Cambridgeshire and Peterborough Formulary


	Cambridgeshire and Peterborough Formulary

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Formulary Chapter 4: Central nervous system - Full Chapter

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MHRA Drug Safety Update March 2020: Benzodiazepines and opioids - reminder of risk of potentially fatal respiratory depression

MHRA drug safety update May 2020 Valproate Pregnancy Prevention Programme: temporary advice for management during coronavirus (COVID-19)

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04.02.01

Antipsychotic Drugs

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
For new onset psychosis seek specialist psychiatric advice.
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
Oro-dispersible tablets and oral solutions are more expensive therefore reserved for poorly compliant patients or those with swallowing difficulties.
Antipsychotics should not routinely be prescribed to elderly patients with dementia to treat mild to moderate psychotic symptoms, because they are associated with a small increased risk of mortality and increased risk of stroke or transient ischaemic attack.

Advice of Royal College of Psychiatrists on doses of antipsychotic drugs above BNF upper limit

Antipsychotic (excluding clozapine) Prescribing Support in Psychoses and Related Disorders in Adults

CPCCG: Managing Behavioural Problems in Patients with Dementia

CPCCG: Managing Behavioural Problems in Patients with Learning Disabilities

CPFT Medicines Monitoring Guidelines

CUH Rapid tranquillisation in adults with disturbed or psychotic behaviour

CUHFT: Prevention, diagnosis and management of delirium and dementia in older patients

NHS England: Stopping over medication of people with a learning disability, autism or both (STOMP)

NICE CG103: Delirium - prevention, diagnosis and management

NICE CG155: Psychosis and schizophrenia in children and young people - recognition and management

NICE CG178: Psychosis and schizophrenia in adults - prevention and management (NICE CG178)

STOMP and STAMP: A leaflet for families of children and young people with a learning disability, autism or both who may be prescribed (or are prescribed) psychotropic medication

UKMI Q&A: Are atypical antipsychotics safe during breast feeding?

UKMI Q&A: Are first generation antipsychotics safe during breast feeding?

UKMI Q&A: Neuroleptic malignant syndrome - which drugs can cause it?

04.02.01

First-Generation Antipsychotic Drugs

04.02.01

Second-Generation Antipsychotic Drugs

Amisulpride
(Tablet, oral solution)

Restricted

Requires specialist initiation by mental health team

Aripiprazole
(Tablets, orodispersible tablets, short acting injection, liquid)

Restricted

Requires specialist initiation by mental health team

CPFT Guideline for the pharmacological management of acute behavioural disturbance in in-patient wards

NICE TA213: Aripiprazole for the treatment of schizophrenia in people aged 15 -17 years

NICE TA292: Aripiprazole for treating moderate to severe manic episodes in adolescents with bipolar I disorder

Olanzapine
(Tablet, Orodispersible tablet)

Restricted

For mental health conditions - requires specialist initiation by mental health team
CUHFT: use in line with Trust guidelines on delirium and dementia in older patients.
RPH: For management of delirium in critical care.
NWAFT: Restricted to use in palliative care

NeLM in-Focus review: metabolic adverse effects with atypical antipsychotics. Bottom line: Emerging data suggest that the risks of adverse metabolic effects, including hyperglycaemia, diabetes, weight gain and dyslipidaemia, are greater with olanzapine than other atypical antipsychotics (with the exception of clozapine).

CPFT Guideline for the pharmacological management of acute behavioural disturbance in in-patient wards

Quetiapine
(Immediate release (IR) tablet, modified release (MR) tablet, oral suspension)

Restricted

For mental health conditions - requires specialist initiation by mental health team

Immediate release (IR) tablets should be prescribed where possible

Modified release tablets are significantly more expensive and are restricted to where a patient experiences excessive sedation and/or hypotension on quetiapine IR, OR if patient compliance is improved compared to twice daily dosing with quetiapine IR.

If a patient is discharged on a modified release preparation then the rationale for this should be communicated to the GP. NB Only the modified release tablets are licensed for the adjunctive treatment of major depression

In primary care Biquelle® XL is the preferred choices of quetiapine XL if clinically required.

CUHFT: Neurologist/DME consultants for management of drug induced psychoses in Parkinson's Disease patients (off-label).

NWAFT: Restricted to use in palliative care

RPH: Restricted to the management of delirium when haloperidol is contra-indicated

CPJPG Recommendations for Quetiapine XL

NICE Evidence summary ESUOM12 : Quetiapine for generalised anxiety disorder

Risperidone
(Tablet, orodispersible tablet, oral solution)

Restricted

For mental health conditions - Requires specialist initiation by mental health team, with the exception of low dose risperidone which can be initiated in primary care

CUHFT: Restricted to use in line with Trust guidelines on delirium and dementia in older patients

NWAFT: Restricted to use in palliative care

RPH: Restricted to the continuation of treatment initiated external to the Trust

Doses above 8-10mg daily may not increase therapeutic benefit but may result in extrapyramidal side effects.

September 2020 - Discontinuation of Risperdal tablets

Janssen-Cilag are discontinuing all strengths of Risperdal film-coated tablets and oral solution from the UK market in September 2020.

Risperidone tablets and oral solution remains available from a number of other generic suppliers.

CPFT Guideline for the pharmacological management of acute behavioural disturbance in in-patient wards

CUHFT: Prevention, diagnosis and management of delirium and dementia in older patients

Clozapine (Denzapine^®, Clozaril®, Zaponex®)
(Tablet, oral suspension)

Restricted

Initiation by consultant psychiatrist only.

Patients should receive the brand specific to the monitoring service with which they are registered.

CPFT brand of choice is DENZAPINE^®

All patients must be registered with the Fulbourn Pharmacy or the Cavell Centre Pharmacy.

WARNING: Missed doses are particularly significant in someone taking Clozapine. Please contact your local CPFT pharmacy department (including the out of hours service if applicable) and the patient’s psychiatrist if you are aware of a patient that has missed doses of Clozapine.

MHRA drug safety update August 2020: Clozapine and other antipsychotics: monitoring blood concentrations for toxicity

CPFT clozapine information webpage

CPFT Clozapine Initiation and Prescribing Guidelines

Drug-induced hypersalivation – what treatment options are available? (UKMI Q&A)

MHRA Drug Safety Update October 2017: Clozapine - impairment of intestinal peristalsis

Lurasidone (Latuda^®)
(Tablet)

Restricted

CPFT: Formulary

Non-formulary at all other Trusts and in Primary Care

NICE Evidence summary ESNM48: Schizophrenia - Lurasidone

Olanzapine
(Injection)

Restricted

CPFT: unlicensed Short acting IM injection available for rapid tranquillisation.

Olanzapine IM injection must not be given within 1 hour of any parenteral benzodiazepine (including lorazepam IM injection and midazolam IM injection)

Non-formulary at all other Trusts and in Primary Care

CPFT Guideline for the pharmacological management of acute behavioural disturbance in in-patient wards

....

Non Formulary Items

Cariprazine (Reagila^®)
(Capsule)

Non Formulary

Clozapine (Zaponex^®)
(Tablet)

Non Formulary

Initiation by consultant psychiatrist only.

Patients should receive the brand specific to the monitoring service with which they are registered.

Paliperidone
(MR tablets)

Non Formulary

MR tablets are non-formulary

MHRA: Risk of intraoperative floppy iris syndrome in people undergoing cataract surgery (Oct 13)

Key

	Notes
	Section Title (top level)
	Section Title (sub level)
	First Choice item
	Non Formulary section
	Restricted Drug
	Unlicensed
	Display tracking information
	Link to adult BNF
	Link to children's BNF
	Link to SPCs
	Scottish Medicines Consortium

	Cytotoxic Drug
	Controlled Drug
	High Cost Medicine
	Cancer Drugs Fund
	NHS England
	Homecare
	CCG

Traffic Light Status Information

Status	Description
	Available Over the Counter. Consider Self Care
	Formulary - Can be prescribed in both secondary and primary care.
	Formulary - Specialist Advice, secondary care advice provided for primary care initiation.
	Formulary - Specialist initiation without shared care guidance.
	Formulary - Specialist initiation with shared care guidance.
	Restricted - Prescribing (and monitoring where applicable) to remain with the hospital or specialist service. Not to be prescribed in Primary Care
	Not recommended for prescribing. Switch to alternative cost-effective option.
	Not recommended for prescribing in primary or secondary care.
	Not recommended as no formal application made for addition to the formulary. Contact relevant pharmacy team for further information.
	Non-Formulary (category under review).