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 Formulary Chapter 4: Central nervous system - Full Chapter
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04.01.02  Expand sub section  Anxiolytics
 note  Management of acute anxiety generally involves the use of a benzodiazepine. For chronic anxiety (of longer than 4 weeks duration) it may be appropriate to use antidepressants.

Acute anxiety state
  • Treatment with benzodiazepines should be limited to the use of the lowest possible dose for the shortest possible time
  • Beta blockers (propranolol) may be helpful in reducing palpitations and tremor in patients who suffer with predominantly somatic symptoms of anxiety
  • 04.01.02  Expand sub section  Benzodiazepines
    Diazepam
    (Tablet, oral solution, oral suspension, rectal solution, injection, emulsion injection)
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    Formulary
    Green

     

    • Diazepam injection comes in two forms - solution (IM or IV) and emulsion Diazemuls® (IV only). Emulsion is preferred for IV as it is less irritant to the vein.
    • CPFT: lorazepam IM injection is used for rapid tranquillisation, as diazepam injection (both formulations) is non-formulary.
    • Injection formulations are hospital only.

     



     

     
    Link  CUHFT: Rapid tranquillisation in adults with disturbed or psychotic behaviour
    Link  Diazemuls emulsion SPC
    Link  Diazepam injection solution SPC
       
    Lorazepam
    (Tablet, Injection.)
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    Formulary
    Green

     

    • Tablets disperse in water if needed
    • Several brands of lorazepam tablets can be administered sublingually (unlicensed) - check with pharmacy for further information.
    • Store injection in fridge.
    • Dilute Ativan® UK brand with an equal volume of WFI or 0.9% NaCl before IM injection. Hospira and Baxter brands (unlicensed imports from US) should NOT be diluted before IM administration - see individual box leaflets.
    • NWAFT: Tablets are restricted to use in Palliative Care only.
    • RPH: 2nd line formulary option for the management of delerium (haloperidol is 1st line formulary choice)
    • CPFT: When used for rapid tranquillisation, lorazepam IM injection must not be given within 1 hour of unlicensed olanzapine IM injection

    June 2020 - Supply disruption of Lorazepam (Ativan®) 4mg/ml Solution for injection

    • Ativan® (lorazepam) 4mg/ml solution for injection will be out of stock from w/c 27th April until w/c 15th June 2020.
    • The US product, lorazepam injection 2mg/ml, supplied in Carpuject™ single dose cartridges will be available to Trusts from early May 2020 on an ‘unlicensed’ basis.
    • CarpujectTM single dose cartridges can be considered bioequivalent to the UK brand Ativan® (lorazepam) 4mg/ml solution for injection and no dosing adjustments should be required.
    • Carpuject™ cartridges must be used in combination with the Carpuject™ holder provided. Injection in cartridge is diluted with an equal volume of compatible solution for IV administration (IM injection is administered undiluted).
    • Ativan® (lorazepam) 4mg/ml solution for injection supplies will remain available for primary care customers throughout this period. 
    • See Supply Disruption Alert below for further information. 

     

     
    Link  CPFT Guideline for the pharmacological management of acute behavioural disturbance in in-patient wards
    Link  June 2020: Supply Disruption Alert - Lorazepam (Atrivan) 4mg/ml solution for injection (issued 28th April 2020)
    Link  Letters sent to healthcare professionals March 2020: Ativan 4mg/ml Solution for Injection (Lorazepam) - interim supply of Irish stock to mitigate supply disruption
       
    Oxazepam
    (Tablet)
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    Restricted Drug Restricted
    Amber No SCG

    • CPFT and CUHFT: For short term management of anxiety

    • Non- formulary at all other Trusts


     

     
       
    Chlordiazepoxide
    (Capsule)
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    Restricted Drug Restricted
    Amber No SCG

    • For use in alcohol withdrawal only


     

     
    Link  CPFT Alcohol Detoxification (Inpatient) Prescribing Guidelines
    Link  CUHFT Acute alcohol withdrawal
    Link  CUHFT Alcohol and substance misuse policy
    Link  CUHFT Care of the woman who misuses drugs and alcohol in pregnancy
    Link  NICE CG115: Alcohol-use disorders - diagnosis, assessment and management of harmful drinking and alcohol dependence
       
    Controlled Drug Midazolam
    (Injection)
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    Restricted Drug Restricted
    Red Hospital
    • CPFT only: Alternative injection for rapid tranquillisation if IM lorazepam unavailable. ‘Off-label’ use

     

     
    Link  CPFT Guideline for the pharmacological management of acute behavioural disturbance in in-patient wards
       
    04.01.02  Expand sub section  Buspirone
    04.01.02  Expand sub section  Meprobamate
     ....
     Non Formulary Items
    Alprazolam

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    Non Formulary
    Grey
     
      
    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

    OTC

    Available Over the Counter. Consider Self Care   

    Green

    Formulary - Can be prescribed in both secondary and primary care.   

    Advice

    Formulary - Specialist Advice, secondary care advice provided for primary care initiation.  

    Amber No SCG

    Formulary - Specialist initiation without shared care guidance.  

    Amber SCG

    Formulary - Specialist initiation with shared care guidance.  

    Red Hospital

    Restricted - Hospital only, not to be prescribed in primary care.  

    Switch

    Not recommended for prescribing. Switch to alternative cost-effective option.   

    Black

    Not recommended for prescribing in primary or secondary care.  

    Grey

    Not recommended as no formal application made for addition to the formulary. Contact relevant pharmacy team for further information.   

    Non Formulary

    Non-Formulary (category under review).  

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