BNF Chapter 4

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Central Nervous System

BNF CODE – 4.1 DEMENTIA
NICE TA
NICE GuidanceDementia: assessment, management and support for people living with dementia and their carers (NG97)
NICE Guidance (Applicable to RIVASTIGMINE under this section)Parkinson’s disease: Diagnosis and management in primary and secondary care [CG35]
PCN policy statementMemantine with anticholinesterase inhibitors PCN Policy StatementAPC Policy Statement: AChEi and memantine for frontotemporal dementia

APC Policy statement: AChEi and memantine for cognitive impairment

 

RESTRICTED USE:

The following Consultants can initiate these agents in accordance with Dementia NICE Guidance (NG97 – 2018)
1) Psychiatrists 
2)  Neurologists
3) Care of Elderly Consultants
ANTICHOLINESTERASES – Centrally ActingNOTES
DONEPEZIL HYDROCHLORIDE Tablets 5mg, 10mgAPC has listed Donepezil as ‘Black’ for treating frontotemporal dementia and congintive impairment caused by Multiple Sclerosis as per NG97. Donepezil is not on the formulary for these indications.
GALANTAMINETablets 8mg, 12mg

SR capsules 8mg, 16mg, 24mg

APC has listed Galantamine as ‘Black’ for treating frontotemporal dementia and congintive impairment caused by Multiple Sclerosis as per NG97. Galantamine is not on the formulary for these indications.
RIVASTIGMINECapsules 1.5mg, 3mgAPC has listed Rivastigmine as ‘Black’ for treating frontotemporal dementia and congintive impairment caused by Multiple Sclerosis as per NG97. Rivastigmine is not on the formulary for these indications.
DOPAMINERGIC DRUGS – NMDA Receptor AntagonistsNOTES
MEMANTINETablets 10mgAPC has listed Memantine as ‘Black’ for treating frontotemporal dementia and congintive impairment caused by Multiple Sclerosis as per NG97. Memantine is not on the formulary for these indications.
BNF CODE – 4.2 EPILEPSY AND OTHER SEIZURE DISORDERS
ANTIEPILEPTICSNOTES
NICE PathwayEpilepsy overview
NICE GuidanceThe epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care [CG137]
UKCPA – Consensus view on use of generic anti-epilepticsUKCPA-Generic-Antiepileptics
MHRA – Switching between different Manufacturers’ Products for a particular drugAntiEpileptics MHRA
MHRA – Antiepileptic drugs: changing between different manufacturers’ products (Patient Information)AntiEpileptics MHRA [Patients]
BRIVARACETAMTablets 10mg, 25mg, 50mg, 75mg, 100mgRESTRICTED FOR NEUROLOGY TEAM

Adjunctive therapy in treatment of partial onset seizures who remain uncontrolled or are intolerant of all other adjunctive anti-epileptics

Brivaracetam can only be prescribed if levetiracetam has been shown to be ineffective or not tolerated

PCN Policy Statement

CARBAMAZEPINE Tablets 100mg, 200mg, 400mg

CR Tablets (Tegretol Retard) 200mg, 400mg

Liquid 100mg in 5ml

 

Suppositories 125mg, 250mg

 

 

 

 

Suppositories are licensed for up to 7 days use 125mg PR = 100mg oral dose Max dose PR = 1g in 4 divided doses

ESLICARBAZEPINE800mg, 200mg tabletsRefractory epilepsy patients who have tried and failed 2+ epilepsy agents

Refer to Shared Care Guideline

ETHOSUXIMIDE Capsules 250mg

Syrup 250mg in 5ml

absence seizures (also myoclonic & atypical seizures)
GABAPENTINCapsules 100mg, 300mg, 400mgadjunctive therapy (partial seizures); dose titration required also used for diabetic neuropathy

Controlled Drug

How do you switch between pregabalin and gabapentin for neuropathic pain, and vice versa?

PREGABALINCapsules 25mg, 50mg, 75mg, 100mg, 150mg, 200mg, 300mgRESTRICTED for NEUROLOGY
Refractory Cases of epilepsy uncontrolled by other agentsRESTRICTED for PAIN/DIABETES Team
Neuropathic PainControlled drug
LACOSAMIDE Tablets 50mg, 100mg, 150mg, 200mg

Liquid 10mg/ml (200ml bottle)

Surrey PCN Amber Star
LAMOTRIGINE Tablets 25mg, 50mg, 100mg, 200mg

Tablets dispersible 5mg, 25mg, 100mg


Partial seizures & generalised tonic clonic; either sole treatment or adjunctive;
LEVETIRACETAM

 

Tablets 250mg, 500mg, 750mg, 1g

Oral solution 100mg / ml

250mg, 500mg, 1g sachets

RESTRICTED for NEUROLOGY team

1. partial seizures & with or without secondary generalisation (monotherapy or adjunctive treatment)
2. myoclonic seizures (adjunctive therapy) 3. generalised tonic clonic seizures (adjunctive)Sachets are restricted to paediatric prescribing in patients on a ketogenic diet or where oral solution is not tolerable e.g. gastronomy patients
Concentrate for IV infusion 100mg / ml
PERAMPANEL Tablets 2mg, 4mg, 8mg, 10mg, 12mgRESTRICTED for NEUROLOGY team initiationSurrey PCN Perampanel Amber Prescribing Guidelines
1. adjunctive treatment of partial onset siezures (with or without generalised secondary seizures)

NICE Evidence Summary (2012)
Shared Care Guideline
PHENYTOIN SodiumCapsules 25mg, 50mg, 100mg, 300mgPhenytoin sodium is NOT EQUIVALENT to phenytoin base. When switching between products, 100mg of phenytoin sodium is approximately equivalent to 92mg of phenytoin base.
Injection 250mg in 5ml
PHENYTOIN BaseSuspension 30mg in 5mlPhenytoin sodium is NOT EQUIVALENT to phenytoin base. When switching between products, 100mg of phenytoin sodium is approximately equivalent to 92mg of phenytoin base.
RUFINAMIDE Tablets 100mg, 200mg, 400mgRESTRICTED to paediatrics

shared care document not currently available

SODIUM VALPROATECrushable Tablets 100mg

EC Tablets 200mg, 500mg

CR Tablets (Epilim Chrono) 200mg, 300mg, 500mg

Liquid 200mg in 5ml

 

For the treatment of women of childbearing potential with epilepsy OR bipolar disorder .

Shared Care Guidelines

APC Policy Statement: Sodium valproate (child bearing potential)

ACP has classified valproate as ‘Black’ to manage agitation or aggression in people living with dementia (unless for another condition). Valproate is not on the formualary for this indication.

APC Policy Statement: Valproate NICE do not offer

SODIUM VALPROATECrushable Tablets 100mg

EC Tablets 200mg, 500mg

CR Tablets (Epilim Chrono) 200mg, 300mg, 500mg

Liquid 200mg in 5ml

For the treatment in men and women who are NOT of childbearing potential with epilepsy OR bipolar disorder.

Blue information sheets

APC Policy Statement: Sodium valproate in men and women not of child bearing potential

ACP has classified valproate as ‘Black’ to manage agitation or aggression in people living with dementia (unless for another condition). Valproate is not on the formualary for this indication.

APC Policy Statement: Valproate NICE do not offer

SODIUM VALPROATEInjection 400mg in 4ml
TOPIRAMATE Tablets 25mg, 50mg, 100mg, 200mg

Capsules “sprinkle” 15mg, 25mg

 

Restricted to paediatrics

No information sheet

VIGABATRIN Tablets 500mg

Sachets 500mg


Specialist initiation only; usually adjunctive treatment though can be used as monotherapy for infantile spasms (Wests Syndrome)
ZONISAMIDE Capsules 25mg, 50mg, 100mgRESTRICTED Consultant Neurologist

No information sheet
NICE CG37 Epilepsy Diagnosis & Management
SMC Rejection ZONISAMIDE (monotherapy)
SMC Approval ZONISAMIDE (adjunctive therapy)
ANTIEPILEPTICS – BARBITURATESNOTES
PHENOBARBITALTablets 15mg, 30mg, 60mg

Elixir 15mg in 5ml (SF/alcohol free)


Controlled DrugNo information sheet
PRIMIDONETablets 250mg

Suspension 250mg in 5ml

Controlled drug
HYPNOTICS, SEDATIVES & ANXIOLYTICS – BENZODIAZEPINESNOTES
CLOBAZAM Tablets 10mgLicensed from 3yr – adult; use as adjunctive therapy in epilepsy

No information sheet

CLONAZEPAM Tablets 500 micrograms, 2mgUsed in all forms of epilepsy, status & myoclonus

No information sheet

STATUS EPILEPTICUS – BenzodiazepinesNOTES
LORAZEPAM Injection 4mg/ml
MIDAZOLAM10mg / 2ml Oromusocal solution – 2.5mg, 5mg, 7.5mg, 10mg pre-filled syringesSASH Prescribing Information on Buccal Midazolam- Changing from Epistatus to BuccolamMidazolam Buccal [Pan-Surrey CCG Prescribing Guidance]UKCPA Statement on Generic AEDsEpilepsy Evidence Review Document

MHRA Buccal Midazolam Drug Safety Alert NPSA Alert [Buccal Midazolam]

No information sheet

MIDAZOLAM 10mg/ml (Epistasis)10mg / ml Oral Solution 5ml bottle + 1ml oral syringes (not pre-filled)SASH Prescribing Information on Buccal Midazolam- Changing from Epistatus to BuccolamMidazolam Buccal [Pan-Surrey CCG Prescribing Guidance]UKCPA Statement on Generic AEDsEpilepsy Evidence Review Document

MHRA Buccal Midazolam Drug Safety Alert NPSA Alert [Buccal Midazolam]

UNLICENSED

CLONAZEPAMInjection 1mg in 1ml
DIAZEPAMInjection solution 10mg in 2ml, injection emulsion 10mg in 2ml

Rectal solution 2.5mg, 5mg, 10mg

PHENYTOINInjection 250mg in 5mlIntravenous Phenytoin for Status Epilepticus in Adults
PHENOBARBITAL SODIUM 200 mg in 1ml Injection Injection 200mg in 1ml
PARALDEHYDE (WITH OLIVE OIL) ENEMA Unlicensed, Paediatrics only
BNF CODE – 4.3 MENTAL HEALTH DISORDERS
BNF CODE – 4.3.1 Anxiety
ANTIDEPRESSANTS – Serotonin receptor agonists NOTES
BUSPIRONETablets 5mg, 10mgRESTRICTED on PSYCHIATRIC advice only
 HYPNOTICS, SEDATIVES & ANXIOLYTICS – Benzodiazepines
CSM Advice on BenzodiazepinesBenzodiazepines used for Insomnia –  Benzodiazepines should be used to treat insomnia only when it is severe, disabling, or subjecting the individual to extreme distress
Medicines Q&A: What are the equivalent doses of oral benzodiazepines?

What are the equivalent doses of oral benzodiazepines?

DIAZEPAMTablets 2mg, 5mg

Liquid 2mg/5ml, 5mg/5ml

Injection 10mg/2ml (Diazemuls)

LORAZEPAM Tablets 1mg

Injection 4mg in 1ml

OXAZEPAM Tablets 10mg, 15mg
BNF CODE – 4.3.2 Attention deficit hyperactivity disorder
CENTRAL NERVOUS STIMULANTSNOTES

NG87: Attention deficit hyperactivity disorder: diagnosis and management

ATOMOXETINE Capsules 10mg, 18mg, 25mg, 40mg, 60mg2nd  line for ADHD – RESTRICTED to prescribing  PAEDIATRIC / PSYCHIATRIC advice

No shared care currently in use as not initiated at SaSH.

DEXAMFETAMINE Tablets 5mg, 10mg

Liquid 5mg/5ml (unlicensed)

CONTROLLED DRUG RESTRICTED on PAEDIATRIC / PSYCHIATRIC advice only Specialising in treatment of ADHD

No shared care currently in use as not initiated at SaSH.

METHYLPHENIDATE Tablets (Equasym) 5mg, 10mg, 20mg

Tablets (Ritalin) 10mg, MR 20mg

Tablets SR (Concerta XL) 18mg, 36mg

CONTROLLED DRUG RESTRICTED on PAEDIATRIC / PSYCHIATRIC advice only Specialising in treatment of ADHD

No shared care currently in use as not initiated at SaSH.

BNF CODE – 4.3.3 BIPOLAR DISORDER & MANIA
Important information on Lithium:
.
1. Therapeutic drug monitoring
2. Toxicity
3. Prescribe by brand name
4. NPSA Alert Lithium
1) Plasma Monitoring Required Serum level aim for 0.4-1mmol / litre Take blood sample 12hr post dose Monitor Li+ levels WEEKLY on initiation & after dose change. Thereafter when levels are stable monitor every 3-MONTHLY
2) Toxicity includes : tremour, ataxia, dysarthria,  nystagmus, renal impairment and convulsions Serum levels over 2mmol / litre require Emergency Treatment of Poisoning
.
Seek advice from National Poisons Centre
http://www.toxbase.org/
YOU WILL NEED A USERNAME AND PASSWORD
.
3) Lithium preparations vary widely in bioavailability Prescribe by Brand name
4) NPSA Lithium Alert – All patients should be provided with a Lithium card. Lithium for prophylaxis of Cluster Headaches (unlicensed)
NPSA Alert LithiumNPSA Alert Lithium
Important information on Lithium:
.
1. Therapeutic drug monitoring
2. Toxicity
3. Prescribe by brand name
4. NPSA Alert Lithium
1) Plasma Monitoring Required Serum level aim for 0.4-1mmol / litre Take blood sample 12hr post dose Monitor Li+ levels WEEKLY on initiation & after dose change. Thereafter when levels are stable monitor every 3-MONTHLY
2) Toxicity includes : tremour, ataxia, dysarthria,  nystagmus, renal impairment and convulsions Serum levels over 2mmol / litre require Emergency Treatment of Poisoning
.
Seek advice from National Poisons Centre
http://www.toxbase.org/
YOU WILL NEED A USERNAME AND PASSWORD
.
3) Lithium preparations vary widely in bioavailability Prescribe by Brand name
4) NPSA Lithium Alert – All patients should be provided with a Lithium card. Lithium for prophylaxis of Cluster Headaches (unlicensed)
VALPROIC ACID  (Depakote) Tablets 250mg, 500mgRESTRICTED on PSYCHIATRIC advice only

MHRA Safety Alert

For women on child bearning potential.

APC Policy Statement: Sodium valproate (child bearing potential)

VALPROIC ACID  (Depakote) Tablets 250mg, 500mgRESTRICTED on PSYCHIATRIC advice only

MHRA Safety Alert

For men, and women who are not of childbearing potential.

APC Policy Statement: Sodium valproate in men and women not of child bearing potential

LITHIUM CARBONATE 200 mg MR Tablets (Priadel) MR Tablets 200mg, 400mg
LITHIUM CITRATESF Liquid (Priadel) 520mg in 5ml
BNF CODE – 4.3.4 DEPRESSION
NICE GuidelinesDepression in adults: The treatment and management of depression in adults [CG90]
NICE GuidelinesDepression in adults with chronic physical and health problems: The treatment and management [CG91]
NICE GuidelinesDepression in children and young people: Identification and management in primary, community and secondary care [CG28]
MONOAMINE-OXIDASE INHIBITORS – IrreversibleNOTES

Caution of risk of dietary and drug interactions. See BNF for stopping ans starting criteria.

PHENELZINE Tablets 15mgRESTRICTED on PSYCHIATRIC advice only
TRANYLCYPROMINETablets 10mgRESTRICTED on PSYCHIATRIC advice only
MONOAMINE-OXIDASE INHIBITORS – ReversibleNOTES

Caution of risk of dietary and drug interactions. See BNF for stopping ans starting criteria.

MOCLOBEMIDE Tablets 150mgRESTRICTED on PSYCHIATRIC advice only
NORADRENALINE RE-UPTAKE INHIBITORSNOTES
REBOXETINE 4 mg Tablets Tablets 4mgRESTRICTED on PSYCHIATRIC advice only
SELECTIVE SEROTONIN RE-UPTAKE INHIBITORSNOTES
NICE GuidelinesGeneralised anxiety disorder and panic disorder (with or without agoraphobia) in adults: Management in primary, secondary and community care [CG113]
MHRA/CSM Advice on SSRIs Safety in Children & AdolescentsSelective Serotonin Reuptake Inhibitors (SSRIs): Overview of regulatory status and CSM advice relating to major depressive disorder (MDD) in children and adolescents including a summary of available safety and efficacy data
MHRA GuidanceSSRIs and SNRIs: Use and safetyGuidance
UKMI Medicines Q&A What is the risk of gastrointestinal bleeding associated with selective serotonin reuptake inhibitors (SSRIs)

What is the risk of gastrointestinal bleeding associated with selective serotonin reuptake inhibitors (SSRIs)?

UKMI Medicines Q&A

NOACs and Antidepressants – What are the risks of using these together and how should these risks be managed?

CITALOPRAM Tablets 10mg, 20mg, 40mg

Oral drops 40mg/ml

 4 drops (8mg) is equivalent in therapeutic effect to a 10mg tablet. Mix with water, orange juice or apple juice before talking
FLUOXETINE Capsules 20mg

Liquid 20mg/5ml

FLUVOXAMINE MALEATE Tablets 50mgRESTRICTED on PSYCHIATRIC advice only
PAROXETINE Tablets 20mg, 30mg

Oral suspension 10mg/5ml

SERTRALINE Tablets 50mg, 100mg
SEROTONIN & NORADRENALINE RE-UPTAKE INHIBITORSNOTES
DULOXETINE Capsules 30mg, 60mgRESTRICTED for diabetic neuropathy pain NICE Neuropathic Pain Guidelines

PCN Treatment of Diabetic Neuropathy Guideline

VENLAFAXINE Tablets 37.5mg, 75mg

Capsules XL 75mg, 150mg

MHRA Update on CSM Advice Pre-ECG no longer pre-requisite for all patients BP monitoring required throughout treatmentMHRA – Venlafaxine
SEROTONIN UPTAKE INHIBITORSNOTES
TRAZODONE Capsules 50mg, 100mg

Suspension 50mg in 5ml

TETRACYCLIC ANTIDEPRESSANTSNOTES
MIANSERIN Tablets 10mg, 30mgRESTRICTED on PSYCHIATRIC advice only
MIRTAZAPINE Tablets 15mg, 30mg

Dispersible Tablets 15mg, 30mg, 45mg

RESTRICTED on PSYCHIATRIC advice only
TRICYCLIC AND RELATED ANTIDEPRESSANT DRUGSNOTES
AMITRIPTYLINE Tablets 10mg, 25mg, 50mg

Solution 25mg in 5ml

CLOMIPRAMINE Tablets 10mg, 25mg, 50mg, SR 75mg
DOSULEPIN  Capsules 25mg,  Tablets 75mg

Solution 25mg in 5ml (Unlicensed)

Not recommended for depression or neuropathic pain

RESTRICTED on specialist PSYCHIATRIC advice only

(black-listed by PCN – not routinely recommended for prescribing in Primary or Secondary Care)

IMIPRAMINETablets 10mg, 25mg
LOFEPRAMINE Tablets 70mg

SF Suspension 70mg/5ml

TRICYCLIC AND RELATED ANTIDEPRESSANT DRUGSNOTES
VORTIOXETINENICE TA 367

Not for initiation at SASH

BNF CODE – 4.3.5 INAPPROPRIATE SEXUAL BEHAVIOUR
ANTIPSYCHOTICS – first generationNOTES
BENPERIDOL Tablets 250 microgramsRESTRICTED on PSYCHIATRIC advice only
BNF CODE – 4.3.6 PSYCHOSES & SCHIZOPHRENIA
Advice of Royal College of Psychiatrists on doses above  BNF upper limit1) Consider alternative approaches (new atypicals, adjuvant therapy). Bear risk factors in mind (obesity) & caution (older patients)
2) Consider potential drug interactions. Carry out ECG to check for prolonged QT interval 3) Increase dose SLOWLY and not more often than ONCE WEEKLY
4) Carry out regular BP, pulse & temperature
5) Maintain adequate fluid intake
6) Abandon high dose therapy if no improvement after 3 months
Royal College of Psychiatrists – Consensus statement on high dose antipsychotic medicationConsensus Statement High Dose Antipsychotics [RCPsych]
NICE Guidance on Atypical Antipsychotics www.nice.org.uk
Atypical Antipsychotics & Stroke The CSM has advised that olanzapine & risperidone are associated with an increased risk of stroke in elderly patients with dementia.
Following new safety concerns and the absence of formal guidance from appropriate medical organisations, the unlicensed prescribing of antipsychotics for behavioural symptoms of dementia will be restricted to Consultant Prescribing only. Statement from Chief Executive Alzheimers Society
ANTIPSYCHOTICS – first generationNOTES
CHLORPROMAZINE Tablets 10mg, 25mg, 50mg, 100mg

Syrup 25mg/5ml, 100mg/5ml

Suppositories 100mg

Injection 25mg/ml (Deep IM)

FLUPENTIXOL Tablets 500micrograms, 1mg, 3mg
HALOPERIDOL Tablets 500microgram, 1.5mg, 5mg, 10mg

Liquid 5mg/5ml, 10mg in 5ml

Injection 5mg in 1ml

PERPHENAZINE Tablets 2mg, 4mgRESTRICTED on PSYCHIATRIC advice only
PIMOZIDE Tablets 2mg, 4mgRESTRICTED on PSYCHIATRIC advice only
PROCHLORPERAZINE Tablets 5mg

Syrup 5mg in 5ml

Suppositories 5mg, 25mg

Injection 12.5mg/ml

SULPIRIDE Tablets 200mg

Solution 200mg in 5ml

RESTRICTED on PSYCHIATRIC advice only
TRIFLUOPERAZINE Tablets 1mg, 5mg

Syrup 1mg/5ml, 5mg /5ml

ZUCLOPENTHIXOL DIHYDROCHLORIDETablets 2mg, 10mg, 25mg

Oral drops 20mg/ml

RESTRICTED on PSYCHIATRIC advice only
ZUCLOPENTHIXOL ACETATE Injection 50mg in 1ml, 100mg in 2ml (Accuphase)RESTRICTED on PSYCHIATRIC advice only
ANTIPSYCHOTICS – First Generation (Depot Injections)NOTES
FLUPENTIXOL DECANOATE Injection 20mg in 1ml, 40mg in 2ml

Injection 50mg in 0.5ml, 100mg in 1ml (Depixol Conc)

Injection 200mg in 1ml (‘low volume’)

All antipsychotic depot injections are RESTRICTED on PSYCHIATRIC advice only
HALOPERIDOL DECANOATE Injection 50mg in 1ml, 100mg in 1mlAll antipsychotic depot injections are RESTRICTED on PSYCHIATRIC advice only
ZUCLOPENTHIXOL DECANOATE Injection 200mg in 1ml, 500mg in 1ml (Conc.)All antipsychotic depot injections are RESTRICTED on PSYCHIATRIC advice only
ANTIPSYCHOTICS – Second GenerationNOTES
AMISULPRIDETablets 50mg, 100mg, 200mg, 400mg

Solution 500mg in 5ml

RESTRICTED on PSYCHIATRIC advice only
ARIPIPRAZOLE Tablets 5mg, 10mg, 15mgRESTRICTED on PSYCHIATRIC advice only
CLOZAPINE Tablets 25mg, 50mg, 100mg

Suspension 100mg in 5ml (extemporaneous)

RESTRICTED on PSYCHIATRIC advice only. Patient, prescriber and supplying pharmacist must be registered with Patient Monitoring Service.  Monitor for agranulocytosis.
OLANZAPINE Tablets 2.5mg, 5mg, 7.5mg, 10mg, 15mg

Dispersible 5mg, 10mg, 15mg

QUETIAPINE Tablets 25mg, 100mg, 150mg, 200mg, 300mgRESTRICTED on PSYCHIATRIC advice only (Patients being treated for behavioural psychotic symptoms of dementia are exempt from this restriction)
RISPERIDONE Tablets 500micrograms, 1mg, 2mg, 3mg, 4mg, 6mg

Dispersible tablets 1mg, 2mg

Liquid 1mg/ml

ANTIPSYCHOTICS – Second Generation (Depot Injections)NOTES
RISPERIDONE (Risperdal Consta) Injection 25mg, 37.5mg, 50mgAll antipsychotic depot injections are RESTRICTED on PSYCHIATRIC advice only
BNF CODE – 4.4 MOVEMENT DISORDERS
BNF CODE 4.4.1 Dystonias & Other Involuntary Movements
ANTIPSYCHOTICS – first generationNOTES
PROMAZINE Tablets 25mg

Syrup 25mg in 5ml

MONOAMINE DEPLETING DRUGSNOTES
TETRABENAZINE Tablets 25mgRESTRICTED USE Neurology Team Only Restricted for Huntingdons, movement disorders and choreas
MUSCLE RELAXANTS – Peripherally Acting – NeurotoxinsNOTES
BOTOX (Botulinum Toxin A)Powder for Reconstitution 100units & 200unitsRESTRICTED for NEUROLOGY team

Botox for Migraine – PbREX Drug (CCG Reimbursement Pre-Authorisation Required)

NICE TA Botox for Migraine NICE Guidance Headache

PCN statement: Botulinum for chronic migraine

BNF CODE – 4.4.2 Parkinson’s Disease
ANTIMUSCARINICSNOTES
ORPHENADRINETablets 50mg

Oral solution 25mg in 5ml, 50mg in 5ml

PROCYCLIDINE Tablets 5mg

Syrup 2.5mg in 5ml, 5mg in 5ml

Injection 10mg in 2ml

TRIHEXYPHENIDYL HYDROCHLORIDETablets 2mg, 5mgRESTRICTED on PSYCHIATRIC advice only
DOPAMINERGIC DRUGS -Catechol-O-Methytransferase InhibitorsNOTES
ENTACAPONE Tablets 200mgCOMTESS Used in adjunct to levodopa with dopa-decarboxylase inhibitor in Parkinson’s Disease & ‘end-of-dose’ motor fluctuations
OPICAPONE50mg capsulesAdjunctive therapy in adult patients with Parkinson’s Disease and end of dose motor fluctuations.

PCN Policy Statement: Opicapone use in Parkinsons Disease

DOPAMINERGIC DRUGS – Dopamine Precursors 

NOTES
CO-BENELDOPA (MADOPAR)Capsules 62.5mg, 125mg, 250mg

Dispersible tablets 62.5mg, 125mg

Controlled release capsules 125mg

How do you convert from co-beneldopa (Madopar®) prolonged-release capsules to dispersible tablets?

CO-CARELDOPA (SINEMET)Tablets 62.5mg, 110mg, 125mg, 275mg

Controlled release tablets 125mg, 250mg

LEVODOPA/ENTACAPONE/CARBIDOPATablets 50mg/12.5mg/200mg,
75mg/18.75mg/200mg, 100mg/25mg/200mg,
125mg/31.25mg/200mg,
150mg/37.5mg/200mg,
200mg/50mg/200mg
DOPAMINERGIC DRUGS – Dopamine Receptor AgonistsNOTES
APOMORPHINE Subcutaneous injection 10mg/ml in 2ml and 5ml amps

Pen injector (APO-go PFS) 10mg/ml 3ml 

RESTRICTED
.
Parkinson’s disease prescribing only
Apomorphine AMBER Shared Care [CCG/PCN]MHRA – Domperidone and risk of cardiac side-effects
BROMOCRIPTINE Tablets 2.5mg

Society for Endocrinology position statement on the use of dopamine agonists in endocrine disorders
.
CSM Warning : Fibrotic Reactions The CSM (updated by MHRA/CHM July & October 2008) has advised that ergot-derived dopamine receptor agonists (bromocriptine, cabergoline & pergolide) have been associated with pulmonary, retroperitoneal and pericardial fibrotic reactions.

CABERGOLINE Tablets 1mg, 2mg, 4mg
PERGOLIDE MESYLATE Tablets 50micrograms, 250micrograms, 1mg
PRAMIPEXOLE Tablets Tablets 88mcg, 180mcg, 350mcg, 700mcgRESTRICTED Parkinson’s disease prescribing only
ROPINIROLE Tablets Tablets 250mcg, 500mcg, 1mg, 2mg, 5mgRESTRICTED Parkinson’s disease prescribing only
ROTIGOTINE (Neupro) Patches 2mg/24hr, 4mg/24hr, 8mg/24hr RESTRICTED USE Parkinson’s Prescribing Team Only
.
Shared Care Amber*
SMC Approval (Neupro Patches) [early Parkinson’s]
SMC Approval (Neupro Patches) [advanced Parkinson’s]
Parkinson’s disease: Diagnosis and management in primary and secondary care [CG35]
MONO-AMINE OXIDASE INHIBITORSNOTES
RASAGILINE  Tablets 1mgRESTRICTED USE Parkinson’s Prescribing Team Only
.
Shared Care Amber*
This agent is 2nd line for patients who fail/unable to tolerate selegiline
SMC Rejection RASAGILINE (monotherapy)
SMC Rejection RASAGILINE (adjunctive therapy)
Parkinson’s disease: Diagnosis and management in primary and secondary care [CG35]
SELEGILINE Tablets 5mg

Oral liquid 10mg in 5ml

Parkinson’s disease: Diagnosis and management in primary and secondary care [CG35]
.
NOTE: Used in conjunction with levodopa to reduce ‘end-of-dose deterioration’ Monotherapy in early disease may delay need for levodopa therapy for a few months Start low dose 2.5mg daily in elderly to prevent confusion
AMANTADINE Capsules 100mg

Syrup 50mg in 5ml

Parkinson’s disease: Diagnosis and management in primary and secondary care [CG35]
BNF CODE – 4.5 NAUSEA & LABYRINTH DISORDERS
ANTIEMETICS & ANTINAUSEANTS – AntihistaminesNOTES
CYCLIZINE Tablets 50mg

Injection 50mg/ml

Suppositories 50mg (unlicensed)

ANTIEMETICS & ANTINAUSEANTS – Cannabinoids
NABILONE Capsules 1mg
PHENOTHIAZINESNOTES
CHLORPROMAZINE Refer to Sec 4.2.1
PROCHLORPERAZINE Refer to Sec 4.2.1
TRIFLUOPERAZINE Refer to Sec 4.2.1
BNF CODE – 4.6.0
ANTIEMETICS & ANTINAUSEANTS – Dopamine Receptor AntagonistsNOTES
DOMPERIDONE Tablets 10mg

Suspension 5mg in 5ml

Suppositories 30mg

MHRA Domperidone WarningNPPG Revised Dosing (Babies & Children)
METOCLOPRAMIDE Tablets 10mg

Solution 5mg in 5ml

Injection 10mg in 2ml

 MHRA Safety Alert
ANTIEMETICS & ANTINAUSEANTS – Neurokinin Receptor Antagonists NOTES
APREPITANT  Capsules 80mg, 125mgRESTRICTED for CHEMOTHERAPY patientsCancer Network CINV Guidelines
ANTIEMETICS & ANTINAUSEANTS – 5HT3 Receptor AntagonistsNOTES
GRANISETRON Tablets 1mg

Injection 1mg in 1ml, 3mg in 3ml

RESTRICTED for CHEMOTHERAPY patients
ONDANSETRON Tablets 4mg, 8mg

Oral Solution 4mg in 5ml

Injection 4mg in 2ml

ANTIEMETICS & ANTINAUSEANTS – Anihistamines (Sedating)NOTES
CINNARIZINE Tablets 15mg
ANTIEMETICS & ANTINAUSEANTS – AntimuscarinicsNOTES
HYOSCINE HYDROBROMIDE Tablets 300micrograms

Patches 1.5mg (1mg/72 hrs)

Injection 400micrograms, 600 micrograms

ANTIEMETICS & ANTINAUSEANTS – Antipsychotics (first generation)NOTES
LEVOMEPROMAZINETablets 25mg

Injection 25mg/ml

RESTRICTED use only palliative care & oncology only (Cancer Network)
BNF CODE 4.5.1 Menierer’s Disease
BETAHISTINE Tablets 8mg, 16mg
BNF CODE – 4.6 PAIN
ANALGESICS
NHS Surrey Chronic Pain Management GuidelineNHS Surrey Chronic Pain Management [non-malignant]
NPSA alertsNOTE: Between 2002 and 2012 patient safety alerts were issued by the National Patient Safety Agency (NPSA) – the NPSA website was archived in 2012. Please use any material with caution. NPSA Alerts were only updated to reflect changes in current safety knowledge or clinical care until the point their ‘action complete’ date was reached. Some of these ‘action complete’ dates for NSPA Alerts, Safety Notices and Rapid Response Reports are now over fifteen years in the past, and no NPSA publications have been updated since the closure of the NPSA in 2012. 
NON-OPIOID ANALGESICSNOTES
PARACETAMOLTablets 500mg, Dispersible Tablets 500mg

SF Suspension 120mg in 5ml, 250mg in 5ml

Suppositories 60mg, 125mg, 240mg, 500mg

Injection 10mg/ml

NPSA Alert – Detecting harm following paracetamol overdose

NPSA Alert – Overdose of intravenous paracetamol in infants and childrenRisk of accidental overdose with IV paracetamol

 

What is the evidence to support the use of IV paracetamol for the short-term treatment of moderate to severe pain in adults?

CENTRALLY ACTING ANALGESICSNOTES
NEFOPAMTablets 30mg
NON-STEROIDAL ANTI-INFLAMMATORY DRUGSNOTES
ASPIRINTablets EC 300mg, Dispersible 300mg

Suppositories 300mg

OPIOID ANALGESICS NOTES
NPSA ALERTNOTE: Between 2002 and 2012 patient safety alerts were issued by the National Patient Safety Agency (NPSA) – the NPSA website was archived in 2012. Please use any material with caution. NPSA Alerts were only updated to reflect changes in current safety knowledge or clinical care until the point their ‘action complete’ date was reached. Some of these ‘action complete’ dates for NSPA Alerts, Safety Notices and Rapid Response Reports are now over fifteen years in the past, and no NPSA publications have been updated since the closure of the NPSA in 2012.NPSA Opioid Rapid Response AlertNOTE: This guidance applies to the following opioids: buprenorphine, diamorphine, dipipanone, fentanyl, hydromorphone, meptazinol, methadone, morphine, oxycodone, papaveretum, pethidine
Medicines Q&A – what are the equivalent doses of oral morphine to other oral opioids when used as analgesia in adult palliative care?

What are the equivalent doses of oral morphine to other oral opioids when used as analgesics in adult palliative care?

Medicines Q&A – How should conversion from oral morphine to fentanyl patches be carried out?

How should conversion from oral morphine to fentanyl patches be carried out?

BUPRENORPHINES/L Tablets (Temgesic) 200 micrograms & 400 micrograms

7 days Patches (Butrans) 5micrograms/hr, 10micrograms/hr, 15micrograms/hr, 20micrograms/hr

96 hour Patches (Transtec) 35 micrograms/hour, 52.5micrograms/hour, 70 micrograms/hour

CONTROLLED DRUG NPSA Opioid Rapid Response Alert

CQC Guidance

CODEINE PHOSPHATE Tablets 15mg, 30mg

Syrup 25mg in 5ml, Linctus 15mg in 5ml (licensed for cough)

Injection 60mg in 1ml (CD)

)DIAMORPHINEIntra Nasal Diamorphine EPaediatric Prescribing ONLY

SASH Intra Nasal DiamorphineCollege of Emergency Medicine

 Injection 5mg, 10mg, 15mg

Injection 30mg, 100mg, 500mg

CONTROLLED DRUG RESTRICTED SUPPLIES Discuss with pharmacy

CONTROLLED DRUG RESTRICTED SUPPLIES NPSA Alert on High Dose Morphine/Diamorphine NPSA Safer Practice Notice 12 (Actions for the NHS) New regulations on high dose storage/acquisition & supply  Discuss with pharmacy

NPSA Opioid Rapid Response AlertNPSA – Safer Practice Notice – High dose ampoules of Diamorphine and Morphine

DIHYDROCODEINETablets 30mg

Solution 10mg in 5ml

Injection 50mg in 1ml (CD)

NPSA Opioid Rapid Response Alert
FENTANYLSublingual tablets (Abstral) 100mcg, 200mcg, 300mcg, 400mcg, 600mcg, 800mcg

Buccal lozenges (Actiq) 200mcg, 400mcg, 600mcg, 800mcg

Controlled Drug

RESTRICTED : Palliative Care &  Pain Management

Patches (72 hour) 25mcg/hr, 50mcg/hr, 75mcg/hr, 100mcg/hrCQC Guidance

Controlled Drug CAUTION : Fever or External Heat CAUTION : Risk of Fatal Respiratory Depression

RESTRICTED: for prescribing in palliative care

MORPHINE SULPHATE Tablets 10mg, 20mg, 50mg (Sevredol)Dose every 4-6 hours / prn
 Tablets 5mg

Injection 50mg in 5ml

Solution 10mg in 5ml, 100mg in 5ml (Oramorph Conc.)

MR Tablets 5mg (MST)

MR Capsules (Zomorph) 10mg, 30mg, 60mg, 100mg, 200mg

MR Sachet 30mg (MST Continus)

Injection 10mg in 1ml, 15mg, 20mg

30mg in 1ml, 60mg in 2ml, 50mg in 50ml, 100mg in 100ml (PCA bags)

 

 

TOPICAL MORPHINE 10mg with INTRASITE GEL 10ml
TOPICAL USE / DRESSING

*** HOSPITAL SPECIAL ***
*** UNLICENSED ***

Controlled Drug

For SUSTAINED RELEASE ORAL MORPHINE  Dose every 12 hours / twice daily

PARENTAL MORPHINE RESTRICTED SUPPLIES New regulations on high dose storage/acquisition & supply – Discuss with pharmacy NPSA – Safer Practice Notice – High dose ampoules of Diamorphine and Morphine

 

 

 

 

 

 

 

 

RSCH Treatment of Radiotherapy Side-Effects

RSCH Management of Acute Perineal Skin Toxicity During Radiotherapy
Journal of Pain & Symptom Management

OXYCODONECapsules (Shortec) 5mg, 10mg, 20mg

Oral solution 5mg in 5ml , 10mg in 1ml

MR Tablets (Oxylan) 10mg, 20mg, 40mg, 80mg

Injection 10mg in 1ml, 20mg in 2ml

Oxycodone is a second-line option for patients with intolerable side-effects or poor response to morphine

Short Acting Oral Oxycodone CQC – Safer use of Controlled Drugs – Preventing harm from Oral Oxycodone preparations Dose every 4-6 hours / prn

Sustained Release Oral Oxycodone CQC – Safer use of Controlled Drugs – Preventing harm from Oral Oxycodone preparations Dose every 12 hours / twice daily

PETHIDINE Tablets 50mg

Injection 50mg in 1ml, 100mg in 2ml, 50mg in 5ml, 100mg in 5ml

 Controlled Drug
TAPENTADOL Tablets SR 50mg, 100mg, 200mg

Tablets 50mg

RESTRICTED to patients who have previously been treated with Morphine and with Oxycodone Amber* Surrey PCN

Refer to SCG

Blue Crawley CCG and Horsham & Mid Sussex CCG

TRAMADOL Capsules 50mg

Dispsersible Tablets 50mg

SR Capsules 50mg, 100mg, 200mg

Injection 100mg in 2ml

 CONTROLLED DRUG
COMPOUND ANALGESIC PREPARATIONSNOTES
CO-CODAMOL (PARACETAMOL + CODEINE)Tablets 8/500, 30/500

Effervescent Tablets 8/500, 30/500

CO-DYDRAMOLTablets 10/500
BNF CODE – 4.6.1 HEADACHE
ANTIHISTAMINES – Sedating
PIZOTIFEN Tablets 500micograms
 MIGRAINE – TriptansNOTES
SUMATRIPTAN SUCCINATE Tablets 50mg, 100mg

Nasal spray 10mg in 0.1ml

Injection 6mg in 0.5ml

 MIGRAINE – ProphylaxisNOTES
PROPRANOLOLTablets 10mg, 40mg, 80mg
BNF CODE – 4.7 SLEEP DISORDERS
BNF CODE 4.7.1 Insomnia
Important informationThere is no convincing evidence that these agents are useful in the elderly. The use of hypnotics in children is not usually justified
HYPNOTICS & ANXIOLYTICS – benzodiazepinesNOTES
LOPRAZOLAM Tablets 1mg
LORMETAZEPAM Tablets 500micrograms, 1mg
NITRAZEPAM Tablets 5mg

Oral Liquid 2mg/5ml

Long acting; avoid in elderly
TEMAZEPAMTablets 10mg

Elixir 10mg in 5ml

Controlled Drug
HYPNOTICS, SEDATIVES & ANXIOLYTICS – Non-Benzodiazepine NOTES
CHLORAL HYDRATE Elixir 500mg in 5ml
CLOMETHIAZOLE Capsules 192mg

Syrup 250mg in 5ml

MELATONIN Tablets MR 2mgSecond line for adult patients with primary insomnia when conventional ‘z’ drugs are ineffective or contraindicated.

Licensed for 13 week use only.

APC has classified melatonin as ‘Black’ for insomnia in people with Alzheimer’s disease (unless indicated for another condition). It is not on the formulary for this indication. See NICE guidance (NG97) – Dementia: assessment, management and support for people living with dementia and their carers.

APC Policy Statement: Melatonin NICE do not offer
Melatonin Policy in Critical Care-ESH May 14

Off-label in paediatrics

RESTRICTED SURREY APC Guidance for PAEDIATRIC sleep disturbances
Surrey PCN [Circadin] Paed Sleep Disorders

 Liquid 1mg/mlRESTRICTED Paediatrics & ITU Patients Only UNLICENSED PRODUCT
Slenyto MR Tablets 1mg, 5mg tablets.RESTRICTED Only for treatment of insomnia in children and adolescent ages 2-18years with autism spectrum disorder (ASD) and / or Smith-Magenis Syndrome, where sleep hygiene measures have been insufficient
ZOLPIDEM Tablets 5mg, 10mgThough these agents are non-benzodiazepines hypnotics, they act at the benzodiazepine receptor. None of these drugs are licensed for long term use Dependence has been reported in a small number of patients
ZOPICLONE Tablets 3.75mg, 7.5mgThough these agents are non-benzodiazepines hypnotics, they act at the benzodiazepine receptor. None of these drugs are licensed for long term use Dependence has been reported in a small number of patients
BNF CODE – 4.7.2 Narcolepsy
CNS STIMULANTS – Centrally Acting SympathomimeticsNOTES
MODAFINIL Tablets 100mg
BNF CODE – 4.8 SUBSTANCE DEPENDENCE
BNF CODE – 4.8.1  Alcohol Dependence
CHLORDIAZEPOXIDE Capsules 5mg, 10mgUsed 1st line for alcohol withdrawal
ACAMPROSATE Tablets 333mgRESTRICTED USE Drugs & Alcohol Team Only Restricted for treatment of Alcohol Dependence
DISULFIRAM Tablets 200mgRESTRICTED USE Drugs & Alcohol Team Only Restricted for treatment of Alcohol Dependence
BNF CODE – 4.8.2  Nicotine Dependence
NICOTINENICORETTE Microtab 2mg Up to 20 cigarettes daily More than 20 cigarettes daily
NICORETTE Chewing Gum 2mg & 4mg Up to 20 cigarettes daily More than 20 cigarettes daily
NICORETTE Inhalator 10mg cartridges (1×6)NICOTINELL TTS Patches Additional Prescribing Information Step 1 = ’30’ Patch (21mg/24hr) Step 2 = ’20’ Patch (14mg/24hr) Step 3 = ’10’ Patch (7mg/24hr)
PATIENTS EXPERIENCING NICOTINE WITHDRAWAL
BNF CODE – 4.8.2  Opioid Dependence
OPIOIDSNOTES
METHADONEOral solution 1mg in 1ml

Concentrated oral solution 10mg in 1ml

CONTROLLED DRUG
BUPRENORPHINE Sublingual tablets 400micrograms, 2mg, 8mgSUBUTEX CONTROLLED DRUG
LOFEXIDINE Tablets 200 micrograms
NALTREXONE Tablets 50mg
MIGRALEVE (PARACETAMOL + CODEINE) Pink Tablets, Duo Tablets
BNF CODE 4.7.3
AMITRIPTYLINETablets 10mg, 25mg
DULOXETINE
BENZATROPINE MESILATE 2 mg Tablets

2mg in 2ml Injection

DOPAMINERGIC DRUGS USED IN PARKINSONISMNOTES
NICE GuidanceParkinson’s disease: Diagnosis and management in primary and secondary care [CG35]
CCG Shared Care Prescribing GuidelineCCG Tolcapone Shared Care (Parkinson’s) Guideline
ANTIPSYCHOTICS – Second Generation (Depot Injections)NOTES
FLUPENTIXOL Refer to 4.2.1RESTRICTED on PSYCHIATRIC advice only
FLUPHENAZINE Tablets 1mg
RETIGABINE Tablets 50mg, 100mg, 200mg, 300mg & 400mgRESTRICTED for NEUROLOGY TEAM !! MHRA WARNING !! Surrey PCN Retigabine PolicySurrey PCN Retigabine Epilepsy (CCG Shared Care) Amber NICE Tag 232 Retigabine SMC Approval Retigabine

Drug Safety Update – being withdrawn from market June 2017

DRUGS USED IN ESSENTIAL TREMOR,CHOREA,TICS ETC.NOTES
RILUZOLE  Tablets 50mgRESTRICTED USE Neurology Team Only
.
Restricted for amyotrophic lateral sclerosis and motor neurone diseaseRiluzole MS Shared Care SASH PbRE Intention to Treat NICE TAG Riluzole [TA20]
BOTULINUM TYPE A TOXIN (Botox) Vial 100 unitsRESTRICTED USE See APC/D&T Guidance for Approved Use
ADDITIONAL TOPICS
CLADRIBINE10mg Tablet

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