Search
4. Central Nervous System

For information on prescribing of unlicensed medicines and off-label use of medicines in this chapter, see TEWV Guidelines on unlicensed and off-label use of medicines

TEWV: Safe transfer of prescribing guidance

MHRA Drug Safety Alert (Feb 2015):  Drugs and driving: blood concentration limits set for certain drugs

Guidelines

County Durham and Darlington - Opioid Prescribing for Persistent (Non-Cancer) Pain in Adults
County Durham and Darlington - Key Messages: For Pain Management Scenarios
County Durham and Darlington - Pharmacological Treatment of Neuropathic Pain

Tees Primary Care Pain Management Guideline

North of England Cancer Network Palliative and End of Life Care Pathway

NICE NG41: Spinal injury: assessment and initial management

NICE NG42: Motor neurone disease: assessment and management

NICE NG62: Cerebral palsy in under 25s: assessment and management

NICE NG71: Parkinson’s disease in adults

NICE NG92: Stop smoking interventions and services

NICE NG116: Post-traumatic stress disorder 

NICE NG134: Depression in children and young people: identification and management

NICE CG100: Alcohol-use disorders: diagnosis and management of physical complications

The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or 
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

CD&D Patient Decision Aids Resource available at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington/

NHS England Guidance on “Conditions for which over the counter items should not routinely be prescribed” available at: https://www.england.nhs.uk/medicines/conditions-for-which-over-the-counter-items-should-not-routinely-be-prescribed/

Conditions for which over the counter items should not routinely be prescribed in primary care: exception criteria

Prescribing of medicines available to purchase over the counter for self-care

Self-Care and Medicines Available Over The Counter (OTC)

Common medicines available to purchase over the counter (OTC) for minor illnesses and self-limiting conditions

 

 

Please refer to NICE guidelines NICE TA77

All hypnotics should be prescribed for short periods of time only.

Switching from one drug to another should only occur if the patient experiences side effects that are specifically related to the medicines.

Patients who have not responded to one of these hypnotics should not be prescribed any of the others.

Use in the elderly is discouraged.

 

First choice

Zopiclone

Temazepam

Alternatives

Zolpidem: MHRA Drug Safety Alert (May 2014) – risk of drowsiness and reduced driving ability

Promethazine

 

CSM Advice:

  1. Benzodiazepines are indicated for short term relief (2-4 weeks only) of anxiety that is severe, disabling or causing the patient unacceptable distress, occurring alone or in association with insomnia or short term psychotic illness.
  2. The use of benzodiazepines to treat short term anxiety is inappropriate. 
  3. Benzodiazepines should be used to treat insomnia only when it is severe, disabling or causing the patient extreme distress. 
Chloral hydrate
BNF | BNFC | SPC

Only approved for use in Tees.

Chloral hydrate is not recommended in the BNF for the management of insomnia.

Chloral Hydrate 500mg in 5mL - Unlicensed liquid for use in paediatrics only

Chloral Hydrate (Suppositories) - Unlicensed for paediatrics only - 100mg and 500mg strengths available

Flurazepam
BNF | BNFC | SPC

The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or 
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

Melatonin (Circadin®)
BNF | BNFC | SPC

MR Tabs - 2mg

MR tabs licensed only for adults over 55years. Classed as Amber for children and young adults and prescribed off label. 

MR tablets are not approved on the formulary for the management of primary insomina in adults.

Circadin® - melatonin 2 mg prolonged-release tablets - swallowed whole or crushed (if unable to swallow whole or immediate-release action required)

Shared Care Guideline: Melatonin

CDDFT Intranet: Melatonin – available here

Melatonin (Slenyto®)
BNF | BNFC | SPC

1 mg and 5 mg prolonged release tablets

Treatment of insomnia in children and adolescents aged 2 - 18 years with ASD and/or Smith-Magenis Syndrome (SMS) where sleep hygiene measures have been insufficient a formulary application for this limited indication is pending

Melatonin 3mg tablets (Colonis Pharma)
BNF | BNFC | SPC

NHS prescribing of melatonin for jet lag is not appropriate.

(N.B. only licensed for short term treatment of jet lag in adults)

Off-label used in paediatric not cost-effective instead use Circadin® - melatonin 2 mg prolonged-release tablets - swallowed whole or crushed (if unable to swallow whole or immediate-release action required)

Melatonin oral solution (Colonis Pharma)
BNF | BNFC | SPC

1mg/ml oral solution

NHS prescribing of melatonin for jet lag is not appropriate.

(N.B. only licensed for short term treatment of jet lag in adults)

Formulation contains:
 Sorbitol 140 mg/ml (may cause osmotic diarrhoea, GI discomfort);
 Propylene glycol 150.37 mg/ml (accumulation can lead to CNS depression);
 Ethanol 0.00045 mg/ml (risk of acute intoxication with accidental overdose and chronic toxicity)
Therefore, there are safety concerns in children & adolescents relative to the unlicensed preparation which does not contain these excipients

Promethazine
BNF | BNFC | SPC

10mg & 25mg tablets
5mg in 5ml sugar-free elixir
25mg in 1ml injection

TEWV Rapid Tranquilisation Policy

Temazepam
BNF | BNFC | SPC

Tablets - 10mg

Liquid - 10mg/5ml

Zolpidem
BNF | BNFC | SPC

Zolpidem: MHRA Drug Safety Alert (May 2014) – risk of drowsiness and reduced driving ability

Zopiclone
BNF | BNFC | SPC

FIRST LINE

Tablets - 3.75mg, 7.5mg

 

 

See NICE NG10 - Violence and aggression: short-term management in mental health, health and community settings

See NICE guidelines for the management of Anxiety Disorders

If a person with generalised anxiety disorder (GAD) chooses drug treatment, offer a selective serotonin reuptake inhibitor (SSRI) (see section 4.3)

Consider offering sertraline first as it is the most cost-effective, but is unlicensed for GAD.

 Do not offer a benzodiazepine for the treatment of GAD except as a short-term measure during crises. Follow the advice in the ‘British national formulary’ on the use of a benzodiazepine in this context: should not be used as an anxiolytic for more than 4 weeks without being reviewed.

Use in the elderly is discouraged.

 

First choice

Diazepam

Diazepam
BNF | BNFC | SPC

Tabs - 2mg, 5mg

Oral solution - 2mg/5ml

Rectal tubes - 2mg/ml, 4mg/ml

Chlordiazepoxide
BNF | BNFC | SPC

5mg & 10mg capsules

Chlordiazepoxide: used for acute alcohol withdrawal syndrome. See NICE guidance on the withdrawal of alcohol.

Lorazepam
BNF | BNFC | SPC

Tabs - 1mg

4mg in 1ml injection

SECOND LINE where rapid action is required and no suitable alternative or palliative care

Lorazepam: shorter acting benzodiazepines e.g lorazepam may be preferred in patients with hepatic impairment but carry greater risk of withdrawal symptoms.
Injection when used for rapid control of agitated or disturbed behaviour in patients with schizophrenia or manic episode where oral treatment is not appropriate. See TEWV Rapid Tranquilisation prescribing guidelines.

Tablets can be used for sublingual administration

TEWV Rapid Tranquilisation Policy

 

Meprobamate
BNF | BNFC | SPC

The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or 
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

Buspirone
BNF | BNFC | SPC

Buspirone: patients must be stabilised on this prior to transfer of prescribing responsibility to GP. It is expected that they will have completed at least one month of treatment and be suitable for 28 day prescriptions.

Pregabalin
BNF | BNFC | SPC

(see also section 4.8)
Pregabalin: For those unable to tolerate SSRIs and SNRIs patients must be stabilised on this prior to transfer of prescribing responsibility to GP. It is expected that they will have completed at least one month of treatment and be suitable for 28 day prescriptions.

TEWV Psychotropic Medication Monitoring Guide

Refer to NICE guidance for schizophrenia CG 178

See also: NICE NG11 - Challenging behaviour and learning disabilities: prevention and interventions for people with learning disabilities whose behaviour challenges

The choice of antipsychotic should take into account the relative side-effect profile and the views of the user.

 

Refer to TEWV policies:

Guidance for safe transfer of prescribing (TEWV website)

HDAT - High Dose Antipsychotic Treatment (TEWV website)

TEWV website: Hyperprolactinaemia guidance

 

Prescribing antipsychotics in the elderly

The balance of risks and benefits should be considered.  See Pharmacological management guidelines for Behavioural & Psychological Symptoms of Dementia

Haloperidol
BNF | BNFC | SPC

Tabs - 500microgram, 1.5mg, 5mg, 10mg, 20mg

Oral Liquid - 2mg/ml

Haloperidol: Injection for rapid control of agitated or disturbed behaviour in patients with schizophrenia or manic episode where oral treatment is not appropriate.

See NICE NG10 - Violence and aggression: short-term management in mental health, health and community settings

Initiation by specialist; Prescribing follows psychosis care pathway; Baseline monitoring completed; Stabilised on treatment; Minimum of one month's supply on transfer; Annual review of medication by specialist services whilst actively involved in providing treatment.

TEWV Rapid Tranquilisation Policy

Chlorpromazine
BNF | BNFC | SPC

Tabs - 25mg, 50mg, 100mg

Oral solution - 25mg/5ml, 100mg/5ml

Initiation by specialist; Prescribing follows psychosis care pathway; Baseline monitoring completed; Stabilised on treatment; Minimum of one month's supply on transfer; Annual review of medication by specialist services whilst actively involved in providing treatment

Trifluoperazine
BNF | BNFC | SPC

Tabs - 1mg, 5mg

Oral Solution - 5mg/5ml

For initiation by specialists only

Trifluoperazine: Patients must be stabilised on this prior to transfer of prescribing responsibility to GP. It is expected that they will have completed at least one month of treatment and be suitable for 28 day prescriptions.

Initiation by specialist; Prescribing follows psychosis care pathway; Baseline monitoring completed; Stabilised on treatment; Minimum of one month's supply on transfer; Annual review of medication by specialist services whilst actively involved in providing treatment

Sulpiride
BNF | BNFC | SPC

Tablets - 200mg & 400mg

Oral solution - 200mg in 5ml sugar-free 

Sulpiride: Patients must be stabilised on this prior to transfer of prescribing responsibility to GP. It is expected that they will have completed at least one month of treatment and be suitable for 28 day prescriptions.

Initiation by specialist; Prescribing follows psychosis care pathway; Baseline monitoring completed; Stabilised on treatment; Minimum of one month's supply on transfer; Annual review of medication by specialist services whilst actively involved in providing treatment

 

Zuclopenthixol (oral)
BNF | BNFC | SPC

Tabs - 2mg, 10mg, 25mg

Zuclopenthixol: Patients must be stabilised on this prior to transfer of prescribing responsibility to GP. It is expected that they will have completed at least one month of treatment and be suitable for 28 day prescriptions.

For initiation by specialists only

Initiation by specialist; Prescribing follows psychosis care pathway; Baseline monitoring completed; Stabilised on treatment; Minimum of one month's supply on transfer; Annual review of medication by specialist services whilst actively involved in providing treatment

Promazine
BNF | BNFC | SPC

The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or 
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

Zuclopenthixol acetate
BNF | BNFC | SPC

50mg in 1ml injection

For short term use by specialists in TEWV and in an in-patient setting. Clopixol Acuphase - TEWV Guidelines for the use of

Benperidol
BNF | BNFC | SPC

0.25mg tablets

For the control of deviant anti-social sexual behaviour.

Risperidone (oral)
BNF | BNFC | SPC

Tabs - 500microgram, 1mg, 2mg, 3mg, 4mg, 6mg

Orodispersible tabs - 500micrograms, 1mg, 2mg, 3mg, 4mg

Orodispersible tablets should only be prescribed for patients who are unable to swallow solid dose form.

MHRA Alert – risk of intraoperative floppy iris syndrome in patients undergoing cataract surgery. More details here.

Amisulpride
BNF | BNFC | SPC

Tabs - 50mg, 100mg, 200mg

Solution - 100mg/ml

Aripiprazole (oral)
BNF | BNFC | SPC

Tabs - 5mg, 10mg, 15mg

Orodispersible Tabs - 10mg, 15mg

Oral Solution - 1mg/ml

Orodispersible tablets should only be prescribed for patients who are unable to swallow solid dose forms

Enhanced efficacy above 15mg per day has not been demonstrated for any indication. However, some individuals may benefit from higher doses; such cases should be considered in conjunction with secondary care.

Approved for use in accordance with the following NICE TAs

  • NICE TA213: Aripiprazole for the treatment of schizophrenia in people aged 15 to 17 years
  • NICE TA292: Aripiprazole for treating moderate to severe manic episodes in adolescents with bipolar I disorder
Olanzapine (oral)
BNF | BNFC | SPC

Tabs - 2.5mg, 5mg, 7.5mg, 10mg, 15mg, 20mg

Orodispersible Tabs - 5mg, 10mg, 20mg

Orodispersible tablets should only be prescribed for patients who are unable to swallow solid dose forms

Do not prescribe as Lyophilisates.

Quetiapine
BNF | BNFC | SPC

Tabs - 25mg, 100mg, 150mg, 200mg, 300mg

M/R Tabs - 50mg, 150mg, 200mg, 300mg, 400mg

Quetiapine immediate release should be used 1st line, MR preparations should be reserved for those with a clinical need e.g. poor compliance

See Guidelines for the use of quetiapine XL

Clozapine
BNF | BNFC | SPC
Paliperidone (oral)
BNF | BNFC | SPC

Paliperidone oral not approved.

The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or 
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

Lurasidone
BNF | BNFC | SPC

Lurasidone not approved – see NTAG recommendation

The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or 
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

Refer to NICE Guideline Bipolar Disorder CG185

Antipsychotics drugs can be useful in acute episodes of mania and hypomania.

Asenapine
BNF | BNFC | SPC
Carbamazepine
BNF | BNFC | SPC

See section 4.8

Lamotrigine
BNF | BNFC | SPC

See section 4.8

Lithium Carbonate
BNF | BNFC | SPC

Tabs 200mg, 400mg (Priadel) - brand of choice

Tabs - 400mg  (Camcolit) - for exisiting patients only

Tabs - 250mg (Essential Pharma) - for exisiting patients only

MR Tabs - 450mg (Liskonum)- for exisiting patients only

Lithium should be prescribed by brand name

Unsuitable for discharge to GP from TEWV

See Safety Guidance: Lithium on admission to CDDFT – intranet link (CDDFT only)

See TEWV Lithium - Shared Care Guidelines

See TEWV Lithium on admission to an acute hospital - safety guidance

 

For patients maintained on lithium levels above 1.0mmol/l – lithium is classed as a red drug

Lithium Citrate
BNF | BNFC | SPC

Oral Solution - 520mg/5ml (Priadel) - brand of choice

Oral Solution - 509mg/5ml (Li-Liquid)  - for existing patients only

See BNF for conversion of lithium citrate to lithium carbonate as the salts are not equivalent.

Lithium should be prescribed by brand name

Unsuitable for discharge to GP from TEWV

See Safety Guidance: Lithium on admission to CDDFT – intranet link (CDDFT only)

See TEWV: Lithium Shared Care Guideline

Olanzapine (oral)
BNF | BNFC | SPC

2.5mg, 5mg, 7.5mg & 10mg, 15mg & 20mg tablets
5mg, 10mg & 15mg orodispersible tablets

Orodispersible tablets - should only be used in situations where the plain tablets are unsuitable

Quetiapine
BNF | BNFC | SPC

25mg, 100mg, 150mg 200mg & 300mg tablets
50mg, 200mg, 300mg & 400mg prolonged release tablets

Immediate release should be used 1st line, MR preparations should be reserved for those with a clinical need e.g. poor compliance.

See Guidelines for the use of quetiapine XL

Risperidone (oral)
BNF | BNFC | SPC

500microgram, 1mg, 2mg, 3mg, 4mg & 6mg tablets
1mg per ml liquid

Orodispersible tablets - should only be used in situations where the plain tablets are unsuitable. MHRA Alert – risk of intraoperative floppy iris syndrome in patients undergoing cataract surgery. More details here.

Sodium Valproate ▼
BNF | BNFC | SPC

See section 4.8

Prevention and treatment of manic episodes associated with bipolar disorder

MHRA Drug Safety Update (Feb 2016): Valproate and of risk of abnormal pregnancy outcomes: new communication materials

MHRA Drug Safety Update (Jan 2015): Medicines related to valproate: risk of abnormal pregnancy outcomes 

MHRA Drug Safety Update (Nov 2013): Sodium valproate: Risk of neurodevelopmental delay in children following maternal use

MHRA Drug Safety Update (April 2017): Valproate and developmental disorders: new alert asking for patient review and further consideration of risk minimisation measures 

MHRA Drug Safety Update (April 2018): Valproate medicines (Epilim▼, Depakote▼): contraindicated in women and girls of childbearing potential unless conditions of Pregnancy Prevention Programme are met 

MHRA Drug Safety Update (May 2018): Valproate medicines (Epilim▼, Depakote▼): Pregnancy Prevention Programme materials online

MHRA Drug Safety Update (Sept 2018): Valproate Pregnancy Prevention Programme: actions required now from GPs, specialists, and dispensers

MHRA Drug Safety Update (April 2019): Valproate medicines and serious harms in pregnancy: new Annual Risk Acknowledgement Form and clinical guidance from professional bodies to support compliance with the Pregnancy Prevention Programme

Local Shared Care guideline to support Valproate Pregnancy Prevention Programme available here

Sodium valproate▼ in females
BNF | BNFC | SPC

Patient Group: Girls (of any age) and women of child bearing potential

See section 4.8 for preparations

Prevention and treatment of manic episodes associated with bipolar disorder

MHRA Drug Safety Update (Feb 2016): Valproate and of risk of abnormal pregnancy outcomes: new communication materials

MHRA Drug Safety Update (Jan 2015): Medicines related to valproate: risk of abnormal pregnancy outcomes 

MHRA Drug Safety Update (Nov 2013): Sodium valproate: Risk of neurodevelopmental delay in children following maternal use

MHRA Drug Safety Update (April 2017): Valproate and developmental disorders: new alert asking for patient review and further consideration of risk minimisation measures 

MHRA Drug Safety Update (April 2018): Valproate medicines (Epilim▼, Depakote▼): contraindicated in women and girls of childbearing potential unless conditions of Pregnancy Prevention Programme are met 

MHRA Drug Safety Update (May 2018): Valproate medicines (Epilim▼, Depakote▼): Pregnancy Prevention Programme materials online

MHRA Drug Safety Update (Sept 2018): Valproate Pregnancy Prevention Programme: actions required now from GPs, specialists, and dispensers

MHRA Drug Safety Update (April 2019): Valproate medicines and serious harms in pregnancy: new Annual Risk Acknowledgement Form and clinical guidance from professional bodies to support compliance with the Pregnancy Prevention Programme

Local Shared Care guideline to support Valproate Pregnancy Prevention Programme available here

Valproic Acid▼
BNF | BNFC | SPC

Tabs E/C - 250mg, 500mg (as semi sodium valproate)

Depakote® and Convulex® licensed alternative to sodium valproate for treatment of manic episodes.

MHRA Drug Safety Update (Feb 2016): Valproate and of risk of abnormal pregnancy outcomes: new communication materials

MHRA Drug Safety Update (Jan 2015): Medicines related to valproate: risk of abnormal pregnancy outcomes 

MHRA Drug Safety Update (Nov 2013): Sodium valproate: Risk of neurodevelopmental delay in children following maternal use

MHRA Drug Safety Update (April 2017): Valproate and developmental disorders: new alert asking for patient review and further consideration of risk minimisation measures 

MHRA Drug Safety Update (April 2018): Valproate medicines (Epilim▼, Depakote▼): contraindicated in women and girls of childbearing potential unless conditions of Pregnancy Prevention Programme are met 

MHRA Drug Safety Update (May 2018): Valproate medicines (Epilim▼, Depakote▼): Pregnancy Prevention Programme materials online

MHRA Drug Safety Update (Sept 2018): Valproate Pregnancy Prevention Programme: actions required now from GPs, specialists, and dispensers

MHRA Drug Safety Update (April 2019): Valproate medicines and serious harms in pregnancy: new Annual Risk Acknowledgement Form and clinical guidance from professional bodies to support compliance with the Pregnancy Prevention Programme

Local Shared Care guideline to support Valproate Pregnancy Prevention Programme available here

 

Valproic acid▼ in females
BNF | BNFC | SPC

Patient Group: Girls (of any age) and women of child bearing potential

Tabs E/C - 250mg, 500mg (as semi sodium valproate)

Depakote® and Convulex® licensed alternative to sodium valproate for treatment of manic episodes.

MHRA Drug Safety Update (Feb 2016): Valproate and of risk of abnormal pregnancy outcomes: new communication materials

MHRA Drug Safety Update (Jan 2015): Medicines related to valproate: risk of abnormal pregnancy outcomes 

MHRA Drug Safety Update (Nov 2013): Sodium valproate: Risk of neurodevelopmental delay in children following maternal use

MHRA Drug Safety Update (April 2017): Valproate and developmental disorders: new alert asking for patient review and further consideration of risk minimisation measures 

MHRA Drug Safety Update (April 2018): Valproate medicines (Epilim▼, Depakote▼): contraindicated in women and girls of childbearing potential unless conditions of Pregnancy Prevention Programme are met 

MHRA Drug Safety Update (May 2018): Valproate medicines (Epilim▼, Depakote▼): Pregnancy Prevention Programme materials online

MHRA Drug Safety Update (Sept 2018): Valproate Pregnancy Prevention Programme: actions required now from GPs, specialists, and dispensers

MHRA Drug Safety Update (April 2019): Valproate medicines and serious harms in pregnancy: new Annual Risk Acknowledgement Form and clinical guidance from professional bodies to support compliance with the Pregnancy Prevention Programme

Local Shared Care guideline to support Valproate Pregnancy Prevention Programme available here

Refer to NICE guidance for schizophrenia CG 178

Consider offering depot/long-acting injectable antipsychotics when:

− service users would prefer this after an acute episode

− avoiding covert non-adherence to medication is a clinical priority

NTAG September 2017: The Northern (NHS) Treatment Advisory Group recommends the use of
Paliperidone LAI and 3-monthly injection as per its licensed indications and as outlined in the updated Guidance on the Use of Antipsychotic Long-acting Injections in the North of England.

Flupentixol Decanoate
BNF | BNFC | SPC

20mg in 1ml, 40mg in 2ml, 50mg in 0.5ml,
100mg in 1ml & 200mg in 1ml injections

Haloperidol Decanoate
BNF | BNFC | SPC

50mg in 1ml & 100mg in 1ml injections

Risperidone Long-acting
BNF | BNFC | SPC

25mg, 37.5mg and 50mg long acting injections

Risperidone long acting only for use by specialists in TEWV in accordance with TEWV Psychosis pathway

NTAG September 2017: The Northern (NHS) Treatment Advisory Group recommends the use of
Paliperidone LAI and 3-monthly injection as per its licensed indications and as outlined in the updated Guidance on the Use of Antipsychotic Long-acting Injections in the North of England.

Zuclopenthixol Decanoate
BNF | BNFC | SPC

200mg in 1ml & 500mg in 1ml injections

Aripiprazole Long-acting injection
BNF | BNFC | SPC
Paliperidone Long-acting injection
BNF | BNFC | SPC

50mg, 100mg & 150mg pre-filled syringe

Both monthly and three-monthly preparations of Paliperidone LAI are included in the formulary.

NTAG September 2017: The Northern (NHS) Treatment Advisory Group recommends the use of
Paliperidone LAI and 3-monthly injection as per its licensed indications and as outlined in the updated Guidance on the Use of Antipsychotic Long-acting Injections in the North of England.

Paliperidone 3 monthly injection may be considered for patients clinically stable for at least 4 months on 1 monthly paliperidone palmitate injection.

Paliperidone LAI - TEWV shared care guidelines

Olanzapine injection
BNF | BNFC | SPC

210 mg, 300 mg, and 405 mg, powder and solvent for prolonged release suspension for injection.

TEWV Olanzapine LA Prescribing Administration guidelines

See TEWV policies:

Depression pathway handy hints when prescribing antidepressants

Depression Medication Pathway for Adults

CYP Depression Pathway - guidance for pharmacological management

 

Additional guidance for prescribing in the elderly is available.

NICE NG134: Depression in children and young people: identification and management 

Recommended for 2nd line treatment.

First ChoicAntidepressant

Trazodone

Other Indications

Amitriptyline

See TEWV policies:

Depression pathway handy hints when prescribing antidepressants

Depression Medication Pathway for Adults

CYP Depression Pathway - guidance for pharmacological management

 

Amitriptyline
BNF | BNFC | SPC

Tabs - 10mg, 25mg, 50mg

Oral Solution - 25mg/5ml, 50mg/5ml

For use unlicensed for neuropathic pain

Imipramine
BNF | BNFC | SPC

Tablets - 10mgs, 25mg

 

Lofepramine
BNF | BNFC | SPC

Tabs - 70mg,

Oral Solution - 70mg/5ml

Nortriptyline
BNF | BNFC | SPC

Tabs - 10mg, 25mg

 

Trimipramine
BNF | BNFC | SPC

Caps - 50mg

Tabs - 10mg, 25mg

Trimipramine prescribing is not recommended.  For existing patients prescribed Trimipramine this TEWV guidance applies.

The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or 
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

Trazodone
BNF | BNFC | SPC

Caps - 50mg, 100mg

Tabs - 150mg

Liquid - 50mg/5ml

Dosulepin
BNF | BNFC | SPC

Dosulepin prescribing is not recommended.  For existing patients prescribed dosulepin this TEWV guidance applies.

The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or 
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

Moclobemide
BNF | BNFC | SPC

Tabs - 150mg, 300mg

Initiation to be recommended by secondary care

Phenelzine
BNF | BNFC | SPC

15mg tablets

Initiation to be recommended by secondary care

Indicated when there is no response to other antidepressant groups

See TEWV policies:

Depression pathway handy hints when prescribing antidepressants

Depression Medication Pathway for Adults

CYP Depression Pathway - guidance for pharmacological management

 

Isocarboxazid
BNF | BNFC | SPC

The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or 
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

Tranylcypromine
BNF | BNFC | SPC

The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or 
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

SSRIs are considered 1st line intervention for depression in those requiring activation.

See TEWV policies:

Depression pathway handy hints when prescribing antidepressants

Depression Medication Pathway for Adults

CYP Depression Pathway - guidance for pharmacological management

 

Citalopram
BNF | BNFC | SPC

Tabs - 10mg, 20mg, 40mg

Oral Drops - 40mg/ml

Citalopram: See MHRA guidance regarding dose related QT prolongation and TEWV guidance on dose reduction and ECG monitoring

MHRA Drug Safety Update (July 2016): Citalopram: suspected drug interaction with cocaine; prescribers should consider enquiring about illicit drug use

Fluoxetine
BNF | BNFC | SPC

Caps - 20mg

Liquid - 20mg/5ml

Sertraline
BNF | BNFC | SPC

Tabs - 50mg, 100mg

Escitalopram
BNF | BNFC | SPC

Escitalopram: See MHRA guidance regarding dose related QT prolongation and TEWV guidance on dose reduction and ECG monitoring

 

Duloxetine
BNF | BNFC | SPC

Caps - 30mg, 60mg

For use in diabetic neuropathy where other treatments are unsuitable or inadequate and initiated by a specialist

Agomelatine
BNF | BNFC | SPC

Tabs - 25mg

Recommended for the treatment of depression only following an adequate trial of at least three alternative antidepressant drugs at maximally tolerated doses.  See NTAG recommendation.

MHRA Drug safety Update (Nov’ 2014): risk of liver toxicity – reminder to test LFTs before and during treatment

Mirtazapine
BNF | BNFC | SPC

Tabs - 15mg, 30mg, 45mg

Orodispersible Tabs - 15mg, 30mg, 45mg 

1st line intervention for depression in those requiring sedation.

See TEWV policies:

Depression pathway handy hints when prescribing antidepressants

Depression Medication Pathway for Adults

CYP Depression Pathway - guidance for pharmacological management

Orodispersible tablets should only be prescribed for patients who are unable to swallow solid dose forms

Venlafaxine
BNF | BNFC | SPC

Tabs - 37.5mg, 75mg 

When prescribed in doses less than 225mg per day.
Immediate release should be used 1st line, MR preparations should be reserved for those with a clinical need e.g. poor compliance. The reason should be stated in GP communications when transferring prescribing.
In low doses is as expensive as an SRRI.
See TEWV Depression Pathway Medication Guidelines Primary and Secondary Care Monotherapies

When prescribed in doses above 225mg per day (Amber Specialist initiation drug)

Must be recommended by a specialist and arrangements for 6-monthly monitoring of blood pressure agreed with GP.
Immediate release should be used 1st line, MR preparations should be reserved for those with a clinical need e.g. poor compliance. The reason should be stated in GP communications when transferring prescribing.

Reboxetine
BNF | BNFC | SPC

4mg tablets

Vortioxetine▼
BNF | BNFC | SPC

5mg, 10mg & 20mg film-coated tablets

For use as 3rd line treatment option for the management of depression as per NICE TA367

See TEWV policies:

Depression pathway handy hints when prescribing antidepressants

Depression Medication Pathway for Adults

CYP Depression Pathway - guidance for pharmacological management

 

NG86: Attention deficit hyperactivity disorder: diagnosis and management

TEWV ADHD prescribing algorithm (ADULTS)

TEWV ADHD prescribing algorithm (CYPS)

 

Atomoxetine
BNF | BNFC | SPC

Caps - 10mg, 18mg, 25mg, 40mg, 60mg or 80mg hard capsules

TEWV: Atomoxetine Shared Care Guideline

Dexamfetamine▼
BNF | BNFC | SPC
Lisdexamfetamine▼
BNF | BNFC | SPC

Capsules- 30mg, 50mg, and 70mg 

TEWV: Lisdexamfetamine Shared Care Guideline

Lisdexamfetamine – approved with the following restrictions

Second or third line option when response to previous methylphenidate treatment is considered clinically inadequate and where any of the following apply:

·         a liquid preparation is required

·         response to dexamfetamine established but control would be improved with a long acting preparation

·         covert administration has been deemed in the person’s best interests (mental capacity or children act)

Methylphenidate
BNF | BNFC | SPC

Tabs - 5mg, 10mg, 20mg

MR Tabs - 18mg, 27mg, 36mg, 54mg (Concerta XL, Delmosart, Xenidate XL, Xaggitin XL, Matoride XL)

MR Caps - 5mg, 10mg, 20mg, 30mg, 40mg, 50mg, 60mg (Medikinet XL)

Unlicensed in adults, but NICE recommend that following a decision to start drug treatment in adults, methylphenidate should normally be tried first.

TEWV: Methylphenidate Shared Care Guideline

 

Guanfacine▼
BNF | BNFC | SPC

Guanfacine to be used to be used Treatment of Attention Deficit Hyperactivity Disorder in children and adolescents 6-17 years old for whom stimulants are not suitable, not tolerated or have been shown to be ineffective AND in those whom Atomoxetine is not suitable, not tolerated or has been shown to be ineffective.

TEWV: Guanfacine Shared Care Guideline

Modafinil
BNF | BNFC | SPC

100mg tablets
– only approved for limited use in the treatment of patients with narcolepsy

Modafinil (Provigil) (Neurology) Shared Care Guideline

Mazindol
BNF | BNFC | SPC

For narcolepsy

Sodium Oxybate
BNF | BNFC | SPC

NTAG June 2017: The Northern (NHS) Treatment Advisory Group only recommends the use
of sodium oxybate in adult patients who have received and benefited
from treatment with sodium oxybate as commissioned by NHS England.
i.e. continuing treatment for those >19 years old. 

Pitolisant
BNF | BNFC | SPC

4.5mg and 18mg film-coated tablets

NTAG Nov 2018: recommends the use of Pitolisant only in narcoleptic patients with residual severe daytime sleepiness who have an Epworth score of 14 or over if they have already tried modafinil and dexamfetamine or methylphenidate, and where therapy will make a substantial difference to their quality life.
Prescription of this medication will be limited to Sleep Centres with adequate expertise in managing narcolepsy and using this medication:
The James Cook University Hospital, Department of Sleep Medicine and
Royal Victoria Infirmary

Only for use in accordance with NICE guidelines

Naltrexone-Bupropion (Mysimba▼)
BNF | BNFC | SPC

Naltrexone hydrochloride/bupropion hydrochloride 8mg/90mg tablets

Not approved as per NICE TA494

MHRA Drug Safety Update (Aug 2019): Naltrexone/bupropion (Mysimba▼): risk of adverse reactions that could affect ability to drive

Liraglutide (Saxenda)
BNF | BNFC | SPC

18mg/3ml solution for injection in a prefilled pen

NTAG September 2017: The Northern (NHS) Treatment Advisory Group does not recommend the use of liraglutide (Saxenda®) for the treatment of obesity. 

The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or 
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

Naltrexone-Bupropion (Mysimba▼)
BNF | BNFC | SPC

Naltrexone hydrochloride/bupropion hydrochloride 8mg/90mg tablets

Not approved as per NICE TA494

Cyclizine
BNF | BNFC | SPC

Tablets - 50mg

Cinnarizine
BNF | BNFC | SPC

Tablets - 15mg

Promethazine
BNF | BNFC | SPC

Tablets - 5mg

Haloperidol
BNF | BNFC | SPC

500 microgram capsules,1.5mg, 5mg & 10mg tablets
1mg in 1ml & 2mg in 1ml oral liquid
5mg in 1ml & 20mg in 2ml inject

 

Prochlorperazine
BNF | BNFC | SPC

5mg tablets; 5mg in 5ml syrup
12.5mg in 1ml injection
3mg tablets (buccal) (Buccastem®)

Levomepromazine
BNF | BNFC | SPC

6mg tabletsu, 25mg tablets
25mg in 1ml injection - For use in palliative care

25mg tablets can be halved or quartered
6mg tablets are unlicensed and should only be used in palliative care

Domperidone
BNF | BNFC | SPC

Tablets - 10mg

Suspension - 5mg/5ml

MHRA Drug Safety Alert (May 2014): indication now restricted to nausea and vomiting

Metoclopramide
BNF | BNFC | SPC

Tablets - 10mg

Oral Solution - 5mg/5ml

Caution in elderly, young adults and children

Do not use in people under 20 years

MHRA Drug Safety Update Alert (Aug 2013) Metoclopramide– restricted dose and duration

Ondansetron
BNF | BNFC | SPC

4mg & 8mg tablets
4mg in 5ml sugar-free solution
4mg in 2ml & 8mg in 4ml injections
16mg suppositories

MHRA Drug Safety Alert (Jul 2013): Ondansetron for intravenous use: dose-dependent QT interval prolongation

Palonosetron
BNF | BNFC | SPC

250 microgram in 5ml injection, 500 microgram capsules
- for 2nd line of treatment for chemotherapy induced nausea vomiting only

Only injection available STHFT

Palonosetron with Netupitant▼
BNF | BNFC | SPC
Granisetron
BNF | BNFC | SPC

1 mg film-coated tablets

1 mg/ml concentrate for solution for injection or infusion

3.1 mg/24 hours transdermal patch

Nausea and vomiting induced by cytotoxic chemotherapy or radiotherapy.

Patches restricted to patients unable to swallow.

Hyoscine Hydrobromide
BNF | BNFC | SPC

300 microgram oral/sublingual tablets
1mg/72 hour patches
- for the management of excessive secretions where tablets are unsuitable

Aprepitant
BNF | BNFC | SPC

80mg & 125mg capsules
- for the prevention of chemotherapy induced nausea and vomiting (CINV) in high risk patients in accordance with North of England Cancer Network: CINV Guidelines in adult oncology and haematology patients

Nabilone
BNF | BNFC | SPC

1mg caps

Betahistine
BNF | BNFC | SPC

Tablets - 8mg, 16mg

Meniere's disease

County Durham and Darlington - Opioid Prescribing for Persistent (Non-Cancer) Pain in Adults
County Durham and Darlington  - Key Messages: For Pain Management Scenarios
County Durham and Darlington  - Pharmacological Treatment of Neuropathic Pain

Tees Primary Care Pain Management Guideline

Paediatric Analgesia: Quick Reference Guide (CDDFT intranet access only)

Paediatric Analgesia Protocol (CDDFT intranet access only)

NICE CG173: Neuropathic pain

Effervescent / soluble tablets not generally recommended except in acute treatment of migraine.

CD&D Grey List: Short courses of analgesics for acute common ailments can be purchased by
the patient under self-care with community pharmacist support. Continue to prescribe for children and when required for chronic conditions although patients should be reminded that these medications are also available to purchase. Prescribing short courses of pain relief for acute conditions costs the NHS more than the equivalent products purchased over the counter (prescription fees, GP consultation time
etc.)

 

 

Paracetamol
BNF | BNFC | SPC

500mg plain & soluble tabletsOTC
120mg & 250mg in 5ml suspensions (sugar-free)OTC
1g injection for IV infusion

60mg, 125mg, 250mg & 500mg suppositories

See CDDFT drug protocol for IV paracetamol

Paracetamol IV
BNF | BNFC | SPC
NSAIDs
BNF | BNFC | SPC

See section 10.1.1

Nefopam
BNF | BNFC | SPC

Prescribing of nefopam is not supported by Hartlepool & Stockton-on-Tees and South Tees CCGs.

Nefopam should not be initiated for acute or chronic pain, or continued post discharge following secondary care acute initiation. Only continue nefopam in line with recommendations of the specialist pain service. Review existing patients - assess benefits versus adverse effects and consider stopping; withdraw slowly over 1-2 weeks following chronic use.

Adverse effects are common, nefopam is toxic in overdose and has abuse potential through its psychostimulant-like effects. Nefopam is very expensive.

Tees CCGs Position Statement on Nefopam

The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or 
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

Co-proxamol
BNF | BNFC | SPC

The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or 
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

Co-codaprin
BNF | BNFC | SPC

The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or 
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

Tramacet
BNF | BNFC | SPC

The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or 
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

Nabilone
BNF | BNFC | SPC

1mg capsules

Nabilone: approved for very limited use in the treatment of chronic pain (unlicensed indication) that has not responded to other treatments. Treatment must be initiated by pain consultants and reviewed after about one month. Treatment to be stopped immediately in non-responders.

Ziconotide
BNF | BNFC | SPC

Intrathecal Analgesia

NHS England – Not routinely commissioned

While Co-codamol 8/500 is commonly used, no advantages over paracetamol have been substantiated. The low dose of codeine may be enough to cause opioid side-effects (in particular, constipation) and can complicate the treatment of overdose, yet may not provide significant additional relief of pain. Use is therefore discouraged.

County Durham and Darlington  APC - Opioid Prescribing for Persistent (Non-Cancer) Pain in Adults
County Durham and Darlington  APC - Key Messages: For Pain Management Scenarios

Buprenorphine
BNF | BNFC | SPC

200 microgram sublingual tablets
300 micrograms in 1ml injection
5 & 10 microgram/hour transdermal patch (BuTrans®)
35microgram, 52.5microgram, 70microgram/hour transdermal patch over 96 hours

Prescribe by brand

The preferred brand of choice for weekly buprenorphine patches within North Durham and DDES is Butec(R) patches.

72 hour transdermal patches (e.g. Hapoctasin and Penotrix) are non-formulary.

North of England Cancer Network Palliative and End of Life Care Pathway

Codeine
BNF | BNFC | SPC

Tablets - 15mg, 30mg

Syrup - 25mg/5ml

30mg in 1ml injectionu  & 60mg in 1ml injection

Codeine is the preferred weak opioid analgesic.

MHRA Drug Safety Alert (Nov 2003): significant restrictions in paediatrics and breast feeding mothers

Interim CDDFT advice available via CDDFT intranet

Diamorphine
BNF | BNFC | SPC

5mg, 10mg, 30mg, 100mg & 500mg injections

Drug protocol: diamorphine for pain relief during labour (CDDFT intranet access only)

North of England Cancer Network Palliative and End of Life Care Pathway

Dihydrocodeine Tartrate
BNF | BNFC | SPC

Tablets - 30mg

Oral Solution - 10mg/5ml

Dipipanone/Cyclizine (Diconal)
BNF | BNFC | SPC

Dipipanone hydrochloride/Cyclizine hydrochloride 10mg/30mg tab

The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or 
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

Fentanyl
BNF | BNFC | SPC

Patches - 12microgram/hour, 25microgram/hour, 50microgram/hour, 75microgram/hour, 100microgram/hour

Prescribe by brand

The preferred brand of choice within North Durham and DDES is Mezolar Matrix(R) patches.

Transdermal fentanyl – MHRA Drug Safety Update (July 2014) – reminder of potential life threatening harm from accidental exposure, especially in children

MHRA Drug Safety Update (Oct 2018): Transdermal fentanyl patches: life-threatening and fatal opioid toxicity from accidental exposure, particularly in children

Refer to palliative care guidelines for advice on swapping to/from patches: North of England Cancer Network Palliative and End of Life Care Pathway

CD&D Grey List: Novel Fentanyl preparations should not be prescribed as these have been rejected by NTAG

 

Fentanyl citrate immediate release sublingual tablet (Abstral)
BNF | BNFC | SPC

100, 200, 300, 400, 600, 800 microgram tablets to replace the use of Actiq lonzenge.

For breakthrough / rescue pain relief in palliative care patients (patients with life-limiting illness requiring specialist palliative care team member review) who have:

1. Intolerance of morphine / oxycodone

2. Renal impairment which necessitates strong opioid choice other than morphine /oxycodone

3. Dysphagia

Fentanyl Immediate Release Preparations
BNF | BNFC | SPC

Sublingual tablets, buccal tablets, lozenges, nasal sprays

Tees Do Not Prescribe/Grey List

NHS England (November 2017) advises that primary care prescribers should not initiate immediate-release fentanyl preparations for new patients. NHS England also supports the deprescribing of immediate-release fentanyl preparations. More cost-effective preparations are available.

NHS England recommendations for immediate-release fentanyl do not apply to patients undergoing palliative care treatment arranged with a suitable specialist

Methadone
BNF | BNFC | SPC

1mg/1ml liquid and 5mg tablets available.

Use in pain management should be under the advice of palliative care
 Concentrated liquid and injection can be ordered if required

Morphine Sulphate
BNF | BNFC | SPC

Tablets - 10mg, 20mg, 50mg (Sevredol),

MR capsules - 10mg, 30mg, 60mg, 100mg, 200mg (Zomorph)

MR tablets - 10mg, 15mg, 30mg, 60mg, 100mg, 200mg (MST)

10mg in 5ml Liquid                                                              

Injection - 10mg/ml, 15mg/ml, 20mg/ml, 30mg/ml

Zomorph is the preferred modified release preparation in County Durham and Darlington

Drug protocol: neonatal morphine sulphate for ventilation (CDDFT intranet access only)

North of England Cancer Network Palliative and End of Life Care Pathway

Oxycodine with naloxone (Targinact)
BNF | BNFC | SPC

The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or 
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

Oxycodone
BNF | BNFC | SPC

Capsules - 5mg, 10mg, 20mg,

Liquid - 5mg/5ml

MR Tablets - 5mg, 10mg, 15mg, 20mg, 40mg, 60mg80mg, 120mg

Oral solution should be used instead of immediate release tablets.

Prescribe by brand

See CQC - safer use oxycodone

Oxycodone only to be used in patients who are intolerant of morphine.

Oxycodone should be prescribed by brand to avoid confusion between different preparations – Longtec® is currently the local formulary modified release preparation of choice.

North of England Cancer Network Palliative and End of Life Care Pathway

 

Pentazocine
BNF | BNFC | SPC
Pethidine
BNF | BNFC | SPC

50mg in 1ml & 100mg in 2ml injections

Drug protocol: pethidine for pain relief during labour (CDDFT intranet access only)

Tapentadol
BNF | BNFC | SPC

50mg, 100mg, 150mg, 200mg and 250mg m/r tablets
50mg and 75mg immediate release tablets

CD&D APC Grey List: Tapentadol – Third line treatment for the relief of severe chronic pain in adults which can be adequately managed only with opioid analgesics AND in whom morphine and oxycodone has failed to provide adequate pain relief or is not tolerated.

MHRA Drug Safety Update (Jan 2019): Tapentadol (Palexia): risk of seizures and reports of serotonin syndrome when co-administered with other medicines

Tramadol
BNF | BNFC | SPC

Capsules - 50mg

50mg dispersible tablets
100mg in 2ml injection

Tramadol - only recommended for use in patients where treatment with possible alternatives such as paracetamol, NSAIDs, and codeine is insufficiently effective, not tolerated or considered unsuitable for other reasons. Modified release tramadol is not recommended.

See CDDFT Tramadol Schedule 3 CD prescribing memo – intranet link (CDDFT only)

See NICE CG173: Neuropathic pain and County Durham and Darlington APC - Pharmacological Treatment of Neuropathic Pain

First Choice:
Amitriptyline

Second Choice:
Gabapentin
Pregabalin

Alternatives:
Carbamazepine
Duloxetine
Phenytoin
Tramadol

N.B. Other drugs such as Ketamine (see section 15.1.1) may also be advised by pain/palliative care specialists in the management of neuropathic pain.

Amitriptyline
BNF | BNFC | SPC

See section 4.3

Gabapentin
BNF | BNFC | SPC

See section 4.8.1

Also approved for hospital use as an adjunct to other treatment in the management of peri/post-operative pain. GPs should not be asked to prescribe gabapentin for this unlicensed indication.

MHRA Drug Safety Alert (Oct 2017): Gabapentin (Neurontin): risk of severe respiratory depression 

Pregabalin
BNF | BNFC | SPC

See section 4.8.1

Restricted to use in the management neuropathic pain as a second choice where treatment with gabapentin has been unsuccessful or not tolerated.

The preferred brand of choice within North Durham and DDES is Alzain(R) where licensing allows.

Carbamazepine
BNF | BNFC | SPC

See section 4.8.1

Duloxetine
BNF | BNFC | SPC

30mg & 60mg capsules 30mg & 60mg capsules

For third-line use (after drugs such as the tricyclic antidepressants and gabapentin) in the treatment of neuropathic pain on the advice of pain specialists.

Phenytoin
BNF | BNFC | SPC

See section 4.8.1

Capsaicin Cream
BNF | BNFC | SPC

0.075% cream

For Postherpetic Neuralgia

Capsaicin Patch (Qutenza)
BNF | BNFC | SPC

179 mg cutaneous patch

NTAG June 2017: The Northern (NHS) Treatment Advisory Group recommends use of
Qutenza® as a fourth line agent for neuropathic pain and in line with the regionally agreed pathway.

 

Lidocaine Plasters
BNF | BNFC | SPC

5% medicated plasters (700mg lidocaine/plaster)

Lidocaine patches are only licensed for the treatment of postherpatic neuralgia (PHN).
In addition, they are approved locally for use in the following:
• the treatment of chronic neuropathic pain on the advice of pain specialists only, subject to an appropriate trial of efficacy in each individual patient and as part of a directed management plan
• the treatment of multiple rib fractures on the advice of pain specialists only, in line with the procedure for pain management and rehabilitation following multiple rib fractures
• palliative care – please note that prescribers in primary care can initiate prescribing in palliative care patients.

CD&D APC Grey List 

Mexiletine
BNF | BNFC | SPC

167mg capsules

Unlicensed for use management of pain.

Sumatriptan
BNF | BNFC | SPC

Tablets - 50mgOTC

Injection - (Auto-injector) 12mg/ml (6mg/0.5ml syringe)    

  

Paracetamol
BNF | BNFC | SPC

See section 4.7.1

Aspirin
BNF | BNFC | SPC

See section 4.7.1

NSAIDs
BNF | BNFC | SPC

See section 10.1.1

Frovatriptan
BNF | BNFC | SPC

2.5mg tablets

Zolmitriptan
BNF | BNFC | SPC

2.5mg tablets

Ergotamine (Migril)
BNF | BNFC | SPC

The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or 
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

Rizatriptan
BNF | BNFC | SPC

10mg Orodispersible tablets or standard tablets

DO NOT PRESCRIBE AS LYOPHILISATES

Pizotifen
BNF | BNFC | SPC

500 microgram & 1.5mg tablets
250 microgram in 5ml sugar-free elixir

Sodium Valproate▼
BNF | BNFC | SPC

100mg crushable tablets, 200mg & 500mg e/c tablets 200mg, 300mg & 500mg m/r tablets (Epilim Chrono).
150mg & 300mg m/r capsules

500mg & 1000mg m/r granules (Episenta) - for use in those who have difficulty swallowing sodium valproate tablets. May be more convenient to use than large volumes of liquid formulations
200mg in 5ml sugar-free liquid

Unlicensed Indication

MHRA Drug Safety Alert (April 2017): Valproate and developmental disorders: new alert asking for patient review and further consideration of risk minimisation measures 

MHRA Drug Safety Update (April 2018): Valproate medicines (Epilim▼, Depakote▼): contraindicated in women and girls of childbearing potential unless conditions of Pregnancy Prevention Programme are met 

MHRA Drug Safety Update (May 2018): Valproate medicines (Epilim▼, Depakote▼): Pregnancy Prevention Programme materials online

MHRA Drug Safety Update (Sept 2018): Valproate Pregnancy Prevention Programme: actions required now from GPs, specialists, and dispensers

MHRA Drug Safety Update (April 2019): Valproate medicines and serious harms in pregnancy: new Annual Risk Acknowledgement Form and clinical guidance from professional bodies to support compliance with the Pregnancy Prevention Programme

Local Shared Care guideline to support Valproate Pregnancy Prevention Programme available here

Propranolol
BNF | BNFC | SPC

10mg, 40mg & 80mg tablets

Amitriptyline
BNF | BNFC | SPC

10mg, 25mg & 50mg tablets

25mg in 5ml sugar free oral solution

Unlicensed Indication

Sodium Valproate▼ in females
BNF | BNFC | SPC

Patient Group: Girls (of any age) and women of child bearing potential

100mg crushable tablets, 200mg & 500mg e/c tablets 200mg, 300mg & 500mg m/r tablets (Epilim Chrono).
150mg & 300mg m/r capsules

500mg & 1000mg m/r granules (Episenta) - for use in those who have difficulty swallowing sodium valproate tablets. May be more convenient to use than large volumes of liquid formulations
200mg in 5ml sugar-free liquid

Unlicensed Indication

MHRA Drug Safety Alert (April 2017): Valproate and developmental disorders: new alert asking for patient review and further consideration of risk minimisation measures 

MHRA Drug Safety Update (April 2018): Valproate medicines (Epilim, Depakote): contraindicated in women and girls of childbearing potential unless conditions of Pregnancy Prevention Programme are met 

MHRA Drug Safety Update (May 2018): Valproate medicines (Epilim, Depakote): Pregnancy Prevention Programme materials online

MHRA Drug Safety Update (Sept 2018): Valproate Pregnancy Prevention Programme: actions required now from GPs, specialists, and dispensers

MHRA Drug Safety Update (April 2019): Valproate medicines and serious harms in pregnancy: new Annual Risk Acknowledgement Form and clinical guidance from professional bodies to support compliance with the Pregnancy Prevention Programme

Local Shared Care guideline to support Valproate Pregnancy Prevention Programme available here

Botulinum Toxin Type A (Botox®)
BNF | BNFC | SPC

To be initiated by specialist in patients who meet NICE criteria

Refer to NICE guidance CG 137. The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care.

Control of epilepsy

All green plus drugs in this section should be recommended by a specialist and are suitable for transfer to primary care.

See Commission on Human Medicines advice on branded / manufacturer based prescribing here

MHRA Antiepileptic drugs: new advice on switching between different manufacturer’s products for a particular drug. More details here.

Category 1 in epilepsy treatment - ensure patient is maintained on specific manufacturers product.
Category 2 in epilepsy treatment - treatment the need for continued supply of a particular manufacturers produce should be based on clinical judgment and consultation with the patient taking into account factors such as seizure frequency and treatment history.
Category 3 in epilepsy treatment - it is usually unnecessary to ensure the patient is maintained on a specific manufacturers product unless there are specific concerns.

MHRA Drug Safety Update (Nov 2017): Antiepileptic drugs: updated advice on switching between different manufacturers’ products - In addition to the 3 risk-based categories of antiepileptic drugs, patient-related factors should be considered when deciding whether it is necessary to maintain continuity of supply for a specific product.

MHRA Drug Safety Update (Dec 2018): Valproate medicines: are you acting in compliance with the pregnancy prevention measures?

See also CDDFT intranet site for CDDFT information.

Drug protocol: PAEDIATRIC Management of Convulsive Status Epilepticus – available here  (CDDFT intranet access only)

MHRA Drug Safety Alert (Nov 2017): Antiepileptic drugs: updated advice on switching between different manufacturers’ products - In addition to the 3 risk-based categories of antiepileptic drugs, patient-related factors should be considered when deciding whether it is necessary to maintain continuity of supply for a specific product.

Category 1 in epilepsy treatment - ensure patient is maintained on specific manufacturers product.
Category 2 in epilepsy treatment  - the need for continued supply of a particular manufacturers produce should be based on clinical judgment and consultation with the patient taking into account factors such as seizure frequency and treatment history.
Category 3 in epilepsy treatment - it is usually unnecessary to ensure the patient is maintained on a specific manufacturers product unless there are specific concerns.

Brivaracetam▼
BNF | BNFC | SPC

10mg, 25mg, 50mg, 75mg and 100mg film coated tablets

10mg/mL oral solution 

Brivaracetam has been approved as third line treatment option for use as adjuvant therapy in patients with focal onset seizures. Not currently indicated in generalised epilpesy syndromes. 

Category 3 in epilepsy treatment - it is usually unnecessary to ensure the patient is maintained on a specific manufacturers product unless there are specific concerns.

Carbamazepine
BNF | BNFC | SPC

Tablets - 100mg, 200mg, 400mg

MR Tablets - 200mg, 400mg

Liquid - 100mg/5ml

Category 1 in epilepsy treatment - ensure patient is maintained on specific manufacturers product.

Carbamazepine Suppositories
BNF | BNFC | SPC
200mg tablets = 250mg suppository. Maxiumum rectal dose = 250mg qds for 7 days. (see UKMI advice below) 
Link  UKMI Q&A: Why is there a limit on the dose and duration of use for carbamazepine suppositories?
Clobazam
BNF | BNFC | SPC

Tablets - 10mg

1mg/ml and 2mg/ml oral suspension

Only prescribable on NHS for epilepsy. Must be endorsed SLS

Category 2 in epilepsy treatment  - the need for continued supply of a particular manufacturers produce should be based on clinical judgment and consultation with the patient taking into account factors such as seizure frequency and treatment history.

Clonazepam
BNF | BNFC | SPC

Tablets - 500microgram, 2mg

Category 2 in epilepsy treatment  - the need for continued supply of a particular manufacturers produce should be based on clinical judgment and consultation with the patient taking into account factors such as seizure frequency and treatment history.

Eslicarbazepine
BNF | BNFC | SPC

800mg tablets
- approved for use by specialists only in those patients for whom intolerance of carbamazepine is a major concern and when use of this agent is more cost effective than alternatives available.

Category 2 in epilepsy treatment  - the need for continued supply of a particular manufacturers produce should be based on clinical judgment and consultation with the patient taking into account factors such as seizure frequency and treatment history.

Ethosuximide
BNF | BNFC | SPC

Capsules - 250mg

Syrup - 250mg/5ml

Category 3 in epilepsy treatment - it is usually unnecessary to ensure the patient is maintained on a specific manufacturers product unless there are specific concerns.

Gabapentin
BNF | BNFC | SPC

Capsules - 100mg, 300mg, 400mg

Also licensed for neuropathic pain

MHRA Drug Safety Alert (Oct 2017): Gabapentin (Neurontin): risk of severe respiratory depression 

Category 3 in epilepsy treatment - it is usually unnecessary to ensure the patient is maintained on a specific manufacturers product unless there are specific concerns.

Lacosamide
BNF | BNFC | SPC

50mg, 100mg, 150mg & 200mg tablets
10mg per ml syrup, 10mg per ml intravenous infusion
- on advice from consultant neurologists, in patients that are refractory to treatment with other drugs

Category 3 in epilepsy treatment - it is usually unnecessary to ensure the patient is maintained on a specific manufacturers product unless there are specific concerns.

Lamotrigine
BNF | BNFC | SPC

Tablets - 25mg, 50mg, 100mg, 200mg

Dispersible Tablets - 2mg (only Chewable), 5mg, 25mg, 100mg

Category 2 in epilepsy treatment  - the need for continued supply of a particular manufacturers produce should be based on clinical judgment and consultation with the patient taking into account factors such as seizure frequency and treatment history.

Levetiracetam
BNF | BNFC | SPC

Tablets 250mg, 500mg, 750mg and 1g
Sugar Free solution 100mg/ml

Category 3 in epilepsy treatment - it is usually unnecessary to ensure the patient is maintained on a specific manufacturers product unless there are specific concerns.

Levetiracetam IV
BNF | BNFC | SPC
Oxcarbazepine
BNF | BNFC | SPC

150mg, 300mg & 600mg tablets

60mg/ml, 250ml oral suspension - N.B. double the cost of tablets so only use when patient is unable to swallow tablets.

Category 2 in epilepsy treatment  - the need for continued supply of a particular manufacturers produce should be based on clinical judgment and consultation with the patient taking into account factors such as seizure frequency and treatment history.

Perampanel▼
BNF | BNFC | SPC

2mg, 4mg, 6mg, 8mg, 10mg, 12mg tablets.
- NETAG approved for partial (focal) seizure epilepsy only when other treatment options recommended by NICE have been tried or fully considered.

Category 2 in epilepsy treatment  - the need for continued supply of a particular manufacturers produce should be based on clinical judgment and consultation with the patient taking into account factors such as seizure frequency and treatment history.

Phenobarbital
BNF | BNFC | SPC

15mg, 30mg & 60mg tablets; 15mg in 5ml elixir; 20mg in 1ml suspension (alcohol free)
15mg in 1ml, 30mg in 1ml & 200mg in 1ml injections

Category 1 in epilepsy treatment - ensure patient is maintained on specific manufacturers product.

Phenytoin (Sodium Salt)
BNF | BNFC | SPC

Capsules - 25mg, 50mg, 100mg, 300mg,

Chewable Tablets - 50mg

Suspension - 30mg/5ml

Phenytoin: different preparations may vary in bioavailability; always prescribe by brand name. Therapeutic drug monitoring required.

Drug protocol: phenytoin loading in adults, children and neonates (CDDFT intranet access only)

Suspension contains phenytoin base - care need when changing to or from capsules

Category 1 in epilepsy treatment - ensure patient is maintained on specific manufacturers product.

Piracetam
BNF | BNFC | SPC
Pregabalin
BNF | BNFC | SPC

Capsules - 25mg50mg, 75mg, 100mg, 150mg, 200mg, 225mg, 300mg

Also licensed for neuropathic pain

The preferred brand of choice within North Durham and DDES is Alzain(R) where licensing allows.

Category 3 in epilepsy treatment - it is usually unnecessary to ensure the patient is maintained on a specific manufacturers product unless there are specific concerns.

Primidone
BNF | BNFC | SPC

Category 1 in epilepsy treatment - ensure patient is maintained on specific manufacturers product.

Rufinamide
BNF | BNFC | SPC

Category 2 in epilepsy treatment  - the need for continued supply of a particular manufacturers produce should be based on clinical judgment and consultation with the patient taking into account factors such as seizure frequency and treatment history.

Sodium Valproate▼
BNF | BNFC | SPC

Tablets e/c - 200mg, 500mg,

Tablets MR - 200mg, 300mg, 500mg,

Oral Solution - 200mg/5ml,

Tablets (crushable) - 100mg

MHRA Drug Safety Update (Feb 2016): Valproate and of risk of abnormal pregnancy outcomes: new communication materials

MHRA Drug SafetyAlert (Jan2015): Medicines related to valproate: risk of abnormal pregnancy outcomes

MHRA Drug Safety Alert (Nov 2013): Sodium Valproate - special reminder on risk of neurodevelopmental delay in children following maternal use. 

MHRA Drug Safety Alert (April 2017): Valproate and developmental disorders: new alert asking for patient review and further consideration of risk minimisation measures 

MHRA Drug Safety Update (April 2018): Valproate medicines (Epilim▼, Depakote▼): contraindicated in women and girls of childbearing potential unless conditions of Pregnancy Prevention Programme are met 

MHRA Drug Safety Update (May 2018): Valproate medicines (Epilim▼, Depakote▼): Pregnancy Prevention Programme materials online

MHRA Drug Safety Update (Sept 2018): Valproate Pregnancy Prevention Programme: actions required now from GPs, specialists, and dispensers

MHRA Drug Safety Update (April 2019): Valproate medicines and serious harms in pregnancy: new Annual Risk Acknowledgement Form and clinical guidance from professional bodies to support compliance with the Pregnancy Prevention Programme

Local Shared Care guideline to support Valproate Pregnancy Prevention Programme available here

Category 2 in epilepsy treatment  - the need for continued supply of a particular manufacturers produce should be based on clinical judgment and consultation with the patient taking into account factors such as seizure frequency and treatment history.

Sodium valproate▼ in females
BNF | BNFC | SPC

Patient Group: Girls (of any age) and women of child bearing potential

100mg crushable tablets, 200mg & 500mg e/c tablets 200mg, 300mg & 500mg m/r tablets (Epilim Chrono).
150mg & 300mg m/r capsules

500mg & 1000mg m/r granules (Episenta) - for use in those who have difficulty swallowing sodium valproate tablets. May be more convenient to use than large volumes of liquid formulations
200mg in 5ml sugar-free liquid

Unlicensed Indication

MHRA Drug Safety Alert (April 2017): Valproate and developmental disorders: new alert asking for patient review and further consideration of risk minimisation measures 

MHRA Drug Safety Update (April 2018): Valproate medicines (Epilim, Depakote): contraindicated in women and girls of childbearing potential unless conditions of Pregnancy Prevention Programme are met 

MHRA Drug Safety Update (May 2018): Valproate medicines (Epilim, Depakote): Pregnancy Prevention Programme materials online

MHRA Drug Safety Update (Sept 2018): Valproate Pregnancy Prevention Programme: actions required now from GPs, specialists, and dispensers

MHRA Drug Safety Update (April 2019): Valproate medicines and serious harms in pregnancy: new Annual Risk Acknowledgement Form and clinical guidance from professional bodies to support compliance with the Pregnancy Prevention Programme

Local Shared Care guideline to support Valproate Pregnancy Prevention Programme available here

Sodium Valproate▼ Injection
BNF | BNFC | SPC
Stiripentol
BNF | BNFC | SPC
Tiagabine
BNF | BNFC | SPC

Category 3 in epilepsy treatment - it is usually unnecessary to ensure the patient is maintained on a specific manufacturers product unless there are specific concerns.

Topiramate
BNF | BNFC | SPC

Tablets - 25mg, 50mg, 100mg, 200mg

Capsules (Sprinkle) - 15mg, 25mg, 50mg

CD&D APC Grey List: Topiramate hard capsules are expensive and should not be prescribed. For those patients unable to swallow topiramate tablets “sprinkle capsules” may be considered. 

Category 2 in epilepsy treatment  - the need for continued supply of a particular manufacturers produce should be based on clinical judgment and consultation with the patient taking into account factors such as seizure frequency and treatment history.

Vigabatrin
BNF | BNFC | SPC

Tablets - 500mg

Powder (Sugar free) - 500mg/Sachet

Category 3 in epilepsy treatment - it is usually unnecessary to ensure the patient is maintained on a specific manufacturers product unless there are specific concerns.

Zonisamide
BNF | BNFC | SPC

25mg, 50mg and 100mg capsules
- for specialist use only in patients that are refractory to treatment with other drugs - use in children is unlicensed.

Category 2 in epilepsy treatment  - the need for continued supply of a particular manufacturers produce should be based on clinical judgment and consultation with the patient taking into account factors such as seizure frequency and treatment history.

Diazepam
BNF | BNFC | SPC

Rectal Solution - 2mg/ml, 4mg/ml

Midazolam Buccal
BNF | BNFC | SPC

Oromucosal Solution - 5mg/ml

Pre-filled syringes - 0.5ml, 1ml, 1.5ml, 2ml (Buccolam)

Other unlicensed formulations are available - check dose

Lorazepam
BNF | BNFC | SPC

1mg & 2.5mg tablets; 4mg in 1ml injection

Paraldehyde
BNF | BNFC | SPC

Rectal liquid u

Phenobarbital Sodium
BNF | BNFC | SPC

Drug protocol: neonatal IV and oral phenobarbital (CDDFT intranet access only)

Phenytoin Sodium
BNF | BNFC | SPC

250mg in 5ml injection

All green plus drugs in this section should be recommended by a specialist and are suitable for transfer to primary care.

South Tees Parkinson's Intergrated Care Pathway

NICE CG186:  Multiple sclerosis: management of multiple sclerosis in primary and secondary care

NTAG Nov 2014: The Northern (NHS) Treatment Advisory Group does not recommend the use of Sativex® for the management of non-MS pain.

South Tees Parkinson's Intergrated Care Pathway

Co-beneldopa (Madopar)
BNF | BNFC | SPC

Capsules - 62.5mg, 125mg, 250mg

Dispersible Tablets - 62.5mg, 125mg

MR Capsules - 125mg

benserazide + levodopa

Co-careldopa (Sinemet)
BNF | BNFC | SPC

Tablets - 62.5mg, 110mg, 125mg, 275mg

MR Tablets - 125mg, 250mg

carbidopa + levodopa

Stalevo
BNF | BNFC | SPC

Tablets containing:
50mg levodopa/12.5mg carbidopa/200mg entacapone
75mg levodopa/18.75mg carbidopa/200mg entacapone
100mg levodopa/25mg carbidopa/200mg entacapone
125mg levodopa/31.25mg carbidopa/200mg entacapone
150mg levodopa/37.5mg carbidopa/200mg entacapone
200mg levodopa/50mg carbidopa/200mg entacapone

Patients should be initiated on entacapone and co-careldopa separately and switched to Stavelo if necessary to aid compliance.

Pramipexole
BNF | BNFC | SPC

Tablets (as Base) - 88microgram, 180microgram, 350microgram, 700microgram

Care should be taken when prescribing as confusion can occur beween strength of salt and drug

Ropinirole
BNF | BNFC | SPC

Tablets - 250microgram, 500microgram, 1mg, 2mg, 5mg

Tablets MR - 2mg, 4mg, 8mg

Rotigotine
BNF | BNFC | SPC

Patches - 1mg/24hours, 2mg/24hours, 3mg/24hours, 4mg/24hours6mg/24hours, 8mg/24hours

Selegiline Hydrochloride
BNF | BNFC | SPC

Tablets - 5mg, 10mg

Oral Liquid - 10mg/5ml

Rasagiline
BNF | BNFC | SPC

1mg tablets

Entacapone
BNF | BNFC | SPC

Tablets - 200mg

Opicapone
BNF | BNFC | SPC

500mg capsules

For the treatment of Parkinson’s disease – second or third line - used in patients who have tried and failed on entacapone.

Tolcapone
BNF | BNFC | SPC

100mg tablets

Initiated by specialist only
Only in patients who have failed on entacapone

Tolcapone (Neurology) Shared Care Guideline

Apomorphine Injection
BNF | BNFC | SPC

20mg in 2ml & 50mg in 5ml injections & 30mg in 3ml
pre-filled multiple dose pen injection device
5mg in 1ml pre-filled syringe

Apomorphine shared care: Apomorphine Shared Care Guidelines

MHRA Drug Safety Update (April 2016): Apomorphine with domperidone: minimising risk of cardiac side effects

Co-careldopa intestinal gel
BNF | BNFC | SPC

The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or 
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

Amantadine
BNF | BNFC | SPC

100mg capsules; 50mg in 5ml syrup-
For use on the advice of neurologists

Safinamide
BNF | BNFC | SPC

50mg and 100mg tablets

For treatment of Parkinson’s disease as an adjunct to levodopa alone or in combination with other antiparkinsonian drugs.

Pramipexole (restless legs)
BNF | BNFC | SPC

Tablets (as Base) - 88microgram, 180microgram, 350microgram

For treatment of restless legs.

Ropinirole (restless legs)
BNF | BNFC | SPC

Tablets - 250microgram, 500microgram, 2mg

For the treatment of restless legs.

Orphenadrine
BNF | BNFC | SPC

Tablets - 50mg

Oral Solution - 50mg/5ml

Procyclidine
BNF | BNFC | SPC

Tablets - 5mg

Syrup - 2.5mg/5ml

Trihexyphenidyl hydrochloride
BNF | BNFC | SPC

2mg & 5mg tablets
5mg in 5ml syrup

Tetrabenazine
BNF | BNFC | SPC

Tablets - 25mg

Haloperidol
BNF | BNFC | SPC

See section 4.2.1

Unlicensed indication

Riluzole
BNF | BNFC | SPC

50mg tablets and 5mg/1ml oral suspension

Shared care: Riluzole for MND (ALS presentation)Riluzole shared care agreement & guidelines

NICE TA20

Botulinum toxin type A
BNF | BNFC | SPC

Botulinum Toxin Type A products should normally be prescribed by brand name.

NICE Guidance: NICE TA260

Botulinum toxin type B
BNF | BNFC | SPC

Unless used in accordance with Local Protocol – naltrexone, acamprosate & disulfiram prescribing should be retained within the commissioned service within County Durham

 

Acamprosate
BNF | BNFC | SPC

Tablets - 333mg

Disulfiram
BNF | BNFC | SPC

Tablets - 200mg

Nalmefene
BNF | BNFC | SPC

Tablets - 18mg

Requires prescribing in accordance with NICE guidance: http://www.nice.org.uk/guidance/ta325. For patients who:

  • Who have a high drinking risk level (defined as alcohol consumption of more than 60 g per day for men and more than 40 g per day for women, according to the World Health Organization's drinking risk levels) without physical withdrawal symptoms and
  • Who do not require immediate detoxification.

The marketing authorisation states that nalmefene should:

  • Only be prescribed in conjunction with continuous psychosocial support focused on treatment adherence and reducing alcohol consumption and
  • Be initiated only in patients who continue to have a high drinking risk level 2 weeks after initial assessment

Link to Nalmefene primary care bulletin

Chlordiazepoxide
BNF | BNFC | SPC

5mg & 10mg capsules

When used for alcohol dependence.

Naltrexone
BNF | BNFC | SPC
Bupropion
BNF | BNFC | SPC

Tablets - 150mg

Prescribe according to Smoking Cessation policy

Nicotine Replacement Therapy
BNF | BNFC | SPC

From 1st April 2017, a revised NRT formulary will only allow the County Durham Stop Smoking Service to issue a single NRT product to each client rather than combination therapy.

However even providing one NRT product plus ongoing support from the Service will still double clients chances of quitting compared to no support.

Evidence shows that adding in a second NRT product can further increase the chances of quitting. Therefore the Service will advise that clients can purchase small packs of a second NRT product (such as chewing gum, lozenges which typically cost £5-£6 for a pack of 20) or choose to purchase an unlicensed nicotine containing product such as an e-cigarette.

GP practices should continue NOT to prescribe NRT or licensed e-cigarettes.

 

NRT Formulary Choices of the County Durham Stop Smoking Service from 1st April 2017

16 Hour Patch 

Nicorette 25mg Invisi patch (x7)

Nicorette 15mg Invisi patch (x7)

Nicorette 10mg Invisi patch (x7)

24 Hour Patch

NiQuitin CQ 21mg Patch (x7)

NiQuitin CQ 14mg Patch (x7)

NiQuitin CQ 7mg Patch (x7)

Nicotinell TTS 30 (21mg) Patch (x7)

Nicotinell TTS 20 (14mg) Patch (x7)

Nicotinell TTS 10 (7mg) Patch (x7)

Nasal Spray

Nicorette 500microgram Nasal Spray (10ml - 1 bottle)

Mouth Spray

Nicorette QuickMist 1mg/spray (13.2ml - 1 bottle)

Nicorette QuickMist 1mg/spray (26.4ml - 1 bottle)

Inhalator

Nicorette 15mg Inhalator (x20)

Nicorette 15mg Inhalator (x36)

Varenicline
BNF | BNFC | SPC

Tablets - 500micrograms, 1mg

Prescribe according to Smoking Cessation policy

NICE TA123

e-Voke electronic inhaler▼
BNF | BNFC | SPC

NTAG April 2016: The Northern (NHS) Treatment Advisory Group does not recommend the use of e-Voke® as a stop smoking aid on the NHS.

The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or 
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

Buprenorphine
BNF | BNFC | SPC

Sublingual tablets - 400micrograms, 2mg, 8mg

NICE TA114

TEWV Methadone Buprenorphine In-Patient Prescribing Guideline

Methadone Hydrochloride
BNF | BNFC | SPC

Oral Solution - 1mg/ml

Sugar Free Oral Solution - 1mg/ml

NICE TA114

TEWV Methadone Buprenorphine In-Patient Prescribing Guideline

Suboxone
BNF | BNFC | SPC

2mg/500microgram sublingual tablets containing, buprenorphine 2 mg, & naloxone 500 micrograms
8mg/2mg tablets sublingual tablets containing buprenorphine 8 mg & naloxone 2 mg

Naltrexone
BNF | BNFC | SPC

50mg tablets

NICE TA115

Lofexidine
BNF | BNFC | SPC

0.2mg film coated tablets

See NICE guidance Dementia: Supporting people with dementia and their carers in health and social care NICE NG 97

Only specialists in the care of patients with dementia should initiate treatment.

Treatment should be reviewed regularly and only be continued when it is considered to be having a worthwhile effect.

Carers views on the patient’s condition should be sought.

Each product has been classified as Green + which in this case means:

  • Initiation by a specialist
  • Prescribing follows Dementia Care Pathway AChEI Decision Aid
  • Stabilised on treatment
  • Indications within NICE guidance for cognitive and non-cognitive symptoms of Alzheimer’s disease
  • A minimum of one month’s supply provided on transfer
  • Six monthly review of cognitive symptoms, global, functional and behavioural assessment by specialist services according to local Protocol

First line

Donepezil

Donepezil
BNF | BNFC | SPC

NICE TA217

Tablets - 5mg, 10mg

Orodispersible Tablets - 5mg, 10mg

Orodispersible tablets - should only be used in situations where the plain tablets are unsuitable

Galantamine
BNF | BNFC | SPC

NICE TA217

Tablets - 8mg, 12mg

Oral solution - 4mg/ml

MR Capsules - 8mg, 16mg, 24mg

MR capsules only to be used when a once a day dose is essential or patient has tried standard release galantamine and is intolerant.

Letter was sent to healthcare professionals for:

Galantamine hydrobromide (Reminyl): risk of serious skin reactions (Dec 2015)

 

Rivastigmine
BNF | BNFC | SPC

NICE TA217

Capsules - 1.5mg, 3mg, 4.5mg, 6mg

Oral solution - 2mg/ml

Patches - 4.6mg / 24hours; 9.5mg/24hours

Patches should only be used when other formulations inappropriate

Memantine
BNF | BNFC | SPC

NICE TA217

Tablets - 10mg 20mg

Oral Solution - 5mg / actuation (10mg/ml)

Option for managing moderate Alzheimer’s Disease in people who cannot take AChE inhibitors