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4. Central Nervous System

For information on prescribing of unlicensed medicines and off-label use of medicines in this chapter, see TEWV Guidelines on unlicensed and off-label use of medicines

TEWV: Safe transfer of prescribing guidance

MHRA Drug Safety Alert (Feb 2015):  Drugs and driving: blood concentration limits set for certain drugs

Guidelines

County Durham and Darlington  APC - Initial Prescribing Protocol: Oral Analgesia in Adults with Non-Cancer – July 2015

NICE NG41: Spinal injury: assessment and initial management

NICE NG42: Motor neurone disease: assessment and management

NICE NG62: Cerebral palsy in under 25s: assessment and management

NICE CG100: Alcohol-use disorders: diagnosis and management of physical complications

CD&D APC Patient Decision Aids Resource available at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington/

CD&D APC “Do Not Prescribe List” and “Grey List – drugs prescribed under limited circumstances” available at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington/

 

 

Please refer to NICE guidelines NICE TA77

All hypnotics should be prescribed for short periods of time only.

Switching from one drug to another should only occur if the patient experiences side effects that are specifically related to the medicines.

Patients who have not responded to one of these hypnotics should not be prescribed any of the others.

Use in the elderly is discouraged.

 

First choice

Zopiclone

Temazepam

Alternatives

Zolpidem: MHRA Drug Safety Alert (May 2014) – risk of drowsiness and reduced driving ability

Promethazine

 

CSM Advice:

  1. Benzodiazepines are indicated for short term relief (2-4 weeks only) of anxiety that is severe, disabling or causing the patient unacceptable distress, occurring alone or in association with insomnia or short term psychotic illness.
  2. The use of benzodiazepines to treat short term anxiety is inappropriate. 
  3. Benzodiazepines should be used to treat insomnia only when it is severe, disabling or causing the patient extreme distress. 
Temazepam
BNF | BNFC | SPC

Tablets - 10mg

Liquid - 10mg/5ml

Zopiclone
BNF | BNFC | SPC

FIRST LINE

Tablets - 3.75mg, 7.5mg

 

 

Melatonin
BNF | BNFC | SPC

MR Tabs - 2mg

MR tabs licensed only for adults over 55years. Classed as Amber for children and young adults and prescribed off label. 

MR tablets are not approved on the formulary for the management of primary insomina in adults.

Shared Care Guideline: Melatonin

CDDFT Intranet: Melatonin – available here

Zolpidem
BNF | BNFC | SPC

Zolpidem: MHRA Drug Safety Alert (May 2014) – risk of drowsiness and reduced driving ability

Promethazine
BNF | BNFC | SPC

10mg & 25mg tablets
5mg in 5ml sugar-free elixir
25mg in 1ml injection

Flurazepam
BNF | BNFC | SPC
Chloral hydrate
BNF | BNFC | SPC

Chloral hydrate is not recommended in the BNF for the management of insomnia.

Sodium Oxybate
BNF | BNFC | SPC

Not approved: sodium oxybate – see NTAG recommendation

See NICE NG10 - Violence and aggression: short-term management in mental health, health and community settings

See NICE guidelines for the management of Anxiety Disorders

If a person with generalised anxiety disorder (GAD) chooses drug treatment, offer a selective serotonin reuptake inhibitor (SSRI) (see section 4.3)

Consider offering sertraline first as it is the most cost-effective, but is unlicensed for GAD.

 Do not offer a benzodiazepine for the treatment of GAD except as a short-term measure during crises. Follow the advice in the ‘British national formulary’ on the use of a benzodiazepine in this context: should not be used as an anxiolytic for more than 4 weeks without being reviewed.

Use in the elderly is discouraged.

 

First choice

Diazepam

Diazepam
BNF | BNFC | SPC

Tabs - 2mg, 5mg

Oral solution - 2mg/5ml

Rectal tubes - 2mg/ml, 4mg/ml

Chlordiazepoxide
BNF | BNFC | SPC

5mg & 10mg capsules

Chlordiazepoxide: used for acute alcohol withdrawal syndrome. See NICE guidance on the withdrawal of alcohol.

Lorazepam
BNF | BNFC | SPC

Tabs - 1mg

4mg in 1ml injection

SECOND LINE where rapid action is required and no suitable alternative or palliative care

Lorazepam: shorter acting benzodiazepines e.g lorazepam may be preferred in patients with hepatic impairment but carry greater risk of withdrawal symptoms.
Injection when used for rapid control of agitated or disturbed behaviour in patients with schizophrenia or manic episode where oral treatment is not appropriate. See TEWV Rapid Tranquilisation prescribing guidelines.

Meprobamate
BNF | BNFC | SPC
Buspirone
BNF | BNFC | SPC

Buspirone: patients must be stabilised on this prior to transfer of prescribing responsibility to GP. It is expected that they will have completed at least one month of treatment and be suitable for 28 day prescriptions.

Pregabalin
BNF | BNFC | SPC

(see also section 4.8)
Pregabalin: For those unable to tolerate SSRIs and SNRIs patients must be stabilised on this prior to transfer of prescribing responsibility to GP. It is expected that they will have completed at least one month of treatment and be suitable for 28 day prescriptions.

Refer to NICE guidance for schizophrenia CG 178

See also: NICE NG11 - Challenging behaviour and learning disabilities: prevention and interventions for people with learning disabilities whose behaviour challenges

The choice of antipsychotic should take into account the relative side-effect profile and the views of the user.

 

Refer to TEWV policies:

Guidance for safe transfer of prescribing (TEWV website)

HDAT - High Dose Antipsychotic Treatment (TEWV intranet only)

TEWV website: Hyperprolactinaemia guidance

 

Prescribing antipsychotics in the elderly

The balance of risks and benefits should be considered.  See Pharmacological management guidelines for Behavioural & Psychological Symptoms of Dementia (available via TEWV intranet only)

Haloperidol
BNF | BNFC | SPC

Tabs - 500microgram, 1.5mg, 5mg, 10mg, 20mg

Oral Liquid - 2mg/ml

Haloperidol: Injection for rapid control of agitated or disturbed behaviour in patients with schizophrenia or manic episode where oral treatment is not appropriate.

Link to TEWV Rapid Tranquilisation prescribing guidelines

See NICE NG10 - Violence and aggression: short-term management in mental health, health and community settings

Chlorpromazine
BNF | BNFC | SPC

Tabs - 25mg, 50mg, 100mg

Oral solution - 25mg/5ml, 100mg/5ml

Trifluoperazine
BNF | BNFC | SPC

Tabs - 1mg, 5mg

Oral Solution - 5mg/5ml

For initiation by specialists only

Trifluoperazine: Patients must be stabilised on this prior to transfer of prescribing responsibility to GP. It is expected that they will have completed at least one month of treatment and be suitable for 28 day prescriptions.

Sulpiride
BNF | BNFC | SPC

Tablets - 200mg & 400mg

Oral solution - 200mg in 5ml sugar-free 

Sulpiride: Patients must be stabilised on this prior to transfer of prescribing responsibility to GP. It is expected that they will have completed at least one month of treatment and be suitable for 28 day prescriptions.

 

Zuclopenthixol (oral)
BNF | BNFC | SPC

Tabs - 2mg, 10mg, 25mg

Zuclopenthixol: Patients must be stabilised on this prior to transfer of prescribing responsibility to GP. It is expected that they will have completed at least one month of treatment and be suitable for 28 day prescriptions.

For initiation by specialists only

Promazine
BNF | BNFC | SPC
Zuclopenthixol acetate
BNF | BNFC | SPC

50mg in 1ml injection

For short term use by specialists in TEWV

Risperidone (oral)
BNF | BNFC | SPC

Tabs - 500microgram, 1mg, 2mg, 3mg, 4mg, 6mg

Orodispersible tabs - 500micrograms, 1mg, 2mg, 3mg, 4mg

Orodispersible tablets should only be prescribed for patients who are unable to swallow solid dose form.

MHRA Alert – risk of intraoperative floppy iris syndrome in patients undergoing cataract surgery. More details here.

Amisulpride
BNF | BNFC | SPC

Tabs - 50mg, 100mg, 200mg

Solution - 100mg/ml

Aripiprazole (oral)
BNF | BNFC | SPC

Tabs - 5mg, 10mg, 15mg

Orodispersible Tabs - 10mg, 15mg

Oral Solution - 1mg/ml

Orodispersible tablets should only be prescribed for patients who are unable to swallow solid dose forms

Enhanced efficacy above 15mg per day has not been demonstrated for any indication. However, some individuals may benefit from higher doses; such cases should be considered in conjunction with secondary care.

NICE TA213

Olanzapine (oral)
BNF | BNFC | SPC

Tabs - 2.5mg, 5mg, 7.5mg, 10mg, 15mg, 20mg

Orodispersible Tabs - 5mg, 10mg, 20mg

Orodispersible tablets should only be prescribed for patients who are unable to swallow solid dose forms

Quetiapine
BNF | BNFC | SPC

Tabs - 25mg, 100mg, 150mg, 200mg, 300mg

M/R Tabs - 50mg, 150mg, 200mg, 300mg, 400mg

Quetiapine immediate release should be used 1st line, MR preparations should be reserved for those with a clinical need e.g. poor compliance

See Guidelines for the use of quetiapine XL

Clozapine
BNF | BNFC | SPC

1st choice in treatment-resistant schizophrenia.

TEWV: Clozapine treatment guidance

TEWV: Clozapine treatment for psychosis in Parkinson’s disease

Paliperidone (oral)
BNF | BNFC | SPC

Paliperidone not approved – see NTAG recommendation

Lurasidone
BNF | BNFC | SPC

Lurasidone not approved – see NTAG recommendation

Refer to NICE Guideline Bipolar Disorder CG185

Antipsychotics drugs can be useful in acute episodes of mania and hypomania.

Lithium Carbonate
BNF | BNFC | SPC

Tabs 200mg, 400mg (Priadel) - brand of choice

Tabs - 250mg, 400mg  (Camcolit) - for exisiting patients only

MR Tabs - 450mg (Liskonum)- for exisiting patients only

Lithium should be prescribed by brand name

Unsuitable for discharge to GP from TEWV

See TEWV policy Safe Lithium Treatment Shared Care Guidelines (TEWV intranet only)

See Safety Guidance: Lithium on admission to CDDFT – intranet link (CDDFT only)

See Lithium Shared Care Guideline

 

For patients maintained on lithium levels above 1.0mmol/l – lithium is classed as a red drug

Lithium Citrate
BNF | BNFC | SPC

Oral Solution - 520mg/5ml (Priadel) - brand of choice

Oral Solution - 509mg/5ml (Li-Liquid)  - for existing patients only

See BNF for conversion of lithium citrate to lithium carbonate as the salts are not equivalent.

Lithium should be prescribed by brand name

Unsuitable for discharge to GP from TEWV

See Safety Guidance: Lithium on admission to CDDFT – intranet link (CDDFT only)

See TEWV: Lithium Shared Care Guideline

Valproic Acid
BNF | BNFC | SPC

Tabs E/C - 250mg, 500mg (as semi sodium valproate)

Depakote® and Convulex® licensed alternative to sodium valproate for treatment of manic episodes.

MHRA Drug Safety Update (Feb 2016): Valproate and of risk of abnormal pregnancy outcomes: new communication materials

MHRA Drug Safety Update (Jan 2015): Medicines related to valproate: risk of abnormal pregnancy outcomes 

MHRA Drug Safety Update (Nov 2013): Sodium valproate: Risk of neurodevelopmental delay in children following maternal use

MHRA Drug Safety Alert (April 2017): Valproate and developmental disorders: new alert asking for patient review and further consideration of risk minimisation measures 

Olanzapine (oral)
BNF | BNFC | SPC

2.5mg, 5mg, 7.5mg & 10mg, 15mg & 20mg tablets
5mg, 10mg & 15mg orodispersible tablets

Orodispersible tablets - should only be used in situations where the plain tablets are unsuitable

Risperidone (oral)
BNF | BNFC | SPC

500microgram, 1mg, 2mg, 3mg, 4mg & 6mg tablets
1mg per ml liquid

Orodispersible tablets - should only be used in situations where the plain tablets are unsuitable. MHRA Alert – risk of intraoperative floppy iris syndrome in patients undergoing cataract surgery. More details here.

Quetiapine
BNF | BNFC | SPC

25mg, 100mg, 150mg 200mg & 300mg tablets
50mg, 200mg, 300mg & 400mg prolonged release tablets

Immediate release should be used 1st line, MR preparations should be reserved for those with a clinical need e.g. poor compliance.

Carbamazepine
BNF | BNFC | SPC

See section 4.8

Sodium Valproate
BNF | BNFC | SPC

See section 4.8

Prevention and treatment of manic episodes associated with bipolar disorder

MHRA Drug Safety Update (Feb 2016): Valproate and of risk of abnormal pregnancy outcomes: new communication materials

MHRA Drug Safety Update (Jan 2015): Medicines related to valproate: risk of abnormal pregnancy outcomes 

MHRA Drug Safety Update (Nov 2013): Sodium valproate: Risk of neurodevelopmental delay in children following maternal use

MHRA Drug Safety Alert (April 2017): Valproate and developmental disorders: new alert asking for patient review and further consideration of risk minimisation measures 

Lamotrigine
BNF | BNFC | SPC

See section 4.8

Asenapine
BNF | BNFC | SPC

Refer to NICE guidance for schizophrenia CG 178

Consider offering depot/long-acting injectable antipsychotics when:

− service users would prefer this after an acute episode

− avoiding covert non-adherence to medication is a clinical priority

Flupentixol Decanoate
BNF | BNFC | SPC

20mg in 1ml, 40mg in 2ml, 50mg in 0.5ml,
100mg in 1ml & 200mg in 1ml injections

Fluphenazine Decanoate
BNF | BNFC | SPC

12.5mg in 0.5ml, 25mg in 1ml,
50mg in 0.5ml & 100mg in 1ml injections

Haloperidol Decanoate
BNF | BNFC | SPC

50mg in 1ml & 100mg in 1ml injections

Risperidone Long-acting
BNF | BNFC | SPC

25mg, 37.5mg and 50mg long acting injections

Risperidone long acting only for use by specialists in TEWV in accordance with TEWV Psychosis pathway

Zuclopenthixol Decanoate
BNF | BNFC | SPC

200mg in 1ml & 500mg in 1ml injections

Aripiprazole Long-acting injection
BNF | BNFC | SPC

400mg long acting injection

Paliperidone Long-acting injection
BNF | BNFC | SPC

50mg, 100mg & 150mg pre-filled syringe

Both monthly and three-monthly preparations of Paliperidone LAI are included in the formulary.

See TEWV policies:

Depression Pathway Medication Guidelines Primary and Secondary Care Monotherapies

Depression Pathway Medication Guidelines Secondary Care other monotherapies combination and augmentation

Antidepressant prescribing handy hints for healthcare professionals (to follow)

Additional guidance for prescribing in the elderly is available.

NICE CG28: Depression in children and young people: Identification and management in primary, community and secondary care

Recommended for 2nd line treatment.

First ChoicAntidepressant

Trazodone

Other Indications

Amitriptyline

See TEWV Depression Pathway Medication Guidelines Primary and Secondary Care Monotherapies

Amitriptyline
BNF | BNFC | SPC

Tabs - 10mg, 25mg, 50mg

Oral Solution - 25mg/5ml, 50mg/5ml

For use unlicensed for neuropathic pain

Imipramine
BNF | BNFC | SPC

Tablets - 10mgs, 25mg

 

Clomipramine
BNF | BNFC | SPC

Caps - 10mg, 25mg, 50mg

Lofepramine
BNF | BNFC | SPC

Tabs - 70mg,

Oral Solution - 70mg/5ml

Nortriptyline
BNF | BNFC | SPC

Tabs - 10mg, 25mg

 

Trimipramine
BNF | BNFC | SPC

Caps - 50mg

Tabs - 10mg, 25mg

Trazodone
BNF | BNFC | SPC

Caps - 50mg, 100mg

Tabs - 150mg

Liquid - 50mg/5ml

Clomipramine SR
BNF | BNFC | SPC
Doxepin
BNF | BNFC | SPC
Dosulepin
BNF | BNFC | SPC

Dosulepin prescribing is not recommended.  For existing patients prescribed dosulepin this TEWV guidance applies.

Moclobemide
BNF | BNFC | SPC

Tabs - 150mg, 300mg

Initiation to be recommended by secondary care

Phenelzine
BNF | BNFC | SPC

15mg tablets

Initiation to be recommended by secondary care

Indicated when there is no response to other antidepressant groups

See TEWV Depression pathway medication guidelines Secondary Care other monotherapies Combination and augmentation

Isocarboxazid
BNF | BNFC | SPC
Tranylcypromine
BNF | BNFC | SPC

SSRIs are considered 1st line intervention for depression in those requiring activation.

See TEWV Depression Pathway Medication Guidelines Primary and Secondary Care Monotherapies

Citalopram
BNF | BNFC | SPC

Tabs - 10mg, 20mg, 40mg

Oral Drops - 40mg/ml

Citalopram: See MHRA guidance regarding dose related QT prolongation and TEWV guidance on dose reduction and ECG monitoring

MHRA Drug Safety Update (July 2016): Citalopram: suspected drug interaction with cocaine; prescribers should consider enquiring about illicit drug use

Fluoxetine
BNF | BNFC | SPC

Caps - 20mg

Liquid - 20mg/5ml

Sertraline
BNF | BNFC | SPC

Tabs - 50mg, 100mg

Fluvoxamine
BNF | BNFC | SPC
Escitalopram
BNF | BNFC | SPC

Escitalopram: initiation to be recommended by secondary care

Escitalopram: See MHRA guidance regarding dose related QT prolongation and TEWV guidance on dose reduction and ECG monitoring

 

Duloxetine
BNF | BNFC | SPC

Caps - 30mg, 60mg

For use in diabetic neuropathy where other treatments are unsuitable or inadequate and initiated by a specialist

Agomelatine
BNF | BNFC | SPC

Tabs - 25mg

Recommended for the treatment of depression only following an adequate trial of at least three alternative antidepressant drugs at maximally tolerated doses.  See NTAG recommendation.

MHRA Drug safety Update (Nov’ 2014): risk of liver toxicity – reminder to test LFTs before and during treatment

Mirtazapine
BNF | BNFC | SPC

Tabs - 15mg, 30mg, 45mg

Orodispersible Tabs - 15mg, 30mg, 45mg 

1st line intervention for depression in those requiring sedation.

See Depression Pathway Medication Guidelines Primary and Secondary Care Monotherapies

Orodispersible tablets should only be prescribed for patients who are unable to swallow solid dose forms

Venlafaxine
BNF | BNFC | SPC

Tabs - 37.5mg, 75mg 

When prescribed in doses less than 225mg per day.
Immediate release should be used 1st line, MR preparations should be reserved for those with a clinical need e.g. poor compliance. The reason should be stated in GP communications when transferring prescribing.
In low doses is as expensive as an SRRI.
See TEWV Depression Pathway Medication Guidelines Primary and Secondary Care Monotherapies


When prescribed in doses above 225mg per day (Green+)

Must be recommended by a specialist and arrangements for 6-monthly monitoring of blood pressure agreed with GP.
Immediate release should be used 1st line, MR preparations should be reserved for those with a clinical need e.g. poor compliance. The reason should be stated in GP communications when transferring prescribing.

Reboxetine
BNF | BNFC | SPC

4mg tablets

Tryptophan
BNF | BNFC | SPC

Initiation to be recommended by secondary care

Indicated when there is no response to other antidepressant groups

See TEWV Depression pathway medication guidelines Secondary Care other monotherapies Combination and augmentation

Vortioxetine▼
BNF | BNFC | SPC

5mg, 10mg & 20mg film-coated tablets

For use as 3rd line treatment option for the management of depression as per NICE TA367

See TEWV Depression Pathway Medication Guidelines Primary and Secondary Care Monotherapies

TEWV Children and Young People’s Service ADHD Prescribing Guideline available at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington/

 NICE TA98

Atomoxetine
BNF | BNFC | SPC

Caps - 10mg, 18mg, 25mg, 40mg, 60mg or 80mg hard capsules

TEWV: Atomoxetine Shared Care Guideline

Dexamfetamine▼
BNF | BNFC | SPC

Tabs - 5mg

 

Lisdexamfetamine▼
BNF | BNFC | SPC

Capsules- 30mg, 50mg, and 70mg 

TEWV: Lisdexamfetamine Shared Care Guideline

Lisdexamfetamine – approved with the following restrictions

Second or third line option when response to previous methylphenidate treatment is considered clinically inadequate and where any of the following apply:

·         a liquid preparation is required

·         response to dexamfetamine established but control would be improved with a long acting preparation

·         covert administration has been deemed in the person’s best interests (mental capacity or children act)

Methylphenidate
BNF | BNFC | SPC

Tabs - 5mg, 10mg, 20mg

MR Tabs - 18mg, 27mg, 36mg (Concerta XL)

MR Caps - 5mg, 10mg, 20mg, 30mg, 40mg (Medikinet XL)

Unlicensed in adults, but NICE recommend that following a decision to start drug treatment in adults, methylphenidate should normally be tried first.

TEWV: Methylphenidate Shared Care Guideline

 

Guanfacine▼
BNF | BNFC | SPC

Guanfacine to be used to be used Treatment of Attention Deficit Hyperactivity Disorder in children and adolescents 6-17 years old for whom stimulants are not suitable, not tolerated or have been shown to be ineffective AND in those whom Atomoxetine is not suitable, not tolerated or has been shown to be ineffective.

Modafinil
BNF | BNFC | SPC

100mg tablets
– only approved for limited use in the treatment of patients with narcolepsy

Only for use in accordance with NICE guidelines

Liraglutide (Saxenda)
BNF | BNFC | SPC

18microgram/3ml solution for injection in a prefilled pen

Licensed for use in the management of obesity but has not yet been reviewed by APC and as such should not be prescribed.

Cyclizine
BNF | BNFC | SPC

Tablets - 50mg

Cinnarizine
BNF | BNFC | SPC

Tablets - 15mg

Promethazine
BNF | BNFC | SPC

Tablets - 5mg

Haloperidol
BNF | BNFC | SPC

500 microgram capsules,1.5mg, 5mg & 10mg tablets
1mg in 1ml & 2mg in 1ml oral liquid
5mg in 1ml & 20mg in 2ml inject

Prochlorperazine
BNF | BNFC | SPC

5mg tablets; 5mg in 5ml syrup
12.5mg in 1ml injection
3mg tablets (buccal) (Buccastem®)

Levomepromazine
BNF | BNFC | SPC

6mg tabletsu, 25mg tablets
25mg in 1ml injection - For use in palliative care

Domperidone
BNF | BNFC | SPC

Tablets - 10mg

Suspension - 5mg/5ml

MHRA Drug Safety Alert (May 2014): indication now restricted to nausea and vomiting

Metoclopramide
BNF | BNFC | SPC

Tablets - 10mg

Oral Solution - 5mg/5ml

Caution in elderly, young adults and children

Do not use in people under 20 years

MHRA Drug Safety Update Alert (Aug 2013) Metoclopramide– restricted dose and duration

Ondansetron
BNF | BNFC | SPC

4mg & 8mg tablets
4mg in 5ml sugar-free solution
4mg in 2ml & 8mg in 4ml injections
16mg suppositories

MHRA Drug Safety Alert (Jul 2013): Ondansetron for intravenous use: dose-dependent QT interval prolongation

Palonosetron
BNF | BNFC | SPC

250 microgram in 5ml injection, 500 microgram capsules
- for 2nd line of treatment for chemotherapy induced nausea vomiting only

Palonosetron with Netupitant▼
BNF | BNFC | SPC
Hyoscine Hydrobromide
BNF | BNFC | SPC

300 microgram oral/sublingual tablets
1mg/72 hour patches
- for the management of excessive secretions where tablets are unsuitable

Aprepitant
BNF | BNFC | SPC

80mg & 125mg capsules
- for the prevention of chemotherapy induced nausea and vomiting (CINV) in high risk patients in accordance with North of England Cancer Network: CINV Guidelines in adult oncology and haematology patients

Nabilone
BNF | BNFC | SPC

1mg caps

Betahistine
BNF | BNFC | SPC

Tablets - 8mg, 16mg

Meniere's disease

See Prescribing Protocol for oral analgesia in adults with non-cancer pain CDDFT link or primary care website

Paediatric Analgesia: Quick Reference Guide (CDDFT intranet access only)

Paediatric Analgesia Protocol (CDDFT intranet access only)

NICE CG173: Neuropathic pain

Effervescent / soluble tablets not generally recommended except in acute treatment of migraine.

Paracetamol
BNF | BNFC | SPC

500mg plain & soluble tablets
120mg & 250mg in 5ml suspensions (sugar-free)
1g injection for IV infusion

60mg, 125mg, 250mg & 500mg suppositories

See CDDFT drug protocol for IV paracetamol

Aspirin
BNF | BNFC | SPC

300mg dispersible & enteric coated tablets

NSAIDs
BNF | BNFC | SPC

See section 10.1.1

Nefopam
BNF | BNFC | SPC
Co-proxamol
BNF | BNFC | SPC
Co-cadaprin
BNF | BNFC | SPC
Tramacet
BNF | BNFC | SPC
Nabilone
BNF | BNFC | SPC

1mg capsules

Nabilone: approved for very limited use in the treatment of chronic pain (unlicensed indication) that has not responded to other treatments. Treatment must be initiated by pain consultants and reviewed after about one month. Treatment to be stopped immediately in non-responders.

Ziconotide
BNF | BNFC | SPC

Intrathecal Analgesia

NHS England – Not routinely commissioned

While Co-codamol 8/500 is commonly used, no advantages over paracetamol have been substantiated. The low dose of codeine may be enough to cause opioid side-effects (in particular, constipation) and can complicate the treatment of overdose, yet may not provide significant additional relief of pain. Use is therefore discouraged.

Dihydrocodeine Tartrate
BNF | BNFC | SPC

Tablets - 30mg

Oral Solution - 10mg/5ml

Codeine
BNF | BNFC | SPC

Tablets - 15mg, 30mg

Syrup - 25mg/5ml

30mg in 1ml injectionu  & 60mg in 1ml injection

Codeine is the preferred weak opioid analgesic.

MHRA Drug Safety Alert (Nov 2003): significant restrictions in paediatrics and breast feeding mothers

Interim CDDFT advice available via CDDFT intranet

Tramadol
BNF | BNFC | SPC

Capsules - 50mg

50mg dispersible tablets
100mg in 2ml injection

Tramadol - only recommended for use in patients where treatment with possible alternatives such as paracetamol, NSAIDs, and codeine is insufficiently effective, not tolerated or considered unsuitable for other reasons. Modified release tramadol is not recommended.

See CDDFT Tramadol Schedule 3 CD prescribing memo – intranet link (CDDFT only)

Fentanyl
BNF | BNFC | SPC

Patches - 12microgram/hour, 25microgram/hour, 50microgram/hour, 75microgram/hour, 100microgram/hour

The preferred brand of choice within North Durham and DDES is Mezolar Matrix(R) patches.

Transdermal fentanyl – MHRA Drug Safety Update (July 2014) – reminder of potential life threatening harm from accidental exposure, especially in children

CD&D APC Grey List: Novel Fentanyl preparations should not be prescribed as these have been rejected by NTAG

Methadone
BNF | BNFC | SPC

Tablets - 5mg

Morphine Sulphate
BNF | BNFC | SPC

Tablets - 10mg, 20mg, 50mg (Sevredol),

MR capsules - 10mg, 30mg, 60mg, 10mg, 200mg (Zomorph)

10mg in 5ml Liquid                                                              

Injection - 10mg/ml, 15mg/ml, 20mg/ml, 30mg/ml

Zomorph is the preferred modified release preparation

Drug protocol: neonatal morphine sulphate for ventilation (CDDFT intranet access only)

Oxycodone
BNF | BNFC | SPC

Capsules - 5mg, 10mg, 20mg,

Liquid - 5mg/5ml

MR Tablets - 5mg, 10mg, 15mg, 20mg, 40mg, 60mg80mg, 120mg

Oral solution should be used instead of immediate release tablets.

See CQC - safer use oxycodone

Oxycodone only to be used in patients who are intolerant of morphine.

Oxycodone should be prescribed by brand to avoid confusion between different preparations – Longtec® is currently the local formulary modified release preparation of choice.

 

Diamorphine
BNF | BNFC | SPC

5mg, 10mg, 30mg, 100mg & 500mg injections

Drug protocol: diamorphine for pain relief during labour (CDDFT intranet access only)

Buprenorphine
BNF | BNFC | SPC

200 microgram sublingual tablets
300 micrograms in 1ml injection
5 & 10 microgram/hour transdermal patch (BuTrans®)

The preferred brand of choice for weekly buprenorphine patches within North Durham and DDES is Butec(R) patches.

Hydromorphone
BNF | BNFC | SPC

1.3mg & 2.6mg capsules
2mg, 4mg, 8mg, 16mg & 24mg m/r capsules

Pethidine
BNF | BNFC | SPC

50mg in 1ml & 100mg in 2ml injections

Drug protocol: pethidine for pain relief during labour (CDDFT intranet access only)

Oxycodine with naloxone (Targinact)
BNF | BNFC | SPC
Tapentadol
BNF | BNFC | SPC

50mg, 100mg, 150mg, 200mg and 250mg m/r tablets
50mg and 75mg immediate release tablets

CD&D APC Grey List: Tapentadol – Third line treatment for the relief of severe chronic pain in adults which can be adequately managed only with opioid analgesics AND in whom morphine and oxycodone has failed to provide adequate pain relief or is not tolerated.

See NICE CG173: Neuropathic pain

First Choice:
Amitriptyline

Second Choice:
Gabapentin
Pregabalin

Alternatives:
Carbamazepine
Duloxetine
Phenytoin
Tramadol

N.B. Other drugs such as Ketamine (see section 15.1.1) may also be advised by pain/palliative care specialists in the management of neuropathic pain.

Amitriptyline
BNF | BNFC | SPC

See section 4.3

Gabapentin
BNF | BNFC | SPC

See section 4.8.1

Also approved for hospital use as an adjunct to other treatment in the management of peri/post-operative pain. GPs should not be asked to prescribe gabapentin for this unlicensed indication.

Pregabalin
BNF | BNFC | SPC

See section 4.8.1

Restricted to use in the management neuropathic pain as a second choice where treatment with gabapentin has been unsuccessful or not tolerated.

The preferred brand of choice within North Durham and DDES is Alzain(R) where licensing allows.

Carbamazepine
BNF | BNFC | SPC

See section 4.8.1

Duloxetine
BNF | BNFC | SPC

30mg & 60mg capsules 30mg & 60mg capsules

For third-line use (after drugs such as the tricyclic antidepressants and gabapentin) in the treatment of neuropathic pain on the advice of pain specialists.

Phenytoin
BNF | BNFC | SPC

See section 4.8.1

Capsaicin Cream
BNF | BNFC | SPC

0.075% cream

For Postherpetic Neuralgia

Qutenza
BNF | BNFC | SPC

Qutenza should not be used – not recommend by NTAG

Lidocaine
BNF | BNFC | SPC

5% medicated plasters (700mg lidocaine/plaster)

Lidocaine patches are only licensed for the treatment of postherpatic neuralgia (PHN).
In addition, they are approved locally for use in the following:
• the treatment of chronic neuropathic pain on the advice of pain specialists only, subject to an appropriate trial of efficacy in each individual patient and as part of a directed management plan
• the treatment of multiple rib fractures on the advice of pain specialists only, in line with the procedure for pain management and rehabilitation following multiple rib fractures
• palliative care – please note that prescribers in primary care can initiate prescribing in palliative care patients.

CD&D APC Grey List 

Sumatriptan
BNF | BNFC | SPC

Tablets - 50mg

Injection - (Auto-injector) 12mg/ml (6mg/0.5ml syringe)    

  

Paracetamol
BNF | BNFC | SPC

See section 4.7.1

Aspirin
BNF | BNFC | SPC

See section 4.7.1

NSAIDs
BNF | BNFC | SPC

See section 10.1.1

Frovatriptan
BNF | BNFC | SPC

2.5mg tablets

Zolmitriptan
BNF | BNFC | SPC

2.5mg tablets

Ergotamine (Migril)
BNF | BNFC | SPC
Metoclopramide
BNF | BNFC | SPC

10mg tablets
5mg in 5ml sugar-free syrup

Adjunctive Therapy - used to help promote absorption of analgesics.

Do not use in under 20 years.

Pizotifen
BNF | BNFC | SPC

500 microgram & 1.5mg tablets
250 microgram in 5ml sugar-free elixir

Sodium Valproate▼
BNF | BNFC | SPC

100mg crushable tablets, 200mg & 500mg e/c tablets 200mg, 300mg & 500mg m/r tablets (Epilim Chrono).
150mg & 300mg m/r capsules

500mg & 1000mg m/r granules (Episenta) - for use in those who have difficulty swallowing sodium valproate tablets. May be more convenient to use than large volumes of liquid formulations
200mg in 5ml sugar-free liquid

Unlicensed Indication

MHRA Drug Safety Alert (April 2017): Valproate and developmental disorders: new alert asking for patient review and further consideration of risk minimisation measures 

Propranolol
BNF | BNFC | SPC

10mg, 40mg & 80mg tablets

Metoprolol
BNF | BNFC | SPC

50mg & 100mg tablets, 200mg m/r tablets

Amitriptyline
BNF | BNFC | SPC

10mg, 25mg & 50mg tablets

25mg in 5ml sugar free oral solution

Unlicensed Indication

Lithium Carbonate
BNF | BNFC | SPC

200mg & 400mg m/r tablets (5.4 & 10.8 mmol Li+) = Priadel = brand of choice

250mg tablets (6.8 mmol Li+)

Lithium should be prescribed by brand name. Approved for use in the treatment of cluster headaches.

TEWV: Lithium Shared Care Guideline

Refer to NICE guidance CG 137. The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care.

Control of epilepsy

All green plus drugs in this section should be recommended by a specialist and are suitable for transfer to primary care.

See Commission on Human Medicines advice on branded / manufacturer based prescribing here

MHRA Antiepileptic drugs: new advice on switching between different manufacturer’s products for a particular drug. More details here.

See also CDDFT intranet site for CDDFT information.

Drug protocol: PAEDIATRIC Management of Convulsive Status Epilepticus – available here  (CDDFT intranet access only)

Carbamazepine
BNF | BNFC | SPC

Tablets - 100mg, 200mg, 400mg

MR Tablets - 200mg, 400mg

Liquid - 100mg/5ml

Clobazam
BNF | BNFC | SPC

Tablets - 10mg

1mg/ml and 2mg/ml oral suspension

Only prescribable on NHS for epilepsy. Must be endorsed SLS

Clonazepam
BNF | BNFC | SPC

Tablets - 500microgram, 2mg

Eslicarbazepine
BNF | BNFC | SPC

800mg tablets
- approved for use by specialists only in those patients for whom intolerance of carbamazepine is a major concern and when use of this agent is more cost effective than alternatives available.

Ethosuximide
BNF | BNFC | SPC

Capsules - 250mg

Syrup - 250mg/5ml

Gabapentin
BNF | BNFC | SPC

Capsules - 100mg, 300mg, 400mg

Also licensed for neuropathic pain

Lacosamide
BNF | BNFC | SPC

50mg, 100mg, 150mg & 200mg tablets
10mg per ml syrup, 10mg per ml intravenous infusion
- on advice from consultant neurologists, in patients that are refractory to treatment with other drugs

Lamotrigine
BNF | BNFC | SPC

Tablets - 25mg, 50mg, 100mg, 200mg

Dispersible Tablets - 2mg (only Chewable), 5mg, 25mg, 100mg

Levetiracetam
BNF | BNFC | SPC

Tablets 250mg, 500mg, 750mg and 1g
Sugar Free solution 100mg/ml

Oxcarbazepine
BNF | BNFC | SPC

150mg, 300mg & 600mg tablets

Perampanel▼
BNF | BNFC | SPC

2mg, 4mg, 6mg, 8mg, 10mg, 12mg tablets.
- NETAG approved for partial (focal) seizure epilepsy only when other treatment options recommended by NICE have been tried or fully considered.

Phenobarbital
BNF | BNFC | SPC

15mg, 30mg & 60mg tablets; 15mg in 5ml elixir; 20mg in 1ml suspension (alcohol free)
15mg in 1ml, 30mg in 1ml & 200mg in 1ml injections

Phenytoin (Sodium Salt)
BNF | BNFC | SPC

Capsules - 25mg, 50mg, 100mg, 300mg,

Chewable Tablets - 50mg

Suspension - 30mg/5ml

Phenytoin: different preparations may vary in bioavailability; always prescribe by brand name. Therapeutic drug monitoring required.

Drug protocol: phenytoin loading in adults, children and neonates (CDDFT intranet access only)

Suspension contains phenytoin base - care need when changing to or from capsules

Piracetam
BNF | BNFC | SPC
Pregabalin
BNF | BNFC | SPC

Capsules - 25mg50mg, 75mg, 100mg, 150mg, 200mg, 225mg, 300mg

Also licensed for neuropathic pain

The preferred brand of choice within North Durham and DDES is Alzain(R) where licensing allows.

Primidone
BNF | BNFC | SPC
Rufinamide
BNF | BNFC | SPC
Sodium Valproate▼
BNF | BNFC | SPC

Tablets e/c - 200mg, 500mg,

Tablets MR - 200mg, 300mg, 500mg,

Oral Solution - 200mg/5ml,

Tablets (crushable) - 100mg

MHRA Drug Safety Update (Feb 2016): Valproate and of risk of abnormal pregnancy outcomes: new communication materials

MHRA Drug SafetyAlert (Jan2015): Medicines related to valproate: risk of abnormal pregnancy outcomes

MHRA Drug Safety Alert (Nov 2013): Sodium Valproate - special reminder on risk of neurodevelopmental delay in children following maternal use. 

MHRA Drug Safety Alert (April 2017): Valproate and developmental disorders: new alert asking for patient review and further consideration of risk minimisation measures 

Stiripentol
BNF | BNFC | SPC
Tiagabine
BNF | BNFC | SPC
Topiramate
BNF | BNFC | SPC

Tablets - 25mg, 50mg, 100mg, 200mg

Capsules (Sprinkle) - 15mg, 25mg, 50mg

CD&D APC Grey List: Topiramate hard capsules are expensive and should not be prescribed. For those patients unable to swallow topiramate tablets “sprinkle capsules” may be considered.

Vigabatrin
BNF | BNFC | SPC

Tablets - 500mg

Powder (Sugar free) - 500mg/Sachet

Zonisamide
BNF | BNFC | SPC

25mg, 50mg and 100mg capsules
- for specialist use only in patients that are refractory to treatment with other drugs - use in children is unlicensed.

Diazepam
BNF | BNFC | SPC

Rectal Solution - 2mg/ml, 4mg/ml

Midazolam Buccal
BNF | BNFC | SPC

Oromucosal Solution - 5mg/ml

Pre-filled syringes - 0.5ml, 1ml, 1.5ml, 2ml (Buccolam)

Other unlicensed formulations are available - check dose

Lorazepam
BNF | BNFC | SPC

1mg & 2.5mg tablets; 4mg in 1ml injection

Paraldehyde
BNF | BNFC | SPC

Rectal liquid u

Phenobarbital Sodium
BNF | BNFC | SPC

Drug protocol: neonatal IV and oral phenobarbital (CDDFT intranet access only)

Phenytoin Sodium
BNF | BNFC | SPC

250mg in 5ml injection

All green plus drugs in this section should be recommended by a specialist and are suitable for transfer to primary care.

NICE CG186:  Multiple sclerosis: management of multiple sclerosis in primary and secondary care

NTAG Nov 2014: The Northern (NHS) Treatment Advisory Group does not recommend the use of Sativex® for the management of non-MS pain.

Co-beneldopa (Madopar)
BNF | BNFC | SPC

Capsules - 62.5mg, 125mg, 250mg

Dispersible Tablets - 62.5mg, 125mg

MR Capsules - 125mg

benserazide + levodopa

Co-careldopa (Sinemet)
BNF | BNFC | SPC

Tablets - 62.5mg, 110mg, 125mg, 275mg

MR Tablets - 125mg, 250mg

carbidopa + levodopa

Cabergoline
BNF | BNFC | SPC

Tablets - 1mg, 2mg

Pergolide
BNF | BNFC | SPC

Tablets - 50microgram, 250microgram, 1mg

Pramipexole
BNF | BNFC | SPC

Tablets (as Base) - 88microgram, 180microgram, 350microgram, 700microgram

Ropinirole
BNF | BNFC | SPC

Tablets - 250microgram, 500microgram, 1mg, 2mg, 5mg

Tablets MR - 2mg, 4mg, 8mg

Rotigotine
BNF | BNFC | SPC

Patches - 1mg/24hours, 2mg/24hours, 3mg/24hours, 4mg/24hours6mg/24hours, 8mg/24hours

Selegiline Hydrochloride
BNF | BNFC | SPC

Tablets - 5mg, 10mg

Oral Liquid - 10mg/5ml

Entacapone
BNF | BNFC | SPC

Tablets - 200mg

Apomorphine Injection
BNF | BNFC | SPC

20mg in 2ml & 50mg in 5ml injections & 30mg in 3ml
pre-filled multiple dose pen injection device
5mg in 1ml pre-filled syringe

Apomorphine shared care: Apomorphine Shared Care Guidelines

MHRA Drug Safety Update (April 2016): Apomorphine with domperidone: minimising risk of cardiac side effects

Bromocriptine
BNF | BNFC | SPC

2.5mg tablets

Co-careldopa intestinal gel
BNF | BNFC | SPC
Stalevo
BNF | BNFC | SPC

Tablets containing:
50mg levodopa/12.5mg carbidopa/200mg entacapone
75mg levodopa/18.75mg carbidopa/200mg entacapone
100mg levodopa/25mg carbidopa/200mg entacapone
125mg levodopa/31.25mg carbidopa/200mg entacapone
150mg levodopa/37.5mg carbidopa/200mg entacapone
200mg levodopa/50mg carbidopa/200mg entacapone

Patients should be initiated on entacapone and co-careldopa separately and switched to Stavelo if necessary to aid compliance.

Rasagiline
BNF | BNFC | SPC

1mg tablets

Tolcapone
BNF | BNFC | SPC

100mg tablets

Amantadine
BNF | BNFC | SPC

100mg capsules; 50mg in 5ml syrup-
For use on the advice of neurologists

Orphenadrine
BNF | BNFC | SPC

Tablets - 50mg

Oral Solution - 50mg/5ml

Procyclidine
BNF | BNFC | SPC

Tablets - 5mg

Syrup - 2.5mg/5ml

Trihexyphenidyl hydrochloride
BNF | BNFC | SPC

2mg & 5mg tablets
5mg in 5ml syrup

Tetrabenazine
BNF | BNFC | SPC

Tablets - 25mg

Haloperidol
BNF | BNFC | SPC

See section 4.2.1

Unlicensed indication

Riluzole
BNF | BNFC | SPC

50mg tablets and 5mg/1ml oral suspension

Shared care: Riluzole for MND (ALS presentation)

NICE TA20

Botulinum toxin type A
BNF | BNFC | SPC

Botulinum Toxin Type A products should normally be prescribed by brand name.

Botulinum toxin type B
BNF | BNFC | SPC

See TEWV prescribing guidance for drug misuse

Unless used in accordance with Local Protocol – naltrexone, acamprosate & disulfiram prescribing should be retained within the commissioned service within County Durham

TEWV: Alcohol Misuse and Dependence - Management in the Community

Acamprosate
BNF | BNFC | SPC

Tablets - 333mg

Disulfiram
BNF | BNFC | SPC

Tablets - 200mg

Nalmefene
BNF | BNFC | SPC

Tablets - 18mg

Requires prescribing in accordance with NICE guidance: http://www.nice.org.uk/guidance/ta325. For patients who:

  • Who have a high drinking risk level (defined as alcohol consumption of more than 60 g per day for men and more than 40 g per day for women, according to the World Health Organization's drinking risk levels) without physical withdrawal symptoms and

 

  • Who do not require immediate detoxification.

The marketing authorisation states that nalmefene should:

  • Only be prescribed in conjunction with continuous psychosocial support focused on treatment adherence and reducing alcohol consumption and
  • Be initiated only in patients who continue to have a high drinking risk level 2 weeks after initial assessment

Link to Nalmefene primary care bulletin

Chlordiazepoxide
BNF | BNFC | SPC

5mg & 10mg capsules

Naltrexone
BNF | BNFC | SPC
Bupropion
BNF | BNFC | SPC

Tablets - 150mg

Prescribe according to Smoking Cessation policy

Nicotine Replacement Therapy
BNF | BNFC | SPC

From 1st April 2017, a revised NRT formulary will only allow the County Durham Stop Smoking Service to issue a single NRT product to each client rather than combination therapy.

However even providing one NRT product plus ongoing support from the Service will still double clients chances of quitting compared to no support.

Evidence shows that adding in a second NRT product can further increase the chances of quitting. Therefore the Service will advise that clients can purchase small packs of a second NRT product (such as chewing gum, lozenges which typically cost £5-£6 for a pack of 20) or choose to purchase an unlicensed nicotine containing product such as an e-cigarette.

GP practices should continue NOT to prescribe NRT or licensed e-cigarettes.

 

NRT Formulary Choices of the County Durham Stop Smoking Service from 1st April 2017

16 Hour Patch 

Nicorette 25mg Invisi patch (x7)

Nicorette 15mg Invisi patch (x7)

Nicorette 10mg Invisi patch (x7)

24 Hour Patch

NiQuitin CQ 21mg Patch (x7)

NiQuitin CQ 14mg Patch (x7)

NiQuitin CQ 7mg Patch (x7)

Nicotinell TTS 30 (21mg) Patch (x7)

Nicotinell TTS 20 (14mg) Patch (x7)

Nicotinell TTS 10 (7mg) Patch (x7)

Nasal Spray

Nicorette 500microgram Nasal Spray (10ml - 1 bottle)

Mouth Spray

Nicorette QuickMist 1mg/spray (13.2ml - 1 bottle)

Nicorette QuickMist 1mg/spray (26.4ml - 1 bottle)

Inhalator

Nicorette 15mg Inhalator (x20)

Nicorette 15mg Inhalator (x36)

Varenicline▼
BNF | BNFC | SPC

Tablets - 500micrograms, 1mg

Prescribe according to Smoking Cessation policy

e-Voke electronic inhaler▼
BNF | BNFC | SPC

NTAG April 2016: The Northern (NHS) Treatment Advisory Group does not recommend the use of e-Voke® as a stop smoking aid on the NHS.

Buprenorphine
BNF | BNFC | SPC

Sublingual tablets - 400micrograms, 2mg, 8mg

NICE TA114

 

Methadone Hydrochloride
BNF | BNFC | SPC

Oral Solution - 1mg/ml

Sugar Free Oral Solution - 1mg/ml

NICE TA114

Suboxone
BNF | BNFC | SPC

2mg/500microgram sublingual tablets containing, buprenorphine 2 mg, & naloxone 500 micrograms
8mg/2mg tablets sublingual tablets containing buprenorphine 8 mg & naloxone 2 mg

Naltrexone
BNF | BNFC | SPC

50mg tablets

NICE TA115

See NICE guidance Dementia: Supporting people with dementia and their carers in health and social care CG 42

Only specialists in the care of patients with dementia should initiate treatment.

Treatment should be reviewed regularly and only be continued when it is considered to be having a worthwhile effect.

Carers views on the patient’s condition should be sought.

Each product has been classified as Green + which in this case means:

  • Initiation by a specialist
  • Prescribing follows Dementia Care Pathway AChEI Decision Aid
  • Stabilised on treatment
  • Indications within NICE guidance for cognitive and non-cognitive symptoms of Alzheimer’s disease
  • A minimum of one month’s supply provided on transfer
  • Six monthly review of cognitive symptoms, global, functional and behavioural assessment by specialist services according to local Protocol

First line

Donepezil

Donepezil
BNF | BNFC | SPC

NICE TA217

Tablets - 5mg, 10mg

Orodispersible Tablets - 5mg, 10mg

Orodispersible tablets - should only be used in situations where the plain tablets are unsuitable

Galantamine
BNF | BNFC | SPC

NICE TA217

Tablets - 8mg, 12mg

Oral solution - 4mg/ml

MR Capsules - 8mg, 16mg, 24mg

MR capsules only to be used when a once a day dose is essential or patient has tried standard release galantamine and is intolerant.

Letter was sent to healthcare professionals for:

Galantamine hydrobromide (Reminyl): risk of serious skin reactions (Dec 2015)

 

Rivastigmine
BNF | BNFC | SPC

NICE TA217

Capsules - 1.5mg, 3mg, 4.5mg, 6mg

Oral solution - 2mg/ml

Patches - 4.6mg / 24hours; 9.5mg/24hours

Patches should only be used when other formulations inappropriate

Memantine
BNF | BNFC | SPC

NICE TA217

Tablets - 10mg 20mg

Oral Solution - 5mg / actuation (10mg/ml)

Option for managing moderate Alzheimer’s Disease in people who cannot take AChE inhibitors