4.1.1 Hypnotics
4.1.2 Anxiolytics
4.2.1 Antipsychotic Drugs
Typicals
Atypicals
4.2.2 Antipsychotic Depot Injections
4.2.3 Antimanic Drugs
4.3 Antidepressant Drugs
4.3 1 Tricyclic Antidepressants
4.3.3 SSRIs
4.3.4 Third Line Antidepressants
4.4 CNS Stimulants
4.5 Anti-Obesity Drugs
4.6 Drugs Used in Nausea and Vertigo
4.7.1 Non-Opioid Analgesics
4.7.2 Opioid Analgesics
4.7.3 Neuropathic Pain
4.7.4 Antimigraine Drugs
4.8 Antiepileptics
4.9 Parkinson’s Disease
4.10 Drugs used in substance dependence
4.11 Drugs for Dementia

Link to Devon PCT Effective Practice Committee Statements

 

Link to NICE guidance

Delerium. Clinical Guideline No. 103

 

Common mental health disorders.  Clinical Guideline No 123.

 

4.1.1 Hypnotics

NICE Guidance

Link to NICE guidance

Insomnia - newer hypnotic drugs. TAG 77.

 

Benzodiazepines

First choice: Temazepam tabs (G): 10mg [28tabs £2.57], 20mg tabs [28tabs £1.91].
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.
Links:             Hospital Formulary:

Non-Benzodiazepines

First choice: Zopiclone tabs (G): 3.75mg [28tabs £1.62], 7.5mg [28tabs £1.60].
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.
Links:             Hospital Formulary:

4.1.2 Anxiolytics

Link to NICE guidance

Generalised anxiety disorder and panic disorder in adults Clinical Guideline No.113

Benzodiazepines

First choice: Diazepam tabs (G): 2mg [84tabs £2.43], 5mg [84tabs £2.46], 10mg [84tabs £2.61].
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.
Links:             Hospital Formulary:

Second choice: Lorazepam tabs (G): 1mg [28tabs £3.81], 2.5mg [28tabs £5.11].
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.
Links:             Hospital Formulary:

Non-Benzodiazepines

First choice: Propranolol tabs (G): 40mg [84tabs £2.73].
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.
Links:             Hospital Formulary:

4.2.1 Antipsychotic Drugs

Link to NICE guidance

Schizophrenia - Clinical Guideline No.82

Typicals
Phenothiazines

Chlorpromazine tabs (G): 25mg [84tabs £4.50], 50mg [84tabs £4.83], 100mg [84tabs £6.60].
Dose: 25 to 100mg three times a day.
Prescribing notes: 10mg tablets no longer manufactured.
Links:             Hospital Formulary:

Trifluoperazine tabs (G): 1mg [84tabs £6.51], 5mg [84tabs £4.40].
Dose: initially 5mg twice a day then increase according to response, age and body-weight.
Prescribing notes:
Links:             Hospital Formulary:

Butyrophenones

Haloperidol (G): 500micrograms [84caps £3.30], 1.5mg [84tabs £5.07], 5mg [84tabs £7.02], 10mg [84tabs £22.14], 20mg [84tabs £51.00].
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:
Links:             Hospital Formulary:

Thioxanthenes

Flupentixol tabs: 3mg [84tabs £5.23].
Dose: 3 to 9mg twice daily (in psychosis).
Prescribing notes: Lower dose tabs (0.5mg & 1mg) used in depression).
Links:             Hospital Formulary:

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:
Links:             Hospital Formulary:

Substituted Benzamides

First choice: Sulpiride tabs (G): 200mg [84tabs £21.90], 400mg [84tabs £63.22].
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.
Links:             Hospital Formulary:

Atypicals

Link to NICE guidance

Schizophrenia - Clinical Guideline No. 82

Risperidone tabs (G): 500micrograms [60tabs £2.76], 1mg [60tabs £1.56], 2mg [60tabs £1.97], 3mg [60tabs £2.28]; 4mg [60tabs £2.60].
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. 
Links:             Hospital Formulary:

Olanzapine tabs (G): 2.5mg [28tabs £1.74], 5mg [28tabs £3.25], 7.5mg [28tabs £2.66], 10mg [28tabs £5.30], 15mg [28tabs £9.01]; 20mg [28tabs £9.14].
Dose: 5 to 20mg once daily.
Prescribing notes: Generic products now available.
Links:             Hospital Formulary:

Quetiapine tabs: 25mg [60tabs £40.05], 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:
Links:             Hospital Formulary:

Aripirazole tabs: 5mg [28tabs £96.04], 10mg [28tabs £96.04], 15mg [28tabs £96.04], 30mg [28tabs £192.08].
Dose: 10 to 15mg once daily; maximum 30mg daily.
Prescribing notes:
Links:             Hospital Formulary:

4.2.2 Antipsychotic Depot Injections

Flupentixol 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.
Links:             Hospital Formulary:

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.
Links:             Hospital Formulary:

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.
Links:             Hospital Formulary:

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.
Links:             Hospital Formulary:

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.
Links:             Hospital Formulary:

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).
Links:             Hospital Formulary:

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:
Links:             Hospital Formulary:

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 Antidepressants

First choice: Lofepramine tabs (G): 70mg [56tabs £15.03].
Dose: 140 to 210mg daily in divided doses.
Prescribing notes: Less likely to cause side effects than other TCAs.

Links:

Antidepressant Guideline:

Hospital Formulary:


4.3.3 SSRIs

First choice: Fluoxetine caps (G): 20mg [30caps £1.01].
Dose: 20mg once daily.
Prescribing notes:

Links:

Antidepressant Guideline:

Hospital Formulary:


Alternative choice: Citalopram tabs (G): 10mg [28tabs £1.01], 20mg [28tabs £1.13], 40mg [28tabs £1.29].
Dose: 20mg once daily increasing to a maximum of 40mg daily (max 20mg in elderly).
Prescribing notes:

Links:

Antidepressant Guideline:

Hospital Formulary:

 

See also New Advice for the Safer Prescribing of Citalopram


Alternative choice: Sertraline tabs (G): 50mg [28tabs £3.25], 100mg [28tabs £3.53].
Dose: 50mg once daily increasing to a maximum of 200mg daily.
Prescribing notes: Patent expiry due Oct 2005.

Links:

Antidepressant Guideline:

Hospital Formulary:

4.3.4 Third Line Antidepressants

Mirtazapine (G): 15mg [28tabs £2.66]; 30mg [28tabs £1.77]; 45mg [28tabs £3.00].
Dose: 15 to 45mg at night.
Prescribing notes:

Links:

Antidepressant Guideline:

Hospital Formulary:

 

4.4 CNS Stimulants

Methylphenindate tabs (G) (CD): 5mg [30tabs £3.03], 10mg [30tabs £5.49], 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.
Links:             Hospital Formulary:

Link to NICE guidance

Attention deficit hyperactivity disorder (ADHD). TAG 98

 

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

4.5 Anti-Obesity Drugs
4.5.1Drugs 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 Vertigo
Antihistamines

First Choice: Cyclizine tabs: 50mg [84tabs £7.47].
Dose: 50mg up to three times a day.
Prescribing notes: First choice in pregnancy.
Links:             Hospital Formulary:

Phenothiazines

First Choice: Prochlorperazine tabs (G): 5mg [84 tabs £1.94]; 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.
Links:             Hospital Formulary:

Dopamine Antagonists

First Choice: Metoclopramide tabs (G): 10mg [84tabs £2.94].
Dose: 10mg three times a day.
Prescribing notes: Third Choice in pregnancy. Avoid in patients under 20 years old especially females.
Links:             Hospital Formulary:

Second Choice: Domperidone tabs (G): 10mg [84tabs £1.66].
Dose: 10 to 20mg every four to eight hours.
Prescribing notes: Anti-nauseant of choice for patients with Parkinson’s Disease. OTC.
Links:             Hospital Formulary:

Travel Sickness

First Choice: Cinnarizine tabs (G): 15mg [10tabs 62p].
Dose: 30mg two hours before travel then 15mg every eight hours during journey.
Prescribing notes: OTC.
Links:             Hospital Formulary:

Meniere’s Disease

First Choice: Betahistine tabs (G): 8mg [84tabs £5.07], 16mg [84tabs £2.47].
Dose: 8 to 16mg three times a day.
Prescribing notes:
Links:             Hospital Formulary:

4.7 Analgesics
4.7.1 Non-Opioid Analgesics

First Choice: Paracetamol (G): 500mg tabs [224tabs £3.09], 500mg soluble tabs [224tabs £22.40].
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.
Links:             Hospital Formulary:

Paracetamol 120mg/5ml sugar free paediatric solution [200ml 78p].  Dose:
3 to 6 months, 2.5ml four times a day
6 to 24 months,  5ml four times a day
2 to 4 years,   7.5ml four times a day
4 to 6 years,    10ml four times a day.

Paracetamol 250mg/5ml sugar free suspension [200ml £1.40]. Dose:
6 to 8 years,       5ml four times a day
8 to 10 years,  7.5ml four times a day
10 to 12 years, 10ml four times a day.

Second Choice: Aspirin (G): tabs 300mg [224tabs £2.17], dispersible tabs 300mg [224tabs £4.93].
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.
Links:             Hospital Formulary:

4.7.1.1 Compound Analgesics

Co-codamol 8/500 (G): tabs [224tabs £3.52].
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
Links:             Hospital Formulary:

Co-codamol 30/500 (G): tabs [224tabs £7.66].
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.
Links:             Hospital Formulary:

Co-dydramol 10/500 tabs (G): [224tabs £3.99].
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.
Links:             Hospital Formulary:

4.7.2 Opioid Analgesics

Non-Controlled Drugs

First Choice: Dihydrocodeine tabs (G): 30mg [224tabs £11.12].
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.
Links:             Hospital Formulary:

Second Choice: Codeine Phosphate tabs (G): 15mg [224tabs £8.08], 30mg [224tabs £9.12], 60mg [112tabs £14.56].
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.
Links:             Hospital Formulary:

Alternative choice for patients intolerant, or unresponsive, to codeine:
Tramadol capsules (G): 50mg [224 caps £4.21].
Dose: 50-100mg, not more frequently than every four hours.
Prescribing notes: Daily dose greater than 400mg not usually required.
Links:             Hospital Formulary:

Strong Opiates
Oral Preparations (tablets)

First Choice: Morphine Sulphate MR tabs (MST) (CD): 5mg [60tabs £3.29], 10mg [60tabs £5.17], 15mg [60tabs £9.61], 30mg [60tabs £12.44], 60mg [60tabs £24.27], 100mg [60tabs £38.42], 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.
Links:             Hospital Formulary:

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.
Links:             Hospital Formulary:

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:
Links:             Hospital Formulary:

Parenteral Preparations

First Choice: Diamorphine injection (G) (CD): 5mg [amp £2.42], 10mg [amp £3.40], 30mg [amp £3.62], 100mg [amp £9.20], 500mg [amp £40.84].
Dose:
Prescribing notes: Parenteral diamorphine is approximately three times a strong as oral morphine.
Links:             Hospital Formulary:

Transdermal Preparations

First 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

 

50 micrograms/hr

135 to 189 mg/day

 

62 micrograms/hr

190 to 224 mg/day

 

75 micrograms/hr

225 to 314 mg/day

 

100 micrograms/hr

315 to 404 mg/day

 

125 micrograms/hr

405 to 494 mg/day

 

150 micrograms/hr

495 to 584 mg/day

 

175 micrograms/hr

585 to 674 mg/day

 

200 micrograms/hr

675 to 764 mg/day

 

225 micrograms/hr

765 to 854 mg/day

 

250 micrograms/hr

855 to 944 mg/day

Links:             Hospital Formulary:

4.7.3 Neuropathic Pain

Link to NICE guidance

Neuropathatic pain – pharmacological management. Clinical Guideline No. 96

First Choice: Amitriptyline tabs (G): 10mg [56tabs £1.66], 25mg [56tabs £1.68], 50mg [56tabs £1.86].
Dose: Initially 10 to 25mg at night, increased gradually to 75mg at night.
Prescribing notes: Unlicensed use.
Links:             Hospital Formulary:

Second Choice: Gabapentin (G): Caps 100mg [84caps £3.60], 300mg [84caps £5.51], 400mg [84caps £5.39]; Tabs 600mg [84tabs £12.62]; 800mg [84tabs £23.28].
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:
Links:             Hospital Formulary:

4.7.4 Antimigraine Drugs

Treatment

Paracetamol soluble tabs (G): 500mg [60tabs £6.00].
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.
Links:             Hospital Formulary:

PLUS

Ibuprofen tabs (G): 200mg [84tabs £1.72], 400mg [84tabs £1.91].
Dose: 800mg stat then 400mg three times a day if needed.
Prescribing notes: OTC (200mg).
Links:             Hospital Formulary:

Prophylaxis

First choice: Propranolol tabs (G): 40mg [56 tabs £1.82].
Dose: Initially 40mg two or three times a day.
Prescribing notes:
Links:             Hospital Formulary:

Second Choice: Amitriptyline tabs (G): 10mg [56tabs £1.66], 25mg [56tabs £1.68], 50mg [56tabs £1.86].
Dose: l0mg at night increasing by l0mg every fifth night up to the recommended dose (usually l00mg).
Prescribing notes:
Links:             Hospital Formulary:

Triptans
Oral

First Choice: Sumatriptan tabs (G): 50mg [6tabs £1.73] , 100mg [6tabs £2.30]
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.
Links:             Hospital Formulary:

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:
Links:             Hospital Formulary:

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.
Links:             Hospital Formulary:

Phenobarbital (Phenobarbitone) tabs (G): 15mg [56tabs £3.48], 30mg [56tabs £1.96], 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)
Links:             Hospital Formulary:

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.
Links:             Hospital Formulary:

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.
Links:             Hospital Formulary:

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 £3.60], 300mg [84caps £5.51], 400mg [84caps £5.39]; Tabs 600mg [84tabs £12.62]; 800mg [84tabs £23.28].
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:
Links:             Hospital Formulary:

Lamotrigine: Tabs 25mg [56tabs £1.98], 50mg [56tabs £2.61], 100mg [56tabs £3.66], 200mg [56tabs £5.93]; Dispersible tabs 2mg [56tabs £19.51], 5mg [56tabs £3.88], 25mg [56tabs £3.00], 100mg [56tabs £4.84].
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.
Links:             Hospital Formulary:

Levetiracetam tabs: 250mg [60tabs £18.02], 500mg [60tabs £36.46], 750mg [60tabs £53.43], 1000mg [60tabs £69.33].
Dose: 500mg twice a day, adjusted in increments of 1g every 2 to 4 weeks; max 3g daily in two divided doses.
Prescribing notes:
Links:             Hospital Formulary:

Oxcarbazepine tabs: 150mg [56tabs £16.58], 300mg [56tabs £26.00]; 600mg [56tabs £51.99].
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.
Links:             Hospital Formulary:

Tiagabine tabs: 5mg [56tabs £29.14], 10mg [56tabs £58.29]; 15mg [56tabs £87.43].
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:
Links:             Hospital Formulary:

Topiramate tabs: 25mg [60tabs £3.56], 50mg [60tabs £3.90], 100mg [60tabs £3.49], 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.
Links:             Hospital Formulary:

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.
Links:             Hospital Formulary:

4.8.2 Status Epilepticus

RECTAL


First Choice: Diazepam Rectal tubes: 5mg [tube £1.13], 10mg [tube £1.51].
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.
Links:             Hospital Formulary:

INTRAVENOUS

First 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.
Links:            Hospital Formulary:

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:
Links:             Hospital Formulary:

Second Choice: Co-carledopa: Tabs 62.5mg [84tabs £5.86], 110mg [84tabs £6.13], 125mg [84tabs £20.11], 275mg [84tabs £29.23]; 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:
Links:             Hospital Formulary:

Dopamine Agonists (Oral)
Ergot

First Choice: Cabergoline tabs: 1mg [28tabs £80.99], 2mg [28tabs £97.55].
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.
Links:             Hospital Formulary:

Second Choice: Pergolide tabs (G): 50micrograms [84tabs £23.81], 250micrograms [84tabs £25.82], 1000micrograms [84tabs £90.70].
Dose: Building gradually to a maintenance dose of 2 to 2.5mg daily in divided doses.
Prescribing notes: Specialist initiation only.
Links:             Hospital Formulary:

Dopamine Agonists (Oral)
Non-Ergot

First Choice: Ropinirole tabs: 1mg [84tabs £6.97], 2mg [84tabs £9.95], 5mg [84tabs £30.36].
Dose: Building gradually to a maintenance dose of 3 to 9mg daily in divided doses.
Prescribing notes:
Links:             Hospital Formulary:

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.
Links:             Hospital Formulary:

MAOB Inhibitors

First Choice: Selegiline tabs (G): 5mg [60tabs £10.38], 10mg [30tabs £7.60].
Dose: 10mg daily in the morning or 5mg twice daily in the morning and midday.
Prescribing notes:
Links:             Hospital Formulary:

COMP Inhibitors

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

Levodopa + COMP Inhibitor Combined

First 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.
Links:             Hospital Formulary:

4.9.2 Antimuscarinic Drugs

Procyclidine tabs (G): 5mg [84tabs £6.54].
Dose: 2.5mg three times a day increase gradually to a max of 30mg daily.
Prescribing notes:
Links:             Hospital Formulary:

Orphenadine tabs (G): 50mg [84tabs £62.19].
Dose: 50mg three times a day increase gradually to a max of 400mg daily.
Prescribing notes:
Links:             Hospital Formulary:

4.9.3 Riluzole

Link to NICE guidance

Motor Neurone disease - riluzole. TAG 20

4.10 Drugs used in substance dependence

4 10.1 Nicotine Replacement Therapy

Link to NICE Guidance

Smoking cessation services. PH10

Smoking cessation – varenicline. TAG 123

Alcohol-use disorders: physical disorders
Clinical Guideline No. 100

Alcohol-use disorders. Diagnosis, assessment and management of harmful drinking and alcohol dependence.  Clinical Guideline No. 115.

 
Patches

Nicorette patches: 5mg [7patches £9.97], 10mg [7patches £9.97], 15mg [7patches £9.97].
Dose: Apply on waking to dry, non-hairy skin on 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:

Gum

Nicorette gum: 2mg [30pieces £3.25, 105pieces £9.27], 4mg [30pieces £3.99, 105pieces £11.30].
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 Microtabs

Nicotinell 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 £4.83, 105tab refill pack £13.12].
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 Spray

Nicorette inhalator: 10mg [6 cartridges starter pack £4.46, 42 cartridges refill pack £14.65]; 15mg [6 cartridges starter pack £4.14, 42 cartridges refill pack £14.03].
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 £13.40].
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:

Bupropion

Bupropion 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

Varenicline

Varenicline 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.

4.10.2 Alcohol Dependence

4.10.3 Opiate Dependence

Link to NICE guidance

Drug misuse – methadone & buprenorphine TAG 114

Drug misuse – naltrexone TAG 115

Drug misuse: psychosocial interventions. Clinical guideline No. 51.

Drug misuse: opioid detoxification. Clinical guideline No. 52.

4.11 Drugs for Dementia

Link to NICE guidance

Dementia. Clinical Guideline No. 42.

Alzheimer's disease. TAG 111


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:
Links:              Hospital Formulary:

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:
Links:              Hospital Formulary:

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:
Links:              Hospital Formulary: