| Formulary Chapter 4: Central nervous system - Full Chapter
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| 04.02.03 |
Drugs used for mania and hypomania |
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Lamotrigine
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Formulary
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Tablets 25mg, 50mg, 100mg, 200mg
Dispersible tablets 5mg, 25mg, 100mg
Bipolar disorder.
Prevention of depressive episodes in adult patients with bipolar I disorder who experience predominantly depressive episodes.
Dose titration required. See BNF/SPC for further information on titration, titration with valproate, and tritration with enzyme inducing drugs.
Consider withdrawal if rash or signs of hypersensitivity syndrome develop. See BNF/SPC for more detail.
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 MHRA: Antiepileptics: risk of suicidal thoughts and behaviour
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| 04.02.03 |
Benzodiazepines |
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Clonazepam
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Formulary
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Tablets 500micrograms, 2mg
Oral solution 500micrograms/5mL, 2mg/5ml
for use in all forms of epilepsy and in the treatment of mood disorders
 for the treatment of anxiety (off-label indication)
Clonazepam has been confused with clobazam; care must be taken to ensure the correct drug is prescribed and dispensed.
Other than epilepsy the use of clonazepam is off-labeL.
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MHRA: Benzodiazepines and opioids: reminder of risk of potentially fatal respiratory depression
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| 04.02.03 |
Antipsychotic drugs |
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| 04.02.03 |
Carbamazepine |
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Carbamazepine
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Formulary
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ablets 100mg, 200mg, 400mg
Modified-release tablets 200mg, 400mg
Liquid 100mg/5mL
Suppositories 125mg, 250mg
Prophylaxis of bipolar disorder unresponsive to lithium.
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MHRA: Antiepileptics: risk of suicidal thoughts and behaviour
MHRA: Carbamazepine, oxcarbazepine and eslicarbazepine: potential risk of serious skin reactions
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| 04.02.03 |
Valproic acid |
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Sodium valproate
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Formulary
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Mood stabiliser (unlicensed indication)
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In November 2023, due to known significant risk of serious harm to a baby after exposure to valproate the MHRA has stipulated that new regulatory measures will be put in place in January 2024 for oral valproate medicines as follows:
- Valproate must not be initiated in patients male or female under the age of 55 years, unless two specialists independently consider and document that there is no other effective or tolerated treatment and any use of valproate in women of childbearing potential should be in accordance with the Pregnancy Prevention Programme.
- At their next annual review females of childbearing potential will require the signature of a second specialist if valproate is to be continued
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MHRA: Antiepileptic drugs in pregnancy: updated advice following comprehensive safety review
MHRA: Antiepileptics: risk of suicidal thoughts and behaviour
MHRA: Full pack dispensing of valproate-containing medicines
MHRA: Valproate use in men: as a precaution, men and their partners should use effective contraception
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Valproic Acid
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Formulary
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E/C tablets 250mg, 500mg
Manic episodes associated with bipolar disorder.
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In November 2023, due to known significant risk of serious harm to a baby after exposure to valproate the MHRA has stipulated that new regulatory measures will be put in place in January 2024 for oral valproate medicines as follows:
- Valproate must not be initiated in patients male or female under the age of 55 years, unless two specialists independently consider and document that there is no other effective or tolerated treatment and any use of valproate in women of childbearing potential should be in accordance with the Pregnancy Prevention Programme.
- At their next annual review females of childbearing potential will require the signature of a second specialist if valproate is to be continued
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MHRA: Antiepileptic drugs in pregnancy: updated advice following comprehensive safety review
MHRA: Antiepileptic drugs: updated advice on switching between different manufacturers’ products
MHRA: Antiepileptics: risk of suicidal thoughts and behaviour
MHRA: Valproate use in men: as a precaution, men and their partners should use effective contraception
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| 04.02.03 |
Lithium |
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Due to differences in bioavailability prescribing should be by brand name. For new patients Priadel is recommended. Lithium carbonate 200mg is equivalent to Lithium citrate 509mg.
There are significant interactions with lithium, see BNF. |
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Lithium Carbonate (Camcolit®)
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Formulary
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Modified-release tablets 400mg
Treatment and prophylaxis of mania, bipolar disorder and recurrent depression. Aggressive or self-mutilating behaviour.
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 LSCMMG: Shared care guideline
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Lithium Carbonate (Priadel®)
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Formulary
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M/R tablets 200mg, 400mg
Treatment and prophylaxis of mania, bipolar disorder and recurrent depression. Aggressive or self-mutilating behaviour.
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LSCMMG: Shared care guideline
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Lithium Citrate (Priadel®)
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Formulary
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Liquid 520mg/5mL
Treatment and prophylaxis of mania, bipolar disorder and recurrent depression. Aggressive or self-mutilating behaviour.
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LSCMMG: Shared care guideline
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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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