAFT: Non-formulary


     

     
    Link  BNF advice about antidepressants and the risk of hyponatraemia (especially in the elderly)
    Link  BNF advice about antidepressants and the risk of suicidal thoughts and behaviour (especially in young people)
    Link  CPFT - Citalopram Escitalopram and QT prolongation
    Link  CPFT - Medicines Monitoring Guidelines
    Link  Management of depression in breastfeeding mothers – are selective serotonin reuptake inhibitors (SSRIs) safe? (UKMI Q&A)
    Link  MHRA safety advice regarding maximum doses and QT prolongation
    Link  Triptans and SSRI or SNRI antidepressants – is there an interaction? (UKMI Q&A)
    Link  What issues should be considered regarding drug induced QT prolongation? (UKMI Q&A)
       
    Fluvoxamine Maleate (Fluvoxamine®)
    (Tablet)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Advice

    • CPFT: Not recommended for first line use.

    • Non-formulary at all other Trusts

    • Where Primary Care is requested to prescribe, it should be clear why formulary choices are unsuitable 


     


     

     
    Link  BNF advice about antidepressants and the risk of hyponatraemia (especially in the elderly)
    Link  BNF advice about antidepressants and the risk of suicidal thoughts and behaviour (especially in young people)
    Link  Management of depression in breastfeeding mothers – are selective serotonin reuptake inhibitors (SSRIs) safe? (UKMI Q&A)
    Link  Triptans and SSRI or SNRI antidepressants – is there an interaction? (UKMI Q&A)
       
    04.03.04  Other antidepressant drugs
    Mirtazapine
    (Tablet, Orodispersible tablet, Oral solution)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Second Choice
    Green

     

    • May cause sedation and weight gain.
    • An option for patients where one SSRI has failed and a trial of a second SSRI is inappropriate.
    • NWAFT: Restricted to use in palliative care.

     

     
    Link  BNF advice about antidepressants and the risk of hyponatraemia (especially in the elderly)
    Link  BNF advice about antidepressants and the risk of suicidal thoughts and behaviour (especially in young people)
    Link  CPFT - Medicines Monitoring Guidelines
    Link  Management of depression in breastfeeding mothers – Are reboxetine, venlafaxine, duloxetine, mirtazapine, agomelatine and MAOIs safe? (UKMI Q&A)
    Link  Medicine Supply Notification August 2020: Mirtazapine oro-dispersible tablets (published 25th June 2020)
    Link  Triptans and SSRI or SNRI antidepressants – is there an interaction? (UKMI Q&A)
       
    Venlafaxine
    (Tablet, MR tablet, MR Capsule)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Advice

     

    • Requires specialist advice from mental health team.
    • CPFT and CUHFT: Formulary.
    • NWAFT: Non-formulary.
    • RPH: Restricted to initiation by Sleep Consultants for cataplexy.

     

     
    Link  BNF advice about antidepressants and the risk of hyponatraemia (especially in the elderly)
    Link  BNF advice about antidepressants and the risk of suicidal thoughts and behaviour (especially in young people)
    Link  CPFT - Medicines Monitoring Guidelines
    Link  Management of depression in breastfeeding mothers – Are reboxetine, venlafaxine, duloxetine, mirtazapine, agomelatine and MAOIs safe? (UKMI Q&A)
    Link  Triptans and SSRI or SNRI antidepressants – is there an interaction? (UKMI Q&A)
       
    Duloxetine
    (Capsule)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • Requires specialist initiation by mental health team when being prescribed as an antidepressant

    • Be aware of drug interactions.

    • Ensure correct strength formulation is prescribed for indication.

    • For the treatment of major depressive disorder 30mg and 60mg capsules are licensed.

    • RPH: Restricted to initiation by Sleep Consultants for cataplexy

     
    Link  BNF advice about antidepressants and the risk of hyponatraemia (especially in the elderly)
    Link  BNF advice about antidepressants and the risk of suicidal thoughts and behaviour (especially in young people)
    Link  CPFT - Medicines Monitoring Guidelines
    Link  Management of depression in breastfeeding mothers – Are reboxetine, venlafaxine, duloxetine, mirtazapine, agomelatine and MAOIs safe? (UKMI Q&A)
    Link  Triptans and SSRI or SNRI antidepressants – is there an interaction? (UKMI Q&A)
       
    04.04  CNS stimulants and other drugs used for attention deficit hyperactivity disorder
    Atomoxetine (Strattera®)
    (Capsule, oral solution)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber SCG

    • Requires specialist initiation by mental health team in line with Shared Care Guidelines


     

     
    Link  CPFT - Medicines Monitoring Guidelines
    Link  CPFT and CCG Shared Care Guideline - Methylphenidate, Dexamfetamine, Lisdexamfetamine and Atomoxetine for Adults with ADHD
    Link  CPFT and CCG Shared Care Guideline - The drug treatment of ADHD in Children and Young People using Methylphenidate, Dexamfetamine, Lisdexamfetamine and Atomoxetine
    Link  Drug Safety Update - Risk of psychotic or manic symptoms in children and adolescents (2009)
    Link  MHRA information on BP and heart rate increases (2012)
       
    Controlled Drug Dexamfetamine
    (Tablet, oral solution)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber SCG

    • For management of ADHD - requires specialist initiation by mental health team in line with Shared Care Guideline.

    • RPH: Restricted to the management of excessive sleepiness associated with narcolepsy in line with the Shared Care Guideline


     

     
    Link  CPFT - Medicines Monitoring Guidelines
    Link  CPFT and CCG Shared Care Guideline - Methylphenidate, Dexamfetamine, Lisdexamfetamine and Atomoxetine for Adults with ADHD
    Link  CPFT and CCG Shared Care Guideline - The drug treatment of ADHD in Children and Young People using Methylphenidate, Dexamfetamine, Lisdexamfetamine and Atomoxetine
    Link  RPH Shared Care Guideline: Dexamfetamine – Excessive sleepiness associated with narcolepsy
       
    Guanfacine (Intuniv®)
    (prolonged-release tablets)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber SCG

    • CPFT: Approved for the treatment of attention deficit hyperactivity disorder (ADHD) in children and adolescents 6-17 years old for whom stimulants are not suitable, not tolerated or have been shown to be ineffective.



    • Specialist initiation (1 month) with shared care for prescribing to be continued in primary care.



    • Use in adults is outside of the product license and is NOT RECOMMENDED. 



    • Non-formulary at all other Trusts unless patient is admitted on treatment

     
       
    Controlled Drug Methylphenidate
    (Tablet, MR Tablet, MR Capsule )
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber SCG

     

    • Requires specialist initiation by mental health team
    • MR tablets and MR capsules should always be prescribed by brand and are not interchangeable due to differences in bioavailability.
    • Where methylphenidate MR tablets are required, Xaggitin XL® is the preferred brand.

     

     
    Link  CPFT - Medicines Monitoring Guidelines
    Link  CPFT and CCG Shared Care Guideline - Methylphenidate, Dexamfetamine, Lisdexamfetamine and Atomoxetine for Adults with ADHD
    Link  CPFT and CCG Shared Care Guideline - The drug treatment of ADHD in Children and Young People using Methylphenidate, Dexamfetamine, Lisdexamfetamine and Atomoxetine
    Link  UKMI Q&A: Methylphenidate for adults with ADHD
       
    Modafinil (Provigil®)
    (Tablet)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber SCG

    • RPH: Restricted to the management of Excessive sleepiness associated with narcolepsy and cataplexy in line with the Shared Care Guideline

    • CUHFT: Neurologists/DME - for patients with excessive daytime sleepiness (Hospital Only

    • Non-formulary at all other Trusts 

     
    Link  Letters sent to healthcare professionals February 2020: Modafinil - potential risk of congenital malformations during pregnancy
    Link  MHRA: Modafinil - EMA recommends restricted use (Aug 2010)
    Link  NICE Evidence Summary: Modafinil for excessive daytime sleepiness in Parkinson’s disease
    Link  NICE Evidence Summary: Modafinil for fatigue in multiple sclerosis
    Link  RPH Shared Care Guideline: Modafinil – Excessive sleepiness associated with narcolepsy and cataplexy
       
    Controlled Drug Lisdexamfetamine (Elvanse®)
    (Capsule)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber SCG

    • Requires specialist initiation by mental health team in line with Shared Care Guidelines


     

     
    Link  CPFT - Medicines Monitoring Guidelines
    Link  CPFT and CCG Shared Care Guideline - Methylphenidate, Dexamfetamine, Lisdexamfetamine and Atomoxetine for Adults with ADHD
    Link  CPFT and CCG Shared Care Guideline - The drug treatment of ADHD in Children and Young People using Methylphenidate, Dexamfetamine, Lisdexamfetamine and Atomoxetine
       
    04.05  Drugs used in the treatment of obesity
     note  NICE guideline obesity
    04.05.01  Anti-obesity drugs acting on the gastro-intestinal tract
    Orlistat
    (Capsule)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    OTC

     

      • Recommend self-care: Can be purchased from a Community Pharmacist (Alli 60mg capsules)
      • Primary Care: Prescribe Orlistat ONLY as part of a weight management plan (which includes diet modification, activity and behavioural approaches) for managing obesity in adults.
      • Patients must be motivated to engage with a weight management plan and meet one of the following criteria:
        • BMI ≥28kg/m2 with comorbidities, e.g. type 2 diabetes, hypertension, sleep apnoea
        • BMI ≥30kg/m2
      • CUHFT: Endocrinologists and the Diabetologists for use in selected obese patients to assist weight loss.
      • Non-formulary at all other Trusts

     

     
    Link  Orlistat Prescribing and Medication Review Guidelines for adult over 16 years of age
    Link  MHRA: Interaction with HIV medicines
    Link  NICE Guideline CG189: Obesity - identification, assessment and management
       
    04.05.02  Centrally acting appetite suppressants to top
    04.06  Drugs used in nausea and vertigo
    04.06  Antihistamines
    Cyclizine (Valoid®)
    (Tablet, Injection)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Second Choice
    Green
    • Primary Care:
      • Consider after 1st line choices (prochlorperazine or metoclopramide).
      • Cyclizine orally is a first line option for moderate symptoms of nausea and vomiting in pregnancy (unlicensed unlicensed). 
    • CUHFT: 2nd line formulary choice after ondansetron
    • Formulary at all other Trusts

     

     
    Link  C & P CCG: Nausea and vomiting in pregnancy pathway
    Link  RCOG Green-top Guideline No. 69 June 2016 - The Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum
       
    Cinnarizine
    (Tablet)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Green
  • For vestibular disorders, vertigo, motion sickness
  • If needed tablets can be dispersed in water. (They disperse within 1 minute).

     
  •    
    Promethazine Hydrochloride (Phenergan)
    (Tablets, Elixir, Injection)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Green

    • Primary Care:

      • Promethazine hydrochloride orally is a first line option for moderate symptoms of nausea and vomiting in pregnancy (unlicensed unlicensed). 



    • When used for other indication than urticaria/allergy or nausea/vomiting, then this should be on advice from Mental Health only.

    • CUHFT: Only tablets are on formulary

    • RPH: Non-formulary

    • Injection is not recommended for prescribing in primary care

     
    Link  C & P CCG: Nausea and vomiting in pregnancy pathway
    Link  CPFT Guideline for the pharmacological management of acute behavioural disturbance in in-patient wards
       
    04.06  Phenothiazines and related drugs
    Prochlorperazine
    (Tablet, Buccal tablet (Buccastem®), Injection)
    View adult BNF View SPC online View childrens BNF  Track Changes
    First Choice
    Green
    • Primary Care: 
      • Oral formulations are 1st line formulary choice.
      • Prochlorperazine orally or buccally are second line choices for moderate symptoms of nausea and vomiting in pregnancy (unlicensedunlicensed).
    • Injection is for IM route only. Not for IV or SC use (hospital only).

     

     

     

     
    Levomepromazine
    (Injection, tablet)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Green

     

    • For use in palliative care.
    • RPH: for persistent nausea in those taking highly emetogenic antibiotics (hospital only). 



     

     
    Link  Standard anticipatory medicines for end of life care
       
    Chlorpromazine
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    See section 4.2.1



    • CUHFT and NWAFT only: May be used in the treatment of hiccup

     
       
    Droperidol (Xomolix®)
    (Injection )
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CUHFT only: FoR use in PONV. For IV use can be administered undiluted as a slow bolus.

    • Non-formulary at all other Trusts

     
       
    Perphenazine
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CUHFT: Formulary

    • Non-formulary at all other Trusts and in Primary Care

     
       
    04.06  Domperidone and metoclopramide
    Metoclopramide
    (Tablet, Liquid, Injection)
    View adult BNF View SPC online View childrens BNF  Track Changes
    First Choice
    Green

    • Primary Care:

      • Metoclopramide is a 1st line formulary choice in Primary Care.

      • Metoclopramide orally are a third line option for moderate symptoms of nausea and vomiting in pregnancy. To only be prescribed for courses of no longer than 5 days then reviewed.



    • Limited efficacy post-operatively

    • Not recommended for patients under 20 years of age due to risk of dystonic reactions. For restrictions for use in younger patients see MHRA guidance below.

    • Metoclopramide should only be prescribed for short-term use (up to 5 days).

    • For adults, the maximum dose in 24 hours is 30 mg (or 0.5 mg per kg bodyweight).

    • Can be given S/C (unlicenced but accepted practice)

     
    Domperidone
    (Tablet, Suspension)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Second Choice
    Green

    • Primary Care: 2nd line formulary choice after prochlorperazine and metoclopramide.

    • See link below for MHRA advice about dose restrictions and contraindications

    • Non-formulary (grey) for promoting tolerance of enteral feeds in children / young people. See NICE evidence summary.

     
    Link  MHRA Drug Safety Update December 2014: Advice for domperidone
    Link  MHRA Drug Safety Update December 2014: Domperidone no longer available without prescription
    Link  MHRA Drug Safety Update December 2019: Domperidone for nausea and vomiting - lack of efficacy in children; reminder of contraindications in adults and adolescents
    Link  NICE: Enteral feeds in children and young people: domperidone
    Link  UKMI: Domperidone - New restrictions in GI conditions (May 2014)
    Link  UKMI: Domperidone use in chemotherapy guideline (May 2014)
       
    04.06  5HT3 antagonists to top
    Ondansetron
    (Tablet, Suppository, Solution for injection, Oral solution, Orodispersible film, Oral lyophilisate, Orodispersible tablet. )
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CUHFT:

      • For COD, D9, C10 and C2 following protocol.

      • General theatres: For post-op nausea and vomiting in adults and children - see protocol

      • Neurotheatres

      • Rapid opiate detoxification programme for 5 patient days per annum.

      • For Pain Clinic, protocol for vomiting with Ketamine Infusion for back pain.

      • For Rosie Theatre Recovery for post-op nausea and vomiting.

      • Patches have been agreed on Formulary for oncology only.

      • For the off label indication of diarrhoea predominant IBS (tablet). Prescribing for this indication should remain in secondary care.



    • NWAFT and RPH: Formulary

    • MHRA guidance - the maximum single intravenous dose of ondansetron for the management of chemotherapy-induced nausea and vomiting in adults is 16 mg (infused over at least 15 minutes)

    • In secondary care the syrup and orodispersible film are available but are much more expensive than tablets. If needed tablets can be crushed and dispersed in water.

    • Primary care:

      • Ondansetron orally is a third line option for moderate symptoms of nausea and vomiting in pregnancy (unlicensed unlicensed). To only be prescribed for courses of no longer than 5 days then reviewed. 

      • All other indications NON-FORMULARY. 



     
    Link  C & P CCG: Nausea and vomiting in pregnancy pathway
    Link  MHRA Drug Safety Update December 2014: Ondansetron for intravenous use - dose-dependent QT interval prolongation
    Link  MHRA Drug Safety Update January 2020: Ondansetron - small increased risk of oral clefts following use in the first 12 weeks of pregnancy
    Link  Ondansetron for vomiting in children with gastroenteritis- NICE evidence summary
       
    Granisetron transdermal patch (Sancuso®)
    (3.1mg/24hrs)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital
    • CUHFT only: As per anti-emetic protocol. Patients who are having 3-5 day MEC or HEC regimens AND who cannot swallow may be prescribed a granisetron transdermal patch (Sancuso) to be applied 24 hours before start of chemotherapy and left in place until at least 24 hours after chemotherapy is finished.

     

    • Non-formulary at all other Trusts
     
       
    Granisetron
    (Tablet, Injection)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CUHFT only:

      • Oncology department following anti-emetic protocol.

      • Anaesthetists for PONV (as prophylaxis).



    • Non-formulary at all other Trusts

     
       
    04.06  Neurokinin receptor antagonist
     note 
    Aprepitant (Emend®)
    (Capsules.)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CUHFT and NWAFT: For oncology patients only.

    • RPH: 4th line choice in Cystic Fibrosis (unlicensed)

    • Non-formulary at all other Trusts and in Primary Care

     
       
    Netupitant and Palonosetron (Akynzeo®)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CUHFT: approved for use for chemotherapy induced nausea and vomiting (adults and paediatrics unlicensed unlicensed)

    • NWAFT: approved for use for chemotherapy induced nausea and vomiting - adults only

    • Non-formulary at all other Trusts and in Primary Care 

     
       
    04.06  Cannabinoid
     note 
    Nabilone
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CUHFT: Formulary

    • Non-formulary at all other Trusts and in Primary Care

     
       
    04.06  Hyoscine
    Hyoscine Hydrobromide
    (tablets/patches)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Green

    • Palliative Care.

    • Paediatric Oncologistists

    • Rehab for hypersecretions.

    • For management of clozapine-induced hypersalivation (off-label) - on the advice of a specialist in mental health

    • Patches are 1.5mg total dose, but only release 1mg over 72 hours.

    • If needed tablets can be crushed and dispersed in water.

     
    Link  UKMI Q&A - Drug-induced hypersalivation – what treatment options are available?
       
    04.06  Other drugs for Ménière's disease
    Betahistine Dihydrochloride
    (Tablet)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Green

    • Menières disease, vertigo.  


     
       
    04.07  Analgesics to top
     note  Avoid using compound analgesic preparations wherever possible
    04.07.01  Non-opioid analgesics and compound analgesic preparations
    04.07.01  Compound analgesic preparations
     note  Avoid using compound analgesic preparations wherever possible
    Paracetamol
    (Tablet, Soluble tablet, Injection, Liquid, Suppositories (Unlicensed))
    View adult BNF View SPC online View childrens BNF  Track Changes
    First Choice
    OTC

    • Consider self-care where the patient is willing and able (oral formulations only)

    • Community pharmacists can sell up to a maximum of 3x32 tablets at their discretion.

    • Dose should be reduced in patients weighing less than 50kg (in paediatrics 15mg/kg qds), 500mg QDS.

     
    Aspirin
    (Tablet, dispersible tablet , suppository)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    OTC

     

    • Consider self care - where the patient is willing and able.
    • Enteric Coated tablets (EC) are non-formulary. 

     

     
       
    04.07.02  Opioid analgesics
     note 

    Transdermal opioids

    Transdermal opioid patches should NOT be used for acute pain or in patients whose analgesic requirements are changing rapidly because the long time to steady state prevents rapid titration of the dose.

    They may be considered where at least ONE of the following applies: 

    •  Swallowing difficulties and cannot tolerate oral or liquid opioid formulations. 
    • Intolerable adverse effects to oral morphine and oxycodone, e.g. nausea and vomiting, constipation, hallucinations, dysphagia. 
    • Subcutaneous route for opioid is inappropriate for the patient. 
    • Poor absorption from the GI tract, e.g. short bowel syndrome. 
    • Patients with mental health problems where compliance with oral opioids is a concern
    • Patients with compliance issues associated with oral opioids or for those who are socially isolated with limited access to care. 
    • Patients with severe renal impairment (where oral oxycodone is inappropriate).
    Codeine
    (Tablet, Syrup, Injection, Suppositories)
    View adult BNF View SPC online View childrens BNF  Track Changes
    First Choice
    Green

     

    • Low strength co-codamol products can be purchased from a Community Pharmacist for short term supply only
    • Injection is non-formulary, no advantages over morphine and is a CD.
    • Works by small amounts (~10%) being converted to morphine (some people do not convert).
    • Restrictions on use of codeine in children and breastfeeding mothers - see MHRA advice below. 
      • Consider alternative analgesia in paediatrics
    • Suppositories are non-formulary at NWAFT and in Primary Care
     
    Controlled Drug Morphine and Morphine Salts
    (Oral formulations, injection, intravenous infusion, suppositories)
    View adult BNF View SPC online View childrens BNF  Track Changes
    First Choice
    Green

     

    • Oral forms:
      • Prescribe by BRAND name in primary care to prevent confusion between formulations.
      • Morphgesic® SR tablets or Zomorph® capsules are the preferred brand in primary care where a modified release formulations is required (both 12 hourly release)
      • MXL capsules should be used at 24-hourly intervals are restricted to  ARH, Oncologists/Radiology pts (CUHFT only)
    • Injection: Morphine has superseded diamorphine as the end of life choice of opioid in primary and secondary care.
    • Preservative free injection is unlicensed and restricted (Hospital only)
    • Suppositories (non formulary at all Trusts excluding CUHFT).  
     
    Dihydrocodeine
    (Tablet, Tablet MR)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Second Choice
    Green

     

    • Poor analgesic when used alone, probably similar to or theoretically slightly better than codeine, but based on minimal evidence.
    • Where combination products are prescribed (not routinely recommended) co-dydramol products must be prescribed and dispensed by strength to minimise dispensing errors and the risk of accidental opioid overdose.
    • NWAFT: Non-formulary. 

     

     
    Link  MHRA Opioids: risk of dependence and addiction (Sept 2020)
    Link  MHRA PIL: Opioid Medicines and The Risk Of Addiction Sept 2020
    Link  MHRA Drug safety Update: Co-dydramol - prescribe and dispense by strength to minimise risk of medication error
       
    Controlled Drug Diamorphine
    (Injection)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Green
    • In palliative care should be used 2nd line to morphine.

    October 2020 - Shortage of Diamorphine Hydrochloride powder for reconstitution and injection 5mg and 10mg ampoules: 

    • There are two suppliers of diamorphine hydrochloride 5mg and 10mg in the UK, Wockhardt and Accord.
    • Accord are out of stock of both 5mg and 10mg strengths, with a re-supply date of Summer 2020.
    • Wockhardt's 5mg and 10mg strengths are currently available with limited supplies. 
    • The indication from both suppliers of diamorphine 5mg and 10mg strengths is that the supply will remain unpredictable for the foreseeable future. 
    • Diamorphine hydrochloride 30mg ,100mg, 500mg are available but manufacturers are unable to support an increase in demand on these strengths.
    • Please note - Morphine has superseded diamorphine as the end of life choice of opioid in adults in primary and secondary care. Sufficient supplies of morphine sulfate 10mg/ml injection are available from Ethypharm and Hameln to support this supply disruption. The Hameln presentation is preservative free. Morphine and diamorphine are not equipotent, and care should be taken when switching patients or amending guidelines, see shortage memo below for further information.
    • Please refer to the Central Alerting System (CAS) alert issued 25/03/2020: https://www.cas.mhra.gov.uk/ViewandAcknowledgment/ViewAttachment.aspx?Attachment_id=103486 
    • See shortage memo below for further information also. 

     

     
    Link  June 2020: Shortage of diamorphine 5mg and 10mg injection
       
    Controlled Drug Buprenorphine (Temgesic®)
    (Tablet sublingual)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CUHFT: Restricted to

      • DME.

      • Palliative Care.

      • Pain team for chronic pain.



    • Non-formulary at all other Trusts and in Primary Care

     
    Link  MHRA Opioids: risk of dependence and addiction (Sept 2020)
    Link  MHRA PIL: Opioid Medicines and The Risk Of Addiction Sept 2020
       
    Controlled Drug Pethidine
    (Tablet, Injection)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Red Hospital

     

    • Not recommended for prescribing in Primary Care.

    October 2020 - Shortage of Pethidine 50mg tablets

    • Martindale and Teva are out of stock with no current resupply date 
    • There are no alternative suppliers.
    • Patients should be reviewed by a clinician to assess ongoing need.
    • For support with individual patients in Primary Care, please contact the Medicines Optimisation Team for further advice via CAPCCG.prescribingpartnership@nhs.net

     

     
    Link  August 2020 - Shortage of Pethidine Tablets 50mg
    Link  MHRA Opioids: risk of dependence and addiction (Sept 2020)
    Link  MHRA PIL: Opioid Medicines and The Risk Of Addiction Sept 2020
       
    Controlled Drug Fentanyl (Durogesic®, Fencino®, Mezolar Matrix®)
    (Patch)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Green

    • Restricted for use in cancer pain or palliative care only in line with place in therapy (as above)

    • Reservoir patches are not recommended.

    • When prescribed in Primary Care preferred brands are

      • Fencino® or Mezolar Matrix®

      • prescribe by BRAND name



     
    Link  MHRA Transdermal fentanyl patches for non-cancer pain: do not use in opioid-naive patients
    Link  MHRA Opioids: risk of dependence and addiction (Sept 2020)
    Link  MHRA PIL: Opioid Medicines and The Risk Of Addiction Sept 2020
    Link  MHRA warning regarding accidental exposure
    Link  UKMI Q &A: switching from morphine to fentanyl patches
    Link  CUHFT: Medicines Safety Factsheet Fentanyl
       
    Controlled Drug Buprenorphine (BuTrans®, Reletrans®, Sevodyne®)
    (Patch)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Green

    • Patch (Weekly patch)

    • When compared to other opiates weekly buprenorphine patches are very weak and expensive.

    • See above for place in therapy.

    • CAUTION when switching between patches as different brands are not interchangeable.

    • When prescribed in Primary Care, preferred brands are Reletrans® or Sevodyne®. Prescribe by BRAND name and not generically.

    • CUHFT and RPH: Non-formulary

     
    Link  MHRA Opioids: risk of dependence and addiction (Sept 2020)
    Link  MHRA PIL: Opioid Medicines and The Risk Of Addiction Sept 2020
       
    Controlled Drug Buprenorphine (Transtec®, Bupeaze®)
    (Patch)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Green

     

    • Patch (96 hours (4 days) patch)
    • When compared to other opiates weekly buprenorphine patches are very weak and expensive.
    • See above for place in therapy.
    • CAUTION when switching between patches as different brands are not interchangeable.
    • When prescribed in Primary Care, preferred brands is Bupeaze®. Prescribe by BRAND name and not generically.
    • RPH: Non-formulary.

    November 2020 - Supply Issues with Bupeaze Patches (Buprenorphine 96 hour patches)

    • Dr Reddy's have confirmed that the:
      • 35mcg patches are currently unavailable, due to be replenished in first week December 
      • 52.5mcg and 70mcg patches are available.

     

     

     
    Link  MHRA Opioids: risk of dependence and addiction (Sept 2020)
    Link  MHRA PIL: Opioid Medicines and The Risk Of Addiction Sept 2020
       
    Controlled Drug Oxycodone (Liquid, Concentrated Liquid, Immediate release capsules, Slow release tablets, injection)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Advice
    • Oral forms:
      • Trusts only stock oxycodone liquid (immediate release) and slow release tablets.
      • Prescribe by BRAND name in primary care to prevent confusion between formulations.
      • Shortec® capsules are the preferred immediate release brand in primary care.
      • Renocontin® tablets are the preferred slow release brand in primary care. For chronic pain (excluding palliative care and cancer pain), strengths above 30mg MR oxycodone are NO LONGER RECOMMENDED.
      • Be careful not to confuse oxycodone liquid (5mg/5ml) and oxycodone concentrated liquid (10mg/1ml). 
    • Restricted to use in Chronic pain and Palliative Care only, in patients who cannot tolerate morphine or with severe renal impairment (< 30mls/min).
    • For the management of acute pain including post operative use - Hospital only. 
    • Injection is Hospital only.
       
       

     

     
    Link  MHRA Opioids: risk of dependence and addiction (Sept 2020)
    Link  MHRA PIL: Opioid Medicines and The Risk Of Addiction Sept 2020
    Link  CUHFT: Oxycodone policy: prescribing and supply
    Link  Faculty of Pain Medicine: Resource at a Glance - Opioids Aware
       
    Controlled Drug Fentanyl (Abstral®)
    (Sublingual tablets)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Advice
    • Very expensive (~£3-6 per dose)
    • To be prescribed only on the advice of a palliative care specialist
    • Not recommended for any other indication
    • When recommended by a Palliative care Specialist ABSTRAL sublingual tablets are formulary choice. 
    • All other formulations including EFFENTORA buccal tablet, RECIVIT sublingual tablet, BREAKYL buccal film, PECFENT and INSTANYL nasal sprays are NOT recommended for prescribing. 
    • ACTIQ lozenges are HOSPITAL only - see separate monograph.

     

     
    Link  MHRA Opioids: risk of dependence and addiction (Sept 2020)
    Link  MHRA PIL: Opioid Medicines and The Risk Of Addiction Sept 2020
    Link  CUHFT: Transmucosal fentanyl policy
       
    Controlled Drug Fentanyl  (Actiq®)
    (Lozenges)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital
    • CUH: as per transmucosal fentanyl policy - where there is severe uncontrolled pain in a paediatric patient with profound and intractable compliance issues or unsafe swallow, the specialist Paediatric Pain Service may authorise the use of fentanyl lozenges as a means of achieving immediate pain relief where other measures cannot be implemented.
      • Treatment must be authorised by the Paediatric Pain Service consultant.
      • Treatment is for inpatients only. 
     
    Link  MHRA Opioids: risk of dependence and addiction (Sept 2020)
    Link  MHRA PIL: Opioid Medicines and The Risk Of Addiction Sept 2020
    Link  CUHFT: Transmucosal fentanyl policy
       
    Controlled Drug Hydromorphone (Palladone®)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

     

    • CUHFT: Prescribable by or on the advice of Dr. Sarah Booth only. To be used as an alternative to oral morphine for palliative care patients when side effects to morphine become intolerable.

     

    • Non-formulary at all other Trusts and in Primary Care.

     

     
    Link  MHRA Opioids: risk of dependence and addiction (Sept 2020)
    Link  MHRA PIL: Opioid Medicines and The Risk Of Addiction Sept 2020
       
    Meptazinol (Meptid®)
    (Tablet)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CUHFT: formulary

    • Non-formulary at all other Trusts and in Primary Care.

    • Existing patients to be reviewed in Primary Care or at next routine Pain Clinic appointment

     
    Link  MHRA Opioids: risk of dependence and addiction (Sept 2020)
    Link  MHRA PIL: Opioid Medicines and The Risk Of Addiction Sept 2020
       
    Controlled Drug Methadone
    (Tablet, Liquid)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CUHFT: For initiation by pain team only when used as an analgesic.

    • Non-formulary at all other Trusts and in Primary Care

     
       
    Controlled Drug Tramadol
    (Soluble tablet, Capsule, Modified realease tablets / capsules, Injection)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • 400mg/day oral tramadol = approx 40mg oral morphine

    • Tramadol (all formulations) are non-formulary in Primary Care and should not routinely be prescribed as there is no advantage over other formulary analgesics.

    • For existing patients the preferred modified release formulation in primary care is MAROL PROLONGED RELEASE TABLETS (twice daily dosing). Prescribe modified release preparations by BRAND to prevent confusion between formulations

     
    Link  MHRA Opioids: risk of dependence and addiction (Sept 2020)
    Link  MHRA PIL: Opioid Medicines and The Risk Of Addiction Sept 2020
    Link  UKMi Q&As relating to Tramadol
       
    Controlled Drug Diamorphine (Ayendi®)
    (Nasal Spray)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • NWAFT: Ayendi Nasal Spray (paediatrics) should only be administered by practitioners experienced in the administration of opioids and with appropriate monitoring. (Unlicensed in adults and children 16yrs and over)

    • Non-formulary at all other Trusts and in Primary Care

     
       
    Controlled Drug Fentanyl
    (IV solution)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CUHFT only: Restricted to intranasal administration within the emergency department. (Hospital only) - unlicensed use

    • Non-formulary at all other Trusts and in Primary Care

    •  


     

     
       
    04.07.03  Neuropathic pain
    Amitriptyline
    (Neuropathic pain )
    View adult BNF View SPC online View childrens BNF  Track Changes
    First Choice
    Green

    • Tricyclic antidepressants are first-line for neuropathic pain (unlicensed).

     
    Gabapentin
    (Capsule)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Second Choice
    Green

    • Recommended 2nd line after amitriptyline (Formulary at all Trusts).



    • CUHFT: Also on formulary for the management of facial pain (patients under the care of Mr Adlam).

     
    Controlled Drug Schedule 3
    Link  MHRA Drug Safety Update April 2019: Pregabalin (Lyrica), gabapentin (Neurontin) and risk of abuse and dependence - new scheduling requirements from 1 April
       
    Duloxetine
    (Neuropathic pain)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Third Choice
    Green

    • Recommended third line after failure of TCA and gabapentin for painful diabetic peripheral neuropathy.



    • RPH: Non-formulary.



    • NOTE: Different strengths of duloxetine have different licensed indications. 30mg and 60mg capsules are licensed for diabetic peripheral neuropathy.

     
       
    Pregabalin
    (Capsule)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • Should only be considered after both amitriptyline and gabapentin (and possibly duloxetine) have failed at optimised doses. Although, there is no evidence of efficacy in this group of patients.



    • Prescribe twice daily dosing as this is more cost effective than three times daily dosing (both are licensed).



    • Prescribe generically.

     
    Controlled Drug Schedule 3
    Link  MHRA Drug Safety Update April 2019: Pregabalin (Lyrica), gabapentin (Neurontin) and risk of abuse and dependence - new scheduling requirements from 1 April
       
    Controlled Drug Ketamine
    (Oral solution (Neuropathic Pain))
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • Oral Solution 50mg/5ml- named patient use (unlicensed).



    • CUHFT: Restricted to use in palliative care for the management of neuropathic pain.



    • Non-formulary at all other Trusts and in Primary Care.

     
    Link  NICE Chronic pain: oral ketamine
       
    Nortriptyline
    (Neuropathic pain)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CUHFT: Similar to amitriptyline only less likely to cause drowsiness or anticholinergic side effects.



    • Non-formulary at all other Trusts and in Primary Care (for this indication).

     
       
    04.07.03  Trigeminal neuralgia to top
    Carbamazepine
    (Trigeminal neuralgia and neuropathic pain)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Green
     
       
    Phenytoin (Capsule)
    (Trigeminal neuralgia)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

     

    • CUHFT and RPH: Formulary.
    • Non-formulary at all other Trusts and in Primary Care for this indication.

    March 2020 - Shortage of Phenytoin Sodium NRIM 100mg capsules (Accord)

     

     
       
    04.07.03  Postherpetic neuralgia
    Carbamazepine
    (Postherpetic neuralgia)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Green

    • Approved for neuropathic pain.

     
       
    04.07.04  Antimigraine drugs
    04.07.04.01  Treatment of the acute migraine attack
    04.07.04.01  Analgesics
     note 

    Simple analgesics first line e.g paracetamol, or ibuprofen. Antiemetic for patients with nausea and vomiting eg prochlorperazine, domperidone, metoclopramide. Soluble preparations may aid absorption.

    04.07.04.01  5HT1 agonists to top
    Sumatriptan
    (Tablets, Pre-filled syringe, Nasal Spray)
    View adult BNF View SPC online View childrens BNF  Track Changes
    First Choice
    OTC

     

      • First line formulary choice in Primary Care (Prescribe generically)

     

      • Trusts: For the management of migraine, only supply as an inpatient / outpatient in exceptional circumstances, where treatment is required and the patient does not have their own supply.

     

      • CUHFT: Tablets and pre-filled subcutaneous syringe are only formulations on formulary

     

      • Can be purchased from a Community Pharmacist (infrequent use and no comorbidities or interacting medications)

     

     
    Zolmitriptan
    (Tablets, Orodispersible tablets )
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Green

    • Second line formulary choice in Primary Care (Prescribe generically)

    • Trusts (excluding NWAFT): For the management of migraine, only supply as an inpatient / outpatient in exceptional circumstances, where treatment is required and the patient does not have their own supply.

    • NWAFT: Non-formulary


     


     

     
       
    Rizatriptan
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • RPH: Formulary

    • Non-formulary at all other Trusts and in Primary Care

     
       
    04.07.04.01  Ergot alkaloids
     note 
    04.07.04.02  Prophylaxis of migraine
    Propranolol
    View adult BNF View SPC online View childrens BNF  Track Changes
    First Choice
    Green

    • 1st line formulary choice in Primary Care for this indication

     
    Amitriptyline
    (Migraine prophylaxis)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Green

    • Unlicensed indication.

    • 2nd line formulary choice in Primary Care after propranolol

    • NWAFT: Non-formulary

     
       
    Pizotifen
    (Tablet)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Green

    • Prescribe generically

    • Propranolol and amitriptyline are first line formulary choices in Primary Care.

     
       
    Sodium valproate
    (Migraine prophylaxis)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • Unlicensed indication.

    • MHRA/CHM advice: Valproate is contraindicated in women and girls of childbearing potential unless conditions of the Pregnancy Prevention Programme are met

    • NWAFT: Non-formulary for this indication

     
    Link  March 2019: Stock availability of Valproate-containing products (Sanofi)
    Link  MHRA Drug Safety Update April 2019: Valproate medicines and serious harms in pregnancy - new Annual Risk Acknowledgement Form and clinical guidance from professional bodies to support compliance with the Pregnancy Prevention Programme
    Link  MHRA Drug Safety Update February 2020: Valproate (Epilim▼, Depakote▼) pregnancy prevention programme - updated educational materials
    Link  MHRA Drug Safety Update May 2018: Valproate medicines (Epilim▼, Depakote▼) - Pregnancy Prevention Programme
    Link  MHRA Drug Safety Update September 2018: Valproate Pregnancy Prevention Programme - actions required now from GPs, specialists, and dispensers
    Link  Valproate Risk Materials
       
    Topiramate
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Advice

    • Unlicensed indication.

    • Can be prescribed generically

    • NWAFT: Non-formulary

     
       
    Clonidine
    (Tablet)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Advice

     

    • Prescribe generically.
    • Primary care initiation following specialist advice from the neurologist for the prophylaxis of migraine.
    • Primary care initiation following specialist advice from the mental health team for attention deficit-hyperactivity disorder (unlicensed unlicensed indication) and Tourette’s syndrome (unlicensedunlicensed indication).
    • NWAFT: Non-formulary for this indication.

     

     
       
    Fremanezumab (Ajovy®)
    (Injection)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital
    High Cost Medicine
    CCG
    BlueTeq
    • CUHFT: Consultant recommendation only in line with NICE TA631 for the prevention of chronic migraine in adults.
    • Treatment not initiated at other Trusts

     

     
    Link  Group Prior Approval Forms for CCG Commissioned Indications
    Link  NICE TA631: Fremanezumab for preventing migraine in adults
       
    Botulinum Toxin Type A (botox®)
    (Migraine prophylaxis, Injection)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital
    High Cost Medicine
    CCG
    BlueTeq
    •  CUHFT: Consultant recommendation only in line with NICE TA260
    • Treatment not initiated at other Trusts

     

     
    Link  Group Prior Approval Forms for CCG Commissioned Indications
    Link  NICE TA260 Botulinum toxin type A for the prevention of headaches in adults with chronic migraine
       
    04.07.04.03  Cluster headache
    Melatonin
    (Cluster headache)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • RPH: Formulary

    • Non-formulary at all other Trusts and in Primary Care

     
    Link  UKMI Q&A: review of effectiveness in cluster headache
       
    04.08  Antiepileptics
    04.08.01  Control of epilepsy to top
     note 
  • Monotherapy is encouraged where possible as combination therapy can lead to increased side effects via drug interactions and toxicity
  • Antiepileptic drugs show a variety of drug interactions via hepatic enzmye induction or inhibition, many of which are unpredictable in extent and nature
  • 04.08.01  Carbamazepine and Oxcarbazepine
    Carbamazepine (Tegretol®)
    (Tablet, MR tablet, liquid, suppository)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Advice

    • May be appropriate for specialist GP to initiate or any GP to prescribe whilst awaiting hospital referral (Specialist advice).

    • If using carbamazepine, offer controlled-release carbamazepine preparations [NICE 2012].

    • Patients should be maintained on an agreed brand.

    • Care when switching between formulations as bioavailability varies and the patient may require a change in dose.

    • In Primary Care - Tegretol® is the preferred brand.

     
    Link  UKMI Q&A: Why is there a limit on the dose and duration of use for carbamazepine suppositories?
       
    Eslicarbazepine (Zebinix®)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • CUHFT: Formulary for the management of epilepsy

    • Non-formulary at all other Trusts

    • Base the need for continued supply of a particular brand on clinical judgement and consultation with patient and/or carer, taking into account factors such as seizure frequency and treatment history.

     
       
    Oxcarbazepine (Trileptal®)
    (Tablet, Oral Suspension)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • CUHFT and NWAFT: Formulary for the management of epilepsy

    • RPH: Non-formulary

    • Base the need for continued supply of a particular brand on clinical judgement and consultation with patient and/or carer, taking into account factors such as seizure frequency and treatment history.

     
       
    04.08.01  Ethosuximide
    Ethosuximide
    (Capsule, Syrup)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Amber No SCG

    • CUHFT and NWAFT: Formulary for the management of epilepsy

    • RPH: Non-formulary

    • The potential for clinically relevant differences to exist between different manufacturers’ products is considered to be extremely low - consider prescribing generically
       

     
       
    04.08.01  Gabapentin and pregabalin
    Gabapentin
    (Epilepsy, Capsule)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • Formulary for the management of epilepsy.



    • Tablet  is much more expensive than capsules and is non-formulary.



    • The potential for clinically relevant differences to exist between different manufacturers’ products is considered to be extremely low - consider prescribing generically.


     
    Controlled Drug Schedule 3
    Link  MHRA Drug Safety Update April 2019: Pregabalin (Lyrica), gabapentin (Neurontin) and risk of abuse and dependence - new scheduling requirements from 1 April
       
    Pregabalin
    (Epilepsy, Capsule)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • CUHFT: Approved for prescribing by consultant neurologists and paediatricians for adjunctive therapy for partial seizures with/without secondary generalisation when other therapy has failed.



    • NWAFT: Formulary.



    • RPH: Non-formulary for this indication.



    • For these drugs, the potential for clinically relevant differences to exist between different manufacturers’ products is considered to be extremely low - consider prescribing generically.

     
    Controlled Drug Schedule 3
    Link  MHRA Drug Safety Update April 2019: Pregabalin (Lyrica), gabapentin (Neurontin) and risk of abuse and dependence - new scheduling requirements from 1 April
       
    04.08.01  Lacosamide
    Lacosamide  (Vimpat ® )
    (Tablets, Syrup, Infusion.)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • CUHFT and NWAFT: Formulary

    • RPH: Non-formulary

    • The potential for clinically relevant differences to exist between different manufacturers’ products is considered to be extremely low - consider prescribing generically

       

     
       
    04.08.01  Lamotrigine to top
    Lamotrigine
    (Tablet, Dispersible tablet)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Advice

    • Formulary for the management of epilepsy

    • Can be initiated in Primary Care on the advice of a specialist

    • Base the need for continued supply of a particular brand on clinical judgement and consultation with patient and/or carer, taking into account factors such as seizure frequency and treatment history.

     
       
    04.08.01  Levetiracetam
    Levetiracetam
    (Tablet, Oral solution, Infusion)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Advice

    • CUHFT and NWAFT: Formulary for the management of epilepsy

    • When given IV, required dose of concentrate for infusion should be diluted in 100ml of sodium chloride 0.9%. and given over 15 minutes.

    • Levels not usually needed.

    • RPH: Non-formulary

    • Can be initiated in Primary Care on the advice of a specialist

    • The potential for clinically relevant differences to exist between different manufacturers’ products is considered to be extremely low - consider prescribing generically


     



    • Desitrend® brand is restricted to patients:

      • On a ketogenic diet

      • Who are enterally tube fed



     
       
    04.08.01  Phenobarbital and other barbiturates
    Controlled Drug Phenobarbital
    (Tablet, Oral solution, Injection)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Amber No SCG

     

    • CUHFT and NWAFT:

      • Solution alcohol free - named patient use within the Trusts for paediatric use.unlicensed unlicensed
      • If needed tablets can be crushed and dispersed in water.
      • Phenobarbital elixir 15mg/5ml contains 38% alcohol and not considered suitable for use in children.
    • RPH: Non-formulary for the management of epilepsy
    • Primary Care: Where treatment is continued in Primary Care ensure that the patient is maintained on a specific brand and that this is clear on the prescription (adults and paediatrics).
    • Where a liquid preparation is clinically required in paediatric patients, Phenobarbital (alcohol free) 50mg/5mL is the standardised liquid strength which should be prescribed in children (unlicensed unlicensed):
      • Using standardised strengths of unlicensed liquid medicines in children, will reduce the risk of errors being made in the doses given to children and prevent hospitalisation from accidental under and overdoses.
      • See link below for further information.
     
    Link  RCPCH and NPPG Position Statement 18-01: Using Standardised Strengths of Unlicensed Liquid Medicines in Children (April 2020)
       
    Primidone
    (Tablet)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Amber No SCG

    • CUHFT and NWAFT: Formulary

    • RPH: Non-formulary

    • Ensure that the patient is maintained on a specific brand

     
       
    04.08.01  Phenytoin
    Phenytoin
    (Capsule, Infatabs, Suspension)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Amber No SCG

     

    • Concentrated suspension is non formulary. 
    • Important - 90mg liquid equivalent to 100mg tablets, capsules or injection.
    • Do not administer liquid within 2 hours of NG or PEG feed.
    • Ensure that the patient is maintained on a specific brand.

    November 2020 - Shortage of Epanutin Infatabs

    • Pfizer are out of stock with resupply expected mid-October 2020. Epanutin Infatabs due to a delay in manufacturing. Please see link below for further guidance relating to this shortage. 

    November  2020 - Shortage of Phenytoin Sodium NRIM 100mg capsules (Accord)

     

     
    Link  Canadian Product Monograph: Dilantin Infatabs, Dilantin - 30 suspension and Dilantin - 125 suspension
    Link  MHRA Letters sent to healthcare professionals in May 2019: Epanutin (phenytoin) oral solution shortage
    Link  Pfizer - Supply Disruption of Epanutin 50mg Infatabs
    Link  UKMI Q&A: Information on change of phenytoin capsules to tablets and vice versa
       
    04.08.01  Retigaine
    Retigabine
    (Tablet)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • CUHFT and RPH: Formulary

    • NWAFT: Non-formulary

    • Commercially available titration pack is not suitable for slower regimens. Individual strengths should be supplied.

    • The need for continued supply of a particular brand should be based on clinical judgement and consultation with patient and/or carer, taking into account factors such as seizure frequency and treatment history.

     
    Link  MHRA safety update on pigmentation July 2013
    Link  NICE TA232: Retigabine for the adjunctive treatment of adults with partial onset seizures in epilepsy with and without secondary generalisation
       
    04.08.01  Rufinamide to top
    Rufinamide (Inovelon®)
    (Tablet, Oral Suspension)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Amber No SCG

    • CUHFT and NWAFT: Formulary

    • RPH: Non-formulary

    • Base the need for continued supply of a particular brand on clinical judgement and consultation with patient and/or carer, taking into account factors such as seizure frequency and treatment history

     
       
    04.08.01  Tiagabine
    Tiagabine (Gabitril®)
    (Tablet)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • CUHFT and NWAFT: Formulary

    • RPH: Non-formulary

    • The potential for clinically relevant differences to exist between different brands is considered to be extremely low - consider prescribing generically
       

     
       
    04.08.01  Topiramate
    Topiramate
    (Tablet, Sprinkle capsule)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • CUHFT and NWAFT: Formulary for the management of epilepsy

    • RPH: Non-formulary

    • Base the need for continued supply of a particular brand on clinical judgement and consultation with patient and/or carer, taking into account factors such as seizure frequency and treatment history.

     
       
    04.08.01  Valproate
    Sodium valproate (Epilepsy)
    (EC tablet, MR tablet, crushable tablet, oral solution, granules)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Advice

    • Formulary for the management of epilespy

    • Can be initiated in Primary Care on the advice of a specialist

    • MHRA/CHM advice: Valproate is contraindicated in women and girls of childbearing potential unless conditions of the Pregnancy Prevention Programme are met 

    • Base the need for continued supply of a particular brand on clinical judgement and consultation with patient and/or carer, taking into account factors such as seizure frequency and treatment history.



     

     
    Link  March 2019: Stock availability of Valproate-containing products (Sanofi)
    Link  MHRA Drug Safety Update September 2018: Valproate Pregnancy Prevention Programme - actions required now from GPs, specialists, and dispensers
    Link  MHRA Drug Safety Update April 2019: Valproate medicines and serious harms in pregnancy - new Annual Risk Acknowledgement Form and clinical guidance from professional bodies to support compliance with the Pregnancy Prevention Programme
    Link  MHRA Drug Safety Update February 2020: Valproate (Epilim▼, Depakote▼) pregnancy prevention programme - updated educational materials
    Link  MHRA Drug Safety Update May 2018 - Valproate medicines (Epilim, Depakote): Pregnancy Prevention Programme
    Link  Valproate Risk Materials
       
    04.08.01  Vigabatrin
    Vigabatrin (Sabril®)
    (Tablet, Powder)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • CUHFT and NWAFT: Formulary for the management of epilepsy

    • RPH: Non-formulary

    • The potential for clinically relevant differences to exist between different brands is considered to be extremely low - consider prescribing generically

     
       
    04.08.01  Zonisamide to top
    Zonisamide (Zonegran®)
    (Capsule)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Amber No SCG

     

    • CUHFT and NWAFT: Formulary for the management of epilepsy
    • RPH: Non-formulary
    • If needed capsules can be opened and contents dispersed in water or mixed with soft food (eg apple sauce, chocolate pudding).
    • Base the need for continued supply of a particular brand on clinical judgement and consultation with patient and/or carer, taking into account factors such as seizure frequency and treatment history.

    November 2020: Shortage of Zonisamide 25mg, 50mg and 100mg Capsules.

    • Teva are out of stock of zonisamide 25mg and 50mg capsules until February 2021.
    • Teva are out of stock of zonisamide 100mg capsules until December 2020.
    • Glenmark are out of stock of zonisamide 100mg until mid November 2020. 
    • All strengths of zonisamide capsules remain available from Eisai Ltd.

    Zonisamide is a category 2 anti-epileptic drug as designated by the MHRA. For these drugs the need for continued supply of a particular manufacturer’s product should be based on clinical judgement and consultation with the patient and/or carer considering factors such as seizure frequency and treatment history.

    As a result of this shortage patients may have to switch to an alternative manufacturer’s zonisamide capsules. Clinicians advise that prescribers should closely monitor patients for any changes in seizure frequency and/or breakthrough seizures when they are switched over to alternative manufacturer’s zonisamide capsules. 

    Patients should be informed of the change in manufacturer’s product and advise them to report any changes in seizure frequency to their GP

    • See Supply Disruption Alert link below (issued 28th October 2020) for further information on how to manage patients during this shortage. 
     
    Link  Zonisamide capsules various strengths (Glenmark and Teva) - Supply disruption notification (issued 28/10/2020)
       
    04.08.01  Benzodiazepines
    Clobazam
    (Tablet, liquid)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

     

    • CUHFT and NWAFT: Formulary for the management of epilepsy
    • RPH: Non-formulary
    • Base the need for continued supply of a particular brand on clinical judgement and consultation with patient and/or carer, taking into account factors such as seizure frequency and treatment history.

     

     
       
    Clonazepam
    (Epilepsy/ restless legs/ psychiatry) (Tablet, oral solution)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • NWAFT and CUHFT: Formulary for the management of epilepsy

    • Base the need for continued supply of a particular brand on clinical judgement and consultation with patient and/or carer, taking into account factors such as seizure frequency and treatment history

    • CUHFT: Also restricted to the following off-label uses:


      • prevent seizures in high risk neuroblastoma

      • REM Sleep Behaviour Disorder (REMSBD) in Parkinson's Disease

      • restless legs syndrome in renal patients


    • RPH: Non-formulary

    • CPFT: Also restricted to the following off-label uses:


      • behavioural control (Hospital only)

      • anxiety

      • tardive dyskinesia



     


     

     
    Link  BNF advice on recommended maximum period of treatment for benzodiazepines
    Link  MHRA patient information: New law on driving having taken certain drugs
    Link  MHRA: Drugs and driving: blood concentration limits to be set for certain controlled drugs in a new legal offence
       
    04.08.01  Other Drugs
    Acetazolamide
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    See also section 11.6 for glaucoma indication

    • CUHFT: Formulary for the management of epilepsy
    • Non-formulary at all other Trusts for this indication

     

     
       
    Perampanel (Fycompa®)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

     

    • CUHFT and NWAFT: In line with locally agreed treatment pathway for epilepsy in adults as fourth or fifth line option when other anti-epileptics have failed.
    • RPH: Non-formulary
    • Base the need for continued supply of a particular brand on clinical judgement and consultation with patient and/or carer, taking into account factors such as seizure frequency and treatment history.

     

     
    Link  NICE CG137: The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care
    Link  NICE evidence summary
       
    Cannabidiol (Epidyolex® )
    (Solution)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital
    • Approved for use in line with NICE TA614 - Cannabidiol with clobazam for treating seizures associated with Dravet syndrome.
    • Approved for use in line with NICE TA615 - Cannabidiol with clobazam for treating seizures associated with Lennox–Gastaut syndrome. 
     
    Link  NICE TA614: Cannabidiol with clobazam for treating seizures associated with Dravet syndrome
    Link  NICE TA615: Cannabidiol with clobazam for treating seizures associated with Lennox–Gastaut syndrome
       
    Brivaracetam (Briviact®)
    ((Tablets, solution, injection) )
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

     



    • NWAFT and CUHFT: Specialist initiation for patients who experience behaviour side effects with levetiracetam (epilepsy)

    • RPH: Non-formulary

    • The potential for clinically relevant differences to exist between different brands is considered to be extremely low - consider prescribing generically

     
       
    Felbamate
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CUHFT: Formulary for the management of epilepsy

    • Non-formulary at all other Trusts and in Primary Care

     
       
    Stiripentol  (Diacomit®)
    ((Tablet, Sachet, Capsules))
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber SCG

    • CUHFT: Severe myoclonic epilepsy in infancy in line with Shared Care Guideline.

    • Non-formulary at all other Trusts

     
    Link  CUHFT SCG: Stiripentol use for Severe Myoclonic Epilepsy in
       
    04.08.02  Drugs used in status epilepticus
    Clonazepam
    (Epilepsy)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • NWAFT and CUHFT: Formulary for the management of statis epilepticus 

    • (see section 04.08.01 for other indications)

    • Base the need for continued supply of a particular brand on clinical judgement and consultation with patient and/or carer, taking into account factors such as seizure frequency and treatment history.

     
       
    Diazepam
    (Rectal tubes, injection)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Amber No SCG

    • Note: Diazepam injection comes in two forms - solution (IM or IV) and emulsion

    • Diazemuls® (IV only). Emulsion is preferred for IV as it is less irritant to the vein.

    • Injectable formulations are Hospital only

     
    Link  Diazemuls emulsion SPC
    Link  Diazepam injection solution SPC
       
    Controlled Drug Midazolam (Epilepsy)
    (Oromucosal solution)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Advice

    • CUHFT: Buccolam® is on formulary (Epistatus® is restricted to patients needing doses <2.5mg) in whom rectal diazepam is not suitable. For use in both inpatients and outpatients.

    • RPH: Only Buccolam® is on formulary

    • NWAFT: Both Buccolam® (Licensed in infants, toddlers, children and adolescents (to 18 years old)) and Epistatus® are on formulary

    • Epistatus and Buccolam not interchangeable

    • Where there is an urgent clinical need the trusts will initiate. 

    • Where there is no clinical urgency secondary care will provide advice for primary care to initiate.


    CD prescribing regulations apply, although does not need to be entered in CD register or stored in CD cupboard.


     





     

     
       
    Controlled Drug Midazolam (Injection)
    (Epilepsy)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Red Hospital

    • Low strength midazolam on formulary.

    • To comply with NPSA Rapid Response Report ‘Reducing risk of overdose with midazolam injection in adults’, high strengths midazolam injection(>1mg/ml) is restricted to a limited number of wards who have this on the ward stock list. Other wards, not stocking high strengths midazolam, should NOT borrow from wards that do but should contact pharmacy.


     





     

     
    Link  CUH Midazolam policy and procedure
       
    Paraldehyde
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Red Hospital

     

      • NWAFT & CUH: 50% in olive oil rectal solution(formulary). unlicensed unlicensed

     

      • Non-formulary at all other Trusts and in Primary Care 

     

     
       
    Controlled Drug Phenobarbital
    (Injection)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • NWAFT: Formulary

    • Non-formulary at all other Trusts

     
       
    Phenytoin
    (Injection)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital
  • Loading doses need to be given as an infusion through a 0.2 to 0.5 micron filter.  
  •    
    Lorazepam (Epilepsy)
    (Injection)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Red Hospital

    June 2020 - Supply disruption of Lorazepam (Ativan®) 4mg/ml Solution for injection

    • Ativan® (lorazepam) 4mg/ml solution for injection will be out of stock from w/c 27th April until w/c 15th June 2020.
    • The US product, lorazepam injection 2mg/ml, supplied in Carpuject™ single dose cartridges will be available to Trusts from early May 2020 on an ‘unlicensed’ basis.
    • CarpujectTM single dose cartridges can be considered bioequivalent to the UK brand Ativan® (lorazepam) 4mg/ml solution for injection and no dosing adjustments should be required.
    • Carpuject™ cartridges must be used in combination with the Carpuject™ holder provided. Injection in cartridge is diluted with an equal volume of compatible solution for IV administration (IM injection is administered undiluted).
    • See Supply Disruption Alert below for further information. 
     
    Link  June 2020: Supply Disruption Alert - Lorazepam (Atrivan) 4mg/ml solution for injection (issued 28th April 2020)
       
    04.08.03  Febrile convulsions
    Paracetamol
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Green
    See section 4.7.1 
       
    Diazepam
    (febrile convulsions)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Red Hospital

    See section 4.8.2

     
       
    04.09  Drugs used in parkinsonism and related disorders to top
    04.09.01  Dopaminergic drugs used in Parkinsons disease
    04.09.01  Dopamine receptor agonists
    Ropinirole
    (Tablet, MR tablet)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Amber No SCG

    • Formulary for the treatment of Parkinson's Disease

    • RPH only: May be initiated by Sleep Consultants for restless legs

    • If needed standard release tablets can be crushed and dispersed in water or mixed with soft food.

     
    Link  ReQuip (ropinorole hydrochloride) 0.25mg, 1mg, 2mg and 5mg Tablets: Important changes to the colour of carton and blister packs (Apr 2020)
       
    Apomorphine
    (Injection, Infusion)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Amber SCG

    • CUHFT and NWAFT: For use by Consultant Neurologists and Geriatricians ONLY in line with Shared Care Guideline

    • RPH: Non-formulary
       

     
    Link  Shared Care Guideline: Apomorphine use in Parkinson’s disease
    Link  Apo-Go Manufacturers guide: Setting the flow rate and bolus/priming dose
    Link  Apo-Go Manufacturers guide: Setting up the APO-go Infusion and Pump
       
    Bromocriptine
    (Parkinsons)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Amber No SCG

    • CUHFT: For use by Consultant Neurologists and Geriatricians ONLY.

    • Non-formulary at all other Trusts

    • For hyperprolactinaemia see section 6.7.1

    • If needed tablets can be dispersed in water. Give immediately and flush well with water.

     
       
    Cabergoline
    (Tablet)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • CUHFT and RPH: Consultant Neurologists and Geriatricians

    • If needed tablets can be dispersed in water. Give immediately and flush well with water.

    • NWAFT: Non-formulary

     
       
    Pergolide
    (Tablet)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Amber No SCG

    • CUHFT: For use by Consultant Neurologists and Geriatricians ONLY.

    • Non-formulary at all other Trusts 

     
       
    Pramipexole
    (Tablet, MR tablet)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Amber No SCG

    • CUHFT and NWAFT: For use by Consultant Neurologists and Geriatricians ONLY.

    • RPH only: May be initiated by Sleep Consultants for restless legs

    • If needed immediate release tablets can be crushed and dispersed in water.

    • Doses and strengths are stated in terms of pramipexole (base).

     
       
    Rotigotine
    (Patch)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Amber SCG

    • CUHFT and NWAFT: For prescription by consultant Parkinson Disease specialists only in line with Shared Care Guideline

    • RPH: May be initiated by Sleep Consultants for restless legs in line with Shared Care Guideline

     
    Link  Rotigotine patch change in storage requirements (PIL)
    Link  RPH SCG: Rotigotine for treatment of moderate to severe idiopathic Restless Legs Syndrome
    Link  SCG: Rotigotine for Parkinsons Disease
       
    04.09.01  Levodopa
    Co-Beneldopa (Madopar®)
    (Capsule, Dispersible tablet, Capsule MR)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Advice

     

     

     
    Link  UKMI Q&A:Guidance on converting from MR formulation to dispersible tablets
       
    Co-Careldopa (Sinemet®)
    (Tablet, Tablet MR )
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Advice

     

    • Prescribe generically.

    October 2020 - Shortage of co-careldopa 25mg/100mg tablets (Teva)

    • Teva, a generic supplier is out of stock and is currently unable to provide a resupply date.
    • MSD, the supplier of the brand Sinemet Plus can cover supply for the whole market during this time.
     
       
    Co-Careldopa and Entacapone (Stalevo®, Stanek®, Sastravi®, )
    (Tablets )
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Amber No SCG

     

    • For initiation by Consultant Neurologists and Geriatricians ONLY.
    • A combination product is preferable to administering the components separately as per NICE guidance.
    • Please prescribe by brand. Brands available include Sastravi®, Stanek® and Stalevo®
    • For new patients the current preferred brand is Stanek®.
    • CUHFT only the preferred brand is Sastravi®.

    October 2020 - Supply issues with Stanek and Sastravi (levodopa/carbidopa/entacapone) tablets 

    • Teva and Accord have informed the DHSC that there are supply issues impacting on the following presentations of Stanek and Sastravi tablets.
    • Anticipated resupply dates as per table below:
    •  
       

      Pack size

      Anticipated resupply dates

      Sastravi 175mg/43.75mg/200mg

      30 

      100 

      Mid  November 2020 

      150mg/37.5mg/200mg

      100 

      To be confirmed 

    • All other Stanek and Sastravi presentations remain available during this time.
    • Supplies of Stalevo tablets which are considered equivalent, continue to remain available. 
    • For patients with insufficient supplies of Stanek or Sastravi until the anticipated resupply date, clinicians should consider prescribing levodopa/carbidopa/entacapone tablets generically so that pharmacies can supply an equivalent preparation of an available product.  
    • Patients who are required to change brand should be monitored for side effects/change in disease control. 
    • Patients should be counselled on any changes to avoid medication errors, especially for those patients on more than one strength of  tablets. 
    • See Medicine Supply Notification below for further information. 



     
    Link  June 2020: Medicine Supply Notification - Levodopa/carbidopa/entacapone tablets (published 16th June 2020)
       
    04.09.01  Monoamine-oxidase-B inhibitors
    Selegiline Hydrochloride
    (Tablet, Liquid)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Advice
     
       
    Rasagiline
    (Tablets)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

     

    • CUHFT and RPH: Formulary.
    • Non-formulary at NWAFT.

    June 2020 - Supply issues with rasagiline 1mg tablets 

    • Supplies of generic rasagiline 1mg tablets are currently on transit to the wholesalers and should be available shortly. 
    • Teva have reported they have good supplies of Azilect® (branded rasagiline) available.

     

     
       
    Safinamide (Xadago®)
    (Tablets )
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber No SCG

    • Prescribable in primary care after specialist initiation (2 months) for patients where existing oral agents (amantadine and other MAO-inhibitor B medications) are contra-indicated or have failed to improve motor fluctuations in idiopathic PD. 

     
       
    04.09.01  Catachol-O-methyltransferase inhibitors to top
    Entacapone (Comtess®)
    (Tablet)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Advice
     
       
    Tolcapone (Tasmar®)
    (Tablet)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CUHFT: For use by Consultant Neurologists and Geriatricians ONLY.

    • Non-formulary at all other Trusts and in Primary Care

    • Regular LFT monitoring required

    • Previously withdrawn due to liver problems. Relaunched August 2005.

     
       
    Opicapone
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

     

    • NWAFT only (HOSPITAL ONLY): For use when patients cannot be stabilised on entacapone and does not meet the criteria below in relation to persistent diarrhoea.
    • Specialist Initiation (CUHFT and NWAFT) 2-month trial by secondary care for continuation in primary care only For patients with Parkinson’s and motor fluctuations who are eligible for a 2 month trial of opicapone will necessarily first have had a trial of entacapone, and will have experienced the unacceptable adverse effect of persistent diarrhoea causing incontinence, or frequent passing of loose stool disturbing sleep or lifestyle, as defined by Bristol stool chart 6/7, which resolves when stopping entacapone.
    • Non-formulary at all other Trusts.
     
       
    04.09.01  Amantadine
    Amantadine
    (Parkinson's, Capsule, Syrup)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Amber No SCG
     
       
    04.09.02  Antimuscarinic drugs used in parkinsonism
     note 
  • These medicines have some benefit but have a high incidence of side effects
  • Contraindicated in the elderly, untreated urinary retention, angle-closure glaucoma, GI obstruction and prostatic hypertrophy
  • Procyclidine
    (Tablet, oral solution, injection.)
    View adult BNF View SPC online View childrens BNF  Track Changes
    First Choice
    Advice

    • Formulary for use in Parkinson's Disease

    • CPFT: Additionally recommended for the management of extra-pyramidal side effects

    • Injection is Hospital only

     
    Trihexyphenidyl
    (Tablet, syrup)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Second Choice
    Advice

    • CUHFT and NWAFT: Formulary for use in Parkinson's Disease

    • CUHFT: Also, used in paediatrics (off-label) for dystonias and is documented in guidelines with sugegsted dosing in BNFC 

    • CPFT: Also recommended for the management of extra-pyramidal side effects

    • RPH: Non-formulary

    • Formerly known as benzhexol.


     

     
       
    Orphenadrine
    (Oral solution)
    View adult BNF View SPC online  Track Changes
    Restricted Drug Restricted
    Advice

    • CUHFT and NWAFT: Formulary for use in Parkinson's Disease

    • RPH: Non-formulary

    • CPFT: Formulary for the management of extrapyramidal side effects

    • More likely to cause insomnia.

    • Now only available as a liquid formulation

    • More expensive than alternatives (procyclidine and trihexyphenidyl)


     

     
       
    04.09.03  Drugs used in essential tremor, chorea, tics, and related disorders
    Primidone
    (essential tremor)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Amber No SCG

    • CUHFT: Formulary

    • Non-formulary at all other Trusts

     
       
    Propranolol
    (essential tremor)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Amber No SCG

    • CUHFT: Formulary

    • Non-formulary at all other Trusts for this indication

     
       
    Riluzole (Rilutek®)
    (Tablet)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber SCG

    • Recommended in line with the Shared Care Guideline for the treatment of adult patients with the amyotrophic lateral sclerosis form of motor neurone disease.

    • Commissioned in line with NICE TA20

    • Prescribe generically

    • Oral suspension is very expensive compared to generic tablets (suspension is non-formulary within the Trusts)

     
    Link  CUHFT SCG: Riluzole – For the treatment of adult patients with the amyotrophic lateral sclerosis form of motor neurone disease.
    Link  NICE TA20: Riluzole for the treatment of Motor Neurone Disease
       
    Tetrabenazine (Xenazine® 25)
    (Tablet)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Amber No SCG

    • CUHFT and NWAFT: Formulary for the treatment of movement disorders

    • Non-formulary at all other Trusts and in Primary Care

     
       
    Botulinum Toxin (Dysport®, Botox®, Neurobloc®, )
    (Injection)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital
    BlueTeq

    • CUHFT and NWAFT: Consultant recommendation only in line with Commissioned Indications.

    • CUHFT only: Dysport® is the formulary choice preferred product for new patients (Botox® is normally reserved for historic patients as not supposed to switch between products).

    • (Neurobloc® is non-formulary at NWAFT)

    • For CCG commissioned treatments a GPA is required prior to treatment commencing.

    • Botulinum toxin formulations are not interchangeable

    • Non-formulary at all other Trusts



     
    Link  Group Prior Approval Forms for CCG Commissioned Indications
       
    Haloperidol
    (essential tremor)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CUHFT: Unlicensed indication.unlicensed unlicensed See section 4.2.1

    • Non-formulary at all other Trusts and in Primary Care for this indication

     
       
    04.09.03  Torsion dystonias and other involuntary movements
    Botulinum neurotoxin type A (Xeomin®)
    (Injection)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital
    • Approved for use in line with NICE TA605 - Xeomin (botulinum neurotoxin type A) for treating chronic sialorrhoea. 
    • CUHFT: Approved for focal spasticity after brain or spinal lesions or neurodegenerative conditions in adults - requires GPA. 

     

     
    Link  Group Prior Approval Forms for CCG Commissioned Indications
    Link  NICE TA605: Xeomin (botulinum neurotoxin type A) for treating chronic sialorrhoea
       
    Botulinum Toxin (Dysport®, Botox®, Neurobloc®, )
    (Injection)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • CUHFT and NWAFT: Consultant recommendation only in line with Commissioned Indications.

    • (Neurobloc® is non-formulary at NWAFT)

    • CUHFT only: Dysport® is the formulary choice preferred product for new patients (Botox® is normally reserved for historic patients as not supposed to switch between products).

    • For CCG commissioned treatments a GPA is required prior to treatment commencing.

    • Botulinum toxin formulations are not interchangeable

    • Non-formulary at all other Trusts



     
    Link  Group Prior Approval Forms for CCG Commissioned Indications
       
    04.09.04  Restless leg syndrome to top
    04.10  Drugs used in substance dependence
    04.10.01  Alcohol dependence
    Acamprosate
    (EC tablet)
    View adult BNF View SPC online  Track Changes
    Formulary
    Amber No SCG

     

    • CUHFT, CPFT and RPH: Formulary

     

    • NWAFT: Non- formulary (not to be initiated within the Trust)

     

    • Prescribing can be continued in Primary care following initiation from an appropriate specialist at CUHFT, CPFT, RPH and the drug and alcohol services. 

     

     
       
    Disulfiram
    (Tablets)
    View adult BNF View SPC online  Track Changes
    Formulary
    Amber No SCG

    • CUHFT, CPFT and RPH: Formulary

    • NWAFT: Non- formulary (not to be initiated within the Trust)

     
       
    Nalmefene  (Selincro®)
    (Tablets)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Advice

    • Should only be prescribed in conjunction with continuous psychosocial support provided by the local drug and alcohol services,  focused on treatment adherence and reducing alcohol consumption  and in line with NICE TA325

     
    Link  NICE TA325: Nalmefene for reducing alcohol consumption in people with alcohol dependence
    Link  Cambridgeshire (Inclusion) Nalmefene Pathway
    Link  Peterborough Nalmefene Pathway
       
    04.10.02  Nicotine dependence
     note 


     

    Nicotine
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Green

    • Within the CUHFT and RPH supply is limited to:

      • Those who want to quit AND have been referred to a support service or

      • Patient is admitted to ICU/ NCCU. (Following transfer to a non-intensive care setting Pharmacy will no longer supply NRT unless they have been referred to a support service) or

      • Enforced isolation.



    • Alternatively, replacement therapies can be purchased through Outpatient pharmacy.

    • Within Primary Care, prescriptions should not be provided unless recommended by a stop smoking service. Patients can purchase NRT products from their Community Pharmacist.

    • CPFT: All NRT products are on formulary. Wards stock:


      • Nicorette® 2mg and 4mg lozenge

      • Niquitin® 14mg and 21mg 24 hour patches

      • Nicorette® 15mg inhalators

      • Please see CPFT Smoke Free Policy and CPFT Nicotine Replacement Therapy Guidelines below.


    • NWAFT:

      • Recommends self-care for all patients.

      • Niquitin CQ patches all strengths available for patients who require them as inpatients. 



     
    Link  Cambridgeshire and Peterborough Stop Smoking Pharmacological Products Guidance
    Link   CPFT - Smoke Free Policy
    Link  CPFT - Nicotine Replacement Therapy Guidelines
    Link  CUH Nicotine replacement therapy (NRT): supply to inpatients
    Link  UKMI Q & A: Evidence for NRT for the treatment of UC
    Link  What are the clinically significant drug interactions with cigarette smoking?
       
    Bupropion Hydrochloride (Zyban®)
    (Tablet)
    View adult BNF View SPC online  Track Changes
    Restricted Drug Restricted
    Green

     

    • Prescribable in Primary Care only in combination with intensive behavioural support
    • Non-formulary at all other Trusts

    October 2020 - Supply issues with Zyban (bupropion hydrochloride) 150mg prolonged release tablets

    • Zyban® (bupropion hydrochloride) 150mg prolonged release tablets will be out of stock until early December 2020.
    • See Supply Disruption Alert link below (issued 29th May 2020) for further information on how to manage patients during this shortage. 

     



     

     
    Link  Supply Disruption Alert: Zyban (bupropion hydrochloride) 150mg prolonged-release tablets (issued 29th May 2020)
       
    Varenicline (Champix®)
    (Tablets)
    View adult BNF View SPC online  Track Changes
    Restricted Drug Restricted
    Green

    • In line with NICE TA123

    • To be prescribed only as part of a programme of behavioural support.


     

     
    Link  MHRA Drug Safety Update: Varenicline and suicidal behaviour: cohort study provides some reassurance
    Link  NICE TA123: Varenicline for smoking cessation
       
    04.10.03  Opioid dependence
    04.10.03  Opioid substitution therapy to top
    Controlled Drug Buprenorphine (Espranor®)
    (Oral Lyophilisate)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital
    • Espranor is not interchangeable with other buprenorphine products e.g. Subutex or generic sublingual buprenorphine tablets. This is because the bioavailability of buprenorphine is 25-30% higher with Espranor as it is more completely absorbed compared to sublingual tablets.
    • For use by psychiatrists/dependence service only
    • Trusts: For continuation of established treatment only. Not currently commissioned to provide specialist prescribing for substance misuse services
    • Treatment to be retained by the specialist dependence service and not prescribed in Primary Care

     

     
    Link  Espranor (buprenorphine oral lyophilisate) 2mg and 8mg: Considerations for opioid substitution therapy use in community settings and secure environments
       
    Controlled Drug Buprenorphine (Subutex®)
    (Sublingual Tablet)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    Sublingual burpenorphine (Subutex) is not interchangeable with oral lyophilisate buprenorphine (Espranor). 

      • For use by psychiatrists/dependence service only
      • Trusts: For continuation of established treatment only. Not currently commissioned to provide specialist prescribing for substance misuse services
      • Treatment to be retained by the specialist dependence service and not prescribed in Primary Care



     

     
       
    Controlled Drug Methadone
    (Dependance)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Red Hospital

    • Oral solution 1mg in 1mL

    • For use by psychiatrists/dependence service only

    • Trusts: For continuation of established treatment only. Not currently commissioned to provide specialist prescribing for substance misuse services

    • Treatment to be retained by the specialist dependence service and not prescribed in Primary Care


     

     
       
    04.10.03  Adjunctive therapy and symptomatic treatment
    Lofexidine (BritLofex®)
    (Tablet)
    View adult BNF View SPC online