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Nottinghamshire Area Prescribing Committee
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 Formulary Chapter 4: Central nervous system - Full Chapter
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.
    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 which may lead 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 (Adult Critical Care)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red

    Capsules 1mg, 2mg, 3mg, 5mg, 10mg (all unlicensed)

    NUH only:

    • Review prior to discharge from Critical Care.
    • If needed capsules can be opened and the contents dispersed in water, milk, yoghurt or fruit juice for administration (More Info)
     
    Link  Price comparison of melatonin products
    Link  Price comparison of melatonin products (standardised to 10mg)
       
    Melatonin (Circadin)
    (Parkinson's Disease with REM sleep disorder)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2

    MR tablets (Circadin® brand only)

     
    Link  Price comparison of melatonin products
    Link  Price comparison of melatonin products (standardised to 10mg)
       
    Melatonin (Paediatrics)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    • M/R tablets (Circadin®), Capsules 2mg, 3mg, 5mg, 10mg (unlicensed), Liquid (1mg/mL is preferred strength locally).
      For paediatric consultant use only.
    • On FP10 the most cost-effective option is 2mg MR tablets. These may be crushed or halved but this will destroy the MR properties.
    • For supplies through hospital pharmacies, unlicensed immediate release capsules are preferred and if needed these can be opened and the contents dispersed in water, milk, yoghurt or fruit juice for administration (More Info). For children in whom prolonged release is absolutely necessary then the more expensive 2mg MR tablets are available but these are only suitable for children who can swallow tablets. There is no longer a MR product available suitable for children with swallowing difficulties.
    • Melatonin for primary insomnia in adults is non formulary (see below).
    • Nottingham Childrens Hospital: Melatonin Guideline
    • At SFH send patients to SFH pharmacy for supplies of unlicensed medicines
     
    Link  Link to reviews
    Link  NICE Evidence summary: Melatonin for sleep disorders in children with ADHD
    Link  Price comparison of melatonin products
    Link  Price comparison of melatonin products (standardised to 10mg)
    Link  SFH melatonin cost calculator
    Link  SFH order form for unlicensed melatonin
       
    Melatonin
    (Adults with intellectual disability)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2

    MR tablets (Circadin® brand only)

    • Specialist initiation for the treatment of sleep regulation in adults with a learning disability and behaviour that challenges as per NICE guideline 11.
    • Prescribing should be retained by secondary care until effectiveness is established and only transferred to primary care if a continued need is demonstrated after review.
    • not approved for dementia-reviewed and turned down Nov 2017. 
     
    Link  NICE guideline [NG11]:Challenging behaviour and learning disabilities
    Link  Price comparison of melatonin products
    Link  Price comparison of melatonin products (standardised to 10mg)
       
    04.01.01  Benzodiazepines
    Controlled Drug Temazepam
    (hypnotic)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
  • Tablet, Oral solution
  • CD storage requirements apply within SFHT and NottsHC for ALL temazepam products  
  •    
    04.01.01  Zaleplon, Zolpidem and Zopiclone
    Zopiclone
    View adult BNF View SPC online
    Formulary
    Green
    Tablets
  • 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.
     
  • Link  NICE TAG 77: Zaleplon, zolpidem and zopiclone for the management of insomnia
       
    Zolpidem
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    Tablet
  • 2nd line if patients have not tolerated zopiclone 
  • Link  MHRA: Risk of drowsiness and reduced driving ability
    Link  NICE TAG 77: Zaleplon, zolpidem and zopiclone for the management of insomnia
       
    04.01.01  Chloral and derivatives to top
    Chloral Betaine (Welldorm®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Chloral Betaine 707mg tablets

    • For paediatric use for the treatment of insomnia, as a substitute for Chloral Hydrate liquid, where liquid is unsuitable due to ketogenic diet
    • NB: Welldorm® Chloral Betaine 707mg tablets contain the equivalent of 414mg of chloral hydrate. See table of liquid medicines requiring dose adjustment.

     
       
    Chloral Hydrate
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Available as:
    - Oral solution (sugar free) 500mg/5ml is recommended strength (unlicensed*) as per RCPCH guidance
    - Suppository (Unlicensed, NUH only) Red Traffic Light

    • GreyTraffic Light *Licensed liquid 143.3mg/5ml is not recommended locally due to bitter taste and excessive volume - See 500mg/5ml instead above.

    •  See table of liquid medicines requiring dose adjustment.

     
       
    04.01.01  Clomethiazole (Chlormethiazole)
    04.01.01  Sodium oxybate
    Controlled Drug Sodium Oxybate (Xyrem®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine
    NHS England

    Oral solution (500mg/mL)

    NUH only: Approved in accordance with commissioning policy for narcolepsy with cataplexy in children.

     
    Link  Link to reviews
    Link  NHS England Policy: Sodium oxybate for symptom control of narcolepsy with cataplexy (children)
       
    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
    Chlordiazepoxide
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Capsule.
  • Only for use in alcohol withdrawal.
  • In primary care, GPs/NMPs who have received appropriate training may initiate in line with the Nottinghamshire Primary Care Alcohol Community Detox Protocol (see below)
  • If needed capsules can be opened and contents dispersed in water. More Info
     
  • Link  Nottinghamshire Primary Care Alcohol Community Detoxification Protocol
    Link  NUH alcohol withdrawal guidelines
    Link  SFH Alcohol withdrawal guidelines, contains links to DTs and Korsakoffs guidelines
       
    Diazepam
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablet, Oral suspension or solution 2mg/5ml, Injection 10mg/2ml, Rectal tube

    • 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 veins.

    Rectal tube, injection:

    • Convulsions or agitation related to overdose / poisoning 
     
    Link  Diazemuls emulsion SPC
    Link  Diazepam injection solution SPC
       
    Lorazepam
    (anxiety)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablet, oral solution (see below), Injection.

    • Supply problem with injection Nov 2020: SFH see alternative options compilation table.
    • Tablets dissolve under the tongue if the patient has a sufficiently moist mouth (ref. NEWT Guide to enteral feeding and swallowing difficulties). Licensed oral solution (1mg/1mL) available if absolutely necessary, but is expensive (>£100 for 150ml), expires 3 months after first opening.
    • Tablets disperse in water if needed. See here for general advice on dispersing tablets.
    • The generic tablets manufactured by Genus are preferred if sublingual administration or doses of 500 micrograms are required (tablets are scored), but other manufacturers also produce scored tablets.
    • Store injection in fridge.
    • Dilute Ativan® UK brand with an equal volume of WFI or 0.9% NaCl before i.m. injection. Hospira and Baxter brands (unlicensed imports from US) should NOT be diluted before IM administration - see individual box leaflets.
     
    Link  COVID19: Is there a shortage of EOL anticipatory medicines? (Notts CCG)
    Link  COVID19: NICE (NG163) Managing symptoms (incl EOL) in the community
    Link  COVID19: Notts CCG - Managing Symptoms of Covid-19 (End of Life) in Community and Non-acute Hospital Settings
    Link  SFH: Alcohol Withdrawal Delerium Guidance (DT)
    Link  SFH: Alternatives to lorazepam IV during shortage
       
    04.01.02  Buspirone to top
    Buspirone
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2

    Tablets

    • Initiated following specialist psychiatric referral only
    • For use in learning disabilities only.
     
       
    04.01.02  Beta blockers
    Propranolol
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    See main propranolol entry in section 2.4

     
       
    04.01.02  Gabapentinoids
    Controlled Drug Pregabalin
    (Anxiety)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Capsules, Oral Solution (20mg/mL)

    • Specialist initiation only
    • Licensed for generalised anxiety disorder (GAD). Due to limited head-to-head comparison data with other treatments it should be reserved as a 4th line option for GAD after SSRIs/venlafaxine.
    • Oral solution is expensive (£99.48 for 473mL DT Oct20). 
    • If needed capsules can be opened and contents dispersed in water (not licensed). More Info
     
    Link  MHRA: reports of severe respiratory depression with pregabalin
    Link  NHS England: Rescheduling of Gabapentin and Pregabalin as Controlled Drugs
    Link  Patient leaflet: Are you taking gabapentin or pregabalin? (NHS England)
    Link  Link to reviews
       
    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
    • 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 
    • Orodispersible tablets and oral solutions are more expensive therefore reserved for poorly compliant patients or those with swallowing difficulties.

     

    Chlorpromazine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
  • Tablet, Oral solution, Suppository, Injection (Use of intramuscular chlorpromazine is not recommended - can cause marked postural hypotension)
     
  •    
    Flupentixol (Depixol®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablet

    • To be initiated on specialist advice only.
    • Tablets disperse in water if needed. See here for general advice on dispersing tablets.
     
       
    Haloperidol
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablet, Capsule, Oral liquid
    Injection : Now only licensed for IM administration. IV administration is unlicensed, if administered IV continuous ECG monitoring must be performed for QTc interval prolongation and ventricular arrhythmias. 

    • Optimum dose of oral haloperidol for the treatment of schizophrenia is less than or equal to 10mg/day. The maximum licensed oral dose is 20mg/day.
    • A baseline ECG is recommended before intramuscular administration.
    • October 2020: supply issues with Haloperidol 5mg/5mL oral solution sugar free. See DHSC Medicine Supply Notification
    • December 2020: SFH Haloperidol supply issue solutions
     
    Link  COVID19: Is there a shortage of EOL anticipatory medicines? (Notts CCG)
    Link  COVID19: NICE (NG163) Managing symptoms (incl EOL) in the community
    Link  COVID19: Notts CCG - Managing Symptoms of Covid-19 (End of Life) in Community and Non-acute Hospital Settings
    Link  Haloperidol supply issue
    Link  Notts APC: End of life care guideline
    Link  NUH: Haloperidol licence change reminder Jan 2013
       
    Levomepromazine
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Green
    See entry in
    section 4.6

     
       
    Sulpiride
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Tablet
  • To be initiated on specialist advice only.
  • Employed mainly within the Mental Health Services for Older People directorate (Notts HC).
  • Tablets disperse in water if needed. See here for general advice on dispersing tablets. 
  •    
    Trifluoperazine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablet, Oral solution

    • To be initiated on specialist advice only.
    • Modified release preparations to be used only in patients with compliance problems.
     
       
    Zuclopenthixol (Clopixol®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Tablet
  • To be initiated on specialist advice only.
  • Tablets disperse in water if needed. Tablets are film coated so flush enteral tubes well to prevent blockage. See here for general advice on dispersing tablets. 
  •    
    04.02.01  First-Generation Antipsychotic Drugs
    Penfluridol
    Unlicensed Drug Unlicensed
    Red
    Tablet
  • NottsHC use only
  • May be useful in patients that are not tolerant of depot injection
  • Cochrane Review, 2012  
  •    
    04.02.01  Second-Generation Antipsychotic Drugs
    Amisulpride
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablet, Oral Solution (100mg/mL)

    • To be initiated on specialist advice only for schizophrenia. Prescribing guidance should accompany request to prescribe.
     
    Link  NottsAPC: Amisulpride prescribing guidance
       
    Aripiprazole
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablet, Orodispersible Tablet, Oral Solution (1mg/mL) 

    • To be initiated on specialist advice only for:
      -schizophrenia
      -the treatment of moderate to severe manic episodes in Bipolar I Disorder
      -the prevention of a new manic episode in patients who experienced predominantly manic episodes and whose manic episodes responded to aripiprazole treatment.
    • Prescribing guidance to accompany request to prescribe.
    • Oral solution 1mg/mL should only be used for swallowing difficulties where orodispersible tablets cannot be used to make up the required dose (i.e. dose <10mg).
     
    Link  Aripiprazole for the treatment of schizophrenia in people aged 15 -17 years (NICE TA 213)
    Link  Bipolar disorder (children) - aripiprazole (NICE TA292)
    Link  Notts APC:Aripiprazole prescribing guidance
       
    Clozapine (Zaponex®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Tablet
  • Prescribe by brand
  • For treatment-resistant schizophrenia. Initiated by consultant psychiatrist only.
  • NUH: For psychotic disorders occurring during the course of Parkinson’s disease.
    24 hour helpline number for ZTAS - 020 7365 5842
     
  • Link  COVID19: Clozapine monitoring for stable adult patients (National Guidance)
    Link  COVID19: Clozapine monitoring during COVID19 (Notts CCG)
    Link  Fact sheet: Clozapine and constipation
    Link  Hypersalivation induced by clozapine - management guide
    Link  MHRA Drug Safety Update 2017 - Clozapine and Intestinal Peristalsis
    Link  MHRA Drug Safety Update 2020: monitoring antipsychotic levels for toxicity
    Link  NottsAPC: Clozapine prescribing information for primary care
    Link  NUH: Therapeutic Drug Monitoring in Adults at NUH
    Link  SFH: Clozapine pharmacy flowchart
    Link  SFH: Red alert advice
    Link  UKMI Q&A: Which medicines require extra care when switching between liquid and tablet/capsule formulations?
       
    Lurasidone (Latuda®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red

    Tablet

    • To be initiated on specialist advice for the long-term treatment of “non-treatment resistant” schizophrenia where patients have not been able to tolerate other antipsychotics, including a trial on aripiprazole or where patients have a preference for this drug.
     
    Link  Link to reviews
    Link  NottsAPC: Lurasidone prescribing guidance
       
    Olanzapine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablet, Orodispersible tablet (sugar-free)

    • To be initiated on specialist advice only for schizophrenia, mania and preventing recurrence in bipolar disorders. Prescribing guidance to accompany request to prescribe.

    Approved at NUH only for:

    • Red  Prophylaxis of chemotherapy-induced nausea and vomiting
     
    Link  NottsAPC: Olanzapine prescribing guidance
       
    Quetiapine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablet, MR Tablet, Oral suspension (20mg/mL sugar-free)

    • To be initiated on specialist advice only for:
      -schizophrenia
      -treatment of mania and major depressive episodes associated with bipolar disorder
      -preventing relapse in schizophrenia and preventing recurrence in bipolar disorder in patients whose have responded to quetiapine treatment.
    • Prescribing guidance to accompany request to prescribe.
    • New patients to be started on immediate release tablets. MR tablets reserved for existing stable patients.
    • Sondate® is the current recommended brand of modified release tablet for primary care. See Preferred Prescribing List.
    • Oral suspension available (£99.28 for 150ml, DT Oct20).
    • Standard release tablets disperse in water if needed - not licensed (or add to soft food as they taste bitter). Do not crush MR tablets. See here for general advice on dispersing tablets.
     
    Link  Link to reviews
    Link  NICE Evidence summary: Quetiapine for generalised anxiety disorder
    Link  Notts APC: Quetiapine prescribing guidance
    Link  NottsHC advice on standard release vs MR quetiapine
    Link  Quetiapine QIPP detail aid
       
    Risperidone
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablets, Oral Solution (1mg/mL)

    • To be initiated on specialist advice only for:
      -schizophrenia
      -treatment of manic episodes in bipolar disorder.
      -short term use for persistent aggression in patients with moderate to severe Alzheimer’s dementia. Refer to local dementia guidelines
    • Prescribing guidance to accompany request to prescribe
    • Generic risperidone remains one of the least expensive oral atypicals. 
    • Doses above 8-10mg daily may not increase therapeutic benefit but may result in extrapyramidal side effects.
    • Orodispersible tablets are non-formulary. Use liquid if a patient is experiencing swallowing difficulties; this is the more cost effective option.
     
    Link  Link to reviews
    Link  MHRA: Risk of intraoperative floppy iris syndrome in people undergoing cataract surgery (Oct 13)
    Link  Risperidone prescribing guidance (Notts APC)
       
    04.02.02  Antipsychotic depot injections
    Aripiprazole (Abilify Maintena®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Depot injection
  • Specialist initiation for the maintenance treatment of schizophrenia. 
  • Link  Nottinghamshire APC Depot Antipsychotics Prescribing Information
    Link  Notts APC prescribing info sheet
       
    Flupentixol Decanoate (Depixol®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Depot injection
  • 200mg/ml low volume injection is more expensive so reserve for higher dose prescriptions (>250mg) 
  • Link  Nottinghamshire APC Depot Antipsychotics Prescribing Information
       
    Fluphenazine Decanoate
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Depot injection

    • Grey Traffic Light  For new patients where treatment duration likely to extend beyond 2018.
    • September 2019 - Supply stable, though these overlabelled packs imported from Germany (through Mawdsleys) are unlicensed products in the UK.
     
    Link  Nottinghamshire APC Depot Antipsychotics Prescribing Information
       
    Haloperidol (Haldol Decanoate®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Depot injection 
    Link  Nottinghamshire APC Depot Antipsychotics Prescribing Information
       
    Olanzapine Embonate (ZypAdhera®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Depot injection
  • Requirement for patients to be observed for at least 3hrs after each injection for signs and symptoms of olanzapine overdose "post-injection syndrome". 
  • Link  Link to reviews
    Link  Nottinghamshire APC Depot Antipsychotics Prescribing Information
       
    Paliperidone (Xeplion®, Trevicta®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Xeplion®
    Deep intramuscular depot injection

    Trevicta®
    Deep intramuscular depot injection

    • An option for specialist prescribing for carefully selected stable patients who have had at least four injections of the monthly paliperidone palmitate (Xeplion) formulation, where a 3-monthly injection is considered to offer a clear advantage.
     
    Link  Link to reviews
    Link  MHRA: Risk of intraoperative floppy iris syndrome in people undergoing cataract surgery (Oct 13)
    Link  Nottinghamshire APC Depot Antipsychotics Prescribing Information
    Link  Notts APC Paliperidone prescribing information sheet
       
    Risperidone (Risperdal Consta®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2
    Depot injection
  • Store in a fridge
  • On specialist initiation for the maintenance treatment of schizophrenia in patients currently stabilised with oral antipsychotics.
  • Prescribing guidance to accompany request to prescribe 
  • Link  MHRA: Risk of intraoperative floppy iris syndrome in people undergoing cataract surgery (Oct 13)
    Link  Nottinghamshire APC Depot Antipsychotics Prescribing Information
    Link  Nottinghamshire APC Risperidone Prescribing Information
       
    Zuclopenthixol Decanoate (Clopixol®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Depot injection
    Do not confuse with zuclopenthixol acetate (Clopixol Accuphase®). Packaging is very similar 
    Link  Nottinghamshire APC Depot Antipsychotics Prescribing Information
       
    04.02.03  Drugs used for mania and hypomania
     note  Aripiprazole, olanzapine, quetiapine and risperidone are licensed for acute mania and in the case of olanzapine for prevention of recurrence in bipolar disorder.  Quetiapine is also licensed for bipolar depression and the XL 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
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Specialist initiation only
    Lamotrigine is now licensed for the prevention of depressive episodes in patients with bipolar I disorder who experience predominantly depressive episodes. A slow six week dose titration regimen is recommended in BNF/product SPC to reduce the risk of serious skin rash. Lower doses are required when co-prescribing with valproate.  
    Link  Link to reviews
    Link  Notts APC: Information sheet on use of lamotrigine in bipolar disorder
       
    04.02.03  Benzodiazepines to top
    Clonazepam
    (Mania)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Specialist initiation only
  • Not licensed as an antimanic, however, there is published evidence to support its use in the initial stages of mania.
  • Initial dose 1mg nocte, increasing to 4-8mg/day, in divided doses. Clonazepam is a benzodiazepine so prescribe short-term and review regularly.
     
  •    
    04.02.03  Carbamazepine
     note  Check U&Es, LFTs and FBC at baseline and at 6 months.  Continue to check U&Es every 6 months.  Trough levels of 8-12mg/l are generally associated with efficacy.  Check levels every 6 months. 
    Carbamazepine
    (mania)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    • For prophylaxis of bipolar disorder. Not recommended for acute mania.
    • No longer recommended under NICE guidance, however BAP Bipolar Guidelines present some useful information on its place in therapy.
    • Consider drug interactions.
    • Modified-release (m.r.) tablets may help reduce incidence of dose-related side-effects.
     
    Link  SFH Drug levels information - compilation table
       
    04.02.03  Valproic acid
     note 
    • For Sodium Valproate and Valproate Semisodium check LFTs and FBC at baseline, after 6 months and then annually.
    • Valproate should not be offered to women or girls of child-bearing age unless other options are ineffective or not tolerated and the Pregnancy Prevention Programme is in place. See MHRA safety advice on valproate use by women and girls.
    • Trough plasma levels within the range 50-100mg/l may be optimal. 
    • The equivalent amount of valproic acid in a Depakote/Syonell 500mg tablet and a sodium valproate 500mg tablet are 500mg and 433mg respectively.
    Sodium valproate
    (Mania)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablet, MR Tablet

    • Specialist initiation only
    • Although not licensed as an antimanic/mood stabiliser, NICE supports its use in bipolar disorder.
    • Modified-release (Epilim Chrono) tablets can be taken once daily. Prescribe as “Chrono” when using the MR formulation.
    • Contraindicated in women and girls of childbearing potential unless conditions of Pregnancy Prevention Programme are met. See MHRA safety advice on valproate use in women and girls
     
    Link  MHRA Drug Safety Update (April 2018)
    Link  MHRA Valproate Pregnancy Prevention Programme: temporary advice for management during coronavirus (COVID-19)
    Link  MHRA Valproate Toolkit and Resources
    Link  NICE 2019: Valproate: Summary of NICE guidance and safety advice
    Link  Risk Management Material: Information for Women of childbearing potential
    Link  SFH Drug levels information - compilation table
       
    Valproate semisodium
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablet

    • Specialist initiation only.
    • Depakote® & Syonell®  are preferred brands locally - bioequivalent and share the same licensed indications.
    • Brand-specific prescribing is recommended locally to minimise confusion with sodium valproate.
    • Licensed for the treatment of manic episodes associated with bipolar disorder. 
    • Avoid confusion with sodium valproate.
    • Contraindicated in women and girls of childbearing potential unless conditions of Pregnancy Prevention Programme are met. See MHRA safety advice on valproate use in women and girls
     
    Link  MHRA Drug Safety Update (April 2018)
    Link  MHRA Valproate Pregnancy Prevention Programme; temporary advice for management during coronavirus (COVID-19)
    Link  MHRA Valproate Toolkit and Resources
    Link  NICE 2019: Valproate: summary of NICE guidance and safety advice
    Link  Risk Management Material: Information for Women of childbearing potential
    Link  SFH Drug levels information - compilation table
    Link  UKMI Q&A: Which medicines require extra care when switching between liquid and tablet/capsule formulations?
       
    04.02.03  Lithium
     note 

    There are bioavailability differences between brands/formulations of lithium therefore check with the patient what brand they take and prescribe by brand name (e.g. Priadel, Li-Liquid, Priadel Liquid). 

    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.

    Check eGFR, thyroid function (TSH) and calcium levels 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®)
    View adult BNF View SPC online View childrens BNF
    First Choice
    Amber 2

    Tablet MR 200mg (5.4mmol Li+), 400mg (10.8mmol Li+)

    • October 2020: An announcement has been made by Government that the withdrawal of Priadel® from the UK market has been suspended. There is no longer a need to progress any system-wide switching of patients from Priadel® to an alternative brand of lithium. 
     
    Lithium Citrate
    (Liquid)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Available as:

    - Priadel® Liquid 520mg (approx 5.4mmol Li+) in 5ml.
    - Li-Liquid® Liquid 509mg (5.4mmol Li+) in 5ml. (Not stocked at SFH)

    • Prescribe the (Li-Liquid/Priadel Liquid brands) liquid formulation as a twice daily dose to minimise peak plasma levels. See table of liquid medicines requiring dose adjustment 
    • Prescribing guidance should accompany request for primary care to prescribe.
    • Approx equivalents, but avoid unecessary switching: Li-Liquid 509mg/5ml = Priadel Liquid 520mg/5ml = Priadel 200mg tablet. (See table of liquid medicines requiring dose adjustment) 
     
       
    04.03  Antidepressant drugs
     note  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
    View adult BNF View SPC online View childrens BNF
    First Choice
    Green

    Tablet
    Oral suspension

    • Lofepramine is safer in overdose and less cardiotoxic than older TCAs and is the first-choice agent in this section.
     
    Amitriptyline
    (Antidepressant)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2

    Tablet, Oral solution

    • 10mg/5ml Solution is surprisingly expensive. Use 25mg/5ml or 50mg/5ml where possible

    Grey Traffic Light Not recommended for depression/anxiety
    Amber Traffic Light Dermatology use for the treatment of urticaria and pruritus.

     
       
    Clomipramine
    View adult BNF View childrens BNF
    Formulary
    Green

    Capsules

    • An alternative to SSRIs in obsessive-compulsive disorder (OCD).
    • MR Capsules are non- formulary.
    • Capsules can be opened and contents mixed with water if needed (unlicensed), click here for more information.
    • MHRA for SPCs
     
       
    Imipramine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablet, Oral solution (25mg/5ml)

    • Oral solution, sugar free, available (approx £42 for 150ml vs £1 for tablets, DT May18). Expires 30 days after opening.
    • July 2020: supply issues with 25mg tablets. See DHSC Medicine Supply Notification.
     
       
    Nortriptyline
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablet

    • Tablets were temporarily very expensive but now relatively inexpensive again. [see price history]
    • Licensed liquid is VERY expensive, so consider alternative (e.g. amitriptyline) if liquid is needed.
     
       
    Doxepin
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2

    Capsule

    • GreyTraffic Light Not for use as an antidepressant
    • AmberTraffic Light Restricted for dermatology use only for the treatment of urticaria and pruritus.
    • Second line to amitriptyline.
    • See also doxepin cream in topical section.
    • Doxepin and amitriptyline have the most potent antihistamine activity of all tricyclic antidepressants.
    • Cost: £100-150 per box
     
    Link  See unexpectedly expensive medicines list
       
    04.03.01  Related antidepressants
    Trazodone
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Capsule, tablet, liquid

    • Liquid is expensive: 100mg daily, £80 (50mg/5ml) per month and £270 (100mg/5ml) per month. Capsules are relatively cheap: 100mg daily £5 per month. SFH: Consider opening and dispersing capsule contents for inpatients.
    • Note: Second line after mirtazapine in the treatment of severe anxiety in dementia patients in the context of behavioural and psychological symptoms of dementia
     
       
    04.03.02  Monoamine-oxidase inhibitors
    Isocarboxazid
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    • Note dietary restrictions. Hypertensive crisis can develop in those taking MAOIs and who eat tyramine-rich food. See fact sheet below.
    • Warn patients against self-medication with proprietary 'cold-cure' preparations and nasal decongestants. See fact sheet below.
    • GPs may prescribe only after initiation and stabilisation by NHCT.
    • Fact sheet: Isocarboxazid
     
       
    Phenelzine (Nardil®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    • Note dietary restrictions and toxicity in overdose.
    • Out of stock due to manufacturing issues. A resupply date for the licensed product (Nardil®) is currently not available from the manufacturer. 
    • UKMI Shortage Guidance Memo
     
    Link  DHSC: Phenelzine Supply Disruption Alert
       
    Tranylcypromine
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red

    Tablets

    • Red for use within Nottinghamshire Healthcare NHS Foundation Trust 

     

     
       
    04.03.02  Reversible MAOIs
    Moclobemide
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    • Need washout period if switching from another antidepressant
    • Tablets disperse in water if needed. See here for general advice on dispersing tablets.
    • GPs may prescribe only after initiation and stabilisation by NHCT
     
       
    04.03.03  Selective serotonin re-uptake inhibitors to top
     note 

    Generic 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)).

    Sertraline
    View adult BNF View SPC online View childrens BNF
    First Choice
    Green

    Tablet

    • First-choice antidepressant.
    • Tablets disperse in water if needed (for whole tablet doses). See here for general advice on dispersing tablets.
    • NB: Crushed tablets may cause slight numbing of tongue and taste bitter.
    • If liquid is needed for paediatrics and dispersing tablets / switching to alternative licensed SSRI liquid is not possible, the recommended strength is 50mg/5mL oral suspension (unlicensed) as per RCPCH guidance.
     
    Citalopram
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablet, Oral drops

    • Tablets disperse in water if needed. See here for general advice on dispersing tablets.
    • 8mg (4 drops) citalopram 40mg/ml oral drops is equivalent in therapeutic effect to 10mg citalopram tablet. (See table of liquid medicines requiring dose adjustment) 
     
    Link  MHRA Drug Safety Update (July 2016)
    Link  NottsHC flowchart on citalopram/escitalopram maximum dose reductions
    Link  UKMI Q&A: What issues should be considered regarding drug induced QT prolongation?
       
    Escitalopram
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablet

    • Escitalopram (the active isomer of citalopram) may be considered as third-line option in resistant depression/anxiety disorders only
     
    Link  Link to reviews
    Link  MHRA safety advice regarding maximum doses and QT prolongation
    Link  NottsHC flowchart on citalopram/escitalopram maximum dose reductions
       
    Fluoxetine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Capsule, dispersible tablets, liquid

    • Long half-life- caution when making dose adjustments and switching to other antidepressants
    • Note drug interactions.
    • Fluoxetine 10mg tablets/capsules are not cost-effective. The 20mg dispersible tablets (Olena® brand) can be halved to give 10mg doses if required. Alternatively use  Fluoxetine 20mg/5ml oral solution (NOT THE SUGAR-FREE VERSION).
    • October 2020: supply issues with Fluoxetine 30mg capsules. See DHSC Serious Shortage Protocol
     
    Link  MHRA Drug Safety Update (Dec 2014)
    Link  NICE evidence summary: Fluoxetine for hypersexuality
       
    Vortioxetine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablet

    • As per NICE TA 367, recommended as an option for treating major depressive episodes in adults whose condition has responded inadequately to 2 antidepressants within the current episode.
     
    Link  NICE TA 367 - Vortioxetine for treating major depressive episodes
       
    04.03.04  Other antidepressant drugs
    Venlafaxine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablet, Capsule MR

    • Prescribe generically in primary care.
    • Note: MR 225mg caps/tabs are not cost-effective. Instead prescribe as 150mg + 75mg.
    • Venlafaxine (an SNRI) may be considered as a third-line option in resistant depression/anxiety disorders.
    • (specialist initiation) when using doses of 300mg - 375mg/day.
    • Green if using doses <300mg/ day
    • If needed capsules can be opened and beads mixed with water (do not crush). More Info
     
    Link  Notts APC: Venlafaxine information sheet for higher doses
       
    Esketamine HydrochlorideBlack Triangle (Spravato® nasal spray)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red

    Nasal spray solution

    •  Red for use within Nottinghamshire Health Care Trust 
     
       
    Mirtazapine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablets, orodispersible tablets, oral solution (expensive)

    • Oral solution is expensive and should only be used if orodisperible tablets are unsuitable.
    • June 2020 supply issues with Orodispersible tablets 15mg and 45mg. See DHSC Medicine Supply Notification.
     
       
    Tryptophan
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
  • On recommendation from NHCT only 
  •    
    Duloxetine (Cymbalta®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    • 3rd line option for depression/anxiety
    • Also used for the treatment of urinary incontinence, but preparation and dosage different - see Yentreve (section 7.4.2
    • For side effects in the BNF see Yentreve (section 7.4.2)Be aware of drug interactions
    • Capsules can be opened and their contents mixed (do not crush beads) with soft food (unlicensed), click here for more information.  
     
    Link  Independent reviews
       
    04.04  CNS stimulants and other drugs used for attention deficit hyperactivity disorder
    Controlled Drug Methylphenidate
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted

    Tablet Immediate Release (Generic, Ritalin®, Medikinet®)                       

    Tablet Modified Release (Delmosart®,Xaggitin XL®, Xenidate XL®, Concerta® XL)

    Capsule Modified Release (Medikinet® XL, Equasym® XL, Ritalin® XL)

    PRESCRIBE MR FORMULATIONS BY BRAND. Different versions of MR preparations may not have the same clinical effect. IR formulations can be prescribed generically. Preferred brands for modified release tablet in primary care are Delmosart® or Xaggitin XL®. See Preferred Prescribing List

    Attention Deficit Hyperactivity Disorder (ADHD)

    • Treatment with methylphenidate should only be initiated by a specialist with expertise in ADHD following a comprehensive assessment and diagnosis
    •  Patients under 6 years old.

    Narcolepsy

    The contents of Equasym XL® capsules, and Medikinet XL® capsules can be sprinkled on a tablespoon of soft food (e.g. apple sauce or yoghurt), then swallowed immediately without chewing.

     
    Atomoxetine
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted

    Capsules, Liquid (Strattera®) 4mg/mL

    Attention Deficit Hyperactivity Disorder (ADHD)

    • Treatment with atomoxetine should only be initiated by a specialist with expertise in ADHD following a comprehensive assessment and diagnosis.
    • : Patients under 6 years old
    • Liquid is restricted to patients that are unable to swallow capsules.
     
    Link  Blood Pressure and Heart Rate Monitoring in Children
    Link  Chart: BP by age and height centiles
    Link  COVID19: ADHD monitoring during COVID19 (Notts CCG)
    Link  Link to reviews
    Link  MHRA information on BP and heart rate increases (2012)
    Link  Risk of psychotic or manic symptoms in children and adolescents (2009)
    Link  UKMI Q&A: Methylphenidate for adults with ADHD
       
    Controlled Drug Dexamfetamine
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted

    Tablet

    Attention Deficit Hyperactivity Disorder (ADHD)

    • Treatment with dexamfetamine should only be initiated by a specialist with expertise in ADHD following a comprehensive assessment and diagnosis.
    •  : Patients under 6 years old.

     Substance misuse

      - Specialist use only

    Narcolepsy (adults)

     Amber 2 - See NottsAPC information sheet

     Oral solution is non-formulary (grey, no formal assessment), APC Sept 14.

     
    Link  Blood Pressure and Heart Rate Monitoring in Children
    Link  COVID19: ADHD monitoring during COVID19 (Notts CCG)
    Link  UKMI Q&A: Methylphenidate for adults with ADHD
       
    Guanfacine (Intuniv®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Tablet
  • For use in paediatrics and adolescents in those requiring a non-stimulant. To be used second line to atomoxetine or as an alternative if atomoxetine is clinically inappropriate. 
  • Link  Link to reviews
    Link  NICE ESNM70: Attention deficit hyperactivity disorder in children and young people
       
    Modafinil
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2

    Tablet

    • Amber 2 when initiated by specialists for treatment of excessive sleepiness associated with narcolepsy in adults (only licensed indication).
    • Unlicensed indications (e.g. fatigue in MS) are non-formulary and classified grey.
     
    Link  NottsAPC: Modafinil in narcolepsy information sheet
    Link  MHRA: Modafinil - EMA recommends restricted use (Aug 2010)
    Link  MHRA: Risk of birth defects and also reduced effectiveness of contraception
    Link  NICE Evidence Summary: Modafinil for excessive daytime sleepiness in Parkinson’s disease
    Link  NICE Evidence Summary: Modafinil for fatigue in multiple sclerosis
    Link  Link to reviews
       
    Controlled Drug Lisdexamfetamine (Elvanse®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted

    Capsules

    Attention Deficit Hyperactivity Disorder (ADHD)

    •  : Patients under 6 years old
     
    Link  Blood Pressure and Heart Rate Monitoring in Children
    Link  COVID19: ADHD monitoring during COVID19 (Notts CCG)
    Link  Link to reviews
    Link  UKMI Q&A: Methylphenidate for adults with ADHD
       
    04.05  Drugs used in the treatment of obesity
    04.05.01  Anti-obesity drugs acting on the gastro-intestinal tract
    Liraglutide (Saxenda®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red

    NICE TA664 - Liraglutide (Saxenda) for managing overweight and obesity.

    The use of Liraglutide for this indication is restricted to prescribing in secondary care by a specialist multidisciplinary Tier 3 weight management service with a commercial agreement in place. Nottinghamshire has no Tier 3 weight management service so patients should be referred to Derby.

     
    Link  Link to reviews
       
    Orlistat
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    Capsule
  • GPs can prescribe as part of an obesity management program, in accordance with NICE guidance. Continual monitoring makes it inappropriate for the hospital to initiate.
     
  • Link  Nottingham & Nottinghamshire CCG: Orlistat information for prescribers
    Link  NICE CG189: Obesity: identification, assessment and management
    Link  MHRA: Interaction with HIV medicines
    Link  Link to reviews
       
    04.05.02  Centrally acting appetite suppressants to top
    04.06  Drugs used in nausea and vertigo
    Netupitant and Palonosetron (Akynzeo®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red

    NUH & SFHT:

    Approved for adult Oncology patients only (NUH) and Oncology and Haematology (SFHT)

    • Prevention of acute and delayed nausea and vomiting associated with highly emetogenic cisplatin-based cancer chemotherapy.
    • Prevention of acute and delayed nausea and vomiting associated with moderately emetogenic cancer chemotherapy.
     
    Link  NICE ESNM69: Prevention of chemotherapy induced nausea and vomiting in adults
       
    04.06  Antihistamines
    Cinnarizine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablet

    • For vestibular disorders, vertigo, motion sickness
    • Tablets disperse in water if needed (they disperse within 1 minute). See here for general advice on dispersing tablets.
    • OTC Patients should be advised to purchase a suitable product over the counter for travel sickness

     
       
    Cyclizine (Valoid®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablet, Injection

    • SFH: Cyclizine is now more expensive, £16 per box of 5, previously £3. See price graph
    • If needed tablets can be dispersed in water (unlicensed). NB: They taste bitter. More Info
    • Can be given S/C (unlicensed but accepted practice)
     
    Link  Notts APC: End of life care guideline
    Link  NUH: Cyclizine cost awareness memo
    Link  SFH: Anti-emetic one side guide
       
    Promethazine Hydrochloride (Phenergan)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablets, Liquid, Injection.

    • Nausea and vomiting during pregnancy
    • See Section 4.1 for use as antihistamine
     
       
    04.06  Phenothiazines and related drugs
    Chlorpromazine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    See section 4.2.1
  • May be used in the treatment of hiccup 
  •    
    Droperidol (Xomolix®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Injection 2.5mg/ml
  • For use in PONV.
  • For IV use can be administered undiluted as a slow bolus. 
  • Link  Droperidol risk reduction poster
       
    Levomepromazine
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Green
    -Tablets 25mg. £0.26 per tablet (scored for doses of 12.5mg and can be quartered for doses of 6.25mg)
    -Tablets 6mg. £2.40 per tablet! NUH only (Unlicensed- named patient use only).
    -Injection
  • Palliative care use only
  • Tablets disperse in water if needed. See here for general advice on dispersing tablets.
  • Used to be called methotrimeprazine 
  • Link  COVID19: Is there a shortage of EOL anticipatory medicines? (Notts CCG)
    Link  COVID19: NICE (NG163) Managing symptoms (incl EOL) in the community
    Link  COVID19: Notts CCG - Managing Symptoms of Covid-19 (End of Life) in Community and Non-acute Hospital Settings
    Link  Notts APC: End of life care guideline
    Link  Standard anticipatory medicines for end of life care
       
    Prochlorperazine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablet, Buccal tablet, Injection (IM route only. Not for IV or SC use.)

    • Buccal prochlorperazine available OTC containing 8 tablets. Patients should be advised to self care for infrequent migraine.
    • Liquid discontinued 2019.
     
       
    04.06  Domperidone and metoclopramide
    Metoclopramide
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    Tablet, Liquid, Injection
  • Nausea and vomiting, post cytotoxic treatment
  • 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)
  • The MHRA dose restrictions for metoclopramide do not apply to palliative care as the guidance only covers the licensed indications.(Ref:www.palliativedrugs.com) 
  • Link  MHRA update on restricted dose information (Aug 13)
    Link  Notts APC: End of life care guideline
    Link  NUH Medicines Matters Bulletin regarding Metoclopramide
    Link  SFH memo regarding MHRA guidance in oncology & haematology
    Link  SFH: Anti-emetic One-Side Guide
    Link  UKMI interpretation of restricted dose information (Dec 13)
       
    Domperidone
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablet, Suspension

    • Nausea and vomiting associated with cytotoxic therapy and nausea caused by dopaminergic drugs and apomorphine.
    • See link below for MHRA advice about dose restrictions and contraindications and SFH memo regarding MHRA guidance in oncology & haematology.
    • Amber 2 specialist initiation / recommendation for G.I. motility in children under 12 years.
    • Grey for nausea and vomiting in children under 12 years and less than 35kg as per MHRA advice (lack of efficacy).
    • Grey non-formulary for promoting tolerance of enteral feeds in children / young people. See NICE evidence summary.
     
    Link  MHRA: Advice for domperidone (April 2014)
    Link  MHRA: Apomorphine with domperidone - risks of cardiac side effects (April 2016)
    Link  MHRA: Domperidone no longer available without prescription (Sept 14)
    Link  NICE: Enteral feeds in children and young people: domperidone
    Link  UKMI: Domperidone use in chemotherapy guideline (May 2014)
       
    04.06  5HT3 antagonists to top
    Ondansetron
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablets, Injection, Syrup and orodispersible film.

    • Usual 1st or 2nd choice for Post Operative Nausea and Vomiting. 
    • The box may state IV only but it is OK for IM or SC use if needed (unlicensed but accepted practice).
    • Amber 2 when used for nausea and vomiting in pregnancy- see MHRA advice
    • for the off label indication of diarrhoea predominant IBS (tablet). Prescribing for this indication should remain in secondary care.
    • MHRA guidance - the new 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) - see local antiemetic guidance (links above) and SFH memo regarding MHRA guidance.
    • NB in secondary care the syrup and orodispersible film are available but are much more expensive than tablets [see here]. Tablets disperse in water if needed. See here for general advice on dispersing tablets.
     
    Link  Link to reviews
    Link  MHRA: New dose restrictions for ondansetron (2013)
    Link  NUH: Medicines Matters Bulletin - Ondansetron
    Link  Ondansetron for vomiting in children with gastroenteritis- NICE evidence summary
    Link  SFH: Anti-emetics One-Side Guide
       
    Granisetron
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2
    Tablet, Injection
  • Restricted for oncology and haematology use only, second line after ondansetron
  • N.B. 3.1mg/24hrs transdermal patch (Sancuso®) - is non-formulary, Grey awaiting submission 
  • Link  Link to reviews
       
    04.06  Neurokinin receptor antagonist
     note 
    Aprepitant
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red

    Capsules

    • For oncology patients only

    Oral suspension

    • NUH only for paediatric oncology patients
     
       
    Fosaprepitant (Ivemend®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
  • For oncology patients only (IV prodrug of aprepitant)
  • Stocked on WTC (But has to be booked to the patient when replacing stock for payment purposes)
  • Restricted to use in oncology patients per antiemetic guidelines for these patients (See above) 
  •    
    04.06  Cannabinoid
     note 
    04.06  Hyoscine
    Hyoscine Hydrobromide
    (tablets/patches)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Patches, Tablets (Kwells® and Joy-Rides®).

    • Patches are 1.5mg total dose, but only release 1mg over 72 hours. Cost £6.50 each = £65 per month.
    • Tablets disperse in water if needed. See here for general advice on dispersing tablets.
     
    Link  Hypersalivation index page
    Link  Hypersalivation treatment options (UKMi Q&A’s)
    Link  Price comparison of hypersalivation treatments
       
    04.06  Other drugs for Ménière's disease
    Betahistine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablet

    • Menières disease, vertigo
    • Evidence of efficacy lacking (Cochrane 2001BMJ 2016)
    • Consider trial withdrawal as patient may be deriving no benefit.
    • Tablets disperse in water if needed, click here for more information. See here for general advice on dispersing tablets.
     
       
    04.07  Analgesics to top
     note  Avoid using compound analgesic preparations wherever possible
    Methoxyflurane (Penthrox®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red

    Inhalation vapour.

    • NUH Only: Emergency relief of moderate to severe pain in the Emergency Department.
     
       
    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
    View adult BNF View SPC online View childrens BNF
    First Choice
    Green

    Tablet, Soluble tablet, Injection, Liquid, Suppositories

    • Recent updates to the dosing of paracetamol and the use of intravenous preparations mean that the usual 1g four times a day may not be suitable for all. Care should be taken when dosing paracetamol for patients weighing less than 50kg, and particularly in the frail, elderly population. Patients weighing more than 50kg may also have conditions which mean a dose reduction would also be appropriate e.g. chronic alcoholism, liver dysfunction, malnutrition. [BMJ article (2010)] [NUH paracetamol podcast].
    • Suppositories - note that lower strength suppositories (less than 60mg) are unlicensed.
    • OTC
     
    Aspirin
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablet, Tablet e/c, Tablet dispersible, Suppository

    • OTC
     
    Link  Aspirin in RECOVERY trial
       
    Nefopam
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2

    Tablet.

    • On pain team/ renal consultant advice only. Only to be considered if paracetamol, NSAIDs and opioids are unsuitable. Unknown efficacy (see Cochrane review) and has many side effects eg nausea, nervousness, anticholinergic side effects (dry mouth, constipation, blurred vision urinary retention, light headedness, reduced cognition, hypotension etc.). Such effects are particularly bad in the elderly - who are prone to falls [See Prescqipp].
    • Manufacturers advise not to crush or disperse the tablets for patients with swallowing difficulties as drug has a local anaesthetic effect. For patients with enteral tubes use tablets dispersed in water immediately prior to administration. See here for general advice on dispersing tablets.
    • Cost of common analgesics.
     
    Link  Analgesic prices
    Link  See unexpectedly expensive medicines list
    Link  SFH one side guide to analgesia
       
    Paracetamol and codeine (Co-codamol® 30/500)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Green

    Tablet, Effervescent tablet

    • Not recommended. Causes all the usual opioid side effects (constipation, drowsiness, nausea etc).
    • Usually better to use separate paracetamol, with codeine, dihydrocodeine or tramadol added only when required.
     
    Link  Analgesic prices
       
    Paracetamol and codeine (Co-codamol® 8/500)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Green

    Tablet, Soluble tablet.

    • Not recommended. Not enough codeine to have any effect other than cause constipation.
    • Usually better to use separate paracetamol, with codeine, dihydrocodeine or tramadol added only when required.
     
       
    04.07.02  Opioid analgesics
    Codeine
    (analgesia)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablet, Syrup (25mg/5mL), Injection (not recommended as no advantages over morphine and is a CD)

    • Very poor analgesic when used alone. Only use in addition to paracetamol. Works by small amounts (~10%) being converted to morphine (some people do not convert!).
    • New restrictions on use of codeine in children and breastfeeding mothers - see MHRA advice below.
    • Further information about use of codeine in breastfeeding here (UKMI Q&A).
    • Restricted Item NUH Medicines Matters Bulletin regarding Codeine
     
    Link  Equivalent doses of opioids
    Link  MHRA: Children restrictions for codeine (June 2013)
    Link  Analgesic prices
    Link  COVID19: NICE (NG163) Managing symptoms (incl EOL) in the community
    Link  COVID19: Notts CCG - Managing Symptoms of Covid-19 (End of Life) in Community and Non-acute Hospital Settings
    Link  MHRA: Children restrictions for codeine (July 2013)
    Link  Relative strengths graph of analgesics
    Link  SFH: Analgesia one side guide
    Link  SFH: Basic opioid advice
       
    Dihydrocodeine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    Tablet, Tablet MR, Oral solution.
  • Poor analgesic when used alone, probably similar to or theoretically slightly better than codeine, but based on minimal evidence. Only use in addition to paracetamol. 
    Controlled Drug Injection Only
  • Link  Analgesic prices
       
    Controlled Drug Morphine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    - Normal release (~4 hours effect): Tablet (Sevredol®), Oral solution (e.g. Oramorph®), NUH only: Low strength concentration of oral solution (100micrograms/mL - unlicensed)
    - Slow release (~12hr effect): Zomorph® Capsule MR 10mg, 30mg, 60mg, 100mg, 200mg, (MST® Tablet MR 5mg and 15mg ONLY, 15mg not available at NUH), Injection.

    • First line strong opioid
    • Prescribe by brand name. See Preferred Prescribing list for recommended brands in primary care.
    • For chronic non-cancer pain, doses greater than 60mg every 12 hours by specialist recommendation or advice only. See Opioids for non-cancer pain APC guidelines.
    • Low strength concentration of oral solution (100micrograms/mL) for use as per Nottingham Children's Hospital: Oral Analgesia Guideline.
    • If needed Zomorph capsules can be opened and beads mixed with semi solid food (puree, jam, yoghurt). Do not crush the beads. More Info on opening capsules
    • The beads can also go down via NG/PEG tubes of a diameter of more than 16Fr with an open distal end or lateral pores. Flush the tube with 30ml to 50ml of water.
    • Always give prophylactic laxatives with regular opioids.
     
    Link  Analgesic prices
    Link  Converting from parenteral morphine to Zomorph
    Link  COVID19: Is there a shortage of EOL anticipatory medicines? (Notts CCG)
    Link  COVID19: Managing End of Life in Community (Notts CCG)
    Link  COVID19: NICE (NG163) Managing symptoms (incl EOL) in the community
    Link  Equivalent doses of opioids
    Link  Guide to different morphine preparations
    Link  Nottingham Children’s Hospital: Oral Analgesia Guideline
    Link  Notts APC: End of life care guideline
    Link  NUH Zomorph FAQs
    Link  Opioid Deprescribing for Non-Cancer Pain (Notts APC)
    Link  Opioids for non-cancer pain - APC guidelines
    Link  Relative prices of long acting opioids
    Link  SFH basic opioid advice
    Link  SFH Opioids further information page
    Link  SFH: Morphine FAQs index
    Link  Standard anticipatory medicines for end of life care
       
    Controlled Drug Tramadol
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    Soluble tablet, Capsule, Injection
  • 400mg/day oral tramadol = approx 40mg oral morphine
  • Became a Sch 3 Controlled Drug on 10th June 2014.
  • Prescriptions now need to comply with CD requirements, with the total quantity to be supplied given in both words and figures and limits to validity of prescriptions and length of supply that can be provided. However tramadol is not subject to storage in a CD cupboard. 
  • Link  Analgesic prices
    Link  Equivalent doses of opioids
    Link  Opioid choice guide (SFH)
    Link  Relative strengths graph of analgesics
    Link  UKMI Q&A: Serotonin Syndrome risk with tramadol and SSRIs
       
    Controlled Drug Tramadol MR
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    MR tablets

    • Prescribe by brand. Preferred brands in primary care are Marol® MR tablets or Tamulief® SR tablets. See Preferred Prescribing list.
     
       
    Controlled Drug Buprenorphine (Patch)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 3

    Butec® Patch (Weekly patch) - available as 5, 10, 15 & 20microgram strengths
    Bupeaze® Patch (Twice weekly patch) - available as 35, 52.5 & 70microgram strengths

    • Not for first line use.
    • Prescribe by brand in primary care. See Preferred Prescribing List.
    • GPs may initiate in line with Notts APC Opioids for non-cancer pain - APC guideline
    • For chronic non-cancer pain, doses greater than 70 micrograms / hour by specialist recommendation or advice only. See Opioids for persistent non-cancer pain - APC guidelines. This does not apply to cancer related pain.
    • May be considered for patients with swallowing difficulties on stable dose of opiates or patients in whom morphine isn't tolerated
    • Considered to have a low place in therapy. Only for patients where other options eg codeine, tramadol or low dose morphine have been exhausted. Morphine preferred if a strong opioid needed.
    • When compared to other opiates Butec® patches are relatively weak and expensive
     
    Link  Analgesic prices
    Link  Buprenorphine patches QIPP aid
    Link  Buprenorphine patches QIPP aid supporting document
    Link  Equivalent doses of opioids
    Link  Independent drug reviews
    Link  Minimising errors with buprenorphine patches UKMI Q&A
    Link  Opioid Deprescribing for Non-Cancer Pain (Notts APC)
    Link  Opioids for non-cancer pain - APC guidelines
    Link  Relative prices of long acting opioids
    Link  NUH: brand switch information - Jan 2017
    Link  SFH: brand switch information - Jan 2017
    Link  SFH: buprenorphine preparations information
       
    Controlled Drug Buprenorphine (Temgesic®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Tablet sublingual
     
    Link  SFH: buprenorphine preparations information
       
    Controlled Drug Diamorphine
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Green

    Injection

     
    Link  Anticipatory medicines guidelines
    Link  Link to reviews
    Link  SFH advice for managing drug misusers maintained on IV diamorphine
    Link  SFH opioid misusers guideline
       
    Controlled Drug Fentanyl
    (Patch)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2

    Patch

     
    Link  Analgesic prices
    Link  Equivalent doses of opioids
    Link  MHRA warning regarding accidental exposure
    Link  MHRA warning: Do not use in opioid naive patients (Sep2020)
    Link  Moderate to severe acute post-operative pain: fentanyl transdermal patch
    Link  NUH Medicines Matter: Fentanyl patches
    Link  Opioid Deprescribing for Non-Cancer Pain (Notts APC)
    Link  Opioids for non-cancer pain - APC guidelines
    Link  Relative prices of long acting opioids
    Link  SFH dose equivalence tables (via opioids links page)
    Link  UKMI Q &A: switching from morphine to fentanyl patches
       
    Controlled Drug Oxycodone
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2

    -Normal release: Capsule and 5mg in 5mL liquid  (Shortec®). Concentrate liquid (50mg in 5mL) and Injection (Oxynorm®)
    -Slow release: Tablet (Longtec®)

    • Potent opioid - on pain team specialist advice only for non-cancer pain.
    • See Opioids for non-cancer pain - APC guideline.
    • Green Green for cancer / end of life pain
    • Prescribe by brand. Longtec®/ Shortec® preferred in Nottinghamshire for new patients. See Preferred Prescribing list.
    • In secondary care restricted for pain management service use and palliative care use only.
    • More expensive, and not superior to morphine. Only for patients unable to tolerate idiosyncratic side effects with morphine.
    • Always give prophylactic laxatives
    • Oxycodone injection 10mg/ml and 50mg/ml are available, but 50mg/ml comparatively more expensive and so only for use where high doses will not fit into syringe. Using a 30ml syringe you have approx 17ml volume available to measure 48mm. So doses of over 170mg using 10mg/ml oxycodone will not fit, and high strength oxycodone will be required. If other drugs are included this amount will be less. Seek advice from hospice if required.
     
    Link  Opioids for non-cancer pain - APC guidelines
    Link  Notts APC: End of life care guideline
    Link  NUH: Change of Oxycodone 5mg/5mL oral solution brands
    Link  Opioid Deprescribing for Non-Cancer Pain (Notts APC)
    Link  Relative prices of long acting opioids
    Link  Analgesic prices
    Link  Equivalent doses of opioids
    Link  SFH: Oxycontin/ Oxynorm switching to Longtec/ Shortec MEMO
       
    Controlled Drug Tapentadol (Palexia®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Modified release: Palexia SR
    Standard release (tablets, oral solution 20mg/ml): Palexia

    • Amber 2 - specialist initiation by pain teams only - for chronic pain in patients either unresponsive or unable to tolerate morphine, fentanyl, oxycodone and buprenorphine (i.e. fifth line strong opioid). Tapentadol can be used 3rd line only if the patient has not responded to morphine and buprenorphine and was showing symptoms of neuropathic pain. See Opioids for non-cancer pain - APC guidance for details
    • Pain teams are to provide the first 28 days treatment and evaluate patient response. Only responders may be referred to primary care for further prescriptions.
     
    Link  Click here for Prescribing Information (APC)
    Link  Link to reviews
    Link  MHRA: risk of seizures and serotonin syndrome with tapentadol
    Link  Opioid Deprescribing for Non-Cancer Pain (Notts APC)
    Link  Opioids for non-cancer pain - APC guidance
    Link  Relative prices of long acting opioids
       
    Controlled Drug Methadone
    (Analgesic)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2
    Tablet, Liquid
  • For initiation by pain team only when used as an analgesic 
  • Link  SFH: Methadone for analgesia guidelines (see tab 'PMH Text'))
       
    Controlled Drug Pethidine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    Tablet, Injection
  • Morphine usually preferred (except in obstetrics) 
  •    
    Controlled Drug Alfentanil Sublingual Spray 5 mg in 5mL
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    • Unlicensed medicine - named patient use only
    • For palliative care use only
     
    Link  Link to reviews
       
    Controlled Drug Fentanyl Nasal Spray (PecFent®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red

    Nasal spray:
    - 100 micrograms / spray (~£43 per 8 sprays)
    - 400 micrograms / spray (~£43 per 8 sprays)

    • Restriction: Specialist initiation only for the management of breakthrough pain in adult patients using opioid therapy for chronic cancer pain, when other short-acting opioids are unsuitable
    • Grey Non-formulary for use in non-cancer related pain.
    • On the Nottinghamshire list of Medicines & Appliances of Limited Clinical Value.
     
    Link  Price graph for breakthrough opioids
    Link  see independent reviews
       
    Controlled Drug Fentanyl sublingual tablets (Abstral®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red

    Sublingual tablets. £5 each tablet.

    • Restriction: Specialist initiation only for the management of breakthrough pain in adult patients using opioid therapy for chronic cancer pain, when other short-acting opioids are unsuitable
    • Grey Non-formulary for use in non-cancer related pain.
    • On the Nottinghamshire list of Medicines & Appliances of Limited Clinical Value.
     
    Link  Price graph of breakthrough opioids
    Link  See independent drug reviews
       
    04.07.03  Neuropathic pain
    Amitriptyline
    (Neuropathic Pain)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 3

    Tablets, oral solution*

     
       
    Nortriptyline
    (Neuropathic Pain)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 3

    Tablets

    • Only use nortriptyline if amitriptyline effective but patient unable to tolerate side effects.Use as per APC Neuropathic Pain Guideline
    • See section 04.07.04.02 for use in migraine prophylaxis
    • Licensed liquid is VERY expensive, so consider alternative treatment if liquid is needed.

     

     
       
    Controlled Drug Gabapentin
    (Neuropathic pain)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 3

    Capsule (100mg, 300mg and 400mg strengths), Oral solution (50mg/ml)

    • GPs may initiate in line with Notts APC Neuropathic Pain Guidelines.
    • Tablet is non formulary as is much more expensive than capsules.
    • Oral solution (sugar free) available (>£200 for 28 days at 300mg TDS dose vs approx £4 for capsules, DT May18)
    • If needed capsules can be opened and contents dispersed in water (not licensed). Give immediately due to limited stability. More Info. Mask taste by mixing with orange juice or sprinkling on food.
    • Latest advice on switching between pregabalin and gabapentin for neuropathic pain here (UKMI Q & A) Nov 2014
     
    Link  NHS England Guidance on Reclassification (1st April 2019)
    Link  Patient leaflet: Are you taking gabapentin or pregabalin? (NHS England)
    Link  CKS - Restless legs syndrome
    Link  Illicit use: Gabapentin and Pregabalin Advice for Prescribers (Notts APC: Feb 2019)
    Link  MHRA Drug Safety Update (October 2017)
       
    Controlled Drug Pregabalin
    (Neuropathic pain)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 3

    Capsule, Oral solution (20mg/ml)

    • Should only be considered after both amitriptyline and gabapentin have failed at optimised doses. Although, there is no evidence of efficacy in this group of patients.
    • Pregabalin may be used in preference to gabapentin for palliative care patients (helps to reduce tablet burden).
    • GPs may initiate in line with Notts APC Neuropathic Pain Guidelines.
    • Has the same mode of action as gabapentin .
    • Oral solution available (approx £50 for 28 days, DT May18)
    • If needed capsules can be opened and contents dispersed in water (not licensed). More Info
    • Advice on switching between pregabalin and gabapentin for neuropathic pain here (UKMI Q&A).

    Treatment of restless legs:

    • Treatment option for restless legs when symptoms seriously impair quality of life and non-drug based measures have failed.
     
    Link  NHS England Guidance on Reclassification (1st April 2019)
    Link  Patient leaflet: Are you taking gabapentin or pregabalin? (NHS England)
    Link  CKS - Restless legs syndrome
    Link  Illicit use: Gabapentin and Pregabalin Advice for Prescribers (Notts APC: Feb 2019)
    Link  Lyrica brand prescribing no longer necessary: NHS guidance 2017
    Link  MHRA: reports of severe respiratory depression with pregabalin
       
    Duloxetine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 3
    • GPs may initiate in line with Notts APC Neuropathic Pain Guidelines.
    • If needed, the capsules can be opened and their contents mixed (do not crush beads) with soft food (unlicensed), click here for more information.  
     
    Link  Link to reviews
       
    Controlled Drug Ketamine oral solution
    Formulary Oral Solution 50mg/5ml - unlicensed product.
  • At SFH: Available as 300ml bottles, orange flavour (Or on request: 100ml vanilla )
  • From Dec 2015 classified as a schedule 2 controlled drug.
  • Restricted for pain management service or on the advice of palliative care team only.
  • Prescribing for patients under the care of palliative care teams may be continued by primary care after specialist initiation (classified Amber Traffic Light). Prescribing for other patients should remain in secondary care (classifed Red Traffic Light).
  • SFH outpatients should be sent to SFH pharmacy for supplies of unlicensed medicines. Don’t prescribe on FP10HP.
     
  • Link  Link to reviews
    Link  NICE Unlicensed medicine review 27: Ketamine for chronic pain
       
    04.07.03  Trigeminal neuralgia to top
    Carbamazepine
    (Trigeminal neuralgia)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    See section 4.8.1 for epilepsy indication 
    Link  SFH Drug levels information - compilation table
    Link  SFH information on switching brands
       
    04.07.03  Postherpetic neuralgia
    Capsaicin
    (Postherpetic neuralgia)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    Cream
    See also section 10.3.2
  • 0.075% Axsain® for post-herpetic neuralgia 
  •    
    Carbamazepine
    (Postherpetic neuralgia)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    See section 4.8.1 for use as an antiepileptic
     
    Link  SFH Drug levels information - compilation table
    Link  SFH information on switching brands
       
    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, aspirin, 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
     note 

    The prices of triptans are currently variable so treatment choices should be based on the most cost-effective option. See price graph for current prices.

    Sumatriptan
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    • Available as:
      - Tablets 50mg & 100mg. Do not prescribe as Imigran brand
      - Nasal Spray (£6 per dose)- zolmitriptan nasal spray more effective if patient is vomiting.
      - Auto-injector (£21 per dose) - Firm pressure required. Upper arm or thigh preferred to a soft belly.
    • Prescribe as pre-filled disposable devices to ensure cost effectiveness not pre-filled syringes with device
    • Tablets first line. Nasal spray or injection are available if tablets not acceptable.
    • OTC Patients suffering mild migraine should be advised to purchase a suitable product over the counter first line. See NHSE guidance.

     

     
       
    Zolmitriptan
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablets, Orodispersible tablets, Nasal spray

    • If patient requires a dispersible tablet, rizatriptan orodispersible is most cost-effective option.
    • Cost effective Triptans
     
       
    Rizatriptan
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablets, orodispersible tablets, oral lyophilisate*

    • *If a patient requires a dispersible tablet,  orodispersible more most cost-effective than oral lyophilisate.
     
       
    Frovatriptan
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablets

    • Third line option if other triptans are not tolerated or ineffective. Long half life may be advantageous in patients with recurrent migraine attacks.
     
    Link  Link to reviews
       
    Naratriptan
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablets

     
       
    04.07.04.01  Ergot alkaloids
     note 
    04.07.04.02  Prophylaxis of migraine
    Propranolol
    (Migraine prophylaxis)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 3

    Tablets, oral solution

     
       
    Topiramate
    (Migraine prophylaxis)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 3

    Tablets (preferred as more cost effective), capsules

     
       
    Amitriptyline
    (Migraine prophylaxis)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 3

    Tablets, oral solution*

     
       
    Nortriptyline
    (Migraine prophylaxis)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 3

    Tablets

    • For migraine prophylaxis only if amitriptyline was effective, but side effects intolerable as per Notts APC Adult Headache Pathway.
    • Licensed liquid is VERY expensive, so consider alternative treatment if liquid is needed.
     
       
    Botulinum Toxin Type A (botox®)
    (Migraine prophylaxis)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    High Cost Medicine
    Injection
    Consultant recommendation only - in line with NICE TA260.
  • For other indications see section 4.9.3
     
  • Link  Link to reviews
       
    Galcanezumab (Emgality®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine
    Homecare

    Pre-filled pen

    NUH Consultant neurologist recommendation only:

    • Approved in accordance with NICE TA659 for preventing migraine.
    • Available through homecare for NUH patients. Please contact pharmacy medicines homecare team for further information.
     
    Link  NICE TA659: Galcanezumab for preventing migraine
       
    FremanezumabBlack Triangle (Ajovy®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine
    Homecare

    NUH Consultant neurologist recommendation only
    Pre-filled syringe/pre-filled pen for subcutaneous injection

    • Approved in accordance with NICE TA631 for preventing migraine
    • Available through homecare for NUH patients. Please contact pharmacy medicines homecare team for further information.
     
    Link  NICE TA631: Fremanezumab for preventing migraine
       
    04.07.04.03  Cluster headache
    Melatonin
    (Cluster headache)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
  • 10mg daily of immediate release preparation should be used as this dose is supported by trial evidence.  
  • Link  Independent reviews
    Link  Melatonin products price comparison graph
    Link  Price comparison of melatonin products (standardised to 10mg)
    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
    (epilepsy)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablet (modified release or standard release), Liquid, Suppository.

    • May be appropriate for specialist GP to initiate or any GP to prescribe whilst awaiting hospital referral.
    • Chewtabs discontinued.
    • If using carbamazepine, offer controlled-release carbamazepine preparations [NICE 2012]
    • Try not to switch brands. Tegretol is the preferred brand.
    • Suppository 125mg = oral 100mg. Tegretol brand suppositories no longer available, now rebranded as "Essential Pharma" brand and cost £120 for a pack of 5!
    • Suppositories, see UKMI Q+A . SFH: Use of more than a few days must be discussed with MI/Formulary team on x3163
    • Care with dose frequency when switching from modified release preperations to liquid. Same total daily dose needs to be given, but split into 3-4 doses (See table of liquid medicines requiring dose adjustment) 
     
    Link  SFH Drug levels information - compilation table
    Link  SFH information on switching brands
    Link  Therapeutic Drug Monitoring in Adults at NUH
    Link  UKMI Q&A: carbamazepine suppositories - Why is there a limit on the dose and duration?
       
    Eslicarbazepine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablet and oral suspension

    • Patients may be managed in primary care on the advice of a specialist, however clear guidance on dose titration and maximum doses should be provided by the Neurologist. 
    • For those unable to swallow tablets, oral suspension is available or tablets are licensed to be crushed and mixed with water or soft foods, such as apple sauce.
     
       
    Oxcarbazepine (Trileptal®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2

    Tablet, Oral Suspension

    • Restricted for specialist and paediatric specialist initiation only
     
       
    04.08.01  Gabapentin and pregabalin
    Controlled Drug Gabapentin
    (Epilepsy)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Capsule, (Tablet is non formulary), Oral solution (50mg/ml)

    • Specialist initiation
    • Tablet is non formulary as is much more expensive than capsules.
    • Oral solution (sugar free) available (>£200 for 28 days at 300mg TDS dose vs approx £4 for capsules, DT May18).
    • If needed capsules can be opened and contents dispersed in water (not licensed). Give immediately due to limited stability. More Info. Mask taste by mixing with orange juice or sprinkling on food.
     
    Link  NHS England Guidance on Reclassification (1st April 2019)
    Link  Patient leaflet: Are you taking gabapentin or pregabalin? (NHS England)
    Link  Illicit use: Gabapentin and Pregabalin Advice for Prescribers (Notts APC: Feb 2019)
    Link  MHRA Drug Safety Update (October 2017)
       
    Controlled Drug Pregabalin
    (Epilepsy)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2

    Capsule, Oral solution (20mg/ml)

    • Restricted for use only if had a trial of gabapentin and has been stabilised on treatment by specialist.
    • Oral solution available (approx £50 for 28 days, DT May18).
    • If needed capsules can be opened and contents dispersed in water (not licensed). More Info
     
    Link  NHS England Guidance on Reclassification (1st April 2019)
    Link  Patient leaflet: Are you taking gabapentin or pregabalin? (NHS England)
    Link  Illicit use: Gabapentin and Pregabalin Advice for Prescribers (Notts APC: Feb 2019)
    Link  MHRA: reports of severe respiratory depression with pregabalin
       
    04.08.01  Levetiracetam
    Levetiracetam
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablet, Oral solution, Infusion, Granules

    • 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. [More details here]
    • SFH palliative care specialists may recommend levetiracetam in a subcutaneous syringe driver over 24 hours for selected patients. The PO:SC dose ratio is 1:1 and WFI is used as a diluent. Due to a lack of official compatibility data it is usually be administered alone in it's own syringe driver. Seek pharmacy advice before using any combination in a single driver.
     
    Link  Link to reviews
    Link  NUH: Levetiracetam – Change from Keppra® brand to generic suppliers memo Nov 2015
    Link  NUH: Therapeutic Drug Monitoring in Adults at NUH
    Link  SFH - Prolonged seizures guidance
       
    Brivaracetam
    (epilepsy)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablet, Oral Solution, Injection

    • For the treatment of partial-onset seizures with or without secondary generalisation in adult and adolescent patients from 16 years of age with epilepsy. Use in children is classified Grey (no formal assessment)
    • Patients may be managed in primary care on the advice of a specialist, however clear guidance on dose titration and maximum doses should be provided by the Neurologist.
     
    Link  Link to reviews
       
    04.08.01  Phenobarbital and other barbiturates
    Controlled Drug Phenobarbital
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Available as:
    - Tablet
    - Liquid 15mg/5ml (contains 38% alcohol and not considered suitable for use in children).
    - Paediatric liquid (specify alcohol free) preferred strength is 50mg/5ml - Unlicensed special.
    - Injection (see status epilepticus section).

    • Tablets disperse in water if needed. See here for general advice on dispersing tablets.
     
    Link  SFH Drug levels information - compilation table
    Link  SFH outpatients should be sent to SFH pharmacy for supplies of unlicensed medicines. Don’t prescribe on FP10HP
       
    Primidone
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Tablet
  • Tablets disperse in water if needed. See here for general advice on dispersing tablets. 
  •    
    04.08.01  Valproate to top
    Sodium Valproate
    (Epilepsy)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablet, Tablet MR, Crushable tablet, Oral solution, Liquid (Syrup is non formulary), MR granules, injection.

    • Episenta modified release granules are available for once or twice daily dosing where tablets are not appropriate. These are considerably cheaper than Epilim Chronospheres and come in 150mg & 300mg (open capsules), 500mg & 1g (sachets).
    • Epilim Chronospheres very expensive in comparison to other options so only to be used if only possible option.
    • Try not to switch brands.
    • If needed the crushable tablets can be crushed and dispersed in water or soft food. NB: They are extremely bitter. More Info
    • Valproate treatment must be started and supervised by a doctor experienced in managing epilepsy or bipolar disorder
    • At SFH: IV 400mg vial size is stocked.
    • Contraindicated in women of childbearing potential unless part of a Pregnancy Prevention Programme. MHRA info. Amended guidance during Covid-19
     
    Link  SFH - Guideline for managing prolonged tonic-clonic seizures
    Link  MHRA Drug Safety Update (April 2017)
    Link  NICE 2019: Valproate: Summary of NICE guidance and safety advice
    Link  Risk Management Material: Information for Women of childbearing potential
    Link  SFH Drug levels information - compilation table
    Link  SFH: Advice on drugs to be prescribed by brand
    Link  Sodium valproate dosing conversions suggestions
    Link  Toolkit: risks of valproate medicines in females
    Link  UKMI Q&A: Which medicines require extra care when switching between liquid and tablet/capsule formulations?
    Link  UKMI suggested drug monitoring schedule
       
    04.08.01  Benzodiazepines
    Clobazam
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablet, Oral suspension (10mg/5ml)

    • Oral suspension (10mg/5ml) available (approx £95 for 150ml, DT May18)
    • Tablets disperse in water if needed (not licensed). See here for general advice on dispersing tablets.
    • The 5mg/5ml liquid is non-formulary (rationalised to one strength for safety reasons, APC Sept 14)
    • Clobazam is only available on the NHS for the treatment of epilepsy. FP10's should be endorsed 'SLS'.
     
    Link  FDA: Drug Safety Communication - Risk of Serious Skin Reactions (Mar13)
       
    Clonazepam
    (epilepsy/ restless legs)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablet, Oral solution - local recommended strength is 2mg/5mL (contains alcohol*)

    • Tablets can be dispersed in at least 30ml of water if licensed oral solution not suitable  (More Info).
    • *Licensed liquid contains ethanol, but local paediatric pharmacists consider ethanol content of 2mg/5mL oral solution to be within acceptable limits for children.
    • GPs may initiate for restless legs as per treatment algorithm
    • Injection: discontinued by manufacturer Oct 2013. If prescribed in adults discuss possible alternatives with neurologists.
    • At SFH injection still on neonatal guidelines, so unlicensed stock is being purchased from IDIS until the guidelines are reviewed.
     
    Link  SFH outpatients should be sent to SFH pharmacy for supplies of unlicensed medicines. Don’t prescribe on FP10HP.
       
    04.08.01  Other Drugs
    Acetazolamide
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    • See also section 11.6 for glaucoma indication
    • Specialist initiation only
    • Standard tablets disperse in water if needed. See here for general advice on dispersing tablets.
     
       
    Cannabidiol (CBD)
    Restricted Drug Restricted
    Red

    100mg/1mL oral solution (Epidyolex®)

    • Available through NUH only:
    • Approved in adults and paediatrics in accordance with NICE TA614 with clobazam for treating seizures associated with Dravet syndrome and TA615 with clobazam for treating seizures associated with Lennox–Gastaut syndrome
    • Approved in accordance with paediatric Early Access Programme (EAP) for patients with Dravet Syndrome (DS) and Lennox-Gastaut Syndrome (LGS).
    • Further information can be found here - NHS England FAQ
     
    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
       
    Ethosuximide
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    • Capsule, syrup
    • Absence seizures
     
       
    Lacosamide
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2
    • Tablets, Syrup, Infusion.
    • Intractable partial epilepsy in adults when other adjuvant agents have failed or have not been tolerated.
    • Patients may be managed in primary care on the advice of a specialist, however clear guidance on dose titration and maximum doses should be provided by the Neurologist.
     
    Link  Link to reviews
       
    Lamotrigine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    • Tablet, dispersible tablet
    • May be appropriate for specialist GP to initiate or any GP to prescribe whilst awaiting hospital referral
     
    Link  Lamotrigine and breastfeeding UKMI Q&A
    Link  MHRA advice on generic antiepileptics
    Link  NUH information on supplying generic lamotrigine
    Link  NUH: Therapeutic Drug Monitoring in Adults at NUH
    Link  SFH information on switching brands
       
    Perampanel
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    • Tablets and oral suspension
    • Adult patients may be managed in primary care on the advice of a specialist, however clear guidance on dose titration and maximum doses should be provided by the Neurologist.
    • Approved for adjunctive treatment of partial-onset seizures with or without secondary generalisation, when standard adjunctive treatment has not provided an adequate response, or has not been tolerated (as per NICE guidance).
    • Indication of adjunctive treatment of primary generalised tonic clonic seizures is classified grey (no formal submission).
    •  Oral suspension 0.5mg/ml
     
    Link  Link to reviews
    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
       
    Phenytoin
    (Oral)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Capsule, Infatabs, Suspension 30mg/5ml.

    • Important - 90mg liquid equivalent to 100mg tablets, capsules or injection.(See table of liquid medicines requiring dose adjustment) 
    • Prescribe by brand/ formulation in epilepsy. Epanutin capsules discontinued Sept 2012. 'Phenytoin Sodium Flynn Hard Capsules' brand now preferred.
    • Amber2, but may be appropriate for specialist GP to initiate or any GP to prescribe whilst awaiting hospital referral.
    • Do not administer liquid within 2 hours of NG or PEG feed.
    • For IV phenytoin see here.

     

    • Epanutin Infatabs Phenytoin 50mg tab (Pfizer) are expected to be out of stock until November 2019.
    • Further information from Pfizer can be found here
     
    Link  NUH: Therapeutic drug monitoring guidance
    Link  SFH Drug levels information - compilation table
       
    Rufinamide
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red

    Tablets, Oral Suspension

    • Restricted to paediatric neurology for use as adjunctive treatment for Lennox-Gastaut syndrome- see local guidelines.
     
       
    Stiripentol (Diacomit®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red

    Capsules, Sachets

    • NUH Neurologist recommendation only
    • NB. If using half of a 250mg sachet to give a 125mg dose, the manufacturers recommend halving the contents of the sachet FIRST and then dissolving that half in a small amount of water. The remaining half can be saved out of the sachet for up to one day.
     
       
    Tiagabine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablet

    • Specialist initiation
     
       
    Topiramate
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2

    Tablet

    • Sprinkle capsule
    • Restricted for initiation by neurology and paediatrics only
     
    Link  NUH information on supplying generic topiramate
       
    Vigabatrin
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2

    Tablet

    • Powder
    • Specialist initiation
     
    Link  Link to reviews
       
    Zonisamide
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2

    Capsules, Oral Suspension (Desizon®) 20mg/ml

    • AMBER 2 for adults and paediatrics.
    • Adult patients may be managed in primary care on the advice of a specialist, however clear guidance on dose titration and maximum doses should be provided by the Neurologist. 
    • If needed capsules can be opened and contents dispersed in water or mixed with soft food (eg apple sauce, chocolate pudding). More Info
    • Oral suspension is restricted to paediatric patients. 
     
    Link  Link to reviews
       
    04.08.02  Drugs used in status epilepticus
    Diazepam (epilepsy)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    •  See section 4.1.2 for information. 

     

     
       
    Lorazepam
    (seizures)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
     
    Link  SFH: Possible alternatives during IV lorazepam shortage
       
    Controlled Drug Midazolam
    (Epilepsy)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Buccal Liquid: two strengths available, prescribe by brand:
    - 5mg/ml, BUCCOLAM® (prefilled syringes 2.5mg, 5mg, 7.5mg, 10mg).
    - 10mg/ml, EPISTATUS® (bottle). (EPISTATUS® Prefilled syringes are non-formulary).

    • Use in paediatric patients should be in accordance with Notts APC paediatric guideline.
    • If patients are switched to the more cost effective Buccolam in primary care, advice should be clearly documented and the approved information leaflet given to patients
    • CD prescribing regulations apply, although does not need to be entered in CD register or stored in CD cupboard. However at NUH, full CD regulations apply including the need for register entries and storage in a CD cupboard.
    • Patient info leaflets: Prefilled syringes or Bottle.
     
    Link  Buccolam Prefilled Plastic Syringes: instructions for correct administration
    Link  Children’s Epilepsy Workstream in Trent (CEWT) resources
    Link  EMC Buccolam Package leaflet
    Link  Medicines for children - Midazolam for stopping seizures
    Link  MHRA: inspect Buccolam oral syringes before use
    Link  Notts APC: Guideline for the use of Buccal Midazolam in children
    Link  NUH Medicines Matter - Midazolam - April 2013
    Link  SFH outpatients should be sent to SFH pharmacy for supplies of unlicensed medicines. Don’t prescribe on FP10HP.
       
    Paraldehyde
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Injection - named patient use
    Rectal solution - unlicensed, named patient use
  • Rectal doses in reference texts and guidelines usually stated in terms of ml or ml/kg of paraldehyde. May be available as injection which requires dilution with olive oil prior to rectal administration, or ready diluted enema (50% paraldehyde: 50% olive oil), depending on availability.
    Do not confuse the dose/volume of paraldehyde with the volume of paraldehyde 50% enema.
    E.g., 0.3ml/kg paraldehyde = 0.6ml/kg paraldehyde 50% enema.
     
  •    
    Controlled Drug Phenobarbital injection
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Injection 
       
    Phenytoin
    (IV)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red

    Injection

    • SFH - No longer first line for prolonged seizures, see valproate
    • Complicated drug. For full instructions see IV phenytoin guide.
    • Loading doses need to be given as an infusion through a 0.2 to 0.5 micron filter. (At SFH see filters guide).
     
    Link  NUH Guideline: Status epilepticus - management
    Link  NUH: Therapeutic Drug Monitoring in Adults
    Link  SFH Drug levels information - compilation table
    Link  SFH IV phenytoin guideline
    Link  SFH: Information about IV filters
       
    04.08.03  Febrile convulsions
    Diazepam
    (febrile convulsions)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    See section 4.8.2 
       
    Paracetamol
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    See section 4.7.1 
       
    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
    Apomorphine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 1

    Injection

    • Specialist initiation only in line with Shared Care Protocol (see below)
    • Prescribe by brand name: Apo-go® or Dacepton®
    • APO-go® helpline: 0844 880 1327 (24 hours a day, 365 days a year)
    • Dacepton® Helpline: 0800 254 0175
     
    Link  Manufacturers guide: APO-go pen
    Link  Manufacturers guide: Setting up the APO-go pump
    Link  Manufacturers guide: Setting the APO-go infusion flow rate
    Link  Information about Neria infusion device
    Link  MHRA: Apomorphine with domperidone - risks of cardiac side effects (April 2016)
    Link  Notts APC SCP: Apomorphine information sheet
    Link  Notts APC SCP: Overarching SCP
    Link  NUH intranet information on apomorphine
       
    Bromocriptine
    (Parkinsons)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    For hyperprolactinaemia see section 6.7.1

    • If needed tablets can be dispersed in water. Give immediately and flush well with water. More Info
     
    Link  See unexpectedly expensive medicines list
       
    Cabergoline
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Tablet
  • Use of Cabergoline is no longer recommended unless the patient is already established on it and attempts to change to alternative therapy have failed.
  • Amber 2: Specialist initation
  • If needed tablets can be dispersed in water. Give immediately and flush well with water. More Info
     
  • Link  Notts APC Prescribing Information Sheet: Cabergoline
       
    Pergolide
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Tablet
  • Use of Pergolide is no longer recommended unless already established on it and attempts to change to alternative therapy have failed.
  • Amber 2: Specialist initiation in line with prescribing information sheet 
  • Link  Notts APC Prescribing Information Sheet: Pergolide
       
    Pramipexole
    View adult BNF View SPC online View childrens BNF
    Formulary

    Tablet, Tablet MR

    • Pipexus® is the current recommended brand in primary care. See Preferred Prescribing List for details.
    • Immediate release tablets disperse in water if needed. See here for general advice on dispersing tablets.

    Treatment of Parkinson's Disease:

    • On specialist initiation for the treatment of Parkinson's disease.
    • MR pramipexole should be reserved for current stable patients and those where ropinirole MR (1st line dopamine agonist) isn't suitable (APC Jan15). Pramipexole MR is much more expensive than ropinirole MR- see Parkinsons drugs prices

    Treatment of restless legs:

     
    Link  Link to reviews
    Link  NICE CKS: Restless legs syndrome guidance
    Link  Notts APC prescribing information sheet: Pramipexole
    Link  Notts APC restless legs treatment algorithm
       
    Ropinirole
    View adult BNF View SPC online View childrens BNF
    Formulary

    Tablet, Tablet MR

    • Standard release tablets disperse in water or mix with soft food if needed. See here for general advice on dispersing tablets.
    • MR ropinirole should be prescribed by brand in primary care. Ipinnia® XL or Repinex® XL are the preferred brands in primary care. See Preferred Prescribing List.
    • Note that Spiroco® XL has been discontinued, stocks of 4mg likely to be depleted by Nov20 and other strengths by 2022.

    Treatment of Parkinson's Disease:

    • On specialist initiation for the treatment of Parkinson's disease. Ropinirole MR is first line dopamine agonist.

    Treatment of restless legs:

     
    Link  Link to reviews
    Link  NICE CKS: Restless legs syndrome guidance
    Link  Notts APC prescribing information sheet: Ropinirole
    Link  Notts APC restless legs treatment algorithm
       
    Rotigotine
    (Parkinsons)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Patch
  • For specialist initiation for the treatment of Parkinson's disease only
     
  • Link  Link to reviews
    Link  Notts APC prescribing information sheet: Rotigotine
    Link  Rotigotine patch change in storage requirements (PIL)
    Link  SFH: Rotigotine patch dose calculator (now full NBM Parkinsons guide)
       
    04.09.01  Levodopa
    Co-Beneldopa (Madopar®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Capsule
    Dispersible tablet
    Capsule MR

    • Madopar prolonged release hard capsules contain soya oil. Therefore, contraindicated in patients allergic to peanut or soya. SPC updated Jan 21
     
    Link  UKMI Q&A:Guidance on converting from MR formulation to dispersible tablets
       
    Co-Careldopa (Sinemet®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablet, Tablet MR

    • If needed standard tablets can be dispersed in water. Do not crush modified release tablets. More Info
    • Brand prescribing as Sinemet® is most cost effective in primary care - see Preferred Prescribing List.
    • MSD is updating its manufacturing for Sinemet which will result in changes to the appearance of these products. Other Sinemet tablets remain unchanged. Transition to these new presentions in supply chain is expected to commence in May 2019, followed by Sinemet Plus by Aug 2019.More Info
     
       
    Co-Careldopa and Entacapone
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablets

    • Specialist initiation only.
    • Combined levodopa, carbidopa & entacapone.
    • Sastravi® or Stanek® are the current recommended brands for prescribing in primary care - see Preferred Prescribing List. Other less cost effective brands include Stalevo®.
    • Tablets disperse in water if needed. See here for general advice on dispersing tablets.
     
       
    Co-Careldopa (Duodopa®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine
    Intestinal gel
  • For the treatment of advanced Parkinson's disease in accordance with NHS England commissioning policy.
  • Patients must be assessed by a specialist clinician based at a designated PD MDT at a specialist neurosciences centre (e.g. NUH) that is experienced in all potential advanced PD therapies.
  • Supplied via homecare.
  • Prior approval via Blueteq system required.
  • Only commissioned through specialist centre. Must be prescribed and dispensed at NUH.
  • Patients have a back-up kit in case of failure/unplanned admission. However, 24 hours helpline available on 08004584410 
  • Link  Link to reviews
    Link  NHS England: Clinical Commissioning Policy: Levodopa-Carbidopa Intestinal Gel (July 2015)
       
    04.09.01  Monoamine-oxidase-B inhibitors
    Selegiline
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    • Tablet 5mg and 10mg, oral lyophilisate (see below)
    • Oral lyophilisate tablets (Zelapar®) 1.25mg available for patients with swallowing difficulties. One month's treatment of 1.25mg once daily costs £43 vs £9 for 10mg tablets (DT Feb 19). 1.25-mg oral lyophilisate is equivalent to 10-mg tablet vs.
     
       
    Rasagiline
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2
    Tablets
  • Specialist initiation only if selegiline not suitable 
  • Link  Link to reviews
       
    Safinamide (Xadago®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    • For patients (established on levodopa containing preparations) with motor fluctuations experiencing off-periods and dyskinesia.
     
    Link  Link to reviews
       
    04.09.01  Catachol-O-methyltransferase inhibitors to top
    Entacapone
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Tablet
  • Specialist initiation only 
  •    
    Opicapone
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Capsules

    • 2nd line COMT inhibitor for the treatment of Parkinson's Disease after entacapone.
    • Opicapone may decrease tablet burden in patients needing to take entacapone and levodopa as separate tablets, but is significantly more expensive.
     
    Link  Link to reviews
       
    04.09.01  Amantadine
    Amantadine
    (Parkinson's)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Capsule, Oral solution
  • For initiation in specialist Parkinson's disease clinic only.
  • If needed capsules can be opened and the contents mixed with water. General info on opening capsules.
  • Oral solution costs ~£130 per bottle and should only be used for patients with swallowing difficulties if opening capsules isn't appropriate (APC Jan 15).
     
  • Link  See unexpectedly expensive medicines list
       
    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
  • Benzatropine
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red

    Injection (unlicensed)

    • For the treatment of acute dystonia
    • See section 18 for more information
    • See Toxbase for guidance and dosing information
    • Not routinely stocked at SFH
     
       
    Procyclidine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Tablet, Syrup, Injection.
     
    Link  NottsHC: Management options for clozapine induced hypersalivation
       
    Trihexyphenidyl
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Tablet, syrup
  • Formerly known as benzhexol.
     
  • Link  SFH adverse reactions to drug withdrawal information
       
    04.09.03  Drugs used in essential tremor, chorea, tics, and related disorders
    Haloperidol
    (essential tremor)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    See section 4.2.1 
       
    Primidone
    (essential tremor)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
     
       
    Propranolol
    (essential tremor)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
     
       
    Riluzole
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 1
    High Cost Medicine

    Tablet

    • Restricted to specialist consultant request only
    • If needed tablets can be dispersed in water or mixed with soft food e.g. yoghurt. Flush enteral tubes well. See here for general advice on dispersing tablets.
    • Oral suspension classified Grey post March APC 2018. 
     
    Link  COVID19: Riluzole shared care monitoring during COVID19 (Notts CCG)
    Link  NICE TA20: Motor neurone disease - riluzole
    Link  Notts APC: Riluzole MND Information Sheet
    Link  Notts APC: Riluzole MND Overarching SCP
       
    Tetrabenazine (Xenazine® 25)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Tablet
  • For the treatment of movement disorders
  • Tablets disperse in water if needed. See here for general advice on dispersing tablets. 
  •    
    04.09.03  Torsion dystonias and other involuntary movements
    Botulinum Toxin Type A (Botox®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red

    Injection

    • Warning: Units are not equivalent to Dysport units. See information onhere.
    • Classified RED for bladder dysfunction in adults (APC, Jan14)
    • For migraine prophylaxis see section 4.7.4.2.
    • Consultant recommendation only.
     
    Link  Link to reviews
       
    Botulinum Toxin Type A (Dysport®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red

    Injection

    • Consultant recommendation only
    • Warning: Units are not equivalent to Botox units. See information on here
     
    Link  Link to reviews
       
    Botulinum Toxin Type A (Xeomin®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red

    Injection

    • NUH only: Approved in accordance with NICE TA605, for treating chronic sialorrhoea.
    • NUH DTC approval for cervical dystonia and post stroke spasticity of the upper limb in adults only.
    • Consultant recommendation only
    • Warning: Units are not equivalent to Dysport units. See information on here
     
    Link  NICE TA605: Xeomin (botulinum neurotoxin type A) for treating chronic sialorrhoea
       
    Botulinum Toxin Type B (NeuroBloc®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red

    Injection

    • Restricted for patients unresponsive to Botulinum Toxin Type A
      Consultant recommendation only
    • Warning: Units are not equivalent to Botox or Dysport units. See information on here.
     
    Link  MHRA safety update regarding toxin spread
       
    04.10  Drugs used in substance dependence to top
    04.10.01  Alcohol dependence
    Acamprosate (Campral EC®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
  • In primary care, GPs/NMPs who have received appropriate training may initiate as per Notts Primary Care Alcohol Community Detox Protocol (see below).
  • Specialist advice of Alcohol and Drug Liaison Team in secondary care 
  • Link  Primary care alcohol community detox protocol
       
    Disulfiram (Antabuse®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablet

    • In primary care, GPs/NMPs who have received appropriate training may initiate as per Notts Primary Care Alcohol Community Detox Protocol. In secondary care on specialist advice of Alcohol and Drug Liaison Team
    • Loading dose not considered necessary
     
    Link  Primary care alcohol community detox protocol
       
    Nalmefene
    (Selincro)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Tablets
  • Specialist initiation by community based specialist alcohol services in line with NICE TA325 . GPs are not expected to prescribe in County CCGs (prescribing should remain with CRI) but GPs in City CCG may be requested to prescribe after initiation by alcohol service.  
  • Link  Link to reviews
       
    Naltrexone
    (alcohol dependence)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Tablet
  • Some brands are licensed for treatment of alcohol dependence.
  • In primary care, GPs/NMPs who have received appropriate training may initiate as per Notts Primary Care Alcohol Community Detox Protocol.
  • In secondary care on specialist advice of Alcohol and Drug Liaison Team. 
  • Link  Notts APC Naltrexone information sheet (June 2019)
    Link  Primary Care Alcohol Community Detox Protocol
       
    04.10.02  Nicotine dependence
    Bupropion Hydrochloride (Zyban®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablet

    • Supply problems expected until November 2020For use in accordance with Smoking Cessation - Position Statement
    • In secondary care only to be prescribed on the advice of smoking cessation specialist as part of a package of continued care.
    • Off-label use as an option for resistant/refractory depression by specialists in Nottinghamshire Healthcare Trust. BAP guidelines for information.
     
    Link  MHRA: Risk of serotonin syndrome with bupropion
    Link  SFHT Prescribing guidelines
       
    Nicotine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    • For use in accordance with Smoking Cessation - Position Statement
      Products usually available in secondary care:
    • Inhalator (starter (£4 for 4) and refill packs (£15 for 20)
    • Chewing gum (2mg and 4mg)
    • Lozenge (1mg, 2mg and 4mg)
    • Patches: Nicotinell 24hr patches (7mg, 14mg, and 21mg) and Nicorette 16 hour patches (10mg, 15mg and 25mg)
      Other products may be available in primary care:
    • Microtab 2mg
    • Lozenge 1mg
    • Oral spray 1mg (Quickmist)
    • Nasal spray 500mcg
    • Patches- NiQuitin CQ 24 hour patches (7mg,14mg,21mg)
     
    Link  Starting doses of patches
    Link  CHM Guidance on NRT in pregnancy, breastfeeding, cardiovascular disease, diabetes, adolescents, renal and hepatic impairment (Aug 2007)
    Link  Cost per day of nicotine patches
    Link  Cost per dose of nicotine gums etc
    Link  SFHT smoking cessation website
    Link  UKMI Q&A: Evidence for NRT for the treatment of UC
       
    Varenicline (Champix®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablets

    • For use in accordance with Smoking Cessation - Position Statement
    • In secondary care only to be prescribed on the advice of smoking cessation specialist as part of a package of continued care.
     
    Link  Cardiovascular disease and varenicline (Champix) - August 2013
    Link  Independent reviews
    Link  MHRA safety update (Oct 2009)
    Link  NICE TA123: Varenicline
       
    04.10.03  Opioid dependence
    04.10.03  Opioid substitution therapy
    Controlled Drug Buprenorphine
    (dependence)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Confirm brand before prescribing. Now available as:
    - Subutex® sublingual tablet
    - Espranor® ora-dispersible (lyophilisate) (prescribe by brand)

    • Espranor® and Subutex® are not dose equivalent and not interchangeable.
    • Opioid dependance, after recommendation from specialist service.
    • In primary care follow Drug Misuse and Dependence: Guidelines on Clinical Management (orange book)
     
    Link  Drug misuse and dependence: UK guidelines on clinical management (Orange Book)
    Link  SFH buprenorphine preparations information
    Link  SFH: Hospitalised Opioid Misuser Management Guideline
       
    Controlled Drug Methadone
    (Dependance)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Oral solution 1mg in 1mL

    • Opioid dependance, after recommendation from specialist service.
    • In primary care follow Drug Misuse and Dependence: Guidelines on Clinical Management (orange book)&n