| Formulary Chapter 4: Central nervous system - Full Chapter
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| Chapter Links... |
 Gabapentinoid (pregabalin and gabapentin):De-prescribing guidance for non-cancer pain in adults in primary care |
| LSCMMG Paracetamol – prescribing weight-adjusted paracetamol in adults in the community |
| LSCMMG: ADHD combined adult and child shared care guideline |
| LSCMMG: Opioid reduction: best interests opioid reduction position statement |
| LSCMMG: Opioid treatment: patient-prescriber opioid treatment agreement |
| LSCMMG: Restless Legs Syndrome in Adults in Primary Care |
| Details... |
| 04.06 |
Drugs used in nausea and vertigo |
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| 04.06 |
Vomiting during pregnancy |
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| 04.06 |
Postoperative nausea and vomiting |
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Motion sickness |
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| 04.06 |
Other vestibular disorders |
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| 04.06 |
Cytotoxic chemotherapy |
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Olanzapine
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Formulary
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Treatment of post-chemotherapy nausea and vomiting (unlicensed indication).
For oncology use only.
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| 04.06 |
Palliative care |
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| 04.06 |
Migraine |
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| 04.06 |
Antihistamines |
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Cyclizine
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Formulary
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Tablets 50mg
Injection 50mg/mL
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Cinnarizine
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Formulary
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Tablets 15mg
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Promethazine Hydrochloride (Phenergan)
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Formulary
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Tablets 10mg, 25mg
Nausea and vertigo.
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Doxylamine and pyridoxine (Xonvea®)
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Formulary
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Tablets Doxylamine succinate 10 mg, Pyridoxine hydrochloride 10 mg.
Treatment of nausea and vomiting of pregnancy in women who do not respond to conservative management.
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LSCMMG: Doxylamine and Pyridoxine NMR
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| 04.06 |
Phenothiazines and related drugs |
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Droperidol
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Formulary
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Injection 2.5mg/ml
For the prevention and treatment of post operative nausea and vomiting.
 Restricted use: Theatre use only, when other treatment options are not suitable.
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Levomepromazine (Methotrimeprazine)
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Formulary
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Tablets 25mg
Tablets 6.25mg
Injection 25mg/1mL
For palliative care use only.
Nausea and vomiting and agitation/terminal restlessness in the last days of life.
 for schizophrenia (new patients)
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Prochlorperazine
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Formulary
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Tablets 5mg
Buccal tablets 3mg
Injection 12.5mg/1mL
Severe dystonic reactions sometimes occur with phenothiazines, especially in children and young people. Prochlorperazine should be avoided in patients with Parkinson’s disease and should be used cautiously in the elderly.
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| 04.06 |
Domperidone and metoclopramide |
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Metoclopramide
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Formulary
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Tablets 10mg
Liquid 5mg/5ml
Injection 10mg/2mL
Metoclopramide can induce acute dystonic reactions involving facial and skeletal muscle spasms and oculogyric crises. These dystonic effects are more common in the young (especially girls and young women) and the very old.
Metoclopramide should only be prescribed for short-term use (up to 5 days).
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 MHRA: Metoclopramide: risk of neurological adverse effects
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Domperidone
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Formulary
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Tablets 10mg
Liquid 5mg/5mL![]()
Domperidone is no longer indicated for the relief of nausea and vomiting in children aged under 12 years or those weighing less than 35 kg.
Healthcare professionals are advised to adhere to the licensed dose and to use the lowest effective dose for the shortest possible duration (max. treatment duration should not usually exceed 1 week).
As an aid to the initiation and maintenance of breast milk supply
Appropriate for initiation and ongoing prescribing in both primary and secondary care for a maximum period of seven days at a total maximum daily dose not exceeding 30mg.
Any health professional or lactation consultant with the appropriate skills, knowledge and competency within midwifery, health visiting and neonatal services can signpost a woman to her GP for discussion about the use of galactagogues where there is evidence of:
• an effective breastfeeding or expressing assessment and
• implementation of a breastfeeding care-plan to increase maternal lactation and
• an assessment of the need for the use of a galactagogue
See link below for full details
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LSCMMG: Domperidone Green (restricted) As an aid to the initiation and maintenance of breast milk supply
MHRA: Apomorphine with domperidone: minimising risk of cardiac side effects
MHRA: Domperidone for nausea and vomiting: lack of efficacy in children; reminder of contraindications in adults and adolescents
MHRA: Domperidone: risks of cardiac side effects
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| 04.06 |
5HT3 antagonists |
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Ondansetron
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Formulary
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Tablets 4mg, 8mg
Liquid 4mg/5mL
Injection 4mg/2mL, 8mg/4mL
Nausea & vomiting post operatively or chemotherapy induced.
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MHRA: Ondansetron for intravenous use: dose-dependent QT interval prolongation
MHRA: Ondansetron: small increased risk of oral clefts following use in the first 12 weeks of pregnancy
NICE: Management of vomiting in children and young people with gastroenteritis: ondansetron
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Granisetron
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Formulary
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Tablets 1mg
Injection 1mg/1ml, 3mg/3ml
Nausea & vomiting post operatively or chemotherapy induced.
Second line 5HT3 anatagonist.
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Ondansetron
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Formulary
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Second line for hyperemesis (unlicensed indication) in line with RCOG guidance.
Consultant initiation only.
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MHRA: Ondansetron for intravenous use: dose-dependent QT interval prolongation
MHRA: Ondansetron: small increased risk of oral clefts following use in the first 12 weeks of pregnancy
RCOG: The Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No.69)
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| 04.06 |
Neurokinin receptor antagonist |
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Aprepitant
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Formulary
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Capsules 80mg, 125mg
Adjunct treatment to prevent nausea and vomiting associated with moderately and highly emetogenic chemotherapy.
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Palonosetron with netupitant
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Formulary
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Capsules 300 mg/0.5 mg
Prevention of acute and delayed nausea and vomiting associated with highly emetogenic cisplatin-based cancer chemotherapy.
Prevention of acute and delayed nausea and vomiting associated with moderately emetogenic cancer chemotherapy.
Oncology use only, only when aprepitant is ineffective.
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| 04.06 |
Cannabinoid |
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| 04.06 |
Hyoscine |
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Hyoscine Hydrobromide
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Formulary
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Tablets 300micrograms
Patch 1mg/72hours
Hyoscine patches are currently unavailable. Healthcare professionals in primary and secondary care should not initiate any new patients on hyoscine hydrobromide (Scopoderm) 1.5mg patches, see: https://www.sps.nhs.uk/shortages/shortage-of-hyoscine-hydrobromide-scopoderm-1-5mg-patches/
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MHRA: Hyoscine hydrobromide patches (Scopoderm 1.5mg Patch or Scopoderm TTS Patch): risk of anticholinergic side effects, including hyperthermia
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| 04.06 |
Other drugs for Ménière's disease |
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Betahistine Dihydrochloride
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Formulary
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Tablets 8mg, 16mg
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Key |
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Restricted Drug |
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Unlicensed |
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Link to adult BNF
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Link to children's BNF
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Link to SPCs
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Scottish Medicines Consortium |
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Cytotoxic Drug |
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Controlled Drug |
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High Cost Medicine
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Cancer Drugs Fund
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Homecare |
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ICB commissioned |
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NHS England commissioned |
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Blueteq form needed |
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Low carbon footprint |
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Medium carbon footprint |
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High carbon footprint |
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| Status |
Description |
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Green:
Appropriate for initiation and ongoing prescribing in both primary and secondary care.
Generally, little or no routine drug monitoring is required. |
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Green (Restricted):
Appropriate for initiation and ongoing prescribing in both primary and secondary care provided:
Additional criteria specific to the medicine or device are met, or
The medicine or device is used following the failure of other therapies as defined by the relevant LSCMMG pathway.
Generally, little or no routine drug monitoring is required.
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Red medicines:
Medicine is supplied by the hospital for the duration of the treatment course.
Primary care initiation or continuation of treatment is not recommended unless exceptional circumstances such as specialist GP.
Red medicines are those where primary care prescribing is not recommended. These treatments should be initiated by specialists only and prescribing retained within secondary care. They require specialist knowledge, intensive monitoring, specific dose adjustments or further evaluation in use. If however, a primary care prescriber has particular specialist knowledge or experience of prescribing a particular drug for a particular patient it would not always be appropriate for them to expect to transfer that prescribing responsibility back to secondary care. There should be a specific reason and a specific risk agreement, protocol and service set up to support this.
Primary care prescribers may prescribe RED medicines in exceptional circumstances to patients to ensure continuity of supply while arrangements are made to obtain ongoing supplies from secondary care. |
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Amber level 0:
Suitable for prescribing in primary care following recommendation or initiation by a specialist.
Little or no specific monitoring required.
Patient may need a regular review, but this would not exceed that required for other medicines routinely prescribed in primary care.
Brief prescribing document or information sheet may be required.
Primary care prescribers must be familiar with the drug to take on prescribing responsibility or must get the required information.
When recommending or handing over care, specialists should ask primary care prescribers to take over prescribing responsibility, and should give enough information about the indication, dose, monitoring requirements, use outside product licence and any necessary dose adjustments to allow them to confidently prescribe. |
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Amber level 1 (with shared care):
Suitable for prescribing in primary care following recommendation or initiation by a specialist.
Minimal monitoring required.
Patient may need a regular review, but this would not exceed that required for other medicines routinely prescribed in primary care.
Full prior agreement about patient’s on-going care must be reached under the shared care agreement.
Primary care prescribers are advised not to take on prescribing of these medicines unless they have been adequately informed by letter of their responsibilities with regards monitoring, side effects and interactions and are happy to take on the prescribing responsibility. A copy of locally approved shared care guidelines should accompany this letter which outlines these responsibilities. Primary care prescribers should then tell secondary care of their intentions as soon as possible by letter so that arrangements can be made for the transfer of care. |
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Amber level 2 (with shared care and enhanced service):
Initiated by specialist and transferred to primary care following a successful initiation period.
Significant monitoring required on an on-going basis.
Full prior agreement about patient’s on-going care must be reached under the shared care agreement.
Suitable for enhanced service.
These medicines are considered suitable for GP prescribing following specialist initiation of therapy, as per shared care document which will be sent out with the request to prescribe, with on-going communication between the primary care prescriber and specialist. Amber Level 2 medicines require significant monitoring for which an enhanced service may be suitable. (Subject to local commissioning agreements). |
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Do not prescribe: NOT recommended for use by the NHS in Lancashire and South Cumbria.
Includes medicines that NICE has not recommended for use and terminated technology appraisals, unless there is a local need. |
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Grey medicines:
Medicines which have not yet been reviewed or are under the review process.
GPs and specialists are recommended not to prescribe these drugs.
This category includes drugs where funding has not yet been agreed.
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Refer to local guidance. |
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