| Formulary Chapter 4: Central nervous system - Full Chapter
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| 04.01.01 |
Non-benzodiazepine hypnotics and sedatives |
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Avoid prescribing hypnotics. Hypnotics licensed for short term use only - If needed, use for 1-3 days only. Do not supply on discharge from hospital.
On specialist advice only, some patients with long term psychiatric problems may require long term use.
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Zopiclone
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Formulary
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Tablets 3.75mg, 7.5mg
First line short-term hypnotic.
If commenced in hospital, not to be continued at discharge.
May have CD status in some hospital Trusts, refer to local policy.
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Daridorexant
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Formulary
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Tablets 25mg, 50mg
Treatment of long-term insomnia
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 NICE TA922: Daridorexant for treating long-term insomnia
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Melatonin
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Formulary
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Children with learning disabilities
Children with ADHD
Children and adolescents with Autism Spectrum Disorder (ASD) and / or Smith-Magenis syndrome
Cerebral palsy
Children with complex neurodevelopmental disorders that the specialist considers eligible
Initiation of melatonin must be by a specialist in the indication being prescribed for and have a clear plan for review.
Prescribing and review of melatonin in children must follow the principles outlined in the Melatonin Pathway (Children)
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 LSCMMG: Melatonin Pathway (Children)
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Melatonin
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Formulary
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For the Treatment of Rapid Eye Movement (REM) Sleep Behaviour Disorder (RBD) in Parkinson’s Disease and Lewy Body Dementia
Adults with learning disabilities
Sleep disturbance in adults with ADHD
Sleep disorders in the blind
Adults with complex neurodevelopmental disorders that the specialist considers eligible
Initiation of melatonin must be by a specialist in the indication being prescribed for and have a clear plan for review.
Prescribing and review of melatonin in adults must follow the principles outlined in the Melatonin Pathway (adults) **Under development**.
Melatonin is suitable for prescribing for the treatment of REM RBD in PD and LBD when clonazepam is not considered to be appropriate.
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LSCMMG: Melatonin
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Melatonin
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Formulary
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Primary insomnia in those over 55
Sleep problems in patients with dementia associated with Alzheimer’s
Colonis liquid 1mg/ml and 3mg tablets for all indications, including insomnia and jet lag
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LSCMMG: Melatonin
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Zolpidem
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Formulary
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Tablets 5mg, 10mg
If commenced in hospital, not to be continued at discharge.
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MHRA: Zolpidem: risk of drowsiness and reduced driving ability
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Benzodiazepines |
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Nitrazepam
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Formulary
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Tablets 5mg
Liquid 2.5mg/5mL
Insomnia (short term use).
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Temazepam
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Formulary
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Tablets 10mg
Liquid 10mg/5mL
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Flurazepam
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Formulary
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Insomnia (short term use).
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Loprazolam
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Formulary
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Lormetazepam
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Formulary
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Insomnia (short term use).
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Zaleplon, Zolpidem and Zopiclone |
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Chloral and derivatives |
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Chloral Hydrate 500mg in 5mL
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Formulary
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Liquid 500mg/5mL
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MHRA: Chloral hydrate, cloral betaine (Welldorm): restriction of paediatric indication
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Clomethiazole (Chlormethiazole) |
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Antihistamines |
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Promethazine
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Formulary
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BNF considers promethazine less suitable for prescribing than alternatives for insomnia.
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Alcohol |
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Sodium oxybate |
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Sodium Oxybate
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Formulary
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Oral solution 500mg/mL
Narcolepsy with cataplexy (under expert supervision)
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Key |
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Cytotoxic Drug
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Controlled Drug
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High Cost Medicine
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Cancer Drugs Fund
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NHS England |
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Homecare |
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CCG |
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Low carbon footprint |
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Medium carbon footprint |
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High carbon footprint |
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Traffic Light Status Information
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Description |
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Green:
Appropriate for initiation and ongoing prescribing in both primary and secondary care.
Generally, little or no routine drug monitoring is required. |
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Green (Restricted):
Appropriate for initiation and ongoing prescribing in both primary and secondary care provided:
Additional criteria specific to the medicine or device are met, or
The medicine or device is used following the failure of other therapies as defined by the relevant LSCMMG pathway.
Generally, little or no routine drug monitoring is required.
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Red medicines:
Medicine is supplied by the hospital for the duration of the treatment course.
Primary care initiation or continuation of treatment is not recommended unless exceptional circumstances such as specialist GP.
Red medicines are those where primary care prescribing is not recommended. These treatments should be initiated by specialists only and prescribing retained within secondary care. They require specialist knowledge, intensive monitoring, specific dose adjustments or further evaluation in use. If however, a primary care prescriber has particular specialist knowledge or experience of prescribing a particular drug for a particular patient it would not always be appropriate for them to expect to transfer that prescribing responsibility back to secondary care. There should be a specific reason and a specific risk agreement, protocol and service set up to support this.
Primary care prescribers may prescribe RED medicines in exceptional circumstances to patients to ensure continuity of supply while arrangements are made to obtain ongoing supplies from secondary care. |
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Amber level 0:
Suitable for prescribing in primary care following recommendation or initiation by a specialist.
Little or no specific monitoring required.
Patient may need a regular review, but this would not exceed that required for other medicines routinely prescribed in primary care.
Brief prescribing document or information sheet may be required.
Primary care prescribers must be familiar with the drug to take on prescribing responsibility or must get the required information.
When recommending or handing over care, specialists should ask primary care prescribers to take over prescribing responsibility, and should give enough information about the indication, dose, monitoring requirements, use outside product licence and any necessary dose adjustments to allow them to confidently prescribe. |
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Amber level 1 (with shared care):
Suitable for prescribing in primary care following recommendation or initiation by a specialist.
Minimal monitoring required.
Patient may need a regular review, but this would not exceed that required for other medicines routinely prescribed in primary care.
Full prior agreement about patient’s on-going care must be reached under the shared care agreement.
Primary care prescribers are advised not to take on prescribing of these medicines unless they have been adequately informed by letter of their responsibilities with regards monitoring, side effects and interactions and are happy to take on the prescribing responsibility. A copy of locally approved shared care guidelines should accompany this letter which outlines these responsibilities. Primary care prescribers should then tell secondary care of their intentions as soon as possible by letter so that arrangements can be made for the transfer of care. |
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Amber level 2 (with shared care and enhanced service):
Initiated by specialist and transferred to primary care following a successful initiation period.
Significant monitoring required on an on-going basis.
Full prior agreement about patient’s on-going care must be reached under the shared care agreement.
Suitable for enhanced service.
These medicines are considered suitable for GP prescribing following specialist initiation of therapy, as per shared care document which will be sent out with the request to prescribe, with on-going communication between the primary care prescriber and specialist. Amber Level 2 medicines require significant monitoring for which an enhanced service may be suitable. (Subject to local commissioning agreements). |
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Do not prescribe: NOT recommended for use by the NHS in Lancashire and South Cumbria.
Includes medicines that NICE has not recommended for use and terminated technology appraisals, unless there is a local need. |
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Grey medicines:
Medicines which have not yet been reviewed or are under the review process.
GPs and specialists are recommended not to prescribe these drugs.
This category includes drugs where funding has not yet been agreed.
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Refer to local guidance. |
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