Medicines Formulary Revised March 2014

Transcription

1 Medicines Formulary Revised March 2014

2 Disclaimer Whilst every effort has been made to ensure that the information contained within this formulary is accurate, no responsibility or liability can be accepted by those involved in its production for any loss, injury or damage which is suffered as a consequence of any errors, omissions or inaccuracies contained within it. In particular, prescribers should always check the suitability of the drug and dosage in the BNF or the SPC provided by the manufacturer. 2

3 CONTENTS Introduction 6 1. Gastro-intestinal system Dyspesia and gastro-oesophageal reflux disease Antispasmodics and other drugs affecting gut motility Antisecretory drugs and mucosal protectants Acute diarrhoea Chronic bowel disorders Laxatives Local preparations for anal and rectal disorders Stoma care Drugs affecting intestinal secretions Cardiovascular system Positive inotropic drugs Diuretics Anti-arrhythmic drugs Beta-adrenoceptor blocking drugs Hypertension and heart failure Nitrates, calcium-channel blockers andother antianginal drugs Sympathomimetics Anticoagulants and protamine Antiplatelet drugs Myocardial infarction and fibrinolysis Antifibrinolytic drugs and haemostatics Lipid-regulating drugs Local sclerosants Respiratory system Bronchodilators Corticosteroids Cromoglicate and related therapy and leukotriene receptor antagonists Antihistamines, hyposensitisation and allergic emergencies Respiratory stimulants and pulmonary surfactants Oxygen see BNF 3.7 Mucolytics Aromatic inhalations Cough preparations Systemic nasal decogestants Central nervous system Hypnotics and anxiolytics Drugs used in psychoses and related disorders Antidepressant drugs CNS stimulants and drugs used for attention deficit hyperactivity disorder Drugs used in the treatment of obesity Drugs used in nausea and vertigo Analgesics Antiepileptics Drugs used in parkinsonism and related disorders Drugs used in substance dependence Drugs for dementia 48 3

4 5. Infections Antibacterial drugs Antifungal drugs Antiviral drugs Antiprotozoal drugs Anthelmintics Endocrine system Drugs used in diabetes Thyroid and antithyroid drugs Corticosteroids Sex hormones Hypothalamic and pituitary hormones and anti-oestrogens Drugs affecting bone metabolism Other endocrine drugs Obstetrics, gynaecology and urinary-tract disorders Drugs used in obstetrics Treatment of vaginal and vulval conditions Contraceptives Drugs for genito-urinary disorders Malignant disease and immunosuppression Cytotoxic drugs Drugs affecting the immune response Sex hormones and hormone antagonists in malignant disease Nutrition and blood Anaemias and some other blood disorders Fluids and electrolytes Intravenous nutrition Oral nutrition Minerals Vitamins Bitters and tonics no preparations included 9.8 Metabolic disorders Musculoskeletal and joint diseases Drugs used in rheumatic diseases and gout Drugs used in neuromuscular disorders Drugs for the relief of soft-tissue inflammation Eye Administration of drugs to the eye see BNF 11.2 Control of microbial contamination see BNF 11.3 Anti-infective eye preparations Corticosteroids and other anti-inflammatory preparations Mydriatics and cycloplegics Treatment of glaucoma Local anaesthetics Miscellaneous ophthalmic preparations Contact lenses see BNF 4

5 12. Ear, nose and oropharynx Drugs acting on the ear Drugs acting on the nose Drugs acting on the oropharynx Skin Management of skin conditions see BNF 13.2 Emollient and barrier preparations Topical local anaesthetics and antipruritics Topical corticosteroids Preparations for eczema and psoriasis Acne and rosacea Preparations for warts and calluses Sunscreens and camouflages Shampoos and other preparations for scalp and hair conditions Anti-infective skin preparations Skin cleansers and antiseptics Antiperspirants no preparations included Topical circulatory preparations no preparations included 14. Immunological products and vaccines Active immunity see BNF 14.2 Passive immunity see BNF 14.3 Storage and use see BNF 14.4 Vaccines and antisera Immunoglobulins International travel see BNF 15. Anaesthesia General anaesthesia Local anaesthesia Treatment of poisoning 120 5

6 INTRODUCTION University Hospitals of Morecambe Bay NHS Foundation Trust The aim of the formulary The main aim of this formulary is to promote safe, evidence-based, cost-effective prescribing. Limiting the range of medicines included in the formulary and promoting the use of generic medicines where appropriate:- Enhances safety through familiarity with the medicines in use in the hospital by all staff involved in the prescribing, dispensing and administration of medicines Ensures efficient use of NHS resources Ensures efficient use of limited storage space both within the hospital pharmacies and on the wards, enhances good stock control and reduces the pharmacy stock holding Development of the formulary The formulary has been drawn up following full and wide consultation with consultant medical staff, senior pharmacists and other interested parties and has been approved by the joint UHMB NHS Trust, Cumbria PCT & North Lancs PCT Drugs and Therapeutics Group. The most up to date version will be accessible and maintained in an electronic format on the UHMB intranet. Updates are made bi-monthly following the joint Drug and Therapeutics Group meetings. How should the formulary be used? Formulary drugs, including the range of approved preparations for each drug, are listed according to the BNF classification system. Unlicensed drugs and preparations approved for use in the hospital are included in the most relevant section. First, second, and occasionally third line drugs are indicated where appropriate. First line drugs should be used unless there is a contraindication; the patient has suffered an adverse effect, or has not responded to the first line drug. The formulary is not intended to replace the BNF which will need to be referred to for information on licensed indications, contraindications, cautions, side-effects, interactions and dosage etc. (also available online at ). Does the formulary apply to out-patient prescribing including referrals to GPs? In general yes, as it is our aim to promote safe, evidence-based, cost effective prescribing in primary care also. However there are some medicines that are not stocked by the hospital pharmacies and hence are not included in the formulary simply because we would not expect them to be initiated whilst patients are in hospital or in out-patients e.g. topical preparations for acne, drugs for smoking cessation, HRT (only a very limited range of NRT & HRT is stocked). Non-formulary drugs There are two distinct situations that may lead to the request for a non-formulary drug:- i) Patient admitted on non-formulary drug prescribed by their GP/tertiary centre Where appropriate the pharmacist will advise that the drug be changed to one that is on formulary. He/she will advise the prescriber on choice of drug/dose. The prescriber should ascertain that the patient has not previously had an adverse reaction to the recommended therapy or found the recommended therapy to be ineffective. If it is deemed inadvisable to switch therapy, the pharmacy will ask the ward to use the patient s own supply. If the patient does not have any of their own or runs out the pharmacy will obtain a small supply specifically for that patient. 6

7 ii) Initiation of non-formulary drug If appropriate; a pharmacist will suggest the use of an alternative formulary drug. If there is no suitable drug on formulary, urgent clinical need and appropriateness can be demonstrated and the cost is minimal, a senior pharmacist may authorise the purchase of a small supply specifically for that patient. If there are significant cost implications the consultant will be asked to seek permission to obtain the drug from the Clinical Director. The Consultant will also be asked to complete a New Product Request form for a D&T Group decision should the drug be required again in the future. If there is not an urgent need for the drug the Consultant will be asked to complete a New Product Request form and the drug will not be purchased until D&T Group approval is received. This applies equally to new drugs, new formulations of formulary drugs and new uses for formulary drugs. New Product Request forms are available from the pharmacy area on the intranet. (UMBHT Formulary Application Form) What do the traffic lights mean? Many of the drugs listed will only ever be used in hospital; likewise many other drugs are suitable for prescribing in both primary and secondary care and by any grade of doctor or a non-medical prescriber. Where there is unlikely to be any doubt about a drug s status no traffic light has been assigned to it. Some drugs however have been assigned as either RED or AMBER RED or AMBER drugs should not normally be initiated by FY or ST doctors. Exceptions are indicated in the formulary. Non-medical prescribers should initiate these drugs only if they fall within their area of expertise. Classification RED Explanation Red medicines should be initiated by a specialist (consultant or SpR) only and prescribing retained within secondary care. GPs should not normally be asked to prescribe these drugs. Drugs that are considered suitable for initiation/prescribing by consultants only are annotated as such. AMBER Amber medicines are considered suitable for GP prescribing following specialist initiation or recommendation. AMBER (SCG) with shared care guideline Medicines in this category are identified by the superscript (SCG). These drugs require the GP to be provided with additional information about managing the patient including dose adjustment, side-effects, significant drug interactions and blood monitoring if required. The SCG also includes what actions to take in the event of abnormal blood results, when to refer back to secondary care and who to contact. GPs should be sent a copy of the SCG by the specialist when making the referral. Copies are available via the Heritage Library For any enquiries regarding the Formulary, please contact:- Pauline Bourne Professional Secretary to the Drug and Therapeutic Group Tel: (01524) pauline.bourne@mbht.nhs.uk 7

8 1: GASTRO-INTESTINAL SYSTEM 1.1 DYSPEPSIA AND GASTRO-OESOPHAGEAL REFLUX DISEASE Antacids and simeticone Aluminium and magnesium containing antacids A mixture of Aluminium Hydroxide and Magnesium Hydroxide balances the tendency of aluminium to constipate against that of magnesium to cause diarrhoea. Maalox liquid Antacid preparations containing simeticone Asilone liquid Antacid preparations containing local anaesthetic Antacid with oxetacaine liquid (Unlicensed) Compound alginates and proprietary indigestion preparations Gaviscon Advance liquid Gaviscon Infant sachets 1.2 ANTISPASMODICS AND OTHER DRUGS ALTERING GUT MOTILITY Antispasmodics may be useful in irritable bowel syndrome and diverticular disease but their value has not been established. Reassurance, advice on diet, fluid intake, bulking agents, exercise and lifestyle are all important. Antimuscarinics Antimuscarinics relax the oesophageal sphincter and should be avoided in patients with symptoms of reflux. Dicycloverine (Dicyclomine) tablets 10mg liquid10mg/5ml Hyoscine Butylbromide tablets 10mg injection 20mg/1mL Other antispasmodics First line Mebeverine tablets 135mg 8

9 Alternatives Alverine capsules 60mg Peppermint Oil e/c capsules 0.2mL Peppermint oil can cause irritation to the mouth and/or the oesophagus and may cause symptoms of heartburn. Motility stimulants Domperidone and metoclopramide stimulate gastric emptying and small intestinal transit, and enhance the strength of oesophageal sphincter contraction First line Metoclopramide tablets 10mg liquid 5mg/5mL injection 10mg/2mL Metoclopramide may induce acute dystonic reactions and should be avoided in patients under 20 years see BNF section 4.6 Second line Domperidone tablets 10mg liquid 5mg/5mL suppositories 30mg 1.3 ANTISECRETORY DRUGS AND MUCOSAL PROTECTANTS Helicobacter pylori eradication First line 7 day course of Omeprazole Capsules 20mg bd Amoxicillin Capsules 1g bd Clarithromycin Tablets 500mg bd For patients allergic to penicillin 7-day course of Omeprazole Capsules 20mg bd Metronidazole Tablets 400mg bd Clarithromycin Tablets 250mg bd Patient education is vital to maximise the likelihood of success. Prescribers and pharmacists should ensure that patients are counselled appropriately. 9

10 1.3.1 H2-receptor antagonists First line Ranitidine tablets 150mg dispersible tablets 150mg injection 50mg/2mL Paediatric use only Ranitidine liquid 75mg/5mL Cimetidine tablets 400mg also stocked for patients admitted on it and provided there are no contraindications to its use Chelates and complexes Sucralfate tablets 1g liquid 1g/5mL Proton pump inhibitors First line Omeprazole capsules 10mg, 20mg intravenous infusion 40mg 20mg once daily is the standard treatment dose for most indications. 40mg daily should be prescribed only if disease is refractory to standard treatment or on consultant advice. intravenous omeprazole should be prescribed only for patients who require a PPI where the oral route is unavailable. Second line Lansoprazole capsules 15mg, 30mg orodispersible tablets 15mg, 30mg (FasTab ) Lansoprazole FasTabs are for paediatric use and adults with swallowing difficulties only Esomeprazole injection 40mg For prevention of rebleeding following therapeutic endoscopy for acute bleeding gastric or duodenal ulcers on the advice of an endoscopist. Paediatric use only Omeprazole (Losec MUPS ) dispersible tablets 10mg 10

11 1.4 ACUTE DIARRHOEA The priority in acute diarrhoea is the prevention or reversal of fluid and electrolyte depletion. Oral rehydration salts Antimotility drugs First line Loperamide tablets 2mg liquid 1mg/5mL Second line Codeine Phosphate tablets 15mg, 30mg liquid 15mg/5mL 1.5 CHRONIC BOWEL DISORDERS Aminosalicylates Advice re blood disorders - see BNF First line Mesalazine e/c m/r tablets 400mg, 800mg (Octasa ) m/r tablets 500mg (Pentasa ) foam enema 1g/metered application (Salofalk ) enema 2g in 59ml (Salofalk ) suppositories 250mg, 500mg, 1g (Asacol ) Specify brand when prescribing as the delivery characteristics of enteric-coated preparations vary and therefore should not be considered interchangeable Second line Balsalazide AMBER (Consultant gastroenterologist/surgeon initiation only) capsules 750mg Olsalazine AMBER (Consultant gastroenterologist/surgeon initiation only) capsules 250mg tablets 500mg Sulfasalazine AMBER tablets 500mg e/c tablets 500mg liquid 250mg/5mL 11

12 1.5.2 Corticosteroids CSM warning: ensure patients receive PIL, and Steroid Card if treatment >3weeks Prednisolone tablets 5mg e/c tablets 2.5mg, 5mg foam 20mg/metered application (Predfoam ) retention enema 20mg/100mL (Predsol ) suppositories 5mg When prescribing oral prednisolone for patients with acute colitis uncoated tablets should be specified. Beclometasone Dipropionate m/r tablets 5mg Budesonide AMBER (Consultant gastroenterologist/surgeon initiation only) e/c m/r capsules 3mg Drugs affecting the immune response Cytokine modulators Consultant gastroenterologist initiation only Only to be prescribed in accordance with NICE guidance NICE Guidance TA140 Ulcerative colitis (subacute manifestations) - infliximab TA163 Ulcerative colitis (acute exacerbations) - infliximab TA187 Crohn's disease - infliximab (review) and adalimumab (review of TA40) Adalimumab RED s/c pre-filled pen or syringe 40mg Infliximab RED intravenous infusion 100mg Supplied to patients by a home delivery company Other drugs used in IBD [unlicensed indication] Azathioprine see section Mercaptopurine see section Methotrexate see section

13 1.6 LAXATIVES University Hospitals of Morecambe Bay NHS Foundation Trust Bulk forming laxatives First line Ispaghula Husk granules 3.5g Alternative Methylcellulose tablets 500mg Stimulant laxatives First line Senna tablets 7.5mg liquid 7.5mg/5mL Alternatives Bisacodyl tablets 5mg suppositories 5mg, 10mg rectal solution 2.74mg/1mL (Unlicensed Consultant initiation only) Co-danthramer (Dantron with poloxamer) liquid 25mg/200mg in 5mL, 75mg/1000mg in 5mL Co-danthrusate (Dantron with docusate) capsules 50mg/60mg liquid 50mg/60mg in 5mL Restricted to constipation in the terminally ill. Docusate capsules 100mg liquid 50mg/5mL Glycerol suppositories 1g, 2g, 4g Sodium Picosulfate liquid 5mg/5mL Faecal softeners Arachis Oil enema Osmotic laxatives First line oral route Lactulose liquid 13

14 Lactulose must be taken regularly for up to 3 days before an effect is seen making it unsuitable for rapid relief of constipation or for as required dosing Second line oral route Macrogols oral powder Movicol, Movicol Paediatric Plain Rectal route Phosphate enema Sodium Citrate micro-enema Micralax Bowel cleansing solutions Moviprep oral powder Sodium picosulfate oral powder (Picolax, Citrafleet ) Klean-Prep oral powder HT4 receptor agonists NICE Guidance TA211 Constipation (women) - prucalopride Linaclotide AMBER (Cumbria) capsules 290 micrograms Prucalopride AMBER tablets f/c 1mg, 2mg 1.7 LOCAL PREPARATIONS FOR ANAL AND RECTAL DISORDERS Soothing haemorrhoidal preparations Anusol ointment suppositories Compound haemorrhoidal preparations with corticosteroids Anusol-HC ointment Scheriproct ointment suppositories Preparations containing corticosteroids and/or local anaesthetics should be used for short periods only (no longer than a few days) Rectal sclerosants 14

15 Oily Phenol injection 5% 5mL Management of anal fissures Glyceryl Trinitrate AMBER ointment 0.4% (Rectogesic ) Diltiazem AMBER cream 2% (Anoheal - Unlicensed) 1.8 STOMA CARE For advice contact the stoma nurse. 1.9 DRUGS AFFECTING INTESTINAL SECRETIONS Drugs affecting biliary composition and flow Ursodeoxycholic Acid AMBER tablets 150mg capsules 250mg liquid 250mg/5mL Bile acid sequestrants Colestyramine powder 4g/sachet Pancreatin CSM advice: use of higher-strength preparations in children with cystic fibrosis see BNF There is great variation in patient response to these products. Fat malabsorption has the most bearing on the clinical picture. Therefore lipase content has been used as the basis for selection. Theoretically 60,000 BPU of lipase should enable a completely achylic patient to digest the fat in a normal meal; the quantity of protease and amylase that comes with this dose of lipase is more than sufficient to digest the protein and carbohydrate. Creon capsules 10,000units, 25,000units, 40,000units 15

16 2: CARDIOVASCULAR SYSTEM 2.1 POSITIVE INOTROPIC DRUGS Cardiac glycosides Digoxin tablets 62.5micrograms, 125micrograms, 250micrograms liquid 50micrograms/1mL injection 500micrograms/2mL When converting a tablet dose to: liquid reduce dose by 20% injection reduce dose by 40% Digoxin-specific antibody Digibind injection 38mg Phosphodiesterase inhibitors Enoximone injection 100mg/20mL (Consultant initiation only) 2.2 DIURETICS Thiazides and related diuretics Indapamide tablets 2.5mg first line for hypertension Bendroflumethiazide (Bendrofluazide) tablets 2.5mg Paediatric use only Chlorothiazide liquid 250mg/5mL AMBER (Unlicensed) Loop diuretics First line Furosemide (Frusemide) tablets 20mg, 40mg, 500mg liquid 40mg/5mL, 50mg/5mL injection 20mg/2mL, 50mg/5mL, 250mg/25mL Second line Bumetanide tablets 1mg, 5mg Restricted to second line use if poor response to furosemide 16

17 2.2.3 Potassium-sparing diuretics Amiloride tablets 5mg liquid 5mg/5mL Aldosterone antagonists First line (except for NYHA Class ll heart failure) Spironoloactone tablets 25mg, 100mg Paediatric use only Spironolactone liquid 25mg/5mL (Unlicensed) NYHA Class ll heart failure First line Eplerenone AMBER tablets 25mg, 50mg Drug of choice to reduce the risk of cardiovascular mortality and morbidity in adult patients with NYHA Class II (chronic) heart failure and left ventricular systolic dysfunction (LVEF 30%). Eplerenone may also be prescribed for patients who develop gynaecomastia with spironolactone. Eplerenone is the second line choice for other indications Potassium-sparing diuretics with other diuretics Co-amilofruse tablets (amiloride/furosemide) 2.5mg/20mg, 5mg/40mg Co-amilozide tablets (amiloride/hydrochlorothiazide) 2.5mg/25mg, 5mg/50mg Osmotic diuretics Mannitol intravenous infusion 10%, 20% 2.3 ANTI-ARRHYTHMIC DRUGS Drugs for arrhythmias Supraventricular arrhythmias Adenosine injection 6mg/2mL Verapamil see section Digoxin see section Supraventricular and ventricular arrhythmias 17

18 NICE Guidance TA197 Atrial fibrillation - dronedarone Amiodarone tablets 100mg, 200mg injection 150mg/3mL injection 300mg in 10mL prefilled syringe Disopyramide AMBER (Consultant initiation only) capsules 100mg m/r tablets 250mg injection 50mg/5mL Dronedarone AMBER (RED in Lancs) tablets 400mg Flecainide tablets 50mg, 100mg injection 150mg/15mL Propafenone AMBER (Consultant initiation only) tablets 150mg Ventricular arrhythmias Lidocaine (Lignocaine) injection 2% (20mg/mL) 100mg in 5mL prefilled syringe infusion 0.4% (4mg/mL) in 5% glucose, 500mL 2.4 BETA-ADRENOCEPTOR BLOCKING DRUGS CSM advice: Beta-blockers should not be given to patients with a history of asthma see BNF Angina, arrhythmias, hypertension and following myocardial infarction First line Atenolol tablets 25mg, 50mg, 100mg liquid 25mg/5mL injection 5mg/10mL Second line Metoprolol tablets 50mg injection 5mg/5mL Use when a beta-blocker with a short half-life (3-4hours) is required. Arrhythmias Esmolol injection 100mg/10mL Propranolol injection 1mg/1mL Sotalol (CSM advice: Restricted use see BNF) tablets 40mg, 80mg 18

19 Heart failure University Hospitals of Morecambe Bay NHS Foundation Trust First line Bisoprolol tablets 1.25mg, 2.5mg, 3.75mg, 5mg, 7.5mg, 10mg Second line Carvedilol tablets 3.125mg, 6.25mg, 12.5mg, 25mg Restricted to second line use when the vasodilating action of carvedilol may be useful. Hypertension in pregnancy and hypertensive crisis Labetalol tablets 100mg, 200mg injection 100mg/20mL Non-cardiac use (relief of thyrotoxic symptoms, anxiety, migraine prophylaxis) Propranolol tablets 10mg, 40mg, 80mg m/r capsules 80mg, 160mg injection 1mg/1mL Paediatric use only Propranolol liquid 10mg/5mL 2.5 HYPERTENSION AND HEART FAILURE Vasodilator antihypertensive drugs Hydralazine tablets 25mg injection 20mg/2mL Centrally-acting antihypertensive drugs Clonidine injection 150micrograms/1mL Methyldopa tablets 125mg, 250mg Moxonidine tablets 200micrograms, 300micrograms, 400micrograms 19

20 2.5.4 Alpha-adrenoceptor blocking drugs Doxazosin tablets 1mg, 2mg, 4mg Doxazosin m/r tablets are not recommended. All prescriptions for doxazosin m/r will be changed to standard release tablets. Phaeochromocytoma Phenoxybenzamine AMBER capsules 10mg Phentolamine injection 10mg/1mL Drugs affecting the rennin-angiotensin system Angiotensin-converting enzyme inhibitors Lisinopril tablets 2.5mg, 5mg, 10mg, 20mg Ramipril capsules 1.25mg, 2.5mg, 5mg, 10mg Enalapril tablets 2.5mg, 5mg, 10mg also stocked for patients admitted on it, patients should not be initiated on enalapril in hospital. Paediatric use only Captopril liquid (Various strengths available on request) (Unlicensed) Angiotensin-II receptor antagonists Use only if cough is troublesome on ACE inhibitors First line for hypertension Losartan tablets 25mg, 50mg First line for heart failure Candesartan tablets 2mg, 4mg, 8mg, 16mg, 32mg Valsartan capsules 40mg, 80mg also stocked for patients admitted on this. Patients should not be initiated on valsartan in hospital. 20

21 2.6 NITRATES, CALCIUM-CHANNEL BLOCKERS, AND OTHER ANTIANGINAL DRUGS Nitrates Glyceryl Trinitrate aerosol spray 400 micrograms/dose tablets 500micrograms patches 5mg/24hr, 10mg/24hr injection 50mg/50mL Patches should only be considered in patients unable to comply with or tolerate oral isosorbide mononitrate Isosorbide mononitrate tablets 10mg, 20mg m/r tablets 60mg Normal release isosorbide mononitrate tablets should be prescribed asymmetrically (early morning and about 8 hours later) to avoid nitrate tolerance. Modified release preparations should be prescribed once daily and should only be considered in patients for whom compliance with a twice daily regimen is a problem Calcium-channel blockers First line dihydropyridine Amlodipine (as maleate or mesilate) tablets 5mg, 10mg Nifedipine m/r once daily tablets 20mg, 30mg, 60mg and nifedipine m/r twice daily tablets 10mg, 20mg also stocked for patients admitted on these. First line diltiazem Diltiazem (Slozem ) m/r capsules 120mg, 180mg, 240mg, 300mg (all once daily) (Adizem SR (twice daily) and XL (once daily) & Tildiem Retard (twice daily) and LA (once daily) also stocked for patients admitted on these brands) BNF states that different versions of modified release preparations may not have the same clinical effect and to avoid confusion they should be prescribed by brand name. Consultant cardiologists agree however that in-patients may be switched between brands if admitted on a brand not stocked by pharmacy and/or a dose change is needed, but that patients who are stable should, whenever possible, be maintained on the brand they are admitted on. Diltiazem m/r tablets 60mg Use only for initiation of therapy when a preparation with a shorter half-life is required, change to Slozem once it is established that the patient is tolerating therapy 21

22 Verapamil tablets 40mg, 80mg m/r tablets 120mg (Half Securon SR ), 240mg (Securon SR ) liquid 40mg/5mL injection 5mg/2mL Nimodipine tablets 30mg intravenous infusion 10mg/50mL Nimodipine is licensed only for the prevention of ischaemic neurological deficits following aneurysmal subarachnoid haemorrhage Other antianginal drugs NICE Guidance TA267 Chronic heart failure - ivabradine Nicorandil tablets 10mg, 20mg Ivabradine (UHMB INFO SHEET) AMBER (Consultant cardiologist initiation only) tablets 5mg, 7.5mg Ranolazine AMBER tablets m/r 375mg, 500mg, 750mg, Peripheral vasodilators and related drugs NICE Guidance TA223 Peripheral arterial disease - cilostazol, naftidrofyryl oxalate, pentoxifylline and inositol nicotinate Nifedipine capsules 5mg, 10mg Naftidrofuryl capsules 100mg 1st line intravenous peripheral vasodilator Iloprost (Unlicensed Consultant only) injection 50micrograms/0.5mL 2 nd line intravenous peripheral vasodilator Epoprostenol (Unlicensed use consultant only) infusion 500 microgam Nifedipine capsules are included in formulary for patients with Raynaud s syndrome (m/r tablets may also be used but are not licensed for Raynaud s). Nifedipine capsules are not recommended for the treatment of hypertension or angina. 2.7 SYMPATHOMIMETICS 22

23 2.7.1 Inotropic sympathomimetics Dobutamine injection 250mg/20mL Dopamine injection 200mg/5mL Dopexamine injection 50mg/5mL Vasoconstrictor sympathomimetics Ephedrine injection 30mg/1mL, 30mg/10mL & 3mg in 1 ml prefilled syringe Metaraminol injection 10mg/1mL Noradrenaline acid tartrate/ Norepinephrine bitartrate injection 4mg/2mL, 8mg/4mL (noradrenaline acid tartrate 2mg is equivalent to noradrenaline base 1mg) Phenylephrine injection 10mg/1mL Midodrine RED (Unlicensed Consultant initiation only) tablets 2.5mg, 5mg Cardiopulmonary resuscitation Adrenaline / Epinephrine 1 in 10,000 injection 1mg/10mL amp & 1mg in 10mL prefilled syringe Amiodarone see section 2.3 Atropine see section Calcium chloride see section ANTICOAGULANTS AND PROTAMINE Parenteral anticoagulants CSM advice: platelet and plasma potassium monitoring with heparin & LMWH see BNF Refer to UHMB guidelines for VTE prophylaxis in adult medical and surgical patients. Low molecular weight heparin for the treatment and prophylaxis of VTE Enoxaparin (SCG) AMBER injection 20mg in 0.2mL, 40mg in 0.4mL, 60mg in 0.6mL, 80mg in 0.8mL, 100mg in 1mL, 120mg in 0.8mL, 150mg in 1mL prefilled syringes Enoxaparin may be prescribed by any grade of doctor or non-medical prescriber. GPs may be asked to prescribe enoxaparin for patients requiring long-term treatment or prophylaxis of VTE, see SCG. Fondaparinux for the treatment of Acute Coronary Syndrome Fondaparinux injection 2.5mg in 0.5mL 23

24 Heparin University Hospitals of Morecambe Bay NHS Foundation Trust Heparin sodium injection 1000units/1mL, 10,000units/10mL, 20,000units/20ml flush 50units/5mL Heparinoids Danaparoid sodium injection 1250 units/ml 0.6mL amp (750 units) Restricted for use in patients who have previously experienced heparin induced thrombocytopenia Epoprostenol Epoprostenol injection 500microgram vial with diluent Oral anticoagulants NB: Follow UHMB guideline for initiation and maintenance of warfarin do not guess First line Warfarin tablets 1mg, 3mg, 5mg 1mg and 3 mg tablets only will be dispensed on out-patient prescriptions and TTOs unless 5mg tablets are specifically requested for patients on a maintenance dose of 10mg or more. Warfarin 0.5mg tablets are not stocked but are available on request for paediatric use only. Second line Acenocoumarol (Nicoumalone) tablets 1mg Restricted to second line use if patient allergic or resistant to warfarin. Newer oral anticoagulants NICE Guidance TA157 Venous thromboembolism - dabigatran TA170 Venous thromboembolism - rivaroxaban TA249 Atrial fibrillation - dabigatran etexilate TA256 Atrial fibrillation (stroke prevention) - rivaroxaban TA261 Venous thromboembolism (treatment and long term secondary prevention) - rivaroxaban TA275 Stroke and systemic embolism (prevention, non-valvular atrial fibrillation) - apixaban TA287 Pulmonary embolism and recurrent venous thromboembolism - rivaroxaban Apixaban tablets 2.5mg Rivaroxaban tablets 10mg, 15mg, 20mg Dabigatran capsules 110mg, 150mg Rivaroxaban 10mg tablets are indicated for prophylaxis of VTE in adults after hip or knee replacement surgery, and patients with lower limb plaster cast (unlicensed indication) 24

25 Rivaroxaban 15mg and 20mg tablets are indicated for prophylaxis of stroke and systemic embolism in patients with non-valvular AF and for the treatment of DVT and prophylaxis of recurrent DVT and PE. Dabigatran 110mg and 150mg capsules and apixaban 2.5mg tablets are indicated for prophylaxis of stroke and systemic embolism in patients with non-valvular AF. See Lancashire and Cumbria Cardiac and Stroke Network Guidance and consensus statement. Rivaroxaban is the preferred agent Protamine sulphate Protamine sulphate injection 50mg/5mL 2.9 ANTIPLATELET DRUGS NICE GUIDANCE TA80 Acute Coronary Syndromes - clopidogrel TA210 Vascular disease - clopidogrel and dipyridamole TA236 Acute coronary syndromes - ticagrelor Aspirin dispersible tablets 75mg, 300mg suppositories 150mg, 300mg There is no evidence to support the use of e/c aspirin 75mg to prevent gastrointestinal side-effects. All prescriptions for e/c aspirin 75mg will be changed to dispersible tablets. Clopidogrel tablets 75mg, Dipyridamole tablets 25mg, 100mg m/r capsules 200mg Standard release tablets or dipyridamole liquid should not be prescribed or dispensed in place of m/r capsules for patients with swallowing difficulties for the secondary prevention of transient ischaemic attacks. Contact pharmacy for advice (Asasantin Retard (aspirin/dipyridamole 25mg/200mg) is not stocked prescribe aspirin 75mg od and dipyridamole m/r 200mg bd separately). Ticagrelor AMBER f/c tablets 90mg Restricted use. Initiation by tertiary cardiac centres only 2.10 MYOCARDIAL INFARCTION AND FIBRINOLYSIS NICE GUIDANCE TA52 Myocardial infarction - thrombolysis TA264 Stroke (acute, ischaemic) - alteplase 25

26 Fibrinolytic drugs For the treatment of acute ST elevation myocardial infarction Tenecteplase injection 40mg (8000unit) vial, 50mg (10000unit) vial both with pre-filled syringe of water for injection For the treatment of acute stroke, acute massive pulmonary embolism and peripheral arterial occlusive disease [unlicensed indication] Alteplase (Consultant only) injection 50mg vial with diluent (Actilyse ) injection 2mg vial with diluent (Actilyse Cathflo ) 2.11 ANTIFIBRINOLYTIC DRUGS AND HAEMOSTATICS Etamsylate tablets 500mg Tranexamic Acid tablets 500mg injection 500mg/5mL Blood products Other blood products - contact pathology LIPID-REGULATING DRUGS Refer to Lancashire and Cumbria Cardiac and Stroke Networks Lipid Modification Guidelines. Anion-exchange resins Colestyramine powder 4g/sachet NICE Guidance TA132 Hypercholesterolaemia - ezetimibe Ezetimibe Ezetimibe tablets 10mg Fibrates CSM advice: muscle effects with fibrates and statins see BNF Bezafibrate tablets 200mg m/r tablets 400mg Fenofibrate capsules (micronized) 200mg, 267mg (dose form not appropriate for children or in renal impairment) Bezafibrate may be prescribed in addition to a statin if triglycerides remain high despite adequate lowering of LDL-C. Statins CSM advice: muscle effects with fibrates and statins see BNF NICE Guidance TA94 Cardiovascular disease - statins 26

27 First line statin (except for ACS) Simvastatin tablets 10mg, 20mg, 40mg Simvastatin 40mg daily is the recommended starting dose for secondary prevention of CVD. Check the guidelines for detailed information including drug interactions and dosing in severe renal impairment. First line statin for ACS Atorvastatin tablets 80mg Second line statin for other indications Atorvastatin (first line in ACS) tablets 10mg, 20mg, 40mg, 80mg Pravastatin tablets 10mg, 20mg, 40mg Pravastatin is an alternative for use in any indication where there are contraindications to other statins or drug interactions expose the patient to a high risk of myopathy. Third line Rosuvastatin (Consultant initiation only) tablets 5mg, 10mg, 20mg Restricted to third line use in patients unresponsive or intolerant to simvastatin, atorvastatin and pravastatin LOCAL SCLEROSANTS Sodium Tetradecyl Sulphate injection 3% 2mL amp 27

28 3: RESPIRATORY SYSTEM When prescribing inhalers the drug, device (e.g. mdi, easibreathe, autohaler, accuhaler), strength (micrograms per inhalation), number of puffs per dose and frequency MUST be specified. Note: Accuhalers are normally 1 blister bd. 3.1 BRONCHODILATORS Adrenoceptor agonists Selective beta 2 agonists Short-acting beta 2 agonists Salbutamol liquid 2mg/5mL (Paediatric use only) nebuliser solution 2.5mg/2.5mL, 5mg/2.5mL injection 500micrograms/1mL solution for intravenous infusion 5mg/5mL metered dose inhaler 100micrograms/inhalation Airomir Autohaler 100micrograms/inhalation Salamol Easi-Breathe 100micrograms/inhalation Ventolin Accuhaler 200micrograms/inhalation Terbutaline Bricanyl Turbohaler 500micrograms/inhalation Long-acting beta 2 agonists CHM advice: long-acting beta 2 agonists in the management of chronic asthma see BNF Indacaterol hard capsule 150micrograms, 300 micrograms per inhalation with Onbrez Breezhaler device Salmeterol Serevent metered dose inhaler 25micrograms/inhalation Serevent Accuhaler 50micrograms/inhalation Formoterol (Eformoterol) Oxis 6 Turbohaler 4.5micrograms/inhalation Oxis 12 Turbohaler 9micrograms/inhalation Antimuscarinic bronchodilators First line Ipratropium nebuliser solution 250micrograms/1mL, 500micrograms/2mL metered dose inhaler 20micrograms/inhalation 28

29 Second line Tiotropium Spiriva hard capsules 18micrograms with HandiHaler Respimat 2.5micrograms/inhalation Aclindinium bromide (Eklira Genuair )Inhalation powder 400micrograms/metered inhalation Glycopyrronium hard capsule 50 micrograms per inhalation with Seebri Breezhaler device 5micrograms (2puffs) via the Respimat is equivalent to 18micrograms via the HandiHaler Theophylline Theophylline m/r capsules Slo-Phyllin 60mg, 125mg, 250mg m/r tablets Nuelin SA 175mg, 250mg m/r tablets Uniphyllin Continus 200mg, 300mg, 400mg Theophylline has a narrow therapeutic index; different preparations are not interchangeable and should be prescribed by brand name. Aminophylline m/r tablets Phyllocontin Continus 225mg injection 250mg/10mL Compound bronchodilator preparations No preparations are recommended Peak flow meters, inhaler devices and nebulisers Peak flow meters Mini-Wright standard range peak flow meter litres/minute Mini-Wright low range peak flow meter litres/minute Spacer devices and inhaler aids Aerochamber standard device (blue), child device with mask (yellow), infant device with mask (orange) for use with any metered dose inhaler Volumatic for use with Flixotide, Seretide, Serevent and Ventolin metered dose inhalers Haleraid 120 & 200 to aid the use of metered dose inhalers when strength in hands is impaired 29

30 NICE Guidance TA10 Asthma (children under 5) - inhaler devices TA38 Asthma (older children) - inhaler devices TA131 Asthma (in children) - corticosteroids TA138 Asthma (in adults) - corticosteroids 3.2 CORTICOSTEROIDS First line Beclometasone metered dose inhalers (CFC free) Clenil Modulite 50micrograms/inhalation 100micrograms/inhalation QVAR metered dose inhaler (CFC free) 50micrograms/inhalation 100micrograms/inhalation QVAR Autohaler (CFC free) 50micrograms/inhalation 100micrograms/inhalation QVAR Easi-Breathe (CFC free) 50micrograms/inhalation 100micrograms/inhalation QVAR beclometasone CFC-free inhalers are approximately twice as potent as Clenil Modulite at the same microgram doses. They are not interchangeable and should be prescribed by brand name (see BNF for guidance on transferring a patient from a CFC containing inhaler to a CFC-free inhaler). In Morecambe Bay Clenil Modulite is the preferred choice for children and young people up to the age of 16; Qvar is the preferred choice for adults. Second line Budesonide Pulmicort Turbohaler 100micrograms/inhalation 200micrograms/inhalation 400micrograms/inhalation Respules (nebuliser solution) 500micrograms/2mL, 1mg/2mL Fluticasone Flixotide metered dose inhaler (CFC free) 50micrograms/inhalation 125micrograms/inhalation 250micrograms/inhalation Flixotide Accuhaler 50micrograms/inhalation 100micrograms/inhalation 250micrograms/inhalation 500micrograms/inhalation Nebules (nebuliser solution) 500micrograms/2mL, 2mg/2mL 30

31 Compound preparations Beclometasone dipropionate plus formoterol fumarate Fostair 100/6 aerosol inhalation Budesonide plus formoterol Symbicort Turbohaler 100/6, 200/6, 400/12 Fluticasone plus salmeterol Seretide metered dose inhaler 50/25, 125/25, 250/25 Seretide Accuhaler 100/50, 250/50, 500/ CROMOGLICATE AND RELATED THERAPY AND LEUKOTRIENE RECEPTOR ANTAGONISTS Cromoglicate and related therapy No preparations are recommended Leukotriene receptor antagonists Montelukast tablets 10mg chewable tablets 4mg, 5mg granules 4mg 3.4 ANTIHISTAMINES, HYPOSENSITISATION AND ALLERGIC EMERGENCIES Antihistamines Non-sedating antihistamines Cetirizine tablets 10mg liquid 5mg/5mL Loratadine tablets 10mg liquid 5mg/5mL There is no evidence to support the use of levocetirizine or desloratidine. All prescriptions for these products will be changed to cetirizine or loratadine respectively. 31

32 Sedating antihistamines Chlorphenamine (Chlorpheniramine) tablets 4mg liquid 2mg/5mL injection 10mg/1mL Alimemazine (Trimeprazine) tablets 10mg liquid 30mg/5mL Hydroxyzine tablets 10mg, 25mg Promethazine hydrochloride (Phenergan ) tablets 10mg, 25mg liquid 5mg/5mL injection 25mg/1mL Allergen Immunotherapy See BNF. Contact pharmacy for advice on availability of specific allergen extracts NICE Guidance TA133 Asthma (uncontrolled) - omalizumab TA201 Asthma (in children) - omalizumab TA278 Asthma (severe, persistent, patients aged 6+, adults) - omalizumab (rev TA133, TA201) Omalizumab RED pre-filled syringe 0.5-mL (75-mg), 1-mL (150-mg) Allergic Emergencies See BNF Adrenaline / Epinephrine injection 1 in mg/1mL EpiPen Auto-injector single dose 150micrograms, 300micrograms Chlorphenamine see section Hydrocortisone see section Hereditary angioedema C 1 esterase inhibitor (Berinert) Kept in A&E at RLI & FGH injection 500units Icatibant Pre-filled syringe (as acetate) 10mg/mL 3.5 RESPIRATORY STIMULANTS AND PULMONARY SURFACTANTS Respiratory stimulants Doxapram injection 100mg/5mL 32

33 intravenous infusion 2mg/mL in glucose 5%, 500mL Caffeine citrate (for neonatal use) liquid 50mg/5ml (Unlicensed) see BNFC injection 10mg/1mL see BNFC caffeine citrate 2mg is equivalent to caffeine base 1mg Pulmonary surfactants Poractant alfa (Curosurf ) suspension 80mg/mL 1.5mg vial Caffeine Injection 10mg/2ml (unlicensed) 3.6 OXYGEN See BNF 3.7 MUCOLYTICS Carbocisteine capsules 375mg liquid 250mg/5mL Dornase alfa nebuliser solution 1000units (1mg/mL) 2.5mL vial Sodium chloride nebules 6% 3.8 AROMATIC INHALATIONS Benzoin Tincture, Compound, BP (Friar s Balsam) 3.9 COUGH PREPARATIONS Cough suppressants Pholcodine Pholcodine Linctus, BP 5mg/5mL Expectorant and demulcent cough preparations Simple Linctus, BP (citric acid monohydrate 2.5%) 3.10 SYSTEMIC NASAL DECONGESTANTS Pseudoephedrine tablets 60mg liquid 30mg/5mL 33

34 3.11 ANTIFIBROTICS N-Acetylcysteine Capsules 600mg (unlicensed) 34

35 4: CENTRAL NERVOUS SYSTEM 4.1 HYPNOTICS AND ANXIOLYTICS NICE Guidance TA77 Insomnia - Newer hypnotic drugs Hypnotics CSM advice: Benzodiazepines should be used to treat insomnia only when it is severe, disabling or subjecting the individual to extreme distress Hypnotics may be prescribed for in-patients as required. They should not normally be prescribed on discharge for patients not previously taking a sleeping tablet and will not be dispensed by pharmacy except in exceptional circumstances. For patients taking a sleeping tablet regularly prior to admission it will be assumed that they have a supply at home (or if brought into hospital that these will be returned to the patient on discharge), prescribers must notify pharmacy of any patient taking a sleeping tablet prior to admission who is not returning to their own home and may therefore need a supply on discharge. First line Zopiclone CD (Trust Policy) tablets 3.75mg, 7.5mg Second line Temazepam CD (Trust Policy) tablets 10mg liquid 10mg/5mL (Nitrazepam tablets 5mg and liquid 2.5mg/5mL and zolpidem tablets 5mg also stocked for patients admitted on these and for Mental Health patients) Paediatric use only Melatonin RED (Unlicensed) capsules 3mg m/r capsules 2mg (AMBER SCG, consultant paediatricican recommendation), m/r capsules 3mg liquid 1mg/1mL Chloral Hydrate liquid 500mg/5mL (Unlicensed) Anxiolytics CSM advice: Use of benzodiazepines for relief of anxiety - see BNF Anxiolytics should be used at the lowest possible dose for the shortest possible time. Benzodiazepines Chlordiazepoxide tablets 5mg capsules 10mg Chlordiazepoxide is also used in a reducing regime for the management of acute alcohol withdrawal. See UHMB Clinical Guidelines. 35

36 Diazepam tablets 2mg, 5mg, 10mg liquid 2mg/5mL, 5mg/5mL injection (solution) 10mg/2mL injection (emulsion) (Diazemuls ) 10mg/2mL rectal tubes 2.5mg/1.25mL, 5mg/2.5mL, 10mg/2.5mL Lorazepam tablets 1mg injection 4mg/1mL Oxazepam tablets 10mg, 15mg Clonazepam see section Buspirone Buspirone tablets 5mg Beta-blockers Propranolol see section Barbiturates No barbiturates are recommended. For phenobarbital in epilepsy see sections and and secobarbital in sedation (paediatrics only) see section DRUGS USED IN PSYCHOSES AND RELATED DISORDERS Antipsychotic drugs Chlorpromazine tablets 10mg, 25mg, 50mg, 100mg liquid 25mg/5mL, 100mg/5mL Flupentixol (Depixol ) tablets 3mg Fluphenazine tablets 1mg Haloperidol tablets 1.5mg, 5mg, 10mg capsules 500micrograms liquid 2mg/mL injection 5mg/1mL Pericyazine tablets 2.5mg, 10mg Promazine tablets 25mg, 50mg liquid 25mg/5mL, 50mg/5mL Sulpiride tablets 200mg liquid 200mg/5mL 36

37 Trifluoperazine tablets 1mg liquid 1mg/5mL, 5mg/5mL Zuclopenthixol dihydrochloride tablets 2mg Zuclopenthixol acetate (Clopixol Acuphase ) injection 50mg/1mL Second-generation (atypical) antipsychotic drugs CSM advice: Second-generation (atypical) antipsychotics and increased risk of stroke see BNF Refer to Dementia Related Behavioural Disturbance (DRBD) Guideline on Trust Intranet NICE Guidance TA213 Schizophrenia - aripiprazole Amisulpride (SCG) AMBER tablets 50mg, 200mg liquid 100mg/mL Aripiprazole (SCG) AMBER (Consultant psychiatrist initiation only) tablets 5mg,10mg,15mg, 30mg dispersible tablets 10mg,15mg liquid 1mg/mL Clozapine RED (Consultant psychiatrist initiation only) tablets 25mg,100mg liquid 100mg/5mL Patients must be registered with the Clozapine Patient Monitoring Service (CPMS) Olanzapine (SCG) AMBER tablets 2.5mg, 5mg, 7.5mg, 10mg, 15mg dispersible tablets (Velotabs ) 5mg, 10mg, 15mg, 20mg injection 10mg/2mL Quetiapine (SCG) AMBER tablets 25mg, 100mg, 150mg, 200mg, 300mg m/r tablets 50mg, 200mg, 300mg, 400mg Risperidone (SCG) AMBER tablets 500micrograms, 1mg, 2mg, 3mg dispersible tablets (Quicklets ) 1mg, 2mg liquid 1mg/mL Antipsychotic depot injections Flupentixol Decanoate AMBER injection 20mg/1mL, 40mg/2mL concentrate injection 50mg/0.5mL, 100mg/1mL Fluphenazine Decanoate AMBER injection 12.5mg/0.5mL, 25mg/1mL concentrate injection 100mg/1mL Haloperidol Decanoate AMBER injection 50mg/1mL, 100mg/1mL Paliperidone RED, BLACK in Lancs Injection 75mg, 100mg, 150mg Pipotiazine palmitate AMBER injection 50mg/1mL, 100mg/2mL Risperidone (SCG) (Risperdal Consta ) Cumbria AMBER Lancs RED injection 25mg, 37.5mg, 50mg (Consultant psychiatrist initiation only) 37

38 Zuclopenthixol Decanoate AMBER injection 200mg/1mL concentrate injection 500mg/1mL Antimanic drugs Valproic acid (Depakote ) AMBER e/c tablets 250mg, 500mg Lithium carbonate (SCG) AMBER m/r tablets (Camcolit ) 400mg m/r tablets (Priadel ) 200mg, 400mg Lithium citrate AMBER liquid 520mg/5mL (Priadel ) Lithium preparations vary widely in bioavailability and should therefore be prescribed by brand name. Lithium carbonate 200mg lithium citrate 509mg. Carbamazepine, lamotrigine and sodium valproate m/r see section ANTIDEPRESSANT DRUGS CSM advice: Hyponatraemia and antidepressant therapy see BNF Tricyclic and related antidepressant drugs Tricyclic antidepressants Amitriptyline tablets 10mg, 25mg, 50mg liquid 25mg/5mL Clomipramine capsules 10mg, 25mg, 50mg m/r tablets 75mg liquid 25mg/5mL (Unlicensed) Doxepin capsules 25mg, 50mg Imipramine tablets 10mg, 25mg Lofepramine tablets 70mg liquid 70mg/5mL Nortriptyline tablets 10mg, 25mg Trimipramine tablets 10mg, 25mg capsules 50mg (Dosulepin (Dothiepin) capsules 25mg and tablets 75mg also stocked for patients admitted on these but not recommended due to association with cardiac arrhythmias and fatalities following overdose) 38

39 Related antidepressants Mianserin tablets 10mg, 30mg Trazodone capsules 50mg, 100mg liquid 50mg/5mL Monoamine-oxidase inhibitors (MAOIs) Phenelzine tablets15mg Reversible MAOIs Moclobemide tablets 150mg Selective serotonin re-uptake inhibitors CSM advice: SSRIs and depressive illness in children and adolescents see BNF First line Citalopram tablets (as hydrobromide) 10mg, 20mg oral drops (as hydrochloride) 40mg/mL (2mg/drop) Note: 8mg(4drops) equivalent in therapeutic effect to 10mg citalopram tablet Fluoxetine capsules 20mg liquid 20mg/5mL Alternatives Escitalopram Cumbria AMBER Lancs RED for depression GREEN for GAD tablets 5mg, 10mg, 20mg (Consultant psychiatrist initiation only) Paroxetine tablets 20mg, 30mg liquid 10mg/5mL Sertraline tablets 50mg Citalopram or Sertraline are the antidepressant of choice in epilepsy Sertraline is the antidepressant of choice in patients with ischaemic heart disease and is recommended first line by NICE in patients with recent MI or unstable angina Other antidepressant drugs Duloxetine (Cymbalta ) Cumbria AMBER Lancs RED Prescribe by brand name capsules 30mg, 60mg (Consultant psychiatrist initiation only) Flupentixol (Fluanxol ) tablets 500micrograms, 1mg Mirtazapine tablets 15mg, 30mg, 45mg dispersible tablets 15mg, 30mg, 45mg (only for patients with swallowing difficulties) 39

40 Reboxetine AMBER (Consultant psychiatrist initiation only) tablets 4mg Tryptophan AMBER (Consultant psychiatrist initiation only) tablets 500mg Venlafaxine tablets 37.5mg, 75mg m/r capsules 75mg, 150mg 4.4 CENTRAL NERVOUS SYSTEM STIMULANTS AND OTHER DRUGS USED FOR ATTENTION DEFICIT HYPERACTIVITY DISORDER NICE Guidance TA98 Attention Deficit Hyperactivity Disorder (ADHD) - Methylphenidate, Atomoxetine and Dexamfetamine (Review) Atomoxetine AMBER capsules 10mg, 18mg, 25mg, 40mg, 60mg Dexamfetamine (SCG) AMBER tablets 5mg Lisdexamfetamine (SCG) AMBER in Cumbria capsules 30mg, 50mg, 70mg Methylphenidate (SCG) AMBER tablets 5mg, 10mg m/r tablets (Concerta XL) 18mg, 36mg m/r capsules (Equasym XL) 10mg, 20mg, 30mg Restricted to initiation by child or adolescent psychiatrists or paediatricians experienced in the management of ADHD. Modafinil AMBER (Consultant neurologist initiation only) tablets 100mg 4.5 DRUGS USED IN THE TREATMENT OF OBESITY Anti-obesity drugs acting on the gastro-intestinal tract Orlistat capsules 120mg 4.6 DRUGS USED IN NAUSEA AND VERTIGO Antihistamines Cinnarizine tablets 15mg Cyclizine tablets 50mg injection 50mg/1mL Promethazine hydrochloride (Phenergan ) - see section Promethazine teoclate (Avomine ) tablets 25mg 40