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 Formulary Chapter 4: Central nervous system - Full Chapter
Notes:

Review date: June 2020

Non-formulary drugs: Any drug or formulation not listed in the formulary is deemed to be non-formulary.

Off-label use: Drugs are included in the formulary for their licensed indications – where inclusion of off-label use is considered to be included in the formulary this is specifically stated in the formulary entry for the drug N.B. also see Paediatrics note below.

Paediatrics: Drugs are included in the formulary for paediatric use for their BNF for Children recommended indications (indicated by symbol View childrens BNF) which may be off-label, unless otherwise stated. All drugs are deemed to have the same RAG status as they have for adults unless stated otherwise.

NHS England Specialised Commissioning
Drugs carrying the NHS England logo are commissioned by them. Links to key documents, national programmes of care, and clinical reference groups are found below.

NHSE NHS England Specialised Commissioning: Key documents

NHSE NHS England Specialised Commissioning: National programmes of care and clinical reference groups

Chapter Links...
 Details...
04.01  Hypnotics and anxiolytics
04.01.01  Hypnotics
 note 

Non-pharmacological measures should be considered before drug therapy for insomnia.

When a hypnotic is used it should be for a short period of time only, ideally for 2 weeks only, in strict accordance with the licensed indications.

NICE recommends zaleplon, zolpidem, zopiclone or the shorter-acting benzodiazepine hypnotics (loprazolam, lormetazepam and temazepam) as options.

Patients who have not responded to one of these hypnotic drugs should not be prescribed any of the others. The only acceptable reason to change hypnotics should be intolerance to the current drug.

Drug driving

Guidance for healthcare professionals on drug driving

Information for patients: new law on drug driving

Drugs and driving: blood concentration limits set for certain drugs

Melatonin  (Circadin®)
View adult BNF View SPC online View childrens BNF
Formulary
Amber Retained

Tablets M/R 2 mg; ‘off-label’ use in adults, children and young people

N.B. AMBER RETAINED designation in children and young people is pending Pan Mersey CCGs approval

Amber Initiated Chronic sleep disorders in adults in Halton CCG

BLACK for primary insomnia in adults

 
Link  MELATONIN modified release tablets 2mg (Circadin®) ‘off – label’ use in adults. Pan Mersey Area Prescribing Committee Policy Statement
   
Melatonin (Slenyto®)
View adult BNF View SPC online View childrens BNF
Formulary
Grey

prolonged-release tablets 1mg, 5mg

Licensed for the treatment of insomnia in children and adolescents aged 2-18 with Autism Spectrum Disorder (ASD) and / or Smith-Magenis syndrome, where sleep hygiene measures have been insufficient.

 
Link  Pan Mersey APC (2019): Melatonin prolonged-release tablets (Slenyto®) for the treatment of insomnia in children
   
Melatonin
(Unlicensed specials)
View adult BNF View childrens BNF
Formulary
Red

Alder Hey uses 2mg capsules

Amber Retained Wirral CCG - use in children who have a feeding tube that has previously been blocked by Circadin

 
   
04.01.01  Benzodiazepines
Temazepam
View adult BNF View SPC online View childrens BNF
Second Choice
Green
Tablets 10 mg, 20 mg
Oral solution 10 mg/5 mL
 
Controlled Drug Schedule 3
   
Loprazolam
View adult BNF View SPC online
Third Choice
Green

Tablets 1 mg

No BNFc entry – seek specialist advice

 
Controlled Drug Schedule 4 Part 1
   
Lormetazepam
View adult BNF View SPC online
Third Choice
Green

Tablets 500 microgram, 1 mg

No BNFc entry – seek specialist advice

 
Controlled Drug Schedule 4 Part 1
   
04.01.01  Zaleplon, Zolpidem and Zopiclone
Zolpidem
View adult BNF View SPC online
First Choice
Green

Tablets 5 mg, 10 mg

No BNFc entry – seek specialist advice

 
Controlled Drug Schedule 4 Part 1
Zopiclone
View adult BNF View SPC online
First Choice
Green

Tablets 3.75 mg, 7.5 mg

No BNFc entry – seek specialist advice

 
Controlled Drug  Schedule 4 Part 1
04.01.01  Chloral and derivatives to top
Chloral Hydrate
View adult BNF View SPC online View childrens BNF
Formulary
Amber Initiated

Oral solution 143.3mg /5mL

Oral mixture 500mg /5mL (Specials)

 
   
04.01.01  Antihistamines
Promethazine Hydrochloride
View adult BNF View SPC online View childrens BNF
Formulary
Green

Tablets 10 mg, 25 mg
Elixir 5 mg/5 mL
Specific ‘off-label’ use in pregnant women with a severe or chronic sleep problem

Paediatrics: short-term use only

Injection 25 mg/mL
Red in combination with i.m. haloperidol for rapid tranquilisation.

 
Link  NICE NG10; Violence and aggression: short-term management
   
04.01.01  Sodium oxybate
Sodium Oxybate
View adult BNF View SPC online
Formulary
Red

Oral Solution 500 mg/mL For narcolepsy with cataplexy only when recommended by a consultant in a specialist commissioned sleep service.

PLEASE NOTE: new patients are by prior approval only for South Sefton, and Southport and Formby CCGs.

Black Traffic Light in West Lancashire CCG

NHS Paediatric use (<19 years): NHSE commissioned drug - see NHS England Clinical Commissioning Policy 16065/P and Specialised Commissioning: Key documents.  No BNFc entry – seek specialist advice

 
Controlled Drug Schedule 2
Link  Pan Mersey APC (2019): SODIUM OXYBATE oral solution (Xyrem®) for Narcolepsy with cataplexy
Link  Pan Mersey APC(2019): NARCOLEPSY, University Hospital Aintree Sleep Service Pathway
   
04.01.01  Pitolisant
PitolisantBlack Triangle (Wakix®)
View adult BNF View SPC online View childrens BNF
Formulary
Red

4.5mg, 18mg tablets

For use by specialists working within a regional or national tertiary commissioned sleep service only

 
Link  Pan Mersey APC (2019): NARCOLEPSY, University Hospital Aintree Sleep Service Pathway
Link  Pan Mersey APC (2019): PITOLISANT tablets (Wakix®▼) for the treatment of narcolepsy with or without cataplexy
   
04.01.02  Anxiolytics
 note 

Complex cases should be referred to specialist mental health services.

Drug driving

Guidance for healthcare professionals on drug driving

Information for patients: new law on drug driving

Drugs and driving: blood concentration limits set for certain drugs

04.01.02  Benzodiazepines to top
Diazepam
View adult BNF View SPC online
First Choice
Green

Tablets 2 mg, 5 mg, 10 mg
Oral solution 2 mg/5 mL

Amber InitiatedPaediatrics

 
Controlled Drug Schedule 4 Part 1
Lorazepam
View adult BNF View SPC online
First Choice
Green

Tablets 1 mg, 2.5 mg (can be used sublingually)
Injection 4 mg/1 mL

Red injection for rapid tranquilisation

No BNFc entry – seek specialist advice

 
Controlled Drug Schedule 4 Part 1
04.01.02  Buspirone
Buspirone Hydrochloride
View adult BNF View SPC online
Second Choice
Green

Tablets 5 mg, 10 mg

Amber Initiated Paediatrics

 

 
   
04.01.03  Barbiturates
04.02  Drugs used in psychoses and related disorders
 note 

All persons with a recent-onset suspected psychosis should be seen urgently (within 2 weeks) by a specialist in mental health. This is to ensure precise and early diagnosis and initiation of therapy as appropriate to their needs.

Always consider non-adherence when treatment is ineffective.

Patients who have not responded adequately to treatment despite the sequential use of adequate dose and duration of at least two different antipsychotic drugs, one of which must have been an atypical, should be offered clozapine.

All children/young people with a first presentation of sustained psychotic symptoms should be referred to a specialist mental health service, either a child and adolescent mental health service or an early intervention in psychosis service if ≥14 years.  Oral antipsychotic medication in conjunction with psychological interventions may be prescribed for acute psychosis or schizophrenia in children/young people by or under the guidance of a specialist.  NB: Most antipsychotic medicines are unlicensed for use in children/young people and informed consent must be obtained and documented.

04.02.01  Antipsychotic Drugs
 note 

Oral Antipsychotics (except clozapine)
The RAG status of oral antipsychotics is supported in principle as Amber Initiated. However this recommendation is subject to assurance from the respective Mental Health Trusts that robust systems are in place to support patients and GPs, and that patients can be discussed and/or seen in a timely manner if the GP considers it to be necessary.
See Mersey Care and North West Boroughs Healthcare referral information at links below.

Benperidol
View adult BNF View SPC online
Formulary
Amber Initiated

Tablets 250 micrograms
(only licensed for control of deviant antisocial sexual behaviour)

No BNFc entry – seek specialist advice

 
   
Chlorpromazine
View adult BNF View SPC online View childrens BNF
Formulary
Amber Initiated

Tablets 25 mg, 50 mg, 100 mg
Oral solution 25 mg/5 mL, 100 mg/5 mL

Amber Patient Retained Paediatrics

 
   
Flupentixol
View adult BNF View SPC online
Formulary
Amber Initiated

Tablets 500micrograms, 1mg, 3mg

No BNFc entry – seek specialist advice

 
   
Haloperidol
View adult BNF View SPC online View childrens BNF
Formulary
Amber Initiated

Capsules 500 micrograms
Tablets 500 micrograms, 1.5 mg, 5 mg, 10 mg, 20 mg
Liquid SF 1 mg/mL, 2 mg/mL
Injection 5 mg/mL (in primary care syringe driver)

Amber Patient Retained Paediatrics


 Red Injection 5 mg/mL in combination with i.m. promethazine for rapid tranquilisation

 

 
Link  NICE NG10; Violence and aggression: short-term management
   
Levomepromazine
View adult BNF View SPC online View childrens BNF
Formulary
Amber Initiated

Tablets 25 mg
Injection 25 mg/mL (in primary care syringe driver)

Amber Patient Retained Paediatrics

 
   
Loxapine
View adult BNF View SPC online
Formulary
Grey

inhalation powder, 9.1mg

 
Link  LOXAPINE inhalation powder (Adasuve®▼), Pan Mersey Area Prescribing Committee policy statement
   
Pericyazine
View adult BNF View SPC online View childrens BNF
Formulary
Amber Initiated

Tablets 2.5 mg, 10 mg
Syrup 10 mg/5 mL

Amber Patient Retained Paediatrics

 
   
Perphenazine
View adult BNF View SPC online View childrens BNF
Formulary
Amber Initiated

Tablets 2 mg, 4 mg

 

Amber Patient Retained Paediatrics (in children aged 14 years and above)

 
   
Pimozide
View adult BNF View SPC online View childrens BNF
Formulary
Amber Initiated

Tablets 4 mg

Amber Patient Retained Paediatrics

 
   
Promazine Hydrochloride
View adult BNF View SPC online
Formulary
Amber Initiated

Tablets 25 mg, 50 mg
Oral solution 25 mg/5 mL, 50 mg/5 mL

No BNFc entry – seek specialist advice

 
   
Sulpiride
View adult BNF View SPC online View childrens BNF
Formulary
Amber Initiated

Tablets 200 mg, 400mg
Oral solution SF 200 mg/5 mL

Amber Patient Retained Paediatrics

 
   
Trifluoperazine
View adult BNF View SPC online View childrens BNF
Formulary
Amber Initiated

Tablets 1 mg, 5 mg
Syrup SF 1 mg/5 mL
Oral solution 5 mg/5 mL

Amber Patient Retained Paediatrics

 
   
Zuclopenthixol
View adult BNF View SPC online
Formulary
Amber Initiated

Tablets 2 mg, 10 mg, 25 mg

No BNFc entry – seek specialist advice

 
   
Zuclopenthixol Acetate
(must state )
View adult BNF View SPC online
Formulary
Red

Injection 50mg in 1mL

No BNFc entry – seek specialist advice

 
   
04.02.01  First-Generation Antipsychotic Drugs to top
04.02.01  Second-Generation Antipsychotic Drugs
 note 

Pan Mersey APC (2018). ATYPICAL ANTIPSYCHOTICS, prescribing support information

Amisulpride
View adult BNF View SPC online View childrens BNF
Formulary
Amber Initiated

Tablets 50 mg, 100 mg, 200 mg, 400 mg
Solution 100 mg/mL

Amber Patient Retained Paediatrics (in children aged 15 years and above)

 

 
   
Aripiprazole
View adult BNF View SPC online View childrens BNF
Formulary
Amber Initiated

Tablets 5 mg, 10 mg, 15 mg, 30 mg
Orodispersible tablets10 mg, 15 mg
Oral solution 1 mg/1 mL (very expensive - use orodispersible tablets where possible)

Amber Patient Retained Paediatrics

 
Link  NICE TA213: Aripiprazole for the treatment of schizophrenia in people aged 15 -17 years
Link  NICE TA292: Bipolar disorder (adolescents) - aripiprazole
   
Lurasidone
View adult BNF View SPC online
Formulary
Amber Initiated

Tablets 18.5mg, 37mg, 74mg

Lurasidone should only be prescribed as an alternative treatment option when existing antipsychotic treatments are unsuitable for adult patients with schizophrenia who have experienced or are at risk of excessive weight gain and metabolic adverse events.

No BNFc entry – seek specialist advice

 

 
   
Olanzapine
View adult BNF View SPC online View childrens BNF
Formulary
Amber Initiated

Tablets 2.5 mg, 5 mg, 7.5 mg, 10 mg, 15 mg, 20 mg
Orodispersible tablets 5 mg, 10 mg, 15 mg, 20 mg
NB oral lyophylisate form is not cost effective.

Amber Patient Retained Paediatrics (in children aged 12 years and above)

 
   
Quetiapine
View adult BNF View SPC online View childrens BNF
Formulary
Amber Initiated

Immediate release formulations
Tablets 25 mg, 100 mg, 150 mg, 200 mg, 300 mg

Modified release formulations <!> Expensive
M/R Tablets 50 mg, 150 mg 200 mg, 300 mg, 400 mg
Use of QUETIAPINE M/R tablets should be reserved for individual patients identified as having a defined clinical need for the modified release formulation. Justification of the decision to continue prescribing the QUETIAPINE M/R formulation should be documented in the clinical notes and made clear in any discharge/appointment letters to the GP e.g. compliance, over-sedation or other adverse effect issues

Oral liquid 20mg/mL Amber Patient Retained Paediatrics (in children aged 12 years and above)

 

 
Link  QUETIAPINE Immediate Release I/R Tablets (All Brands), Pan Mersey Area Prescribing Committee Policy Statement
   
Risperidone
View adult BNF View SPC online View childrens BNF
Formulary
Amber Initiated

Tablets 500 micrograms, 1 mg, 2 mg, 3 mg, 4 mg, 6 mg
Liquid 1 mg/mL
Orodispersible tablets 500 micrograms, 1 mg, 2 mg, 3 mg, 4mg

 

Amber Patient Retained Paediatrics

 
   
Cariprazine
View adult BNF View SPC online
Formulary
Grey

Capsules 1.5mg, 3mg, 4.5mg and 6mg

 
Link  Pan Mersey Area Prescribing Committee Prescribing Policy Statement: CARIPRAZINE capsules (Reagila®▼) for Schizophrenia in Adults
   
Clozapine (Denzapine®)
View adult BNF View SPC online View childrens BNF
Formulary
Red
Tablets 25 mg, 100 mg
Suspension 50 mg/mL
 
   
04.02.02  Antipsychotic depot injections
 note  Antipsychotic depot injections (except olanzapine)
Whilst the RAG status of Antipsychotic depot injections is supported as Amber Initiated, current practice is that patients remain under Mental Health services and are prescribed and administered their antipsychotic depot injection by these specialist services, therefore they are designated as Red below. However where historically a patient has had their depot antipsychotic prescribed by their GP and administered by mental health nurse, this arrangement may continue.
Aripiprazole
View adult BNF View SPC online
Formulary
Red

Prolonged-release for injection 300mg & 400mg

No BNFc entry – seek specialist advice

 
   
Flupentixol Decanoate
View adult BNF View SPC online
Formulary
Red

Injection 20 mg/mL, 40 mg/2 mL
Concentrated injection 50 mg/0.5 mL, 100 mg/mL
Low volume injection 200 mg/mL

No BNFc entry – seek specialist advice

 
   
Fluphenazine Decanoate
View adult BNF View SPC online
Formulary
Red

Injection 12.5 mg/0.5 mL, 25 mg/mL, 50 mg/2 mL
Concentrated injection 50 mg/0.5 mL, 100 mg/mL

No BNFc entry – seek specialist advice

 
   
Haloperidol decanoate
View adult BNF View SPC online
Formulary
Red

Injection 50 mg/mL, 100 mg/mL

Red Paediatrics

No BNFc entry – seek specialist advice

 
   
Olanzapine Embonate
View adult BNF View SPC online
Formulary
Red

Injection 210mg, 300mg, 405mg.

Post-injection reactions have been reported leading to signs and symptoms of overdose. After each injection, patients should be observed in a healthcare facility by appropriately qualified personnel for at least 3 hours for signs and symptoms consistent with olanzapine overdose.

No BNFc entry – seek specialist advice

 
   
Paliperidone palmitate
View adult BNF View SPC online
Formulary
Red

Prolonged-release suspension for injection 50mg, 100mg, 150mg (1 month depot)Prolonged-release suspension for injection 175mg, 263mg, 350mg, 525mg (3 month depot)

No BNFc entry – seek specialist advice

 
   
Risperidone
View adult BNF View SPC online
Formulary
Red

Injection 25 mg (powder), Injection 37.5 mg (powder), Injection 50 mg (powder)

No BNFc entry – seek specialist advice

 
   
Zuclopenthixol Decanoate
(must state “decanoate” to distinguish from other products)
View adult BNF View SPC online
Formulary
Red

Injection 200 mg/mL
Concentrated injection 500 mg/mL

No BNFc entry – seek specialist advice

 
   
04.02.03  Drugs used for mania and hypomania
 note 

All persons with a recent-onset suspected mania / hypomania or severe depression should be seen urgently by a specialist in mental health. This is to ensure precise and early diagnosis and initiation of therapy as appropriate to their needs.

Acute episodes of rapid-cycling bipolar disorder and treatment refractory bipolar depression should normally be managed in specialist mental health services.

When managing depressive symptoms of bipolar disorder those prescribed an antidepressant should also be prescribed an antimanic drug under the guidance of a specialist in mental health.

Women of child-bearing age must be given accurate information and counselling about contraception, conception, pregnancy and breastfeeding.

Pan Mersey APC (2019). Valproate, safe prescribing and dispensing to women and girls of child bearing potential

Always consider non-adherence when treatment is ineffective.

Treatment should continue for at least 2 years from the last manic episode and up to 5 years if there are risk factors for relapse.

Asenapine
View adult BNF View SPC online
Formulary
Amber Initiated

Sublingual tablets 5mg, 10mg

No BNFc entry – seek specialist advice

 
   
Lamotrigine
View adult BNF View SPC online
Formulary
Amber Initiated

Tablets, 25 mg; 50 mg; 100 mg; 200 mg
Dispersible tablets, 2 mg; 5 mg; 25 mg; 100 mg

No BNFc entry – seek specialist advice

 
   
04.02.03  Benzodiazepines
04.02.03  Antipsychotic drugs to top
04.02.03  Carbamazepine
 note 

Teratogenic risk

Anticonvulsants are potentially teratogenic and so all women of childbearing age need to be counselled of the risks. In general the risk of major congenital malformations related to anticonvulsant monotherapy is around 4%.

Carbamazepine
View adult BNF View SPC online View childrens BNF
Formulary
Amber Initiated
Red Triangle Take care when prescribing and dispensing
A given dose of carbamazepine oral suspension will produce higher peak levels than the same dose in tablet form. When switching a patient from tablets to liquid the same overall dose may be used but in smaller, more frequent, doses.[SPS (2018)]
Standard release tablets 100 mg, 200 mg, 400 mg
Modified release tablets 200 mg, 400 mg
Oral suspension 100 mg/5 ml

 

 
   
04.02.03  Valproic acid
Valproic Acid Semisodium (Depakote®)
View adult BNF View SPC online
Formulary
Amber Initiated

Tablets 250 mg, 500 mg

Amber Retained Paediatrics

Amber Retained Women of childbearing potential

 
Link  Pan Mersey APC (2019). VALPROATE: safe prescribing and dispensing to girls of any age and women of child bearing potential
   
04.02.03  Lithium
 note 

Lithium has been the subject of a National Patient Safety Agency Patient Safety Alert: ARCHIVED NPSA Alert – Safer lithium therapy 2009

Lithium Carbonate
(Prescribe by brand)
View adult BNF View childrens BNF
Formulary
Purple
Red Triangle Take care when prescribing and dispensing
All lithium preparations vary widely in bioavailability. Prescriptions should specify brand and formulation; changing the preparation requires the same precautions as initiation of treatment. [SPS (2018)]
Camcolit 400 mg modified release tablets
Liskonium 450 mg modified release tablets
Priadel 200 mg modified release tablets
400 mg modified release tablets

Purple Paediatrics (in children above 12 years)

 
   
Lithium Citrate
(Prescribe by brand)
View adult BNF View childrens BNF
Formulary
Purple
Red Triangle Take care when prescribing and dispensing
All lithium preparations vary widely in bioavailability. Prescriptions should specify brand and formulation; changing the preparation requires the same precautions as initiation of treatment. As most lithium tablets are modified-release, when lithium is given as a liquid the total daily dose of lithium will need to be given in divided doses.

Lithium citrate tetrahydrate 520 mg is equivalent to lithium carbonate 204 mg. This means that:
  • 5mL Li-Liquid 509mg/5mL oral syrup (509mg) is approximately equivalent to 200mg lithium carbonate.
  • 5mL Li-Liquid 1018mg/5mL oral syrup (1018mg) is approximately equivalent to 400mg lithium carbonate.
  • 5mL Priadel 520mg/5mL liquid (520mg) is approximately equivalent to 204mg lithium carbonate.

[SPS (2018)]

Li-Liquid 509 mg per 5 ml oral solution (101.8 mg per 1 ml)
Li-Liquid 1.018 g per 5 ml oral solution (203.6 mg per 1 ml)
Priadel 520 mg per 5 ml (104 mg per 1 ml)

Purple Paediatrics (in children above 12 years)

 
   
04.03  Antidepressant drugs
 note 

Depression that is severe, complex, psychotic or treatment refractory; refer to specialist mental health services.

04.03.01  Tricyclic and related antidepressant drugs to top
04.03.01  Tricyclic antidepressants
 note 

Tricyclic antidepressants (TCAs) are not usually recommended as a first-line treatment for depression because they are associated with a greater risk of side effects than SSRIs or SNRIs and are generally more toxic in overdose.


NICE CG28 does not recommend tricyclic antidepressants for the treatment of depression in children and young people.

Take into account toxicity in overdose for people at significant risk of suicide.

Lofepramine has the lowest risk of cardiac toxicity in overdose of the tricyclic antidepressants.

Trazodone is a tricyclic related antidepressant generally believed to have low cardiotoxicity, although there have been some reports of postural hypotension and, rarely, arrhythmias. It may be particularly useful where sedation is required or anxiety is prominent.

Amitriptyline
View adult BNF View SPC online View childrens BNF
Second Choice
Green

Tablets 10 mg, 25 mg, 50 mg
Oral solution 10mg/5mL, 25 mg/5 mL, 50 mg/5 mL

Amber Initiated  Paediatrics

 
   
Clomipramine
View adult BNF View SPC online
Second Choice
Green

Capsules 10 mg, 25 mg, 50 mg

No BNFc entry – seek specialist advice

 
   
Imipramine
View adult BNF View SPC online View childrens BNF
Second Choice
Green

Tablets 10 mg, 25 mg
Oral solution 25 mg/5 mL

Amber Initiated  Paediatrics

 
   
Lofepramine
View adult BNF View SPC online
Second Choice
Green

Tablets 70 mg
Oral suspension 70 mg/5 mL

No BNFc entry – seek specialist advice

 
   
Nortriptyline
View adult BNF View SPC online View childrens BNF
Second Choice
Green

Tablets 10 mg, 25 mg

Nortriptyline is significantly more expensive then amitriptyline. Use only as an option where amitriptyline has not been tolerated.

Amber Initiated  Paediatrics

 
   
Dosulepin
View adult BNF View SPC online
Formulary
Black
 
Link  Pan Mersey Area Prescribing Committee (April 2019): DOSULEPIN capsules and tablets
   
Trimipramine
View adult BNF View SPC online
Formulary
Black
 
Link  Pan Mersey Area Prescribing Committee (April 2019): TRIMIPRAMINE capsules and tablets (Surmontil®)
   
04.03.01  Related antidepressants
Trazodone
View adult BNF View SPC online View childrens BNF
Second Choice
Green

Capsules 50 mg, 100 mg
Tablets 150 mg
Oral solution SF 50 mg/5 mL

 
   
04.03.02  Monoamine-oxidase inhibitors
 note 

Caution: dietary and drug interactions

Link UKMi: What is the risk of interaction between opioids and monoamine oxidase inhibitors (MAOIs)? 27 Sep 2017

Phenelzine
View adult BNF View SPC online
Formulary
Amber Initiated

Tablets 15 mg

No BNFc entry – seek specialist advice

 
   
04.03.02  Reverible MAOIs
Moclobemide
View adult BNF View SPC online
Formulary
Amber Recommended

Tablets 150 mg, 300 mg

No BNFc entry – seek specialist advice

 
   
04.03.03  Selective serotonin re-uptake inhibitors to top
Citalopram
View adult BNF View SPC online View childrens BNF
First Choice
Green
Red Triangle Take care when prescribing and dispensing
Citalopram oral drop solution has an approximately 25% higher bioavailability compared to tablets. FOUR oral drops (8 mg) is equivalent to ONE 10mg tablet.[SPS (2018)]
Tablets 10 mg, 20 mg, 40 mg
Oral drops sugar free 40 mg/ml

Amber Initiated Paediatrics

 
Sertraline
View adult BNF View SPC online View childrens BNF
First Choice
Green

Tablets 50 mg, 100 mg

Oral suspension 50mg in 5mL (Special)

Amber Initiated  Paediatrics

 
Fluoxetine
View adult BNF View SPC online View childrens BNF
First Choice
Green

Capsules 10mg, 20 mg

10mg capsules are significantly more expensive than 20mg capsules or liquid. Use only as an option where difficulty accurately administering the liquid.

Oral solution 20 mg/5 mL

Dispersible SF tablets 20mg

Amber Initiated  Paediatrics

 
Escitalopram
View adult BNF View SPC online
First Choice
Green

Tablets 5 mg, 10 mg, 20 mg
Oral drops SF 20 mg/mL

No BNFc entry – seek specialist advice

 
Paroxetine
View adult BNF View SPC online
Second Choice
Green

Tablets 10 mg, 20 mg, 30 mg
Oral suspension SF10 mg/5 mL

No BNFc entry - Not recommended by NICE (CG28) for use in children.

 
   
04.03.04  Other antidepressant drugs
Duloxetine
View adult BNF View SPC online
Formulary
Green

Capsules 30 mg, 60 mg

NB - Other strengths available for a different 'non chapter 4' indication - urinary incontinence.

No BNFc entry - seek specialist advice.

 
   
Flupentixol
View adult BNF View SPC online
Formulary
Green

Tablets 500 micrograms, 1 mg, 3mg

No BNFc entry – seek specialist advice

 
   
Mirtazapine
View adult BNF View SPC online
Formulary
Green

Tablets 15 mg, 30 mg, 45 mg
Orodispersible tablets 15 mg, 30 mg, 45 mg
Oral solution 15 mg/mL

No BNFc entry – seek specialist advice

 
   
Venlafaxine
View adult BNF View SPC online
Formulary
Green

Tablets 37.5 mg, 75 mg
MR capsules 37.5mg, 75 mg, 150 mg
MR tablets 37.5 mg, 75 mg, 150 mg, 225 mg

No BNFc entry – seek specialist advice

 
   
Vortioxetine
View SPC online View childrens BNF
Formulary
Green

Tablets 5mg, 10mg, 20mg

No BNFc entry – seek specialist advice

 
Link  VORTIOXETINE tablets (Brintellix®▼) Pan Mersey Area Prescribing Committee policy statement
Link  NICE TA367: Vortioxetine for treating major depressive episodes
   
Agomelatine
View adult BNF View SPC online
Formulary
Black

Tablets 25mg

No BNFc entry – seek specialist advice

 
Link  NICE TA231, Agomelatine for the treatment of major depressive episodes (terminated appraisal)
   
04.04  CNS stimulants and other drugs used for attention deficit hyperactivity disorder
 note 

Attention Deficit Hyperactivity Disorder (ADHD)

A diagnosis should only be made by, and treatment started only under the guidance of,  a specialist psychiatrist or other specialist with training and expertise in ADHD.

Methylphenidate and dexamfetamine do not have a UK product licence for use in adults with ADHD.

Atomoxetine is licensed for adults with ADHD when the drug has been started in childhood. Informed consent for off-label use should be obtained and documented.

Baseline physical health checks should be carried out including height (children and adolescents), weight, blood pressure, pulse, and where appropriate an ECG and blood tests.

The above checks should be repeated and the efficacy and tolerability of drug treatment reviewed as per BNF, SPC or Shared Care documents as appropriate. 

For people taking methylphenidate, dexamfetamine and lisdexamfetamine a risk assessment should be made for substance misuse and drug diversion.

Young people continuing treatment into adulthood should be reassessed to establish the need for continuing treatment.

Atomoxetine
(Children and adults diagnosed in childhood)
View adult BNF View SPC online View childrens BNF
Formulary
Red

Capsules 10 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80mg, 100mg
Oral liquid 4mg/mL
 
Purple Knowsley CCG, Liverpool CCG, Wirral CCG - Adults and Children
 
Purple  Halton CCG, South Sefton CCG and Southport & Formby CCG - for the treatment of ADHD in Adults only 

 
   
Dexamfetamine
View adult BNF View SPC online View childrens BNF
Formulary
Red

Tablets 5 mg, 10mg, 20mg

Oral solution 5mg/5mL
For the treatment of ADHD. In addition, for the treatment of narcolepsy in adults
 
Purple Knowsley CCG, Liverpool CCG, Wirral CCG - Adults and Children
 
Purple  Halton CCG, South Sefton CCG and Southport & Formby CCG - for the treatment of ADHD in Adults only 

 
Controlled Drug Schedule 2
   
Guanfacine
View adult BNF View SPC online View childrens BNF
Formulary
Red

Prolonged-release tablets; 1mg, 2mg, 3mg, 4mg
 
Purple Knowsley CCG, Liverpool CCG, Wirral CCG - Adults and Children
 
Purple  Halton CCG, South Sefton CCG and Southport & Formby CCG - for the treatment of ADHD in Adults only 

 
   
Lisdexamfetamine
View adult BNF View SPC online View childrens BNF
Formulary
Red

Capsule 20mg, 30 mg, 40mg, 50 mg, 60mg, 70 mg

There can be variation in the licensing of different medicines containing the same drug.
 
Elvanse Adult® to treat ADHD in adults - TEMPORARY RED POSITION WITH THE FOLLOWING EXCEPTIONS

Purple Knowsley CCG, Liverpool CCG, Wirral CCG (Adults and Children) and Halton CCG (Adults only).

 
Controlled Drug Schedule 2
   
Methylphenidate
View adult BNF View SPC online View childrens BNF
Formulary
Red

Tablets 5 mg, 10 mg, 20 mg
Modified-release tablets 18 mg, 27 mg, 36 mg, 54mg.

Modified-release capsules 5mg, 10mg, 20mg, 30mg, 40mg, 50mg, 60mg.

IMPORTANT: Different modified release preparations have different release profiles and different dosages. Therefore the brand of modified release methylphenidate should be maintained and stated on the prescription.


Purple Knowsley CCG, Liverpool CCG, Wirral CCG - Adults and Children
 
Purple  Halton CCG, South Sefton CCG and Southport & Formby CCG - for the treatment of ADHD in Adults only 

 
Controlled Drug Schedule 2
   
Modafinil
View adult BNF View SPC online
Formulary
Amber Retained

Tablets 100 mg, 200 mg

Modafinil is indicated for excessive sleepiness associated with narcolepsy with or without cataplexy only.

Red Paediatrics

 

 
   
04.04  Cocaine
04.05  Drugs used in the treatment of obesity
 note 

Obesity should be managed in an appropriate setting by staff who have been trained in the management of obesity; the individual should receive advice on diet and lifestyle modification and be monitored for change in weight as well as in blood pressure, blood lipids and other associated conditions.

An anti-obesity drug should be considered only for those with a body mass index (BMI) of 30kg/m2 or greater in whom at least 3 months of managed care involving supervised diet, exercise and behaviour management fails to achieve a realistic reduction in weight.  In the presence of risk factors (such as diabetes, coronary heart disease, hypertension and obstructive sleep apnoea), it may be appropriate to prescribe a drug to individuals with a BMI of 28kg/m2 or greater.  Drugs should never be used as the sole element of treatment.  The individual should be monitored on a regular basis; drug treatment should be discontinued if the individual regains weight at any time whilst receiving drug treatment.

Thyroid hormones have no place in the treatment of obesity except in biochemically proven hypothyroid patients.  The use of diuretics, chorionic gonadotrophin or amphetamines is not appropriate for weight reduction.
04.05.01  Anti-obesity drugs acting on the gastro-intestingal tract to top
Orlistat
View adult BNF View SPC online View childrens BNF
Formulary
Green

Capsules, 120mg

Amber Initiated Paediatrics

 
   
04.05.02  Centrally acting appetite suppressants
Naltrexone/BupropionBlack Triangle (Mysimba®)
View adult BNF View SPC online
Formulary
Black

Prolonged-release tablets; 8mg naltrexone hydrochloride/90mg bupropion hydrochloride

No BNFc entry – seek specialist advice

 
Link  NALTREXONE/BUPRIOPION prolonged-release tablets (Mysimba®▼); Pan Mersey Area Prescribing Committee policy statement
Link  NICETA494: Naltrexone–bupropion for managing overweight and obesity
   
04.06  Drugs used in nausea and vertigo
04.06  Vomiting during pregnancy
 note 

UKMi Q&A: Anti-emetic treatment during pregnancy

Doxylamine + pyridoxine
View adult BNF View SPC online
Formulary
Grey

Tablets 10 mg doxylamine succinate and 10 mg pyridoxine hydrochloride

 
Link  Pan Mersey Area Prescribing Committee - DOXYLAMINE/PYRIDOXINE tablets (Xonvea®▼) for Nausea and Vomiting in Pregnancy
   
04.06  Postoperative nausea and vomiting
 note 

Local guidelines may exist for the management of PONV and should be consulted where available.

04.06  Motion sickness to top
04.06  Other vestibular disorders
04.06  Cytotoxic chemotherapy
 note 

For the management of nausea and vomiting induced by cytotoxic chemotherapy, please refer to chapter 8.1 in the most current BNF. Consult local guidelines/ protocols where available.

Dexamethasone
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended

Tablets 500micrograms, 2mg
Soluble tablets 2mg
Oral solution SF2mg/5mL
Injection 3.8mg/mL (Note has replaced Dexamethasone 4 mg/mL Injection) and 3.3mg/mL

Notes

Dexamethasone has antiemetic effects and is used in vomiting associated with cancer chemotherapy and postoperative nausea and vomiting (unlicenced use). It may be used alone or with metoclopramide, prochlorperazine, or a 5HT3-receptor antagonist.

When prescribing or administering dexamethasone, it must be taken into account that different preparations may contain different salts which are not equivalent to each other. Therefore care is needed to ensure that the patient receives the correct dose.

 
Link  Pan Mersey APC: DEXAMETHASONE injection – different injection strengths, November 2014
   
Controlled Drug Cannabis-based products for medicinal use
View adult BNF View childrens BNF
Formulary
Grey

Unlicensed "Special" products

 
Link  Pan Mersey APC (2018). CANNABIS-BASED products for medicinal use
   
04.06  Palliative care
 note 

For the management of nausea and vomiting in palliative care, see prescribing in palliative care section in current BNF.Consult local guidelines / protocols where available. Drugs used include haloperidol, levomepromazine.Medicines information services can also be contacted for general advice or for advice on administering antiemetics via continuous subcutaneous infusion

The Association of Paediatric Palliative Medicine Master Formulary 4th Edition (2017)

Haloperidol
View adult BNF View SPC online View childrens BNF
Formulary
Green

Tablets 500micrograms, 1.5mg, 5mg, 10mg
Capsules 500micrograms
Oral liquid SF 1mg/1mL, 2mg/mL
Injection 5mg/mL

 Amber Recommended Paediatrics

In palliative care, haloperidol is used to prevent nausea and vomiting associated with opioid therapy and for most metabolic causes of vomiting.

 
   
Levomepromazine
View adult BNF View SPC online View childrens BNF
Formulary
Green

Tablets 25mg
(a 6.25mg dose of levomepromazine tablet can be achieved by quartering a 25mg tablet- note however that this is unlicensed. Where this is not practical an unlicensed “special” 6mg tablet is available and may be considered)
Injection 25mg/mL

Amber Recommended Paediatrics


 Levomepromazine is also used as an antiemetic in palliative care

 
   
04.06  Migraine
04.06  Antihistamines to top
Cyclizine
View adult BNF View SPC online View childrens BNF
Formulary
Green

Tablets 50mg
Injection 50mg/mL
Suppositories available as ‘special order’

Amber Recommended Paediatrics

 
   
Cinnarizine
View adult BNF View SPC online View childrens BNF
Formulary
Green
Tablets 15mg 
   
Promethazine Hydrochloride
View adult BNF View SPC online View childrens BNF
Formulary
Green

Tablets 10mg, 25mg
Elixir 5mg/5mL
Injection 25mg/mL

Red Paediatrics: short term use only

 
   
04.06  Phenothiazines and related drugs
Droperidol
View adult BNF View SPC online View childrens BNF
Formulary
Red
Injection 2.5mg/1ml 
   
Prochlorperazine
View adult BNF View SPC online View childrens BNF
Formulary
Green

Tablets 5mg
Syrup 5mg/5mL
Intramuscular injection 12.5mg/1mL
Buccal tablets 3mg

Amber Recommended Paediatrics. In children under 12 years.

Notes
Severe dystonic reactions sometimes occur with phenothiazines, especially in children. Prochlorperazine should be avoided in patients with Parkinson’s disease and should be used cautiously in the elderly.

 
   
04.06  Domperidone and metoclopramide
 note 

 

Domperidone
View adult BNF View SPC online View childrens BNF
Formulary
Green
Tablets 10mg
Suspension 5mg/5mL

Notes
Domperidone is associated with a small increased risk of serious cardiac side effects. Its use is now restricted to the relief of symptoms of nausea and vomiting and the dosage and duration of use have been reduced. Domperidone is now contraindicated in those with underlying cardiac conditions and other risk factors (see below).
 
Link  Domperidone: Update - treatment advice Pan Mersey APC Safety Statement
Link  MHRA: Domperidone: risk of cardiac side effects
Link  NPPG Statement: The use of domperidone in infants and children (May 2015)
   
Metoclopramide
View adult BNF View SPC online View childrens BNF
Formulary
Green

Tablets 10mg
Oral solution 5mg/5mL
Injection 5mg/mL
 
Black PaediatricsAmber Recommended Paediatrics Palliative Care

Notes

The European Medicines Agency’s Committee on Medicinal Products for Human Use has reviewed the benefits and risks of the antiemetic metoclopramide in 2013. The review recommended changes that include a restriction to the dose and duration of use to help minimise the risk of potentially serious neurological adverse effects. The risk of acute neurological effects is higher in children than in adults.

 
Link  METOCLOPRAMIDE: risk of neurological adverse effects - restricted dose and duration of use; Medicines and Healthcare Products Regulatory Agency Drug Safety Update
   
04.06  5HT3 antagonists
 note 

QT interval prolongation has been reported with ondansetron and granisetron. Therefore they should be avoided or administered with caution to patients with risk factors for developing QT interval prolongation. These include patients with congenital long QT syndrome, electrolyte abnormalities, cardiac rhythm or conduction disturbances or patients taking other medicines that prolong the QT interval.

In light of new study data showing a greater risk of QTcprolongation whenondansetronis used at the higher doses previously authorised for chemotherapy-induced nausea and vomiting (CINV), the new maximum single intravenous dose of ondansetron for CINV in adults is now 16 mg (infused over at least 15 minutes).

Ondansetron
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended

Tablets, orodispersible film tablets and “Melt” tablets 4mg, 8mg
Oral solution 4mg/5mL
Injection 4mg/2mL, 8mg/4mL

 
   
Granisetron
View adult BNF View SPC online View childrens BNF
Formulary
Red
Tablets 1mg
Injection (as hydrochloride) for dilution before use 1mg/mL, 3mg/3mL
 
   
04.06  Neurokinin receptor antagonist
Aprepitant
View adult BNF View SPC online
Formulary
Red

Capsules 80mg, 125mg

No BNFc entry - seek specialist advice

 
   
Fosaprepitant
View adult BNF View SPC online
Formulary
Red

Injection, powder for reconstitution 150mg

No BNFc entry - seek specialist advice

 
   
04.06  Hyoscine to top
Hyoscine Hydrobromide (Scopolamine Hydrobromide)
View adult BNF View SPC online View childrens BNF
Formulary
Green
Chewable tablets 150micrograms, 300micrograms
Patches (Scopoderm®) 1mg/72hours
 
   
04.06  Other drugs for Ménière's disease
Betahistine Dihydrochloride
View adult BNF View SPC online
Formulary
Green

Tablets 8mg, 16mg

No BNFc entry - seek specialist advice

 
   
04.07  Analgesics
Electromagnetic Pulse Therapy  (Actipatch®)
Formulary
Grey

Drug-free medical device

 
Link  PAN MERSEY AREA PRESCRIBING COMMITTEE PRESCRIBING POLICY STATEMENT: ELECTROMAGNETIC PULSE THERAPY (Actipatch®)
   
04.07.01  Non-opioid analgesics and compound analgesic preparations
Nefopam
View adult BNF View SPC online
Second Choice
Green

Tablets, 30 mg

No BNFc entry – seek specialist advice

 
   
Aspirin
View adult BNF View SPC online
Formulary
Green

Tablets and Dispersible Tablets, 300 mg

BLACK paediatrics - do not use in children

 
   
Paracetamol
View adult BNF View SPC online View childrens BNF
Formulary
Green

Tablets, 500 mg
Soluble Tablets, 500 mg, 120 mg

Melts 250mg

Oral Suspension, 120 mg/5ml, 250 mg/5ml

Suppositories, 60 mg, 80mg, 120 mg, 125mg, 240mg, 250 mg, 500 mg, 1 g


RED i/v 10 mg/ml, *switch to oral as soon as possible*

Intravenous paracetamol: risk of accidental overdose especially in infants, neonates and adults with low body weight.

 
Link  Intravenous paracetamol (Perfalgan): risk of accidental overdose
   
Ziconotide
View adult BNF View SPC online
Formulary
Red

Intrathecal infusion 100micrograms /mL

No BNFc entry - seek specialist advice

NHS NHSE commissioned drug - see Specialised Commissioning: Key documents

 
   
Ketamine
View adult BNF View SPC online
Formulary
Amber Retained

Oral Solution 50 mg/5ml (unlicensed)
Injection s/c 10 mg/ml, 50 mg/ml, 100 mg/ml (off label - in palliative care only)

 

REDi/v 10 mg/ml, 50 mg/ml, 100 mg/ml

Red Opioid cross-tapering and weaning

Amber Recommended In paediatric palliative care 

 
Controlled Drug Schedule 2
   
Controlled Drug Cannabis-based products for medicinal use
View adult BNF View childrens BNF
Formulary
Grey

Unlicensed "Special" preparations

 
Link  Pan Mersey APC (2018). CANNABIS-BASED products for medicinal use
   
04.07.01  Compound analgesic preparations
 note 

Compound analgesic preparations that contain a simple analgesic (such as aspirin or paracetamol) with an opioid component reduce the scope for effective titration of the individual components in the management of pain of varying intensity. The use of compound preparations is not recommended.

Co-codamol
View adult BNF View SPC online View childrens BNF
Formulary
Green

Second line

Tablets 8 / 500 (codeine phosphate 8 mg, paracetamol 500 mg)
Soluble tablets, 8 / 500 (codeine phosphate 8 mg, paracetamol 500 mg)

Tablets 15 / 500 (codeine phosphate 15mg, paracetamol 500mg)
Soluble tablets 15 / 500 (codeine phosphate 15mg, paracetamol 500mg)

Tablets, 30 / 500 (codeine phosphate 30 mg, paracetamol 500 mg)
Soluble tablets, 30 / 500 (codeine phosphate 30 mg, paracetamol 500 mg)

Black Paediatrics in children less than 12 years

Compound preparations are considered to be less suitable for prescribing than the separate components. Although such preparations may not be considered as drugs of first choice, their use may be justifiable in certain circumstances.

 
Link  Pan Mersey APC: CODEINE: USE IN CHILDREN, September 2013
   
Co-dydramol
View adult BNF View SPC online View childrens BNF
Formulary
Green

Tablets, 10 / 500 (dihydrocodeine 10 mg, paracetamol 500 mg)

Paediatrics: Not recommended in children under 12 years.

Compound preparations are considered to be less suitable for prescribing than the separate components. Although such preparations may not be considered as drugs of first choice, their use may be justifiable in certain circumstances.

 
   
Paracetamol and Tramadol (Tramacet®)
View adult BNF View SPC online View childrens BNF
Formulary
Black

Tablets and effervescent tablets

 
Link  PAN MERSEY AREA PRESCRIBING COMMITTEE PRESCRIBING POLICY STATEMENT: ORAL COMBINATION PRODUCTS
   
Co-proxamol
Unlicensed Drug Unlicensed
Black

Tablets paracetamol 325mg and dextroproxyphene 32.5mg

 

 
Link  PAN MERSEY AREA PRESCRIBING COMMITTEE PRESCRIBING POLICY STATEMENT: CO-PROXAMOL tablets
   
04.07.02  Opioid analgesics to top
 note 

Strong opioids

Notes

All patients started on weak or strong opioids should undergo a trial with a clear upper dose limit in place. An improvement in function and quality of life is more important than pain relief as such. If there is a significant improvement in function (more than 50% pain relief) an opioid management plan should be in place and weaning encouraged at the earliest opportunity. See Faculty of Pain Medicine “Opioids Aware: A resource for patients and healthcare professionals to support prescribing of opioid medicines for pain” http://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-aware. Deprescribing of strong opioids should be encouraged whenever possible. Patients requiring high doses of opioids should be reviewed and consideration given to referring to a specialist for review. (Pan Mersey specialist recommendation).

Alternative routes should only be considered for people who are unable to take oral medicines because of medical conditions and/or disability.

There are NPSA alerts regarding high dose morphine and diamorphine and reducing dosing errors with opioid medicines.

There is Care Quality Commission guidance on prescribing of fentanyl and buprenorphine transdermal patches

For details on conversion from one drug to another please contact Pharmacy or the Medicines Management Team

Use of strong opioids in Paediatrics: Neonates and infants show an increased susceptibility to respiratory depression to strong opioids. However, this should not exclude them from adequate analgesia.

Chronic pain:

See Faculty of Pain Medicine “Opioids Aware: A resource for patients and healthcare professionals to support prescribing of opioid medicines for pain” http://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-aware

Opioids are very good analgesics for acute pain and for pain at the end of life but there is little evidence that they are helpful for long term pain.

Red Retained Traffic Light Opioid Cross-Titration

Where a patient is undergoing transition from one strong opioid to another under supervision of a pain clinic specialist using “cross-titration” (gradual reduction of dose of the opioid being stopped with simultaneous gradual increase in dose of the new opioid), prescribing of both opioids should be undertaken by the specialist until the first opioid has been stopped (RED RAG rating).

Strong opioids are morphine, oxycodone, buprenorphine, diamorphine, hydromorphone, methadone, pethidine, tapentadol, fentanyl, and do not include codeine, morphine sol’n 10mg/5ml, tramadol or dihydrocodeine.

This does not apply where the first opioid is stopped with immediate effect and the new opioid started afterwards (i.e. no simultaneous use of 2 opioid drugs). It does not apply where a patient is switched from a strong opioid to a strong opioid patch (e.g. fentanyl, buprenorphine patch), where administration of the previous strong opioid is continued intermittently and/or temporarily until the patch provides steady state pain relief as recommended in the patch Summary of Product Characteristics.

This also does not apply when one opioid is used for background analgesia and a different opioid is used intermittently for breakthrough pain.

NICE Clinical Guideline 140 Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults recommends that:-

Patients with advanced and progressive disease who require strong opioids should be offered a choice of regular oral sustained-release or oral immediate-release morphine, with rescue doses of oral immediate release morphine for breakthrough pain

Provided there is no renal or hepatic comorbidities, a typical starting total daily dose of oral morphine of 20-30mg of oral morphine, plus 5mg oral immediate release morphine for rescue doses during the titration phase should be offered

The dose should be adjusted until a balance exists between acceptable pain control and side-effects

Fast-acting fentanyl should not be offered as first line rescue medication in patients who can take oral opioids

Transdermal patch formulations should not be routinely offered as first-line maintenance treatment for patients in whom oral opioids are suitable. In those patients unsuitable for oral opioids whose analgesic requirements are stable, consider initiating transdermal patches with the lowest acquisition cost

When calculating opioid equivalence for transdermal patches please contact Pharmacy or the Medicines Management Team

In patients for whom oral opioids are not suitable and analgesic requirements are unstable, consider initiating subcutaneous opioids with the lowest acquisition cost

Ensure that patients are informed of the side-effects which may occur when starting strong opioid treatment and treatment increase, including constipation, nausea and drowsiness.

Ensure that laxative treatment is prescribed regularly at an effective dose, in all patients initiating strong opioids and ensure that patients are aware that treatments for constipation take time to work

Patients should be advised that nausea may occur, but that this is likely to pass

Prescribe and optimise anti-emetic treatment if nausea persists before considering switching opioid treatment

Specialist advice should be sought if there are any complications e.g. moderate to severe renal or hepatic impairment, inadequate pain control despite optimising first-line maintenance treatment, initiating subcutaneous opioids, uncontrolled breakthrough pain or uncontrolled drowsiness

 

Codeine
View adult BNF View SPC online View childrens BNF
Formulary
Green

Codeine use in children and adolescents under 18 years of age

MHRA has recommended restricting codeine use in children. It should only be used in children over 12 years old and only if other pain killers such as paracetamol or ibuprofen are not sufficient. Codeine presents well-known safety and efficacy problems related to genetic variability in biotransformation. Codeine is a prodrug that is converted into its active metabolite morphine. The efficacy of a prodrug depends on the amount of active metabolite formed. Variable expressions of the enzymes involved in the biotransformation of prodrugs can lead to substantial inter-individual and inter-ethnic differences in the conversion rate and the plasma concentration of the active metabolite. As a consequence, the analgesic effect is (very) low or absent in neonates and young children. Furthermore, the percentage of poor metabolizers can vary in ethnic groups, resulting in ineffectiveness in large numbers of patients, including children. Conversely, individuals who metabolize codeine quickly and extensively are at risk of severe opioid toxicity, given the high and uncontrolled conversion of codeine into morphine.Black Initiated Traffic Light Children under 12 yearsRed Triangle Pan Mersey APC: CODINE: USE IN CHILDREN, November 2017

Codeine use in Adults

Codeine is a prodrug that is converted into its active metabolite morphine. The efficacy of a prodrug depends on the amount of active metabolite formed. Variable expressions of the enzymes involved in the biotransformation of prodrugs can lead to substantial inter-individual and inter-ethnic differences in the conversion rate and the plasma concentration of the active metabolite. Furthermore, the percentage of poor metabolizers can vary in ethnic groups, resulting in ineffectiveness in large numbers of patients. Conversely, individuals who metabolize codeine quickly and extensively are at risk of severe opioid toxicity, given the high and uncontrolled conversion of codeine into morphine.
Tablets 15mg, 30mg, 60mg
Linctus 15mg/5ml (3 mg per 1 ml)
Linctus, sugar free 15mg/5ml (3 mg per 1 ml)
Oral liquid 25mg/5ml (5 mg per 1 ml)
Injection
CD Schedule 2
60mg/ml
Red Retained Traffic Light Paediatrics

 

Red Retained Traffic Light  when used in cross titration

 
   
Morphine
View adult BNF View SPC online View childrens BNF
Formulary
Green
Red Triangle Take care when prescribing and dispensing
Morphine modified release capsules are avialable as both 12 hourly and 24 hourly dosage forms. All modified release morphine preparations should be prescribed by brand name to avoid confusion.
Patients requiring high doses of morphine(> 60mg BD) should be reviewed and consideration given to referring to a pain specialist for review.
Hyperlink NPSA: High dose morphine and diamorphine injections, 25 May 2006
Oral solution 100micrograms/ml (special order medicine)
10mg/5ml (2 mg per 1 ml)
100mg/5ml (20 mg per 1 ml) CD Schedule 2
Tablets
CD Schedule 2
10mg, 20mg, 50mg
Modified-release tablets
CD Schedule 2
12-hourly 5mg, 10mg, 15mg, 30mg, 60mg, 100mg, 200mg
Modified-release capsules
CD Schedule 2
12-hourly 10mg, 30mg, 60mg, 100mg, 200mg
24-hourly 30 mg, 60 mg, 90 mg, 120 mg, 150 mg, 200 mg
Modified-release granules
CD Schedule 2
12-hourly 20mg, 30mg, 60mg, 100mg, 200mg
Suppositories
CD Schedule 2
10 mg, 15 mg, 30 mg
Solution for injection
CD Schedule 2
1mg/ml, 10mg/ml, 15mg/ml, 20mg/ml, 30mg/ml
Amber Retained Traffic Light Paediatrics
Amber Recommended Traffic Light Paediatric palliative care

 

Red Retained Traffic Light  when used in cross titration

 
   
Tramadol
View adult BNF View SPC online View childrens BNF
Formulary
Green
Red Triangle Take care when prescribing and dispensing
Tramadol modified release capsules are avialable as both 12 hourly and 24 hourly dosage forms. All modified release tramadol preparations should be prescribed by brand name to avoid confusion.
Capsules
CD Schedule 3
50mg
Amber Initiated Traffic Light Children under 12 years will remain under the care of the paediatric specialist pain team.
Orodispersible tablets
CD Schedule 3
50mg
Amber Initiated Traffic Light Children under 12 years will remain under the care of the paediatric specialist pain team.
Oral drops
CD Schedule 3
100mg/1ml (100 mg per 1 ml)
Amber Initiated Traffic Light Children under 12 years will remain under the care of the paediatric specialist pain team.
Modified-release tablets
CD Schedule 3
12-hourly 50mg, 100mg, 150mg, 200mg
24-hourly 100 mg, 150 mg, 200 mg, 300 mg, 400 mg
Amber Initiated Traffic Light Children under 12 years will remain under the care of the paediatric specialist pain team.
Modified-release capsules
CD Schedule 3
12-hourly 50 mg, 100 mg, 150 mg, 200 mg
Amber Initiated Traffic Light Children under 12 years will remain under the care of the paediatric specialist pain team.
Solution for injection
CD Schedule 3
50mg/ml
Red Recommended Traffic Light Paediatrics

 

Red Retained Traffic Light  when used in cross titration

 
   
Dihydrocodeine Tartrate
View adult BNF View SPC online View childrens BNF
Formulary
Green

Tablets, 30 mg
Oral solution, 10 mg/5ml

Weak opioid – oral preparation

 

Red Retained Traffic Light  when used in cross titration

 
   
Oxycodone
View adult BNF View SPC online View childrens BNF
Formulary
Green
Red Triangle Take care when prescribing and dispensing
Oxycodone modified release tablets are available as both 12 hourly and 24 hourly dosage forms. All modified release oxycodone preparations should be prescribed by brand name to avoid confusion.
Patients requiring high doses of oxycodone(> 30mg BD) should be reviewed and consideration given to referring to a pain specialist for review.
CD CQC Safer use of oral oxycodone medicines
Capsule
CD Schedule 2
5mg, 10mg, 20mg
Modified-release tablet
CD Schedule 2
12-hourly 5mg, 10mg, 15mg, 20mg, 30mg, 40mg, 60mg, 80mg, 120mg
Oral solution
CD Schedule 2
5mg/5ml (1 mg per 1 ml)
10mg/ml (10 mg per 1 ml)
Solution for injection
CD Schedule 2
10mg/ml, 50mg/ml
Amber Retained Traffic Light Paediatrics
Amber Recommended Traffic Light Paediatric palliative care

 

Red Retained Traffic Light  when used in cross titration

 
   
Buprenorphine
View adult BNF View SPC online View childrens BNF
Formulary
Green
Red Triangle Take care when prescribing and dispensing
All transdermal patch preparations should be prescribed by brand name to avoid confusion. Buprenorphine transdermal patches are avialable as 72-hourly, 96-hourly and 7-day dosage form. To avoid confusion and reduce the risk of prescribing and dispensing errors, the 72-hour patch is non-formulary and should not be used.
CD CQC: Safer use of fentanyl and buprenorphine transdermal patches
Sublingual tablets
CD Schedule 3
200microgram, 400microgram
Amber Initiated Traffic Light Paediatrics. Patient will remain under the care of the paediatric specialist pain team.
Transdermal patch
CD Schedule 3
96-hourly 35microgam/hr, 52.5microgram/hr, 70microgram/hour
7-day 5microgram/hr, 10microgram/hr, 15microgram/hr, 20microgram/hr
Amber Initiated Traffic Light Paediatrics. Patient will remain under the care of the paediatric specialist pain team.

 

Red Retained Traffic Light  when used in cross titration

 
   
Hydromorphone
View adult BNF View SPC online View childrens BNF
Formulary
Green
note Patients requiring high doses of Hydromorphone(> 8mg BD) should be reviewed and consideration given to referring to a pain specialist for review.
Capsules
CD Schedule 2
1.3mg, 2.6mg
Amber Initiated Traffic Light Paediatrics. Patient will remain under the care of the paediatric specialist pain team.
Modified release capsules
CD Schedule 2
2mg, 4mg, 8mg,16mg, 24mg
Amber Initiated Traffic Light Paediatrics. Patient will remain under the care of the paediatric specialist pain team.

 

Red Retained Traffic Light  when used in cross titration

 
   
Controlled Drug Methadone
View adult BNF View SPC online
Formulary
Amber Retained

tablets 5mg

Use only following initiation by a consultant in pain medicine in a tertiary centre for the treatment of:

  1. Refractory neuropathic pain, unresponsive to any other opioid
  2. Severe, iatrogenic opioid dependency patients with positive response to oral ketamine treatment, who require a stabilisation phase prior to rotation to a different opioid or cessation of all opioid therapy.
  3. Patients with chronic pain responsive to doses of strong opioids (

Paediatrics: No BNFc entry - seek specialist advice

Red Retained Traffic Light Opioid Cross-Titration

Red Retained Traffic Light Halton CCG

 

 
Link  PAN MERSEY AREA PRESCRIBING COMMITTEE PRESCRIBING POLICY STATEMENT: Methadone tablets (Physeptone)
Link  PAN MERSEY AREA PRESCRIBING COMMITTEE PRESCRIBING SUPPORT INFORMATION: Methadone tablets in pain management
Link  Pan Mersey Area Prescribing Committee: Methadone GP letter
   
Pethidine
View adult BNF View SPC online View childrens BNF
Formulary
Red

Injection
CD Schedule 2 
 10mg/ml, 50mg/ml, 100mg/2ml

 

 
   
Diamorphine HCl
View adult BNF View SPC online View childrens BNF
Formulary
Green

Injection, 5 mg, 10 mg, 30 mg, 100 mg, 500 mg

Amber Patient Retained Paediatrics

Amber Recommended  Paediatrics, palliative care
 Opioid – parenteral preparation

Red Retained Traffic Light  when used in cross titration

 
Controlled Drug Schedule 2
Link  NPSA: High dose morphine and diamorphine injections, 25 May 2006
   
Fentanyl
View adult BNF View SPC online View childrens BNF
Formulary
Green

Patches, 12 micrograms/hr, 25 micrograms/hr, 37.5 micrograms/hr, 50 micrograms/hr, 75 micrograms/hr, 100 micrograms/hr
Amber Initiated Paediatrics

Patients requiring high doses of fentanyl (>25mcg/hr) should be reviewed and consideration given to referring to a pain specialist for review.

2nd line - Strong opioid – alternative route

Red Retained Traffic Light  when used in cross titration
 

 
Controlled Drug Schedule 2
Link  Pan Mersey APC: TRANSDERMAL OPIOID ANALGESIC PATCHES ENSURING SAFETY, March 2016
Link  CQC: Safer use of fentanyl and buprenorphine transdermal patches
   
Buprenorphine
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended

Injection, 300 mcg/ml

Opioid – parenteral preparation

Amber InitiatedPaediatrics

Red Retained Traffic Light  when used in cross titration

 
Controlled Drug Schedule 3
   
Fentanyl
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended

(as citrate) sublingual tablets, 100 micrograms, 133 micrograms, 200 micrograms, 267 micrograms, 300 micrograms, 400 micrograms, 533 micrograms, 600 micrograms, 800 micrograms
(as citrate) buccal tablets, 100 micrograms, 200 micrograms, 400 micrograms, 600 micrograms, 800 micrograms
(as citrate) lozenge with oromucosal appliactor 200 micrograms, 400 micrograms, 600 micrograms, 800 micrograms, 1.2 mg, 1.6 mg
(as citrate) nasal spray, 50 micrograms, 100 micrograms/metered spray, 200 micrograms/metered spray, 400 micrograms/metered spray

2nd line strong opioid – alternative route. For use in palliative care breakthrough pain only.

 
Controlled Drug Schedule 2
   
Methadone
View adult BNF View SPC online
Formulary
Amber Recommended

Injection 10 mg/ml

Opioid – parenteral preparation

Amber Initiated  Paediatrics: palliative care 

Red Retained Traffic Light  when used in cross titration

 
Controlled Drug Schedule 2
   
Oxycodone with naloxone
View adult BNF View SPC online
Formulary
Black

Tablets M/R 5 mg/2.5 mg, 10 mg/5 mg, 20 mg/10 mg, 40 mg/20 mg

GREY for restless legs syndrome

No BNFc entry – seek specialist advice

 
Controlled Drug Schedule 2
Link  CQC Safer use of oral oxycodone medicines
Link  Pan Mersey APC policy statement: OXYCODONE with NALOXONE modified release tablets (Targinact®) for adults with chronic pain
Link  PAN MERSEY AREA PRESCRIBING COMMITTEE PRESCRIBING POLICY STATEMENT: OXYCODONE with NALOXONE modified release tablets (Targinact®) for restless legs syndrome
   
Tapentadol
View adult BNF View SPC online
Formulary
Amber Initiated

Tablets M/R, 50 mg, 100 mg, 150 mg, 200 mg, 250 mg

Strong opioid – oral preparation, modified release

Red Retained Traffic Light  when used in cross titration

BLACKTablets, 50 mg, 75 mg immediate release, Oral solution 20 mg per 1 ml 

 

No BNFc entry – seek specialist advice

 
Controlled Drug Schedule 2
Link  TAPENTADOL prolonged release tablets (Palexia® SR) Pan Mersey APC Policy Statement
Link  TAPENTADOL immediate release tablets (Palexia®) Pan Mersey APC Policy Statement
   
Dihydrocodeine Tartrate
View adult BNF View SPC online View childrens BNF
Formulary
Red
Injection 50 mg/ml

Opioid – parenteral preparation 
Controlled Drug Schedule 2
   
Morphine
View adult BNF View SPC online View childrens BNF
Formulary
Red

Solution for infusion 1mg/ml, 2mg/ml

 
Controlled Drug Schedule 2
   
Fentanyl
View adult BNF View SPC online View childrens BNF
Formulary
Red
Injection, 50 micrograms/ml

Opioid – parenteral preparation 
Controlled Drug Schedule 2
   
Alfentanil
View adult BNF View SPC online View childrens BNF
Formulary
Red

Injection 500 micrograms/ml, 5 mg/ml
Amber Recommended Only when recommended by the palliative care team
 

Amber Recommended Paediatrics - Only when recommended by the palliative care team

Opioid – parenteral preparation

 
Controlled Drug Schedule 2
   
Tramadol + dexketoprofen (Skudexa®)
View adult BNF View SPC online View childrens BNF
Formulary
Black

Tablets tramadol 75mg + dexketoprofen 25mg

 
Link  PAN MERSEY AREA PRESCRIBING COMMITTEE PRESCRIBING POLICY STATEMENT: ORAL COMBINATION PRODUCTS
   
04.07.03  Neuropathic pain
Amitriptyline
View adult BNF View SPC online View childrens BNF
First Choice
Green

Tablets, 10 mg, 25 mg, 50 mg
Oral Solution, 25 mg/5ml, 50 mg/5ml

Amber Initiated Paediatrics

 
Gabapentin
View adult BNF View SPC online
First Choice
Green

Capsules, 100 mg, 300 mg, 400 mg
Tablets 600 mg, 800 mg (please note that tablets are significantly more expensive than capsules)
Oral solution 250mg in 5mL (sugar free)

Amber Initiated Paediatrics 

 
Controlled Drug Schedule 3
Duloxetine
View adult BNF View SPC online
Second Choice
Green

 Capsules, 30 mg, 60 mg

No BNFc entry - seek specialist advice

 
   
Nortriptyline
View adult BNF View SPC online
Second Choice
Green

 Tablets, 10 mg, 25 mg

No BNFc entry - seek specialist advice
 
Nortriptyline is significantly more expensive then amitriptyline. Use only as an option where amitriptyline has not been tolerated.

 
   
Pregabalin
View adult BNF View SPC online
Second Choice
Green

Capsules, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg, 200mg, 225 mg, 300 mg
Oral solution 20mg/ml

Amber Initiated Paediatrics

 
Controlled Drug Schedule 3
Link  PHE (2014). Pregabalin and gabapentin: advice for prescribers on the risk of misuse
   
Capsaicin
View adult BNF View SPC online
Formulary
Green

Cream 0.025%, 0.075%

No BNFc entry - seek specialist advice

 
   
Carbamazepine
View adult BNF View SPC online View childrens BNF
Formulary
Green
Red Triangle Take care when prescribing and dispensing
A given dose of carbamazepine oral suspension will produce higher peak levels than the same dose in tablet form. When switching a patient from tablets to liquid the same overall dose may be used but in smaller, more frequent, doses.[SPS (2018)]
Standard release tablets 100 mg, 200 mg, 400 mg
Modified release tablets 200 mg, 400 mg
Oral suspension 100 mg/5 ml
Suppositories 125 mg, 250 mg

Purple Paediatrics

 
   
Imipramine
View adult BNF View SPC online
Formulary
Green

Tablets, 10 mg, 25 mg
Oral solution, 25 mg/5ml

No BNFc entry - seek specialist advice

 
   
Lamotrigine
View adult BNF View SPC online
Formulary
Amber Recommended

Tablets, 25mg, 50mg, 100mg, 200mg
Dispersible tablets, 2mg, 5mg, 25mg, 100mg
N.B. Unlicensed indication

No BNFc entry - seek specialist advice

 
   
Phenytoin sodium
View adult BNF View SPC online
Formulary
Amber Initiated
Red Triangle Take care when prescribing and dispensing
Preparations containing phenytoin sodium (capsules and tablets) are not bioequivalent to those containing phenytoin base (chewable tablets and suspension). 100 mg phenytoin sodium is approximately equivalent to 92 mg phenytoin base. The dose is the same for all phenytoin products when initiating therapy. However, if switching between these products the difference in phenytoin content may be clinically significant. Therefore plasma-phenytoin concentration monitoring is recommended.[SPS (2018)]
Tablets 100 mg
Capsules 25 mg, 50 mg, 100 mg, 300 mg
Chewable tablets (as base) 50 mg
Suspension (as base) 30 mg /5 ml

No BNFc entry - seek specialist advice

 
   
Capsaicin
View adult BNF View SPC online
Formulary
Red

Patches, 179 mg (8%)

No BNFc entry - seek specialist advice

 
   
Lidocaine
View adult BNF View SPC online
Formulary
Black

Plaster, 5% (700 mg per medicated plaster)

Green post herpetic neuralgia ONLY in patients who have been treated in line with NICE CG173 Neuropathic pain in adults, but are still experiencing neuropathic pain.

 Amber Initiated For neuropathic pain ONLY following pain specialist or palliative care specialist initiation and ONLY in the limited circumstances described in Pan Mersey APC Prescribing Policy Statement - see link below.

Amber Initiated Paediatrics - only as described in Pan Mersey APC Pharmacological Management of Chronic Pain in Children guideline and Pan Mersey APC Prescribing Policy Statement - see links below. No BNFc entry - seek specialist advice.

 
Link  Pan Mersey APC (2018). LIDOCAINE plaster 5% (Ralvo®, Versatis®) in adults and children in primary care
Link  Alder Hey (2017). Lidocaine 5% Patches (Versatis) - Information for parents, carers and adolescents
   
04.07.04  Antimigraine drugs
04.07.04.01  Treatment of the acute migraine attack
04.07.04.01  Analgesics
Aspirin
View adult BNF View SPC online
Formulary
Green
Tablets, 300 mg
Soluble tablets should be used in preference.
600-900mg at onset of attack of migraine, 600mg for subsequent attacks

BLACK Paediatrics
Do not use in children < 16 years  
   
Paracetamol
View adult BNF View SPC online View childrens BNF
Formulary
Green

Tablets, 500 mg

Soluble Tablets, 500 mg, 120 mg

Melts 250mg

Oral Suspension, 120 mg/5ml, 250 mg/5ml

Suppositories, 60mg, 80mg, 120mg, 125mg, 240mg, 250mg, 500mg, 1g

Paracetamol paediatric dosing – see MHRA advice

 
Link  MHRA Advice - Paracetamol: updated dosing for children to be introduced
   
Ibuprofen
View adult BNF View SPC online View childrens BNF
Formulary
Green

Tablets 200mg, 400mg, 600mg
Melts 200mg
Orodispersible tablet 200mg
Oral suspension 100mg/5ml

 
   
Naproxen
View adult BNF View SPC online View childrens BNF
Formulary
Green

Tablets 250mg, 500mg 
Effervescent tablets 250mg
 
 
 Amber Recommended Paediatrics 


Do not use in routinely in children - no BNFc entry for migraine

 
   
Diclofenac (for use only in acute treatment where oral route not possible)
View adult BNF View SPC online View childrens BNF
Formulary
Green

Suppositories 12.5mg, 25mg, 50mg, 100mg

Paediatrics: There is a lack of information surrounding the cardiovascular effects of diclofenac in children, and evidence that diclofenac is more effective for the treatment of common paediatric pain conditions than other NSAIDs is limited (see Pan Mersey link).

 
Link  MHRA, Diclofenac: new contraindications and warnings after a Europe-wide review of cardiovascular safety
   
04.07.04.01  5HT1 agonists to top
 note 

Where prescribing a 5HT1-receptor agonist start with one that has the lowest acquisition cost (naratriptan, sumatriptan); if this is consistently ineffective, try one or more alternatives.

If the triptan is ineffective, consider whether it is being taken early enough. Also, consider a parenteral route if nausea, vomiting or woken from sleep with severe migraine.

Naratriptan
View adult BNF View SPC online
First Choice
Green

Tablets 2.5mg
No BNFc entry – seek specialist advice

 
Sumatriptan
View adult BNF View SPC online View childrens BNF
First Choice
Green

Tablets 50mg, 100mg
Injection 6mg/0.5ml
Nasal spray 10mg per actuation, 20mg per actuation

Advise patient to bend forward for one minute after administration of nasal spray to avoid swallowing the dose.
 
 Amber Recommended Paediatrics < 12 years
May be prescribed for ages lower than stated in BNFc under specialist advice.

 
Zolmitriptan
View adult BNF View SPC online View childrens BNF
Second Choice
Green

Tablets 2.5mg
Orodispersible tablets 2.5mg
Nasal spray 5mg per actuation

Advise patient to bend forward for one minute after administration of nasal spray to avoid swallowing the dose.
 
 Amber Recommended Paediatrics < 12 years
May be prescribed for ages lower than stated in BNFc under specialist advice.

 
   
04.07.04.01  Anti-emetics
 note 

Antiemetics

Uncommonly used in <12 years old, consider specialist referral before use.

Domperidone
View adult BNF View SPC online View childrens BNF
First Choice
Green

Tablets, 10mg
Suspension, 5mg/5mL
 Amber Recommended Paediatrics 
 
 
In the May 2014 Drug Safety Update, the MHRA published evidence showing that domperidone carries a small risk of serious ventricular arrhythmia and sudden cardiac death. Domperidone is now contraindicated in those with underlying cardiac conditions and other risk factors. See MHRA Drug Safety Update May 2014.

 
Metoclopramide
View adult BNF View SPC online
First Choice
Green

Tablets, 10mg
Tablets / sachets, 5mg with paracetamol 500mg
Oral solution, 5mg/5mL
Injection, 5mg/ml

BLACK Paediatrics


Metoclopramide can induce acute dystonic reactions and oculogyric crisis. These effects are more common in the young (especially girls and young women) and the very old. Metoclopramide should also be avoided in patients with Parkinson’s disease. It should not be used for migraine in children, and use should be restricted to 5 days or less for all other ages. See MHRA Drug Safety Update August 2013.

 
Cinnarizine
View adult BNF View SPC online View childrens BNF
Formulary
Green
Tablets, 15mg  
   
Cyclizine
View adult BNF View SPC online View childrens BNF
Formulary
Green

Tablets, 50mg
Injection, 50mg/ml
Solution - unlicensed, 5mg/5ml
Suppositories - unlicensed, 12.5mg

 
   
Prochlorperazine
View adult BNF View SPC online View childrens BNF
Formulary
Green

Tablets, 5mg
Syrup, 5mg/5mL
Buccal tablets, 3mg


Amber Recommended Intramuscular injection, 12.5mg/1mL


Amber Recommended Paediatrics < 12 years

Severe dystonic reactions sometimes occur with prochlorperazine, especially in children. It should be avoided in patients with Parkinson’s disease and should be used cautiously in the elderly. Prochlorperazine should not be used frequently and when it is used, this should be in conjunction with a prokinetic antiemetic medication

 
   
04.07.04.01  Other drugs for migrane
04.07.04.02  Prophylaxis of migraine
Propranolol
View adult BNF View SPC online View childrens BNF
First Choice
Green

Tablets 10mg, 40mg, 80mg, 160mg
Modified release capsule, 80mg, 160mg
Oral solution 5mg/5ml, 10mg/5ml, 40mg/5ml, 50mg/5ml
It is important to use adequate doses of 80 – 240mg daily in divided doses to obtain benefit.

Amber Recommended Paediatrics under 12 years. Green for older children.

 
Topiramate
View adult BNF View SPC online View childrens BNF
First Choice
Green

Tablets 25mg, 50mg, 100mg, 200mg
Sprinkle capsules 15mg, 25mg, 50mg

As cognitive and mood-related side effects are common with topiramate, patients should be specifically warned about these and advised to stop if they occur. More gradual withdrawal is only recommended if there is a history of epilepsy.

Amber Initiated Paediatrics

 
Erenumab
View adult BNF View SPC online
Formulary
Grey

Injection 70mg pre-filled syringe/ pen 

 
Link  Pan Mersey APC (2018): ERENUMAB pre-filled syringes (Aimovig®▼)
   
Fremanezumab
View adult BNF View SPC online View childrens BNF
Formulary
Grey

Injection 225mg pre-filled syringe

 
Link  Pan Mersey APC (2019): FREMANEZUMAB pre-filled syringe for injection (Ajovy®▼)
   
Galcanezumab
View adult BNF View SPC online View childrens BNF
Formulary
Grey

Injection 120mg pre-filled pen

 
Link  Pan Mersey APC (2019): GALCANEZUMAB solution for injection (Emgality®▼)
   
Pizotifen (limited effectiveness and poor tolerability, not encouraged for new patients, but should be continued for those already taking it)
View adult BNF View SPC online View childrens BNF
Formulary
Black

Tablets 500 micrograms, 1.5 mg

 
   
Botulinum toxin type A
View adult BNF View SPC online
Formulary
Red

Injection, 200unit vial (Botox®),
No BNFc entry – seek specialist advice

 
Link  NICE TA260 Botulinum toxin type A for the prevention of headaches in adults with chronic migraine
   
Amitriptyline
View adult BNF View SPC online
Unlicensed Drug Unlicensed
Green

Tablets 10 mg, 25 mg, 50 mg
Oral solution 10mg/mL, 25 mg/5 mL, 50 mg/5 mL
It is important to use adequate maintenance doses of 50 – 75mg at night, max. 150mg to obtain benefit

No BNFc entry – seek specialist advice

 
   
Candesartan
View adult BNF View SPC online
Unlicensed Drug Unlicensed
Green

Tablets 2mg, 4mg, 8mg, 16mg

No BNFc entry – seek specialist advice

 
   
Gabapentin
View adult BNF View SPC online
Unlicensed Drug Unlicensed
Green

3rd line

Capsules 100mg, 300mg, 400mg
Oral solution 50 mg/mL
It is important to use adequate doses up to 2.4g daily to obtain benefit.No BNFc entry – seek specialist advice

 
Controlled Drug Schedule 3
Link  Gabapentin (Neurontin): risk of severe respiratory depression
   
Imipramine
View adult BNF View SPC online
Unlicensed Drug Unlicensed
Green

Tablets 10 mg, 25 mg
Oral solution 25 mg/5 mL

No BNFc entry – seek specialist advice

 
   
Nortriptyline
View adult BNF View SPC online
Unlicensed Drug Unlicensed
Green

Tablets 10 mg, 25 mg
No BNFc entry – seek specialist advice

 Nortriptyline is significantly more expensive then amitriptyline. Use only as an option where amitriptyline has not been tolerated.

 
   
Sodium valproate
View adult BNF View SPC online
Unlicensed Drug Unlicensed
Amber Initiated

Tablets 100mg
Modified-release tablets 200mg, 300mg, 500mg
Modified-release capsules 150mg, 300mg
Gastro-resistant tablets 200mg, 500mg
Modified release granules 50mg, 100mg, 250mg, 500mg, 750mg, 1000mg
Oral solution 200mg/5ml

Green Males only

Green Headache pathway

Amber Initiated Paediatrics: seek specialist advice

Amber Retained for girls and women of childbearing potential

 
Link  Pan Mersey APC 2019): VALPROATE: safe prescribing and dispensing to girls of any age and women of child bearing potential
   
Zonisamide (on recommendation of consultant neurologist only)
View adult BNF View SPC online
Unlicensed Drug Unlicensed
Amber Recommended

Capsules 25 mg, 50mg, 100mg
No BNFc entry – seek specialist advice

As cognitive and mood-related side effects are common with zonisamide, patients should be specifically warned about these and advised to stop if they occur. More gradual withdrawal is only recommended if there is a history of epilepsy.

 
   
Flunarizine
Unlicensed Drug Unlicensed
Red

Capsules 5mg, 10mg

No BNFc entry – seek specialist advice

 
   
04.07.04.03  Cluster headache and the trigeminal autonomic cephalagias
Oxygen
View adult BNF View SPC online View childrens BNF
Formulary
Green

Acute treatment of Cluster Headache

100%, flow rate at least 12L/minute, non-rebreathing mask and reservoir bag

Maximum 25 minutes treatment at any one time

N.B. Refer to specialist. Prescribing of oxygen requires completion of a Home Oxygen Order Form (HOOF) by specialist.

No BNFc entry - seek specialist advice

 
   
Phenytoin
View adult BNF View SPC online View childrens BNF
Formulary
Green
Red Triangle Take care when prescribing and dispensing
Preparations containing phenytoin sodium (capsules and tablets) are not bioequivalent to those containing phenytoin base (chewable tablets and suspension). 100 mg phenytoin sodium is approximately equivalent to 92 mg phenytoin base. The dose is the same for all phenytoin products when initiating therapy. However, if switching between these products the difference in phenytoin content may be clinically significant. Therefore plasma-phenytoin concentration monitoring is recommended.[SPS (2018)]
Only for trigeminal neuralgia if allergic to carbamazepine
Capsules 25 mg, 50 mg, 100 mg, 300 mg
Tablets 100 mg
Chewable tablets (as base) 50 mg
Suspension (as base) 30 mg /5 ml

 

 
   
Prednisolone Intermittent short courses
View adult BNF View SPC online
Formulary
Green

Acute treatment of Cluster Headache.

Tablets 1mg, 2.5mg, 5mg, 10mg and 25mg, 30mg 
Oral solution 5mg in 5ml single-dose units
Oral solution 10mg in 1ml
Soluble tablets 5mg (more expensive than oral liquid) 
 
No BNFc entry - seek specialist advice
 
BLACK e/c tablets

 
Link  PREDNISOLONE ENTERIC COATED tablets, PAN MERSEY AREA PRESCRIBING COMMITTEE PRESCRIBING POLICY STATEMENT
   
Sumatriptan
View adult BNF View SPC online View childrens BNF
Formulary
Green

Acute treatment of Cluster Headache
 
Injection 6mg/0.5ml
Nasal spray 10mg per actuation, 20mg per actuation - unlicensed.

Advise patient to bend forward for one minute after administration of nasal spray to avoid swallowing the dose.

Amber Recommended Paediatrics

 
   
Carbamazepine
View adult BNF View SPC online
Unlicensed Drug Unlicensed
Green
Red Triangle Take care when prescribing and dispensing
A given dose of carbamazepine oral suspension will produce higher peak levels than the same dose in tablet form. When switching a patient from tablets to liquid the same overall dose may be used but in smaller, more frequent, doses.[SPS (2018)]
Trigeminal neuralgia and SUNCT (Short lasting unilateral neuralgiform headache with conjunctival injection and tearing)
Standard release tablets 100 mg, 200 mg, 400 mg
Modified release tablets 200 mg, 400 mg
Oral suspension 100 mg/5 ml

No BNFc entry - seek specialist advice

 
   
Indometacin
View adult BNF View SPC online
Unlicensed Drug Unlicensed
Green

Ice-pick headache, Paroxysmal Hemicrania and Hemicrania Continua
 
Capsules 25mg, 50mg
 
No BNFc entry - seek specialist advice

 
   
Lamotrigine
View adult BNF View SPC online
Unlicensed Drug Unlicensed
Green

SUNCT (Short lasting unilateral neuralgiform headache with conjunctival injection and tearing), Trigeminal neuralgia - only if allergic to carbamazepine
 
Tablets 25mg, 50mg, 100mg, 200mg
Dispersible tablets 2mg, 5mg, 25mg, 100mg
 
No BNFc entry - seek specialist advice

 
   
Verapamil
View adult BNF View SPC online
Unlicensed Drug Unlicensed
Green

Termination of attack and prophylaxis of Cluster Headache - 1st line
 
Standard-release tablets, 40mg, 80mg, 120mg, 160mg
Modified-release tablets, 120mg, 240mg
Modified-release capsules, 120mg, 180mg, 240mg
Oral solution, 40mg/5ml


Careful ECG monitoring is required and doses up to 960mg per day can be considered. ECG monitoring should continue at stable dose as PR interval may prolong over time. 

No BNFc entry -seek specialist advice

 
   
Zolmitriptan
View adult BNF View SPC online View childrens BNF
Unlicensed Drug Unlicensed
Green

Acute treatment of Cluster Headache
 
Nasal spray 5mg/0.5mL unit dose

Advise patient to bend forward for one minute after administration of nasal spray to avoid swallowing the dose.

Amber Recommended Paediatrics

 
   
Gabapentin
View adult BNF View SPC online
Unlicensed Drug Unlicensed
Amber Recommended

Hemicrania Continua
SUNCT (Short lasting unilateral neuralgiform headache with conjunctival injection and tearing)
 
Capsules 100mg, 300mg, 400mg

Oral solution 50mg/5mL
 
No BNFc entry - seek specialist advice

 
Controlled Drug Schedule 3
Link  Gabapentin (Neurontin): risk of severe respiratory depression
   
Lithium carbonate (prescribe by brand)
View adult BNF View SPC online
Unlicensed Drug Unlicensed
Purple

Prophylaxis of Cluster Headache- Shared Care

Priadel® MR tablets 200 mg, 400 mg
Lithium Carbonate Essential Pharma® tablets 250 mg (previously known as Camcolit® 250mg)
Camcolit® M/R tablets 400 mg
Liskonum® M/R tablets 450 mg

No BNFc entry - seek specialist advice.

 
   
Lithium citrate (prescribe by brand)
View adult BNF View SPC online
Unlicensed Drug Unlicensed
Purple

Prophylaxis of Cluster Headache -Shared care

Priadel® Liquid SF 520 mg/5 mL
Li-Liquid® 509 mg/5 mL, 1.018 g/5 mL
 
No BNFc entry - seek specialist advice

 
   
Sodium valproate
View adult BNF View SPC online
Unlicensed Drug Unlicensed
Green

Prophylaxis of Cluster Headache

Tablets 100mg
Modified-release tablets, 200mg, 300mg, 500mg
Modified-release capsules, 150mg, 300mg
Gastro-resistant tablets, 200mg, 500mg
Modified-release granules, 50mg, 100mg, 250mg, 500mg, 750mg, 1000mg
Oral solution 200mg/5ml

No BNFc entry - seek specialist advice

Amber Retained for girls and women of childbearing potential

 
Link  Pan Mersey APC (2019): VALPROATE: safe prescribing and dispensing to girls of any age and women of child bearing potential
   
Topiramate
View adult BNF View SPC online
Unlicensed Drug Unlicensed
Amber Recommended

Prophylaxis of Cluster Headache,  Hemicrania Continua
 
Tablets 25mg, 50mg, 100mg, 200mg

As cognitive and mood-related side effects are common with topiramate, patients should be specifically warned about these and advised to stop if they occur.

 No BNFc entry - seek specialist advice

 
   
04.08  Antiepileptics to top
04.08.01  Control of epilepsy
 note 

Brand / generic prescribing of anticonvulsants in epilepsy – Pan Mersey advice

  • Prescribe phenytoin, carbamazepine, phenobarbital, primidone, valproate, lamotrigine, perampanel, rufinamide, clobazam, clonazepam, oxcarbazepine, eslicarbazepine, zonisamide, topiramate by specific brand name
  • Prescribe lacosamide, tiagabine, gabapentin, pregabalin, ethosuximide, vigabatrin generically. Prescribe levetiracetam generically for new patients (or for currently-prescribed patients lacking disease stability undergoing review), but it is suggested existing stable patients who are prescribed Keppra® brand may remain on this brand.
  • The brand or the fact the drug is to be prescribed generically should be documented in patient notes and stated on prescriptions, and community pharmacists should confirm with patients that they have correct brand or generic, at point of dispensing.

Summary Table of Formulary Choices by Seizure Type

Focal onset epilepsy
Lamotrigine AMBER – 1st line
Levetiracetam AMBER RECOMMENDED – 1st line ALTERNATIVE
Carbamazepine AMBER RECOMMENDED – 1st line ALTERNATIVE
Focal onset epilepsy – add‑on drug options
Zonisamide AMBER RECOMMENDED
Clobazam AMBER RECOMMENDED
Lacosamide AMBER RECOMMENDED
Sodium valproate AMBER RECOMMENDED/INITIATED
Oxcarbazepine AMBER RECOMMENDED
Eslicarbazepine AMBER RECOMMENDED
Topiramate AMBER RECOMMENDED
Perampanel AMBER RECOMMENDED
Pregabalin AMBER RECOMMENDED
Gabapentin AMBER RECOMMENDED
Tiagabine AMBER INITIATED
Focal onset epilepsy – drugs only to be prescribed by a specialist in epilepsy
Sultiame RED – UNLICENSED
Stiripentol RED
Focal onset epilepsy – drugs only to be used when all other options have been tried or when prescribed by a specialist in epilepsy
Vigabatrin AMBER RETAINED
Brivaracetam AMBER INITIATED
Felbamate RED – UNLICENSED
Generalised epilepsy
Sodium valproate AMBER RECOMMENDED – 1st line men and children both sexes
AMBER INITIATED – 1st line women for efficacy but consider potential teratogenic effects
Lamotrigine AMBER RECOMMENDED – 1st line
Levetiracetam AMBER – 1st line
Generalised epilepsy – other drugs which can be used
Topiramate AMBER RECOMMENDED
Zonisamide AMBER RECOMMENDED
Clobazam AMBER RECOMMENDED
Ethosuximide AMBER RECOMMENDED
Rufinamide AMBER RECOMMENDED
Phenytoin AMBER INITIATED
Prolonged or repeated seizures and convulsive status epilepticus in the community
Diazepam Rectal tubes AMBER RECOMMENDED – 1st line
Paraldehyde Rectal enema RED
Lorazepam Parenteral: IV injection AMBER RECOMMENDED – 2nd line
Diazepam Parenteral: IV injection (as emulsion) AMBER RECOMMENDED – 2nd line
04.08.01  Carbamazepine, Eslicarbazepine and Oxcarbazepine
Carbamazepine
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended
Red Triangle Take care when prescribing and dispensing
A given dose of carbamazepine oral suspension will produce higher peak levels than the same dose in tablet form. When switching a patient from tablets to liquid the same overall dose may be used but in smaller, more frequent, doses.[SPS (2018)]
Offer a modified release product.
Modified release tablets 200 mg, 400 mg
Standard release tablets 100 mg, 200 mg, 400 mg
Oral suspension 100 mg/5 ml
Suppositories 125 mg, 250 mg

Purple Paediatrics

Focal onset epilepsy - 1st line ALTERNATIVE

Generalised epilepsy – may be best avoided; Carbamazepine has been shown to exacerbate some seizure types in generalised epilepsy, in particular absences and myoclonus.
However, if tonic-clonic seizures are resistant to other treatments in generalised epilepsy then occasionally carbamazepine can be used effectively, but the patients should be warned of the possibility of exacerbating the seizure types.

 
   
Eslicarbazepine
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended

Tablets 800mg

Focal onset epilepsy - add on drug option.

 
   
Oxcarbazepine
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended

Tablets 150mg, 300mg, 600mg
Oral suspension 300mg/5mL

Focal onset epilepsy - add on drug option.

Amber Initiated Paediatrics

 
   
04.08.01  Ethosuximide
Ethosuximide
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended

Capsules 250mg 
Oral solution 250mg/5mL

Amber Initiated Paediatrics


Absence seizures and occasionally myoclonic absence seizures

 
   
04.08.01  Gabapentin and pregabalin
Gabapentin
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended

Capsules 100mg, 300mg, 400mg
Oral solution 50mg/mL


Amber Initiated Paediatrics
Focal onset epilepsy - add on drug option.

 
Controlled Drug Schedule 3
Link  Gabapentin (Neurontin): risk of severe respiratory depression
   
Pregabalin
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended

Capsules 25mg, 50mg, 75mg, 100mg, 150mg, 200mg, 225mg, 300mg
Oral solution 20mg/mL
Amber Initiated Paediatrics
Focal onset epilepsy - add on drug option.

 
Controlled Drug Schedule 3
   
04.08.01  Lacosamide to top
Lacosamide
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended

Tablets 50mg, 100mg, 150mg, 200mg
 Oral solution 10mg/mL


Amber Initiated Paediatrics
Focal onset epilepsy - add on drug option.

 
   
04.08.01  Lamotrigine
Lamotrigine
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended

Tablets 25mg, 50mg, 100mg, 200mg,
Dispersible tablets 2mg, 5mg, 25mg, 100mg
Amber Initiated Paediatrics
Focal onset epilepsy - 1st line
If a more rapid titration of drug is required then consider an alternative first-line AED such as levetiracetam or carbamazepine.

Generalised epilepsy - 1st line

Lamotrigine is a 1st line option in women of childbearing age, if the main seizure type is tonic clonic seizures and if, after discussion, the young person or woman does not wish to take sodium valproate

 
   
04.08.01  Levetiracetam
Levetiracetam
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended

Tablets 250mg, 500mg, 750mg, 1g
Oral Solution 100mg/mL

Granules 250mg, 500mg, 1g (expensive - for use in tube-fed patients only)


Amber Initiated Paediatrics
Focal onset epilepsy - 1st line ALTERNATIVE

Generalised epilepsy - 1st line
Levetiracetam is a 1st line option in women of childbearing age, if myoclonus is prominent, for example in juvenile myoclonic epilepsy and if after discussion, the young person / woman does not wish to take valproate.

 
Link  BGMA: Levetiracetam containing products 100 mg/mL oral solution presentations: Risk of medication errors associated with overdose, April 2017
   
04.08.01  Perampanel
Perampanel
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended

Tablets 2mg, 4mg, 6mg, 8mg, 10mg, 12mg
Amber Initiated Paediatrics
Focal onset epilepsy - add on drug option.

 
   
04.08.01  Phenobarbital and other barbiturates
Controlled Drug Phenobarbital
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended

Tablets 15mg, 30mg, 60mg
Elixir 15mg/5mL (licensed) contains 38% alcohol, unsuitable for use in children
Alcohol free oral solution 50mg/5mL (Specials)
CD schedule 3
May be initiated in secondary care by a paediatric neurologist to manage difficult cases of epilepsy.

Amber Initiated Paediatrics

 
   
04.08.01  Phenytoin to top
Phenytoin
View adult BNF View SPC online View childrens BNF
Formulary
Amber Initiated
Red Triangle Take care when prescribing and dispensing
Preparations containing phenytoin sodium (capsules and tablets) are not bioequivalent to those containing phenytoin base (chewable tablets and suspension). 100 mg phenytoin sodium is approximately equivalent to 92 mg phenytoin base. The dose is the same for all phenytoin products when initiating therapy. However, if switching between these products the difference in phenytoin content may be clinically significant. Therefore plasma-phenytoin concentration monitoring is recommended.[SPS (2018)]
Capsules 25 mg, 50 mg, 100 mg, 300 mg
Tablets 100 mg
Chewable tablets (as base) 50 mg
Suspension (as base) 30 mg /5 ml
90 mg /5 ml (Special Order)

May be initiated in secondary care in an acute situation (e.g., following an IV loading dose for status epilepticus), not necessarily by an epilepsy specialist.

Note caution below:
Phenytoin has been shown to exacerbate some seizure types in generalised epilepsy, in particular absences and myoclonus.
However, if tonic-clonic seizures are resistant to other treatments in generalised epilepsy then occasionally phenytoin can be used effectively, but the patients should be warned of the possibility of exacerbating the seizure types.

 
   
04.08.01  Retigabine
04.08.01  Rufinamide
Rufinamide
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended

Tablets 100mg, 200mg, 400mg
Oral suspension 40mg/mL


Amber Initiated Paediatrics
 
For atonic and tonic seizures and atypical absences as part of Lennox-Gastaut syndrome.

 
   
04.08.01  Tiagabine
Tiagabine
View adult BNF View SPC online View childrens BNF
Formulary
Amber Initiated

Tablets 5mg, 10mg, 15mg


Amber Initiated Paediatrics
Focal onset epilepsy - add on drug options.

Generalised epilepsy – may be best avoided. Tiagabine and vigabatrin has been shown to exacerbate some seizure types in generalised epilepsy, in particular absences and myoclonus.

 
   
04.08.01  Topiramate
Topiramate
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended

Tablets 25mg, 50mg, 100mg, 200mg
Sprinkle capsules 15mg, 25mg, 50mg 


Amber Initiated Paediatrics
Focal onset epilepsy - add on drug option.
 

 
   
04.08.01  Valproate to top
Sodium Valproate
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended

Tablets 100mg
Modified-release tablets 200mg, 300mg, 500mg
Modified-release capsules 150mg, 300mg
Gastro-resistant tablets 200mg, 500mg
Modified-release granules 50mg, 100mg, 250mg, 500mg, 750mg, 1g
Oral solution 200mg/5mL

Amber Patient Retained for girls and women of childbearing potential

Amber Initiated Paediatrics

Focal onset epilepsy
Add on drug option

Generalised epilepsy

  • Men: First line
  • Women: Valproate carries more risks in pregnancy than other AEDs, so although it would be 1st line in women from an efficacy point of view, potential teratogenic effects must be considered and fully discussed.
  • Children of both sexes: First line
 
Link  Pan Mersey APC (2019). VALPROATE: safe prescribing and dispensing to girls of any age and women of child bearing potential
   
04.08.01  Vigabatrin
Vigabatrin
View adult BNF View SPC online View childrens BNF
Formulary
Amber Retained

Tablets 500mg
Oral powder 500mg
 
Testing of visual fields every 6 months is recommended.

Focal onset epilepsy – drugs only to be used when all other options have been tried or when prescribed by a specialist in epilepsy.

Generalised epilepsy – may be best avoided. Vigabatrin has been shown to exacerbate some seizure types in generalised epilepsy, in particular absences and myoclonus.

 
   
04.08.01  Zonisamide
Zonisamide
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended

Capsules 25mg, 50mg, 100mg


Amber Initiated Paediatrics
Focal onset epilepsy - add on drug option.

 
   
04.08.01  Benzodiazepines
 note 
   
Clobazam
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended

Tablets 10mg
Oral suspension 5mg/5ml, 10mg/5mL


Amber Initiated Paediatrics
Focal onset epilepsy - add on drug option.

 
   
Clonazepam
View adult BNF View SPC online View childrens BNF
Formulary
Amber Initiated

Tablets 500mcg, 2mg

Oral solution 2mg/5mL (sugar free)

Oral drops 2.5mg.mL (import)

 
Controlled Drug schedule 4 (CD Benz)
   
Nitrazepam
View adult BNF View SPC online
Formulary
Green

Tablets 5mg

Oral suspension 2.5mg/5mL

Amber Patient Retained Paediatrics for epilepsy

No BNFc entry – seek specialist advice

 
Controlled Drug Schedule 4 (CD Benz)
Link  Pan Mersey APC Prescribing Support Information Nitrazepam for epilepsy in children
   
04.08.01  Other Drugs
Acetazolamide
View adult BNF View SPC online View childrens BNF
Formulary
Amber Retained

250mg tablets, 250mg m/r capsules

Paediatrics only. Children's dose: 8-30mg/kg in daily divided doses and not to exceed 750mg/day.

 
   
Brivaracetam
View adult BNF View SPC online View childrens BNF
Formulary
Amber Initiated

Tablets 10mg, 25mg, 50mg, 75mg, 100mg

Oral solution 10mg/ml

Red Solution for injection 10mg/ml 

 

Red in West Lancashire CCG

Grey for use in adolescents and children from 4 years of age to under 16 years of age.

 
Link  BRIVARACETAM tablets and oral solution (Briviact®▼) Pan Mersey Area Prescribing Committee Prescribing Policy Statement
Link  PAN MERSEY AREA PRESCRIBING COMMITTEE PRESCRIBING POLICY STATEMENT: BRIVARACETAM tablets and oral solution (Briviact®▼) for the treatment of epilepsy in children and adolescents
   
Controlled Drug Cannabis-based products for medicinal use
View adult BNF View childrens BNF
Formulary
Grey

Unlicensed "Special" products

 
Link  Pan Mersey APC (2018). CANNABIS-BASED products for medicinal use
   
Stiripentol
View childrens BNF
Formulary
Red

Capsules 250mg, 500mg
Powder 250mg/sachet, 500mg/sachet

Only for Dravet syndrome.

Focal onset epilepsy – only to be prescribed by a specialist in epilepsy.

Purple Wirral CCG

 
   
Felbamate
Unlicensed Drug Unlicensed
Red

Tablets 400mg, 600mg
Oral suspension 600mg/5mL

Focal onset epilepsy – only to be used when all other options have been tried or when prescribed by a specialist in epilepsy.

No BNFc entry – seek specialist advice

 
   
Sultiame
Unlicensed Drug Unlicensed
Red

Tablets 200mg

Also known as sulthiame.

Focal onset epilepsy – only to be prescribed by a specialist in epilepsy.

No BNFc entry – seek specialist advice

 
   
04.08.02  Drugs used in status epilepticus to top
 note 

Drug driving

Information for patients

Guidance for healthcare professionals on drug driving

Drugs and driving: blood concentration limits set for certain drugs

It is very important that a first prescription of rescue medication should not be prescribed and dispensed by any pharmacy without the family having been instructed in:
a) When to use rescue medication
b) How to administer rescue medication
c) When an ambulance should be called after a child or patient has received rescue medication 


The above advice should be given by the initiating specialist in secondary care. It would be inappropriate and potentially unsafe to issue a prescription for rescue medication and expect the family to administer this at home without prior instruction.

Controlled Drug Midazolam
View adult BNF View SPC online View childrens BNF
First Choice
Amber Recommended

Red Triangle Take care when prescribing and dispensing

Buccal midazolam is available as both a 5mg/ml and 10mg/ml solution. To avoid confusion prescribe midazolam buccal solution using the brand name and state the dose in milligrams (mg) and millilitres (ml)

Buccal solution (Buccolam®) 5mg/mL in prefilled syringe:
0.5mL (2.5mg) prefilled syringe
1mL (5mg) prefilled syringe
1.5mL (7.5mg) prefilled syringe
2mL (10mg) prefilled syringe

Buccal solution (Epistatus®):

1mL (10mg) prefilled syringe

N.B. 10mg strength available in two different concentrations

Prolonged or repeated seizures and convulsive status epilepticus in the community. Only prescribe buccal midazolam or rectal diazepam for children, young people and adults who have had a previous episode of prolonged or serial convulsive seizures.

 
Diazepam
View adult BNF View SPC online View childrens BNF
First Choice
Amber Recommended

Rectal tubes (enema):
2mg/mL 1.25mL (2.5mg) tube
2mg/mL 2.5mL (5mg) tube
4mg/mL 2.5mL (10mg) tube
 
Prolonged or repeated seizures and convulsive status epilepticus in the community.

Only prescribe buccal midazolam or rectal diazepam for children, young people and adults who have had a previous episode of prolonged or serial convulsive seizures.

 
Lorazepam
View adult BNF View SPC online View childrens BNF
Second Choice
Amber Recommended

Parenteral: IV injection 4mg/mL

Prolonged or repeated seizures and convulsive status epilepticus in the community.

Only use IV products if IV access is already established and resuscitation facilities are available.

Red Paediatrics

 
   
Diazepam
View adult BNF View SPC online View childrens BNF
Second Choice
Amber Recommended

Parenteral: IV injection (as emulsion)5mg/mL (0.5%)

Prolonged or repeated seizures and convulsive status epilepticus in the community.

Only use IV products if IV access is already established and resuscitation facilities are available.

Red Paediatrics

 
   
Paraldehyde
Unlicensed Drug Unlicensed
Red

Rectal enema

Prolonged or repeated seizures and convulsive status epilepticus in the community.

No BNFc entry – seek specialist advice

 
   
04.08.03  Febrile convulsions
04.09  Drugs used in parkinsonism and related disorders
 note 

Although PD is predominantly a movement disorder, other impairments frequently develop including dementia. 48% to 80% of people may develop dementia at some point in the course of the condition. Refer to Chapter 4 subsection 11 for drugs used in dementia.

04.09.01  Dopaminergic drugs used in Parkinson's disease
 note 


Safinamide
View adult BNF View SPC online
Formulary
Amber Recommended

Tablets 50mg, 100mg

No BNFc entry – seek specialist advice

 
Link  Pan Mersey APC (2019). SAFINAMIDE tablets (Xadago®▼) for Parkinson’s Disease
   
04.09.01  Dopamine receptor agonists
 note 

Impulse control disorders

Treatment with dopamine-receptor agonists (and rarely with levodopa) is associated with impulse control disorders, including pathological gambling, binge eating, compulsive shopping and hypersexuality. An enquiry as to whether the patient has a history of impulse control disorders should be made prior to prescribing dopaminergic therapy for Parkinson’s disease and Restless Legs because of the potential risk of impulse control disorders. Patients and their carers should be informed about the risk and told to report any change in such behaviour. Patients with a significant history of impulse control disorders should seek specialist advice before initiation of dopaminergic therapy. If the patient develops an impulse control disorder, the dopamine-receptor agonist or levodopa should be withdrawn or the dose reduced until the symptoms resolve.

MHRA: Dopamine agonists: pathological gambling,increased libido and hypersexuality

 

Pramipexole
View adult BNF View SPC online
Formulary
Amber Recommended

Tablets 88micrograms, 180micrograms, 350micrograms, 700micrograms
MR Tablets 260micrograms, 520micrograms, 1.05mg, 1.57mg, 2.1mg, 2.62mg, 3.15mg
 
Green Restless legs syndrome -
Tablets 88micrograms, 180micrograms, 350micrograms

(Strengths above expressed as base; see BNF for salt equivalence; pramipexole doses may be expressed as either.)

No BNFc entry - seek specialist advice

 
Link  NICE (2015). CKS: Restless legs syndrome
   
Ropinirole
View adult BNF View SPC online
Formulary
Amber Recommended

Tablets  (Requip®, Accord brand generic ropinirole) 250micrograms, 500micrograms, 1mg, 2mg, 5mg
MR Tablets 2mg, 3mg, 4mg, 6mg, 8mg
 
Green Restless legs syndrome
Tablets (Adartrel®, Actavis brand generic ropinirole) 250micrograms, 500micrograms, 1mg, 2mg

No BNFc entry - seek specialist advice

 
Link  NICE (2017). CKS: Restless legs syndrome
   
Rotigotine
View adult BNF View SPC online
Formulary
Amber Recommended

Patches (Neupro®) 2mg/24 hours, 4mg/24 hours, 6mg/24 hours, 8mg/24 hours
28 day Starter pack (Neupro®) (7x2mg/24hr, 7x4mg/24hr, 7x6mg/24hr, and 7x8mg/24hr patches)

Green Restless legs syndrome
Patches (Neupro®) 1mg/24 hours, 2mg/24 hours, 3mg/24 hours

No BNFc entry – seek specialist advice 

 
Link  NICE (2017). CKS: Restless legs syndrome
   
Apomorphine
View adult BNF View SPC online
Formulary
Amber Retained

SC Injection 50mg/5mL
SC Injection (APO-go® Pen)30mg/3mL pen injector
SC Injection (APO-go® PFS) 50mg/10mL pre-filled syringes

Notes
Apomorphine should be initiated in a specialist clinic with at least two days pre-treatment with domperidone for nausea and vomiting. Treatment with apomorphine should remain under specialist supervision.

No BNFc entry – seek specialist advice

 
Link  Pan Mersey APC (2016). APOMORPHINE, prescribing support information
   
04.09.01  Levodopa to top
 note 

Impulse control disorders

Treatment with dopamine-receptor agonists (and rarely with levodopa) is associated with impulse control disorders, including pathological gambling, binge eating, compulsive shopping and hypersexuality. An enquiry as to whether the patient has a history of impulse control disorders should be made prior to prescribing dopaminergic therapy for Parkinson’s disease, and Restless Legs because of the potential risk of impulse control disorders. Patients and their carers should be informed about the risk and told to report any change in such behaviour. Patients with a significant history of impulse control disorders should seek specialist advice before initiation of dopaminergic therapy. If the patient develops an impulse control disorder, the dopamine-receptor agonist or levodopa should be withdrawn or the dose reduced until the symptoms resolve.

MHRA (2014). Dopamine agonists: pathological gambling, increased libido and hypersexuality

Co-Beneldopa (Benserazide/Levodopa)
View adult BNF View SPC online
Formulary
Amber Recommended

Capsules 12.5mg/50mg, 25mg/100mg, 50mg/200mg
Dispersible tablets (Madopar®) 12.5mg/50mg, 25mg/100mg
MR capsules (Madopar® CR) 25mg/100mg

No BNFc entry – seek specialist advice

 
   
Co-Careldopa (Carbidopa/Levodopa)
View adult BNF View SPC online
Formulary
Amber Recommended

Tablets 10mg/100mg, 12.5mg/50mg, 25mg/100mg, 25mg/250mg
MR Tablets 25mg/100mg, 50mg/200mg

Oral suspension 125mg in 10mL (extemporaneous preparation under Specials Scheme)

Amber Initiated Paediatrics

 

 
   
Co-Careldopa (Carbidopa/Levodopa)
View adult BNF View SPC online
Formulary
Red

Intestinal Gel 100ml cassette (Duodopa®)
NHS NHSE commissioned drug - see Specialised Commissioning: Key documents

 No BNFc entry - seek specialist advice

 
   
04.09.01  Monoamine-oxidase-B inhibitors
Rasagiline
View adult BNF View SPC online
Formulary
Amber Recommended

Tablets 1mg

No BNFc entry – seek specialist advice

 
   
Selegiline
View adult BNF View SPC online
Formulary
Amber Recommended
Red Triangle Take care when prescribing and dispensing
ONE 10 mg selegiline hydrochloride tablet is equivalent to ONE 1.25 mg oral lyophilisate tablet (Zelapar®).[SPS (2018)]
Tablets 5 mg, 10 mg
Oral liquid 10 mg/5 ml
Oral lyophilisates 1.25 mg (Zelapar®)

No BNFc entry - seek specialist advice

 
   
04.09.01  Catachol-O-methyltransferase inhibitors
 note 

Entacapone should not be given concurrently with non-selective Monoamine-oxidase inhibitors; selective Monoamine-oxidase inhibitors should not be used at higher doses than recommended when used concurrently with entacapone.

Tolcapone is associated with potentially life-threatening hepatotoxicity and should be prescribed under specialist supervision only, when other COMT inhibitors combined with co-beneldopa or co-careldopa are ineffective. Patients should be told how to recognise symptoms of liver disorder and advised to seek medical attention if they occur.

Entacapone
View adult BNF View SPC online
Formulary
Amber Recommended

Tablets 200mg

No BNFc entry – seek specialist advice

 
   
Levodopa/carbidopa/entacapone
View adult BNF View SPC online
Formulary
Amber Recommended

Tablets 50mg/12.5mg/200mg
Tablets 75mg/18.75mg/200mg
Tablets 100mg/25mg/200mg
Tablets 125mg/31.25mg/200mg
Tablets 150mg/37.5mg/200mg
Tablets 175mg/43.75mg/200mg
Tablets 200mg/50mg/200mg

No BNFc entry – seek specialist advice

 
   
Opicapone
View adult BNF View SPC online
Formulary
Amber Recommended

Capsules (Ongentys(r) ) 50mg

No BNFc entry – seek specialist advice

 
Link  Pan Mersey APC (2019). OPICAPONE capsules (Ongentys®▼) for Parkinson’s Disease
   
Tolcapone
View adult BNF View SPC online
Formulary
Red

Tablets (Tasmar®) 100mg

No BNFc entry – seek specialist advice

 
   
04.09.01  Amantadine
Amantadine
View adult BNF View SPC online
Formulary
Amber Recommended

Capsules 100mg
Syrup 50mg/5mL

Amber Initiated Paediatrics

 

NICE recommends offering amantadine to treat fatigue in people with multiple sclerosis.

 
Link  NICE (2014). Multiple sclerosis in adults: management [CG186]
   
04.09.02  Antimuscarinic drugs used in parkinsonism
Orphenadrine
View adult BNF View SPC online
Formulary
Amber Recommended

Tablets 50mg - manufacture ceased 30 Nov 2015.

Oral liquid 50mg/5mL
Oral liquid SF 25mg/5mL (unlicensed Special)
 
Advice on alternative treatment from local specialists:
Patients treated with orphenadrine for Parkinsons’ Disease may be changed to procyclidine at a dose of 5mg * for each 50mg of orphenadrine.
Patients treated with orphenadrine for management of extra-pyramidal side effects of antipsychotic drugs may be changed to procyclidine or trihexyphenidyl at a dose equivalence of orphenadrine 50mg = procyclidine 5mg * = trihexyphenidyl 2mg
Some patients may experience anticholinergic side effects (dry mouth, blurred vision, urinary hesitancy, confusion) after any switch and others may find control of tremor / dystopia / extra-pyramidal side effects not as good, and dose may need to be adjusted appropriately.

* Bazire. Psychotropic Drug Directory 2016. Lloyd-Reinhold Communications, 2016, Page 216. 


Amber Initiated Paediatrics

 
   
Procyclidine
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended

Tablets 5mg
Oral solution 2.5mg/5mL, 5mg/5mL

Amber Initiated Paediatrics

Red Injection 10mg/2mL

 
   
Trihexyphenidyl
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended

Tablets 2mg, 5mg
 Oral solution 5mg/5mL

Amber Initiated Paediatrics

 
   
04.09.03  Drugs used in essential tremor, chorea, tics, and related disorders to top
 note 

Chlorpromazine and haloperidol are used for intractable hiccup.

Haloperidol can also improve motor tics, symptoms of Tourette syndrome and related choreas.

Sulpiride (unlicensed indication) may be used to treat chorea.

Propranolol may be useful in essential tremors, or tremors associated with anxiety or thyrotoxicosis.

Primidone sometimes provides relief from benign essential tremor.

Gabapentin (unlicensed indication) and topiramate (unlicensed indication) may also be useful for tremors.

Piracetam is used as an adjunctive treatment for myoclonus of cortical origin.

Clonazepam and Levetiracetam may sometimes be required for myoclonus.

Tetrabenazine is mainly used to control movement disorders in Huntington's chorea and related disorders. It can also be prescribed for tardive dyskinesia if switching or withdrawing the causative antipsychotic drug is ineffective.

Riluzole is used to extend life in patients with motor neurone disease who have amyotrophic lateral sclerosis.

Drug driving

Guidance for healthcare professionals on drug driving

Information for patients

Drugs and driving: blood concentration limits set for certain drugs

Clonazepam
View adult BNF View SPC online
Formulary
Amber Recommended

Tablets 500micrograms, 2mg

No BNFc entry – seek specialist advice

 
Controlled Drug Schedule 4-1
   
Chlorpromazine
View adult BNF View SPC online
Formulary
Amber Recommended

Tablets 25mg, 50mg, 100mg 
Oral solution 25mg/5mL

No BNFc entry - seek specialist advice

 
   
Gabapentin
View adult BNF View SPC online
Formulary
Amber Recommended

Capsules 100mg, 300mg, 400mg
Oral solution 50mg/5mL
Gabapentin is off-label for tremors

Green Restless legs syndrome (off-label) second-line after dopamine agonist

No BNFc entry - seek specialist advice

 
Controlled Drug Schedule 3
Link  Gabapentin (Neurontin): risk of severe respiratory depression
   
Haloperidol
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended

Capsules 500micrograms
Tablets 1.5mg, 5mg, 10mg
Oral liquid, SF 1mg/mL, 2mg/mL

Amber Patient Retained Paediatrics

 
   
Levetiracetam
View adult BNF View SPC online
Formulary
Amber Recommended

Tablets 250mg, 500mg, 750mg, 1g
Oral solution 100mg/mL

Granules 250mg, 500mg, 1g (expensive - for use in tube-fed patients only)

No BNFc entry - seek specialist advice

 
Link  BGMA: Levetiracetam containing products 100 mg/mL oral solution presentations: Risk of medication errors associated with overdose, April 2017
   
Piracetam
View adult BNF View SPC online
Formulary
Amber Recommended

Tablets (Nootropil®) 800mg, 1.2g
Oral solution (Nootropil®) 333.3mg/mL

Amber Initiated Paediatrics

No BNFc entry - seek specialist advice

 
   
Pregabalin
View adult BNF
Formulary
Green

Capsules, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg, 200mg, 225 mg, 300 mg
Oral solution 20mg/ml

Restless legs syndrome (off-label) second-line after dopamine agonist

Paediatrics: no BNFc entry - seek specialist advice

 
Controlled Drug Schedule 3
   
Primidone
View adult BNF View SPC online
Formulary
Amber Recommended

Tablets (Mysoline®) 50mg, 250mg

No BNFc entry – seek specialist advice

 
   
Propranolol
View adult BNF View SPC online View childrens BNF
Formulary
Green

Tablets 40mg, 80mg
Oral solution 40mg/5mL

Amber Initiated Paediatrics

 
   
Riluzole
View adult BNF View SPC online
Formulary
Purple

Tablets 50mg

Oral solution 5mg in 1mL
Motor Neurone Disease- Riluzole NICE TA20 
 
NICE: Riluzole for motor neurone disease (January 2001)
Riluzole is recommended for treating the amyotrophic lateral sclerosis (ALS) form of motor neurone disease (MND). Treatment should be initiated by a specialist in MND but it can then be supervised under a shared-care arrangement involving the general practitioner.

 

Red  for new patients, current patients continue with current practice until shared care framework is implemented.

No BNFc entry – seek specialist advice

 
Link  NICE TA20: Motor neurone disease - riluzole National Institute for Health and Care Excellence
   
Sodium valproate
View adult BNF View SPC online
Formulary
Amber Recommended

Tablets 100mg
Modified-release tablets 200mg, 300mg, 500mg
Modified-release capsules 150mg, 300mg
Gastro-resistant tablets 200mg, 500mg
Modified-release granules 50mg, 100mg, 250mg, 500mg, 750mg, 1g
Oral solution 200mg/5mL

May provoke or increase postural tremor, and rarely Parkinsonism.

Amber Retained for girls and women of child bearing potential. Valproate carries more risk in pregnancy than other AEDs, potential teratogenic effects must be considered and fully discussed.No BNFc entry – seek specialist advice

 
Link  Pan Mersey APC (2019). VALPROATE: safe prescribing and dispensing to girls of any age and women of child bearing potential
   
Sulpiride
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended

Tablets 200mg
Oral solution 200mg/5mL
Sulpiride is off-label for chorea

Amber Initiated Paediatrics

 
   
Topiramate
View adult BNF View SPC online
Formulary
Amber Recommended

Tablets 25mg, 50mg, 100mg, 200mg
Sprinkle capsules 15mg, 25mg, 50mg
Topiramate is off-label for tremors

No BNFc entry - seek specialist advice

 
   
Tetrabenazine
View adult BNF View SPC online
Formulary
Amber Recommended

Tablets 25mg

Tetrabenazine is effective in only a proportion of patients and its use may be limited by the development of depression

No BNFc entry – seek specialist advice

 
   
04.09.03  Torsion dystonias and other involuntary movements
Baclofen
View adult BNF View SPC online
Formulary
Amber Recommended

Tablets 10mg
Oral solution 5mg / 5mL

Amber Initiated Paediatrics

 

 
   
Baclofen
View adult BNF View SPC online
Formulary
Red

Intrathecal injection 500micrograms/ml and 2mg/ml – specialist use only.

NHS NHSE commissioned drug - see Specialised Commissioning: Key documents

No BNFc entry – seek specialist advice

 
   
Botulinum Toxin Type A
View adult BNF View SPC online View childrens BNF
Formulary
Red
Injection, powder for reconstitution
Botox® 50-unit vial, 100-unit vial, 200-unit vial
Xeomin® 50-unit vial, 100-unit vial
Dysport® 300-unit vial, 500-unit vial

Note
Botulinum Toxin preparations are NOT interchangeable

NHS NHSE commissioned drug - see Specialised Commissioning: Key documents
 
   
Botulinum Toxin Type B
View adult BNF View SPC online
Formulary
Red

Injection (NeuroBloc®) 5000 units/mL
For use by The Walton Centre only within its licensed indications and only when Botulinum Toxin Type A fails.

Note
Botulinum Toxin preparations are NOT interchangeable

No BNFc entry – seek specialist advice

NHS NHSE commissioned drug - see Specialised Commissioning: Key documents

 
   
Clonazepam
View adult BNF View SPC online
Formulary
Amber Recommended

unlicensedunlicensed

Tablets 500 micrograms, 2mg
Oral solution 500 micrograms / 5mL

Amber Initiated Paediatrics

 
Controlled Drug Schedule 4 - 1
   
Co-beneldopa
(Benserazide/Levodopa)
View adult BNF View SPC online
Formulary
Amber Recommended

unlicensedunlicensed

Capsules 12.5mg/50mg, 25mg/100mg, 50mg/200mg
Dispersible tablets (Madopar®) 12.5mg/50mg, 25mg/100mg
MR capsules (Madopar® CR) 25mg/100mg

No BNFc entry – seek specialist advice

 
   
Co-careldopa
(Carbidopa/Levodopa)
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended

unlicensedunlicensed

Tablets 10mg/100mg, 12.5mg/50mg, 25mg/100mg, 25mg/250mg
MR Tablets 25mg/100mg, 50mg/200mg 

Amber Initiated Paediatrics

 
   
Orphenadrine
View adult BNF View SPC online
Formulary
Amber Recommended

unlicensedunlicensed

Tablets 50mg - manufacture ceased 30 Nov 2015.

Oral liquid 50mg/5mL
Oral liquid SF 25mg/5mL (unlicensed Special)

No BNFc entry – seek specialist advice

Advice on alternative treatment from local specialists:
Patients treated with orphenadrine for Parkinsons’ Disease may be changed to procyclidine at a dose of 5mg * for each 50mg of orphenadrine.
Patients treated with orphenadrine for management of extra-pyramidal side effects of antipsychotic drugs may be changed to procyclidine or trihexyphenidyl at a dose equivalence of orphenadrine 50mg = procyclidine 5mg * = trihexyphenidyl 2mg
Some patients may experience anticholinergic side effects (dry mouth, blurred vision, urinary hesitancy, confusion) after any switch and others may find control of tremor / dystopia / extra-pyramidal side effects not as good, and dose may need to be adjusted appropriately.

* Bazire. Psychotropic Drug Directory 2016. Lloyd-Reinhold Communications, 2016, Page 216. 

 
   
Trihexyphenidyl
View adult BNF View SPC online View childrens BNF
Formulary
Amber Recommended

unlicensedunlicensed

Tablets 2mg, 5mg
Oral solution 5mg/5ml

Amber Initiated Paediatrics

 
   
04.10  Drugs used in substance dependence
04.10.01  Alcohol dependence
 note 

All interventions for alcohol dependence should be delivered and monitored by specialist or appropriately trained and competent staff.

Acute Alcohol Withdrawal

People who are dependent on alcohol should be offered alcohol detoxification followed by a range of psychological and pharmacological interventions to prevent relapse.

Benzodiazepines are effective in reducing signs and symptoms of alcohol withdrawal, and are the treatment of choice. Long-acting benzodiazepines (e.g. chlordiazepoxide or diazepam) are preferred for acute alcohol withdrawal. Benzodiazepines with limited liver metabolism (e.g. lorazepam, oxazepam) may be better tolerated in liver impairment. Carbamazepine [unlicensed indication] may be considered by specialists as an alternative treatment in acute alcohol withdrawal when benzodiazepines are contra-indicated or not tolerated.

Alcohol Dependence

Acamprosate or naltrexone, in combination with an individual psychological intervention, are treatment options for maintaining abstinence in people with alcohol dependence following successful withdrawal. Disulfiram is also effective but should only be used under specialist supervision when acamprosate and naltrexone are not suitable, or if the patient prefers it and there are no contraindications. Baclofen may be used in specialist settings for relapse prevention in patients when other medications for alcohol dependence are not suitable. Nalmefene in combination with psychosocial support is licensed for the reduction of alcohol consumption in patients with alcohol dependence who have a high drinking risk level, without physical withdrawal symptoms, and who do not require immediate detoxification. Benzodiazepines should not be used as ongoing treatment for alcohol dependence.

Patients with alcohol dependence may suffer from severe nutritional and vitamin deficiencies and associated health consequences. Fluid and electrolyte defects and nutritional deficiencies should be corrected. Vitamin B deficiency can interfere with recovery and, in particular, thiamine deficiency can lead to the development of Wernicke-Korsakoff syndrome. Thiamine supplementation should be used for the treatment and/or prevention in people with suspected or established Wernicke's encephalopathy. NICE CG100 states that once alcohol is stopped, oral thiamine absorption may take six weeks to return to normal.
 

Drug driving

Guidance for healthcare professionals on drug driving

Information for patients

Drugs and driving: blood concentration limits set for certain drugs

Chlordiazepoxide
View adult BNF View SPC online
First Choice
Red

Tablets 5mg, 10mg
Capsules 5mg, 10mg

For Acute Alcohol Withdrawal
 
Prescribed by specialist services

Amber Recommended Warrington CCG

No BNFc entry - seek specialist advice

 
Diazepam
View adult BNF View SPC online
Second Choice
Red

Tablets 2mg, 5mg, 10mg

For Acute Alcohol Withdrawal

Prescribed by specialist services

No BNFc entry – seek specialist advice

 
   
Lorazepam
View adult BNF View SPC online
Third Choice
Red

Tablets 1mg, 2.5mg

For Acute Alcohol Withdrawal
 
Prescribed by specialist services

No BNFc entry – seek specialist advice

 
   
Oxazepam
View adult BNF View SPC online
Third Choice
Red

Tablets 10mg, 15mg

For Acute Alcohol Withdrawal

Prescribed by specialist services

No BNFc entry – seek specialist advice

 
   
Carbamazepine
View adult BNF View SPC online
Third Choice
Red

Tablets 100mg, 200mg, 400mg
M/R Tablets 200mg, 400mg

Off-label indication

For Acute Alcohol Withdrawal
 
Prescribed by specialist services

No BNFc entry – seek specialist advice

 
   
Clomethiazole
View adult BNF View SPC online
Third Choice
Red
Red Triangle Take care when prescribing and dispensing
Clomethiazole syrup contains 50 mg/mL clomethiazole edisilate equivalent to 31.5 mg/mL clomethiazole. Clomethiazole capsules contain 192 mg clomethiazole; as a result of differences in bioavailability between the capsules and the syrup, ONE capsule is considered therapeutically equivalent to 5 mL syrup.[SPS (2018)]
For acute alcohol withdrawal
Prescribed by specialist services
Capsules 192 mg
Oral solution 31.5 mg/ml

 

 
   
Acamprosate
View adult BNF View SPC online
Formulary

Tablets e/c 333mg

For Alcohol Dependence

RED South Sefton CCG, Southport & Formby CCG - Prescribing retained by local commissioned alcohol service.

Amber Initiated Halton CCG, St Helen's CCG, Knowsley CCG, Liverpool CCG

Amber Recommended Warrington CCG

RAG status to be confirmed by individual CCGs

No BNFc entry – seek specialist advice

 
   
Baclofen
View adult BNF View SPC online
Formulary

Tablets 10mg
Oral solution 5mg / 5ml

Off label indication.

For Alcohol Dependance

RED Liverpool CCG, South Sefton CCG, Southport & Formby CCG - Prescribing retained by local commissioned alcohol service.

Red St Helen's CCG

Amber Initiated Halton CCG, Knowsley CCG

Amber Recommended Warrington CCG

RAG status to be confirmed by individual CCGs

Paediatrics: No BNFc entry – seek specialist advice

 
   
Disulfiram
View adult BNF View SPC online
Formulary

Tablets scored 200mg

For Alcohol Dependence

RED Liverpool CCG, South Sefton CCG, Southport & Formby CCG - Prescribing retained by local commissioned alcohol service.

Amber Initiated Halton CCG, St Helen's CCG, Knowsley CCG

Amber Recommended Warrington CCG, Wirral CCG

RAG status to be confirmed by individual CCGs

Paediatrics: No BNFc entry – seek specialist advice

 
   
Naltrexone
View adult BNF View SPC online
Formulary

Tablets f/c scored 50mg

For Alcohol Dependence

Off-label indication

RED Liverpool CCG, South Sefton CCG, Southport & Formby CCG, Wirral CCG - Prescribing retained by local commissioned alcohol service.

Amber Initiated Halton CCG, St Helen's CCG, Knowsley CCG

Amber Recommended Warrington CCG

RAG status to be confirmed by individual CCGs

Paediatrics: No BNFc entry – seek specialist advice

 
   
Nalmefene
View adult BNF View SPC online
Formulary

Tablets f/c 18mg

For Alcohol Dependance

RED Liverpool CCG, South Sefton CCG, Southport & Formby CCG, Wirral CCG - Prescribing retained by local commissioned alcohol service.

Amber Patient Retained Knowsley CCG

Amber Initiated St Helens CCG

Amber Recommended  Halton CCG, Warrington CCG

RAG status to be confirmed by individual CCGs

No BNFc entry – seek specialist advice

 
Link  NALMEFENE film coated tablets (Selincro®▼) Pan Mersey Area Prescribing Committee Policy Statement
Link  Nalmefene for reducing alcohol consumption in people with alcohol dependence National Institute for Health and Care Excellence Technology Appraisal
   
04.10.02  Nicotine dependence
 note 

Therapy to assist patients to stop smoking is selected according to the patient’s compliance, availability of counselling and support, previous experience of attempts to stop smoking, contra-indications and adverse effects of the products, and smoker’s preference.

Concomitant Medication

Cigarette smoking increases the metabolism of some medicines by stimulating the hepatic enzyme CYP1A2. When smoking is discontinued, the dose of these drugs, in particular theophylline, cinacalcet, ropinirole, and some antipsychotics (including clozapine, olanzapine, chlorpromazine and haloperidol) may need to be reduced. Regular monitoring of adverse effects is advised.

Contact details for smoking cessation services

Knowsley
Tel: 0800 3247 111
www.readytostopsmoking.co.uk

 

St Helen's
Tel: 01744 586 247
www.readytostopsmoking.co.uk

 

Warrington
Tel: 0300 003 0818
https://livewirewarrington.co.uk/lifestyle/stop-smoking
Email: lifestyles@warrington.org 

 

Halton
Tel: 0300 029 0029

http://hit.activehalton.co.uk/live-well/

 

Sefton
Tel: 0300 100 1000

https://www.smokefreesefton.co.uk/

 

Liverpool

Tel: 0800 061 4212 or 0151 374 2535

https://www.smokefreeliverpool.co.uk/Locations.aspx

Nicotine Replacement Therapy
View adult BNF View SPC online View childrens BNF
Formulary
Green
Patches: 16 hour: 10mg, 15mg, 25mg
24 hour: 7mg, 14mg, 21mg

Sublingual tablets: 2mg
Chewing Gum: 2mg, 4mg, 6mg
Lozenges: 1mg, 1.5mg, 2mg, 4mg
Oral Spray: 1mg/metered dose
Nasal Spray: 500micrograms/metered spray
Inhalator: 10mg/cartridge, 15mg/cartridge
Oral film: 2.5mg

Notes
• The use of nicotine replacement products in an individual who is already accustomed to nicotine introduces few new risks and it is widely accepted that there are no circumstances in which it is safer to smoke than to use NRT.
• Some patients benefit from having more than one type of NRT prescribed.
• The combination of NRT with varenicline or bupropion is not recommended.
 
   
Bupropion Hydrochloride
View adult BNF View SPC online
Formulary
Green

Tablets m/r 150mg

Notes
• Bupropion has been used as an antidepressant. Its mode of action in smoking cessation is unclear and may involve an effect on noradrenaline and dopamine transmission.
• Bupropion is contraindicated in patients with previous or current seizure disorder.
• Bupropion should not be offered to young people under 18 nor pregnant or breastfeeding women.
• Bupropion may impair performance of skilled tasks (e.g., driving)

No BNFc entry – seek specialist advice

 
   
Varenicline
View adult BNF View SPC online
Formulary
Green

Tablets 500micrograms, 1mg

Notes
• Patients should be advised to discontinue treatment and seek prompt medical advice if they develop agitation, depressed mood or suicidal thoughts. Patients with a history of psychiatric illness should be monitored closely while taking varenicline.
• Varenicline is recommended as an option for smokers who have expressed a desire to quit smoking. Varenicline should normally be prescribed only as part of a programme of behavioural support.
• Varenicline should not be offered to young people under 18 nor pregnant or breastfeeding women.

No BNFc entry – seek specialist advice

 
Link  NICE TA123: Varenicline NICE technology appraisal | Issued July 2007
   
E-Cigarettes
Formulary
Black
e-Voke® 
Link  MHRA: e-cigarettes and refill containers (e-liquids): report suspected side effects and safety concerns, June 2017
Link  Pan Mersey APC. E - Cigarettes, July 2018
   
04.10.03  Opioid dependence to top
 note 

Treatments for opioid dependence should be initiated under the supervision of an appropriately qualified and experienced prescriber.

Opioid Substitution Therapy

Oral methadone and buprenorphine are effective first line options in the management of opioid dependence. The decision about which drug to use should be made on a case by case basis taking into account individual risks and benefits. NICE recommends that if both drugs are equally suitable, methadone should be prescribed as the first choice. Buprenorphine may be preferred in some cases because compared to methadone, it is less sedating, less affected by interactions involving hepatic enzymes and safer in overdose. Buprenorphine should not normally be used in liver dysfunction.

Methadone and buprenorphine should be administered daily, under supervision, for at least the first 3 months or as appropriate to individual needs and risks. Supervision should be relaxed only when the patient's compliance is assured.

People receiving opioid substitution therapy should be fully advised of the actions and effects of treatment; the consequences of missed doses; the potential side effects and interactions; warning signs of toxicity; and the importance of safe storage of medication.

Adjunctive therapy and symptomatic treatment

Some withdrawal symptoms may be alleviated by specific pharmacological treatment. Adjunctive medications should only be used when clinically indicated for the management of opioid withdrawal symptoms. The minimum effective dose and number of drugs should be used.

Lofexidine is licensed for the management of symptoms of opioid withdrawal (specifically those associated with the noradrenergic system, e.g. sweating, shivering, runny nose and eyes). Monitoring of blood pressure and pulse rate is recommended.

Opioid-Receptor Antagonists

Naloxone is used in emergency situations to reverse the effects of opioid overdose. It should be given preferably by intravenous injection; intramuscular or subcutaneous routes are also licensed. Due to its short duration of action, the patient should be monitored closely for at least 6 hours and further doses given if necessary. Excessive doses of naloxone can precipitate withdrawal symptoms in those with opioiddependency.

Naltrexone can precipitate withdrawal symptoms in opioid-dependent people. It is used as an adjunct for the prevention of relapse in detoxified, formerly opioid-dependent people who are highly motivated to remain abstinent. 

Notes

Methadone 1mg/ml oral solution or 1mg/ml sugar free solutions should be preferred as first choice. Other formulations of methadone should be used only after seeking specialist advice.

Injectable methadone may be suitable for a small minority of patients who have failed on optimised oral treatment. Oral concentrates containing methadone hydrochloride 10 mg/ml or 20 mg/ml, should normally be dispensed only after dilution, as appropriate.

Drug driving

Guidance for healthcare professionals on drug driving

Information for patients

Drugs and driving: blood concentration limits set for certain drugs

Buprenorphine
View adult BNF View SPC online
Formulary
Red

Tablets s/l 400micrograms, 2mg, 8mg

Oral lyophilisate tablets 2mg, 8mg (Espranor®)

Black St Helens CCG (Espranor®)

Espranor®  has different bioavailability to other buprenorphine products and is not interchangeable - consult product literature.  

Prescribed by the Drug Service

No BNFc entry – seek specialist advice

 
   
Buprenorphine and naloxone
View adult BNF View SPC online
Formulary
Red

Tablets s/l 2mg/500micrograms, 8mg/2mg

Prescribed by the Drug Service

No BNFc entry – seek specialist advice

 
   
Methadone (see notes)
View adult BNF View SPC online View childrens BNF
Formulary
Red

Oral solution 1mg/mL
Oral solution s/f 1mg/mL
Injection 25mg/mL

Prescribed by the Drug Service

 
   
Methadone (see notes)
View adult BNF View SPC online
Formulary
Red

Oral Concentrate 10mg/ml, 20mg/mL

No BNFc entry – seek specialist advice

 
   
Lofexidine
View adult BNF View SPC online
Formulary
Red

Tablets f/c 200micrograms

Prescribed by the Drug Service

No BNFc entry – seek specialist advice

 
   
Naltrexone
View adult BNF View SPC online
Formulary
Red

Tablets f/c scored 50mg

Prescribed by the Drug Service

No BNFc entry – seek specialist advice

 
   
Naloxone (for opioid overdose)
View adult BNF View SPC online View childrens BNF
Formulary
Red

Injection 20micrograms/mL, 400micrograms/mL, 1mg/mL

Prescribed by the Drug Service

 
   
04.11  Drugs for dementia
 note 

Treatment with drugs for dementia should be initiated by specialists experienced in the management of dementia although treatment may be continued in primary care.

Dementia Prescribing Support Documentation for Primary Care approved by the Pan Mersey APC is available (see links below) 

Donepezil
View adult BNF View SPC online
Formulary
Amber Initiated

Tablets 5 mg, 10mg
Orodispersible tablets 5 mg, 10 mg
Oral solution 1 mg/ml

Purple NHS South Sefton CCG and NHS Southport and Formby CCG – historic shared care agreement in place.

No BNFc entry – seek specialist advice

 
   
Galantamine
View adult BNF View SPC online
Formulary
Amber Initiated

Tablets 8 mg, 12 mg
MR Capsules 8 mg, 16 mg, 24 mg
Oral solution 4 mg/mL

Purple NHS South Sefton CCG and NHS Southport and Formby CCG – historic shared care agreement in place.

No BNFc entry – seek specialist advice

 
   
Memantine
View adult BNF View SPC online
Formulary
Amber Initiated

Treatment initiation pack
Tablets 10 mg, 20 mg
Orodispersible tablets 10mg, 20mg
Oral solution 10 mg/mL

Purple NHS South Sefton CCG and NHS Southport and Formby CCG – historic shared care agreement in place.

No BNFc entry – seek specialist advice

 
   
Rivastigmine
(Also licensed for mild to moderately severe dementia in idiopathic Parkinson's disease.)
View adult BNF View SPC online
Formulary
Amber Initiated

Capsules 1.5 mg, 3 mg, 4.5 mg, 6 mg
Oral solution 2 mg/mL
Patch 4.6 mg/24hr, 9.5 mg/24hr, 13.3mg/24hr

Purple NHS South Sefton CCG and NHS Southport and Formby CCG – historic shared care agreement in place.

No BNFc entry – seek specialist advice

 
   
Souvenaid®
Formulary
Black

Oral nutritional supplement

 
   
04.12  New Sub Section
 ....
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