| Formulary Chapter 5: Infections - Full Chapter
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| Notes: |
This chapter of the formulary is under development, please use local/national antimicrobial guidelines to support prescribing choices.
Prescribers must follow the relevant local and national guidance when treating an infection. Some anti-infectives require approval from the local Trust microbiology team for use, consult local guidance for further information.
Not all anti-infectives listed in this chapter will be available in all localities; availability will be guided by local need and resistance patterns.
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| Chapter Links... |
 Blackpool Teaching Hospitals: Antimicrobial Formulary |
| Central Lancashire/LSCFT/Morecambe Bay Primary Care: NICE Summary of antimicrobial prescribing guidance - managing common infections |
| East Lancashire Primary Care: Antimicrobial guide primary care |
| East Lancashire Secondary Care: Antimicrobial guide secondary care |
| Lancashire Teaching Hospitals Secondary Care: Tap on the bugs app (App store) |
| Lancashire Teaching Hospitals Secondary Care: Tap on the bugs app (Google) |
| University Hospitals of Morecambe Bay: Antimicrobial guide secondary care |
| West Lancashire Primary Care: Pan Mersey antimicrobial guide |
| British Association for Sexual Health and HIV |
| NICE CG165: Hepatitis B (chronic): diagnosis and management |
| NICE NG120: Cough (acute): antimicrobial prescribing |
| NICE NG125: Surgical site infections: prevention and treatment |
| NICE NG19: Diabetic foot problems: prevention and management |
| NICE NG191: COVID-19 rapid guideline: managing COVID-19 |
| NICE NG240: Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management |
| WHO: AWaRe classification of antibiotics for evaluation and monitoring of use, 2023 |
| NICE NG51: Sepsis: recognition, diagnosis and early management |
| NICE NG78: Cystic fibrosis: diagnosis and management |
| Details... |
| 05.03 |
Antiviral drugs |
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Baricitinib
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Formulary
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Use in line with NG191.
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 NICE NG191: COVID-19 rapid guideline: managing COVID-19
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Molnupiravir
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Formulary
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Use in line with NG191.
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NICE NG191: COVID-19 rapid guideline: managing COVID-19
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Nirmatrelvir with Ritonavir (Paxlovid®)
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Formulary
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Tablets 150mg/100mg
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LSCMMG: Nirmatrelvir plus ritonavir, sotrovimab and tocilizumab
MHRA: COVID-19 antivirals: reporting to the UK COVID-19 Antivirals Pregnancy Registry
MHRA: Nirmatrelvir, ritonavir (Paxlovid▼): be alert to the risk of drug interactions with ritonavir
NICE TA878: Nirmatrelvir plus ritonavir, sotrovimab and tocilizumab for treating COVID-19
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Remdesivir (Veklury®)
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Formulary
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Concentrate for solution for infusion 100mg
Agreed as a pass through cost to the ICB.
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MHRA: COVID-19 antivirals: reporting to the UK COVID-19 Antivirals Pregnancy Registry
NICE TA971: Remdesivir and tixagevimab plus cilgavimab for treating COVID-19
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Sotrovimab (Xevudy®)
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Formulary
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Concentrate for solution for infusion
500mg
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LSCMMG: Nirmatrelvir plus ritonavir, sotrovimab and tocilizumab
NICE TA878: Nirmatrelvir plus ritonavir, sotrovimab and tocilizumab for treating COVID-19
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Tocilizumab
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Formulary
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Infusion
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LSCMMG: Nirmatrelvir plus ritonavir, sotrovimab and tocilizumab
MHRA: Tocilizumab (RoActemra): rare risk of serious liver injury including cases requiring transplantation
NICE TA878: Nirmatrelvir plus ritonavir, sotrovimab and tocilizumab for treating COVID-19
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| 05.03.01 |
HIV infection |
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All drugs in this section are classed as RED - Primary care prescribers must not be asked to prescribe. Treatment of HIV infection should be undertaken by specialists only. Occupational Health and A&E doctors and Consultant Microbiologists may recommend the use of antiretrovirals for post exposure prophylaxis. |
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Atazanavir sulfate and cobicistat (Evotaz®)
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Formulary
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Tablets atazanavir 300 mg, cobicistat 150 mg
 Specialist prescribing only
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MHRA: Cobicistat, ritonavir and coadministration with a steroid: risk of systemic corticosteroid adverse effects
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Cobicistat
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Formulary
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Tablets 150mg
 Specialist prescribing only
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MHRA: Cobicistat, ritonavir and coadministration with a steroid: risk of systemic corticosteroid adverse effects
MHRA: Elvitegravir boosted with cobicistat: avoid use in pregnancy due to risk of treatment failure and maternal-to-child transmission of HIV-1
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Fostemsavir (Rukobia®)
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Formulary
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Prolonged release tablets 600mg
Specialist prescribing only
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Tenofovir alafenamide, elvitegravir, cobicistat & emtricitabine (Genvoya®)
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Formulary
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Tablets Cobicistat 150mg, Elvitegravir 150mg, Emtricitabine 200mg, Tenofovir alafenamide 10mg
Specialist prescribing only
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MHRA: Cobicistat, ritonavir and coadministration with a steroid: risk of systemic corticosteroid adverse effects
MHRA: Elvitegravir boosted with cobicistat: avoid use in pregnancy due to risk of treatment failure and maternal-to-child transmission of HIV-1
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| 05.03.01 |
HIV-integrase inhibitors |
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Cabotegravir (Vocabria®)
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Formulary
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Tablets 30mg
Prolonged-release injection 600mg/3ml
Specialist prescribing only
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NICE TA757: Cabotegravir with rilpivirine for treating HIV-1
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Dolutegravir (Tivicay®)
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Formulary
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Tablets 50mg
Specialist prescribing only
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MHRA: Dolutegravir (Tivicay▼, Triumeq▼, Juluca▼): updated advice on increased risk of neural tube defects
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Emtricitabine with Tenofovir alafenamide (Descovy®)
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Formulary
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Tablets 200mg emtricitabine and tenofovir alafenamide fumarate equivalent to 10 mg of tenofovir alafenamide,
200 mg of emtricitabine and tenofovir alafenamide fumarate equivalent to 25 mg of tenofovir alafenamide
Specialist prescribing only
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Raltegravir (Isentress ®)
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Formulary
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Tablets 400mg, 600mg
Specialist prescribing only
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| 05.03.01 |
Nucleoside reverse transcriptase inhibitors |
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Abacavir
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Formulary
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Tablets 300mg
Liquid 20mg/mL (only available when tablets are unsuitable)
Specialist prescribing only
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MHRA: Abacavir: risk of myocardial infarction—update from epidemiological studies
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Abacavir and Lamivudine
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Formulary
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Tablets abacavir 600mg with lamivudine 300mg
Specialist prescribing only
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MHRA: Abacavir: risk of myocardial infarction—update from epidemiological studies
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Elvitegravir with cobicistat, emtricitabine and tenofovir disoproxil (Stribild®)
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Formulary
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Tablets Cobicistat 150 mg, Elvitegravir 150 mg, Emtricitabine 200 mg, Tenofovir disoproxil (as Tenofovir disoproxil fumarate) 245 mg
Specialist prescribing only
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MHRA: Cobicistat, ritonavir and coadministration with a steroid: risk of systemic corticosteroid adverse effects
MHRA: Elvitegravir boosted with cobicistat: avoid use in pregnancy due to risk of treatment failure and maternal-to-child transmission of HIV-1
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Emtricitabine (Emtriva®)
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Formulary
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Capsules 200mg
Bluteq required if prescribing for pre-exposure prophylaxis (PrEP).
Specialist prescribing only
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Lamivudine
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Formulary
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Tablets 100mg, 150mg
Liquid 50mg/5ml (only available when tablets are unsuitable)
Specialist prescribing only
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Lamivudine with tenofovir disoproxil and doravirine (Delstrigo®)
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Formulary
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Tablets Doravirine 100 mg, Lamivudine 300 mg, Tenofovir disoproxil (as Tenofovir disoproxil fumarate) 245 mg
Specialist prescribing only
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Rilpivirine hydrochloride
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Formulary
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Tablets 25mg (Edurant)
Prolonged-release injection 900mg/3ml (Rekambys)
Specialist prescribing only
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NICE TA757: Cabotegravir with rilpivirine for treating HIV-1
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Tenofovir 245mg, Efavirenz 600mg and Emtricitabine 200mg
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Formulary
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Tablets efavirenz 600mg with emtricitabine 200mg and tenofavir 245mg
Specialist prescribing only
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Tenofovir and Emtricitabine
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Formulary
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Tablets tenofovir 245mg with emtricitabine 200mg
Specialist prescribing only
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Tenofovir Disproxil
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Formulary
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Tablets 245mg
Specialist prescribing only
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NICE CG165: Hepatitis B (chronic): diagnosis and management
NICE TA173: Tenofovir disoproxil for the treatment of chronic hepatitis B
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Zidovudine
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Formulary
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Capsules 100mg, 250mg
Oral solution 100mg/10ml
Infusion 200mg/20ml
Specialist prescribing only
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| 05.03.01 |
Protease inhibitors |
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Atazanavir
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Formulary
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Capsules 150mg, 200mg, 300mg
Specialist prescribing only
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Darunavir
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Formulary
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Tablets 400mg, 600mg, 800mg
Oral suspension 100mg/mL (only available when tablets are unsuitable)
Specialist prescribing only
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MHRA: Darunavir boosted with cobicistat: avoid use in pregnancy due to risk of treatment failure and maternal-to-child transmission of HIV-1
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Lopinavir and Ritonavir
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Formulary
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Tablets lopinavir 200mg with ritonavir 50mg
Liquid available on request.
Specialist prescribing only
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MHRA: Cobicistat, ritonavir and coadministration with a steroid: risk of systemic corticosteroid adverse effects
MHRA: Ritonavir-containing products: reports of interaction with levothyroxine leading to reduced thyroxine levels
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Ritonavir
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Formulary
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Tablets 100mg
Specialist prescribing only
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MHRA: Cobicistat, ritonavir and coadministration with a steroid: risk of systemic corticosteroid adverse effects
MHRA: Ritonavir-containing products: reports of interaction with levothyroxine leading to reduced thyroxine levels
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| 05.03.01 |
Non-nucleoside reverse transcriptase inhibitors |
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Doravirine (Pifeltro®)
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Formulary
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Tablets 100mg
Specialist prescribing only
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Efavirenz
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Formulary
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Tablets 600mg
Specialist prescribing only
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Etravirine (Intelence®)
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Formulary
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Tablets 100mg, 200mg
Specialist prescribing only
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MHRA: Etravirine: reports of severe hypersensitivity reactions
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Nevirapine
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Formulary
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Tablets 200mg
Specialist prescribing only
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| 05.03.01 |
Other antiretrovirals |
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Other drugs for the treatment of HIV infection are available on request. Contact pharmacy for advice. |
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Abacavir with Dolutegravir and Lamivudine (Triumeq®)
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Formulary
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Tablets abacavir (as abacavir sulfate) 600 mg, dolutegravir (as dolutegravir sodium) 50 mg, lamivudine 300 mg
Specialist prescribing only
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MHRA: Abacavir: risk of myocardial infarction—update from epidemiological studies
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Darunavir with Cobicistat (Rezolsta®)
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Formulary
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Tablets cobicistat 150mg, darunavir (as darunavir ethanolate) 800mg
Specialist prescribing only
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MHRA: Cobicistat, ritonavir and coadministration with a steroid: risk of systemic corticosteroid adverse effects
MHRA: Darunavir boosted with cobicistat: avoid use in pregnancy due to risk of treatment failure and maternal-to-child transmission of HIV-1
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Darunavir with Cobicistat, Emtricitabine and Tenofovir alafenamide (Symtuza®)
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Formulary
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Tablets cobicistat 150 mg, darunavir (as darunavir ethanolate) 800 mg, emtricitabine 200 mg, tenofovir alafenamide (as tenofovir alafenamide fumarate) 10 mg
Specialist prescribing only
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MHRA: Cobicistat, ritonavir and coadministration with a steroid: risk of systemic corticosteroid adverse effects
MHRA: Darunavir boosted with cobicistat: avoid use in pregnancy due to risk of treatment failure and maternal-to-child transmission of HIV-1
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Dolutegravir and Lamivudine (Dovato®)
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Formulary
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Tablets dolutegravir (as dolutegravir sodium) 50mg, Lamivudine 300mg
Specialist prescribing only
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MHRA: Dolutegravir (Tivicay▼, Triumeq▼, Juluca▼): updated advice on increased risk of neural tube defects
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Dolutegravir and Rilpivirine (Juluca®)
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Formulary
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Tablets 50mg/25mg
Specialist prescribing only
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MHRA: Dolutegravir (Tivicay▼, Triumeq▼, Juluca▼): updated advice on increased risk of neural tube defects
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Emrticitabine with Rilpivirine and Tenofovir disoproxil (Eviplera®)
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Formulary
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Tablets Emtricitabine 200mg, Rilpivirine (as Rilpivirine hydrochloride) 25mg, Tenofovir disoproxil 245mg
Specialist prescribing only
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Emtricitabine with Rilpivirine and Tenofovir alafenamide (Odefsey®)
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Formulary
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Tablets emtricitabine 200mg, rilpivirine (as rilpivirine hydrochloride) 25mg, tenofovir alafenamide (as tenofovir alafenamide fumarate) 25mg
Specialist prescribing only
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Maraviroc (Celsentri®)
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Formulary
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Tablets 150mg, 300mg
Specialist prescribing only
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| 05.03.02 |
Herpesvirus infections |
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| 05.03.02.01 |
Herpes simplex and varicella-zoster infection |
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Aciclovir injection
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Formulary
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Intravenous infusion 250mg, 500mg
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Aciclovir oral
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Formulary
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Tablets 200mg, 400mg, 800mg
Dispersible tablets 200mg, 400mg, 800mg
Oral suspension 200mg/5ml
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| 05.03.02.02 |
Cytomegalovirus infection |
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Ganciclovir
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Formulary
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Intravenous infusion 500mg
Specialist prescribing only
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Letermovir (Prevymis® )
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Formulary
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Tablets 240mg
Specialist prescribing only
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NICE TA591: Letermovir for preventing cytomegalovirus disease after a stem cell transplant
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Maribavir (Livtencity® )
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Formulary
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Tablets 200mg
Specialist prescribing only
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NICE TA860: Maribavir for treating refractory cytomegalovirus infection after transplant
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Valganciclovir
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Formulary
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Tablets 450mg
Suspension 250mg/5mL
Specialist prescribing only
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| 05.03.03 |
Viral hepatitis |
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Adefovir Dipivoxil (Hepsera®)
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Formulary
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Tablets 10mg
Specialist prescribing only
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NICE TA96: Adefovir dipivoxil and peginterferon alfa-2a for the treatment of chronic hepatitis B
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Bulevirtide (HEPCLUDEX®)
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Formulary
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Powder for solution for injection 2mg
Specialist prescribing only
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NICE TA896: Bulevirtide for treating chronic hepatitis D
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Entecavir
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Formulary
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Tablets 500micrograms, 1mg
Specialist prescribing only
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NICE TA153: Entecavir for the treatment of chronic hepatitis B
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Ribavirin
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Formulary
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Capsules 200mg
Specialist prescribing only
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NICE TA106: Peginterferon alfa and ribavirin for the treatment of mild chronic hepatitis C
NICE TA200: Peginterferon alfa and ribavirin for the treatment of chronic hepatitis C
NICE TA300: Peginterferon alfa and ribavirin for treating chronic hepatitis C in children and young people
NICE TA75: Interferon alfa (pegylated and non-pegylated) and ribavirin for the treatment of chronic hepatitis C
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Sofosbuvir
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Formulary
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Tablets 200mg, 400mg
Specialist prescribing only
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MHRA: Direct-acting antiviral interferon-free regimens to treat chronic hepatitis C: risk of hepatitis B reactivation
MHRA: Direct-acting antivirals for chronic hepatitis C: risk of hypoglycaemia in patients with diabetes
MHRA: Direct-acting antivirals to treat chronic hepatitis C: risk of interaction with vitamin K antagonists and changes in INR
MHRA: Simeprevir with sofosbuvir: risk of severe bradycardia and heart block when taken with amiodarone
MHRA: Sofosbuvir with daclatasvir; sofosbuvir and ledipasvir: risks of severe bradycardia and heart block when taken with amiodarone
NICE TA330: Sofosbuvir for treating chronic hepatitis C
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| 05.03.03.01 |
Chronic hepatitis B |
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| 05.03.03.02 |
Chronic hepatitis C |
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Hepatitis C therapy is based on genotype and cirrhosis status. Treatment options are dictated by the 'rate card' which is published by NHSE.
All cases in this region are discussed at the hepatitis C MDT for all local Trusts. |
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Elbasvir with grazoprevir (Zepatier®)
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Formulary
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Tablets elbasvir 50mg, grazoprevir 100mg
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NICE TA413: Elbasvir–grazoprevir for treating chronic hepatitis C
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Glencaprevir with pibrentasvir
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Formulary
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Tablets glecaprevir 100mg, pibrentasvir 40mg
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NICE TA499: Glecaprevir–pibrentasvir for treating chronic hepatitis C
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Ledipasvir and Sofosbuvir (Harvoni®)
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Formulary
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Tablets 45mg/200mg, 90mg/400mg
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MHRA: Sofosbuvir with daclatasvir; sofosbuvir and ledipasvir: risks of severe bradycardia and heart block when taken with amiodarone
NICE TA363: Ledipasvir–sofosbuvir for treating chronic hepatitis C
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Ribavirin
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Formulary
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Capsules 200mg
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NICE TA106: Peginterferon alfa and ribavirin for the treatment of mild chronic hepatitis C
NICE TA200:Peginterferon alfa and ribavirin for the treatment of chronic hepatitis C
NICE TA300: Peginterferon alfa and ribavirin for treating chronic hepatitis C in children and young people
NICE TA75: Interferon alfa (pegylated and non-pegylated) and ribavirin for the treatment of chronic hepatitis C
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Sofosbuvir (Sovaldi® )
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Formulary
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Tablets 200mg, 400mg
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NICE TA330: Sofosbuvir for treating chronic hepatitis C
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Sofosbuvir and Velpatasvir (Epclusa®
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Formulary
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Tablets 200mg/50mg, 400mg/100mg
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NICE TA430: Sofosbuvir–velpatasvir for treating chronic hepatitis C
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Sofosbuvir with Velpatasvir and Voxilaprevir (Vosevi®)
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Formulary
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Tablets Sofosbuvir 400 mg, Velpatasvir 100mg, Voxilaprevir 100mg
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NICE TA507: Sofosbuvir–velpatasvir–voxilaprevir for treating chronic hepatitis C
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| 05.03.04 |
Influenza |
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Oseltamivir
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Formulary
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Capsules 30mg, 45mg, 75mg
Oral suspension 30mg/5mL
Public Health England advises that oseltamivir oral suspension should be reserved for children under the age of 1 year. Children over 1 year of age, adults with swallowing difficulties, and those receiving nasogastric oseltamivir, should use capsules which can be opened and mixed into an appropriate sugary liquid.
Tamiflu® is not prescribable in NHS primary care except for the treatment and prophylaxis of influenza as indicated in the NICE guidance; endorse prescription ‘SLS’.
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LSCMMG: Oseltamivir
NICE TA158: Oseltamivir, amantadine (review) and zanamivir for the prophylaxis of influenza
NICE TA168: Amantadine, oseltamivir and zanamivir for the treatment of influenza
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Zanamivir (Relenza®)
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Formulary
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Dry powder for inhalation 5mg/blister
Relenza® is not prescribable in NHS primary care except for the treatment and prophylaxis of influenza as indicated in the NICE guidance; endorse prescription ‘SLS’.
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LSCMMG: Zanamivir
NICE TA158: Oseltamivir, amantadine (review) and zanamivir for the prophylaxis of influenza
NICE TA168: Amantadine, oseltamivir and zanamivir for the treatment of influenza
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Amantadine
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Formulary
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LSCMMG: Amantadine
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| 05.03.05 |
Respiratory syncytial virus |
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Palivizumab (Synagis®)
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Formulary
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Injection 50mg, 100mg
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MHRA: Respiratory syncytial virus: the green book, chapter 27a
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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
| 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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