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...
04.07  Expand sub section  Analgesics
04.07.01  Expand sub section  Non-opioid analgesics and compound analgesic preparations
Aspirin tabs

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Formulary
   
Dilofenac sodium tabs, m/r tabs, dispersible tabs, suppositories

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Formulary

Link  MHRA Jun 2013: Diclofenac: new contraindications and warnings    
Ibuprofen tabs, suspension

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Formulary

Link  MHRA Jun 2015: High-dose ibuprofen (≥2400mg/day): small increase in cardiovascular risk    
Nefopam tabs

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Paracetamol injection

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Formulary 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

    Short-term treatment of moderate pain and fever when administration by the intravenous route is clinically justified
  •    
    Paracetamol tabs, soluble tabs, oral suspension, suppositories

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    Formulary
       
    04.07.01  Expand sub section  Compound analgesic preparations
    Co-codamol tabs, dispersible tabs (paracetamol and codeine)

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    Formulary Strengths available:
  • Co-codamol 8/500
  • Co-codamol 30/500
  •    
    Co-dydramol 10/500 tabs (paracetamol and dihydrocodeine)

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    Formulary
       
    04.07.02  Expand sub section  Opioid analgesics
    Controlled Drug  Morphine salts tabs, m/r tabs, m/r caps, m/r suspension, oral solution, injection

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    First Choice First line strong oral opioid
    Controlled Drug  Oxycodone caps, m/r tabs, liquid, injection

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    Second Choice Second line opioid

    Restricted to use where morphine is not tolerated or contra-indicated
       
    Controlled Drug  Tapentadol m/r tabs

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    Restricted Drug Restricted
    Amber 1
    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.
       


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    Controlled Drug  Alfentanil injection

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    Formulary USE UNDER SPECIALIST SUPERVISION ONLY
       
    Controlled Drug  Buprenorphine patch (BuTrans®)

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    Restricted Drug Restricted INITITIATION 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

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    Codeine tabs, injection

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    Formulary
    Controlled Drug = injection
       
    Controlled Drug  Diamorphine injection

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    Formulary
       
    Dihydrocodeine m/r tabs

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    Formulary
       
    Dihydrocodeine tabs, injection

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    Formulary
    Controlled Drug = injection
       
    Controlled Drug  Fentanyl injection

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    Formulary USE UNDER SPECIALIST SUPERVISION ONLY
       
    Controlled Drug  Fentanyl patches

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    Formulary
       
    Controlled Drug  Fentanyl sublingual tabs, buccal tabs and nasal spray

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    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

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    Formulary
       
    Meptazinol tabs, injection

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    Restricted Drug Restricted PAIN TEAM ONLY
       
    Controlled Drug  Methadone tabs, injection

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    Restricted Drug Restricted USE UNDER SPECIALIST SUPERVISION ONLY
       
    Controlled Drug  Morphine suppositories

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    Formulary
       
    Controlled Drug  Papaveretum and hyoscine injection

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    Formulary
       
    Controlled Drug  Papaveretum injection

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    Formulary
       
    Controlled Drug  Pethidine tabs, injection

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    Formulary
       
    Controlled Drug  Tramadol caps, soluble tabs, injection

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    Formulary m/r preparations are Non-Formulary
       
    Controlled Drug  Morphine 0.1%, 0.2% w/v topical gel

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    Restricted 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 to top
    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
    04.07.03  Expand sub section  Neuropathic pain to top
    Amitriptyline tabs, oral solution

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    Formulary Use in neuropathic pain is off-label

    Refer to SEL APC neuropathic pain guideline (link below)
       
    Carbamazepine tabs, liquid (neuropathic pain)

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    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

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    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

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    Formulary For painful diabetic neuropathy

    Refer to SEL APC neuropathic pain guideline (link below)
       
    Gabapentin caps (pain)

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    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    
    Imipramine tabs

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    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

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    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)

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    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)

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    Restricted Drug Restricted
    High Cost Medicine
    Red
    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

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    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

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    Restricted Drug Unlicensed Neuropathic pain when systemic administration is required in the Palliative Care setting
       
    04.07.03  Expand sub section  Postherpetic neuralgia
    Capsaicin 0.075% cream

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    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

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    Formulary
       
    Paracetamol tabs, soluble tabs

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    Formulary
       
    Lidocaine infusion

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    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

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    Restricted 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

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    Restricted 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
    Rizatriptan wafers

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    Formulary
       
    Sumatriptan tabs, injection

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    Formulary
       
    04.07.04.01  Expand sub section  Ergot alkaloids to top
    Dihydroergotamine injection

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    Restricted 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

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    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

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    Formulary
       
    04.07.04.02  Expand sub section  Prophylaxis of migraine
    Amitriptyline tabs (migraine prophylaxis - off-label)

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    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)

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    Restricted Drug Restricted
    High Cost Medicine
    Red
    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)

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    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)

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    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)

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    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

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    Formulary
       
    Propranolol tabs (migraine prophylaxis)

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    Formulary
       
    Sodium valproate tabs (migraine prophylaxis - off-label)

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    Formulary
    Amber 2
    USE ON SPECIALIST ADVICE
    Use in migraine prophylaxis is off-label

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

    Link  MHRA: Valproate and risk of abnormal pregnancy outcomes: new communication materials    
    Topiramate tabs, sprinkles (migraine prophylaxis)

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    Formulary
    Amber 2
       
    Methysergide tabs

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    Formulary REQUIRES HOSPITAL SUPERVISION
       
    04.07.04.03  Expand sub section  Cluster headache
     ....
    Key
    note Notes First Choice Item First Choice item
    Section Title Section Title (top level) Non Formulary Item Non Formulary section
    Section Title Section Title (sub level)
    Cytotoxic Drug
    Cytotoxic Drug
    Restricted Drug
    Restricted Drug
    CD
    Controlled Drug
    Unlicensed Drug
    Unlicensed
    High Cost Medicine
    High Cost Medicine
    click to search medicines.org.uk
    Link to SPCs
    click to search medicines.org.uk
    Link to adult BNF
    Track Changes
    Display tracking information
    click to search medicines.org.uk
    Cancer Drugs Fund
    Cancer Drugs Fund
       

     

    Traffic Light Status Information

    Status Description
      Red   Specialist Prescribing only. The responsibility for prescribing, monitoring, dose adjustment and review should remain with the specialist. 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