North East and North Cumbria Formulary


	North East and North Cumbria ICS Formulary

Search

Formulary Chapter 11: Eye - Full Chapter

Notes:

Preservative Free Eye Drops
Microbial contamination of multidose bottles of eye drops can cause eye infections that may lead to damage of the eye and in extreme cases loss of sight. To minimise the risk, multidose bottles of eye drops contain an antimicrobial preservative such as benzalkonium chloride. The preservatives used in eye drops are normally well tolerated, but they are not completely harmless. They can cause irritation and damage to the corneal epithelium. This risk is understood to be greater in patients with pre-existing damage to the ocular surface and where large quantities of preservative containing eye drops are applied repeatedly over a prolonged period (e.g. if applied more than 4 to 6 times daily for several weeks/ months).
To avoid these problems the use of preservative-free eye drops is recommended in:
 Patients who have experienced hypersensitivity reactions or irritation due to preservatives in eye drops.
 Patients who have received corneal grafts.
 Patients with conditions where there is already damage to the ocular surface as a result of disease or trauma, such as dry eye, blepharitis, ocular burns etc.
Treatment with preservative-free eye drops will usually be initiated by an ophthalmologist.

Chapter Links...

NICE NG242 : Diabetic retinopathy: management and monitoring

North of Tyne, Gateshead and North Cumbria - Ophthalmology Referral Guidelines

Details...

11.04.01

Corticosteroids

Betamethasone 0.1% eye drops

First Choice

Dexamethasone 0.05%, framycetin sulf. 0.5%, gramicidin 0.005% eye drops (Sofradex)

Formulary

Hydrocortisone Sodium Phosphate (Softacort^®)

Formulary

3.35 mg per 1 ml eye drops (0.4ml unit dose)
- Approved for patients who require a preservative-free low potency ocular corticosteroid

Rimexolone

Formulary

ophthalmology advice only - second line if flurometholone unsuitable

Betamethasone 0.1% with Neomycin 0.5% eye drops

Alternatives

Dexamethasone 0.1% eye drops (Maxidex^®)

Alternatives

Preservative-free eye drops are also approved.
- 0.1% Minims® - first choice.
- 0.1% preservative free eye drops unlicensed - approved only for patients who are unable to use Minims®due to dexterity problems.

Dexamethasone 0.1% Preservative-free

Alternatives

First choice

Unit dose vials (Minims®)

Alternative

Eye drops (unlicensed) - only for patients who are unable to use Minims® due to dexterity problems

Dexamethasone with Neomycin and Polymyxin B sulphate (Maxitrol^®)

Alternatives

Eye drops and eye ointment

Fluorometholone 0.1% Eye drops (FML^®)

Alternatives

For use in patients who experience ocular hypertension with other corticosteroids – treatment to be initiated with the advice of an ophthalmologist.

Loteprednol Eye drops

Alternatives

Approved as a second line agent to conventional corticosteroid eye drops, treatment to be imitated with the advice of an ophthalmologist only.

Prednisolone 0.5% Single Use Minims^®

Alternatives

Prednisolone eye drops

Alternatives

The following formulations are approved
- 0.5% eye drops and 1% (Pred-Forte).
- 0.1% and 0.3% eye drops - both unlicensed.
Approved preservative free formulations include
- 0.5% minims.
- 0.1%, 0.3%, 0.5% and 1% - all unlicensed.

Dexamethasone 700 microgram intravitreal implant (Ozurdex^®)

Alternatives

Approved for macular oedema following central retinal vein occlusion
in line with NICE.
Approved for treating diabetic macular oedema in line with NICE.
Approved for the treatment of non-infectious uveitis in line with NICE and NHS England Commissioning Policy

Note: The Northern (NHS) Treatment Advisory Group recommends the sequential pharmacological management of MO secondary to RVO as per the North East Retina Group (NERG) RVO treatment pathway.

NICE TA229 Dexamethasone intravitreal implant for the treatment of macular oedema secondary to retinal vein occlusion

NICE TA460 Adalimumab and dexamethasone for treating non-infectious uveitis

NICE TA824: Dexamethasone intravitreal implant for treating diabetic macular oedema

Fluocinolone 190 microgram intravitreal implant

Alternatives

Recommended as a possible treatment for people with chronic diabetic macular oedema who have an artificial lens in their eye if the implant is used in the eye with the artificial lens and their diabetic macular oedema has not got better with other treatments - in line with NICE.
Approved for the treatment of recurrent non-infectious uveitis in line with NICE
Approved for treating chronic diabetic macular oedema in phakic eyes after an inadequate response to previous therapy in line with NICE
Approved for treating chronic diabetic macular oedema in line with NICE

NICE TA301: Fluocinolone acetonide intravitreal implant for treating chronic diabetic macular oedema after an inadequate response to prior therapy

NICE TA590: Fluocinolone acetonide intravitreal implant for treating recurrent non-infectious uveitis

NICE TA613: Fluocinolone acetonide intravitreal implant for treating chronic diabetic macular oedema in phakic eyes after an inadequate response to previous therapy

NICE TA953: Fluocinolone acetonide intravitreal implant for treating chronic diabetic macular oedema

MHRA Drug Safety Update (Aug 2017): Corticosteroids: rare risk of central serous chorioretinopathy with local as well as systemic administration

....

Key

	Restricted Drug
	Unlicensed
	Link to adult BNF
	Link to children's BNF
	Link to SPCs
	Cytotoxic Drug
	Controlled Drug

	High Cost Medicine
	NHS England
	Homecare
	ICB
	Low carbon footprint
	Medium carbon footprint
	High carbon footprint

Status	Description
	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.
	Drugs initiated by hospital specialist, but where continuing treatment by GPs may be appropriate under a shared care arrangement. These medicines are considered suitable for primary care prescribing following specialist initiation of therapy and stabilisation, with ongoing communication between the primary care prescriber and specialist as set out in the associated shared care guideline (SCG). Shared care should be initiated by the specialist, which includes consultant, suitably trained specialist non-medical prescriber or GPwER within a secondary, tertiary, or primary care clinic. The specialist should send the primary care prescriber a copy of the NENC Clinical Effectiveness and Governance (CEG) Subcommittee approved SCG to sign. The primary care prescriber should sign the SCG or indicate reasons why they are unable to accept the agreement and return a copy back to the specialist, as soon as possible. SCGs are available or are being developed for most of the drugs listed as AMBER.
	Drugs normally recommended or initiated by a hospital specialist who is a prescriber, a GP with an extended role [GPwER], or a specialist within primary care which can be safely maintained in primary care and monitored in primary care. In some cases, a further restriction for use may be defined. The primary care prescriber must be familiar with the drug to take on prescribing responsibility or must obtain the required information from the specialist. Therefore, provision of additional information, or an information leaflet, may be appropriate in some cases to facilitate continuing treatment by primary care prescriber or provide information re stopping criteria. These are considered suitable for primary care prescribing following specialist assessment and recommendation of therapy, with ongoing communication between the primary care prescriber and specialist, if necessary. In some case these drugs require specialist initiation and short to medium term monitoring of efficacy or toxicity until the patient’s dose is stable. Following specialist review the patient may be transferred to primary care for ongoing prescribing. Ongoing prescribing by primary care can include, if required, additional dose titrations and assessment of efficacy, with ongoing communication between the primary care prescriber and specialist, if necessary. If the drug requires urgent initiation, it is expected that the specialist undertakes the initial prescribing responsibility for an appropriate period of time, usually a minimum of 28 days. A GREEN+ drug can only be recommended to primary care for initiation if does not need to be initiated within 28 days.
	Medicines suitable for initiation, ongoing prescribing and discontinuation in all care settings, subject to appropriate communication between those responsible.
	UNDER REVIEW: drugs whose current formulary status or RAG status is currently under review.
	Drugs that have been considered by the NENC Clinical Effectiveness and Governance (CEG) Subcommittee (or other approved body) and are not approved for prescribing within the North East and North Cumbria ICS. These may also include all medicines with a “not NHS” or “DLCV” classification in the BNF, those agents as included within the NICE “Do not do” list, and those agents included with the NHS England: Items which should not routinely be prescribed in primary care.