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 Formulary Chapter 4: Central nervous system - Full Chapter
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04.03.03  Expand sub section  Selective serotonin re-uptake inhibitors
 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)
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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)
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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)
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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.

September 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 - Shortage of Fluoxetine 30mg capsules

  • Advanz, sole supplier is out of stock until mid-December 2020.
  • Fluoxetine 10mg and 20mg capsules remain available.

 

 
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  June 2020: Medicine Supply Notification - Fluoxetine 10mg tablets (published 12th March 2020)
Link  June 2020: Medicine Supply Notification - Fluoxetine 40mg capsules (published 29th May 2020)
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
Link  Q&A SSP05 March 2020: Fluoxetine 10mg tablets - valid until 12th June 2020
Link  SSP05 March 2020: Fluoxetine 10mg tablets - valid until 12th June 2020
Link  Triptans and SSRI or SNRI antidepressants – is there an interaction? (UKMI Q&A)
   
Paroxetine
(Tablet, oral suspension)
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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
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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)
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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)
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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)
   
 ....
 Non Formulary Items
Fluoxetine TABLETS

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Non Formulary
Black

  • Very expensive compared to alternative fluoxetine formulations

  • For 10mg dose consider 20mg dispersible tablets (e.g. Olena brand) which can be halved if required (more cost effective May 2014 than giving licensed liquid)

 
  
Key
note Notes
Section Title Section Title (top level)
Section Title Section Title (sub level)
First Choice Item First Choice item
Non Formulary Item Non Formulary section
Restricted Drug
Restricted Drug
Unlicensed Drug
Unlicensed
Track Changes
Display tracking information
click to search medicines.org.uk
Link to adult BNF
click to search medicines.org.uk
Link to children's BNF
click to search medicines.org.uk
Link to SPCs
SMC
Scottish Medicines Consortium
Cytotoxic Drug
Cytotoxic Drug
CD
Controlled Drug
High Cost Medicine
High Cost Medicine
Cancer Drugs Fund
Cancer Drugs Fund
NHSE
NHS England
Homecare
Homecare
CCG
CCG

Traffic Light Status Information

Status Description

OTC

Available Over the Counter. Consider Self Care   

Green

Formulary - Can be prescribed in both secondary and primary care.   

Advice

Formulary - Specialist Advice, secondary care advice provided for primary care initiation.  

Amber No SCG

Formulary - Specialist initiation without shared care guidance.  

Amber SCG

Formulary - Specialist initiation with shared care guidance.  

Red Hospital

Restricted - Hospital only, not to be prescribed in primary care.  

Switch

Not recommended for prescribing. Switch to alternative cost-effective option.   

Black

Not recommended for prescribing in primary or secondary care.  

Grey

Not recommended as no formal application made for addition to the formulary. Contact relevant pharmacy team for further information.   

Non Formulary

Non-Formulary (category under review).  

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