netFormulary South East London Joint Medicines Formulary NHS
Guy's and St Thomas' NHS Foundation Trust
Kings College Hospital NHS Foundation Trust
Lewisham and Greenwich NHS Trust
 
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 Formulary Chapter 4: Central nervous system - Full Chapter
Notes:
In this section "SPECIALISTS" refer to medical prescribers specialising in Mental Health unless otherwise stated. At Guy's and St Thomas' and Lewisham Hospitals this would refer to SLAM employed consultants
 Details...
04.01  Expand sub section  Hypnotics and anxiolytics
04.01.01  Expand sub section  Hypnotics
Melatonin m/r tabs (sleep disorders in children - off-label)
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Restricted Drug Restricted
Amber 3

SPECIALIST INITIATION ONLY

Sleep disorders in children (off-label)

 
Link  SE London APC Shared Care Guidancance for Melatonin for the treatment of Sleep disorders in Children and Adolescents (age 1 - 17 years)
   
Melatonin m/r tabs, liquid (adult sleep clinic use - off-label)
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Restricted Drug Restricted
Amber 3

SLEEP DISORDER CENTRE USE ONLY

  • REM sleep behaviour disorder (off-label)
  • Delayed sleep phase disorder (off-label)
  • Free running disorder (off-label)
  • The liquid (unlicensed preparation) is restricted to use in swallowing difficulties, or in patients on a specific dose that is not practical to be given from the 2mg m/r tabs
 
   
Venlafaxine m/r tabs (adult sleep clinic use - off-label)
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Restricted Drug Restricted

SLEEP DISORDER CENTRE USE ONLY

Cataplexy (off-label)

 
   
Melatonin tabs (Bio-melatonin brand) (adult sleep clinic use)
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Unlicensed Drug Unlicensed
Red
SLEEP DISORDER CENTRE USE ONLY
  • Restricted to use in adult circadian rhythm disorders where a more sedative and immediate acting melatonin is required  
  •    
    04.01.01  Expand sub section  Benzodiazepines
    Nitrazepam tabs, oral suspension
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    Formulary  
       
    Controlled Drug Temazepam tabs, oral solution
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    Formulary  
       
    Loprazolam tabs
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    Formulary  
       
    Clonazepam tabs (Parasomnias and REM sleep disorder - off-label)
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    Restricted Drug Restricted
    Amber 2

    SLEEP DISORDER CENTRE USE ONLY

    • Parasomnias (off-label)
    • REM sleep behaviour disorder (off-label)
     
       
    04.01.01  Expand sub section  Zaleplon, Zolpidem and Zopiclone
    Zolpidem tabs (insomnia)
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    Formulary  
       
    Zopiclone tabs (insomnia)
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    Formulary  
       
    04.01.01  Expand sub section  Chloral and derivatives to top
    Chloral hydrate liquid
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    Restricted Drug Restricted INITIATION BY SPECIALIST ONLY 
       
    04.01.01  Expand sub section  Clomethiazole (Chlormethiazole)
    Clomethiazole caps
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    Formulary  
       
    04.01.01  Expand sub section  Sodium oxybate
    Controlled Drug Sodium oxybate oral solution
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    Restricted Drug Restricted
    Amber 2
    High Cost Medicine

    RESTRICTED USE – NAMED SPECIALIST CONSULTANTS AT GSTFT ONLY

    For disabling cataplexy in patients objectively diagnosed with narcolepsy and suffering from cataplexy of severity similar to the entry criteria for the positive US clinical trial.

     
       
    04.01.02  Expand sub section  Anxiolytics
    04.01.02  Expand sub section  Benzodiazepines
    Chlordiazepoxide caps, tabs
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    Formulary

    FIRST LINE FOR ACUTE ALCOHOL WITHDRAWAL

    Refer to local guidelines

     
       
    Diazepam tabs, oral solution, injection, rectal tubes
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    Formulary  
       
    Lorazepam tabs, injection
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    Formulary  
       
    04.01.02  Expand sub section  Buspirone to top
    Buspirone Hydrochloride tabs
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    Restricted Drug Restricted INITIATION BY SPECIALIST ONLY 
       
    04.01.03  Expand sub section  Barbiturates
    04.02  Expand sub section  Drugs used in psychoses and related disorders
    04.02.01  Expand sub section  Antipsychotic Drugs
    Chlorpromazine tabs, syrup
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    Formulary
    Amber 2
     
       
    Haloperidol caps, tabs, oral liquid, injection
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    Formulary
    Amber 2
     
       
    Levomepromazine tabs, injection
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    Restricted Drug Restricted
    Amber 2
    INITIATION BY SPECIALIST ONLY 
       
    Loxapine  (Adusave 9.1 mg inhalation powder)
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    Restricted Drug Restricted
    Red

    USE IS RESTRICTED TO THE SLAM AND OXLEAS TRUSTS ONLY

    For rapid control of mild-moderate agitation in schizophrenia or bipolar disorder in adults 

     
       
    Pimozide tabs
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    Formulary
    Red
     
       
    Prochlorperazine tabs, injection
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    Formulary  
       
    Promazine hydrochloride tabs
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    Formulary  
       
    Sulpiride tabs, oral solution
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    Restricted Drug Restricted
    Amber 2
    INITIATION BY SPECIALIST ONLY 
       
    Trifluoperazine tabs, caps, oral solution
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    Restricted Drug Restricted
    Amber 2
    INITIATION BY SPECIALIST ONLY 
       
    Zuclopenthixol acetate injection
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    Restricted Drug Restricted
    Red
    INITIATION BY SPECIALIST ONLY 
       
    Zuclopenthixol dihydrochloride tablets
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    Restricted Drug Restricted
    Amber 2
    INITIATION BY SPECIALIST ONLY 
       
    Haloperidol injection
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    Restricted Drug Restricted
    Red

    Approved off-label indication:
    Sedation in the ICU

    Restricted to use in accordance with a local critical care guideline

     
       
    04.02.01  Expand sub section  Second-Generation Antipsychotic Drugs
    Amisulpride tabs, solution
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    Restricted Drug Restricted
    Amber 2
    INITIATION BY SPECIALIST ONLY 
       
    Aripiprazole tabs
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    Restricted Drug Restricted
    Amber 2
    INITIATION BY SPECIALIST ONLY 
    Link  NICE TA213: Aripiprazole for the treatment of schizophrenia in people aged 15 -17 years
    Link  NICE TA292: Aripiprazole for treating moderate to severe manic episodes in adolescents with bipolar I disorder
       
    Clozapine tabs
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    Restricted Drug Restricted
    Red
    INITIATION BY SPECIALIST ONLY 
    Link  MHRA Oct 17: Clozapine: reminder of potentially fatal risk of intestinal obstruction, faecal impaction, and paralytic ileus
       
    Lurasidone tabs
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    Restricted Drug Restricted
    Red

    INITIATION BY SPECIALIST ONLY

    Restricted to use where a metabolically neutral atypical antipsychotic is required and aripiprazole is not suitable due to contraindication or intolerance

     
    Link  SEL APC recommendation - Lurasidone for the treatment of schizophrenia in adults aged 18 years and over
       
    Olanzapine tabs, orodispersible tabs
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    Restricted Drug Restricted
    Amber 2
    INITIATION BY SPECIALIST ONLY 
       
    Quetiapine tabs
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    Restricted Drug Restricted
    Amber 2
    INITIATION BY SPECIALIST ONLY 
       
    Risperidone tabs, liquid, orodispersible tabs
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    Restricted Drug Restricted
    Amber 2
    INITIATION BY SPECIALIST ONLY 
       
    04.02.02  Expand sub section  Antipsychotic depot injections to top
    Aripiprazole depot injection
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    Restricted Drug Restricted
    Amber 3

    SPECIALIST INITIATION

    GPs may be asked to take on prescribing under a the APC shared care agreement

     
    Link  SEL APC Shared Care Guidance for Aripiprazole prolonged- release suspension for injection (depot) for the treatment of schizophrenia in adults
       
    Flupentixol decanoate injection
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    Restricted Drug Restricted
    Amber 2
    INITIATION BY SPECIALIST ONLY 
       
    Fluphenazine decanoate injection
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    Restricted Drug Restricted
    Amber 2
    INITIATION BY SPECIALIST ONLY 
       
    Haloperidol deconate injection
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    Restricted Drug Restricted
    Amber 2
    INITIATION BY SPECIALIST ONLY 
       
    Paliperidone palmitate injection
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    Restricted Drug Restricted
    Amber 3

    INITIATION BY SPECIALIST ONLY

    GPs may be asked to take on prescribing under the APC shared care agreement for the monthly depot preparation only (Xeplion®)

     

    Red Traffic Light

    The 3-monthly preparation (Trevicta® - 175mg, 263mg, 350mg and 525mg strengths) is currently for hospital pescribing only

     
    Link  SE London APC Recommendation: Paliperidone depot injection for schizophrenia in adults
    Link  SE London APC Shared Care Guidance for Paliperidone long-acting injection for the treatment of schizophrenia in adults
       
    Pipotiazine palmitate injection
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    Restricted Drug Restricted INITIATION BY SPECIALIST ONLY 
       
    Risperidone depot injection
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    Restricted Drug Restricted
    Amber 2
    INITIATION BY SPECIALIST ONLY 
       
    Zuclopenthixol decanoate injection
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    Restricted Drug Restricted
    Amber 2
    INITIATION BY SPECIALIST ONLY 
       
    04.02.03  Expand sub section  Drugs used for mania and hypomania
    Asenapine tabs
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    Restricted Drug Restricted INITIATION BY SPECIALIST ONLY 
       
    04.02.03  Expand sub section  Benzodiazepines
    Clonazepam tabs (mania - off-label)
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    Restricted Drug Restricted
    Amber 2

    Approved off-label indication:

    Mania (off-label)

    Dose = up to 2mg three times a day, tailored to patient response

    INITIATION BY SPECIALIST ONLY

     
       
    04.02.03  Expand sub section  Carbamazepine
    Carbamazepine tabs, m/r tabs, liquid (bipolar disorder)
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    Restricted Drug Restricted
    Amber 2
    INITIATION BY SPECIALIST ONLY 
       
    04.02.03  Expand sub section  Valproic acid
    Sodium valproate m/r tabs (mood stabiliser - off-label)
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    Restricted Drug Restricted
    Amber 2

    Approved off-label indication:

    Mood stabiliser

    Dose = 500mg once daily increasing up to 2.5g daily in divided doses

    INITIATION BY SPECIALIST ONLY

    Valproate must no longer be used in any girls or women able to have children unless she agrees to comply with a pregnancy prevention programme.

    All women and girls who are prescribed valproate should contact their GP and arrange to have their treatment reviewed.

    Communication materials have been provided by the manufacturers to discuss the risk of abnormal pregnancy outcomes with women and girls of childbearing potential. See links below.

     
    Link  Treatment with valproate for female patients: Checklist for patients and prescribers
    Link  Valproate- Patient Card – Risks in Female patients
    Link  Valproate- Patient Guide – Risks in Female patients
    Link  Valproate- Letter for Prescribers -Risks in Female patients
    Link  Important Information for Healthcare Professionals on the Risks of Valproate in Female Patients
    Link  MHRA Guidance Mar 2018: Valproate use by women and girls
    Link  MHRA Apr 2017: Valproate and developmental disorders: new alert asking for patient review and further consideration of risk minimisation measures
    Link  MHRA Feb 2016: Valproate and risk of abnormal pregnancy outcomes: new communication materials
       
    Valproic acid tablets (as semisodium valproate) (mood stabiliser)
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    Restricted Drug Restricted
    Amber 2

    INITIATION BY SPECIALIST ONLY

    Valproate must no longer be used in any girls or women able to have children unless she agrees to comply with a pregnancy prevention programme.

    All women and girls who are prescribed valproate should contact their GP and arrange to have their treatment reviewed.

    Communication materials have been provided by the manufacturers to discuss the risk of abnormal pregnancy outcomes with women and girls of childbearing potential. See links below.

     
    Link  Treatment with valproate for female patients: Checklist for patients and prescribers
    Link  Valproate- Patient Card – Risks in Female patients
    Link  Valproate- Patient Guide – Risks in Female patients
    Link  Valproate- Letter for Prescribers -Risks in Female patients
    Link  Important Information for Healthcare Professionals on the Risks of Valproate in Female Patients
    Link  MHRA Guidance Mar 2018: Valproate use by women and girls
    Link  MHRA Apr 17: Valproate and developmental disorders: new alert asking for patient review and further consideration of risk minimisation measures
    Link  MHRA Feb 2016: Valproate and risk of abnormal pregnancy outcomes: new communication materials
       
    04.02.03  Expand sub section  Lithium to top
    Lithium carbonate m/r tabs
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    Restricted Drug Restricted
    Amber 2
    INITIATION BY SPECIALIST ONLY 
       
    Lithium citrate liquid
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    Restricted Drug Restricted
    Amber 2
    INITIATION BY SPECIALIST ONLY 
       
    04.03  Expand sub section  Antidepressant drugs
    04.03.01  Expand sub section  Tricyclic and related antidepressant drugs
    04.03.01  Expand sub section  Tricyclic antidepressants
    Amitriptyline tabs, oral soution
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    Formulary  
       
    Clomipramine caps
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    Restricted Drug Restricted

    INITIATION BY SPECIALIST ONLY

    Approved use includes the following off-label indication:

    Panic disorder - use in accordance with NICE CG113

     
    Link  NICE CG113: Generalised anxiety disorder and panic disorder in adults: management
       
    Dosulepin tabs, caps
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    Formulary Red Traffic Light for new initiations Amber Traffic Light for existing patients 
       
    Doxepin caps
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    Formulary  
       
    Imipramine tabs
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    Formulary

    INITIATION BY SPECIALIST ONLY

    Approved use includes the following off-label indication:

    Panic disorder - use in accordance with NICE CG113

     
    Link  NICE CG113: Generalised anxiety disorder and panic disorder in adults: management
       
    Lofepramine tabs, oral suspension
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    Formulary  
       
    Nortriptyline tabs
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    Formulary  
       
    Trimipramine tabs, caps
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    Restricted Drug Restricted INITIATION BY SPECIALIST ONLY 
       
    04.03.01  Expand sub section  Related antidepressants
    Trazodone caps
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    Restricted Drug Restricted INITIATION BY SPECIALIST ONLY 
       
    04.03.02  Expand sub section  Monoamine-oxidase inhibitors to top
    Phenelzine tabs
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    Restricted Drug Restricted
    Amber 2
    INITIATION BY SPECIALIST ONLY 
       
    Tranylcypromine tabs
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    Restricted Drug Restricted
    Amber 2
    INITIATION BY SPECIALIST ONLY 
       
    04.03.02  Expand sub section  Reverible MAOIs
    Moclobemide tabs
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    Restricted Drug Restricted INITIATION BY SPECIALIST ONLY 
       
    04.03.03  Expand sub section  Selective serotonin re-uptake inhibitors
     note  Refer to MHRA guidance for SSRIs and SNRIs use and safety
    Citalopram tabs, oral drops
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    Formulary  
       
    Escitalopram tabs
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    Restricted Drug Restricted INITIATION BY SPECIALIST ONLY 
       
    Fluoxetine caps, liquid
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    Formulary  
       
    Fluvoxamine tabs
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    Restricted Drug Restricted INITIATION BY SPECIALIST ONLY 
       
    Paroxetine tabs, liquid
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    Formulary  
       
    Sertraline tabs
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    Formulary  
       
    04.03.04  Expand sub section  Other antidepressant drugs
     note  Refer to MHRA guidance for SSRIs and SNRIs use and safety
    Agomelatine tabs
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    Restricted Drug Restricted
    Red
    SPECIALIST PRESCRIBING ONLY 
       
    Duloxetine caps
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    Restricted Drug Restricted INITIATION BY SPECIALIST ONLY 
       
    Flupentixol tabs
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    Formulary
    Amber 2
     
       
    Mirtazapine tabs, orodispersible tabs
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    Formulary INITIATION BY SPECIALIST ONLY 
       
    Reboxetine tabs
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    Restricted Drug Restricted INITIATION BY SPECIALIST ONLY 
       
    Venlafaxine m/r tabs, m/r caps
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    Formulary  
       
    Venlafaxine tabs (vasomotor symptoms in the menopause - off-label)
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    Formulary
    Amber 2

    Approved off-label indication:

    • Treatment of vasomotor symptoms in the menopause where hormonal treatment is ineffective or inappropriate

    Dose = 37.5mg twice a day 

     
       
    Vortioxetine tabs
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    Formulary
    Green
     
    Link  NICE CG367: Vortioxetine for treating major depressive episodes
       
    04.04  Expand sub section  CNS stimulants and other drugs used for attention deficit hyperactivity disorder
    Atomoxetine caps, oral solution
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    Restricted Drug Restricted
    Amber 3

    INITIATION BY SPECIALIST ONLY

    Treatment of ADHD in children and adults Refer to links in this section for ADHD shared care documentation

     
       
    Controlled Drug Dexamfetamine tabs (ADHD)
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    Restricted Drug Restricted
    Amber 3

    INITIATION BY SPECIALIST ONLY

    • Treatment of ADHD in children
    • Treatment of ADHD in adults (off-label)

    Refer to links in this section for ADHD shared care documentation

     
    Link  SEL APC recommendation - Dexamfetamine for the treatment of ADHD in adults
       
    Guanfacine m/r tabs
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    Restricted Drug Restricted
    Red

    SPECIALIST PRESCRIBING ONLY

    Restricted to use in ADHD in children where methyphenidate and atomoxetine are not suitable, not tolerated or have been ineffective

     
    Link  SEL APC Recommendation: Guanfacine for ADHD in children
       
    Controlled Drug Lisdexamfetamine caps
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    Restricted Drug Restricted
    Amber 3

    INITIATION BY SPECIALIST ONLY

    Treatment of ADHD in children and adults

    Refer to links in this section for ADHD shared care documentation

     
    Link  SEL APC Recommendation - Lisdexamfetamine for the treatment of ADHD in adults
    Link  SEL APC Recommendation - Lisdexamfetamine for the treatment of ADHD in children aged 6 years and over
       
    Controlled Drug Methylphenidate tabs, m/r tabs, m/r caps (ADHD)
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    Restricted Drug Restricted
    Amber 3

    INITIATION BY SPECIALIST ONLY

    Treatment of ADHD in children Treatment of ADHD in adults (off-label)

    Refer to links in this section for ADHD shared care documentation

    Note: extended release formulations to be prescribed by brand, as different formulations are not bioequivalent. Patients should remain on the same m/r brand they are initiated on. 

    m/r brands available:

    • Concerta XL
    • Xenidate XL
    • Matoride XL
    • Delmosart
    • Xaggitin XL 
    • Equasym XL (caps)
    • Medikinet XL (caps)
     
       
    Controlled Drug Dexamfetamine tabs (sleep centre indications)
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    Restricted Drug Restricted
    Red

    SLEEP CENTRE USE ONLY

    Narcolepsy and idiopathic hypersomnia (off-label)

    Restricted to patients who have not responded to modafinil, or where modafinil is contra-indicated

     
    Link  SEL APC Recommendation: Dexamfetamine for narcolepsy
    Link  SEL APC Recommendation: Methylphenidate and dexamfetamine for idiopathic hypersomnia in adults
       
    Controlled Drug Methylphenidate tabs, m/r tabs, m/r caps (sleep centre use - off-label)
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    Restricted Drug Restricted
    Red

    SLEEP CENTRE USE ONLY

    Narcolepsy and idiopathic hypersomnia (off-label) Restricted to patients who have not responded to modafinil, or where modafinil is contra-indicated

    Refer to APC recommendations for detailed information

    Extended release formulations to be prescribed by brand, as different formulations are not bioequivalent. Brands available:

    • Concerta
    • Xenidate
    • Matoride
    • Equasym
    • Medikinet
     
    Link  SE London APC Recommendation: Methylphenidate and dexamfetamine idiopathic hypersomnia in adults
       
    Modafinil tabs
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    Restricted Drug Restricted
    Amber 3

    INITIATION BY SPECIALIST ONLY

    Symptomatic relief of excessive sleepiness associated with narcolepsy

    Approved off-label indication:

    Idiopathic hypersomnia: Dose = 200 – 400 mg daily.

    Subject to production of a shared care agreement and patient information leaflet

     
       
    Pitolisant tablets
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    Restricted Drug Restricted
    Red

    SLEEP CENTRE USE ONLY

    • Approved for use in narcolepsy, with or with cataplexy in adults
    • Restricted to use as a last line treatment where modafinil and dexamfetamine or methylphenidate have failed to improve symptoms.

    See APC recommendation for further information

     
    Link  SE London APC recommendation: Pitolisant hydrochloride for the treatment of narcolepsy with or without cataplexy in adults
       
    Mazindol tabs
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    Unlicensed Drug Unlicensed
    Red

    SLEEP CENTRE USE ONLY

    Narcolepsy and idiopathic hypersomnia after failure or intolerance to modafinil and amphetamines.

    Dose: 1–4mg daily.

    Subject to production of a shared care agreement and patient information leaflet

     
       
    04.05  Expand sub section  Drugs used in the treatment of obesity to top
    04.05.01  Expand sub section  Anti-obesity drugs acting on the gastro-intestingal tract
    Orlistat caps
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    Formulary

    For treatment of obesity. Use in accorandance with NICE guidance (CG189)

     
    Link  NICE CG189: Obesity: identification, assessment and management
       
    Orlistat caps (Type V hypertriglyceridaemia - off-label)
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    Restricted Drug Restricted

    Approved off-label indication (specialist intiation only):

    Type V hypertriglyceridaemia: Dose = 120 mg three times a day with meals

     
       
    04.05.02  Expand sub section  Centrally acting appetite suppressants
    04.06  Expand sub section  Drugs used in nausea and vertigo
    04.06  Expand sub section  Antihistamines
    Cinnarizine tabs
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    Formulary  
       
    Cyclizine tabs, injection
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    Formulary Follow local guidelines for use in post-operative nausea and vomiting 
       
    Promethazine tabs, elixir, injection
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    Formulary  
       
    04.06  Expand sub section  Phenothiazines and related drugs to top
    Droperidol injection
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    Formulary
    Red
    Prophylaxis and treatment of postoperative nausea and vomiting in accordance with its marketing authorisation. 
       
    Prochlorperazine tabs, buccal tabs, syrup, injection
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    Formulary  
       
    04.06  Expand sub section  Domperidone and metoclopramide
    Domperidone tabs, suspension
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    Formulary  
    Link  MHRA advice May 2014: Domperidone: risks of cardiac side effects
       
    Domperidone tabs, suspension (use as galactagogue - off-label)
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    Formulary
    Red

    Approved off-label indication:

    Treatment of inadequate lactation

    Dose = 10mg three times a day

     
       
    Metoclopramide tabs, syrup, injection
    View adult BNF View SPC online
    Formulary Daily doses >30 mg and duration >5 days (off-label) may be used for symptom control in palliative care patients only 
    Link  MHRA advice August 2013: Metoclopramide: risk of neurological adverse effects
       
    04.06  Expand sub section  5HT3 antagonists
    Granisetron tabs, injection
    View adult BNF View SPC online
    Restricted Drug Restricted
    Amber 2
     
       
    Granisetron transdermal patch
    View adult BNF View SPC online
    Restricted Drug Restricted
    Red

    Prevention of nausea and vomiting associated with moderately or highly emetogenic chemotherapy

    Restricted to use where where oral antiemetic administration is complicated by factors making swallowing difficult

     
       
    Ondansetron tabs, injection
    View adult BNF View SPC online
    Formulary
    Amber 2
     
       
    04.06  Expand sub section  Neurokinin receptor antagonist
    Aprepitant caps
    View adult BNF View SPC online
    Formulary
    Red

    Approved for:

    Prevention of acute and delayed nausea and vomiting associated with highly emetogenic cisplatinbased cancer chemotherapy

    Prevention of nausea and vomiting associated with moderately emetogenic cancer chemotherapy only for subsequent chemotherapy cycles if the standard antiemetic regimen has failed with the initial chemotherapy cycle.

     
       
    Aprepitant caps
    View adult BNF View SPC online
    Restricted Drug Restricted
    Red

    Approved off-label indication:

    For the treatment of dihydroergotamine induced nausea where domperidone or 5HT3 antagonists have failed or are inappropriate

    For consultant headache specialist use only as per locally approved protocol

     
       
    04.06  Expand sub section  Cannabinoid
    Nabilone caps
    View adult BNF View SPC online
    Formulary
    Red
     
       
    04.06  Expand sub section  Hyoscine to top
    Hyoscine hydrobromide patch
    View adult BNF View SPC online
    Formulary  
       
    04.06  Expand sub section  Other drugs for Méničre's disease
    Betahistine dihydrochloride tabs
    View adult BNF View SPC online
    Formulary  
       
    04.07  Expand sub section  Analgesics
    04.07.01  Expand sub section  Non-opioid analgesics and compound analgesic preparations
    Aspirin tabs
    View adult BNF View SPC online
    Formulary  
       
    Dilofenac sodium tabs, m/r tabs, dispersible tabs, suppositories
    View adult BNF View SPC online
    Formulary  
    Link  MHRA Jun 2013: Diclofenac: new contraindications and warnings
       
    Ibuprofen tabs, suspension
    View adult BNF View SPC online
    Formulary  
    Link  MHRA Jun 2015: High-dose ibuprofen (≥2400mg/day): small increase in cardiovascular risk
       
    Nefopam tabs
    View adult BNF View SPC online
    Formulary  
       
    Paracetamol injection
    View adult BNF View SPC online
    Formulary

    Restricted to short-term treatment of moderate pain and fever when administration by the intravenous route is clinically justified

    For patients weighing less than 50 kg:

    • Max dose = 15 mg/kg
    • Minimum dose interval of 4 hours
    • Maximum daily dose must not exceed 60 mg/kg (without exceeding 3g)

     In severe renal insufficiency (creatinine clearance ≤30 mL/min):

    • Minimum dose interval of 6 hours

    Not to exceed 3g as total daily dose in the following patients:

    • Hepatocellular insufficiency
    • Chronic alcoholism
    • Chronic malnutrition or dehydration
     
       
    Paracetamol tabs, soluble tabs, oral suspension, suppositories
    View adult BNF View SPC online
    Formulary  
       
    04.07.01  Expand sub section  Compound analgesic preparations
    Co-codamol tabs, dispersible tabs (paracetamol and codeine)
    View adult BNF View SPC online
    Formulary Strengths available:
  • Co-codamol 8/500
  • Co-codamol 30/500 
  •    
    Co-dydramol 10/500 tabs (paracetamol and dihydrocodeine)
    View adult BNF View SPC online
    Formulary  
       
    04.07.02  Expand sub section  Opioid analgesics to top
    Controlled Drug Morphine salts tabs, m/r tabs, m/r caps, m/r suspension, oral solution, injection
    View adult BNF View SPC online
    First Choice First line strong oral opioid 
    Controlled Drug Oxycodone caps, m/r tabs, liquid, injection
    View adult BNF View SPC online
    Second Choice

    Second line opioid

    Restricted to use where morphine is not tolerated or contra-indicated

     
       
    Controlled Drug Tapentadol m/r tabs
    View adult BNF View SPC online
    Restricted Drug Restricted
    Amber 2

    INITIATION BY PAIN CONSULTANTS ONLY

    Third-line treatment for the management of severe chronic pain following the treatment failure/intolerance of morphine and one other strong opioid.

    When successfully treated patients are on a stable dose, care can be transferred to the patient’s GP with an accompanying letter explaining the change in chronic pain management.

     
       
    Controlled Drug Alfentanil injection
    View adult BNF View SPC online
    Formulary USE UNDER SPECIALIST SUPERVISION ONLY 
       
    Controlled Drug Buprenorphine patch (weekly preparation)
    View adult BNF View SPC online
    Restricted Drug Restricted

    INITIATION BY CONSULTANT ONLY

    Second line option for patients with chronic severe pain who:

    • Cannot tolerate large, oral, regular doses of weak opioids or non-opioid + weak opioid combination analgesics
    • Have conditions where use of anti-inflammatory drugs is not recommended or who have not tolerated such drugs
     
       
    Controlled Drug Buprenorphine sublingual tabs, injection, patches (96 hour)
    View adult BNF View SPC online
    Formulary

     
       
    Codeine tabs, injection
    View adult BNF View SPC online
    Formulary  
    Controlled Drug = injection
       
    Controlled Drug Diamorphine injection
    View adult BNF View SPC online
    Formulary  
       
    Dihydrocodeine m/r tabs
    View adult BNF View SPC online
    Formulary  
       
    Dihydrocodeine tabs, injection
    View adult BNF View SPC online
    Formulary  
    Controlled Drug = injection
       
    Controlled Drug Fentanyl injection
    View adult BNF View SPC online
    Formulary USE UNDER SPECIALIST SUPERVISION ONLY 
       
    Controlled Drug Fentanyl patches
    View adult BNF View SPC online
    Formulary  
       
    Controlled Drug Fentanyl sublingual tabs, buccal tabs and nasal spray
    View adult BNF View SPC online
    Restricted Drug Restricted

    PALLIATIVE CARE ONLY

    Management of breakthrough pain in adult patients already receiving maintenance opioid therapy for chronic cancer pain that is unresponsive to morphine sulphate oral solution

    Use in accordance with local guideline

     
       
    Controlled Drug Hydromorphone caps
    View adult BNF View SPC online
    Formulary  
       
    Meptazinol tabs, injection
    View adult BNF View SPC online
    Restricted Drug Restricted PAIN TEAM ONLY 
       
    Controlled Drug Methadone tabs, injection
    View adult BNF View SPC online
    Restricted Drug Restricted USE UNDER SPECIALIST SUPERVISION ONLY 
       
    Controlled Drug Morphine suppositories
    View adult BNF View SPC online
    Formulary  
       
    Controlled Drug Papaveretum and hyoscine injection
    View adult BNF View SPC online
    Formulary  
       
    Controlled Drug Papaveretum injection
    View adult BNF View SPC online
    Formulary  
       
    Controlled Drug Pethidine tabs, injection
    View adult BNF View SPC online
    Formulary  
       
    Controlled Drug Tramadol caps, soluble tabs, injection
    View adult BNF View SPC online
    Formulary m/r preparations are Non-Formulary 
       
    Controlled Drug Morphine 0.1%, 0.2% w/v topical gel
    View adult BNF View SPC online
    Unlicensed Drug Unlicensed

    CONSULTANT SPECIALISTS ONLY

    Use in accordance with local guideline

    Treatment of pain localised to a cutaneous ulceration in a palliative care setting (PIL available on GTi)

     
       
    04.07.02  Expand sub section  Weak opioids
    04.07.02  Expand sub section  Strong opioids
    04.07.02  Expand sub section  Breakthrough pain
    04.07.02  Expand sub section  Injectable
    04.07.02  Expand sub section  Other to top
    04.07.03  Expand sub section  Neuropathic pain
    Amitriptyline tabs, oral solution
    View adult BNF View SPC online
    Formulary

    Use in neuropathic pain is off-label

    Refer to SEL APC neuropathic pain guideline (link below)

     
       
    Carbamazepine tabs, liquid (neuropathic pain)
    View adult BNF View SPC online
    Formulary SPECIALIST INITIATION ONLY
  • Use in neuropathic pain is off-label
  • Dose = 100 mg twice daily, increased gradually to a maximum of 200mg three times a day 
  •    
    Clonazepam tabs (neuropathic pain - off-label)
    View adult BNF View SPC online
    Formulary

    Use in neuropathic pain is off-label

    Dose = 0.5mg at night, increased slowly up to 1mg twice daily as per response

     
       
    Duloxetine caps (neuropathic pain)
    View adult BNF View SPC online
    Formulary

    For painful diabetic neuropathy

    Refer to SEL APC neuropathic pain guideline (link below)

     
       
    Gabapentin caps (pain)
    View adult BNF View SPC online
    Formulary

    Green Traffic Light Neuropathic pain - refer to SEL APC guideline (link below)

    Red Traffic Light Approved off-label indication:

    • Post-operative pain as a short course supplied by the hospital
     
    Link  MHRA Oct 17: Gabapentin (Neurontin): risk of severe respiratory depression
       
    Gabapentin caps (vasomotor symptoms in the menopause - off-label)
    View adult BNF View SPC online
    Formulary
    Amber 2

    Approved off-label indication:

    Treatment of vasomotor symptoms in the menopause where hormonal treatment is ineffective or inappropriate

    Dose = starting at 300mg daily increased slowly to a max of 900mg three times a day

     
       
    Imipramine tabs
    View adult BNF View SPC online
    Formulary

    Use in neuropathic pain is off-label

    Restricted to use where amitriptyline is not tolerated

    • Dose = 10 mg at night
    • May be increased gradually to 75 mg
     
       
    Nortriptyline tabs
    View adult BNF View SPC online
    Restricted Drug Restricted

    Use in neuropathic pain is off label

    Restricted to use where sedation is a significant problem with amitriptyline Refer to SEL APC neuropathic pain guideline (link below)

     
       
    Pregabalin caps (neuropathic pain)
    View adult BNF View SPC online
    Restricted Drug Restricted

    Third line choice for neuropathic pain after amitriptyline and gabapentin

    Refer to SEL APC neuropathic pain guideline (link below)

     
       
    Botulinum toxin type A (Xeomin® - myofascial pain and temporomandibular joint disorder)
    View adult BNF View SPC online
    Restricted Drug Restricted
    Red
    High Cost Medicine

    Approved off-label indication:

    Myofascial pain in temporomandibular joint disorder:

    Category B* form required

    • Oral and maxillofacial surgery use only
    • Xeomin brand to be used
    • Dose = up to 100 units
    • Restricted to use in patients who fail standard treatments with jaw splints, NSAIDs and jaw exercises
     
    Link  SE London APC Recommendation: Botulinum toxin A for myofascial pain syndrome in temporomandibular jaw dysfunction
       
    Nabilone caps
    View adult BNF View SPC online
    Restricted Drug Restricted
    Red

    Approved off-label indication:

    For neuropathic pain in patients who have not responded to all other available anti-neuropathic agents (given alone or in combination) or where use of these has induced unmanageable side effects.

    • Dose: 1 mg twice dialy
    • Some patients may use 1 mg when required 2-3 times per week

    CONSULTANT SPECIALISTS ONLY

     
       
    Clonazepam injection (unlicensed product)
    View adult BNF View SPC online
    Unlicensed Drug Unlicensed

    Neuropathic pain when systemic administration is required in the Palliative Care setting

     
       
    Phenol 6% aqueous injection
    View adult BNF View SPC online
    Unlicensed Drug Unlicensed
    Red

    Approved for peripheral nerve neurolysis in chronic pain management.

    Pain clinic use only

    Restricted to use where where all standard neuropathic agents (oral and topical) have failed, or are inappropriate due to adverse effects or contra-indications.

    Refer to online guideline for use at GSTT: "Phenol aqueous injection in Chronic Non-malignant Pain"

     
       
    04.07.03  Expand sub section  Postherpetic neuralgia
    Capsaicin 0.075% cream
    View adult BNF View SPC online
    Formulary

    For localised neuropathic pain or for those who wish to avoid or cannot tolerate oral treatment Licensed for post-herpetic neuralgia and diabetic peripheral neuropathy only

    Refer to SEL APC neuropathic pain guideline (link above)

     
       
    04.07.04  Expand sub section  Antimigraine drugs
    04.07.04.01  Expand sub section  Treatment of the acute migraine attack
    Ibuprofen tabs
    View adult BNF View SPC online
    Formulary  
       
    Paracetamol tabs, soluble tabs
    View adult BNF View SPC online
    Formulary  
       
    Lidocaine infusion
    View adult BNF View SPC online
    Restricted Drug Restricted
    Red

    Joint Formulary Committee approved off-label use (specialist headache clinic use only):

    • Short-lasting Unilateral Neuralgiform Headache attacks with conjunctival injection and Tearing (SUNCT)
    • Short-lasting Unilateral Neuralgiform Headache attacks with Cranial Autonomic Symptoms (SUNA)

    See dosing protocol from KCH for further information

     
       
    Aspirin injection
    View adult BNF
    Unlicensed Drug Unlicensed
    Red

    SPECIALIST USE ONLY

    Inpatient management of severe withdrawal headache

    Dose = 1g once to three times daily for up to 4 days

     
       
    Indometacin injection
    View adult BNF
    Unlicensed Drug Unlicensed
    Red

    SPECIALIST USE ONLY

    For the diagnosis of indometacin sensitive headaches (paroxysmal hemicranias)

    Dose = 100-200mg intramuscular test dose

     
       
    04.07.04.01  Expand sub section  5HT1 agonists to top
    Rizatriptan wafers
    View adult BNF View SPC online
    Formulary  
       
    Sumatriptan tabs, injection
    View adult BNF View SPC online
    Formulary  
       
    04.07.04.01  Expand sub section  Ergot alkaloids
    Dihydroergotamine injection
    View adult BNF
    Unlicensed Drug Unlicensed
    Red

    SPECIALIST USE ONLY

    Inpatient treatment of medical refractory disabling migraine and cluster headaches.

    See dosing protocol from KCH for further information

     
       
    04.07.04.01  Expand sub section  Anti-emetics
    Metoclopramide tabs
    View adult BNF View SPC online
    Formulary Maximum daily dose of 30mg for a maximum of 5 days. See MHRA davice. 
    Link  MHRA advice August 2013: Metoclopramide: risk of neurological adverse effects
       
    Prochlorperazine suppositories
    View adult BNF View SPC online
    Formulary  
       
    04.07.04.02  Expand sub section  Prophylaxis of migraine
    Amitriptyline tabs (migraine prophylaxis - off-label)
    View adult BNF View SPC online
    Formulary

    Use for migraine prophylaxis is off-label

    Dose = 10mg at night increasing to 50-75mg at night as per response

     
       
    Botulinum Toxin Type A (Botox® - migraine)
    View adult BNF View SPC online
    Restricted Drug Restricted
    Red
    High Cost Medicine
    Approved for use as per resctritions in the NICE guidance for the use of botulinum toxin in chronic migraine 
    Link  NICE TA260: Botox for migraine prophylaxis
       
    Dosulepin tabs, caps (migraine prophylaxis - off-label)
    View adult BNF View SPC online
    Formulary

    Use for migraine prophylaxis is off-label

    Dose = 25 mg at night, increasing if necessary to 75-150mg at night or in divided doses

    Red Traffic Light for new initiations

    Amber Traffic Light for existing patients

     
       
    Lidocaine injection 2% (chronic headache - off-label)
    View adult BNF View SPC online
    Restricted Drug Restricted
    Red

    Approved off-label indication (specialist headache clinic use only):

    Greater occipital nerve block for treatment of chronic headache.

    • Restricted to use where oral and other conventional treatments are insufficient or not tolerated.
    • Dose = 3ml (60mg)
     
       
    Methylprednisolone acetate 80mg (Depo-Medrone® - chronic headache)
    View adult BNF View SPC online
    Restricted Drug Restricted
    Red

    Approved off-label indication (specialist headache clinic use only):

    Greater occipital nerve block for treatment of chronic headache.

    • Restricted to use where oral and other conventional treatments are insufficient or not tolerated.
    • Given in conjunction with with 3ml of lidocaine 2% (i.e. 60mg of lidocaine plus 80mg methylprednisolone acetate)
     
       
    Pizotifen tabs, elixir
    View adult BNF View SPC online
    Formulary  
       
    Propranolol tabs (migraine prophylaxis)
    View adult BNF View SPC online
    Formulary  
       
    Sodium valproate tabs (migraine prophylaxis - off-label)
    View adult BNF View SPC online
    Restricted Drug Restricted
    Amber 2

    USE ON SPECIALIST ADVICE ONLY

    Use in migraine prophylaxis is off-label

    Valproate must no longer be used in any girls or women able to have children unless she agrees to comply with a pregnancy prevention programme.

    All women and girls who are prescribed valproate should contact their GP and arrange to have their treatment reviewed.

    Communication materials have been provided by the manufacturers to discuss the risk of abnormal pregnancy outcomes with women and girls of childbearing potential. See links below.

     
    Link  Treatment with valproate for female patients: Checklist for patients and prescribers
    Link  Valproate- Patient Card – Risks in Female patients
    Link  Valproate- Patient Guide – Risks in Female patients
    Link  Valproate- Letter for Prescribers -Risks in Female patients
    Link  Important Information for Healthcare Professionals on the Risks of Valproate in Female Patients
    Link  MHRA Mar 2018: Valproate use by women and girls
    Link  MHRA Apr 2017: Valproate and developmental disorders: new alert asking for patient review and further consideration of risk minimisation measures
    Link  MHRA Feb 2016: Valproate and risk of abnormal pregnancy outcomes: new communication materials
       
    Topiramate tabs, sprinkles (migraine prophylaxis)
    View adult BNF View SPC online
    Formulary
    Amber 2
     
       
    Methysergide tabs
    View adult BNF View SPC online
    Formulary REQUIRES HOSPITAL SUPERVISION 
       
    04.07.04.03  Expand sub section  Cluster headache
    04.08  Expand sub section  Antiepileptics to top
    04.08.01  Expand sub section  Control of epilepsy
    04.08.01  Expand sub section  Carbamazepine and Oxcarbazepine
    Carbamazepine tabs, m/r tabs, liquid, suppositories (epilepsy)
    View adult BNF View SPC online
    Formulary
    Amber 2

     
       
    Eslicarbazepine tabs
    View adult BNF View SPC online
    Formulary
    Amber 3
    USE UNDER SPECIALIST SUPERVISION ONLY 
       
    Oxcarbazepine tabs
    View adult BNF View SPC online
    Formulary
    Amber 2
     
       
    04.08.01  Expand sub section  Ethosuximide
    Ethosuximide caps, elixir
    View adult BNF View SPC online
    Formulary
    Amber 2
    USE UNDER SPECIALIST SUPERVISION ONLY 
       
    04.08.01  Expand sub section  Gabapentin and pregabalin
    Gabapentin caps (epilepsy)
    View adult BNF View SPC online
    Formulary
    Amber 2
    USE UNDER SPECIALIST SUPERVISION ONLY 
    Link  MHRA Oct 17: Gabapentin (Neurontin): risk of severe respiratory depression
       
    Pregabalin caps (epilepsy)
    View adult BNF View SPC online
    Formulary
    Amber 2
    USE UNDER SPECIALIST SUPERVISION ONLY 
       
    04.08.01  Expand sub section  Lacosamide to top
    Lacosamide tabs, syrup, injection
    View adult BNF View SPC online
    Formulary
    Amber 3

    USE UNDER SPECIALIST SUPERVISION ONLY

    First 2 months supply to come from hospital GP information sheet requires completion for transfer of prescribing

     

     
    Link  SEL APC Lacosamide GP information sheet
       
    04.08.01  Expand sub section  Lamotrigine
    Lamotrigine tabs, disp tabs
    View adult BNF View SPC online
    Formulary
    Amber 2
    USE UNDER SPECIALIST SUPERVISION ONLY 
       
    04.08.01  Expand sub section  Levetiracetam
    Levetiracetam tabs, oral soution, injection
    View adult BNF View SPC online
    Formulary
    Amber 2
    USE UNDER SPECIALIST SUPERVISION ONLY 
       
    04.08.01  Expand sub section  Perampanel
    Perampanel tabs
    View adult BNF View SPC online
    Formulary
    Amber 3

    SPECIALIST INITIATION ONLY

    First 2 months supply to come from hospital.

    Transfer of Care documentation requires completion before GP will take over prescribing

     
    Link  Perampanel Screening Checklist, Notification of Initiation to GP and Transfer of Care / Prescribing Agreement
       
    04.08.01  Expand sub section  Phenobarbital and other barbiturates
    Controlled Drug Phenobarbital tabs, elixir, injection
    View adult BNF View SPC online
    Formulary USE UNDER SPECIALIST SUPERVISION ONLY 
       
    Primidone tabs
    View adult BNF View SPC online
    Formulary USE UNDER SPECIALIST SUPERVISION ONLY 
       
    04.08.01  Expand sub section  Phenytoin to top
    Phenytoin tabs, caps, suspension
    View adult BNF View SPC online
    Formulary
    Amber 2
     
       
    04.08.01  Expand sub section  Retigaine
    04.08.01  Expand sub section  Rufinamide
    04.08.01  Expand sub section  Tiagabine
    Tiagabine tabs
    View adult BNF View SPC online
    Formulary
    Amber 3

    SPECIALIST INITIATION ONLY

    First 2 months supply to come from hospital GP information sheet requires completion for transfer of prescribing

     
    Link  SEL APC Tiagabine GP Information Sheet
       
    04.08.01  Expand sub section  Topiramate
    Topiramate tabs, sprinkles (epilepsy)
    View adult BNF View SPC online
    Formulary
    Amber 2
    USE UNDER SPECIALIST SUPERVISION ONLY 
       
    04.08.01  Expand sub section  Valproate to top
    Sodium Valproate tabs, m/r tabs, oral solution, injection (epilepsy)
    View adult BNF View SPC online
    Formulary
    Amber 2

    Valproate must no longer be used in any girls or women able to have children unless she agrees to comply with a pregnancy prevention programme.

    All women and girls who are prescribed valproate should contact their GP and arrange to have their treatment reviewed.

    Communication materials have been provided by the manufacturers to discuss the risk of abnormal pregnancy outcomes with women and girls of childbearing potential. See links below.

     
    Link  Treatment with valproate for female patients: Checklist for patients and prescribers
    Link  Valproate- Patient Card – Risks in Female patients
    Link  Valproate- Patient Guide – Risks in Female patients
    Link  Valproate- Letter for Prescribers -Risks in Female patients
    Link  Important Information for Healthcare Professionals on the Risks of Valproate in Female Patients
    Link  MHRA Mar 2018: Valproate use by women and girls
    Link  MHRA Apr 2017: Valproate and developmental disorders: new alert asking for patient review and further consideration of risk minimisation measures
    Link  MHRA Feb 2016: Valproate and risk of abnormal pregnancy outcomes: new communication materials
       
    04.08.01  Expand sub section  Vigabatrin
    Vigabatrin tabs
    View adult BNF View SPC online
    Formulary
    Amber 2
    USE UNDER SPECIALIST SUPERVISION ONLY 
       
    04.08.01  Expand sub section  Zonisamide
    Zonisamide caps
    View adult BNF View SPC online
    Formulary
    Amber 3

    SPECIALIST INITIATION ONLY

    GP may take over prescribing responsibility via SEL APC shared care guidance.

    First 2 months supply to come from hospital.

     
    Link  SEL APC Zonisamide for the treatment of epilepsy in adults
       
    04.08.01  Expand sub section  Benzodiazepines
    Clobazam tabs
    View adult BNF View SPC online
    Formulary
    Amber 2
     
       
    Clonazepam tabs (epilepsy)
    View adult BNF View SPC online
    Formulary
    Amber 2

     
       
    04.08.01  Expand sub section  Other Drugs
    Brivaracetam tabs, oral solution
    View adult BNF View SPC online
    Restricted Drug Restricted
    Amber 3

    Initiation by consultant neurologist only

    Adjunctive third line treatment option for partial-onset seizures with or without secondary generalisation in adults

    Not be used concomitantly with levetiracetam as available evidence suggests there is no additional benefit from use of this combination

     
    Link  SE London APC recommendation: Brivaracetam for partial onset sesizures in epilepsy
       
    04.08.02  Expand sub section  Drugs used in status epilepticus to top
    Diazepam injection, rectal tubes
    View adult BNF View SPC online
    Formulary  
       
    Levetiracetam injection
    View adult BNF View SPC online
    Formulary

    Approved off-label indication:

    Status epilepticus

    Restricted to neurology consultant advice only

     
       
    Lorazepam injection
    View adult BNF View SPC online
    Formulary The SPC for Ativan® injection supports intravenous and intramuscular use 
       
    Controlled Drug Midazolam buccal liquid
    View adult BNF View SPC online
    Formulary
    Amber 2

    The first-line product is Buccolam® which is available as 10 mg/2 mL in a pre-filled syringe.

    The dose for patients 10 years and older is 10 mg. If a more specific dose than those available using Buccolam® pre-filled syringes is required a second-line product, Epistatus® (unlicensed product), is available as 50mg/5mL

     
       
    Paraldehyde injection (given as an enema)
    View adult BNF View SPC online
    Formulary  
       
    Phenytoin sodium injection
    View adult BNF View SPC online
    Formulary  
       
    04.08.03  Expand sub section  Febrile convulsions
    04.09  Expand sub section  Drugs used in parkinsonism and related disorders
    04.09.01  Expand sub section  Dopaminergic drugs used in Parkinsons disease
    04.09.01  Expand sub section  Dopamine receptor agonists
    Apomorphine injection, infusion
    View adult BNF View SPC online
    Formulary
    Amber 3
    SPECIALIST INITIATION ONLY 
    Link  SE London APC Shared Care Agreement: Apomorphine for Parkinson’s Disease
       
    Bromocriptine tabs
    View adult BNF View SPC online
    Formulary  
       
    Cabergoline tabs
    View adult BNF View SPC online
    Formulary
    Amber 2
    SPECIALIST INITIATION ONLY 
       
    Pergolide tabs
    View adult BNF View SPC online
    Formulary

    Red Traffic Light For all new patients

    Amber Traffic Light For existing patients managed in primary care

     
       
    Pramipexole tabs, m/r tabs (Parkinson's disease)
    View adult BNF View SPC online
    Formulary
    Amber 2
     
       
    Ropinirole tabs, m/r tabs (Parkinson's disease)
    View adult BNF View SPC online
    Formulary
    Amber 2
     
    Link  SE London APC Recommendation: Ropinirole MR tabs for Parkinson’s Disease
       
    Rotigotine patches (Parkinson's disease)
    View adult BNF View SPC online
    Formulary
    Amber 2

    SPECIALIST INITIATION ONLY

    Treatment of the signs and symptoms of early-stage idiopathic Parkinson’s disease as monotherapy (i.e. without levodopa) or in combination with levodopa (i.e. over the course of the disease) through to late stages when the effect of levodopa wears off or becomes inconsistent and fluctuations of the therapeutic effect occur.

     
       
    04.09.01  Expand sub section  Levodopa to top
    Co-beneldopa caps, disp tabs, m/r caps
    View adult BNF View SPC online
    Formulary  
       
    Co-careldopa and Entacapone tabs
    View adult BNF View SPC online
    Formulary
    Amber 2
     
       
    Co-careldopa intestinal gel (Duodopa®)
    View adult BNF View SPC online
    Formulary
    Red
    High Cost Medicine
    BlueTeq

    RESTRICTED USE - ALL REFERRALS FOR PRESCRIBING SHOULD BE MADE TO PROFESSOR RAY CHAUDHURI AT KCH

    Treatment of advanced levodopa responsive Parkinson’s disease in patients with severe motor fluctuations and hyper-/dyskinesia when available combinations of Parkinson medicinal products have not given satisfactory results.

    Refer to NHSE commissioning criteria

     
    Link  NHS England Commissioning position on levodopa/carbidopa intestinal gel (DO4/P/e) (July 2015)
       
    Co-careldopa tabs, m/r tabs
    View adult BNF View SPC online
    Formulary  
       
    04.09.01  Expand sub section  Monoamine-oxidase-B inhibitors
    Rasagiline tabs
    View adult BNF View SPC online
    Formulary
    Amber 2

    INITIATION BY SPECIALIST ONLY

    Treatment for early Parkinson’s disease.

    To be used as monotherapy and gradually withdrawn when more symptomatic treatments are required.

    Not to be used in combination with levodopa

     
       
    Selegiline hydrochloride tabs, liquid
    View adult BNF View SPC online
    Formulary
    Amber 2
    SPECIALIST INITIATION ONLY 
       
    04.09.01  Expand sub section  Catachol-O-methyltransferase inhibitors
    Entacapone tabs
    View adult BNF View SPC online
    Formulary
    Amber 2
     
       
    04.09.01  Expand sub section  Amantadine
    Amantadine caps, syrup
    View adult BNF View SPC online
    Formulary
    Amber 2

    Approved for use in:

     
    Link  NICE CG186: Multiple sclerosis in adults: management
       
    04.09.01  Expand sub section  Mild to moderate dementia in Parkinsons disease
    04.09.02  Expand sub section  Antimuscarinic drugs used in parkinsonism to top
    Benzatropine injection
    View adult BNF View SPC online
    Formulary  
       
    Orphenadrine tabs
    View adult BNF View SPC online
    Formulary  
       
    Procyclidine tabs, syrup, injection
    View adult BNF View SPC online
    Formulary  
       
    Trihexyphenidyl (benzhexol) tabs
    View adult BNF View SPC online
    Formulary  
       
    04.09.03  Expand sub section  Drugs used in essential tremor, chorea, tics, and related disorders
    Haloperidol tabs
    View adult BNF View SPC online
    Formulary
    Amber 2
     
       
    Riluzole tabs
    View adult BNF View SPC online
    Formulary
    High Cost Medicine
     
    Link  NICE TA20: Guidance on the use of Riluzole (Rilutek) for the treatment of Motor Neurone Disease
       
    Tetrabenazine tabs
    View adult BNF View SPC online
    Formulary
    Red
     
       
    04.09.03  Expand sub section  Torsion dystonias and other involuntary movements
    Botulinum Toxin Type A (Botox® Xeomin® Dysport®)
    View adult BNF View SPC online
    Formulary
    Red
    High Cost Medicine
    To be prescribed by brand, as different preparations are not dose equivalent 
       
    Botulinum Toxin Type B (NeuroBloc®)
    View adult BNF View SPC online
    Formulary
    Red
    High Cost Medicine

    For use as an alternative to Botulinum toxin A in the presence of antibodies to Botulinum toxin A

    Category B* form required

     
    Link  MHRA March 2013: Botulinum toxin type B (Neurobloc): serious known risks
       
    04.09.04  Expand sub section  Restless legs syndrome
     note 
    Pramipexole tabs (restless legs syndrome)
    View adult BNF View SPC online
    First Choice
    Amber 2
    Immediate release preparation only 
    Ropinirole tabs (restless legs syndrome)
    View adult BNF View SPC online
    First Choice
    Amber 2
    Immediate release preparation only 
    Gabapentin caps (restless legs syndrome - off-label)
    View adult BNF View SPC online
    Second Choice
    Amber 2

    Approved for use in restless legs syndrome (off-label) with the following restrictions:

    • Specialist neurologist or sleep centre use only
    • In patients intolerant to dopamine agonists, or who have a history of insomnia or compulsive behaviours
    • Dose = 300 mg to 1200 mg at night

    Refer to SE London treatment pathway below

     
    Link  MHRA Oct 17: Gabapentin (Neurontin): risk of severe respiratory depression
    Link  SE London APC Recommendation: Gabapentin and Pregabalin for Restless Legs Syndrome
       
    Pregabalin caps (restless legs syndrome - off-label)
    View adult BNF View SPC online
    Second Choice
    Amber 2

    Approved for use in restless legs syndrome (off-label) with the following restrictions:

    • Specialist neurologist or sleep centre use only
    • In patients intolerant to dopamine agonists, or who have a history of insomnia or compulsive behaviours
    • Reserved for patients intolerant to gabapentin for this indication
    • Dose = 25 mg to 300 mg at night

    Refer to SE London treatment pathway below

     
    Link  SE London APC Recommendation: Gabapentin and Pregabalin for Restless Legs Syndrome
       
    Rotigotine patches (restless legs syndrome)
    View adult BNF View SPC online
    Second Choice
    Amber 2

    Restricted to use in restless legs syndrome in patients where who have experiences augmentation of symptoms with oral dopamine agonists or where there is a predominant presence of daytime symptoms

     
       
    Clonazepam tabs (restless legs syndrome - off-label)
    View adult BNF View SPC online
    Third Choice
    Amber 2

    Approved for use in restless legs syndrome (off-label) with the following restrictions:

    • Specialist neurologist or sleep centre use only
    • Refractory cases where dopamine agonists and gabapentin/pregabalin have failed, and insomnia is a significant symptom
    • Dose = 0.25mg to 4mg at night

    Refer to SE London treatment pathway below

     
    Link  SE London APC Recommendation: Hypnotics for Restless Legs Syndrome
       
    Zolpidem tabs (restless legs syndrome - off-label)
    View adult BNF View SPC online
    Third Choice
    Amber 2

    Approved for use in restless legs syndrome (off-label) with the following restrictions:

    • Specialist neurologist or sleep centre use only
    • Refractory cases where dopamine agonists and gabapentin/pregabalin have failed, and insomnia is a significant symptom
    • Dose = 5mg to 10 mg at night

    Refer to SE London treatment pathway below

     
    Link  SE London APC Recommendation: Hypnotics for Restless Legs Syndrome
       
    Zopiclone tabs (restless legs syndrome - off-label)
    View adult BNF View SPC online
    Third Choice
    Amber 2

    Approved for use in restless legs syndrome (off-label) with the following restrictions:

    • Specialist neurologist or sleep centre use only
    • Refractory cases where dopamine agonists and gabapentin/pregabalin have failed, and insomnia is a significant symptom
    • Dose = 3.75mg to 15mg at might

    Refer to SE London treatment pathway below

     
    Link  SE London APC Recommendation: Hypnotics for Restless Legs Syndrome
       
    Codeine tabs (restless legs syndrome - off-label)
    View adult BNF View SPC online
    Third Choice
    Amber 2

    Approved for use in restless legs syndrome (off-label) with the following restrictions:

    • Specialist neurologist or sleep centre use only
    • Refractory cases where dopamine agonists and gabapentin/pregabalin have failed and pain is a significant symptom
    • Dose = 30 mg to 90 mg at night

    Refer to SE London treatment pathway below

     
    Link  SE London APC Recommendation: Opioids for Restless Legs Syndrome
       
    Tramadol caps (restless legs syndrome - off-label)
    View adult BNF View SPC online
    Third Choice
    Amber 2

    Approved for use in restless legs syndrome (off-label) with the following restrictions:

    • Specialist neurologist or sleep centre use only
    • Refractory cases where dopamine agonists and gabapentin/pregabalin have failed and pain is a significant symptom
    • Dose = 50 to 200mg nocte

    Refer to SE London treatment pathway below

     
    Link  SE London APC Recommendation: Opioids for Restless Legs Syndrome
       
    Oxycodone/naloxone SR tabs (Targinact® - restless leg syndrome)
    View adult BNF View SPC online
    Third Choice
    Amber 2

    Approved for use in restless legs syndrome (off-label) with the following restrictions:

    • Specialist neurologist or sleep centre use only
    • Refractory cases where dopamine agonists and gabapentin/pregabalin have failed and pain is a significant symptom
    • Reserved for patients who have failed to tolerate other opioids for management of pain in restless legs syndrome
    • Dose = 5mg/2.5mg to 60mg/30mg twice daily

    Refer to SE London treatment pathway below

     
    Link  SE London APC Recommendation: Opioids for Restless Legs Syndrome
       
    04.10  Expand sub section  Drugs used in substance dependence
    04.10.01  Expand sub section  Alcohol dependence to top
    Acamprosate tabs
    View adult BNF View SPC online
    Formulary
    Amber 3
     
       
    Disulfiram tabs
    View adult BNF View SPC online
    Formulary
    Amber 2
    SPECIALIST INITIATION ONLY 
       
    Nalmefene tabs
    View adult BNF View SPC online
    Restricted Drug Restricted
    Red

    INITIATION BY SUBSTANCE MISUSE SPECIALISTS ONLY

    Use in accordance with NICE guidance for reducing alcohol consumption in people with alcohol dependence.

    Nalmefene should only be prescribed in conjunction with continuous psychosocial support focused on treatment adherence and reducing alcohol consumption.

    Patients requiring treatment with nalmefene should be referred to their local drug and alcohol services

     
    Link  NICE TA325: Nalmefene for reducing alcohol consumption in people with alcohol dependence
       
    Alcohol infusion
    Restricted Drug Restricted
    Red

    RESTRICTED USE

    Acute alcohol withdrawal in patients unable to take chlordiazepoxide.

    Dose = 30 mL of 90% alcohol injection in 500 mL 5% dextrose solution, over a 24 hour period

     
       
    04.10.02  Expand sub section  Nicotine dependence
    Nicotine Replacement Therapy
    View adult BNF View SPC online
    Formulary

    Products available:

    • Nicotinell® patches
    • Nicorette® invisi patches
    • Sublingual tablet
    • Orodispersible film
    • Lozenge
    • Medicated chewing gum
    • Spray
    • Inhalator

    Follow local guidelines for nicotine replacement therapy

     
       
    Varenicline tabs
    View adult BNF View SPC online
    Formulary  
    Link  NICE TA123: Varenicline
       
    04.10.03  Expand sub section  Opioid dependence
    04.10.03  Expand sub section  Opioid substitution therapy
    Controlled Drug Buprenorphine and Naloxone sublingual tabs
    View adult BNF View SPC online
    Restricted Drug Restricted SLAM ONLY 
       
    Controlled Drug Buprenorphine sublingual tabs
    View adult BNF View SPC online
    Formulary  
       
    Controlled Drug Methadone hydrochloride oral solution
    View adult BNF View SPC online
    Formulary  
       
    04.10.03  Expand sub section  Adjunctive therapy and symptomatic treatment
    Lofexidine tabs
    View adult BNF View SPC online
    Formulary
    Red
     
       
    04.10.03  Expand sub section  Opioid-receptor antagonists to top
    Naltrexone tabs
    View adult BNF View SPC online
    Formulary  
    Link  NICE TA115: Naltrexone for the management of opioid dependence
       
    04.11  Expand sub section  Drugs for dementia
    Donepezil tabs
    View adult BNF View SPC online
    First Choice
    Amber 3
     
    Rivastigmine caps, oral solution, patches
    View adult BNF View SPC online
    Second Choice
    Amber 3
    Mild to moderate dementia in Alzheimer’s disease, in patients that are intolerant to, or do not have a sustained response to, donepezil 
       
    Galantamine tabs, m/r tabs, oral solution
    View adult BNF View SPC online
    Third Choice
    Amber 3
     
       
    Memantine tabs, oral solution
    View adult BNF View SPC online
    Formulary
    Amber 3
     
       
    Memantine tabs, oral solution
    View adult BNF View SPC online
    Formulary
    Red

    Approved off-label indication:

    Management of behavioural and psychological symptoms in dementia, when nonpharmacological interventions have failed and there is severe distress or risk of harm to the patient or others

    Restricted to Consultant Clinical Gerontologists with a special interest in dementia, Consultants in Mental Health for Older Adults and Consultants in Liaison Psychiatry – prescribing to be continued by consultant

     
       
    04.12  Expand sub section  Miscellaneous preparations
    3,4 Diaminopyridine tabs
    Unlicensed Drug Unlicensed Congenital myaesthenia, Eaton- Lamberts myaesthenic syndrome, multiple sclerosis 
       
    Fluorescein sodium injection 10%
    Unlicensed Drug Unlicensed

    For the visualisation of cerebrospinal fluid rhinorrhoea following endoscopic skull base surgery.

    Maximum dose: 50mg

    Only Martindale brand has QA approval for this intrathecal administration

     
       
     ....
    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