West Sussex Health and Social Care NHS Trust

SUSSEX PARTNERSHIP NHS FOUNDATION TRUST MEDICINES FORMULARY

GUIDELINE VERSION 26 RATIFYING GROUP (individual formulary Drugs and Therapeutics Group (DTG) decisions and linked guidelines) DATE PUBLISHED July 2021 NEXT REVIEW DATE July 2023 FORMULARY SPONSOR Chief Medical Officer FORMULARY EDITOR Chief Pharmacist

LINKED POLICIES AND GUIDELINES

Linked policies and antipsychotic Physical health linked guidelines guidelines • Antipsychotics, guidelines for cardiac • Antipsychotics, prescribing guidelines rhythm screening (ECGs) • Asenapine, prescribing guidelines • Antipsychotics, guidelines for the • Clozapine inpatient and community management of weight gain and team policies metabolic disturbances • Clozapine, protocol for the use of • Metformin, information for GPs on its intramuscular injection use with antipsychotics • Clopixol Acuphase, prescribing • Hyperprolactinaemia, prescribing guideline guidelines on the treatment of • Lurasidone, prescribing guidelines antipsychotic induced symptoms • Perinatal mental health, prescribing • Anticoagulants, prescribing guidelines guidelines • Insulin, prescribing guidelines • Rapid tranquilisation policy • Medicines code

Long acting antipsychotic guidelines Anxiolytics and hypnotic guidelines • Long acting antipsychotic injections, • Alcohol and benzodiazepine guidelines for use dependence (adults), prescribing • Aripiprazole long acting injection, guidelines for inpatients • Benzodiazepine as anxiolytics (adults), prescribing guidelines prescribing guidelines • Olanzapine long-acting injection, • Benzodiazepines, calculating prescribing guidelines equivalent doses • Paliperidone monthly long acting • Hypnotics (including benzodiazepines) injection, prescribing guidelines and insomnia, prescribing guidelines

• Paliperidone palmitate 3-monthly long

acting Injection, prescribing guidelines

Antidepressant prescribing guidelines Emotionally unstable personality disorder • Antidepressants, prescribing (EUPD), prescribing guidelines guidelines (note there are separate guidelines for adults and CAMHS) • Agomelatine, prescribing guidelines in major depressive episode

Bipolar affective disorder linked Substance dependence guidelines guidelines • Alcohol and benzodiazepine • Mood stabilizers, prescribing dependence (adults), prescribing guidelines in bipolar affective disorder guidelines for inpatients • Lithium, prescribing guidelines for • Opiate dependence, prescribing guidelines for inpatients inpatients • Substances and drugs of abuse, a guide to how long they can be detected in the body after consumption • Tobacco dependence pathway

Dementia and SOAMHs linked guidelines Attention Deficit Hyperactivity Disorder • Dementia, prescribing guidelines (ADHD) • Behavioural problems in older people, • ADHD Shared care guidelines prescribing guidelines (CAMHS) • Dementia, non-pharmacological • ADHD (adults), prescribing guidelines approaches to challenging behaviour • Guanfacine (CAMHS), prescribing

guidelines • Melatonin Shared care guidelines (CAMHS)

All prescribing guidelines and policies can be found on the Trust website from the following link: https://www.sussexpartnership.nhs.uk/medication

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Index

1. Sussex Partnership NHS Foundation Trust: Formulary principles 4 2. SPFT formulary medicines for mental health diagnoses 6 2.1 Hypnotics 6 2.2 Anxiolytics 7 2.3 Antipsychotics 9 2.4 Mood stabilisers 17 2.5 Antidepressants 20 2.6 Medicines used in alcohol and substance dependence 23 2.7 Medicines used in dementia 24 2.8 Medicines used in the treatment of Attention Deficit Hyperactivity Disorder (ADHD) 26 2.9 Approved unlicensed medicines use for behaviour that challenges in Autism Spectrum Disorder (ASD) and Learning Difficulties (LD) 28

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1. Sussex Partnership NHS Foundation Trust: Formulary principles

Only the following medicines can be prescribed to patients within Sussex Partnership NHS Foundation Trust (SPFT):

• Medicines associated with their mental health need and diagnoses which are detailed in this formulary and have been approved for use by the Trust’s Drugs and Therapeutics Group (DTG). Senior medical staff in this formulary are defined as consultants, associate specialists and speciality doctors with at least 3 years’ experience.

Please note that all medicines in every Trust must be approved for use by the local Area Prescribing Committee (APC) which is led by the Clinical Commissioning Group (CCG) according to each geographical location (East Sussex/ Brighton and Hove/ West Sussex). The newly formed Sussex Health and Care Partnership (SHCP) which spans across all 3 counties is working to align the separate formularies into a single SHCP formulary.

Currently the links to each of these formularies can be accessed from the Trust website via this link: https://www.sussexpartnership.nhs.uk/formularies

In the joint formularies, each medicine is colour coded. • Only medicines colour coded as green are permitted to be prescribed by the patient’s General Practitioner (GP). If your intention is that the patient’s GP will continue the prescription, please ensure it is coded green before initiating, • Blue coded medicines can only be transferred for GP prescribing once treatment is stabilised (usually after 3 months), • Amber coded medicines are approved for shared care with details outlined in individual shared care guidelines (SCGs), • Red medicines are specialist only medicines which can only be prescribed by a specialist. These include mental health medicines. The prescribing of red coded medicines for mental health can only be prescribed by SPFT clinicians, they cannot be transferred for GP prescribing.

• Physical health medicines as approved for use according to the joint formulary by geographical location. You must only prescribe physical health medicines that are coded as green on the joint formularies.

Please note that physical health medicines can only be prescribed for inpatients. Physical health medicines must not be prescribed on FP10 in community teams or clinics, except in exceptional and urgent circumstances. The responsibility for prescribing and monitoring physical medicines for patients in community teams or clinics is with the patient’s general practitioner (GP).

• Over-the-counter (OTC) medicines if approved for use in the Trust formulary or in the relevant CCG’s joint formulary.

• Complementary, essential oils, herbal and homeopathic medicines, if approved for use in the Trust formulary or in the relevant CCG’s joint formulary. N.B. Medicine supply for complementary, essential oils, herbal and homeopathic medicines is only permitted for those included within the formulary. However, if the patient has their own supply of a non-formulary medicine within these product groups then they may be prescribed for use only after a pharmacist has assessed their safety and clinical appropriateness (including assessment of drug interactions).

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For inpatients; the pharmacist must endorse within the additional information on the front of the drug chart that they have clinically screened each item for use before administration may take place. For non-formulary items; the patient’s own supply must be used for administration.

In order to request a new medicine or a new indication (diagnosis) for an existing medicine to be used within the Trust, the process within the ‘formulary, named-patient and unlicensed medicine use request protocol’ must be followed.

This protocol is available through this link: https://www.sussexpartnership.nhs.uk/medication-related-guidance All associated forms to this protocol can be accessed through this link: https://www.sussexpartnership.nhs.uk/charts-and-forms

• Unlicensed medicines

o Wherever clinically appropriate, medicines must be prescribed within their product licence (PL) and within their marketing authorisation (MA). A medicine maybe used outside of its PL (unlicensed medicine) or MA (“off-label” medicine) where there is significant clinical evidence base to support its use and that use has been approved for use by the Drugs and Therapeutic Group (DTG). In the majority of cases, this is for an unlicensed indication but in rare situations may also include route and/ or dosage.

o Every request for an unlicensed use of a medicine must be ratified by the Trust’s DTG. A prescriber is not authorised to prescribe an unlicensed medicine in this Trust, unless that use has been ratified by the DTG. A database of all unlicensed uses of medicines including named-patient forms where appropriate will be maintained by the Trust’s pharmacy team. Please ask your pharmacy team for a current copy of the approved unlicensed medicines database.

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2. SPFT formulary medicines for mental health diagnoses

2.1 Hypnotics

Please refer to the following SPFT clinical guidelines and NICE Technical Appraisals (where applicable) for prescribing, administration and monitoring advice:

SPFT clinical guidelines NICE Technical Appraisals (found here: https://www.sussexpartnership.nhs.uk/medication- (TA) related-guidance) Hypnotics (including benzodiazepines) and insomnia, TA77: prescribing guidelines http://guidance.nice.org.uk/TA77

Z Drugs (oral) Additional notes, including where unlicensed

Zolpidem TA77 First line in older people

Zopiclone TA77

Benzodiazepines (oral)

Loprazolam TA77

Temazepam TA77 Controlled drug – schedule 3

Oxazepam Only to be used when all other options have failed - unlicensed use (see below)

Other oral hypnotics

Chloral hydrate Can only be initiated by senior medical staff

Clomethiazole

Melatonin See unlicensed uses below

Promethazine

Approved Level 1 (low risk) unlicensed uses. Medicines with a manufacturing licence but are being prescribed for the following indications that are outside of that licence i.e. "off- label" usage:

Hypnotics: Approved level 1 (low risk) unlicensed indication Melatonin 2mg MR Sleep disturbance (licensed for up to 13 weeks) tablets (Circadin®) Oxazepam tablets Hypnotic

Anxiolytics

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2.2 Anxiolytics

Please refer to the following SPFT clinical guidelines and NICE Technical Appraisals (where applicable) for prescribing, administration and monitoring advice:

SPFT clinical guidelines NICE (found here: https://www.sussexpartnership.nhs.uk/medication-related- Technical guidance) Appraisals (TA) Alcohol and benzodiazepine dependence (adults), prescribing None at guidelines for inpatients present Benzodiazepine as anxiolytics (adults), prescribing guidelines Benzodiazepines, calculating equivalent doses Behavioural problems in older people, prescribing guidelines Substances and drugs of abuse, a guide to how long they can be detected in the body after consumption

Benzodiazepines (oral) Additional notes, including where unlicensed Chlordiazepoxide

Clonazepam Anxiolytic See unlicensed uses below

Diazepam Rapid tranquillisation Adjunct to treatment resistant schizophrenia See unlicensed uses below

Lorazepam See unlicensed uses below

Oxazepam Short term use

Other oral anxiolytics

Buspirone

Pregabalin Generalised anxiety disorder; prescribe as a twice daily dose rather than three times a day. Controlled drug – schedule 3

Hydroxyzine See unlicensed uses below

Promethazine See unlicensed uses below

Propranolol See unlicensed uses below

Citalopram See unlicensed uses below

Fluoxetine See unlicensed uses below

Mirtazapine See unlicensed uses below

Sertraline Panic disorder, social anxiety disorder. See unlicensed uses below

Injectable anxiolytics

Lorazepam Rapid tranquillisation

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Approved Level 1 (low risk) unlicensed uses. Medicines without a manufacturing licence in the United Kingdom but are licensed in a European Economic area (EEA) agreed framework. Assessed as lower end of risk so can be stock or ‘named-patient’:

Anxiolytics: Approved level 1 (low risk) unlicensed indication

Lorazepam injection Agitation, anxiolytic, rapid tranquillisation - please refer to the 4mg/ml (Mawdsley® rapid tranquillisation policy for the algorithm for use brand) Diazepam 10mg/5ml Agitation, anxiolytic, rapid tranquillisation - please refer to the oral solution rapid tranquillisation policy for the algorithm for use

Approved Level 1 (low risk) unlicensed uses. Medicines with a manufacturing licence but are being prescribed for the following indications that are outside of that licence i.e. "off- label" usage:

Anxiolytics: Approved level 1 (low risk) unlicensed indication Clonazepam Akathisia tablets/oral solution Clonazepam Mania tablets/oral solution Diazepam tablets/oral Akathisia solution Diazepam tablets/oral Mania solution Lorazepam 1mg Catatonia tablets/oral solution Lorazepam 1mg Rapid tranquillisation - please refer to the rapid tablets/oral solution tranquillisation policy for the algorithm for use Lorazepam 1mg Behavioural disturbances tablets/oral solution Lorazepam 1mg Delirium (severe only) tablets/oral solution Hydroxyzine Generalised anxiety disorder tablets/oral solution

Promethazine Anxiety/agitation tablets/oral solution Propranolol Akathisia tablets/capsules/oral solution Citalopram tablets/oral Generalised anxiety disorder drops Fluoxetine Generalised anxiety disorder tablets/capsules/oral solution Mirtazapine tablets/oral Generalised anxiety disorder solution/ orodispersible Sertraline tablets Generalised anxiety disorder

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2.3 Antipsychotics

Please refer to the following SPFT clinical guidelines and NICE Technical Appraisals, NICE Clinical Guidelines and NICE Quality Standards (where applicable) for prescribing, administration and monitoring advice:

SPFT clinical guidelines NICE Technical Appraisals (TA), (found here: Clinical Guidelines (CG) and Quality https://www.sussexpartnership.nhs.uk/medication- Standards (QS) related-guidance) Antipsychotics, prescribing guidelines Aripiprazole for the treatment of schizophrenia in people aged 15 to 17 years Technical Appraisal TA213: http://guidance.nice.org.uk/TA213 Asenapine, prescribing guidelines Aripiprazole for treating moderate to severe manic episodes in adolescents with bipolar I disorder Technical Appraisal TA292: https://www.nice.org.uk/guidance/ta292 Antipsychotics, guidelines for cardiac rhythm Psychosis and schizophrenia in adults: screening (ECGs) prevention and management Clinical Guidelines CG178: https://www.nice.org.uk/guidance/cg178 Antipsychotics, guidelines for the Psychosis and schizophrenia in adults. management of weight gain and metabolic Quality Standard QS80: disturbances https://www.nice.org.uk/guidance/qs80 Antipsychotics, reducing antipsychotic use in Psychosis and schizophrenia in children people with dementia - GP Resource Pack and young people: recognition and management Clinical Guidelines CG155: https://www.nice.org.uk/guidance/cg155 Clozapine, community teams policy Bipolar disorder, psychosis and schizophrenia in children and young people. Quality Standard QS102: https://www.nice.org.uk/guidance/qs102 Clozapine, inpatient policy Coexisting severe mental illness (psychosis) and substance misuse: assessment and management in healthcare settings Clinical Guidelines CG120: https://www.nice.org.uk/guidance/cg120 Lurasidone, prescribing guidelines Coexisting severe mental illness and substance misuse. Quality Standard QS188: https://www.nice.org.uk/guidance/qs188 Hyperprolactinaemia, prescribing guidelines on the treatment of antipsychotic induced symptoms Smoking cessation, effect on psychotropic medicines including clozapine Long acting antipsychotics Long acting antipsychotic injections (LAAI), prescribing guidelines Aripiprazole long acting injection, prescribing guidelines Olanzapine long-acting injection, prescribing guidelines Paliperidone monthly long acting injection, prescribing guidelines

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Paliperidone palmitate 3-monthly long acting Injection, prescribing guidelines Short use only: Clopixol Acuphase, prescribing guidelines Specialist areas: Perinatal mental health, prescribing guidelines

Oral antipsychotics

Atypical antipsychotics Additional notes, including where unlicensed

Amisulpride Clozapine augmentation See unlicensed uses below

Aripiprazole TA213 Schizophrenia 15 to 17 year olds TA292 Bipolar affective disorder Rapid tranquillisation (specialist advice only) See unlicensed uses below

Asenapine See Trust guidelines: ‘Asenapine, prescribing guidelines’

Cariprazine See unlicensed uses below

Clozapine Named patient only. See Trust Clozapine, community teams policy and Clozapine, inpatient policy th Bipolar and schizoaffective disorders (5 line) See unlicensed uses below Lurasidone Only to be used third line (second line if significant risk of diabetes) but always after aripiprazole has been tried (see Trust guidelines: ‘Lurasidone, prescribing guidelines’) See unlicensed uses below

Olanzapine Rapid tranquillisation See unlicensed uses below

Quetiapine Behavioural disturbances with dementia Rapid tranquillisation (specialist advice only) See unlicensed uses below

Risperidone Rapid tranquillisation (specialist advice only) See unlicensed uses below Typical antipsychotics

Benperidol Can only be initiated by senior medical staff

Chlorpromazine Can only be initiated by senior medical See unlicensed uses below

Flupentixol

Haloperidol Delirium (severe only). See unlicensed uses below

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Levomepromazine Rapid tranquillisation (specialist advice only) See unlicensed uses below

Pimozide Can only be initiated by senior medical staff

Promazine Can only be initiated by senior medical staff

Sulpiride Clozapine augmentation

Thioridazine See unlicensed uses below

Trifluoperazine Can only be initiated by senior medical staff

Zuclopenthixol See unlicensed uses below

Injectable antipsychotics

Shorter acting antipsychotics

Clozapine Named patient only. See Trust Clozapine, community teams policy and Clozapine, inpatient policy See unlicensed uses below

Haloperidol Delirium (severe only)

Olanzapine Rapid tranquillisation See unlicensed uses below

Zuclopenthixol Acetate See Trust guidelines; ‘Clopixol Acuphase, prescribing guidelines’

Long acting atypical antipsychotics

See Trust guidelines ‘Long acting antipsychotic injections (LAAI), prescribing guidelines’

Aripiprazole See Trust guidelines; ‘Aripiprazole long acting injection, prescribing guidelines’. See unlicensed uses below

Olanzapine Named patient only. See Trust guidelines ‘Olanzapine long-acting injection, prescribing guidelines’ See unlicensed uses below

Paliperidone (1 and 3 monthly) See Trust guidelines; ‘Paliperidone monthly long acting injection, prescribing guidelines’ and ‘Paliperidone palmitate 3-monthly long acting Injection, prescribing guidelines’. See unlicensed uses below

Risperidone Effective from July 2021; no new patients are permitted to be initiated on risperidone LAAI. It remains on the formulary only for use in those patients who cannot be switched to paliperidone. See unlicensed uses below

Long acting typical antipsychotics

See Trust guidelines ‘Long acting antipsychotic injections, prescribing guidelines’

Flupentixol decanoate See unlicensed uses below

Fluphenazine decanoate

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Haloperidol decanoate See unlicensed uses below

Pipotiazine palmitate See unlicensed uses below

Zuclopenthixol decanoate See unlicensed uses below

Linked medicines for use in the treatment of psychosis

Lamotrigine See unlicensed uses below

Lithium See unlicensed uses below

Midazolam (buccal use) See unlicensed uses below

Promethazine (oral and injection) See unlicensed uses below

Sodium valproate See unlicensed uses below

Linked physical health medicines to alleviate symptoms associated with antipsychotic use

See Trust guidelines ‘Hyperprolactinaemia, prescribing guidelines on the treatment of antipsychotic induced symptoms’ and ‘Antipsychotics, guidelines for the management of weight gain and metabolic disturbances’

Atropine eye drops See unlicensed uses below

Glycopyrronium bromide (oral) See unlicensed uses below

Hyoscine hydrobromide See unlicensed uses below

Ipratropium nasal spray See unlicensed uses below

Pirenzepine See unlicensed uses below

Metformin See Trust guidelines ‘Metformin, information for GPs on its use with antipsychotics’ See unlicensed uses below

Granulocyte- Colony Stimulating Factor (G-CSF) (injection) See unlicensed uses below

Modafanil See unlicensed uses below

Topiramate See unlicensed uses below

Zonisamide See unlicensed uses below

Medicine for essential tremors, tics and related disorders

Tetrabenazine

Antimuscarinic medicines for medicine-induced parkinsonism

Orphenadrine Greater risk of fatality in overdose. Not to be used first line or a risk of self- harm Procyclidine

Trihexiphenidyl (Benzhexol) Can only be initiated by senior medical staff

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Approved Level 1 risk) unlicensed uses. Medicines without a manufacturing licence in the United Kingdom but are licensed in a European Economic area (EEA) agreed framework. To only be used within SPFT as ‘named-patient’ use:

Antipsychotics: Approved level 1 (low risk) unlicensed indication Clozapine IM 25mg/ml Treatment resistant schizophrenia when refusing oral injection (PICU and Secure and Forensic units only) Thioridazine 100mg Schizophrenia tablets (if unlicensed sourced – Mawdsley®)

Antipsychotics: Approved level 1 (low risk) unlicensed indication

Atypical antipsychotics: Olanzapine 10mg IM Rapid tranquillisation - please refer to the rapid injection tranquillisation policy for the algorithm for use Typical antipsychotics: Fluphenazine decanoate Schizophrenia 25mg/ml long acting injection (LAAI) Fluphenazine decanoate Schizophrenia 100mg/ml long acting injection (LAAI) Pipotiazine palmitate Schizophrenia 25mg/ml long acting injection (LAAI) Pipotiazine palmitate Schizophrenia 100mg/4ml long acting injection (LAAI)

Approved Level 1 (low risk) unlicensed uses. Medicines with a manufacturing licence but are being prescribed for the following indications that are outside of that licence i.e. "off- label" usage:

Atypical antipsychotics Approved level 1 (low risk) unlicensed indication (oral): Amisulpride tablets/oral Clozapine augmentation solution Amisulpride tablets/oral Bipolar affective disorder solution Amisulpride tablets/oral Persistent delusional disorder solution Aripiprazole tablets/oral Rapid tranquillisation (specialist advice only) - please solution/ orodispersible refer to the rapid tranquillisation policy for the algorithm for use Aripiprazole tablets/oral Hyperprolactinaemia solution/ orodispersible Aripiprazole tablets/oral Persistent delusional disorder solution/ orodispersible

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Aripiprazole tablets/oral Depression augmentation solution/ orodispersible Aripiprazole tablets/oral Behavioural and psychological symptoms of dementia solution/ orodispersible (BPSD) Cariprazine capsules Schizophrenia

Clozapine tablets/oral Bipolar affective disorder solution Clozapine tablets/oral Schizoaffective disorder solution Clozapine tablets/oral Paranoia with auditory hallucinations syndrome solution Clozapine tablets/oral Persistent delusional disorder solution Clozapine tablets/oral Organic delusional disorder solution Clozapine tablets/oral Post partum psychosis solution Lurasidone tablets Bipolar affective disorder Lurasidone tablets Persistent delusional disorder Lurasidone tablets Psychotic depression Olanzapine tablets/ Rapid tranquillisation - please refer to the rapid orodispersible tranquillisation policy for the algorithm for use Olanzapine tablets/ Depression augmentation orodispersible Olanzapine tablets/ Obsessive compulsive disorder (OCD) orodispersible Olanzapine tablets/ Post traumatic stress disorder (PTSD) orodispersible Olanzapine tablets/ Behavioural and psychological symptoms of dementia orodispersible (BPSD) Quetiapine tablets/oral Rapid tranquillisation - please refer to the rapid solution tranquillisation policy for the algorithm for use Quetiapine tablets/oral Obsessive compulsive disorder (OCD) solution Quetiapine tablets/oral Post traumatic stress disorder (PTSD) solution Quetiapine tablets/oral Behavioural and psychological symptoms of dementia solution (BPSD) Quetiapine tablets/oral Persistent delusional disorder solution Risperidone tablets/oral Rapid tranquillisation - please refer to the rapid solution tranquillisation policy for the algorithm for use Risperidone tablets/oral Obsessive compulsive disorder (OCD) solution Risperidone tablets/oral Post traumatic stress disorder (PTSD) solution

Typical antipsychotics Approved level 1 (low risk) unlicensed indication (oral): Chlorpromazine Emotionally unstable personality disorder (EUPD) tablets/oral solution (maximum dose of 100mg per day) for anxiolytic effect to avoid benzodiazepines

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Haloperidol Delirium (severe only) tablets/capsules/oral solution Levomepromazine tablets Rapid tranquillisation - please refer to the rapid tranquillisation policy for the algorithm for use Zuclopenthixol tablets/oral Bipolar affective disorder drops

Injectable antipsychotic Approved level 1 (low risk) unlicensed indication medicines: Aripiprazole 7.5mg/ml IM Rapid control of acute episode injection Aripiprazole IM long acting Bipolar affective disorder antipsychotic injection (LAAI) Aripiprazole IM LAAI Persistent delusional disorder Flupenthixol decanoate Bipolar affective disorder LAAI Haloperidol IM injection Delirium (severe only) Haloperidol decanoate Bipolar affective disorder LAAI Paliperidone monthly IM Bipolar affective disorder LAAI Paliperidone monthly IM Persistent delusional disorder LAAI Risperidone IM LAAI Bipolar affective disorder Risperidone IM LAAI Persistent delusional disorder Zuclopenthixol decanoate Bipolar affective disorder LAAI

Antihistamine Approved level 1 (low risk) unlicensed indication (sedating): Promethazine tablet/oral Rapid tranquillisation (specialist advice WAMHS/ solution SOAMS) – please refer to the rapid tranquillisation policy for the algorithm for use Promethazine tablet/oral Rapid tranquillisation (CAMHS) – please refer to the solution rapid tranquillisation policy for the algorithm for use Promethazine IM 25mg/ml Rapid tranquillisation - please refer to the rapid injection tranquillisation policy for the algorithm for use

Hypersalivation: Approved level 1 (low risk) unlicensed indication Atropine 1% eye drops Antipsychotic induced hypersalivation Glycopyrronium bromide Antipsychotic induced hypersalivation tablets/oral solution Hyoscine hydrobromide Antipsychotic induced hypersalivation tablets Ipratropium nasal spray Antipsychotic induced hypersalivation Pirenzepine 50mg tablets Antipsychotic induced hypersalivation

Antipsychotic weight Approved level 1 (low risk) unlicensed indication management: Metformin tablets/oral Antipsychotic weight management solution

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Other injectables Approved level 1 (low risk) unlicensed indication medicines: G-CSF Neutrophil augmentation on clozapine

Other oral medicines: Approved level 1 (low risk) unlicensed indication Lamotrigine tablets Clozapine augmentation in schizophrenia Lithium tablets Neutrophil augmentation on clozapine Modafinil tablets Clozapine related sedation Midazolam (buccal) Rapid tranquillisation (specialist advice) Sodium valproate Schizophrenia augmentation tablets/capsules/granules/oral solution Sodium valproate Seizure prophylaxis due to high clozapine level tablets/capsules/granules/oral solution Topiramate Weight loss, appetite suppression (with tablets/capsules/oral solution antipsychotics) Zonisamide capsules/ oral Weight loss, appetite suppression (with suspension antipsychotics)

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2.4 Mood stabilisers

SPFT clinical guidelines NICE Technical Appraisals (TA), (found here: Clinical Guidelines (CG) and Quality https://www.sussexpartnership.nhs.uk/medication- Standards (QS) related-guidance) Mood stabilizers, prescribing guidelines in Bipolar disorder: assessment and bipolar affective disorder management Clinical Guideline CG185 https://www.nice.org.uk/guidance/cg185 Lithium, prescribing guidelines for inpatients Aripiprazole for treating moderate to severe manic episodes in adolescents with bipolar I disorder Technical Appraisal TA292 https://www.nice.org.uk/guidance/ta292 Bipolar disorder, psychosis and schizophrenia in children and young people Quality Standard QS102 https://www.nice.org.uk/guidance/qs102 Bipolar disorder in adults Quality Standard QS95 https://www.nice.org.uk/guidance/qs95

Additional notes, including where unlicensed Mood stabilisers

Carbamazepine See unlicensed uses below

Lamotrigine Bipolar affective disorder prophylaxis See unlicensed uses below

Lithium See Trust guidelines: ‘Lithium, prescribing guidelines for inpatients’ Adjunct treatment of schizophrenia with mood disturbance Bipolar affective disorder CAMHS See unlicensed uses below

Sodium valproate* Acute and prophylactic treatment of mania Bipolar affective disorder CAMHS See unlicensed uses below

* Note that valproate medicines are contraindicated in women and girls of childbearing potential unless conditions of the Pregnancy Prevention Programme are met; see link: https://www.gov.uk/drug-safety-update/valproate-epilim-depakote-pregnancy-prevention- programme-updated-educational-materials

Atypical antipsychotics

Amisulpride See unlicensed uses below

Aripiprazole TA292 Bipolar affective disorder

Asenapine See Trust guidelines: ‘Asenapine, prescribing guidelines’ Page 17 of 29

Clozapine Named patient only. See Trust Clozapine, community teams policy and Clozapine, inpatient policy. th Bipolar and schizoaffective disorders (5 line) See unlicensed uses below Lurasidone See unlicensed uses below

Typical antipsychotics

Zuclopenthixol See unlicensed uses below

Injectable antipsychotics

Aripiprazole IM LAAI See unlicensed uses below

Flupenthixol decanoate LAAI See unlicensed uses below

Haloperidol decanoate LAAI See unlicensed uses below

Paliperidone monthly IM LAAI See unlicensed uses below

Risperidone IM LAAI See unlicensed uses below

Zuclopenthixol decanoate LAAI See unlicensed uses below

Approved Level 1 (low risk) unlicensed uses. Medicines with a manufacturing licence but are being prescribed for the following indications that are outside of that licence i.e. "off- label" usage:

Mood stabilisers: Approved level 1 (low risk) unlicensed indication Carbamazepine tablets/oral Bipolar affective disorder - acute mania, rapid cycling solution Lamotrigine tablets Bipolar affective disorder prophylaxis Lithium tablets Bipolar affective disorder (CAMHS) Sodium valproate Acute and prophylactic treatment of mania tablets/capsules/granules/oral solution Sodium valproate Bipolar affective disorder (CAMHS) tablets/capsules/granules/oral solution

Atypical antipsychotics (oral): Approved level 1 (low risk) unlicensed indication Amisulpride tablets/oral solution Bipolar affective disorder

Clozapine tablets/oral solution Bipolar affective disorder

Lurasidone tablets Bipolar affective disorder

Typical antipsychotics (oral): Approved level 1 (low risk) unlicensed indication Zuclopenthixol tablets/oral drops Bipolar affective disorder

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Injectable antipsychotic Approved level 1 (low risk) unlicensed indication medicines: Aripiprazole IM LAAI Bipolar affective disorder Flupenthixol decanoate LAAI Bipolar affective disorder Haloperidol decanoate LAAI Bipolar affective disorder Paliperidone monthly IM LAAI Bipolar affective disorder Risperidone IM LAAI Bipolar affective disorder Zuclopenthixol decanoate LAAI Bipolar affective disorder

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2.5 Antidepressants

SPFT clinical guidelines NICE Technical Appraisals (TA), (found here: Clinical Guidelines (CG) and Quality https://www.sussexpartnership.nhs.uk/medication- Standards (QS) related-guidance) Antidepressants, prescribing guidelines (note Depression in adults: recognition and there are separate guidelines for adults and management Clinical Guideline CG90 CAMHS) https://www.nice.org.uk/guidance/cg90 Agomelatine, prescribing guidelines in major Depression in adults Quality standard depressive episodes Quality Standard QS8 https://www.nice.org.uk/guidance/qs8 First-choice antidepressant use in adults with depression or generalised anxiety disorder Key Therapeutic Topic KTT8 https://www.nice.org.uk/advice/ktt8 Vortioxetine for treating major depressive episodes Technical Appraisal TA367 https://www.nice.org.uk/guidance/ta367 Depression in children and young people: identification and management NG134 https://www.nice.org.uk/guidance/ng134 Depression in children and young people Quality Standard QS48 https://www.nice.org.uk/guidance/qs48

Additional notes, including where unlicensed

Selective Serotonin Reuptake Inhibitors (SSRIs)

Citalopram See unlicensed uses below

Escitalopram See unlicensed uses below

Fluoxetine See unlicensed uses below

Fluvoxamine

Paroxetine Post Traumatic Stress Disorder (PTSD) (general use where psychology is not appropriate)

Sertraline See unlicensed uses below

Tricyclic antidepressants and related antidepressant medicines

Amitriptyline PTSD (specialist only)

Clomipramine

Imipramine

Lofepramine

Nortriptyline

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Trazodone Behavioural disturbances/agitation in dementia See unlicensed uses below

Monoamine-Oxidase Inhibitors (MAOIs)

Phenelzine Can only be initiated by senior medical staff PTSD (specialist only)

Reversible Inhibitors of Monoamines (RIMAs)

Moclobemide

Other

Methohexitone Named patient only See unlicensed uses below

Other antidepressants

Agomelatine See Trust guidelines ‘Agomelatine, prescribing guidelines in major depressive episodes’

Duloxetine

Flupentixol

Lithium (for recurrent depression) Refractory depression

Mirtazapine PTSD (general use where psychology is not appropriate) See unlicensed uses below

Tri-iodothyronine (T3) Refractory depression (very high cost) See unlicensed uses below

Tryptophan Can only be initiated by senior medical staff Special ordering criteria applies

Venlafaxine See unlicensed uses below

Vortioxetine Third-line use only in major depressive illness

Linked medicines for the treatment of depression and symptoms related to PTSD

Bupropion See unlicensed uses below

Prazosin See unlicensed uses below

Other Methohexitone Electroconvulsive treatment (ECT)/ Anaesthesia 500mg IV injection MAOI Approved Level 1 (low risk) unlicensed indication Phenelzine 15mg Post traumatic stress disorder (PTSD) tablets (if unlicensed sourced)

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Approved Level 1 (low risk) unlicensed uses. Medicines with a manufacturing licence but are being prescribed for the following indications that are outside of that licence i.e. "off- label" usage:

SSRI's Approved level 1 (low risk) unlicensed indication Citalopram tablets/oral Post traumatic stress disorder (PTSD) drops Citalopram tablets/oral Generalised anxiety disorder drops Citalopram tablets/oral Obsessive compulsive disorder (OCD) drops Escitalopram Post traumatic stress disorder (PTSD) tablets/oral drops Fluoxetine Post traumatic stress disorder (PTSD) tablets/capsules/oral solution Fluoxetine Generalised anxiety disorder tablets/capsules/oral solution Sertraline tablets Generalised anxiety disorder

Other Approved level 1 (low risk) unlicensed indication antidepressants: Mirtazapine tablets/oral Generalised anxiety disorder solution/ orodispersible Mirtazapine tablets/oral Behavioural and psychological symptoms of dementia (BPSD) solution/ orodispersible Trazodone Behavioural and psychological symptoms of dementia (BPSD) tablets/capsules Tri-iodothyronine Refractory depression tablets Venlafaxine Post traumatic stress disorder (PTSD) tablets/capsules

Other approved linked Approved level 1 (low risk) unlicensed indication uses: Bupropion MR tablets Depression Modafinil tablets Treatment resistant depression Prazosin tablets Post traumatic stress disorder (PTSD) induced nightmares

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2.6 Medicines used in alcohol and substance dependence

Please refer to the following SPFT clinical guidelines and NICE Technical Appraisals for prescribing, administration and monitoring advice:

SPFT clinical guidelines NICE Technical Appraisals (TA) (found here: https://www.sussexpartnership.nhs.uk/medication- related-guidance) Alcohol and benzodiazepine dependence Methadone and buprenorphine for the (adults), prescribing guidelines for inpatients management of opioid dependence TA114 https://www.nice.org.uk/guidance/TA114 Opiate dependence, prescribing guidelines Naltrexone for the management of for inpatients opioid dependence TA115 https://www.nice.org.uk/guidance/TA115 Substances and drugs of abuse, a guide to how long they can be detected in the body after consumption

Tobacco dependence pathway

Additional notes, including where unlicensed Acamprosate Buprenorphine TA114 Chlordiazepoxide Clomethiazole Diazepam Lofexidine Methadone TA114 Naltrexone TA115 Adjunct therapy to prevent relapse in formerly alcohol- dependent patients. Suboxone® Combination of buprenorphine and naloxone Essential Tremors

Naloxone

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2.7 Medicines used in dementia

SPFT clinical guidelines NICE Technical Appraisals (TA), (found here: Clinical Guidelines (CG) and Quality https://www.sussexpartnership.nhs.uk/medicati Standards (QS) on-related-guidance) Dementia, prescribing guidelines Donepezil, galantamine, rivastigmine and memantine for the treatment of Alzheimer's disease Technology appraisal guidance Technical Appraisal TA217 https://www.nice.org.uk/guidance/ta217 Behavioural problems in older people, Dementia: assessment, management and prescribing guidelines support for people living with dementia and their carers Clinical Guideline NG97 https://www.nice.org.uk/guidance/ng97

Antipsychotics in people living with dementia Key therapeutic topic KTT7 https://www.nice.org.uk/advice/ktt7

Additional notes, including where unlicensed

Rivastigmine TA217 and NG97 See unlicensed uses below Galantamine XL TA217 and NG97 See unlicensed uses below Donepezil TA217 and NG97 See unlicensed uses below Memantine TA217 and NG97 See unlicensed uses below

Other linked medicines to support the treatment of behavioural and psychological symptoms of dementia (BPSD)

Aripiprazole See unlicensed uses below

Olanzapine See unlicensed uses below

Quetiapine See unlicensed uses below

Risperidone Licensed for BPSD for up to 6 weeks

Haloperidol Licensed for BPSD for up to 6 weeks

Trazodone See unlicensed uses below

Mirtazapine See unlicensed uses below

Approved Level 1 (low risk) unlicensed uses. Medicines with a manufacturing licence but are being prescribed for the following indications that are outside of that licence i.e. "off- label" usage:

Medicines for dementia: Approved level 1 (low risk) unlicensed indication Donepezil tablets/oral solution/ Severe alzheimers disease orodispersible Donepezil tablets/oral solution/ Mild/moderate/severe dementia with lewy bodies orodispersible

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Donepezil tablets/oral solution/ Mild/moderate/severe dementia in parkinsons orodispersible disease Donepezil tablets/oral solution/ Mild/moderate/severe mixed dementia orodispersible Galantamine XL capsules/ tablets Severe alzheimers disease Galantamine XL capsules/ tablets Mild/moderate/severe dementia with lewy bodies (when donepezil/rivastigmine not tolerated) Galantamine XL capsules/ tablets Mild/moderate/severe mixed dementia Memantine tablets/oral solution/ Mild/moderate/severe dementia with lewy bodies orodispersible Memantine tablets/oral solution/ Mild/moderate/severe mixed dementia orodispersible Memantine tablets/oral solution/ Mild/moderate/severe dementia in parkinsons orodispersible disease (when acetylcholinesterase contraindicated or not tolerated) Rivastigmine capsules/oral Mild/moderate/severe dementia with lewy bodies solution/ patch Rivastigmine capsules/oral Mild/moderate/severe mixed dementia solution/ patch Rivastigmine capsules/oral Severe alzheimers disease solution/ patch

Atypical antipsychotics: Approved level 1 (low risk) unlicensed indication Aripiprazole tablets/oral solution/ Behavioural and psychological symptoms of orodispersible dementia (BPSD) Olanzapine tablets/ orodispersible Behavioural and psychological symptoms of dementia (BPSD) Quetiapine tablets/oral solution Behavioural and psychological symptoms of dementia (BPSD)

Tricyclic antidepressants & Approved level 1 (low risk) unlicensed related antidepressant indication medicines: Trazodone tablets/capsules Behavioural and psychological symptoms of dementia (BPSD) Mirtazapine tablets/oral solution/ Behavioural and psychological symptoms of orodispersible dementia (BPSD)

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2.8 Medicines used in the treatment of Attention Deficit Hyperactivity Disorder (ADHD)

SPFT clinical guidelines NICE Technical Appraisals (TA), (found here: Clinical Guidelines (CG) and Quality https://www.sussexpartnership.nhs.uk/medication- Standards (QS) related-guidance) ADHD Shared care guidelines (CAMHS) Attention deficit hyperactivity disorder: diagnosis and management Clinical Guideline NG87 https://www.nice.org.uk/guidance/NG8 7 Guanfacine (CAMHS), prescribing guidelines

Melatonin Shared care guidelines (CAMHS) ADHD (adults), prescribing guidelines

Additional notes, including where unlicensed

Atomoxetine NG87 Second-line when stimulants have proved ineffective or there are intolerable side effects

Bupropion Third-line when stimulants and atomoxetine are ineffective or inappropriate See unlicensed uses below

Clonidine Hyperactive behaviour

Dexamfetamine NG87 Third-line when other stimulants or atomoxetine is ineffective or inappropriate

Imipramine Third-line when other stimulants or atomoxetine is ineffective or inappropriate

Guanfacine NG87 Third-line when other stimulants or atomoxetine is ineffective of inappropriate. See Trust guidelines ‘Guanfacine (CAMHS), prescribing guidelines’. Initiation in adults must be supported by a specialist centre. See unlicensed uses below

Lisdexamfetamine Second-line when methylphenidate has proven ineffective or there are intolerable side effects. Controlled drug – schedule 2

Methylphenidate NG87 First-line. Controlled drug – schedule 2. See unlicensed uses below. • Plain • Xaggitin® XL • Equasym® XL • Medikinet® XL Only brand licensed for adult initiation

Melatonin (unlicensed) Sleep disturbance due to neurodevelopment (Ramatonin®(first-line), Circadin® conditions or stimulant medicines.

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brands only. Most localities have a postal service using Ramatonin® prescribed only by secondary care.

Approved Level 1 (low risk) unlicensed uses. Medicines with a manufacturing licence but are being prescribed for the following indications that are outside of that licence i.e. "off- label" usage:

ADHD: Approved level 1 (low risk) unlicensed indication Methylphenidate ADHD - initiation in adults (except Medikinet® XL). All preparations brands except Medikinet® XL are approved to continue into adulthood if started prior to the patient’s 18th birthday and deemed to be clinically indicated. Guanfacine ADHD - initiated in CAMHS but unlicensed after subsequent transfer to adulthood, to be continually reviewed

Miscellaneous: Approved level 1 (low risk) unlicensed indication Bupropion MR tablets ADHD

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2.9 Approved unlicensed medicines use for behaviour that challenges in Autism Spectrum Disorder (ASD) and Learning Difficulties (LD)

SPFT clinical guidelines NICE Technical Appraisals (TA), (found here: Clinical Guidelines (CG) and Quality https://www.sussexpartnership.nhs.uk/medication- Standards (QS) related-guidance) Autism spectrum disorder in adults: diagnosis and management Clinical Guideline CG142 https://www.nice.org.uk/guidance/cg142

Autism spectrum disorder in under 19s: support and management Clinical Guideline CG170 https://www.nice.org.uk/guidance/cg170

In 2015, NHS England led a ‘call to action’ after reports from Public Health England, NHS Improving Quality and the Care Quality Commission showed that: • There is a much higher rate of prescribing of medicines used for mental illness amongst people with a learning disability than the general population, often more than one medicine in the same class, and in the majority of cases with no clear justification;

• Medicines are often used for long periods without adequate review, and there is poor communication with parents and carers, and between different healthcare providers.

The call to action led to the setting up of the STOMP (Stopping Over Medication of People with a learning disability, autism spectrum disorder (ASD) or both) project led by NHS England and other partners. Additional notes, including where unlicensed Mood stabilisers:

Sodium valproate

Lamotrigine

Atypical antipsychotics as mood stabilisers Can only be initiated by senior medical staff Aripiprazole for exceptional circumstances only. Only for short term use. Use to be continually Olanzapine reviewed in line with STOMP principles.

Quetiapine Oral treatment should always be used in preference to LAAI formulations (where Risperidone available).

For Risperidone LAAI effective from July

2021; no new patients are permitted to be

initiated on risperidone LAAI. It remains

on the formulary only for use in those

patients who cannot be switched to an

alternative.

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Typical antipsychotics as mood stabilisers Can only be initiated by senior medical

staff for exceptional circumstances only. Haloperidol Only for short term use. Use to be

continually reviewed in line with STOMP Zuclopenthixol principles. Oral treatment should always be used in preference to LAAI

formulations (where available).

Approved Level 1 (low risk) unlicensed uses. Medicines with a manufacturing licence but are being prescribed for the following indications that are outside of that licence i.e. "off- label" usage:

Mood stabilisers: Approved level 1 (low risk) unlicensed indication Sodium valproate Behaviour that challenges – ASD/LD tablets/capsules/granules/oral solution Lamotrigine tablets Behaviour that challenges – ASD/LD

Mood stabilisers (atypical Approved level 1 (low risk) unlicensed indication antipsychotics): Aripiprazole tablets/oral Behaviour that challenges-ASD/LD - exceptional solution/ orodispersible/ LAAI circumstances for a very short period of time Olanzapine tablets/ Behaviour that challenges-ASD/LD - exceptional orodispersible circumstances for a very short period of time Quetiapine tablets/oral solution Behaviour that challenges-ASD/LD - exceptional circumstances for a very short period of time Risperidone tablets/oral Behaviour that challenges-ASD/LD - exceptional solution/ LAAI circumstances for a very short period of time Mood stabilisers (typical Approved level 1 (low risk) unlicensed indication antipsychotics): Haloperidol Behaviour that challenges-ASD/LD - exceptional tablets/capsules/oral solution/ circumstances for a very short period of time LAAI Zuclopenthixol tablets/oral Behaviour that challenges-ASD/LD - exceptional drops/ LAAI circumstances for a very short period of time

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