Bramley Health Formulary March 2016 Review Date March 2017 This provides a formulary for use within Bramley Health. This only relates to psychiatric indications. Some of the medicines listed are also used for other indications which are outside the remit of this document. Non psychotropic medications should only be prescribed after consultation with the GP. The only exceptions are Paracetamol, Ibuprofen, Simple Linctus, Senna and Lactulose. All drugs prescribed must be shared with the person s GP. Prescribers have the responsibility to be familiar with prescribing guidelines for all medications including recommended monitoring if necessary. Prescribers are solely responsible to carry out the necessary monitoring. PURPLE Medicines not recommended for prescribing (non formulary) RED Medicines are only to be prescribed with authorisation from the medical director in writing. The prescriber will have to provide a full rationale of the use of these medicines prior to commencing them. AMBER Medicines can be initiated by the consultant only. The decision and rationale to prescribe must be documented by the consultant in the clinical records. GREEN Formulary medicines which can be initiated by any doctor or other prescriber deemed competent to use the particular type of medicine. BLUE Nutritional supplement guidance. Consider this guidance when the organisation carries the cost, rather than a GP. GENERIC/TRADE NAMES Please prescribe by generic name only, as the brand may be considerably more expensive. There are a few notable exceptions, for example Lithium, which has varying bioavailability. If no brand is specified Priadel will be supplied. Prescribers are responsible to issue brand specific prescriptions as appropriate when bioavailability is a consideration. PRESCRIBING GUIDANCE Prescribers are advised to refer to the latest BNF www.bnf.org, the Maudsley Guidelines, or the Psychotropic Drug Directory latest edition (Stephen Bazire). Prescribes should also be familiar with all relevant NICE guidance. Prescribers are responsible to familiarise themselves and follow this guidance as appropriate. Deviation from established guidance must be acknowledged and justified in the clinical notes. In these cases prescribers should consider requesting a second opinion. PURPLE: NON FORMULARY Not recommended for prescribing in Bramley Health Alprazolam (Xanax) Anxiety Amoxapine (Asendis) Antidepressant. May cause tardive dyskinesia Amphetamines mixed (Adderall) ADHD. Withdrawn in Canada due to s/e Asenapine (Sycrest) Acute phase Bipolar 1, 14 weeks max. Calcium Methylfolate Tablet 15mg Clorazepate (Tranxene) Anxiety Chlorpromazine injection (Largactil and generic) Erratic unpredictable absorption. Cardiac risk.
Dosulepin,Dothiepin (formerly Prothiaden) Antidepressant. Toxic in overdose. Cardiotoxic. Except existing patients with no contraindications (see yellow). Alternatives include Lofepramine, Amitriptyline, Trazodone, Mirtazapine Ethosuximide Epilepsy. Discontinued by manufacturers. Existing patients to be reviewed by specialist care. Flunitrazepam (Rohypnol) Hypnotic of misuse Fluphenazine oral (Moditen 1mg) Antipsychotic DISCONTINUED REVIEW EXISTING PATIENTS Flurazepam (formerly Dalmane) Insomnia Galantamine tablets (Reminyl) Alzheimer s. USE SR CAPSULES (ONCE DAILY) OR LIQUID to avoid prescribing errors Gingko Biloba Alzheimer s. Risk of cerebral haemorrhage. No evidence of efficacy. Isocarboxazid Antidepressant MAOI Ketamine infusion Injection 10mg/mL Loprazolam (formerly Dormonoct) Insomnia Lormetazepam Insomnia Maprotiline (formerly Ludiomil) Antidepressant. May cause convulsions. Meprobamate Anxiety. Methadone injection (Physeptone) Opioid dependence. Mianserin (formerly Bolvidon) Antidepressant. S/e blood dyscrasias Nalmefene For alcohol use reduction. Olanzapine embonate long acting injection (ZypAdhera) Antipsychotic long acting IM injection which requires at least 3 hours observation after every administration. Penfluridol Tablet 20mg Pipotiazine palmitate IM injection (Piportil depot) DISCONTINUED REVIEW EXISTING PATIENTS Primidone (formerly Mysoline) Prodrug for Phenobarbitone. Except existing reviewed patients. Difficulties with supply. Promazine (formerly Sparine) Antipsychotic. Erratic unpredictable absorption, not recommended by the BNF (see SPC). Not recommended to avoid benzodiazepine addiction. Alternatives include promethazine, levomepromazine, pericyazine, chlorpromazine, fluphenazine. Promazine IM Difficult to obtain. Unlicensed in UK. St. John s Wort (Natures Aid 333 mg or 500 mg, Power 200 mg, 500 mg, Complex caps 334 mg by Vega, or FSC 500 mg) Antidepressant. Selegiline Patch 6mg/24hours, 9mg/ 24hours, 12mg/24hours Tranylcipromine Antidepressant MAOI Triclofos Paediatric insomnia Tryptophan herbal Advise patients of risk of eosinophilia myalgia syndrome Vardenafil Erectile dysfunction. Restricted in NHS. See BNF 7.4.5 Vigabactrin For epilepsy. Except for existing reviewed patients Zaleplon (Sonata) Short acting for insomnia Zotepine (Zoleptil) For schizophrenia. High side effect profile. Discontinued. RED: RESTRICTED FORMULARY Medical Director Authorisation Required.
Atomoxetine (Strattera) ADHD Agomelatine (Valdoxan) 3rd line antidepressant for adults under 65. Baseline, 3 week, 6 week and 12 week LFT. Aripiprazole injection IM Agitation and disturbed behaviour in schizophrenia Asenapine Desvenlafaxine Duloxetine (Cymbalta) 4th line alternative for depression. 3rd line for people over 65 Escitalopram (Cipralex) Antidepressant. Named patient, consultant initiation only using 10mg Escitalopram is equivalent to 20mg Citalopram Please prescribe Citalopram instead unless there are strong clinical reasons. Levetiracetam (Keppra) Adjunct for partial seizures Lofexidine Opioid dependence Lurasidone (Latuda) Schizophrenia. Please note Lurasidone not licensed for the treatment of depression or bipolar disorder in the UK. Melatonin SR (Circadin) for adults Short course for people over 55 with primary insomnia. Memantine (formerly Ebixa) Alzheimer s disease, moderate to severe only. Please use continuing care guidance. Ref. NICE 217 Methylphenidate (Ritalin, Equasym, Concerta, Medikinet XL) ADHD. Specify the brand Methadone tablets (Physeptone) Opioid dependence. Midazolam oral liq. as Epistat 10 mg/ml Epilepsy. Alternative to rectal diazepam. Individual care protocol required. Prescribe Buccolam 5 mg/ml in preference by brand. Not recommended for rapid tranquillisation. Buccolam is licensed for children, Epistat is unlicensed. Change from Epistat to Buccolam is advised. Modafinil Used off label in ADHD and schizophrenia Nitrazepam (formerly *Mogadon) Insomnia. Review existing patients. Long half life, muscle relaxant, increases reaction time, leads to falls in elderly/debilitated. Attempt withdrawal/change to shorter acting drug if appropriate. Olanzapine IM injection (Zyprexa) Antipsychotic for rapid tranquillisation. No longer marketed in UK. Not stocked. Omega 3 acid ethyl esters (Omacor) Dose 5 capsules daily. Flax seed oils. Some evidence for improvement in schizophrenia, psychoses, Alzheimer s and bipolar disorder. Advise patient to purchase if possible. Review adherence. Omega 3 marine triglycerides (Maxepa) Dose 10 capsules a day. Advise to purchase and check adherence. Orlistat (Xenical) High BMI. See BNF for monitoring Paliperidone long acting injection Schizophrenia. Pimozide (Orap or generic) Antipsychotic with marked cardiac side effects. Annual ECG recommended. Piracetam Epilepsy Pirenzapine Not licenced. For S/E of Clozapine Primidone Prodrug of phenobarbitone. Existing reviewed patients only Reboxetine Antidepressant NARI NOT RECOMMENDED Risperidone long acting IM injection Schizophrenia. Sertindole Antipsychotic for named patients only Sibutramine (Reductil) High BMI See BNF for C/I & monitoring Sildenafil Erectile dysfunction. Pulmonary hypertension. See BNF 7.4.5 Acute hospital initiation only (urology).
Tadalafil Erectile dysfunction. Pulmonary hypertension. See BNF 7.4.5 Acute hospital initiation only (urology) Tiagabine (Gabitril) Epilepsy Topiramate (Topamax) Epilepsy Tryptophan Antidepressant for named patients only AMBER: CONSULTANT ONLY FORMULARY Consultant only with clear rationale recorded in the notes. Buprenorphine (Subutex) Opioid dependence Buprenorphine with Naloxone (Suboxone) Opioid dependence where appropriate, instead of above. Clonazepam injection To be used I.M. for rapid tranquillisation if Lorazepam injection is not available. (Note: Unlicensed route in UK, but licensed in Europe). Clozapine (Clozaril) Treatment resistant schizophrenia Disulfiram (formerly Antabuse) Alcohol withdrawal usually up to a year Methadone liquid (Physeptone SF) Opioid dependence Please prescribe Physeptone SF brand Naltrexone Opioid dependence Acamprosate Alcohol dependence (1 year course) Stop if patient starts drinking again. Acetazolamide Epilepsy Aripiprazole (Abilify) oral Schizophrenia. Bipolar disorder. Psychosis. Benperidol Antipsychotic sexual disinhibition. Longstanding patients should be referred to specialist care. Reasons for continuation MUST be recorded in the notes, and it must be regularly reviewed. Bupropion Depression (unlicensed use) (licensed for smoking cessation) Buspirone Anxiety with lower dependence and abuse potential than benzodiazepines. Second line. Licensed for short term use only. Clobazam Epilepsy only. Clonidine Hyperactivity Tourette s syndrome Cyproterone Sexual disinhibition. Reasons for continuation MUST be recorded in the notes, and it must be regularly reviewed. Ineffective with chronic alcoholism. Effective in agitation i dementia (males and females). Dexamphetamine Narcolepsy. ADHD. Donepezil (formerly Aricept) Alzheimer s disease, with continuing care guidance for cholinesterase inhibitors Flupentixol decanoate IM injection (Generic or Depixol) Antipsychotic oily depot injection. Fluphenazine decanoate IM (Generic or Modecate) Antipsychotic oily depot injection. Gabapentin Epilepsy, chronic pain, anxiety. Galantamine capsules(sr) or liquid Alzheimer s disease. Once daily sustained release capsule recommended (Reminyl XL or liquid) NOTE. Do not prescribe tablets (taken BD) to avoid errors. Haloperidol injection Antipsychotic. Should have ECG before use if at all possible. Alternatives include Risperidone orodispersible, Olanzapine orodispersible Haloperidol decanoate IM injection Antipsychotic oily depot injection. Lamotrigine Epilepsy. Mood disorder Lithium (Priadel, Camcolit, Liskonum, Li liquid) Mania. Adjunct in depression. Priadel is brand of choice in Bramley Health. Specify brand. Monitor as NICE guidance and record results in clinical notes.
Moclobemide Depression (Beta MAOI) Oxcarbazepine Epilepsy Phenelzine MAOI for depression Phenobarbital Epilepsy Phenytoin (Epanutin capsules) Epilepsy. Specify brand. Pregabalin Prescribe twice a day (BD) not TDS Epilepsy. Generalised anxiety disorder as a third line for severely affected patients only. Chronic pain. Not licensed for bipolar disorder. Perphenazine Antipsychotic Propranolol Anxiety Rivastigmine (Exelon) Alzheimer s disease. Temazepam Insomnia. Short term prn treatment (max 2 weeks) Trifluoperazine (formerly Stelazine) Schizophrenia, psychoses, anxiety. In short supply. Valproate semisodium (Depakote) Mood disorder Valproate & salts (Epilim, Epilim chrono, Epicenta and others) Epilepsy. Mood disorder. Venlafaxine 300 mg or more Antidepressant. Monitoring required. Cardiac risk. Zuclopenthixol acetate injection (Acuphase 50mg 100mg) Post acute psychosis or mania. Inpatient use only. Rapid tranquillisation Policy must be followed, with monitoring Zuclopenthixol decanoate IM injection (Clopixol) Antipsychotic oily depot injection. GREEN: CAN BE INITIATED BY SPECIALTY DOCTORS To be reviewed by the consultant at the first opportunity Amisulpride Atypical antipsychotic Amitriptyline Antidepressant TC Carbamazepine (For mood disorder use SR preparation) Chloral hydrate/betaine (formerly Welldorm) Insomnia. Short term prn treatment Chlordiazepoxide (formerly Librium) Alcohol withdrawal Chlorpromazine Antipsychotic Citalopram Antidepressant Clomipramine Antidepressant Clonazepam Anxiety/agitation. Amber for epilepsy. Clomethiazole (formerly Chlormethiazole, Heminevrin) Rarely for addiction/withdrawal Clonazepam Anxiety, agitation Diazepam Anxiolytic for short term use. Fluoxetine Antidepressant SSRI Flupentixol (Depixol 3mg or Fluanxol 500 mcg or 1 mg) Antipsychotic/ antidepressant. Haloperidol oral Antipsychotic Imipramine Antidepressant TC with other indications Levomepromazine oral and inj (formerly methotrimeprazine, Nozinan) Antipsychotic also used for anxiety in terminal care. Do not use in ambulant patients over 50 yr Lofepramine Antidepressant Tricyclic of first choice, after two SSRIs, and possibly mirtazapine Lorazepam Anxiolytic for short term/prn use. High addiction potential. Mirtazapine Antidepressant Nortryptyline Antidepressant Olanzapine (Zyprexa) Atypical antipsychotic Olazapine orodispersible Atypical antipsychotic Orphenadrine EPSE. May be sedative Oxazepam Anxiolytic for short term use Paroxetine Antidepressant SSRI
Pericyazine (Neulactil) Antipsychotic Prochlorperazine (formerly Stemetil ) Antiemetic, dizziness. Not recommended for psychosis Procyclidine EPSE. Can be stimulant and addictive Promethazine Insomnia or agitation (not to be confused with Promazine) Quetiapine (Seroquel) Antipsychotic do not prescribe liquid. Tablets can be crushed. Risperidone Antipsychotic Risperidone orodisp. Antipsychotic Sertraline Antidepressant SSRI recommended by NICE as first line for GAD. Tetrabenazine Tardive dyskinesia & other indications Trazodone Antidepressant. Sedative Trifluoperazine (formerly Stelazine) Anxiety. Antipsychotic. Now available again. Trimipramine (formerly Surmontil) Antidepressant TC Venlafaxine 3rd line for doses below 300 mg for depression, 75mg SR for anxiety. Zolpidem Insomnia. Short term prn treatment (no more than 2 weeks) Zopiclone Insomnia. Short term prn treatment (no more than 2 weeks) Zuclopenthixol (Clopixol) Antipsychotic NOTE: Please do not prescribe unlicensed liquids unless absolutely necessary, as the cost can be very high. Consider tablet crushers or alternative preparations NUTRITIONAL SUPPLEMENTS Nutritional supplements should be used only on the recommendation of the GP. They should not be prescribed on discharge unless there is prior agreement with the GP. Resource shake Milk based supplement for nutritionally compromised patients Complan shake Can be mixed with whole milk or water Calogen High calorie addition to adequate amounts of other foods. Dose 30ml Fresubin Jucy (formerly Provide Extra) To increase energy and protein intake for those who prefer a clear fruity drink NOTE: Does contain whey protein. Maxijul supersoluble powder Carbohydrate to fortify food and drinks with extra energy for weight gain Thick and easy For thickening foods in Dysphagia.