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)

MR tablets (Circadin^® brand only)

• Specialist initiation for the treatment of REM sleep disorders in patients with Parkinson's Disease in line with NICE Guideline 71; Parkinson's Disease in adults
  
  

• 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

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. 

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.

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

• *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.

Oral solution (500mg/mL)

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

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 

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.

Tablets

• Initiated following specialist psychiatric referral only
• For use in learning disabilities only.

See main propranolol entry in section 2.4

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

Tablet

• To be initiated on specialist advice only.
• Tablets disperse in water if needed. See here for general advice on dispersing tablets.

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

Tablet, Oral solution

• To be initiated on specialist advice only.
• Modified release preparations to be used only in patients with compliance problems.

Tablet, Oral Solution (100mg/mL)

• To be initiated on specialist advice only for schizophrenia. Prescribing guidance should accompany request to prescribe.

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).

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.

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:

•   Prophylaxis of chemotherapy-induced nausea and vomiting

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.

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.

Depot injection

•   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.

Xeplion^®
Deep intramuscular depot injection

• Only for use in line with the Nottinghamshire APC Depot Antipsychotics prescribing information sheet.

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.

• 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.

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. 

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. 

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) 

Tablet, Oral solution

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

Not recommended for depression/anxiety
 Dermatology use for the treatment of urticaria and pruritus.

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

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.

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.

Capsule

•  Not for use as an antidepressant
• 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

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

• 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

• 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

Tablets

• Red for use within Nottinghamshire Healthcare NHS Foundation Trust 

• 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

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) 

Tablet

• Escitalopram (the active isomer of citalopram) may be considered as third-line option in resistant depression/anxiety disorders only

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. 

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.

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

Nasal spray solution

•  Red for use within Nottinghamshire Health Care Trust 

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.

• 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.  

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.

•  (shared care): Attention Deficit Hyperactivity Disorder (ADHD) in children of 6 years and older and in adolescents as part of a comprehensive treatment program.
• ADHD children and young people - shared care protocol
• ADHD children and young people - atomoxetine information sheet

•  (shared care): Attention Deficit Hyperactivity Disorder (ADHD) in adults as part of a comprehensive treatment program.
• ADHD adult - shared care protocol
• ADHD adult - atomoxetine information sheet

• : Patients under 6 years old

• Liquid is restricted to patients that are unable to swallow capsules.

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.

•  (shared care): Attention Deficit Hyperactivity Disorder (ADHD) in children of 6 years and older and in adolescents as part of a comprehensive treatment program.
• ADHD children and young people - shared care protocol
• ADHD children and young people - dexamfetamine information sheet

•  (shared care): Attention Deficit Hyperactivity Disorder (ADHD) in adults as part of a comprehensive treatment program. 
• ADHD adult - shared care protocol
• ADHD adult - dexamfetamine information sheet

•  : Patients under 6 years old.

 Substance misuse

  - Specialist use only

Narcolepsy (adults)

  - See NottsAPC information sheet

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

Tablet

•  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.

Capsules

Attention Deficit Hyperactivity Disorder (ADHD)

• Tretament with lisdexamfetamine should only be initiated by a specialist with expertise in ADHD following a comprehensive assessment and diagnosis.
•  (shared care): Attention Deficit Hyperactivity Disorder (ADHD) in children of 6 years and older and in adolescents as part of a comprehensive treatment program. 
• ADHD children and young people - shared care protocol
• ADHD children and young people - lisdexamfetamine information sheet

•  (shared care): Attention Deficit Hyperactivity Disorder (ADHD) in adults as part of a comprehensive treatment program
• ADHD adult - shared care protocol
• ADHD adult - lisdexamfetamine information sheet

•  : Patients under 6 years old

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.

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.

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.

•  Patients should be advised to purchase a suitable product over the counter for travel sickness

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)

Tablets, Liquid, Injection.

• Nausea and vomiting during pregnancy
• See Section 4.1 for use as antihistamine

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

• Buccal prochlorperazine available containing 8 tablets. Patients should be advised to self care for infrequent migraine.

• Liquid discontinued 2019.

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.
• specialist initiation / recommendation for G.I. motility in children under 12 years.
• for nausea and vomiting in children under 12 years and less than 35kg as per MHRA advice (lack of efficacy).
• non-formulary for promoting tolerance of enteral feeds in children / young people. See NICE evidence summary.

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).
•  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.

Capsules

• For oncology patients only

Oral suspension

• NUH only for paediatric oncology patients

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.

Tablet

• Menières disease, vertigo
• Evidence of efficacy lacking (Cochrane 2001, BMJ 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.

Inhalation vapour.

• NUH Only: Emergency relief of moderate to severe pain in the Emergency Department.

Tablet, Tablet e/c, Tablet dispersible, Suppository

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.

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.

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.

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).
•  NUH Medicines Matters Bulletin regarding Codeine

- 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.

MR tablets

• Prescribe by brand. Preferred brands in primary care are Marol^® MR tablets or Tamulief^® SR tablets. See Preferred Prescribing list.

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

Injection

• March 2020 - Long term supply problem. More information here.
• In palliative care should be used 2nd line to morphine when morphine volumes are too large to administer.
• SFH: Intranasal diamorphine in children and young people in ED
  

  NUH only:

• For intranasal use in adults with acute painful sickle crisis as per guideline.
• For intranasal use in paediatric patients within the ED for acute severe pain.

Patch

• Potent opioid - on pain team specialist advice only for non-cancer pain. 
• See Opioids for non-cancer pain - APC guideline.
• Green for end of life care.
• Relatively expensive compared to Zomorph^®
• Same side effect profile as morphine, but there is a small chance patients may tolerate one better than the other (but this is likely to be due to giving a relatively smaller dose.)
• Recommended brands in primary care and on hospital outpatient prescriptions are Matrifen^® or Mezolar^®. See Preferred Prescribing List.
• Fentanyl patch QIPP detail aid and supporting info.
• For information regarding the safety of cutting fentanyl patches please see the NUH guideline for the management of sedation and analgesia withdrawal.
• For practical information on changing to and from fentanyl patches see Palliative Adult Network Guidelines on the SFH intranet.

-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 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.

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.

• Unlicensed medicine - named patient use only
• For palliative care use only

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
• Non-formulary for use in non-cancer related pain.
• On the Nottinghamshire list of Medicines & Appliances of Limited Clinical Value.

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
• Non-formulary for use in non-cancer related pain.
• On the Nottinghamshire list of Medicines & Appliances of Limited Clinical Value.

Tablets, oral solution*

• For use in neuropathic pain as per Notts APC Neuropathic Pain Guideline
• See section 4.3.1 for use as an antidepressant
• See section 4.7.4.2 for use in migraine prophylaxis
• *If oral solution required use 25mg/5mL or 50mg/5mL (10mg/5mL is very expensive)

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.

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

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:

• GPs may initiate in line with Notts APC restless legs treatment algorithm.

• Treatment option for restless legs when symptoms seriously impair quality of life and non-drug based measures have failed.

• 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.  

• 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.
•  Patients suffering mild migraine should be advised to purchase a suitable product over the counter first line. See NHSE guidance.

Tablets, Orodispersible tablets, Nasal spray

• If patient requires a dispersible tablet, rizatriptan orodispersible is most cost-effective option.
  
• Cost effective Triptans

Tablets, orodispersible tablets, oral lyophilisate*

• *If a patient requires a dispersible tablet,  orodispersible more most cost-effective than oral lyophilisate.

Tablets

• Third line option if other triptans are not tolerated or ineffective. Long half life may be advantageous in patients with recurrent migraine attacks.

Tablets

Tablets, oral solution

• First line option for migraine prophylaxis as per Nottinghamshire APC headache guideline

Tablets (preferred as more cost effective), capsules

• First line option for migraine prophylaxis as per Nottinghamshire APC headache guideline
• Oral solution is very expensive, consider switch to propranolol or amitriptyline

Tablets, oral solution*

• 2nd line for migraine prophylaxis as per Notts APC Adult Headache Pathway
• *If oral solution required use 25mg/5mL or 50mg/5mL (10mg/5mL is very expensive)

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.

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.

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.

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) 

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.

Tablet, Oral Suspension

• Restricted for specialist and paediatric specialist initiation only

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.

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

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.

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.

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.

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

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'.

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.

• 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.

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

• Capsule, syrup
• Absence seizures

• 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.

• Tablet, dispersible tablet
• May be appropriate for specialist GP to initiate or any GP to prescribe whilst awaiting hospital referral

• 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

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

Tablets, Oral Suspension

• Restricted to paediatric neurology for use as adjunctive treatment for Lennox-Gastaut syndrome- see local guidelines.

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.

Tablet

• Specialist initiation

Tablet

• Sprinkle capsule
• Restricted for initiation by neurology and paediatrics only

Tablet

• Powder
• Specialist initiation

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. 

•  See section 4.1.2 for information. 

• Supply problem with injection Nov 2020: SFH see alternative options compilation table.
• See section 4.1.2 for full lorazepam entry. 

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.

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).