GP formulary

GI - GASTROINTESTINAL

1.1.1 AntacidsFirst choice: Magnesium trisilicate mixture: [200ml £1.01].Dose: 10ml three times daily. Prescribing notes: Magnesium salts can have laxative effect. More potent antacid effect than alginates. Contain sodium (3mmol per 5ml). OTC. :Low sodium choice: Asilone® suspension: [500ml £1.95]. Dose: 5-10ml after meals and at bedtime or when required up to four times a day.Prescribing notes: Contains the antifoaming agent simeticone which will help to relieve flatulence. OTC. :1.1.2 AlginatesFirst choice: Peptac® suspension [500ml £1.95].Dose: 10-20ml four times daily after meals and at bedtime. Prescribing notes: Alginates should be reserved for the treatment of gastro-oesophageal reflux disease. Peptac® contain sodium (3mmol per 5ml) but is sugar free. Available as peppermint and aniseed flavours, but the majority of patients prefer peppermint. OTC. If tablet formulation required recommend OTC products initially; if this is ineffective then prescribe Gastrocote tablets (1mmol sodium per tablet). :

Second choice: Acidex® suspension [500ml £1.70].Dose: 10-20ml four times daily after meals and at bedtime. Prescribing notes: Alginates should be reserved for the treatment of gastro-oesophageal reflux disease. Acidex® contain sodium (3mmol per 5ml) but is sugar free. Available as peppermint and aniseed flavours, but the majority of patients prefer peppermint. OTC. If tablet formulation required recommend OTC products initially; if this is ineffective then prescribe Gastrocote tablets (1mmol sodium per tablet).

1.2 Drugs altering gut motility

Links to NICE guidance Irritable Bowel Syndrome. Clinical Guideline No. 61

Mebeverine tabs 135mg (G): [84 tabs £5.07].Dose: One three times daily, 20 mins before meals.

Hyoscine Butylbromide tabs 10mg: [224 tabs £9.00].Dose: 20mg four times daily.Prescribing notes: Poor absorption, brief action.

Side effects include dry mouth, hesitancy, constipation and blurred vision. :1.3 Ulcer healing and H pyloriH. Pylori Eradiation

See also North Devon Joint Formulary antibiotic recommendations for primary care

First choice:Lansoprazole 30mg twice daily for 7 days, plusClarithromycin 250mg twice daily for 7 days, plusMetronidazole 400mg twice daily for 7 days. [Total cost =£4.47].Prescribing notes: Please note lower strength of clarithromycin than the regimen above. Do not use clarithromycin or metronidazole if used in the past 12 months for ANY infection, refer to BNF for an alternative regimen. 1.3.1 H2 Receptor antagonistsFirst choice: Ranitidine tabs (G): 150mg [60tabs £1.59], 300mg [30tabs £1.58].Dose: 150mg twice daily or 300mg at night.Prescribing notes: 1.3.5 Proton pump inhibitors

Links to NICE Guidance

Dyspepsia – Managing Dyspepsia in Adults in Primary Care. NICE Clinical Guideline No. 17

Lansoprazole caps (G): 15mg caps [28caps £1.02], 30mg caps [28caps £1.56].Dose: 15mg to 30mg once daily.Prescribing notes: Also available as orodispersible tablet formulation 15mg [28tabs £2.99], 30mg [28tabs £5.50]. These should only be prescribed for patients with swallowing difficulties. Orodispersible tablets will be treated as a Non-Formulary drug. Omeprazole (G): 10mg caps [28caps £1.34], 20mg caps [28caps £1.36].Dose: 20mg daily (treatment); 10mg daily (maintenance).Prescribing notes: Capsules are more cost effective than EC tablets. Dispersible tablets are only available as a branded product and do not attract generic cost savings 10mg dispersible tabs [28 disp tabs £7.75], 20mg dispersible tabs [28 disp tabs £11.60]. If a dispersible tablet is required then lansprazole dispersible tablets are more cost effective. If patient on warfarin or phenytoin it is preferable to prescribe lansoprazole.

1.4 Acute DiarrhoeaOral RehydrationSee section 9.2.1.2.

1.4.2 Antimotility drugs First Choice: Loperamide caps (G): 2mg [30 caps 89p].Dose: 4mg initially followed by 2mg after each loose stool for up to 5 days.Prescribing notes: Low systemic absorption. OTC.

Second Choice: Codeine Phosphate tabs (G): 15mg [28 tabs 87p], 30mg [28 tabs £1.02], 60mg [28 tabs £1.62].Dose: 30mg three or four times daily (range 15-60mg).Prescribing notes: :1.5 Chronic Bowel DisordersCaution: Patients receiving aminosalicylates should be advised to report any unexplained bleeding, bruising, purpura, sore throat, fever or malaise that occurs during treatment. A blood count should be performed and the drug stopped immediately if there is a suspicion of a blood dyscrasia.

First Choice: Sulfasalazine EC tabs (G): 500mg [112 tabs £13.03].Dose: 500mg four times a day (maintenance).Prescribing notes: For monitoring see Shared Care Guideline :

Second Choice:Mesalazine EC tabs (Asacol MR®): 400mg [90 tabs 29.41], 800mg [90 tabs £58.81].Dose: see BNF

Mesalazine MR tabs (Pentasa®): 500mg [90 tabs £27.67].Dose: see BNF

Prescribing notes: Test renal function initially and every 3 months for the first year then every 6 months for the next 4 years and annually thereafter. Brands are not interchangeable; patients should stay on the brand that stabilised their condition. May stain soft contact lenses. : 1.6 Laxatives1.6.1 Bulk forming laxatives

Link to NICE guidance Constipation in children and young people. Clinical Guideline No. 99

First choice: Ispaghula husk sachets: [60 sachets £3.56].Dose: 1 sachet twice dailyPrescribing notes: Fybogel sachets are now sugar free and gluten free. OTC. Available as plain, orange & lemon flavours.

Links: Constipation Guidelines:

1.6.2 Stimulant laxatives

First choice: Senna tabs(G): [60 tabs £1.34].Dose: 2 to 4 tabs usually at night, then gradually reduce.Prescribing notes: No stimulant laxative should be given long term as they cause atony of the colon and significant electrolyte imbalance. Senna can give a red tint to urine. OTC.

Links: Constipation Guidelines: :

Second choice: Docusate caps (G): 100mg [60 caps £3.84].Dose: up to 500mg daily in divided doses.Prescribing notes: No stimulant laxative should be given long term as they cause atony of the colon and significant electrolyte imbalance. OTC.


1.6.4 Osmotic laxativesFirst choice: Macrogol 3350 compound sachets: [30 sachets £4.45].Dose: see BNF.Prescribing notes: OTC.


Chronic Constipation and Faecal Impaction in Children:First Choice: Movicol Paediatric Plain Sachets [20 sachets £4.45, 30 sachets £6.68].Dose: see BNF for children.Prescribing notes: Prescription Only Medicine (POM).1.6.5 Rectally administered laxativesBisacodyl suppositories: [10mg supps 22p each].Glycerin suppositories: [4g supps 10p each].Phosphates enema BP: [enema 46p each]Sodium citrate microenema: [enema 41p each].1.7 Local preparations for anal and rectal disorders1.7.1 Soothing haemorrhoidal preparationsFirst choice: Anusol® cream and ointment: [25g tube £1.84], suppositories [15p each]. Dose: use rectally night and morning and after each bowel movement.Prescribing notes: May sensitise anal skin so they should not be used for more than 2 weeks. OTC. :1.7.2 Compound haemorrhoidal preparations with corticosteroidsFirst choice: Anusol HC® ointment: [tube £3.50], suppositories [21p each]. Dose: use rectally night and morning and after each bowel movement. Available OTC as Anusol Plus HC.Prescribing notes: Do not use for more than 7 days. :1.7.4 Management of Anal Fissures

First choice: Glyceryl Trinitate 0.4% rectal

ointment (Rectogesic®): [30g tube £34.80]. Dose: for the relief of pain associated with chronic anal fissure, apply 2.5cm of ointment to anal canal every 12 hours until pain stops. Maximum duration of use 8 weeks.Prescribing notes: The management of anal fissures requires stool softening by increasing dietary fibre in the form of bran or by using a bulk-forming laxative. Short-term use of local anaesthetic agents may help. :1.8 Faecal Incontinence

Links to NICE guidance

Faecal Incontinence. Clinical Guideline No. 49

1.9 G.I.InfectionsClostridium difficileClostridium difficile should be suspected in patients with diarrhoea, especially if there are risk factors such as age over 65, co-morbidities, recent hospital admission or recent antibiotic use (particularly ciprofloxacin or other quinolones).Stop unnecessary antibiotics and/or PPIs. 70% of patients respond to Metronidazole in 5 days; 94% in 14 daysSend a stool sample for toxin testing.

First or second episode: Metronidazole 400mg 3 times a day for 10-14 days, [42tabs £3.06].Third episode or severe* disease: Vancomycin 125mg 4 times a day 7 - 10 days, [40caps £174.10].* Severe if temp above 38.5°C; WCC above 15; rising creatinine or signs/symptoms of severe colitisDiscuss patients with consultant microbiologist.

Traveller’s DiarrhoeaMost diarrhoea is self limiting so antibiotic treatment is not routinely indicated. Send stool sample for identification of pathogens which may indicate treatment. Please indicate time and place of travel on request. Some pathogens, eg Giardia, need 3 samples to be excludedIf empiric treatment is required use ciprofloxacin 500mg bd for 5 days, [10tabs 91p]. If not settling within 48 hours seek advice as metronidazole may be indicated.

DiverticulitisThe diagnosis of diverticulitis can be difficult. If there is confirmed diverticulitis then first choice antibiotic therapy is co-amoxiclav 625mg three times daily for 5 days, [15tabs £1.81]. If there is failure to respond then advise refer to secondary care.

Cholecystitis (Low Grade)

The diagnosis of cholecystitis can be difficult. First choice antibiotic therapy is ciprofloxacin 500mg twice daily for 7-10days, [20tabs £1.30]. If there is failure to respond then refer to secondary care.

ThreadwormsFirst Choice: Mebendazole (G): 100mg tabs [2tabs 45p], 100mg/5ml suspension [10ml 53p].Dose: Adults and Child over 2 years, 100mg as a single dose repeat after 2 weeks if reinfection occurs.Prescribing notes: Only licensed above the age of 2 years but BNF for Children states that the dose for 6months onwards is as above. :

Second Choice: Piperazine 4g with Senna 15.3mg (Pripsen): [2 sachets £1.47].Dose: 3 months to 1 year one level 2.5ml spoonful as a single dose in the morning repeated after 14 days; 1 to 6 years one level 5ml spoonful as a single dose in the morning repeated after 14 days; above 6 years the contents of one sachet as a single dose in the morning repeated after 14 daysPrescribing notes: OTC. :

CARDIOVASCULAR

2.1.1 Cardiac GlycosidesFirst choice: Digoxin tabs (G): 62.5micrograms [28 tabs £2.67] 125micrograms [28 tabs 91p], 250micrograms [28 tabs 91p].Dose: 62.5 to 250 micrograms daily.Prescribing notes: :

Summary of antihypertensive treatment choices & treatment steps Step Age 55 years or

lessAge over 55 years, or any age people of Afro-Caribbean origin

1 A C 2 A + C 3 A + C + D 4 Resistant hypertension: A + C + D +

additional diuretic or alpha-blocker or beta-blocker. Consider seeking specialist advice

A = ACE inhibitor or low cost ARB; C = calcium-channel blocker; D = thiazide-like diuretic

2.2 Diuretics2.2.1 Thiazides and related diureticsFirst Choice: Indapamide tabs (G): 2.5mg [28 tabs £1.09].Dose: 2.5mg daily.Prescribing Notes: First line diuretic in newly diagnosed patients with stage 3 hypertension or those requiring a change of therapy (see NICE 127) :

Second choice: Bendroflumethiazide tabs (G): 2.5mg [28 tabs 66p].Dose: 2.5mg in the morning (higher doses rarely necessary).Prescribing notes: Oedema, or to continue in patients with stage 3 hypertension already established and well controlled on it. :

Links: Hypertension – Lifestyle Measures

Hypertension. Clinical Guideline No. 127.

2.2.2 Loop DiureticsFirst choice: Furosemide tabs (G): 20mg [28 tabs 71p], 40mg [28 tabs 70p].Dose: 20 to 80mg daily.Prescribing notes: :

Second choice: Bumetanide tabs 1mg (G):

[28tabs 91p].Dose: 1 to 5mg daily.Prescribing notes: Bumetanide has no advantage over furosemide in the majority of cases. :2.2.3 Potassium Sparing DiureticsFirst choice: Amiloride tabs 5mg (G): [28tabs £1.00]Dose: 5 to 20mg daily.Prescribing notes: On its own amiloride is a weak diuretic, best used in combination with a loop diuretic where it is more effective than potassium supplements in conserving potassium. :

Second choice: Spironolactone tabs (G): 25mg [28tabs £1.33], 50mg [28tabs £2.11], 100mg [28tabs £2.30].Dose: moderate to severe heart failure and first choice additional treatment in Stage4 hypertension, initially 25mg daily; for other indications see BNF.Prescribing notes: High doses used in oedema and ascites in cirrhosis of the liver malignant ascites etc. Low doses in heart failure. :2.3 Anti-Arrhythmic Drugs

Links to NICE guidance

Dronedarone for the treatment on non-permanent atrial fibrillation. TAG 197

Amiodarone tabs (G): 100mg [28 tabs £1.22], 200mg [28 tabs £1.68].Dose: 100 to 200mg daily (maintenance).Prescribing notes: Needs loading dose see BNF. Liver & thyroid function tests and a chest Xray required before treatment started. Check SPC and BNF for Cautions, Contra-indications, Adverse Effects and Drug Interactions. Patients should be warned about long term side effects, to shield their skin from sunlight and to use a total sunscreen because of risk of phototoxicity. :

Disopyramide caps (G): 100mg [84 caps £20.37], 150mg [84 caps £27.21].Dose: 300 to 800mg daily in divided dosesPrescribing notes: Antimuscarinic activity. Caution with glaucoma and prostatic enlargement. :

Flecainide tabs (G): 50mg [60 tabs £4.35], 100mg [60 tabs £6.26]Dose: 50 to 200mg twice daily.Prescribing notes: Flecainide must only be initiated

under the direction of a hospital consultant. When prescribed for “prn” use in arythmia (e.g. “pill in the pocket” approach) the dose must be explicit, unambiguous and include a clear statement of dose frequency and the maximum daily dose to be taken. See BNF for further information. :

Propafenone tabs: 150mg [90 tabs £7.37], 300mg [90 tabs £14.01]Dose: 150 to 300mg three times a day.Prescribing notes: Antimuscarinic activity. Caution with glaucoma and prostatic enlargement. :2.4 Beta- Blockers

Hypertension Angina and ArrythmiasFirst choice: Atenolol tabs (G): 25mg [28 tabs 71p], 50mg [28 tabs 73p], 100mg [28 tabs77p].Dose: 25 to 100mg once daily.Prescribing notes: Do not co-prescribe with verapamil. Caution with any beta-blocker in asthmatic patients. If combination of beta-blocker and diuretic is needed use atenolol and bendroflumethiazide separately. Tenoretic / Tenoret (co-tenidone) contains chlorthalidone which is longer acting and may cause nocturia. Prescribing notes:



Second choice: Metoprolol tabs (G): 50mg [56 tabs £1.40], 100mg [56 tabs £3.73].Dose: 50 to 200mg daily in one to three divided doses.Prscribing notes: Do not co-prescribe with verapamil. Caution with any beta-blocker in asthmatic patients. :AnxietyFirst choice: Propranolol tabs (G): 10mg [28 tabs 76p], 40mg [28 tabs 79p], 80mg [28 tabs 69p], 160mg [28 tabs £2.34].Dose: 40mg once daily increased to three times a day if necessaryPrescribing notes: Do not co-prescribe with verapamil. Caution with any beta-blocker in asthmatic patients.

Chapter 4 - Anxiolytics :

Heart FailureFirst choice: Bisoprolol tabs (G): 1.25mg [28tabs £1.62]; 2.5mg [28tabs £1.42]; 3.75mg [28tabs £4.92]; 5mg [28 tabs 92p]; 7.5mg [28tabs £5.33]; 10mg [28 tabs 99p].Dose: 1.25mg once daily (in the morning) for one week then, if well tolerated, increase to 2.5mg once daily for 1 week, then 3.75mg once daily for 1 week, then 5mg once daily for 4 weeks, then 7.5mg

once daily for 4 weeks, then 10mg once daily. Maximum 10mg daily.Prescribing notes: Do not co-prescribe with verapamil. Caution with any beta-blocker in asthmatic patients. :Second choice: Carvedilol tabs (G): 3.125mg [56 tabs £1.94]; 6.25mg [56 tabs £2.14]; 12.5mg [56 tabs £2.38]; 25mg [56 tabs £2.92].Dose: initially 3.125mg twice daily (with food), dose increased at intervals of at least two weeks to 6.25mg twice daily, then to 12.5mg twice daily, then to 25mg twice daily; increase to highest dose tolerated. Maximum 25mg twice daily in patients with severe heart failure or body-weight less than 85kg and 50mg twice daily in patients over 85kg.Prescribing notes: Do not co-prescribe with verapamil. Caution with any beta-blocker in asthmatic patients. :Life-Threatening ArrhythmiasFirst Choice: Sotalol tabs (G): 40mg [56tabs £1.29]; 80mg [56tabs £1.91].Dose: with ECG monitoring and measurement of QT interval, arrhythmias, initially 80mg daily in one to two divided doses increasing gradually at intervals of 2 to 3 days to usual dose of 80 to 160mg twice daily.Prescribing notes: Usually only initiated in secondary care. CSM advice. The use of sotalol should be limited to the treatment of ventricular arrhythmias . It should no longer be used for angina, hypertension, thyrotoxicosis or for secondary prevention of myocardial infarction; when stopping sotalol for these indications, the dose should be gradually reduced. More cost effective to prescribe 160mg dose as 2 x 80mg tablets. :2.5.4 Alpha-BlockersFirst choice: Doxazosin tabs (G): 1mg [28 tabs 82p], 2mg [28 tabs 85p], 4mg [28 tabs £1.21].Dose: 1mg daily increasing slowly to a maximum of 16mg daily.Prescribing notes: Initiate therapy gradually. First dose on retiring to bed to avoid collapse. May be used in conjunction with a thiazide diuretic or betablocker :2.5.5.1 ACE InhibitorsFirst choice: Ramipril caps (G): 1.25mg [28 caps 97p], 2.5mg [28 caps £1.04], 5mg [28 caps £1.11], 10mg [28 caps £1.23].Dose: 1.25 to 10mg daily (hypertension), 1.25 to 10mg daily (heart failure), 2.5 to 5mg twice daily (post MI). Prescribing notes: Tablets are more expensive than capsules at all strengths.

Hypertension – Lifestyle Measures


Second choice: Lisinopril tabs (G): 2.5mg [28 tabs 75p], 5mg [28 tabs 80p], 10mg [28 tabs 89p], 20mg [28 tabs £1.02]. Dose: 2.5 to 40mg daily (hypertension), 2.5 to 20mg daily (heart failure), 5 to 10mg daily (post MI), 2.5 to 20mg daily (diabetic nephropathy). Prescribing notes:



2.5.5.2 Angiotensin-2 Antagonists (ARB)First choice: Losartan tabs (G): 12.5mg [28 tabs £6.61], 25mg [28 tabs 99p], 50mg [28 tabs £1.07]; 100mg [28 tabs £1.24].Dose: HYPERTENSION: diabetic nephropathy in type 2 diabetes mellitus, usually 50mg once daily (intravascular volume depletion, initially 25mg once daily); if necessary increased after several weeks to 100mg once daily; ELDERLY over 75 years initially 25mg daily.Prescribing notes: ARBs should be reserved for those patients who cannot tolerate ACE inhibitors. Losartan is now available as a generic product. New patients who require an ARB due to true intolerance to an ACEI should be initiated on losartan for treatment of hypertension.



Second choice: Candesartan tabs: 2mg [28 tabs £14.32], 4mg [28 tabs £9.78], 8mg [28 tabs £9.89], 16mg [28 tabs £12.72], 32mg [28 tabs £16.13].Dose: HYPERTENSION: the recommended initial dose and usual maintenance dose is 8 mg once daily. Increase to 16mg once daily after 4 weeks and 32mg once daily after a further 4 weeks.HEART FAILURE: the usual recommended initial dose is 4 mg once daily. Titrate up to the target dose of 32 mg once daily or the highest tolerated dose by doubling the dose at intervals of at least 2 weeks Prescribing notes: Angiotensin II antagonists should be reserved for those patients who cannot tolerate ACE inhibitors. Dose 4mg daily in hepatic and renal impairment.



2.6.1 NitratesSublingual PreparationsFirst choice: Glyceryl Trinitrate 400micrograms spray: aerosol spray [180 doses £2.63, 200

doses £3.29]; pump spray [180 doses £2.63, 200 doses £3.44]. Dose: Use one or two doses under the tongue, and close mouth, at onset of angina. If pain has not subsided within five minutes, dial 999.Prescribing notes: May prove more cost effective than GTN tablets if attacks are infrequent due to short shelf life of tablets once opened. :

Second choice: Glyceryl Trinitrate tabs (G): 500micrograms [100 tabs £2.77]. Dose: 1 to 2 tabs as required.Prescribing notes: Tablets must be discarded 8 weeks after opening. :Oral PreparationsFirst choice: Isosorbide Mononitrate tabs: 10mg [56 tabs 94p], 20mg [56 tabs £1.02], 40mg [56 tabs £1.33].Dose: 10 to 40mg twice daily, preferably asymmetrically in the morning and 2pm. Maximum 120mg daily.Prescribing notes: :

Second choice: Isosorbide Mononitrate SR tabs (Monomax XL tabs): 60mg [28 tabs £5.25].Dose: One tablet in the morning (half a tablet for the first 2 to 4 days to minimise the possibility of headache), increased if necessary to two tablets in the morning.Prescribing notes: NB please ensure the prescription states tablets as the capsules are more expensive. DO NOT prescribe SR isosorbide mononitrate generically. :2.6.2 Calcium Channel BlockersHypertension and AnginaFirst Choice: Amlodipine tabs (G): 5mg [28 tabs 82p], 10mg [28 tabs 91p].Dose: 5 to 10mg once daily. Prescribing notes: Grapefruit juice increases the bioavailability of amlodipine.



Second Choice: Diltiazem tabs (G) 60mg tabs [84 tabs £4.43];MR caps (Slozem): 120mg MR caps [28 caps £7.00], 180mg MR caps [28 caps £7.80], 240mg MR caps [28 caps £8.20], 300mg MR caps [28 caps £8.50].Dose: Tabs, 60 to 120mg three times a day; MR Caps, 120mg to 360mg once daily. Prescribing notes: Once daily preparations improve concordance. They should be prescribed by brand name to avoid bioavailability differences.

Other brands of diltiazem include Adizem & Tildiem but Slozem provides is the most cost effective preparation. Appropriate patients should be transferred onto Slozem.



Third Choice: Nifedipine MR (Adalat LA tabs): 20mg [28 tabs £5.27], 30mg [28 tabs £6.85], 60mg [28 tabs £9.03]; (Coracten XL caps): 30mg [28caps £4.89], 60mg [28caps £7.34].Dose: 20 to 90mg once daily. Prescribing notes: Avoid use if hepatic impairment or where there is a history of oesophageal or gastro-intestinal obstruction, decreased lumen diameter of the GI tract or inflammatory bowel disease (including Crohn’s disease). Grapefruit juice increases the bioavailability of nifedipine. It is recommended MR nifedipine should be prescribed by brand name to avoid bioavailability differences.



ArrythmiasFirst choice: Verapamil tabs (G): 40mg [84 tabs £1.32], 80mg [84 tabs £1.67], 120mg [84 tabs £3.96].Dose: 40 to 120mg three times a day.Prescribing notes: :2.6.3 Potassium Channel ActivatorsNicorandil tabs: 10mg [60 tabs £7.88], 20mg [60 tabs £14.44].Dose: 10 to 30mg twice daily.Prescribing notes: :2.8.1 Parenteral Anticoagulants

Links: Enoxaparin administration record

2.8.2 Oral Anticoagulants

Oral Anticoagulation Guideline

Treatment guidelines for anticoagulated patients with an INR greater than 7

First Choice: Warfarin tabs (G): 500micrograms [28tabs £1.41]; 1mg [28 tabs 75p], 3mg [28 tabs 78p], 5mg [28 tabs 81p].Dose: As per PTT.Prescribing notes: :2.9 Antiplatelet Drugs

Acute coronary syndromes - glycoprotein IIb/IIIc inhibitors. No.47.

Acute coronary syndromes - clopidogrel. No.80.

Prevention of occlusive vascular events - clopidogrel and MR dipyridamole. TAG 210.

AFTER ISCHAEMIC STOKE or TRANSIENT ISCHAEMIC ATTACK

First Choice: Clopidogrel tabs (G): 75mg [30 tabs £1.94].Dose: 75mg once daily. Prescribing notes: No limit on duration of treatment. Link to EPC statement.

Second Choice: Aspirin dispersible tabs (G): 75mg [28 tabs 82p].Dose: 75mg once daily.PlusDipyridamole 200mg MR caps [60 caps £9.00].Dose: one cap twice a day.Prescribing notes: only if clopidogrel is contraindicated or not tolerated, but treatment is no longer limited to 2 years duration. Link to EPC statement.

Third Choice:Dipyridamole: 200mg MR caps: [60 caps £9.00].Dose: one cap twice a day.Prescribing notes: MR dipyridamole alone is recommended after an ischaemic stroke only if both aspirin and clopidogrel cannot be used as above because they are contraindicated or not tolerated, again with no limit on duration of treatment. Link to EPC statement.

AFTER A MYOCARDIAL INFARCTION

First Choice: Aspirin dispersible tabs (G): 75mg [28 tabs 82p].Dose: 75mg once daily.Prescribing notes: Link to EPC statement.

Second Choice: Clopidogrel tabs (G): 75mg [30 tabs £1.94].Dose: 75mg once daily. Prescribing notes: only if aspirin is contraindicated or not tolerated. This guidance should be considered alongside existing NICE guidance on clopidogrel in combination with aspirin in people with unstable angina or NSTEMI (see CG94) and those who have had an MI (see CG48). Link to EPC statement.

PERIPHERAL ARTERIAL DISEASE (PAD) OR MULTIVASCULAR DISEASE.

First Choice: Clopidogrel tabs (G): 75mg [30 tabs £1.94].Dose: 75mg once daily. Prescribing notes: . Link to EPC statement..

Second Choice: Aspirin dispersible tabs (G): 75mg [28 tabs 82p]. Dose: 75mg once daily.Prescribing notes: Although not discussed in the guidance, aspirin monotherapy would seem to be the logical choice if clopidogrel were contraindicated or not tolerated. Link to EPC statement. 2.10 Myocardial Infarction and Fibrinolysis

Link to NICE guidance

Alteplase for the treatment of acute ischaemic stroke No.122

Myocardial infarction - thrombolysis. No.52

2.11 Antifibrinolytic Drugs and HaemostaticsFirst Choice: Tranexamic Acid tabs (G): 500mg [60 tabs £4.56].Dose: For menorrhagia, two to three tabs three or four times a day for 3 or 4 days, starting on first day of period.Prescribing notes:

Links: Menorrhagia Guideline:

2.12 Lipid-Regulating Drugs

Links NICE guidance:

Cardiovascular disease - statins. No.94.

Ezetimibe for Hypercholesterolemia No.132

StatinsFirst Choice: Simvastatin tabs (G): 10mg [28 tabs 72p], 20mg [28 tabs 90p], 40mg [28 tabs £1.17]; 80mg [28 tabs £1.98].Dose: 10 to 80mg once daily at night.Prescribing notes:

Second Choice: Atorvastatin tabs: 10mg [28 tabs £13.00], 20mg [28 tabs £24.64], 40mg [28 tabs £24.64], 80mg [28 tabs £28.21].Dose: 10 to 80mg once daily.Prescribing notes:

RESPIRATORY

Management of Chronic Asthma in Adults & Children(based on the recommendations of the British Thoracic Society and Scottish Intercollegiate Guidelines Network (updated June 2009)Adult and Child over 5 yearsStep 1: occasional relief bronchodilators.Inhaled short acting beta2 agonist as required (up to once daily).

NOTE: Move to step 2 if needed more than twice a week (or if night-time symptoms more than once a week or if exacerbation in last 2 years).

Step 2: Regular inhaled preventer therapy.Inhaled short acting beta2 agonist as requiredplusRegular standard-dose inhaled corticosteroid (alternatives are considerably less effective).

Step 3: inhaled corticosteroids + long-acting inhaled beta2 agonist.Inhaled short acting beta2 agonist as requiredplusRegular standard-dose inhaled corticosteroidplusRegular inhaled long acting beta2 agonist (salmeterol or formoterol)

If asthma not controlledIncrease dose of inhaled corticosteroid to upper end of standard dose.andEither stop long acting beta2 agonist if of no benefitOr continue long acting beta2 agonist if of some benefit

If asthma still not controlled and long acting beta2 agonist stopped add one of:leukotriene receptor antagonist modified release oral theophyllinea modified release oral beta2 agonist.

Step 4: high-dose inhaled corticosteroids + regular bronchodilators.Inhaled short acting beta2 agonist as requiredwithRegular high-dose inhaled corticosteroid plusRegular inhaled long acting beta2 agonist plusIn adults a six week sequential therapeutic trial of one or more of:: leukotriene receptor antagonist modified release oral theophylline modified release oral beta2 agonist.

Step 5: regular corticosteroid tablets.Inhaled short acting beta2 agonist as requiredwithRegular high-dose inhaled corticosteroid andOne or more long acting bronchodilators (see step 4)plusRegular prednisolone tablets (as a single daily dose). NOTE. In addition to regular prednisolone, continue high-dose inhaled corticosteroid (in exceptional cases may exceed licensed doses); these patients should normally be referred to an asthma clinic.Stepping down.Review treatment every 3 months; if control achieved stepwise reduction may be possible, reduce dose of inhaled corticosteroid slowly (consider reduction every 3 months, decreasing dose by approximately 50% each time). Chronic asthma: children under 5 yearsStep 1: occasional relief bronchodilators.Short acting beta2 agonist as required (not more than once daily).

NOTE. Preferably by inhalation (less effective and more side-effects when given by mouth).Move to step 2 if needed more than twice a week, or if night-time symptoms more than once a week or if exacerbation in last 2 years.

Step 2: Regular preventer therapy.Inhaled short acting beta2 agonist as requiredplusEither regular standard-dose inhaled corticosteroidOr (if inhaled corticosteroid cannot be used) leukotriene receptor antagonist.

Step 3: add-on therapy.Child under 2 years:Refer to respiratory paediatrician.

Child 2-5 years:Inhaled short acting beta2 agonist as requiredplusRegular inhaled corticosteroid in standard-doseplusLeukotriene receptor antagonist

Step 4: persistent poor control.Refer to respiratory paediatrician.Stepping downRegularly review need for treatment.3.1 Bronchodilators3.1.1.1 Selective Beta-2 AgonistsShort ActingFirst choice: Salbutamol CFC-Free Aerosol Inhaler (G): 100 mcg/dose [200 doses £1.50].Dose: 1 or 2 puffs up to three or four times daily

Prescribing notes: Beware hypokalaemia, monitor plasma potassium levels in severe asthmatics. If more than two doses are used regularly consider inhaled steroids. In severe attacks 2 puffs, via a spacer half-hourly is as effective as nebuliser. :

Link to NICE guidance Inhaler devices for children under 5. TAG 10.

Inhaler devices for older children. TAG 38.

Second choice: Salbutamol nebuliser solution (G): 2.5mg [20 UDVs £1.91], 5mg [20 UDVs £3.82].Dose: 2.5mg repeated up to four times daily; may be increased to 5mg if necessary.Prescribing notes: For chronic bronchospasm unresponsive to conventional therapy and severe acute attack. :Breath Actuated InhalerFirst Choice: Salamol Easi-Breathe CFC-Free Aerosol Inhaler: 100 mcg/dose [200 doses £6.30].Prescribing notes: Beware hypokalaemia, monitor plasma potassium levels in severe asthmatics. If more than two doses are used regularly consider inhaled steroids. Long Acting Beta-2 AgonistFirst choice: Salmeterol CFC-Free Aerosol Inhaler: 25mcg/dose [120 doses £29.26].Dose: 50 to 100mcg twice daily.Prescribing notes: Salmeterol is licensed for children 4 years and over. Aerosol inhalers should be prescribed in preference to dry powder devices. Co-prescribe a spacer if there are compliance issues. :Second choice: Formoterol Turbohaler: 6mcg/dose [60 doses £24.80], 12mcg/dose [60 doses £24.80].Dose: 6 to 12mcg once or twice daily.Prescribing notes: Formoterol is licensed for children 6 years and over. :

3.1.2 AntimuscarinicsShort Acting BronchodilatorFirst choice: Ipratropium CFC-free Aerosol Inhaler (G): 20mcg/dose [200doses £5.05]. Dose: 20 to 80mcg three or four times a day.Prescribing notes: Ipratropium is more effective in relieving bronchoconstriction associated with chronic bronchitis. Aerosol inhalation slower acting than salbutamol. Trial for one week before prescribing long term. Paradoxical bronchospasm may occur. First weeks treatment needs close medical supervision. Black triangle. :



Second choice: Ipratropium nebuliser solution (Atrovent): 250mcg [20 UDVs £4.14], 500mcg [20 UDVs £4.87].Dose: 100 to 500mcg up to four times a day.Prescribing notes: Because paradoxical bronchospasm has occurred the first dose should be inhaled under medical supervision. :Long Acting BronchodilatorTiotropium inhalation capsules: 22.5mcg [30caps + HandiHaler £34.87, 30caps refill £31.89].Dose: Inhale the contents of one capsule at the same time each day. Prescribing notes: Initially for 30day trial period. Discontinue if no improvement. Black triangle. :3.1.3 TheophyllineAdultsFirst choice: Theophylline MR tabs (Uniphyllin): 200mg [56tabs £2.95], 300mg [56tabs £4.77], 400mg [56tabs £5.65].Dose: 200 to 400mg twice daily.Prescribing notes: Theophylline should be prescribed by brand name. Half life increased in heart failure and by some drugs eg cimetidine and oral contraceptives and is decreased in smokers and heavy drinkers. Oral aminophylline is no longer recommended. Co-prescription with ciprofloxacin and macrolides is not recommended as they inhibit its metabolism. Consider ofloxacin in these circumstances. :

Second choice: Theophylline MR tabs (Nuelin): 175mg [60tabs £3.19], 250mg [60tabs £4.46].Dose: 250 to 500mg twice daily.Prescribing notes: Theophylline should be prescribed by brand name. Half life increased in heart failure and by some drugs eg cimetidine and oral contraceptives and is decreased in smokers and heavy drinkers. Oral aminophylline is no longer recommended. Co-prescription with ciprofloxacin and macrolides is not recommended as they inhibit its metabolism. Consider ofloxacin in these circumstances. :ChildrenFirst Choice: Theophylline MR Caps (Slo-Phyllin): 60mg [56caps £2.76], 125mg [56caps £3.48], 250mg [56caps £4.34].Dose: 2- 6 years, 60 to 120mg every twelve hours; 7- 12 years, 125 to 250mg every twelve hours.Prescribing notes: Swallow whole with fluid or swallow enclosed granules with soft food (eg

yoghurt). :3.1.4 Compound Bronchodilator PreparationsLong Acting BronchodilatorBudesonide with Formoterol Inhaler (Symbicort): 100/6 [120 doses £33.00]; 200/6 [120 doses £38.00]; 400/12 [60 doses £38.00]Dose: see BNF, (licensed for asthma and COPD).Prescribing notes: See also Devon PCT Effective Practice Committee’s statement re Symbicort SMART. :

Fluticasone with Salmeterol Aerosol Inhaler (Seretide 50 CFC-Free Evohaler): 50mcg/25mcg [120 doses £18.00]; (Seretide 500 Accuhaler): 500mcg/50mcg [60 doses £40.92].Dose: asthma, 2 puffs Seretide 50 twice daily; COPD: 1 blister Seretide 500 Accuhaler twice a day.Prescribing notes: In general patients are best treated with single ingredient preparations so that the dose of each drug can be adjusted. However, for patients stabilised on this combination it is more cost effective to prescribe as Seretide 50. Aerosol inhalers should be prescribed in preference to dry powder devices. Co-prescribe a spacer if there are compliance issues. :3.1.5 Peak flow meters and drug inhaler devicesPeak Flow MetersDrug Delivery Devices



AeroChamber Plus: standard (blue) [£4.61], standard (blue) with mask [£7.70], child (yellow) with mask [£7.70], infant (orange) with mask [£7.70].Dose: Prescribing notes: Medium volume device. For use with, Atrovent, Salbulin & Qvar inhalers. :

Volumatic standard [£2.86], paediatric with mask [£2.86].Dose: Prescribing notes: Large volume device. For use with Becotide, Flixotide, Serevent, Ventolin & Clenil inhalers. :

Peak Flow Meter: Standard Range 60 to 800 litres/min [£6.86], Low Range 30 to 400 litres/min [£6.90].Dose:

Prescribing notes: :3.2 Corticosteroids

Link to NICE guidance Corticosteroids for asthma in children TAG 131

Corticosteroids for asthma in adults TAG 138

CFC FreeBeclometasone CFC-Free Inhaler (Qvar®): 50mcg/dose [200doses £7.87], 100mcg/dose [200doses £17.21]Dose: 50 to 200 mcg twice a day; maximum 400mcg twice daily.Prescribing notes: Prescribe by brand name. Because of increased solubility of beclometasone in the CFC-free propellant Qvar® is approximately twice as potent as standard inhalers. Newly diagnosed patients should be prescribed the CFC-free inhaler. For converting from standard beclometasone inhalers to beclometasone cfc-free inhalers see below. Not licensed in children less than 12 years old. Maximum high dose corticosteroid inhalers are associated with adrenal suppression so steroid cards should be considered and corticosteroid cover may be necessary during times of stress (eg an operation). :

Converting patients to Qvar ® Beclometasone Aerosol InhalersFor patients with well controlled asthma by a CFC-containing inhalerinitially prescribe 100mcg CFC-free beclometasone (Qvar®) for:200 - 250mcg CFC-containing beclometasone aerosol inhaler200 - 250mcg budesonide aerosol inhaler100mcg fluticasone aerosol inhaler

For patients with poorly controlled asthma by a CFC-containing inhalerinitially prescribe 100mcg CFC-free beclometasone (Qvar®) for:100mcg CFC-containing beclometasone aerosol inhaler100mcg budesonide aerosol inhaler100mcg fluticasone aerosol inhaler.

Beclometasone CFC-Free Inhaler (Clenil Modulite®): 50mcg/dose [200doses £3.70], 100mcg/dose [200doses £7.42], 200mcg/dose [200doses £16.17], 250mcg/dose [200doses £16.29].Dose: The usual starting dose is 200mcg twice a day. In severe cases this may be increased to 200mcg three or four times a day. This may then be reduced when the patient’s asthma has stabilised.Prescribing notes: Prescribe by brand name.

Clenil Modulite® is equipotent with CFC- containing inhalers so dose adjustment should not be needed on conversion. Newly diagnosed patients should be prescribed the CFC-free inhaler. Can be prescribed for children less than 12 years old. Maximum high dose corticosteroid inhalers are associated with adrenal suppression so steroid cards should be considered and corticosteroid cover may be necessary during times of stress (eg an operation). :



Breath Actuated InhalerFirst Choice: Qvar Easi-Breathe® Aerosol Inhaler: 50mcg/dose [200 doses £7.74]; 100mcg/dose [200doses £16.95].Dose: 50 to 200 mcg twice a day; maximum 400mcg twice daily.Prescribing notes: See Prescribing notes for Qvar. 3.3.2 Leukotriene Receptor AntagonistsFirst choice: Montelukast tabs: 4mg [28 tabs £25.69]; 5mg [28 tabs £25.69]; 10mg [28 tabs £26.97].Dose: prophylaxis of asthma: adult and child over 15years, 10mg once daily in the evening; child 6 months to 6 years, 4mg once daily in the evening; child 6 to 15 years, 5mg once daily in the evening.Prescribing notes: 4mg and 5mg strengths of tablet are chewable. : 3.4.1 AntihistaminesSedatingFirst choice: Chlorphenamine (Chlorpheniramine) (G): 4mg tabs [112tabs £3.72], 2mg/5ml sugar free oral solution [150ml £2.49].Dose: 4mg every four to six hours, max 24mg a day.Prescribing notes: OTC. :

Second choice: Promethazine HCl (G): 25mg tabs [56tabs £4.34], 5mg/5ml sugar free oral solution [100ml £2.67].Dose: 25mg at night, increased to 25mg twice daily.Prescribing notes: OTC. :Non-SedatingFirst choice: Cetirizine (G): 10mg tabs [30tabs 95p], 5mg/5ml sugar free oral solution [100ml 85p].Dose: 10mg once daily.Prescribing notes: OTC.

:

Second choice: Loratadine tabs (G): 10mg [30 tabs £1.00; 5mg/5ml oral solution [100ml £2.15].Dose: 10mg once daily.Prescribing notes: OTC. :PruritisFirst choice: Hydroxyzine tabs (G): 25mg [56 tabs £2.22].Dose: initially 25mg at night increasing to 25mg three or four times a day.Prescribing notes: :3.4.2 Allergen Immunotherapy

Link to NICE guidance Omalizumab for uncontrolled asthma TAG 133

3.4.3 Allergic EmergenciesFirst Choice: Adrenaline (Epinephrine) injection: Epipen 300mcg [£26.45 each], Epipen Jr 150mcg [£26.45 each].Dose: Adult and child over 30kg, 300mcg by IM injection repeated after 15mins as necessary. Child 15 to 30kg, 10mcg/kg by intramuscular injection repeated after 10mins as necessary.3.7 MucolyticsFirst choice: Carbocisteine 375mg caps (G): [120caps £17.57]Dose: Initially 2.25g daily in divided doses, then 1.5g daily in divided doses as condition improves.Prescribing notes: Also available as syrup 125mg in 5ml and 250mg in 5ml. :3.8 Aromatic InhalationsFirst choice: Menthol and Eucalyptus Inhalation BP 1980: [100ml £1.01]Dose: Add one teaspoonful to a pint of hot, not boiling, water and inhale the vapour.Prescribing notes: OTC. :

Second choice: Benzoin Tincture Compound BP: [100ml £2.11].Dose: Add one teaspoonful to a pint of hot, not boiling, water and inhale the vapour.Prescribing notes: OTC. :3.9.1 Cough SuppressantsFirst choice: Pholcodine Linctus BP: 5mg/5ml [200ml £1.03], 5mg/5ml sugar-free [200ml 38p].Dose: 5 to 10ml three or four times a day.Prescribing notes: Preferable to codeine linctus. :

Second choice: Codeine Linctus BP: 15mg/5ml [200ml £1.56], 15mg/5ml sugar-free [200ml 76p].Dose: 5 to 10ml three or four times a day.Prescribing notes: :

3.9.2 ExpectorantsFirst choice: Simple Linctus BP: [200ml 58p], paediatric [200ml 87p], sugar-free [200ml 78p].Dose: 5ml three or four times a day.Prescribing notes:. :

Second choice: Ammonium and Ipecacuanha Mixture BP: [200ml £1.14].Dose: 10 to 20ml three or four times a day.Prescribing notes:.Links:

CNS

4.1.1 HypnoticsNICE Guidance

Link to NICE guidance Insomnia - newer hypnotic drugs. TAG 77.

BenzodiazepinesFirst choice: Temazepam tabs (G): 10mg [28tabs £2.31], 20mg tabs [28tabs £1.65].Dose: 10 to 20mg at bedtime, for a maximum of 28 days.Prescribing notes: Before a hypnotic is prescribed the cause of the insomnia should be established and, where possible, underlying factors should be treated. Some patients have unrealistic sleep expectations, and others understate their alcohol consumption which is often the cause of the insomnia. Chronic insomnia is rarely benefited and is more often due to mild dependence caused by injudicious prescribing. Temazepam is short acting and has little or no hangover effect. Withdrawal phenomena, however, are more common with short-acting benzodiazepines. :Non-BenzodiazepinesFirst choice: Zopiclone tabs (G): 3.75mg [28tabs £1.51], 7.5mg [28tabs £1.51].Dose: 7.5mg at bedtime, for a maximum of 28 days.Prescribing notes: Before a hypnotic is prescribed the cause of the insomnia should be established and, where possible, underlying factors should be treated. Some patients have unrealistic sleep expectations, and others understate their alcohol consumption which is often the cause of the insomnia. Chronic insomnia is rarely benefited and is more often due to mild dependence caused by injudicious prescribing. Zopiclone is short acting and has little or no hangover effect. Zopiclone is not licensed for long-term use as there is evidence of dependence in a small number of patients. :

4.1.2 Anxiolytics

Link to NICE guidance Generalised anxiety disorder and panic disorder in adults Clinical Guideline No.113

BenzodiazepinesFirst choice: Diazepam tabs (G): 2mg [84tabs £2.13], 5mg [84tabs £2.16], 10mg [84tabs £2.31].Dose: 2 to 10mg three times a day.Prescribing notes: Benzodiazepines are indicated for the short-term relief of severe anxiety but long term use should be avoided. Diazepam has a sustained action. :

Second choice: Lorazepam tabs (G): 1mg

[28tabs £3.35], 2.5mg [28tabs £5.04].Dose: 1 to 4mg daily in divided doses.Prescribing notes: Benzodiazepines are indicated for the short-term relief of severe anxiety but long term use should be avoided. Lorazepam has a short action and as such may be more prone to withdrawal symptoms. :Non-BenzodiazepinesFirst choice: Propranolol tabs (G): 40mg [84tabs £2.37].Dose: 40mg once daily increased to three times a day if necessary.Prescribing notes: Indicated for patients with predominantly somatic symptoms. Patients with predominantly psychological symptoms may obtain no benefit. :

4.2.1 Antipsychotic Drugs

Link to NICE guidance Schizophrenia - Clinical Guideline No.82

TypicalsPhenothiazinesChlorpromazine tabs (G): 25mg [84tabs £4.44], 50mg [84tabs £4.68], 100mg [84tabs £4.65].Dose: 25 to 100mg three times a day.Prescribing notes: 10mg tablets no longer manufactured. :

Promazine tabs (G): 25mg [84tabs £10.40].Dose: Prescribing notes: :

Trifluoperazine tabs (G): 1mg [84tabs £6.43], 5mg [84tabs £4.40].Dose: initially 5mg twice a day then increase according to response, age and body-weight.Prescribing notes: :ButyrophenonesHaloperidol (G): 500micrograms [84caps £3.30], 1.5mg [84tabs £3.78], 5mg [84tabs £6.15], 10mg [84tabs £20.94], 20mg [84tabs £49.44].Dose: initially 1.5 to 3mg two or three times a day; 3 to 5mg two or three times a day in severely affected patients.Prescribing notes: :ThioxanthenesFlupentixol tabs: 3mg [84tabs £5.23].Dose: 3 to 9mg twice daily (in psychosis).Prescribing notes: Lower dose tabs (0.5mg & 1mg) used in depression). :

Zuclopenthixol tabs: 2mg [84 tabs £2.64], 10mg [84 tabs £4.74], 25mg [84 tabs £6.06].

Dose: initially 20 to 30mg daily in divided doses.Prescribing notes: :Substituted BenzamidesFirst choice: Sulpiride tabs (G): 200mg [84tabs £20.02], 400mg [84tabs £29.29].Dose: 200 to 400mg twice a day (in predominantly negative symptoms); may be increase to a maximum of 2.4g in mainly positive symptoms.Prescribing notes: More cost effective to prescribe 400mg dose as 2 x 200mg. :Atypicals

Link to NICE guidance Schizophrenia - Clinical Guideline No. 82

Risperidone tabs (G): 500micrograms [60tabs £2.40], 1mg [60tabs £1.38], 2mg [60tabs £1.74], 3mg [60tabs £2.13]; 4mg [60tabs £2.31].Dose: 2 to 6mg in one or two divided doses. Prescribing notes: Generic products now available. 6mg tablets have been removed from formulary on cost-effectiveness grounds. :

Olanzapine tabs: 2.5mg [28tabs £21.85], 5mg [28tabs £43.70], 7.5mg [28tabs £65.55], 10mg [28tabs £87.40], 15mg [28tabs £119.18]; 20mg [28tabs £158.90].Dose: 5 to 20mg once daily.Prescribing notes: Generic products now available. :Quetiapine tabs: 25mg [60tabs £33.83], 100mg [60tabs £113.10], 150mg [60tabs £113.10], 200mg [60tabs £113.10], 300mg [60tabs £170.00].Dose: maintenance 300mg to 450mg daily in two divided doses (max 750mg daily).Prescribing notes: :

Aripirazole tabs: 5mg [28tabs £95.74], 10mg [28tabs £95.74], 15mg [28tabs £95.74], 30mg [28tabs £191.47].Dose: 10 to 15mg once daily; maximum 30mg daily.Prescribing notes: :4.2.2 Antipsychotic Depot InjectionsFlupentixol Decanoate: 20mg/1ml [amp £1.27], 40mg/2ml [amp £2.49], 50mg/0.5ml [amp £1.53], 100mg/1ml [amp £1.84], 200mg/1ml [amp £3.01].Dose: 50 to 300mg every two weeks (max 400mg weekly).Prescribing notes: Deep IM injection into the gluteal muscle. :

Fluphenazine Decanoate: 12.5mg/0.5ml [amp £1.30], 25mg/1ml [amp £2.26], 50mg/0.5ml [amp £4.47], 50mg/2ml [amp £4.44], 100mg/1ml [amp £8.79].

Dose: 12.5 to 100mg repeated every 14 to 35 days.Prescribing notes: Deep IM injection into the gluteal muscle. Also available as pre-loaded syringes. :

Haloperidol Decanoate: 50mg/ml [amp £3.81], 100mg/ml [amp £5.05].Dose: 50 to 300mg every four weeks.Prescribing notes: Deep IM injection into the gluteal muscle. :

Pipothiazine Palmitate: 50mg/ml [amp £16.29], 100mg/2ml [amp £26.65].Dose: 50 to 200mg every four weeks.Prescribing notes: Deep IM injection into the gluteal muscle. :

Zuclopenthixol Decanoate: 200mg/ml [amp £1.99], 500mg/ml [amp £3.64].Dose: 200 to 600mg repeated every 7 to 28 days.Prescribing notes: Deep IM injection into the gluteal muscle. :4.2.3 Antimanic Drugs

Link to NICE guidance Bipolar Disorder – Clinical Guideline No. 38

First choice: Lithium Carbonate SR tabs (Priadel): 200mg [56tabs £1.29], 400mg [56tabs £1.88].Dose: 200 to 1200mg daily in one or two divided doses, adjusted according to serum levels.Prescribing notes: Lithium preparations should be prescribed by brand name. Lithium levels should be monitored after 4 to 7 days of starting lithium therapy or after a change in dose, then every week until dosage has remained constant for 4 weeks and every 3 months thereafter. For once daily dosage, serum lithium concentrations should fall within the range 0.7 to 1.0 mmol/litre on samples taken 12 hours after last dose, and 0.5 to 0.8 mmol/litre on samples taken 24 hours after last dose. For twice daily dosage, serum lithium concentrations should fall within the range 0.5 to 0.8 mmol/litre on samples taken 12 hours after last dose.Thyroid and kidney function should be monitored before starting treatment and yearly thereafter. Lithium is subject to a large number of drug interactions (see BNF). :

Second choice: Valproate semisodium tabs (Depakote): 250mg [90tabs £12.17], 500mg [90tabs £24.29].Dose: initially 750mg daily in 2 to 3 divided doses, increased according to response, usual dose 1 to 2 g daily.

Prescribing notes: :4.3 Antidepressant Drugs

Link to NICE guidance Depression in adults – Clinical Guideline No.90

Depression in children and young people – Clinical Guideline No.28

Obsessive-compulsive disorder - Clinical Guideline No.31

CSM Statement on the Safety of SSRIs

4.3 1 Tricyclic AntidepressantsFirst choice: Lofepramine tabs (G): 70mg [56tabs £11.55].Dose: 140 to 210mg daily in divided doses.Prescribing notes: Less likely to cause side effects than other TCAs.

Links: Antidepressant Guideline:

4.3.3 SSRIsFirst choice: Fluoxetine caps (G): 20mg [30caps 90p].Dose: 20mg once daily.Prescribing notes:


Alternative choice: Citalopram tabs (G): 10mg [28tabs £1.47], 20mg [28tabs £1.85], 40mg [28tabs £1.83].Dose: 20mg once daily increasing to a maximum of 40mg daily (max 20mg in elderly).Prescribing notes:


See also New Advice for the Safer Prescribing of Citalopram

Alternative choice: Sertraline tabs (G): 50mg [28tabs £6.60], 100mg [28tabs £13.91].Dose: 50mg once daily increasing to a maximum of 200mg daily.Prescribing notes: Patent expiry due Oct 2005.


4.3.4 Third Line AntidepressantsMirtazapine (G): 15mg [28tabs £3.08]; 30mg [28tabs £1.77]; 45mg [28tabs £5.49].Dose: 15 to 45mg at night.Prescribing notes:


4.4 CNS StimulantsMethylphenindate tabs (G) (CD): 5mg [30tabs £3.03], 10mg [30tabs £6.46], 20mg [30tabs £10.92].

Dose: Initially 5mg once or twice a day, increased if necessary at weekly intervals by 5 to 10mg daily to a maximum of 60mg daily in divided doses. Discontinue if no response after 1 month, also suspend periodically to assess child’s condition (usually finally discontinue during or after puberty).Prescribing notes: Not recommended for children under the age of 6 years. :

Link to NICE guidance Attention deficit hyperactivity disorder (ADHD). TAG 98

Attention deficit hyperactivity disorder (ADHD). Clinical Guideline No. 72.

4.5 Anti-Obesity Drugs4.5.1Drugs acting on GI tract

Links to NICE guidance Obesity. Clinical Guideline No.43

First Choice: Orlistat caps: 120mg [84caps £31.63].Dose: 120mg taken immediately before, during or up to one hour after each main meal (maximum 360mg daily).Prescribing notes: Only to be prescribed in accordance with the NICE guideline. If a meal is missed or contains no fat the dose of orlistat should be omitted. OTC pack available “Alli”.4.6 Drugs Used in Nausea and VertigoAntihistaminesFirst Choice: Cyclizine tabs: 50mg [84tabs £6.83].Dose: 50mg up to three times a day.Prescribing notes: First choice in pregnancy. :PhenothiazinesFirst Choice: Prochlorperazine tabs (G): 5mg [84 tabs £1.74]; 3mg buccal tablets [84 tabs £9.90].Dose: prevention 5 to 10mg two or three times a day; buccal one or two tablets twice daily.Prescribing notes: Second choice in pregnancy. :Dopamine AntagonistsFirst Choice: Metoclopramide tabs (G): 10mg [84tabs £2.73].Dose: 10mg three times a day.Prescribing notes: Third Choice in pregnancy. Avoid in patients under 20 years old especially females. :

Second Choice: Domperidone tabs (G): 10mg [84tabs £1.50].Dose: 10 to 20mg every four to eight hours.Prescribing notes: Anti-nauseant of choice for patients with Parkinson’s Disease. OTC. :Travel SicknessFirst Choice: Cinnarizine tabs (G): 15mg [10tabs 58p].Dose: 30mg two hours before travel then 15mg

every eight hours during journey.Prescribing notes: OTC. :Meniere’s DiseaseFirst Choice: Betahistine tabs (G): 8mg [84tabs £1.78], 16mg [84tabs £1.94].Dose: 8 to 16mg three times a day.Prescribing notes: :4.7 Analgesics4.7.1 Non-Opioid AnalgesicsFirst Choice: Paracetamol (G): 500mg tabs [224tabs £2.64], 500mg soluble tabs [224tabs £13.81]. Dose: One to two tabs every four to six hours when necessary (max 4g daily).Prescribing notes: Soluble paracetamol tabs are approximately five times more expensive than standard paracetamol tabs. Soluble paracetamol tabs contain 425mg of sodium per tablet. OTC. :

Paracetamol 120mg/5ml sugar free paediatric solution [200ml £1.12]. Dose:3 to 6 months, 2.5ml four times a day6 to 24 months, 5ml four times a day2 to 4 years, 7.5ml four times a day4 to 6 years, 10ml four times a day.

Paracetamol 250mg/5ml sugar free suspension [200ml £1.26]. Dose:6 to 8 years, 5ml four times a day8 to 10 years, 7.5ml four times a day10 to 12 years, 10ml four times a day.

Second Choice: Aspirin (G): tabs 300mg [224tabs £2.17], dispersible tabs 300mg [224tabs £6.07].Dose: One to three tabs every four to six hours when necessary (max 4g daily).Prescribing notes: Dispersible aspirin tabs are approximately six times more expensive than standard aspirin tabs. OTC. :4.7.1.1 Compound AnalgesicsCo-codamol 8/500 (G): tabs [224tabs £3.11].Dose: One to two tabs every four to six hours when necessary (max 8 tabs daily) daily).Prescribing notes: OTC. BNF denotes preparation that is considered to be less suitable for prescribing :

Co-codamol 30/500 (G): tabs [224tabs £6.76].Dose: One to two tabs every four to six hours when necessary (max 8 tabs daily) daily).Prescribing notes: Co-codamol 30/500 tablets more cost effective than capsules. :Co-dydramol 10/500 tabs (G): [224tabs £3.34].Dose: One to two tabs every four to six hours when necessary (max 8 tabs daily) daily).

Prescribing notes: BNF denotes preparation that is considered to be less suitable for prescribing. :

4.7.2 Opioid AnalgesicsNon-Controlled DrugsFirst Choice: Dihydrocodeine tabs (G): 30mg [224tabs £5.31].Dose: 30mgevery four to six hours when necessary (max 240mg daily).Prescribing notes: Doubling the dose to 60mg may provide some additional pain relief but this may be at the cost of more nausea and vomiting. :

Second Choice: Codeine Phosphate tabs (G): 15mg [224tabs £6.96], 30mg [224tabs £8.16], 60mg [112tabs £12.96].Dose: 30 to 60mg every four hours when necessary (max 240mg daily).Prescribing notes: Codeine is effective for relief of mild to moderate pain relief but is too constipating for long-term use. :Alternative choice for patients intolerant, or unresponsive, to codeine:Tramadol capsules (G): 50mg [224 caps £3.63].Dose: 50-100mg, not more frequently than every four hours.Prescribing notes: Daily dose greater than 400mg not usually required. :Strong OpiatesOral Preparations (tablets)First Choice: Morphine Sulphate MR tabs (MST) (CD): 5mg [60tabs £3.29], 10mg [60tabs £5.16], 15mg [60tabs £9.61], 30mg [60tabs £12.41], 60mg [60tabs £24.22], 100mg [60tabs £38.34], 200mg [60tabs £81.34].Dose: initially 10 to 30mg twice daily, increased to 60mg twice daily then by further increments of 25 to 50% if needed.Prescribing notes: Patients should not be switched between brands without retitration, although the evidence suggests that the release characteristics of MST and Morphgesic are very similar. :

Alternative Choice: Morphine Sulphate MR tabs (Morphgesic) (CD): 10mg [60tabs £3.85], 30mg [60tabs £9.24], 60mg [60tabs £18.04], 100mg [60tabs £28.54].Dose: initially 10 to 30mg twice daily, increased to 60mg twice daily then by further increments of 25 to 50% if needed.Prescribing notes: Patients should not be switched between brands without retitration, although the evidence suggests that the release characteristics of MST and Morphgesic are very similar. :

Oral Preparations (liquids)First Choice: Morphine Sulphate Solution: 10mg in 5ml [100ml £1.78, 300ml £4.95, 500ml £7.47], 20mg/ml (CD) [30ml £4.98, 120ml £18.59]. Dose: Prescribing notes: :Parenteral PreparationsFirst Choice: Diamorphine injection (G) (CD): 5mg [amp £2.70], 10mg [amp £3.51], 30mg [amp £3.75], 100mg [amp £9.82], 500mg [amp £43.34].Dose: Prescribing notes: Parenteral diamorphine is approximately three times a strong as oral morphine. :Transdermal PreparationsFirst Choice: Fentanyl Patches (Durogesic D-Trans) (CD): 12micrograms/hr [patch £2.52], 25micrograms/hr [patch £3.60], 50micrograms/hr [patch £6.73], 75micrograms/hr [patch £9.40], 100micrograms/hr [patch £11.57].Dose: 25micrograms/hr to 300micrograms/hr. Patch should be changed once every 72 hours.Prescribing notes: Prescribe by trade name not generically.

Prescribing notes: Durogesic Patch Oral Morphine

25 micrograms/hr <90 mg/day

37 micrograms/hr 90 to 134 mg/day











:4.7.3 Neuropathic Pain

Link to NICE guidance Neuropathatic pain – pharmacological management. Clinical Guideline No. 96

First Choice: Amitriptyline tabs (G): 10mg [56tabs £1.46], 25mg [56tabs £1.48], 50mg [56tabs £1.62].Dose: Initially 10 to 25mg at night, increased

gradually to 75mg at night.Prescribing notes: Unlicensed use. :

Second Choice: Gabapentin (G): Caps 100mg [84caps £4.71], 300mg [84caps £7.03], 400mg [84caps £5.70]; Tabs 600mg [84tabs £11.58]; 800mg [84tabs £13.69].Dose: 300mg on day 1, 300mg twice daily on day 2, 300mg three times a day on day 3. Then increase according to response in steps of 300mg daily to a maximum of 1.8g a day.Prescribing notes: :4.7.4 Antimigraine DrugsTreatmentParacetamol soluble tabs (G): 500mg [60tabs £3.70].Dose: Three tablets stat then two tabs every six hours if needed.Prescribing notes: OTC. Domperidone 10mg tabs can be co-prescribed for nausea and gastric stasis. :

PLUS

Ibuprofen tabs (G): 200mg [84tabs £1.55], 400mg [84tabs £1.70].Dose: 800mg stat then 400mg three times a day if needed.Prescribing notes: OTC (200mg). :

ProphylaxisFirst choice: Propranolol tabs (G): 40mg [56 tabs £1.58].Dose: Initially 40mg two or three times a day.Prescribing notes: :

Second Choice: Amitriptyline tabs (G): 10mg [56tabs £1.46], 25mg [56tabs £1.48], 50mg [56tabs £1.62].Dose: l0mg at night increasing by l0mg every fifth night up to the recommended dose (usually l00mg).Prescribing notes: :TriptansOralFirst Choice: Sumatriptan tabs (G): 50mg [6tabs £1.50] , 100mg [6tabs £2.07]Dose: 50mg (some patients may require 100mg); dose may be repeated after at least 2 hours if migraine recurs; max 300mg in 24 hours. Patient not responding to initial dose should not take second dose for same attack.Prescribing notes: Following reports of chest pain and tightness (coronary vasoconstriction) CSM has emphasised that sumatriptan should not be used in ischaemic heart disease or Prinzmetal’s angina, and that use with ergotamine should be avoided. :

Second Choice: Almotriptan tabs: 12.5mg [3 tabs £9.07]Dose: 12.5mg as soon as possible after onset repeated after 2 hours if migraine recurs (patient not responding should not take second dose for same attack); max 25mg in 24 hours.Prescribing notes: :4.8 Antiepileptics

Links to NICE guidance Epilepsy (adults) - newer drugs. TAG 76.

Epilepsy (children) - newer drugs. TAG 79.

Epilepsy - Clinical Guideline No. 20

Traditional Drugs Carbamazepine tabs (Tegretol): 100mg [84tabs £2.07], 200mg [84tabs £3.83], 400mg [84tabs £7.53].Dose: Initially 100 to 200mg once or twice daily increasing to 400mg three times a day (in some cases up to 2g daily maybe necessary)Prescribing notes: If being used as an anti-epileptic then prescribe as Tegretol. Plasma concentration for optimal response 20 to 50 micromols per litre. Double vision can occur and there are rare reports of leukopenia. Carbamazepine is also indicated for trigeminal neuralgia but avoid chronic use here. Plasma concentrations for optimum response 4 to 12 mg/litre (20 to 50 micromol/litre). NB 250mg rectal = 200mg oral. :

Phenobarbital (Phenobarbitone) tabs (G): 15mg [56tabs £3.40], 30mg [56tabs £1.70], 60mg [56tabs £1.42].Dose: 60 to 180mg at night.Prescribing notes: Plasma concentration for optimal response 60 to 180 micromols per litre. Also available as Phenobarbitone Sodium Solution 15mg/5ml (NB Phenobarbitone Elixir BP contains 38% alcohol and is unsuitable for children).Plasma concentrations for optimum response 15 to 40 mg/litre (60 to 180 micromol/litre) :

Phenytoin sodium caps (Epanutin): 25mg [56caps £1.32], 50mg [56caps £1.34], 100mg [56caps £1.89], 300mg [56caps £5.66].Dose: 150 to 300mg daily at night or in two divided doses, max 600mg daily.Prescribing notes: Brand prescribing of phenytoin as Epanutin capsules will help ensure consistent bioavailability. Prescribing as Epanutin capsule is also more cost effective. 56x100mg generic phenytoin tablets cost £120.00 compared to £1.34 for 56x100mg Epanutin capsules.Ataxia, nystagmus and slurred speech especially common in the elderly. Plasma concentration for optimal response 10 to 20mg/litre (40 to 80

micromols per litre). NB 90mg phenytoin suspension = 100mg phenytoin sodium caps. :

Sodium Valproate tabs (Epilim): 100mg [84tabs £4.70], 200mg [84tabs £6.47], 500mg [84tabs £16.17]Dose: 200mg three times a day, increasing to a max of 2.5g daily.Prescribing notes: If being used as an anti-epileptic then prescribe as Epilim. Plasma valproate levels are not a good indicator of efficacy. False positive urine test for ketones possible with valproate. :Newer Agents

Links to NICE guidance Epilepsy (adults) - newer drugs. TAG 76.

Epilepsy (children) - newer drugs. TAG 79.

Epilepsy - Clinical Guideline No.20

Gabapentin (G): Caps 100mg [84caps £4.71], 300mg [84caps £7.03], 400mg [84caps £5.70]; Tabs 600mg [84tabs £11.58]; 800mg [84tabs £13.69].Dose: 300mg on day 1, 300mg twice daily on day 2, 300mg three times a day on day 3. Then increase according to response in steps of 300mg daily to a maximum of 2.4g a day.Prescribing notes:

Lamotrigine: Tabs 25mg [56tabs £1.77], 50mg [56tabs £2.35], 100mg [56tabs £3.44], 200mg [56tabs £5.44]; Dispersible tabs 2mg [56tabs £19.51], 5mg [56tabs £3.40], 25mg [56tabs £2.41], 100mg [56tabs £4.43].Dose: Monotherapy, initially 25mg daily for 14 days, then 50mg daily for 14 days, then increase by 50 to 100mg daily every 7 to 14 days. Usual maintenance 100 to 200mg daily in one or two divided doses but up to 500mg daily has been required. For adjunctive therapy see BNF.Prescribing notes: Dispersible tabs can be chewed.

Levetiracetam tabs: 250mg [60tabs £26.86], 500mg [60tabs £47.31], 750mg [60tabs £82.10], 1000mg [60tabs £93.09].Dose: 500mg twice a day, adjusted in increments of 1g every 2 to 4 weeks; max 3g daily in two divided doses.Prescribing notes:

Oxcarbazepine tabs: 150mg [56tabs £16.57], 300mg [56tabs £25.69]; 600mg [56tabs £51.34].Dose: Initially 300mg twice a day increased according to response in steps of up to 600mg daily at weekly intervals; usual dose range 0.6 to 2.4g

daily in divided doses.Prescribing notes: In adjunctive therapy patients may require dose reduction of concomitant antiepileptics when using high doses of oxcarbazepine.

Tiagabine tabs: 5mg [56tabs £22.92], 10mg [56tabs £45.84]; 15mg [56tabs £68.76].Dose: Adjunctive therapy, with enzyme inducing drugs, 5mg twice daily for 1 week , the increased at weekly intervals in steps of 5 to 10mg daily ; usual maintenance dose 30 to 45mg daily (doses above 30mg given in 3 divided doses).Adjunctive therapy, with non-enzyme inducing drugs initial maintenance should be 15 to 30mg daily.Prescribing notes:

Topiramate tabs: 25mg [60tabs £3.60], 50mg [60tabs £2.94], 100mg [60tabs £4.11], 200mg [60tabs £7.10].Dose: Monotherapy, initially 25mg daily at night for 1 week, then increased in steps of 25 to 50mg daily at intervals of 1 to 2 weeks taken in 2 divided doses; usual dose 100mg daily in 2 divided doses; max 400mg daily.Adjunctive therapy, 25mg daily for 1 week, then increased in steps of 25 to 50mg daily at intervals of 1 to 2 weeks taken in 2 divided doses; usual dose 200 to 400mg daily in 2 divided doses; max 800mg daily.Prescribing notes: Tabs more cost effective than capsules. If patient cannot tolerate regimen recommended above then smaller steps or longer interval between steps may be used.

Vigabatrin tabs: 500mg [56tabs £17.27].Dose: with current antiepileptic therapy, initially 1g daily in a single or 2 divided doses then increased according to response in steps of 500mg at weekly intervals; usual range 2 to 3g daily; max 3g daily.Prescribing notes: VISUAL FIELD DEFECTS. The CSM has advised that onset of symptoms varies from 1 month to several years after starting vigabatrin. In most cases visual field defects have persisted despite discontinuation. Manufacturer advises visual field testing before treatment and at 6-month intervals. Patients should be warned to report any new visual symptoms that develop and those with symptoms should be referred for an urgent ophthalmological opinion. Gradual withdrawal of vigabatrin should be considered.

4.8.2 Status EpilepticusRECTAL

First Choice: Diazepam Rectal tubes: 5mg [tube £1.18], 10mg [tube £1.60].Dose: Adult and child over 10kg, 500micrograms/kg.

Prescribing notes: Absorption from suppository too slow therefore rectal solution must be used. Febrile convulsions if brief need only tepid sponging and paracetamol. Those lasting more than 15mins should be treated with diazepam rectal solution. Intermittent prophylaxis with diazepam rectal solution at onset of fever may be considered in a small proportion of children.

INTRAVENOUSFirst Choice: Lorazepam injection: 4mg/ml [amp 35p].Dose: by slow intravenous injection 100 micrograms per kg (max 4mg) as a single dose (repeated once if initial dose ineffective). Dilute with an equal volume of sodium chloride 0.9% or water for injection; give slowly into a large vein at a rate not exceeding 50 micrograms per kg over 3 to 5 minutes. In neonates dilute intravenous injection to 100 micrograms per ml.Prescribing notes: Currently unavailable until May 2013.

4.9 Parkinson’s Disease

Levodopa

First Choice: Co-beneldopa: Caps 62.5mg [84caps £4.17], 125mg [84caps £5.80], 250mg [84caps £9.90]; Dispersible Tabs 62.5mg [84tabs £4.96], 125mg [84tabs £8.78]; SR Caps 125mg [84caps £10.73].Dose: Usual maintenance dose 400 to 800mg (of levodopa) daily in divided doses.Prescribing notes:

Second Choice: Co-carledopa: Tabs 62.5mg [84tabs £5.86], 110mg [84tabs £6.13], 125mg [84tabs £20.87], 275mg [84tabs £30.31]; SR Tabs 125mg [84tabs £16.24], 250mg [84tabs £16.24]. Dose: Usual maintenance dose 400 to 800mg (of levodopa) daily in divided doses.Prescribing notes:

Dopamine Agonists (Oral)ErgotFirst Choice: Cabergoline tabs: 1mg [28tabs £80.99], 2mg [28tabs £97.58].Dose: Initially 1mg daily, increased by increments of 0.5 to 1mg at 7 to 14 day intervals; usual range 2 to 3mg daily. Prescribing notes: Specialist initiation only.

Second Choice: Pergolide tabs (G): 50micrograms [84tabs £21.85], 250micrograms [84tabs £22.30], 1000micrograms [84tabs £79.80].Dose: Building gradually to a maintenance dose of 2 to 2.5mg daily in divided doses.Prescribing notes: Specialist initiation only.

Dopamine Agonists (Oral)Non-ErgotFirst Choice: Ropinirole tabs: 1mg [84tabs £11.39], 2mg [84tabs £19.83], 5mg [84tabs £49.74].Dose: Building gradually to a maintenance dose of 3 to 9mg daily in divided doses.Prescribing notes:

Dopamine Agonists (Parenteral)First Choice: Apomorphine injection: 20mg/2ml [amp £6.07], 50mg/5ml [amp £11.70]; Pen 30mg in 3ml [£24.78 each]; prefilled syringe 50mg/10ml [£14.62 each].Dose: Max 100mg daily.Prescribing notes: Specialist initiation only.

MAOB InhibitorsFirst Choice: Selegiline tabs (G): 5mg [60tabs £8.92], 10mg [30tabs £7.58].Dose: 10mg daily in the morning or 5mg twice daily in the morning and midday.Prescribing notes:

COMP InhibitorsFirst Choice: Entacapone tabs: 200mg [84tabs £48.26].Dose: 200mg with each dose of Madopar or Sinemet, max 2g daily.Prescribing notes:

Levodopa + COMP Inhibitor CombinedFirst Choice: Stalevo tabs (levodopa/carbidopa/entacapone): 50mg/12.5mg/200mg [84 tabs £58.22]; 100mg/25mg/200mg [84tabs £58.22]; 150mg/37.5mg/200mg [84tabs £58.22]; 200mg/50mg/200mg [84tabs £58.22].Dose: as per expert advice.Prescribing notes: Use to improve concordance in patients taking large numbers of tablets or if there is a doubt that entacapone is being taken within 20 minutes of levodopa/dopa-decarboxylase inhibitor. Other strengths have now been added to the above range – see BNF.NB 2 x 50mg Stalevo tabs are NOT equivalent to 1 x 100mg tab.

4.9.2 Antimuscarinic DrugsProcyclidine tabs (G): 5mg [84tabs £6.33].Dose: 2.5mg three times a day increase gradually to a max of 30mg daily.Prescribing notes:

Orphenadine tabs (G): 50mg [84tabs £61.67]. Dose: 50mg three times a day increase gradually to a max of 400mg daily.Prescribing notes:

4.9.3 Riluzole

Link to NICE guidance Motor Neurone disease - riluzole. TAG 20

http://www.northdevonhealth.nhs.uk/ndht/departments/clinical_support/pharmacy/FORMULARIES/PCT - Effective Practice Statements.htm4.10 Drugs used in substance dependence

4 10.1 Nicotine Replacement Therapy

Link to NICE Guidance

http://www.northdevonhealth.nhs.uk/ndht/departments/clinical_support/pharmacy/FORMULARIES/HF - ch4 main.htm



PatchesNicorette patches: 5mg [7patches £9.07], 10mg [7patches £9.07], 15mg [7patches £9.07].Dose: Apply on waking to dry, non-hairy skin on

http://www.northdevonhealth.nhs.uk/ndht/departments/clinical_support/pharmacy/FORMULARIES/HF%20-%20ch4%20main.htm






http://www.northdevonhealth.nhs.uk/ndht/departments/clinical_support/pharmacy/FORMULARIES/PCT%20-%20Effective%20Practice%20Statements.htm



hip, chest or upper arm, removing after approx 16 hours usually when retiring to bed, site next patch on different area (avoid using same site on consecutive days). Initially 15mg patch for 16 hours daily for 8 weeks, then if abstinence achieved, 10mg patch for 16 hours daily for 2 weeks then 5mg patch for 16 hours daily for 2 weeks. Review treatment if abstinence is not achieved in 3 months. Prescribing notes: OTC. Links:

Nicotinell patches: ‘10’ [7patches £9.11], ‘20’ [7patches £9.40], ‘30’ [7patches £9.97].Dose: Apply to dry, non-hairy skin on trunk or upper arm removing after 24 hours and siting replacement patch on a different area (avoid using the same area for several days).Individuals smoking more than 20 cigarettes daily, initially one '30' patch daily, withdraw gradually, reducing dose every three to four weeks. Review treatment if abstinence is not achieved in 3 months.Individuals smoking 20 cigarettes daily or fewer, initially one '20' patch daily.Prescribing notes: A ‘10’ patch releases approximately 7mg of nicotine in 24 hours, a ‘20’ 14mg in 24 hours and a ‘30’ 21mg in 24hours. OTC.Links:

NiQuitin CQ patches: 7mg [7patches £9.97], 14mg [7patches £9.97], 21mg [7patches £9.97].Dose: Apply on waking to dry, non-hairy skin site, removing after 24 hours and siting replacement patch on different area (avoid using same area for 7 days). Individuals smoking 10 or more cigarettes daily, initially 21mg patch daily for 6 weeks, then 14mg patch daily for 2 weeks, then 7mg patch daily for 2 weeks. Review treatment if abstinence not achieved in 10 weeks.Individuals smoking less than 10 cigarettes daily, initially 14mg patch daily for 6 weeks, then 7mg patch daily for 2 weeks.Prescribing notes: Patients using the 21mg patch who experience excessive side-effects, which do not resolve within a few days, should change to 14mg patch for the remainder of the initial 6 weeks before switching to the 7mg patch for the final 2 weeks. OTC. Links:GumNicorette gum: 2mg [30pieces £3.25, 105pieces £8.89], 4mg [30pieces £3.99, 105pieces £10.83].Dose: Individuals smoking 20 cigarettes or fewer, initially one 2mg chewed slowly for approx 30 mins when urge to smoke occurs.Individuals smoking more than 20 cigarettes or needing more than 15 pieces of 2mg gum a day may need the 4mg strength. Maximum 15 x 4mg daily. Withdraw gradually after 3 months. Prescribing notes: OTC.

Links:

Nicotinell gum: 2mg [24pieces £2.67, 96pieces £8.26], 4mg [24pieces £3.30, 96pieces £10.26].Dose: Initially one 2mg piece chewed for approx 30 mins when urge to smoke occurs. Maximum 60mg daily. Withdraw gradually after 3 months.Prescribing notes: OTC. Links:

Niquitin CQ gum: 2mg [12pieces £1.71, 24pieces £3.25, 96pieces £9.97], 4mg [12pieces £1.71, 24pieces £3.25, 96pieces £9.97].Dose: Initially one piece chewed slowly for approx 30 mins when urge to smoke occurs. Maximum 15 pieces daily. Withdraw gradually after 3 months.Prescribing notes: OTC. Links:Lozenges and MicrotabsNicotinell lozenge: 1mg [12 loz £1.71, 36 loz £4.27, 96 loz £9.12], 2mg [12 loz £1.99, 36 loz £4.95, 96 loz £10.60].Dose: Initially one lozenge every one to two hours when urge to smoke occurs. Maximum 30mg daily. Withdraw gradually after 3 months. Maximum period of treatment should not usually exceed 6 months.Prescribing notes: OTC. Links:

Niquitin CQ lozenge: 2mg [36 loz £5.12, 72 loz £9.97], 4mg [36 loz £5.12, 72 loz £9.97].Dose: Initially one lozenge every one to two hours when urge to smoke occurs (maximum 15 lozenges daily) for 6 weeks, then one lozenge every two to four hours for 3 weeks, then one lozenge every four to eight hours for 3 weeks, withdraw gradually after 3 months. Maximum period of treatment should not exceed 6 months.Prescribing notes: OTC. Links:

Nicorette sublingual microtab: 2mg [30tab starter pack £3.99, 105tab refill pack £11.12].Dose: Individuals smoking 20 cigarettes or less daily, sublingually 2mg each hour, for patients who fail to stop smoking or have significant withdrawal symptoms, consider increasing to 4mg each hour.Individuals smoking more than 20 cigarettes, 4mg every hour. Maximum 80mg daily. Treatment should continue for at least 3 months followed by a gradual reduction in dosage. Maximum period of treatment should not exceed 6 months.Prescribing notes: OTC.Links:Inhalator and Nasal SprayNicorette inhalator: 10mg [6 cartridges starter pack £3.99, 42 cartridges refill pack £12.81].Dose: inhale when urge to smoke occurs; initially use between 6 and 12 cartridges daily for up to 8 weeks, then reduce the number of cartridges used by half over next 2 weeks and stop altogether at

end of further 2 weeks; review treatment if abstinence not achieved in 3 months.Prescribing notes: OTC.Links:

Nicorette nasal spray: 0.5mg/metered spray [200 sprays £12.26].Dose: 1 spray into each nostril as required to a maximum of twice an hour for 16 hours daily (max 64 sprays daily) for 8 weeks, then reduce gradually over next 4 weeks (reduce by half at end of first 2 weeks), stop altogether at end of next two weeks. Maximum treatment length 3 months.Prescribing notes: OTC.Links:BupropionBupropion tablets: 150mg [60tabs £41.76].Dose: initially 150mg daily for 6 days then 150mg twice daily; maximum period of treatment 7 to 9 weeks; discontinued if abstinence not achieved at 7 weeks. Consider 150mg daily throughout treatment in patients with risk factors for seizures (see CSM Advice).Prescribing notes: Adjunct to smoking cessation in combination with motivational support.

Link to NICE Guidance Smoking cessation – bupropion and nicotine replacement therapy TAG 39

VareniclineVarenicline tablets: 500micrograms [56tabs £54.60]; 1mg [56tabs £54.60].Dose: Start 1 to 2 weeks before target stop date. Initially 500micrograms once daily for 3 days, increased to 500micrograms twice daily for 4 days, then 1mg twice daily for 11 weeks. Reduce to 500micrograms twice daily if not tolerated.Prescribing notes: Treatment can be repeated in abstinent individuals to reduce risk of relapse.https://nww.devonpctinfo.nhs.uk/EPC/4.10.2 Alcohol Dependence4.10.3 Opiate Dependence


http://www.nice.org.uk/pdf/NiceNRT39GUIDANCE.pdf



http://www.nice.org.uk/pdf/NiceNRT39GUIDANCE.pdf4.11 Drugs for Dementia


http://www.northdevonhealth.nhs.uk/ndht/departments/clinical_support/pharmacy/FORMULARIES/PCT - ch4 NICE39 - NRT.htm

Donepezil tabs: 5mg [28tabs £59.85], 10mg [28tabs £83.89].Dose: 5mg at night, increased if necessary after one month to 10mg daily.Prescribing notes: :

Galantamine: 8mg tabs [56tabs £68.32], 12mg tabs [56tabs £84.00]; 8mg MR caps.[28caps £51.88]; 16mg MR caps [28caps £64.90]; 24mg MR caps.[28caps £79.80].Dose: Tablets: initially 4mg twice a day for 4 weeks, increased to 8mg twice a day for 4 weeks, maintenance 8 to 12mg twice a day; MR caps initially 8mg once daily for 4 weeks, increased to 16mg once daily for 4 weks, maintenance 16 to 24mg daily.Prescribing notes: :Rivastigmine caps: 1.5mg [56caps £66.50], 3mg [56caps £66.50], 4.5mg [56caps £66.50], 6mg [56caps £66.50].Dose: 1.5mg twice a day increased in steps of 1.5mg twice daily at intervals of at least two weeks according to response and tolerance. Usual range 3 to 6mg twice daily.Prescribing notes: :

INFECTIONS

5.1 Antibiotics

Link to NORTH DEVON JOINT FORMULARY ANTIBIOTIC RECOMMENDATIONS FOR PRIMARY CARE

5.2 Antifungal DrugsMiconazole oral gel: 2% [15g £2.85, 80g £4.38].Dose: Adults 5 - 10ml four times a day in the mouth after food, retain near lesions before swallowing.Neonates (oral fungal infections only) 1ml twice daily smeared around the mouth after feeds; 1 month to 2 years 2.5ml twice daily in the mouth after food, retain near lesions before swallowing; 2 to 6 years 5ml twice daily in the mouth after food, retain near lesions before swallowing;6 to 12 years 5ml four times a day in the mouth after food, retain near lesions before swallowing.

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https://nww.devonpctinfo.nhs.uk/EPC/

Prescribing notes: Continue treatment until 48hours after lesions have resolved. Miconazole oral gel is not licensed for use in children under 4 months of age or during the first 5 – 6 months of life of an infant born pre-term. The doses quoted above for neonates are taken from the BNF for Children. :

Nystatin oral suspension (G): 100,000 units/ml [30ml £19.32].Dose: 1ml four times a day after food, usually for 7 days (continue for 48 hours after lesions have resolved). Prescribing notes: Immunosuppressed patients may require 500,000 units (5ml) four times a day. :

Vaginal fungal infectionsOral therapyFirst choice: Fluconazole caps (G): 150mg [1cap 79p].Dose: a single dose of 150mg. Prescribing notes: Avoid oral antifungals in pregnancy; topical therapy may be used. see also chapter 7.2.2 . OTC.Links: :

Topical therapy

First Choice: Clotrimazole (G): 1% cream [20g £1.24, 50g £3.19], 200mg pessaries [3pess £3.63], 500mg pessaries [1pess £2.78]; 10% vaginal cream [5g £5.86].Dose: see BNFPrescribing notes: Both cream and pessaries can damage latex condoms and diaphragms. OTC.Links: :

Second Choice: Miconazole: 2% intravaginal cream [78g £4.33], 1200mg vaginal capsule [1cap £2.94].Dose: see BNFPrescribing notes: All the above products can damage latex condoms and diaphragms. see also chapter 7.2.2.Links: :5.3 Antiviral DrugsHerpes Simplex and ZosterFirst Choice: Aciclovir (G): 200mg tabs [25tabs £3.70], 400mg tabs [25tabs £3.00], 800mg tabs [35tabs £8.46]; 200mg dispersible tabs [25tabs £2.06], 400mg dispersible tabs [25tabs £4.50], 800mg dispersible tabs [35tabs £9.84].Dose: Herpes simplex, treatment 200mg five times a day for 5 days; 400mg five times a day if immunocompromised or if absorption impaired.Varicella and herpes zoster, treatment 800mg five times a day for 7 days.

Prescribing notes: :InfluenzaRefer to the NICE guidance below. Should only be considered following advice from the Department of Health.

Amantadine, oseltamivir and zanamivir for the treatment of influenza No. 168

Oseltamivir, amantadine and zanamivir for the prophylaxis of influenza No. 158

Oseltamivir caps: 75mg [10caps £15.41].Dose: Treatment, 75mg twice a day for 5 days starting within 2 days of onset of symptoms; Prevention, 75mg once daily starting within 2 days of exposure and continued for at least 7 days or up to six weeks during an epidemic. .Prescribing notes: Should only be prescribed when clearly indicated by NICE guidelines. Links:

Zanamivir diskhaler: 5mg [pack £16.36].Dose: by inhalation of powder, 10mg twice a day for 5 days.Prescribing notes: Should only be prescribed when clearly indicated by NICE guidelines, ie at-risk adults who present within 36 hours of the onset of an influenza like illness. Links: 5.4.1 Antimalarials

Current advice should be sought concerning appropriate prophylaxis for various parts of the world. For treatment of malaria seek urgent specialist advice.5.5 Anthelmintics

Threadworms

First Choice: Mebendazole (G): 100mg tabs [2tabs 45p], 100mg/5ml suspension [10ml 53p].Dose: Adults and Child over 2 years, 100mg as a single dose repeat after 2 weeks if reinfection occurs.Prescribing notes: Only licensed above the age of 2 years but BNF for Children states that the dose for 6months onwards is as above. :

Second Choice: Piperazine 4g with Senna 15.3mg (Pripsen): [2 sachets £1.98].Dose: 3 months to 1 year one level 2.5ml spoonful as a single dose in the morning repeated after 14 days; 1 to 6 years one level 5ml spoonful as a single dose in the morning repeated after 14 days; above 6 years the contents of one sachet as a single dose in the morning repeated after 14 daysPrescribing notes: OTC. :

ENDOCRINOLOGY

6.1.1 Insulin

Diabetes (types 1 & 2) - long acting insulin analogues. (TAG 53).

Diabetes (type 1) - insulin pump therapy. (TAG 151).

Diabetes (types 1 & 2) - patient education modules. (TAG 60).

Diabetes (type 2) - glitazones. (TAG 63).

Type 2 diabetes - footcare. Clinical guideline No.10.

Type 1 diabetes - children and young people and adults.Clinical guideline No.15.

Diabetes in Pregnancy. Clinical Guideline No.63.

Diabetes Type 2 - Clinical Guideline No. 87

6.1.1.1 Short-acting insulinsActrapid® insulin: 100 units/ml [10ml vial £7.48].Humulin® S insulin: 100 units/ml [10ml vial £15.68; 5 x 3ml cartridge £19.08].

Insulin aspart (NovoRapid®): 100 units/ml [10ml vial £16.28; 5 x 3ml cartridge £28.31; 5 x 3ml preloaded pens £30.60].Insulin lispro (Humalog®): 100 units/ml [10ml vial £16.61; 5 x 3ml cartridge £28.31; 5 x 3ml preloaded pens £29.46].6.1.1.2 Intermediate and long-acting insulinsInsulatard®: 100 units/ml [10ml vial £7.48; 5 x 3ml cartridge £22.90; 5 x 3ml Innolet® £20.40].Humulin® I: 100 units/ml [10ml vial £15.68; 5 x 3ml cartridge £19.08; 5 x 3ml preloaded Kwikpens £21.70].

Insulin glargine (Lantus®): 100units/ml [10ml vial £30.68; 5 x 3ml cartridge £41.50; 5 x 3ml preloaded pens (Solostar®) £41.50].Please note the preloaded disposable pen Optiset® replaced with Solostar® preloaded disposable pen.Please re-usable pens Opiticlik® and Optipen® replaced with Clikstar re-usable pen.

Biphasic InsulinHumulin® M3: (30% soluble, 70% isophane) 100 units/ml [10ml vial £15.68; 5 x 3ml cartridge £19.08; 5 x 3ml preloaded Kwikpens £21.70].

Humalog® Mix25: (25% insulin lispro, 75% insulin lispro protamine) 100units/ml [10ml vial £16.61; 5 x 3ml cartridge 29.46; 5 x 3ml preloaded pens 30.98].

Humalog® Mix50: (50% insulin lispro, 50% insulin lispro protamine) 100units/ml [5 x 3ml cartridge 29.46; 5 x 3ml preloaded pens 30.98].Novomix® 30: (30% insulin aspart, 70% insulin aspart protamine) 100 units/ml [5 x 3ml cartridge £28.84; 5 x 3ml preloaded pens £30.98].

:6.1.1.3 Hypodermic EquipmentNeedle Clipping (Chopping) Device: [137p each].Sharpsguard: [1 litre 85p].Sharpsafe: [1 litre 85p].6.1.2 Oral Antidiabetic Drugs

Links to NICE guidance Type 2 diabetes. Clinical Guideline No.66

6.1.2.1 SulphonylureasLonger Duration of ActionFirst Choice: Gliclazide tabs 80mg (G): [60 tabs £1.30].Dose: Initially 40 to 80mg daily with breakfast, increased up to a maximum of 160mg as a single dose or 320mg daily in divided doses.Prescribing notes: Also available as MR tabs but avoid prescribing as different bioavailability may cause confusion. Oral hypoglycaemics should be used to augment the effects of diet and NOT to replace it. :Shorter Duration of ActionFirst Choice: Tolbutamide tabs (G): 500mg [56tabs £4.42].Dose: 500mg to 2g daily in divided doses. Prescribing notes: Large tablets may present swallowing difficulties. Oral hypoglycaemics should be used to augment the effects of diet and NOT to replace it. :6.1.2.2 BiguanidesFirst Choice: Metformin tabs (G): 500mg [84 tabs £1.25], 850mg [56 tabs £1.09].Dose: 500mg daily with breakfast (week 1), 500mg twice daily with breakfast and evening meal (week 2), 500mg three times a day with breakfast, lunch and evening meal (week 3). Usual max 2g daily. Prescribing notes: Metformin may be preferred for initial treatment of severely obese patients as it does not cause weight gain. Usually used in combination when sulphonylurea alone is insufficient. Risk of lactic acidosis increases with age and in COPD. Metformin should be stopped 48 hours before elective use of IV Xray contrast media to avoid lactic acidosis. It should be restarted 48 hours after the procedure, or later if more time is needed for renal function to return to pre-investigation levels. Large tablets may present swallowing difficulties.Metformin MR: Clinical trial data for fewer gastrointestinal adverse events with Metformin MR is weak and metformin MR was substantially more

expensive than non-MR metformin. (SMC rejected use of MR formulation for this reason). Experience with non-XL metformin has shown that starting at a low dose and titrating according to an individual patient’s tolerance level resulted in the majority of patients being able to tolerate metformin.

:6.1.2.3 Other antidiabetic drugs

Diabetes (type 2) - glitazones. TAG 63.

Diabetes (type 2) – Clinical Guideline No. 66

Pioglitazone tabs: 15mg [28tabs £25.19], 30mg [28tabs £35.00], 45mg [28tabs £38.56].Dose: Initially 15 to 30mg once daily. Maximum 45mg daily.Prescribing notes: Should only be prescribed when clearly indicated by NICE guidelines, ie for patients who are inadequately controlled on a combination of metformin and a sulphonylurea or where there are contraindications or tolerability problems, in accordance with the NICE guideline. Glitazones tend to be more effective when prescribed with metformin than with a sulphonylurea.

MRHA warning – Rosiglitazone and Cardiovascular Risk

6.2.1 Thyroid HormonesFirst Choice: Levothyroxine (Thyroxine) tabs (G): 25mcg [28tabs £1.78], 50mcg [28tabs 97p], 100mcg [28tabs 92p].Dose: Initially 50 to 100mcg daily before breakfast, adjusted in steps of 50mcg every three to four weeks until normal metabolism maintained (usually 100 to 200mcg daily). Prescribing notes: Because of long half life (7 days) full effects may not be seen for several weeks.Combination products of liothyronine (T3) and levothyroxine (T4), e.g Armathyroid, are not recommended. :6.2.2 Antithyroid DrugsFirst Choice: Carbimazole tabs: 5mg [28tabs £1.08], 20mg [28tabs £3.20].Dose: Maintenance dose, 5 to 15mg daily. Prescribing notes: CSM Warning (neutropenia and agranulocytosis). Doctors are reminded of the importance or recognising bone marrow suppression induced by carbimazole and the need to stop treatment promptly. 1. Patients should be asked to report symptoms and signs suggestive of infection, especially sore throat. 2. A white blood cell count should be performed if there is any clinical evidence of infection. 3. Carbimazole should be stopped promptly if there is clinical or laboratory evidence of neutropenia. Most patients become euthyroid in one to three

months. Lack of compliance is a significant cause of treatment failure. Carbimazole should be used in pregnancy only when propylthiouracil is not suitable. A blocking- replacement regimen of levothyroxine and carbimazole is NOT suitable during pregnancy. Propylthiouracil and carbimazole cross the placenta and appear in breast milk; both should be used at the lowest effective dose to control the hyperthyroid state. :

Second Choice: Propylthiouracil tabs (G): 50mg [28tabs £20.67].Dose: Maintenance dose, 50 to 150mg daily. Prescribing notes: Propylthiouracil should only be used in preference to carbimazole during pregnancy, for patients who are or might be breast feeding, or those who have had a reaction to carbimazole. Propylthiouracil and carbimazole cross the placenta and appear in breast milk; both should be used at the lowest effective dose to control the hyperthyroid state. :6.3 Corticosteroids6.3.1 MineralocorticoidFirst Choice: Fludrocortisone tabs: 100mcg [28tabs £1.41].Dose: 50 to 300mcg once daily. Prescribing notes: :6.3.2 GlucocorticoidFirst Choice: Prednisolone tabs (G): 1mg [28tabs 91p], 5mg [28tabs £2.91], 25mg [28tabs £15.00], 2.5mg EC [28tabs £6.71], 5mg EC [28tabs £5.97], 5mg Soluble [28tabs £9.89].Dose: Prescribing notes:

Corticosteroid Withdrawal: Osteoporosis Prevention:

Equivalent Strengths: :

Second Choice: Dexamethasone tabs (G): 2mg [28tabs £3.43].Dose: Prescribing notes: 500mcg tablets have been discontinued by the manufacturer.

Replacement TherapyFirst Choice: Hydrocortisone tabs: 10mg [30tabs £43.56], 20mg [30tabs £46.06].Dose: 10 to 30mg daily in divided doses. Prescribing notes: For the treatment of Addison’s disease only

6.4.1.1 Oestrogens and HRTOestrogen onlyPrescribing Note: Low strength versions of several HRT variants are available to facilitate the tapering-off of doses when discontinuing

treatment. They are not considered as formulary items because any use will only constitute a small percentage of overall HRT prescribing.First Choice: Elleste Solo tabs: 1mg [3x28tabs £5.04], 2mg [3x28tabs £5.34].Dose: Prescribing notes: Synthetic source of oestrogens. Contains estradiol.Links:

Second Choice: Premarin tabs: 625mcg [3x28tab £4.02], 1.25mcg [3x28tabs £3.58].Dose: Prescribing notes: Animal source of oestrogens. Contains conjugated oestrogens. Links: Oestrogens with Progestogen Synthetic source of oestrogensFirst Choice: Elleste Duet tabs: 1mg/1mg [3x28tabs £9.17], 2mg/1mg [3x28tabs £9.72].Dose: Prescribing notes: Contains estradiol & norethisterone. Links:

Second Choice: Femoston tabs:1mg/10mg [3x28tabs £13.47], 2mg/10mg [3x28tabs £13.47].Dose: Prescribing notes: Contains estradiol & dydrogesterone. Links: Animal source of oestrogens.Prempak C tabs: 625mcg/150mcg [3x28tab £6.25], 1.25mcg/150mcg [3x28tabs £7.40].Dose: Prescribing notes: Contains conjugated oestrogens. & norgestrel. Links: Continuous Preparations Synthetic source of oestrogens.First Choice: Elleste Duet Conti tabs: 2mg/1mg [3x28tabs £16.95].Dose: Prescribing notes: Contains estradiol & norethisterone. Links:

Second Choice: Femoston-Conti tabs:1mg/5mg [3x28tabs £20.36].Dose: Prescribing notes: Contains estradiol & dydrogesterone. Links: Animal source of oestrogens.Premique tabs: 625mcg/5mg [3x28tabs £10.61]. Dose: Prescribing notes: Contains conjugated oestrogens. & medroxyprogesterone. Links: 6.4.1.2 Progestogens

First Choice: Norethisterone tabs (G): 5mg [30tabs £1.81].Dose: Prescribing notes: Although oral progestogens have been used widely for menorrhagia they are relatively ineffective compared with tranexamic acid or, particularly where dysmenorrhoea is also a factor, mefenamic acid. A Mirena coil may particularly useful for women also requiring contraception. :6.4.2 Anti-androgensFinasteride tabs: 5mg [28tabs £1.68].Dose: benign prostatic hyperplasia, 5mg daily, review treatment after 6 months. Prescribing notes: :

6.5.1 Gonadotrophins

Human growth hormone (children). TAG 42

Human growth hormone (adults). TAG 64

6.6.2 Bisphosphonates

Osteoporosis – primary prevention TAG 160

Osteoporosis – secondary prevention including strontium ranelate TAG 161

First Choice: Alendronic acid tabs (G): 10mg [28tabs £1.29], 70mg [4tabs 95p].Dose: Treatment of postmenopausal osteoporosis and osteoporosis in men 70mg once weekly. Prescribing notes: Alendronic acid 70mg once weekly is the most cost effective way to prescribe a bisphosphonate. Swallow tablets whole with a full glass of water on an empty stomach at least 30 mins before breakfast (and any other oral medication); stand or sit upright for at least 30 mins and do not lie down until after eating breakfast. Do not take the tablets at bedtime or before rising. :

Second Choice: Risedronate tabs: 5mg [28tabs £10.90], 35mg [4tabs £1.66].Dose: Treatment of postmenopausal osteoporosis to reduce risk of vertebral or hip fractures 5mg daily or 35mg once weekly. Prevention of osteoporosis (including corticosteroid induced osteoporosis) in postmenopausal women, 5mg daily.Prescribing notes: Swallow tablets whole with a full glass of water on an empty stomach at least 30 mins before first food or drink of the day; stand or sit upright for at least 30 mins. Do not take the tablets at bedtime or before rising. :

OBSTETRICS, GYNAECOLOGY AND URINARY TRACT

7.1 Drugs Used in ObstetricsSee :7.2.1 Vaginal AtrophyFirst Choice: Estradiol 25mcg vaginal tablets in disposable applicators (Vagifem®): [15 applicators £10.56].Dose: Insert one tablet daily for 2 weeks then reduce to one tablet twice weekly; discontinue after 3 months to assess need for further treatment.Prescribing notes: No evidence of damage to latex condoms and diaphragms. :

Second Choice: Estriol 0.1% intravaginal cream (Ovestin®): [15g £4.45].Dose: Insert 1 applicator-dose daily for 2–3 weeks, then reduce to twice a week (discontinue every 2–3 months for 4 weeks to assess need for further treatment); vaginal surgery, 1 applicator-dose daily for 2 weeks before surgery, resuming 2 weeks after surgery.Prescribing notes: Effect on latex condoms and diaphragms not yet known. :

7.2.2 Anti-Infective DrugsVaginal fungal infections

Topical therapy

First Choice: Clotrimazole (G): 1% cream [20g £1.24, 50g £3.19], 200mg pessaries [3pess £3.63], 500mg pessaries [1pess £2.78]; 10% vaginal cream [5g £5.86].Dose: Prescribing notes: Both cream and pessaries can damage latex condoms and diaphragms. See also 5.2. OTC.Links: :

Second Choice: Miconazole: 2% intravaginal cream [78g £4.33], 1200mg vaginal capsule [1cap £2.94].Dose: Prescribing notes: All the above products can damage latex condoms and diaphragms. See also 5.2. Links: :

Oral therapyFirst choice: Fluconazole caps: 150mg [1cap 79p].Dose: a single dose of 150mg. Prescribing notes: Avoid oral antifungals in

pregnancy; topical therapy may be used. See also 5.2. OTC.Links: :7.3 ContraceptivesNICE recommend LARC as first line contraceptive choice, for effectiveness and cost-effectiveness reasons. Patients should be informed about these options in the first instance.

Long acting reversible contraception. Clinical Guideline No. 30

Long Acting Reversible ContraceptivesParenteral Contraceptive: Medroxyprogesterone Acetate injection (Depo-Provera®): 150mg/ml [1ml syringe £6.01].Dose: 150mg every 12 weeks.Prescribing notes: Prescribe by brand name to avoid confusion. :

Subdermal Implant: Etonogestrel radiopaque implant (Nexplanon®): 68mg [£79.46]Dose: see BNF.Prescribing notes: Effective for three years but may be removed sooner. Contraceptive cover ceases upon removal of implant :

Intra-uterine DeviceLevonorgestrel Intra-uterine System (Mirena®): [£88.00].Dose: Releases 20 micrograms over 24 hours.Prescribing notes: A levonorgestel coil may particularly useful for treating menorrhagia in women also requiring contraception. Effective for 5 years.

Links: Menorrhagia Guideline: :

7.3.1 Combined Oral ContraceptivesLow StrengthFirst Choice: Loestrin® 20 tabs: [3x21tabs £2.85].Dose: Prescribing notes: Each tablet contains ethinylestradiol 20mcg & norethisterone 1mg. :

Second Choice: Mercilon® tabs: [3x21tabs £7.67].Dose: Each tablet contains ethinylestradiol 20mcg & desogestrel 150mcg. Prescribing notes: :Standard StrengthFirst Choice: Ovranette® tabs: [3x21tabs £2.20].Dose: Prescribing notes: Each tablet contains

ethinylestradiol 30mcg & levonorgestrel 150mcg. Ovranette® and Microgynon® contain the same active ingredients in the same doses and as such may be considered interchangeable. :

ORMicrogynon® 30 tabs: [3x21tabs £2.82].Dose: Prescribing notes: Each tablet contains ethinylestradiol 30mcg & levonorgestrel 150mcg. Ovranette® and Microgynon® contain the same active ingredients in the same doses and as such may be considered interchangeable. :

Second Choice: Marvelon® tabs: [3x21tabs £6.45].Dose: Prescribing notes: Each tablet contains ethinylestradiol 30mcg & desogestrel 150mcg. Some studies have reported a greater risk of venous thromboembolism in women using preparations containing the third-generation progestogens desogestrel and gestodene. :Emergency ContraceptionFirst Choice: Levonelle® 1500 tabs: [1tab £5.20].Dose: One tablet should be taken as soon as possible, preferably within 12 hours, and no later than 72 hours after unprotected intercourse. If vomiting occurs within three hours of taking the tablet, another tablet should be taken immediately.Prescribing notes: Each tablet contains levonorgestrel 1500mcg. “Levonelle One Step” can be sold to women over 16 years. :7.3.2 Progesterone-Only ContraceptivesOralCerazette® tabs: [3x28tabs £8.68].Dose: 1 tablet daily at same time each day, starting on day 1 of cycle then continuously; if administration delayed for 12 hours or more it should be regarded as a ‘missed pill’.Prescribing notes:. Each tablet contains desogestrel 75mcg. The following advice is recommended by family planning organisations if a pill is missed. “If you forget a pill , take it as soon as you remember and carry on with the next pill at the right time. If the Cerazette pill was more than 12 hours overdue you are not protected. Continue normal pill-taking but you must also use another method, such as the condom for the next 2 days. :

Micronor® tabs: [3x28tabs £2.11].Dose: 1 tablet daily at same time each day, starting on day 1 of cycle then continuously; if administration delayed for 3 hours or more it should be regarded as a ‘missed pill’.Prescribing notes: Each tablet contains norethisterone 350mcg. The following advice is

recommended by family planning organisations if a pill is missed. “If you forget a pill , take it as soon as you remember and carry on with the next pill at the right time. If the Micronor pill was more than 3 hours overdue you are not protected. Continue normal pill-taking but you must also use another method, such as the condom for the next 2 days. :7.4.1 Benign Prostatic HyperplasiaFirst Choice: Tamsulosin MR caps (G): 400mcg [30caps £4.41].Dose: 400mcg daily after food. Prescribing notes: MR tablets are more than twice as expensive. :7.4.2 Urinary frequency, enuresis and incontinence

Link to NICE guidance Urinary Incontinence. Clinical Guideline No. 40.

Lower urinary tract symptoms in men.

First Choice: Oxybutynin tabs (G): 2.5mg [56tabs £5.78], 5mg [56tabs £5.62]; 5mg MR [30tabs £13.77], 10mg MR [30tabs £27.54].Dose: 5mg two or three times a day increased if necessary to a max of 5mg four times a day. Elderly 2.5mg twice a day increased to 5mg twice a day according to response and tolerance.MR tabs, initially 5mg daily adjusted according to response in 5mg steps at weekly intervals; maximum 30mg daily as a single dose. The need for continuing antimuscarinic drug therapy should be review after 6 months.Prescribing notes: ::

Second Choice: Tolterodine tabs: 1mg [56tabs £29.03], 2mg [56tabs £30.56]; 4mg MR caps [28caps £25.78].Dose: 2mg twice daily, reduce to 1mg twice daily if necessary to reduce side-effects OR 4mg MR once daily (dose form not appropriate for hepatic and renal impairment).Prescribing notes: Tolterodine should only be prescribed for patients who cannot tolerate oxybutynin. Taking MR caps at night may reduce incidence of dry mouth. The need for continuing antimuscarinic drug therapy should be review after 6 months. :7.4.5 Drugs for Erectile DysfunctionFirst Choice: Sildenafil tabs: 25mg [4tabs £16.59], 50mg [4tabs £21.27], 100mg [4tabs £23.50].Dose: Initially 50mg approximately one hour before sexual activity, adjust dose according to response to 25 to 100mg as a single dose, maximum one dose in 24hours.Prescribing notes: Sildenafil (and the other phosphodiesterase type-5 inhibitors) can only be

prescribed on the NHS to men who: 1. have diabetes, multiple sclerosis, Parkinson’s disease, poliomyelitis, prostate cancer, severe pelvic injury, single gene neurological disease, spina bifida or spinal cord injury;2. are receiving dialysis for renal failure;3. have had radical pelvic surgery, prostatectomy, or kidney transplant;4. were receiving Caverject®, Erecnos®, MUSE®, Viagra® or Viridal® for erectile dysfunction, at the expense of the NHS, on 14 September 1998;5. are suffering severe distress as a result of impotence (prescribed in specialist centres only, see notes above).The prescription must be endorsed ‘SLS’.

EYE

11.0 Prescribing NotePreservative-free (PF) formulations“Preservative intolerance should be diagnosed by an ophthalmologist. PF eye drops may be of benefit in patients needing several doses of eye drops each day, where likelihood of irritation is greater. If PF formulation is warranted, proprietary preservative-free formulations (often available as unit dose preparations) should be prescribed if at all possible. Manufactured “specials” are unlicensed and almost invariably cost significantly more.”11.3 Anti-Infective Eye Preparations11.3.1 AntibacterialFirst Choice: Chloramphenicol (G): 0.5% eye drops [10ml £1.63], 1% eye ointment [4g £2.03].Dose: Drops; 1 or 2 drops four times a day, Ointment; apply four times a day or just at night when used in combination with eye drops. If chloramphenicol fails, consider viral infection or “user failure”. For more serious infections see :Prescribing notes: OTC (for acute bacterial conjunctivitis only). Ointment is preservative free. Preservative free drops available as Minims [20 = £9.55]. :

Second Choice: Gentamicin eye drops (G): 0.3% [10ml £2.13].Dose: 1 or 2 drops up to six times a day, or more frequently if required. Prescribing notes: :11.3.3 AntiviralFirst Choice: Aciclovir eye ointment: 3% [4.5g £9.34].Dose: Apply five times a day, continue for at least 7 days after complete healing. Prescribing notes: Steroid preparations should not be used in combination with antivirals. :11.4.1 CorticosteroidsFirst Choice: Prednisolone eye drops: 0.5% [10ml £2.00], 1% [5ml £1.52, 10ml £3.05].Dose: 0.5%; 1 or 2 drops every one or two hours until controlled, then reduce frequency. 1%: 1 or 2 drops two to four times a day. Prescribing notes: Topical steroids should be used with great care due to the dangers of producing steroid glaucoma or masking an underlying infection. Preservative free prednisolone 0.5% drops available as Minims [20 = £9.78]. :

Second Choice: Betamethasone 0.1% eye drops: (G) [10ml £2.32]; 0.1% eye ointment: [3g £1.41].

Dose: 1 or 2 drops every one or two hours until controlled, then reduce frequency. Prescribing notes: Topical steroids should be used with great care due to the dangers of producing steroid glaucoma or masking an underlying infection. Eye ointment is frequently unavailable. :

Third Choice: Dexamethasone with hypromellose eye drops (Maxidex®): 0.1% [5ml £1.42, 10ml £2.80].Dose: 1 or 2 drops every four to six hours; in severe conditions every 30 to 60 minutes until controlled then reduce frequency.Prescribing notes: Topical steroids should be used with great care due to the dangers of producing steroid glaucoma or masking an underlying infection. Preservative free dexamethasone 0.1% drops available as Minims [20 = £9.04]. :11.4.2 Other Anti-Inflammatory PreparationsFirst Choice: Sodium Cromoglicate eye drops (G): 2% [13.5ml £2.08].Dose: 1 or 2 drops four times a day. Prescribing notes: OTC (10ml). :11.6 Glaucoma

Link to NICE guidance Diagnosis and management of glaucoma. Clinical Guideline No.85

Prescribing Note: No more than one drop at a time is required to deliver the correct dose of active ingredient in glaucoma treatment products. Use of more than one drop increases likelihood of localised side effects and systemic absorptionBeta-BlockersFirst Choice: Timolol eye drops (G): 0.25% [5ml £1.34], 0.5% [5ml £1.38].Dose: 1 drop twice a day. Prescribing notes: :Carbonic Anhydrase InhibitorsFirst Choice: Dorzolamide eye drops (G): 2% [5ml £4.78].Dose: Used alone 1 drop three times a day; with beta-blocker 1 drop twice a day. Prescribing notes: :

Second Choice: Brinzolamide eye drops: 1% [5ml £6.56].Dose: 1 drop twice a day, increase to three times a day if necessary. Prescribing notes: Reported to cause less stinging than dorzolamide. :Alpha-Blockers

Brimonidine eye drops (G): 0.2% [5ml £3.49].Dose: 1 drop twice a day. Prescribing notes: :Prostaglandin AnaloguesFirst Choice: Latanoprost eye drops: 0.005% [2.5ml £12.48].Dose: 1 drop once daily, preferably in the evening. Prescribing notes: Now licensed for first line use but timolol more cost effective unless beta-blockers are contra-indicated. One bottle contains 83 drops so should be sufficient for one month’s treatment in both eyes. Devices to aid drop administration are available. :

Second Choice: Bimatoprost eye drops: 0.03% [2.5ml £10.30].Dose: 1 drop once daily, preferably in the evening. Prescribing notes: For patients who cannot tolerate or who do not reach target intraocular pressure with latanoprost. Now licensed for first line use but timolol more cost effective unless beta-blockers are contra-indicated. : Beta-Blockers + Prostaglandin Analogues CombinedFirst Choice: Xalacom® eye drops (timolol 0.5% + latanoprost 0.005%): [2.5ml £14.32].Dose: 1 drop once daily.Prescribing notes: :Beta-Blockers + Carbonic Anhydrase Inhibitors CombinedFirst Choice: Dorzolamide 2% + timolol 0.5% eye drops (G): [5ml £4.78].Dose: 1 drop twice a day.Prescribing notes: Previously only available as branded Cosopt® but generic formulations now available. : 11.7 Eye Drop Dispensers Designed to help patients administer correct single drop dose. Arthro versions have lever function to help patients with particular dexterity problems. Opticare (for 2.5ml, 5ml, 10ml,15ml, 20ml bottles) £4.92Opticare Arthro 5 ( for 2.5ml, 5ml bottles) £4.92, Opticare Arthro 10 (for 10ml, 15ml, 20ml bottles) £4.9211.8.1 Tear Deficiency & Ocular LubricantsDropsFirst Choice: Hypromellose eye drops (G): 0.3% [10ml £1.35].Dose: One or two drops as required depending on the need for lubrication. Prescribing notes: OTC. If PF product needed, prescribe as “Minims Artificial Tears” [20 = £7.48]. Generic PF hypromellose 0.3% UDVs available but

costs may vary depending upon supplier and on-costs etc. :

GelsFirst Choice: Carbomer 980 liquid gel: 0.2% [10g £2.80], 0.2% preservative-free [30 x 0.6ml £5.42].Dose: 1 drop three or four times a day or as required depending on the severity of the disease. Prescribing notes: OTC. Viscotears® brand preserved with cetrimide, not benzalkonium chloride so may be considered where benzalkonium chloride intolerance is suspected. :OintmentsFirst Choice: Lacri-Lube® eye ointment: [3.5g £2.51, 5g £3.32]. Dose: Apply a small amount as required. Prescribing notes: OTC. Preservative free. Contains lanolin alcohols. :

ENT

12.1.Otitis ExternaSteroid OnlyFirst Choice: Betamethasone ear drops: 0.1% [10ml £2.32].Dose: 2 or 3 drops every two to three hours, reduce frequency when relief obtained. Prescribing notes: Avoid prolonged use as with all ear drops. Care with perforated eardrum. :

Second Choice: Prednisolone sodium phosphate ear drops: 0.5% [10ml £2.00].Dose: 2 or 3 drops every two to three hours, reduce frequency when relief obtained.Prescribing notes: Avoid prolonged use as with all ear drops. Care with perforated eardrum. :Steroid + Anti-Infective AgentFirst Choice: Locorten-Vioform ear drops®: 0.2%/1% [7.5ml £1.76; 10ml £2.35].Dose: 2 or 3 drops twice a day for up to 7 to 10 days; not recommended for children under 2 years.

Prescribing notes: Limit use to about a week as excessive use may result in fungal infections which may be difficult to treat and require expert advice.Contains flumetasone and clioquinol. :

Second Choice: Otomize® ear spray: [5ml £3.50].Dose: 1 spray three times a day. Prescribing notes: Limit use to about a week as excessive use may result in fungal infections which may be difficult to treat and require expert advice.Contains 0.1% dexamethasone, 3250 units/ml neomycin sulphate & 2% glacial acetic acid. :Anti-Infective Agent OnlyFirst Choice: Gentamicin ear drops (G): 0.3% [10ml £2.13].Dose: 2 or 3 drops every three or four times a day and at night.Prescribing notes: Limit use to about a week as excessive use may result in fungal infections which may be difficult to treat and require expert advice. In view of reports of ototoxicity in patients with a perforated tympanic membrane (eardrum), the CSM has stated that treatment with a topical aminoglycoside antibiotic is contra-indicated in those with a tympanic perforation. However, many specialists do use these drops cautiously in the presence of a perforation in patients with otitis media and where other measures have failed for otitis externa. :Anti-Fungal Agent

First Choice: Clotrimazole solution: 1% [20ml £2.43].Dose: 3 or 4 drops two to three times a day for at least 14 days after the disappearance of infection.Prescribing notes: Avoid prolonged use as with all ear drops. Care with perforated eardrum. :12.1.2 Acute Otitis MediaSee BNF.12.1.3 Removal of Ear WaxFirst Choice: Sodium Bicarbonate ear drops (G): 5% [10ml £1.25].Dose: 3 drops two or three times a day. Prescribing notes: Avoid prolonged use as with all ear drops. Care with perforated eardrum. OTC. :

Second Choice: Olive Oil ear drops (G): [10ml £1.42].Dose: 3 drops two or three times a day.Prescribing notes: Avoid prolonged use as with all ear drops. Care with perforated eardrum. OTC. :12.2.1 Drugs used in Nasal AllergyCorticosteroidsFirst Choice: Beclometasone nasal spray (G): 50microgram/spray [200doses £2.27].Dose: 2 sprays into each nostril twice a day. Prescribing notes: 200 dose pack is least expensive pack size. OTC versions (100 & 180 doses) available for adults over 18 only. :

Second Choice: Mometasone 50 microgram /pray: [140doses £7.68].Dose: For allergic rhinitis in children over 6 years of age, one spray into each nostril once daily; for allergic rhinitis in adults children over 12 years of age, two sprays into each nostril once daily increased if necessary to a maximum of four sprays into each nostril once daily, when control is achieved reduce to one spray into each nostril once daily. For nasal polyps in adults over 18 years: 2 sprays into each nostril once daily, increased if necessary after 5 to 6 weeks to 2 sprays into each nostril twice daily (consider alternative treatment if no improvement after further 5 to 6 weeks), reduce to the lowest effective dose when control achieved.Prescribing notes: :12.2.2 Topical Nasal DecongestantsSympathomimeticsFirst Choice: Xylometazoline nasal drops (G): 0.05% [10ml £1.59], 0.1% [10ml £1.91], 0.1% spray [10ml £1.91].Dose: 2 or 3 drops (or 1 spray) into each nostril two or three times a day.Prescribing notes: OTC. :

AntimuscarinicsFirst Choice: Ipratropium nasal spray: 0.03% [15ml £3.99].Dose: 2 sprays into each nostril two or three times a day. Prescribing notes: NB for rhinorrhoea only, ipratropium is not a decongestant. :12.2.3 Nasal Preparations for InfectionFirst Choice: Mupirocin nasal ointment (Bactroban® Nasal): 2% [3g £3.54].Dose: For eradication of nasal carriage of staphylococci, including meticillin-resistant Staphylococcus aureus (MRSA), apply 2–3 times daily to the inner surface of each nostril.Prescribing notes: A nasal ointment containing mupirocin is also available; it should probably be held in reserve for resistant cases. In hospital or in care establishments, mupirocin nasal ointment should be reserved for the eradication (in both patients and staff) of nasal carriage of meticillin-resistant Staphylococcus aureus (MRSA). The ointment should be applied 3 times daily for 5 days and a sample taken 2 days after treatment to confirm eradication. The course may be repeated if the sample is positive (and the throat is not colonised). To avoid the development of resistance, the treatment course should not exceed 7 days and the course should not be repeated on more than one occasion. If the MRSA strain is mupirocin-resistant or does not respond after 2 courses, consider alternative products such as Naseptin® cream. :

Second Choice: Naseptin® nasal cream: [15g £1.90].Dose: For eradication of nasal carriage of staphylococci, apply to nostrils 4 times daily for 10 days; for preventing nasal carriage of staphylococci apply to nostrils twice daily.Prescribing notes: Contains chlorhexidine 0.1% and neomycin 3250 units/g. NB includes arachis (peanut) oil. :12.3.1 Drugs for Oral Ulceration & InflammationBenzydamine oral rinse: 0.15% [300ml £4.64].Dose: Rinse or gargle with 15ml every 1½ to 3 hours as required, usually for not more than 7 days.Prescribing notes: OTC. :

12.3.2 Oral Fungal InfectionsMiconazole oral gel: 2% [15g £2.85, 80g £4.38].Dose: Adults 5 - 10ml four times a day in the mouth after food, retain near lesions before swallowing.Neonates (oral fungal infections only) 1ml twice daily smeared around the mouth after feeds; 1 month to 2 years 2.5ml twice daily in the mouth after food, retain near lesions before swallowing; 2 to 6 years 5ml twice daily in the mouth after food,

retain near lesions before swallowing;6 to 12 years 5ml four times a day in the mouth after food, retain near lesions before swallowing.Prescribing notes: Continue treatment until 48hours after lesions have resolved. Miconazole oral gel is not licensed for use in children under 4 months of age or during the first 5 – 6 months of life of an infant born pre-term. The doses quoted above for neonates are taken from the BNF for Children. :

Nystatin oral suspension (G): 100,000 units/ml [30ml £20.80].Dose: 1ml four times a day after food, usually for 7 days (continue for 48 hours after lesions have resolved). Prescribing notes: Immunosuppressed patients may require 500,000 units (5ml) four times a day. :12.3.4 MouthwashesFirst Choice: Chlorhexidine mouthwash (G): 0.2% [300ml £3.30]Dose: 10ml rinsed around the mouth for about one minute twice a day. Prescribing notes: OTC. :12.3.5 Treatment of Dry MouthFirst Choice: Glandosane® spray: [50ml £4.99].Dose: As required. Prescribing notes: OTC. ACBS: patients suffering from dry mouth as a result of having undergone radiotherapy or having sicca syndrome. Neutral, lemon or peppermint flavour. :

SKIN

13.2.1 EmollientsNational Patient Safety Agency warning: Potential fire hazard with paraffin based skin products on dressings and clothing.

FOR DIRECT APPLICATION TO THE SKINCream-like productsFirst Choice:Diprobase® Cream: [50g £1.28, 500g £6.32].

Also:E45 Cream®: [50g £1.40, 350g £4.46]. Doublebase® Hydrating Gel: [100g £2.65, 500g £5.83]. Cetraben® Cream: [50g £1.40, 150g £3.98, 500g £5.99, 1.05kg £11.62].

Ointment-like productsLiquid Paraffin and White Soft Paraffin Ointment (50:50): [500g £6.09].Epaderm® Ointment: [125g £.3.69, 500g £6.26].Diprobase® Ointment: [50g £1.28].

Urea containing productsAquadrate® Cream: [30g £1.64, 100g £4.37].Calmurid® Cream: [100g £5.70, 500g £27.42]. NB also contains lactic acid – use sparingly.

EMOILLIENT BATH & SHOWER PREPARATIONSEmulsifying Ointment BP: [500g £2.10].Dermalo® Bath Emollient: [500ml £3.44]Oilatum® Emollient: [250ml £2.75, 500ml £4.57].Aveeno® Bath Oil: [250ml £4.49]Diprobath® Emollient: [500ml £6.74].Balneum® Plus Bath Oil: [500ml £6.66]. Useful for itching skin.

AS A SOAP SUBSTITUTEEmulsifying Ointment BP: [500g £2.10].Aqueous Cream BP: [500g pot £1.72, 100g tube £1.25].

Prescribing notes: The constituents of all the above products may be found in the BNF or MIMS (which also has a chart of potential skin sensitisers included as ingredients in various products).Links: :

13.2.2 BARRIERSFirst line: Sudocrem®: [30g tube £1.13]Prescribing notes: Tube has longer in-use shelf life than larger pots; a little goes a long way. Water repellent; protects skin from moisture, irritants, chafing. Reduces inflammation, weak local anaesthetic action. May be used for patients using continence pads.

Second line: Conotrane® cream: [100g tube 88p]Prescribing notes: For nappy rash and pressure sores. Tube has longer in-use shelf life than pots; a little goes a long way. Water repellent, protects skin from moisture, irritants, chafing and contamination with yeasts or bacteria. Useful in urinary rash, but not suitable for use on patients with continence pads.

Note: Cavilon cream [28g £3.92] and film [5x3ml £7.83] are included as part of the NHS Devon Dressings, Appliance and Stoma formulary but should not be used for routine barrier cream application.

13.3 AntipruriticsFirst Choice: Crotamiton cream 10% [30g £2.38, 100g £4.15].Dose: Apply two or three times a day.Prescribing notes: Although crotamiton is helpful and widely used, it may modify the appearance of scabies making subsequent diagnosis more difficult. It is important that scabies is excluded befoe use. OTC. Links: :13.4 Topical Corticosteroids

NICE GuidanceTopical corticosteroids for atopic eczema should be prescribed only once or twice a day (there is no great evidence that twice daily is more effective than once daily.)Where more than one alternative topical steroid is considered clinically appropriate within a potency class the drug with the lowest acquisition cost should be prescribed. This should take into account the pack size and the frequency of application.Atopic dermatitis (eczema) - topical steroids. No.81.The British Association of Dermatologists suggests that the best way to use topical steroids is probably twice a day for 10 to 14 days when the eczema is active followed by the use of emollients only.

Mild PotencyFirst Choice: Hydrocortisone 1% (G): cream [30g £1.61], ointment [30g £2.15].Dose: Apply thinly once or twice a day. Prescribing notes: Prescribe in multiples of 30g, avoid the 50g size. Hydrocortisone Cream can be purchased from a pharmacy but it can only be sold for specific indications and excludes use on genitals, face and broken skin. Not to be sold for use by pregnant women or children under ten.Links: :Moderate PotencyFirst Choice: Betamethasone 0.025%: cream & ointment [100g £3.15].Dose: Apply thinly once or twice a day. Prescribing notes: Links: :

Second Choice: Clobetasone 0.05%: cream & ointment [30g £1.86, 100g £5.44].Dose: Apply thinly once or twice a day.

Prescribing notes: Links: :

PotentFirst Choice: Betamethasone 0.1% (G): cream [30g £2.25, 100g £4.49], ointment [30g £2.83, 100g £5.46], scalp application [100ml £3.75].Dose: Cream or Ointment, apply thinly once or twice a day. Scalp application, apply twice daily until noticeable improvement then once daily.Prescribing notes: Use betamethasone lotion if the alcoholic base of scalp application stings.Links: :

Second Choice: Hydrocortisone Butyrate 0.1%: cream & ointment [30g £1.60, 100g £4.93].Dose: Apply thinly once or twice a day. Prescribing notes: Links: :Very PotentFirst Choice: Clobetasol 0.05%: cream & ointment [30g £2.69, 100g £7.90].Dose: Apply thinly once or twice a day for up to 4 weeks; maximum 50g per week. Prescribing notes: Links: :Corticosteroid plus Anti-infective AgentCorticosteroid plus AntibioticFirst choice: Fucidin H cream [30g £4.99].Dose: apply sparingly, twice daily, for one week.Prescribing notes: contains hydrocortisone acetate 1%, fusidic acid 2%. May be useful for infected eczema. Do not use for longer than one week due to risk of sensitisation and resistance. Potency: mild.

Second choice: Fucibet cream [30g £5.29].Dose: apply sparingly, twice daily, for one week.Prescribing notes: contains Betametasone valerate 0. 1%, fusidic acid 2%. May be useful for infected eczema. Do not use for longer than one week due to risk of sensitisation and resistance. Potency: potent.Corticosteroid plus Anti-Fungal AgentFirst Choice: Daktacort®: cream [30g £2.28]; ointment [30g £2.28].Dose: Apply thinly twice daily.Prescribing notes: Contains hydrocortisone 1% & miconazole 2%. A 15g tube is available OTC for the treatment of athlete’s foot and candidal intertrigo. Mild potency steroid. Links: :

Second Choice: Canesten® HC cream: [30g £2.42].Dose: Apply thinly twice daily.Prescribing notes: Contains hydrocortisone 1% & clotimazole1%. A 15g tube is available OTC for the treatment of athlete’s foot and fungal infection of skin folds with associated inflammation. Mild potency steroid. Links: :

Corticosteroid plus Anti-Fungal Agent plus AntibioticFirst Choice: Trimovate® cream: [30g £3.29].Dose: Apply to the affected area up to four times a day.Prescribing notes: Contains clobetasone 0.05% & nystatin 100,000 units/g & oxytetracycline 3%. Moderate potency steroid. Links: :13.5.2 Psoriasis

Link to NICE guidance Psoriasis – efalizumab and etanercept TAG 103

Psoriasis – infliximab TAG 134

Psoriasis – adalimumab TAG 146

Psoriatric arthritis – etanercept and infliximab TAG 104

Coal TarAlphosyl® HC cream: [100g £3.54].Dose: Apply thinly once or twice daily. Prescribing notes: Not recommended for under 5 year olds.Links: :

Polytar® Emollient: [500ml £6.50].Dose: Use 2 to 4 capfuls (15 to 30ml) in bath and soak for 20 mins. Prescribing notes: OTC. Links: :DithranolDithrocream®: 0.1% [50g £3.77], 0.25% [50g £4.04], 0.5% [50g £4.66], 1% [50g £5.42], 2% [50g £6.79].Dose: For application to skin or scalp; 0.1% to 0.5% cream suitable for overnight treatment, 1 and 2%cream for a maximum of one hour.Prescribing notes: OTC (0.1 to 1%).Links: :

Vitamin D analoguesCalcipotriol 0.005%: cream [120g £22.66]; ointment [120g £23.10]; scalp solution [60ml £12.70].Dose: apply twice a day, max 100g per week. Scalp solution, apply to the scalp twice daily, max 60ml weekly.Prescribing notes: When preparations are used together the maximum is 5mg in any one week (eg 60g cream with 30ml scalp application). Calcipotriol should be used twice a day. However, care in the flexures as it can irritate and therefore use daily at first. Care is required on application to the face and in particular to prevent it getting in the eyes where it might irritate. Not recommended for under 6 year olds.Links: :

Calcipotriol 0.005% with betamethasone 0.05% (Dovobet®): ointment [60g £32.99, 120g £61.27].Dose: Apply once daily, max 15g daily, 100g per

week. Prescribing notes:. Dovobet should be applied once daily for a maximum of 4 weeks (risk of flare and rebound if continued). Usage should not exceed 100g per week. Not recommended for under 18 year olds.Links: :

Calcitriol 0.003% ointment: [100g £13.87].Dose: Apply twice a day, max 30g daily. Prescribing notes: May be less irritant. Apply twice daily, maximum 30g daily and not more than 35% of body surface. Not recommended in children.Links: :Scalp psoriasisBetamethasone 0.1% (G): scalp application [100ml £3.75].Dose: Apply twice daily until noticeable improvement then once daily.Prescribing notes: Use betamethasone lotion if the alcoholic base of scalp application stings.Links: :

Calcipotriol 0.005%: scalp solution [60ml £12.70].Dose: Apply to the scalp twice daily, max 60ml weekly.Prescribing notes: When used together with other calcipotriol preparations the maximum is 5mg in any one week (eg 60g cream with 30ml scalp application). Care is required on application in particular preventing it getting in the eyes where it might irritate. Not recommended for under 6 year olds.Links: :

Cocois® Ointment: [40g £6.22, 100g £11.69].Dose: Apply to the scalp once a week as necessary (if severe use daily for first 3 to 7 days). Shampoo off after one hour. Prescribing notes: Contains coal tar solution, salicylic acid, precipitated sulphur and coconut oil. OTC.Links: :13.5.3 Drugs Affecting the Immune Response

Link to NICE guidance Atopic dermatitis (eczema) - pimecrolimus and tacrolimus TAG 82.

First choice: Tacrolimus ointment: 0.03% [30g £19.44, 60g £35.46]; 0.1% [30g £21.60, 60g £39.40].Dose: Initially apply 0.1% ointment thinly twice daily for up to 3 weeks then reduce to 0.03% (with further reduction to once daily where appropriate) until lesions clear.Prescribing notes: Initial prescription should be by a specialist. Treatment can be transferred to primary care. Avoid excessive exposure to sunlight and sunlamps. Do not apply other topical preparations within 2 hours of application.

Links :

13.6.1 Topical Preparations for Acne

Links NHS Clinical Knowledge Summaries – Acne Vulgaris

Topical Preparations (non-antbiotics)PanOxyl®: 5% acne gel [40g £1.89], 5% cream [40g £1.89]; 10% acne gel [40g £1.99]; 2.5% Aquagel [40g £1.76], 5% Aquagel [40g £1.92], 10% Aquagel [40g £2.13].Dose: Apply once daily. Prescribing notes: OTC. Links: :

Quinoderm®: 5% cream [50g £2.43], 10% cream [25g £1.58, 50g £2.55].Dose: Apply once to three times daily.Prescribing notes: OTC. Links: :

Topical AntibioticsFirst Choice: Clindamycin 1%: alcoholic solution [30ml £4.34], aqueous lotion [30ml £5.08]. Dose: Apply twice a day.Prescribing notes: Links: :Topical RetinoidsFirst Choice: Tretinoin 0.01% gel [60g £5.28], 0.025% gel [60g £5.28].Dose: Apply thinly once or twice a day.Prescribing notes: Useful for comedones and inflammatory lesions in mild to moderate acne. May cause initial redness and peeling, which ususlly settles with time.

Second Choice: Isotretinoin 0.05% gel [30g £5.24].Dose: Apply thinly once or twice a day.Prescribing notes: Less irritating than tretinoin but twice as expensive.13.6.2 Oral Preparations for AcneAntibioticsFirst Choice: Oxytetracycline tabs (G): 250mg [56tabs £2.38].Dose: 500mg twice a day for 1 to 4 weeks then 250mg twice a day until improvement.Prescribing notes: 3 months treatment initially. Avoid taking with food, milk, antacids, iron preps etc.Links: :

Second Choice: Lymecycline caps: 408mg [28caps £7.77].Dose: one daily for at least 8 weeks.Prescribing notes: Once daily administration may aid compliance. No need to avoid food but antacids, iron and zinc containing medication should not be taken at the same time of day.Links:

HormonesFirst Choice: Co-Cyprindiol tabs: [3 x 21tabs £4.03].Dose: 1 tab daily for 21 days starting on day 1 of the menstrual cycle. Prescribing notes: See MRHA’s advice on the prescribing of co-cyprindiol. Contains ethinylestradiol 35mcg & cyproterone 2mg. Links: :13.8.1 PhotodamageFirst choice: Diclofenac sodium 3% gel: [50g £38.30].Dose: apply thinly twice daily for 60- 90 days; max 8g per day.Prescribing Notes: superficial lesions in mild non-hypertrophic actinic keratosis.Links: :

Second choice: Fluorouracil 5% cream: [40g £32.76]Dose: apply thinly to affected area twice a day, usually for 3-4 weeks at a time. Prescribing notes: No more than 500cm2 to be treated at a time (23cmx23cm).Links: :13.10 Anti-Infective Skin Preparations13.10.1 Topical AntibioticsFusidic Acid 2%: cream [15g £1.92, 30g £3.57], ointment [15g £2.23, 30g £3.79].Dose: Apply three or four times a day. Prescribing notes:Links: :

Metronidazole 0.75% (Rozex®): cream [40g £6.86]; gel [40g £6.86]. Dose: Apply twice daily for 3 to 4 months. Prescribing notes: For inflammatory papules, pustules and erythema of acne rosacea.Links:

Metronidazole 0.8% (Metrotop®): gel [15g £4.59]. Dose: Apply to clean wound once or twice daily and cover (flat wounds apply liberally; cavities, smear on paraffin gauze and pack loosely).Prescribing notes: For malodorous fungating tumours and malodorous gravitational and decubitus ulcers.Links: 13.10.1.1 MRSAMinor soft tissue infections could be treated with doxycycline 100mg twice daily. IF the isolate is sensitive to tetracyclines. Other infections may need hospital admission. Please discuss patients with consultant microbiologist.

MRSA screeningMRSA screens are required before most elective admissions, including elective admissions to community hospitals.The MRSA screen consists of swabs moistened

with sterile saline from the nose, axilla, perineum/ groin, any wounds, sores or eczema. Plus, if applicable, catheter specimen of urine and sputum.

Links: MRSA patient information leaflet

Mupirocin 2% ointment (Bactroban®): [15g £4.38].Dose: Apply up to three times daily for up to 10 days.Prescribing notes: Reserve for MRSA infections, although Staphylococcus aureus strains with low-level resistance to mupirocin are emerging. To avoid the development of resistance, mupirocin should not be used for longer than 10days.Cream and ointment are not interchangeable, the prescription should specify the formulation required.Links: :13.10.2 Topical Anti-FungalsClotrimazole 1% cream (G): [20g £1.40].Dose: Apply two or three times a day.Prescribing notes: OTC. Links: :

Ketoconazole 2% cream: [30g £4.24].Dose: Apply once or twice a day.Prescribing notes: Endorse all scripts SLS. 15g tube OTC for the treatment of tinea pedis, tinea cruris, and candidal intertrigo. Links: :

Terbinafine cream 1% [30g £2.70].Dose: Apply twice daily. Duration dependent on indication- see BNF.Prescribing Notes: For tinea infections, candidiasis, pityriasis versicolor. 30g pack size cheaper than 15g.Links: :

Ketoconazole 2% Shampoo (G): [120ml £3.65]Dose: Seborrhoeic dermatitis; use twice a week for 2 to 4 weeks then reduce to once every 1 to 2 weeks. Pityriasis versicolor; once daily for a maximum of 5 days. Prescribing notes: OTC. Ketoconazole shampoo is the preferred treatment for seborrhoeic eczema since this is fungal. Do not use within two weeks of a topical steroid.Links: :13.10.3 Topical Anti-ViralsAciclovir 5% cream (G): [2g £1.36, 10g £1.99].Dose: Apply every four hours (five times a day) for 5 to 10 days, starting at first sign of attack. Prescribing notes: OTC (2g). Links: :13.10.4 Topical Parasiticidal PreparationsLink to Prevention and Treatment of Head Lice13.11.6 Potassium PermanganatePotassium permanganate 400mg solution tablets (Permitabs®): [30 £9.85].

Dose: For External Use Only, dissolve one tablet in 4 litres of water to give a 1 in 10,000 solution. Soak twice daily for 15 minutes. Stop soaks as soon as the rash has dried up - usually a few days.Prescribing notes: Potassium permanganate soaks are very useful for weeping hand and/or foot eczema. Warn patients about staining of the skin, nails, towels and the bowl. Links: :

13.13 DressingsWOUND DRESSINGS FORMULARY

Documents

GP formulary