Gateshead Primary Care Formulary Incorporating Gateshead Medicines Management Committee, Gateshead NHS Foundation Trust and North of Tyne Area

Transcription

1 Gateshead Primary Care Formulary Incorporating Gateshead Medicines Management Committee, Gateshead NHS Foundation Trust and North of Tyne Area Prescribing Committee formulary decisions Prepared by Pharmicus November 2015

2 CHANGES TO ULARY SINCE LAST UPDATE ADDITIONS Section Details Reason for addition 1.5.2, 6.3.2, Predisolone solution GMMC approved Captopril solution To ensure use of licensed product Nicardipine GMMC approved 4.3 Vortioxetine To reflect approval under NICE TA Ondansetron oro-dispersible GMMC approved 4.8 Clobazam suspension To ensure use of licensed product Gentamicin Intravesical GMMC approved Ombitasvir-paritaprevir-ritonavir with or without Dasabuvir To reflect approval under NICE TA Ledipasvir-Sofosbuvir To reflect approval under NICE TA Daclatasvir To reflect approval under NICE TA Midodrine tablets GMMC approved Whitmore cocktail GMMC approved Sayana Press (medroxyprogesterone) GMMC approved Dinoprostone pessary GMMC approved Pembrolizumab To reflect approval under NICE TA Ciclosporin eye drops To reflect approval under NICE TA369 REMOVALS Section Details Reason for removal AMENDMENTS Section Details Reason for amendment Circadin amended to Melatonin generic description Now in drug tariff Melatonin solution To avoid selection errors 4.6 Nabilone Clarity on prescribing responsibilities Erlotinib amended entry To reflect approval under NICE TA Bortezomib To reflect approval under NICE TA Nutramigen To reflect changed description 9.4 Aptamil Pepti To match status of similar products Abatacept, Adalimumab, Etanercept, Tocilizumab To reflect approval under NICE TA373

3 INTRODUCTION This formulary is designed to encourage safe, cost-effective prescribing of medicines. The layout follows the chapters and subsections of the BNF. Within primary care IT systems some medicines on this formulary may not be on formulary (above the ----line on EMIS LV or in bold text on EMIS Web). This is where a medicine has restrictions associated with its use or is not a first-line product. Where possible, all such medicines have been annotated as such throughout this guide. Prescribers may select items not on formulary but they should be able to clinically justify why an item on formulary, if there is such an item, was not selected instead. Medicines that are either shared care or for hospital prescribing only are appropriately annotated throughout this formulary.

4 Medicines that should be prescribed by brand name are listed in this formulary Rx as brand name and are listed on EMIS by their brand name Drugs are categorised via a traffic light system: Drugs that should remain under the total responsibility of the Primary or Secondary care specialist prescriber (i.e. consultant) should only be prescribed under the direct supervision of that clinician and are not suitable for shared care arrangements (e.g., HIV and chemotherapy drugs). RED drugs AMBER drugs Drugs that require frequent, specialist, long-term, monitoring of efficacy by the Primary Care or Secondary Care Specialist Prescribers. Drugs requiring Secondary Care or specialist facilities or high-cost environment for preparation or reconstitution. Drugs specified as hospital only by product license or DoH legislation. Drugs with no UK product license. Drugs with unlicensed indications without recommendation from local or national guidance e.g. NICE. Drugs without substantial wholesale body of support unless in the BNF or Children s BNF. These are specialist drugs which must be initiated by Primary Care or Secondary Care Specialist Prescribers, but with the potential to transfer to primary care within written and agreed shared care protocols and according to the agreed process for transfer of care. The patient s condition and/or treatment should normally be stabilised before the GP should be asked to participate in shared care. This time period can be variable dependent on the condition being treated and the individual patient s response to the treatment. A minimum of one months stabilised dose would be expected to be provided by the Primary or Secondary Care Specialist Prescriber before considering transfer of prescribing. Criteria for an Amber drug are as follows: GREEN + drugs GREEN drugs A Primary or Secondary Care Specialist is required to start the medication. Both the Primary Care or Secondary Care Specialist and GP have a shared responsibility in maintaining the patient progress and prescribing (details will be defined in a Shared Care Protocol). Both the Primary Care and Secondary Care Specialist and GP may share the responsibility for stopping the medication. It is accepted that some drugs should be initiated by a Primary Care or Secondary Care Specialist but can be safely maintained in primary care without on-going specialist monitoring and will be classified as GREEN+ rather than AMBER. A minimum of one month supply should be given to patients with their first prescription by the Primary Care or Secondary Care Specialist Prescriber before transferring responsibility to primary care. If a patient uses compliance aids, consider the best interests of the patient when deciding the length of the first supply. These are defined as new and established drugs, which may be prescribed, initiated, changed or maintained on FP10 by the GP and if appropriate discontinued without recourse to secondary care.

5 CONTENTS CHANGES TO ULARY SINCE LAST UPDATE... 1 ADDITIONS... 1 REMOVALS... 1 AMENDMENTS... 1 INTRODUCTION... 2 Section 1: Gastrointestinal Dyspepsia and gastro-oesophageal reflux disease Antacids and simeticone Compound alginates Antispasmodics and other drugs altering gut motility Antisecretory drugs and mucosal protectants H2-receptor antagonists Chelates and complexes Prostaglandin analogues Proton pump inhibitors Acute diarrhoea Antimotility drugs Chronic bowel disorders Aminosalicylates Corticosteroids Drugs affecting the immune response Laxatives Bulk-forming laxatives Stimulant laxatives Faecal softeners Osmotic laxatives Bowel cleansing solutions Other drugs used in constipation Local preparations for anal and rectal disorders... 30

6 1.7.1 Soothing haemorrhoidal preparations Compound haemorrhoidal preparations with corticosteroids RECTAL SCLERANTS Drugs affecting intestinal secretions Drugs affecting biliary composition and flow Pancreatin Section 2: Cardiovascular Positive inotropic drugs Diuretics Thiazides and related diuretics Loop diuretics Potassium-sparing diuretics potassium-sparing diuretics with other diuretics Osmotic Diuretics Anti-arrhythmic drugs drugs for arrhythmias Beta-adrenoceptor blocking drugs Drugs affecting the renin-angiotensin system and other antihypertensive drugs Vasodilator antihypertensive drugs Centrally acting antihypertensive drugs Alpha-adrenoceptor blocking drugs Drugs affecting the Renin-Angiotensin system OTHER Nitrates, calcium-channel blockers, and potassium-channel activators Nitrates Calcium-channel blockers Other Anti-anginal drugs Peripheral vasodilators and related drugs Sympathomimetics INOTROPIC SYMPATHOMIMETICS VASOCONSTRICTOR SYMPATHOMIMETICS... 56

7 2.7.3 Cardiopulmonary resuscitation Anticoagulants and protamine Parenteral anticoagulants Oral anticoagulants Antiplatelet drugs stable angina, acute coronary syndromes and fibrinolysis fibrinolytic drugs Antifibrinolytic drugs and haemostatics Lipid-regulating drugs Local sclerosants Section 3: Respiratory Bronchodilator Adrenoceptor agonists Antimuscarinic bronchodilators Theophylline Peak flow meters, inhaler devices and nebulisers Corticosteroids Cromoglicate and related therapy, leukotriene receptor antagonists, and phosphodiesterase type-4 inhibitors cromogligate and related therapy leukotriene receptor antagonists phosphodiesterase type-4 inhibitors Antihistamines, hyposensitisation, and allergic emergencies Antihistamines Allergen immunotherapy Allergic emergencies Respiratory stimulants and pulmonary surfactants Respiratory stimulants Pulmonary surfactants Oxygen Mucolytics Aromatic Inhalations... 86

8 3.9 Cough preparations Cough suppressants Demulcent cough preparations Systemic nasal decongestants ANTIFIBROTICS Section 4: CNS Hypnotics and anxiolytics Hypnotics Anxiolytics Drugs used in psychoses and related disorders Antipsychotic drugs Antipsychotic depot injections Antimanic drugs Antidepressant drugs Tricyclic and related antidepressant drugs Monoamine-oxidase inhibitors Selective serotonin re-uptake inhibitors Other antidepressant drugs Central nervous system stimulants Drugs used in the treatment of obesity Drugs used in nausea and vertigo Analgesics Non-opioid analgesics Opioid analgesic preparations Neuropathic pain Antimigraine drugs Antiepileptics Drugs used in status epilepticus Drugs used in parkinsonism and related disorders Dopaminergic drugs used in parkinsonism Antimuscarinic drugs used in parkinsonism

9 4.9.3 Drugs used in essential tremor, chorea, tics and related disorders Drugs used in substance dependence Drugs for dementia Section 5: Infections Antibacterial drugs Penicillins Cephalosporins, carbapenems and other beta-lactams Tetracyclines Aminoglycosides Macrolides Antituberculosis drugs Antileprotic drugs Antifungal drugs Antiviral drugs HIV infection herpesvirus infections Viral hepatitis influenza Antiprotozoal drugs Antimalarials amoebicides antigiardial drugs Anthelmintics Section 6: Endocrine Drugs used in diabetes Insulins Oral diabetic drugs Treatment of hypoglycaemia Diagnostic and monitoring devices for diabetes mellitus Thyroid and antithyroid drugs Thyroid hormones

10 6.2.2 Antithyroid drugs Corticosteroids Replacement therapy Glucocorticoid therapy Sex hormones Female sex hormones Male sex hormones and antagonists Hypothalamic and pituitary hormones and anti-oestrogens Hypothalmic and anterior pituitary hormones and anti-oestrogens HYPOTHALMIC HORMONES Posterior pituitary hormones and antagonists Drugs affecting bone metabolism Calcitoninand parathyroid hormone Bisphosphonates Other endocrine drugs Bromocriptine and other dopaminergic drugs Drugs affecting gonadotrophins Obstetrics, gynaecology and urinary-tract disorders Drugs used in obstetrics Prostaglandins and oxytocics Treatment of vaginal and vulval conditions Preparations for vaginal atrophy Anti-infective drugs Contraceptives Combined oral contraceptives Progesterone only contraceptives Spermicidal contraceptives Contraceptive devices Emergency contraception Drugs for genito-urinary disorders Drugs for urinary retention

11 7.4.2 Drugs for urinary frequency, enuresis and incontinence Drugs used in urological pain Bladder instillations and urological surgery Drugs for impotence Section 8: Malignant disease & Immunosuppression Cytotoxic drugs Drugs for cytotoxic induced side effects Alkylating drugs Anthracyclines and other cytotoxic antibiotics Antimetabolites VINCA ALKALOIDS AND ETOPOSIDE Other antineoplastic drugs PENTOSTATIN Platinum compounds PROCARBAZINE Protein Kinase Inhibitors Taxanes TOPOISOMERASE I INHIBITORS TRETINOIN Drugs affecting the immune response Antiproliferative immunosuppressants Corticosteroids and other immunosuppressants anti-lymphocyte Monoclonal antibodies Other immunomodulating drugs Sex hormones and hormone antagonists in malignant disease Progestogens Hormone antagonists Section 9: Nutrition & Blood Anaemias and some other blood disorders Iron deficiency anaemias Drugs used in megaloblastic anaemias

12 9.1.3 Drugs used in neoplastic, haemolytic and renal anaemias Drugs used in platelet disorders Drugs used in neutropenia drugs used to mobilise stem cells Fluids and electrolytes Oral preparations for fluid and electrolyte imbalance Parenteral preparations for fluid and electrolyte imbalance PLASMA AND PLASMA SUBSTITUTES Intravenous nutrition Oral nutrition Minerals Calcium and magnesium Phosphorus Fluoride Zinc Vitamins Vitamin B group Vitamin C group Vitamin D group Vitamin E group Vitamin K group Multivitamin preparations Metabolic disorders drugs used in metabolic disorders Section 10: Musculoskeletal & Joint diseases Drugs used in rheumatic disorders and gout Non-steroidal anti-inflammatory drugs Corticosteroids Systemic corticosteroids Local corticosteroid injections Drugs which suppress the rheumatic disease process

13 Drugs for treatment of gout Drugs used in neuromuscular disorders Drugs which enhance neuromuscular transmission Skeletal muscle relaxants Drugs for the relief of soft-tissue inflammation Enzymes Rubefaciants and other topical antirheumatics Intra-articular preparation Section 11: Eye Anti-infective eye preparations Antibacterials Antivirals Corticosteroids and other anti-inflammatory preparations Corticosteroids Other anti-inflammatory preparations Mydriatics and cycloplegics Treatment of glaucoma LOCAL ANAESTHETICS Miscellaneous ophthalmic preparations Tear deficiency, ocular lubricants and astringents Ocular diagnostic and peri-operative preparations and photodynamic treatment Section 12: Ear, Nose & Oropharynx Drugs acting on the ear Otitis externa Removal of ear wax Drugs acting on the nose Drugs used in nasal allergy Topical nasal decongestants Nasal preparations for infection MISCELLANEOUS Drugs acting on the oropharynx

14 Drugs used for oral ulceration and inflammation Oropharyngeal anti-infective drugs Lozenges and sprays Mouthwashes, gargles and dentifrices Treatment of dry mouth Section 13:Skin Emollient and barrier preparations Emollients SOAP SUBSTITUTES Barrier preparations Topical local anaesthetics and antipruritics Topical corticosteroids Preparations for eczema and psoriasis Preparations for eczema Preparations for psoriasis Drugs affecting the immune response Acne and rosacea Topical preparations for acne Oral preparations for acne Preparations for warts and calluses Sunscreens and camouflagers Sunscreen preparations Camoflagers Shampoos and some other scalp preparations Anti-infective skin preparations Antibacterial preparations Antifungal preparations Antiviral preparations Parasiticidal preparations Preparations for minor cuts and abrasions Skin cleansers, antiseptics and preparations for promotion of wound healing

15 13.12 Antiperspirants Topical circulatory preparations MISCELLANEOUS APPLIANCES

16 SECTION 1: GASTROINTESTINAL 1.1 DYSPEPSIA AND GASTRO-OESOPHAGEAL REFLUX DISEASE ANTACIDS AND SIMETICONE SPECIFIC RELATED INATION Comagaldrox Suspension 195/200 Green On EMIS formulary as brand and to be prescribed as Mucogel (NB: This is different to the QEH. If any requests are received for Maalox, please automatically switch to Mucogel) Simeticone Prescribe generically, not as Infacol Suspension SF 40mg/ml Green COMPOUND ALGINATES SPECIFIC RELATED INATION Peptac Suspension Green Aniseed or peppermint flavours Gaviscon Advance Chewable tablets SF Green Not for routine use, only as an alternate to Peptac for portability Not on QEH formulary; anticipated use is within primary care Gaviscon Infant Powder (Sachets) Green Each pack has 15 dual sachets which contains 30 doses 1.2 ANTISPASMODICS AND OTHER S ALTERING GUT MOTILITY Antimuscarinics / Antispasmodics

17 SPECIFIC RELATED INATION Hyoscine butylbromide Tablets 10mg Green Injection 20mg/ml Green Mebeverine Tablets 135mg Green SF Liquid 50mg/5ml Green Not on EMIS formulary to ensure used appropriately. Peppermint oil Capsules EC 0.2ml Green Not the M/R capsules Peppermint Water Not recommended for primary care prescribing due to high dispensing error risk Green Not on EMIS formulary; anticipated use is within secondary care. Propantheline bromide Tablets 15mg Green Not on QEH formulary; included as on NoT formulary Gut Motility SPECIFIC RELATED INATION Metoclopramide Caution with patients aged under 20 years. A lower dose is required New MHRA guidance: maximum of 5 days use is now recommended for all patients Tablets 10mg Green Injection 10mg/2ml Green Oral Solution SF 5mg/5ml Green Domperidone Tablets 10mg Green

18 Recent MHRA alert Caution in use with other drugs that prolong QT interval. A maximum daily dose of 30mg is now recommended Suspension SF 1mg/ml Green Suppositories 30mg Green Not on QEH formulary; included to allow cost effective choice of formulation for patients who cannot swallow. 1.3 ANTISECRETORY S AND MUCOSAL PROTECTANTS H2-RECEPTOR ANTAGONISTS SPECIFIC RELATED INATION Ranitidine 1st choice H2- antagonist Tablets 150mg Green Tablets 300mg Green Not on QEH formulary; included to allow cost effective choice of strength. Solution SF 150mg/10ml Green Effervescent Tablets 150mg Green Not on QEH formulary; included to allow cost effective choice of formulation. Injection 50mg/2ml Green Not on EMIS formulary; anticipated use is within secondary care. Cimetidine 2nd choice H2- antagonist Tablets 200mg Green Not on QEH formulary; included to allow

19 cost effective choice of strength. Tablets 400mg Green Solution SF 200mg/5ml Green CHELATES AND COMPLEXES SPECIFIC RELATED INATION Sucralfate Tablets 1g Green Suspension SF 1g/5ml Green Tri-potassium dicitratobismuthate Tablets 120mg Green PROSTAGLANDIN ANALOGUES SPECIFIC RELATED INATION Misoprostol Tablets 200micrograms Green PROTON PUMP INHIBITORS For current recommended H.pylori eradication regimens consult BNF. SPECIFIC RELATED INATION Omeprazole Capsules 10mg Green

20 Capsules 20mg Green Use 2 x 20mg for a 40mg dose. Dispersible tablets 10mg Green Not on EMIS formulary to ensure appropriate use Paediatrics only. Dispersible tablets 20mg Green Not on EMIS formulary to ensure appropriate use Paediatrics only. Injection 40mg Green Not on EMIS formulary; anticipated use is within secondary care. Lansoprazole Capsules 15mg Green Capsules 30mg Green Orodispersible tablets 15mg Green Not on EMIS formulary to ensure appropriate use. Restricted to patients with true swallowing difficulties Orodispersible tablets 30mg Green Not on EMIS formulary to ensure appropriate use Restricted to patients with true swallowing difficulties. Esomeprazole Tablets 20mg GREEN PLUS Not on EMIS formulary to ensure appropriate use On recommendation

21 of gastroenterology only. Tablets 40mg GREEN PLUS Not on EMIS formulary to ensure appropriate use. On recommendation of gastroenterology only. 1.4 ACUTE DIARRHOEA First-line treatment for acute diarrhoea is rehydration therapy. Faecal impaction can give rise to "overflow diarrhoea" and must be excluded before antidiarrhoeals are started. Kaolin is considered less appropriate for prescribing Oral rehydration therapy SPECIFIC RELATED INATION Dioralyte Sachets Green Patients can request their preferred flavour from the pharmacy ANTIMOTILITY S Avoid if Clostridium difficile infection suspected or present SPECIFIC RELATED INATION Loperamide Capsules 2mg Green Do not use orodispersible, liquid is readily available

22 Oro-dispersible tablets 2mg Green Only to be prescribed where requested by North of Tyne hospital for patients with high stoma output. Not on EMIS formulary to ensure appropriate use. Syrup SF 1mg/5ml Green Codeine phosphate Tablets 15mg Green 2 nd line Tablets 30mg Green 2 nd line 1.5 CHRONIC BOWEL DISORDERS Aminosalicylates can cause blood disorders; patients should report any unexplained bleeding, bruising, purpura, sore throat, fever or malaise occurring during therapy. A blood count should be performed and the drug stopped immediately if a blood dyscrasia is suspected AMINOSALICYLATES SPECIFIC RELATED INATION Balsalazide Capsules 750mg Green Mesalazine MR Tablets 400mg Green Prescribe by brand name. On EMIS as preferred brand of Asacol. MR Tablets 800mg Green Prescribe by brand name. On EMIS as preferred brand of Asacol.

23 MR Tablets 500mg Green Prescribe by brand name. On EMIS as preferred brand of Pentasa MR Tablets 1.2g Green Prescribe by brand name. On EMIS as preferred brand of Mezavant MR Sachets (Granules) 500mg Green Prescribe by brand name. On EMIS as preferred brand of Salofalk MR Sachets (Granules) 1g Green Rx brand name: Salofalk or Pentasa. On EMIS as Salofalk & Pentasa. Not on QEH formulary. Included to allow patients to be maintained on same brand where possible. MR Sachets (Granules) 1.5g Green Rx by brand name. On EMIS as Salofalk. Not on QEH formulary. Included to allow patients to be maintained on same brand where possible. MR Sachets (Granules) 2g Green Rx by brand name On EMIS as Pentasa

24 Suppositories 250mg Green Suppositories 500mg Green Suppositories 1g Green Foam Enema 1g Green Retention Enema 1g/100ml Green Enema 2g Green Olsalazine Capsules 250mg Green Tablets 500mg Green Not on QEH formulary; included to allow cost effective choice of strength. Sulfasalazine Tablets 500mg Amber EC Tablets 500mg Amber Suspension SF 250mg/5ml Amber CORTICOSTEROIDS SPECIFIC RELATED INATION Budesonide MR Capsules 3mg Green Capsules 3mg Green Not on QEH formulary in this section; included to allow cost effective choice of formulation.

25 Hydrocortisone acetate Foam 10% Green Not on QEH formulary; included as on NoT formulary Prednisolone Foam 20mg/dose Green Retention Enema 20mg/100ml Green Suppositories 5mg Green Solution 1mg/ml Green For patients with swallowing difficulties Tablets 5mg Green Not used routinely for this indication. Tablets 1mg Green Not used routinely for this indication S AFFECTING THE IMMUNE RESPONSE SPECIFIC RELATED INATION Azathioprine Tablets 25mg Amber (for noncancer indications) Not on QEH formulary in this section; included as on NoT formulary Tablets 50mg Amber (for noncancer indications) Not on QEH formulary in this section; included as on NoT formulary Ciclosporin Injection RED (Sandimmum) Mercaptopurine Unlicensed indication Tablets 50mg Amber (for noncancer indications) Not on QEH formulary in this section; included

26 as on NoT formulary Not on EMIS formulary to ensure used appropriately. Methotrexate Unlicensed indication Tablets 2.5mg Amber (for noncancer indications) Not on QEH formulary in this section; included as on NoT formulary Patient safety: Do not prescribe 10mg tablets. Dosing errors have occurred. Cytokine modulators Infliximab Prescribe as brand name -Inflectra -Remsima Vial 100mg RED Prescribed in accordance with NICE TA140, TA163 and TA187. Adalimumab Vial 40mg RED Prescribed in accordance with NICE TA187. Funded by NHS England for paediatric indications. Vedolizumab Vial 300mg RED Prescribed in accordance with NICE 342 & 352 and appropriate funding and criteria 1.6 LAXATIVES Guidelines for the management of constipation in adults and children is available on GIN BULK-ING LAXATIVES

27 SPECIFIC RELATED INATION Ispaghula husk Effervescent granules (Sachets) 3.5g Green Only on local guideline as 1 st - line choice in pregnancy Not for PRN use, should be taken with plenty of water and no later than 6pm Orange, Lemon or Plain flavours STIMULANT LAXATIVES SPECIFIC RELATED INATION Bisacodyl Suppositories 5mg Green Suppositories 10mg Green Tablets 5mg Green Used in preference to Senna as more cost-effective Co-danthrusate Palliative care only Capsules 50/60 Green Not on EMIS formulary to ensure appropriate use Suspension 50/60 Green Not on EMIS formulary to ensure appropriate use Docusate sodium Capsules 100mg Green Solution SF 12.5mg/5ml Green

28 Solution SF 50mg/5ml Green Glycerol Suppositories 1g Green Suppositories 2g Green Suppositories 4g Green Senna Tablets 7.5mg Green Avoid 15mg strength, this is an OTC product Solution SF 7.5mg/5ml Green Sodium picosulphate Solution SF 5mg/5ml Green Children only FAECAL SOFTENERS SPECIFIC RELATED INATION Arachis oil Enema Green Liquid Paraffin Liquid Green Not on EMIS formulary; identified locally as less suitable for prescribing OSMOTIC LAXATIVES SPECIFIC RELATED INATION Lactulose Solution Green Not for PRN use

29 Macrogol Sachets NPF SF 13.8g Green Prescribe generically Sachets 6.9g Green Not on EMIS formulary to ensure selection of the appropriately licensed product. Care halfstrength product is identical to paediatric product Movicol-Paediatric Sachets 6.9g Green Rx by brand name to ensure paediatric product chosen Micolette (Sodium citrate) Enema Green Only on EMIS as brand name product Phosphate Enema Long tube Green (Fleet enema) Enema Standard tube Green BOWEL CLEANSING SOLUTIONS SPECIFIC RELATED INATION Klean-Prep Oral Powder Green Not on EMIS formulary Provided by secondary care when needed preoperatively Moviprep Sachets RED Not on EMIS formulary

30 Provided by secondary care when needed preoperatively Sodium Picosulphate Sachets Green Not on EMIS formulary Provided by secondary care when needed preoperatively OTHER S USED IN CONSTIPATION SPECIFIC RELATED INATION Lubiprostone Prescribed in accordance with NICE TA318 Capsules 24mcg GREEN PLUS Not on EMIS formulary to ensure appropriate use Naloxegol Prescribed in accordance with NICE TA345 & local funding and criteria being met Tablets 12.5mg GREEN PLUS Tablets 25mg GREEN PLUS Prucalopride Prescribed in accordance with NICE TA211 Tablets 1mg GREEN PLUS Not on EMIS formulary to ensure appropriate use Tablets 2mg GREEN PLUS Not on EMIS formulary to ensure appropriate use. Linaclotide Capsules 290mcg GREEN PLUS Not on EMIS formulary to ensure appropriate use. Only for treatment of IBS-C

31 1.7 LOCAL PREPARATIONS FOR ANAL AND RECTAL DISORDERS SOOTHING HAEMORRHOIDAL PREPARATIONS SPECIFIC RELATED INATION Glyceryl trinitrate Rectal Ointment 0.4% Green Avoid 0.2% ointment - unlicensed Anusol Suppositories Green Only on EMIS as branded product Ointment Green Only on EMIS as branded product Not on QEH formulary; anticipated use is within primary care Cream Green Only on EMIS as branded product Not on QEH formulary; anticipated use is within primary care Diltiazem 2 nd line Cream 2% Green Not on EMIS formulary to ensure appropriate use Not on QEH formulary; included to allow cost effective choice of formulation. Ointment 2% GREEN PLUS Not on EMIS formulary to ensure appropriate use

32 Do not use ointment, cream is more cost effective

33 COMPOUND HAEMORRHOIDAL PREPARATIONS WITH CORTICOSTEROIDS SPECIFIC RELATED INATION Anusol-HC Suppositories Green Only on EMIS as branded product Ointment Green Only on EMIS as branded product Scheriproct Suppositories Green Not on QEH formulary; included to allow cost effective choice of preparation. Ointment Green Not on QEH formulary; included to allow cost effective choice of preparation. Proctofoam HC Foam Green Not on EMIS formulary; an alternative formulation is more cost effective for use in primary care. May be prescribed if specifically requested by secondary care RECTAL SCLERANTS SPECIFIC RELATED INATION Oily Phenol Injection 5% Green Not on EMIS formulary; anticipated use is

34 within secondary care. 1.9 S AFFECTING INTESTINAL SECRETIONS S AFFECTING BILIARY COMPOSITION AND FLOW SPECIFIC RELATED INATION Ursodeoxycholic acid Tablets 150mg Green Tablets 300mg Green Not on QEH formulary; included to allow cost effective choice of strength. Capsules 250mg Green Suspension SF 250mg/5ml Green BILE ACID SEQUESTRANTS SPECIFIC RELATED INATION Colestyramine Affects the absorption of many other medications. Check BNF for each individual interaction. Sachets 4g Green SF Sachets 4g Green Not on QEH formulary; included to allow cost effective choice of formulation.

35 1.9.4 PANCREATIN SPECIFIC RELATED INATION Creon Initiate on specialist advice only Capsules Green Capsules Green Capsules Green Creon Micro Initiate on specialist advice only Capsules 100mg Green Not on QEH formulary; included as on NoT formulary Pancrex V Initiate on specialist advice only Powder Green Capsules Green Not on QEH formulary; included to allow cost effective choice of strength/formulation Capsules 125 Green Not on QEH formulary; included to allow cost effective choice of strength/formulation EC Tablet Green Not on QEH formulary; included to allow cost effective choice of strength/formulation EC Tablets Forte Green Not on QEH formulary; included to allow cost effective choice of strength/formulation

36 SECTION 2: CARDIOVASCULAR 2.1 POSITIVE INOTROPIC S SPECIFIC RELATED INATION Digoxin Care to ensure loading doses are not continued. Doses above 250micrograms daily are unusual in adults and above 125micrograms unusual in over 70's. Tablets 62.5micrograms Green Tablets 125micrograms Green Tablets 250micrograms Green Elixir 50micrograms/ml Green Injection 250micrograms/ml Green Not on EMIS formulary; anticipated use is within secondary care. Enoximone Injection 100mg/20ml RED Digifab For digoxin toxicity Injection 40mg RED 2.2 DIURETICS THIAZIDES AND RELATED DIURETICS SPECIFIC RELATED INATION Bendroflumethiazide Tablets 2.5mg Green

37 Tablets 5mg Green Not on EMIS formulary High dose not recommended Indapamide Tablets 2.5mg Green Not on QEH formulary; included due to national guidance recommending use. Chlorothiazide Suspension 100mg/5ml Green Not on EMIS formulary Unlicensed Suspension 250mg/5ml Green Not on EMIS formulary Unlicensed Metolazone Tablets 2.5mg GREEN PLUS Tablets 5mg GREEN PLUS LOOP DIURETICS SPECIFIC RELATED INATION Furosemide Tablets 20mg Green Tablets 40mg Green Tablets 500mg Green Not on EMIS formulary to ensure appropriate use. High dose. Solution SF 20mg/5ml Green Solution SF 40mg/5ml Green

38 Injection 10mg/ml Green Not on EMIS formulary; anticipated use is within secondary care. Bumetanide Tablets 1mg Green Tablets 5mg Green Liquid SF 1mg/5ml Green Injection 500micrograms/ml Green Not on EMIS formulary; anticipated use is within secondary care. Torasemide Initiated by heart failure team Tablets 5mg GREEN PLUS Tablets 10mg GREEN PLUS

39 2.2.3 POTASSIUM-SPARING DIURETICS SPECIFIC RELATED INATION Amiloride Tablets 5mg Green Solution SF 5mg/5ml Green Aldosterone antagonists SPECIFIC RELATED INATION Eplerenone Tablets 25mg GREEN PLUS Tablets 50mg GREEN PLUS Spironolactone Tablets 25mg Green Tablets 50mg Green Not on QEH formulary; included to allow cost effective choice of strength. Tablets 100mg Green Suspension 50mg/5ml Green Not on EMIS formulary Unlicensed POTASSIUM-SPARING DIURETICS WITH OTHER DIURETICS SPECIFIC RELATED INATION

40 Spironolactone & Chlorothiazide Unlicensed Included on formulary for use by paediatric cardiology Manufactured to have 1:10 ratio of spironolactone to chlorothiazide Capsules 1mg / 10mg Amber Not on EMIS formulary to ensure appropriate use Not on QEH formulary; included as on NoT formulary for this indication Capsules 2mg /20mg Amber Not on QEH formulary; included as on NoT formulary for this indication Not on EMIS formulary to ensure appropriate use Capsules 3mg /30mg Amber Not on QEH formulary; included as on NoT formulary for this indication Not on EMIS formulary to ensure appropriate use Capsules 5mg /50mg Amber Not on QEH formulary; included as on NoT formulary for this indication Not on EMIS formulary to ensure appropriate use Capsules 10mg /100mg Amber Not on QEH formulary; included as on NoT formulary for this indication Not on EMIS formulary to ensure appropriate use OSMOTIC DIURETICS SPECIFIC RELATED INATION Mannitol IV Infusion 10% RED

41 IV infusion 20% RED 2.3 ANTI-ARRHYTHMIC S S FOR ARRHYTHMIAS SUPRAVENTRICULAR ARRHYTHMIAS SPECIFIC RELATED INATION Dronedarone Prescribed in accordance with NICE TA197 Tablets 400mg Amber Not on QEH formulary; included as on NoT formulary Adenosine Injection 3mg/ml RED IV Infusion 30mg/10ml RED SUPRAVENTRICULAR AND VENTRICULAR ARRHYTHMIAS SPECIFIC RELATED INATION Amiodarone Care not to continue loading doses. May need sunscreen Rx also Tablets 100mg GREEN PLUS Tablets 200mg GREEN PLUS Injection 150mg/3ml AMBER Not on EMIS formulary as anticipated use is within secondary care Syringe 300mg/10ml AMBER Not on EMIS formulary as anticipated use is within secondary care Atenolol Tablets 25mg Green

42 Tablets 50mg Green Tablets 100mg Green Syrup SF 25mg/5ml Green Injection 5mg/10ml Green Not on EMIS formulary; anticipated use is within secondary care. Disopyramide Capsules 100mg Green Capsules 150mg Green Not on QEH formulary; included to allow cost effective choice of strength. Injection 50mg/5ml Green Not on EMIS formulary; anticipated use is within secondary care. Flecainide Tablets 50mg Green Tablets 100mg Green Injection 150mg/15ml Green Not on EMIS formulary; anticipated use is within secondary care. Propafenone Tablets 150mg Green Sotalol Tablets 40mg Green Tablets 80mg Green Tablets 160mg Green

43 Ventricular arrhythmias SPECIFIC RELATED INATION Lidocaine Infusion 0.2% Green Not on EMIS formulary; anticipated use is within secondary care. Injection 1% Green On EMIS formulary but not for this indication No primary care use for this indication Mexiletine Capsules 50mg Green Not on EMIS formulary Unlicensed 2.4 BETA-ADRENOCEPTOR BLOCKING S SPECIFIC RELATED INATION Atenolol First-line except stable chronic heart failure Tablets 25mg Green Tablets 50mg Green Tablets 100mg Green Syrup SF 25mg/5ml Green Injection 5mg/10ml Green Not on EMIS formulary; anticipated use is within secondary care. Bisoprolol First-line for stable chronic heart failure Tablets 1.25mg Green Tablets 2.5mg Green

44 Tablets 3.75mg Green Tablets 5mg Green Tablets 7.5mg Green Not on QEH formulary; included to allow cost effective choice of strength. Tablets 10mg Green Esmolol Injection 100mg/10ml RED Carvedilol LVSD only (second-line to bisoprolol) Tablets 3.125mg Green Not on QEH formulary; included as on NoT formulary Tablets 6.25mg Green Not on QEH formulary; included as on NoT formulary Tablets 12.5mg Green Not on QEH formulary; included as on NoT formulary Tablets 25mg Green Not on QEH formulary; included as on NoT formulary Labetalol Tablets 50mg Green Tablets 100mg Green Tablets 200mg Green Not on QEH formulary; included to allow cost effective choice of strength. Tablets 400mg Green Not on QEH formulary; included to allow cost effective choice of strength. Injection 5mg/ml Green Not on EMIS formulary; anticipated use is within secondary care. Metoprolol Tablets 50mg Green Tablets 100mg Green

45 Injection 5mg/5ml Green Not on EMIS formulary; anticipated use is within secondary care. Suspension 25mg/5ml Green Not on EMIS formulary Unlicensed Nebivolol LVSD only (second-line to bisoprolol) Tablets 5mg GREEN PLUS Propranolol Tablets 10mg Green Tablets 40mg Green Tablets 80mg Green Not on QEH formulary; included to allow cost effective choice of strength. MR Capsules 80mg Green MR Capsules 160mg Green Solution SF 10mg/5ml Green Solution SF 40mg/5ml Green Not on QEH formulary; included to allow cost effective choice of strength. Sotalol Tablets 40mg Green Tablets 80mg Green Tablets 160mg Green 2.5 S AFFECTING THE RENIN-ANGIOTENSIN SYSTEM AND OTHER ANTIHYPERTENSIVE S VASODILATOR ANTIHYPERTENSIVE S

46 SPECIFIC RELATED INATION Ambrisentan Tablets 5mg RED Not on QEH formulary; listed as included within local ToPR document. Funded by NHS England. Tablets 10mg RED Not on QEH formulary; listed as included within local ToPR document. Funded by NHS England. Bosentan Tablets 62.5mg RED Not on QEH formulary; listed as included within local ToPR document Funded by NHS England Tablets 125mg RED Not on QEH formulary; listed as included within local ToPR document Funded by NHS England Hydralazine Tablets 25mg Green Tablets 50mg Green Not on QEH formulary; included to allow cost effective choice of strength. Injection 20mg Green Not on EMIS formulary; anticipated use is within secondary care. Minoxidil Tablets 2.5mg Green Not on QEH formulary; included to allow cost effective choice of strength. Tablets 5mg Green Tablets 10mg Green Not on QEH formulary; included to allow cost effective choice of strength. Macitentan Pulmonary Hypertension RED Funded by NHS England

47 Sildenafil Pulmonary hypertension and secondary Raynaud's disease Tablets 20mg RED Not on QEH formulary; listed as included within local ToPR document CENTRALLY ACTING ANTIHYPERTENSIVE S SPECIFIC RELATED INATION Methyldopa Tablets 125mg Green Tablets 250mg Green Tablets 500mg Green Moxonidine Tablets 200micrograms Green Tablets 300micrograms Green Tablets 400micrograms Green Clonidine Tablets 100micrograms Green Not on EMIS formulary; identified locally as less suitable for prescribing ALPHA-ADRENOCEPTOR BLOCKING S SPECIFIC RELATED INATION Doxazosin 1st line Tablets 1mg Green Tablets 2mg Green

48 Tablets 4mg Green MR Tablets 4mg Green Not on EMIS formulary; an alternative formulation is more cost effective for use in primary care MR Tablets 8mg Green Not on EMIS formulary; an alternative formulation is more cost effective for use in primary care Prazosin Tablets 1mg Green Tablets 500micrograms Green Not on QEH formulary; included to allow cost effective choice of strength. Terazosin Tablets 2mg Green Tablets 5mg Green Tablets 10mg Green Not on QEH formulary in this section; included to allow cost effective choice of strength S AFFECTING THE RENIN-ANGIOTENSIN SYSTEM ANGIOTENSIN-CONVERTING ENZYME INHIBITORS SPECIFIC RELATED INATION Captopril Tablets 12.5mg Green Not on EMIS formulary to ensure appropriate use. Alternate products are preferred. Tablets 25mg Green Not on EMIS formulary to ensure appropriate use. Alternate products are preferred.

49 Solution SF 1mg/1ml Green On EMIS formulary to ensure selection of licensed product. Enalapril Tablets 2.5mg Green Tablets 5mg Green Tablets 10mg Green Tablets 20mg Green Not on QEH formulary; included to allow cost effective choice of strength. Lisinopril Tablets 2.5mg Green Tablets 5mg Green Tablets 10mg Green Tablets 20mg Green Perindopril Tablets 2mg Green Tablets 4mg Green Tablets 8mg Green Not on QEH formulary; included to allow cost effective choice of strength. Ramipril Capsules 1.25mg Green Capsules 2.5mg Green Capsules 5mg Green Capsules 10mg Green Solution 2.5mg/5ml Green Not on EMIS formulary to ensure appropriate use. Restricted to patients with swallowing difficulties/enteral tubes.

50 ANGIOTENSIN-II RECEPTOR ANTAGONISTS Angiotensin-II receptor antagonists should be reserved for patients who develop a persistent cough with ACE inhibitors. SPECIFIC RELATED INATION Candesartan First-line if used for heart failure Tablets 2mg Green Tablets 4mg Green Tablets 8mg Green Tablets 16mg Green Tablets 32mg Green Irbesartan Tablets 75mg Green Tablets 150mg Green Tablets 300mg Green Not on QEH formulary; included to allow cost effective choice of strength. Losartan First-line if used for hypertension Tablets 12.5mg Green Not on QEH formulary; included to allow cost effective choice of strength. Tablets 25mg Green Tablets 50mg Green Tablets 100mg Green Not on QEH formulary; included to allow cost effective choice of strength. Suspension SF 2.5mg/ml Green Not on QEH formulary; included to allow cost effective choice of preparation.

51 Valsartan For Post-MI LVSD. Capsules 40mg Green Not on EMIS formulary to ensure appropriate use for specified indication. Capsules 80mg Green Not on EMIS formulary to ensure appropriate use for specified indication. Capsules 160mg Green Not on EMIS formulary to ensure appropriate use for specified indication. OTHER SPECIFIC RELATED INATION Phenoxybenzamine Capsules 10mg Green Phentolamine Injection 10mg/ml Green Not on EMIS formulary; anticipated use is within secondary care. Guanethidine Unlicensed Injection 10mg/ml Green Not on EMIS formulary; anticipated use is within secondary care. Iloprost Pulmonary hypertension Nebules 10micrograms/ml RED Funded by NHS England 2.6 NITRATES, CALCIUM-CHANNEL BLOCKERS, AND POTASSIUM-CHANNEL ACTIVATORS NITRATES

52 SPECIFIC RELATED INATION Glyceryl Trinitrate Aerosol Spray 400micrograms Green Pump Spray 400micrograms Green Patches 5mg Green Patches 10mg Green Injection 5mg/5ml Green Not on EMIS formulary; anticipated use is within secondary care. Isosorbide mononitrate BD dosing 6-8 hrs apart, AVOID M/R preparations Tablets 10mg Green Tablets 20mg Green Tablets 40mg Green Not on QEH formulary; included to allow cost effective choice of strength. Isosorbide dinitrate Tablets 10mg Green Not on EMIS formulary to avoid accidental/routine use Tablets 20mg Green Not on EMIS formulary to avoid accidental/routine use Injection 1mg/ml RED Not on EMIS formulary; anticipated use is within secondary care CALCIUM-CHANNEL BLOCKERS

53 SPECIFIC RELATED INATION Amlodipine 1st line Tablets 5mg Green Tablets 10mg Green Diltiazem Maintain patients on same brand. Rx by brand name (except 60mg tablets) Tablets 60mg Green Designated as MR, however duration of action corresponds to TDS dosing. Care with M/R preps. OD are normally XL or LA, BD are normally SR MR Capsules 120mg Green On EMIS formulary as preferred brand of Viazem MR Capsules 180mg Green On EMIS formulary as preferred brand of Viazem MR Capsules 200mg Green On EMIS formulary as Tildiem LA MR Capsules 240mg Green On EMIS formulary as preferred brand of Viazem MR Capsules 300mg Green On EMIS formulary as preferred brand of Viazem MR Capsules 360mg Green On EMIS formulary as preferred brand of Viazem Lercanidipine 2nd line Tablets 10mg Green Tablets 20mg Green Not on QEH formulary; included to allow cost effective choice of strength. Nicardipine For aortic dissection and preeclampsia Injection 10mg/1ml RED Nifedipine Patients should be maintained on the same brand of MR preparations. Rx these as brand name. Capsules 5mg Green Capsules 10mg Green MR Tablets 10mg Green Adalat Retard (BD)

54 Not on EMIS formulary; an alternative formulation is more cost effective for use in primary care. If requested by secondary care, maintain the patient on this product. MR Tablets 20mg Green Adalat Retard (BD) Not on EMIS formulary; an alternative formulation is more cost effective for use in primary care. If requested by secondary care, maintain the patient on this product. LA Tablets 40mg Green On EMIS formulary as Fortipine (OD) Not on QEH formulary; included to allow cost effective choice of strength. LA Tablets 20mg Green On EMIS formulary as Adalat LA (OD) Not on QEH formulary; included as on NoT formulary MR Capsules 10mg Green On EMIS formulary as Coracten SR (BD). Preferred product MR Capsules 20mg Green On EMIS formulary as Coracten SR (BD). Preferred product MR Capsules 30mg Green On EMIS formulary as Coracten XL (OD). Preferred product MR Capsules 60mg Green On EMIS formulary as Coracten XL (OD). Preferred product. Nimodipine Tablet 30mg Green Not on EMIS formulary to ensure appropriate use within licensed indication.

55 Injection 10mg/50ml Green Not on EMIS formulary; anticipated use is within secondary care. Verapamil Avoid with beta-blockers Tablets 40mg Green Tablets 80mg Green Tablets 120mg Green Solution SF 40mg/5ml Green Injection 2.5mg/ml Green Not on EMIS formulary; anticipated use is within secondary care. MR Capsules 120mg Green MR Capsules 180mg Green Not on QEH formulary; included to allow cost effective choice of strength. MR Capsules 240mg Green Not on QEH formulary; included to allow cost effective choice of strength OTHER ANTI-ANGINAL S SPECIFIC RELATED INATION Nicorandil Tablets 10mg Green Tablets 20mg Green Ivabradine Prescribed in accordance with NICE TA267 Tablets 5mg Green Tablets 7.5mg Green

56 Ranolazine Tablets 375mg GREEN PLUS Tablets 500mg GREEN PLUS

57 2.6.4 PERIPHERAL VASODILATORS AND RELATED S SPECIFIC RELATED INATION Naftidrofuryl Prescribed in accordance with NICE TA223 Capsules 100mg GREEN PLUS Pentoxyfilline Tablets 400mg GREEN PLUS Not on EMIS formulary; identified locally as less suitable for prescribing 2.7 SYMPATHOMIMETICS INOTROPIC SYMPATHOMIMETICS SPECIFIC RELATED INATION Dobutamine Injection 250mg/20ml RED Dopamine Injection 200mg/5ml RED Dopexamine Injection 50mg/5ml RED Isoprenaline Unlicensed Injection 2.25mg/2ml RED Levosimendan Unlicensed Infusion 12.5mg/5ml RED Not on QEH formulary; listed as included within local ToPR document VASOCONSTRICTOR SYMPATHOMIMETICS

58 SPECIFIC RELATED INATION Ephedrine Injection 30mg/ml Green Not on EMIS formulary; anticipated use is within secondary care. Metaraminol Unlicensed Injection 10mg/ml RED Noradrenaline/Norepinephrine Injection 2mg/ml (salt) Green Not on EMIS formulary; anticipated use is within secondary care. Phenylephrine ITU only Injection 10mg/ml Green Not on EMIS formulary; anticipated use is within secondary care CARDIOPULMONARY RESUSCITATION SPECIFIC RELATED INATION Adrenaline / epinephrine NB: See section 3 for patient held products for anaphylaxis Injection 1:1000 Green Not on EMIS formulary; anticipated use is within secondary care. 2.8 ANTICOAGULANTS AND PROTAMINE PARENTERAL ANTICOAGULANTS

59 SPECIFIC RELATED INATION Fondaparinux Haematology advice only Injection 5mg/ml Green Not on EMIS formulary to ensure appropriate use within licensed indication Danaparoid sodium Haematology advice only Injection 750units/0.6ml Green Not on EMIS formulary to ensure appropriate use within licensed indication Bivalirudin Prescribed in accordance with NICE TA230 Vial 250mg RED Heparin Injection 1000units/ml Green Not on EMIS formulary; anticipated use is within secondary care. Heparin Calcium Injection 5000units/0.2ml Green Not on EMIS formulary; anticipated use is within secondary care. Enoxaparin Syringe 100mg/1ml GREEN PLUS Syringe 60mg/0.6ml GREEN PLUS Syringe 80mg/0.8ml GREEN PLUS Syringe 120mg/0.8ml GREEN PLUS Not on QEH formulary; included to allow cost effective choice of strength. Syringe 150mg/1ml GREEN PLUS Syringe 20mg/0.2ml GREEN PLUS Syringe 40mg/0.4ml GREEN PLUS TInzaparin Syringe 10000units/0.5ml GREEN PLUS Syringe 14000units/0.7ml GREEN PLUS

60 Syringe 18000units/0.9ml GREEN PLUS Syringe 3500units/0.35ml GREEN PLUS Syringe 4500units/0.45ml GREEN PLUS Syringe 2500units/0.25ml GREEN PLUS Vial 20000units/2ml GREEN PLUS Not on EMIS formulary to avoid accidental selection Vial 40000units/2ml GREEN PLUS Not on EMIS formulary to avoid accidental selection Epoprostenol Pulmonary hypertension Vial 500micrograms RED Funded by NHS England

61 2.8.2 ORAL ANTICOAGULANTS SPECIFIC RELATED INATION Apixaban Tablets 2.5mg GREEN When prescribed in accordance with NICE TA275 & TA341 RED When prescribed in accordance with NICE TA245 Tablets 5mg GREEN When prescribed in accordance with NICE TA275 & TA341 RED When prescribed in accordance with NICE TA245 Dabigatran Ensure patient has received GMMC patient info letter Capsules 75mg RED When prescribed in accordance with NICE TA157 Capsules 110mg GREEN Prescribed in accordance with NICE TA249 and TA327 RED when prescribed in accordance with NICE TA157 Capsules 150mg GREEN Prescribed in accordance with NICE TA249 and NICE TA327 RED when prescribed in accordance with NICE TA157 Edoxaban Prescribed in accordance with NICE TA354 & TA355 Tablets 15mg Green Tablets 30mg Green Tablets 60mg Green Phenindione Tablets 10mg Green