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:

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.

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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Formulary  
   
Paracetamol injection
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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
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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 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
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    Formulary USE UNDER SPECIALIST SUPERVISION ONLY 
       
    Controlled Drug Buprenorphine patch (weekly preparation)
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    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)
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    Formulary

     
       
    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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    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 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 (neuropathic pain - off-label)
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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 (neuropathic pain)
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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
       
    Gabapentin caps (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 = starting at 300mg daily increased slowly to a max of 900mg three times a day

     
       
    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
    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
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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 (unlicensed product)
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    Unlicensed Drug Unlicensed

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

     
       
    Phenol 6% aqueous injection
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    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
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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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    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
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    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
    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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    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
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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
    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)
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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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    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  Valproate Annual Risk Acknowledgement Form
    Link  Valproate- Patient Guide-Educational material- Pregnancy prevention programme
    Link  Valproate- Healthcare professionals (HCPs) Educational material Pregnancy prevention programme
    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)
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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
     ....
     Non Formulary Items
    Co-proxamol tabs

    Non Formulary
    Grey

    Not for prescribing in SE London

    Link  SE London APC: Patient Information Leaflet: Changes to co-proxamol prescribing
    Link  Unlicensed Co-proxamol (dextropropoxyphene and paracetamol) Prescribing Factsheet
     
    Oxycodone/naloxone SR tabs  (Targinact - pain management)

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    Non Formulary
    Grey

    Not approved for use in pain management in SE London

     
    Tramadol with paracetamol combination preparations  (Tramacet)

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    Non Formulary
    Grey

    Not approved for use in SE London

     
      
    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  

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