Approved for prevention of uterine atony following caesarean section

Follow local guideline for use

Approved off-label indications:

• To soften and open the cervix facilitating vaginal termination of pregnancy.
• Use in ectopic pregnancy and miscarriage

Use in line with local Trust policies

USE UNDER SPECIALIST SUPERVISION ONLY

Use in accordance with local guideline at KCH

Approved off-label indication

Tocolysis in preterm labour

Use in accordance with local procedures and NICE NG25: Preterm labour and birth

Restricted to use where the following have been insufficient to control symptoms:

• Topical lubricants
• At least two topical oestrogen preparations

Refer to APC recommendation (link below) for further information

RESTRICTED TO GUM CONSULTANTS ONLY

For resistant vulvo-vaginal candidiasis in accordance with GUM guidelines

For the treatment of resistant vulvovaginal candida and candida in patients with azole hypersensitivities

Dose (in accordance with BASHH guidance): 1 to 2 pessaries for 14 nights

Restricted to Gynaecology and Sexual Health Clinics

Refer to BNF for “Risk of venous thromboembolism” notes

Restricted to Gynaecology and Sexual Health Clinics

Refer to BNF for “Risk of venous thromboembolism” notes

Approved as an option for:

Long acting reversible contraception (effective for up to 3 years)

Approved as an option for:

Long acting reversible contraception (effective for up to 5 years)

Approved as an option for:

• Long acting reversible contraception (effective for up to 5 years)
• Hormonal treatment of heavy menstrual bleeding

See APC recommendation (link below)

Approved as an option for:

• Long acting reversible contraception (active for up to 5 years)
• Idiopathic menorrhagia
• Protection from endometrial hyperplasia during oestrogen replacement therapy

Restricted to GUM and Sexual Health clinics after consultation with one of the Contraceptive Leads

Emergency contraceptive agent for use between 72 and 120 hours post-unprotected sexual intercourse or contraceptive failure, where a coil is unsuitable or inappropriate

Use in accordance with local guideline

Approved for licensed uses, and the following off-label indication:

Medical expulsive therapy of urolithiasis (including extracorporeal shockwave lithotripsy) in men and women (consultant use only).

Dose: 400 micrograms daily for 7-14 days

For stress urinary incontinence in women who prefer pharmacological treatment to surgical management, and in whom conservative treatment has failed

Approved off-label indication:

Also approved for off-label use for stress-urinary incontinence in men (same dosing as licensed use in women)

Consider fesoterodine for elderly patients or those with cognitive impairment

Can consider as first line overactive bladder treatment, only for patients in whom anticholingerics are contraindicated 

Restricted to use in patients unable to tolerate oral medication only

Consider trospium m/r for elderly patients or those with cognitive impairment

Approved for:

• Nocturnal enuresis
• Bladder pain syndrome (off-label indication, usual dose 10 mg to 50 mg nocte)

Approved for as per licensed indication only nocturia due to idiopathic nocturnal polyuria.

See APC recommendation (link below) for more detailed prescribing guidance. 

Approved for:

Vasopressin-sensitive cranial diabetes insipidus (DDAVP brand)

Primary nocturnal enuresis (Desmomelts/Desmotabs brand)

Follow dosing instructions in individual SPCs

Approved for (via intravesical injection):

• Neurogenic detrusor overactivity
• Overactive bladder
• Category B* form required
• Consultant urologists and urogynaecologists only

For treatment of cystitis

Approved for:

• Cystinuria

Specialist initiation only

Approved for the following off-label indication:

• Urine alkalinisation in cystinuria in patients who cannot tolerate regular potassium citrate liquid

Usual dose = up 2 tabs three times a day (regular dosing)

Approved for the following off-label indication:

• Urine alkalinisation in cystinuria

Usual dose = 10mL diluted in water up to three times a day (regular dosing)

For cystinuria clinic use only

Usual dose range: 2-6 tablets per day

For cystinuria clinic use only

Starting dose: 2-4 tablets daily Maximum dose: 8 tablets per day

Approved for:

• Interstitial cystitis
• Cystitis caused by infection, neoplasia or radiation therapy Restricted to use in patients who have failed on oral therapies

Approved for:

• Interstitial cystitis
• Cystitis caused by infection, neoplasia or radiation therapy Restricted to use in patients who have failed on oral therapies

Approved for:

• Interstitial cystitis
• Chemical or radiation induced cystitis
• Recurrent urinary tract infections (restricted to use in patients who have failed on oral therapies)

USE ON CONSULTANT UROLOGIST ADVICE ONLY

For the detection of bladder cancer, such as carcinoma in-situ, in patients with known bladder cancer or high suspicion of bladder cancer

Approved as per NICE Technology recommendation (link below)

USE ON SPECIALIST ADVICE

Interstitial cystitis (Hunner’s ulcer)

Alternative treatment option after intracavernosal alprostadil 

Refer to South East London guidance for managing erectile dysfunction (ED) in primary and secondary care for more detailed prescribing guidance (see link below)

Second line option for erectile dysfunction after failure of PDE-5 inhibitors.

Refer to SE London erectile dysfunction pathway (link above)

Second line option for erectile dysfunction after failure of PDE-5 inhibitors.

Refer to SE London erectile dysfunction pathway (link above)

Second line option for erectile dysfunction after failure of PDE-5 inhibitors.

Refer to SE London erectile dysfunction pathway (link above) and SE London IMOC recommendation (link below)

For patients who have not tolerated or failed treatment on the maximum dose of prn sildenafil (100 mg)

Once daily regular dosing for erectile dysfunction (except for use in penile rehabilitation post radical prostatectomy) is non-formulary.  See entries below.

Approved off-label indication: 

Penile rehabilitation post robotic nerve sparing radical prostatectomy

Dose = 5 mg daily for 3 months only(full 3 month course to be supplied by the hospital)

Approved off-label indication:

Drug-induced priapism once physical measures to direct blood from penis and aspiration have failed

USE UNDER SPECIALIST SUPERVISION ONLY Use with caution – risk of hypertensive crisis. Continual monitoring of blood pressure and pulse is essential.

• Dose: 10-20 micrograms (0.5-1 mL diluted solution as below) injected into corpus cavernosum after aspiration of blood has failed to produce a response.
• Dilution: 1 mg in 1 mL epinephrine is diluted to 50 mL with sodium chloride 0.9% (49 mL) to give 20 micrograms/mL solution

Approved off-label indication:

Drug-induced priapism once physical measures to direct blood from penis and aspiration have failed.

USE UNDER SPECIALIST SUPERVISION ONLY Use with caution – risk of hypertensive crisis. Continual monitoring of blood pressure and pulse is essential.

• Dose: 1 mg (1mL diluted solution) metaraminol injected into corpus cavernosum after aspiration of blood has failed to produce a response. Repeat if no response.
• Dilution: 10 mg in 1mL metaraminol is diluted to 10 mL with sodium chloride 0.9% 9 mL to give 1 mg/mL solution

Approved off-label indication:

Drug-induced priapism once physical measures to direct blood from penis and aspiration have failed.

USE UNDER SPECIALIST SUPERVISION ONLY Use with caution – risk of hypertensive crisis. Continual monitoring of blood pressure and pulse is essential.

• Dose: 100-200 micrograms (0.5-1 mL diluted solution as below) injected into corpus cavernosum after aspiration of blood has failed to produce a response.
• Repeat every 5 – 10 minutes as necessary up to a total dose of 1 mg.
• Dilution: 10 mg in 1 mL phenylephrine is diluted to 50 mL with sodium chloride 0.9% (49mL) to give 200 micrograms/mL solution

USE UNDER SPECIALIST SUPERVISION ONLY

Priapism in sickle cell crisis

Dose = 5 mg -10 mg at night with an alarm dose of 5 mg - 10 mg four hours later, increasing if required. Max of 30 mg/day.

At GSTT refer to the "Sickle Cell Disease Adult Guidelines" for dosing and monitoring