Download Prescribing Guide/Formulary 2014 - City Hospitals Sunderland NHS

CITY HOSPITALS SUNDERLAND
PRESCRIBING GUIDE
DISCLAIMER
Although great care has been taken in compiling and checking the information given in this guide to
ensure that it is accurate, the pharmacy department shall not be responsible or in any way liable for
the continued currency of the information or for any errors, omissions or inaccuracies in this guide
whether arising from negligence or otherwise howsoever or for any consequences arising
therefrom.
Copyright
All rights reserved. No part of this document may be reproduced, stored in a retrieval system
or transmitted in any form or by any means, without permission.
© City Hospitals Sunderland Drugs and Therapeutics Group 1998-2014
CONTENTS
CONTENTS ................................................................................................................ 1
GENERAL INFORMATION ........................................................................................ 2
1. GASTROINTESTINAL SYSTEM ........................................................................... 8
2. CARDIOVASCULAR SYSTEM ............................................................................ 20
3. RESPIRATORY SYSTEM .................................................................................... 51
4. CENTRAL NERVOUS SYSTEM .......................................................................... 69
5. INFECTIONS ........................................................................................................ 99
6. ENDOCRINE SYSTEM ...................................................................................... 111
7. OBSTETRICS, GYNAECOLOGY, AND URINARY-TRACT DISORDERS ........ 130
8. MALIGNANT DISEASE AND IMMUNOSUPRESSION ..................................... 138
9. NUTRITION AND BLOOD ................................................................................. 150
10. MUSCULOSKELETAL AND JOINT DISEASES ............................................. 171
11. EYE .................................................................................................................. 183
12. EAR, NOSE, AND OROPHARYNX ................................................................. 198
13. SKIN ................................................................................................................. 204
14. IMMUNOLOGICAL PRODUCTS AND VACCINES ......................................... 225
15. ANAESTHESIA ................................................................................................ 237
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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GENERAL INFORMATION
THE FORMULARY
The Formulary consists of medicines, which have been recommended by
Consultants and other specialist staff. The range of medicines included in this
formulary is intended to encourage safe, effective and economical prescribing. These
medicines are routinely available to prescribe on EP, but use of some may be
restricted. Medicines in the formulary are listed in chapters and subsections that
generally correspond with those in the British National Formulary (BNF).
Recommended International Non-proprietary Names (INNs) are used throughout the
text, but proprietary names are used for some combination and modified release
products where brand name prescribing is recommended, or to clarify which product
is listed.
Products listed in the formulary alphabetically with no ranking unless specified in the
text. Products are flagged to indicate if they are hospital only products, suitable for
shared care, are unlicensed or have been approved for an unlicensed indication.
Hospital doctors should not ask GPs to prescribe hospital only medicines (‘Red’
drugs) unless there is a very exceptional reason and agreement with the GP.
When prescribing unlicensed medicines it is important that prescribers are aware that
they are taking on additional responsibilities regarding the patient’s safety.
NAVIGATION AROUND THE GUIDE
Medicines are listed alphabetically in chapters and subsections that generally
correspond with those in the British National Formulary (BNF).
Specific drugs can be searched by using the Find function (Ctrl+F).
PRESCRIBING NON-FORMULARY DRUGS
For hospital-initiated therapy or patients admitted on non-formulary drugs,
prescribers are requested to choose, or change to, drugs included in the formulary as
far as possible.
On EP, non-formulary drugs are pre-fixed with the character ~ (tilde), e.g.
~rabeprazole. Consequently, these drugs are not available on normal drug lists. In
order to view and prescribe on EP, enter ~ before the drug name.
When initiating a non-formulary drug, the form APPLICATION FOR THE REQUEST
OF A NON-FORMULARY DRUG FOR A SPECIFIC PATIENT must be completed.
Forms are available on the Intranet: Drugs and Therapeutics Group. Multiple
requests for the same drug from the same consultant will be queried and, if
necessary, supply may be refused. In such circumstances, a formal request to the
Drugs and Therapeutics Group for inclusion in the Formulary IS necessary.
The patient's own supply may be used however (but must still be prescribed on EP).
Before prescribing, prescribers must ensure that sufficient is available for the
admission and discharge.
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Please note:

The Pharmacy Department has been given the authority to query prescriptions
for non-formulary items.

Non-formulary drugs will be supplied only in exceptional cases, when all
alternatives have been tried and failed, or when there is no alternative.

There may be a delay (up to 48 hours) in obtaining non-formulary drugs, as
these are not routinely held in stock.

Supply is considered to be a ‘one-off’ and is only for the specific patient
named on the form. Stock will not be held in pharmacy.

The use of non-formulary drugs will be monitored and use will be reported
back to the relevant Directorate.
UNLICENSED MEDICINES AND USE OF MEDICINES FOR UNLICENSED
INDICATIONS
This formulary contains a number of unlicensed medicines, and medicines that have
been approved for unlicensed or ‘off-label’ indications. Many unlicensed medicines
are formulations of well established drugs that are included the BNF, whereas others
are products that are less well known, but considered to be of benefit in the treatment
of patients with conditions where licensed medicines cannot be used or fail to
produce an adequate response.
Unlicensed medicines included in the Formulary are marked using the notation U,
and that are considered unsuitable for prescribing by GPs (even if treatment has
been started and stabilised by a hospital clinician) are classified as ‘RED’, or hospital
only, medicines.
When prescribing an unlicensed or a licensed product ‘off-label’ for an unlicensed
indication it is important prescribers are aware that it is not only they who take on
additional responsibilities regarding the patient’s safety and welfare, but the burden is
shared with others involved in supply and administration.
While further information and guidance can be obtained from the Intranet, prescribers
are reminded that when prescribing unlicensed or off-label licensed products:

The clinical and/or pharmaceutical benefits, not cost, must outweigh the
potential risks of treatment and be justifiable.

They should not be used if there is an equally appropriate licensed medicine
that would meet the patient's needs.

Patients, their carers and/or healthcare staff should be given sufficient
information to use the product correctly and safely (manufacturer’s information
leaflets may not be adequate when a medicine is used for an unlicensed
indication).
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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
Where common practice is not being followed, the reasons for prescribing the
medicine should be recorded. Documented patient consent should be
obtained in high-risk situations.
NICE GUIDANCE
Where appropriate, the Formulary will list important and relevant NICE Clinical
Guidance (CG)
A list of published Clinical Guidelines by NICE, which is searchable, can be found on
the NICE website: http://guidance.nice.org.uk/CG/Published.
NICE technology appraisal recommendations are reviewed on a regular basis.
Where a NICE technology appraisal states ‘option for treatment’, assessment is
made of its place in a treatment pathway. All decisions are ratified by the local
formulary and decision-making groups, which are then incorporated in the Formulary.
A list of published Technical Appraisals by NICE, which is searchable, can be found
on the NICE website: http://www.nice.org.uk/Guidance/TA/Published
Alternatively, a table of all the TA recommendations can be viewed or printed as a
Word document: Full table of TA recommendations.
ESTIMATION OF RENAL IMPAIRMENT AND DRUG DOSING
Renal function in adults is routinely reported on the basis of estimated glomerular
filtration rate (eGFR), which is normalised to a body surface area of 1.73 m2 and
derived from the Modification of Diet in Renal Disease (MDRD) formula. It is
calculated using serum creatinine concentration, age, sex and ethnic origin.
Published information on the effects of renal impairment on drug elimination is
usually stated in terms of creatinine clearance (CrCl) – based on the Cockcroft &
Gault (C&G) estimation - as a substitute for glomerular filtration rate (GFR).
Although the two measures of renal function are not interchangeable, in practice, for
most drugs and for most patients (over 18 years) of average build and height, eGFR
(MDRD) can be used to determine dosage adjustments in place of CrCl (C&G).
The information on dosage adjustment in the BNF is usually expressed as eGFR as
opposed to CrCl, and this can be used for a large number of drugs and patients.
However, there are exceptions where the absolute GFR or CrCl calculated by the
C&G formula should be used:



Patients at extremes of body weight (BMI <18.5 Kg/m2 or >30 Kg/m2).
If using absolute GFR for these patients it may be necessary to base the
calculation on ideal body weight.
Children under 18 years
Potentially toxic drugs with a narrow therapeutic index. In the BNF, values for
creatinine clearance or another measure of renal function are included where
possible.
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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An individual's absolute glomerular filtration rate can be calculated from the eGFR as
follows:
GFR Absolute = eGFR × (individual's body surface area/1.73)
The BNF is generally not a good resource for patients with renal impairment. It does
not make a distinction between steady-state chronic kidney disease (CKD) and acute
kidney injury (AKI). The Renal Drug Handbook is a more useful guide, although the
emphasis is largely on the word “guide”, for making dose adjustments in patients with
AKI, where GFR may be changing rapidly. Clinical interpretation is necessary.
Pharmacy
Renal Department
July 2013
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Abbreviations
Some products are also marked with a suffix (es) to give additional information:
General Formulary
R
Red Drug - hospital only
A
Amber Drug - shared Care
G+
Green+ Drug - initiated in hospital which can be continued in primary
care once the patient is stable
P
Included in the Sunderland Primary Care recommend list
S
Specialist use recommended
U
Unlicensed drug or use
Antibiotic Formulary
M
Restricted antimicrobials requiring approval by a microbiologist
S
Specific-Use antimicrobials reserved for speciality use, specific
indications or Microbiology approval
U
Unrestricted use of antimicrobials
CONTACT DETAILS
For enquiries and queries contact:
Robert Lapham – Medicines Information/Formulary Pharmacist
[email protected]
Ext. 49031 OR Bleep 51656
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Changes to the Formulary - 2014
Section
Drug
6.1.2.3
G+ Lixisenatide 10 mcg/dose prefilled pen
6.5.2
R Tolvaptan tablets 15 mg
Change
ADDED to the
Formulary
ADDED to the
Formulary
Reason for Change
Approval by D&T
Approval by D&T
For explanation of symbols see ABBREVIATIONS
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
1. GASTROINTESTINAL SYSTEM
Local guidance
Trust guidelines for prophylaxis of gastrointestinal infections: link to guidelines
Trust guidelines for treatment of gastrointestinal infections: link to guidelines
Trust guidelines for use of ciclosporin: link to guidelines
National Guidance
NICE Clinical Guidance (CG)
Dyspepsia, August 2004 (CG17)
http://guidance.nice.org.uk/CG17 (Quick Reference Guide)
Irritable Bowel Syndrome, February 2008 (CG61)
http://guidance.nice.org.uk/CG61 (Quick Reference Guide)
Faecal Incontinence, June 2007 (CG49)
http://www.nice.org.uk/CG49 (Quick Reference Guide)
NICE Technology Appraisal (TA)
A list of published Technical Appraisals which is searchable can be found on the
NICE website: http://www.nice.org.uk/Guidance/TA/Published
Alternatively, a table of all the TA recommendations can be viewed or printed as a
Word document: Full table of TA recommendations.
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
1.1 DYSPEPSIA AND GASTRO-OESOPHAGEAL REFLUX DISEASE (GORD)
Adults - see BNF for further information
Children – see BNFC for further information
1.1.1 Antacids
Aluminium containing products:
PCo-magaldrox:
Aluminium hydroxide suspension
Co-magaldrox suspension
1.1.2 Compound alginates
Gaviscon Advance® liquid and Tablets:
Gaviscon Infant® sachets
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
1.2 ANTISPASMODICS AND OTHER DRUGS ALTERING GUT MOTILITY
Adults - see BNF for further information
Children – see BNFC for further information
Antimuscarinics
PHyoscine butylbromide
Tablets: 10 mg
Injection: 20 mg/1 mL
Other antispasmodics
PMebeverine
Tablets: 135 mg
Peppermint oil
Capsules: 0.2 mL
Motility stimulants
PDomperidone
Tablets: 10 mg
Liquid: 5 mg/5 mL
Domperidone: small risk of serious ventricular arrhythmia and sudden cardiac death.
See Drug Safety Update, May 2012
PMetoclopramide
Tablets: 10 mg
Liquid: 5 mg/5 mL
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
1.3 ANTISECRETORY DRUGS AND MUCOSAL PROTECTANTS
Adults - see BNF for further information
Children – see BNFC for further information
1.3.1 H-2 antagonists
PCimetidine
Tablets: 200 mg, 400 mg
Syrup: 200 mg/5 mL
PRanitidine
Tablets: 150 mg, 300 mg
Liquid: mg/10 mL
Liquid may contain alcohol; up to 405 mg per 5 ml spoonful, which is equivalent to about 11 mL of
beer or 5 mL of wine
Injection: 50 mg/2 mL
1.3.2 Selective antimuscarinics
No preparations
1.3.3 Chelates and complexes
Sucralfate
Tablets: 1 g
Suspension: 1 g/5 mL
1.3.4 Prostaglandin analogues
Misoprostol
Tablets: 200 micrograms
1.3.5 Proton-pump inhibitors
PLansoprazole
Capsules: 15 mg, 30 mg
POmeprazole
Tablets: 10 mg, 20 mg
Infusion vials: 40 mg
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
1.4 ACUTE DIARRHOEA
Adults - see BNF for further information
Children – see BNFC for further information
1.4.1 Adsorbents and bulk forming drugs
Colestyramine
Sachets: 4 g
1.4.2 Antimotility drugs
PCodeine phosphate
Tablets: 15 mg, 30 mg
Syrup: 25 mg/5 mL
Variation in metabolism: the capacity to metabolise codeine can vary considerably between individuals
and lead to either reduced therapeutic effect or marked increase in side-effects – particularly in
children.
PLoperamide
Capsules: 2 mg
Syrup: 1 mg/5 mL
Others
Oral Rehydration Solution (ORS)
1.4.3 Enkephallinase inhibitors
No preparations
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
1.5 CHRONIC BOWEL DISORDERS
Adults - see BNF for further information
Children – see BNFC for further information
1.5.1 Aminosalicylates
SBalsalazide SPECIALIST USE ONLY
Capsules: 750 mg
PMesalazine
Tablets: 400 mg, 800 mg (Asacol®)
SR Tablets: 500 mg (Pentasa®)
SR Tablets: 1.2 g, 2.4 g (Mezavant XL®)
Granules: 1 g sachet (Pentasa®)
Suppositories: 500 mg (Asacol®), 1 g (Pentasa®)
Foam enema: 1 g (Asacol®)
Retention enema: 1 g/100 mL (Pentasa®)
PSulfasalazine (sulphasalazine)
Tablets: 500 mg (Salazopyrin®)
1.5.2 Corticosteroids
SBudesonide SPECIALIST USE ONLY
CR capsules: 3 mg
Hydrocortisone
Foam: 10% (Colifoam®)
Injection: 100 mg
PPrednisolone
Tablets: 1 mg, 5 mg
Retention enema: 20 mg/100 mL (Predenema®)
Suppositories: 5 mg
1.5.3 Drugs affecting the immune response
SAzathioprine
SCiclosporin
SMercaptopurine
SMethotrexate
Cytokine modulators
S Adalimumab
S Infliximab
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
1.5.4 Food allergy
No preparations
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
1.6 LAXATIVES
Adults - see BNF for further information
Children – see BNFC for further information
1.6.1 Bulk laxatives
PIspaghula 3.5 g/sachet
1.6.2 Stimulant laxatives
PBisacodyl
Tablets: 5 mg
Suppositories: 10 mg
Co-danthramer
Capsules: 25/200, liquid 25/200 (danthron 25 mg/poloxamer ‘188’ 200 mg)
Capsules: 37.5/500, liquid 37.5/500 (danthron 37.5 mg/poloxamer ‘188’ 500 mg)
PDocusate sodium
Capsules: 100 mg
Glycerol suppositories 4 g
PSenna
Tablets: 7.5 mg
Syrup: 7.5 mg/5 mL
1.6.3 Faecal softeners
Arachis oil enema
1.6.4 Osmotic laxatives
PLactulose liquid
PMacrogols sachets (brand depends upon contract)
PSodium citrate micro-enema
Phosphate enema
1.6.5 Bowel cleansing preparations
Fleet Phospho Soda® solution
Klean Prep® sachets
Picolax® sachets
1.6.6 Peripheral opioid-receptor antagonists
No preparations
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
1.6.7 Other drugs used in constipation
Linaclotide
Capsules: 290 micrograms
Prucalopride
Tablets: 1 mg, 2 mg
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
1.7 PREPARATIONS FOR ANAL AND RECTAL DISORDERS
Adults - see BNF for further information
Children – see BNFC for further information
1.7.1 Soothing haemorrhoidal preparations
PAnusol® cream / suppositories
Lidocaine
1%, 2% gel; 5% ointment
Prolonged use of lidocaine (more than 2 weeks) should be avoided. Can cause
sensitivity reactions.
1.7.2 Compound haemorrhoidal preparations with corticosteroids
PAnusol HC® suppositories
1.7.3 Rectal sclerosants
Oily phenol injection BP
Ampoule: 5%, 5 mL
1.7.4 Management of anal fissures
Diltiazem
UCream 2%
For use in patients with anal fissures who do not respond to or cannot tolerate topical
glyceryl trinitrate. This is an unlicensed product
Glyceryl trinitrate
Ointment 0.4% (Rectogesic®)
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
1.8 STOMA CARE
Adults - see BNF for further information
Children – see BNFC for further information
There are stoma care nurses working within the Trust. Please contact them direct for
advice.
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
1.9 DRUGS AFFECTING INTESTINAL SECRETIONS
Adults - see BNF for further information
Children – see BNFC for further information
1.9.1 Drugs affecting biliary composition and flow
Ursodeoxycholic acid
Tablets: 150 mg (Destolit®); Capsules: 250 mg (Ursofalk®)
1.9.2 Bile acid sequestrants
Colestyramine
Sachets: 4 g
1.9.3 Aprotinin
No preparations
1.9.4 Pancreatin
Creon 10,000®
Creon 25,000®
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
2. CARDIOVASCULAR SYSTEM
Local guidance
Trust guidelines for prophylaxis of cardiovascular and vascular infections:
link to guidelines
Trust guidelines for treatment of cardiovascular and vascular infections:
link to guidelines
National Guidance
NICE Clinical Guidance (CG)
Angina and acute coronary syndromes
Management of Stable Angina, July 2011 (CG126)
www.nice.org.uk/Guidance/CG126 (Quick Reference Guide)
The North West Medicines Information Service produce summaries of NICE
guidance (NICE Bites) – Bulletin No 33 (August 2011) summarises the key
prescribing points from NICE guidance (CG126) for the treatment of stable angina.
Management of Unstable Angina and Non-ST-Segment Elevation Myocardial
Infarction (NSTEMI), April 2010 (CG94)
www.nice.org.uk/Guidance/CG94 (Quick Reference Guide)
Myocardial infarction - secondary prevention, May 2007 (CG48)
www.nice.org.uk/CG48 (Quick Reference Guide)
The North West Medicines Information Service produce summaries of NICE
guidance (NICE Bites) – Bulletin No 9 (September 2009) summarises the key
prescribing points from NICE guidance (CG48) for the treatment of MI: secondary
prevention
Chest Pain of recent Onset, March 2010 (CG95).
http://guidance.nice.org.uk/CG95 (Quick Reference Guide)
Arrhythmias
The management of atrial fibrillation, June 2006. (CG36)
http://www.nice.org.uk/Guidance/CG36 (Quick Reference Guide)
Hypertension and Heart Failure
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Hypertension: management of hypertension in adults in primary care, August 2011
(CG127) http://www.nice.org.uk/Guidance/CG127 (Quick Reference Guide).
See NICE hypertension treatment pathway
The North West Medicines Information Service produce summaries of NICE
guidance (NICE Bites) – Bulletin No 34 (September 2011) summarises the key
prescribing points from NICE guidance (CG127) for the treatment of hypertension
Chronic heart failure: management of chronic heart failure in adults in primary and
secondary care, August 2010 (CG108)
http://www.nice.org.uk/Guidance/CG108 (Quick Reference Guide)
See NICE heart failure treatment pathway
The North West Medicines Information Service produce summaries of NICE
guidance (NICE Bites) – Bulletin No 21 (Sept 2010) summarises the key prescribing
points from NICE guidance (CG108) for the treatment of heart failure.
Hypercholesterolemia
Lipid modification, May 2008 - reissued March 2010 (CG67)
http://guidance.nice.org.uk/CG67 (Quick Reference Guide)
The North West Medicines Information Service produce summaries of NICE
guidance (NICE Bites) –Bulletin No 27 (Feb 2011) summarises the key prescribing
points from NICE guidance (CG67) lipid modification.
Familial hypercholesterolaemia, August 2008 (CG71)
http://guidance.nice.org.uk/CG71 (Quick Reference Guide)
Venous thromboembolic diseases and stroke
Venous thromboembolism: reducing the risk: Reducing the risk of venous
thromboembolism (deep vein thrombosis and pulmonary embolism) in patients
admitted to hospital, January 2010 (CG92)
www.nice.org.uk/Guidance/CG92 (Quick Reference Guide)
The North West Medicines Information Service produce summaries of NICE
guidance (NICE Bites) – Bulletin No 14 (Feb 2010) summarises the key prescribing
points from NICE guidance (CG92) for the treatment of venous thromboembolism:
reducing the risk.
See NICE venous thromboembolism pathway
Venous thromboembolic diseases: the management of venous thromboembolic
diseases and the role of thrombophilia testing, June 2012 (CG144)
www.nice.org.uk/Guidance/CG144
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
The North West Medicines Information Service produce summaries of NICE
guidance (NICE Bites) – Bulletin No 44 (August 2012) summarises the key
prescribing points from NICE guidance (CG144) for the treatment of venous
thromboembolic diseases.
Stroke: Diagnosis and initial management of acute stroke and transient ischaemic
attack (TIA), July 2008 (CG68)
www.nice.org.uk/Guidance/CG68 (Quick Reference Guide)
See NICE stroke pathway
NICE Technology Appraisal (TA)
A list of published Technical Appraisals which is searchable can be found on the
NICE website: http://www.nice.org.uk/Guidance/TA/Published
Alternatively, a table of all the TA recommendations can be viewed or printed as a
Word document: Full table of TA recommendations.
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
2.1 POSITIVE INOTROPIC DRUGS
Adults - see BNF for further information
Children – see BNFC for further information
2.1.1 Digoxin
 Care with digoxin is recommended because it has a narrow therapeutic index
and therefore should be used with caution in the elderly and in renal
impairment.
 Regular measurements of plasma digoxin concentrations are not usually
necessary except to confirm toxic or sub-therapeutic levels, or to check
compliance.
Loading Doses
The National Patient Safety Agency (NPSA) issued an alert regarding the
administration of loading doses in November 2010: Preventing fatalities from
medication loading doses.
 A loading dose may be given on initiation of therapy to achieve a rapid
therapeutic effect; otherwise, it will take about a week to obtain maximal effect.
 Care must be taken when prescribing and administering digoxin for rapid
digitalisation – usually given orally for no longer than 24 hours. Very rarely
should it be necessary to use the intravenous route and should only be
undertaken with Specialist advice. . Intramuscular injection should be avoided
as it is painful and absorption is variable
 Doses of digoxin greater than 250 microgram once daily in adults and greater
than 125 microgram in people over 70 years of age should rarely be seen.
Hypokalaemia and Electrolyte Disturbances
 Hypokalaemia can increase tissue sensitivity to digoxin, and is one of the most
common factors for adverse effects.
 Careful monitoring of potassium levels is recommended. If potassium levels
are low, digoxin toxicity can be assumed without waiting for digoxin levels.
 Hypercalcaemia and hypomagnesaemia may also be associated with
increased tissue sensitivity to digoxin.
See Therapeutic Drug Monitoring for advice on monitoring, pharmacokinetics,
interactions and equivalences
Digoxin
Injection: 500 micrograms/2 mL
PLiquid: 50 micrograms/1 mL
PTablets: 62.5 micrograms, 125 micrograms, 250 micrograms
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
2.1.2 Phosphodiesterase type-3 inhibitors
Milrinone
Ampoules: 10 mg/10 mL
Incompatible with furosemide and bumetanide, and it should not be diluted with sodium bicarbonate
injection
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
2.2 DIURETICS
Adults - see BNF for further information
Children – see BNFC for further information
General Points
 Regular review of diuretic use is desirable to confirm continued need and to
monitor adverse effects such as dehydration, which may cause renal
impairment (particularly in the elderly).

Thiazide diuretics may increase lithium levels to a dangerous extent and
should be avoided in patients on lithium therapy.
Hypokalaemia
 Thiazide and loop diuretics cause serum-potassium levels to fall particularly
during the first few weeks of treatment. Drugs with a long duration of action
tend to have the most pronounced effect. Routine use of potassium
supplements is not necessary.

Potassium supplements are seldom required with the small doses of
diuretics given to treat hypertension; potassium-sparing diuretics (rather
than potassium supplements) are recommended for prevention of
hypokalaemia due to diuretics such as furosemide or the thiazides when these
are given to eliminate oedema.

Individual patients’ requirements for potassium supplements or potassiumsparing diuretics should be re-assessed regularly by measuring serumpotassium levels.
2.2.1 Thiazides and related diuretics
PBendroflumethiazide
Tablets: 2.5 mg, 5 mg
PIndapamide
Tablets: 2.5 mg
PMetalazone
Tablets: 5 mg
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
2.2.2 Loop diuretics
PBumetanide
Tablets: 1 mg, 5 mg
Liquid: 1 mg/5 mL
Injection: 1 mg/2 mL, 2 mg/4 mL, 5 mg/10 mL
PFurosemide
Tablets: 20 mg, 40 mg, 500 mg
Liquid: 1 mg/ mL, 40 mg/5 mL
Injection: 20 mg/2 mL, 50 mg/5 mL, 250 mg/25 mL
2.2.3 Potassium sparing diuretics and aldosterone antagonists
PAmiloride
Tablets: 5 mg
Liquid: 5 mg/5 mL
Eplerenone
Tablets: 25 mg, 50 mg
PSpironolactone
Tablets: 25 mg, 100 mg
2.2.4 Potassium sparing diuretics with other diuretics
No preparations
2.2.5 Osmotic diuretics
Mannitol
Intravenous infusion: 10%, 500 mL; 20%, 500 mL
2.2.6 Mercurial diuretics
No preparations
2.2.7 Carbonic anhydrase inhibitors
The carbonic anhydrase inhibitor acetazolamide is a weak diuretic and is little used
for its diuretic effect
2.2.8 Diuretics with potassium
No preparations
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
2.3 ANTI-ARRHYTHMIC DRUGS
Adults - see BNF for further information
Children – see BNFC for further information
DRUGS IN THIS SECTION SHOULD ONLY BE USED WITH SPECIALIST ADVICE
Loading Doses
The National Patient Safety Agency (NPSA) issued an alert regarding the
administration of loading doses in November 2010: Preventing fatalities from
medication loading doses.
 Amiodarone has a very long half-life and many weeks or months may be
required to achieve steady-state plasma-concentration. IV administration
allows more rapid loading; if amiodarone has already been given as an IV
infusion, the oral loading dose may need to be reduced depending on the
length of the infusion. Intervals of at least 6-8 weeks should be allowed to
assess the effect of dosage adjustments during long-term therapy. Its use is
limited by potential multiple adverse drug reactions.
 Maintenance therapy should be undertaken only if necessary because of longterm side effects; the lowest effective dose should be used and careful follow
up of patients is mandatory.
 Amiodarone doses higher than 200 mg daily should be queried (the
maximum licensed dose for maintenance is 200 mg).
 See Trust guideines: Loading Doses
Dronedarone
 The European Medicines Agency Committee for Medicinal Products for
Human Use (CHMP) has assessed the benefits and risks - see the Summary
of Product Characteristics (SPC) for further updated advice.
 It is now only indicated in adult clinically stable patients with paroxysmal or
persistent atrial fibrillation (AF) for the maintenance of sinus rhythm after
successful cardioversion.
 It is now contraindicated in patients with:
o Unstable Haemodynamic conditions
o History of, or current heart failure or left ventricular systolic dysfunction
o Permanent AF (AF duration ≥ 6 months or unknown, and attempts to
restore sinus rhythm no longer considered by the physician).
o Liver and lung toxicity related to previous use of amiodarone.
 Patients should be carefully monitored during treatment by regular
assessment of cardiac, hepatic and pulmonary function. Liver function tests
(LFTs) should be measured before initiation, after one week and one month
following initiation and then repeated monthly for six months, at months 9 and
12, and periodically thereafter.
 If the patient develops any condition that would be considered a contraindication, then treatment must be stopped.
 A prescribing checklist has been developed – see LINK
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
SAdenosine
Vials: 6 mg/2 mL
SAmiodarone
Injection: 150 mg/3 mL
Tablets: 100 mg, 200 mg
SDisopyramide
Capsules: 100 mg, 150 mg
Injection: 50 mg/5 mL
SDronedarone
Tablets: 400 mg
SFlecainide
Tablets: 100 mg;
Injection: 150 mg/15 mL
SLidocaine
Injection: 1% (10 mg / mL), 2% (20 mg / mL)
Infusion: 0.2% (2 mg/ mL) in dextrose 5%
SSotalol
Tablets: 40 mg, 80 mg
SVerapamil
Injection: 5 mg/2 mL;
Tablets: 40 mg, 80 mg, 120 mg
Important: serious interaction hazard with beta-blockers see BNF
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
2.4 BETA-BLOCKING DRUGS
Adults - see BNF for further information
Children – see BNFC for further information

Beta-blockers can precipitate asthma and should be avoided in patients with
a history of asthma or bronchospasm; if there is no alternative, a
cardioselective beta-blocker can be used with extreme caution under
specialist supervision.

Avoid abrupt withdrawal of beta-blockers; this should be done gradually over
several weeks.

Although not contraindicated, cardioselectivity is desirable in diabetes; avoid in
those with frequent episodes of hypoglycaemia. Beta blockers, especially
when combined with a thiazide diuretic, should be avoided for the routine
treatment of uncomplicated hypertension in patients with diabetes or in those
at high risk of developing diabetes.

Caution in combination with calcium-channel blockers (such as diltiazem and
verapamil) since depression of myocardial function and conduction may occur.
Concurrent use of verapamil and beta-blockers is contraindicated.
PAtenolol
Tablets: 25 mg, 50 mg and 100 mg
Liquid: 25 mg/5 mL
PBisoprolol
Tablets: 1.25 mg, 2.5 mg, 3.75 mg, 5 mg, 7.5 mg and 10 mg
PCarvedilol
Tablets: 3.125 mg, 6.25 mg, 12.5 mg and 25 mg
Labetalol
Tablets: 50 mg, 100 mg and 400 mg
Injection: 100 mg/20 mL
Metoprolol
Tablets: 50 mg and 100 mg
SR Tablets: 200 mg
Injection: 5 mg/50 mL
Propranolol
Tablets: 10 mg, 40 mg and 80 mg
SR capsules: 40 mg and 80 mg
Liquid: 10 mg/5 mL
Injection: 1 mg/1 mL
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Sotalol
Tablets: 40 mg and 80 mg
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
2.5 HYPERTENSION AND HEART FAILURE
Adults - see BNF for further information
Children – see BNFC for further information
2.5.1 Vasodilator and antihypertensive drugs
Hydralazine
Tablets: 25 mg
Ampoules: 20 mg
Minoxidil
Tablets: 2.5 mg, 5 mg, 10 mg
Sildenafil
Tablets: 20 mg
Sodium nitroprusside
Vial: 50 mg
2.5.2 Centrally acting antihypertensive drugs
Clonidine hydrochloride
Tablets: 25 micrograms, 100 micrograms
Ampoules: 150 micrograms/1 mL
Methyldopa
Tablets: 125 mg, 250 mg
Moxonidine
Tablets: 200 micrograms, 300 micrograms
2.5.3 Adrenergic neurone blocking drugs
No preparations
2.5.4 Alpha-adrenoceptor blocking drugs
PDoxazosin
Tablets: 1 mg, 2 mg and 4 mg
Prazosin
Tablets: 500 micrograms, 1 mg
Phaeochromocytoma
Phenoxybenzamine hydrochloride
Capsules: 10 mg
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
2.5.5 Drugs affecting the renin-angiotensin system
2.5.5.1 Angiotensin-converting enzyme inhibitors
ACE inhibitors and angiotensin-II receptor antagonists should not be used at any
stage during pregnancy.
See Drug Safety Update December 2007.
ACE inhibitors and angiotensin-II receptor antagonists should not be used by breast
feeding mothers in the first few weeks after delivery because of profound neonatal
hypotension; pre-term babies may at particular risk
For more details, see Drug Safety Update, May 2009
Captopril
Tablets: 12.5 mg, 25 mg and 50 mg
Enalapril maleate
Tablets: 2.5 mg, 5 mg, 10 mg and 20 mg
PLisinopril
Tablets: 2.5 mg, 5 mg, 10 mg and 20 mg
PPerindopril erbumine
Tablets: 2 mg, 4 mg and 8 mg
PRamipril
Capsules: 1.25 mg, 2.5 mg, 5 mg and 10 mg
2.5.5.2 Angiotensin-II receptor antagonists
PCandesartan cilexetil
Tablets: 2 mg, 4 mg and 8 mg
Indicated for heart failure
PIrbesartan
Tablets: 75 mg and 150 mg
Valsartan
Capsules: 40 mg and 80 mg
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
2.5.5.3 Renin inhibitors
Aliskiren
Tablets: 150 mg
The combination of aliskiren with angiotensin-converting enzyme (ACE) inhibitors or
angiotensin receptor blockers (ARBs) has been associated with serious adverse
cardiovascular and renal outcomes in a recent large clinical trial (ALTITUDE). This
combination is now contraindicated in:
 diabetic patients (type I or type II); and
 non-diabetic patients with an estimated glomerular filtration rate (eGFR) <60
mL/min per 1.73 m2
In all other patient groups, aliskiren in combination with an ACE inhibitor or an ARB is
not recommended.
Any use of aliskiren (either as monotherapy or in combination with other medicines)
is no longer recommended in any patient with severe renal impairment: eGFR <30
mL/min per 1.73 m2
For more details, see Drug safety Update March 2012
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
2.6 NITRATES, CALCIUM-CHANNEL BLOCKERS, AND OTHER ANTIANGINAL
DRUGS
Adults - see BNF for further information
Children – see BNFC for further information
2.6.1 Nitrates
 Isosorbide mononitrate is a long acting metabolite of isosorbide dinitrate (ISDN)
with more predictable dosing than the dinitrate (which undergoes pre-systemic
metabolism).

Slow release preparations of isosorbide offer no real benefit over ordinary
tablets. They are very expensive so are not recommended.
Glyceryl trinitrate
PSpray: 400 micrograms/spray
Topical: ointment 2%
Ampoules: 10 mg/10 mL
PIsosorbide monontrate
Tablets: 10 mg, 20 mg
Isosorbide dinitrate
Infusion: 25 mg/50 mL (0.05%),
50 mg/50 mL (0.1%)
2.6.2 Calcium-channel blockers
PAmlodipine
Tablets: 5 mg, 10 mg
PDiltiazem hydrochloride
Tablets: 60 mg
SR preparation (twice daily): 90 mg, 120 mg, 180 mg
XL preparation (once daily): 120 mg, 180 mg
PLercanidipine hydrochloride
Tablets: 10 mg
Nifedipine
LA Tablets: 20 mg, 30 mg, 60 mg
Short acting formulations of nifedipine are not recommended for angina or long-term management of
hypertension, as use may be associated with large variations in blood pressure and reflex tachycardia.
Nimodipine
Tablets: 30 mg
Infusion: 10 mg/50 mL (200 micrograms/ mL)
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Verapamil hydrochloride
Tablets: 40 mg, 80 mg, 120 mg
SR Tablets: 240 mg
Injection: 5 mg/2 mL (2.5 mg/ mL)
2.6.3 Other antianginal drugs
Nicorandil is associated with a risk of gastrointestinal tract ulceration including
perianal ulceration. Ulceration is refractory to treatment and responds only to
withdrawal of nicorandil. Withdrawal should be under the supervision of a
cardiologist. See Drug Safety Update, June 2008.
Ivabradine
Tablets: 5 mg, 7.5 mg
PNicorandil
Tablets: 10 mg, 20 mg
Ranolazine
Tablets: 375 mg, 500 mg
2.6.4 Peripheral vasodilators and related drugs
Naftidrofuryl
Capsules: 100 mg
Nifedipine
Capsules: 5 mg, 10 mg
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
2.7 SYMPATHOMIMETICS
Adults - see BNF for further information
Children – see BNFC for further information
2.7.1 Inotropic Sympathomimetics
Dobutamine
Injection: 250 mg, 20 mL and 50 mL; pre-filled syringe in 5% dextrose
Dopamine hydrochloride
Injection: 200 mg, 5 mL ampoule and prefilled syringe in 5% dextrose.
2.7.2 Vasoconstrictor sympathomimetics
Ephedrine hydrochloride
Ampoules: 30 mg/1 mL
Pre-filled syringe: 30 mg/10 mL
Metaraminol
Ampoules: 10 mg/1 mL
Noradrenaline acid tartrate / norepinephrine bitartrate
Ampoules (as acid tartrate): 200 micrograms/2 mL, 4 mg/2 mL, 8 mg/4 mL,
40 mg/20 mL
Phenylephrine hydrochloride
Ampoules: 10 mg/1 mL
2.7.3 Cardiopulmonary resuscitation
The algorithm for cardiopulmonary resuscitation (see the BNF Adult or Children)
reflects the most recent recommendations of the Resuscitation Council (UK). These
guidelines are available at www.resus.org.uk.
Adrenaline/Epinephrine
Ampoules: 1 mg/1 mL (1 in 1,000), 1 mg/10 mL (1 in 10,000)
Pre-filled syringe: 1 mg/10 mL (1 in 10,000)
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
2.8 ANTICOAGULANTS AND PROTAMINE
Adults - see BNF for further information
Children – see BNFC for further information
2.8.1 Parenteral anticoagulants
Link to Trust guidelines for prophylaxis of venous thromboembolism and (risk
assessment tool).
Unfractionated Heparin (UFH)
Heparin initiates anticoagulation rapidly but has a short duration of action. For
patients at high risk of bleeding, heparin is more suitable than low molecular weight
heparin because its effect can be terminated rapidly by stopping the infusion.

A baseline FBC and PT and APTT should be measured in all patients prior to
commencing Heparin.

A standard preparation of 1000 units per mL will be used across the Trust for
heparin infusions.

Heparin infusions should be prescribed on E.P. for all areas that routinely use
E.P. Paper heparin charts should no longer be used.

The product for infusions is heparin sodium 20, 000 units as a 20 mL ampoule
following a loading dose of 5,000 units IV (5 mL of 1,000 units per mL)

APTT ratio should be ordered and checked according to the protocol overleaf.

The person administering the heparin will be required to check the rate of the
infusion four times a day and adjust it if necessary as per the protocol below.

For areas that do not use EP, heparin 1,000 units/mL should be prescribed on
the standard heparin chart according to the regime below.

A FBC should be checked on day 5 and day 7 of Heparin infusions to exclude
Heparin Induced Thrombocytopaenia (HITT).
Heparin IV regime
 Available as an order set – Prescriber should enter Set then HeparinInf

A Loading Dose of 5,000 units is prescribed as ONCE by IV bolus
injection - [Heparin 5,000 units as a 5 mL ampoule (Concentration 1,000
units per mL).

In addition a Regular Order will appear

Heparin 20,000 units in 20 mL amp with dose Instructions (See Administration
Criteria) administered as an IV Infusion.

The administration criteria are automatically provided to the nurse but can be
used by prescribers without EP on standard heparin charts.
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Starting rate (dose)
< 40kg
then 0.8 mL (800 units) per hour
41 - 60kg
1 mL (1,000units) per hour
61 - 80kg
1.3 mL (1,300 units) per hour
81 - 100kg
1.6 mL (1,600 units) per hour
>100kg
2 mL (2,000 units) per hour
Order and arrange check of APTT ratio after 4 to 6 hours

If adjustment to the dosage of heparin sodium infusion 1000 units per mL is
need to bring APTT ratio into range the following infusion rate change is
advised. (Note ideally aim for low end of range for AF/mural thrombi and
higher end for prosthetic mitral values).

If APTT ratio fluctuates widely seek Haematologist advice.
APTT Ratio
>7
5.1 – 7.0
4.1 – 5.0
3.3 – 4.0
1.8 – 3.2
1.4 – 1.7
1.0 – 1.4
ACTION
Stop infusion for 1 hour, check APTT ratio
is falling before reducing rate by
0.7 mL (700 units) per hour
Reduce by 0.5 mL (500 units) per hour
Reduce by 0.3 mL (300 units) per hour
Reduce by 0.1 mL (100 units) per hour
No change
Increase by 0.1 mL (100 units) per hour
Increase by 0.3 mL (300 units) per hour
Check APTT
ratio
After a further
2 hours
After 4 hours
After 6 hours
After 12 hours
After 24 hours
After 12 hours
After 4 hours

This regime uses 1,000 units per mL heparin, which is double the
strength of the previous regime if prescribing on paper please check
documentation.

Please Note - The Electronic Prescription system will display the last
APTT ratio measured at the point of prescribing (likely to be no result).

When full documenting (FD) on administration (fixed as four times a day) the
last APTT ratio will be also be displayed and the rate should be confirmed as
appropriate by the nurse and recorded.
Low Molecular Weight Heparins (LMWH)
Low molecular weight heparins are as effective and safe as unfractionated heparin,
and appear to be more effective in orthopaedic surgery. They are advantageous in
that only one subcutaneous injection is required daily, instead of two or three with
conventional heparin. No monitoring is required for prophylaxis. Monitoring may be
necessary in patients at increased risk of bleeding (e.g. in renal impairment and
those who are underweight or overweight); they can be given by subcutaneous
injection; and have less incidence of heparin induced thrombocytopenia (HIT).
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Dalteparin
Prophylaxis Dosing (1)
 Dalteparin is the LMWH used at CHS except in Trauma and Orthopaedics
where enoxaparin is used.

Standard dose of dalteparin 5,000 Units given once daily by subcutaneous
injection for surgical patients (enoxaparin 40 mg for Trauma and Orthopaedic
patients).
Treatment Dosing and Monitoring (2)
 This must be prescribed on E.P.

Treatment of venous thromboembolism (VTE). - dalteparin is usually given
once daily by subcutaneous injection based on bodyweight (200 IU/kg). For
patients with an increased risk of bleeding requiring treatment, it is
recommended that dalteparin be administered according to the twice daily
regimen.

The single daily dose should not exceed 18,000 IU (but see below for advice
on extremes of body weight).

Please note dosing schedule is different in pregnancy.

Caution in acute asthma.

Adjust dose in severe renal impairment (see below for advice)
Patient Weight
< 46 kg
46 – 56 kg
57 – 68 kg
69 – 82 kg
≥ 83 kg
Dose of Dalteparin
7,500 units
10,000 units
12,500 units
15,000 units
See below
Frequency
SC once daily
SC once daily
SC once daily
SC once daily
SC once daily
Monitoring of Anti-Xa Levels is not usually required but should be considered for
specific patient populations such as paediatrics, those with renal failure, patients
very thin or morbidly obese, pregnant or at increased risk for bleeding or rethrombosis. Doses should be adjusted accordingly.
Dosing in Obese Patients
There is, at present a lack of good evidence-based data to inform the prescribing of
low molecular weight heparin for thromboprophylaxis or treatment in obese patients.
Thromboprophylaxis
In light of so little evidence, a pragmatic approach is to base increased prophylactic
doses on weight. All obese patients should be classed as high risk for venous
thromboembolism as they have at least one risk factor in addition to their
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
surgery/medical condition, therefore the available evidence points towards higher
LMWH dosing in this patient group. (3)
There is a dosing protocol for enoxaparin which has been extrapolated to dalteparin
and the following are suggested doses for thromboprophylaxis. (3)
Dalteparin
< 50 kg
2,500 Units
daily
50 – 100 kg
5,000 Units
daily
100 – 150 kg
5,000 Units
twice daily
> 150 kg
7,500 Units
twice daily
Treatment
Once again, there is little information as morbidly obese patients are excluded from
clinical trials.
The manufacturer of dalteparin (Fragmin®, Pfizer) recommends a dose of 200
units/kg (dose capped at 18,000 units). However, studies show that doses should not
be capped and be based on actual body weight. (5-8)
Doses should be given once a day; for patients weighing >120kg, a dose of 100
units/kg BD is suggested to reduce the risk of bleeding. Seek advice from a
haematologist for patients weighing >190kg.and monitoring of anti-Xa levels is
recommended. (6)
Anti-Xa levels should be checked after every 3rd dose and after 10 days, or if actively
bleeding. Take 4 hours post dose. This service is only available Monday to Friday.
The Haematology lab should be contacted before sending the sample at weekends.
Renal impairment and dosing (4)
Low molecular weight heparins are renally excreted and hence accumulate in severe
renal impairment. Dose adjustment is not necessary for prophylactic doses of
dalteparin. However, the doses recommended for treatment of DVT and PE has been
associated with severe, sometimes fatal, bleeding.
In patients with acute kidney injury (AKI) please seek the advice of haematology or
renal team.
In patients with Chronic Kidney Disease (CKD)


if GFR (Cockcroft-Gault) is 20 - 50 mL/min - normal dosing but review after 3
days, if still required switch to unfractionated heparin
if GFR (Cockcroft-Gault) is < 20 mL/min – use unfractionated heparin
In patients with GFR (Cockcroft-Gault) ≤ 30 mL/min, monitoring for anti-Xa levels is
recommended to determine the appropriate dalteparin dose. Target anti- Xa range is
0.5-1.5 IU/m.
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Anti-Xa levels should be checked after every 3rd dose and after 10 days, or if actively
bleeding. Take 4 hours post dose. This service is only available Monday to Friday.
The Haematology lab should be contacted before sending the sample at weekends.
Frequency of administration
 Ideally, dalteparin should be given once every 24 hours at the same time each
day. Less than 24 hours will mean that there is a risk of over-anticoagulation
and more than 24 hours will mean that there is a risk of under-coagulation (i.e.
sub-therapeutic levels).

However, sometimes it is deemed necessary to change the timing of
administration to coincide with community nurse visits. The manufacturer of
dalteparin (Fragmin® – Pfizer) has stated that a delay of 1-2 hours would most
probably not lead to any risk for the patient. (9)
Pharmacy/Haematology/Renal
May 2013
References
1. Fragmin 5000 IU SPC (Date of last update: 5/3/13). Electronic Medicines Compendium (eMC):
http://www.medicines.org.uk/emc/medicine/26896/SPC/. Accessed 15/5/13).
2. Fragmin 100,000 IU / 4ml Multidose Vial SPC (Date of last update: 5/3/13). Electronic
Medicines Compendium (eMC): http://www.medicines.org.uk/emc/medicine/26902/SPC/.
Accessed 15/5/13).
3. UKMI Medicines Q&A: What doses of thromboprophylaxis are appropriate for adult patients at
extremes of body weight? (Q&A 326.1, April 2010). National electronic Library for Medicines
(NeLM) - http://www.nelm.nhs.uk. Date accessed: 13/3/13
4. Ashley C and Currie A (Editors). The Renal Drug Handbook, 3rd ed. Oxford: Radcliffe Medical
Press; 2009
5. Patel JP, Roberts LN and Arya R. Anticoagulating obese patients in the modern era. British
Journal of Haematology 2011; 155: 137-149
6. Nutescu EA, Spinler SA, Wittkowsky A,Dager WE. Low-molecular-weight heparins in renal
impairment and obesity: Available evidence and clinical practice recommendations across
medical and surgical settings. Ann Pharmacother 2009;43(6):1064-83.
7. Al-Yaseen E, Wells PS, Anderson J, Martin J, Kovacs MJ. The safety of dosing dalteparin
based on actual body weight for the treatment of acute venous thromboembolism in obese
patients. J Thromb Haemost 2005; 3:100-2.
8. Smith J, Canton EM. Weight-based administration of dalteparin in obese patients. Am J Health
Syst Pharm 2003;60:683-7.
9. Written communication (14/1/12). Pfizer medicines information department. Pfizer Limited,
Sandwich, Kent
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Preparations
Heparin
Injection (ampoule): 5,000 units/5 mL, 20,000 units/20mL
Heparin (for flushing)
Injection: 50 units/5 mL, 200 units/2 mL
Dalteparin
Injection (pre-filled syringe): 2, 500 units/0.2 mL, 5,000 units/0.2 mL,
10,000 units/0.4 mL, 12,500 units/0.5 mL, 15, 000 units/0.6 mL,
18,000 units/0.72 mL
Enoxaprin (for prophylaxis in Trauma and Orthopaedics only)
Injection (pre-filled syringe): 20 mg/0.2 mL, 40 mg/0.4 mL
SBivalirudin
Injection: 250 mg
Ensure that the correct dosing schedule is used (January 2013)
SDanaporoid sodium
Injection (ampoule): 750 units/0.6 mL
SFondaparinux
Injection (pre-filled syringe): 2.5 mg/0.5 mL
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
2.8.2 Oral anticoagulants
Phenindione
Tablets: 10 mg, 25 mg, 50 mg
PWarfarin
Tablets: 1 mg, 3 mg, 5 mg
SApixaban – an option in a managed pathway
SDabigatran– an option in a manged pathway
SRivaroxaban – an option in a managed pathway
Dabigatran - Updated advice on contraindications and warnings:
Dabigatran is contraindicated in clinical conditions associated with a significant risk of
bleeding, such as:
 current or recent gastrointestinal ulceration
 malignant neoplasms
 recent brain or spinal injury
 recent brain, spinal or ophthalmic surgery
 recent intracranial haemorrhage
 oesophageal varices
 arteriovenous malformations
 vascular aneurysms
 major intraspinal or intracerebral vascular abnormalities
The benefits and risks of starting dabigatran should also be considered carefully for
patients who may have other conditions that put them at an increased risk of major
bleeding (but in whom treatment with dabigatran is not contraindicated)
Use of dabigatran is contraindicated with dronedarone, and with other
anticoagulants, except when switching treatment to or from dabigatran, or with the
use of unfractionated heparin for maintenance of venous or arterial catheter patency
Concomitant use of antiplatelet agents increases the risk of major bleeding with
dabigatran approximately two-fold, therefore a careful benefit-risk assessment should
be made prior to initiation of treatment
See Drug Safety Update, July 2012.
Dabigatran is now contraindicated in patients with prosthetic heart valves requiring
anticoagulant treatment (January 2013).
2.8.3 Protamine sulphate
Protamine
Injection: 50 mg/5 mL
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
2.9 ANTIPLATELET DRUGS
Adults - see BNF for further information
Children – see BNFC for further information
Clopidogrel and proton pump inhibitors: interaction – MHRA updated advice
(April 2010)
 Concomitant use of clopidogrel and omeprazole or esomeprazole is to be
discouraged unless considered essential
 Doctors should check whether patients who are taking clopidogrel are also
buying over-the-counter omeprazole and consider whether other
gastrointestinal therapies would be more suitable
 Pharmacists should check whether patients buying omeprazole are also taking
clopidogrel
 Consider PPIs other than omeprazole or esomeprazole in patients who are
taking clopidogrel. Other gastrointestinal therapy such as H2 blockers (except
cimetidine) or antacids may be more suitable in some patients
 Discourage concomitant use of other known CYP2C19-inhibiting medicines
with clopidogrel because these are expected to have a similar effect to
omeprazole and esomeprazole (CYP2C19 inhibitors include fluvoxamine,
fluoxetine, moclobemide, voriconazole, fluconazole, ticlopidine, ciprofloxacin,
cimetidine, carbamazepine, oxcarbazepine, and chloramphenicol)
For more details, see Drug Safety Update, April 2010
Abciximab
Vial: 10 mg/5 mL
PAspirin (antiplatelet)
Soluble Tablets: 75 mg
PClopidogrel
Tablets: 75 mg, 300 mg
Dipyridamole
Tablets: 25 mg, 100 mg
SR capsules: 200 mg
SPrasugrel
Tablets: 10 mg
STicagrelor
Tablets: 50 mg
STirofiban
Infusion: 125 mg/250 mL
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
2.10 STABLE ANGINA, ACUTE CORONARY SYNDROMES, AND FIBRINOLYSIS
Adult - see BNF for further information
Children – see BNFC for further information
2.10.1 Management of stable angina and acute coronary syndromes
2.10.2 Fibrinolytic drugs
Alteplase
Vials: 20 mg, 50 mg
Streptokinase
Vials: 1.5 million-unit (MU)
Tenecteplase
Vials: 40 mg, 50 mg
Urokinase
Vials: 25,000 units, 100,000 units
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
2.11 ANTIFIBRINOLYTIC DRUGS AND HAEMOSTATICS
Adult - see BNF for further information
Children – see BNFC for further information
Tranexamic acid
Tablets: 500 mg
Injection: 500 mg/5 mL
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
2.12 LIPID LOWERING DRUGS
Adult - see BNF for further information
Children – see BNFC for further information






Muscle effects – see the BNF
Statin use may be associated with a level of hyperglycaemia in some patients
particularly those already at increased risk of developing diabetes. See Drug
Safety Update, January 2012
Fibrates should not be prescribed to newly diagnosed patients as first-line
treatment, except for those with severe hypertriglyceridaemia or those who
cannot take statins. See Drug Safety Update, December 2010
There is an increased risk of myopathy associated with high-dose (80 mg)
simvastatin. The 80-mg dose should be considered only in patients with
severe hypercholesterolaemia and high risk of cardiovascular complications
who have not achieved their treatment goals on lower doses, when the
benefits are expected to outweigh the potential risks. See Drug Safety Update,
May 2010. In addition, the risk of myopathy is increased when administered
with other medicines. See Drug Safety Update, August 2012.
Several additional side-effects—sleep disturbances, memory loss, sexual
dysfunction, depression, and interstitial lung disease—have been recognised
with statins. The product information for the class as a whole has been
updated (Nov 2009). See Drug Safety Update, November 2009. See also the
Regional Drugs and Therapeutics Centre (RDTC) advice
Co-administration with potent inhibitors of CYP3A4 enzyme increases plasma
levels of simvastatin and atorvastatin. This increases the risk dose related side
effects including serious myopathy and rhabdomyolysis. See Drug Safety
Update, January 2008 - updated advice on drug interactions with statins
including co-prescribing with fibrates - a table of drug interactions is included.
See also the Regional Drugs and Therapeutics Centre (RDTC) advice
Statins
PAtorvastatin
Tablets: 10 mg, 20 mg, 40 mg
PSimvastatin
Tablets: 10 mg, 20 mg, 40 mg
Bile acid sequestrants
Colestyramine
Sachets: 4 g
Ezetimibe
Ezetimibe
Tablets: 10 mg
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Fibrates
Bezafibrate
Tablets: 200 mg
SR Tablets: 400 mg
Fenofibrate
Capsules: 200 mg, 267 mg
Nicotinic acid group
Acipimox
Capsules: 250 mg
Omega-3 fatty acid compounds
Omega-3-acid etyl esters
Capsules: 1 g (Omacor®)
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
2.13 LOCAL SCLEROSANTS
Adult - see BNF for further information
Sodium tetradecyl
Injection: 1%, 2 mL ampoule
Injection: 3%, 2 mL, 5 mL ampoule
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
2.14 DRUGS AFFECTING THE DUCTUS ARTERIOSUS
Children – see BNFC for further information
Ibuprofen
Injection: 10 mg/2 mL
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
3. RESPIRATORY SYSTEM
Local guidance
Trust guidelines for prophylaxis of respiratory infections: link to guidelines
Trust guidelines for treatment of respiratory infections: link to guidelines
Sunderland Clinical Commissioning Group COPD Treatment Guide
https://www.sip.sotw.nhs.uk/WorkArea/DownloadAsset.aspx?id=8580
National Guidance
NICE Clinical Guidance (CG)
Management of chronic obstructive pulmonary disease in adults in primary and
secondary care (partial update). June 2010 (CG101)
This guideline partially updates and replaces NICE clinical guideline 12
http://www.nice.org.uk/Guidance/CG101 (Quick Reference Guide)
The North West Medicines Information Service produce summaries of NICE
guidance (NICE Bites) – Bulletin No 19 (July 2010) summarises the key prescribing
points from NICE guidance (CG101) for the treatment of COPD.
NICE evidence update 5 for COPD (Feb 2012)
https://www.evidence.nhs.uk/evidence-update-5
BTS/SIGN guidance - British Guideline on the Management of Asthma, May 2008
(revised June 2009)
http://www.sign.ac.uk/guidelines/fulltext/101/index.html (Quick Reference Guide)
NICE Technology Appraisal (TA)
A list of published Technical Appraisals which is searchable can be found on the
NICE website: http://www.nice.org.uk/Guidance/TA/Published
Alternatively, a table of all the TA recommendations can be viewed or printed as a
Word document: Full table of TA recommendations.
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
CHM advice
To ensure safe use, the CHM has advised that for the management of chronic
asthma, long-acting beta2 agonists (formoterol and salmeterol) should:
 be added only if regular use of standard-dose inhaled corticosteroids has
failed to control asthma adequately;
 not be initiated in patients with rapidly deteriorating asthma;
 be introduced at a low dose and the effect properly monitored before
considering dose increase;
 be discontinued in the absence of benefit;
 not be used for the relief of exercise-induced asthma symptoms unless regular
inhaled corticosteroids are also used;
 be reviewed as clinically appropriate: stepping down therapy should be
considered when good long-term asthma control has been achieved.
Patients should be advised to report any deterioration in symptoms following initiation
of treatment with a long-acting beta-2 agonist

Generally, manually actuated pressurised metered dose inhalers (MDIs) are
the cheapest devices available and should be first choice provided that the
patient can use them efficiently. When use is inefficient, alternatives include
large volume spacers, dry powder inhalers (DPIs) or breath-actuated MDIs.
Choice of device should be considered on basis of ability to use the inhaler,
patient-acceptability and cost. If a patient elects not to use a prescribed
spacer, then an alternative device should be used.

BTS/SIGN guidance for prescribing: There is no evidence to dictate an order
in which devices should be tested for those patients who cannot use an MDI.
In the absence of evidence, the most important points to consider are patient
preference and local cost.
o The choice of device may be determined by the choice of drug.
o If the patient is unable to use a device satisfactorily, an alternative
should be found.
o The patient should have their ability to use an inhaler device assessed
by a competent healthcare professional.
o The medication needs to be titrated against clinical response to ensure
optimum efficacy.
o Reassess inhaler technique as part of structured clinical review.
o In children aged 0-5 years, an MDI and spacer are the preferred
method of delivery of beta-2 agonists or inhaled steroids. A face mask
is required until the child can breathe reproducibly using the spacer
mouthpiece. Where this is ineffective, a nebuliser may be required.

Inhaler-induced cough by MDI may be an indicator for change of device.

Changing the type of inhaler device may affect the effectiveness of therapy
and the incidence of adverse effects.
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Other Guidance
MIMS Guide to Asthma and COPD Preparations and Compatible Devices - LINK
Patient Guides to Inhaler devices: LINK
Metered Dose
Inhaler (MDI)
Patient able to
use properly?
Co-ordination
problem
NO
MDI +
Spacer
YES
Physical
weakness
MDI +
Haleraid®
Patient
counselling and
re-assessment
Patient able to
use properly?
YES
NO
Try a dry powder
Device or a
Breath Actuated
Device
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
Review
technique
regularly
53
Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
3.1 BRONCHODILATORS
Adult - see the BNF for further information
Children – see BNFC for further information
3.1.1 Adrenoreceptor agonists
3.1.1.1 Selective beta-2 agonists
Short-acting
PSalbutamol
Inhaler: 100 micrograms/puff
Nebules: 2.5 mg/2.5 mL, 5 mg/2.5 mL
Injection: 500 micrograms/ mL. 5 mg/5 mL
PTerbutaline
Inhaler: 250 micrograms/puff
Turbohaler: 500 micrograms/puff
Long-acting
Indacaterol
Breezhaler® device: 150 micrograms
PSalmeterol
Inhaler: 25 micrograms/puff
3.1.1.2 Other adrenoreceptor agonists
No preparations
3.1.2 Antimuscarinic bronchodilators
Aclidinium bromide
Inhaler: 400 micrograms
Each 400 microgram metered inhalation of aclidinium bromide delivers 322 micrograms of aclidinium
Glycopyrronium
Inhaler: 50 micrograms
Each 50 microgram capsule of glycopyrronium delivers 44 micrograms of glycopyrronium
PIpratropium
Inhaler: 20 micrograms/puff
Nebules: 250 micrograms/ mL, 500 micrograms/2 mL
It is recommended that nebulised ipratropium should be administered via a mouthpiece and NOT a
facial mask due to the risk of precipitating glaucoma.
PTiotropium
HandiHaler® device: 18 micrograms
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
3.1.3 Theophylline preparations
 Theophylline is a bronchodilator with a minor anti-inflammatory action used for
reversible airways obstruction. It may have an additive effect when used in
conjunction with small doses of beta-2 adrenoceptor stimulants: the combination
may increase the risk of side effects e.g. hypokalaemia.

Theophylline has a narrow margin between the therapeutic and toxic dose. The
therapeutic range is 10 - 20 mg/L (55 - 110 micromol/L). There is wide interindividual variability in dosage requirements and therapy should be monitored.
Ideally, therapy should be monitored after 2 weeks initially and then every 6
months Adult - see Therapeutic Drug Monitoring).

Theophylline/aminophylline levels may be increased by a number of drugs
including macrolide antibiotics, ciprofloxacin and verapamil. For more
information on drug interactions see the BNF

Concomitant disease and drugs may affect plasma levels Adult - see
Therapeutic Drug Monitoring). Smoking cessation may increase theophylline
levels; this is independent of any nicotine replacement therapies that may be
prescribed.

Different brands of modified-release theophylline have different bioavailability
and so it is recommended that patients do not switch brands. The brand must
be stated on prescriptions.

Aminophylline is a stable mixture or combination of theophylline and
ethylenediamine; the ethylenediamine confers greater solubility in water but can
cause an allergic reaction.

Aminophylline IV: Patients already taking oral theophylline or aminophylline
should routinely not be given IV aminophylline unless plasma levels are
available to guide dosing.

UKMI Medicines Q & A: How is an intravenous aminophylline dose converted
to an oral aminophylline or theophylline dose? See link:
http://www.medicinesresources.nhs.uk/upload/NHSE_Aminophylline_IV_to_oral
_130.3final[1].doc
Aminophylline:
Injection: 250 mg/10 mL
SR Tablets: 225 mg
Theophylline SR
Neulin SA® Tablets: 135 mg
Slo-Phyllin® Capsules: 250 mg
PUniphyllin® Tablets: 200 mg, 300 mg, 400 mg
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
3.1.4 Compound bronchodilator preparations
No preparations recommended
3.1.5 Peak flow meters, inhaler devices and nebulisers
Spacer devices
Adult - see the BNF for further information
Children – see BNFC for further information

Spacer devices may be useful for patients with poor inhalation technique,
children, and for those prone to oral candidiasis with inhaled steroids.

The choice of spacer depends upon the inhaler device and the patient’s ability
to use it.

Spacers are available from supplies (not pharmacy). The BNF lists currently
available spacer devices and their compatibility with various inhalers.

The BTS guidelines makes recommendations about the use and care of
spacers:
i.
The spacer should be compatible with the MDI being used.
ii.
The drug should be administered by repeated single actuations of the
metered dose inhaler into the spacer, each followed by inhalation.
iii.
There should be minimal delay between MDI actuation and inhalation.
iv.
Tidal breathing is as effective as single breaths.
v.
Spacers should be cleaned monthly rather than weekly as per
manufacturer's recommendations or performance is adversely affected.
They should be washed in detergent and allowed to dry in air. The
mouthpiece should be wiped clean of detergent before use.
vi.
Drug delivery may vary significantly due to static charge. Metal and
other antistatic spacers are not affected in this way.
vii.
Plastic spacers should be replaced at least every 12 months but some
may need changing at six months.
Haleraid® inhalation aid
PNebuhaler®
PVolumatic®
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Nebulisers
Adult - see the BNF for further information
Children – see BNFC for further information

Nebulisers are not currently prescribable in general practice; patients should
be referred for respiratory assessment. A spacer should be tried before
considering a nebuliser.

All nebulisers should be serviced regularly. However, difficulties are often
encountered in the servicing of privately owned nebulisers.

Asthma UK (http://www.asthma.org.uk/) produce a factsheet for patients on
nebulisers which includes advice on buying a nebuliser:
http://www.asthma.org.uk/media/4883/FF-HP036nebuliserNEW-6.0.QXD_FFHP036nebuliserNEW.QXD.pdf

UKMI Medicines Q & A: Which commonly used nebuliser solutions are
compatible? See Link:
http://www.medicinesresources.nhs.uk/upload/documents/Evidence/Medicines%20Q
%20&%20A/QA100_6_compatibility_neb.doc
Peak Flow Meters
Adult - see the BNF for further information
Children – see BNFC for further information
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
3.2 CORTICOSTEROIDS
Adult - see the BNF for further information
Children – see BNFC for further information
MHRA/CHM advice (July 2008)
 Beclometasone dipropionate CFC-free pressurised metered-dose inhalers
(Qvar® and Clenil Modulite®) are not interchangeable and should be
prescribed by brand name; Qvar® has extra-fine particles, is more potent than
traditional beclometasone dipropionate CFC-containing inhalers, and is
approximately twice as potent as Clenil Modulite®;
 Fostair® is a combination beclometasone dipropionate and formoterol
fumarate CFC-free pressurised metered-dose inhaler; Fostair® has extra-fine
particles and is more potent than traditional beclometasone dipropionate CFCfree inhalers.
 For general information, see Drug Safety Update, July 2008
Use of inhaled corticosteroids in COPD patients may be associated with a significant
increase in frequency of hospitalisation for pneumonia compared to non-use. It is
recommended that any patient with severe COPD who has had pneumonia during
treatment with inhaled steroids have their treatment reviewed. See Drug Safety
Update October 2007.
Psychological and behavioural side effects may occur in association with use of
inhaled and intranasal formulations of corticosteroids, see Drug Safety Update,
September 2010.
Inhalers
PBeclometasone
Inhaler (per puff): 100 micrograms, 200 micrograms, 250 micrograms
Inhaler (per puff) – as QVAR®: 50 micrograms, 100 micrograms
Compound preparations
Beclometasone with formoterol
Fostair® inhaler containing beclometasone dipropionate 100 micrograms with
formoterol 6 micrograms/puff.
PBudesonide
Turbohaler (per puff): 200 micrograms, 400 micrograms
Respules: 500 micrograms/2 mL, 1 mg/2 mL
Compound preparations
PBudesonide with formoterol fumarate
Symbicort Turbohaler®
100/6: budesonide 100 micrograms with formoterol 6 micrograms/puff;
200/6: budesonide 200 micrograms with formoterol 6 micrograms/puff;
400/12: budesonide 400 micrograms with formoterol 12 micrograms/puff):
Fluticasone
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Inhaler: 125 micrograms, 250 micrograms
Compound inhalers
PFluticasone propionate with formoterol
Flutiform® inhaler containing fluticasone propionate 50 micrograms or 125
micrograms with formoterol 5 micrograms/puff.
Flutiform® inhaler containing fluticasone propionate 250 micrograms with formoterol
10 micrograms/puff.
PFluticasone propionate with salmeterol
Seretide Evohaler® containing fluticasone propionate 50 micrograms, 125
micrograms or 250 micrograms with salmeterol 25 micrograms/puff.
Seretide Accuhaler® containing fluticasone propionate 100 micrograms, 250
micrograms or 500 micrograms with salmeterol 50micrograms/blister.
Oral
Prednisolone
Tablets: 1 mg. 2.5 mg, 5 mg
Parenteral
Hydrocortisone
Injection: 100 mg
City Hospitals Sunderland Prescribing Guide v2014.1 (Jan 2014)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
3.3 CROMOGLICATE AND RELATED THERAPY AND LEUKOTRIENE RECEPTOR
ANTAGONISTS
Adult - see the BNF for further information
Children – see BNFC for further information
3.3.1 Cromoglicate and related therapy
Nedocromil sodium
Inhaler: 2 mg/puff
Sodium cromoglicate
Inhaler: 5 mg/puff
3.3.2 Leukotriene receptor antagonists
PMontelukast
Tablets: 10 mg
Chewable Tablets: 4 mg
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
3.4 ANTIHISTAMINES, HYPOSENSITISATION, AND ALLERGIC EMERGENCIES
Adult - see the BNF for further information
Children – see BNFC for further information
3.4.1 Antihistamines
Sedating
PChlorphenamine
Tablets: 4 mg
Syrup: 2 mg/5 mL
Injection: 10 mg/ mL
PHydroxyzine
Tablets: 25 mg, 50 mg
Non-sedating
PCetirizine
Tablets: 10 mg
Oral solution: 5 mg/5 mL
PLoratadine
Tablets: 10 mg
Syrup: 5 mg/5 mL
3.4.2 Allergen Immunotherapy
SGrass pollen extract
Oral lyophilisates (= freeze-dried tablets), grass pollen extract 75 000 units
(Grazax®)
SOmalizumab
Omalizumab
Vial: 150 mg (Xolair®)
Omalizumab should be initiated and prescribed only by a specialist in the
treatment of asthma, and used strictly within its licensed indications.
There is a possibility of a patient developing anaphylaxis after any dose, even if there
was no reaction to the first dose. In addition, anaphylaxis after administration of the
drug may be delayed for up to 24 hours after the dose is given.
Bee and wasp allergen extracts
SPharmalgen
Bee or wasp venom extract
Available through a managed pathway.
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
3.4.3 Allergic emergencies
Anaphylaxis
Adult - see the BNF for further information
Children – see BNFC for further information

Adrenaline IM should be given immediately for an acute anaphylactic reaction
(laryngeal oedema, bronchospasm and hypotension).
Age
Dose
Adult and adolescent
500 micrograms
Volume of adrenaline 1
in 1000 (1 mg/1 mL)
0.5 mL

In extreme emergency, the IV route may be necessary - refer to the BNF Adult
or Children

Chlorphenamine injection is a useful adjunctive treatment given after
adrenaline injection and continued for 24-48 hours to prevent relapse.

Hydrocortisone injection is of secondary value in the initial management of
anaphylactic shock because the onset of action is delayed for several hours,
but should be given to prevent further deterioration in severely affected
patients.

Individuals who are particularly at risk of anaphylactic reactions (e.g. severe
allergy to insect stings, foods or peanuts) should carry, and receive instruction
for the use of, prefilled syringes for self-administration. Patients should usually
be prescribed two.
Resuscitation Council UK Guidance: Algorithm for initial treatment
Resuscitation Council UK Guidance: Anaphylaxis algorithm
Resuscitation Council UK Guidance: Full guidance
Adrenaline (epinephrine)
Injection: 1 in 1,000 (1 mg in 1 mL)
Adrenaline (epinephrine)
PAuto-injector (EpiPen ®) – For home use only
300 micrograms (1 mg in 1 mL or 1 in 10,000), 150 micrograms (500 micrograms in 1
mL or 1 in 2,000)
Angioedema
SC1-esterase inhibitor
Injection: powder for reconstitution, 500 unit vial (Berinert®)
SIcatibant
Pre-filled syringe: 30 mg/3 mL (Firazyr®)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
3.5 RESPIRATORY STIMULANTS AND PULMONARY SURFACTANTS
Adult - see the BNF for further information
Children – see BNFC for further information
3.5.1 Respiratory stimulants
SDoxapram hydrochloride
Injection: 100 mg in 5 mL
Infusion: 2 mg/ mL in 5% glucose (500 mL)
3.5.2 Pulmonary surfactants
SPoractant alfa (Curosurf®)
Vial: 120 mg/1.5 mL
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
3.6 OXYGEN
Adult - see the BNF for further information
Children – see BNFC for further information
Contact portering staff for availability of oxygen cylinders.

Oxygen is a drug and should therefore be prescribed. Inappropriate
concentrations may have serious or even lethal effects.

Patients should be advised of the fire risks with oxygen and they or their
contacts must not smoke in the same environment.

The prescription should include the percentage of oxygen to be administered
(24% - 100%), duration, whether continuous or as required, if humidification is
indicated and delivery system i.e. specified mask type and flow rate. For nasal
cannulae, the oxygen flow rate in L/minute should be specified.

High concentration oxygen therapy (35%-100%) is used for short periods in
cases of Type I Respiratory Failure (e.g. asthma, pulmonary embolism,
pneumonia, congestive cardiac failure, and pulmonary fibrosis) where there is
a combination of a low arterial oxygen and normal or low carbon dioxide
concentration.

Low concentration oxygen therapy (24% - 28%) is used for patients with
Type II Respiratory Failure and is most commonly prescribed in chronic
obstructive pulmonary disease (COPD).
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
3.7 MUCOLYTICS
Adult - see the BNF for further information
Children – see BNFC for further information
Carbocisteine
Capsules: 375 mg
Oral liquid: 250 mg/5 mL
Mecysteine hydrochloride
Tablets: 100 mg
Dornase alfa
Dornase alfa
Vial: 2.5 mg (2500 units)/2.5 mL
A Shared-care Protocol exists for this medicine
Hypertonic sodium chloride
Sodium chloride: 7%, 4 mL (Nebusal®)
Mannitol
Mannitol: Inhalation powder, hard capsule (for use with disposable inhaler device):
40 mg
Available through a managed pathway.
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
3.8 AROMATIC INHALATIONS
Adult - see the BNF for further information
Children – see BNFC for further information
Benzoin Tincture, Compound (Friars’ Balsam)
Menthol & Eucalyptus inhalation
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
3.9 COUGH PREPARATIONS
Adult - see the BNF for further information
Children – see BNFC for further information
The MHRA/CHM has advised that children under 18 years should not use codeinecontaining over-the-counter liquid medicines for cough suppression
See Drug Safety Update October 2010
The MHRA/CHM has advised that children under 6 years should not be given cough
and cold medicines containing the following ingredients:
 brompheniramine, chlorphenamine, diphenhydramine, doxylamine,
promethazine, or triprolidine (antihistamines);
 dextromethorphan or pholcodine (cough suppressants);
 guaifenesin or ipecacuanha (expectorants);
 phenylephrine, pseudoephedrine, ephedrine, oxymetazoline, or
xylometazoline (decongestants).
Cough and cold medicines can be considered for children aged 6–12 years after
basic principles of best care have been tried, but treatment should be restricted to 5
days or less. Children should not be given more than 1 cough or cold preparation at a
time because different brands may contain the same active ingredient; care should
be taken to give the correct dose. See Drug Safety Update April 2009
Codeine
Linctus: 15 mg/5 mL
Pholcodine
Linctus: 5 mg/5 mL
Simple linctus
Simple linctus, paediatric
Palliative care
Methadone
Linctus: 2 mg/5 Ml
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
3.10 SYSTEMIC NASAL DECONGESTANTS
No preparations recommeded
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
4. CENTRAL NERVOUS SYSTEM
As psychiatric services are provided by Northumberland, Tyne and Wear NHS
Foundation Trust (NTW) the drugs available for Sections 4.1, 4.2, 4.3 and 4.4
are those listed in the Formulary used by NTW which is the The North of Tyne
Formulary: http://www.northoftyneapc.nhs.uk/formulary/
Local Guidance - Shared Care Protocols
Atomoxetine Shared Care Guideline for SoTW (November 2011)
Lithium Shared Care Guideline for SoTW (June 2011)
Methylphenidate Shared Care Guideline for SoTW (May 2010)
National Guidance
NICE Clinical Guidance (CG)
Depressive Disorders
Depression in adults (update), October 2009 (CG90).
http://www.nice.org.uk/Guidance/CG90 (Quick Reference Guide)
Depression with chronic physical health problem, October 2009 (CG91).
http://www.nice.org.uk/Guidance/CG91 (Quick Reference Guide
The North West Medicines Information Service produce summaries of NICE guidance
(NICE Bites) – Bulletin No. 11 (November 2009) summarises the key prescribing
points from NICE guidance (CG90/91) for the treatment of depression
Generalised anxiety disorder and panic disorder (with or without agoraphobia) in
adults, January 2011 (CG113)
www.nice.org.uk/Guidance/CG113 (Quick Reference guide)
See NICE GAD treatment pathway
The North West Medicines Information Service produce summaries of NICE
guidance (NICE Bites) – Bulletin No. 26 (Feb 2011) summarises the key prescribing
points from NICE guidance (CG113) for the treatment of generalised anxiety
disorder.
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Depression in children and young people, September 2005 (CG28)
http://www.nice.org.uk/Guidance/CG28 (Quick Reference Guide)
Pyschoses
Obsessive-compulsive disorder, November 2005 (CG31).
http://www.nice.org.uk/Guidance/CG31 (Quick Reference Guide)
Bipolar disorder, July 2006 (CG38).
http://www.nice.org.uk/Guidance/CG38 (Quick Reference Guide)
Schizophrenia, March 2009 (CG82).
http://www.nice.org.uk/Guidance/CG82 (Quick Reference Guide)
The North West Medicines Information Service produce summaries of NICE
guidance (NICE Bites) – Bulletin No 4 (April 2009) summarises the key prescribing
points from NICE guidance (CG82) for the treatment of schizophrenia.
Attention deficit hyperactivity disorder (ADHD)
Attention deficit hyperactivity disorder (ADHD): September 2008 (CG72).
http://www.nice.org.uk/Guidance/CG72 (Quick Reference Guide)
The North West Medicines Information Service produce summaries of NICE
guidance (NICE Bites) – Bulletin No 1 (January 2009) summarises the key
prescribing points from NICE guidance (CG72) for the treatment of ADHD
Obesity
Obesity: the prevention, identification, assessment and management of overweight
and obesity in adults and children, December 2006 (CG43)
http://www.nice.org.uk/Guidance/CG43 (Quick Reference guide)
Pain
Opioids in palliative care: safe and effective prescribing of strong opioids for pain in
palliative care of adults, May 2012 (CG140)
http://guidance.nice.org.uk/CG140
SeeNICE opioids in palliative care pathway
Neuropathic pain: the pharmacological management of neuropathic pain, March
2010 (CG96)
http://guidance.nice.org.uk/CG96 (Quick Reference Guide)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
The North West Medicines Information Service produce summaries of NICE
guidance (NICE Bites) – Bulletin No 16 (April 2010) summarises the key prescribing
points from NICE guidance (CG96) for the treatment of neuropathic pain.
Headaches: diagnosis and management of headaches in young people and adults,
September 2012. (CG150)
http://guidance.nice.org.uk/CG150
See NICE Headache treatment pathway
The North West Medicines Information Service produce summaries of NICE
guidance (NICE Bites) – Bulletin No 46 (Oct 2012) summarises the key prescribing
points from NICE guidance (CG150) for the treatment of headache.
Epilepsy
The epilepsies: diagnosis and management of the epilepsies in adults in primary and
secondary care, January 2012 (CG137)
http://www.nice.org.uk/Guidance/CG137
The North West Medicines Information Service produce summaries of NICE
guidance (NICE Bites) – Bulletin No 38 (Janury 2012) summarises the key
prescribing points from NICE guidance (CG82) for the treatment of epilepsy
Parkinson’s disease
Parkinson's disease: diagnosis and management in primary and secondary care,
June 2006 (CG35).
http://www.nice.org.uk/Guidance/CG35 (Quick Reference guide)
Dementia
Dementia, November 2006 (CG42)
http://www.nice.org.uk/Guidance/CG42 (Quick Reference guide)
See NICE dementia pathway
NICE Technology Appraisal (TA)
A list of published Technical Appraisals which is searchable can be found on the
NICE website: http://www.nice.org.uk/Guidance/TA/Published
Alternatively, a table of all the TA recommendations can be viewed or printed as a
Word document: Full table of TA recommendations.
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
4.1 HYPNOTIC AND ANXIOLYTIC DRUGS
Adult - see the BNF for further information
Children – see BNFC for further information
The CHS Formulary does not have a recommended list of preparations – all
patients admitted on these types of drug should not have their medication
changed or stopped and will be supplied by pharmacy. The commonly used
preparations are routinely available, but it is possible that some of the rarely
used preparations may not be immediately available and may have to be ordered.
The Committee on Safety of Medicines (CSM) has issues the following advice
regarding benzodiazepines:
1. Benzodiazepines are indicated for the short-term relief (two to four weeks
only) of anxiety that is severe, disabling, or causing the patient unacceptable
distress, occurring alone or in association with insomnia or short-term
psychosomatic, organic, or psychotic illness.
2. The use of benzodiazepines to treat short-term ‘mild’ anxiety is inappropriate.
3. Benzodiazepines should be used to treat insomnia only when it is severe,
disabling, or causing the patient extreme distress
4.1.1 Hypnotics
Recommended:
PTemazepam
Tablets: 10 mg
Elixir 10 mg/5 mL
Alternative:
PZopiclone
Tablets: 3.75 mg, 7.5 mg
4.1.2 Anxiolytics
Recommended:
PDiazepam
Tablets: 2 mg, 5 mg, 10 mg
Syrup: 2 mg/5 mL, 5 mg/5 mL
Alternative:
PLorazepam
Tablets: 1 mg, 2.5 mg
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Panic disorder
Citalopram
Tablets: 10 mg, 20 mg
Oral drops: 40 mg/ mL
Paroxetine
Tablets: 20 mg, 30 mg
Liquid: 10 mg/5 mL.
4.1.3 Barbiturates
Barbiturates should only be prescribed to patients already taking them, who have
severe intractable insomnia, when attempts to discontinue treatment have been
unsuccessful.
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
4.2 DRUGS USED IN PSYCHOSES AND RELATED DISORDERS
Adult - see the BNF for further information
Children – see BNFC for further information
The CHS Formulary does not have a recommended list of preparations – all
patients admitted on antipsychotics should not have their medication changed or
stopped and will be supplied by pharmacy. The commonly used preparations are
routinely available, but it is possible that some of the rarely used preparations
may not be immediately available and may have to be ordered.
General Points
 Patients established on antipsychotic treatment should not have their medication
changed or stopped (discontinuation of all antipsychotic treatment should be
phased over a period of about four weeks). SEEK SPECIALIST ADVICE.

The elderly are much more susceptible to the extrapyramidal side effects of
antipsychotics, as well as to orthostatic hypotension and antimuscarinic effects
of these agents. In addition, there is an increased risk of stroke and mortality
when used in elderly people with dementia. When indicated, they should be
used in much lower doses and titrated more slowly, with frequent monitoring.
BNF advice on prescribing in the elderly is available HERE. For MHRA advice
see Drug safety Update, March 2009

The MHRA issued a reminder to monitor and manage weight, glucose, and
lipid levels in patients on second-generation (atypical) antipsychotic drugs.
This is because people with schizophrenia are three times more likely to die
prematurely from natural causes (mainly cardiovascular disease). Some
atypical antipsychotics are associated with weight gain, dyslipidaemia, and
hyperglycaemia (available data suggest that clozapine, olanzapine, and
quetiapine are especially implicated). See Drug safety update, April 2011.

Clozapine and lithium require monitoring and caution in their use.
o Clozapine is reserved for individuals with evidence of treatment
resistant schizophrenia (TRS). The patient, prescriber, and supplying
pharmacist must be registered with the relevant Patient Monitoring
Service.
o Lithium preparations should always be prescribed by brand name
because of major differences in bioavailability.
o Lithium salts have a narrow therapeutic/toxic ratio and should therefore
not be prescribed unless facilities for monitoring are available. For
advice on monitoring, cautions and drug interactions see Therapeutic
Drug Monitoring .
o The National Patient Safety Agency (NPSA) has issued a safety alert in
December 2009, see NPSA alert: Safer Lithium Therapy
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).

Long acting antipsychotic depot injections are useful for maintenance therapy
especially when compliance with oral treatment is unreliable. They are given
by deep IM injection every 1 - 4 weeks for maintenance therapy and no more
than 2 – 3 mL should be injected into any one site. They can cause more
extrapyramidal reactions so treatment should be monitored carefully. During
transfer from oral to depot therapy, the oral dose should be phased out
gradually. SEEK SPECIALIST ADVICE.
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
4.3 ANTIDEPRESSANTS
Adult - see the BNF for further information
Children – see BNFC for further information
The CHS Formulary does not have a recommended list of preparations – all
patients admitted on antidepressants should not have their medication changed
or stopped and will be supplied by pharmacy. The commonly used preparations
are routinely available, but it is possible that some of the rarely used
preparations may not be immediately available and may have to be ordered.
General Points
 Patients already taking medication for depression should not have their
medication changed or stopped (discontinuation of all antidepressant treatment
should be phased over a period of about four weeks). SEEK SPECIALIST
ADVICE.


NICE do not recommend the use antidepressants routinely to treat persistent
subthreshold depressive symptoms or mild depression because the risk–
benefit ratio is poor, SEEK SPECIALIST ADVICE.
Hyponatraemia can occur with all antidepressants. It is most common in
elderly patients.

The use of antidepressants has been linked with suicidal thoughts and
behaviour (particularly in children, young adults, and patients with a history of
suicidal behaviour).

Great care should be taken when prescribing any antidepressant for epileptic
patients as they all lower the convulsive threshold.

Treatment with more than one antidepressant of the same type is not
recommended.

All antidepressants have a potentially dangerous interaction with MAOIs - refer
to the BNF.

Antimuscarinic effects of tricyclic and related antidepressant drugs limit their
use (particularly in the elderly). They should be used with caution in patients
with cardiovascular disease and are contra-indicated in the immediate
recovery period after myocardial infarction, in arrhythmias (particularly heart
block), and in the manic phase of bipolar disorder. Avoid in acute porphyria.

There is an increased risk of bleeding when SSRIs are given with NSAIDs or
aspirin. If no alternatives are appropriate, NICE guidance recommends
that gastroprotection is offered.

Fluoxetine has an extremely long half-life and should be used with caution in
the elderly.
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Citalopram and dose dependant QT prolongation
The MHRA have sent out an update regarding safety concerns with citalopram on
31st October 2011 following an FDA review of a recent unpublished study. New
recommendations have been made as a result of a QT study which revealed a dosedependant increase in the QT interval
New Recommendations
 Maximum dose of citalopram is now 40 mg daily
 In elderly and reduced hepatic function, the maximum dose is 20 mg daily
 Citalopram is now contra-indicated in patients with known QT interval
prolongation or congenital long QT syndrome.
 Use of citalopram with other medicinal products known to prolong the QT
interval is contraindicated.
 Caution is advised in patients at higher risk of developing Torsades de Pointes
e.g. patients with congestive heart failure, recent MI, bradyarrhythmias or a
predisposition to hypokalaemia or hypomagnesaemia because of concomitant
illness or medicines.

Citalopram oral drops have approximately 25% increased bioavailability
compared to tablets. The tablet corresponds to the number of drops as
follows:
Tablets
10 mg
20 mg
30 mg
40 mg
Drops dose equivalence
8 mg (4 drops)
16 mg (8 drops)
24 mg (12 drops)
32 mg (16 drops)
The following are routinely stocked and available from pharmacy:
PCitalopram
Tablets: 10 mg, 20 mg
Oral drops: 40 mg/ mL
PFluoxetine
Tablets: 20 mg
Liquid: 20 mg/5 mL.
Paroxetine
Tablets: 20 mg, 30 mg
Liquid: 10 mg/5 mL
PSertraline
Tablets: 50 mg, 100 mg
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
4.4 CNS STIMULANTS AND DRUGS USED FOR ATTENTION DEFICIT
HYPERACTIVITY DISORDER
Adult - see the BNF for further information
Children – see BNFC for further information
For key safety information and advice on prescribing methylphenidate, see
Drug Safety Update March 2009.
Atomoxetine is associated with treatment emergent psychotic or manic symptoms in
children and adolescents without a history of such disorders. If these occur, consider
discontinuation of treatment. For more information, see
Drug Safety Update March 2009
Atomoxetine: increases in blood pressure and heart rate—new contraindications,
warnings, and advice for monitoring. See Drug Safety Update, January 2012
Narcolepsy
SDexamfetamine sulphate
Tablets: 5 mg
SModafinil
Tablets: 100 mg
Attention deficit hyperactivity disorder (ADHD)
SAtomoxetine
Tablets: 18 mg, 25 mg, 40 mg, 60 mg
SMethylphenidate hydrochloride
Tablets: 5 mg, 10 mg
SR Tablets: 18 mg, 36 mg
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
4.5 DRUGS USED IN THE TREATMENT OF OBESITY
Adult - see the BNF for further information
Children – see BNFC for further information
POrlistat
Tablets: 120 mg
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
4.6 DRUGS USED IN NAUSEA AND VERTIGO
Adult - see the BNF for further information
Children – see BNFC for further information
General Points
 Antiemetics should only be prescribed when the cause of vomiting is known;
symptomatic relief may delay diagnosis or mask an underlying cause, e.g.
digoxin toxicity. If treatment is indicated, then choice of drug depends upon the
aetiology of vomiting.
 Nausea and vomiting associated with chemotherapy – see the North of England
Cancer Network (NECN) Chemotherapy Induced Nausea and Vomiting (CINV)
Guidelines: LINK
 Nausea and vomiting associated with palliative care – see the North of England
Cancer Network (NECN) Palliative Care Guidelines LINK
 Sickness in pregnancy is best left untreated unless severe. Specialist
advice should be sought before using an antiemetic in pregnancy.
Metoclopramide: risk of neurologicaladverse effects - restricted dose and
duration of use
Indications and use in adults and children:
 In adults, metoclopramide remains indicated for: prevention of postoperative
nausea and vomiting; radiotherapy-induced nausea and vomiting; delayed (but
not acute) chemotherapy-induced nausea and vomiting; and symptomatic
treatment of nausea and vomiting, including that associated with acute
migraine (where it may also be used to improve absorption of oral analgesics)

In children, age 1–18 years, metoclopramide should only be used as a
second-line option for prevention of delayed chemotherapy-induced nausea
and vomiting, and for treatment of established postoperative nausea and
vomiting

Use of metoclopramide is contraindicated in children younger than 1 year

Metoclopramide should only be prescribed for short-term use (up to 5 days)
Dosing:
 For adults, the maximum dose in 24 hours is 30 mg (or 0.5 mg per kg
bodyweight). The usual dose is 10 mg up to three times a day

In children age 1 year or older, the recommended dose is 0.1–0.15 mg per kg
bodyweight, repeated up to three times a day. The maximum dose in 24 hours
is 0.5 mg per kg bodyweight
Administration:
 Intravenous doses should be administered as a slow bolus over at least 3
minutes to reduce the risk of adverse effects

Oral liquid formulations should be given via an appropriately designed,
graduated oral syringe to ensure dose accuracy in children.
For more information, see Drug Safety Update, August 2013
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
PBetahistine
Tablets: 8 mg
Domperidone
Tablets: 10 mg
Liquid: 5 mg/5 mL
Suppository: 30 mg
PCinnarizine
Tablets: 15 mg
PCyclizine
Tablets: 50 mg
Injection: 50 mg/1 mL
Hyoscine
Transdermal patch: 1 mg/72hrs
Metoclopramide
Tablets: 10 mg
Liquid: 5 mg/5 mL
Injection: 10 mg/2 mL
PProchlorperazine
Tablets: 5 mg
Syrup: 5 mg/5 mL
Injection: 12.5 mg/1 mL
PPromethazine hydrochloride
Tablets: 10 mg, 25 mg
Liquid: 5 mg/5 mL
Injection: 25 mg/1 mL
Ondansetron
Tablets: 4 mg, 8 mg
Melts: 4 mg, 8 mg
Injection: 4 mg/2 mL, 8 mg/4 mL
New advice on administration of high dose intravenous ondansetron
The new maximum single intravenous dose of ondansetron for the management of
chemotherapy-induced nausea and vomiting (CINV) in adults is now 16 mg (8 mg for
patients aged 75 years or older )infused over at least 15 minutes.
See Drug Safety Update, July 2013
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
4.7 ANALGESICS
Adult - see the BNF for further information
Children – see BNFC for further information
4.7.1 Non-opioid analgesics
PParacetamol
Tablets: 500 mg,
Soluble Tablets: 500 mg
Suspension: 250 mg/5 mL
Suppository: 60 mg, 125 mg, 240 mg, 500 mg
Injection: 500 mg/50 mL, 1 g/100 mL
IV PARACETAMOL DOSING - WARNING OF POTENTIAL TOXIC LEVELS
The dose of intravenous paracetamol must be reduced in patents under 50 kg
A fatality occurred when a patient weighing less than 50 kg was prescribed IV
paracetamol at a dose of 1 g QDS without being properly reviewed.
The BNF states that the dose of IV paracetamol for adults and children between 1050 kg is 15 mg/kg every 4-6 hours up to a maximum of 60 mg/kg/daily.
 Please ensure that the weight of the patient is recorded on the front of the
prescription chart.
 When prescribing IV paracetamol check the weight of the patient and reduce
the dose in patients weighing less than 50 kg.
See Drug Safety Update July 2010 for dosing and administration advice
Paracetamol: New oral dosing recommendations for children
Updated dosing for paediatric paracetamol liquids has been developed to ensure
children receive the optimum dose for their age.
See Drug Safety Update July 2010 for dosing and administration advice
U Sucrose 24%, 1.5 mL unidose
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
4.7.2 Opioid analgesics
NATIONAL PATIENT SAFETY AGENCY (NPSA) ALERT - Reducing Dosing Errors with
Opioid Medicines – July 2008
When opioid medicines are prescribed, dispensed or administered, in anything other than
acute emergencies, the following action should be taken:
 Confirm any recent opioid dose, formulation, frequency of administration and any
other analgesic medicines prescribed for the patient. This may be done for example
through discussion with the patient or their representative (although not in the case of
treatment for addiction), the prescriber or through medication records.
 Ensure where a dose increase is intended, that the calculated dose is safe for the
patient (e.g. for oral morphine or oxycodone in adult patients, not normally more than
50% higher than the previous dose).
 Ensure they are familiar with the following characteristics of that medicine and
formulation: usual starting dose, frequency of administration, standard dosing
increments, symptoms of overdose, common side effects.
Link to NPSA Rapid Response Report
Codeine: restricted use as analgesic in children and adolescents after
European safety review – June 2013

Codeine should only be used to relieve acute moderate pain in children older than 12
years and only if it cannot be relieved by other painkillers such as paracetamol or
ibuprofen alone
 Codeine is now contraindicated in:
 all children age 0–18 years who undergo tonsillectomy or
adenoidectomy (or both) for obstructive sleep apnoea
 all patients of any age known to be CYP2D6 ultra-rapid metabolisers
 Codeine is not recommended for use in children whose breathing might be
compromised, including those with: neuromuscular disorders; severe cardiac or
respiratory conditions; upper respiratory or lung infections; multiple trauma; or
extensive surgical procedures. Morphine toxicity may be increased in these settings
 In children age 12–18 years, the maximum daily dose should not exceed 240 mg.
This may be taken in divided doses up to four times a day at intervals of no less than
6 hours. It should be used at the lowest effective dose for the shortest period.
Duration of treatment should be limited to 3 days and if no effective pain relief is
achieved, treatment should be reviewed by a physician
 Information should be given to parents and caregivers on how to recognise the signs
and symptoms of morphine toxicity, and advice should be given to stop giving the
child codeine and to seek medical attention immediately if the child shows these
signs or symptoms, which include: reduced levels of consciousness; somnolence;
respiratory depression; ‘pin-point’ pupils; lack of appetite; constipation; or nausea and
vomiting
 Codeine should not be used by breastfeeding mothers because it can pass to the
baby through breast milk and potentially cause harm
See Drug Safety Update, June 2013
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Codeine phosphate
PTablets: 30 mg, 60 mg
PSyrup: 25 mg/5 mL
Injection: 60 mg/ mL (CD)
Diamorphine hydrochloride (CD)
UNasal spray: 144 mg vial; 0.72 mg/spray
Morphine
PIR tablets: 10 mg, 20 mg (CD)
PSR capsules: 10 mg, 30 mg, 60 mg, 100 mg (CD)
SR tablets: 5 mg (CD)
SR solution (as sachets): 20 mg, 30 mg (CD)
POral solution: 10 mg/5 mL, 20 mg/ mL (POM)
Injection: 10 mg/ mL, 15 mg/ mL, 30 mg/ mL (CD)
Suppositories: 10 mg (CD)
Oxycodone hydrochloride (CD)
IR capsules: 5 mg, 10 mg, 20 mg
Liquid: 5 mg/5 mL, 10 mg/ mL.
PInjection: 10 mg/1 mL, 20 mg/2 mL
MR tablets: 5 mg, 10 mg, 20 mg, 40 mg, 80 mg
Tapentadol MR® (CD)
Tablets: 50 mg, 100 mg, 150 mg
PTramadol
Capsules: 50 mg, 100 mg
Soluble Tablets: 100 mg
The following are generally considered for palliative use only and palliative specialists
should be consulted
There have been reports of serious and fatal overdose from dosing errors, accidental
exposure and inappropriate use of fentanyl patches. Exposure to heat sources may
possibly result in increased fentanyl absorption. Remember to check the prescribed
dose and frequency of application, ensure old patches are removed before a new
one is applied, do not cut patches, wash hands after applying the patch. N.B:
increased body temperature, external heat sources and concomitant use of CYP304
inhibitors may lead to dangerous rises in fentanyl levels. Full details see
Drug Safety Update, September 2008
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
There is the possibility of serotonin syndrome when serotonergic drugs are
administered concomitantly with fentanyl-containing patches
 Caution is advised when fentanyl patches are co-administered with drugs that
affect serotonergic neurotransmitter systems.
 The development of a potentially life-threatening serotonin syndrome may
occur with the concomitant use of
Serotonergic drugs such as Selective Serotonin Re-uptake Inhibitors
(SSRIs)
Serotonin Norepinephrine Re-uptake Inhibitors (SNRIs)
Drugs which impair the metabolism of serotonin (including Monoamine
Oxidase Inhibitors [MAOIs])
 This may occur within the recommended dose.
Serotonin syndrome may include one or more of the following:
 mental-status changes (e.g., agitation, hallucinations, coma)
 autonomic instability (e.g., tachycardia, labile blood pressure, hyperthermia)
 neuromuscular abnormalities (e.g., hyperreflexia, incoordination, rigidity)
 gastrointestinal symptoms (e.g., nausea, vomiting, diarrhoea)
If serotonin syndrome is suspected, patches should be discontinued.
PDiamorphine (CD)
Injection: 5 mg, 10 mg, 30 mg, 100 mg, 500 mg
Fentanyl (CD)
Transdermal patches: 25 micrograms/hr, 50 micrograms/hr, 75 micrograms/hr,
100 micrograms/hr
Hydromorphone (CD)
IR capsules (Palladone®): 1.3 mg, 2.6 mg
SR capsules (Palladone SR®): 2 mg, 4 mg, 8 mg, 16 mg, 24 mg
Methadone (CD)
Linctus: 2 mg/5 mL
Injection: 10 mg/1 mL
Pethidine (CD)
Injection: 50 mg/1 mL, 100 mg/2 mL
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
4.7.3 Neuropathic pain
P UAmitriptyline (unlicensed use)
Tablets: 10 mg, 25 mg, 50 mg
Oral solution: 50 mg/5 mL
Capsaicin (Axsain®)
Cream: 0.075%
PGabapentin
Capsules: 100 mg, 300 mg, 400 mg
Lidocaine (Versatis®)
Plasters 5%
Nortriptyline (unlicensed use)
Tablets: 10 mg, 25 mg
Pregabalin
Capsules: 25 mg, 50 mg, 75 mg
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
4.7.4 Antimigraine drugs
4.7.4.1 Treatment of acute migraine
Aspirin
Soluble Tablets: 300 mg
Diclofenac
Suppositories: 25 mg, 50 mg, 100 mg
Ibuprofen
Tablets: 200 mg, 400 mg
Suspension: 100 mg/5 mL
Migraleve®
Pink Tablets: buclizine 6.25 mg + paracetamol 500 mg + codeine 8 mg and
Yellow Tablets: paracetamol 500 mg + codeine 8 mg
Paracetamol
Soluble Tablets: 500 mg
PSumatriptan
Tablets: 50 mg
Injection: 6 mg/0.5 mL syringe
Nasal spray: 10 mg/0.1 mL actuation
4.7.4.2 Prophylaxis of migraine
Amitriptyline
Tablets: 10 mg, 25 mg
Liquid: 50 mg/5 mL
PPizotifen
Tablets: 500 micrograms, 1.5 mg;
Elixir 250 micrograms/5 mL
Propranolol
Tablets: 40 mg
Solution: 40 mg/5 mL
Sodium valproate
Tablets: (Epilim®), crushable: 100 mg
Tablets: (Epilim®): 200 mg, 500 mg
Liquid (Epilim®), sugar-free, 200 mg/5m
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
4.8 ANTIEPILEPTICS
Adult - see the BNF for further information
Children – see BNFC for further information
General points
 Patients established on antiepileptic treatment should not have their medication
changed or stopped unless under SPECIALIST ADVICE.
 For new patients – seek SPECIALIST ADVICE.
 Most antiepileptics, when used in the usual dosage, are given twice daily.
Lamotrigine, phenobarbital, and phenytoin, which have long half-lives, can be
given once daily at bedtime. However, if large doses are administered, some
antiepileptics may need to be given more frequently to avoid adverse effects
associated with high peak plasma-drug concentration.
Safety warnings
CSM advice has been issued for the following antiepileptics Adult - see individual
BNF monographs for details):
Phenytoin
- Blood and skin disorders
Carbamazepine - Blood, liver and skin disorders
Oxcarbazepine
- Blood, liver and skin disorders
Topiramate
- Acute myopia with secondary angle closure glaucoma
Sodium valproate - Blood disorders, liver toxicity and pancreatitis
Lamotrigine
- Serious skin disorders, bone marrow depression
Available data suggests phenytoin, carbamazepine, primidone and sodium valproate
are associated with decreased bone mineral density, which may lead to osteopenia,
osteoporosis and increased fracture in at-risk patients. At-risk patients include those
immobilised for long periods and those with inadequate sun exposure or inadequate
dietary calcium. Vitamin D supplements should be considered for at-risk patients. For
full details, see Drug Safety Update, April 2009
Interactions
 Interactions between antiepileptics are complex and may increase toxicity
without a corresponding increase in antiepileptic effect. Interactions are
usually caused by hepatic enzyme induction or inhibition; displacement from
protein binding sites is not usually a problem. These interactions are highly
variable and unpredictable.
 For interactions of antiepileptic drugs, see BNF Appendix 1; for advice on
hormonal contraception and enzyme-inducing drugs, see BNF Section 7.3.1
and BNF Section 7.3.2.
 Alcohol can cause enzyme induction, which further contributes to seizure
control.
 Concomitant use of St Johns Wort and antiepileptic medication is not
recommended due to significant interactions. See
Drug Safety Update November 2007
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Generic or brand prescribing
 The bioavailability of a generic drug compared to a branded drug may differ 
10%. For most drugs, this is not a problem.
 However, some antiepileptic drugs have a narrow therapeutic index (for
example, phenytoin), minor changes in bioavailability could cause breakthrough
seizures and increased toxicity.
 The cost difference between branded and generic products is often minimal there is no cost benefit in switching and patients should remain on their own
brand.
 The MHRA and NICE advises against switching formulations of antiepileptic
drugs, and patient organisations oppose generic substitution or switching
between brands. The MHRA issued guidance in November 2013:
o Following a review of the available evidence, the UK Commission on
Human Medicines (CHM) considered the characteristics of antiepileptic
drugs and advised that they could be classified into three categories,
based on therapeutic index (a comparison of the amount of a
therapeutic agent that causes the therapeutic effect to the amount that
causes or toxicity), solubility and absorption, to help prescribers and
patients decide whether it is necessary to keep using a supply of a
specific manufacturer’s product.
o Category 1 – Phenytoin, carbamazepine, phenobarbital, primidone
For these drugs, doctors are advised to ensure that their patient is
maintained on a specific manufacturer’s product.
o Category 2 – Valproate, lamotrigine, perampanel, retigabine,
rufinamide, clobazam, clonazepam, oxcarbazepine,
eslicarbazepine, zonisamide, topiramate
For these drugs the need for continued supply of a particular
manufacturer’s product should be based on clinical judgement and
consultation with patient and/or carer taking into account factors such
as seizure frequency and treatment history.

o Category 3 - Levetiracetam, lacosamide, tiagabine, gabapentin,
pregabalin, ethosuximide, vigabatrin
For these drugs it is usually unnecessary to ensure that patients are
maintained on a specific manufacturer’s product unless there are
specific concerns such as patient anxiety, and risk of confusion or
dosing errors.
See Drug Safety Update, November 2013
The brand name or manufacturer's name should be quoted on prescriptions and
in correspondence.
Therapeutic drug monitoring
 Routine plasma drug level monitoring is generally unnecessary as plasma
concentrations do not correlate well with therapeutic effect (this is especially true
for sodium valproate). Therefore, it is important to treat the patient and not the
plasma levels.
 Therapeutic drug monitoring may be useful in the following situations:
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).

o When drug therapy is initiated and after dosage adjustments (especially
with phenytoin or phenobarbital dosage adjustments);
o check on compliance;
o changes in drug formulation and generic substitution;
o seizures in a previously well controlled patient;
o suspected toxicity or adverse effects;
o suspected drug interactions;
o hepatic or renal disease;
o pregnancy
For advice on therapeutic drug monitoring, see guidance
Midazolam
 Buccolam® is a licensed formulation of midazolam suitable for
buccal administration in a range of pre-filled syringes and doses.
 Buccolam® is half the strength of some other unlicensed
preparations.
 For infants aged 3–6 months, treatment should only be in
hospital, where monitoring is possible and resuscitation
equipment is available.
 Four different size syringes (of the same strength) are available
and colour coded accordingly, depending on the age range of the
child – please see table below.
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
4.8.1 Control of the epilepsies
Carbamazepine
Tablets: 100 mg 200 mg, 400 mg
SR Tablets: 200 mg, 400 mg
Liquid: 100 mg/5 mL
Suppositories: 125 mg, 250 mg
Ethosuximide
Capsules (Emeside®): 250 mg
Liquid (Zarontin®): 250 mg/5 mL
Gabapentin
Capsules: 100 mg, 300 mg, 400 mg
Liquid: 250 mg/5 mL
Lacosamide
Tablets: 50 mg, 100 mg, 150 mg, 200 mg
Syrup 15 mg/ mL
Lamotrigine
Tablets: 25 mg, 50 mg, 100 mg
Dispersible Tablets: 2 mg, 5 mg, 25 mg, 100 mg
Levetiracetam
Tablets: (Keppra®), 250 mg, 500 mg
Oral solution (Keppra®), sugar-free: 100 mg/mL
Oxcarbamazepine
Tablets: (Trileptal®): 150 mg, 600 mg
Liquid (Trileptal®): 300 mg/5 mL
Phenobarbital
Tablets: 15 mg, 30 mg, 60 mg
Elixir (alcohol-free): 15 mg/5 mL (available from the pharmacy, SRH)
Phenytoin
Chewable Tablets: (Infatabs®): 50 mg
Capsules (as phenytoin sodium) (Epanutin®): 25 mg, 50 mg, 100 mg
Suspension (Epanutin®): 30 mg/5 mL, 90 mg/5 mL
Injection: 250 mg/500 mL
Pregabalin
Capsules (Lyrica®): 25 mg, 75 mg
Primidone
Tablets: (Mysoline®): 250 mg
Suspension: 250 mg/5 mL (available as a special)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Retigabine
Tablets: 50 mg, 100 mg, 200mg, 300 mg, 400 mg
Available through a managed pathway.
Topiramate
Tablets: (Topamax®): 25 mg, 50 mg, 100 mg
Sprinkle capsules (Topamax®):15 mg, 25 mg, 50 mg
Valproate
Tablets: (Epilim®), crushable: 100 mg
Tablets: (Epilim®): 200 mg, 500 mg
Liquid (Epilim®), sugar-free, 200 mg/5 mL
Injection: (Epilim®): 400 mg vial
Suppositories: 300 mg (unlicensed in the UK)
SR Tablets: (Epilim Chrono®): 200 mg, 300 mg, 500 mg
Vigabatrin
Tablets: (Sabril®): 500 mg
Powder (Sabril®), sugar-free: 500 mg/sachet
Zonisamide
Capsules (Zonegran®): 25 mg, 50 mg, 100 mg
Benzodiazepines
Clobazam (hospital only)
Tablets: (Frisium®): 10 mg
Suspension: mg/1 mL (available from pharmacy, SRH)
Clonazepam
Tablets: (Rivotril®): 500 micrograms, 2 mg
Suspension: 500 micrograms/5 mL (available as a special)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
4.8.2 Drugs used in status epilepticus
Diazepam
Injection: 5 mg/ mL
Rectal solution: 10 mg
Lorazepam
Injection: 4 mg/ mL
Midazolam (CD3)
Oromucosal solution 5 mg/mL (pre-filled syringe): 0.5-mL (2.5 mg), 1-mL (5 mg),
1.5-mL (7.5 mg), 2-mL (10 mg) – Buccolam®
Dose depends upon age:
Age Range
3 to 6 months
hospital setting
> 6 months to < 1 year
Dose
2.5 mg (0.5 mL)
Label colour
Yellow
2.5 mg (0.5 mL)
Yellow
1 year to < 5 years
5 years to < 10 years
10 years to < 18 years
5 mg (1 mL)
7.5 mg (1.5 mL)
10 mg (2 mL)
Blue
Purple
Orange
Phenobarbital
Injection: 200 mg/ mL
Phenytoin
Injection: 50 mg/ mL
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
4.9 DRUGS USED IN PARKINSONISM AND RELATED DISORDERS
Adult - see the BNF for further information
Children – see BNFC for further information
General notes
 Patients established on antiparkinsonian treatment should not have their
medication changed or stopped unless under SPECIALIST ADVICE.

Patients should take their medication at the same time they normally do at
home. Medication regimens should only be adjusted after discussion with a
specialist.

The optimal regimen depends on several factors such as age, cognitive state,
nature and stage of disease and SPECIALIST ADVICE should be sought
before the initiation of drug therapy.
4.9.1 Dopaminergic drugs used in Parkinson’s disease
Dopamine - containing drugs
Co-careldopa
Tablets: 10/100, 25/100, 25/250
MR Tablets: 25/100, 50/200
With entacapone:
Stalevo® 50 mg/12.5 mg/200 mg Tablets: levodopa 50 mg, carbidopa 12.5 mg,
entacapone 200 mg
Stalevo® 100 mg/25 mg/200 mg Tablets: levodopa 100 mg, carbidopa 25 mg,
entacapone 200 mg
Stalevo® 150 mg/37.5 mg/200 mg Tablets: levodopa 150 mg, carbidopa 37.5 mg,
entacapone 200 mg
Co-beneldopa
Capsules: 12.5/50, 25/100, 50/200
Disp Tablets: 12.5/50, 25/100
CR capsules: 25/100
Dopamine-agonists
Dopamine agonists have been associated with pathological gambling, increased
libido and hypersexuality. Patients and/or carers should be warned of those possible
side effects. See Drug Safety Update, August 2007
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Cabergoline
Tablets: 1 mg, 2 mg, 4 mg
Pergolide
Tablets: 50 micrograms, 250 micrograms, 1 mg
Pramipexole (as base)
Tablets: 88 micrograms, 180 micrograms, 700 micrograms
Ropinirole
Tablet: 250 micrograms, 1 mg, 2 mg, 5 mg
Rotigotine
Transdermal patches: 2 mg, 4 mg, 6 mg, 8 mg
Catechol-O-methyl transferase (COMT) inhibitors
Entacapone
Tablet: 200 mg
With co-careldopa:
Stalevo® 50 mg/12.5 mg/200 mg Tablets: levodopa 50 mg, carbidopa 12.5 mg,
entacapone 200 mg
Stalevo® 100 mg/25 mg/200 mg Tablets: levodopa 100 mg, carbidopa 25 mg,
entacapone 200 mg
Stalevo® 150 mg/37.5 mg/200 mg Tablets: levodopa 150 mg, carbidopa 37.5 mg,
entacapone 200 mg
Monoamine-oxidase-B inhibitors
Rasagiline
Tablets: 1 mg
Selegiline
Tablets: 5 mg
Suspension: 10 mg/5 mL
4.9.2 Antimuscarinic drugs used in Parkinsonism
Benzatropine
Injection: 2 mg/2 mL
Orphenadrine
Tablet: 50 mg
Suspension: 50 mg/5 mL
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Procyclidine
Tablets: 5 mg
Solution: 5 mg/5 mL
Injection: 10 mg/2 mL
Trihexyphenidyl
Tablet: 2 mg, 5 mg
4.9.3 Drugs used in essential tremor, chorea, tics, and related disorders
Riluzole
Tablets: 50 mg
Tetrabenazine
Tablets: 25 mg
Torsion dystonias and other involuntary movements
Botulinum toxin type A:
50 units, 100 units, 200 units (Botox®)
300 units, 500 units (Dysport®)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
4.10 DRUGS USED IN SUBSTANCE DEPENDENCE
Adult - see the BNF for further information
Children – see BNFC for further information
Alcohol dependence
Acamposate
Tablets: 333 mg
Disulfiram
Tablets: 200 mg
Cigarette smoking
Bupropion
Tablets: 150 mg
Nicorette®
Microtab (sublingual):
2 mg
Chewing gum:
2 mg, 4 mg
Patches:
‘5 mg' patch (releasing approx. 5 mg/16 hours)
‘10 mg' patch (releasing approx. 10 mg/16 hours)
‘15 mg' patch (releasing approx. 15 mg/16 hours)
Nasal spray:
500 micrograms/metered spray
Inhalator:
10 mg/cartridge
Nicotinell®
Lozenge:
1 mg, 2 mg
Patches:
TTS 10 patch (releasing approx. 10 mg/24 hours)
TTS 20 patch (releasing approx. 20 mg/24 hours)
TTS 30 patch (releasing approx. 30 mg/24 hours)
Vareniclline
Tablets: 500 micrograms, 1 mg
For patients requiring treatment are normally referred to primary care
Opioid dependence
Buprenorphine
Sublingual Tablets: (Subutex®): 400 micrograms, 2 mg, 8 mg
Lofexidine hydrochloride
Tablets: 200 micrograms
Methadone hydrochloride
Oral solution: 1 mg/1 mL
Injection: 10 mg/1 mL
Naltrexone hydrochloride
Tablets: 50 mg
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Medicines in the formulary are listed in chapters and subsections that generally
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4.11 DRUGS FOR DEMENTIA
Adult - see the BNF for further information


Patients already taking medication for Alzheimer's disease should not have their
medication changed or stopped unless under SPECIALIST ADVICE.
For new patients – seek SPECIALIST ADVICE.
Donepezil
Tablets: 5 mg, 10 mg
Galantamine
Tablets: 8 mg, 12 mg
Oral solution: 4 mg/mL
MR capsules: 8 mg, 16 mg, 24 mg
Memantine
Tablet: 10 mg
Oral solution: 5 mg/actuation (10 mg/mL)
Rivastigmine
Capsules: 1.5 mg, 3 mg, 4.5 mg, 6 mg
Oral solution: 2 mg/mL
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Medicines in the formulary are listed in chapters and subsections that generally
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5. INFECTIONS
Local guidance
Trust guidelines for antibiotic prophylaxis guidelines: link to guidelines
Trust guidelines for antibiotic treatment guidelines: link to guidelines
CHS Anti-Infective Formulary v5
Antimicrobial Management Team Date: March 2013 Review by: March 2015
Restricted antimicrobials requiring approval by a microbiologist (M)
Specific-Use antimicrobials reserved for speciality use, specific indications or
Microbiology approval (S)
Unrestricted use of antimicrobials (U)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
5.1 ANTIBACTERIAL DRUGS
Adult - see the BNF for further information
Children – see BNFC for further information
5.1.1 Penicillins
5.1.1.1 Benzylpenicillin and phenoxymethylpenicillin
UBenzylpenicillin
Injection: 600 mg
UPhenoxymethylpenicillin (Penicillin V)
Tablets: 250 mg
Oral solution: 125 mg/5 mL, 250 mg/5 mL
5.1.1.2 Penicillinase-resistant penicillins
UFlucloxacillin
Capsules: 250 mg & 500 mg
Oral solution: 125 mg in 5 mL & 250 mg in 5 mL
Injection: 250 mg, 500 mg, 1 g
5.1.1.3 Broad spectrum penicillins
UAmoxicillin
Capsules: 250 mg & 500 mg
Oral solution: 125 mg in 5 mL, 250 mg in 5 mL
Injection: 250 mg, 500 mg, 1 g
UCo-amoxiclav (amoxicillin with clavulanic acid)
(Quantities are indicated in the form of x/y where x = mg amoxicillin and y = mg clavulanic acid)
Tablets: 250/125, 500/125
Oral solution: 125/31, 250/62
Injection: 500/100 (600 mg), 1,000/200 (1.2g)
5.1.1.4 Antipseudomonal penicillins
SPiperacillin with tazobactam (generic equivalent to Tazocin)
Microbiology approval (except policies for treating neutropenic sepsis)
Injection (as vials) 2.25 g containing piperacillin 2 g, tazobactam 250 mg
4.5 g containing piperacillin 4 g, tazobactam 500 mg
5.1.1.5 Mecillinams
UPivmecillinam hydrochloride
Tablets: 200 mg
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Medicines in the formulary are listed in chapters and subsections that generally
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function (Ctrl+F).
5.1.2 Cephalosporins, carbapenems and other beta-lactams
5.1.2.1 Cephalosporins
UCefalexin
Capsules: 250 mg, 500 mg
Oral solution: 125 mg/5 mL, 250 mg/5 mL
SCeftazidime
Microbiology approval (except in neonatology and cystic fibrosis)
Injection: 250 mg, 500 mg, 1 g, 2 g
SCefixime
Use for PID only
Tablets: 200 mg tablets
Oral solution
SCefotaxime
Meningitis/intracranial infections only
Injection: 500 mg, 1 g, 2 g
SCeftriaxone
Microbiology approval (except paediatrics)
Injection: 250 mg, 1 g, 2 g
: 100 mg/5 mL
UCefuroxime
Injection: 250 mg, 750 mg, 1.5g
5.1.2.2 Carbapenems
MErtapenem
Injection: 1 g
SMeropenem
Microbiology approval (except policies for treating neutropenic sepsis)
Injection: 500 mg, 1 g
5.1.2.3 Other beta-lactam antibiotics
MAztreonam
Microbiology approval (except policies for treating sepsis in liver failure)
Injection: 500 mg, 1 g, 2 g
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
5.1.3 Tetracyclines
UDoxycycline
Capsules: 50 mg, 100 mg
Dispersible tablets: 100 mg
UMinocycline
Tablets: 50 mg, 100 mg tablets
ULymecycline
Capsules: 408 mg ( tetracycline 300 mg)
UOxytetracycline
Tablets: 250 mg
MTigecycline
Injection: 50 mg
5.1.4 Aminoglycosides
MAmikacin
Injection: 500 mg/2 mL
UGentamicin – refer to gentamicin policy
Injection: 20 mg/2 mL, 80 mg/2 mL
STobramycin
Microbiology approval (except paediatrics)
Injection: 40 mg/1 mL, 80 mg/2 mL, 240 mg/6 mL
5.1.5 Macrolides
UClarithromycin
Tablets: 250 mg, 500 mg tablets
Oral solution: 125 mg/5 mL, 250 mg/5 mL
Injection (for IV infusion): 500 mg
UAzithromycin
Capsules: 250 mg
Oral solution: 200 mg in 5 mL
UErythromycin
Tablets: 250 mg, 500 mg
Oral solution: 125 mg/5 mL, 250 mg/5 mL, 500 mg/5 mL
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
5.1.6 Clindamycin
UClindamycin
Capsules: 75 mg, 150 mg
Oral solution: 75 mg/5 mL suspension (unlicensed)
Injection: 300 mg/2 mL, 600 mg/4 mL
5.1.7 Some other antibacterials
MChloramphenicol
Systemic use on Microbiology approval
Capsules: 250 mg
Injection (for IV infusion): 1 g
MColistin
Systemic use on Microbiology approval
Injection: 1,000,000 units
MDaptomycin
Injection
(for IV infusion): 350 mg, 500 mg
MFidaxomicin
Tablets: 200 mg
Treatment of C. difficile infection on Microbiology advice only
M UFosfomycin – unlicensed
Recommendation will be via urine microbiology report
Capsules: 500 mg
Oral solution: 250 mg/5 mL
Sachets: 3 g
MLinezolid
Tablets: 600 mg
Oral solution: 100 mg/5 mL
IV infusion: 600 mg/300 mL
USodium fusidate
A second agent is usually required to prevent the emergence of resistance
Tablets: 250 mg
Oral solution: 250 mg/5 mL (as fusidic acid)
Equivalent in therapeutic effect to 175 mg sodium fusidate
STeicoplanin
Microbiology approval (except Haematology)
Injection (for IV infusion): 200 mg, 400 mg
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
UVancomycin – refer to vancomycin policy
Capsules: 125 mg
Injection (for IV infusion): 500 mg, 1 g
5.1.8 Sulphonamides and trimethoprim
UTrimethoprim
Tablets: 100 mg, 200 mg
Oral solution: 50 mg/5 mL
5.1.9 Antituberculous drugs
Mycobacterial diseases such as TB should be managed by a clinician with expertise such as
a respiratory physician
SEthambutol
Tablets: 100 mg, 400 mg tablets
SIsoniazid
Tablets: 50 mg
Oral solution: 50 mg/5 mL
Injection: 50 mg/2 mL injection
SRifampicin
A second agent is usually required to prevent the emergence of resistance
Capsules: 150 mg, 300 mg
Oral solution: 100 mg/5 mL
Injection (for IV infusion): 600 mg
SRifampicin and Isoniazid
Rifinah® 150 tablets - rifampicin 150 mg + isoniazid 100 mg
Rifinah® 300 tablets - rifampicin 300 mg + isoniazid 150 mg
SUPyrazinamide
Tablets: 500 mg (unlicensed)
SRifampicin, isoniazid and pyrazinamide
Rifater® tablets - rifampicin 120 mg + isoniazid 50 mg + pyrazinamide 300 mg
SUStreptomycin (unlicensed)
Injection: 1 g
5.1.10 Antileprotic drugs
SDapsone
Used for the treatment of leprosy and some skin conditions (e.g. dermatitis herpetiformis, pemphigoid
on the advice of dermatologists)
Tablets: 50 mg, 100 mg tablets
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
5.1.11 Metronidazole
UMetronidazole
Tablets: 200 mg, 400 mg
Oral solution: 200 mg/5 mL
Suppositories: 500 mg, 1 g
Injection (for IV infusion): 50 mg/10 mL
IV infusion: 500 mg/100 mL
5.1.12 Quinolones
Ciprofloxacin
Restricted indications e.g. bacterial diarrhoea and some infections
complicating liver failure
STablets: 250 mg, 500 mg, 750 mg
SOral solution: 250 mg/5 mL
MIV infusion: 100 mg, 200 mg, 400 mg – Microbiology approval needed
SMoxifloxacin
Use with reference to policies on the management of respiratory tract
infections and of intraocular infections
Tablets: 400 mg
SOfloxacin
Use for PID only
Tablets: 200 mg, 400 mg
IV infusion: 200 mg/100 mL
5.1.13 Urinary-tract infections
UNitrofurantoin
Tablets: 50 mg, 100 mg
MR capsule: 100 mg
Oral solution: 25 mg/5 mL
Should not be used in patients with a renal function < 30 mL/min
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
5.2 ANTIFUNGAL DRUGS
Adult - see the BNF for further information
Children – see BNFC for further information
5.2.1 Triazole antifungals
Fluconazole
IV Microbiology approval (except Haematology, Neonatology)
UCapsules: 50 mg, 150 mg, 200 mg
UOral solution: 50 mg/5 mL, 200 mg/5 mL
SIV infusion: 50 mg/25 mL, 200 mg/100 mL
SItraconazole
Capsules: 100 mg
Oral solution: 50 mg/5 mL
MPosaconazole
Oral solution: 200 mg/5 mL oral suspension.
SVoriconazole
Microbiology approval (except Haematology)
Tablets: 50 mg, 200 mg
Injection (for IV infusion): 200 mg
5.2.2 Imidazole antifungals
No preparations
5.2.3 Polyene antifungals
SAmphotericin
Microbiology approval (except Haematology, Neonatology)
Injection (for IV infusion): 50 mg liposomal injection (Ambisome®)
UNystatin
Tablets: 500,000 units
Oral solution: 100,000 units/mL
5.2.4 Echinocandin antifungals
SCaspofungin
Microbiology approval (except Haematology)
Injection: 50 mg, 70 mg
5.2.5 Other antifungals
UTerbinafine
Tablets: 250 mg
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
5.3 ANTIVIRAL DRUGS
Adult - see the BNF for further information
Children – see BNFC for further information
5.3.1 HIV infection
SKaletra®
HIV Post-Exposure Prophylaxis: refer to Occupational Health policy
Tablets containing: 100 mg lopinavir/25 mg ritonavir and 200 mg lopinavir/50 mg
ritonavir
STruvada®
HIV Post-Exposure Prophylaxis: refer to Occupational Health policy
Tablets containing: 200 mg of emtricitabine and 245 mg of tenofovir disoproxil
(equivalent to 300 mg of tenofovir disoproxil fumarate or 136 mg of tenofovir)
5.3.2 Herpesvirus infections
5.3.2.1 Herpes simplex and varicella–zoster infection
UAciclovir (Acyclovir)
Dispersible tablets: 200 mg, 400 mg, 800 mg
Oral solution: 200 mg/5 mL
Injection (for IV infusion): 250 mg, 500 mg
5.3.2.2 Cytomegalovirus infection
SGanciclovir
Microbiology approval (except Renal)
IV infusion: 500 mg
5.3.3 Viral hepatitis
5.3.3.1 Chronic Hepatitis B
SAdefovir dipivoxil
Available through a managed pathway.
SEntecavir
Available through a managed pathway.
STenofovir
Available through a managed pathway.
5.3.3.2 Chronic Hepatitis C
SBoceprevir– option in a manged pathway
STelaprevir – option in a manged pathway
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
5.5.4 Influenza
SOseltamivir
Influenza only: refer to NICE guidance
Capsules: 30 mg, 45 mg, 75 mg
Oral solution: 6 mg/1 mL (65 mL)
SZanamivir
Influenza only: refer to NICE guidance
Dry powder for inhalation: 5 mg/blister
5.3.5 Respiratory syncytial virus
SPalivizumab
Paediatric use only
Injection: 50 mg, 100 mg
SRibavirin
Capsules: 200 mg
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
5.4 ANTIPROTOZOAL DRUGS
Adult - see the BNF for further information
Children – see BNFC for further information
Seek SPECIALIST ADVICE.
5.4.8 Drugs for pneumocystis pneumonia
SCo-trimoxazole (sulphamethoxazole 5 parts, trimethoprim 1 part)
PCP prophylaxis and treatment, treatment of S. maltophilia infection
Tablets: 480 mg, 960 mg
Oral solution: 240 mg/5 mL, 480 mg/5 mL
Injection (for IV infusion): 480 mg/5 mL
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
5.5 ANTHELMINTICS
Adult - see the BNF for further information
Children – see BNFC for further information
5.5.1 Drugs for threadworms
UMebendazole
Tablets: 100 mg
Oral solution: 100 mg/5 mL
UPripsen
Sachets: containing piperazine phosphate 4g, sennosides 15.3 mg/sachet
For other infestations, seek SPECIALIST ADVICE.
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
6. ENDOCRINE SYSTEM
Local Guidance
Trust guidelines for prophylaxis of endocrine infections: link to guidelines
Trust guidelines for treatment of endocrine infections: link to guidelines
Diabetes
SoTW Guidelines for the Management of Type-2 Diabetes (2010)
Trust guidelines for treatment of hyponatraemia
Osteoporosis
Follow the NHS South of Tyne and Wear Prescribing Guidelines for the Management
of Osteoporosis - LINK
FIRST-LINE – Alendronate
SECOND-LINE – Risidronate
THIRD-LINE – Strontium ranelate / IV bisphosphonate / Denosumab
National Guidance
Diagnosis and management of type 1 diabetes in children, young people and adults,
July 2004 (CG15)
http://www.nice.org.uk/Guidance/CG15. See NICE Diabetes treatment pathway
Type 2 Diabetes (partially updated by CG87), May 2008 (update May 2009) (CG66).
http://www.nice.org.uk/Guidance/CG66 (Quick Reference guide)
See NICE Preventing Type-2 Diabetes treatment pathway
The North West Medicines Information Service produce summaries of NICE
guidance (NICE Bites) – Bulletin No. 6 (June 2009) summarises the key prescribing
points from NICE guidance (CG87) for the treatment of type 2 diabetes.
Diabetes in pregnancy, March 2008 (CG63).
http://www.nice.org.uk/Guidance/CG63 (Quick Reference guide)
See NICE Diabetes in Pregnancy treatment pathway
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
NICE Technology Appraisal (TA)
A list of published Technical Appraisals which is searchable can be found on the
NICE website: http://www.nice.org.uk/Guidance/TA/Published
Alternatively, a table of all the TA recommendations can be viewed or printed as a
Word document: Full table of TA recommendations.
Other Guidance
National Osteoporosis Guidelines Group (NOGG) - Guideline for the diagnosis and
management of osteoporosis (in postmenopausal women and men from the age of
50 years in the UK), July 2010
http://www.shef.ac.uk/NOGG/NOGG_Pocket_Guide_for_Healthcare_Professionals.pdf
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
6.1 DRUGS USED IN DIABETES
Adult - see the BNF for further information
Children – see BNFC for further information
6.1.1 Insulins
6.1.1.1 Short acting insulins
Insulin (Insulin Injection; Neutral Insulin; Soluble Insulin)
Human Actrapid® : 10 mL vials
Insuman® Rapid: 3 mL cartridge
Insulin aspart
NovoRapid® : 10 mL vials, 3 mL cartridges
Insulin lispro
Humalog® : 10 mL vials, 3 mL cartridges
Humulin S® is still going to be listed on EP
to allow patients to use their own supplies.
There will be a message stating: This is not
available – use alternative
Patients who do not have their own supply
can be given Actrapid® using vials and
syringes as a temporary measure
WARNING – fast acting soluble human
insulin NOT a rapid acting insulin analogue
NOT SUITABLE FOR IV INFUSION
Minimal stock levels of vials held
NovoRapid®: pre-loaded pen, FlexTouch®
– not stocked but available on request
Minimal stock levels of vials held
6.1.1.2 Intermediate and long acting insulins
Isophane Insulin (Intermediate acting)
Human Insulatard® : 10 mL vials, 3 mL
cartridges
Humulin I® is still going to be listed on EP to
allow patients to use their own supplies. There
will be a message stating: This is not available
– use alternative
Patients who do not have their own supply can
be given Human Insulatard® using vials and
syringes as a temporary measure
Insulatard InnoLet® pre-loaded injection device
– not stocked but available on request
Insulin glargine
Lantus®: 10 mL vials, pre-loaded pen
device: SoloStar®
Minimal stock levels of vials held
Insulin detemir
Levemir®: 3 mL cartridges, pre-loaded
pen: FlexPen®
Minimal stock levels of cartridges held
Levemir InnoLet® pre-loaded injection device
– not stocked but available on request
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Biphasic insulins
Biphasic insulin aspart
Insulin aspart 30% & insulin aspart protamine 70%
Novomix 30® : 3 mL cartridges, pre-loaded pen:
FlexPen®
Biphasic insulin lispro
Insulin lispro 25% & insulin lispro protamine 75%
Humalog Mix 25®: 10 mL vials, 3 mL cartridges,
pre-loaded pen: KwikPen®
Insulin lispro 50% & insulin lispro protamine 50%
Humalog Mix 50®: 3 mL cartridges
Minimal stock levels of cartridges
held
Humalog Mix 50®: pre-loaded pen,
KwikPen® – not stocked but
available on request
Biphasic isophane insulin
(Biphasic Isophane Insulin Injection—intermediate acting)
Soluble 70% & Isophane 30%
Humulin M3®: 10 mL vials, 3 mL cartridges, preloaded pen: KwikPen®
MIMS Quick-reference table for Insulin Preparations: LINK
Patient Guides for insulin deviices: LINK
Storage and use of insulins
 Not-in-use (unopened) insulin products, including vials, pens, and cartridges
should be stored in a refrigerator (2°C to 8°C) (Summaries of Product
Characteristics)
 In-use insulin vials (opened, i.e., after the vial stopper has been punctured
with a needle) should, ideally, be stored at room temperature (below 30°C).
The preservatives insulins are more effective at around room temperature
than in cooler environments. In addition, it is more difficult to re-suspend a
cold insulin suspension than one kept at room temperature.
 In-use pens (opened, i.e., after a pen needle has been attached) should be
stored at room temperature (below 30°C) and should not be refrigerated. This
is because of the increased risk of microbial contamination, potential for air
bubbles occurring - air may enter the cartridge through the needle as the liquid
contracts at the lower temperature. There is a tendency for leakage out
through the needle as the liquid expands at higher temperatures (if been
stored in a refrigerator). Ideally, the needle should be removed.
 Cartridges are not designed for multi-use and cannot be considered the same
as vials. However, a single dose (In an emergency) can be withdrawn using
an insulin syringe and needle.
Information supplied by Lilly and NovoNordisk – April 2011
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
6.1.2 Antidiabetic drugs
6.1.2.1 Sulfonylureas
Gliclazide
Tablets: 80 mg
Glimepiride
Tablets: 1 mg, 2 mg, 3 mg, 4 mg
Tolbutamide
Tablets: 500 mg
6.1.2.2 Biguanides
Metformin hydrochloride
Tablets: 500 mg, 850 mg
Tablets: SR: 500 mg, 750 mg – Restricted use
For patients with gastrointestinal intolerance or concordance/compliance issues
6.1.2.3 Other antidiabetic drugs
Thiazolidinediones (TZDs)
Pioglitazone
Tablets: 15 mg, 30 mg
MHRA/CHM advice
Pioglitazone cardiovascular safety (December 2007 and January 2011)
Incidence of heart failure is increased when pioglitazone is combined with insulin
especially in patients with predisposing factors e.g. previous myocardial infarction.
Patients who take pioglitazone should be closely monitored for signs of heart failure;
treatment should be discontinued if any deterioration in cardiac status occurs.
Pioglitazone should not be used in patients with heart failure or a history of heart
failure
DDP4 Inhibitors (Gliptins)
Saxagliptin
Tablets: 2.5 mg, 5 mg
Sitagliptin
Tablets: 100 mg
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
GLP-1 Mimics/Analogues
G+Exenatide
Injection: 250 micrograms/ mL (5 microgram/dose pre-filled pen)
Injection MR: 2 mg vial (with solvent)
G+Liraglutide
Injection: 6 mg/ mL (0.6 mg/dose pre-filled pen)
G+Lixisenatide
Injection: 50 micrograms/ mL (10 micrograms/dose pre-filled pen)
MHRA/CHM advice
Suspected adverse reaction reports of necrotising and haemorrhagic pancreatitis
have been received in association with exenatide. Some of these reports had a fatal
outcome. If pancreatitis is diagnosed, exenatide should be permanently discontinued.
Reports of renal impairment, including acute renal failure and worsened chronic renal
failure have also been received. Exenatide is not recommended for use in patients
with end-stage renal disease or severe renal impairment.
See Drug Safety Update March 2009.
Acarbose
Acarbose
Tablets: 50 mg, 100 mg
Metiglinides
Nateglinide
Tablets: 60 mg
Repaglinide
Tablets: 500 micrograms, 1 mg
Sodium-glucose co-transporter 2 inhibitors (SGLT2)
G+Dapagliflozin (as propanediol monohydrate)
Tablets: 5 mg, 10 mg
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Medicines in the formulary are listed in chapters and subsections that generally
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function (Ctrl+F).
6.1.3 Diabetic ketoacidosis
Seek SPECIALIST advice
6.1.4 Treatment of hypoglycaemia
Oral
Dextro Energy® Tablets: (47g) – glucose 80%
GlucoGel® – glucose 40% (3 x 25g tubes), each tube is equivalent to 10g
carbohydrate
Parenteral
Glucagon
Injection: 1 mg
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
6.2 THYROID AND ANTITHYROID DRUGS
Adult - see the BNF for further information
Children – see BNFC for further information
6.2.1 Thyroid hormones
Many drugs can affect absorption and blood levels, for a full list of drug interactions –
see the BNF
PLevothyroxine
Tablets: 25 micrograms, 50 micrograms, 100 micrograms
Liothyronine
Tablets: 20 micrograms
Injection: 20 micrograms amp
6.2.2 Antithyroid drugs
Neutropenia and agranulocytosis
Doctors are reminded of the importance of recognising bone marrow suppression
induced by carbimazole and the need to stop treatment promptly.
1. Patients should be told to report unexplained fever, malaise or sore throat
2. A white blood cell count should be performed if there is any clinical evidence
of infection.
Carbimazole should be stopped promptly if there is clinical or laboratory evidence of
neutropenia.
PCarbimazole
Tablets: 5 mg, 20 mg
PPropythiouracil
Tablets: 50 mg
Iodine
(Lugol’s Iodine)
Total iodine 130 mg/ mL
Dilute well with water or milk
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Medicines in the formulary are listed in chapters and subsections that generally
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6.3 CORTICOSTEROIDS
Adult - see the BNF for further information
Children – see BNFC for further information
6.3.1 Replacement therapy
Fludrocortisone
Tablets: 500 micrograms
6.3.2 Glucocorticoid therapy
Equivalent anti-inflammatory doses of corticosteroids
See the current BNF Adult or Children for more information
Infections
See the current BNF Adult or Children for more information
Vaccination
The following is taken from Immunisation against infectious disease (electronic
version). Department of Health. Accessed: 21/8/13
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/14782
4/Green-Book-Chapter-6-v2_0.pdf
Live vaccines, in some situations, can cause severe or fatal infections in
immunosuppressed individuals due to extensive replication of the vaccine strain. For
this reason, severely immunosuppressed individuals should not be given live
vaccines, and vaccination in immunosuppressed individuals should only be
conducted in consultation with an appropriate specialist.
This includes patients receiving systemic high-dose steroids, until at least three
months after treatment has stopped. This would include children who receive
prednisolone, orally or rectally, at a daily dose (or its equivalent) of 2mg/kg/day for at
least one week, or 1mg/kg/day for one month. For adults, an equivalent dose is
harder to define but immunosuppression should be considered in those who receive
at least 40mg of prednisolone per day for more than one week. Occasionally,
individuals on lower doses of steroids may be immunosuppressed and at increased
risk from infections. In those cases, live vaccines should be considered with caution,
in discussion with a relevant specialist physician
Inactivated vaccines cannot replicate and so may be administered to
immunosuppressed individuals, although they may elicit a lower response than in
immunocompetent individuals.
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Corticosteroid cover for infection and surgery
An increase in replacement therapy is required during periods of stress. In mild
infection, a doubling of the maintenance dose of hydrocortisone may be appropriate
but for major infection, or severe stress such as surgery, parenteral therapy is
required. It is generally considered safer to overestimate rather than underestimate
the appropriate cover.
Adrenocortical insufficiency (Latest modification: 02-Jan-2011). Sweetman S (Editor), Martindale: The
Complete Drug Reference. [online] London: Pharmaceutical Press
<http://www.medicinescomplete.com/> Accessed on: 14/5/13
See also:
CHS Pre Admission Assessment Clinics guidance on Perioperative management of
oral medication in surgical patients. Anaesthetics/Pharmacy (December 2010)
Mood behaviour changes
See the current BNF Adult or Children for more information
Corticosteroid treatment especially with high doses can alter mood and behaviour
early in treatment. Patients can become confused, irritable; suffer from delusions and
suicidal thoughts. These symptoms can also occur when treatment is being
withdrawn. Early psychiatric side effects are discussed in the Drug Safety Update
September 2007.
Corticosteroids and osteoporosis
See the BNF for more information
Withdrawal of Corticosteroids
See the BNF Adult or Children for more information
Steroid Treatment Card
Patients on long-term corticosteroid treatment should carry a Steroid Treatment Card
which gives guidance on minimising risk and provides details of prescriber, drug,
dosage and duration of treatment
Betamethasone
Soluble Tablets: 500 micrograms
Injection: (as sodium phosphate): 4 mg/1 mL
PDexamethasone
Tablets: 500 micrograms, 2 mg
Oral solution: 2 mg/ mL. 2 mg/5 mL
Injection: (as sodium phosphate) 3.3 mg/1 mL, 6.6 mg/2 Ml
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Hydrocortisone
Tablets: 10 mg, 20 mg
MR tablets: 5 mg, 20 mg
Injection: (as sodium succinate): 100 mg
Methylprednisolone
Tablets: 16 mg, 100 mg
Injection: (as sodium succinate): 40 mg, 125 mg, 500 mg, 1 g
PPrednisolone
Tablets: 1 mg, 5 mg
Soluble Tablets: 5 mg
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
6.4 SEX HORMONES
Adult - see the BNF for further information
Children – see BNFC for further information
6.4.1 Female sex hormones and their modulators
6.4.1.1 Oestrogens and HRT
It is assumed that initiation of HRT is non-urgent and can be referred to the patient’s
own GP
For information on Oestrogens in HRT see the BNF
Risks and benefits
For a quick summary – refer to the BNF
For an assessment of risks and benefits - link to MHRA advice
Royal College of Obstetricians and Gynaecologists (RCOG) briefing –
link to briefing
Surgery
CHS Pre Admission Assessment Clinics guidance on Perioperative management of
oral medication in surgical patients. Anaesthetics/Pharmacy (December 2010)
Other preparations
Raloxifene
Tablets: 60 mg
Tibilone
Tablets: 2.5 mg
6.4.1.2 Progestogens and progesterone receptor modulators
Medroxyprogesterone acetate
Tablets: 2.5 mg, 5 mg, 10 mg
Norethisterone
Tablets: 5 mg
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correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
6.4.2 Male sex hormones and antagonists
Testosterone and esters
Oral
Testosterone undecanoate: oral capsules, 40 mg (Restandol®)
Intramuscular
Testosterone undecanoate 1,000 mg/4 mL (Nebido®)
Testosterone esters: depot Injection: 250 (Sustanon 250®)
Testosterone: implant, 100 mg and 200 mg
Transdermal
Testosterone: gel, testosterone 2% (10 mg/metered application) (Tostran®)
Others
Mesterolone
Tablets: 25 mg
Anti-androgens
Cyproterone acetate
Tablets: 50 mg
Dutasteride
Capsules: 500 mg
PFinasteride
Tablets: 5 mg
6.4.3 Anabolic steroids
No preparations
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correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
6.5 HYPOTHALAMIC AND PITUITARY HORMONES AND ANTI-OESTROGENS
Adult - see the BNF for further information
Children – see BNFC for further information
The drugs in this section are restricted to SPECIALIST USE or to be prescribed
under SPECIALIST SUPERVISION
6.5.1 Hypothalamic and anterior pituitary hormones and anti-oestrogens
Anti-oestrgens
SClomifene
Tablets: 50 mg
Corticotrophins
STetracosactide
Injection: 250 micrograms/1 mL
Depot injection: 1 mg/1 mL
Gonadotrophins
SChorionic gonadotrophin
Injection: 5,000 units (Pregnyl®)
SChoriogonadotrophin alfa
Injection (pre-filled syringe): 6,500 inits/0.5 mL (250 micrograms/0.5 mL) (Ovitrelle®)
SFollitropin alfa
Injection (pre-filled pen): 300 units/0.5 mL (Gonal-F®)
SFollitropin beta
Injection (cartridge): 300 units, 600 units (Puregon®)
Growth hormone
SSomatropin
Preparation depends upon contract
Hypothalamic hormones
SGonadorelin
Injection: 100 micrograms
SU Proterelin - unlicensed
Injection: 200 micrograms/1 mL
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
6.5.2 Posterior pituitary hormones and antagonists
Posterior pituitary hormones
Desmopressin nasal spray is no longer licensed for primary nocturnal enuresis
(PNE) due to the increased risk of hyponatraemia compared to the oral
formulation. See Drug Safety update, September 2007
Remain vigilant for signs and symptoms of hyponatraemia associated with the use of
desmopressin. These may include (in mild cases) anorexia, headache, nausea or
vomiting; or (in more severe cases) coma, convulsions, confusion, muscle cramps
and weakness.
The CSM advise that patients being treated for PNE are warned to avoid fluid
overload and to stop desmopressin during episodes of diarrhoea and vomiting. For
more information
See Drug Safety Update January 2008 and BNF
SDesmopressin
Metered nasal spray: 10 micrograms/spray
Tablets: 200 micrograms
Orodispersible Tablets: 120 micrograms
Injection: 4 micograms/1 mL
STerlipressin
Injection: 1 mg/1 mL
SVasopressin (argipressin)
Injection: 20 micrograms/1 mL
Antidiuretic hormone antagonists
SDemeclocycline
Capsules: 150 mg
Tolvaptan
RTolvaptan:
Tablets: 15 mg
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
6.6 DRUGS AFFECTING BONE METABOLISM
Adult - see the BNF for further information
Children – see BNFC for further information
Osteonecrosis of the jaw has been reported in patients receiving intravenous
bisphosphonates and very rarely in those on oral bisphosphonates. Adequate oral
hygiene should be maintained before and after treatment. Remedial dental work
should be carried out before starting treatment in patients with concomitant risk
factors. See the BNF and Drug Safety Update, November 2009

Atypical femoral fractures have been reported rarely with bisphosphonate
treatment, mainly in patients receiving long-term treatment for osteoporosis.
 The need to continue bisphosphonate treatment for osteoporosis should be reevaluated periodically based on an assessment of the benefits and risks of
treatment for individual patients, particularly after 5 or more years of use.
 Patients should be advised to report any thigh, hip, or groin pain during
treatment with a bisphosphonate.
 Discontinuation of bisphosphonate treatment in patients suspected to have an
atypical femoral fracture should be considered after an assessment of the
benefits and risks of continued treatment.
For more details, please see Drug Safety Update, June 2011.
6.6.1 Calcitonin and parathyroid hormone
SCalcitonin (salmon)/salcatonin
Ampoule: 100 Units/1 mL
Vial: 400 Units/2 mL
STeriparatide – Restricted to Specialist use only
Pre-filled pen: 750 micrograms/3 mL
6.6.2 Bisphosphonates and other drugs affecting bone metabolism
PAlendronic acid
Tablets: 10 mg, 70 mg
SDisodium pamidronate
Vial: 15 mg/5 mL
SIbandronic acid
Pre-filled syringe: 3 mg/3 mL
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Risedronate sodium
Tablets: 5 mg, 30 mg, 35 mg
SZoledronic acid
Vial: 4 mg/5 mL, (Zometa®)
Infusion: 5 mg/100 mL, (Aclasta®)
Note the different indications for the above products:
Zometa® - reduction of bone damage/advanced malignancies involving bone and
hypercalcaemia of malignancy
Aclasta® - treatment of postmenopausal osteoporosis and Paget’s disease.
Denosumab
SDenosumab
Injection (pre-filled syringe): 60 mg/1 mL
For osteoporosis indications: should not be used in patients with hypocalcaemia, regardless of
severity. See Drug Safety Update, October 2012
Rare cases of atypical femoral fracture with long-term use. See Drug Safety Update, February 2013
Strontium ranelate
Strontium ranelate is restricted to use when bisphosphonates are contra-indicated or
not tolerated and then only/women aged over 75 years with a previous fracture and
low bone mineral density or/other women at equivalent risk. It is not stocked or
supplied by pharmacy.
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function (Ctrl+F).
6.7 OTHER ENDOCRINE DRUGS
Adult - see the BNF for further information
Children – see BNFC for further information
6.7.1 Bromocriptine and other dopaminergic drugs
Although bromocriptine and cabergoline are licensed to suppress lactation, they are
not recommended for routine suppression (or for the relief of symptoms of
postpartum pain and engorgement) that can be adequately treated with simple
analgesics and breast support. If a dopamine-receptor agonist is required,
cabergoline is preferred. Quinagolide is not licensed for the suppression of lactation.



CSM advice: the ergot derived dopamine receptor agonists bromocriptine,
cabergoline, lisuride and pergolide have been associated with pulmonary,
retroperitoneal and pericardial fibrotic reactions. The CSM has advised that
before starting treatment with these ergot derivatives, investigations such as
measurement of ESR, U&Es and a chest X-ray may be appropriate. If longterm treatment is expected than lung function tests may be useful. Patients
should be monitored for progressive fibrotic disorders.
Dopamine agonists have been associated with excessive daytime sleepiness
and sudden onset of sleep. Patients starting treatment with these drugs should
be warned of the possibility of these effects and the need for caution if driving
or operating machinery.
Hypotensive reactions can occur during the first few days of treatment with
bromocriptine, cabergoline, or quinagolide - monitor blood pressure for a few
days after starting treatment and following dosage increases.
Bromocriptine
Tablets: 1 mg, 2.5 mg
Cabergoline
Tablets: 500 micrograms
UQuinagolide
Tablets: 25 micrograms, 50 micrograms, 75 micrograms
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
6.7.2 Drugs affecting gonadotrophins
Danazol
Capsules: 100 mg, 200 mg
Gonadorelin Analogues
Goserelin
Implant: 3.6 mg (as acetate)
Triptorelin
Injection: 3.75 mg (as acetate), pre-filled syringe (Gonapeptyl Depot®)
Injection: 15 mg (as acetate), vial (Decapeptyl SR®)
6.7.3 Metyrapone
Metyrapone
Capsules: 250 mg
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correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
7. OBSTETRICS, GYNAECOLOGY, AND URINARY-TRACT
DISORDERS
Local guidance
Trust guidelines for prophylaxis of obstetrics, gynaecology, and urinary-tract
infections: link to guidelines
Trust guidelines for treatment of obstetrics, gynaecology, and urinary-tract infections:
link to guidelines
Drugs for urinary frequency, enuresis, and incontinence
 First Line - Immediate release oxybutinin is first line treatment unless
contraindicated Adult - see below). The use of oxybutynin may be limited by
side effects. These may be reduced by commencing with a low dose and
increasing gradually - usual starting dose is 2.5 mg three times a day
increased weekly as tolerated to a maximum of 5 mg four times a day.

Contraindications to first line immediate release oxybutinin - If a patient is
unlikely to comply with three times a day dosing or is already on multiple
medications it may be reasonable to try a modified release preparation before
trying third-line therapy. In an elderly patient or someone at high risk of
cognitive impairment, consider a second-line drug such as trospium.

Second Line - A modified-release preparation of oxybutynin is effective and
has fewer side-effects and therefore may be better tolerated (usually 10 mg
for patients who move from 2.5 mg three times a day increased to a maximum
of 20 mg daily in 5 mg steps per week) An alternative antimuscarinic, such as
trospium

Third Line -Third-line agents may still have good effect in patients who have
failed to respond to other preparations and include solifenacin, and
propiverine. Solifenacin is substantially more expensive but may be an option
for those who do not tolerate oxybutynin. NICE recommends propiverine for
overactive bladder but not for urinary incontinence. Mirabegron should be
considered as third lline (at least 2 “standard” treatments to be tried - unless
side effects are intolerable) as an alternative to more costly options such as
botulinum and sacral neuromodulation.
Antimuscarinic therapy should be reviewed after 6 months and if symptoms are
well-controlled therapy may be reduced or discontinued, as symptoms may not
recur.
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correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
National Guidance
NICE Clinical Guidance (CG)
Urinary incontinence (management in women), October 2006 (CG40)
www.nice.org.uk/Guidance/CG40 (Quick Reference Guide)
NICE Technology Appraisal (TA)
A list of published Technical Appraisals which is searchable can be found on the
NICE website: http://www.nice.org.uk/Guidance/TA/Published
Alternatively, a table of all the TA recommendations can be viewed or printed as a
Word document: Full table of TA recommendations.
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
7.1 DRUGS USED IN OBSTETRICS
Adult - see the BNF for further information
The drugs in this section are restricted to SPECIALIST USE or to be prescribed
under SPECIALIST SUPERVISION
7.1.1 Prostaglandins and oxytocics
Carboprost
Injection: 250 micrograms /1 mL
Dinoprostone
Injection: 750 micrograms/0.75 mL
Vaginal gel: 1 mg/2.5 mL, 2 mg/2.5 mL
Vaginal tablet: 3 mg
Ergometrine maleate
Injection: 500 micrograms/1 mL
Gemeprost
Pessaries: 1 mg
Oxytocin
Injection: 10 Units/1 mL
Syntometrine®
Injection: ergometrine maleate 500 micrograms, oxytocin 5 Units/1 mL.
7.1.1.1 Drugs affecting the ductus arteriosus
UIndometacin – unlicensed
Injection: 1 mg
7.1.2 Mifeprostone
Mifepristone
Tablets: 200 mg
7.1.3 Myometrial relaxants
Atosiban
Injection: 6.75 mg/0.9 mL
Infusion: 37.5 mg/5 mL
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correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
7.2 TREATMENT OF VAGINAL AND VULVAL CONDITIONS
Adult - see the BNF for further information
Children – see BNFC for further information
7.2.1 Preparations for vaginal and vulval infections
PEstriol (oestriol)
Cream: 0.01% (Ortho-Gynest®), 0.1% (Ovestin®)
Damages latex condoms and diaphragms
7.2.2 Vaginal and vulval infections
Clindamycin
Vaginal cream: 10% (Dalacin®)
Damages latex condoms and diaphragms
PClotrimazole
Vaginal cream: 10%
Pessaries: 100 mg, 200 mg, 500 mg
Damages latex condoms and diaphragms
Metronidazole
Vaginal gel: 0.75% (Zidoval®)
Cautions: not recommended during menstruation; some absorption may occur
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correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
7.3 CONTRACEPTIVES
Adult - see the BNF for further information
Children – see BNFC for further information
7.3.1 Combined hormonal contraceptives
Oral preparations are not included/this section. Please contact Pharmacy if you have
an enquiry regarding stocks held.
For information on: choice, risk of venous thromboembolism, interactions (including
antibiotics), missed pill, surgery and when to stop, refer to the BNF.
Vaginal
Ethinylestradiol 15 micrograms/24 hours with Etonogestrel 120 micrograms/24 hours
(NuvaRing®)
7.3.2 Progestogen- only contraceptives
7.3.2.1 Oral progestogen-only contraceptives
Oral preparations are not included/this section. Please contact Pharmacy if you have
an enquiry regarding stocks held.
7.3.2.2 Parenteral progestogen-only contraceptives
Etonogestrel
Implant: 68 mg (Nexplanon®)
Medroxyprogesterone acetate
Depot Injection: 150 mg/1 mL (Depo-Provera®)
7.3.2.3 Intra-uterine progestogen-only device
Mirena®
7.3.3 Spermicidal contraceptives
Supplied by Family Planning
7.3.4 Contraceptive devices
Supplied by Family Planning
7.3.5 Emergency Contraception
PLevonorgestrel
Tablets: 1.5 mg (Levonelle®)
PUlipristal acetate
Tablets: 30 mg (ellaOne®)
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function (Ctrl+F).
7.4 DRUGS FOR GENITO-URINARY DISORDERS
Adult - see the BNF for further information
Children – see BNFC for further information
7.4.1 Drugs for urinary retention
Alfuzosin hydrochloride
Tablets: 2.5 mg
MR tablets: 10 mg
PTamsulosin hydrochloride
MR capsules: 400 micrograms.
5-alpha-reductase inhibitors
See Section 6.4.2
7.4.2 Drugs for urinary frequency, enuresis, and incontinence
Mirabegron
MR tablets: 25 mg, 50 mg
POxybutynin hydrochloride
Tablets: 2.5 mg, 5 mg
MR tablets: 5 mg, 10 mg
Propiverine hydrochloride
MR capsules: 30 mg
Solifenacin succinate
Tablets: 5 mg, 10 mg
Trospium chloride
Tablets: 20 mg
MR capsules: 60 mg
Stress urinary incontinence (UI) in women
Duloxetine
Capsules: 20 mg, 40 mg
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function (Ctrl+F).
Primary nocturnal enuresis (PNE)
MHRA advice for healthcare professionals:
 Nasal formulations of desmopressin should not be used for treatment of PNE
 All patients with PNE should start oral desmopressin at the lowest
recommended dose, which should be increased only if necessary to achieve
control of symptoms.
 Risk of hyponatraemic convulsions - patients should be warned to avoid fluid
overload (including during swimming) and to stop taking desmopressin during
an episode of vomiting or diarrhoea (until fluid balance normal). The risk of
hyponatraemic convulsions can also be minimised by keeping to the
recommended starting doses and by avoiding concomitant use of drugs which
increase secretion of vasopressin (e.g. tricyclic antidepressants)
See Drug Safety update, September 2007
Desmopressin (DDAVP)
Tablets: 200 micrograms
Orodispersible tablets: 120 micrograms
7.4.3 Drugs used in urological pain
Potassium citrate
Effervescent tablets: 1.5 g
7.4.4 Bladder instillations and urological surgery
Chlorhexidine 0.02%
Bladder irrigation: 100 mL
Sodium chloride 0.9%
Bladder irrigation: 100 mL
Solution G (citric acid 3.23%, magnesium oxide 0.38%, sodium bicarbonate 0.7%,
disodium edetate 0.01%)
Bladder irrigation: 100 mL
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
7.4.5 Drugs for erectile dysfunction
Alprostadil
Injection: 5 micrograms, 10 micrograms, 20 micrograms, 50 micrograms
Urethral application: 250 micrograms, 500 micrograms, 1 mg
PSildenafil
Tablets: 25 mg, 50 mg
PTadalafil
Tablets: 10 mg, 20 mg
Vardenafil
Tablets: 5 mg, 10 mg, 20 mg
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correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
8. MALIGNANT DISEASE AND IMMUNOSUPRESSION
The prescribing of cytotoxic chemotherapy is RESTRICTED TO SPECIALIST USE
ONLY.


The only staff who are able to prescribe cytotoxic chemotherapy are oncology
consultants (or other career grade staff who are competent) and SpRs - for
oncology patients and haematology consultants and SpRs for haematology
patients.
Physicians and their teams who admit unselected medical emergencies are
not expected to either initiate or continue the prescription of chemotherapy.
The responsibility for the prescription lies with the consultant in charge of that
patient or whoever is providing cover for that service. It would of course be
appropriate to notify the relevant team of that patient’s admission.
Local guidance
Trust guidelines for prophylaxis of infections relating to malignant disease and
immunosuppression: link to guidelines
Trust guidelines for treatment of infections relating to malignant disease and
immunosuppression: link to guidelines
Link to Trust Chemotherapy Prescriptions and Documentation
Link to Trust oral chemotherapy Standard Operating Procedures (SOPs)
North of England Cancer Network (NECN) website:
http://www.necn.nhs.uk/
North of England Cancer Network (NECN) guidelines and documents
Chemotherapy Administration Policy
Oral Chemotherapy Handbook
Prescribing Advice
Standards for the Safe Use of Oral Anticancer Medicines
The chemotherapy regimen protocols can be located within each individual
Network Site Specific Group pages.
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
8.1 CYTOTOXIC DRUGS
Adult - see the BNF for further information
Children – see BNFC for further information
Chemotherapy-induced mucositis and myelosuppression
Folinic acid (as calcium folinate)
Tablets: 15 mg
Injection: 30 mg/10 mL
Urothelial toxicity
MESNA
Tablets: 400 mg
Injection: 400 mg/4 mL, 1 g/10 mL
8.1.1 Alkylating agents
SBendamustine
Injection: 100 mg
SBusulphan
Tablets: 5 mg
SChlorambucil
Tablets: 2 mg
SCyclophosphamide
Tablets: 50 mg
Injection: 500 mg, 1 g
SIfosfamide
Injection: 1 g, 2 g
SLomustine
Capsules: 40 mg
SMelphalan
Tablets: 2 mg
Injection: 50 mg
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correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
8.1.2 Anthracyclines and other cytotoxic antibiotics
SBleomycin
Injection: 15,000 units
SDaunorubicin
Injection: 20 mg
SDoxorubicin hydrochloride
Injection: 10 mg, 50 mg
SEpirubicin
Injection: 10 mg, 50 mg, 200 mg
SIdarubicin
Capsules: 5 mg, 10 mg
Injection: 5 mg, 10 mg
SMitomycin
Injection: 2 mg, 10 mg, 20 mg, 40 mg
SMitoxantrone
Injection: 25 mg/12.5 mL
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correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
8.1.3 Antimetabolites
SAzacitidine
Injection: 100 mg
SCapecitabine
Tablets: 150 mg, 500 mg
SCytarabine
Injection: 100 mg/5 mL. 1 g/10 mL, 2 g /20 mL
SFludarabine phosphate
Tablets: 10 mg
Injection: 50 mg
SFluorouracil
Injection: 250 mg/10mL, 500 mg/20 mL. 2.5 g/100 mL
SGemcitabine
Injection: 200 mg, 1 g
SMercaptopurine
Tablets: 50 mg
SMethotrexate
Tablets: 2.5 mg
Injection: various in pre-filled syringes
SPemetrexid
Injection: 500 mg
STegafur with Uracil
Capsules: 100 mg
STioguanine
Tablets: 40 mg
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correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
8.1.4 Vinca alkaloids and etoposide
SEtoposide
Capsules: 50 mg, 100 mg
Injection: 100 mg/5 mL
SVinblastine sulphate
Injection: 10 mg
SVincristine sulphate
Injection: 1 mg/1 mL, 2 mg/2 mL
SVindesine sulphate
Injection: 5 mg
SVinorelbine
Capsules: 20 mg
Injection: 10 mg/1 mL, 50 mg/5 mL
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correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
8.1.5 Other neoplastic drugs
SAmsacrine
Injection: 75 mg/1.5 mL
SBevacizumab
Injection: 100 mg/4 mL
SBexarotene
Capsules: 75 mg
SBortezomib
Injection: 3.5 mg injection
SCetuximab
Injection: 100 mg/20mL, 500 mg/100 mL
SCisplatin
Injection: 10 mg/10 mL, 50 mg/50 mL
SCrisantaspase
Injection: 10,000 units
SDacarbazine
Injection: 200 mg, 500 mg
SDasatinib
Tablets: 20 mg, 50 mg
SDocetaxel
Injection: 20 mg/0.5 mL, 80 mg/4 mL
SEribulin
Injection: 800 micrograms/2 mL
SErlotinib
Tablets: 100 mg, 150 mg
SEverolimus
Tablets: 10 mg
SGefitinib
Tablets: 250 mg
SHydroxycarbamide
Capsules: 500 mg
SImatinib
Capsules: 100 mg, 400 mg
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
SIpilimumab
Vial: 50 mg/10 mL
Available through a managed pathway according to a NECDAG protocol.
SIrinotecan
Injection: 100 mg/5 mL
SNilotinib
Capsules: 200 mg
SOxaliplatin
Injection: 50 mg/10 mL, 100 mg/20 mL
SPaclitaxel
Injection: 30 mg/5 mL, 100 mg/16.7 mL concentrate for preparing IV infusion
SPazopanib
Tablets: 200 mg, 400 mg
SPentostatin
Injection: 10 mg
SProcarbazine
Capsules: 50 mg
SSunitinib
Capsules: 12.5 mg 25 mg, 50 mg
STemozolomide
Capsules: 5 mg, 20 mg, 100 mg, 140 mg, 180 mg, 250 mg
Available through a managed pathway according to a NECDAG protocol.
STopotecan
Capsules: 250 micrograms, 1 mg
STrastuzumab
Injection: 150 mg vial concentrate for preparing IV infusion
STrabectedin
Vial: 250 micrograms, 1 mg
Available through a managed pathway according to a NECDAG protocol.
STretinoin
10 mg
SVemurafenib
Tablets: 240 mg
Available through a managed pathway according to a NECDAG protocol.
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function (Ctrl+F).
8.2 DRUGS AFFECTING THE IMMUNE RESPONSE
Adult - see the BNF for further information
Children – see BNFC for further information
Immunosuppressants are used to suppress rejection/organ transplant recipients and
to treat a variety of chronic inflammatory and autoimmune diseases. Specialist
management is required and therefore these drugs are RESTRICTED TO
SPECIALIST USE ONLY.
When prescribing, prescribe by brand name only, to minimise the risk of
inadvertent switching between products, which has been associated with reports of
toxicity and graft rejection.
8.2.1 Antiproliferative immunosuppressants
SAzathioprine
Tablets: 25 mg, 50 mg
Injection: 50 mg
SMycophenolate mofetil
Capsules: 250 mg
Tablets; 500 mg
Oral solution: 1g in 5 mL (200 mg/ mL)
SMycophenolate sodium
Tablets EC: 180 mg, 360 mg – 2nd line therapy in patients who do not tolerate
mycophenolate mofetil
8.2.2 Corticosteroids, other immunosuppressants
SBasilixumab
Available through a managed pathway.
SCiclosporin
Capsules: 10 mg, 25 mg, 50 mg, 100 mg (Neoral®)
Oral solution: 100 mg/1 mL (Neoral®)
Injection: 50 mg in 1 mL, 250 mg in 5 mL concentrate (oily) for IV infusion
(Sandimmun®)
STacrolimus
Capsules: 500 micrograms, 1 mg, 5 mg (Prograf®)
Capsules MR: 500 micrograms, 1 mg, 5 mg (Advagraf®)
Injection: 5 mg/1 mL (Prograf®)
SSirolimus
Tablets: 1 mg
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
8.2.3 Anti-lymphocyte monoclonal antibodies
SAlemtuzmab
Injection: 30 mg in 1 mL concentrate for IV infusion
SRituximab
Injection: 100 mg in 10 mL, 500 mg in 50 mL concentrate for IV infusion
8.2.4 Other immunomodulating drugs
SBCG Connaught (ImmuCyst®)
81 mg vial for bladder instillation
SGlatiramer acetate
Injection: 20 mg/1 mL prefilled syringe
Interferon alfa
SInterferon alfa-2b (IntronA®)
18 million units/1.2 mL, 30 million units/1.2 mL prefilled pen
SPeginterferon alfa
Peginterferon alfa 2a (Pegasys®)
135 micrograms, 180 microgram prefilled syringes
SPeginterferon alfa 2b (ViraferonPeg®)
80 micrograms, 100 micrograms, 120 micrograms, 150 micrograms prefilled pens
Interferon beta
SInterferon beta–1a
22 micrograms (6 million units) , 44 micrograms (12 million units) prefilled syringe
(Rebif®)
30 micrograms (6 million units) prefilled syringe (Avonex®)
66 micrograms (18 million units) 1.5 mL cartridge for use in the Rebismart® injection
device
SInterferon beta–1b
Vial: 300 micrograms (9.6 million units) vial (Extavia®)
Vial: 300 micrograms (9.6 million units) vial (Betaferon®)
SFingolimod
Capsules: 500 micrograms
SLenalidomide
Capsules: 5 mg, 10 mg, 15 mg, , 25 mg
Risk of serious hepatic adverse drug reactions – routine monitoring of liver function now
recommended – see Drug Safety Update, January 2013
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
SMifamurtide
Vial: 4 mg
Available through a managed pathway.
SNatalizumab
Injection: 300 mg in 15 mL (20 mg/ mL) vial for preparing infusions
SThalidomide
Capsules: 50 mg
Risk of second primary malignancies – routine monitoring now recommended –
see Drug Safety Update, May 2013
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
8.3 SEX HORMONES AND HORMONE ANTAGONISTS IN MALIGNANT DISEASE
Adult - see the BNF for further information
8.3.1 Oestrogens
Diethylstilbestrol
Tablets: 1 mg
8.3.2 Progestogens
Medroxyprogesterone acetate
Tablets: 100 mg, 200 mg
Megestrol acetate
Tablets: 40 mg, 160 mg
Norethisterone
Tablets: 5 mg
8.3.3 Androgens
Testosterone esters have largely been superseded by other drugs for breast cancer.
8.3.4 Hormone antagonists
8.3.4.1 Breast cancer
SAnastrozole
Tablets: 1 mg
SExemestane
Tablets: 25 mg
SFulvestrant
Pre-filled syringe 250 mg/5 mL
SGoserelin
Depot Injection: 3.6 mg
SLetrozole
Tablets: 2.5 mg
STamoxifen
Tablets: 10 mg, 20 mg, 40 mg
Oral solution: 10 mg/5 mL
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
8.3.4.2 Gonadorelin analogues and gonadotrophin-releasing hormone antagonists
Gonadorelin analogues
SGoserelin
Depot Injection: 3.6 mg
LA depot Injection: 10.8 mg
A Shared-care Protocol exists for this medicine
STriptorelin
Injection: triptorelin 3.75 mg (as acetate), pre-filled syringe (Gonapeptyl Depot®)
Injection: triptorelin 15 mg (as acetate), vial (Decapeptyl SR®)
Anti-androgens
SAbiraterone actetate
Tablets: 250 mg
Available through a managed pathway according to a NECDAG protocol.
SBicalutamide
Tablets: 50 mg, 150 mg
A Shared-care Protocol exists for this medicine
SCyproterone acetate
Tablets: 50 mg
A Shared-care Protocol exists for this medicine
SDegarelix
Injection: 80 mg, 120 mg
8.3.4.3 Somatostatin analogues
SOctreotide
Injection: 50 micrograms/1 mL, 100 micrograms/1 mL, 500 micrograms/1 mL,
1 mg/5 mL
Lar® Injection: 10 mg, 20 mg, 30 mg
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
9. NUTRITION AND BLOOD
Local guidance
Trust guidelines for prophylaxis of haematology infections: link to guidelines
Trust guidelines for treatment of haematology infections: link to guidelines
National guidance
NICE Clinical Guidance (CG)
Alcohol-use Disorders: Physical complications, June 2010 (CG100)
http://guidance.nice.org.uk/CG100 (Quick Reference Guide)
NICE Technology Appraisal (TA)
A list of published Technical Appraisals which is searchable can be found on the
NICE website: http://www.nice.org.uk/Guidance/TA/Published
Alternatively, a table of all the TA recommendations can be viewed or printed as a
Word document: Full table of TA recommendations.
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
9.1 ANAEMIAS AND SOME OTHER BLOOD DISORDERS
Adult - see the BNF for further information
Children – see BNFC for further information
9.1.1 Iron deficiency anaemias
9.1.1.1 Oral Iron
Ferrous sulphate (= 60 mg elemental iron)
Tablets: 200 mg
Sodium feredetate (Sytron®) (= 55 mg elemental iron per 10 mL)
Syrup: 190 mg/5 mL
9.1.1.2 Parenteral Iron



Not all parenteral preparations are INTERCHANGEABLE - please refer to the
Summary of Product Characteristics (SPC) for each drug (links below each
individual preparation).
The dose of parenteral iron must be calculated on an individual basis.
To calculate the appropriate dose, the following needs to be determined: the
target Hb concentration, the actual Hb concentration and the patient's weight.
New recommendations to manage risk of allergic reactions with intravenous
iron-containing medicines
A European wide review of intravenous iron products has issued recommendations
to manage and minimise the risk of hypersensitivity reactions
 Any IV iron product should not be used in patients with known hypersensitivity
to the product itself, or any of its excipients. The risk is higher in patients with
known allergies or have immune or inflammatory conditions (eg, systemic
lupus erythematosus, rheumatoid arthritis); or those with a history of severe
asthma, eczema, or other atopic allergy.
 IV iron should not be used during pregnancy unless clearly necessary.
Treatment should be confined to the 2nd or 3rd trimesters, if the benefit is
clearly judged to outweigh the potential risks for both mother and foetus;
 Parenteral iron should only be administered by appropriately trained staff.
 Caution is needed with every dose of IV iron that is given, even if previous
administrations have been well tolerated. A test dose is no longer
recommended as it may give false reassurance because hypersensitivity
reactions have been reported in patients that had a negative initial test dose.
 Patients should be closely monitored for signs of hypersensitivity during and
for at least 30 minutes after every administration of an IV iron product
 In the event of a hypersensitivity reaction, treatment should be stopped
immediately and appropriate management initiated.
For further information, see Drug Safety Update, August 2013
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function (Ctrl+F).
Ferric carboxymaltose (Ferinject®)
Ampoules: 100 mg/2 mL
See SPC for administration and dosing advice
Iron dextran (CosmoFer®)
Ampoules: 100 mg/2 mL
See SPC for administration and dosing advice
Iron isomaltoside 1000 (Monofer®)
Ampoules: 100 mg/5 mL
See SPC for administration and dosing advice
9.1.2 Drugs used in megaloblastic anaemias
Folic acid
Tablets: 400 micrograms, 5 mg
Solution: 2.5 mg/5 mL
Hydroxocobalamin
Injection: 1000 micrograms
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
9.1.3 Drugs used in hypoplastic, haemolytic, and renal anaemias
MHRA/CHM advice
Erythropoietins - haemoglobin concentration (December 2007)
Overcorrection of haemoglobin concentration in patients with chronic kidney disease
may increase the risk of death and serious cardiovascular events, and in patients
with cancer may increase the risk of thrombosis and related complications:

erythropoietins should not be treated in patients with chronic kidney disease or
those receiving chemotherapy unless symptoms of anaemia are present;

the haemoglobin should be maintained within the range 10–12 g/100 mL;
avoid concentrations higher than 12 g/100 mL.

the aim of treatment is to relieve symptoms of anaemia; the haemoglobin
concentration should not be increased beyond that which provides adequate
control of symptoms of anaemia (in some patients, this may be achieved at
concentrations lower than the recommended range).
MHRA/CHM advice
Erythropoietins - tumour progression and survival in patients with cancer
(December 2007 and July 2008)
Clinical trial data show an unexplained excess mortality and increased risk of tumour
progression in patients with anaemia associated with cancer that has been treated
with erythropoietins. Many of these trials used erythropoietins outside of the licensed
indications (i.e. overcorrected haemoglobin concentration or given to patients who
have not received chemotherapy):

erythropoietins licensed for the treatment of symptomatic anaemia associated
with cancer, are licensed only for patients who are receiving chemotherapy;

the decision to use erythropoietins should be based on an assessment of the
benefits and risks for individual patients; blood transfusion may be the
preferred treatment for anaemia associated with cancer chemotherapy,
particularly in those with a good cancer prognosis.
See Drug Safety Update, August 2008
CSM advice (pure red cell aplasia)
There have been very rare reports of pure red cell aplasia in patients treated with
erythropoietins. In patients who develop a lack of efficacy with erythropoietin therapy
and with a diagnosis of pure red cell aplasia, treatment with erythropoietins must be
discontinued and testing for erythropoietin antibodies considered. Patients who
develop pure red cell aplasia should not be switched to another form of
erythropoietin.
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Erythropoietins
Erythropoietin
Pre-filled syringes: 2,000 Units, 3,000 Units, 4,000 Units, 5,000 Units, 10,000 Units
Methoxy polyethylene glycol-epoetin beta
Pre-filled syringes: 30 micrograms/0.3 mL, 50 micrograms/0.3 mL, 75 micrograms/0.3
mL, 100 micrograms/0.3 mL, 120 micrograms/0.3 mL, 150 micrograms/0.3 mL, 200
micrograms/0.3 mL, 250 micrograms/0.3 mL, 360 micrograms/0.6 mL
Iron Overload
Desferasirox
Dispersible Tablets: 125 mg, 250 mg, 500 mg
Desferrioxamine mesilate
Injection: 500 mg, 2 g
9.1.4 Drugs used in platelet disorders
Anagrelide
Capsules: 500 micrograms
Cardiovascular risk associated with anagrelide regardless of previous medical history, and anagrelide
only is indicated as second line therapy (January 2013).
Eltrombopag
Tablets: 25 mg, 50 mg
Romiplostin
Injection: 250 micrograms
Available through a managed pathway.
9.1.5 G6PD deficiency
Individuals with glucose 6-phosphate dehydrogenase (G6PD) deficiency are
susceptible to developing acute haemolytic anaemia on taking a number of common
drugs – see BNF for advice Adult or Children.
9.1.6 Drugs used in neutropenia
Filgrastim
Injection: 30 million-units (300 micrograms)
Pegfilgastim (Neulasta®)
Pre-filled syringe: 10 mg/ mL, 0.6 mL (6 mg)
Lenograstim
Injection: 13.4 million-unit (105 micrograms), 33.6 million-unit (263 micrograms)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
9.1.7 Drugs used to mobilize stem cells
Plerixafor
Injection: 24 mg/1.2 mL
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Medicines in the formulary are listed in chapters and subsections that generally
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function (Ctrl+F).
9.2 FLUIDS AND ELECTROLYTES
Adult - see the BNF for further information
Children – see BNFC for further information
9.2.1 Oral preparations for fluid and electrolyte imbalance
9.2.1.1 Oral potassium
Potassium chloride
Effervescent tablets: equivalent to potassium 12 mmol (Sando-K®)
Syrup: equivalent to potassium1 mmol/mL (Kay-Cee-L®)
Potassium removal

Intravenous therapy is required in emergencies: see BNF (Adult or Children)
and local guidelines for advice.

Polystyrene sulphonate resins are not absorbed but exchange potassium for
calcium or sodium within the GI tract. The choice of sodium or calcium salt
depends on their relative contra-indications, such as if sodium and fluid
overload (use calcium resin) or in hypercalcaemia (use sodium resin).

Administration of regular laxatives is recommended to reduce the incidence of
faecal impaction

The resin can be given rectally if the patient is unable to take it by mouth.

Administration should be stopped when potassium levels are below 5 mmol/L.
Calcium-polystyrene-sulphonate (Calcium-Resonium®)
Powder, 300 g
Sodium-polystyrene-sulphonate (Resonium-A®)
Powder, 454 g
9.2.1.2 Oral sodium and water
Clinical assessment is important in view of the many possible causes of
hyponatraemia.
Sodium chloride
SR tablets (600mg): equivalent to sodium 10.3 mmol sodium (Slow Sodium®)
Oral Rehydration Salts
Oral powder: sachets containing sodium chloride 470 mg, potassium chloride
300 mg, disodium hydrogen citrate 530 mg, glucose 3.56 g/sachet (Dioralyte®)
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function (Ctrl+F).
9.2.1.3 Oral bicarbonate
Sodium bicarbonate
Tablets (600mg): equivalent to bicarbonate 7 mmol
9.2.2 Parenteral preparations for fluid and electrolyte imbalance
9.2.2.1 Electrolytes and water
 Solutions of electrolytes are given intravenously to meet normal fluid and
electrolyte requirements or to replenish substantial deficits or continuing
losses, when a patient is vomiting and unable to take adequate amounts by
mouth.

When IV administration is not possible, solutions may be infused
subcutaneously. This technique is known as hypodermoclysis. Absorption of
fluid subcutaneously will be quite slow and infusions will need to run more
slowly then when given IV. Normally only crystalloid solutions are used (500
mL). See local policy

Isotonic solutions may be infused safely into a peripheral vein. Solutions more
concentrated than plasma e.g. 20% glucose, should be given through an
indwelling catheter positioned in a large vein.

Clinicians should be aware that intravenous hypotonic saline (0.18%
saline/4% glucose solution) is now contraindicated in children except under
expert medical supervision in paediatric specialist settings – such as renal,
liver, cardiac, high dependency and intensive care units. Use of this solution in
children outside these conditions has resulted in several cases of
hyponatraemia, including some that were fatal

Following advice from the National Patient Safety Agency intravenous
potassium must only be administered using commercial pre-mixed solutions
unless there are exceptional circumstances. See local policy. The pharmacy
now stocks a wider range of pre-mixed potassium infusions.
See the BNF for the electrolyte content of common infusion fluids)
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function (Ctrl+F).
Table of intravenous fluids available from pharmacy
Intravenous crystalloid fluids
Sizes available
Sodium chloride 0.9% (normal saline)
50 mL, 100 mL, 250 mL, 500 mL,
1 litre
Glucose 5%
100 mL, 250 mL, 500 mL, 1 litre
Glucose (dextrose) saline (sodium chloride 0.18%, glucose 4%)
MHRA Advice (Oct 2012). There have been reports of fatal
hyponatraemia in children – do not use in children aged 16 years or less,
except in specialist settings under expert medical supervision
500 mL, 1 litre
Glucose (dextrose) saline (sodium chloride 0.45%, glucose 5%)
500 mL
Hartmann's solution (compound sodium lactate)
500 mL, 1 litre
Other saline solutions
Sodium chloride 0.18%
500 mL
Sodium chloride 0.45%
500 mL
Sodium chloride 1.8%
500 mL
Sodium chloride 2.7%
500 mL
Other glucose solutions
Glucose 10%
500 mL
Glucose 20%*
500 mL
Glucose 40%*
500 mL
Glucose 50%*
500 mL
Pre-mixed potassium infusion bags
0.15% (10 mmol) potassium chloride & 0.9% sodium chloride
500 mL
0.15% (20 mmol) potassium chloride & 0.9% sodium chloride
1 litre
0.15% (10 mmol) potassium chloride & 5% glucose
500 mL
0.15% (20 mmol) potassium chloride & 5% glucose
1 litre
0.15% (10 mmol) potassium chloride & 10% glucose
500 mL
0.15% (10 mmol) potassium chloride, 0.18% sodium chloride & 4% glucose
500 mL
0.15% (20 mmol) potassium chloride, 0.18% sodium chloride & 4% glucose
1 litre
0.15% (10 mmol) potassium chloride, 0.9% sodium chloride & 5% glucose
500 mL
0.2% (13.5 mmol) potassium chloride & 0.9% sodium chloride
500 mL
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Pre-mixed potassium infusion bags
0.2% (27 mmol) potassium chloride & 0.9% sodium chloride
1 litre
0.2% (13.5 mmol) potassium chloride & 5% glucose
500 mL
0.2% (27 mmol) potassium chloride & 5% glucose
1 litre
0.2% (13.5 mmol) potassium chloride, 0.18% sodium chloride & 4% glucose
500 mL
0.2% (27 mmol) potassium chloride, 0.18% sodium chloride & 4% glucose
1 litre
0.3% (20 mmol) potassium chloride & 0.9% sodium chloride
500 mL
0.3% (40 mmol) potassium chloride & 0.9% sodium chloride
1 litre
0.3% (20 mmol) potassium chloride & 5% glucose
500 mL
0.3% (40 mmol) potassium chloride & 5% glucose
1 litre
0.3% (20 mmol) potassium chloride & 10% glucose
500 mL
0.3% (20 mmol) potassium chloride & 20% glucose*
500 mL
0.3% (20 mmol) potassium chloride, 0.18% sodium chloride & 4% glucose
500 mL
0.3% (40 mmol) potassium chloride, 0.18% sodium chloride & 4% glucose
1 litre
0.3% (20 mmol) potassium chloride, 0.45% sodium chloride & 5% glucose
500 mL
0.3% (20 mmol) potassium chloride, 0.9% sodium chloride & 5% glucose
500 mL
0.6% (40 mmol) potassium chloride & 0.9% sodium chloride
500 mL
0.6% (40 mmol) potassium chloride & 5% glucose
500 mL
Others
Sodium bicarbonate 1.26%
500 mL
Sodium bicarbonate 4.2%
500 mL
Sodium bicarbonate 8.4%
500 mL
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function (Ctrl+F).
9.2.2.2 Plasma and plasma substitutes
Albumin solutions
Available from Blood Bank
Plasma substitutes
Gelatin
Infusion: 500 mL
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9.3 INTRAVENOUS NUTRITION
Adult - see the BNF for further information
Children – see BNFC for further information
Please refer to the pharmacy Manufacturing Unit for advice and information (ext:
41489)
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function (Ctrl+F).
9.4 ORAL NUTRITION
Adult - see the BNF for further information
Children – see BNFC for further information
General Points
 Enteral feeding should always be used in preference to TPN if the gut is
available.

Enteral feeding offers a number of advantages over parenteral feeding:
o Sterile technique is not required and the dangers associated with
the parenteral route are avoided, e.g. sepsis with central venous lines.
o Enhanced utilization of nutrients
o Ease and safety of administration
o The maintenance of gastrointestinal structure and functional integrity is
associated with small amounts of nutrients being continuously
presented to the bowel
o Enteral feeding is approximately one-tenth the cost of parenteral
feeding

Advice on enteral feeding is available from the dietitians

It is important to note that some drugs may interact with nasogastric feeds.
NO drugs should ever be mixed with feeds before administration. In addition,
there may be an interaction following ingestion. For information, please
contact your ward pharmacist or dietician, or the Medicines Information
Centre.
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9.5 MINERALS
Adult - see the BNF for further information
Children – see BNFC for further information
9.5.1 Calcium and magnesium
9.5.1.1 Calcium supplements
Oral
Calcium salts
Chewable tablets (as carbonate1.5g): equivalent to calcium 600 mg, 15 mmol
(Adcal®)
Effervescent tablets: equivalent to calcium 1 g, 25 mmol (Sandocal1000®)
Syrup (per 5 mL): equivalent to calcium 108.3 mg, 2.7 mmol (Calcium-Sandoz®)
Parenteral
Calcium chloride
Injection: equivalent to calcium 5 mmol/10 mL
Injection: equivalent to calcium10 mmol/10 mL
Calcium gluconate
Injection: 10%, equivalent to calcium 2.26 mmol/10 mL
9.5.1.2 Hypercalcaemia and hypercalciuria
Alfacalcidol
Capsules: 0.25 micrograms, 1 microgram
Solution: 2 micrograms /1 mL
Injection: 2 micrograms/1 mL
Cinacalcet (Mimpara®)
Tablets: 30 mg, 60 mg, 90 mg
Paricalcitol (Zemplar®)
Capsules: 1 microgram, 2 micrograms, 4 micrograms
Injection: 5 micrograms/1 mL
9.5.1.3 Magnesium
Oral
Magnesium glycerophosphate
Chewable tablets (1 g): equivalent to magnesium 4 mmol; also contains phosphate 4
mmol. Unlicensed ‘Special’
Liquid (per 5 mL): equivalent to magnesium 5 mmol; also contains phosphate 5 mmol
unlicensed ‘Special’
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Parenteral
Magnesium sulphate
Injection: 10%, equivalent to magnesium 4 mmol/10 mL
Injection: 50%, equivalent to magnesium 4 mmol/2 mL and 20 mmol/10 mL
9.5.2 Phosphorous
9.5.2.1 Phosphate supplements
Oral
Effervescent tablets: equivalent to phosphorus 500 mg, 16.1 mmol; sodium
468.8 mg, 20.4 mmol; potassium 123 mg, 3.1 mmol (Phosphate-Sandoz®)
Liquid (per 1 mL): equivalent to phosphate 1 mmol; 100 mL. Unlicensed ‘Special’
Parenteral
Phosphates
Intravenous infusion (500 mL): equivalent to phosphate 50 mmol, potassium
9.5 mmol, and sodium+ 81 mmol
9.5.2.2 Phosphate-binding agents
Calcium salts
Tablets (as carbonate): 1.5 g, (Adcal®)
Tablets (as acetate): 1 g, (Phosex®)
Capsules (as acetate): 667 mg, (PhosLo®)
Calcium/Magnesium salts
Tablets: calcium acetate and magnesium carbonate 435|235 mg tablets (Ovasren®)
Lanthanum (Fosrenol®)
Tablets: 750 mg (as carbonate hydrate)
Sevelamer hydrochloride (Renagel®)
Tablets: 800 mg
Sevelamer carbonate (Renvela®)
Powder for oral suspension: 2.4 g
9.5.3 Fluoride
No preparations
9.5.4 Zinc
Zinc sulphate
Effervescent tablets (125 mg): equivalent to zinc 45 mg (Solvazinc®)
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function (Ctrl+F).
9.5.5 Selenium
Selenium
Tablets: 200 micrograms
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9.6 VITAMIN PREPARATIONS
Adult - see the BNF for further information
Children – see BNFC for further information
9.6.1 Vitamin A
Vitamins A and D capsules BPC
(Each contains 4000 units vitamin A, 400 units vitamin D)
U Vitamin A drops
9.6.2 Vitamin B group
Oral
Pyridoxine
Tablets: 10 mg, 50 mg
Thiamine
Tablets: 50 mg, 100 mg
Parenteral
Vitamins B + C (Pabrinex® High Potency IV and IM)
IM High Potency Injection: ascorbic acid 500 mg, nicotinamide 160 mg, pyridoxine hydrochloride 50
mg, riboflavin 4 mg, thiamine hydrochloride 250 mg/7 mL.
IV High Potency Injection: ascorbic acid 500 mg, anhydrous glucose 1 g, nicotinamide 160 mg,
pyridoxine hydrochloride 50 mg, riboflavin 4 mg, thiamine hydrochloride 250 mg/10 mL.
MHRA/CHM advice (September 2007)
Although potentially serious allergic adverse reactions may rarely occur during, or
shortly after, parenteral administration, the CHM has recommended that:
1. Use be restricted to patients in whom parenteral treatment is essential;
2. Intravenous administration should be by infusion over 30 minutes;
3. Facilities for treating anaphylaxis (including resuscitation facilities) should be
available when parenteral thiamine is administered.
See Drug Safety Update, September 2007
Combination preparations
Vitamin B Compound (Strong)
Tablets: nicotinamide 20 mg, pyridoxine hydrochloride 2 mg, riboflavin 2 mg, thiamine hydrochloride
5 mg
9.6.3 Vitamin C (ascorbic acid)
Ascorbic acid
Tablets: 200 mg, 500 mg
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correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
9.6.4 Vitamin D
Alfacalcidol
Capsules: 0.25 micrograms, 1 microgram
Solution: 2 micrograms /1 mL
Calcitriol
Capsules: 0.25 micrograms
Colecalciferol
UCapsules: 20,000 units (not licensed/the UK)
UOral drops: 1,000 units/1 mL, 10 mL (not licensed/the UK)
Some unlicensed preparations may contain peanut and soya oil.
Combined with calcium
Brand depends upon contracts; see the relevant BNF for details of products available
Ergocalciferol
Injection: 300,000 units/1 mL, 600,000 units/2 mL
9.6.5 Vitamin E (tocopherols)
Alpha tocopheryl acetate
Tablets: 50 mg, 200 mg
Suspension: 500 mg/5 mL
9.6.6 Vitamin K
Menadiol sodium phosphate
Tablets: 10 mg
Phytomenadione
UTablets: 10 mg. This preparation is not licensed in the UK
Oral capsules: 1 mg
Oral drops: 50 micrograms/0.25 mL, 25 mL
Injection: 10 mg/1 mL (Konakion® MM), 2 mg/0.2 mL (Konakion® MM Paediatric)
(NB Konakion® MM Paediatric can be given orally)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
9.6.7 Multivitamin preparations
Vitamins
Capsules
Abidec® drops
Ketovite®
Tablets: and liquid
Vitamin A
Vitamin B
Group
Vitamin C
Vitamin D
Vitamin E
Vitamin K
Others
Retinol
Palmitate
Vitamin B1
(Thiamine)
Vitamin B2
(Riboflavin)
Vitamin B6
(Pyridoxine)
Vitamin B12
(Cyanocobalamin)
Biotin
Inositol
Nicotinamide
Ascorbic acid
Ergocalciferol
Alpha-tocopheryl
acetate
Acetomenaphthone
Choline chloride
Folic acid
ABIDEC®
DROPS
(per 0.6
mL)
1,333 units
VITAMINS
CAPSULES
(per capsule)
KETOVITE®
TABLETS:
(per tablet)
KETOVITE®
LIQUID
(per 5 mL)
2,500 units
2,500 units
0.4 mg
1 mg
1 mg
0.8 mg
0.5 mg
1 mg
0.8 mg
0.33 mg
12.5
microgram
8 mg
40 mg
400 units
7.5 mg
15 mg
300 units
0.17 mg
50 mg
3.33 mg
16.6 mg
400 units
5 mg
0.5 mg
150 mg
0.25 mg
Renavit® (ACBS)
Tablets: 450 mg
ACBS Indications Dietary management of water-soluble vitamin deficiency in adults with renal failure
on dialysis
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correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
9.7 BITTERS AND TONICS
Adult - see the BNF for further information
No preparations
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
9.8 METABOLIC DISORDERS
Adult - see the BNF for further information
Children – see BNFC for further information
9.8.1 Drugs used in metabolic disorders
Please refer to the relevant BNF for general information and to the relevant
Specialists for specific advice.
9.8.2 Acute porphyrias
Adult - see the BNF for further information
Children – see BNFC for further information
The Welsh Medicines Information Centre (WMIC) offers a specialist advisory service
on the safe use of drugs in porphyria which includes a ‘drug safety’ list (link to
website).
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correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
10. MUSCULOSKELETAL AND JOINT DISEASES
Local guidance
Trust guidelines for prophylaxis of musculoskeletal and joint infections:
link to guidelines
Trust guidelines for treatment of musculoskeletal and joint infections:: link to guidelines
NHS South of Tyne and Wear Policy for the Use of Cytokine Modulators in
Rheumatoid Arthritis - Link
National guidance
NICE Clinical Guidance (CG)
Osteoarthritis - the care and management of osteoarthritis in adults, February 2008
(CG59)
www.nice.org.uk/Guidance/CG59 (Quick Reference guide)
The North West Medicines Information Service produce summaries of NICE
guidance (NICE Bites) – Bulletin No. 2 (Feb 2009) summarises the key prescribing
points from NICE guidance (CG59) for the treatment of osteoarthritis.
Rheumatoid arthritis - the management of rheumatoid arthritis in adults, February
2009 (CG79)
www.nice.org.uk/Guidance/CG79 (Quick Reference guide)
The North West Medicines Information Service produce summaries of NICE
guidance (NICE Bites) – Bulletin No. 3 (March 2009) summarises the key prescribing
points from NICE guidance (CG79) for the treatment of rheumatoid arthritis. See
Bulletin No. 39 (March 20120 for an update.
NICE Technology Appraisal (TA)
A list of published Technical Appraisals which is searchable can be found on the
NICE website: http://www.nice.org.uk/Guidance/TA/Published
Alternatively, a table of all the TA recommendations can be viewed or printed as a
Word document: Full table of TA recommendations.
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
10.1 DRUGS USED IN RHEUMATIC DISEASES AND GOUT
Adult - see the BNF for further information
Children – see BNFC for further information
10.1.1 Non-steroidal anti-inflammatory drugs (NSAIDs)
NSAIDs and cardiovascular events
All NSAID use (including cyclo-oxygenase-2 selective inhibitors) can, to varying
degrees, be associated with a small increased risk of thrombotic events (e.g.
myocardial infarction and stroke) independent of baseline cardiovascular risk factors
or duration of NSAID use; however, the greatest risk may be in those receiving high
doses long term.
Cyclo-oxygenase-2 selective inhibitors, diclofenac (150 mg daily) and ibuprofen
(2.4 g daily) are associated with an increased risk of thrombotic events. Available data
indicate that the cardiovascular risk with diclofenac is similar to that of the selective
COX-2 inhibitors. Consequently, diclofenac is now contraindicated in those with:
ischaemic heart disease; peripheral arterial disease; cerebrovascular disease; and
established congestive heart failure (New York Heart Association [NYHA]
classification II–IV). Diclofenac treatment should only be initiated after careful
consideration for patients with significant risk factors for cardiovascular events (e.g.,
hypertension, hyperlipidaemia, diabetes mellitus, and smoking).
Naproxen (1 g daily) is associated with a lower thrombotic risk, and low doses of
ibuprofen (1.2 g daily or less) have not been associated with an increased risk of
myocardial infarction.
NSAIDs and gastro-intestinal events
All NSAIDs are associated with serious gastro-intestinal toxicity; the risk is higher in
the elderly. Evidence on the relative safety of non-selective NSAIDs indicates
differences in the risks of serious upper gastro-intestinal side-effects—piroxicam (see
also CHMP advice), ketoprofen, and ketorolac are associated with the highest risk;
indometacin, diclofenac, and naproxen are associated with intermediate risk, and
ibuprofen with the lowest risk (although high doses of ibuprofen have been associated
with intermediate risk). Selective inhibitors of cyclo-oxygenase-2 are associated
with a lower risk of serious upper gastro-intestinal side-effects than non-selective
NSAIDs.
Recommendations are that NSAIDs associated with a low risk e.g. ibuprofen are
generally preferred, to start at the lowest recommended dose and not to use more
than one oral NSAID at a time. See also Cautions and Contra-indications.
The combination of a NSAID and low-dose aspirin can increase the risk of gastrointestinal side-effects; this combination should be used only if absolutely necessary
and the patient should be monitored closely.
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function (Ctrl+F).
Asthma - CSM warning:
Any degree of worsening of asthma may be related to the ingestion of NSAIDs, either
prescribed or (in the case of ibuprofen and others) purchased over the counter
Renal Impairment - MHRA warning:
Patients at risk of renal impairment or renal failure (particularly elderly people) should
avoid NSAIDs if possible. If NSAID treatment is necessary, then the lowest effective
dose for the shortest possible duration should be used to control symptoms. The renal
function of such patients should be carefully monitored during NSAID treatment.
It is important to consider other concomitant disease states, conditions, or medicines
that may precipitate reduced renal function when prescribing NSAIDs.
GENERAL ADVICE ON PRESCRIBING NSAIDS AND COXIBS

The lowest effective dose of NSAID or coxib should be prescribed for the
shortest time necessary for control of symptoms. The need for long-term
treatment should be reviewed periodically.

Not to use more than one oral NSAID at a time and ALL NSAIDs are
contraindicated in patients with peptic ulceration.

Prescribing should be based on the safety profiles of individual preparations
and on an assessment of a patient’s individual risk factors, including any
history of cardiovascular and gastrointestinal illness

Prescribers should not switch between NSAIDs without careful
consideration of the overall safety profile of the products, a patient’s individual
risk factors, and patient preference.

Concomitant aspirin (and possibly other antiplatelet drugs) greatly
increase the gastrointestinal risks of NSAIDs and severely reduce any
gastrointestinal safety advantages of coxibs. Aspirin should only be coprescribed if necessary.
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Celecoxib
Capsules: 100 mg, 200 mg
Diclofenac sodium
PTablets: EC: 25 mg, 50 mg
Tablets: soluble: 50 mg
Tablets SR: 75 mg
Suppositories: 12.5 mg, 25 mg, 50 mg, 100 mg
Injection: 75 mg/3 mL
Etodolac
Capsule: 300 mg
Tablet SR: 600 mg
PIbuprofen
Tablet: 200 mg, 400 mg, 600 mg
Suspension: 100 mg/5 mL
Indometacin
Capsules: 25 mg, 50 mg
Capsules SR: 75 mg
Suppository: 100 mg
Mefenamic acid
Capsule: 250 mg
Tablet: 500 mg
Suspension: 50 mg/5 mL
PNaproxen
Tablets: 250 mg, 500 mg
Suspension: 125 mg/5 mL (available as a ‘Special’)
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correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
10.1.2 Corticosteroids
10.1.2.1 Systemic corticosteroids
See Section 6.3
10.1.2.2 Local corticosteroid injections
Corticosteroids are injected locally for an anti-inflammatory by intra-articular injection
to relieve pain, increase mobility, and reduce deformity in one or a few joints.
Training is necessary to be able to give injections by the intra-articular route. They
must only be administered by properly trained staff.
Dexamethasone
Injection: (as sodium phosphate) 3.3 mg/1 mL, 6.6 mg/2 mL
Hydrocortisone acetate
Injection: 25 mg/1 mL (Hydrocortistab®)
Methylprednisolone acetate
Injection: 40 mg/1 mL, 80 mg/2 mL, 120 mg/3 mL (DepoMedrone®)
Injection: (with lidocaine, 2 mL ampoule): 80 mg + lidocaine 20 mg (DepoMedrone
with lidocaine®)
Prednisolone acetate
Injection: 25 mg/1 mL (Deltastab®)
Triamcinolone acetonide
Injection: 10 mg/1 mL, 50 mg/5 mL (Adcortyl®)
Injection: 40 mg/1 mL (Kenalog®)
Pre-filled syringe: 40 mg/1 mL, 80 mg/2 mL (Kenalog®)
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function (Ctrl+F).
10.1.3 Drugs which suppress the rheumatic disease process
Initiation of these drugs should be under advice of the Rheumatologists. Careful
monitoring is required
Methotrexate
Important
Note that the above dose is a weekly dose. To avoid error with low-dose
methotrexate, it is recommended that:
 the patient is carefully advised of the dose and frequency and the reason for
taking methotrexate and any other prescribed medicine (e.g. folic acid);
 only one strength of methotrexate tablet (usually 2.5 mg) is prescribed and
dispensed;
 the prescription and the dispensing label clearly show the dose and frequency
of methotrexate administration;
 the patient is warned to report immediately the onset of any feature of blood
disorders (e.g. sore throat, bruising, and mouth ulcers), liver toxicity (e.g.
nausea, vomiting, abdominal discomfort, and dark urine), and respiratory
effects (e.g. shortness of breath).
See also the National Patient Safety Agency guidance and the BNF.
CSM advice
In view of reports of blood dyscrasias (including fatalities) and liver cirrhosis with lowdose methotrexate, the CSM has advised:
 full blood count and renal and liver function tests before starting treatment and
repeated weekly until therapy stabilised, thereafter patients should be
monitored every 2–3 months
 that patients should be advised to report all symptoms and signs suggestive of
infection, especially sore throat
Methotrexate
Tablets: 2.5 mg
Injection: contact pharmacy for advice
Gold
Sodium aurothiomalate
Injection: 10 mg/0.5 mL, 20 mg/0.5 mL, 50 mg/0.5 mL
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Antimalarials
To avoid excessive doses in obese people, doses of hydroxychloroquine should be
calculated on the basis of ideal body weight - calculators
A review group convened by the Royal College of Ophthalmologists has updated
guidelines for screening to prevent ocular toxicity on long term treatment with
chloroquine, hydroxychloroquine, and mepacrine See: Royal College of
Ophthalmologists guidance – October 2009.
Chloroquine
Tablets: 150 mg
Hydroxychloroquine sulphate
Tablets: 200 mg
Drugs affecting the immune response
 Thiopurine drugs (azathioprine, 6-mercaptopurine and thioguanine) are
converted in vivo to provide the therapeutic effect. TPMT provides the major
catabolic pathway for these drugs. If the enzyme is absent then there is a risk
of toxicity resulting in severe bone marrow depression. Complete deficiency of
TPMT occurs in 1:300 Caucasians (it is also known in patients of African
origin). Partial deficiency occurs in more than 1:10.

Ciclosporin should be prescribed and dispensed by brand name. Ciclosporin is
a critical-dose drug with a narrow therapeutic index. Patients should be
stabilised on a single brand of ciclosporin because switching between
formulations without close monitoring may lead to clinically important changes
in bioavailability. All products that contain ciclosporin are interchangeable only
if careful therapeutic monitoring takes place.

Leflunomide has an active metabolite with a very long half life which needs to
be actively removed (using colestyramine or activated charcoal) if there are
serious adverse effects, before starting other DMARDs or before conception.

Hepatotoxicity can occur with leflunomide (potentially life threatening) in the
first 6 months of treatment. Monitor LFTs before treatment and every 2 weeks
for the first 6 months then every 8 weeks.
Azathioprine
Tablets: 25 mg, 50 mg
Ciclosporin
Capsules: 10 mg, 50 mg, 100 mg
Oral solution: 100 mg/ mL
Leflunomide
Tablets: 10 mg, 20 mg, 100 mg
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correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Cytokine modulators
Abatacept
Injection: 250 mg
Available through a managed pathway.
Adalimumab
Pre-filled syringe: 40 mg
Certolizumab pegol
Pre-filled syringe: 200 mg
Available through a managed pathway.
Etanercept
Injection: 25 mg, 50 mg
Golimumab
Injection: 50 mg
For psoriatic arthritis
Infliximab
Injection: 100 mg
Rituximab
Concentrate for intravenous infusion: 100 mg/10 mL, 500 mg/50 mL
Tocilizumab
Concentrate for intravenous infusion: 80 mg/4 mL, 200 mg/20 mL
Others
Penicillamine
Tablets: 125 mg, 250 mg
Sulfasalazine
EC Tablets: 500 mg
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correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
10.1.4 Gout and cytotoxic-induced hyperuricaemia
Acute attacks
PColchicine
Tablets: 500 micrograms
PIndometacin
Capsules: 25 mg, 50 mg
Long-term control of gout
PAllopurinol
Tablets: 100 mg, 300 mg
Febuxostat
Tablets: 80 mg, 120 mg
Febuxostat: stop treatment if signs or symptoms of serious hypersensitivity (eg, serious skin
reactions or systemic hypersensitivity) occur. See Drug Safety Update, June 2012.
Hyperuricaemia associated with cytotoxic drugs
Allopurinol
Tablets: 100 mg, 300 mg
Rasburicase
Vial for infusion: 1.5 mg, 7.5 mg
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correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
10.2 DRUGS USED IN NEUROMUSCULAR DISORDERS
Adult - see the BNF for further information
Children – see BNFC for further information
10.2.1 Drugs which enhance neuromuscular transmission
Neostigmine
Tablets: 15 mg
Injection: 2.5 mg/1 mL
Edrophonium chloride
Injection: 10 mg/1 mL
Pyridostigmine bromide
Tablets: 60 mg
10.2 2 Skeletal muscle relaxants
PBaclofen
Tablets: 10 mg
Oral solution: 5 mg/5 mL
Abrupt withdrawal of baclofen may precipitate serious side effects and the CSM advise gradual
discontinuation of the drug over one to two weeks.
Dantrolene sodium
Capsules: 25 mg, 100 mg
Diazepam
Tablets: 2 mg, 5 mg, 10 mg
Oral solution: 2 mg/5 mL, 5 mg/5 mL
Tizanidine
Tablets: 2 mg, 4 mg
Nocturnal Leg Cramps
 Quinine has been used in the UK for the treatment of nocturnal leg cramps for
many years. Although patient response may vary, overall efficacy is modest;
the frequency of nocturnal leg cramps is reduced by about 20-25% in
ambulatory patients - around one episode a week difference.

The MHRA advises that quinine is not a routine treatment for nocturnal leg
cramps and should only be used if cramps cause regular disruption of sleep.

Consider quinine only when cramps are very painful or frequent; when other
treatable causes of cramp have been ruled out, and when nonpharmacological measures have not worked, (e.g. passive stretching
exercises). After an initial trial of 4 weeks, treatment should be stopped if there
is no benefit.
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correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).

Initially patients should be monitored closely for adverse effects as well as
benefit. Treatment should be interrupted at 3-monthly intervals to assess the
need for further quinine. In patients taking quinine long-term, a trial
discontinuation may be considered.
Adverse events may include tinnitus, impaired hearing, headache, nausea,
disturbed vision, confusion, flushing, and abdominal pain.
A rarer but more serious adverse reaction is thrombocytopenia, thought to be a
hypersensitivity reaction. Patients should be instructed to stop treatment and
consult a physician if signs of thrombocytopenia occur, such as unexplained
petechiae, bruising or bleeding.
Quinine has a number of potentially significant drug interactions, including
with digoxin and warfarin. It also has significant toxicity in overdose, which
can result in death or permanent visual loss.
For more information on the use of quinine for nocturnal leg cramps, see
Drug Safety Update, June 2010.
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correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
10.3 DRUGS FOR THE TREATMENT OF SOFT-TISSUE DISORDERS AND
TOPICAL PAIN RELIEF
Adult - see the BNF for further information
10.3 1 Enzymes
SCollagenese
Vial: Clostridium histolyticum, 900 micrograms (with solvent) – Xiapex®
Clinicians must be trained and registered with the company before supply can be made
10.3 2 Rubefacients, topical NSAIDs, capsaicin, and poultices
Topical NSAIDs
Piroxicam
Gel: 0.5%, 60 g
Capsaicin
Capsaicin
Cream: 0.025% (Zacin®)
Cream: 0.075% (Axsain®)
Poultices
No preparations
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11. EYE
Local guidance
Trust guidelines for prophylaxis of eye infections: link to guidelines
Trust guidelines for treatment of eye infections: link to guidelines
National guidance
NICE Clinical Guidancel (CG)
Glaucoma: diagnosis and management of chronic open angle glaucoma and ocular
hypertension, April 2009 (CG85)
http://www.nice.org.uk/Guidance/CG85 (Quick Reference guide)
The North West Medicines Information Service produce summaries of NICE
guidance (NICE Bites) – Bulletin No. 5 (page 2) (May 2009) summarises the key
prescribing points from NICE guidance (CG85) for the treatment of glaucoma.
NICE Technology Appraisal (TA)
A list of published Technical Appraisals which is searchable can be found on the
NICE website: http://www.nice.org.uk/Guidance/TA/Published
Alternatively, a table of all the TA recommendations can be viewed or printed as a
Word document: Full table of TA recommendations.
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
11.1 ADMINISTRATION OF DRUGS TO THE EYE
Adult - see BNF for further information
Children – see BNFC for further information

Drugs are most commonly administered to the eye by topical application as
eye drops or eye ointments.

Eye drops are usually preferable for daytime use, as they are convenient to
apply and do not blur vision.

The conjunctival sac can normally accommodate volumes of between 7 and
30L. Volumes in excess of this can be systematically absorbed which may give
rise to adverse effects. It is therefore important to instil only one drop at a time.

If two or more sets of eye drops are to be administered at the same time, dilution
and overflow can occur. A few minutes should be left between applications to
minimise this effect. Drops, which sting, should normally be used last as these
cause reflex tear secretion that may reduce the effectiveness of subsequent
instillations.

Eye ointments remain in contact with the conjunctiva or eyelid for long periods
resulting in good levels of drug within the eye. They are, therefore, useful for
night-time therapy. The ointment base also helps to soften crusts in infectious
conditions such as blepharitis and bland ointments can be used to lubricate and
protect the eye. Because of the film that they form, ointments can blur vision and
may be unsuitable for daytime use.

Eye ointments are applied by placing approximately 0.5-1cm ribbon of the
ointment to the inside of the lower lid.

Patients should be warned not to drive or perform other skilled tasks until
vision is clear after using eye drops or eye ointments.

Contact lenses should not generally be worn while using eye drops containing
preservatives, or eye ointments. For further information see the BNF Adult or
Children.
Preservatives
 Various preservatives are used in multidose eye drops. These may be a source
of hypersensitivity reactions. Frequent use of preserved drops can cause toxic
keratopathy.

Minims® are available for many preparations (preservative free bottles are
available also from Moorfields Eye Hospital and other special manufacturers).
They are obviously more expensive, but are very useful in those patients in
whom you suspect sensitivities or allergies to preservatives, for use during or
after surgery, or for patients who wear soft contact lenses. Preservative free
drops are recommended for intensive application (e.g. hourly).
Order of instillation
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correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).

In the case of multiple therapy, it is recommended to leave a minimum of 3
minutes between instilling drops .The order in which different drops are instilled
is not particularly important. Drops that sting should normally be used last as
these cause reflex tear secretion, which may reduce the effectiveness of
subsequent eye drops.

Where ointments and drops are used together, ointments are put in after drops.
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correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
11.2 CONTROL OF MICROBIAL CONTAMINATION
Adult - see BNF for further information
Children – see BNFC for further information
Eye drops in multi-use containers should be discarded 4 weeks after opening to
avoid contamination. Note: preservative-free preparations may be single-use only or
to be discarded 1 week after opening. It is not generally necessary to use separate
bottles for each eye (except immediately after eye surgery), but care should be taken
to avoid touching the eye(s) during use to avoid contamination. Most drops do not
need to be kept in a fridge, unless directed otherwise.
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correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
11.3 ANTI-INFECTIVE EYE PREPARATIONS
Adult - see BNF for further information
Children – see BNFC for further information
Specialist drugs (not listed here) are restricted for use at the Eye Infirmary only as
these should only be used under the guidance of a specialist.
Contact the pharmacy for information on the drugs available:
Internal: 46257
External: 0191 565 6256 ext 46257
Local guidance
See CHS policy for the treatment of Conjunctivitis
11.3.1 Antibacterials
Azithromycin dihydrate
Eye drops: 1.5% (single use)
PChloramphenicol
Eye drops: 0.5%
Eye ointment: 1%
Minims®: 0.5%
Ciprofloxacin
Eye drops: 0.3%
Eye ointment (preservative-free): 0.3%
Fusidic acid
Eye drops: 1%
Gentamicin
Eye drops: 0.3%, 1.5%
Minims: 0.3%
Eye drops (preservative free): 0.3%, 1.5% - special available from Moorfields
Levofloxacin
Eye drops: 0.5%
Unit dose eye drops: 0.5%
Moxifloxacin
Eye drops: 0.5%
Polymixin B sulphate
Eye ointment: polymyxin B sulphate 10 000 units/g, bacitracin zinc 500 units/g
(Polyfax®)
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Medicines in the formulary are listed in chapters and subsections that generally
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function (Ctrl+F).
11.3.2 Antifungals
No preparations
11.3.3 Antivirals
PAciclovir
Eye ointment: 3%
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correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
11.4 CORTICOSTEROIDS AND OTHER ANTI-INFLAMMATORY PREPARATIONS
Adult - see BNF for further information
Children – see BNFC for further information
Specialist drugs (not listed here) are restricted for use at the Eye Infirmary only as
these should only be used under the guidance of a specialist.
Contact the pharmacy for information on the drugs available:
Internal: 46257
External: 0191 565 6256 ext 46257
11.4.1 Corticosteroids
Betamethasone
Eye drops: 0.1%
With neomycin: betamethasone0.1%, neomycin sulphate 0.5%
Eye ointment: 0.1%
With neomycin: betamethasone0.1%, neomycin sulphate 0.5%
Dexamethasone
Eye drops: 0.1%
With antibacterials: dexamethasone 0.1%, neomycin 0.35%, polymyxin B sulphate
6000 units/ mL (Maxitrol®)
With antibacterials: dexamethasone 0.05%, framycetin 0.5%, gramicidin 0.005%.
(Sofradex®)
Fluorometholone
Eye drops: 0.1%
Loteprednol etabonate
Eye drops: 0.5%
Prednisolone
Eye drops: 0.003%, 0.01%, 0.03%, 0.1% and 0.3% - specials from Moorfields
Eye drops (preservative free): 0.01%, 0.03%, 0.1% and 0.3% - specials from
Moorfields
Eye drops: 0.5%, 1%
Minims® (preservative free): 0.5%
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function (Ctrl+F).
Intravitreal corticosteroids
SDexamethasone
Intravitreal implant: 700 micrograms
Available through a managed pathway according to a NETAG protocol.
11.4.2 Other anti-inflammatory preparations
Emedastine
Eye drops: 0.05%
Lodoxamide
Eye drops: 0.1%
Nedocromil sodium
Eye drops: 2%
Olopatadine
Eye drops: 1 mg/ mL
PSodium cromoglicate
Eye drops: 4%
Eye drops (preservative free): 4%- special from Moorfields
Minims® (preservative free): 4%
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11.5 MYDRIATICS AND CYCLOPLEGICS
Adult - see BNF for further information
Children – see BNFC for further information
Antimuscarinics
Atropine Sulphate
Eye drops: 1%
Eye drops (preservative free): 1%- special from Moorfields
Minims® (preservative free): 4%
Eye ointment: 1%
Cyclopentolate hydrochloride
Eye drops: 0.5%, 1%
Minims® (preservative free): 0.5%, 1%
With phenylephrine
Eye drops (preservative free): 1%- special available from SRH
Tropicamide
Eye drops: 0.5%, 1%
Minims® (preservative free): 0.5%, 1%
Sympathomimetics
Phenylephrine hydrochloride
Eye drops: 2.5%
Minims® (preservative free): 2.5%, 10%
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11.6 TREATMENT OF GLAUCOMA
Adult - see BNF for further information
Children – see BNFC for further information
The CSM has advised that all beta-blockers including those with cardioselectivity
should not be used in patients with asthma or obstructive airways disease unless no
other treatment is available. In such cases, the risk of inducing bronchospasm
should be appreciated and appropriate precautions taken.
Beta-blockers
Betaxolol hydrochloride
Eye drops: 0.25%, 0.5%
Carteolol hydrochloride
Eye Drops: 1%, 2%
Levobunolol hydrochloride
Eye drops: 0.5%
Timolol maleate
Eye drops: 0.25%, 0.5%
Eye drops (once daily): 0.25%, 0.5%
Minims® (preservative free): 0.25%, 0.5%
Carbonic anhydrase inhibitors and systemic drugs
Systemic
Acetazolamide
Tablets: 250 mg
Capsules, MR: 250 mg
Injection: 500 mg vial
Topical
Brinzolamide
Eye drops: 10 mg/mL
With timolol
Eye drops: brinzolamide 10 mg, timolol 5 mg/mL (Azarga®)
Dorzolamide
Eye drops: 2%
Single use (preservative free): 2%
With timolol
Eye drops: dorzolamide 2%, timolol 0.5% (Cosopt®)
Single use (preservative free): dorzolamide 2%, timolol 0.5% (Cosopt®)
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Miotics
Pilocarpine
Eye drops: 0.5%, 1%, 2%, 3%, 4%, 6%
Minims® (preservative free): 2%, 4%
Gel (long acting): 4% (Pilogel®)
Prostaglandin analogues and prostamides
Bimatoprost
Eye drops: 300 micrograms/ mL
With timolol
Eye drops: bimatoprost 300 micrograms, timolol 5 mg/mL (Ganfort®)
Latanoprost
Eye drops: 50 micrograms/mL
With timolol
Eye drops: latanoprost 50 micrograms, timolol 5 mg/mL (Xalacom®)
Travoprost
Eye drops: 40 micrograms/ mL
With timolol
Eye drops: travoprost 50 micrograms, timolol 5 mg/mL (DuoTrav®)
Sympathomimetics
Apraclonidine hydrochloride
Eye drops: 0.5%
Single use (preservative free):1%
Brimonidine
Eye drops: 0.2%
With timolol
Eye drops: brimonidine 0.2%, timolol 0.5% (Combigan®)
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correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
11.7 LOCAL ANAESTHETIICS
Adult - see BNFfor further information
Children – see BNFC for further information
Specialist drugs (not listed here) are restricted for use at the Eye Infirmary only as
these should only be used under the guidance of a specialist.
Contact the pharmacy for information on the drugs available:
Internal: 46257
External: 0191 565 6256 ext 46257
Oxybuprocaine hydrochloride (benoxinate)
Minims® (preservative free): 0.4%
Proxymetacaine hydrochloride
Minims® (preservative free): 0.5%
With fluorescein
Minims® (preservative free): proxymetacaine 0.5% + fluorescein 0.25%
Tetracaine hydrochloride (amethocaine)
Minims® (preservative free): 0.5%, 1%
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11.8 MISCELLANEOUS OPHTHALMIC PREPARATIONS
Adult - see BNF for further information
Children – see BNFC for further information
Local guidance
SEI Guidelines for Dry Eye Treatment.
Severity
Mild <4 drops per
day
Moderate 4-6
drops per day
Severe >6 drops
per day; corneal
disturbance;
Schirmer’s <3 mm;
First line
Hypromellose 0.3%
(preserved)
Viscotears® (preserved)
Hypromellose 0.3%
(preserved)
Viscotears® (preserved)
Hylo-Tear®,
Hylo-Forte® or
Optive®
Second line
Hylo-Tear®,
Optive®,
Ilube®.*
Optive®,
Hylo-Tear®,
Hylo-Forte®,
Celluvisc® or
Viscotears® PF.
Oculotect®
Ilube®.*
Celluvisc® or
Viscotears® PF.
Oculotect®
Acetylcysteine PF*
Other
Bed time Lacri-Lube®
ointment.
Bed time Lacri-Lube®
ointment.
Punctal plugs.
Bed time Lacri-Lube®
ointment.
Punctal plugs.
Punctal cautery.
Occlusive
spectacles.
Notes.
1. Schirmer’s Test is an approximate guide to severity and should be taken in the
context of the patient’s symptoms. However, proceed with caution in advising
punctal cautery in patients with Schirmer’s result >3 mm.
2. * Filaments require treatment by debridement followed by Acetylcysteine
drops. These can be given as Ilube® (hypromellose plus acetylcysteine) for
mild to moderate dry eye patients and preservative free 5 or 10%
Acetylcysteine for severe patients.
3. Punctal plugs can be inserted in clinic. Use sizing gauge if using silicone
plugs. Visiplugs® are internal and last about 3 months.
4. Before cauterizing puncta, always syringe to confirm patency. Do not
cauterize a punctum that is blocked on syringing.
5. First line products should be tried first before proceeding to second line
products
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
11.8.1 Tear deficiency, ocular lubricants, and astringents
Acetylcysteine
Eye drops: acetylcysteine 5%, hypromellose 0.35%. (Ilube®)
Eye drops (preservative free): 5%, 10% - special from Moorfields
Carbomers
PLiquid gel (= eye drops), carbomer 980 (polyacrylic acid) 0.2% (Viscotears®)
Also available as single dose units (preservative free)
Carmellose sodium
Eye drops (preservative free) 0.5%, glycerol (Optive®)
Single dose units (preservative free) 0.5% (Celluvisc®)
PHypromellose
Eye drops: 0.3%, 0.5%, 1%, 2%
Eye drops (preservative free): 0.3%, 0.5%, 1%, 2% - special from Moorfields
Liquid paraffin
PEye ointment: white soft paraffin 57.3%, liquid paraffin 42.5%, wool alcohols 0.2%.
(Lacri-Lube®)
Paraffin, yellow, soft
Ointment: liquid paraffin 10%, wool fat 10%, yellow soft paraffin.
(Simple Eye Ointment)
Povidone
Single dose units (preservative free) 5% (Oculotect®)
Sodium hyaluronate
Eye drops (preservative free 0.1% (Hylo-Tears®)
Eye drops (preservative free 0.2% (Hylo-Forte®)
Zinc sulphate
Eye drops: 0.25%
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11.8.2 Ocular diagnostic and peri-operative preparations and photodynamic
treatment
Specialist drugs (not all listed here) are restricted for use at the Eye Infirmary only as
these should only be used under the guidance of a specialist.
Contact the pharmacy for information on the drugs available:
Internal: 46257
External: 0191 565 6256 ext 46257
Ocular diagnostic preparations
Fluorescein sodium
Minims® (preservative free): 1%
Ocular peri-operative drugs
Apraclonidine
Diclofenac sodium
Ketorolac
Nepafenac
Subfoveal choroidal neovascularisation
SAflibercept
SRanibizumab
SVerteporfin
Vitreomacular traction
SOcriplasmin
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correspond with those in the BNF. Specific drugs can be searched by using the Find
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12. EAR, NOSE, AND OROPHARYNX
Local guidance
Trust guidelines for prophylaxis of ENT infections: link to guidelines
Trust guidelines for treatment of ENT infections: link to guidelines
12.1 DRUGS ACTING ON THE EAR
Adult - see BNF for further information
Children – see BNFC for further information
12.1.1 Otitis externa
Astringent preparations
Aluminium acetate
Ear drops: 8%, 13%
Anti-inflammatory preparations
Betamethasone sodium phosphate
Ear drops: 0.1%, 10 mL
With neomycin
Ear drops: 0.1% with neomycin sulphate 0.5%, 10 mL
Dexamethasone
With antibacterial
PEar spray: 0.1% with neomycin sulphate 3250 units/ mL and glacial acetic acid 2%,
5 mL (Otomize®)
PEar drops: 0.05% with framycetin sulphate 0.5% and gramicidin 0.005%, 10 mL
(Sofradex®)
Flumetasone pivalate
With antibacterial
Ear drops: 0.02% with clioquinol 1%, 7.5 mL (Locotern-Vioform®)
Hydrocortisone
With antibacterial
Ear drops: 1% with gentamicin 0.3% (as sulphate), 10 mL (Gentisone HC®)
Prednisolone sodium phosphate
Ear drops: 0.5%, 10 mL
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function (Ctrl+F).
Anti-infective preparations
Chloramphenicol
Ear drops: 5%, 10 mL
Clioquinol
With corticosteroid
Ear drops: 1% with flumetasone pivalate 0.02%, 7.5 mL (Locotern-Vioform®)
Clotrimazole
Ear drops: 1%, 20 mL
Framycetin sulphate
With corticosteroid
Ear drops: 0.5% with dexamethasone 0.05% and gramicidin 0.005%, 10 mL
(Sofradex®)
Gentamicin
Ear drops: 0.3%, 10 mL
With corticosteroid
Ear drops: 0.3% with hydrocortisone acetate 1%, 10 mL (Gentisone HC®)
Neomycin sulphate
With corticosteroid
Ear spray: 3250 units/ mL with dexamethasone 0.1% and glacial acetic acid 2%, 5
mL (Otomize®)
12.1.2 Otitis media
 Local treatment for acute otitis media is ineffective and is therefore not
recommended. The majority of cases are viral/origin therefore treatment with
suitable analgesics will suffice (e.g. paracetamol). More severe attacks of
bacterial aetiology require treatment with systemic antibiotics.
 Recurrent acute otitis media can often be managed using prophylactic
antibiotics during the winter months.
 For complicated patients e.g. those with perforated eardrums or/whom
treatment has failed, referral to a specialist should be undertaken.
12.1.3 Removal of ear wax
POlive/Almond oil
PSodium Bicarbonate
Ear drops: 5%
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12.2 DRUGS ACTING ON THE NOSE
Adult - see BNF for further information
Children – see BNFC for further information
12.2.1 Drugs used in nasal allergy
Psychological and behavioural side effects may occur in association with use of
inhaled and intranasal formulations of corticosteroids, see Drug Safety Update,
September 2010.
Antihistamines
Azelastine hydrochloride
Nasal spray: 140 micrograms (0.14 mL)/metered spray, 22 mL
Corticosteroids
PBeclometasone dipropionate
Nasal spray: 50 micrograms/spray, 200-spray unit
Betamethasone sodium phosphate
Drops: 0.1%., 5 mL
Budesonide
Nasal spray: 100 micrograms/spray, 100-spray unit
Fluticasone
Nasal spray: 27.5 micrograms/spray, 120-spray unit (Avamys®)
PMometasone furoate
Nasal spray: 50 micrograms/spray, 140-spray unit
Cromoglicate
PSodium cromoglicate
Nasal spray: 4% (5.2 mg/spray), 22 mL
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12.2.2 Topical nasal decongestants
Topical preparations are suitable only for short-term use (max 7 days) since they cause
rebound congestion that can lead to habituation and overuse (rhinitis medicamentosa).
The CHM/MHRA has stated that non-prescription cough and cold medicines
containing ephedrine, oxymetazoline, or xylometazoline can be considered for up to
5 days in children aged 6–12 years after basic principles of best care have been
tried; these medicines should not be used in children under 6 years of age. See
(section 3.9.1).
Ephedrine hydrochloride
Nasal drops: 0.5%, 1%, 10 mL
Xylometazoline hydrochloride
Nasal drops: 0.05%, 0.1%, 10 mL
12.2.3 Nasal preparations for infection
PMupirocin
Nasal ointment: 2%/white soft paraffin, 3g
PNaseptin®
Cream: chlorhexidine hydrochloride 0.1%, neomycin sulphate 0.5%, 15g
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12.3 DRUGS ACTING ON THE OROPHARYNX
Adult - see BNF for further information
Children – see BNFC for further information
12.3.1 Drugs for oral ulceration and inflammation
Simple mouthwashes
Mouthwash Solution-Tablets:
Antiseptic mouthwashes
Chlorhexidine gluconate
Mouthwash: 0.2% (Corsodyl®) – contains alcohol
Spray: 0.2% (Corsodyl®) – contains alcohol
Gel: 1% (Corsodyl®)
Mouthwash: 0.2% (Periogard®) – alcohol-free Available from Supplies
For patients who have undergone radiotherapy
Tetracycline
Capsules: 250 mg
Corticosteroids
Betamethasone
Soluble Tablets: 500 micrograms (Betnesol®)
PHydrocortisone
Lozenges: 2.5 mg
Local Analgesics
PBenzydamine
Mouthwash: 0.15% (Difflam®)
Spray: 0.15% (Difflam®)
Oral Mucositis
The following preparations are available to Head and Neck Patients and are not for
routine use
Mucoprotectants
Gelclair® oral gel sachets, 21 x 15 mL
Mucogard® oral rinse, 250 mL
Available from Supplies
Available from Supplies
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12.3.2. Oropharyngeal anti-infective drugs
Amphotericin
Lozenges: 10 mg (Fungilin®)
PFluconazole
Capsules: 50 mg
Suspension: 50 mg/5 mL
Miconazole
Oral gel: 2%, 200 mg/20 mL (Daktarin®)
May enhance effects of warfarin, sulphonylureas and phenytoin
Nystatin
Suspension: 100,000 units/ mL, 30 mL
12.3.3 Lozenges and sprays
No preparations
12.3.4 Mouthwashes, gargles, and dentifrices
Chlorhexidine gluconate
Mouthwash: 0.2% (Corsodyl®) – contains alcohol
Spray: 0.2% (Corsodyl®) – contains alcohol
Gel: 1% (Corsodyl®)
Mouthwash: 0.2% (Periogard®) – alcohol-free Available from Supplies
For patients who have undergone radiotherapy
Hydrogen Peroxide Mouthwash, BP
12.3.5 Treatment of dry mouth
BioXtra® gel, 40 mL; spray, 50 mL
Available from Supplies
The following preparations are available to Head and Neck Patients and are not
meant for routine use.
BioXtra® gum, 20 pieces; toothpaste, 50 mL; mouthrinse, 250 mL
Available from Supplies
Xerotin® spray, 100 mL
Available from Supplies
Caphosol® oral rinse, 30 dose
Available from Supplies
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13. SKIN
The dermatology section of the Formulary comes under the jurisdiction of the
Drugs and Therapeutics Committee for Durham and Darlington Acute Hospitals
NHS Trust. Link to Chapter 13 of the County Durham and Darlington Formulary
Local guidance
Trust guidelines for prophylaxis of skin infections: link to guidelines
Trust guidelines for treatment of skin infections: link to guidelines
National Guidance
NICE Technology Appraisal (TA)
A list of published Technical Appraisals which is searchable can be found on the
NICE website: http://www.nice.org.uk/Guidance/TA/Published
Alternatively, a table of all the TA recommendations can be viewed or printed as a
Word document: Full table of TA recommendations.
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13.1 MANAGEMENT OF SKIN CONDITIONS
Adult - see BNF for further information
Children – see BNFC for further information
Suitable quantities of preparations to be prescribed for specific areas of the body.
These amounts are usually suitable for an adult for twice a day application for one
week.
Emollients
Topical corticosteroids
Creams & ointments
Lotions
Creams & ointments
Face
15 g - 30 g
100 mL
15 g - 30 g
Both hands
25 g - 50 g
200 mL
15 - 30 g
Scalp
50 g - 100 g
200 mL
15 g - 30 g
Both arms
100 g - 200 g
200 mL
30 g - 60 g
Both legs
100 g - 200 g
200 mL
100 g
Trunk
400 g
500 mL
100 g
Groins & genitalia
15 g - 25 g
100 mL
15 - 30 g
Excipients and sensitization
See the current BNF Adult or Children for advice.
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13.2 EMOLLIENTS AND BARRIER PREPARATIONS
Adult - see BNF for further information
Children – see BNFC for further information
Fire hazard with paraffin-based emollients
Adult - see NPSA rapid response report 4, November 2007)
Emulsifying ointment or 50% Liquid Paraffin and 50% White Soft Paraffin Ointment in
contact with dressings and clothing is easily ignited by a naked flame. The risk is
greater when these preparations are applied to large areas of the body, and clothing
or dressings become soaked with the ointment. Patients should be told to keep away
from fire or flames, and not to smoke when using these preparations. The risk of fire
should be considered when using large quantities of any paraffin-based emollient.
General
 These include moisturising ointments and creams, bath oils and soap
substitutes.
 Emollients soothe and hydrate the skin and are indicated for all dry or scaling
disorders. They require frequent application because their effects are shortlived, but when used correctly can be extremely effective in reducing
inflammation and improving skin texture. .
 Aqueous cream is suitable for most patients with dry skin, but more greasy
preparations (white soft paraffin, emulsifying ointment and a white soft
paraffin/liquid paraffin combination) are available. Some patients may be
sensitive to the preserving agent in aqueous cream and may need to be
offered an alternative
 The severity of the condition can be used as a guide as to which preparation is
most appropriate.
 Preparations containing an antibacterial should be avoided unless infection is
present or is a frequent complication.
 A wide range of products is available as patients can become sensitised to or
intolerant to the product.
Eczema and Psoriasis
 Emollients add a protective lipid layer to the skin, reducing dryness and itching
and provide a steroid sparing effect.
 They may have an antipsoriatic effect and prevent fissuring and pruritus but
they have no direct anti-inflammatory effect.
 Bath additives have a marginal effect and some may even make eczema
worse
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13.2.1 Emollients
Non-proprietary preparations
PAqueous Cream, BP, 500 g
May cause skin irritation, particularly in children with eczema, possibly due to sodium lauryl sulfate
content. See Drug Safety Update, March 2013
PEmulsifying Ointment, BP, 500 g
Proprietary preparations
PCetraben® cream, 500 g
PDiprobase® cream and ointment, 50 g, 500 g
Doublebase® gel, 100 g, 500 g
E45® cream, 50 g, 500 g
PEpaderm® ointment, 500 g
Hydromol® cream and ointment, 500 g
Proprietary preparations with antimicrobials
PDermol® 500 lotion, 50 mL
Proprietary preparations with urea
PCalmurid® cream, 100 g
13.2.1.1 Emollient bath and shower preparations
PBalneum® bath oil, 200 mL
POilatum Plus® bath additive, 500 mL - Limited use - should only be used for 2-3
weeks
13.2.2 Barrier preparations
Non-proprietary preparations
PZinc and Castor Oil Ointment, BP, 500 g
Proprietary preparations
Metanium® ointment, 30 g
Sudocrem® cream, 25 g, 125 g, 250 g
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function (Ctrl+F).
13.3 TOPICAL LOCAL ANAESTHETICS AND ANTIPRURITICS
Adult - see BNF for further information
Children – see BNFC for further information
Calamine lotion, 200 mL
Crotamiton
10% cream, 30 g (Eurax®)
UMenthol 1% in aqueous cream, 80 g, 500 g – available as a ‘Special’
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13.4 TOPICAL STEROID PREPARATIONS
Adult - see BNF for further information
Children – see BNFC for further information
General
 Topical corticosteroids are used in the treatment of inflammatory conditions,
particularly eczematous disorders.

The side effects of topical steroids are dependent on the product strength and
duration of use; there are four classifications of potency:
o
o
o
o
Mild
Moderately Potent
Potent
Very Potent

Preparations in the mild and moderately potent groups are rarely associated
with side-effects. This is not the case with potent and very potent
preparations, which can give rise to systemic as well as local effects. The risk
of systemic side-effects is dependent on the potency of preparation used,
duration of treatment and the area treated. Absorption is greatest from thin,
inflamed or raw skin, and is increased by occlusion of the treatment area

The potency of the steroid used should be appropriate to the severity and site
of the condition. Try to use the minimum amount of the least potent steroid at
the lowest effective concentration for the minimum period of time.

Patients should be initiated on the highest potency topical corticosteroid that is
clinically required and then stepped down. The patient may be stepped down
to a lower potency steroid or the frequency of use of a higher potent steroid
can be reduced, for example: Once / Twice Daily → Alternate Days or less
frequently, as necessary.

Only mild steroids should be used on the face. Infants and the elderly tend to
have thinner skin and thus weaker preparations should be used.

Patients and nurses should be advised to use gloves if applying large
quantities of steroid preparations.
Advise patient/carer to wash their hands after applying steroid preparations to
avoid atrophy of skin on fingertips.
Adequate use of emollients may reduce the amount of steroid preparation
required in dry scaly conditions.


Eczema and Psoriasis
 Many forms of eczema tend to be chronic and are best managed on mild and
moderately potent steroids; potent and very potent preparations should only
be used for short periods to control acute episodes.

In psoriasis, potent steroids are generally required for treatment of single
plagues on limbs and trunk, whereas flexures and the face should only be
treated with mild potency steroids.
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Choice of Preparation
 Ointments are preferable to creams as they have a deeper, more prolonged
emollient effect and increase the penetration of steroid. They are also less
likely to cause irritation and/or sensitisation to the product, as they do not
contain preservatives.

Patients may prefer creams for application to the face and they can be more
suitable for moist or weeping lesions.
Frequency of application
 NICE guidance recommends that topical corticosteroids for atopic eczema
should be prescribed for application only once or twice daily. Once a day may
be as effective as twice daily application.

Topical corticosteroids should be spread thinly on the skin but in sufficient
quantity to cover the affected areas. The length of cream or ointment expelled
from a tube may be used to specify the quantity to be applied to a given area
of skin. This length can be measured in terms of a fingertip unit (the distance
from the tip of the adult index finger to the first crease). One fingertip unit
(approximately 500 mg) is sufficient to cover an area that is twice that of the
flat adult palm.
Suitable quantities of preparations to be prescribed for specific areas of the body.
These amounts are usually suitable for an adult for twice a day application for two
weeks.
Topical corticosteroids
Creams & ointments
Face and neck
15 g - 30 g
Both hands
15 - 30 g
Scalp
15 g - 30 g
Both arms
30 g - 60 g
Both legs
100 g
Trunk
100 g
Groins & genitalia
15 - 30 g
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Medicines in the formulary are listed in chapters and subsections that generally
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function (Ctrl+F).
Mildly potent steroids
PHydrocortisone
Cream and ointment: 0.5%, 1%; 15 g, 30 g
Mildly potent combinations
Hydrocortisone / clotrimazole
Cream: hydrocortisone 1% & clotrimazole 1%, 30 g (Canesten HC®)
Hydrocortisone / miconazole nitrate
Cream: hydrocortisone 1% & miconazole nitrate 2%, 30 g (Daktacort®)
PHydrocortisone acetate / fusidic acid
Cream and ointment: hydrocortisone acetate 1% & fusidic acid 2%, 30 g (Fucidin H®)
Moderately potent steroids
Betamethasone esters
Cream and ointment 0.025%, 100 g (Betnovate-RD® or equivalent)
PClobetasone butyrate
Cream and ointment 0.05%, 30 g, 100 g (Eumovate®
Note: when prescribing clobetasol (Dermovate®) and clobetasone (Eumovate®) use brand
names due to the potential for error if prescribed generically.
Fludroxycortide
Tape: polythene adhesive film impregnated with fludroxycortide 4 micrograms /cm2
(Haelan®) - Restricted to Specialist use only
Moderately potent combinations
Betamethasone valerate 0.1% in coal tar paste 25%, 200 g – available as a ‘Special’.
Restricted to Specialist use only
Clobetasone / oxytetracycline / nystatin
Cream, clobetasone butyrate 0.05% & oxytetracycline 3%, nystatin 100 000 units/g,
30 g (Trimovate®)
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Potent steroids
PBetamethasone esters
Cream and ointment: 0.1%, 30 g, 100 g (Betnovate® or equivalent
Lotion: 0.1%, 100 mL (Betnovate® or equivalent)
Scalp application: 0.1%, 100 mL (Betnovate® or equivalent
Fluocinolone acetonide - Restricted to Specialist use only
Cream and ointment: 0.025%, 30 g, 100 g; gel: 0.025%, 30 g (Synalar®)
Mometasone furoate
Cream and ointment: 0.1%, 30 g, 100 g (Elocon®)
Potent combinations
PBetamethasone valerate / clioquinol
Cream and ointment: betamethasone valerate 0.1% and clioquinol 3%, 30 g
PBetamethasone valerate / fusidic acid
Cream: betamethasone valerate 0.1% and fusidic acid 2%, 30 g (Fucibet®)
Betamethasone diproprionate / salicylic acid
Ointment: betamethasone diproprionate 0.05% and salicylic acid 3%, 30 g, 100 g
(Diprosalic®)
Scalp application: betamethasone diproprionate 0.05% and salicylic acid 2%, 100 mL
(Diprosalic®)
Very potent steroids
PClobetasol
Cream and ointment: 0.05%, 30 g, 100 g (Dermovate®)
Scalp application: 0.05%, 30 mL (Dermovate®
Note: when prescribing clobetasol (Dermovate®) and clobetasone (Eumovate®) use brand
names due to the potential for error if prescribed generically.
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13.5 PREPARATIONS FOR ECZEMA AND PSORIASIS
Adult - see BNF for further information
Children – see BNFC for further information
13.5.1 Preparations for Eczema
Topical
Potassium permanganate solution tablets
See section 13.11.6
Zinc Paste and Ichthammol Bandage, BP 1993 – Not from pharmacy, order from
supplies
Oral retinoids for eczema
Alitretinoin
Capsules: 10 mg, 30 mg
13.5.2 Preparations for Psorasis
Vitamin D analogues
PCalcipotriol
Ointment: calcipotriol 50 micrograms/g (Dovonex®)
Calcitriol
Ointment: calcitriol 3 micrograms/g (Silkis®)
Less irritant than calcipotriol, suitable for application to sensitive areas e.g. face,
hairline, flexures
With betamethasone diproprionate
POintment: betamethasone 0.05% (as dipropionate), calcipotriol
50 micrograms/g (Dovobet®)
Coal tar preparations
Coal tar/ hydrocortisone
Cream: coal tar extract 5%, hydrocortisone 0.5%, allantoin 2%, (Alphosyl HC®)
Coal tar lotion
Lotion: prepared coal tar 1% in an emollient basis (Exorex®)
Coal tar bath additive
Liquid: coal tar solution 2.5%, arachis (peanut) oil extract of coal tar 7.5%, tar 7.5%,
cade oil 7.5%, liquid paraffin 35% (Polytar Emollient®)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Dithranol preparations – Restricted to Specialist use only
SDithranol cream
Cream: 0.1%, 0.25%, 0.5%, 1%, 2% (Dithrocream®)
Oral retinoids – Restricted to Specialist use only
SAcitretin
Capsules: 10 mg, 25 mg
Phototherapy – Restricted to Specialist use only
SMethoxsalen
Tablets: 10 mg – unlicensed medicine
13.5.3 Drugs affecting the Immune Response
Specialist management is required and therefore these drugs are RESTRICTED
TO SPECIALIST USE ONLY.
SAdalimumab
SCiclosporin
SEtanercept
SInfliximab
SMethotrexate
SPimecrolimus topical 1%
STacrolimus topical 0.03%, 0.1%
SUstekinumab (Available through a managed pathway)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
13.6 ACNE AND ROSACEA
Adult - see BNF for further information
Children – see BNFC for further information
13.6.1 Topical preparations for acne
PAzeliac acid
Cream: 20%, 30 g (Skinoren®)
PBenzoyl peroxide
Aquagel: 2.5%, 5%, 40 g (PanOxyl®)
Cream or gel: 5% (PanOxyl®)
With clindamycin
Gel: benzoyl peroxide 5% and clindamycin 1%, 25 g (Duac®)
Topical antibiotics for acne
Topical antibiotics are as effective as oral antibiotics but encourage resistance and are
more expensive. For guidance on avoiding development of resistance with topical
antibiotics, see the BNF
PClindamycin
Lotion: clindamycin 1%, 60 mL (Dalacin T®)
PErythromycin
Solution: erythromycin 2% (Zineryt®)
Topical retinoids and related preparations for acne
PAdapalene
Cream and gel: 0.1%, 45 g (Differin®)
13.6.2 Oral preparations for acne
Oral antibacterials for acne
Doxycycline
Capsules: 50 mg, 100 mg
Dispersible tablets: 100 mg
Minocycline
Tablets: 50 mg
Capsules SR: 100 mg
POxytetracycline
Tablets: 250 mg
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Medicines in the formulary are listed in chapters and subsections that generally
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Hormone treatment for acne
PCo-cyprindiol
Tablets: co-cyprindiol 2000/35 (cyproterone acetate 2 mg, ethinylestradiol
35 micrograms)
For severe acne in women refractory to prolonged oral antibiotic therapy who wish to receive oral
contraception
Oral retinoids for acne – specialist use only
SIsotretinoin
Capsules: 5 mg, 20 mg
It is teratogenic and women must be registered with a pregnancy prevention programme.
Topical preparations for rosacea
PMetronidazole
Cream or gel: 0.75%, 40 g (Rozex®)
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13.7 PREPARATIONS FOR WARTS AND CALLUSES
Adult - see BNF for further information
Children – see BNFC for further information
Salicylic acid containing preparations
PPaint: Salicylic acid 16.7% and lactic acid 16.7% in Flexible Collodion, 10 mL.
(Salactol®)
Formaldehyde
Formaldehyde 3% solution
Silver nitrate
Silver nitrate 95% pencil
Anogenital warts
SImiquimod
Cream: 5% (Aldara®)
Restricted to Specialist use only
Podophyllotoxin
Cream: 0.15%, 5 g (Warticon®)
Solution: 0.5%, 3 mL (Warticon®)
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13.8 SUNSCREENS
Adult - see BNF for further information
Children – see BNFC for further information
Uvistat® reflective sunscreen SPF 30
Preparations for photodamage
SDiclofenac sodium - Restricted to Specialist use only
Gel: diclofenac sodium 3%/a sodium hyaluronate basis (Solaraze)
SFluorouracil - Restricted to Specialist use only
Cream: fluorouracil 5% (Efudix®)
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13.9 SHAMPOOS AND OTHER PREPARATIONS FOR SCALP AND HAIR
CONDITIONS
Adult - see BNF for further information
Children – see BNFC for further information
Betamethasone esters
Scalp application: 0.1% (Betnovate® or equivalent)
Betamethasone diproprionate / salicylic acid
Scalp application: betamethasone diproprionate 0.05%, salicylic acid 2%
(Diprosalic®)
Clobetasol
Scalp application: 0.05% (Dermovate®)
Coconut oil compound (Coal tar / coconut oil / salicylic acid)
Shampoo: coal tar 1%, coconut oil 1%, salicylic acid 0.5% (Capasal®)
PKetoconazole
Shampoo: ketoconazole 2%
Polytar®
Liquid: arachis (peanut) oil extract of coal tar 0.3%, cade oil 0.3%, coal tar solution
0.1%, oleyl alcohol 1%, tar 0.3% (Polytar)
PT/Gel®
Shampoo: coal tar extract 2%
Hirsuitism
Co-cyprindiol
Tablets: containing cyproterone acetate 2mg and ethinylestradiol 35 micrograms
See updated prescribing advice - Drug Safety Update, June 2013
SEflornithine - Restricted to Specialist use only
Cream: 11.5%
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13.10 ANTI-INFECTIVE SKIN PREPARATIONS
Adult - see BNF0 for further information
Children – see BNFC for further information
13.10.1 Antibacterial preparations
13.10.1.1 Antibacterial preparations only used topically
Mupirocin
Cream: mupirocin 2% (Bactroban®)
Polymixins
Ointment: polymyxin B sulphate 10 000 units, bacitracin zinc 500 units/g (Polyfax®)
Silver sulfadiazine
Cream: silver sulfadiazine 1% (Flamazine®)
13.10.1.2 Antibacterial preparations also used systemically
Fusidic acid
Cream or ointment: 2%
Metronidazole
Gel: 0.8%
13.10.2 Antifungal preparations
Amorolfine
Nail lacquer: 5% (Loceryl®)
Clotrimazole
Cream / solution / spray: 1%
Miconazole nitrate
Cream: 2%
Terbinafine
Cream: 1% (Lamisil®)
13.10.3 Antiviral preparations
Aciclovir
Cream: 5%
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13.10.4 Parasiticidal preparations
Suitable quantities of parasiticidal preparations
Skin creams
Lotions
Cream rinses
—
50–100 mL
50–100 mL
Body (scabies)
30–60 g
100 mL
—
Body (crab lice)
30–60 g
100 mL
—
Scalp (head lice)
These amounts are usually suitable for an adult for single application.
Scabies
Adult - see the BNF Adult or Children for further information
Head lice
Adult - see the BNF Adult or Children for further information
Crab Lice
Adult - see the BNF Adult or Children for further information
Malathion
Liquid: 0.5% liq. (Derbac M®)
Permethrin
Dermal cream: 5% (Lyclear®)
13.10.5 Preparations for minor cuts and abrasions
Magnesium Sulphate Paste, BP
Proflavine cream, BPC
Excipients include beeswax, wool fat
Tissue adhesives
Enbucrilate
Tissue adhesive: 500 mg unit (Histoacryl®)
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13.11 SKIN CLEANSERS, ANTISEPTICS, AND DESLOUGHING AGENTS
Adult - see BNF1 for further information
Children – see BNFC for further information
13.11.1 Alcohols and saline
Industrial Methylated Spirit (IMS) BP
Sodium chloride 0.9%
13.11.2 Chlorhexidine salts
Chlorhexidine
Solution: 0.05%
13.11.3 Cationic surfactants and soaps
No preparations
13.11.4 Iodine
Povidone Iodine
Spray: 2.5%
Ointment: 10 %
13.11.5 Phenolics
No preparations
13.11.6 Oxidisers and dyes
Hydrogen peroxide
Solution: 3% (10 vols), 6% (20 vols)
Potassium permanganate
Solution tablets: 400 mg
13.11.7 Desloughing agents
No preparations
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13.12 ANTIPERSPIRANTS
Adult - see BNF for further information
Children – see BNFC for further information
Aluminium salts
PSolution: aluminium chloride hexahydrate 20% in an alcoholic basis (Anhydrol®
Forte)
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13.13 TOPICAL CIRCULATORY PREPARATIONS
Adult - see BNF for further information
Children – see BNFC for further information
No preparations
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14. IMMUNOLOGICAL PRODUCTS AND VACCINES
14.1 ACTIVE IMMUNITY
Adult - see BNF for further information
Children – see BNFC for further information
CHILDHOOD IMMUNISATION PROGRAMME
The immunisation programme takes place over the course of five years with the aim
to protect all children against various preventable childhood infections.
Immunisations are often given more than once to make sure the protection
continues. This is known as a booster immunisation. Children usually need booster
immunisations when they have reached pre-school age (five years old), and again
before they leave school (between 13 and 18 years of age).
Immunisation schedule
The Immunisation schedule can be downloaded from Public Health England:
Immuminsation schedule, June 2013 OR from the BNF Adult or Children.
If any course of immunisation is interrupted, it should be resumed and
completed as soon as possible. There is no need to start any course of
immunisation again. An algorithm for vaccinating individuals with uncertain or
incomplete immunisation status is available from Public Health England:
Vaccination of Individuals with Incomplete or Uncertain Immunisation Status
ADULT IMMUNISATION PROGRAMME
Five doses of diphtheria, tetanus and polio vaccines ensure long-term protection
through adulthood. Individuals who have not completed the five doses should have
their remaining doses at the appropriate interval. Where there is an unclear history of
vaccination, adults should be assumed to be unimmunised. A full course of
diphtheria, tetanus and polio should be offered. Older adults (65 years or older)
should be routinely offered a single dose of pneumococcal polysaccharide vaccine, if
they have not previously received it. Annual influenza vaccination should also be
offered.
Selective vaccines should also be considered for young adults unprotected against
diseases including measles, mumps, rubella and meningococcal C.
Other vaccinations should be considered for any adult with underlying medical
conditions and those at higher risk because of their lifestyle. These vaccinations
include Hib, MenC, influenza, pneumococcal and hepatitis B.
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14.2 PASSIVE IMMUNITY
Adult - see BNF for further information
Children – see BNFC for further information
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14.3 STORAGE AND USE
Adult - see BNF for further information
Children – see BNFC for further information
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14.4 VACCINES AND ANTISERA
Adult - see BNF for further information
Children – see BNFC for further information
Bacillus Calmette-Guérin (BCG)
Adult - see the BNF for further Information
Children – see BNFC for further information
Bacillus Calmette-Guérin Vaccine (BCG Vaccine, Dried/Tub/BCG)
Injection: 1 mL multidose vials containing freeze dried powder for preparing
intradermal injections
Tuberculin Purified Protein Derivative (Tuberculin PPD) - unlicensed
Vial (1.5 mL): 20 units/mL (2 units/0.1 mL dose) (for routine use); 100 units/mL
(10 units/0.1 mL dose)
Diphtheria
Adult - see the BNF for further Information
Children – see BNFC for further information
For children under 10 years
Diphtheria/Tetanus/Pertussis (Acellular, Component), Poliomyelitis (Inactivated) and
Haemophilus Type b Conjugate Vaccine (Adsorbed) (DTaP/IPV/Hib)
Vial: 0.5mL (Pediacel®)
Adsorbed Diphtheria, Tetanus, Pertussis (Acellular, Component) and Poliomyelitis
(Inactivated) Vaccine (DTaP/IPV)
Prefilled syringe: 0.5 mL (Infanrix-IPV®)
Adsorbed Diphtheria (low dose), Tetanus, Pertussis (Acellular, Component) and
Poliomyelitis (Inactivated) Vaccine (dTaP/IPV)
Prefilled syringe: 0.5 mL (Reprevax®)
For children over 10 years and adults
Adsorbed Diphtheria (low dose), Tetanus and Poliomyelitis (Inactivated) Vaccine
Prefilled syringe: 0.5 mL (Revaxis®) (Td/IPV)
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Haemophilus
Adult - see the BNF for further Information
Children – see BNFC for further information
Haemophilus type b conjugated vaccine (Hib/MenC)
Injection: vial (with syringe containing 0.5 mL diluent), powder for reconstitution,
Haemophilus influenzae type b and capsular polysaccharide of Neisseria meningitidis
group C (Menitorix®)
Hepatitis A, B and A+ B
Hepatitis A Vaccine
Adult - see the BNF for further Information
Children – see BNFC for further information
Prefilled syringe: 1 mL, suspension of hepatitis A virus 1440 ELISA units/mL
(HavrixMonodose®)
Hepatitis B Vaccine
Adult - see the BNF for further Information
Children – see BNFC for further information
Prefilled syringe: 1 mL, hepatitis B surface antigen 10 micrograms/mL (HBvaxPRO®)
- preferred product
10 micrograms/0.5 mL (paediatric) & 20 micrograms/1 mL (adult) prefilled syringes
(Engerix B®) also available
Hepatitis A & B Vaccine
Adult - see the BNF for further Information
Children – see BNFC for further information
Prefilled syringe: 1 mL inactivated hepatitis A virus and hepatitis B surface antigen
20 micrograms/mL (Twinrix® Adult)
Excipients include neomycin
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correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Human Papilloma Virus
Adult - see the BNF for further Information
Children – see BNFC for further information
Human Papilloma virus vaccine
Prefilled syringe: 0.5 mL (Cervarix®)
Influenza
Adult - see the BNF for further Information
Children – see BNFC for further information
Influenza Vaccine
Prefilled syringe: 0.5 mL containing either split viron or surface antigen vaccine.
Measles, Mumps & Rubella
Adult - see the BNF for further Information
Children – see BNFC for further information
Measles, Mumps & Rubella vaccine
Powder and solvent for suspension for injection in pre-filled syringe (0.5 mL)
(MMRVaxPro®)
Meningococcus
Adult - see the BNF for further Information
Children – see BNFC for further information
Meningococcal polysaccharide A, C, W135 and Y vaccine (MenACWY)
Injection: powder and solvent for suspension for injection in pre-filled syringe,
0.5 mL (ACWY Vax®)
Meningococcal Group C Conjugate Vaccine (MenC)
Injection: powder for reconstitution, antigen of Neisseria meningitidis group C
(conjugated to Corynebacterium diphtheriae protein), single-dose vial with diluent
(Menjugate Kit®)
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correspond with those in the BNF. Specific drugs can be searched by using the Find
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Pneumococcus
Adult - see the BNF for further Information
Children – see BNFC for further information
Pneumococcal Polysaccharide Vaccine (PPV)
Vial: 0.5 mL, polysaccharide from each of 23 capsular types of pneumococcus
(Pneumovax II®)
Pneumococcal Polysaccharide Conjugate Vaccine (adsorbed) (PCV)
Prefilled syringe: 0.5 mL, polysaccharide from each of 13 capsular types of
pneumococcus (Prevenar 13®)
Poliomyelitis
Adult - see the BNF for further Information
Children – see BNFC for further information
Use combined vaccines
Rotavirus
Adult - see the BNF for further Information
Children – see BNFC for further information
Oral suspension: live attenuated rotavirus (RIX4414 strain), (Rotarix®)
Rubella
Adult - see the BNF for further Information
Children – see BNFC for further information
Use combined vaccines
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function (Ctrl+F).
Tetanus
Adult - see the BNF for further Information
Children – see BNFC for further information
Use combined vaccines
Tetanus Immunisation Following Injuries
Clean Wound
Immunisation Status
Vaccine
Fully immunised i.e. has
received a total of 5
doses of tetanus
vaccine at appropriate
intervals
Primary immunisation
complete, boosters
incomplete but up to
date
Tetanus Prone Wound Adult - see definition
below)
Human tetanus
Vaccine
immunoglobulin (TIG)
None required
None required
Only if high risk#
None required (unless
next dose due soon and
convenient to give now)
None required (unless
next dose due soon and
convenient to give now)
Only if high risk#
A reinforcing dose of
A reinforcing dose of
vaccine and further
vaccine and further
Primary immunisation
doses as required to
doses as required to
Yes: one dose of human
incomplete or boosters
complete the
complete the
tetanus immunoglobulin
not up to date
recommended schedule recommended schedule
(TIG) in a different site
(to ensure future
(to ensure future
immunity)
immunity)
An immediate dose of
An immediate dose of
vaccine followed, if
vaccine followed, if
Not immunised or
Yes: one dose of human
records confirm this is
records confirm this is
immunisation status not
tetanus immunoglobulin
needed, by completion
needed, by completion
known or uncertain
(TIG) in a different site
of a full 5 dose course to of a full 5 dose course to
ensure future immunity
ensure future immunity
#High risk is regarded as heavy contamination with material likely to contain tetanus spores and/or
extensive devitalised tissue.
Dose = 250 units IM for most uses; 500 units IM if more than 24 hours have elapsed or there is risk of
heavy contamination or following burns
Tetanus-prone wounds include:
 Wounds sustained more than 6 hours before surgical treatment
 Wounds at any interval after injury and are puncture-type (particularly if
contaminated with soil or manure)
 Wounds that show much devitalised tissue
 Wounds containing foreign bodies
 Compound fractures
 Wounds or burns that are septic.
All wounds should receive thorough cleansing.
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Full course of tetanus and diphtheria vaccines consists of 5 doses as follows:
SCHEDULE
Primary Course
4th dose
5th dose
CHILDREN
3 doses of vaccine (usually as
DTaP/IPV/Hib = Pediacel®) at 2, 3
and 4 months of age
At least 3 years after the primary
course, usually pre-school entry
(as DTaP/IPV = Infanrix-IPV®)
Aged 13-18 years before leaving
school (as Td/IPV = Revaxis®)
ADULTS
3 doses of vaccine (as Td/IPV =
Revaxis®) each one month apart
10 years after primary course (as
Td/IPV – Revaxis®)
10 years after 4th dose (as Td/IPV
= Revaxis®)
Varicella-Zoster
Adult - see the BNF for further Information
Children – see BNFC for further information

The high potency, live varicella–zoster vaccine, Zostavax®, is licensed for the
prevention of herpes zoster (shingles) in adults over 50 years of age.
Varicella-Zoster Vaccine
Vial: 0.5 mL, powder for reconstitution, live attenuated varicella–zoster virus (Oka
strain) (Varlirix®)
Excipients include neomycin
Vial: 0.65 mL, powder for reconstitution, live attenuated varicella–zoster virus (Oka
strain) (Zostavax®)
Excipients include gelatin and neomycin
For adult shingles vaccination programme
CONTRAINDICATIONS AND SPECIAL CONSIDERATIONS
Please refer to the latest version of Chapter 6 (Contraindications and Special
Considerations) from Immunisation against infectious disease - 'The Green Book'
which is found on the Department of Health website: LINK It contains information on:
 Egg allergy
 Severe latex allergy
 Pregnancy
 Vaccines and immunocompromised patients
 Vaccines and HIV infection
Vaccines and asplenia
See the separate policy - Link to policy
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Table: Live vaccines
VACCINE
BCG
Measles, Mumps & Rubella
Poliomyelitis - oral Sabin vaccine
Rotavirus, oral
Typhoid, oral
Varicella-zoster
BRANDS
SSI
MMRVaxPro® Priorix®
Rotarix®
Vivotif®
Varlirix®, Varivax®,
Zostavax®
Yellow fever
Useful Links
Public Health England LINK – including a link to Immunisation against infectious
disease - 'The Green Book': LINK
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
14.5 IMMUNOGLOBULINS
Adult - see BNF for further information
Children – see BNFC for further information
For advice on prescribing – see Link
14.5.1 Normal Immunoglobulin
Human normal Immunoglobulin (HNIG)
Infusion: 2.5 g, 5 g, 10 g (Vigam®)
14.5.2 Disease-specific immunoglobulins
Preparations stocked by pharmacy:
Tetanus immunoglobulin: 250 units
Other immunoglobulins
The following immunoglobulins are kept at the Newcastle Public Health Laboratory:
Hepatitis B (HBIG)
Rabies (HRIG) also vaccine
Varicella-zoster (VZIG)
They are accessed on a 24-hour basis – contact a Consultant Microbiologist for
supply.
From blood bank
Anti D (Rh0) immunoglobulin
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
14.6 TRAVEL IMMUNISATION
Adult - see BNF for further information
Children – see BNFC for further information
Useful Links
1. National Travel Health Network and Centre (NaTHNac)
Website which has been created to promote clinical standards in travel medicine with
the goal of 'protecting the health of the British traveller' and is funded by the
Department of Health: LINK
2. The Travel Doctor
Website produced by a partnership between a doctor and a pharmacist from South
Wales: LINK
3. MIMS Travel Tables
MIMS produces guidance on malaria prophylaxis and travel vaccinations for when
travelling overseas. LINK
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
15. ANAESTHESIA
The drugs in this section should be used only by experienced personnel
and where adequate resuscitative equipment is available.
15.1 GENERAL ANAESTHETICS
15.1.1 Intravenous anaesthetics
Etomidate
Injection (emulsion): 20 mg/10 mL (Lipuro®)
Ketamine
Injection: 200 mg/20 mL, 500 mg/10 mL, 1000 mg/10 mL
Propofol
Injection (emulsion): 0.5% - 100 mg/20 mL (Lipuro®)
Injection (emulsion): 1% - 200 mg/20 mL (Lipuro®), 1 g/100 mL (Lipuro®)
Thiopental (Thiopentone) sodium
Injection: 500 mg
15.1.2 Inhalational anaesthetics
Desflurane 240 mL
Isoflurane 250 mL
Nitrous Oxide (N2O)
Sevoflurane 250 mL
Other Medical Gases
Carbon Dioxide (CO2)
Entonox (N2O 50% : O2 50%)
Nitric Oxide (NO)
Oxygen (O2)
15.1.3 Antimuscarinic drugs
Atropine sulphate
Injection: 600 micrograms/1 mL
Glycopyrrronium bromide
Injection: 200 micrograms/1 mL, 600 micrograms/3 mL
Hyoscine hydrobromide
Injection: 400 micrograms/1 mL
15.1.4 Sedative and analgesic peri-operative drugs
15.1.4.1 Benzodiazepines
Diazepam Adult - see Section 4.1.2, Anxiolytics)
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Lorazepam Adult - see Section 4.1.2, Anxiolytics)
Midazolam
Injection: 2 mg/2 mL, 5 mg/5 mL, 50 mg/50 mL
Temazepam Adult - see Section 4.1.1, Hypnotics)
15.1.4.2 Non-opioid analgesics
For NSAIDs Adult - see Section 10.1.1)
For paracetamol Adult - see Section 4.7)
Parecoxib
Injection: 40 mg
15.1.4.3 Opioid analgesics
Alfentanil
Injection: 1 mg/2 mL, 5 mg /1 mL
Fentanyl
Injection: 100 micrograms/2 mL, 500 micrograms/10 mL
With bupivacaine
Bupivacaine 0.1% with fentanyl 2 micrograms/ mL, 250 mL, 500 mL
Remifentanil
Injection: 2 mg
15.1.5 Neuromuscular blocking drugs
Non-depolarising neuromuscular blocking drugs
Atracurium besilate (besylate)
Injection: 25 mg/2.5 mL, 50 mg/5 mL
Mivacurium
Injection: 10 mg/5 mL, 20 mg/10 mL
Pancuronium bromide
Injection: 4 mg/2 Ml
Rocuronium bromide
Injection: 50 mg/5 mL
Vecuronium bromide
Injection: 10 mg
Depolarising neuromuscular blocking drugs
Suxamethonium chloride
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
Injection: 100 mg/2 mL
15.1.6 Drugs for the reversal of neuromuscular blockade
Anticholinesterases
Edrophonium chloride
Injection: 10 mg/1 mL
Neostigmine metisulfate (methylsulphate)
Injection: 2.5 mg/1 mL
With glycopyrronium
Neostigmine metisulfate (methylsulphate) 2.5 mg with glycopyrronium 500
micrograms, 1 mL
Other drugs for reversal of neuromuscular blockade
Sugammadex
Injection: 500 mg/5 mL
15.1.7 Antagonists for central and respiratory depression
Flumazenil
Injection: 500 micrograms/5 mL
Naloxone hydrochloride
Injection: 400 micrograms/1 mL, 2 mg/2 mL
15.1.8 Drugs for malignant hyperthermia
Dantrolene sodium
Injection: 20 mg
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
15.2 LOCAL ANAESTHESIA
Bupivacaine hydrochloride
Injection: 0.25%, 10 mL; 0.5%, 10 mL
Injection: 0.5%, glucose 80 mg/ mL, 4 mL (Marcain Heavy®)
Ethyl chloride
Spray: 100 mL (Cryogesic®)
Levobupivacaine hydrochloride
Injection: 25 mg/10 mL, 50 mg/10 mL, 75 mg/10 mL (Chirocaine®)
Lidocaine (Lignocaine) hydrochloride - parenteral
Injection: 1% - 5 mL, 10 mL, 20 mL
Injection: 2% - 5 mL, 10 mL, 20 mL
With adrenaline (epinephrine)
Lidocaine 0.5% with adrenaline 1 in 200,000, 20 mL (Xylocaine®)
Lidocaine 1% with adrenaline 1 in 200,000, 20 mL (Xylocaine®)
Lidocaine 2% with adrenaline 1 in 200,000, 20 mL (Xylocaine®)
For dental use
Cartridges: lidocaine 1% with adrenaline 1 in 80,000, 2.2 mL
Lidocaine (Lignocaine) hydrochloride
Topical
Gel: 2%
Ointment: 5%
Cream: 4% (LMX4®)
Plasters: 5% (700 mg/plaster) (Versatis®)
Spray: 10% (supplying 10 mg/dose), 50 mL (500 sprays) (Xylocaine®)
Topical: 4%, 50 mL (UNLICENSED)
With chlorhexidine
Lidocaine 2% and chlorhexidine gluconate 0.25% gel, 11 mL (Instillagel®) – from
supplies
With adrenaline and tetracaine
Gel: Lidocaine 4% + Adrenaline 0.1% + Tetracaine 0.5% (LAT), 3 mL
(UNLICENSED)
Lidocaine (Lignocaine) hydrochloride
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Medicines in the formulary are listed in chapters and subsections that generally
correspond with those in the BNF. Specific drugs can be searched by using the Find
function (Ctrl+F).
ENT and oropharyngeal use
Lolly: 100 mg (UNLICENSED)
With phenylephrine
Lidocaine 5% with phenylephrine 0.5% nasal spray, 2.5 mL
Mepivacaine hydrochloride
For dental use
Injection: 3%, 2.2 mL cartridge (Scandonest® Plain)
Prilocaine hydrochloride
Injection: 500 mg/50 mL (1%) (Citanest®)
For dental use
Injection: 80 mg/2 mL cartridge (4%) (Citanest®)
Ropivacaine
Ropivacaine Injection: 20 mg/10 mL (Naropin®)
Other Local Anaesthetics
Cocaine 4% + Adrenaline 1:1,000, 5 mL nasal pack
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