WORCESTERSHIRE

DRUG FORMULARY

UPDATED – includes APC decisions to February 2010

This Formulary is for use across Worcestershire, both in primary and secondary care. Originating in the Acute Trust, it is now maintained by the Worcestershire Area Prescribing Committee (APC). It is updated following monthly APC meetings and will be regularly reviewed to ensure that the medicines listed are evidence-based and take into consideration recommendations from NICE, MTRAC and APC. Prescribing of medicines within the Acute Trust must be in line with the ‘Strategy for Medicines Use’ in the Acute Trust Medicines Policy.

Where it is specified that an APC guideline must be followed these may be found at: http://www.worcspct.nhs.uk/publications/policies-and-procedures/prescribing.aspx

Notes for Acute Trust Users:

Initiating a new treatment for a patient Trust staff may only initiate treatment with medicines included in the Trust Formulary and Trust staff must comply with any special conditions of use or restrictions noted in the formulary against the medicines.

In emergency situations a Consultant may wish to prescribe a medicine that is not on the formulary. In such circumstances an attempt must be made to contact the Director of Pharmacy who may authorise pharmacy to obtain and supply the medicine. If this is not possible a senior pharmacist may obtain and supply the medicine without authorisation but a retrospective approval must be obtained by following the Trust High Cost Procedure (see Intranet under Clinical departments\Pharmacy). No precedent for further supplies will be set.

If a patient admitted to the Trust is already being treated with a drug not included on the Trust formulary, the patient’s own supply will be used wherever possible. In such circumstances, members of medical, nursing and pharmaceutical staff have responsibility for confirming the authenticity of the medicine.

Requests for to be Included in the Formulary Consultants only may make applications to the APC for additions to the formulary. These must be made on a standard request form available from the Medicines Information Departments at the Alexandra or Worcester Hospitals.

Junior Doctor Prescribing Junior Doctors wishing to prescribe drugs they are unfamiliar with would normally be expected to seek the advice of their Consultant.

Queries Regarding the Formulary

If you have any queries regarding the Formulary, please contact Nick Hubbard (Director of Pharmacy).

1 EMERGENCY TREATMENT OF POISONING

Paracetamol overdose

Acetylcysteine Methionine (only for patients who refuse IV treatment or are allergic to )

1 GASTRO-INTESTINAL SYSTEM

1.1 Dyspepsia and gastro-oesophageal reflux disease

Aluminium hydroxide mixture Magnesium trisilicate mixture Algicon products (low sodium) Peptac or Gaviscon products or equivalent Maalox suspension (low sodium) Mucaine suspension (radiotherapy patients)

See BNF for info on sodium content

1.2 Antispasmodics and other drugs altering gut motility

Mebeverine tablets Peppermint oil capsules Dicyclomine tablets Hyoscine butylbromide injection and tablets (tablets are poorly absorbed) Metoclopramide products Domperidone tablets

1.3 Ulcer-healing drugs

1.3.1. H2-receptor antagonists

Cimetidine products Ranitidine products

1.3.3 Selective antimuscarinics

Sucralfate tablets and suspension

1.3.4 Prostaglandin analogues

Misoprostol can prevent NSAID-associated ulcers (See Section 10.1.1)

1.3.5 Proton pump inhibitors

Omeprazole capsules (first line) Lansoprazole capsules and oro-dispersible tablets (not first line) Esomeprazole tablets (severe cases only, initiated in hospital)

H. pylori eradication regimes:

( Amoxycillin 1g bd ) or if ( Metronidazole 400mg bd ) ( Clarithromycin 500mg bd ) penicillin ( Clarithromycin 500mg bd ) ( Lansoprazole 30mg bd ) allergic ( Lansoprazole 30mg bd )

HeliClear (amoxicillin + clarithromycin + lansoprazole) used in Primary Care

2 A PPI can be continued if necessary once daily 1.4 Acute diarrhoea

1.4.1 Adsorbents and bulk-forming drugs

Ispaghula sachets

1.4.2 Antimotility drugs

Loperamide capsules and syrup phosphate tablets

1.5 Chronic bowel disorders

Infliximab (Crohns NICE guidance and Ulcerative Colitis) Adalimumab (Crohns 2nd line, after infliximab) Prednisolone rectal foam (Predfoam) Prednisolone tablets, soluble tablets and enemas (e/c no longer approved, Feb 2010) Sulphasalazine tablets and e/c tablets Mesalazine tablets, enemas and foam (Mezavant XL 1200mg added to formulary April 2008 for once daily administration) Olsalazine tablets Budesonide capsules and enemas Hydrocortisone rectal foam

1.6 Laxatives

1.6.1 Bulk-forming laxatives

Ispaghula sachets Methylcellulose tablets Sterculia granules

1.6.2 Stimulant laxatives

Senna tablets or syrup Bisacodyl tablets and suppositories Docusate capsules and solution Glycerol suppositories Sodium picosulfate liquid (Paeds) Co-danthramer suspension and capsules (restricted indications - see BNF)

1.6.3 Faecal softeners

Arachis oil enemas

1.6.4 Osmotic laxatives

Lactulose solution Movicol powder (expensive – not 1st line) Micralax or equivalent micro-enema Phosphate enemas

1.6.5 Bowel cleansing solutions (Used prior to colonic surgery, colonoscopy or radiological examination)

Sodium picosulphate powder (Picolax) Fleet Phospho-Soda oral solution Klean-Prep powder

3 1.7 Local preparations for anal and rectal disorders

1.7.1 Soothing haemorrhoidal preparations

Anusol cream and suppositories

1.7.2 Compound haemorrhoidal preparations with corticosteroids

Xyloproct ointment Anusol-HC suppositories Proctosedyl ointment

1.7.4 Management of anal fissures

Glyceryl Trinitrate 0.4% Rectal Ointment

1.8 Stoma care Contact Stoma Care Sister

1.9 Drugs affecting intestinal secretions

Creon

Others available on Consultant request

2 CARDIOVASCULAR SYSTEM

2.1 Positive inotropic drugs

2.1.1 Cardiac glycosides

Digoxin tablets, liquid and injection

2.2 Diuretics

Bendroflumethiazide (bendrofluazide) tablets Furosemide (frusemide) tablets, liquid and injection Bumetanide tablets (2nd line only – in absorption problems) Metolazone tablets (See BNF for guideline) Amiloride tablets Spironolactone tablets Eplerenone tablets (Second-line to spironolactone for heart failure after acute MI with ejection fraction of 40% or less) Co-amilofruse tablets ) Primary Care prefer diuretics Co-amilozide tablets (2nd line) ) to be prescribed separately (a few patients will require a potassium sparing diuretic with a thiazide)

2.3 Anti-arrhythmic drugs

Adenosine injection ) Amiodarone tablets and injection ) Disopyramide capsules and injection ) Flecainide tablets and injection ) Procainamide injection ) CCU protocols Propafenone tablets ) Quinidine tablets ) Bretylium tosilate injection ) Lignocaine injection ) Mexiletine capsules and injection )

4 2.4 Beta-adrenoceptor blocking drugs

Atenolol tablets, syrup and injection Propranolol tablets, modified release tablets and injection Metoprolol tablets and injection Labetalol tablets and injection Sotalol tablets (anti-arrhythmic only) Carvedilol tablets (2nd line) Esmolol injection (for short-term treatment of supraventricular arrhythmias) Bisoprolol tablets (1st choice beta-blocker in heart failure) (3rd line for patients with bronchial asthma or COAD where beta-blockers are considered necessary, at Consultant request)

2.5 Drugs affecting the renin-angiotensin system and other antihypertensive drugs

2.5.1 Vasodilator antihypertensive drugs

Hydralazine tablets and injection Sodium nitroprusside injection (ITU)

2.5.2 Centrally-acting antihypertensive drugs

Methyldopa tablets Clonidine tablets (Paeds and migraine)

2.5.3 Adrenergic neurone blocking drugs

Unavailable

2.5.4 Alpha-adrenoceptor blocking drugs

Prazosin tablets Doxazosin tablets and modified release tablets

2.5.5 Drugs affecting the renin-angiotensin system

2.5.5.1 Angiotensin-converting enzyme inhibitors

Ramipril capsules (First choice) Perindopril tablets (may not be initiated in new patients) Lisinopril tablets Enalapril tablets Captopril tablets

2.5.5.2 Angiotensin-II receptor antagonists

Candesartan tablets Irbesartan tablets Losartan tablets Olmersartan medoxomil tablets Valsartan capsules

2.5.6 Ganglion-blocking drugs

Unavailable

2.6 Nitrates, calcium-channel blockers and potassium-channel activators

2.6.1 Nitrates

Glyceryl trinitrate sublingual tablets, spray, buccal tablets and percutaneous adhesive dressings 5 Glyceryl trinitrate infusion Isosorbide mononitrate tablets, modified release tablets and capsules Isosorbide dinitrate intravenous infusion

2.6.2 Calcium-channel blockers

Felodipine tablets Diltiazem tablets and modified release preps ) Modified release preps should Nifedipine capsules and LA tablets ) be prescribed by brand name Amlodipine tablets Verapamil tablets, modified release preps and injection Nimodipine tablets (See BNF for restricted indications)

2.6.3 Potassium-channel activators

Nicorandil tablets Ivabradine (Cardiologists only may prescribe for patients intolerant of betablockers AND a rate-limiting calcium channel blocker - once-daily diltiazem)

2.6.4 Peripheral and cerebral vasodilators

Naftidrofuryl capsules (limited evidence of benefit – Consultant use only)

2.7 Sympathomimetics

2.7.1 Inotropic sympathomimetics

Dobutamine injection ) Dopamine injection ) See CCU/ITU Protocols Isoprenaline injection ) Dopexamine injection )

2.7.2 Vasoconstrictor sympathomimetics

Ephedrine ) Metaraminol ) Methoxamine ) On advice of Consultant Anaesthetist only Noradrenaline/norepinephrine ) Phenylephrine )

2.7.3 Cardiopulmonary resuscitation

Adrenaline/epinephrine

2.8 Anticoagulants and protamine

2.8.1 Parenteral anticoagulants

See posters and guidelines on wards

Heparin sodium IV (Pump Hep) Heparin sodium injection (Multiparin) (not for unstable angina – Specialist use only) Heparin calcium SC (not 1st line – Consultant advice only) Heparin intravenous flush (long lines and central lines only)

Enoxaparin injection (prophylaxis & treatment of VTE, also unstable angina – see guidelines) Fondaparinux (Unstable angina NSTEMI and STEMI) Must only be supplied and used according to a formally approved Trust Guideline for ACS Dalteparin injection (obstetrics only)

Epoprostenol (prostacyclin) injection – (ITU for haemofiltration) 6

2.8.2 Oral anticoagulants

Dabigatran – 2nd line to rivavroxaban for surgical prophylaxis Warfarin tablets Phenindione tablets (available for patients with warfarin intolerance/allergy) Rivaroxaban – for surgical prophylaxis in orthopaedic surgery on hips and knees and surgical prophylaxis for patient unable to have LMWH e.g. needle phobia or not able to self-administer LMWH when there is nobody else able to administer.

2.8.3 Protamine sulphate

Protamine sulphate injection

2.9 Antiplatelet drugs

Aspirin tablets, low dose soluble Clopidogrel tablets (true aspirin allergy or repeated frequent events despite aspirin, post MI or peripheral artery disease; in combination with aspirin in non-ST-segment elevation ACS for 12 months only; in combination with aspirin for 12 months following stenting or angioplasty; NOT APPROVED by APC for use in ST elevation MI ) Dipyridamole tablets Eptifibatide - as an adjunct to PCI; and in the prevention of early MI in patients with unstable angina or NSTEMI Tirofiban injection (Consultant advice only) Abciximab injection(Acute Coronary Syndrome following NICE) Prasugrel – only when used in accordance with NICE TA 182

2.10 Myocardial infarction and fibrinolysis

Streptokinase injection ) See Coronary Care Protocol Alteplase injection ) Tenectaplase )

2.11 Antifibrinolytic drugs and haemostatics

Aprotinin injection - Aprotinin should only be used after careful consideration in individual cases where, for example, the risk of blood loss during surgery is considered to be particularly high (e.g. redo CABG surgery), where there is no suitable alternative, and only when the likely benefits outweigh any risks to individual patients. Evidence has emerged over the last 2 years suggesting that aprotinin may be associated with an increased risk of cardiac and cerebral disorders, as well as all-cause mortality. Tranexamic acid tablets, syrup and injection Ethamsylate injection (Paediatrics)

Drotrecogin alfa (activated) (severe sepsis with multiple organ failure only. ITU Consultants only – 2 signatures required on prescription) 2.12 Lipid-regulating drugs

Cholestyramine powder Bezafibrate tablets Fenofibrate modified release tablets Simvastatin tablets (1st line statin) Pravastatin tablets Fluvastatin capsules Atorvastatin tablets NOT 10mg strength (initiation on low dose atorvasatin is not approved – use simvasatin, therefore atorvastatin 10mg tablets are non-formulary) Ezetimibe tablets (2nd line if statin inappropriate/not tolerated/not working) Nicotinic acid Modified Release tablets (including as Tredaptive) (Restricted to post-MI patients with type2 diabetes and HDL<1 after 3months on optimal statin therapy) Omega-3-acid ethyl esters(Omacor) – as part of a cardiac rehabilitation package but dietary advice must be included to encourage the dietary intake of omega-3 fatty acids in preference to prescribing Omacor Rosuvastatin – only on the recommendation of a consultant lipidologist for the treatment of 7 carefully selected patients; e.g. those in whom response to other statins is not considered adequate, despite maximum tolerated doses of other statins; familial hypercholesterolaemia

2.13 Local sclerosants

Ethanolamine oleate injection

3 RESPIRATORY SYSTEM

Osmohale - approved as a standardised BHR challenge test in secondary care in line with the product’s marketing authorisation

3.1 Bronchodilators

(All devices are available - metered dose inhalers are less expensive than dry powder devices)

Salbutamol inhaler devices, tablets, nebules and injection Combivent nebules Terbutaline inhaler devices, syrup and injection Ipratropium inhaler devices and nebules Oxitropium inhaler devices Salmeterol inhaler devices Formoterol inhaler devices Aminophylline injection and slow release tablets Theophylline paediatric syrup Theophylline modified release capsules

3.2 Corticosteroids

(All devices are available - metered dose inhalers are less expensive than dry powder devices)

Beclometasone inhaler devices Budesonide inhaler devices and respules Fluticasone inhaler devices

Compound preparations

Seretide MDI and Accuhaler (fluticasone + salmeterol) Symbicort Turbohaler (budesonide + formoterol) Fostair - beclometasone dipropionate 100 micrograms, formoterol fumarate 6 micrograms metered inhalation NOTE: the limitations of this product must be recognised and communicated to patients

3.3 Cromoglicate therapy and leukotriene receptor antagonists

Sodium cromoglycate inhaler devices Ketotifen capsules, tablets and syrup (Paediatrics) Montelukast tablets (not for routine use) Omalizumab (Restricted use – follow APC Guideline on prescribing and monitoring)

3.4 Antihistamines, hyposensitisation and allergic emergencies

Chlorphenamine (chlorpheniramine) tablets, syrup and injection Cetirizine tablets and solution Loratadine tablets and syrup tablets and liquid Hydroxyzine tablets and syrup Alimemazine (trimeprazine) syrup Adrenaline/epinephrine pre-filled syringes (Special order)

3.5 Respiratory stimulants and pulmonary surfactants 8

Caffeine citrate solution and injection (SCBU) Doxapram infusion Poractant alfa (Neonates)

3.6 Oxygen

See BNF

3.7 Mucolytics

Sodium chloride 0.9% sterile solution for nebulisation (Respiratory Physicians only for COPD with chronic productive )

3.8 Aromatic inhalations

Not recommended

3.9 Cough preparations

Simple linctus Codeine linctus Pholcodine linctus

3.10 Systemic nasal decongestants

Not recommended

4 CENTRAL NERVOUS SYSTEM

4.1 Hypnotics and anxiolytics

4.1.1 Hypnotics

(Hypnotics should not generally be prescribed on discharge unless taken regularly prior to admission)

Temazepam tablets and elixir Chloral betaine tablets & chloral hydrate syrup (Welldorm) Clomethiazole (chlormethiazole) capsules & elixir Melatonin - approved for the treatment of sleep disorders in children and adults associated with neurological and/or behavioural problems, including ADHD and autism, and in older adults with dementia where alternative hypnotics have failed. Treatment should be specialist-initiated with transfer to primary care under shared care if specialist and GP in agreement. Promethazine tablets and syrup Zopiclone tablets Zolpidem tablets

4.1.2 Anxiolytics

Diazepam tablets and injection Lorazepam tablets and injection Oxazepam tablets Chlordiazepoxide tablets (alcohol withdrawal) Propranolol tablets Buspirone tablets (Consultant Psychiatrist lead only)

4.2 Drugs used in psychoses and related disorders

9 4.2.1 Antipsychotic drugs

Chlorpromazine tablets, syrup and injection Haloperidol tablets, liquid and injection Flupenthixol tablets Promazine tablets, and suspension Trifluoperazine tablets, modified release capsules and solution Sulpiride tablets Zuclopenthixol tablets Zuclopenthixol acetate injection Benperidol tablets Pericyazine tablets Levomepromazine (methotrimeprazine) injection (Palliative Care) Aripiprazole tablets Amisulpride tablets Clozapine tablets (Consultant Psychiatrist only) Olanzapine tablets Quetiapine tablets (includes Quetiapine XL) Risperidone tablets

Other drugs may be available at the request of Consultant Psychiatrist

4.2.2 Antipsychotic depot injections

Flupentixol decanoate injection Fluphenazine decanoate injection Haloperidol decanoate injection Zuclopenthixol decanoate injection Pipotiazine palmitate injection

4.2.3 Antimanic drugs

Lithium salts - should be prescribed by brand name Lithium carbonate modified release tablets 200mg (Priadel) and 400mg Lithium carbonate 250mg tablets (Camcolit) Lithium citrate 520mg/5ml liquid (Priadel) Valproic acid (as semisodium valproate) tablets 4.3 Antidepressant drugs

4.3.1 Tricyclics and related antidepressants

Amitriptyline tablets and solution Clomipramine capsules Dosulepin (dothiepin) capsules and tablets tablets and syrup Lofepramine tablets Trazodone capsules, tablets and liquid

4.3.2 Monoamine-oxidase inhibitors (MAOI’s) Phenelzine tablets

Reversible MAOI

Moclobemide tablets

4.3.3 Selective serotonin re-uptake inhibitors (SSRIs)

Escitalopram – 3rd line use by psychiatry specialist prescribers (see guidelines) Fluoxetine capsules and liquid Citalopram tablets and oral drops Paroxetine tablets and liquid 10 Sertraline tablets

4.3.4 Other antidepressant drugs (not 1st line)

Flupenthixol tablets tablets Reboxetine tablets Venlafaxine tablets and modified release capsules Duloxetine Not first-line - see APC guidelines for approved indications

4.4 Central nervous stimulants

Dexamphetamine (on Consultant request) Methylphenidate tablets and modified release tablets (on Consultant request) Atomoxetine capsules (on Consultant advice in children 2nd line to methylphenidate)

4.5 Drugs used in the treatment of obesity

Orlistat capsules Sibutramine capsules

Others on Consultant request

4.6 Drugs used in and vertigo

Aprepitant - prevention of acute and delayed nausea and associated with highly emetogenic chemotherapy after failure of first line anti-emetic options Betahistine tablets Cinnarizine tablets Cyclizine tablets and injection Prochlorperazine tablets, buccal tablets, injection and suppositories Metoclopramide tablets, injection and syrup (not if less than 20 years old) Domperidone tablets and suppositories Promethazine hydrochloride injection Promethazine teoclate tablets (hyperemesis gravidarum) Haloperidol tablets, syrup and injection Methotrimeprazine injection (for syringe drivers) Granisetron tablets and injection (not for routine use - very expensive) Ondansetron tablets, syrup, suppositories and injection (not for routine use - very expensive)

4.7

4.7.1 Non- analgesics

Aspirin tablets dispersible 300mg Paracetamol tablets, dispersible tablets, syrup, injection and suppositories Nefopam tablets and injection

Combination analgesics (Paracetamol and codeine should be prescribed separately if possible) Co-dydramol tablets Co-codamol 8/500 tablets and effervescent tablets Co-codamol 30/500 tablets and effervescent tablets 4.7.2 Opioid analgesics

Dihydrocodeine tablets, syrup and injection injection (Obstetrics) injection tablets, SR tablets, elixir and injection Diamorphine injection 11 injection tablets Buprenorphine/ (Suboxone) – by specialists only for substitution treatment of opioid dependence capsules (not first line) and injection Codeine phosphate tablets and injection

Fentanyl patches (for patients unable to tolerate oral morphine preparations as an alternative to a diamorphine syringe driver ) buccal, sublingual and intranasal spray (when prescribed by a palliative care clinician and the use is audited) capsules, modified release tablets and injection (2nd line in cancer pain for patients who, following an adequate trial of morphine, are shown to be morphine- intolerant) mixture and injection (Community Drugs Team)

4.7.3 Neuropathic pain

Amitriptyline tablets (see section 4.3.1) Carbamazepine tablets (see section 4.8.1) Gabapentin capsules (see section 4.8.1) Pregabalin (Restricted to 3rd-line use. Prescribers must follow APC guideline)

4.7.4 Antimigraine drugs

4.7.4.1 Treatment of the acute migraine attack

Paracetamol and metoclopramide (Paramax) Sumatriptan tablets, nasal spray and injection

4.7.4.2 Prophylaxis of migraine

Pizotifen tablets and elixir Clonidine tablets Beta blockers (See Section 2.4) Calcium-channel blockers (See Section 2.6.2)

4.8 Antiepileptics

4.8.1 Control of epilepsy

Phenytoin capsules, syrup and IV injection (dose adjustment necessary when changing formulations) Carbamazepine tablets, syrup and suppositories Phenobarbital (phenobarbitone) tablets, elixir and injection Sodium valproate tablets, Chrono tablets, syrup and injection Lacosamide - as an adjunctive therapy in the treatment of partial-onset secondary generalised seizures on a probationary basis. APC has requested a report in Jan-Mar 2010 months from the neurologists, to include the number of people treated with lacosamide, outcomes and the number of patients in whom lacosamide is subsequently stopped. On-going approval for the use of lacosamide will be considered in light of the report. Lamotrigine tablets and dispersible tablets Gabapentin capsules and titration pack Vigabatrin tablets and sachets (Paeds) Clonazepam tablets Ethosuximide capsules and syrup Levetiracetam

4.8.2 Drugs used in status epilepticus

Diazepam injection and rectal solution 12 Clonazepam injection Lorazepam injection Midazolam buccal (unlicensed) Phenytoin injection Paraldehyde

4.9 Drugs used in parkinsonism and related disorders

4.9.1 Dopaminergic drugs used in parkinsonism

Co-careldopa (Sinemet) preparations Co-beneldopa (Madopar) preparations Selegiline tablets Stalevo (levodopa, carbidopa, entacapone in various combinations)

Apomorphine injection ) Entacapone tablets ) Specialist Use Only Pramipexole tablets ) Ropinirole tablets ) Rotigotine patches

Bromocriptine tablets ) NOTE: ergot-derived dopamine receptor agonists have been associated with Cabergoline tablets ) pulmonary, retroperitoneal, and pericardial fibrotic reactions, Specialist Pergolide tablets ) Use Only

4.9.2 Antimuscarinic drugs used in parkinsonism

Procyclidine tablets, syrup and injection Trihexyphenidyl (benzhexol) tablets Orphenadrine tablets

4.9.3 Drugs used in essential tremors, chorea, tics and related disorders

Tetrabenazine tablets Haloperidol tablets or syrup Botulinum A toxin-haemagglutinin complex (Consultant use only including use in a patient pathway second line to local application of diltiazem for anal fissures)

4.10 Drugs used in substance abuse

Acamprosate tablets Chlordiazepoxide tablets and capsules Chlormethiazole (no longer recommended – use chlordiazepoxide) Disulfiram tablets Lofexidine tablets Methadone preparations Nicotine patches (enforced bed-rest only)

4.10.1 Drugs for dementia

Donepezil tablets ) Galantamine tablets ) Specialist advice only – shared care protocol Rivastigmine capsules ) with primary care

5 INFECTIONS

5.1 Antibacterial drugs

5.1.1 Penicillins

13 5.1.1.1 Benzylpenicillin and phenoxymethylpenicillin

Benzylpenicillin injection Penicillin V tablets and elixir

5.1.1.2 Penicillinase-resistant penicillins

Flucloxacillin capsules, syrup and injection

5.1.1.3 Broad-spectrum penicillins

Amoxicillin capsules, suspension and injection Amoxicillin 3g sachets Co-amoxiclav tablets, dispersible tablets, suspension and injection

5.1.1.4 Antipseudomonal penicillin

Tazocin injection Timentin injection

5.1.2 Cephalosporins, cephamycins and other beta-lactams

Cefalexin capsules and suspension Cefuroxime injection Cefotaxime injection Ceftazidime injection Ceftriaxone injection Cefixime oral - for treatment of gonorrhoea by sexually transmitted disease clinics only Meropenem injection (Microbiologist advice or follow protocol if neutropenic patient) Ertapenem injection(For ESBL organisms while supply problems with Meropenen) (Microbiolgist advice) Imipenem injection(For all other patients where a carbapenem is indicated while supply problems with Meropenem) (Microbiologist advice) 5.1.3 Tetracyclines

Oxytetracycline tablets Doxycycline capsules Minocycline capsules

5.1.4 Aminoglycosides

Gentamicin injection Tobramycin injection and nebuliser solution (for Cystic Fibrosis) Neomycin tablets Palacos R + Gentamicin or Septopal Chains

5.1.5 Macrolides

Clarithromycin injection (CAP if NBM only) Clarithromycin suspension and tablets (H. pylori eradication & erythromycin intolerance) Erythromycin stearate tablets Erythromycin ethylsuccinate suspension Erythromycin lactobionate injection (Pregnancy Only) Azithromycin capsules and suspension

5.1.6 Clindamycin

Clindamycin (Usually on Microbiological advice)

5.1.7 Some other antibacterials

14

Sodium fusidate tablets and suspension ) Vancomycin injection ) (Microbiological advice) Teicoplanin injection )

5.1.8 Sulphonamides and trimethoprim

Trimethoprim tablets and syrup Co-Trimoxazole dispersible tablets, syrup and injection (Specific indications only - on Microbiological advice only)

5.1.9 Antituberculous drugs

Rifampicin capsules, syrup and infusion Isoniazid preparations Ethambutol tablets Pyrazinamide tablets

5.1.10 Antileprotic drugs

Dapsone tablets (Consultant Dermatologist advice only)

5.1.11 Metronidazole and tinidazole

Metronidazole tablets, suppositories and infusion

5.1.12 Quinolones

Ciprofloxacin tablets, syrup and injection Moxifloxacin tablets (Communtity Acquired Pneumonia in secondary care) Ofloxacin tablets (Genitourinary only)

5.1.13 Urinary-tract infections

Nitrofurantoin tablets

5.2 Antifungal drugs

Amphotericin lozenges Amphotericin infusion (Microbiological advice only) Amphotericin (liposomal) infusion Nystatin pastilles and suspension Miconazole oral gel (Paediatrics) Fluconazole capsules, syrup and infusion Griseofulvin tablets (not 1st line) Itraconazole capsules (skin and nail infections only) Terbinafine tablets

NB. Should not be used first line in oral or vaginal conditions except in immunocompromised patients

5.3 Antiviral drugs

Aciclovir tablets, syrup and infusion Atripla ) Lamivudine ) Stavudine ) Zidovudine ) See HIV protocols Indinavir ) Saquinavir ) Enfuvirtide injection (2nd line to other HIV therapy as per protocol) 15 Raltegravir An option for the 3rd line treatment, in combination with optimised background therapy, following failure of 1st and 2nd line antiretroviral treatment of HIV infection in adults, based on genotypic resistance profiling. Raltegravir may have advantages in those patients with cardiovascular risks. Tipranavir capsules (3rd/4th line to other HIV therapy) Darunavir (3rd/4th line to other HIV therapy) Kivexa (abacavir/lamivudine) – NOT first line; see APC HIV protocol Oseltamivir capsules and suspension Palivizumab – see West Midlands Regional Commissioning Policy for approved indications Adefovir dipivoxil for Hepatitis B in line with NICE guidance Tenofovir disoproxil for chronic Hepatitis B

5.4 Antiprotozoal drugs

Quinine sulphate Pentamidine (Kept in stock - Consultant request only)

All others available on Consultant request/Microbiological advice only

5.5 Anthelmintics

Mebendazole

All others available on Consultant request/Microbiological advice only

Drotrecogin alfa (activated) for severe sepsis – see section 2.11

6 ENDOCRINE SYSTEM

6.1 Drugs used in diabetes

6.1.1 Insulins

SHORT Actrapid Velosulin Insulin Lispro (Humalog) Humulin S Insulin glargine (Lantus)(restricted use only) Insulin detemir (Levemir) (2nd line to glargine) Insulin glulisine (Apidra and Solostar) INTERMEDIATE Insulatard Humulin I

SHORT/INTERMEDIATE MIX Mixtard Humulin M3

INTERMEDIATE TO LONG Monotard Humulin Lente

VERY LONG Ultratard

Available in vials, cartridges and disposable pens Inhaled insulin – before prescribing patients must qualify according to the NICE and APC guidelines

6.1.2 Oral antidiabetic drugs

Gliclazide tablets Glipizide tablets Tolbutamide tablets 16 Metformin tablets (plus slow release tabs, 2nd line, if intolerant to minimum effective dose of standard release tabs) Pioglitazone tablets (1st choice glitazone, new patients should not be initiated on Rosiglitazone) Repaglinide 2nd line add-on therapy to metformin for patients with irregular eating habits where HbA1c<8.5% OR As an alternative to adding a glitazone in patients failing targets on metformin/sulphonylurea treatments (or on metformin alone where standard sulphonylureas have been problematic), where HbA1C<8.5% OR Occasionally as monotherapy in lean type 2 patients where standard sulphonylureas have resulted in pre-prandial hypoglycaemia Sitagliptin (3rd line Type 2 diabetes by diabetologists and GP diabetes specialists) NOTE: FDA warning that acute pancreatitis may occur in some patients using sitagliptin Saxagliptin - initiation by Consultant Diabetologists only as an alternative to sitagliptin, in line with NICE guidance for sitagliptin Acarbose tablets

6.1.2.3 Other antidiabetics Exenatide Inj (Endocrinologists Only and restricted to HGV license holders to avoid initiating insulin, insulin poor responders in terms of escalating dose/excessive weight gain, and patients with BMI >=33 on two oral hypoglycaemics) Liraglutide – Endocrinologists only

6.1.3 Diabetic ketoacidosis

See BNF

6.1.4 Treatment of hypoglycaemia

Dextrose injection 50% Hypostop gel Glucagon injection

6.1.6 Diagnostic and monitoring agents for diabetes mellitus

Blood glucose monitoring

BM-Test 1-44 Medisense G2 Medisense Precision Plus

Urinalysis

Combur-5 Diastix Ketodiastix Multistix SG Multistix 8 SG Multistix GP Nephur 6 Uristix Clinitest (Path lab only)

6.2 Thyroid and antithyroid drugs

Thyroxine tablets Liothyronine sodium injection Carbimazole tablets Propranolol tablets Propylthiouracil tablets

6.3 Corticosteroids

Prednisolone tablets 1mg & 5mg, soluble tablets 5mg (e/c no longer approved, Feb 2010) 17 Hydrocortisone tablets and injection Fludrocortisone tablets Dexamethasone injection, liquid and tablets Methylprednisolone injection (Sodium Succinate) and Depot injection (Acetate) Triamcinolone injection - intra-articular Betamethasone injection

6.4 Sex hormones

6.4.1 Female sex hormones

6.4.1.1 Oestrogens and HRT

HRT for women with uterus

Elleste-Duet (estradiol + norethisterone) Elleste Duet Conti (estradiol + norethisterone) (patients requiring continuous combined therapy only) Prempak-C (conjugated oestrogens + norgestrel)

HRT for women without uterus

Estradiol tablets (Elleste-Solo or equivalent) Estradiol patches (FemSeven or equivalent)

Other oestrogens

Tibolone tablets (for persistent breakthrough bleeding only) Ethinyloestradiol tablets

6.4.1.2 Progestogens

Dydrogesterone tablets Medroxyprogesterone acetate tablets and injection Norethisterone tablets

6.4.2 Male sex hormones and antagonists

Testosterone implant Mesterolone tablets tablets Finasteride tablets

6.4.3 Anabolic steroids

Available on Consultant request

6.5 Hypothalamic and pituitary hormones and anti-oestrogens

Clomiphene citrate Tetracosactrin injection and depot injection Desmopressin tablets, melt, intranasal solution, intranasal spray and injection Terlipressin injection Pegvisomant - acromegaly

6.6 Drugs affecting bone metabolism

6.6.1 Calcitonin

Calcitonin (salmon)/Salcatonin injection

18 6.6.2 Bisphosphonates

Alendronic acid tablets (First choice for prevention and treatment of osteoporosis) Didronel PMO (disodium etidronate + calcium cyclical pack) Disodium pamidronate injection Risedronate sodium tablets Sodium clodronate injection and capsules Strontium ranelate granules (for treatment in patients intolerant or unresponsive to bisphosphonates and For secondary prevention in line with NICE guidance) Zoledronic acid injection (restricted use only – please check with pharmacy for current status)

6.7 Other endocrine drugs

Bromocriptine tablets Danazol capsules Goserelin implant Cabergoline tablets (Specialist use only) Nafarelin nasal spray

Others available on Consultant request

7 OBSTETRICS, GYNAECOLOGY, & URINARY-TRACT DISORDERS

7.1 Drugs used in obstetrics

7.1.1 Prostaglandins and oxytocics

Oxytocin injection Syntometrine injection Ergometrine tablets and injection Carboprost injection Dinoprostone pessaries (Propess) (1st line), tablets / gel (not 1st line). Extra-amniotic injection (Prostin E2) is not recommended by BNF Gemeprost pessaries

7.1.2 Mifepristone

Mifepristone

7.1.3 Myometrial relaxants

Atosiban injection Ritodrine tablets and injection

7.2 Treatment of vaginal and vulval conditions

7.2.1 Preparations for vaginal atrophy Estriol 0.1% cream Premarin cream

7.2.2 Anti-infective drugs

Balance Active Gel – recurrent bacterial vaginosis Clotrimazole cream and pessaries Nystatin cream and pessaries Sultrin cream Metronidazole vaginal gel

7.3 Contraceptives

19

7.3.1 Combined oral contraceptives

Cilest Femodene Marvelon Mercilon Microgynon 30 Norimin Ovysmen Trinordiol TriNovum

7.3.2 Progestogen-only contraceptives

Femulen Micronor Norgeston Mirena intrauterine system

Emergency contraception

Levonelle-2 tablets

7.3.4 Contraceptive devices

GyneFix intra-uterine device

7.4 Drugs used for genito-urinary disorders

7.4.1 Drugs for urinary retention

Prazosin tablets Doxazosin tablets Bethanechol tablets

Alfuzosin tablets and modified release tablets ) Tamsulosin modified release capsules ) 2nd line Terazosin tablets )

7.4.2 Drugs for urinary frequency, enuresis and incontinence

Duloxetine capsules (stress incontinence 2nd line after physio and pelvic floor exercises) Imipramine tablets and syrup Oxybutynin tablets and elixir (NICE first choice) Oxybutynin MR tablets, patches Propantheline tablets Propiverine tablets Solifenacin Tolterodine tablets and modified release capsules

7.4.3 Drugs used in urological pain

Potassium citrate mixture

7.4.4 Bladder instillations and urological surgery

Sodium chloride 0.9% Chlorhexidine 0.02% Sodium hyaluronate (Cystistat) (Specialist use only – limited evidence of benefit) 20

7.4.5 Drugs for erectile dysfunction

Alprostadil (Specialist Use Only) Apomorphine sublingual tablets (Specialist Use Only - patients on nitrates unable to have sildenafil) Sildenafil, tadalafil and vardenafil tablets (Specialist Use Only)

8 MALIGNANT DISEASE & IMMUNOSUPPRESSION

8.1 Cytotoxic drugs

Drugs for cytotoxic-induced side-effects

Calcium folinate tablets and injection tablets and injection

8.1.1 Alkylating drugs

Busulfan tablets Carmustine injection Chlorambucil tablets Cyclophosphamide tablets and injection Estramustine capsules Ifosfamide injection Lomustine capsules Melphalan tablets and injection Thiotepa injection Treosulfan capsules and injection

8.1.2 Cytotoxic antibiotics

Bleomycin injection Dactinomycin injection Daunorubicin injection Doxorubicin injection Doxorubicin pegylated liposomal infusion (NICE guidance) Epirubicin injection Idarubicin capsules and injection Mitomycin injection Mitoxantrone/mitozantrone injection

8.1.3 Antimetabolites

Capecitabine tablets Cladribine injection Cytarabine injection Cytarabine liposomal for intrathecal use Fludarabine tablets (NICE guidance) OR with cyclophosphamide for CLL in patients <70years Fluorouracil injection and cream Gemcitabine injection (NICE guidance) Mercaptopurine tablets Methotrexate tablets and injection Permetrexed – when used according to NICE TA181 Ralitrexed injection (NICE guidance) Tioguanine (thioguanine) tablets

8.1.4 Vinca alkaloids and etoposide

Etoposide capsules and injection Vinblastine injection 21 Vincristine injection Vindesine injection Vinorelbine injection (and oral if single agent or for administration at a different time than other IV agents)

8.1.5 Other antineoplastic drugs

Amsacrine injection Bortezomib (NICE guidance) Dacarbazine injection Hydroxycarbamide/hydroxyurea capsules Imatinib capsules (NICE guidance) Carboplatin injection Cetuximab (NICE guidance when for 1st line metastatic colorectal cancer) Cisplatin injection Dasatinib (for CML only if a patient becomes refractory to imatinib) Nilotinib (for CML only if a patient becomes refractory to imatinib and dasatinib) Procarbazine capsules Razoxane tablets Docetaxel injection (NICE guidance) Paclitaxel injection (NICE guidance) Irinotecan injection (NICE guidance) Trastuzumab injection (NICE guidance) Sunitinib – only when used according to NICE TA179

8.2 Drugs affecting the immune response

8.2.1 Antiproliferative immunosuppressants

Azathioprine tablets

8.2.2. Corticosteroids and other immunosuppressants

Ciclosporin capsules and oral solution

8.2.3 Rituximab and alemtuzimab

Rituximab injection (NICE guidance)

8.2.4 Other immunomodulating drugs

Interferon alfa injection BCG bladder instillation Thalidomide (Specialists following approved safety and therapeutic protocols only. Seek pharmacy advice, a high-cost drug application is required for some indications)

8.3 Sex hormones & hormone antagonists in malignant disease

8.3.1 Oestrogens

Ethinylestradiol tablets

8.3.2 Progestogens

Medroxyprogesterone acetate tablets Megestrol acetate tablets Norethisterone tablets

8.3.4 Hormone antagonists

Tamoxifen tablets 22 Anastrozole tablets Exemestane tablets Letrozole tablets Bicalutamide tablets Cyproterone acetate tablets Flutamide tablets Goserelin implant injection

9 NUTRITION AND BLOOD

9.1 Anaemias and some other blood disorders

9.1.1 Iron-deficiency anaemia

Ferrous sulphate tablets Iron and folic acid tablets (Pregaday) Ferrous fumarate syrup Polysaccharide-iron complex elixir Iron sucrose injection (Not for routine use) Iron dextran injection (Not for routine use)

9.1.2 Drugs used in megaloblastic anaemias

Hydroxocobalamin injection Folic acid tablets and injection

9.1.3 Drugs used in hypoplastic, haemolytic, and renal anaemias

Darbopoetin – APC approved in principle (Feb09) the use of darbepoetin in low-risk MDS patients, with agreed positive predictors of response. Agreement of a local service would require a full proposal to be developed and submitted to the PCT for agreement on service delivery. Desferrioxamine Deferasirox – see APC guideline

9.1.4 Drugs used in autoimmune thrombocytopenic purpura

Consultant request

9.2 Fluids and electrolytes

9.2.1 Oral preparations for fluid and electrolyte imbalance

Dioralyte, Rehidrat or Electrolade (Subject to Contract) Potassium chloride effervescent tablets and syrup Slow Sodium tablets Calcium Resonium

9.2.2 Parenteral preparations for fluid and electrolyte imbalance

9.2.2.1 Electrolytes and water

All available

Intravenous potassium

Concentrated potassium solutions (requiring dilution before use) and strong potassium infusions (>40mmol/l) may only be stocked in pharmacy, ITU, HDU, CCU, NICU and Theatre (WRH) as per guidelines from the National Patient Safety Agency. Commercially prepared ready diluted potassium solutions should be used where possible. These are also available out of hours. For further

23 information read ‘Supply, storage and handling of strong potassium infusions and concentrated potassium solutions’ circulated as an addition to the Trust’s Medicines Policy

Potassium chloride and glucose 5% intravenous infusion containing K+ 10mmol/bag 500ml 20mmol/bag 500ml and 1 litre 40mmol/bag 500ml (WRH) and 1 litre

Potassium chloride and glucose 10% intravenous infusion containing K+ 10mmol/bag 500ml (Adult DKA protocol) 20mmol/bag 500ml (WRH)

Potassium chloride and sodium chloride 0.9% intravenous infusion containing K+ 10mmol/bag 500ml 20mmol/bag 500ml and 1 litre 40mmol/bag 500ml and 1 litre 60mmol/bag 1 litre 80mmol/bag 1 litre 100mmol/bag 1 litre (Alex)

Potassium chloride, sodium chloride 0.18% and glucose 4% intravenous infusion containing K+ 10mmol/bag 500ml 20mmol/bag 500ml and 1 litre 40mmol/bag 1 litre

Potassium chloride, sodium chloride 0.45% and glucose 5% intravenous infusion containing K+ 10mmol/bag 500ml (Paediatric DKA protocol) 20mmol/bag 500ml (Paediatric Pyloric Stenosis protocol)

9.2.2.2 Plasma and plasma substitutes

Gelofusine Hespan Dextran 40 & 70 Haemaccel Volulyte (ITU) Volplex

9.3 Intravenous nutrition

24 hours notice required for TPN

9.4 Oral nutrition

Limited range of enteral and supplementary feeds available. For further information contact dietitians who are able to prescribe feeds on the drug chart

9.5 Minerals

Calcium Sandoz tablets and syrup Calcium carbonate tablets (Calcichew or equivalent) Calcium gluconate injection

Others are available on Consultant request NOTE: Hyperphosphataemia in chronic renal failure – prescribing of Lanthanum by confident/competent GPs is supported within the PCT second line following failure/intolerance to Sevelamer

9.6 Vitamins

24 9.6.2 Vitamin B Group

Thiamine tablets 100mg Pyridoxine tablets 10mg and 50mg Vitamin B tablets compound strong High Potency Vitamin B & C injection

Others available on Consultant request

9.6.3 Vitamin C

Ascorbic acid 500mg

9.6.4 Vitamin D

Calcium carbonate and cholecalciferol tablets (Adcal-D3 tablets or Calfovit-D3 granules if patients cannot chew tablets or tolerate Adcal-D3) Calciferol injection and solution (Paediatrics) Alfacalcidol capsules and syrup

9.6.5 Vitamin E

Alpha tocopheryl acetate

9.6.6 Vitamin K

Phytomenadione injection (Konakion MM available for IM or oral use in Paediatrics) Menadiol sodium phosphate tablets

9.6.7 Multivitamin preparations

Dalivit drops or equivalent

9.7 Bitters and tonics

Not available

9.8 Metabolic disorders

Consultant request

10 MUSCULOSKELETAL AND JOINT DISEASES

10.1 Drugs used in rheumatic diseases and gout

10.1.1 Non-steroidal anti-inflammatory drugs

Aspirin soluble and e/c tablets Ibuprofen tablets and suspension Diclofenac tablets, injection and suppositories Naproxen tablets, suspension and suppositories Mefenamic acid tablets (gynaecology only) Indomethacin capsules, suspension and suppositories ) Sulindac tablets ) Not to be used 1st line Benorilate suspension ) Nabumetone tablets ) Meloxicam tablets ) Etodolac capsules ) In line with NICE guidance only Etoricoxib tablets (1st line CoxII inhibitor – prescribing by Rheumatologists only)

25 Celecoxib capsules (2nd line CoxII inhibitor – prescribing by Rheumatologists only) Arthrotec tablets (diclofenac + misoprostol) Ketoprofen injection

10.1.2 Corticosteroids

10.1.2.1 Systemic corticosteroids

See Section 6.3

10.1.2.2 Local corticosteroid injections

Methylprednisolone acetate Triamcinolone hexacetonide Dexamethasone sodium phosphate (W) Hydrocortisone acetate (W)

Other local injections

Hyaluronan - approved for OA of the shoulder and ankle when used as described in a currently approved APC protocol

10.1.3 Drugs which suppress the rheumatic disease process

Penicillamine tablets Hydroxychloroquine tablets Sulphasalzine e/c tablets Methotrexate tablets Azathioprine tablets Cyclosporin capsules Chloroquine sulphate tablets Leflunomide tablets (2nd line only) Infliximab infusion (NICE guidance) Etanercept injection (NICE guidance) Adalimumab injection (For psoriatic arthritis, 2nd line to etanercept) Rituximab restricted to anti-TNF treatment failures, specialist rheumatologist only

10.1.4 Gout and cytotoxic-induced hyperuricaemia

Allopurinol tablets (not in acute attack) Probenecid tablets Colchicine (acute attack - max dose, see BNF)

NSAIDs - See also Section 10.1.1

10.2 Drugs used in neuromuscular disorders

10.2.1 Drugs which enhance neuromuscular transmission

Edrophonium injection Neostigmine tablets and injection Pyridostigmine tablets Distigmine bromide tablets

10.2.2 Skeletal muscle relaxants

Diazepam preparations Baclofen tablets and syrup Dantrolene capsules Tizanidine tablets (Consultant only)

26 Nocturnal leg cramps

Quinine sulphate tablets

10.3 Drugs for the relief of soft-tissue inflammation

10.3.1 Enzymes

Hyaluronidase injection

10.3.2 Rubefacients and other topical antirheumatics

Not recommended – limited evidence of benefit

Ketoprofen 2.5% gel 100g non-proprietary Piroxicam 0.5% gel 60g non proprietary

11 EYE

11.3 Anti-infective eye preparations

Chloramphenicol drops and ointment Sodium fusidate viscous drops Gentamicin drops Ciprofloxacin drops (W) Ofloxacin drops Framycetin drops and ointment (W) Propamidine drops (W)

Others available dependant on sensitivity results

Aciclovir ointment

11.4 Corticosteroids and other anti-inflammatory preparations

Betamethasone drops Betamethasone with neomycin drops Dexamethasone drops (Maxidex), also minims Maxitrol drops (Dexamethasone, Neomycin and Polymyxin) Clobetasone butyrate drops (A) Prednisolone drops 0.1% and 0.5% Fluoromethalone drops Sodium cromoglycate drops

11.5 Mydriatics and cycloplegics

Atropine drops and ointment Cyclopentolate drops 0.5 & 1% Tropicamide drops 0.5 & 1% Phenylephrine drops Homatropine drops

11.6 Treatment of glaucoma

Betaxolol drops 0.25 & 0.5% Carteolol drops 1 & 2% Brinzolamide drops Timolol drops and long acting gel 0.25 & 0.5% Cosopt drops (dorzolamide + timolol) Pilocarpine drops 0.5, 1, 2 & 4% 27 Pilocarpine long acting gel 1, 2, & 4% Dipivefrine drops Levobunolol drops Adrenaline drops Brimonidine drops ) Latanoprost drops ) 2nd line - Travoprost drops ) Specialist advice Duotrav ) Bimatoprost ) 2nd line - Bimatoprost 0.03%/Timolol 0.5%Ganfort ) Specialist advice Xalacom drops (latanoprost + timolol) Acetazolamide tablets, capsules and injection

11.7 Local anaesthetics

Proxymetacaine Proxymetacaine & fluorescein Amethocaine drops

11.8 Miscellaneous ophthalmic preparations

Bevacizumab – unlicensed treatment of proliferative diabetic retinopathy (PDR) and neovascular glaucoma (NVG) Hypromellose drops (1st line) Lacrilube ointment (2nd line only) Hyaluronic acid (Oxyal), Sodium hyaluronate (Vismed) (only after secondary care recommendation) Polyvinyl alcohol drops Sodium chloride drops Fluorescein drops Sodium hyaluronate injection Carbomer drops (Gel Tears or equivalent) Ketorolac drops Apraclonidine drops Ranibizumab – NICE use, see APC guidelines

12 EAR, NOSE AND OROPHARYNX

12.1 Drugs acting on the ear

12.1.1 Otitis externa

Betamethasone ear drops Betamethasone with neomycin ear drops Clotrimazole ear drops Triamcinolone ear ointment Chloramphenicol ear drops Acetic acid ear spray (Consultant request only)

12.1.2 Otitis media

See BNF

12.1.3 Removal of ear wax

Sodium bicarbonate ear drops Olive oil ear drops

12.2 Drugs acting on the nose

28 12.2.1 Drugs used in nasal allergy

Beclomethasone preparations (1st line) Fluticasone propionate preparations Fluticasone furoate (Avamys) - treatment of allergic rhinitis, both seasonal and perennial, in people aged 6 years and over, Mometasone nasal spray Triamcinolone nasal spray Sodium cromoglycate preparations

12.2.2 Topical nasal decongestants

Sodium chloride nasal drops Ephedrine nasal drops Xylometazoline Adult and Paediatric nasal drops

12.2.3 Nasal preparations for infection and epistaxis

Naseptin nasal cream Mupirocin (Bactroban) (for MRSA)

12.3 Drugs acting on the oropharynx

12.3.1 Drugs for oral ulceration and inflammation

Hydrocortisone pellets Choline salicylate gel Benzydamine oral rinse and spray

12.3.2 Oropharyngeal anti-infective drugs

Nystatin mixture and lozenges Amphotericin lozenges Miconazole oral gel (Paediatrics)

Notes: See also BNF for other infections

12.3.4 Mouthwashes, gargles and dentifrices

Thymol mouthwash solution tablets Hydrogen peroxide mouthwash Chlorhexidine gluconate mouthwash

12.3.5 Treatment of dry mouth

Glandosane spray Saliva Orthana

13 DRUGS ACTING ON THE SKIN

13.2 Emollient and barrier preparations

13.2.1 Emollients

Aqueous cream Emulsifying ointment Aveeno cream Yellow soft paraffin Liquid paraffin 50% in white soft paraffin Cetraben cream Diprobase 29 Doublebase gel E45 cream Epaderm cream Kamillosan (sore nipples) Unguentum M Balneum Plus Calmurid cream Urea 10% cream Dermol lotion

13.2.1.1 Emollient bath additives

Diprobath Oilatum emollient Emulsiderm

13.2.2 Barrier preparations

Zinc and castor oil ointment Sudocrem cream

13.3 Topical local anaesthetics and antipruritics

Calamine lotion Crotamiton (Eurax) ointment and lotion Doxepin cream (not 1st line)

13.4 Topical corticosteroids

Preparations containing the lowest potency at lowest strength should be used 1st line

Mild potency

Hydrocortisone cream or ointment Alphaderm cream (hydrocortisone + urea)

Canesten HC (hydrocortisone + clotrimazole) Daktacort (hydrocortisone + miconazole) (W) (K) Nystaform-HC (hydrocortisone + nystatin + chlorhexidine) (W) (K) Fucidin H (hydrocortisone + fusidic acid) (W) (K) Vioform-Hydrocortisone (hydrocortisone + clioquinol) (W) Timodine cream (hydrocortisone + nystatin + benzylkonium chloride) (W)

Moderate potency

Clobetasone butyrate (Eumovate) Betamethasone cream 0.025% and ointment 0.025% (Betnovate RD)

Trimovate (clobetasone + oxytetracycline + nystatin) cream

Potent

Betamethasone 0.1% cream Hydrocortisone butyrate (Locoid) Fluocinonide (Metosyn) ointment Fluocinolone (Synalar) cream, ointment and gel Fluticasone propionate (Cutivate) cream Mometasone furoate (Elocon)

Betnovate-C (betamethasone + clioquinol) cream and ointment 30 Diprosalic (betamethasone + salicylic acid) ointment and scalp application Fucibet (betamethasone + fusidic acid) Locoid-C (hydrocortisone + chlorquinaldol) cream

Very potent

Clobetasol propionate (Dermovate) ) Hospital Consultant Dermovate-NN (clobetasone propionate + neomycin + nystatin) ) use only Diflucortolone valerate (Nerisone Forte) oily cream and ointment )

13.5 Preparations for eczema and psoriasis

Alphosyl HC cream Dithrocream – potent Adalimumab for psoriasis following NICE, specialist dermatologist only Efalizumab for psoriasis following NICE, specialist dermatologist only Etanercept for psoriasis following NICE, specialist dermatologist only Ustekinumab for psoriasis following NICE, specialist dermatologist only see NICE TA180 Pasta Picis Mitis (Mild Coal Tar paste) Polytar emollient Calcipotriol (Dovonex) cream Use Calcitriol (Silkis) if ointment is required Dovobet – only when used as described in the current APC guidelines Xamiol gel - in the treatment of scalp psoriasis, should only be initiated by a Consultant Dermatologist, or GP with Special Interest, in patients who have demonstrated an inadequate response to first line topical steroids Acitretin capsules ) Alitretinoin ) Cyclosporin capsules ) (Specialist Dermatologist only) Methotrexate tablets ) Tacrolimus ointment (Specialist Dermatologist use only for patients unresponsive to all other therapy) Pimecrolimus cream (as per NICE guidance only) See also Section 13.2

13.6 Acne and rosacea

Benzoyl peroxide gel, 5% and 10% Clindamycin (Dalacin T) topical solution Zineryt (erythromycin) solution Oxytetracycline tablets Minocycline tablets (not 1st line) Erythromycin tablets Isotretinoin capsules (Specialist Dermatologist only) Tretinoin (Retin-A) cream and gel (Dermatologist only) Dianette tablets

13.7 Preparations for warts and calluses

Salactol paint Warticon (genital warts) Fluorouracil cream Imiquimod cream (Specialist Use Only) Silver nitrate caustic sticks

13.8 Sunscreens and camouflages

RoC Total Sunblock UVA + UVB 25 Uvistat UVA + UVB 15

31 13.9 Shampoos and other scalp preparations

Polytar liquid Capasal shampoo Ceanel Concentrate shampoo Ketoconazole shampoo Cocois scalp ointment (W) (K)

13.10 Anti-infective skin preparations

Topical antibiotics not generally recommended - See Section 13.11 Mupirocin ointment Silver sulphadiazine cream Fusidic acid cream Clotrimazole cream Metronidazole gel Miconazole cream Nystatin cream Terbinafine cream Aciclovir cream Malathion (Derbac M) Carbaryl lotion (A) Permethrin cream rinse (head lice) and cream (scabies) - Please check local policy

13.11 Skin disinfectants and cleansers

Sodium chloride 0.9% solution Weak iodine solution Povidone-iodine aqueous and alcoholic solutions, spray and ointment Chlorhexidine cream, aqueous and alcoholic solution Chlorhexidine and cetrimide solution (Savlodil or Tisept) Hydrogen peroxide 1:20 solution Potassium permanganate solution tablets Ster-Zac powder

13.12 Antiperspirants

Aluminium chloride hexahydrate 20% solution – Driclor or equivalent

13.13 Wound management products

Dressings are expensive and have specific uses. See dressings information sheet on ward for choice and use of dressings or discuss with a Trust Tissue Viability representative. The following preparations are included in the Worcestershire Acute, Community and Mental Health Tissue Viability Policy, which contains advice on specific preparations.

Alginate dressings

Algisite M dressing Algisite M Rope Melgisorb Aquacel ribbon

Hydrocolloid dressings

Tegasorb Hydrocoll Hydrocoll thin Duoderm extra thin 32 Granuflex

Hydrogels

Intrasite Nu-gel

Polyurethane foam dressings

Lyofoam extra Allevyn

Vapour permeable adhesive film dressings

Mefilm Cutifilm

Paste bandages

Steripaste Ichthopaste

13.14 Topical circulatory preparations

Lasonil

14 IMMUNOLOGICAL PRODUCTS AND VACCINES

14.4 Vaccines and antisera

See BNF for immunisation schedules and details of individual vaccines

BCG vaccine Diphtheria, tetanus and acellular pertussis vaccine (Infanrix) Diphtheria and tetanus vaccine (child) (only if Infanrix contra-indicated) Diphtheria and tetanus vaccine (adults and adolescents) Diphtheria vaccine (adults and adolescents) Haemophilus influenzae type B vaccine (ACT-HIB) Haemophilus influenzae type B + DTP (ACT-HIB DTP) Hepatitis A vaccine Hepatitis B vaccine MMR (Measles, mumps and rubella) vaccine Meningococcal C vaccine Pneumococcal vaccine Polio vaccine (oral and inactivated) Rubella vaccine Tetanus vaccine Tuberculin PPD (Heaf test)

14.5 Immunoglobulins

Human normal immunoglobulin Others available on request

15 ANAESTHESIA

15.1

15.1.1 Intravenous anaesthetics

33 Thiopentone sodium Etomidate emulsion injection Propofol

15.1.2 Inhalational anaesthetics

Isoflurane Sevoflurane

Others by Consultant agreement

15.1.3 Antimuscarinic drugs

Atropine sulphate injection Glycopyrronium bromide injection Hyoscine hydrobromide injection

15.1.4 and peri-operative drugs

15.1.4.1 Anxiolytics and neuroleptics

Diazepam injection Lorazepam tablets Midazolam injection Temazepam tablets

15.1.4.2 Non-opioid analgesics

Ketorolac injection

15.1.4.3 Opioid analgesics

Alfentanil injection Fentanyl injection injection

15.1.5 Muscle relaxants

Atracurium besilate injection Cisatracurium injection Mivacurium injection Rocuronium bromide injection Vecuronium bromide injection Suxamethonium chloride injection

15.1.6 Anticholinesterases used in anaesthesia

Neostigmine methylsulphate injection Neostigmine + glycopyrronium bromide injection Other drugs for reversal of neuromuscular blockade Suggammadex - for the reversal of neuromuscular block in anaesthesia induced by rocuronium or vecuronium, when suxamethonium is contra-indicated.

15.1.7 Antagonists for central and respiratory depression

Doxapram hydrochloride injection Flumazenil injection Naloxone Adult injection 15.1.8 Drugs for malignant hyperthermia

34 Dantrolene sodium injection

15.2 Local anaesthesia

Lignocaine injection Lignocaine/adrenaline injection Bupivacaine injection Bupivacaine/adrenaline injection Levobupivacaine injection Prilocaine injection Ropivacaine injection Lignocaine/prilocaine cream (Emla) Tetracaine (amethocaine) gel (Ametop) Paeds only formularyworcsacute.DOC\DI

35