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Nottinghamshire Area Prescribing Committee
Joint Formulary
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 Formulary Chapter 4: Central nervous system - Full Chapter
04.08.01  Expand sub section  Control of epilepsy
 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  Expand sub section  Carbamazepine and Oxcarbazepine
    04.08.01  Expand sub section  Gabapentin and pregabalin
    04.08.01  Expand sub section  Levetiracetam
    04.08.01  Expand sub section  Phenobarbital and other barbiturates to top
    04.08.01  Expand sub section  Valproate
    04.08.01  Expand sub section  Benzodiazepines
    04.08.01  Expand sub section  Other Drugs
    Acetazolamide
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    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)
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    Restricted Drug Restricted
    Red
    High Cost Medicine

    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
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    Formulary
    Amber 2
    • Capsule, syrup
    • Absence seizures
     
       
    Lacosamide
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    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
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    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
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    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)
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    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
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    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®)
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    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
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    Formulary
    Amber 2

    Tablet

    • Specialist initiation
     
       
    Topiramate
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    Restricted Drug Restricted
    Amber 2

    Tablet

    • Sprinkle capsule
    • Restricted for initiation by neurology and paediatrics only
     
    Link  NUH information on supplying generic topiramate
       
    Vigabatrin
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    Restricted Drug Restricted
    Amber 2

    Tablet

    • Powder
    • Specialist initiation
     
    Link  Link to reviews
       
    Zonisamide
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    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
       
     ....
     Non Formulary Items
    Retigabine

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    Non Formulary
    Grey

    Tablet

    • Prescribing Restrictions imposed by the MHRA July 2013. Monitor for ocular side effects and complete yellow cards as appropriate.
    • For neurologist initiation in line with NICE TA232 (see below).
    • Prescribing should remain in secondary care until initial titration is complete and patient is stable.
    • Initial titration may be carried out slower than that recommended by the manufacturer if considered appropriate. Commercially available titration pack is not suitable for slower regimens. Individual strengths should be supplied.
    • Trobalt® (retigabine) tablets (50mg, 100mg, 200mg, 300mg and 400mg) will no longer be commercially available after June 2017.
    Link  Link to reviews
    Link  Local Protocol for the use of Retigabine for Epilepsy
    Link  MHRA 2016: Risk of acquired vitelliform maculopathy
    Link  MHRA safety update on pigmentation July 2013
    Link  NICE TA232: Retigabine for the adjunctive treatment of adults with partial onset seizures in epilepsy with and without secondary generalisation
    Link  Retigabine withdrawal-Healthcare Professional Letter
     
      
    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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