Formulary Chapter 4: Central nervous system - Full Chapter
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Notes: |
This chapter of the formulary is under continual development, please let the team know if you have any comments about the contents: mlcsu.lscformulary@nhs.net.
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Details... |
04.07 |
Analgesics |
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Methoxyflurane (Penthrox ®)
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Restricted
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Inhalation vapour 3ml bottles with device (Each bottle contains 3 ml of methoxyflurane 99.9%)
Use restricted to consultants/SAS doctors/Registrars in UHMB Emergency Departments and Urgent Treatment Centre only
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04.07.01 |
Non-opioid analgesics and compound analgesic preparations |
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For relief of mild to moderate pain |
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Paracetamol
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First Choice
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Tablets 500mg
Dispersible tablets 500mg
Liquid 120mg/5mL, 250mg/5mL, 1g/10mL
Suppositories 60mg,120mg, 240mg, 500mg
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Paracetamol
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Formulary
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Intravenous infusion 1g/100mL
For short term treatment of moderate pain or fever when the oral route is not available
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04.07.01 |
Compound analgesic preparations |
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04.07.02 |
Opioid analgesics |
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For relief of moderate to severe pain |
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Buprenorphine
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Formulary
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SEVEN day patches only to be prescribed (brands are interchangeable)
Hospital prescriber to prescribe generically and contract patches to be supplied
(To be prescribed as Sevodyne patches in Primary Care - 5,10,15 and 20mcg/hr)
Only for use in patients who are unable to take or tolerate oral medicine (including soluble tablets and liquids) OR where use of the low-dose buprenorphine patches may prevent administration problems for frail, elderly patients in the Community.
Transdermal preparations lack the flexibility required when treating patients with fluctuating or uncontrolled pain. Use should be reserved for patients with stable pain who are unable to take or tolerate oral medicines. Buprenorphine patches are several times more expensive than equivalent doses of oral analgesics, and inappropriate use of transdermal preparations has cost implications for commissioners. It is recommended that the reason for using a patch is documented on initiation and, if appropriate, patients are switched to oral formulations at the earliest opportunity.
**Under review**
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Buprenorphine (Temgesic®)
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Formulary
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s/l tablets 200micrograms See section 4.10 for products used in opioid dependence
**under review**
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Codeine Phosphate
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Formulary
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Tablets 15mg, 30mg
Injection 60mg/1mL
Syrup 25mg/5mL
Linctus, BP 15mg/5mL
Injection Only
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Diamorphine
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Formulary
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Injection 5mg, 10mg, 30mg, 100mg, 500mg
**under review**
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Dihydrocodeine
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Formulary
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Tablets 30mg
For use only in patients who are breastfeeding or after initiation by the pain team. For short term use only.
**under review** Injection Only
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Fentanyl
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Formulary
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Matrix patches 12, 25, 50, 75, 100micrograms/hour for 72hours
Sublingual tablets (Abstral®) 100microgram, 300 microgram, 400microgram, 600microgram, 800 microgram
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MHRA: Transdermal fentanyl patches: life-threatening and fatal opioid toxicity from accidental exposure, particularly in children
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Methadone
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Formulary
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Tablets 5mg Injection 10mg/1mL Methadone, when used as an analgesic, should be initiated by specialists in palliative care only see section 4.10 for products used in opioid dependence
**under review**
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Morphine
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Formulary
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Check local guidance
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Oxycodone
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Formulary
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Check local guidance Oxycodone should be initiated by consultant physicians or specialists in palliative care only, it is indicated only for patients who do not tolerate morphine
**under review**
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Pethidine
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Formulary
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Injection 50mg/1mL
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Tapentadol (Palexia®)
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Formulary
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M/R tablets 50mg, 100mg, 150mg, 200mg, 250mg for palliative care In Morecambe Bay for other indications
**under review**
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MHRA: Tapentadol (Palexia): risk of seizures and reports of serotonin syndrome when co-administered with other medicines
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Tramadol
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Formulary
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Capsules 50mg Dispersible tablets 50mg m/r tablets 100mg, 200mg
Injection 100mg/2mL
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MHRA: Warfarin: be alert to the risk of drug interactions with tramadol
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04.07.03 |
Neuropathic pain |
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Duloxetine (Cymbalta®)
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Second Choice
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See section 4.3.4
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Gabapentin
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Second Choice
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See section 4.8.1
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MHRA: Gabapentin (Neurontin): risk of severe respiratory depression
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Ketamine oral solution
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Restricted
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Liquid 50mg/5mL Unlicensed
For chronic pain - RED For palliative care only AMBER - under review
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Lidocaine
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Formulary
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5% Medicated Plasters
Post Herpetic Neuralgia
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Lidocaine
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Formulary
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5% Medicated Plasters
Use outside of the license of post-herpetic neuralgia for the treatment of localised neuropathic pain with predominance of allodynia and/or hyperalgesia and dysesthesias unresponsive to other neuropathic agents.
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Pregabalin
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Formulary
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See section 4.8.1
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MHRA: Pregabalin (Lyrica): findings of safety study on risks during pregnancy
MHRA: Pregabalin (Lyrica): reports of severe respiratory depression
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04.07.03 |
Trigeminal neuralgia |
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Carbamazepine
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Formulary
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See section 4.8.1
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Nortriptyline
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Formulary
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04.07.03 |
Postherpetic neuralgia |
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Amitriptyline
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Formulary
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04.07.03 |
Chronic facial pain |
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04.07.04 |
Antimigraine drugs |
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04.07.04.01 |
Treatment of the acute migraine attack |
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04.07.04.01 |
Analgesics |
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04.07.04.01 |
5HT1 agonists |
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Sumatriptan
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Formulary
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Tablets 50mg Nasal spray 20mg/0.1mL actuation, 2 unit-dose spray device Injection 6mg/0.5mL, 2 x 0.5mL prefilled syringes and auto-injector
Injection 3mg/0.5ml solution for injection in pre-filled pen
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04.07.04.01 |
Ergot alkaloids |
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04.07.04.01 |
Anti-emetics |
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04.07.04.01 |
Other drugs for migrane |
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04.07.04.02 |
Prophylaxis of migraine |
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Amitriptyline
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Formulary
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See section 4.3.1
Unlicensed indication
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Botulinum Toxin Type A (botox®)
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Formulary
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Powder for solution for injection
Specialist use only
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NICE TA260: Botulinum toxin type A for the prevention of headaches in adults with chronic migraine
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Eptinezumab (Vyepti®)
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Formulary
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Concentrate for solution for infusion.
100mg
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Erenumab (Aimovig®)
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Formulary
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Pre-filled syringe 70mg, 140mg
Pre-filled pen 70mg, 140mg
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NICE TA682: Erenumab for preventing migraine
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Fremanezumab (Ajovy®)
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Formulary
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Pre-filled pens/ pre-filled syringes 225mg/1.5ml solution for injection
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NICE TA764: Fremanezumab for preventing migraine
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Galcanezumab (Emgality® )
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Formulary
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Solution for injection pre-filled pens 120mg/1ml
For NICE TA659: Galcanezumab for preventing migraine
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Pizotifen
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Formulary
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Tablets 500micrograms, 1.5mg
**Under review**
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Propranolol
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Formulary
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See section 2.4
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Sodium valproate
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Formulary
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See section 4.8.1 Unlicensed indication
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
National Patient Safety Alert: Valproate: organisations to prepare for new regulatory measures for oversight of prescribing to new patients and existing female patients https://assets.publishing.service.gov.uk/media/6565ddf162180b0012ce82fd/NatPSA-2023-013-MHRA.pdf
MHRA Drug Safety Update - Valproate medicines (Epilim▼, Depakote▼): contraindicated in women and girls of childbearing potential unless conditions of Pregnancy Prevention Programme are met https://www.gov.uk/drug-safety-update/valproate-medicines-epilim-depakote-contraindicated-in-women-and-girls-of-childbearing-potential-unless-conditions-of-pregnancy-prevention-programme-are-met?utm_source=eshot&utm_medium=email&utm_campaign=DSUApril2018Split2
**Under review**
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MHRA: Valproate use in men: as a precaution, men and their partners should use effective contraception
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Topiramate (prophylaxis of migraine)
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Formulary
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Tablets 25mg, 50mg, 100mg, 200mg
Topiramate is now contraindicated in pregnancy and in women of childbearing potential unless the conditions of a Pregnancy Prevention Programme are fulfilled. This follows a review by the MHRA which concluded that the use of topiramate during pregnancy is associated with significant harm to the unborn child. Harms included a higher risk of congenital malformation, low birth weight and a potential increased risk of intellectual disability, autistic spectrum disorder and attention deficit hyperactivity disorder in children of mothers taking topiramate during pregnancy.
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MHRA: Topiramate (Topamax): introduction of new safety measures, including a Pregnancy Prevention Programme
MHRA: Topiramate (Topamax): start of safety review triggered by a study reporting an increased risk of neurodevelopmental disabilities in children with prenatal exposure
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Zonisamide
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Formulary
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Capsules, 25mg. 50mg, 100mg
Approved for use in patients when at least 3 prior prophylactic treatments have failed and erenumab, galcanezumab and fremanezumab are being considered
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Flunarizine
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Unlicensed
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Capsules 5mg
Specialist consultant use only
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04.07.04.03 |
Cluster headache |
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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 and local commissioning arrangements |
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