Joint Medicines Formulary April 2016
Guy’s and St Thomas’ NHS Foundation Trust King’s College Hospital NHS Foundation Trust Lewisham and Greenwich NHS Trust
ACKNOWLEDGEMENT We wish to thank the Guy’s and St Thomas’ Charity for providing us with a grant to make this work possible
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Preface This formulary is a prescribing list that includes the names of medicines approved by the Joint Formulary Committee or South East London Area Prescribing Committee for use at:
Guy’s and St Thomas’ NHS Foundation Trust (GSTFT) King’s College Hospital NHS Foundation Trust (KCH) Lewisham and Greenwich NHS Trust (LGT)
The availability of medicines approved by the Joint Formulary Committee and Area Prescribing Committee is subject to funding arrangements and clinical practice in individual Trusts. Availability in each Trust is indicated by under the relevant columns. For formulary products used less commonly, there maybe a 24-hour delay before the product is available on site as stocks may not be routinely kept. This formulary does not contain the information necessary for prescribing, dispensing or administration. It should be used in conjunction with the British National Formulary (BNF), supplemented as necessary from specialist publications and manufacturers’ Summaries of Product Characteristics (SPC), local guidelines and national guidelines. It is intended for use by prescribers who have the necessary training and experience to interpret the information it provides.
RED List Drugs This edition of the Joint Medicines Formulary includes the South East London Area Prescribing Committee (APC) agreed “RED list drugs”. RED list drugs are not recommended for GPs to prescribe and responsibility for prescribing, monitoring, dose adjustment and review should remain with the hospital prescriber. In some cases drugs are added to the RED list to enable specialist prescribers to assess safety and effectiveness data, before being evaluated for their suitability to be prescribed in primary care. Within the formulary, RED list drugs and formulations are highlighted in red bold font – in cases where the RED list restrictions apply only to a specific indication, the indication will also be highlighted in red bold font. Supplementary information is available from local Medicines Information/Formulary services: Guy’s and St Thomas’ NHS Foundation Trust (Medicines Information extensions 83849, 83855, 88750; Formulary extension 83854) King’s College Hospital NHS Foundation Trust (extension 0355) Lewisham and Greenwich NHS Trust (Medicines Information 020 8836 4900; Formulary 020 8836 4847). Information on the treatment of poisonings is available from the Guy’s and St Thomas’ Poisons Unit (020 7188 0100). Unlicensed medicines/uses Unlicensed medicines or uses of licensed products that fall outside the marketing authorisation have been included for use in specific clinical settings, where these have been approved for formulary inclusion. Prescribers must take full responsibility for prescribing such products and comply with the Unlicensed Medicines Policy as approved at individual Trust level.
Disclaimer Every attempt has been made to ensure that the information in this formulary is correct at the time of publication, but errors may have occurred. Where there is doubt, information should be verified against relevant specialist publications
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Internet-Based Medicines Resources The following are examples of reliable sources of information on medicines that can be freely accessed via the internet. Basic information on medicines (indications, dosing, interactions)
British National Formulary (BNF) and BNF for Children can now be accessed via the MedicinesComplete website https://www.medicinescomplete.com/about/ Electronic Medicines Compendium http://emc.medicines.org.uk/ Summaries of Product Characteristics (SPCs) and Product Information Leaflets (PILs) for UK licensed products
South East London Area Prescribing Committee (APC)
Information about the South East London APC and new medicine recommendations can be found at http://www.lambethccg.nhs.uk/news-and-publications/meeting-papers/southeast-london-area-prescribing-committee/Pages/default.aspx
NHS Information portals
NICE Evidence Services http://www.evidence.nhs.uk/ NICE Evidence Services (previously NHS Evidence), was launched in April 2009, and is a web-based portal designed to provide NHS healthcare professionals with comprehensive access to a wide range of information in health and social care. A wide range of information types are covered (e.g. primary research, guidelines, policy documents), and logging in with an Athens password allows the user to search healthcare databases (e.g. EMBASE, MEDLINE). Various publications from the BNF, Medicines and Prescribing Centre (MPC) and Clinical Knowledge Summaries (CKS) can be accessed via this portal, as can the Cochrane Library and other evidence-based medicine resources.
Guidelines
National Institute for Health and Clinical Excellence (NICE) http://www.nice.org.uk/
Medicines safety
Medicines and Healthcare products Regulatory Agency (MHRA) www.mhra.gov.uk Monthly ‘Drug Safety Update’ bulletins featured on this site contain information and advice relating to the safety of medicines from the MHRA and CHM. For further advice regarding medicines, please contact your ward pharmacist or local Medicines Information department
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1. Gastro-intestinal system 1.1 Dyspepsia and GORD Formulary Item
Restrictions and/or Advice
Antacids and alginates Co-magaldrox suspension 195/220 Magnesium trisilicate suspension 5% Gaviscon Advance® suspension Peptac® suspension Gastrocote® tablets Use is restricted to the community Health Inclusion Team only Unlicensed Uses Drug Infacol® oral suspension Acetic acid 2.5% solution
Mannitol 2.5% with carob bean gum 0.2% oral solution
Approved Indication Surfactant to improve visualisation in capsule endoscopy For use in Barrett’s oesophagus endoscopy surveillance. 20 mL of 2.5% solution (prepared from acetic acid 5% solution) to be applied topically to the oesophageal mucosa For use by Radiology for outlining the small bowel for MRI scans
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Site Availability GSTFT KCH LGT
Site Availability GSTFT KCH LGT
1.2 Antispasmodics and other drugs altering gut motility Formulary Item
Restrictions and/or Advice
Antimuscarinics Dicycloverine hydrochloride syrup 10 mg/5 mL Hyoscine butylbromide tablets, injection Propantheline bromide tablets Other antispasmodics Alverine citrate capsules Mebeverine hydrochloride tablets Mebeverine hydrochloride liquid 50 mg/5 mL Peppermint oil capsules Peppermint water Motility stimulants Metoclopramide Maximum daily dose is 30 mg and tablets, injection maximum duration of use is 5 days (following EMA and CHMP advice) Unlicensed Uses Drug Erythromycin suspension Erythromycin tablets, injection
Approved Indication Resistant diabetic gastroparesis. 125 mg three times a day before meals Prokinetic agent, motility stimulant
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Site Availability GSTFT KCH LGT
Site Availability GSTFT KCH LGT
1.3 Antisecretory drugs and mucosal protectants Formulary Item
Restrictions and/or Advice
Site Availability GSTFT KCH LGT
H.pylori eradication Refer to local guidelines and NICE Guideline CG184 (Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management) 1.3.1 H2- receptor antagonists Cimetidine tablets Ranitidine tablets, injection 1.3.3 Chelates and complexes Sucralfate tablets, suspension 1 g/5 mL 1.3.4 Prostaglandin analogues Misoprostol tablets 1.3.5 Proton pump inhibitors – Use in accordance with NICE guidance for gastrooesophageal reflux disease in adults: investigation and management (NICE clinical guideline 184) Omeprazole capsules ORAL PPI OF CHOICE AT ALL TRUSTS – Not to be prescribed for patients on clopidogrel Lansoprazole First-line PPI for patients on capsules clopidogrel Pantoprazole injection PARENTERAL PPI OF CHOICE AT GSTFT Omeprazole RESERVED FOR TUBE FED dispersible tablets PATIENTS AT KCH ® (MUPS ) Omeprazole injection PARENTERAL PPI OF CHOICE AT KCH AND LGT Lansoprazole RESERVED FOR TUBE FED orodispersible tablets PATIENTS AT GSTFT AND LGT Unlicensed Uses Site Availability Drug Approved Indication GSTFT KCH LGT Pantoprazole For use in accordance with injection guideline for managing acute upper GI bleed at GSTFT Dose: 80 mg followed by an infusion of 8 mg/h for 72 hours
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1.4 Acute diarrhoea Formulary Item
Restrictions and/or Advice
Oral rehydration Dioralyte® oral powder Electrolade® oral powder 1.4.2 Antimotility drugs Codeine phosphate tablets Co-phenotrope tablets 2.5/0.025 (Lomotil®) Loperamide capsules, Tablets used for stoma patients tablets, syrup 1 mg/5 mL Unlicensed Uses Drug Oral rehydration salts (ORS)
Approved Indication
Site Availability GSTFT KCH LGT
Site Availability GSTFT KCH LGT
RESTRICTED USE Short bowel syndrome, high output stomas and small bowel enterocutaneous fistulae. Producing >1200 mL/24 hours of small bowel contents and at risk of clinical dehydration For standard ORS dissolve 8 sachets of Dioralyte® in 1 litre of water; for drinking over 24 hours For potassium-free ORS dissolve 3.5 g sodium chloride + 2.5 g sodium bicarbonate + 20 g glucose to 1 litre of water; for drinking over 24 hours
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1.5 Chronic bowel disorders Site Availability GSTFT KCH LGT 1.5.1 Aminosalicylates – Refer to BNF for highlighted caution Balsalazide capsules RESTRICTED USE Acute management of ulcerative colitis only Mesalazine m/r tablets Asacol® tablets should only be 400 mg, 800 mg prescribed for continuation of (Octasa®), 500 mg, treatment. All new patients requiring 400 mg or 800 mg m/r tablets 1000 mg (Pentasa®), ® ® should be initiated on Octasa 1200 mg (Mezavant XL) tablets Mesalazine granules 1 g, 2 g (Pentasa®), 1.5 g, 3 g (Salofalk®) Mesalazine suppository 500mg (Asacol®), 1000mg (Salofalk®) Mesalazine foam enema 1 g (Asacol®), enema 2 g/59 mL ® (Salofalk ) Sulfasalazine tablets, Acute management of ulcerative suspension 250 mg/5 colitis only mL Formulary Item
Restrictions and/or Advice
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1.5 Chronic bowel disorders Formulary Item 1.5.2 Corticosteroids Beclometasone dipropionate m/r tablets (Clipper®)
Budesonide capsules, controlled-release capsules Budesonide prolonged release tablets (Cortiment®)
Restrictions and/or Advice Consultant Specialists only Second-line option (after prednisolone tablets) for the treatment of mild or moderate ulcerative colitis in active phase, as add-on therapy to 5-ASA containing drugs in patients who are nonresponders to 5-ASA therapy. Full 4-week therapy cycle must be prescribed by secondary care
Restricted to patients with active ulcerative colitis with insufficient response to 5-ASA who: Would be suitable for beclomethasone m/r capsules (Clipper®) but are at increased risk of severe side effects from systemic steroids or Have failed/not tolerated beclomethasone m/r treatment Refer to the South East London APC recommendation for further information
Budesonide enema Hydrocortisone foam enema Prednisolone tablets, retention enema, rectal foam, suppositories 5 mg Unlicensed Uses Drug Beclometasone dipropionate m/r tablets (Clipper®)
Site Availability GSTFT KCH LGT
Approved Indication Consultant Specialists only Monotherapy for the treatment of mild or moderate ulcerative colitis in active phase where 5-ASA containing drugs and prednisolone are contraindicated or not tolerated. Full 4-week therapy cycle must be prescribed by secondary care
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Site Availability GSTFT KCH LGT
1.5 Chronic bowel disorders 1.5.3 Drugs affecting the immune response Cytokine modulators Formulary Item Infliximab injection
Adalimumab injection
Golimumab injection
Vedolizumab injection
Restrictions and/or Advice Consultant Gastroenterologists only Use in accordance with NICE guidance for Crohn’s disease (NICE technology appraisal 187), acute exacerbations of ulcerative colitis (NICE technology appraisal 163) and treatment of moderately to severely active ulcerative colitis after failure of conventional therapy (NICE technology appraisal 329) Consultant Gastroenterologists only Use in accordance with NICE guidance for Crohn’s disease (NICE technology appraisal 187) and treatment of moderately to severely active ulcerative colitis after failure of conventional therapy (NICE technology appraisal 329) Consultant Gastroenterologists only Use in accordance with NICE guidance for the treatment of moderately to severely active ulcerative colitis after failure of conventional therapy (NICE technology appraisal 329) Consultant Gastroenterologists only Use in accordance with NICE guidance for treating moderately to severely active ulcerative colitis (NICE technology appraisal 342) and moderately to severely active Crohn’s Disease after prior therapy (NICE technology appraisal 352)
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Site Availability GSTFT KCH LGT
1.5 Chronic bowel disorders 1.5.3 Drugs affecting the immune response Unlicensed Uses - USE UNDER SPECIALIST SUPERVISION ONLY Site Availability Drug Approved Indication GSTFT KCH LGT Azathioprine tablets Resistant or frequently relapsing inflammatory bowel disease. Dose: 2 mg/kg daily Ciclosporin injection Severe acute ulcerative colitis refractory to corticosteroid treatment. Dose: 2 mg/kg over 24 hours and dose adjusted according to blood-ciclosporin concentration and response Severe acute inflammatory bowel Mercaptopurine disease; maintenance of remission tablets of inflammatory bowel disease. Dose: 1 – 1.5 mg/kg daily Methotrexate tablets Crohn’s disease. Dose 15-25 mg weekly Tacrolimus capsules Use in accordance with local (Adoport®) guideline at GSTFT. Ongoing prescribing and monitoring remains the Must be prescribed responsibility of the Consultant using brand name Gastroenterologist. Refractory Crohn’s disease or ulcerative colitis, where patients have failed on all other conventional immunosuppressant and biological treatments and where the only other option is surgery. Tacrolimus ointment Ulcerating perianal Crohn’s disease and pyoderma gangrenosum as a last-line option if all other therapies and surgery have failed or are unsuitable For the unlicensed use of tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) in irritable bowel syndrome, refer to NICE clinical guideline 61 and South East London APC Guidelines
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1.6 Laxatives Formulary Item
Restrictions and/or Advice
1.6.1 Bulk forming laxatives Ispaghula husk granules Methylcellulose tablets 1.6.2 Stimulant laxatives Bisacodyl tablets, suppositories Co-danthramer RESTRICTED USE – PALLIATIVE capsules, suspension CARE ONLY 25/200 in 5 mL Co-danthramer strong RESTRICTED USE – PALLIATIVE capsules, strong CARE ONLY suspension 75/1000 in 5 mL Docusate sodium capsules, liquid Docusate sodium enema Glycerol suppositories Senna tablets, syrup 7.5 mg/5 mL Senna granules 15 mg/5 mL Sodium picosulfate elixir 1.6.3 Faecal softeners Arachis oil enema 1.6.4 Osmotic laxatives Lactulose solution Macrogol oral For use when other laxatives have compound powder failed Liquid paraffin and SPECIALIST USE ONLY magnesium hydroxide emulsion 25%/6% Phosphate enema Sodium citrate enema
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Site Availability GSTFT KCH LGT
1.6 Laxatives Formulary Item
Restrictions and/or Advice
1.6.5 Bowel cleansing preparations CitraFleet® oral powder Citramag® oral powder Klean-Prep® oral powder Moviprep® oral powder For use in accoradnace with the consensus guidelines for the safe use of oral bowel cleansing agents in patients: with end-stage chronic kidney disease with congestive cardiac failure on high-dose diuretics where previous colonoscopy failed to achieve adequate preparation with CitraFleet® with UC or CD requiring surveillance colonoscopy ® Picolax oral powder
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Site Availability GSTFT KCH LGT
1.6 Laxatives Formulary Item
Restrictions and/or Advice
1.6.6 Peripheral opioid-receptor antagonists Methylnaltrexone RESTRICTED USE – bromide injection Prescribing is under the supervision of a Consultant Specialist To be used in accordance with local/Palliative Care Network guidelines Last-line pharmacological option for the treatment of opioid-induced constipation in advanced illness patients who are receiving palliative care when response to usual laxative therapy has not been sufficient Naloxegol tablets Use in accordance with NICE guidance for opioid induced constipation (NICE technology appraisal 345) 1.6.7 Other drugs used in constipation Linaclotide capsules For initiation or on recommendation by a specialist or by a GP where a diagnosis of IBS with constipation (IBS-C) is established and prescribing is in line with SE London IBS Pathway: For moderate to severe IBS-C in adults as a third line option if the following have been ineffective or not tolerated: First line antispasmodics or laxatives (not lactulose) Second line tricyclic antidepressants if diarrhoea predominant or selective serotonin reuptake inhibitors if constipation predominant Refer to the South East London APC recommendation and IBS pathway for further information Lubiprostone capsules Use in accordance with NICE guidance for chronic idiopathic constipation (NICE technology appraisal 318) Prucalopride tablets Use in accordance with NICE guidance for chronic constipation in women (NICE technology appraisal 211)
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Site Availability GSTFT KCH LGT
1.7 Local preparations for anal and rectal disorders Formulary Item
Restrictions and/or Advice
Site Availability GSTFT KCH LGT
1.7.1 Soothing haemorrhoidal preparations Anusol® ointment, suppositories ® Anusol-HC ointment, suppositories 1.7.2 Compound haemorrhoidal preparations with corticosteroids Proctofoam HC® foam ® Xyloproct ointment Hydrocortisone ointment 1% Lidocaine gel 2%, ointment 5% 1.7.3 Rectal sclerosants Oily Phenol Injection BP 5% 1.7.4 Management of anal fissures Glyceryl trinitrate ointment 0.4% ® (Rectogesic ) Unlicensed Uses Site Availability Drug Approved Indication GSTFT KCH LGT For anal fissure and post-operative Diltiazem cream 2% anal spasm in high-risk patients following clinical examination For prescribing and supply by hospital only Refer to the South East London APC recommendation for further information
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1.9 Drugs affecting intestinal secretions Formulary Item
Restrictions and/or Advice
1.9.1 Drugs affecting biliary composition and flow Ursodeoxycholic acid tablets, capsules 1.9.2 Bile acid sequestrants Colestyramine sachets 1.9.4 Pancreatin Creon® capsules 10 000, 25 000, 40 000 Pancrease® capsules Pancrex V® capsules Unlicensed Uses Drug Secretin ampoules Colesevelam tablets
Approved Indication Diagnostic agent for pancreatic disease RESTRICTED USE – CONSULTANT HEPATOLOGISTS AND GASTROENTEROLOGISTS ONLY Diarrhoea caused by bile salt malabsorption e.g. in Crohn’s disease or radiation enteritis For pruritus and hyperlipidaemia in primary biliary cirrhosis
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Site Availability GSTFT KCH LGT
Site Availability GSTFT KCH LGT
2. Cardiovascular system 2.1 Positive inotropes Formulary Item
Restrictions and/or Advice
2.1.1 Cardiac glycosides Digoxin tablets, elixir 50 micrograms of elixir is equivalent 50 micrograms/mL, to 62.5 micrograms of tablets injection Digoxin-specific antibody injection 2.1.2 Phosphodiesterase type-3 inhibitors Enoximone injection RESTRICTED USE - ICU AND CARDIAC HIGH DEPENDENCY Milrinone injection RESTRICTED USE - ICU AND CARDIAC HIGH DEPENDENCY Unlicensed Uses Drug Levosimendan infusion
Approved Indication RESTRICTED USE – ICU AND LFU Adjunctive short-term treatment of acutely decompensated severe chronic heart failure. Use according to local guideline
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Site Availability GSTFT KCH LGT
Site Availability GSTFT KCH LGT
2.2 Diuretics Formulary Item
Restrictions and/or Advice
Site Availability GSTFT KCH LGT
2.2.1 Thiazides and related diuretics Bendroflumethiazide tablets Chlortalidone tablets Indapamide tablets, m/r tablets 2.2.2 Loop diuretics Furosemide tablets, oral liquid, injection Bumetanide tablets 2.2.3 Potassium-sparing diuretics and aldosterone antagonists Amiloride tablets Eplerenone tablets Use in accordance with NICE guidance for MI: cardiac rehabilitation and prevention of further MI (NICE clinical guideline 172) Use in accordance with South London Cardiac and Stroke Network guidance for heart failure due to left ventricular systolic dysfunction Spironolactone tablets Use in accordance with South London Cardiac and Stroke Network guidance for heart failure due to left ventricular systolic dysfunction Unlicensed Uses Bumetanide injection
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2.2 Diuretics Formulary Item
Restrictions and/or Advice
2.2.4 Potassium-sparing diuretics with other diuretics Co-amilozide tablets (amiloride and hydrochlorothiazide) Co-amilofruse tablets (amiloride and furosemide) Burinex A® tablets RESTRICTED USE (bumetanide 1 mg and amiloride 5 mg) Co-triamterzide tablets (triamterine 50 mg and hydrochlorothiazide 25 mg) Navispare® tablets (amiloride 2.5 mg and cyclopenthiazide 250 micrograms) 2.2.5 Osmotic diuretics Mannitol intravenous USE UNDER SPECIALIST infusion SUPERVISION ONLY Unlicensed Uses Drug Metolazone tablets Potassium carenoate injection Spironolactone oral suspension 50 mg/5 mL
Eplerenone tablets
Approved Indication Resistant oedema in patients with renal impairment. Dose: 2.5 mg on alternate days to 10 mg daily Aldosterone antagonist. Alternative to oral spironolactone Oedema and ascites in liver cirrhosis, malignant ascites, nephrotic syndrome, congestive heart failure, primary hyperaldosteronism. Dose: As for licensed oral doses for tablet formulation Use in accordance with South London Cardiac and Stroke Network guidance. Moderate to severe heart failure. For patients unable to tolerate spironolactone.
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Site Availability GSTFT KCH LGT
Site Availability GSTFT KCH LGT
2.3 Anti-arrhythmic drugs 2.3.2 Drugs for arrhythmias In all acute tachycardias with a wide QRS complex, it is advisable to seek expert advice unless the precise nature of the arrhythmia is known. The use of the incorrect drug in these circumstances is dangerous. Adenosine can be helpful diagnostically in this setting because its shorter action makes it relatively safe. Failure of the tachycardia to respond suggests that it is ventricular rather than supraventricular Site Availability Formulary Item Restrictions and/or Advice GSTFT KCH LGT Supraventricular arrhythmias Adenosine injection Dronedarone tablets Use in accordance with NICE guidance for non-permanent atrial fibrillation (NICE technology appraisal 197) Supraventricular and ventricular arrhythmias Amiodarone USE UNDER SPECIALIST hydrochloride tablets, SUPERVISION ONLY injection Disopyramide USE UNDER SPECIALIST capsules, injection SUPERVISION ONLY Flecainide acetate USE UNDER SPECIALIST tablets, injection SUPERVISION ONLY Procainamide USE UNDER SPECIALIST hydrochloride injection SUPERVISION ONLY Propafenone USE UNDER SPECIALIST hydrochloride tablets SUPERVISION ONLY Ventricular arrhythmias Lidocaine USE UNDER SPECIALIST hydrochloride injection SUPERVISION ONLY Unlicensed Uses Site Availability Drug Approved Indication GSTFT KCH LGT Ajmaline injection Diagnostic test for Brugada syndrome Dose: 1 mg/kg (actual body weight) up to a maximum dose of 100 mg Mexiletine USE UNDER SPECIALIST hydrochloride injection SUPERVISION ONLY Treatment of life-threatening ventricular arrhythmias Mexiletine USE UNDER SPECIALIST hydrochloride SUPERVISION ONLY capsules Congenital myotonia. Total daily dose: initiate at 1.5 mg/kg and increase to 10 mg/kg (maximum daily dose of 600 mg)
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2.4 Beta-adrenoceptor blocking drugs Formulary Item Propranolol hydrochloride tablets, m/r capsules, oral solution, injection Acebutolol tablets Atenolol tablets, oral syrup 25 mg/5 mL, injection Co-tenidone tablets 100/25 Bisoprolol fumarate tablets Carvedilol tablets
Esmolol hydrochloride injection Labetalol hydrochloride tablets, injection Metoprolol tablets, injection Nebivolol tablets Oxprenolol hydrochloride tablets Sotalol tablets
Restrictions and/or Advice
Site Availability GSTFT KCH LGT
RESTRICTED USE Treatment of NYHA class IV heart failure USE UNDER SPECIALIST SUPERVISION ONLY
INITIATION BY SPECIALIST ONLY For the use of beta-blockers in the management of stable angina, please refer to NICE clinical guideline 126 Unlicensed Uses Site Availability Formulary Item Restrictions and/or Advice GSTFT KCH LGT Metoprolol injection ICU only via local Trust protocol via intravenous Restricted to use where infusion betablockers licensed for infusion are unavailable
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2.5 Hypertension and heart failure Formulary Item
Restrictions and/or Advice
2.5.1 Vasodilator antihypertensive drugs Bosentan tablets INITIATION BY SPECIALIST ONLY Use in accordance with local guideline Last-line option, to reduce the number of new digital ulcers in patients with systemic sclerosis and ongoing digital ulcer disease, who meet the following criteria: Have a history of multiple digital ulcers Have previously failed treatment with iloprost Diazoxide injection Hydralazine hydrochloride tablets, injection Minoxidil tablets USE ON SPECIALIST ADVICE Unlicensed Uses Drug Iloprost injection
Sildenafil tablets
Sodium nitroprusside injection Papaverine injection
Approved Indication RESTRICTED USE – CONSULTANT SPECIALISTS ONLY Use in accordance with local guideline Treatment of digital ulcer disease RESTRICTED USE – CONSULTANT SPECIALISTS ONLY Use in accordance with local guideline Raynaud’s secondary to scleroderma in patients that are contraindicated to or have failed other treatment options USE ON SPECIALIST ADVICE
RESTRICTED USE – CONSULTANT SPECIALISTS ONLY As an intrathecally administered adjunct treatment during aortic aneurysm repair. Use in accordance with local guideline
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Site Availability GSTFT KCH LGT
Site Availability GSTFT KCH LGT
2.5 Hypertension and heart failure Formulary Item
Restrictions and/or Advice
2.5.2 Centrally acting antihypertensive drugs Clonidine hydrochloride tablets Methyldopa tablets DRUG OF CHOICE IN PREGNANCY Moxonidine tablets 2.5.3 Adrenergic neurone blocking drugs Guanethidine monosulphate injection 2.5.4 Alpha-adrenoceptor blocking drugs Doxazosin tablets Indoramin tablets Prazosin tablets Phaeochromocytoma Phenoxybenzamine USE UNDER SPECIALIST hydrochloride SUPERVISION ONLY capsules, injection Phentolamine mesilate USE UNDER SPECIALIST injection SUPERVISION ONLY 2.5 Hypertension and heart failure - Other treatments Midodrine RESTRICTED USE – hydrochloride tablets CONSULTANT USE ONLY Symptomatic hypotension Treatment must be initiated by the hospital, including the initial supply of tablets
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Site Availability GSTFT KCH LGT
2.5 Hypertension and heart failure Unlicensed Uses Formulary Item Clonidine hydrochloride tablets
Midodrine hydrochloride tablets
Restrictions and/or Advice Use in accordance with Critical Care Guideline for Clonidine For use as an opioid sparing, coanalgesic and sedative agent, when opioid requirements and benzodiazepine requirements are increasing without effect. May also be used as a weaning agent. KCH CONSULTANT POTS/IST SPECIALISTS ONLY Postural Orthostatic Tachycardia Syndrome (POTS) and Inappropriate Sinus Tachycardia (IST) where: The predominant presenting symptom is hypotension AND The patient has failed simple measures such as increased fluids, exercise and compression clothing AND Fludrocortisone is considered inappropriate for the patient or has failed to control symptoms Refer to the South East London APC recommendation for further information
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Site Availability GSTFT KCH LGT
2.5 Hypertension and heart failure 2.5.5 Drugs affecting the renin-angiotensin system Formulary Item
Restrictions and/or Advice
2.5.5.1 Angiotensin-converting enzyme inhibitors Captopril tablets Enalapril maleate tablets Fosinopril tablets Lisinopril tablets Ramipril tablets, ACE INHIBITOR OF CHOICE AT capsules KCH Trandolapril capsules 2.5.5.2 Angiotensin-II receptor antagonists Candesartan cilexetil tablets Irbesartan tablets Irbesartan and Treatment of essential hydrochlorothiazide hypertension for patients requiring 300/12.5 tablets irbesartan and a thiazide diuretic Losartan potassium First-line ARB for hypertension tablets 2.5.5.3 Renin inhibitors Aliskiren tablets RESTRICTED USE – CONSULTANT SPECIALISTS ONLY Treatment of resistant hypertension as a last-line option after all other options stated in the British Hypertension Society guideline that are not contraindicated (including alphablockers, beta-blockers, and potassium-sparing diuretics) have failed or are not tolerated Unlicensed Uses Drug Perindopril erbumine tablets Valsartan tablets Valsartan capsules
Approved Indication Secondary prevention of stroke in combination with indapamide RESTRICTED USE Heart failure RESTRICTED USE Heart failure
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Site Availability GSTFT KCH LGT
Site Availability GSTFT KCH LGT
2.6 Nitrates, calcium-channel blockers, and other antianginal drugs Site Availability GSTFT KCH LGT 2.6.1 Nitrates - For the use of nitrates in the management of stable angina, please refer to NICE clinical guideline 126. Long-acting nitrates should only be considered as third line options Glyceryl trinitrate tablets, spray, buccal tablets, injection, topical patches Isosorbide dinitrate tablet Isosorbide dinitrate injection Isosorbide mononitrate tablets, m/r tablets 2.6.2 Calcium-channel blockers - For the use of calcium-channel blockers in the management of stable angina, please refer to NICE clinical guideline 126. Calciumchannel blockers and beta-blockers should be considered as first line treatment options for stable angina. Amlodipine tablets First-line dihydropyridine antagonist Diltiazem hydrochloride tablets, m/r tablets, m/r capsules Felodipine m/r tablets Second-line dihydropyridine antagonist at LGT Lacidipine tablets Nicardipine tablets Nifedipine capsules, m/r tablets, m/r capsules Nimodipine tablets, injection Verapamil hydrochloride tablets, m/r tablets Formulary Item
Restrictions and/or Advice
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2.6 Nitrates, calcium-channel blockers, and other antianginal drugs Site Availability GSTFT KCH LGT 2.6.3 Other antianginal drugs – These drugs (and long-acting nitrates) should only be considered if beta-blockers, calcium-channel blockers or a combination of both do not satisfactorily control symptoms or if first line options are contraindicated or not tolerated. Please refer to NICE clinical guideline 126 Nicorandil tablets Ivabradine tablets INITIATION BY CONSULTANT CARDIOLOGISTS ONLY Use in accordance with NICE and SLCSN guidance for treating chronic heart failure (NICE technology appraisal 267) Formulary Item
Ranolazine m/r tablets
Restrictions and/or Advice
Use in accordance with SLCSN guidance for managing chronic stable angina: for patients in sinus rhythm that have a contraindication to or cannot tolerate either beta-blockers or rate-limiting calcium channel blockers (diltiazem / verapamil) or in combination with betablockers where there are on-going angina symptoms and a heart rate above 60 beats per minute despite optimised beta-blocker therapy INITIATION BY CONSULTANT CARDIOLOGISTS ONLY Use in accordance with SLCSN guidance for managing ongoing symptoms in chronic stable angina despite the use of first-line anti-anginal therapies such as beta-blockers or calcium channel blockers. Ranolazine may be particularly useful where the use of other antianginal therapies is limited by bradycardia (heart rate < 50 beats per minute) or hypotension (systolic blood pressure < 90mmHg), as it has little effect on heart rate or blood pressure. It may also be useful where first-line anti-anginal therapies are contraindicated or not tolerated
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2.6 Nitrates, calcium-channel blockers, and other antianginal drugs Site Availability Formulary Item Restrictions and/or Advice GSTFT KCH LGT 2.6.4 Peripheral vasodilators and related drugs Naftidrofuryl oxalate Use in accordance with NICE capsules guidance for intermittent claudication in people with peripheral arterial disease (NICE technology appraisal 223) Pentoxifylline tablets Oxerutins capsules
2.6 Nitrates, calcium-channel blockers, and other antianginal drugs Unlicensed Uses Site Availability Drug Approved Indication GSTFT KCH LGT Flunarizine capsules, Intermittent claudication, tablets Raynaud’s syndrome, prophylaxis of migraine, vertigo Prophyaxis of migraine dosage: Starting dose of 10 mg at night (5 mg for patients ≥65 years). Treatment should be discontinued if no significant improvement observed after 2 months. Maintenance treatment should continue at the same daily dose but interrupted by two successive drug-free days every week, e.g. Saturday and Sunday. All patients should have treatment stopped after 6 months and it should only be re-initiated if the patient relapses. Ivabradine tablets KCH CONSULTANT POTS/IST SPECIALISTS ONLY Postural Orthostatic Tachycardia Syndrome (POTS) and Inappropriate Sinus Tachycardia (IST) where: The predominant symptom is tachycardia AND The patient has failed simple measures such as fluids, exercise and compression clothing AND A beta-blocker has failed or is inappropriate Refer to the South East London APC recommendation for further information
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2.6 Nitrates, calcium-channel blockers, and other antianginal drugs Unlicensed Uses Drug Pentoxifylline tablets, liquid (unlicensed product)
Approved Indication Prevention of osteonecrosis of the jaw. Used in combination with vitamin E capsules
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Site Availability GSTFT KCH LGT
2.7 Sympathomimetics Formulary Item
Restrictions and/or Advice
2.7.1 Inotropic sympathomimetics Dobutamine injection RESTRICTED USE – ICU AND CARDIAC HIGH DEPENDENCY Dopamine RESTRICTED USE – ICU AND hydrochloride injection CARDIAC HIGH DEPENDENCY Dopexamine injection RESTRICTED USE – ICU AND CARDIAC HIGH DEPENDENCY 2.7.2 Vasoconstrictor sympathomimetics Ephedrine hydrochloride injection Noradrenaline acid tartrate (norepinephrine bitartrate) injection Phenylephrine hydrochloride injection 2.7.3 Cardiopulmonary resuscitation Adrenaline (epinephrine) injection Unlicensed Uses Drug Isoprenaline injection
Metaraminol injection
Approved Indication Short-term emergency treatment of heart block or severe bradycardia. Dose: 0.5 – 10 micrograms/minute Acute hypotension. In emergency: 0.5-5 mg by intravenous injection, then 15-100 mg by intravenous infusion, adjusted according to response.
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Site Availability GSTFT KCH LGT
Site Availability GSTFT KCH LGT
2.8 Anticoagulants and protamine Formulary Item
Restrictions and/or Advice
2.8.1 Parenteral anticoagulants Heparin and Low molecular weight heparins Heparin injection First-line LMWH at GSTFT Dalteparin sodium injection Enoxaparin sodium injection Other parenteral anticoagulants Argatroban For use under the supervision monohydrate injection of a Consultant Haematologist For anticoagulation in patients with HIT type 2 undergoing cardiac surgery or have renal failure in a HDU/ITU setting who are not suitable for treatment with fondaparinux Bivalirudin injection Use in accordance with NICE guidance for ST-segmentelevation myocardial infarction (NICE technology appraisal 230) Epoprostenol USE ON SPECIALIST ADVICE injection Fondaparinux Use in accordance with NICE sodium injection guidance for venous thromboembolism: reducing the risks for patients in hospital (NICE clinical guideline 92) Unlicensed Uses Drug Fondaparinux sodium injection
Approved Indication Use in accordance with local guideline First-line parenteral anticoagulant in adult patients with HIT and patients with an allergy to heparin
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Site Availability GSTFT KCH LGT
Site Availability GSTFT KCH LGT
2.8 Anticoagulants and protamine Site Availability GSTFT KCH LGT 2.8.2 Oral anticoagulants – REFER TO LOCAL TRUST GUIDELINES AND SOUTH EAST LONDON AREA PRESCRIBING COMMITTEE GUIDELINES FOR THE USE OF ORAL ANTICOAGULANTS Warfarin sodium tablets Apixaban tablets Use in accordance with NICE (indications guidance for the prevention of highlighted red venous thromboembolism after remain hospital only) hip or knee replacement surgery (NICE technology appraisal 245) Formulary Item
Restrictions and/or Advice
For the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism (NICE technology appraisal 341)
Use in accordance with SE London APC guidance and NICE guidance for the prevention of stroke and systemic embolism in atrial fibrillation (NICE technology appraisal 275) Acenocoumarol tablets Dabigatran capsules (indications highlighted red remain hospital only)
Use in accordance with NICE guidance for the prevention of venous thromboembolism after hip or knee replacement surgery (NICE technology appraisal 157) For the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism (NICE technology appraisal 327) Use in accordance with SE London APC guidance and NICE guidance for the prevention of stroke and systemic embolism in atrial fibrillation (NICE technology appraisal 249)
33
2.8 Anticoagulants and protamine Site Availability GSTFT KCH LGT 2.8.2 Oral anticoagulants – REFER TO LOCAL TRUST GUIDELINES AND SOUTH EAST LONDON AREA PRESCRIBING COMMITTEE GUIDELINES FOR THE USE OF ORAL ANTICOAGULANTS Edoxaban tablets For treating and preventing deep vein thrombosis and pulmonary embolism (NICE technology appraisal 354) and the prevention of stroke and systemic embolism in atrial fibrillation (NICE technology appraisal 355) Phenindione tablets Formulary Item
Restrictions and/or Advice
34
2.8 Anticoagulants and protamine Site Availability GSTFT KCH LGT 2.8.2 Oral anticoagulants – REFER TO LOCAL TRUST GUIDELINES AND SOUTH LONDON CARDIAC AND STROKE NETWORK (SLCSN) GUIDELINES FOR THE USE OF ORAL ANTICOAGULANTS Rivaroxaban tablets Use in accordance with NICE (indications guidance for the prevention of highlighted in red venous thromboembolism after remain hospital only) hip or knee replacement surgery (NICE technology appraisal 170) Formulary Item
Restrictions and/or Advice
For the treatment of deep vein thrombosis and prevention of recurrent deep vein thrombosis and pulmonary embolism (NICE technology appraisal 261) and treatment of pulmonary embolism and preventing recurrent venous thromboembolism (NICE technology appraisal 287)
Use in accordance with SE London APC guidance and NICE guidance for the prevention of stroke and systemic embolism in atrial fibrillation (NICE technology appraisal 256) Use in accordance with NICE Guidance for preventing adverse outcomes after acute management of acute coronary syndrome (NICE technology appraisal 335) 2.8.3 Protamine sulphate Protamine sulphate injection
35
2.8 Anticoagulants and protamine Unlicensed Uses Drug Defibrotide infusion
Iloprost injection
Approved Indication USE UNDER SPECIALIST SUPERVISION ONLY Treatment of patients with severe veno-occlusive disease following stem cell transplant in line with NHS England Clinical Commissioning Policy B04/P/c USE UNDER SPECIALIST SUPERVISION ONLY Treatment of patients with severe peripheral arterial occlusive disease (PAOD), particularly those at risk of amputation and in whom surgery or angioplasty is not possible; treatment of patients with severe disabling Raynaud’s phenomenon unresponsive to other therapies; treatment of advanced thromboangiitis obliterans (Buerger’s disease) with critical limb ischaemia in cases where revascularisation is not indicated
36
Site Availability GSTFT KCH LGT
2.9 Antiplatelet drugs Formulary Item
Restrictions and/or Advice
Abciximab injection
USE UNDER SPECIALIST SUPERVISION ONLY Use in accordance with NICE guidance for unstable angina and NSTEMI (NICE clinical guideline 94)
Aspirin tablets Clopidrogrel tablets
Dipyridamole tablets and m/r capsules, oral suspension 50 mg/5 mL Eptifibatide injection
Prasugrel tablets Ticagrelor tablets
Tirofiban injection
Use in accordance with NICE guidance for unstable angina and NSTEMI (NICE clinical guideline 94) and prevention of occlusive vascular events (NICE technology appraisal 210) Use in accordance with NICE guidance for prevention of occlusive vascular events (NICE technology appraisal 210) USE UNDER SPECIALIST SUPERVISION ONLY Use in accordance with NICE guidance for unstable angina and NSTEMI (NICE clinical guideline 94) Use in accordance with NICE guidance for ACS with PCI (NICE technology appraisal 317) Use in accordance with South London Cardiac and Stroke Network guidance and NICE guidance for treatment of acute coronary syndromes (NICE technology appraisal 236) USE UNDER SPECIALIST SUPERVISION ONLY Use in accordance with NICE guidance for unstable angina and NSTEMI (NICE clinical guideline 94) Use for reduction of cardiovascular events in patients with STEMI intended for primary PCI
Site Availability GSTFT KCH LGT
Unlicensed Uses Drug Aspirin suppositories (unlicensed product) Ticlopidine tablets
Approved Indication Where treatment is imperative and oral is not possible (e.g stroke) Intolerance to aspirin or clopidogrel. Dose: 250 mg bd
37
Site Availability GSTFT KCH LGT
2.10 Stable angina, acute coronary syndromes and fibrinolysis 2.10.1 Management of stable angina and acute coronary syndromes – Refer to BNF 2.10.2 Fibrinolytic drugs Site Availability Formulary Item Restrictions and/or Advice GSTFT KCH LGT Alteplase injection USE UNDER SPECIALIST SUPERVISION ONLY Use in accordance with NICE guidance for acute ischaemic stroke (NICE technology appraisal 264), also For use in acute massive pulmonary embolism Streptokinase injection Tenecteplase injection Urokinase injection Occluded intravenous catheters and cannulas blocked by fibrin clots Dose: 10 000 units in 2-3 mL of sodium chloride 0.9%, should be retained in the line for 2-4 hours before aspirating Miscellaneous preparations Trisodium citrate Antimicrobial and anticoagulant 46.7% catheter lock catheter locking solution for solution (Citra-Lock® central venous catheters used in renal dialysis patients or Dura-Lock C®) TauroLock® catheter For patients receiving long term, lock solution home parenteral nutrition who have experienced one episode of confirmed catheter-related blood stream infection (CRBSI) TauroLock® HEP500 Restricted as second-line catheter lock solution alternative to trisodium citrate 46.7% for patients who are IVDUs or can not tolerate high levels of citrate Unlicensed Uses Site Availability Formulary Item Restrictions and/or Advice GSTFT KCH LGT Streptokinase Treatment of airway thrombus injection in patients receiving ECMO CONSULTANT ICU SPECIALIST ONLY Urokinase injection Intrapleural use for treatment of loculated malignant pleural effusions. CONSULTANT RESPIRATORY PHYSICIAN PRESCRIBING AND ADMINISTRATION ONLY 100,000 units every 12 hours for 3 doses only
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2.11 Blood-related products Formulary Item
Restrictions and/or Advice
Etamsylate tablets Tranexamic acid tablets, injection Unlicensed Uses Drug Adrenaline solution 1 mg/mL (1 in 1000) Aprotinin injection
Tranexamic acid injection
Tranexamic acid mouthwash 5%
Site Availability GSTFT KCH LGT
Approved Indication Capillary bleeding. Apply gauze soaked in adrenaline solution to the affected area. USE UNDER SPECIALIST SUPERVISION ONLY (NAMED PATIENT DRUG) Refer to advice from CHM For use in accordance with the ECMO guideline for adults in critical care. For continuous administration by infusion Prescribing restricted to Haematology or ENT advice only
39
Site Availability GSTFT KCH LGT
2.12 Lipid-regulating drugs – Refer to BNF for CSM advice Use in accordance with NICE guidance for lipid modification (NICE guideline 181) Formulary Item Statins Simvastatin tablets Atorvastatin tablets Pravastatin tablets Rosuvastatin tablets
Restrictions and/or Advice
RESTRICTED USE – Initiation on the recommendation of a Consultant in the Lipid Clinic, Diabetes Unit, HIV Unit or Cardiology Treatment of dyslipidaemia in accordance with the recommendations made by the South London Cardiac and Stroke Networks (SLCSN). The SLCSN state the following groups of patients may be considered appropriate for rosuvastatin treatment once other strategies have been tried: For patients with familial hyperlipidaemia (FH), where other statins have failed to achieve a >50% fall in LDL cholesterol as endorsed by NICE FH guidance. These patients should be under the care of a lipid clinic Second line for patients requiring ‘high intensity statin’ post ACS, with contraindications or drug interactions that prevent the use of high doses of atorvastatin Third line for patients with CVD or diabetes requiring substantial falls in cholesterol to achieve the minimum QoF audit standard (total cholesterol 5 days may be used for symptom control in palliative care patients
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Site Availability GSTFT KCH LGT
Site Availability GSTFT KCH LGT
4.7 Analgesics 4.7.1 Non-opioid analgesics and compound analgesic preparations Site Availability Formulary Item Restrictions and/or Advice GSTFT KCH LGT Aspirin tablets Paracetamol tablets, soluble tablets, oral suspension 120 mg/5 mL and 250 mg/5 mL, suppositories Paracetamol injection Adolescents and adults weighing less than 50 kg: Maximum dose 15 mg/kg per administration. Minimum interval between each administration must be 4 hours and the maximum daily dose must not exceed 60 mg/kg (without exceeding 3 g). In severe renal insufficiency (creatinine clearance ≤30 mL/min), the minimum interval between each administration is 6 hours. In adults with hepatocellular insufficiency, chronic alcoholism, chronic malnutrition or dehydration; the maximum daily dose must not exceed 3 g
Note: National Poisons Information Service (NPIS) advice states daily doses greater than 60 mg/kg are considered toxic. Therefore a daily dose of 4 g intravenous paracetamol should be used cautiously in patients weighing up to 66 kg.
Diclofenac sodium tablets, m/r tablets, dispersible tablets, suppositories Ibuprofen tablets, suspension 100 mg/5 mL Nefopam hydrochloride tablets
Short-term treatment of moderate pain and fever when administration by the intravenous route is clinically justified Refer to BNF for CSM advice, CSM warning and CHM advice (section 10.1.1) Refer to BNF for CSM advice, CSM warning and CHM advice (section 10.1.1)
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4.7 Analgesics 4.7.1 Non-opioid analgesics and compound analgesic preparations Site Availability Formulary Item Restrictions and/or Advice GSTFT KCH LGT Compound analgesic preparations Co-codamol 8/500 tablets, dispersible tablets Co-codamol 30/500 RESTRICTED USE tablets, dispersible tablets Co-dydramol 10/500 tablets
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4.7 Analgesics 4.7.2 Opioid analgesics Formulary Item Alfentanil injection Buprenorphine sublingual tablets, injection Buprenorphine patch (BuTrans®)
Codeine phosphate tablets Codeine phosphate injection Diamorphine hydrochloride injection Dihydrocodeine tartrate tablets Dihydrocodeine tartrate m/r tablets Dihydrocodeine tartrate injection Fentanyl transdermal patches Fentanyl sublingual tablets (Abstral®), intranasal spray (PecFent®)
Restrictions and/or Advice CONTROLLED DRUG USE UNDER SPECIALIST SUPERVISION ONLY CONTROLLED DRUG
Site Availability GSTFT KCH LGT
CONTROLLED DRUG
CONTROLLED DRUG
CONTROLLED DRUG INITITIATION BY CONSULTANT ONLY Second line option for patients with chronic severe pain who: Can not tolerate large, oral, regular doses of weak opioids or non-opioid + weak opioid combination analgesics Have concomitant conditions where use of anti-inflammatory drugs is not recommended or who have not tolerated such drugs
CONTROLLED DRUG
CONTROLLED DRUG
CONTROLLED DRUG RESTRICTED USE – PALLIATIVE CARE ONLY Use in accordance with local guideline Management of breakthrough pain in adult patients already receiving maintenance opioid therapy for chronic cancer pain that is unresponsive to morphine sulphate oral solution
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4.7 Analgesics 4.7.2 Opioid analgesics Formulary Item Fentanyl injection Hydromorphone hydrochloride capsules Meptazinol tablets, injection Methadone hydrochloride tablets, injection Morphine salts tablets, m/r tablets and suspension, oral solution, injection Morphine suppositories Oxycodone hydrochloride capsules, m/r tablets, liquid 5 mg/5 mL, injection Papaveretum injection Papaveretum and hyoscine injection Pethidine hydrochloride tablets, injection Tapentadol m/r tablets
Tramadol hydrochloride capsules, soluble tablets, injection
Restrictions and/or Advice CONTROLLED DRUG USE UNDER SPECIALIST SUPERVISION ONLY CONTROLLED DRUG
Site Availability GSTFT KCH LGT
PAIN TEAM ONLY CONTROLLED DRUG USE UNDER SPECIALIST SUPERVISION ONLY CONTROLLED DRUG
CONTROLLED DRUG CONTROLLED DRUG Second line opioid restricted to use where morphine is not tolerated or contra-indicated
CONTROLLED DRUG
CONTROLLED DRUG Prescribing is restricted to Pain Consultants only, who remain responsible for the initiation and titration of tapentadol. When successfully treated patients are on a stable dose, care can be transferred to the patient’s GP with an accompanying letter explaining the change in chronic pain management. Third-line treatment for the management of severe chronic pain following the treatment failure/intolerance of morphine and one other strong opioid. m/r preparations are Non-Formulary
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4.7 Analgesics 4.7.2 Opioid analgesics Unlicensed Uses Drug Morphine 0.1%, 0.2% w/v topical gel
Approved Indication CONTROLLED DRUG RESTRICTED USE – CONSULTANT SPECIALISTS ONLY Use in accordance with local guideline Treatment of pain localised to a cutaneous ulceration in a palliative care setting (PIL available on GTi)
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Site Availability GSTFT KCH LGT
4.7 Analgesics 4.7.3 Neuropathic and functional pain Formulary Item Gabapentin capsules Pregabalin capsules
Capsaicin cream 0.025%, 0.075%
Restrictions and/or Advice Use in accordance with NICE guidance for neuropathic pain (NICE clinical guideline 173) Use in accordance with NICE guidance for neuropathic pain (NICE clinical guideline 173) A third-line option if amitriptyline and gabapentin are not effective, not tolerated or contraindicated Use capsaicin cream 0.075% in accordance with NICE guidance for neuropathic pain (NICE clinical guideline 173)
Site Availability GSTFT KCH LGT
Unlicensed Uses Drug Amitriptyline hydrochloride tablets, oral solution Carbamazepine tablets Clonazepam tablets Gabapentin capsules
Imipramine hydrochloride tablets Nabilone capsules
Nortriptyline tablets
Approved Indication Neuropathic pain: 10-25 mg at night. May be increased gradually to 75 mg Neuropathic pain: 100 mg twice daily, increased gradually to a maximum of 200 mg three times a day Neuropathic pain: 0.5 mg at night, increased slowly to 1 mg twice daily Orthopaedics only Post-operative pain: inpatient preand post-operative doses for patients undergoing total hip or knee replacement surgery Neuropathic pain where amitriptyline is not tolerated: 10 mg at night. May be increased gradually to 75 mg Consultant Specialists only Management of neuropathic pain of benign and malignant origin in patients who have not responded to all other available anti-neuropathic agents (given alone or in combination) or where use of these has induced unmanageable side effects. For initiation in hospital only, where the total quantity per week/month must be stated. Dose: 1 mg twice dialy. Some patients may use 1 mg when required 2-3 times per week. Neuropathic pain where amitriptyline is not tolerated: 10 mg at night. May be increased gradually to 75 mg
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Site Availability GSTFT KCH LGT
4.7 Analgesics 4.7.4 Antimigraine drugs 4.7.4.1 Treatment of the acute migraine attack Formulary Item Paracetamol tablets, soluble tablets Ibuprofen tablets Rizatriptan wafers Sumatriptan tablets, injection Metoclopramide hydrochloride tablets
Restrictions and/or Advice
Maximum daily dose is 30 mg and maximum duration of use is 5 days (following EMA and CHMP advice)
Prochlorperazine suppositories 4.7.4.2 Prophylaxis of migraine Botulinum toxin type Use in accordance with NICE A (Botox®) injection guidance for the prevention of headaches in adults with chronic migraine (NICE technology appraisal 260) Pizotifen tablets, elixir 250 micrograms/5 mL Propranolol hydrochloride tablets Methysergide tablets Requires hospital supervision
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Site Availability GSTFT KCH LGT
4.7 Analgesics 4.7.4 Antimigraine drugs Unlicensed Uses Drug Amitriptyline hydrochloride tablets Aspirin injection
Dosulepin hydrochloride tablets, capsules tablets, capsules Dihydroergotamine injection
Indomethacin injection
Sodium valproate tablets
Approved Indication Prophylaxis of migraine: 10 mg at night, increasing to 50-75 mg at night Specialist use only Inpatient management of severe withdrawal headache: 1 g once to three times daily for up to 4 days Prophylaxis of migraine: 25 mg at night, increasing if necessary to 75150 mg at night or in divided doses Specialist use only Inpatient treatment of medical refractory disabling migraine and cluster headaches. See dosing protocol from KCH for further information Specialist use only For the diagnosis of indomethacin sensitive headaches (paroxysmal hemicranias): 100-200 mg intramuscular test dose USE ON SPECIALIST ADVICE Prophylaxis of migraine
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Site Availability GSTFT KCH LGT
4.8 Antiepileptics – Use in accordance with NICE guidance for epilepsies (NICE clinical guideline 137) 4.8.1 Control of epilepsy – Refer to BNF for MHRA/CHM advice Formulary Item Carbamazepine tablets, m/r tablets, liquid 100 mg/5 mL, suppositories Oxcarbazepine tablets Eslicarbazepine tablets Ethosuximide capsules, elixir 250 mg/5 mL Gabapentin capsules Pregabalin capsules Lacosamide tablets, syrup 50 mg/5 mL, injection Lamotrigine tablets, dispersible tablets Levetiracetam tablets, oral solution 500 mg/5 mL, injection Perampanel tablets
Phenobarbital tablets, elixir 15 mg/5 mL, injection Primidone tablets
Restrictions and/or Advice
Site Availability GSTFT KCH LGT
USE UNDER SPECIALIST SUPERVISION ONLY USE UNDER SPECIALIST SUPERVISION ONLY
USE UNDER SPECIALIST SUPERVISION ONLY USE UNDER SPECIALIST SUPERVISION ONLY USE UNDER SPECIALIST SUPERVISION ONLY
USE UNDER SPECIALIST SUPERVISION ONLY USE UNDER SPECIALIST SUPERVISION ONLY
Consultant Specialist initiation only. Prescribing should only be transferred to Primary Care in accordance with an agreed Shared Care guideline CONTROLLED DRUG USE UNDER SPECIALIST SUPERVISION ONLY USE UNDER SPECIALIST SUPERVISION ONLY
Phenytoin tablets, capsules, suspension 30 mg/5 mL
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4.8 Antiepileptics – Use in accordance with NICE guidance for epilepsies (NICE clinical guideline 137) 4.8.1 Control of epilepsy – Refer to BNF for MHRA/CHM advice Formulary Item Retigabine tablets
Tiagabine tablets Topiramate tablets, sprinkle capsules Sodium valproate tablets, m/r tablets, oral solution 200 mg/ 5 mL, injection Vigabatrin tablets Zonisamide capsules
Restrictions and/or Advice Use in accordance with NICE guidance as adjunctive treatment of partial onset seizures in epilepsy (NICE technology appraisal 232) USE UNDER SPECIALIST SUPERVISION ONLY USE UNDER SPECIALIST SUPERVISION ONLY
USE UNDER SPECIALIST SUPERVISION ONLY USE UNDER SPECIALIST SUPERVISION ONLY
Benzodiazepines Clobazam tablets Clonazepam tablets
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Site Availability GSTFT KCH LGT
4.8 Antiepileptics – Use in accordance with NICE guidance for epilepsies (NICE clinical guideline 137) 4.8.2 Drugs used in status epilepticus Formulary Item Diazepam injection, rectal tubes Lorazepam injection Midazolam buccal liquid
Restrictions and/or Advice
The SPC for Ativan® injection supports intravenous and intramuscular use Status epilepticus in accordance NICE guidance for epilepsies (NICE clinical guideline 137) The first-line product is Buccolam® which is available as 10 mg/2 mL in a pre-filled syringe. The dose for patients 10 years and older is 10 mg
Paraldehyde injection (given as an enema) Phenytoin sodium injection Unlicensed Uses Drug
Approved Indication
Clonazepam injection
Neuropathic pain when systemic administration is required in the Palliative Care Restricted to neurology consultant advice only Status epilepticus If a more specific dose than those available using Buccolam® pre-filled syringes is required a second-line product, Epistatus®, is available as 50 mg/5 mL
Levetiracetam injection Midazolam buccal liquid
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Site Availability GSTFT KCH LGT
Site Availability GSTFT KCH LGT
4.9 Drugs used in parkinsonism and related disorders 4.9.1 Dopaminergic drugs used in Parkinson’s disease (Refer to BNF for CSM advice) Levodopa Site Availability Formulary Item Restrictions and/or Advice GSTFT KCH LGT Co-beneldopa capsules, dispersible tablets, m/r capsules Co-careldopa tablets, m/r tablets Co-careldopa RESTRICTED USE - ALL intestinal gel REFERRALS FOR PRESCRIBING (Duodopa®) SHOULD BE MADE TO PROFESSOR RAY CHAUDHURI AT KCH Treatment of advanced levodopa responsive Parkinson’s disease in patients with severe motor fluctuations and hyper-/dyskinesia when available combinations of Parkinson medicinal products have not given satisfactory results Co-careldopa with entacapone tablets
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4.9 Drugs used in parkinsonism and related disorders 4.9.1 Dopaminergic drugs used in parkinsonism (Refer to BNF for CSM advice) Dopamine receptor antagonists Apomorphine INITIATION BY SPECIALIST ONLY hydrochloride injection Bromocriptine tablets Cabergoline tablets INITIATION BY SPECIALIST ONLY Pergolide tablets
INITIATION BY SPECIALIST ONLY
Pramipexole tablets
Parkinson’s disease and moderate to severe restless legs sydrome Parkinson’s disease and moderate to severe restless legs sydrome INITIATION BY SPECIALIST ONLY Treatment of the signs and symptoms of early-stage idiopathic Parkinson’s disease as monotherapy (i.e. without levodopa) or in combination with levodopa (i.e. over the course of the disease) through to late stages when the effect of levodopa wears off or becomes inconsistent and fluctuations of the therapeutic effect occur. RESTRICTED TO CONSULTANTS SPECIALISING IN THE TREATMENT OF RESTLESS LEG SYNDROME (RLS) Treatment of moderate to severe idiopathic RLS (maximum dose: 3 mg/24 hours) in adult patients who: are having distressing symptoms at rest and/or during the day have not achieved meaningful benefit on previous dopamine agonist have demonstrated augmentation of symptoms due to previous agonist treatment
Ropinirole tablets, MR tablets Rotigotine patch
For the treatment of RLS, the initial supply of rotigotine 1 mg and 2 mg patches should be made by the hospital. Care should be transferred to the patient’s GP, in accordance with a Shared Care guideline, only when treatment has been stabilised
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4.9 Drugs used in parkinsonism and related disorders 4.9.1 Dopaminergic drugs used in parkinsonism (Refer to BNF for CSM advice) Other drugs Amantadine hydrochloride capsules, syrup 50 mg/5 mL Entacapone tablets Rasagiline tablets INITIATION BY SPECIALIST ONLY Treatment for early Parkinson’s disease. To be used as monotherapy and gradually withdrawn when more symptomatic treatments are required. Not to be used in combination with levodopa Selegiline INITIATION BY SPECIALIST ONLY hydrochloride tablets, oral liquid 10 mg/5 mL
4.9 Drugs used in parkinsonism and related disorders 4.9.2 Antimuscarinic drugs used in parkinsonism Formulary Item
Restrictions and/or Advice
Benzatropine mesilate injection Orphenadrine hydrochloride tablets Procyclidine hydrochloride tablets, syrup 5 mg/5 mL, injection Trihexyphenidyl hydrochloride (benzhexol) tablets
Site Availability GSTFT KCH LGT
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4.9 Drugs used in parkinsonism and related disorders 4.9.3 Drugs used in essential tremor, chorea, tics and related disorders Site Availability Formulary Item Restrictions and/or Advice GSTFT KCH LGT Haloperidol tablets Riluzole tablets Use in accordance with NICE guidance for motor neurone disease (NICE technology appraisal 20) Tetrabenazine tablets Torsion dystonias and other involuntary movements Botulinum toxin type A injection (Botox®, Dysport® and Xeomin®) Botulinum toxin type For use as an alternative to Botulinum toxin A in the presence of B injection antibodies to Botulinum toxin A (NeuroBloc®)
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4.10 Drugs used in substance dependence Formulary Item
Restrictions and/or Advice
4.10.1 Alcohol dependence Acamprosate calcium tablets Disulfiram tablets INITIATION BY SPECIALIST ONLY Nalmefene tablets Use in accordance with NICE guidance for reducing alcohol consumption in people with alcohol dependence. Nalmefene should only be prescribed in conjunction with continuous psychosocial support focused on treatment adherence and reducing alcohol consumption (NICE technology appraisal 325) Unlicensed Uses Drug
Approved Indication
Site Availability GSTFT KCH LGT
Not for hospital prescribing. Patients requiring treatment with nalmefene should be referred to their local drug and alcohol services
Site Availability GSTFT KCH LGT
Alcohol infusion
RESTRICTED USE Acute alcohol withdrawal in patients unable to take chlordiazepoxide. Dose: 30 mL of 90% alcohol injection in 500 mL 5% dextrose solution, over a 24 hour period 4.10.2 Nicotine dependence Nicotine Replacement Use in accordance with NICE stop Therapy (Nicotinell® smoling services guideline (NICE patches, Nicorette® public health guideline 10) invisi patches, chewing gum, inhalator, microtabs, oral spray and nasal spray, NiQuitin® lozenges, Minis lozenges and orodispersible film) Varenicline tablets Refer to BNF for MHRA/CHM advice. Use in accordance with NICE guidance for smoking cessation as part of a programme of behavioural support (NICE technology appraisal 123)
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4.10 Drugs used in substance dependence Formulary Item
Restrictions and/or Advice
4.10.3 Opioid dependence Opioid substitution therapy Buprenorphine tablets CONTROLLED DRUG Use in accordance with NICE guidance for opioid dependence (NICE technology appraisal 114) Suboxone® tablets CONTROLLED DRUG (buprenorphine and RESTRICTED USE – SLAM ONLY naloxone) Methadone CONTROLLED DRUG hydrochloride oral Use in accordance with NICE solution 1 mg/mL guidance for opioid dependence (NICE technology appraisal 114) Adjunctive therapy and symptomatic treatment Lofexidine Use in accordance with NICE hydrochloride tablets guidance for opioid detoxification (NICE clinical guideline 52) Opioid-receptor antagonists Naltrexone Use in accordance with NICE hydrochloride tablets guidance for treatment in detoxified formerly opioiddependent patients (NICE technology appraisal 115)
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Site Availability GSTFT KCH LGT
4.11 Drugs for dementia – Use in accordance with NICE guidance for Alzheimer’s disease (NICE technology appraisal 217) RESTRICTED USE – CONSULTANT SPECIALISTS ONLY Formulary Item Donepezil hydrochloride tablets Rivastigmine capsules, oral solution 2 mg/mL Galantamine tablets, m/r tablets, oral solution 4 mg/mL Memantine hydrochloride tablets, oral solution 10 mg/mL (oral solution is available as a pump pack, delivering 5 mg/actuation) Unlicensed Uses
Restrictions and/or Advice FIRST-LINE TREATMENT SECOND-LINE TREATMENT of mild to moderate dementia in Alzheimer’s disease, in patients that are intolerant to, or do not have a sustained response to, donepezil THIRD-LINE TREATMENT
Drug
Approved Indication
Memantine hydrochloride tablets, oral solution 10 mg/mL (oral solution is available as a pump pack, delivering 5 mg/actuation)
Restricted to Consultant Clinical Gerontologists with a special interest in dementia, Consultants in Mental Health for Older Adults and Consultants in Liaison Psychiatry – prescribing to be continued by consultant Management of behavioural and psychological symptoms in dementia, when nonpharmacological interventions have failed and there is severe distress or risk of harm to the patient or others
Site Availability GSTFT KCH LGT
Site Availability GSTFT KCH LGT
4.12 Miscellaneous preparations Unlicensed Uses – USE UNDER SPECIALIST SUPERVISION ONLY Site Availability Drug Approved Indication GSTFT KCH LGT 3,4 Diaminopyridine Congenital myaesthenia, Eaton tablets Lamberts myaesthenic syndrome, multiple sclerosis Fluorescein sodium For the visualisation of injection 10% cerebrospinal fluid rhinorrhoea following endoscopic skull base surgery. Maximum dose: 50 mg
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5. Infections This section advises on the choice of anti-infective agents available at each Trust. Doctors should refer to local or departmental antibiotic guidelines for advice regarding specific treatments within specialised units (including prophylaxis for surgical, medical and dental procedures). Different antibiotic policies can be found in different hospitals due to local variations in resistance and antibiotic susceptibility. M: Use of this agent only to be initiated under the advice of a microbiologist or virologist as appropriate. S: Use of this agent only to be initiated under the advice of a relevant clinical specialist. 5.1 Antibacterial drugs 5.1.1 Penicillins Site Availability GSTFT KCH LGT
Formulary Item 5.1.1.1 Benzylpenicillin and phenoxymethylpenicillin Benzylpenicillin (Penicillin G) injection Phenoxymethylpenicillin (Penicillin V) tablets, oral solution 125 mg/5 mL, 250 mg/5 mL 5.1.1.2 Penicillinase-resistant penicillins Flucloxacillin capsules, syrup 125 mg/5 mL, 250 mg/ 5mL, injection Refer to BNF for CSM advice Temocillin injection 5.1.1.3 Broad-spectrum penicillins Amoxicillin capsules, oral suspension 125 mg/5 mL, 250 mg/5 mL, injection Co-amoxiclav tablets, oral suspension 125/31, 250/62, injection 5.1.1.4 Antipseudomonal penicillins Piperacillin with tazobactam injection Timentin® (Ticarcillin with clavulanic acid) injection Unlicensed Uses Drug Procaine Penicillin G, 1.2m units injection
Approved Indication
M
M
M
M
M
S
Site Availability GSTFT KCH LGT
Neurosyphyllis S
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5.1 Antibacterial drugs 5.1.2 Cephalosporins, carbapenams and other beta-lactams 5.1.2.1 Cephalosporins Site Availability GSTFT KCH LGT
Formulary Item Cefalexin capsules, oral suspension 125 mg/5 mL, 250 mg/5 mL Cefotaxime injection Ceftazidime injection Ceftriaxone injection Cefuroxime injection Unlicensed Uses Drug Cefazolin injection
Cefixime tablets
Cefoxitin injection
Approved Indication INFECTIOUS DISEASES/MICROBIOLOGY SPECIALIST RECOMMENDATION ONLY For proven MSSA bloodstream infection in haemodialysis patients only Dose = 2g three days per week after haemodialysis sessions Uncomplicated anogential gonorrhoea. 400 mg as a single dose 2nd generation cephalosporin for parenteral administration
M
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Site Availability GSTFT KCH LGT
M
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M
5.1 Antibacterial drugs 5.1.2 Cephalosporins, carbapenams and other beta-lactams 5.1.2.2 Carbapenams Formulary Item Ertapenem injection Primaxin® injection (imipenem with cilastatin) Meropenem injection
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Site Availability GSTFT KCH LGT M M M M M S M M M
5.1 Antibacterial drugs 5.1.2 Cephalosporins, carbapenams and other beta-lactams 5.1.2.3 Other beta-lactam antibiotics Formulary Item Aztreonam injection Aztreonam nebulised Suppressive therapy of chronic pulmonary infections due to pseudomonas aeruginosa in patients with cystic fibrosis aged 18 years and older Unlicensed Uses Drug
Approved Indication
Benzathine penicillin injection
Treatment of syphilis in accordance with GUM guidelines. IM injection only Treatment of syphilis in HIV positive patients, or when HIV status unknown. IM injection only
Procaine penicillin injection
93
Site Availability GSTFT KCH LGT M S S
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Site Availability GSTFT KCH LGT S
S
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S
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S
5.1 Antibacterial drugs 5.1.3 Tetracyclines Formulary Item Tetracycline tablets Doxycycline capsules Minocycline capsules Oxytetracycline tablets Tigecycline Tigecycline injection – Treatment of complicated skin and soft tissue infections and complicated intra-abdominal infections, especially multi-resistant Acinetobacter infections Unlicensed Uses Drug Doxycycline injection
Approved Indication Use in accordance with local guidelines Treatment of community acquired pneumonia in combination with a beta-lactam for use in severely ill patients. Dose: 400 mg IV stat then 200 mg IV once daily
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Site Availability GSTFT KCH LGT S S S
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Site Availability GSTFT KCH LGT
M
5.1 Antibacterial drugs 5.1.4 Aminoglycosides Formulary Item Gentamicin injection Amikacin injection Neomycin sulphate tablets Netilmicin injection Tobramycin injection Tobramycin nebuliser solution (Bramitob®) Tobramycin dry powder for inhalation (Tobi® Podhaler) Use in accordance with NICE guidance for treatment of pseudomonas lung infection in cystic fibrosis (NICE technology appraisal 276) Unlicensed Uses Drug
Approved Indication
Gentamicin injection
For soaking penile implants, in combination with rifampicin before insertion Topical use into the pocket during pacemaker surgery Intra-tympanic use in unilateral vestibular failure (e.g. Meniere’s Disease, Vestibular Schwannoma). Dose: 80 mg gentamicin buffered with 0.67 mL of sodium bicarbonate 50 mg/mL to fill the middle ear. This procedure is repeated again (at least two hours apart) on the same day Pretreatment vestibular function testing (caloric testing) must be performed to ensure a normally functioning contralateral labyrinth
Gentamicin injection Gentamicin injection
95
Site Availability GSTFT KCH LGT M M M M M S S S S S S S
S
S
Site Availability GSTFT KCH LGT S
S
S
S
S
S
5.1 Antibacterial drugs 5.1.5 Macrolides Site Availability GSTFT KCH LGT
Formulary Item Erythromycin tablets, oral suspension 125 mg/5 mL, 250 mg/5 mL, injection Azithromycin capsules, oral suspension 200 mg/5 mL Clarithromycin tablets, oral suspension 125 mg/5 mL, 250 mg/5 mL, injection Unlicensed Uses Drug Azithromycin tablets
Azithromycin tablets Erythromycin tablets Spiramycin tablets
Approved Indication Second-line drug for treatment of Mycobacterium avium complex or M. avium-intracellulare infection in HIV positive patients Second-line drug for treatment of toxoplasmosis Improve gastric motility Treatment of toxoplasmosis and susceptible bacterial infections under specialist advice
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Site Availability GSTFT KCH LGT S
S
S
S
5.1 Antibacterial drugs 5.1.6 Clindamycin Site Availability GSTFT KCH LGT
Formulary Item Clindamycin capsules, injection
96
5.1 Antibacterial drugs 5.1.7 Some other antibacterials Site Availability GSTFT KCH LGT
Formulary Item Chloramphenicol Chloramphenicol capsules, injection Fusidic acid Sodium fusidate tablets, oral suspension 250 mg/5 mL, injection Vancomycin and teicoplanin Vancomycin capsules, injection Teicoplanin injection Daptomycin Daptomycin injection – Second-line option to vancomycin for patients who have MRSA or VRE infections, when other agents cannot be used.and when bactericidal activity is required, for example, for severe infection in highly compromised patients Linezolid Linezolid tablets, suspension 100 mg/5 mL, injection Refer to BNF for CSM advice and CHM advice Polymixins Colistin injection, nebuliser solution Colistimethate sodium dry powder for inhalation (Colobreathe®) Use in accordance with NICE guidance for treatment of pseudomonas lung infection in cystic fibrosis (NICE technology appraisal 276) Fidaxomicin Fidaxomicin tablets Treatment of laboratory-confirmed clostridium difficile infection (CDI) in the following groups: Patients with a first CDI recurrence following treatment with vancomycin. Patients who require ongoing concomitant antibiotic treatment. Patients who are immunocompromised and who are at risk of a recurrence. Rifaximin Rifaximin tablets 550 mg Consultants specialising in the treatment of chronic or recurrent hepatic encephalopathy. Use in accordance with NICE guidance (NICE Technology Appraisal 337) Gastroenterology initiation only Prescribing responsibility to remain with secondary care for the first 6 months. Refer to SE London Area Prescribing Committee Transfer of Care Agreement for rifaximin for details
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5.1 Antibacterial drugs 5.1.7 Some other antimicrobials Unlicensed Uses Drug
Approved Indication
Fosfomycin injection
Treatment of cystic fibrosispulmonary exacerbations in patients with multiple drug allergies or multiresistant organisms when no other satisfactory licensed alternative is available Treatment of complicated ESBLproducing urinary tract infections. Dose: 3 g followed by another 3 g 72 hours later (PIL available on GTi) Treatment of gonorrhoea caused by penicillin-resistant organisms or in patients allergic to penicillin and unable to receive oral ciprofloxacin. Dose: 2 g as a single dose. Up to 4 g in difficult-to-treat cases and in areas of resistance. Administer by IM injection For continuous administration in accordance with critical care guideline for vancomycin at GSTFT. Dose: 11-125 mg/h titrated to a level of 20-25 mg/L For pre-soaking hamstring tendons once removed from the knee during ACL repair surgery, to prevent infection.
Fosfomycin trometamol sachets
Spectinomycin 2 g injection
Vancomycin injection
Vancomycin injection
98
Site Availability GSTFT KCH LGT
S/M
M
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5.1 Antibacterial drugs 5.1.8 Sulphonamides and trimethoprim Site Availability GSTFT KCH LGT
Formulary Item Co-trimoxazole tablets, oral suspension 240 mg/5 mL, 480 mg/5 mL, injection Refer to BNF for CSM advice Trimethoprim tablets, oral suspension 50 mg/5 mL Unlicensed Uses Drug Sulfadiazine tablets
Approved Indication Toxoplasmic encephalitis
S
Site Availability GSTFT KCH LGT S S S
5.1 Antibacterial drugs 5.1.9 Antituberculosis drugs – USE UNDER SPECIALIST SUPERVISION Site Availability Formulary Item GSTFT KCH LGT Ethambutol hydrochloride tablets Isoniazid tablets, injection Rifabutin capsules S S S Rifampicin capsules, syrup 100 mg/5 mL, injection Rifater® tablets (rifampicin 120 mg, isoniazid 50 mg, pyrazinamide 300 mg) Rifinah® 150/100 tablets (rifampicin 150 mg, isoniazid 100 mg) Rifinah® 300/150 tablets (rifampicin 300 mg, isoniazid 150 mg) Unlicensed Uses Site Availability Drug Approved Indication GSTFT KCH LGT Azithromycin tablets Treatment of tuberculosis in HIV S patients Drug resistant tuberculosis Protionamide S M tablets, injection Pyrazinamide tablets Treatment of tuberculosis in combination with other drugs For soaking penile implants, in Rifampicin injection combination with gentamicin before S S insertion Treatment of tuberculosis in Streptomycin S S combination with other drugs injection
99
5.1 Antibacterial drugs 5.1.10 Antileprotic drugs Site Availability GSTFT KCH LGT S
Formulary Item Dapsone tablets Clofazimine capsules Unlicensed Uses Drug Dapsone tablets
Approved Indication
Site Availability GSTFT KCH LGT
Prescribing must be initiated and continued by a specialist Dose: 50-200 mg daily
Erythema elevatum diutinum Bullous pemphigoid and mucous
Sulfamethoxypyridazine tablets
membrane (cicatricial) pemphigoid Linear IgA disease and chronic bullous disease of childhood Bullous systemic lupus erythematosus Subcorneal pustular dermatosis Sweet’s syndrome Pyoderma gangrenosum Leukocytoclastic vasculitis including Henoch Schonlein purpura Granuloma faciale Eosinophilic pustular folliculitis Hidradenitis suppurativa Alternative option for mucous membrane pemphigoid when dapsone has caused haemolysis or other side effects. Dose: 500 mg three times a day
100
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S
5.1 Antibacterial drugs 5.1.11 Metronidazole and tinidazole Site Availability GSTFT KCH LGT
Formulary Item Metronidazole tablets, oral suspension 200 mg/5 mL, suppositories, injection Tinidazole tablets
5.1 Antibacterial drugs 5.1.12 Quinolones – Refer to BNF for CSM advice Formulary Item Ciprofloxacin tablets, oral suspension 250 mg/5 mL Ciprofloxacin injection Levofloxacin tablets Levofloxacin injection Moxifloxacin tablets MHRA advice: Because of evidence of an increased risk of life-threatening liver reactions and other serious risks (such as QT interval prolongation), oral moxifloxacin should be used only when it is considered inappropriate to use antibacterial agents that are commonly recommended for the initial treatment of the infections below or when these have failed. This restriction now applies to treatment of mild to moderate pelvic inflammatory disease as well as treatment of acute bacterial sinusitis, acute exacerbations of chronic bronchitis, and community acquired pneumonia (except severe cases). Nalidixic acid tablets Norfloxacin tablets Ofloxacin tablets Unlicensed Uses Drug Moxifloxacin tablets
Approved Indication Treatment of: Endogenous and postoperative endophthalmitis and bleb related endophthalmitis in glaucoma patients (Consultant Ophthalmologists only) Multi-Drug Resistant Tuberculosis (MDRTB) or if the patient is intolerant of standard regimens (Respiratory Consultants only) Recurrent/persistent nongonoccocal urethritis (NGU) as recommended in the British Association for Sexual Health and HIV guidelines (GUM Consultants only)
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Site Availability GSTFT KCH LGT M M S M S M S
S
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S
Site Availability GSTFT KCH LGT
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M
5.1 Antibacterial drugs 5.1.13 Urinary-tract infections Site Availability GSTFT KCH LGT
Formulary Item Nitrofurantoin tabs, caps, mr caps, oral suspension 25 mg/5 mL
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5.2 Antifungal drugs Site Availability GSTFT KCH LGT
Formulary Item 5.2.1 Triazole antifungals Fluconazole capsules, oral suspension 50 mg/5 mL, 200 mg/5 mL, injection Refer to BNF for CSM advice Itraconazole capsules, oral liquid 10 mg/mL Refer to BNF for CSM advice Itraconazole injection Posaconazole suspension 200 mg/5 mL Use in accordance with antifungal guidelines Treatment of invasive fungal infections, which are refractory to treatment with standard antifungals Primary prophylaxis in patients who are at high risk of developing invasive fungal infections Secondary prophylaxis in patients who have been successfully treated with posaconazole for an invasive fungal infection Voriconazole tablets, injection 5.2.3 Polyene antifungals Fungizone® (amphotericin) injection Abelcet® (amphotericin lipid complex) injection AmBisome® (amphotericin encapsulated in liposomes) injection Use in accordance with antifungal guidelines Nystatin oral suspension 100 000 units/mL
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5.2 Antifungal drugs Site Availability GSTFT KCH LGT
Formulary Item 5.2.4 Echinocandin antifungals Anidulafungin injection Use in accordance with Liver Institute protocol for antifungal use at KCH Treatment of invasive fungal infections in non-neutropenic patients with liver disease Use in accordance with ICU antifungal guideline at GSTFT and ICU antifungal guideline (non-haem/onc) at KCH Treatment of candidaemia and invasive disease in adult nonneutropenic ICU patients with significant hepatic dysfunction Use in accordance with antifungal guideline at LGT Caspofungin injection Use in accordance with antifungal guidelines Treatment of invasive candidiasis in adult patients Treatment of invasive aspergillosis in adult patients who are refractory to or intolerant of amphoterocin B, lipid formulations of amphoterocin B and/or itraconazole Emperical therapy for presumed fungal infections in febrile, neutropenic adult patients who are refractory to or intolerant of amphoterocin B and lipid formulations of amphoterocin B 5.2.5 Other antifungals Flucytosine injection Griseofulvin tablets Terbinafine tablets Unlicensed Uses Drug Flucytosine 500 mg tablets
Approved Indication Severe and resistant systemic fungal infections
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M S S
S S S
Site Availability GSTFT KCH LGT M
5.3 Antiviral drugs - Use in accordance with NHS England commissioning guidance and London HIV Drugs and Treatments Sub-Group guidelines 5.3.1 HIV infection Site Availability GSTFT KCH LGT
Formulary Item Nucleoside reverse transcriptase inhibitors Abacavir tablets, oral solution 20 mg/mL Kivexa® tablets (abacavir with lamivudine) Trizivir® tablets (abacavir with lamivudine and zidovudine) Didanosine tablets, enteric coated capsules Emtricitabine capsules, oral solution 10 mg/ mL Lamivudine tablets, oral solution 50 mg/5 mL Stavudine capsules, oral solution 1 mg/mL Tenofovir disoproxil tablets Truvada® tablets (tenofovir disoproxil with emtricitabine) Atripla® tablets (tenofovir disoproxil with emtricitabine and efavirenz) Eviplera® tablets (tenofovir disoproxil with emtricitabine and rilpivirine) Stribild® tablets (tenofovir disoproxil with cobicistat, elvitegravir and emtricitabine) Triumeq® tablets (dolutegravir, abacavir and lamivudine) Zidovudine capsules, oral solution 50 mg/5 mL, injection Combivir® tablets (zidovudine with lamivudine) Protease inhibitors Atazanavir capsules Darunavir tablets Fosamprenavir tablets, oral suspension 250 mg/5 mL Kaletra® tablets, oral solution 400/100 mg/5 mL (lopinavir with ritonavir) Ritonavir capsules, oral solution 400 mg/ 5 mL Saquinavir capsules, tablets Non-nucleoside reverse transcriptase inhibitors Efavirenz capsules, tablets, oral solution 30 mg/mL Etravirine tablets Confirm correct tablet formulation Nevirapine tablets 200 mg, m/r tablets 400 mg, oral suspension 50 mg/5 mL Rilpivirine tablets Other antiretrovirals Dolutegravir tablets Enfuvirtide injection Maraviroc tablets Raltegravir tablets Pharmacokinetic enhancers of antiretrovirals Cobicistat tablets Use as per NHSE clinical commissioning policy F03/P/b
105
S S
S S
S S
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S S S S S S
S S S S S S
S S S S S S
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S S S
S S S
S S S
S S S
S S S
S S S
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S S
S S
S S
S S
S S
S S
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S S S S
S S S S
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5.3 Antiviral drugs - Use in accordance with London HIV Drugs and Treatments Sub-Group guidelines 5.3.1 HIV infection Unlicensed Uses Drug
Approved Indication Antiretroviral: 400 mg three times a day. Alternatively 600 mg twice daily Antiretroviral
Delavirdine tablets Didanosine powder 2 g, 4 g Mylanta extra strength liquid cherry flavour
Site Availability GSTFT KCH LGT S S
Antacid, used as a constituent of didanosine solution
5.3 Antiviral drugs 5.3.2 Herpes virus infections Site Availability GSTFT KCH LGT
Formulary Item 5.3.2.1 Herpes simplex and varicella-zoster infection Aciclovir tablets, dispersible tablets, oral suspension 200 mg/5 mL, injection Valaciclovir tablets 5.3.2.2 Cytomegalovirus infection Cidofovir injection Ganciclovir injection Foscarnet sodium injection Valganciclovir tablets
106
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S S M
S S S
5.3 Antiviral drugs 5.3.3 Viral hepatitis Site Availability GSTFT KCH LGT
Formulary Item Adefovir dipivoxil tablets Use in accordance with NICE guidance for chronic Hepatitis B (NICE clinical guideline 165) Boceprevir capsules Prescribing is restricted to Hepatology Specialist use only Use in accordance with NICE guidance for the treatment of genotype 1 chronic hepatitis C (NICE technology appraisal 253) Daclatasvir tablets Use in accordance with NHSE Commissioning Policy: Treatment of Chronic Hepatitis C in Patients with Cirrhosis Use in accordance with NICE guidance for chronic hepatitis C (NICE technology appraisal 364) Blueteq prior approval required Dasabuvir tablets Use in accordance with NHSE Commissioning Policy: Treatment of Chronic Hepatitis C in Patients with Cirrhosis Blueteq prior approval required Entecavir tablets, oral solution 250 micrograms/5 mL Use in accordance with NICE guidance for chronic Hepatitis B (NICE technology appraisal 153) Lamivudine tablets, oral solution 25 mg/5 mL Use in accordance with NICE guidance for chronic Hepatitis B (NICE clinical guideline 165) Ombitasvir/Paritaprevir/Ritonavir tablets (Viekirax®) Use in accordance with NHSE Commissioning Policy: Treatment of Chronic Hepatitis C in Patients with Cirrhosis Use in accordance with NICE guidance for Chronic Hepatitis C (NICE technology appraisal 365) Blueteq prior approval required Peginterferon alfa-2a injection Use in accordance with NICE guidance for moderate to severe chronic hepatitis C (NICE technology appraisal 75), chronic Hepatitis C (NICE technology appraisal 200), chronic Hepatitis B (NICE technology appraisal 96) and chronic hepatitis C in children and young people (NICE technology appraisal 300) Use in accordance with NHSE Commissioning Policy: Treatment of Chronic Hepatitis C in Patients with Cirrhosis
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5.3 Antiviral drugs 5.3.3 Viral hepatitis Site Availability GSTFT KCH LGT
Formulary Item Peginterferon alfa-2b injection Use in accordance with NICE guidance for mild chronic Hepatitis C (NICE technology appraisal 106), chronic Hepatitis C (NICE technology appraisal 200). Use in accordance with NHSE Commissioning Policy: Treatment of Chronic Hepatitis C in Patients with Cirrhosis Ribavirin capsules, tablets Use in accordance with NICE guidance for moderate to severe chronic hepatitis C (NICE technology appraisal 75), mild chronic Hepatitis C (NICE technology appraisal 106), chronic Hepatitis C (NICE technology appraisal 200). Use in accordance with NHSE Commissioning Policy: Treatment of Chronic Hepatitis C in Patients with Cirrhosis Simeprevir capsules Use in accordance with NICE guidance for the treatment of chronic Hepatitis C (NICE technology appraisal 331) and NHSE Commissioning Policy: Treatment of Chronic Hepatitis C in Patients with Cirrhosis Blueteq prior approval required Sofosbuvir tablets Use in accordance with NICE guidance for the treatment of chronic Hepatitis C (NICE technology appraisal 330) and NHSE Commissioning Policy: Treatment of Chronic Hepatitis C in Patients with Cirrhosis Blueteq prior approval required Sofosbuvir/Ledipasvir tablets (Harvoni®) Use in accordance with NHSE Commissioning Policy: Treatment of Chronic Hepatitis C in Patients with Cirrhosis. Use in accordance with NICE guidance for the treatment of chronic hepatitis C (NICE technology appraisal 363) Blueteq prior approval required Telaprevir tablets Prescribing is restricted to Hepatology Specialist use only Use in accordance with NICE guidance for the treatment of genotype 1 chronic hepatitis C (NICE technology appraisal 252) Tenofovir disoproxil tablets Use in accordance with local guidelines First line for new patients with chronic hepatitis B An option for substitution for adefovir in those patients on combination lamivudine/ adefovir Add-on in those patients with suboptimal response/ resistance to lamivudine or entecavir Use in accordance with NICE guidance for chronic Hepatitis B (NICE technology appraisal 173)
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5.3 Antiviral drugs Site Availability GSTFT KCH LGT
Formulary Item 5.3.4 Influenza Oseltamivir capsules, oral suspension 30 mg/5 mL Use in accordance with NICE guidance for treatment of influenza (NICE technology appraisal 168) and prophylaxis of influenza (NICE technology appraisal 158) Please refer to local guideline at GSTFT Zanamivir dry powder for inhalation Use in accordance with NICE guidance for treatment of influenza (NICE technology appraisal 168) and prophylaxis of influenza (NICE technology appraisal 158) Please refer to local guideline at GSTFT 5.3.5 Respiratory syncytial virus Refer to paediatric formulary
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5.4 Antiprotozoal drugs 5.4.1 Antimalarials Site Availability GSTFT KCH LGT
Formulary Item Artemether with lumefantrine Artemether with lumefantrine tablets (Riamet®) Chloroquine Chloroquine tablets, syrup, injection Mefloquine Mefloquine tablets Primaquine Primaquine tablets Proguanil Proguanil hydrochloride tablets Proguanil hydrochloride with atovaquone Proguanil hydrochloride with atovaquone tablets Pyrimethamine Fansidar® (pyrimethamine with sulfadoxine) tablets Quinine Quinine sulphate tablets Quinine dihydrochloride injection Tetracyclines Doxycycline capsules Unlicensed Uses Drug
Approved Indication
Artesunate injection
At GSTFT use in accordance with the guideline “Management of Malaria in Adults” First-line therapy for severe falciparum malaria in non-pregnant adults Prevention of subsequent relapse of non-falciparum malaria. Dose: Orally 15 mg daily for 14 days following the treatment of P. vivax and P.ovale malaria. Please seek expert advice for G6PD deficient individuals and cases where relapse occurs despite primaquine therapy PCP treatment in accordance with BHIVA guidelines. Dose: 15-30 mg once daily
Primaquine tablets
Primaquine tablets
110
Site Availability GSTFT KCH LGT
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5.4 Antiprotozoal drugs 5.4.2 Amoebicides Site Availability GSTFT KCH LGT
Formulary Item Metronidazole tablets, oral suspension 200 mg/5 mL, suppositories, injection Tinidazole tablets
5.4 Antiprotozoal drugs 5.4.4 Antigiardial drugs Unlicensed Uses Drug
Approved Indication Giardiasis Dose: 100 mg every 8 hours for 5-7 days
Mepacrine hydrochloride tablets
Site Availability GSTFT KCH LGT M
M
5.4 Antiprotozoal drugs 5.4.5 Leishmaniacides Site Availability GSTFT KCH LGT
Formulary Item Sodium stibogluconate injection Treatment of visceral and cutaneous leishmaniasis. All cases of leishmaniasis (including any at GSTFT) should be referred to the infectious disease clinic for skin disease at KCH Unlicensed Uses Drug Paromomycin tablets
Approved Indication Leishmaniasis
S
Site Availability GSTFT KCH LGT M
5.4 Antiprotozoal drugs 5.4.7 Drugs for toxoplasmosis Site Availability GSTFT KCH LGT
Formulary Item Pyrimethamine tablets Use in accordance with protocol for the treatment of Toxoplasma gondii at GSTFT. Should be co-prescribed with calcium folinate 15 mg once daily to counteract myelosuppressive effects of pyrimethamine Dose: 200 mg loading dose followed by 50 mg once daily (60 kg), for 6 weeks
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5.4 Antiprotozoal drugs 5.4.8 Drugs for pneumocystis pneumonia Formulary Item Atovaquone oral suspension 750 mg/5 mL Co-trimoxazole tablets, injection Pentamidine isetionate injection, nebuliser solution Unlicensed Uses Drug Dapsone tablets
Approved Indication Treatment of pneumocystis pneumonia
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Site Availability GSTFT KCH LGT S S S S S S Site Availability GSTFT KCH LGT S
S
5.5 Anthelmintics Site Availability GSTFT KCH LGT
Formulary Item 5.5.1 Drugs for threadworms Mebendazole tablets, oral suspension 100 mg/5 mL 5.5.2 Ascaricides (common roundworm infections) Mebendazole tablets, oral suspension 100 mg/5 mL 5.5.3 Drugs for tapeworm infections Unlicensed Uses Drug
Approved Indication
Tapeworm infection Dose: single dose of 10-20 mg/kg after a light breakfast 5.5.4 Drugs for hook worms Mebendazole tablets, oral suspension 100 mg/5 mL 5.5.5 Schistosomicides (bilharziasis) Unlicensed Uses
Site Availability GSTFT KCH LGT
Praziquantel tablets
Drug
Approved Indication
Bilharziasis Dose: 40 mg/kg in 2 divided doses 4-6 hours apart on one day (60 mg/kg in 3 divided doses on one day for S. japonicum infections) 5.5.7 Drugs for cutaneous larva migrans Unlicensed Uses
M
M
Site Availability GSTFT KCH LGT
Praziquantel tablets
Drug
Approved Indication
Albendazole tablets Multiple infections Ivermectin tablets Cutaneous larva migrans 5.5.8 Drugs for strongyloidiasis Unlicensed Uses Drug Ivermectin tablets Tiabendazole tablets
Approved Indication Strongyloidiasis Dose: 200 micrograms/kg daily, for 2 days Strongyloidiasis Dose: 25 mg/kg (max.15 g) 12 hourly, for 3 days
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Site Availability GSTFT KCH LGT M
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6. Endocrine system 6.1 Drugs used in diabetes 6.1.1 Insulins Formulary Item
Restrictions and/or Advice
6.1.1.1 Short-acting insulins Soluble insulin – human sequence (Actrapid®, Humulin S®) Insulin Aspart (NovoRapid®) Insulin Lispro (Humalog®)
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Site Availability GSTFT KCH LGT
6.1 Drugs used in diabetes – Use in accordance with NICE Clinical Guidelines NG17 - Type 1 diabetes in adults: diagnosis and management, and NG28 – Type 2 diabetes in adults: management 6.1.1 Insulins Formulary Item
Restrictions and/or Advice
6.1.1.2 Intermediate- and long- acting insulins Insulin Degludec RESTRICTED USE – Can only be (Tresiba®) initiated by a Specialist (Consultant Diabetologist or GPwSI). Monitoring and continuation of care remains the responsibility of the Specialist for the first 3 months, after which care may be transferred to primary care in accordance with the approved ‘Transfer of Care’ document Only for adults 18 years or over with type 1 diabetes where: psychosocial or other factors indicate the need for longer duration insulin to facilitate continued treatment and avoid decompensation, and where all other therapies have failed Patients under 18 years may be considered for therapy but this must remain under specialist care and treatment must be approved by the Trust’s unlicensed medicines process Insulin Detemir (Levemir®) Insulin Glargine (Lantus®) Isophane insulin – highly purified animal (Hypurin® Bovine Isophane) Isophane insulin – human sequence (Insulatard®, Humulin I®)
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Site Availability GSTFT KCH LGT
6.1 Drugs used in diabetes Use in accordance with NICE Clinical Guidelines NG17 - Type 1 diabetes in adults: diagnosis and management, and NG28 – Type 2 diabetes in adults: management 6.1.1 Insulins Formulary Item
Restrictions and/or Advice
6.1.1.2 Intermediate- and long- acting insulins Biphasic insulins Biphasic insulin aspart (NovoMix® 30) Biphasic isophane insulin – Human sequence (Humulin M3®) Biphasic insulin lispro (Humalog® Mix25, Humalog® Mix50) Unlicensed Uses Drug Approved Indication Soluble insulin injection Humulin® R concentrated insulin injection 500 units/mL
Hyperkalaemia. Use in accordance with locally approved guidelines Restricted use – initiation restricted to named consultants (Dr David Hopkins, KCH) Continuation of supply and monitoring remains the responsibility of the hospital
Site Availability GSTFT KCH LGT
Site Availability GSTFT KCH LGT
6.1 Drugs used in diabetes 6.1.2 Antidiabetic drugs Site Availability GSTFT KCH LGT 6.1.2.1 Sulphonylureas - Use in accordance with NICE guidance for type 2 diabetes (NICE clinical guideline 87) Glibenclamide tablets Gliclazide tablets Glipizide tablets Tolbutamide tablets 6.1.2.2 Biguanides - Use in accordance with NICE guidance for type 2 diabetes (NICE clinical guideline 87) Metformin tablets Metformin m/r tablets Metformin oral solution Prescribing should be restricted for 500 mg/5 mL patients who are unable to swallow tablets Formulary Item
Restrictions and/or Advice
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6.1 Drugs used in diabetes Use in accordance with NICE Clinical Guidelines NG17 - Type 1 diabetes in adults: diagnosis and management, and NG28 – Type 2 diabetes in adults: management 6.1.2.3 Other antidiabetic drugs Formulary Item Acarbose tablets Canagliflozin tablets
Dapagliflozin tablets
Empagliflozin tablets
Exenatide injection (Byetta®)
Restrictions and/or Advice Use in accordance with NICE guidance for type 2 diabetes (NICE clinical guideline 87) For initiation by a Specialist (Consultant Diabetologist, a GPwSI or following consultation with an Intermediate Diabetes Care Team). Monitoring and continuation of care remains the responsibility of the Specialist for the first 6 months. Use in accordance with NICE guidance for use as combination therapy for type 2 diabetes (NICE technology appraisal 315) Treatment and initiation arrangements are as outlined above for canagliflozin Use in accordance with NICE guidance for use as combination therapy for type 2 diabetes (NICE technology appraisal 288) Treatment and initiation arrangements are as outlined above for canagliflozin Use in accordance with NICE guidance for use as combination therapy for type 2 diabetes (NICE technology appraisal 336) For initiation by a Specialist (Consultant Diabetologist, a GPwSI or following consultation with an Intermediate Diabetes Care Team). Use in accordance with NICE guidance for type 2 diabetes (NICE clinical guideline 87) Also supported for initiation by specialists, as add-on therapy to insulin regimens for obese patients with type 2 diabetes. Refer to the South East London APC recommendation for further information
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Site Availability GSTFT KCH LGT
6.1 Drugs used in diabetes Use in accordance with NICE Clinical Guidelines NG17 - Type 1 diabetes in adults: diagnosis and management, and NG28 – Type 2 diabetes in adults: management 6.1.2.3 Other antidiabetic drugs Formulary Item Exenatide prolongedrelease injection (Bydureon®)
Liraglutide injection
Lixisenatide injection
Pioglitazone tablets
Repaglinide tablets Sitagliptin tablets Linagliptin tablets
Restrictions and/or Advice For initiation by a Specialist (Consultant Diabetologist, a GPwSI or following consultation with an Intermediate Diabetes Care Team). Use in accordance with NICE guidance for type 2 diabetes (NICE technology appraisal 248) For initiation by a Specialist (Consultant Diabetologist, a GPwSI or following consultation with an Intermediate Diabetes Care Team). Use of the 1.8mg/day dose is not supported. Use in accordance with NICE guidance for type 2 diabetes (NICE technology appraisal 203) Supported for initiation by specialists, as add-on therapy to insulin regimens for obese patients with type 2 diabetes. Refer to the South East London APC recommendation for further information Refer to BNF for MHRA/CHM advice on cardiovascular safety Refer of BNF for EMA advice on bladder cancer Use in accordance with NICE guidance for type 2 diabetes (NICE clinical guideline 87) Use in accordance with NICE guidance for type 2 diabetes (NICE clinical guideline 87) For initiation by a Specialist (Consultant Diabetologist, a GPwSI or following consultation with an Intermediate Diabetes Care Team). Reserved for use in patients with severe renal impairment (eGFR
