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Pan Mersey
Area Prescribing Committee
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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...
04.02.03  Expand sub section  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  Expand sub section  Benzodiazepines
04.02.03  Expand sub section  Antipsychotic drugs
04.02.03  Expand sub section  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  Expand sub section  Valproic acid to top
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  Expand sub section  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

Red Paediatrics

 
   
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)

Red Paediatrics

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

Traffic Light Status Information

Status Description

Green

Medicines considered suitable for non-specialist prescribing in primary or secondary care.  

Amber Recommended

Requires specialist assessment to enable patient selection.  Amber Recommended medicines must meet criteria: (1) Requires specialist assessment to enable patient selection (2) Following specialist assessment, the medicine is suitable for prescribing in Primary Care.  

Amber Initiated

Amber Initiated. Requires specialist initiation of prescribing. Prescribing to be continued by the specialist until stabilisation of the dose is achieved and the patient has been reviewed. Amber Initiated medicines must meet criteria: (1) Requires specialist assessment to enable patient selection (2) Medicine is suitable for on-going prescribing in Primary Care (3) Requires short to medium term specialist prescribing and monitoring of efficacy or toxicity until the patient’s dose and condition is stable   

Amber Retained

Amber Patient Retained. Requires specialist initiation of prescribing. Prescribing to be continued by specialist until stabilisation of the dose is achieved and the patient had been reviewed. Patient remains under the care of specialist (ie not discharged) as occasional specialist input may be required. Amber Patient Retained medicines must meet criteria: (1)Requires specialist assessment to enable patient selection (2)Medicine is suitable for on-going prescribing in Primary Care (3) Requires short to medium term specialist prescribing and monitoring of efficacy or toxicity until the patient’s dose and condition is stable (4) May require occasional specialist input indefinitely and therefore the patient should not be discharged from specialist care   

Amber

Medicines recommended or initiated by specialists in primary or secondary care. Non-specialist prescribing in primary care may follow according the RAG criteria. In process of being superceded by Amber Recommended, Amber Initiated and Amber Patient Retained.  

Purple

Shared Care. Medicines are considered suitable for Primary Care prescribing and/or management, following specialist initiation of therapy, with on-going communication between the Primary Care prescriber and specialist, within the framework of a Shared Care Agreement. Medicines designated as requiring Shared Care require on-going input from both Specialist and Primary Care clinicians and patients should not be discharged from Specialist care. Where prescribing and monitoring are required under shared care, it is implicit that the responsibility for both of these tasks rests with the prescriber. A Shared Care Agreement will always be available for Shared Care medicines and this document will include a Shared Care Agreement pro-forma which will be completed by all involved clinicians. This pro-forma will record agreement to take on defined aspects of care e.g. monitoring and/or on-going prescribing for the individual patients. A policy detailing clinician responsibilities in Shared Care Agreements must be referred to in all cases of Shared Care. All drugs to be included in this category must meet Shared Care criteria 1 to 3: SC1 Requires specialist assessment to enable patient selection and also initiation, stabilisation and review of treatment and the patient`s condition. SC2 Prescribing and/or management of the drug in Primary Care with specialist support and input, within the framework of the Shared Care Agreement is safe and convenient and that there is an appropriate mechanism for individual patient access in Primary Care. SC3 Requires specific long-term monitoring (blood test or other measurement) for adverse effects and / or efficacy of the drug to be completed in Primary Care, and requires on-going specialist support for the dose changes or management of adverse effects. Monitoring is required on a regular basis (typically four times a year). Implicit in any shared care agreement is the understanding that participation is at the discretion of the Primary Care prescriber subject to their clinical confidence.   

Red

Primary care prescribing of these medicines is NOT recommended. These treatments should be initiated by specialists only; ongoing prescribing is retained within secondary care.   

Black

Not recommended for use. Deviation from the policy may be considered on an individual basis where exceptional circumstances exist.   

Grey

Not recommended for use at this time. Deviation from the policy may be considered on an individual basis where exceptional circumstances exist. Further guidance will be issued when more information or evidence is made available.  

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