Formulary Chapter 4: Central nervous system - Full Chapter
|
Chapter Links... |
MHRA Drug Safety Alert (Feb 2015): Drugs and driving: blood concentration limits set for certain drugs |
NENC Palliative and End of Life Care Symptom Control Guidelines |
NICE NG62: Cerebral palsy in under 25s: assessment and management |
TEWV - Medicines Optimisation – Interactive Guide |
TEWV Guidelines |
TEWV Safe Transfer of Prescribing Guidance |
Details... |
04.07.02 |
Opioid analgesics |
|
|
|
NENC ICB DOES NOT support the routine long-term prescribing (greater than 3 months) of opioids or the use of high dose opioids (higher than 120 mg/day of oral morphine equivalent) for non-cancer, persistent pain in adults. |
|
Codeine
|
Formulary
|
First line
Second line
The following codeine preparations are unlicensed and approved for use:
- 30 mg suppositories.
- codeine 2mg, 3mg, 6mg, 15mg;
- codeine 30mg in 1ml injection
![CD](images/CD.jpg)
|
MHRA Drug Safety Update (Dec 2014): Codeine for analgesia: restricted use in children because of reports of morphine toxicity
MHRA Drug Safety Update (Dec 2014): Codeine: very rare risk of side-effects in breastfed babies
|
Morphine
|
Formulary
|
- Tablets - 10mg, 20mg, 50mg (Sevredol®)
- MR capsules - 10mg, 30mg, 60mg, 100mg, 200mg (Zomorph®)
- MR tablets - 5mg, 10mg, 15mg, 30mg, 60mg, 100mg, 200mg (MST®)
- Oral solution - 10mg in 5ml
- Injection - 10mg/ml, 15mg/ml, 20mg/ml, 30mg/ml
- Zomorph® is the preferred M/R formulation.
Note: the following preparations are also approved for use:
- morphine 5mg in 1ml injection
unlicensed
- 10mg in 1ml preservative free injection
unlicensed
- 2mg in 5ml epidural
unlicensed
- 100 micrograms/1 ml oral solution. For use in neonates.
unlicensed
- 50mg in 50ml PCA injection
|
|
Alfentanil
|
Formulary
|
- Palliative care use
- 500micrograms in 1ml [ST&S], 1mg in 2ml, 5mg in 10ml & 5mg in 1ml injection ampouless - approved for initiation by specialists in palliative care
- All non-palliative care indications
![Red](images/TrafficLightsRedV2.gif)
|
|
Diamorphine
|
Formulary
|
Unlicensed intranasal diamorphine is approved for use in children for the relief of severe pain due to clinically suspected limb fractures, burns and significant fingertip injuries. Appropriate risk assessments are to be conducted by each organisation in order to determine formulation of choice (e.g. ampoules or intranasal spray).
- Note: intranasal diamorhine
|
|
Ketamine
|
Formulary
|
|
|
Tramadol
|
Alternatives
|
- 50mg capsules, 50mg dispersible tablets & 100mg/2ml injection
- Only approved for use as a second-line weak opioid analgesic for use in patients where treatment with possible alternatives such as paracetamol, NSAIDs, and codeine is insufficiently effective, not tolerated or considered unsuitable for other reasons.
- Note: modified release tramadol is not approved or recommended.
|
|
Buprenorphine
|
Alternatives
|
- 200microgram sublingual tablets
- 300microgram in 1ml injection
- Buprenorphine patches (Preferred brand - Butec®) are approved for use in palliative care when fentanyl 12 microgram/hr transdermal patches exceed the patient’s analgesic requirements.
|
|
Fentanyl
|
Alternatives
|
- 12, 25, 50, 75 & 100 microgram/hour transdermal patches
- Prescribe by brand. Mezolar® has replaced Matrifen® as the first choice brand. Patients who currently use Matrifen® can continue to do so if managing well.
- Fentanyl sublingual tablets (Abstral®) NoTGhdNC
only for patients experiencing incident pain during radiotherapy, restricted to palliative care use only
- Fentanyl sublingual tablets (Abstral®) CD&TV
for breakthrough / rescue pain relief in palliative care
- nasal spray
- approved for use in children during diamorphine shortage with appropriate local governance arrangements
|
MHRA Drug Safety Update (Oct 2018): Transdermal fentanyl patches: life-threatening and fatal opioid toxicity from accidental exposure, particularly in children
MHRA Drug Safety Update (Sep 2020): Transdermal fentanyl patches for non-cancer pain: do not use in opioid-naive patients
Transdermal fentanyl – MHRA Drug Safety Update (July 2014): Transdermal fentanyl “patches”: reminder of potential life threatening harm from accidental exposure, especially in children
|
Hydromorphone
|
Alternatives
|
|
|
Methadone
|
Alternatives
|
The following preparations are approved:
- 5mg tablets;
- 5mg in 5ml mixture DTF & 5mg in 5ml sugar free solution
- 20mg in 1ml concentrated oral solution (
unlicensed)
- 10mg in 1ml injection
|
|
Oxycodone
|
Alternatives
|
- Approved only for use in patients who are intolerant of morphine.
![Green](images/TrafficLightsGreenV2.gif)
- Note: Oxycodone 50mg in 1ml injection is also approved for use, but is restricted to controlled circumstances in palliative patients following risk assessment by individual organisations.
![Green Traffic Light](images/TrafficLightsGreenplus.gif)
- Approved for use as part of Enhanced Recovery After Surgery (ERAS) as part of multi-modal enhanced recovery pathway following hip and knee surgery
![Red](images/TrafficLightsRedV2.gif)
- The OxyPro® branded generic is preferred (most cost effective option).
- The oral solution should be used instead of immediate release tablets.
|
|
Pethidine
|
Alternatives
|
|
|
Tapentadol
|
Alternatives
|
- Approved for use by chronic pain specialist in adults with severe pain who have been screened for a neuropathic element to their pain and are uncontrolled or experiencing GI side effects on existing therapy.
|
MHRA Drug Safety Update (Jan 2019): Tapentadol (Palexia): risk of seizures and reports of serotonin syndrome when co-administered with other medicines
|
Dihydrocodeine
|
Alternatives
|
- Note: the use of dihydrocodeine 30mg tablets & 10mg in 5ml oral solution is no longer recommended for regular use. Codeine is the preferred weak opioid analgesic.
- Dihydrocodeine is only approved for use in breast feeding mothers immediately postdelivery/ c-section where adequate pain relief has not been achieved using paracetamol and NSAIDs. Patients requiring continuation of dihydrocodeine following discharge (post delivery/c-section) can have dihydrocodeine prescribed in primary care (for short-term use only).
|
|
|
|
|
|
|
|
04.07.02 |
Weak opioids |
|
|
04.07.02 |
Strong opioids |
|
|
04.07.02 |
Breakthrough pain |
|
|
04.07.02 |
Injectable |
|
|
04.07.02 |
Other |
|
|
.... |
Key |
|
|
Cytotoxic Drug
|
|
Controlled Drug
|
|
High Cost Medicine
|
|
NHS England |
|
Homecare |
|
CCG |
|
Traffic Light Status Information
Status |
Description |
![Red](images/TrafficLightsRedV2.gif)
|
Drugs for hospital use only. The responsibility for initiation and monitoring treatment should rest with an appropriate hospital clinician and the drug should be supplied through the hospital throughout the duration of treatment.
In some very exceptional circumstances (e.g. due to distance from the hospital, storage, supply or mobility/transport problems) it may be appropriate for the GP to be asked to prescribe a Red drug. This should be negotiated on an individual patient basis and should only be done with the GP’s prior informed agreement where the roles of the GP and hospital services are clearly defined and agreed. The GP should not feel under pressure to prescribe in these circumstances.
For all RED drugs automatically added to the formulary in response to a positive NICE TA: Prescribers need to ensure that local Trust new drug governance procedures and pharmacy processes are followed before any prescribing. |
![Amber](images/TrafficLightsAmberV2.gif)
|
Drugs initiated by hospital specialist, but where continuing treatment by GPs may be appropriate under a shared care arrangement.
The specialist should send the GP a copy of the shared care agreement to sign. The GP should sign the shared care agreement, or indicate they do not want to be part of such an agreement, and return a copy back to the specialist. Shared care guidelines are available or are being developed for most of the drugs listed as Amber.
If no shared care guideline is available, the hospital specialist should provide the patient’s GP with sufficient information and support to allow treatment to be continued and managed safely in primary care. |
![Green plus](images/TrafficLightsGreenPlus.gif)
|
Drugs normally recommended or initiated by a specialist (hospital or GP with an extended role https://www.rcgp.org.uk/gpwer), but can be safely maintained in primary care with very little or no monitoring required. In some cases there may be a further restriction for use outlined - these will be defined in each case. Provision of additional information, or an information leaflet, may be appropriate in some cases to facilitate continuing treatment by GPs. |
![Green](images/TrafficLightsGreenV2.gif)
|
Drugs where prescribing by GPs is appropriate. Can be initiated and prescribed in all care settings, and if appropriate, discontinued without recourse to secondary care. |
![Black](images/TrafficLightsBlackV2.gif)
|
NOT APPROVED: Drugs that have been considered by NTAG or the NENC ICB Medicines Subcommittee (or other approved body) and are not approved for prescribing within the North East and North Cumbria. |
![Brown](images/TrafficLightsBrownV2.gif)
|
UNDER REVIEW: drugs whose current formulary status or RAG status is currently under review. |
![Not Recomended](images/TrafficLightsBlueNR.gif)
|
NOT REVIEWED: Drugs that haven not been reviewed yet. This usually means that an application is in progress. These drugs are not normally considered appropriate for prescribing in the North East and North Cumbria until such time that a decision is taken on their formulary status. |
|
|
|