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 Drug 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 Drugs 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 acetylcysteine) 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 Codeine 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