Download Antipsychotics (oral) BNF 4

Formulary for Psychotropic Medicines and the Treatment of Minor Physical Ailments

This formulary is intended for use by 5 Boroughs Partnership NHS Foundation Trust approved prescribers and its purpose is to ensure
that only those medicines that are safe, effective and value for money are used within the Trust.

Only medications that have an ‘approved’ status may be initiated within the Trust. Those that have ‘restricted’ status may only be
initiated in certain circumstances e.g. following approval from the medical director.

Where a service user is admitted onto an inpatient ward and they are already on established on medication that is ‘non-approved’ this
can be continued where clinically appropriate.

Always ensure that the most up to date version of the formulary and any accompanying guidelines are used.

When prescribing for complex individuals e.g. renal impairment, pregnancy contact the medicines management team for advice.
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 1 of 67
Version 3 08/12/2011
Contents
Page
Number
Topic
Reference
1 Introduction – Psychotropic
Medicines Formulary
2-4 Contents
5-8 Hypnotics BNF 4.1.1
NICE TA077
http://guidance.nice.org.uk/TA77/QuickRefGuide/pdf/English
British Association for psychopharmacology guidelines
http://www.bap.org.uk/docsbycategory.php?docCatID=2
The Ashton Manual
http://www.benzo.org.uk/manual/index.htm
9-11 Anxiolytics BNF 4.1.2
NICE CG22
http://guidance.nice.org.uk/CG113
12-23 Antipsychotics BNF 4.2.1
Trust
Antipsychotic Prescribing Guidelines
NICE CG82
http://guidance.nice.org.uk/CG82/Guidance
NICE CG38
http://guidance.nice.org.uk/CG38/Guidance/pdf/English
Royal College of Psychiatrists advice on prescribing above BNF upper limits
http://bnf.org/bnf/bnf/current/3208.htm
24 - 26 Depot Antipsychotics BNF
4.2.2
Maudsley Prescribing Guidelines
10th Edition, pages 35-41
Royal College of Psychiatrists Consensus Statement on High Dose Antipsychotic Prescribing
www.rcpsych.ac.uk/files/pdfversion/CR138.pdf
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 2 of 67
Version 3 08/12/2011
27-29 Antimanic Drugs BNF 4.2.3 Trust
http://5boroughswww/MANAGE/library/documents/5BP9002002_lithiumprocedurev2.2.pdf
NPSA
http://www.nrls.npsa.nhs.uk/resources/?EntryId45=65426
British Association for psychopharmacology guidelines for bipolar disorder
http://www.bap.org.uk/pdfs/Bipolar_guidelines.pdf
30-35 Antidepressants BNF 4.3
NICE CG90
http://guidance.nice.org.uk/CG90
NICE CG28
http://guidance.nice.org.uk/CG28
NICE CG91
http://guidance.nice.org.uk/CG91
36-40 CNS Stimulants and Drugs
Used for Attention Deficit
Hyperactivity Disorder BNF
4.4
NICE CG72
http://www.nice.org.uk/nicemedia/live/12061/42060/42060.pdf
British Association for psychopharmacology guidelines on the management of ADHD in
adolescents in transition to adult services and in adults
http://www.bap.org.uk/pdfs/ADHD_Guidelines.pdf
BNF for children
http://bnfc.org/bnfc/bnfc/current/3373.htm
41-42 Anticholinergic Medication
for the Management of
Extrapyramidal Side
Effects BNF 4.9.2
43-46 Drugs for Dementia BNF
4.11
NICE-SCIE CG42
http://www.nice.org.uk/nicemedia/live/10998/30320/30320.pdf
NICE TA217
http://www.nice.org.uk/nicemedia/live/13419/53619/53619.pdf
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 3 of 67
Version 3 08/12/2011
47-52 Other Drugs That May Be
Considered in the
Management of Bipolar
Disorder
53-55 Drugs approved for ‘off
NICE CG38
http://guidance.nice.org.uk/CG38/Guidance/pdf/English
British Association for psychopharmacology guidelines for bipolar disorder
http://www.bap.org.uk/pdfs/Bipolar_guidelines.pdf
Trust Unlicensed medicines procedure
label’ use
http://nww5boroughsintranet/library/documents/unlicensedmedicinesprocedure.pdf
56-67 Formulary for the treatment
of minor physical ailments
 Laxatives
 Analgesics
 Indigestion remedies
 Sore throat remedies
 Barrier creams
 Emollients
 Non
anti-microbial
ear drops
 Non
anti-microbial
eye drops
 Treatments for warts,
verrucas
and
coldsores
 Treatment
of
haemorrhoids
 Sunscreens
 Nutritional
supplements
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 4 of 67
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Return to Contents Page
Hypnotics BNF 4.1.1
 Prior to prescribing a hypnotic identify and treat any underlying
causes of insomnia. However, it is important to remember that
worsening of a mental health condition may disrupt sleep and in
this situation a short course of a hypnotic may be appropriate.
 Hypnotics are licensed for short term use only.
 Intermittent use better than regular use.
 Tolerance develops with 3 – 14 days of continued use.
 Offer advice on sleep hygiene.
 Keep a sleep chart prior to prescribing.
 Service users who have not responded to one hypnotic drug
from zopiclone, zolpidem or the shorter acting benzodiazepines
should not be switched to another as there is a lack of
compelling evidence to distinguish between them. The only
reason for switching between these drugs is if the service
user experiences side effects thought to be directly related
to a specific drug.
 For inpatients always review hypnotics prior to discharge and
stop if possible. If hypnotics are to be continued at discharge
the GP should be provided with specific instructions about how
long they are to be continued for and how to reduce the dose.
 Service users must be warned that hypnotics may affect their
ability to drive or operate machinery as a result of impaired
judgement and increased reaction time. This may continue the
next day (hangover effect) and the effects of alcohol will also be
increased. Visit http://www.dft.gov.uk/dvla/medical.aspx for full
guidance, including when the DVLA must be notified of a
medical condition and/or treatment.
Signposts to local (GREEN) and national (BLUE) prescribing guidelines
TRUST
NICE TA077
Hypnotic prescribing guidelines
Covers the use of the newer hypnotic drugs in the short term
management of insomnia
http://guidance.nice.org.uk/TA77/QuickRefGuide/pdf/En
glish
British Association for psychopharmacology guidelines
http://www.bap.org.uk/docsbycategory.php?docCatID=2
The Ashton
Manual
Full guidance on management of withdrawal of
benzodiazepines
http://www.benzo.org.uk/manual/index.htm
BNF
Suggested benzodiazepine withdrawal protocol and equivalent
doses http://bnf.org/bnf/bnf/current/3139.htm
Electronic
Medicines
Compendium
Summary of Product Characteristics for individual drugs
www.medicines.org.uk
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 5 of 67
Version 3 08/12/2011
Formulary
Status
Drug
Initial Dose*
Maximum
Dose*
Formulations
Available
Cost of 28 days
treatment
Approved
(first line)
Zopiclone
3.75mg at
bedtime
7.5mg at
bedtime
Tablets
£1.49-£1.57**
Approved
(second
line)
Temazepam
10mg at
bedtime
20mg at
bedtime
Tablets
£1.83-£3.05**
Liquid
£24.02-£48.05**
Zolpidem
5-10mg at
bedtime
10mg at
bedtime
Tablets
£1.79**
Nitrazepam
5-10mg at
bedtime
10mg at
bedtime
Tablets
£2.49-£4.98**
Oral suspension
£9.80-£19.60**
1-2 tablets at
bedtime
5 tablets
daily
Tablets (cloral
betaine 707mg)
£11.29-£56.46**
Approved
(third line)
Cloral betaine***
Comments
Licensed for up to 4 weeks use.
Licensed for up to 4 weeks use.
Cloral betaine 707mg is equivalent
to chloral hydrate 414mg.
Not kept as stock within the Trust –
may be a delay in obtaining.
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 6 of 67
Version 3 08/12/2011
Formulary
Status
Drug
Chloral
hydrate***
Approved
(third line)
Initial Dose*
Maximum
Dose*
5-20ml at
night
20ml at
night
Chloral mixture
500mg/5ml
Prices vary
according to
supplier.
2
capsules
at
bedtime
192mg capsules
£7.00-£35.00**
Clomethiazole
1-2 capsules
(chlormethiazole) at bedtime
Restricted
Melatonin
Formulations
Available
Cost of 28 days
treatment
Comments
Take well diluted with water.
Not kept as stock within the Trust
and only available from ‘special
order’ manufacturers – may be a
delay in obtaining.
Melatonin is available as a 2mg modified release tablet (Circadin®) which is licensed for short term treatment
of primary insomnia in patients over 55 years. Circadin® is not approved for initiation in adult service users
within the Trust.
However, Circadin® may be used within the CAMHS service where use of melatonin is considered
appropriate (prescription must specify that Circadin® is required - see prescribing advice below).
G:\Corporate
Pharmacy\Pharmacy Team\WORKING DOCUMENTS\Formulary\5BP melatonin prescribing advice ver01draFINAL 2009-10-28.doc
Prices vary according to supplier.
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 7 of 67
Version 3 08/12/2011
Formulary
Status
Not
Approved
Drug
Initial Dose*
Maximum
Dose*
Formulations
Available
Cost of 28 days
treatment
Comments
Flurazepam, Loprazolam, Lormetazepam, Triclofos sodium, and Zaleplon are not approved for initiation within the Trust.
*Usual dose for adults. Dose may vary for young people and elderly – see BNF for details
** Prices based on Drug Tariff November 2012 edition
***Identified in the BNF as drugs considered less suitable for prescribing. Although they should not be considered as drugs of first choice their
use may be justifiable in certain circumstances.
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 8 of 67
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Anxiolytics BNF 4.1.2
 Some antidepressants are licensed for use in anxiety and
related disorders (see BNF section 4.3) and are
considered first-line pharmacological treatment.
 Benzodiazepines licensed for short term relief (2-4 weeks
only) of severe anxiety. The use of benzodiazepines to
treat short-term ‘mild’ anxiety is not appropriate.
 Dependence, tolerance and a paradoxical increase in
hostility and aggression may develop with regular use.
 Withdraw benzodiazepines carefully and gradually.
 Beta-blockers reduce autonomic symptoms such as
palpitations and tremor. They do not affect psychological
symptoms of anxiety.
 Invest time in methods to improve medicine adherence
(NICE Medicine Adherence – page 5)
Signposts to local (GREEN) and national (BLUE) prescribing guidelines
NICE CG113
Generalised anxiety disorder and panic disorder (with or without
agoraphobia) in adults
http://guidance.nice.org.uk/CG113
BNF
Suggested benzodiazepine withdrawal protocol and equivalent doses
http://bnf.org/bnf/bnf/current/3139.htm
The Ashton
Manual
Electronic
Medicines
Compendium
Full guidance on management of withdrawal of benzodiazepines
http://www.benzo.org.uk/manual/index.htm
Summary of Product Characteristics for individual drugs
www.medicines.org.uk
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 9 of 67
Version 3 08/12/2011
Formulary
Status
Approved
Drug
Diazepam
Initial Dose*
Maximum
Dose*
Formulations
Available
Cost of 28 days
treatment
2mg three
times a day
30mg daily
in divided
doses
Tablets
£1.98-£2.19**
Oral Solution
£76.36£381.78**
1-4mg daily
in divided
doses
4mg daily
in divided
doses
Tablets
£3.15-£12.60**
Buspirone
5mg two to
three times
daily.
45mg daily
in divided
doses.
Tablets
£24.55-£80.56**
Propranolol
40mg once
daily
40mg
three times
daily.
Immediate
release tablets
£0.73-£2.19**
80mg once a
day of
modified
release
capsules
160mg
once a day
of modified
release
capsules
Modified
release
capsules
£5.06-6.76**
Lorazepam
Comments
Long half life likely to cause next day hang over
effect – consider effect on driving.
Short term use only.
Can also be used in rapid tranquilisation – refer to
Trust Rapid Tranquilisation Policy for details
Slow onset of action – 4 weeks at 10mg three
times a day needed for optimum efficacy.
Licensed for short-term use only.
Poor evidence of effectiveness.
Only to be used for anxiety with somatic symptoms
such as palpitations, sweating and tremor.
Should not be given to patients with a history of
asthma or bronchospasm.
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 10 of 67
Version 3 08/12/2011
Formulary
Status
Maximum
Dose*
Formulations
Available
Drug
Initial Dose*
Reserved
for use in
acute
alcohol
withdrawal
only.
Chlordiazep
oxide
Variable
dosing for
acute alcohol
withdrawal
over several
days.
Not
Approved
Oxazepam is not approved for initiation within the Trust.
Capsules
Cost of 28 days
treatment
Cost varies
according to
reducing regime
prescribed.
Comments
Long half life likely to cause next day hangover
effect – consider effect on driving.
*Usual dose for adults. Dose may vary for young people and elderly – see BNF for details
** Prices based on Drug Tariff November 2012 edition
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 11 of 67
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Signposts to local (GREEN) and national (BLUE) prescribing
guidelines
Antipsychotics BNF 4.2.1
 Physical health checks essential; baseline and annual FBC, LFTs,
U+Es, lipids, fasting glucose, weight/BMI, prolactin, blood pressure,
ECG. Use prescribed medication monitoring form
.http://nww5boroughsintranetcms/MANAGE/library/documents/5BPpre
scribedmedicationmonitoringform.pdf Document results in service
users notes and repeat more often if necessary.
 Review for common side effects including EPSEs, weight gain,
sexual & menstrual dysfunction. Document findings even if no side
effects experienced.
 The following antipsychotics should be considered as first line
treatment where appropriate; risperidone, olanzapine or quetiapine
immediate release or any of the typical antipsychotics as listed in
the table below. However, choice should always be guided by clinical
factors such as previous response, co-morbidities, side effect profile,
interacting medication and patient/carer choice. Where one of these
three antipsychotics is not chosen first line the reason for this
must be recorded in the notes.
 Clozapine should always be offered (unless not clinically appropriate)
when the response to two different antipsychotics, including at least
one second generation ‘atypical’ agent has been inadequate.
 Invest time in methods to improve medicine adherence (NICE
Medicine Adherence – page 5)
 Unless stated otherwise doses stated in this section are those
used for the treatment of schizophrenia and other psychoses.
Doses used in the management of other conditions such as
mania or BPSD may be different – see relevant section of
formulary or BNF for details.
TRUST
Antipsychotic Prescribing Guidelines
NICE CG82
Schizophrenia (update)
http://guidance.nice.org.uk/CG82/Guidance
NICE CG38
Bipolar Disorder
http://guidance.nice.org.uk/CG38/Guidance/pdf/E
nglish
Royal College of Psychiatrists advice on prescribing above BNF
upper limits
http://bnf.org/bnf/bnf/current/3208.htm
BNF
For initial doses, advice on dose titration,
indications and side effects.
http://bnf.org/bnf/bnf/current/3209.htm
Electronic
Medicines
Compendium
Summary of Product Characteristics for individual drugs
www.medicines.org.uk
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 12 of 67
Version 3 08/12/2011
Oral Antipsychotics
Formulary
status
Drug
Approved – Risperidone
first line
Where one
of these
drugs is
ineffective
or not
tolerated
then
another one
may be tried
– see
section
below for
Olanzapine
other
second line
options
Cost of 28
days
treatment
Initial
Dose*
Maximum
Dose*
Formulations
Available
2mg in
1-2
divided
doses
16mg daily
(but see
comments)
Tablets
£0.71£3.43**
Doses above 10mg daily only if benefit considered to outweigh the risks.
Orodispersible
tablets
£35.96130.24**
Many side effects such as EPSEs are dose related.
Liquid
£31.10248.77**
Comments
Orodispersible tablets and liquid are approximately ten
times more expensive than tablets.
Refer to table for the most cost effective way of
prescribing/administering the desired dose.
Can also be used in rapid tranquilisation – refer to Trust
Rapid Tranquilisation Policy for details
5-10mg
daily
20mg daily
Tablets
£1.81£5.62**
Orodispersible tablets are 10% more expensive than
ordinary tablets – see cost comparison table.
Orodispersible
tablets
£16.6160.01**
Refer to table for the most cost effective way of
prescribing/administering the desired dose.
Can also be used in rapid tranquilisation – refer to Trust
Rapid Tranquilisation Policy for details
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 13 of 67
Version 3 08/12/2011
Oral Antipsychotics
Formulary
status
Drug
Approved
– first line
Where one
of these
drugs is
ineffective
or not
tolerated
then
another one
may be tried
– see
section
below for
other
second line
options
Quetiapine
Initial
Dose*
25mg
twice
daily
Maximum
Dose*
Formulations
Available
750mg
daily
Tablets
Cost of 28
days
treatment
£2.73£28.79**
Comments
Can be given with or without food.
Refer to table for the most cost effective way of
prescribing/administering the desired dose.
Can also be used in rapid tranquilisation – refer to Trust
Rapid Tranquilisation Policy for details
Chlorproma
zine
25mg 3
times a
day
1000mg
daily
Tablets
£5.16£21.84**
Oral solution
£6.57£51.32**
Levomepro
mazine
2550mg
daily in
divided
doses
1000mg
daily
Tablets
£6.75£270.13**
Perphenazi
ne
4mg 3
times
daily
24mg daily
Tablets
28.77£57.54****
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 14 of 67
Version 3 08/12/2011
Oral Antipsychotics
Formulary
status
Drug
Initial
Dose*
Approved – Trifluoperazi 2-4mg
first line
ne
daily in
divided
Where one
doses
of these
drugs is
Haloperidol 0.5–3mg
ineffective
2–3
or not
times
tolerated
daily or
then
3–5mg
another one
2–3
may be tried
times
– see
daily in
section
severely
below for
affected
other
or
second line
resistant
options
patients
Flupentixol
3-9mg
twice
daily
Maximum
Dose*
Formulations
Available
6mg daily
Tablets
Oral solution
30mg daily
18mg daily
Cost of 28
days
treatment
Comments
£2.05£6.16****
£32.48£97.44**
Capsules
Tablets
£2.20£18.76**
Liquid
£0.62£18.69****
Tablets
£7.80£23.39**
Carry out ECG prior to commencing.
Can also be used in rapid tranquilisation – refer to Trust
Rapid Tranquilisation Policy for details
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 15 of 67
Version 3 08/12/2011
Oral Antipsychotics
Formulary
status
Drug
Zuclopenthi
Approved – xol
first line
Where one
of these
Sulpiride
drugs is
ineffective
or not
tolerated
then
another one
may be tried
– see
section
below for
other
second line
options
Cost of 28
days
treatment
Initial
Dose*
Maximum
Dose*
Formulations
Available
2030mg
daily in
divided
doses
200400mg
twice
daily
150mg
daily (max
single dose
40mg)
Tablets
£4.51£33.85**
800mg
daily in
predomina
ntly
negative
symptoms.
2.4g daily
in
predomina
ntly
positive
symptoms.
Tablets
£14.20£39.85**
(negative)
119.56**
(positive)
£47.38£94.75**
(negative)
£284.26**
(positive)
Oral solution
Comments
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 16 of 67
Version 3 08/12/2011
Oral Antipsychotics
Formulary
status
Drug
Amisulpride
Approved –
second line
An
alternative
drug from
the first line
section may
also be
considered
as a
possible
second line
option
Aripiprazole
Initial
Dose*
Maximum
Dose*
Formulations
Available
400mg –
800mg
daily in
divided
doses
1200mg
daily
Tablets
1015mg
once
daily
(oral)
30mg daily
Cost of 28
days
treatment
£10.15£87.91**
Comments
For predominantly negative symptoms use 50-300mg
daily
Refer to table for the most cost effective way of
prescribing/administering the desired dose.
Tablets
£96.04192.08**
Orodispersible
tablets
£95.74£191.48****
Liquid –
restricted (see
below)
Limited evidence of additional efficacy at doses above
15mg daily unless prescribed in combination with an
enzyme inducer such as carbamazepine.
Refer to table for the most cost effective way of
prescribing/administering the desired dose.
Can be used in rapid tranquilisation – refer to Trust Rapid
Tranquilisation Policy for details and dosages.
IM injection
(see
comments)
Benperidol
0.251.5mg
daily in
divided
doses
1.5mg
daily
Tablets
£24.44£146.64**
Only licensed for control of deviant antisocial sexual
behaviour
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 17 of 67
Version 3 08/12/2011
Oral Antipsychotics
Formulary
status
Drug
Quetiapine
Approved – XL
second line
An
alternative
drug from
the first line
section may
also be
considered
as a
possible
second line
option
Initial
Dose*
Maximum
Dose*
Formulations
Available
XL
formula
tion:
300mg
once
daily
800mg
once daily
XL tablets
Cost of 28
days
treatment
£79.33£211.12**
Comments
Consider the XL formulation in situations where a rapid
titration is required or where once daily administration
would be beneficial. In all other situations use quetiapine
immediate release where quetiapine is the chosen
antipsychotic.
Absorption affected by food, to maintain consistent levels
give as a single night time dose (without food)
See prescribing advice below:
G:\Corporate
Pharmacy\Pharmacy Team\WORKING DOCUMENTS\Formulary\5BP AZ Seroquel XL awareness cam
Refer to for table he most cost effective way of
prescribing/administering the desired dose.
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 18 of 67
Version 3 08/12/2011
Oral Antipsychotics
Formulary
status
Drug
Clozapine
(Clozaril®)
Use in
Treatment
Resistant
Schizophre
nia or
psychosis
in
Parkinson’
s disease
only
Restricted
– due to
high cost
use must
be agreed
with
locality
pharmacist
NonApproved
Initial
Dose*
12.5mg
once
daily
Maximum
Dose*
Formulations
Available
900mg
daily
Tablets
Cost of 28
days
treatment
£5.40£194.04****
Comments
Only drug licensed and effective for Treatment Resistant
Schizophrenia. Clozapine should always be offered
(unless not clinically appropriate) when the response to
two different antipsychotics, including at least one
atypical has been inadequate. Blood tests are
mandatory. See SOP for commencing and maintaining
clozapine treatment on the ward:
http://5boroughswww/MANAGE/library/documents/clozso
p06.pdf
Service user, prescriber and pharmacist must all be
registered with the Clozaril Patient Monitoring Service.
Aripiprazole
liquid
1015mg
daily
30mg daily
1mg/ml liquid
£191.46£574.39****
Limited evidence of increased efficacy at doses above
15mg daily unless prescribed in combination with an
enzyme inducer such as carbamazepine.
Orodispersible tablets are available – see above.
Paliperidone is not approved for initiation within the Trust – see
http://5boroughswww/MANAGE/library/documents/paliperidonefinalevaluation.pdf for further details
Asenapine, prochlorperazine, pimozide and pericyazine are not approved for initiation within the Trust.
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 19 of 67
Version 3 08/12/2011
Short Acting IM Antipsychotics
Formulary
status
Drug
Initial Dose*
Approved
– see
comments
Maximum
Dose*
Formulations
Available
Cost of 28
days
treatment
Comments
Aripiprazole
Refer to Trust Rapid
Tranquilisation Policy
IM injection
N/A
Choice of medication for rapid
tranquilisation should be based on previous
response, likely side effects, presentation of
the service user and any physical health
problems - refer to Trust Rapid
Tranquilisation Policy for full list of options.
Haloperidol
refer to Trust Rapid
Tranquilisation Policy
IM injection
N/A
Must not be confused with haloperidol
decanoate depot injection.
Choice of IM medication for rapid
tranquilisation should be based on previous
response, likely side effects, presentation of
the service user and any physical health
problems, therefore may be appropriate to
use haloperidol first line for rapid
tranquilisation - refer to Trust Rapid
Tranquilisation Policy for full list of options.
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 20 of 67
Version 3 08/12/2011
Short Acting IM Antipsychotics
Formulary
status
Drug
Initial Dose*
Approved
– see
comments
Maximum
Dose*
Formulations
Available
Cost of 28
days
treatment
Comments
Olanzapine
Refer to Trust Rapid
Tranquilisation Policy
IM injection
N/A
Choice of medication for rapid
tranquilisation should be based on previous
response, likely side effects, presentation of
the service user and any physical health
problems - refer to Trust Rapid
Tranquilisation Policy for full list of options.
Zuclopenthixol
acetate
refer to Trust Rapid
Tranquilisation Policy
50mg/ml IM
injection
N/A
Must not be confused with
zuclopenthixol decanoate depot
injection.
Refer to Trust Rapid Tranquilisation Policy
for information on appropriate use.
*Usual dose for adults. Dose may vary for young people and elderly – see BNF for details
** Prices based on Drug Tariff November 2012
**** Prices based on BNF September 2012 edition 64
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 21 of 67
Version 3 08/12/2011
Return to Start of Antipsychotic Section
Cost effective doses costs for Atypical Antipsychotics
Cost for 28 days supply
Formulation
Drug
Amisulpiride
Aripiprazole
Olanzapine
Quetiapine
Dose
Tablet
Modified Release
Oral dispersible
Liquid
200mg BD
1 x 200mg £10**
£62**
400mg BD
2x 200mg
£123**
600mg BD
3 x 200mg £30**
10mg OD
1 x 10mg £96**
1 x 10mg £96****
£192****
15mg OD
1 x 15mg £96**
1 x 15mg £96****
£287****
20mg OD
2 x10mg £192**
2 x 10mg £192****
£383****
25mg OD
1x15mg + 1x10mg
£192**
1x10mg + 1x15mg
£192****
£479****
30mg OD
1 x 30mg £192**
2 x 15mg £192**
2 x 15mg £192****
£574****
5mg BD
1 x 5mg
£4**
2 x 2.5mg £2**
1 x 5mg
10mg OD
1 x 10mg
£3**
15mg OD
1 x 15mg £4**
1 x 15mg £45**
10mg BD
1 x 10mg £6**
1 x 10mg £60**
20mg ON
2 x 10mg £6**
1 x 10mg £60**
150mg BD
1 x 150mg £8**
£20**
300mg OD
200mg BD
£185**
1x5mg + 1x15mg £192**
£33**
1 x 10mg £30**
1 x 300mg £79**
1x 200mg £8**
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 22 of 67
Version 3 08/12/2011
300mg BD
1 x 300mg £11**
600mg OD
400mg BD
1x400mg + 1x200mg
£158**
2x400mg £211**
2x300mg + 1x200mg
£211**
2 x 200mg £16 **
800mg OD
Risperidone
2x300mg £159**
1mg BD
1 x 1mg £2**
1 x 1mg £40 **
£31 **
2mg OD
1 x 2mg £1**
1 x 2mg £37 **
£31**
3mg OD
1x3mg £1**
1 x 3mg £28 **
£47**
2mg BD
1 x 2mg £2**
1x 2mg £72 **
£62**
4mg OD
1 x 4mg £1**
1 x 4mg £33 **
£62**
5mg OD
1 x 3mg + 1 x 2mg £2**
1 x 1mg + 1 x 4mg £52 **
£78**
3mg BD
1 x 3mg £2 **
1 x 3mg £56 **
£93**
6mg OD
2 x 3mg £2 **
2 x 3mg £56 **
£93**
1 x 4mg £65 **
1 x 1mg + 1 x 4mg £104
**
£124**
4mg BD
2 x 2mg £2 **
1 x 3mg + 1 x 2mg £3
5mg BD
**
Doses shown are the most cost effective, if strengths shown are not available please source
£155**
** Prices based on Drug Tariff November 2012 edition
**** Prices based on BNF September 2012 edition 64
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 23 of 67
Version 3 08/12/2011
Return to Contents Page
Signposts to local (GREEN) and national (BLUE) prescribing
guidelines
Depot Antipsychotics BNF 4.2.2
 Physical health checks essential: baseline and annual FBC, LFTs,
U+Es, lipids, fasting glucose, weight, prolactin, blood pressure, ECG.
Use prescribed medication monitoring form.
.http://nww5boroughsintranetcms/MANAGE/library/documents/5BPpre
scribedmedicationmonitoringform.pdf Document results in service
users notes and repeat more often if necessary.
 Review for common side effects including EPSE, weight gain,
sexual & menstrual dysfunction. Document findings in notes, even if
no side effects experienced.
 Clozapine should always be offered (unless not clinically appropriate)
when the response to two different antipsychotics, including at least
one second generation ‘atypical’ agent has been inadequate.
 Offer depot medication where the service user would prefer this or
where treatment adherence is a problem. Whilst depots may not
necessarily improve adherence they do allow adherence to be
monitored more easily.
 Selection should be influenced by previous response, co-morbidities,
side effect profile, patient/carer choice, interacting medication & cost.
 Invest time in methods to improve medicine adherence (NICE
Medicine Adherence – page 5)
TRUST
Antipsychotic Prescribing Guidelines
NICE CG82
Schizophrenia (update)
http://guidance.nice.org.uk/CG82/Guidance
NICE CG38
Bipolar Disorder
http://guidance.nice.org.uk/CG38/Guidance/pdf/English
MAUDSLEY
PRESCRIBING
GUIDELINES
10th Edition, pages 35-41
Royal College of
www.rcpsych.ac.uk/files/pdfversion/CR138.pdf
Psychiatrists Consensus
Statement on High Dose
Antipsychotic Prescribing
BNF
For further advice on dose titration, indications and side
effects.
http://bnf.org/bnf/bnf/current/3263.htm
Electronic
Medicines
Compendium
Summary of Product Characteristics for individual drugs
www.medicines.org.uk
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 24 of 67
Version 3 08/12/2011
First Generation (Typical Antipsychotics)
Formulary
Status
Drug
Test Dose*
Approved
Haloperidol
(Haldol
Decanoate®)
25-50mg
Pipotiazine
palmitate
(Piportil
Depot®)
25mg
Fluphenazine
decanoate
(e.g.
Modecate®)
Dose Range*
Cost of 28
days
treatment
Comments
50mg - 300mg
every 4 weeks
(half the dose if
given every 2
weeks)
50 – 200mg
every 4 weeks
£3.82£15.18****
Contains sesame oil.
£16.29£53.30****
Contains sesame oil.
12.5mg
12.5mg –
100mg every 25 weeks
£2.25£17.58**
Contains sesame oil.
Flupentixol
decanoate
(Depixol®)
20mg
20mg - 400mg
every one to
four weeks
£1.28£7.36****
Contains fractionated coconut oil.
Zuclopenthix
ol decanoate
(Clopixol®)
100mg
200mg - 600mg £3.15Every one to
£37.81**
four weeks
Contains fractionated coconut oil.
Must not be confused with zuclopenthixol acetate IM injection
Clopixol Acuphase®)
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 25 of 67
Version 3 08/12/2011
Second generation (Atypical antipsychotics)
Formulary
Status
Drug
Test Dose*
Restricted
Approval must
be sought from
the Medical
Director before
prescribing
(application
form below)
Risperidone
(Risperdal
Consta®)
See
comments
Dose Range*
25 - 50mg
every 2 weeks
Cost of 28
days
treatment
£159.38 to
£285.52****
Comments
If approved:
Service user must have a minimum of 3 days oral
risperidone prior to first injection to ensure tolerance. No
intramuscular test dose required.
The dose of oral risperidone guides initial depot dose:
Up to 4mg/day oral = 25mg i/m every 2/52
Over 4mg/day oral = 37.5mg i/m every 2/52
Continue oral risperidone for at least 6 weeks after starting
depot then slowly discontinue over 1-2 weeks according to
tolerance. This is because drug release from the depot
formulation is delayed by 3 weeks.
G:\Corporate
Pharmacy\Pharmacy Team\REQUEST FORMS FOR NEW DRUGS\Risperdal Consta application to Medical Director version 4.doc
.
Dose adjusted according to response in increments of
12.5mg at a minimum interval of 12 weeks.
For advice on switching from a typical depot to Risperdal
Consta® contact a medicines management pharmacist.
Not Approved Olanzapine Embonate (ZypAdhera®) – Contact Medicines Management Committee for more details
*Usual dose for adults. Dose may vary for elderly – see BNF for details
** Prices based on Drug Tariff November 2012 edition
**** Prices based on BNF September 2012 edition 64
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 26 of 67
Version 3 08/12/2011
Return to Contents Page
Antimanic Drugs BNF 4.2.3
 Used to treat acute symptoms and to prevent recurrence of
mania or hypomania.
 Long-term treatment of bipolar disorder should continue for at
least two years from the last manic episode and up to five years
if the patient has risk factors for relapse.
 Avoid antidepressant drugs in patients with rapid-cycling bipolar
disorder, recent history of hypomania/mania, or rapid mood
fluctuations.
 .Carry out regular monitoring of physical health and side effects.
Use prescribed medication monitoring form
http://nww5boroughsintranetcms/MANAGE/library/documents/5
BPprescribedmedicationmonitoringform.pdf
 The doses of olanzapine, risperidone and quetiapine stated
in this section are for the treatment of mania only – for
other indications see relevant section of the formulary or
BNF.
 Invest time in methods to improve medicine adherence (NICE
Medicine Adherence – page 5)
 Please also refer to page 42 of this document – Other drugs
that may be considered in the management of bipolar disorder.
Signposts to local (GREEN) and national (BLUE) prescribing guidelines
TRUST
Procedure for lithium initiation
http://5boroughswww/MANAGE/library/documents/5BP90
02002_lithiumprocedurev2.2.pdf
NICE CG38
covers the use of antimanic drugs in the management of bipolar
disorder
http://guidance.nice.org.uk/CG38/Guidance/pdf/English
NPSA PSA005 see NPSA alert on regular blood and lithium level monitoring
http://www.nrls.npsa.nhs.uk/resources/?EntryId45=6542
6
British Association for psychopharmacology guidelines for bipolar disorder
http://www.bap.org.uk/pdfs/Bipolar_guidelines.pdf
BNF
For initial doses, advice on dose titration,
indications and side effects. http://bnf.org
Electronic
Medicines
Compendium
Summary of Product Characteristics for individual drugs
www.medicines.org.uk
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 27 of 67
Version 3 08/12/2011
Formulary
Status
Approved
Drug
Lithium
Carbonate m/r
tablets
(Priadel®)
Initial Dose*
200-400mg
daily
Maximum
Dose*
Adjust dose
according to
response and
serum levels.
Usual
maximum
1.2g daily
Formulations
Available
Cost of 28
days
treatment
Tablets
£0.64 –
£2.81****
Comments
Adjust dose to achieve target serum levels.
Usual target serum lithium levels are 0.4-1.0
mmol/litre. Take serum levels 12 hours after
a dose.
Where lithium is initiated Priadel® should
always be prescribed. However, if a service
user is already established on another brand
then this should be continued as different
brands have different bioavailabilities.
The brand of lithium should always be
specified on the prescription.
Lithium Citrate
(Priadel®)
520mg/5ml
liquid
1.04-3.12g
daily in 2
divided
doses
(patients less
than 50kg
520mg twice
daily)
Adjust dose
according to
response and
serum levels
Liquid
£10.47£31.41****
Adjust dose to achieve target serum levels.
Usual target serum lithium levels are 0.4-1
mmol/litre take serum levels 12 hours after a
dose.
Where lithium is initiated Priadel® should
always be prescribed. However, if a service
user is already established on another brand
then this should be continued as different
brands have different bioavailabilities.
5ml Priade®l liquid (520mg lithium citrate) is
equivalent to 200mg lithium carbonate
(200mg Priadel® tablet).
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 28 of 67
Version 3 08/12/2011
Formulary
Status
Drug
Initial Dose*
Approved
Semisodium
valproate
(Depakote®)
Approved
(second
line)
Carbamazepine 400mg daily
in divided
doses
750mg daily
in 2-3 divided
doses
Maximum
Dose*
Formulations
Available
Cost of 28
days
treatment
2g daily
Tablets
£13.63£36.28**
1.6g daily
Tablets
£10.03–
£11.16**
Modified
Release
£5.20£20.16**
Comments


Liquid
£11.20£44.80**

Should not be routinely used for
treating acute mania. For patients
who present with mania who are
already taking carbamazepine the
dose should not routinely be
increased.
May be considered if a combination
of first line prophylactic agents is
ineffective (lithium with valproate,
lithium with olanzapine, or valproate
with olanzapine)
Avoid changing brands – variations
in bioavailability.
*Usual dose for adults. Dose may vary for elderly – see BNF for details
** Prices based on Drug Tariff November 2012 edition
**** Prices based on BNF September 2012 edition 64
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 29 of 67
Version 3 08/12/2011
Return to Contents Page
Antidepressants BNF 4.3
 Licensed for depressive illness.
 Review the service user regularly for side effects and
document findings in the notes. Use prescribed medication
monitoring form
.http://nww5boroughsintranetcms/MANAGE/library/documents
/5BPprescribedmedicationmonitoringform.pdf
 Treatment with an antidepressant should usually be continued
for at least 6 months after remission of an episode of
depression.
 Selection should be influenced by previous response, comorbidities, side effect profile, patient/carer choice, interacting
medication & cost.
 Be aware of the need to exercise caution when switching
antidepressants due to the increased risk of side effects and
serotonin syndrome – contact a pharmacist for advice.
 Invest time in methods to improve medicine adherence (NICE
Medicine Adherence – page 5)
Signposts to local (GREEN) and national (BLUE) prescribing guidelines
NICE CG90
Depression – the treatment and management in adults
http://guidance.nice.org.uk/CG90
NICE CG28
Depression in children and young people: identification and management in
primary, community and secondary care
http://guidance.nice.org.uk/CG28
NICE CG91
Depression with a chronic physical health problem
http://guidance.nice.org.uk/CG91
BNF
For advice on dose titration, indications and side effects.
http://bnf.org/bnf/bnf/current/3294.htm
Electronic
Medicines
Compendium
Summary of Product Characteristics for individual drugs
www.medicines.org.uk
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 30 of 67
Version 3 08/12/2011
Formulary
Status
Approved
(First
Line)
Where one
of these
drugs is
ineffective
or not
tolerated
then
another
one may
be tried –
see
section
below for
other
second
line
options
Drug
Citalopram
Fluoxetine
Paroxetine
Sertraline
Initial
Dose*
Max Dose*
20mg
40mg daily
once daily
20mg
60mg once
once daily daily
20mg
50mg once
once daily daily
50mg
daily
200mg daily
Formulations
Available
Cost of 28
days
treatment
Comments
Tablets
£0.86-£1.06**
4 drops (8mg) is equivalent in therapeutic effect to a
10mg tablet.
Oral drops
(40mg/ml)
£8.71-£17.42**
Capsules
£0.75-£2.24**
Use 20mg capsules only – 60mg capsules cost
£48.90**
Liquid
£9.80-£29.40**
Tablets
£1.76-£4.00**
Oral
suspension
£17.02£42.56**
Long half life – Lower rate of discontinuation
symptoms but need to exercise caution when
switching from fluoxetine to other antidepressants.
Higher rate of discontinuation syndrome due to short
half life. Not suitable for service users who are likely
to be poorly compliant.
Tablets
£1.06-£2.66**
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 31 of 67
Version 3 08/12/2011
Formulary
Status
Approved
(Second
line)
Drug
Amitriptyline
An
alternative
drug from
the first
line section
may also
Clomipramine
be
considered
as a
possible
Flupenthixol
second
line option
Initial
Dose*
Max Dose*
75mg
daily in
divided
doses or
as a
single
dose at
bedtime
200mg daily
at bedtime
10mg
daily
1mg in
the
morning
Formulations
Available
Cost of 28
days
treatment
Comments
Tablets
£2.04-£3.04**
Oral solution
£48.05£68.32**
250mg daily
Capsules
£1.44-£9.75**
225mg
MR Capsules
£8.83-£26.49**
MR capsules to be taken once daily.
3mg daily
(doses
above 2mg
in divided
doses)
Tablets
£2.69-£4.08**
Last dose before 4pm. Discontinue if no response
after one week at maximum dose.
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 32 of 67
Version 3 08/12/2011
Formulary
Status
Approved
(Second
line)
Drug
Initial
Dose*
Max Dose*
Formulations
Available
Cost of 28
days
treatment
Imipramine
Up to
75mg
daily in
divided
doses
200mg in
Tablets
divided
doses (up to
150mg can
be given as
a single
dose at
bedtime)
£3.21-£8.56**
Lofepramine
140mg
daily in
divided
doses
210mg daily
in divided
doses
£13.45£20.18**
15-30mg
daily at
bedtime
45mg daily
at bedtime
or in 2
divided
doses.
Tablets
Orodispersible
tablets
£1.81-£2.40**
300mg
daily
600mg daily
Tablets
£11.99-£23.99**
10mg
daily
150mg daily
Tablets
£7.58£113.70**
An
alternative
drug from
Mirtazapine
the first
line section
may also
be
considered
as a
Moclobemide
possible
second
line option Nortriptyline
Tablets
Oral
Suspension
£41.44£62.16**
£2.45-£2.82**
Comments
Less toxicity in overdose than the other Tricyclic
antidepressants.
15mg and 45mg orodispersible tablets are cheaper
than the regular tablets
NB: Knowsley and St Helens locality pharmacy only
stock orodispersible tablets.
Consider dietary restrictions.
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 33 of 67
Version 3 08/12/2011
Formulary
Status
Approved
(Second
line)
Drug
Initial
Dose*
Max Dose*
Formulations
Available
Cost of 28
days
treatment
Reboxetine
4mg twice
daily
12mg daily
Tablets
£17.64£26.47**
Trazadone
An
alternative
drug from
the first
line section
may also
be
considered
as a
possible
Venlafaxine
second
line option
150mg
daily in
divided
doses
after food
or as a
single
dose at
bedtime
300mg daily
Capsules
£3.36-£5.91**
Tablets
£3.99-£7.98**
Liquid
£111.72£223.44**
37.5mg
twice
daily
375mg daily
Tablets
£2.62-£7.87**
Comments
Monitor blood pressure, particularly at doses above
225mg.
Higher rate of discontinuation symptoms due to short
half life.
Venlafaxine
MR
75mg
225mg once
once daily
daily
Capsules
£22.08£58.89**
Monitor blood pressure, particularly at doses above
225mg.
Higher rate of discontinuation symptoms due to short
half life.
Tablets
- £33.60**
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 34 of 67
Version 3 08/12/2011
Formulary
Status
Approved
(third line)
Non
approved
Drug
Initial
Dose*
Formulations
Available
Max Dose*
Cost of 28
days
treatment
Duloxetine
60mg
daily
60mg daily
Capsules
£27.72**
Escitalopram
10mg
daily
20mg daily
Tablets
£14.91£25.20**
Oral drops
£18.82£37.63****
Comments
Fluvoxamine, Agomelatine, Phenelzine, Isocarboxazid, Tranylcypromine, Doxepin, Trimipramine, Mianserin, St Johns Wort
Dosulepin - NICE states that dosulepin should not be prescribed due to increased cardiac risk and toxicity in overdose.
*Usual dose for adults. Dose may vary for young people and elderly – see BNF for details
** Prices based on Drug Tariff November 2012 edition
**** Prices based on BNF September 2012 64 edition
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 35 of 67
Version 3 08/12/2011
Return to Contents Page
CNS Stimulants and drugs used for attention
deficit hyperactivity disorder BNF 4.4
 Drug treatment for ADHD should only be initiated by a healthcare
professional with expertise in ADHD.
 Treatment of ADHD is usually initiated during childhood or
adolescence and may need to be continued into adulthood.
 Drug treatment of ADHD should be part of a comprehensive
treatment programme that includes psychological, behavioural and
educational advice and interventions.
 Drug treatment must take into account co-morbid conditions (e.g.
epilepsy, Tourette syndrome and tic disorders), possible side
effects, potential for drug misuse and the preferences of the
service user or their carer.
 See BNF for children for guidance on dose titration.
 Measure weight and height at 3 and 6 months after the start of
treatment and then every 6 months.
 Monitor heart rate and blood pressure and record on a centile chart
before and after each dose change and at each review.
 The need to continue drug treatment for ADHD should be reviewed
at least annually. This may involve suspending treatment.
 Please note that the doses stated below are for children and
adolescents. Initiation of treatment for of ADHD in adults is
not licensed or commissioned within the Trust.
Signposts to local (GREEN) and national (BLUE) prescribing guidelines
NICE CG72
Covers the diagnosis and management of ADHD in children, young
people and adults, including monitoring and management of side effects.
http://www.nice.org.uk/nicemedia/live/12061/42060/42060.pdf
British Association for psychopharmacology guidelines on the management of
ADHD in adolescents in transition to adult services and in adults
http://www.bap.org.uk/pdfs/ADHD_Guidelines.pdf
BNF
http://bnf.org/bnf/bnf/current/3373.htm
BNF for children http://bnfc.org/bnfc/bnfc/current/3373.htm
Electronic
Medicines
Compendium
Summary of Product Characteristics for individual drugs
www.medicines.org.uk
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 36 of 67
Version 3 08/12/2011
CNS Stimulants and drugs used for attention
deficit hyperactivity disorder BNF 4.4
Formulary
Status
Drug
Approved - Methylphenidate
First Line
Initial Dose*
Standard
release
tablets:
Child 4-6
years 2.5mg
twice daily
Maximum Dose*
Signposts to local (GREEN) and national (BLUE) prescribing guidelines
Cost of 28
Formulations
days
Available
treatment
Standard release
tablets:
Standard
release tablets
(brands include
Child 4 -6 years
Equasym® and
£1.511.4mg/kg daily in 2-3 Ritalin®)
£14.49**
divided doses
Child 6-18 years
Child 6-18
licensed max 60mg
years 5 mg 1- daily in 2-3 divided
2 times daily doses but may be
increased to
2.1mg/kg (max 90mg
daily) under the
direction of a
specialist.
£1.51£45.36**
Comments
Controlled drug requirements apply.
Discontinue if no response after one month.
If the effect wears off in the evening (with
rebound hyperactivity) then a trial of a dose at
bedtime may be appropriate.
Equasym® and Ritalin® tablets may be halved.
Controlled drug requirements apply.
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 37 of 67
Version 3 08/12/2011
CNS Stimulants and drugs used for attention
deficit hyperactivity disorder BNF 4.4
Methylphenidate
Approved –
first line
Concerta®
XL:
Concerta® XL:
Signposts to local (GREEN) and national (BLUE) prescribing guidelines
Modified
release tablets
Child 6-18years max (Concerta® XL) £29.11Child 6-18
licensed dose 54mg
£118.86**
years 18mg once daily but may be
once daily in increased to
the morning 2.1mg/kg daily (max
108mg daily) under
the direction of a
specialist.
Discontinue if no response after one month.
Different modified release preparations have
different release profiles and different dosages.
Therefore the brand of modified release
methylphenidate should always be stated on the
prescription and if newly initiated should be
Concerta® XL. However, if a service user is
already established on another brand of
modified release methylphenidate when they
come into our care then the usual brand should
be continued (please notify pharmacy
immediately as this may need to be ordered in).
Total daily dose of 15mg standard release
methylphenidate is considered equivalent to
Concerta® XL 18mg once daily.
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 38 of 67
Version 3 08/12/2011
CNS Stimulants and drugs used for attention
deficit hyperactivity disorder BNF 4.4
Approved – Atomoxetine
Second line
Child over 6
years (body
weight under
70kg) 500
micrograms/k
g daily
Child over 6
years (body
weight over
70kg) 40mg
daily
Child over 6 years
Capsules
(body weight under
70kg) usual
maintenance dose
1.2mg/kg but may be
increased to
1.8mg/kg daily (max
120mg daily) under
the direction of a
specialist.
Child over 6 years
(body weight under
70kg) usual
maintenance dose
80mg daily but may
be increased to max
120mg daily under
the direction of a
specialist.
Signposts to local (GREEN) and national (BLUE) prescribing guidelines
£62.46124.92**
May be suitable where stimulant diversion is a
problem, or where dopaminergic side effects
such as tics, anxiety and stereotypies occur with
methylphenidate or dexamphetamine.
Monitor for agitation, irritability, suicidal thinking
and self harm, especially during the initial
months of treatment or after a change in dose.
Warn patients and their carers about the rare
potential for liver damage with atomoxetine and
the signs to look for (routine LFTs not
recommended)
Total daily dose may be given either as a single
dose in the morning or in 2 divided doses with
the last dose no later than early evening.
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 39 of 67
Version 3 08/12/2011
CNS Stimulants and drugs used for attention
deficit hyperactivity disorder BNF 4.4
Approved – Dexamphetamine
second line
Child 6-18
Child 6-18 years
Tablets
years 5-10mg usual max 1mg/kg
once daily
daily, up to 20mg
(40mg daily has been
required in some
children).
Maintenance dose
given in 2-4 divided
doses.
Signposts to local (GREEN) and national (BLUE) prescribing guidelines
£18.81£150.48**
Controlled drug requirements apply.
Use with caution in those likely to be at risk of
stimulant misuse or diversion.
Tablets can be halved.
*Usual dose for children and adolescents. Dose may vary for adults – see BNF for details
** Prices based on Drug Tariff November 2012 edition
**** Prices based on BNF September 2012 edition 64
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 40 of 67
Version 3 08/12/2011
Return to Contents Page
Anticholinergic medication for the
management of extrapyramidal side effects
B.N.F 4.9.2
 Do not use routinely in the absence of extrapyramidal side effects.
 Tardive dyskinesia is not improved by anticholinergic drugs and
may be made worse.
 All anticholinergics have the potential to be abused.
 See BNF for further information on dose titration.
Signposts to local (GREEN) and national (BLUE) prescribing guidelines
BNF
http://bnf.org/bnf/bnf/current/3654.htm
Electronic
Medicines
Compendium
Summary of Product Characteristics for individual drugs
www.medicines.org.uk
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 41 of 67
Version 3 08/12/2011
Formulary
Status
Approved
(First Line)
Drug
Procyclidine
Initial Dose*
Maximum Dose*
By mouth:
By mouth: 30mg
2.5mg 3 times daily in 2-4 divided
daily
doses
By intramuscular injection (for
acute dystonia only): 5-10mg,
usually effective in 5-10 minutes but
may need 30minutes for relief.
Formulary
Status
Approved
(second
line)
Drug
Orphenadrine
Trihexyphenidyl
(benzhexol)
Initial Dose*
150mg daily
in divided
doses
1mg daily
Maximum Dose*
400mg daily in
divided doses
20mg daily in 3-4
divided doses
Cost of
Formulations
28 days
Available
treatment
Tablets
£5.10£10.20**
Syrup
£17.64£63.84**
Intramuscular
injection
£1.49****
per dose
Cost of
Formulations
28 days
Available
treatment
Tablets
£60.48£161.28**
Liquid
£20.16£53.76****
£3.38£20.16**
Tablets
Syrup
Comments
Only use liquid if the service user has
swallowing difficulties.
Comments
£1.12£22.40**
*Usual dose for adults. Dose may vary for young people and elderly – see BNF for details
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 42 of 67
Version 3 08/12/2011
** Prices based on Drug Tariff November 2012 edition
**** Prices based on BNF September 2012 edition 64
Return to Contents Page
Drugs for Dementia BNF 4.11
 Donepezil, Galantamine and Rivastigmine are recommended as
options for the management of people with Alzheimer’s disease
of mild to moderate severity (MMSE score 10-20 points)
 Rivastigmine is also licensed for mild to moderate dementia
associated with Parkinson’s disease.
 Assess patient every 6 months and continue drug treatment
only if MMSE score remains at or above 10 points.
 Dose related cholinergic side effects are common so treatment
should be started with a low dose and increased gradually
according to response and tolerability.
 An ECG is advisable prior to starting treatment with donepezil,
galantamine and rivastigmine due to their potential to cause
cardiac side effects including bradycardia and arrhythmias.
 Memantine is approved for use within the Trust for treatment of
severe Alzheimer’s disease or for those with moderate
Alzheimer’s disease who are intolerant to or have a
contraindication to treatment with an AChEI. Memantine is
approved for use as monotherapy only, and must not be
prescribed in combination with an AChEI.
 Invest time in methods to improve medicine adherence (NICE
Medicine Adherence – page 5)
Signposts to local (GREEN) and national (BLUE) prescribing guidelines
NICE-SCIE CG42:
Full Guideline on supporting people with dementia and their
carers
http://www.nice.org.uk/nicemedia/live/10998/30318/30318.pdf
NICE TA217:
Technology appraisal
http://www.nice.org.uk/nicemedia/live/13419/53619/53619.pdf
BNF:
Information on cautions, side effects and interactions
http://bnf.org/bnf/bnf/current/61145.htm
Electronic
Medicines
Compendium
Summary of Product Characteristics for individual drugs
www.medicines.org.uk
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 43 of 67
Version 3 08/12/2011
Formulary
Status
Approved
(First Line)
Drug
Donepezil
Initial
Dose
Maximum
Dose
Formulations
Available
Cost of 28
days
treatment
Tablets
£2.19-£2.89**
Orodispersible
tablets
£36.49£50.85**
Comments
5mg once
daily at
bedtime
10mg daily
Orodispersible tablets should be placed on the
tongue, allowed to disperse and swallowed.
Galantamine
8mg once
daily
(modified
release
capsules)
24mg daily
(modified
release
capsules
Modified
release
capsules
£51.88£79.80**
Also available as oral solution (see below under
restricted drugs)
.
Rivastigmine
1.5mg
twice daily
6mg twice
daily
Tablets
£48.86£56.52**
If treatment interrupted for several days, reintroduce initial dose and increase gradually
Rivastigmine has less potential for interactions than
donepezil or galantamine – may be an advantage in
polypharmacy.
Also available as adhesive patches (see below
under restricted drugs) and oral liquid (see below,
not approved for initiation within the Trust)
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 44 of 67
Version 3 08/12/2011
Formulary
Status
Cost of 28
days
treatment
Initial
Dose
Maximum
Dose
Formulations
Available
Use only if Rivastigmine
patient has adhesive
swallowing patches
difficulties
or for
those who
are not
tolerating
side effects
despite
optimised
oral
therapy.
4.6mg/24
hour patch
9.5mg/24hour
patch
4.6mg/24 hour
patch
£72.77**
9.5mg/24 hour
patch
£72.77**
Use only if
patient has
swallowing
difficulties
4mg twice
daily
4mg/ml oral
solution
£67.20£201.60****
Drug
Galantamine
oral liquid
12mg twice
daily
Comments
See BNF http://bnf.org/bnf/bnf/current/68984.htm
for guidance on switching from oral therapy to
patches.
In patients with swallowing difficulties consider use
of donepezil melt.
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 45 of 67
Version 3 08/12/2011
Formulary
Status
Approved
(but see
comments)
Drug
Memantine
Initial
Dose
5mg once
daily
Maximum
Dose
20mg daily
Formulations
Available
Tablets
Cost of 28
days
treatment
£34.50£69.01**
Comments
Memantine may be prescribed for service users
who have moderate Alzheimer’s disease who
are intolerant of or have a contraindication to
AChE inhibitors or those with severe
Alzheimer’s disease.
Memantine
is
approved
for
use
as
monotherapy only and must not be prescribed
as combination therapy with AChE inhibitors.
Oral drops
£17.36£69.44****
Memantine oral drops contain 10mg of
memantine hydrochloride in each millilitre.
Each actuation or ‘downward pump’
dispenses 0.5ml of liquid i.e. 5mg.
All prescriptions for memantine liquid must be
unambiguous and service users and carers
must be counselled on how to use the pump
correctly in order to minimise the risk of
accidental dosing errors.
** Prices based on Drug Tariff November 2012 edition
**** Prices based on BNF September 2012 edition 64
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 46 of 67
Version 3 08/12/2011
Return to Contents Page
Other drugs that may be considered in
the management of bipolar disorder
 The drugs included in this section may be considered for the
management of bipolar disorder.
 They have been included in this section because they do not fall
into the BNF category 4.2.3 antimanic drugs.
 The doses of olanzapine, risperidone, aripiprazole and
quetiapine stated in this section are for the treatment of
mania only – for other indications see relevant section of
the formulary or BNF.
Signposts to local (GREEN) and national (BLUE) prescribing guidelines
NICE CG38
Covers the use of antimanic drugs in the management of bipolar
disorder
http://guidance.nice.org.uk/CG38/Guidance/pdf/English
British Association for psychopharmacology guidelines for bipolar disorder
http://www.bap.org.uk/pdfs/Bipolar_guidelines.pdf
BNF
For initial doses, advice on dose titration,
indications and side effects. http://bnf.org
Electronic
Medicines
Compendium
Summary of Product Characteristics for individual drugs
www.medicines.org.uk
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 47 of 67
Version 3 08/12/2011
Formulary
Status
Drug
Approved
Sodium
valproate
Formulations
Available
Cost of 28
days
treatment
Refer to BNF and SPC for
doses – doses vary
depending on whether the
service user is also taking
enzyme inducing drugs or
valproate.
Tablets
£0.65-£3.20**
Dispersible
tablets
£0.98-£4.63**
Modified
release
tablets:
600mg
daily in 1-2
divided
doses
Modified
release
tablets: 2.5g
daily
Modified
£9.78release tablets £40.74****
(Epilim
Chrono®)
Liquid:
600mg
daily in 2
divided
doses
Liquid: 2.5g
daily
Initial
Dose
Maximum
Dose
Liquid
Comments
Licensed for the prevention of depressive episodes
associated with bipolar disorder.
Service users who are stabilised on lamotrigine may
require dosage adjustments if other drugs are
added or withdrawn from their treatment regimen –
consult summary of product characteristics for
details.
£10.84£45.15**
Sodium valproate is not licensed for use in
bipolar disorder but Epilim Chrono may be
useful where valproic acid (Depakote®) is a
suitable treatment option but a once daily dose
is preferable.
Sodium valproate liquid may be useful where
valproic acid (Depakote®) is a suitable treatment
option but the service user has swallowing
difficulties.
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 48 of 67
Version 3 08/12/2011
Formulary
Status
Approved
Drug
Aripiprazole
Initial
Dose
15mg once
daily
Maximum
Dose
30mg once
daily
Formulations
Available
Cost of 28
days
treatment
Tablets
£96.04£192.08**
Orodispersible
tablets
£95.74£191.48****
Comments
Licensed for the treatment and prevention of mania.
Liquid –
restricted (see
below)
Olanzapine
Monother
apy for
mania:
15mg daily
Monotherapy
for mania:
20mg daily
Combinati
on
therapy
for mania
or
preventin
g
recurrenc
e in
bipolar
disorder:
10mg daily
Combination
therapy for
mania or
preventing
recurrence in
bipolar
disorder:
20mg daily
Tablets
£4.17-£5.62**
Orodispersible
tablets
(velotabs)
£60.01£61.99**
Tablets
£2.85-£5.62**
Oro
dispersible
tablets
(velotabs)
£30.00£60.01**
Licensed for the treatment of mania, either as
monotherapy or combination therapy. Also licensed
for preventing recurrence of mania in bipolar
disorder.
Velotabs are 10% more expensive than tablets.
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 49 of 67
Version 3 08/12/2011
Formulary
Status
Approved
Drug
Quetiapine
Initial
Dose
Maximum
Dose
Treatment
of mania
in bipolar
disorder:
50mg
twice daily
Treatment of
mania in
bipolar
disorder:
800mg daily in
2 divided
doses
Treatment
of
depressio
n in
bipolar
disorder:
50mg at
bedtime
Treatment of
depression in
bipolar
disorder:
600mg daily
Formulations
Available
Cost of 28
days
treatment
Tablets
£2.73-£15.90**
£2.73-£15.03**
Comments
Licensed for mania either alone or with mood
stabilisers and for the treatment of depression in
bipolar disorder.
For the prevention of mania and depression in
bipolar disorder continue at the dose effective for
the treatment of bipolar disorder and then adjust
according to response. Usual range 300mg-800mg
daily in 2 divided doses. Can be taken with or
without food.
NB: also available as XL tablets for once daily
administration but these should only be considered
where where a rapid titration is required or where
once daily administration would be beneficial.
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 50 of 67
Version 3 08/12/2011
Formulary
Status
Approved
Drug
Initial
Dose
Maximum
Dose
Formulations
Available
Cost of 28
days
treatment
XL
formulatio
n:
XL
formulation:
Treatment
of mania
in bipolar
disorder:
300mg
once daily
Treatment of
mania in
bipolar
disorder:
800mg once
daily
£79.33£211.12**
Treatment
of
depressio
n in
bipolar
disorder:
50mg at
bedtime
Treatment of
depression in
bipolar
disorder:
600mg daily
£31.57£158.66**
XL Tablets
Comments
Absorption affected by food, to maintain consistent
levels give as a single night time dose without food.
Licensed for mania either alone or with mood
stabilisers and for the treatment of depression in
bipolar disorder.
For the prevention of mania and depression in
bipolar disorder continue at the dose effective for
the treatment of bipolar disorder and then adjust
according to response. Usual range 300mg-800mg
as a single dose.
Absorption affected by food, to maintain consistent
levels give as a single night time dose without food.
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 51 of 67
Version 3 08/12/2011
Formulary
Status
Approved
Drug
Risperidone
Haloperidol
Initial
Dose
2mg once
daily
0.5–3mg
2–3 times
daily or 3–
5mg 2–3
times daily
in severely
affected or
resistant
patients
Maximum
Dose
6mg daily
30mg daily
Formulations
Available
Cost of 28
days
treatment
Tablets
£0.71-£19.25**
Licensed for the treatment of mania.
Orodispersible
tablets
£36.96£56.00**
Oro-dispersible and liquid preparations are
significantly more expensive.
Liquid
£31.10£93.29**
£2.20-£21.78**
Licensed for the treatment of mania.
Capsules
Tablets
Comments
Carry out ECG prior to commencing.
Liquid
£0.62£18.69****
*Usual dose for adults. Dose may vary for young people and elderly – see BNF for details
** Prices based on Drug Tariff November 2012 edition
**** Prices based on BNF September 2012 edition 64
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 52 of 67
Version 3 08/12/2011
Return to Contents Page
Licensed Drugs approved for ‘off label’
use
 The following section contains information on licensed
medications that are approved for ‘off label’ use within the
Trust i.e. approved for use outside of their UK product
license.
 The off-label use of a medicine should only be considered
when there is no equivalent product, licensed for the
indication, available, or when the licensed product(s) are
ineffective or cannot be tolerated.
 Service users (and/or their carers) must be made aware that
the medication is being used outside of its product license,
the reasons for this and any known serious or common
adverse drug reactions.
 Refer to the Trust unlicensed medicines procedure for further
guidance on responsibilities on the prescribing and use of ‘off
label’ medicines.
Signposts to local (GREEN) and national (BLUE) prescribing guidelines
Unlicensed Medicines
Procedure
http://nww5boroughsintranet/library/documents/unlicensedmedicinespr
ocedure.pdf
BNF
For initial doses, advice on dose titration,
indications and side effects. http://bnf.org
Electronic
Medicines
Compendium
Summary of Product Characteristics for individual drugs
www.medicines.org.uk
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 53 of 67
Version 3 08/12/2011
Formulary
Status
Drug
Approved
(second line
– see
comments)
Clonazepa
m
Approved for
use in rapid
tranquilisatio
n whilst IM
lorazepam
unavailable
Midazolam
IM injection
Initial Dose*
0.25mg daily
Maximum Dose*
2mg daily as a single or
divided doses.
Refer to midazolam cascade training and
dosage charts
http://nww.5boroughspartnership.nhs.uk/basep
age.aspx?PageID=12344
Formulations
Available
500 microgram tablets
Cost of 28 days
treatment
£0.97-£3.90**
2mg tablets
10mg/2ml injection
Comments
Approved for
treatment of
agitation in
psychosis and
mania where
lorazepam is
ineffective.
Costs approx
58p per vial.****
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 54 of 67
Version 3 08/12/2011
Formulary
Status
Restricted
Drug
Melatonin
Initial Dose*
Maximum Dose*
Formulations
Available
Cost of 28 days
treatment
Comments
Melatonin is available as a 2mg modified release tablet (Circadin®) which is licensed for short term treatment of
primary insomnia in patients over 55 years. Circadin® is not approved for initiation in adult service users within
the Trust.
However, Circadin® may be used within the CAMHS service where use of melatonin is considered appropriate
(prescription must specify that Circadin® is required - see prescribing advice below).
G:\Corporate
Pharmacy\Pharmacy Team\WORKING DOCUMENTS\Formulary\5BP melatonin prescribing advice ver01draFINAL 2009-10-28.doc
Prices vary according to supplier.
*Usual dose for adults. Dose may vary for young people and elderly – see BNF for details
** Prices based on Drug Tariff November 2012 edition
**** Prices based on BNF September 2012 edition 64
NB: This document is only valid on the day of printing. It is only to be used within 5 Boroughs Partnership NHS Foundation Trust and any errors/failed links
should be reported to the medicines management team.
Page 55 of 67
Version 3 08/12/2011
Return to Contents Page
Formulary for Treatment of Minor Physical Ailments
The following section of the formulary provides information on the preparations that are available for the treatment of minor physical ailments. If
further advice is needed on the most suitable treatment for a particular patient please contact a member of the medicines management team.
The Trust policy on the use of discretionary medicines may also be useful when considering the treatment of minor ailments.
http://nww.5boroughspartnership.nhs.uk/library/documents/5BPdiscmedpolicy.pdf
The usual doses stated are those for adults – consult the BNF for Children for the treatment of children and adolescents
(http://bnfc.org/bnfc/index.htm)
The following topics are covered:












Laxatives
Analgesics
Indigestion remedies
Sore throat remedies
Barrier creams
Emollients
Non anti-microbial ear drops
Non anti-microbial eye drops
Treatments for warts, verrucas and coldsores
Treatment of haemorrhoids
Sunscreens
Nutritional supplements
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Laxatives
 Constipation can be defined as the passage of hard stools less frequently than the patient’s normal pattern.
 Where constipation is confirmed to be a problem consider the following possible causes: Lack of exercise, diet, inadequate fluid intake,
medication e.g. including analgesics (especially opioids), calcium or aluminium antacids, anticholinergics, antidepressants (especially
tricyclics), antiparkinsonian drugs, calcium supplements, diuretics, iron preparations, antipsychotics.
 Where diet or lifestyle factors are thought to be contributory factors encourage the patient to increase dietary fibre (e.g. fruit, vegetables,
fibre rich cereals and bread), take regular exercise and drink plenty of fluids. Where constipation is thought to be drug induced stop the
causative drug where possible.
Drug
Usual dose
Senna
7.5mg tablets:
2-4 tablets usually at
bedtime. Low dose
initially then
gradually increase.
Comments
 Stimulant laxative.
 Effect is usually seen within 8-12 hours, therefore bedtime dosing recommended.
 Suitable for short term use only – chronic use may result in electrolyte disturbance and
atonic colon.
 Useful for treatment of drug induced constipation.
7.5mg/5ml liquid:
10-20ml, usually at
bedtime.
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Drug
Usual dose
Sodium docusate
Up to 500mg daily in
divided doses
(available as 100mg
capsules or
50mg/5ml oral
solution)
 Stimulant and softening properties.
 Suitable for short term use only.
 Useful in combination with senna for drug induced constipation where senna alone is
ineffective.
Ispaghula husk
1 sachet or 2 level
5ml spoonfuls in
water 1-3 times daily.
 Bulk-forming laxative.
 Full effect may take a few days to develop.
 May be useful in chronic constipation, or where lack of dietary fibre may be a contributory
factor.
 Adequate amounts of fluid essential to avoid obstruction.
 For immobile patients bulk forming laxatives may be less effective and may even worsen
the problem.
 Contra-indicated in faecal impaction.
1-3 sachets daily in
divided doses,
usually for up to 2
weeks. Each sachet
should be dissolved
in 125ml water.
 Osmotic laxative
 Due to high cost should be reserved for use where other treatment options have failed.
 When Laxidol® is reconstituted with 125mls water it is fluid neutral and so patients must
consume normal amounts of fluid in addition to Laxido®.
(Fybogel®)
Laxido® sachets
Comments
(see BNF for
management of
faecal impaction)
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Analgesics
 Tramadol should be avoided as psychiatric reactions have been known to occur and there is also an increased risk of serotonin syndrome
when prescribed with antidepressants.
Drug
Usual dose
Comments
Paracetamol
500mg-1g QDS
 Maximum frequency is every 4 hours and maximum dose is 4g in 24 hours.
 Prescribe regularly before considering adding/changing analgesic.
Ibuprofen
200-400mg TDS
 Do not prescribe for service users on lithium or who have renal impairment or cardiac
disease. Use with caution in asthma (see BNF for full list of cautions/contra-indications)
 Consider need for gastroprotection if prescribed long term.
 May be useful in mild-moderate musculoskeletal pain, dental pain and dysmenorrhoea.
Co-codamol 8/500
1 or 2 tablets four
times a day
 Monitor for constipation and prescribe laxatives is necessary.
 Contains paracetamol.
 Regular paracetamol plus codeine when required may be more effective where paracetamol
alone is not effective.
Codeine phosphate
30-60mg four times
a day if required.
 May be useful in addition to regular paracetamol where paracetamol alone is not effective.
 Monitor for constipation and prescribe laxatives if necessary.
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Indigestion Remedies
 Offer lifestyle advice e.g. healthy eating, weight reduction and smoking cessation.
 Review medications for possible causes of dyspepsia e.g. NSAIDS, bisphosphonates, steroids.
Drug
Usual dose
Comments
Gaviscon®
Advance
5ml QDS (after
meals and at
bedtime)
 For use in Wigan, Knowsley and St Helens localities only (use Peptac® at Warrington and
Halton)
 Note high sodium content – caution in hypertension and congestive heart failure. Increases
in sodium levels may result in reduced lithium levels.
Peptac®
10-20ml after meals
and at bedtime
 For use in Warrington and Halton localities only (use Gaviscon® Advance at other localities)
 Note high sodium content – caution in hypertension and congestive heart failure. Increases
in sodium levels may result in reduced lithium levels.
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Sore Throat Remedies
Drug
Usual dose
Simple linctus
5ml TDS
Strepsils®
Dissolve one
lozenge slowly in the
mouth every 2-3
hours.
Comments
 An urgent full blood count should always be performed for any service user presenting with
a sore throat and who is prescribed any medication with the potential to suppress bone
marrow e.g. clozapine, carbamazepine.
Barrier Creams
Drug
Usual dose
Conotrane® cream
Apply to the
affected area
several times a day
as often as
required.
Comments
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Emollients
 If emollients are being applied to the whole body twice daily adults may need 600g per week.
 Creams are more cosmetically acceptable than ointments. Gels are particularly suitable for application to the face and scalp while lotions
may be preferred for application to hairy areas. Ointments are much less likely to sensitise and are suitable for chronic dry lesions.
Drug
Usual dose
Comments
Oilatum®
emollient bath
additive
Add 1-3 capfuls to the
bath.
 Caution – this will make the surface of the bath slippery.
Aqueous cream
Use as a soap
substitute
 Should only be used a soap substitute by wetting the skin, washing with the cream and then
rinsing off. Do not use as a leave on emollient as this may result in skin thinning.
Dermol® 500
lotion
Apply after bathing
and as often as
required.
 Use when a less greasy emollient required.
 Can also be used as a soap substitute.
 Contains an antimicrobial.
Hydromol®
Ointment
For use as an
emollient, bath additive
or soap substitute.
 Use when a greasier emollient required.
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Drug
Usual dose
Doublebase® gel
Apply after bathing
and as often as
required.
Comments
 Use when a greasier emollient required.
Non-antimicrobial Ear Drops
Drug
Usual dose
Comments
Olive oil drops
3 drops 2-3 times daily.
 For the treatment of excess ear wax.
 Allow to warm to room temperature before use.
 Syringing may also be required once the wax has been softened.
Sodium
bicarbonate 5%
drops
3 drops 2-3 times daily
 For the treatment of excess ear wax.
 Syringing may also be required once the wax has been softened.
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Non-antimicrobial Eye Drops
Drug
Usual dose
Comments
Hypromellose
0.3% drops
One or two drops three
times a day as needed.
 Do not use if soft contact lenses are being worn.
 Use first line due to lower cost.
Liquifilm Tears®
One or two drops as
required.
 Do not use with soft contact lenses (remove lenses prior to insertion and wait at least 15
minutes prior to reinsertion.)
Viscotears®
Liquid Gel
One drop 3-4 times
daily.
 Contact lenses should not be worn whilst the drops are being instilled. There should be an
interval of at least 30 minutes before reinsertion.
Treatment for Warts, Verrucas and Coldsores
Drug
Usual dose
Comments
Salatac Gel®
Apply once daily at night.
 For the treatment of warts, verrucas, corns and calluses.
 Treatment may take up to 12 weeks for resistant lesions to disappear and it is necessary
to persevere with treatment.
Aciclovir 5%
cream
Use 5 times a day for 510 days at first sign of
attack.
 For treatment of coldsores.
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Treatment of Haemorrhoids
Drug
Usual dose
Comments
Anusol
cream/ointment
Apply to the affected
area in the morning, at
night and after each
bowel evacuation until
the condition is
controlled.
 For the relief of uncomplicated internal and external haemorrhoids.
Anusol
suppositories
Remove wrapper and
insert one suppository
into the anus in the
morning, at night and
after each evacuation.
 For the relief of internal haemorrhoids.
Suncreams
 All antipsychotics have the potential to cause photosensitivity. There is no reliable data comparing the different antipsychotics but
chlorpromazine is known to be the worst.
 Prescribe factor 40 or greater sunscreen for all inpatients prescribed chlorpromazine or other phenothiazines, and for those prescribed
other antipsychotics that are thought to be at risk e.g. previous history of photosensitivity reaction.
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Nutritional supplements
 Please note that different localities stock different brands of nutritional supplement (see table below for details)
 Seek advice from a dietician prior to prescribing wherever possible.
Drug
Usual dose
Comments
Fortijuice®
Each bottle contains
200ml.
 Stocked at Warrington and Halton localities.
 Available as blackcurrant and orange flavours.
 See BNF for nutritional information.
Forticreme®
Each pot contains
125g.
 Stocked at Warrington and Halton localities.
 Available as forest fruits and vanilla flavours.
 See BNF for nutritional information.
Fortisip®
Each bottle contains
200ml.
 Stocked at Warrington and Halton localities.
 Available as strawberry, banana and chocolate flavours.
 See BNF for nutritional information.
Ensure Plus®
milkshakes
Each bottle contains
220ml
 Stocked at Wigan and St Helens and Knowsley localities.
 See BNF for nutritional information.
 Available as banana, strawberry and vanilla flavours
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Drug
Usual dose
Comments
Ensure Plus®
juice
Each bottle contains
220ml
 Stocked at Wigan and St Helens and Knowsley localities.
 See BNF for nutritional information.
 Available as apple, pineapple, lemon and lime flavours
Ensure Plus®
Crème (yoghurt)
Each bottle contains
220ml
 Stocked at Wigan and St Helens and Knowsley localities.
 See BNF for nutritional information.
 Available as chocolate and vanilla.
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