| Formulary Chapter 18: Emergency Treatment of Poisoning - Full Chapter
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| Notes: |
In the event of poisoning please phone the National Poisons Information Service (0344 892 0111) rather than Medicines Information.
For any additional advice please contact Pharmacy (contact details are available on the home page) |
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| Chapter Links... |
 Antidote Availability guide for Emergency Departments - Dec 2013 |
| The Yellow Card Scheme: guidance for healthcare professionals |
| Toxbase: National Poisons Information Service |
| UKMI Q&A: How do I complete a Yellow Card? |
| Yellow card website |
| Details... |
| 18 |
Poisoning |
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Acetylcysteine (Parvolex)
(Paracetamol overdose)
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 Restricted
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Injection
Paracetamol overdose
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 CUH Acetylcysteine dose calculator for paracetamol overdose in adults and children over 12 years
 Manufacturers data sheet (SPC)
MHRA information page about the changes in Sept 2012
Treating paracetamol overdose with intravenous acetylcysteine: new guidance
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Activated charcoal
(antidote)
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Restricted
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Reduction of absorption of poisons in the gastro-intestinal system or for active elimination techniques
Actidose-Aqua® Advance - Oral suspension, activated charcoal 1.04 g/5 mL
Carbomix® - 50g Granules, activated charcoal
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Antivenoms for non-indigenous venomous animals
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Restricted
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Discussion with National Poisons Information Service recommended.
Held supra-regionally for treatment of significant envenomationHeld by the pharmacy, Royal Liverpool Hospital and Guy’s & St Thomas’ NHS Foundation TrustSee European Viper Venom antiserum entry for Viper Berus bite treatment.
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Toxbase: National Poisons Information Service
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Atropine
(Antidote)
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Restricted
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Antidote for organophosphorus, carbamate insecticides poisoning or nerve agents. Discussion with National Poisons Information Service recommended.
Treatment of bradycardia
See also section 15.1.3
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Botulism antitoxin (antidote)
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Restricted
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Not routinely stocked.
Contains specific antitoxic globulins that have the power of neutralising the toxins formed by types A,B & E of Clostridium Botulinum
See also section 14.4
For post-exposure prophylaxis of botulism and for the treatment of persons thought to be suffering from botulism
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Calcium chloride
(antidote)
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Restricted
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Discussion with National Poisons Information Service recommended for serious cases
calcium channel blocker antidote
10% injection or infusion
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Calcium folinate
(Poisoning)
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Restricted
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Methotrexate, methanol or formic acid overdose
See also section 8.1
Discussion with National Poisons Information Service recommended for methanol poisoning
Also known as folinic acid
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Calcium gluconate
(Poisoning)
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Restricted
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Injection
Discussion with National Poisons Information Service recommended for all cases of hydrofluoric acid poisoning and serious cases of calcium channel blocker poisoning
See also section 9.5.1.1
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Calcium gluconate gel
(antidote)
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Restricted
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2.5% Gel
Discussion with National Poisons Information Service recommended in primary care, and for serious cases in secondary care
For hydrofluoric acid burns
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Cyproheptadine (Periactin®)
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Restricted
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Tablets
Discussion with National Poisons Information Service recommended
For the treatment of serotonin syndrome
Link to SPC
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Dantrolene
(Poisoning)
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Restricted
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See also section 15.1.8
Discussion with National Poisons Information Service recommended if treating drug related malignant hyperpyrexia unless due to anaesthetic
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Desferrioxamine
(Poisoning)
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Restricted
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Injection
Discussion with National Poisons Information Service recommended
Iron poisoning
Also see section 9.1.3
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Diazepam
(antidote)
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Restricted
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Rectal tube
Injection
Convulsions or agitation related to overdose / poisoning
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Dicobalt edetate
(cyanide poisoning)
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Restricted
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Injection
Discussion with National Poisons Information Service recommended.Stock sodium nitrate 3%, sodium thiosulphate 50% and hydroxocobalamin 5g. Contact NPIS for advice if required.
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Digoxin specific antibody fragments (Digifab®)
(antidote)
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Restricted
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See section 2.1.1 for information
Contact pharmacy for supply.
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Dimercaprol
(antidote)
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Restricted
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Solution for injection
Discussion with National Poisons Information Service recommended.
Heavy metal poisoning
Held supra-regionally for treatment of heavy metal poisoning
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Toxbase: National Poisons Information Service
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DMPS (unithiol)
(antidote)
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Restricted
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Injection - unlicensed
Hard capsules - unlicensed
Discussion with National Poisons Information Service recommended.Held supra-regionally for treatment of heavy metal poisoning
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Toxbase: National Poisons Information Service
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DMSA (succimer)
(antidote)
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Restricted
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Capsules - unlicensed
Discussion with National Poisons Information Service recommended.Held supra-regionally for treatment of heavy metal poisoning
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Toxbase: National Poisons Information Service
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Ethanol (alcohol) injection
(antidote)
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Restricted
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Injection (unlicensed)
Used in the treatment of antifreeze (ethylene glycol) or methanol poisoningDiscussion with National Poisons Information Service recommended.
Ethanol 100%
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CUH: Use of antidotes in ethylene glycol / methanol poisoning
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European Viper Venom Antivenom
(antiserum / antidote)
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Restricted
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Vial (for intravenous infusion)
Vipera berus (European adder) envenomation
The UK Department of Health now supplies (from April 2014) the viper antivenom (antiserum) product ViperaTAb® - for human use only. This product is unlicensed in the UK.
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Flumazenil
(antidote)
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Restricted
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Injection
Reversal of benzodiazepine effectsDiscussion with National Poisons Information Service recommended if using for poisoned patient or in cases of severe persistent hypotension
Rarely required in benzodiazepine overdose
Not to be used in mixed overdose or as a diagnostic test (see toxbase advice)
Also see section 15.1.7
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Fomepizole
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Restricted
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Injection (unlicensed in UK)
See Toxbase and discuss with National Poisons Information Service to ensure appropriate use.
Costs around £5,000 per treatment course.
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Midlands Rarely Used & Emergency Drugs availability list
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Glucagon (GlucaGen® Hypokit)
(Poisoning)
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Restricted
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Injection
Discussion with National Poisons Information Service recommended when used as a treatment of poisoning (e.g. beta-blocker poisoning)
See also section 6.1.4
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Glyceryl Trinitrate
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Restricted
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Injection
Treatment of hypertension associated with poisoning or overdoses
Injection (secondary care only)- Use Polyethylene (PE), giving set for infusion (NOT PVC!).
Also see section 2.6.1
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Hydroxocobalamin (Cyanokit®)
(antidote)
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Restricted
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Injection (for infusion)
Used for the treatment of cyanide poisoning
Discussion with National Poisons Information Service recommended.
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Lorazepam
(antidote)
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Restricted
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Injection
Convulsions or agitation related to overdose / poisoning.
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Macrogol '3350' (Klean-Prep®)
(Poisoning)
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Restricted
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Oral powder (polyethylene glycol)
Discussion with National Poisons Information Service recommended
Used for whole bowel irrigation for agents not bound by activated charcoal e.g. iron, lithium
Also used for whole bowel irrigation for bodypackers and for slow release medicines
for standard uses see section 1.6.5
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Mesna
(antidote)
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Formulary
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See also section 8.1
Treatment of cyclophosphamide induced haemorrhagic cystitis
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Methylthioninium chloride (Proveblue®)
(methylene blue antidote)
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Restricted
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10ml 0.5% (50mg) for IV use
- For Methaemoglobinaemia or prior to parathyroid surgery. (approx £50 each)
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MHRA safety update April 2009
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Naloxone
(antidote)
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Restricted
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Injection
For treatment of opioid overdose / poisoning
See also section 15.1.7
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CUH: Protocol for the use of IV naloxone in opioid toxic patients > 40kg
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Octreotide
(antidote)
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Restricted
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Injection
Discussion with National Poisons Information Service recommended if severe refractory hypoglycaemia
Sulphonylurea induced hypoglycaemia / poisoning (off-label indication), rarely required
for standard uses see section 8.3.4.3
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Phentolamine
(antidote)
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Restricted
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Injection (unlicensed)
Resistant hypertension due to amphetamines and other sympathomimetic drugs of abuse, MAOIs, clonidine etc
Digital ischaemia related to injection of epinephrine (adrenaline)
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Phytomenadione (Vitamin K1)
(antidote)
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Restricted
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Injection
Vitamin K dependent anticoagulant reversal / poisoning
Konakion MM Paediatric formulation can be given orally
See section 9.6.6 for more details
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Procyclidine
(Poisoning)
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Restricted
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Injection
Treatment of extrapyramidal symptoms
See also section 4.9.2
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Protamine Sulphate
(Heparin overdose / reversal)
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Restricted
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Injection (secondary care only)
Discussion with haematology recommended
Remember maximum dose is 50mg.
See local guidelines for dosing and administration in secondary care
Also see section 2.8.3
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Pyridoxine
(antidote)
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Restricted
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Injection 50 mg in 2mL (unlicensed)
Convulsions in isoniazid poisoning
Discussion with National Poisons Information Service recommended in severe cases
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Sodium bicarbonate
(Poisoning)
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Restricted
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Injection
Sodium bicarbonate 8.4%: Tricyclic antidepressant overdose or treatment of class 1a and 1c antiarrhythmic drugs.
Sodium bicarbonate 1.26%: Urinary alkalinisation (See attached on how to dilute 8.4% polufusor).
Discussion with National Poisons Information Service recommended for severe cases
See also section 9.2.2.1
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Sodium nitrite
(antidote)
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Restricted
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Injection
UK product discontinued by manufacturer July 2013
Discussion with National Poisons Information Service recommended
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| 18 |
Body Temperature |
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| 18 |
Pesticides |
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| 18 |
Prevention of absorption |
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| 18 |
Specific Drugs |
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| 18 |
Analgesics (non-opioid) |
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| 18 |
Analgesics (opioid) |
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| 18 |
Antidepressants |
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| 18 |
Beta Blockers |
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| 18 |
Calcium-channel blockers |
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| 18 |
Hypnotics and anxiolytics |
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| 18 |
Iron Salts |
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| 18 |
Phenothiazines and related drugs |
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| 18 |
Stimulants |
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| 18 |
Other poisons |
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| 18 |
Cyanides |
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| 18 |
Ethylene glycol and methanol |
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| 18 |
Heavy Metals |
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| .... |
| Non Formulary Items |
Benzatropine
(antidote)
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Non Formulary
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Injection (unlicensed)
For extrapyramidal symptoms / acute dystonic reactions
See section 4.9.2
See Toxbase for guidance and dosing information |
Toxbase: National Poisons Information Service
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Methionine
(paracetamol overdose)
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Non Formulary
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Tablet
No longer available in the UK. Seldom used for the treatment of paracetamol poisoningDiscussion with National Poisons Information Service recommendedFollow advice on Toxbase if patient has a reaction to acetylcysteine. |
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Penicillamine (Distamine)
(antidote)
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Non Formulary
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Tablets
Treatment of heavy metal poisoning
See section 10.1.3 for information about use in Rheumatological conditions
See section 9.8.1 Treatment of Wilson's disease and metabolic disorders
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Potassium ferric hexacyanoferrate (Berlin / Prussian Blue)
(antidote)
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Non Formulary
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Discussion with National Poisons Information Service recommended.Also known as Berlin blue or Prussian blueHeld supra-regionally for treatment of thallium poisoning |
Toxbase: National Poisons Information Service
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Pralidoxime chloride (Protopam®)
(antidote)
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Non Formulary
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Injection 1g
Organophosphorus insecticide and nerve agent poisoning (adjunct to atropine)Discussion with National Poisons Information Service required For other local holding centres see Toxbase or Midlands Medicines rarely used drug listSupplies for deliberate release available from National blood service 24/7 |
Midlands Medicines rarely used drug list
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Sodium calcium edetate
(antidote)
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Non Formulary
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Injection 5% (unlicensed in UK)
Discussion with National Poisons Information Service recommendedHeavy metal poisoning especially leadHeld supra-regionally for treatment of heavy metal poisoning |
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Sodium thiosulphate
(antidote)
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Non Formulary
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Injection (50%)
Discussion with National Poisons Information Service recommended Cyanide poisoning (in conjunction with sodium nitrite) if dicobalt edetate is not available
Link to SPC.
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Key |
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Cytotoxic Drug
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Controlled Drug
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High Cost Medicine
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Cancer Drugs Fund
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NHS England |
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Homecare |
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CCG |
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Traffic Light Status Information
| Status |
Description |
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Available Over the Counter. Consider Self Care |
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Formulary - Can be prescribed in both secondary and primary care. |
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Formulary - Specialist Advice, secondary care advice provided for primary care initiation. |
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Formulary - Specialist initiation without shared care guidance. |
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Formulary - Specialist initiation with shared care guidance. |
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Restricted - Prescribing (and monitoring where applicable) to remain with the hospital or specialist service. Not to be prescribed in Primary Care |
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Not recommended for prescribing. Switch to alternative cost-effective option. |
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Not recommended for prescribing in primary or secondary care. |
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Not recommended as no formal application made for addition to the formulary. Contact relevant pharmacy team for further information.
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Non-Formulary (category under review). |
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