| Formulary Chapter 4: Central nervous system - Full Chapter
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| Chapter Links... |
 LSCMMG: Restless Legs Syndrome in Adults in Primary Care |
| Details... |
| 04.01.02 |
Anxiolytics |
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Anxiolytics should be used at the lowest possible dose for the shortest possible time. |
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Pregabalin
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Formulary
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Capsules
Generalised Anxiety Disorder (GAD).
Third line pharmacological option for the treatment of Generalised Anxiety Disorder. Initiation by LSCFT clinicians is considered exceptional and as such a request form for the initiation of pregabalin for GAD needs to be completed by a specialist and submitted for approval within the Trust by the Chief Pharmacist and Deputy Medical Director. LSCFT clinicians initiating the drug must confirm the following:
• I have fully considered the risks and benefits of prescribing this medication for this patient
• I have discussed the likely efficacy of the drugs for management of their symptoms and also about the risk of harms, including dependence
• If the request is approved and the patient has no improvement in symptoms, the drug will be reduced and stopped.
• If the request is approved and treatment is successful, I will consider a reduction on a regular basis to ascertain ongoing effectiveness in line with recommendations in the NHS England document.
• If dependence on pregabalin or gabapentin, or other misuse or diversion, is suspected or identified the patient will be reviewed and concerns discussed sensitively and documented clearly
• If dependence on prescribed medication is suspected or confirmed, the care plan will be revisited. If it appears that the medication is no longer required for the main clinical indication the patient will be reassessed and planned withdrawal of the medication considered.
• If completely inappropriate use is confirmed (e.g., if there is unequivocal objective evidence that the drugs are simply being diverted) the medication will be stopped. If partial diversion is suspected or confirmed the patient will be reassessed and a planned withdrawal of medication considered.
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 LSCMMG: Pregabalin
MHRA: Pregabalin (Lyrica), gabapentin (Neurontin) and risk of abuse and dependence: new scheduling requirements from 1 April
MHRA: Pregabalin (Lyrica): findings of safety study on risks during pregnancy
MHRA: Pregabalin (Lyrica): reports of severe respiratory depression
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Buspirone
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Formulary
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Anxiety (short term use).
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Benzodiazepines |
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Diazepam
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Formulary
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Tablets 2mg, 5mg, 10mg
Liquid 2mg/5mL
Rectal tubes 5mg/2.5mL, 10mg/2.5mL
Anxiety.
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Lorazepam
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Formulary
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Tablets 1mg
Short term use in anxiety and insomnia.
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Chlordiazepoxide
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Formulary
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Capsules 5mg, 10mg
Chlordiazepoxide is also used in a reducing regime for the management of acute alcohol withdrawal. See trust Clinical Guidelines.
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Diazepam
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Formulary
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Injection (solution) 10mg/2mL
Injection (emulsion) (Diazemuls®) 10mg/2mL
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Lorazepam injection
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Formulary
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Short term use in anxiety and insomnia.
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Oxazepam
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Formulary
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Tablets 10mg, 15mg
Depending on local protocols, Oxazepam may be usedfor in-patient alcohol detoxification of patients with significant hepatic impairment where a short-acting benzodiazepine would be preferred.
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Alprazolam
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Formulary
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Short term use in anxiety.
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Chlordiazepoxide
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Formulary
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Anxiety.
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Buspirone |
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Beta blockers |
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Propranolol – see section 02.04 |
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Propranolol
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Formulary
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Tablets 10mg, 40mg, 80mg
M/R capsules 80mg, 160mg
Anxiety with symptoms such as palpitation, sweating and tremor.
Note: significant risks when taken in overdose. Potential for rapid deterioration before medical assistance is received.
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Prescribing Alert - Propranolol
SMU-21-Propranolol-in-anxiety-Final
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| 04.01.02 |
Meprobamate |
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Meprobamate
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Formulary
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Short term use in anxiety.
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Key |
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Restricted Drug |
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Unlicensed |
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Link to adult BNF
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Link to children's BNF
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Link to SPCs
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Scottish Medicines Consortium |
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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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ICB |
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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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| Status |
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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