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Nottinghamshire Area Prescribing Committee
Joint Formulary
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 Formulary Chapter 4: Central nervous system - Full Chapter
04.02.01  Expand sub section  Antipsychotic Drugs
 note 

 

  • All antipsychotics should be employed at the minimum effective doses possible, higher doses will increase the likelihood of side effects. An alternative antipsychotic should be considered rather than resorting to the use of higher than standard doses
  • Atypical and typical antipsychotics should not be prescribed concurrently except when switching from one to another
  • For the treatment of antipsychotic induced extra-pyramidal side effects, refer to section 4.9.2 
  • Orodispersible tablets and oral solutions are more expensive therefore reserved for poorly compliant patients or those with swallowing difficulties.

 

Chlorpromazine
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Formulary
Amber 2
  • Tablet, Oral solution, Suppository, Injection (Use of intramuscular chlorpromazine is not recommended - can cause marked postural hypotension)
     
  •    
    Flupentixol (Depixol®)
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    Formulary
    Amber 2
    Tablet
  • To be initiated on specialist advice only.
  • Tablets disperse in water if needed. See here for general advice on dispersing tablets. 
  •    
    Haloperidol
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    Formulary
    Amber 2
    Tablet, Capsule, Oral liquid
    Injection : Now only licensed for IM administration. IV administration is unlicensed and ECG monitoring is necessary.
  • Optimum dose of oral haloperidol for the treatment of schizophrenia is less than or equal to 12mg/day. The maximum licensed daily dose in resistant schizophrenia is 30mg/day orally.
  • The maximum licensed daily i.m. dose is 18mg. 
  • Link  End of life guideline available on Nottinghamshire APC site
    Link  NUH: Haloperidol licence change reminder Jan 2013
       
    Levomepromazine
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    Restricted Drug Restricted
    Green
    See entry in
    section 4.6

     
       
    Sulpiride
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    Formulary
    Amber 2
    Tablet
  • To be initiated on specialist advice only.
  • Employed mainly within the Mental Health Services for Older People directorate (Notts HC).
  • Tablets disperse in water if needed. See here for general advice on dispersing tablets. 
  •    
    Trifluoperazine
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    Formulary
    Amber 2
    Tablet, Oral solution
  • To be initiated on specialist advice only.
  • Modified release preparations to be used only in patients with compliance problems.
  • 1mg tablets are relatively expensive so liquid (or 5mg tablets) are better options. 
  •    
    Zuclopenthixol (Clopixol®)
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    Formulary
    Amber 2
    Tablet
  • To be initiated on specialist advice only.
  • Tablets disperse in water if needed. Tablets are film coated so flush enteral tubes well to prevent blockage. See here for general advice on dispersing tablets. 
  •    
    04.02.01  Expand sub section  First-Generation Antipsychotic Drugs
    Penfluridol
    Unlicensed Drug Unlicensed
    Red
    Tablet
  • NottsHC use only
  • May be useful in patients that are not tolerant of depot injection
  • Cochrane Review, 2012  
  •    
    04.02.01  Expand sub section  Second-Generation Antipsychotic Drugs
    Amisulpride
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    Formulary
    Amber 2

    Tablet, Oral solution.

    • To be initiated on specialist advice only for schizophrenia. Prescribing guidance should accompany request to prescribe.
     
    Link  NottsAPC: Amisulpride prescribing guidance
       
    Aripiprazole
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    Formulary
    Amber 2
    Tablets, Orodispersible tablets, Injection (secondary care only). Depot injection
  • To be initiated on specialist advice only for:
    -schizophrenia
    -the treatment of moderate to severe manic episodes in Bipolar I Disorder
    -the prevention of a new manic episode in patients who experienced predominantly manic episodes and whose manic episodes responded to aripiprazole treatment.
  • Prescribing guidance to accompany request to prescribe.
  • Solution shouldn't be used routinely as is very expensive (30mg = ~£600 per month!)
     
  • Link  Aripiprazole for the treatment of schizophrenia in people aged 15 -17 years (NICE TA 213)
    Link  Bipolar disorder (children) - aripiprazole (NICE TA292)
    Link  Notts APC:Aripiprazole prescribing guidance
       
    Clozapine (Zaponex®)
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    Formulary
    Red
    Tablet
  • Prescribe by brand
  • For treatment-resistant schizophrenia. Initiated by consultant psychiatrist only.
  • NUH: For psychotic disorders occurring during the course of Parkinson’s disease.
    24 hour helpline number for ZTAS - 020 7365 5842
     
  • Link  Hypersalivation induced by clozapine - management guide
    Link  MHRA Drug Safety Update (October 2017)
    Link  NottsAPC: Clozapine prescribing information for primary care
    Link  SFH: Clozapine pharmacy flowchart
    Link  SFH: Red alert advice
    Link  Therapeutic Drug Monitoring in Adults at NUH
       
    Lurasidone (Latuda®)
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    Formulary
    Red

    Tablets

    • To be initiated on specialist advice for the long-term treatment of “non-treatment resistant” schizophrenia where patients have not been able to tolerate other antipsychotics, including a trial on aripiprazole or where patients have a preference for this drug.
     
    Link  Link to reviews
    Link  NottsAPC: Lurasidone prescribing guidance
       
    Olanzapine
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    Formulary
    Amber 2

    Tablet, Orodispersible tablet. (Injection discontinued 31/08/12)

    • To be initiated on specialist advice only for schizophrenia, mania and preventing recurrence in bipolar disorders. Prescribing guidance to accompany request to prescribe.

    Approved at NUH only for:

    • Red  Prophylaxis of chemotherapy-induced nausea and vomiting
     
    Link  NottsAPC: Olanzapine prescribing guidance
       
    Quetiapine
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    Formulary
    Amber 2

    Tablet, MR tablet, Oral suspension (20mg/ml)

    • To be initiated on specialist advice only for:
      -schizophrenia
      -treatment of mania and major depressive episodes associated with bipolar disorder
      -preventing relapse in schizophrenia and preventing recurrence in bipolar disorder in patients whose have responded to quetiapine treatment.
    • Prescribing guidance to accompany request to prescribe.
    • New patients to be started on immediate release tablets. MR tablets reserved for existing stable patients.
    • Oral suspension available (£95 for 150ml, DT May18).
    • Standard release tablets disperse in water if needed - not licensed (or add to soft food as they taste bitter). Do not crush MR tablets. See here for general advice on dispersing tablets.
     
    Link  Link to reviews
    Link  NICE Evidence summary: Quetiapine for generalised anxiety disorder
    Link  Notts APC: Quetiapine prescribing guidance
    Link  NottsHC advice on standard release vs MR quetiapine
    Link  Quetiapine QIPP detail aid
       
    Risperidone
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    Formulary
    Amber 2
    Tablet, Liquid
  • To be initiated on specialist advice only for:
    -schizophrenia
    -treatment of manic episodes in bipolar disorder.
    -short term use for persistent aggression in patients with moderate to severe Alzheimer’s dementia. Refer to local dementia guidelines
  • Prescribing guidance to accompany request to prescribe
  • Generic risperidone remains one of the least expensive oral atypicals.
  • Doses above 8-10mg daily may not increase therapeutic benefit but may result in extrapyramidal side effects.  
  • Link  Link to reviews
    Link  MHRA: Risk of intraoperative floppy iris syndrome in people undergoing cataract surgery (Oct 13)
    Link  Risperidone prescribing guidance (Notts APC)
       
     ....
     Non Formulary Items
    Benperidol  (Anquil®)

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    Non Formulary
    Grey
     
    Brexpiprazole  (Rexulti®)

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    Non Formulary
    Grey

    No formal assessment

    Link  Aripiprazole for the treatment of schizophrenia in people aged 15 -17 years (NICE TA 213)
    Link  Bipolar disorder (children) - aripiprazole (NICE TA292)
    Link  Notts APC:Aripiprazole prescribing guidance
     
    Cariprazine  (Reagila ®)

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    Non Formulary
    Grey

    Indication: schizophrenia.  Classified as grey; no formal assessment

     
    Clozapine  (Denzapine® or Clozaril®)

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    Non Formulary
    Grey

    Zaponex® preferred brand in Nottinghamshire. See above.

     
    Fluphenazine Hydrochloride  (Moditen®)

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    Non Formulary
    Grey
     
    Paliperidone  (Invega®)
    (Oral)

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    Non Formulary
    Grey

    Oral formulations of paliperidone (brand name Invega) are GREY as they are not considered to offer any clinical advantage over oral risperidone or other oral atypical antipsychotics.

    Paliperidone is an active metabolite of risperidone.

     

    Link  Link to reviews
    Link  MHRA: Risk of intraoperative floppy iris syndrome in people undergoing cataract surgery (Oct 13)
     
    Pericyazine  (Neilactil®)

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    Non Formulary
    Grey
     
    Perphenazine  (Fentazin®)

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    Non Formulary
    Grey
     
    Pimozide  (Orap®)

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    Non Formulary
    Red
     
    Promazine Hydrochloride  (Promazine®)

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    Non Formulary
    Grey
     
    Sertindole  (Serdolect®)

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    Non Formulary
    Red
    Link  Link to reviews
     
    Ziprasidone  (Zeldox®)

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    Non Formulary
    Grey
  • Unlicensed in UK
  •  
    Zotepine  (Zoleptil®)

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    Non Formulary
    Grey
     
    Zuclopenthixol Acetate  (Clopixol Acuphase®)

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    Non Formulary
    Red

    Injection

    • Do not confuse with zuclopenthixol decanoate the long-acting depot injection preparation.
    • Not for neuroleptic naive patients
     
      
    Key
    note Notes
    Section Title Section Title (top level)
    Section Title Section Title (sub level)
    First Choice Item First Choice item
    Non Formulary Item Non Formulary section
    Restricted Drug
    Restricted Drug
    Unlicensed Drug
    Unlicensed
    Track Changes
    Display tracking information
    click to search medicines.org.uk
    Link to adult BNF
    click to search medicines.org.uk
    Link to children's BNF
    click to search medicines.org.uk
    Link to SPCs
    SMC
    Scottish Medicines Consortium
    Cytotoxic Drug
    Cytotoxic Drug
    CD
    Controlled Drug
    High Cost Medicine
    High Cost Medicine
    Cancer Drugs Fund
    Cancer Drugs Fund
    NHSE
    NHS England
    Homecare
    Homecare
    CCG
    CCG

    Traffic Light Status Information

    Status Description

    Grey

    Grey / Non-Formulary: Medicines, which the Nottinghamshire APC has actively reviewed and does not recommend for use at present due to limited clinical and/or cost effective data.
    Grey / Non-Formulary (undergoing assessment): Work is ongoing and will be reviewed at a future APC meeting.
    Grey / Non-Formulary (no formal assessment): APC has not formally reviewed this medicine or indication because it had never been requested for formulary inclusion. Often used for drugs new to market.
      

    Red

    Medicines which should normally be prescribed by specialists only. eg hospital only.
    For patients already receiving prescriptions in primary care - continue. No new patients to receive prescriptions in primary care.
      

    Amber 1

    Medicines that should be initiated by a specialist and prescribed by primary care prescribers only under a shared care protocol, once the patient has been stabilised.
    Prior agreement must be obtained by the specialist from the primary care provider before prescribing responsibility is transferred. The shared care protocol must have been agreed by the relevant secondary care trust Drugs and Therapeutics Committee(s) (DTC) and approved by the Nottinghamshire APC.
      

    Amber 2

    Medicines suitable to be prescribed in primary care / general practice after specialist* recommendation or initiation.
    A supporting prescribing guideline may be requested which must have been agreed by the relevant secondary care trust DTCs and approved by the Nottinghamshire APC.
    *Specialist is defined by the APC as a clinician who has undertaken an appropriate formal qualification or recognised training programme within the described area of practice
      

    Amber 3

    Primary care/ non specialist may initiate as per APC guideline.
    The supporting prescribing guideline must have been agreed by the relevant secondary care trust D&TC(s) and approved by the Nottinghamshire APC.
      

    Green

    Medicines suitable for routine use within primary care.
    Can be initiated within primary care within their licensed indication, in accordance with nationally recognised formularies, for example the BNF, BNF for Children, Medicines for Children or Palliative Care Formulary. Primary care prescribers take full responsibility for prescribing.   

    OTC

      

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