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4. Central Nervous System

MHRA Alert (Feb 2015):  Drugs and driving: blood concentration limits set for certain drugs

Please refer to NICE guidelines NICE TA77

CSM Advice:

  1. Benzodiazepines are indicated for short term relief (2-4 weeks only) of anxiety that is severe, disabling or causing the patient unacceptable distress, occurring alone or in association with insomnia or short term psychotic illness.
  2. The use of benzodiazepines to treat short term anxiety is inappropriate. 
  3. Benzodiazepines should be used to treat insomnia only when it is severe, disabling or causing the patient extreme distress. 
Temazepam
BNF | BNFC | SPC

Tablets - 10mg

Liquid - 10mg/5ml

Zopiclone
BNF | BNFC | SPC

FIRST LINE

Tablets - 3.75mg, 7.5mg

 

 

Melatonin
BNF | BNFC | SPC

MR Tabs - 2mg

Capsules - 1mg, 2mg, 2.5mg, 3mg, 5mg, 10mg

Orodispersible Tabs - 2mg, 3mg

Liquid - 1mg/ml

MR tabs licensed only for adults over 55years. Classed as Amber for children and young adults and prescribed off label. All other products are available from UK specials manufacturers and classed as Amber drugs. Shared care protocol available.

Diazepam
BNF | BNFC | SPC

Tabs - 2mg, 5mg

Oral solution - 2mg/5ml

Rectal tubes - 2mg/ml, 4mg/ml

Chlordiazepoxide
BNF | BNFC | SPC

For use in Community Alcohol Detoxification programme only

Lorazepam
BNF | BNFC | SPC

Tabs - 1mg

SECOND LINE where rapid action is required and no suitable alternative or palliative care

Refer to NICE guidance for schizophrenia CG 178

See also: NICE NG11 - Challenging behaviour and learning disabilities: prevention and interventions for people with learning disabilities whose behaviour challenges

The choice of antipsychotic should take into account the relative side-effect profile and the views of the user.

Chlorpromazine
BNF | BNFC | SPC

Tabs - 25mg, 50mg, 100mg

Oral solution - 25mg/5ml, 100mg/5ml

Haloperidol
BNF | BNFC | SPC

Tabs - 500microgram, 1.5mg, 5mg, 10mg, 20mg

Oral Liquid - 2mg/ml

See NICE NG10 - Violence and aggression: short-term management in mental health, health and community settings

Sulpiride
BNF | BNFC | SPC

Tablets - 200mg & 400mg

Oral solution - 200mg in 5ml sugar-free 

 

Trifluoperazine
BNF | BNFC | SPC

Tabs - 1mg, 5mg

Oral Solution - 5mg/5ml

For initiation by specialists only

Zuclopentixol
BNF | BNFC | SPC

Tabs - 2mg, 10mg, 25mg

For initiation by specialists only

Amisulpride
BNF | BNFC | SPC

Tabs - 50mg, 100mg, 200mg

Solution - 100mg/ml

Aripiprazole
BNF | BNFC | SPC

Tabs - 5mg, 10mg, 15mg, 30mg

Orodispersible Tabs - 10mg, 15mg

Oral Solution - 1mg/ml

Orodispersible tablets should only be prescribed for patients who are unable to swallow solid dose forms

Olanzapine
BNF | BNFC | SPC

Tabs - 2.5mg, 5mg, 7.5mg, 10mg, 15mg, 20mg

Orodispersible Tabs - 5mg, 10mg, 20mg

Orodispersible tablets should only be prescribed for patients who are unable to swallow solid dose forms

Quetiapine
BNF | BNFC | SPC

Tabs - 25mg, 100mg, 150mg, 200mg, 300mg

M/R Tabs - 50mg, 150mg, 200mg, 300mg, 400mg

Risperidone
BNF | BNFC | SPC

Tabs - 500microgram, 1mg, 2mg, 3mg, 4mg, 6mg

Orodispersible tabs - 500micrograms, 1mg, 2mg, 3mg, 4mg

Orodispersible tablets should only be prescribed for patients who are unable to swallow solid dose form.

Palliperidone
BNF | BNFC | SPC

Paliperidone (Trevicta)175mg / 0.875ml; 263mg/1.315ml; 350mg/1.75ml; 525mg/2.625ml prolonged realease suspension for injection prefilled syringes

Paliperidone (Xeplion) 100mg/1ml; 150mg / 1.5ml; 50mg / 0.5ml; 75mg/0.75ml suspension for injection pre-filled syringes

Should be prescribed and administered by NTW specialist nurses according to local guidelines.

Clozapine
BNF | BNFC | SPC

Tablets - 25mg, 100mg

Oral suspension - 50mg/ml

Important safety information:

MHRA/CHM advice: Clozapine: reminder of potentially fatal risk of intestinal obstruction, faecal impaction, and paralytic ileus (October 2017)

 Clozapine has been associated with varying degrees of impairment of intestinal peristalsis. Patients and their carers should be advised to seek immediate medical advice before taking the next dose of clozapine if constipation develops.

Refer to NICE Guideline Bipolar Disorder CG185

 Antipsychotics drugs can be useful in acute episodes of mania and hypomania.

Lithium Carbonate
BNF | BNFC | SPC

Tabs - 250mg, 400mg  (Camcolit), Tabs 200mg, 400mg (Priadel)

MR Tabs - 450mg (Liskonum)

Must be prescribed as brand

Lithium Citrate
BNF | BNFC | SPC

Oral Solution - 509mg/5ml (Li-Liquid), 520mg/5ml (Priadel)

Must be prescribed as brand

Valproic Acid
BNF | BNFC | SPC

Tabs E/C - 250mg, 500mg (as semi sodium valproate)

NICE CG28: Depression in children and young people: Identification and management in primary, community and secondary care

Amitriptyline
BNF | BNFC | SPC

Tabs - 10mg, 25mg, 50mg

Oral Solution - 25mg/5ml, 50mg/5ml

For use unlicensed for neuropathic pain

Imipramine
BNF | BNFC | SPC

Tablets - 10mgs, 25mg

Use in urinary, depression and pain

Clomipramine
BNF | BNFC | SPC

Caps - 10mg, 25mg, 50mg

Lofepramine
BNF | BNFC | SPC

Tabs - 70mg,

Oral Solution - 70mg/5ml

Nortriptyline
BNF | BNFC | SPC

Tabs - 10mg, 25mg

For use unlicensed for neuropathic pain

Trimipramine
BNF | BNFC | SPC

Caps - 50mg

Tabs - 10mg, 25mg

Not formulary for depression. Only to be prescribed in exceptional circumstances when requested by a specialist

Trazodone
BNF | BNFC | SPC

Caps - 50mg, 100mg

Tabs - 150mg

Liquid - 50mg/5ml

Moclobemide
BNF | BNFC | SPC

Tabs - 150mg, 300mg

Citalopram
BNF | BNFC | SPC

Tabs - 10mg, 20mg, 40mg

Oral Drops - 40mg/ml

Fluoxetine
BNF | BNFC | SPC

Caps - 20mg

Liquid - 20mg/5ml

Sertraline
BNF | BNFC | SPC

Tabs - 50mg, 100mg

Paroxetine
BNF | BNFC | SPC

Tablets - 20mg

 Oral solution - 10mg/5ml

Duloxetine
BNF | BNFC | SPC

Caps - 30mg, 60mg

For use in diabetic neuropathy where other treatments are unsuitable or inadequate and initiated by a specialist

Agomelatine
BNF | BNFC | SPC

Tabs - 25mg

Agomelatine (Valdoxan®) is recommended for the treatment of depression only following an adequate trial of at least three alternative antidepressant drugs at maximally tolerated doses. Prescribing and monitoring should be initiated by specialist mental health physicians. After a minimum of 12 week’s treatment, responsibility for prescribing may be transferred to primary care

Mirtazapine
BNF | BNFC | SPC

Tabs - 15mg, 30mg, 45mg

Orodispersible Tabs - 15mg, 30mg, 45mg 

Orodispersible tablets should only be prescribed for patients who are unable to swallow solid dose forms

Venlafaxine
BNF | BNFC | SPC

Tabs - 37.5mg, 75mg 

Vortioxetine
BNF | BNFC | SPC

Tablets - 5mg, 10mg, 20mg

Recommended by NICE as an option for treating major depressive episodes in adults whose condition has responded inadequately to 2 antidepressants within the current episode.

NICE TA98

Methylphenidate
BNF | BNFC | SPC

Tabs - 5mg, 10mg, 20mg

MR Tabs - 18mg, 27mg, 36mg, 54mg (Concerta XL)

MR Caps - 10mg, 20mg, 30mg, 40mg (medikinet XL)

Initiated by specialist only - shared care protocol available, MR products must be prescribed by brand. Use in adults unlicensed

Methylphenidate, Dexamfetamine, Lisdexamfetamine and Atomoxetine for treatment of Attention Deficit Hyperactivity Disorder (ADHD) in Adults

Methylphenidate, Dexamfetamine, Lisdexamfetamine, Atomoxetine and Guanfacine for treatment of Attention Deficit Hyperactivity Disorder (ADHD) in Children and Young People

Guanfacine
BNF | BNFC | SPC

Tablets - 1mg, 2mg, 3mg 4mg  

Third line to atomoxetine and methylphenidate. Only to be initiated by a specialist when 1st line alternatives ineffective or not tolerated. Shared care protocol available 

Methylphenidate, Dexamfetamine, Lisdexamfetamine, Atomoxetine and Guanfacine for treatment of Attention Deficit Hyperactivity Disorder (ADHD) in Children and Young People

Cinnarizine
BNF | BNFC | SPC

Tablets - 15mg

Cyclizine
BNF | BNFC | SPC

Tablets - 50mg

Promethazine
BNF | BNFC | SPC

Tablets - 5mg

Domperidone
BNF | BNFC | SPC

Tablets - 10mg

Suspension - 5mg/5ml

Metoclopramide
BNF | BNFC | SPC

Tabslets - 10mg

Oral Solution - 5mg/5ml

Caution in elderly, young adults and children

Betahistine
BNF | BNFC | SPC

Tablets - 8mg, 16mg

Menieres disease

NICE CG173: Neuropathic pain

Paracetamol
BNF | BNFC | SPC

Non-opioid analgesics and compound analgesic preparations

Dihydrocodeine Tartrate
BNF | BNFC | SPC

Tablets - 30mg

Oral Solution - 10mg/5ml

Codeine
BNF | BNFC | SPC

Tablets - 15mg, 30mg

Syrup - 25mg/5ml

Tramadol
BNF | BNFC | SPC

Capsules - 50mg

Fentanyl
BNF | BNFC | SPC

Patches - 12microgram/hour, 25microgram/hour, 50microgram/hour, 75microgram/hour, 100microgram/hour

Methadone
BNF | BNFC | SPC

Tablets - 5mg

Morphine Sulphate
BNF | BNFC | SPC

Tablets - 10mg, 20mg, 50mg (Sevredol),

MR capsules - 10mg, 30mg, 60mg, 10mg, 200mg (Zomorph) (Morphgesic tablets when Zomorph not appropriate) Liquid                                                              

Injection - 10mg/ml, 15mg/ml, 20mg/ml, 30mg/ml

Oxycodone
BNF | BNFC | SPC

Capsules - 5mg, 10mg, 20mg,

Liquid - 5mg/5ml

MR Tablets - 5mg, 10mg, 15mg, 20mg, 40mg, 60mg80mg, 120mg

Sumatriptan
BNF | BNFC | SPC

Tablets - 50mg, 100mg

Injection - (Autoinjector) 12mg/ml (6mg/0.5ml syringe)    

Also licensed for treatment of cluster headaches. If ineffective an alternative 5HT1-receptor agonist may be tried     

Refer to NICE guidance CG 137. The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care.

Carbamazepine
BNF | BNFC | SPC

Tablets - 100mg, 200mg, 400mg

MR Tablets - 200mg, 400mg

Liquid - 100mg/5ml

Ethosuximide
BNF | BNFC | SPC

Capsules - 250mg

Syrup - 250mg/5ml

Gabapentin
BNF | BNFC | SPC

Capsules - 100mg, 300mg, 400mg

Also licensed for neuropathic pain

Pregabalin
BNF | BNFC | SPC

Capsules - 25mg50mg, 75mg, 100mg, 150mg, 200mg, 225mg, 300mg

Also licensed for neuropathic pain

Lamotrigine
BNF | BNFC | SPC

Tablets - 25mg, 50mg, 100mg, 200mg

Dispersible Tablets - 2mg (only Chewable), 5mg, 25mg, 100mg

Levetiracetam
BNF | BNFC | SPC

Tablets - 25mg, 50mg, 100mg, 200mg

Dispersible Tablets - 2mg (only Chewable), 5mg, 25mg, 100mg

Phenobarbital
BNF | BNFC | SPC

Tablets - 15mg, 30mg, 60mg

Elixir - 15mg/5ml

Phenytoin (Sodium Salt)
BNF | BNFC | SPC

Capsules - 25mg, 50mg, 100mg, 300mg,

Chewable Tablets - 50mg

Suspension - 30mg/5ml

Suspension contains phenytoin base - care need when changing to or from capsules

Topiramate
BNF | BNFC | SPC

Tablets - 25mg, 50mg, 100mg, 200mg

Capsules (Sprinkle) - 15mg, 25mg, 50mg

Sodium Valproate
BNF | BNFC | SPC

Tablets e/c - 200mg, 500mg,

Tablets MR - 200mg, 300mg, 500mg,

Oral Solution - 200mg/5ml,

Tablets (crushable) - 100mg

Vigabatrin
BNF | BNFC | SPC

Tablets - 500mg

Powder (Sugar free) - 500mg/Sachet

Clobazam
BNF | BNFC | SPC

Tablets - 10mg

Only prescribable on NHS for epilepsy. Must be endorsed SLS

Clonazepam
BNF | BNFC | SPC

Tablets - 500microgram, 2mg

Diazepam
BNF | BNFC | SPC

Rectal Solution - 2mg/ml, 4mg/ml

Midazolam Buccal
BNF | BNFC | SPC

Oromucosal Solution - 5mg/ml

Pre-filled syringes - 0.5ml, 1ml, 1.5ml, 2ml (Buccolam)

Other unlicensed formulations are available - check dose

NICE CG186:  Multiple sclerosis: management of multiple sclerosis in primary and secondary care

Co-beneldopa (Madopar)
BNF | BNFC | SPC

Capsules - 62.5mg, 125mg, 250mg

Dispersible Tablets - 62.5mg, 125mg

MR Capsules - 125mg

Co-careldopa (Sinemet)
BNF | BNFC | SPC

Tablets - 62.5mg, 110mg, 125mg, 275mg

MR Tablets - 125mg, 250mg

Cabergoline
BNF | BNFC | SPC

Tablets - 1mg, 2mg

Pergolide
BNF | BNFC | SPC

Tablets - 50microgram, 250microgram, 1mg

Pramipexole
BNF | BNFC | SPC

Tablets (as Base) - 88microgram, 180microgram, 350microgram, 700microgram

Ropinirole
BNF | BNFC | SPC

Tablets - 250microgram, 500microgram, 1mg, 2mg, 5mg

Tablets MR - 2mg, 4mg, 8mg

Rotigotine
BNF | BNFC | SPC

Patches - 1mg/24hours, 2mg/24hours, 3mg/24hours, 4mg/24hours6mg/24hours, 8mg/24hours

Selegiline Hydrochloride
BNF | BNFC | SPC

Tablets - 5mg, 10mg

Oral Liquid - 10mg/5ml

Entacapone
BNF | BNFC | SPC

Tablets - 200mg

Orphenadrine
BNF | BNFC | SPC

Tablets - 50mg

Oral Solution - 50mg/5ml

Procyclidine
BNF | BNFC | SPC

Tablets - 5mg

Syrup - 2.5mg/5ml

Tetrabenazine
BNF | BNFC | SPC

Tablets - 25mg

Haloperidol
BNF | BNFC | SPC

See section 4.2.1

Unlicensed indication

Acamprosate
BNF | BNFC | SPC

Tablets - 333mg

Disulfiram
BNF | BNFC | SPC

Tablets - 200mg

Nalmefene
BNF | BNFC | SPC

Tablets - 18mg

Requires prescribing in accordance with NICE guidance: http://www.nice.org.uk/guidance/ta325. For patients who:

  • Who have a high drinking risk level (defined as alcohol consumption of more than 60 g per day for men and more than 40 g per day for women, according to the World Health Organization's drinking risk levels) without physical withdrawal symptoms and

 

  • Who do not require immediate detoxification.

The marketing authorisation states that nalmefene should:

  • Only be prescribed in conjunction with continuous psychosocial support focused on treatment adherence and reducing alcohol consumption and
  • Be initiated only in patients who continue to have a high drinking risk level 2 weeks after initial assessment
Bupropion
BNF | BNFC | SPC

Tablets - 150mg

Prescribe according to Smoking Cessation policy

Nicotine Replacement Therapy
BNF | BNFC | SPC

Patches, lozenges, chewing gum, inhalator, oral spray, mini lozenge, microtab, nasal spray, strips (oral film)

Prescribe according to Smoking Cessation policy.

Varenicline
BNF | BNFC | SPC

Tablets - 500micrograms, 1mg

Prescribe according to Smoking Cessation policy

Buprenorphine
BNF | BNFC | SPC

Sublingual tablets - 400micrograms, 2mg, 8mg

 

Methadone Hydrochloride
BNF | BNFC | SPC

Oral Solution - 1mg/ml

Sugar Free Oral Solution - 1mg/ml

Oral Concentrate - 10mg/ml, 20mg/ml

Donepezil
BNF | BNFC | SPC

NICE TA217

Tablets - 5mg, 10mg

Orodispersible Tablets - 5mg, 10mg

Only use orodispersible if patient has genuine

Galantamine
BNF | BNFC | SPC

NICE TA217

Tablets - 8mg, 12mg

Oral solution - 4mg/ml

MR Capsules - 8mg, 16mg, 24mg

MR capsules only to be used when a once a day dose is essential or patient has tried standard release galantamine and is intolerant.

Rivastigamine
BNF | BNFC | SPC

NICE TA217

Capsules - 1.5mg, 3mg, 4.5mg, 6mg

Oral solution - 2mg/ml

Patches - 4.6mg / 24hours; 9.5mg/24hours

Patches should only be used when other formulations inappropriate

Memantine
BNF | BNFC | SPC

NICE TA217

Tablets - 10mg 20mg

Oral Solution - 5mg / actuation (10mg/ml)