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Nottinghamshire Area Prescribing Committee
Joint Formulary
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 Formulary Chapter 4: Central nervous system - Full Chapter
04.01.02  Expand sub section  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  Expand sub section  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  Expand sub section  Buspirone
    04.01.02  Expand sub section  Beta blockers
    04.01.02  Expand sub section  Gabapentinoids to top
     ....
     Non Formulary Items
    Alprazolam

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Oxazepam

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

    Traffic Light Status Information

    Status Description

    Grey

    Grey / Non-Formulary: Medicines, which the Nottinghamshire APC has actively reviewed and does not recommend for use at present due to limited clinical and/or cost effective data.
    Grey / Non-Formulary (undergoing assessment): Work is ongoing and will be reviewed at a future APC meeting.
    Grey / Non-Formulary (no formal assessment): APC has not formally reviewed this medicine or indication because it had never been requested for formulary inclusion. Often used for drugs new to market.
      

    Red

    Medicines which should normally be prescribed by specialists only. eg hospital only.
    For patients already receiving prescriptions in primary care - continue. No new patients to receive prescriptions in primary care.
      

    Amber 1

    Medicines that should be initiated by a specialist and prescribed by primary care prescribers only under a shared care protocol, once the patient has been stabilised.
    Prior agreement must be obtained by the specialist from the primary care provider before prescribing responsibility is transferred. The shared care protocol must have been agreed by the relevant secondary care trust Drugs and Therapeutics Committee(s) (DTC) and approved by the Nottinghamshire APC.
      

    Amber 2

    Medicines suitable to be prescribed in primary care / general practice after specialist* recommendation or initiation.
    A supporting prescribing guideline may be requested which must have been agreed by the relevant secondary care trust DTCs and approved by the Nottinghamshire APC.
    *Specialist is defined by the APC as a clinician who has undertaken an appropriate formal qualification or recognised training programme within the described area of practice
      

    Amber 3

    Primary care/ non specialist may initiate as per APC guideline.
    The supporting prescribing guideline must have been agreed by the relevant secondary care trust D&TC(s) and approved by the Nottinghamshire APC.
      

    Green

    Medicines suitable for routine use within primary care.
    Can be initiated within primary care within their licensed indication, in accordance with nationally recognised formularies, for example the BNF, BNF for Children, Medicines for Children or Palliative Care Formulary. Primary care prescribers take full responsibility for prescribing.   

    OTC

      

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