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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.

Paediatrics - all drugs are deemed to have the same RAG status as they have for adults unless stated otherwise.

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04.08.01  Expand sub section  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  Expand sub section  Carbamazepine, Eslicarbazepine and Oxcarbazepine
04.08.01  Expand sub section  Ethosuximide
04.08.01  Expand sub section  Gabapentin and pregabalin
04.08.01  Expand sub section  Lacosamide to top
04.08.01  Expand sub section  Lamotrigine
04.08.01  Expand sub section  Levetiracetam
04.08.01  Expand sub section  Perampanel
04.08.01  Expand sub section  Phenobarbital and other barbiturates
04.08.01  Expand sub section  Phenytoin to top
04.08.01  Expand sub section  Retigabine
04.08.01  Expand sub section  Rufinamide
04.08.01  Expand sub section  Tiagabine
04.08.01  Expand sub section  Topiramate
04.08.01  Expand sub section  Valproate to top
04.08.01  Expand sub section  Vigabatrin
04.08.01  Expand sub section  Zonisamide
04.08.01  Expand sub section  Benzodiazepines
04.08.01  Expand sub section  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
   
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.

 
   
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

 
   
 ....
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

Amber Recommended  

Amber Initiated

Amber Initiated. Requires specialist initiation of prescribing. Prescribing to be continued by the specialist until stabilisation of the dose and the patient’s condition 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 and the patient’s condition 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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