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Nottinghamshire Area Prescribing Committee
Joint Formulary
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 Formulary Chapter 4: Central nervous system - Full Chapter
04.07.01  Expand sub section  Non-opioid analgesics and compound analgesic preparations
04.07.01  Expand sub section  Compound analgesic preparations
 note  Avoid using compound analgesic preparations wherever possible
Paracetamol
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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
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Formulary
Green

Tablet, Tablet e/c, Tablet dispersible, Suppository

  • OTC
 
Link  Aspirin in RECOVERY trial
   
Nefopam
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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)
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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)
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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.
 
   
 ....
 Non Formulary Items
Co-proxamol

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Non Formulary
Grey
Link  MHRA safety warning: Co-proxamol
 
Paracetamol and codeine  (Co-codamol ®15/500)

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Non Formulary
Grey
 
Paracetamol and dihydrocodeine  (Co-dydramol®)

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Non Formulary
Grey
Tablet
Link  MHRA: Prescribe co-dydramol by strength
 
  
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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