| Formulary Chapter 4: Central nervous system - Full Chapter
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| Chapter Links... |
 MHRA Drug Safety Alert (Feb 2015): Drugs and driving: blood concentration limits set for certain drugs |
 NENC Palliative and End of Life Care Symptom Control Guidelines |
| NICE NG62: Cerebral palsy in under 25s: assessment and management |
| TEWV - Medicines Optimisation – Interactive Guide |
| TEWV Guidelines |
| TEWV Safe Transfer of Prescribing Guidance |
| Details... |
| 04.06 |
Drugs used in nausea and vertigo |
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Droperidol
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Formulary
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Granisetron
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Formulary
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Metoclopramide INJECTION
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Formulary
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Nabilone
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Formulary
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Ondansetron INJECTION
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Formulary
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MHRA Drug Safety Alert (Jul 2013): Ondansetron for intravenous use: dose-dependent QT interval prolongation
MHRA Drug Safety Update (Jan 2020): Ondansetron: small increased risk of oral clefts following use in the first 12 weeks of pregnancy
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| 04.06 |
Vomiting during pregnancy |
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Postoperative nausea and vomiting |
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Motion sickness |
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Other vestibular disorders |
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Cytotoxic chemotherapy |
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Palliative care |
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Migraine |
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Antihistamines |
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Cinnarizine
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Formulary
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Cyclizine
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Formulary
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Doxylamine & pyridoxine (Xonvea®)
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Formulary
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- Doxylamine succinate 10 mg/pyridoxine hydrochloride 10 mg tablets
- Approved for use in nausea and vomiting in pregnancy in line with RCOG guidelines.
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Promethazine Hydrochloride (Phenergan)
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Formulary
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| 04.06 |
Phenothiazines and related drugs |
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Prochlorperazine
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Formulary
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- Note: Buccastem® 3mg tablets are only approved for the treatment of nausea associated with migraine when the oral route cannot be used due to vomiting.
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| 04.06 |
Domperidone and metoclopramide |
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Metoclopramide
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Formulary
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- Please refer to MHRA advice
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Metoclopramide: risk of neurological adverse effects
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Domperidone
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 Unlicensed
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- Approved for use as a galactagogue to re-establish breastfeeding on specialist advice and following a cardiovascular risk assessment in light of MHRA advice.
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MHRA Drug Safety Alert (May 2014): Domperidone: risk of cardiac side effect
MHRA Drug Safety Update (Dec 2019): Domperidone for nausea and vomiting: lack of efficacy in children; reminder of contraindications in adults and adolescents
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| 04.06 |
5HT3 antagonists |
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Ondansetron
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First Choice
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- The cheapest available formulation should be used.
- Ondansetron 4mg and 8mg oro-dispersible tablets/films are approved for the treatment of post-operative nausea and vomiting in patients who do not require IV access or are nil by mouth
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MHRA Drug Safety Update (Jan 2020): Ondansetron: small increased risk of oral clefts following use in the first 12 weeks of pregnancy
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Palonosetron
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Alternatives
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- Only approved for the second line treatment of chemotherapy induced nausea vomiting only.
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Netupitant & Palonosetron (Akynzeo®)
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Alternatives
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- To be used in accordance with Northern England Strategic Clincial Cancer Network (NCCN) Guidelines
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| 04.06 |
Neurokinin receptor antagonist |
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Aprepitant
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Formulary
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- For the prevention of chemotherapy induced nausea and vomiting (CINV) in high risk patients in accordance with North of England Cancer Network: CINV Guidelines in adult oncology and haematology patients
- Off label use in children under 12yrs / longer term use, when required, for the prevention of nausea and vomiting in paediatric patients undergoing haematopoietic stem cell transplantation (HSCT).
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Fosaprepitant
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Formulary
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- For the prevention of chemotherapy induced nausea and vomiting (CINV) in high risk patients in accordance with North of England Cancer Network: CINV Guidelines in adult oncology and haematology patients
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| 04.06 |
Cannabinoid |
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Cannabidiol (Epidyolex®)
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Formulary
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- 100mg/1mL oral solution
- Approved for use in combination with clobazam for treating seizuires associated with Dravet syndrome in people aged 2 years and older
- Approved for use in combination with clobazam for treating seizures associated with Lennox-Gastaut syndrome
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NICE TA614: Cannabidiol with clobazam for treating seizures associated with Dravet syndrome
NICE TA615: Cannabidiol with clobazam for treating seizures associated with Lennox–Gastaut syndrome
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| 04.06 |
Hyoscine |
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Hyoscine Hydrobromide
(tablets/patches)
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Formulary
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- For the management of excessive secretions where tablets are unsuitable.
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MHRA Drug Safety Update (July 2023): Hyoscine hydrobromide patches (Scopoderm 1.5mg Patch or Scopoderm TTS Patch): risk of anticholinergic side effects, including hyperthermia
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| 04.06 |
Other drugs for Ménière's disease |
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Betahistine Dihydrochloride
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Formulary
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Key |
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Restricted Drug |
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Unlicensed |
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Link to adult BNF
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Link to children's BNF
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Link to SPCs
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Cytotoxic Drug |
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Controlled Drug |
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High Cost Medicine |
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NHS England |
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Homecare |
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ICB |
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Low carbon footprint |
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Medium carbon footprint |
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High carbon footprint |
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Description |
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Drugs for hospital use only. The responsibility for initiation and monitoring treatment should rest with an appropriate hospital clinician and the drug should be supplied through the hospital throughout the duration of treatment. In some very exceptional circumstances (e.g. due to distance from the hospital, storage, supply or mobility/transport problems) it may be appropriate for the GP to be asked to prescribe a Red drug. This should be negotiated on an individual patient basis and should only be done with the GP’s prior informed agreement where the roles of the GP and hospital services are clearly defined and agreed. The GP should not feel under pressure to prescribe in these circumstances. For all RED drugs automatically added to the formulary in response to a positive NICE TA: Prescribers need to ensure that local Trust new drug governance procedures and pharmacy processes are followed before any prescribing. |
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Drugs initiated by hospital specialist, but where continuing treatment by GPs may be appropriate under a shared care arrangement. These medicines are considered suitable for primary care prescribing following specialist initiation of therapy and stabilisation, with ongoing communication between the primary care prescriber and specialist as set out in the associated shared care guideline (SCG). Shared care should be initiated by the specialist, which includes consultant, suitably trained specialist non-medical prescriber or GPwER within a secondary, tertiary, or primary care clinic.
The specialist should send the primary care prescriber a copy of the NENC Clinical Effectiveness and Governance (CEG) Subcommittee approved SCG to sign. The primary care prescriber should sign the SCG or indicate reasons why they are unable to accept the agreement and return a copy back to the specialist, as soon as possible.
SCGs are available or are being developed for most of the drugs listed as AMBER. |
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Drugs normally recommended or initiated by a hospital specialist who is a prescriber, a GP with an extended role [GPwER], or a specialist within primary care which can be safely maintained in primary care and monitored in primary care. In some cases, a further restriction for use may be defined. The primary care prescriber must be familiar with the drug to take on prescribing responsibility or must obtain the required information from the specialist. Therefore, provision of additional information, or an information leaflet, may be appropriate in some cases to facilitate continuing treatment by primary care prescriber or provide information re stopping criteria.
These are considered suitable for primary care prescribing following specialist assessment and recommendation of therapy, with ongoing communication between the primary care prescriber and specialist, if necessary.
In some case these drugs require specialist initiation and short to medium term monitoring of efficacy or toxicity until the patient’s dose is stable. Following specialist review the patient may be transferred to primary care for ongoing prescribing. Ongoing prescribing by primary care can include, if required, additional dose titrations and assessment of efficacy, with ongoing communication between the primary care prescriber and specialist, if necessary.
If the drug requires urgent initiation, it is expected that the specialist 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. |
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Medicines suitable for initiation, ongoing prescribing and discontinuation in all care settings, subject to appropriate communication between those responsible. |
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UNDER REVIEW: drugs whose current formulary status or RAG status is currently under review. |
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Drugs that have been considered by the NENC Clinical Effectiveness and Governance (CEG) Subcommittee (or other approved body) and are not approved for prescribing within the North East and North Cumbria ICS. These may also include all medicines with a “not NHS” or “DLCV” classification in the BNF, those agents as included within the NICE “Do not do” list, and those agents included with the NHS England: Items which should not routinely be prescribed in primary care. |
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