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Kings College Hospital NHS Foundation Trust
Lewisham and Greenwich NHS Trust
 
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 Formulary Chapter 3: Respiratory system - Full Chapter
Notes:

Where a formulary entry does not detail a medicine’s indications for use, the medicine can be assumed to be approved for all licensed indications.

Formulary approved "off-label" use is detailed separately.

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03.04  Expand sub section  Antihistamines, hyposensitisation, and allergic emergencies
03.04.01  Expand sub section  Antihistamines
03.04.01  Expand sub section  Non-sedating antihistamines
Cetirizine tabs, oral solution
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Formulary

 
   
Fexofenadine tabs
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Formulary


 
   
Loratadine tabs, oral solution
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Formulary

 
   
03.04.01  Expand sub section  Sedating antihistamines
Alimemazine tabs, oral solution
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Formulary  
   
Chlorphenamine tabs, oral solution, injection
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Formulary  
   
Cyproheptadine tabs
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Formulary  
   
Hydroxyzine tabs
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Formulary

Max dose 100mg for adults, 50mg for elderly. Refer to MHRA for recent advice re risks of QT interval prolongation

 
Link  MHRA Drug Safety Update April 2015: Hydroxyzine - risk of QT prolongation
   
Ketotifen tabs, liquid
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Formulary
Amber 2

Approved for:

Food protein gastrointestinal allergies in adults and children aged ≥3 years

Allergy clinic initiation only

 
Link  SE London APC Recommendation: Ketotifen for food protein allergy
   
Promethazine tabs, oral solution, injection
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Formulary  
   
Cyproheptadine tablets
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Formulary

Approved off-label indication:

  • Treatment of serotonin syndrome
  • Loading dose of 12 mg, further doses may be given following clinical review

Prescribing must be initiated under the supervision of the Clinical Toxicology team at the GSTFT Poisons Unit

 
   
03.04.02  Expand sub section  Allergen Immunotherapy to top
 note  Refer to BNF for advice, safety information and cautions for allergen immunotherapy.  RESTRICTED USE - SPECIALIST USE ONLY
Bee and wasp allergen extracts (Alutard SQ® injection)
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Restricted Drug Restricted

SPECIALIST ALLERGIST USE ONLY

Initial and maintenance subcutaneous immunotherapy treatment of hypersensitivity to wasp or bee venom

 
   
Grass and tree pollen extract subcutaneous injection (Pollinex®)
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Restricted Drug Restricted

SPECIALIST ALLERGIST USE ONLY

Initial and extension subcutaneous immunotherapy treatment of seasonal allergic hay fever due to grass or tree pollen in patients who have failed to respond to antiallergy drugs

 
   
Grass pollen extract oral lyophilisates (Grazax®)
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Restricted Drug Restricted
Red

SPECIALIST ALLERGIST USE ONLY

For seasonal allergic grass pollen allergy in those who have failed to respond to medication and at least one of the following apply:

  • Monosensitised to grass pollen or polysensitised with symptoms predominantly related to grass pollen allergy;
  • Perennial asthma which would be considered an unacceptable risk for administration of standard subcutaneous immunotherapy (SCIT);
  • A prior severe reaction to grass pollen SCIT;
  • Unable to undertake SCIT for logistical reasons (distance, working hours, etc)
 
   
Birch pollen extract subcutaneous injection (Allergovit®)
Unlicensed Drug Unlicensed

SPECIALIST ALLERGIST USE ONLY

Initial therapy (pre-seasonal)

 
   
Cat epithelial extract subcutaneous injection (novo-helisen depot®)
Unlicensed Drug Unlicensed

SPECIALIST ALLERGIST USE ONLY

Initial and maintenance therapy

 
   
Dog epithelial extract subcutaneous injection (novo-helisen depot®)
Unlicensed Drug Unlicensed

SPECIALIST ALLERGIST USE ONLY

Initial and maintenance therapy

 
   
Grass and birch pollen mixture extract subcutaneous injection (Allergovit®)
Unlicensed Drug Unlicensed

SPECIALIST ALLERGIST USE ONLY

Initial therapy (pre-seasonal)

 
   
Grass pollen extract or mixed tree pollen extract subcutaneous injection (Allergovit®)
Unlicensed Drug Unlicensed

SPECIALIST ALLERGIST USE ONLY

Initial and maintenance therapy

 
   
Grasses and rye pollen extract or tree pollen extract subcutaneous injection (Pollinex® Quattro)
Unlicensed Drug Unlicensed

SPECIALIST ALLERGIST USE ONLY

Available on a named-patient basis

 
   
House dust mite extract subcutaneous injection (Acaroid®)
Unlicensed Drug Unlicensed

SPECIALIST ALLERGIST USE ONLY

Initial and maintenance therapy

 
   
House Dustmite allergen extract (Acarizax 12-SQ HDM oral lyophilisates®)
Unlicensed Drug Unlicensed
Red

SPECIALIST ALLERGIST USE ONLY

Restricted to use in persistent allergic rhinitis due to house dust mite allergy, uncontrolled by conventional treatment (nasal steroids, oral antihistamines ± leukotriene receptor antagonists) in adults and children >5 years

Acarizax oral lyophysilates is an imported product, licensed for use in Germany for allergic rhinitis due to house dust mite allergy in adults and adolescents aged 12-17, and allergic asthma due to house dust mite allergy in adults

 
   
Mixed grass pollen extract subcutaneous injection (Allergovit®)
Unlicensed Drug Unlicensed

SPECIALIST ALLERGIST USE ONLY

Initial therapy (pre-seasonal)

 
   
Horse epithelial extract sublingual immunotherapy (Oralvac®)
Unlicensed Drug Unlicensed
Red

SPECIALIST ALLERGIST USE ONLY

Restricted to paediatric use only

 
   
Mixed tree pollen, cat epithelial, dog epithelial extract sublingual immunotherapy (Oralvac®)
Unlicensed Drug Unlicensed
Red

SPECIALIST ALLERGIST USE ONLY

These five extracts are first line immunotherapy in paediatrics and second line choice after to subcutaneous immunotherapy (SCIT) in adult patients if one of the following apply:

  • A phobia of injections
  • Insurmountable problems with attending clinic for injections (e.g. immobility, working hours)
  • Previous systemic reactions with SCIT
  • Significant risk of systemic reactions from SCIT.
 
   
Birch pollen extract sublingual immunotherapy (Oralvac®)
Unlicensed Drug Unlicensed
Red
SPECIALIST ALLERGIST USE ONLY
Restricted to paediatric use only

 
   
03.04.02  Expand sub section  Omalizumab, mepolizumab and other therapies
 note 
Benralizumab injection
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Formulary
Red
High Cost Medicine
NHS England
BlueTeq

For use in asthma within the specialist service as per NICE TA 

 
Link  NICE TA565: Benralizumab for treating severe eosinophilic asthma
   
Mepolizumab injection
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Formulary
Red
High Cost Medicine
BlueTeq

For use in asthma within the specialist service as per NICE TA 

 
Link  NICE TA431: Mepolizumab for treating severe refractory eosinophilic asthma
   
Omalizumab injection (asthma)
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Restricted Drug Restricted
Red
High Cost Medicine
BlueTeq

For use in asthma within the specialist service as per NICE TA 

 
Link  NICE TA278: Asthma (severe, persistent, patients aged 6+, adults) - omalizumab (rev TA133, TA201)
   
Omalizumab injection (urticaria)
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Restricted Drug Restricted
Red
High Cost Medicine

For use in chronic spontaneous urticaria (as per NICE TA below), and chronic inducible urticarias (approved off-label use).

NOTE: see formulary section 3.4.4 (management of urticaria), and the SEL APC Urticaria Treatment Pathway for more detailed advice on the management of urticaria (link below)

For use in inducible urticaria (i.e. off-label use), a category B* form must be completed. 

 
Link  NICE TA339: Omalizumab for previously treated chronic spontaneous urticaria
Link  SE London APC recommendation: Omalizumab for the treatment of inducible urticarias (symptomatic dermographism, cholinergic, delayed pressure, cold and solar) in adults
   
Reslizumab injection
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Formulary
Red
High Cost Medicine
NHS England
BlueTeq

For use in asthma within the specialist service as per NICE TA

 
Link  NICE TA479: Reslizumab for treating severe eosinophilic asthma
   
03.04.03  Expand sub section  Allergic emergencies
03.04.03  Expand sub section  Anaphylaxis
Adrenaline / epinephrine 1 in 1,000 injection (licensed use)
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Formulary

 
   
Adrenaline / epinephrine 1 in 1,000 injection (nebulised - for stridor - off-label)
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Formulary

Approved off-label indication:

When required for the short term management of stridor (via nebuliser)

  • 1mL, diluted to 4mL with sodium chloride 0.9% and given via nebuliser.
  • In patients requiring repeat doses within 2 hours of administration contact respiratory, intensive care or palliative care for advice as approrpiate
 
   
Adrenaline / epinephrine IM injection for self-administration
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Formulary

Prescribers should specify the brand to be dispensed

Brands available:

  • Jext
  • Epipen
  • Emerade

Refer to product literature for dosing information

 
Link  MHRA Aug 17: Adrenaline auto-injectors: updated advice after European review
   
03.04.03  Expand sub section  Angioedema
C1 esterase inhibitor injection
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Formulary
Red
High Cost Medicine
NHS England
BlueTeq

Acute attacks of hereditary angioedema, and prophylaxis of attacks as per NHSE Policy 16045/P

 
Link  NHSE 16045/P: C1 - esterase inhibitor for prophylactic treatment of hereditary angioedema (HAE) types I and II
   
Icatibant injection
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Restricted Drug Restricted
Red
High Cost Medicine
NHS England

Initiation by consultants specialising in hereditary angioedema only

Symptomatic treatment of acute attacks of hereditary angioedema (HAE) in adults with C1-esterase inhibitor deficiency. Conditional on the there being a clear rationale for prescribing icatibant instead of C1-esterase inhibitor.

Use in accordance with local guidelines

 
   
Lanadelumab injection
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Formulary
Red
High Cost Medicine
NHS England
BlueTeq

Approved as per NICE Technology Appraisal Guidance (see link below)

 
Link  NICE TA606: Lanadelumab for preventing recurrent attacks of hereditary angioedema
   
Recombinant C1 esterase inhibitor injection (Ruconest, Conestat Alpha)
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Formulary
Red
High Cost Medicine
NHS England
BlueTeq

Acute attacks of hereditary angioedema,  as per NHSE Policy B09/P/b

(see page 7 for specific comissioning criteria that apply)

 
Link  NHSE B09/P/b: Treatment of Acute Attacks in Hereditary Angiodema (Adult)
   
Adrenaline inhaler  (Primatene Mist®)
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Unlicensed Drug Unlicensed
Red

For angioedema Dose: 2-4 sprays to be applied topically, up to hourly as required

Note: this product is currently not available

 
   
03.04.04  Expand sub section  Management of urticaria to top
Cetirizine tabs, oral solution (urticaria)
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First Choice
Green

Up to a four-fold increase from the licensed dose is approved for all types of urticaria i.e. up to 20mg BD (off-label use)

See SEL APC Urticaria Treatment Pathway for more detailed advice (link below)

 
Loratadine tabs, oral solution
(urticaria)
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First Choice
Green

Up to a four-fold increase from the licensed dose is approved for all types of urticaria i.e. up to 20mg BD (off-label use)

See SEL APC Urticaria Treatment Pathway for more detailed advice (link below)

 
Fexofenadine tabs (urticaria)
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Second Choice
Green

Up to a four-fold increase from the licensed dose is approved for all types of urticaria i.e. up to 360mg BD (off-label use)

2nd choice antihistamine after cetirizine/loratidine

See SEL APC Urticaria Treatment Pathway for more detailed advice (link below)

 
   
Amitriptyline tabs (urticaria)
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Formulary
Amber 2

Approved for idiopathic pruritis (off-label use)

Dose = up to 75mg ON

See SEL APC Urticaria Treatment Pathway for more detailed advice (link below)

 
   
Cytotoxic Drug Azathioprine tabs  (urticaria - off-label)
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Formulary
Amber 3

Approved for various chronic urticaria subtypes (off-label use)

Refer to formulary section 13.05.03 for use of azathioprine in dermatology indications and for the link to the SE London Shared Care Guidance

 
   
Ciclosporin caps, oral solution (urticaria)
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Formulary
Amber 3

Approved for various chronic urticaria subtypes (off-label use)

See SEL APC Urticaria Treatment Pathway for more detailed advice, including recommended dosing depending on urticaria subtype (link below)

Refer to formulary section 13.05.03 for use of ciclosporin in dermatology indications and for the link to the SE London Shared Care Guidance

 
   
Colchicine tabs (urticarial vasculitis )
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Formulary
Amber 2

Approved off-label use

Dose = 0.5mg BD up to 2.5mg daily (in divided doses)

See SEL APC Urticaria Treatment Pathway for more detailed advice (link below)

 
   
Dapsone tabs (delayed pressure urticaria)
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Formulary
Red

Approved off-label use

Dose = 50mg/day up to max. 150mg/day

See SEL APC Urticaria Treatment Pathway for more detailed advice (link below)

 
   
Doxepin caps (spontaneous urticaria)
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Formulary
Amber 3

Approved for treatment of coexisting anxiety and/or depressive illness (off-label use)

Dose = 25-50mg at night 

See SEL APC Urticaria Treatment Pathway for more detailed advice (link below)

 
Link  GP Information Sheet: Doxepin for chronic urticaria
   
Gabapentin caps (urticaria)
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Formulary
Amber 2

Approved for idiopathic pruritis (off-label use)

Dose = up to 600mg TDS

See SEL APC Urticaria Treatment Pathway for more detailed advice (link below)

 
   
Hydroxychloroquine tabs (urticaria - off-label)
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Formulary
Amber 3

Approved for various chronic urticaria subtypes (off-label use)

See SEL APC Urticaria Treatment Pathway for more detailed advice (link below)

Refer to formulary section 13.05.03 for use of hydroxychloroquine in dermatology indications and for the link to the SE London Shared Care Guidance

 
   
Hyoscine butylbromide tabs (cholinergic urticaria)
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Formulary
Amber 2

Approved off-label use, where cholinergic urticaria has not responded/patient is intolerant to danazol (in men)/propranolol/oxybutynin

Dose = 10mg TDS, increased to 20mg QDS if neccessary 

See SEL APC Urticaria Treatment Pathway for more detailed advice (link below)

 
   
Cytotoxic Drug Methotrexate tabs (urticaria - off-label)
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Formulary
Amber 3

Approved for various chronic urticaria subtypes (off-label use)

See SEL APC Urticaria Treatment Pathway for more detailed advice (link below)

Refer to formulary section 13.05.03 for use of methotrexate in dermatology indications and for the link to the SE London Shared Care Guidance

 
   
Montelukast tabs  (urticaria)
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Formulary
Green

Approved for use in all urtcaria subtypes (off-label use). 

Dose = 10mg daily

See SEL APC Urticaria Treatment Pathway for more detailed advice on management of urticaria (link below) 

 
   
Mycophenolate mofetil tabs, caps, suspension (spontaneous urticaria - off-label)
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Formulary
Amber 3

Approved for chronic urticaria spontaneous urticaria where automimmune urticaria is suspected (off-label use)

See SEL APC Urticaria Treatment Pathway for more detailed advice (link below)

Refer to formulary section 13.05.03 for use of mycophenolate in dermatology indications and for the link to the SE London Shared Care Guidance

 
   
Mycophenolate sodium tabs (spontaneous urticaria - off-label)
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Formulary
Amber 3

Approved for chronic urticaria spontaneous urticaria where automimmune urticaria is suspected (off-label use)

See SEL APC Urticaria Treatment Pathway for more detailed advice (link below)

Refer to formulary section 13.05.03 for use of mycophenolate in dermatology indications and for the link to the SE London Shared Care Guidance

 
   
Naltrexone tabs
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Formulary
Amber 3

Approved for idiopathic pruritus, that has not responded to optimised doses of amitriptyline, pregabalin or gabapentin (off-label use)

Dose = initially 25mg daily increased to 50mg per day. Total weekly dose may be divided and given on 3 days of the week – max. 350mg per week. 

See SEL APC Urticaria Treatment Pathway for more detailed advice (link below)

 
Link  GP Information Sheet: Naltrexone in idiopathic pruritus
   
Oxybutynin tabs (cholinergic urticaria)
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Formulary
Amber 2

Approved off-label use 

Dose = 5mg 2-3 times daily 

See SEL APC Urticaria Treatment Pathway for more detailed advice (link below)

 
   
Pregabalin caps (urticaria)
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Formulary
Amber 2

Approved for idiopathic pruritis (off-label use)

Dose = up to 75mg BD

See SEL APC Urticaria Treatment Pathway for more detailed advice (link below)

 
   
Propanetheline tabs (cholingeric urticaria)
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Formulary
Amber 2

Approved off-label use, where cholinergic urticaria has not responded/patient is intolerant to danazol (in men)/propranolol/oxybutynin

Dose = up to 30mg QDS

See SEL APC Urticaria Treatment Pathway for more detailed advice (link below)

 
   
Propranolol (cholinergic urticaria )
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Formulary
Amber 2

Approved off-label use 

Dose = up to 40mg BD

See SEL APC Urticaria Treatment Pathway for more detailed advice (link below)

 
   
Ranitidine tabs (urticaria)
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Formulary
Green

Approved for use in all types of urticaria (off-label use). 

Dose = 150mg BD/300mg daily

See SEL APC Urticaria Treatment Pathway for more detailed advice on management of urticaria (link below)

 
   
Sulfasalazine tabs (delayed pressure urticaria)
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Formulary
Amber 3

Approved off-label use (if not aspirin sensitive)

See SEL APC Urticaria Treatment Pathway for more detailed advice on management of urticaria (link below)

Refer to formulary section 13.05.03 for use of sulfasalazine in dermatology indications and for the link to the SE London Shared Care Guidance

 
   
Tranexamic acid tabs (urticaria - off-label)
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Formulary
Amber 2

Approved for use in chronic spontanous urticaria, for the treatment of angiodema without weals specifically (off-label use). 

Dose = 500mg BD - 1.5g TDS

See SEL APC Urticaria Treatment Pathway for more detailed advice on management of urticaria (link below)

 
   
Danazol caps (cholinergic urticaria)
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Unlicensed Drug Unlicensed
Amber 3

Approved off-label use in men only

Dose = 200-600mg daily 

See SEL APC Urticaria Treatment Pathway for more detailed advice (link below)

 
Link  GP Information Sheet: Danazol for cholinergic urticaria
   
 ....
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 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

Red

Specialist or hospital prescribing only. The responsibility for prescribing, monitoring, dose adjustment and review should remain with the specialist or hospital. In very exceptional circumstances a specialist may discuss individual patient need for a RED drug to be prescribed by a GP and the GP should consider informing the Medicines Management team before a decision is made to prescribe for individual patients.   

Amber 1

Treatment can be initiated in primary care after a recommendation from an appropriate specialist  

Amber 2

Specialist initiation followed by maintenance prescribing in primary care  

Amber 3

Specialist initiation with ongoing monitoring required. After dose stabilisation GPs can be requested to take over prescribing responsibilities using the approved APC shared care documentation  

Green

Specialist and non-specialist initiation  

Grey

Not recommended for prescribing  

netFormulary