| Formulary Chapter 4: Central nervous system - Full Chapter
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| Chapter Links... |
 MHRA Drug Safety Alert (Feb 2015): Drugs and driving: blood concentration limits set for certain drugs |
 NENC Palliative and End of Life Care Symptom Control Guidelines |
| NICE NG62: Cerebral palsy in under 25s: assessment and management |
| TEWV - Medicines Optimisation – Interactive Guide |
| TEWV Guidelines |
| TEWV Safe Transfer of Prescribing Guidance |
| Details... |
| 04.02.01 |
Antipsychotic Drugs |
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For more information on prescribing antipsychotics in primary care see the North of Tyne, Gateshead and North Cumbria APC Information leaflet prepared by CNTW or the TEWV Medicines Optimisation Interactive Guide (as appropriate):
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Benperidol
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Formulary
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- Approved for the control of deviant antisocial sexual behaviour
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| 04.02.01 |
First Generation Antipsychotic Drugs |
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Chlorpromazine
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Formulary
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Haloperidol
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Formulary
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 Palliative Care
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MHRA Drug Safety Update Dec 2021: Haloperidol (Haldol): reminder of risks when used in elderly patients for the acute treatment of delirium
NICE NG10: Violence and aggression: short-term management in mental health, health and community settings
TEWV Rapid Tranquilisation Policy
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Perphenazine
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Formulary
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Sulpiride
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Formulary
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Zuclopenthixol
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Formulary
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Flupentixol
(Flupenthixol)
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Alternatives
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Levomepromazine
(Methotrimeprazine)
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Alternatives
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 For use in palliative care.
- Levomepromazine 25mg in 1ml injection is approved for use in palliative care.
- Note: Methotrimeprazine / Levomepromazine 6mg tablets are
 unlicensed
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Trifluoperazine
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Alternatives
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| 04.02.01 |
Second Generation Antipsychotic Drugs |
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Risperidone
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Formulary
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- Note: risperidone orodispersible tablets should only be used in situations where the plain tablets are unsuitable.
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MHRA Drug Safety Update (Nov 2013): Risperidone and paliperidone: risk of intraoperative floppy iris syndrome in patients undergoing cataract surgery
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Amisulpride
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Formulary
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Aripiprazole
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Alternatives
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- Approved for schizophrenia in people aged 15 to 17 years in line with NICE.
- Approved for moderate to severe manic episodes in young people aged 13 and older with bipolar I disorder NICE.
- Aripriprazole 10mg & 15mg orodispersible tablets are approved for doses over 5mg for those patients who have difficulty swallowing.
- Aripiprazole 1mg in 1ml oral solution is only for doses of 5mg or less, or when titrating patients on doses of increments of less than 5mg, in patients who have difficulty swallowing tablets.
- To be used in accordance with NICE criteria.
- Note: Aripiprazole 7.5mg/ml IM Injection is approved for use in rapid tranquilisation in patients with acute psychosis.
 NTW use only.
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MHRA Drug Safety Update (December 2023): Aripiprazole (Abilify and generic brands): risk of pathological gambling
NICE TA213: Aripiprazole for the treatment of schizophrenia in people aged 15 -17 years
NICE TA292: Bipolar disorder (children) - aripiprazole
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Clozapine
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Alternatives
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- First choice in patients with treatment-resistant schizophrenia.
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MHRA Drug Safety Alert (Oct 2017): Clozapine: reminder of potentially fatal risk of intestinal obstruction, faecal impaction, and paralytic ileus
MHRA Drug Safety Update (Aug 2020): Clozapine and other antipsychotics: monitoring blood concentrations for toxicity
North East and North Cumbria ICB - Clozapine supporting guidance for primary care
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Lurasidone (Latuda®)
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Alternatives
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- 18.5mg, 37mg and 74mg tablets
- Approved for the treatment of schizophrenia in adults and adolescents aged 13 years and over
- Approved Unlicensed indications:
- Bipolar Depression: as 2nd line option for monotherapy when 1st line therapies have not been effective or tolerated: quetiapine, olanzapine-fluoxetine combination, or olanzapine monotherapy.
- Major depressive disorder with mixed features, as an alternative option where 1st line therapies have not been effective or tolerated.
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NTAG - Lurasidone Treatment Appraisal: Decision Summary
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Olanzapine
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Alternatives
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- Olanzapine orodispersible tablets should only be used in situations where the plain tablets are unsuitable.
- Olanzapine orodispersible tablets and injection are also approved for 2nd/3rd- line use in the management of delirium in critical care patients unlicensed indication.
- 10 mg injection
- for rapid control of agitation and disturbed behaviours in patients with schizophrenia or manic episode, when oral therapy is not appropriate.
- for delirium at end of life
- 210mg, 300mg & 405mg powder and solvent for suspension for long-acting injection (as olanzapine embonate monohydrate)
- approved for the treatment of schizophrenia in adults within secure psychiatric services
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Quetiapine
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Alternatives
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- 25mg, 100mg, 150mg 200mg & 300mg tablets
- 50mg, 200mg, 300mg & 400mg prolonged release tablets
- Prolonged release tablets are approved for use in patients who require an outside carer to administer their medicines, and for short term use when rapid dose titration is considered important e.g. where its use might avoid the need to admit the patient to hospital.
- Quetiapine 20mg/ml Oral Suspension (Rosemont) - CNTW only
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Key |
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Restricted Drug |
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Unlicensed |
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Link to adult BNF
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Link to children's BNF
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Link to SPCs
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Cytotoxic Drug |
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Controlled Drug |
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High Cost Medicine |
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NHS England |
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Homecare |
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ICB |
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Low carbon footprint |
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Medium carbon footprint |
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High carbon footprint |
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| Status |
Description |
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Drugs for hospital use only. The responsibility for initiation and monitoring treatment should rest with an appropriate hospital clinician and the drug should be supplied through the hospital throughout the duration of treatment. In some very exceptional circumstances (e.g. due to distance from the hospital, storage, supply or mobility/transport problems) it may be appropriate for the GP to be asked to prescribe a Red drug. This should be negotiated on an individual patient basis and should only be done with the GP’s prior informed agreement where the roles of the GP and hospital services are clearly defined and agreed. The GP should not feel under pressure to prescribe in these circumstances. For all RED drugs automatically added to the formulary in response to a positive NICE TA: Prescribers need to ensure that local Trust new drug governance procedures and pharmacy processes are followed before any prescribing. |
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Drugs initiated by hospital specialist, but where continuing treatment by GPs may be appropriate under a shared care arrangement. These medicines are considered suitable for primary care prescribing following specialist initiation of therapy and stabilisation, with ongoing communication between the primary care prescriber and specialist as set out in the associated shared care guideline (SCG). Shared care should be initiated by the specialist, which includes consultant, suitably trained specialist non-medical prescriber or GPwER within a secondary, tertiary, or primary care clinic.
The specialist should send the primary care prescriber a copy of the NENC Clinical Effectiveness and Governance (CEG) Subcommittee approved SCG to sign. The primary care prescriber should sign the SCG or indicate reasons why they are unable to accept the agreement and return a copy back to the specialist, as soon as possible.
SCGs are available or are being developed for most of the drugs listed as AMBER. |
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Drugs normally recommended or initiated by a hospital specialist who is a prescriber, a GP with an extended role [GPwER], or a specialist within primary care which can be safely maintained in primary care and monitored in primary care. In some cases, a further restriction for use may be defined. The primary care prescriber must be familiar with the drug to take on prescribing responsibility or must obtain the required information from the specialist. Therefore, provision of additional information, or an information leaflet, may be appropriate in some cases to facilitate continuing treatment by primary care prescriber or provide information re stopping criteria.
These are considered suitable for primary care prescribing following specialist assessment and recommendation of therapy, with ongoing communication between the primary care prescriber and specialist, if necessary.
In some case these drugs require specialist initiation and short to medium term monitoring of efficacy or toxicity until the patient’s dose is stable. Following specialist review the patient may be transferred to primary care for ongoing prescribing. Ongoing prescribing by primary care can include, if required, additional dose titrations and assessment of efficacy, with ongoing communication between the primary care prescriber and specialist, if necessary.
If the drug requires urgent initiation, it is expected that the specialist provides the first prescription from the inpatient/outpatient setting, of sufficient supply for a patient’s immediate needs. The quantity provided should cover at least up to the point where the discharge/clinic letter has reached the GP, plus reasonable time for the practice to manage the document and issue further supplies. A GREEN+ drug can only be recommended to primary care for initiation if it does not need to be initiated urgently, taking into account clinical need. |
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Medicines suitable for initiation, ongoing prescribing and discontinuation in all care settings, subject to appropriate communication between those responsible. |
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Self-care – available OTC, can be purchased as part of self-care for self-limiting conditions as per NHSE policy guidance |
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UNDER REVIEW: drugs whose current formulary status or RAG status is currently under review. |
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Drugs that have been considered by the NENC Clinical Effectiveness and Governance (CEG) Subcommittee (or other approved body) and are not approved for prescribing within the North East and North Cumbria ICS. These may also include all medicines with a “not NHS” or “DLCV” classification in the BNF, those agents as included within the NICE “Do not do” list, and those agents included with the NHS England: Items which should not routinely be prescribed in primary care. |
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