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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...
04.10.01  Expand sub section  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, Wirral 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  Pan Mersey APC (2019). NALMEFENE film coated tablets (Selincro®▼)
Link  NICE TA325 (2014): Nalmefene for reducing alcohol consumption in people with alcohol dependence
   
 ....
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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