| Formulary Chapter 4: Central nervous system - Full Chapter
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| 04.09.01 |
Dopaminergic drugs used in Parkinsons disease |
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Treatment with levodopa and dopamine-receptor agonists are associated with impulse control disorders, including pathological gambling, binge eating, and hypersexuality. Patients and their carers should be informed about the risk of impulse control disorders.
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| 04.09.01 |
Dopamine receptor agonists |
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Pramipexole
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Formulary
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Tablets 88micrograms, 180micrograms, 350 micrograms, 700micrograms pramipexole base (equivalent to 125micrograms, 250micrograms, 500micrograms and 1mg pramipexole salt)
Restless leg syndrome.
Recommended as the first line pharmacological treatment for restless leg syndrome, in line with the LSCMMG Restless Legs Syndrome Guidance.
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 LSCMMG: The Management of Restless Legs Syndrome in Adults in Primary Care
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Pramipexole
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Formulary
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Tablets 88micrograms, 180micrograms, 350 micrograms, 700micrograms pramipexole base (equivalent to 125micrograms, 250micrograms, 500micrograms and 1mg pramipexole salt)
Modified-release tablets 260 micrograms, 520 micrograms 1.05mg, 1.57mg, 2.1mg, 2.62mg, 3.15mg base (equivalent to 375micrograms, 750micrograms, 1.5mg, 2.25mg, 3mg, 3.75mg, 4.5mg salt)
Parkinson's disease.
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Ropinirole
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Formulary
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Tablets 250micrograms, 500micrograms, 1mg, 2mg
Modified-release tablets 2mg, 3mg, 4mg, 6mg, 8mg
Parkinson's disease.
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 MHRA: Recent drug-name confusion
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Ropinirole
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Formulary
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Tablets 250micrograms, 500micrograms, 1mg, 2mg
Restless leg syndrome.
Recommended as the second line pharmacological treatment for restless leg syndrome, in line with the LSCMMG Restless Legs Syndrome Guidance.
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MHRA: Recent drug-name confusion
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Rotigotine
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Formulary
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Patches 1mg/24 hours, 2mg/24 hours, 3mg/24 hours
Restless Legs Syndrome.
Recommended for restricted use in line with the LSCMMG Restless Legs Syndrome Guidance.
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Rotigotine
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Formulary
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Patches 2mg/24 hours, 4mg/24 hours, 6mg/24 hours, 8mg/24 hours
Parkinson's Disease.
Rotigotine has shown inferiority to ropinirole and should not be used in preference to other dopamine agonists unless such alternative are not suitable (e.g. compliance issues, need for social care to administer other oral therapies, dysphagia), not tolerated (GI disturbance), or ineffective.
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Apomorphine (Dacepton®)
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Formulary
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Injection 50mg/5mL
Pre-filled pen 30mg/3mL
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LSCMMG: Shared care guideline
MHRA: Apomorphine with domperidone: minimising risk of cardiac side effects
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Amantadine
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Formulary
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Capsules 100mg
Liquid 50mg/5mL
Parkinson's disease (but not drug-induced extrapyramidal symptoms).
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| 04.09.01 |
Levodopa |
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Co-Beneldopa
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Formulary
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Capsules 62.5mg (12.5/50), 125mg (25/100), 250mg (50/200)
Dispersible tablets 62.5mg (12.5/50), 125mg(25/100)
Modified-release capsules 125mg (25/100)
Parkinson's disease.
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Co-Careldopa
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Formulary
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Tablets 62.5mg (12.5/50), 110mg (10/100), 125mg (25/100), 275mg (25/250)
Modified-release tablets 125mg (25/100), 250mg (50/200)
Parkinson's disease.
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Co-Careldopa and Entacapone
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Formulary
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Tablets (multiple strength combinations available).
Parkinson's disease.
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Foslevodopa–Foscarbidopa (Produodopa®)
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Formulary
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Solution for infusion 240mg/ml + 12mg/ml
Parkinson's disease.
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NICE TA934: Foslevodopa–foscarbidopa for treating advanced Parkinson’s with motor symptoms
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Levodopa-Carbidopa- Entacapone Intestinal Gel (LECIG)
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Formulary
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Treatment with LECIG for Parkinson’s Disease may be delivered and managed through any acute provider trust which treats patients with Parkinson’s disease under either neurology or elderly care services. Eligibility must be determined through a specialist Parkinson’s clinician in an agreed networked approach with a specialist Parkinson's service in a regional specialised neurology centre. This may be through direct clinical assessment by clinicians with appropriate expertise within the network or through a Parkinson’s disease MDT arrangement managed through a specialised neurology centre.
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Levodopa-Carbidopa Intestinal Gel (LCIG)
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Formulary
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Treatment with LCIG for Parkinson’s Disease may be delivered and managed through any acute provider trust which treats patients with Parkinson’s disease under either neurology or elderly care services. Eligibility must be determined through a specialist Parkinson’s clinician in an agreed networked approach with a specialist Parkinson's service in a regional specialised neurology centre. This may be through direct clinical assessment by clinicians with appropriate expertise within the network or through a Parkinson’s disease MDT arrangement managed through a specialised neurology centre.
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| 04.09.01 |
Monoamine-oxidase-B inhibitors |
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Rasagiline (Azilect®)
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Second Choice
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Tablets 1mg
Parkinson's disease.
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Selegiline Hydrochloride
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Formulary
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Tablets 5mg, 10mg
Parkinson's disease.
See BNF for information on dose equivalence and conversion between tablet and lyophilisate formulations.
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| 04.09.01 |
Catachol-O-methyltransferase inhibitors |
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Entacapone (Comtess®)
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Formulary
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Tablets 200mg
Adjunct to co-beneldopa or co-careldopa in Parkinson's disease.
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Opicapone (Ongentys®)
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Formulary
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Capsules 50mg
Adjunctive therapy in adults with end-of-dose motor fluctuations who cannot be stabilised on preparations of levodopa/DOPA decarboxylase inhibitors.
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Tolcapone (Tasmar®)
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Formulary
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Tablets 100mg
Tolcapone as an adjunct to co-beneldopa or co-careldopa in Parkinson's disease with 'end-of-dose' motor fluctuations if another inhibitor of peripheral catechol-O-methyltransferase is inappropriate.
Third Line.
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| 04.09.01 |
Amantadine |
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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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