ANNEXURE A PROVINCIAL CODE LIST CATALOGUE OF APPROVED PHARMACEUTICALS FOR USE IN THE DEPARTMENT OF HEALTH ISSUE No. 06/13 UPDATED: 03-June-2013 INCLUDES: Supplementary List No: 129 Page 1 GENERIC DESCRIPTION ATC MIMS SUPP LIST *EDL STRENGTH FORM TRADE NAME RESTRICTION COMMENT Available through the HIV/AIDS pgwc programme - for treating AIDS patients abacavir J05AF 18.12 20mg/ml solution ZIAGEN AIDS programme ARV depot according to the appropriate protocols. Also see Circular H34/2012 pgwc abacavir J05AF 18.12 300mg tablet ZIAGEN AIDS programme As above. ARV depot Specialist: neurologist, acetazolamide S01EC 16.1 A 500mg/10ml injection DIAMOX; AZOMID neurosurgeon & opthalmologist General . Supp List neurologist, acetazolamide S01EC 16.1 1 A P 250mg tablet DIAMOX General - for Glaucoma emergencies 119 neurosurgeon & ophthalmologist Initiated Supp List acetic acid S02AA Ø 1 2% in aqueous ear drops 118 acetone X Ø liquid ACETONE 40mg + 200mg/ intraocular Specialist: acetylcholine + mannitol S01EB 15.7 COVOCHOL 4,5ml injection ophthalmologist acitretin D05BB 14.5 A 10mg capsule NEOTIGASON Specialist: dermatologist acitretin D05BB 14.5 A 25mg capsule NEOTIGASON Specialist: dermatologist ACRIFLAVIN acriflavine R02AA Ø 0,1% emulsion EMULSION acyclovir J05AB 18.12 A P 250mg injection ZOVIRAX Specialist acyclovir J05AB 18.12 P 200mg/5ml suspension ZOVIRAX Specialist General: For Primary Genital Herpes, GUS, Chronic Herpetic Ulcer, Herpes Zoster, Eczema Herpeticum, Herpes General & Stomatitis and Ophthalmic Zoster: Suppl List acyclovir J05AB 18.12 1 A P 200mg tablet ZOVIRAX Clinical Nurse According to H135/2002 Addendum A - 119/122 Practitioner Supp List 92. Clinical Nurse Practitioner: according to EDL General: For Primary Genital Herpes, GUS, Chronic Herpetic Ulcer, Herpes Zoster, Eczema Herpeticum, Herpes General & Stomatitis and Ophthalmic Zoster: Suppl List acyclovir J05AB 18.12 1 A P 400mg tablet ZOVIRAX Clinical Nurse According to H135/2002 Addendum A - 119/122 Practitioner Supp List 92. Clinical Nurse Practitioner: according to EDL For ophthalmic zoster. Patients to be acyclovir S01AD 15.1.1 SL 128 A 30mg/g eye ointment ZOVIRAX referred to ophthalmologist urgently. Page 2 Supp List adenosine C01EB 7.2 A P 6mg/2ml injection ADENOCOR 122 Central hospital use at paediatric Supp List EPIPEN AUTO- allergy clinics: non-referable. History adrenaline auto-injector C01CA 5.1 0,3mg/0,3ml auto-injector Specialist paediatrician 125 INJECTOR of severe allergic reaction or anaphylaxis. Central hospital use at paediatric adrenaline auto-injector Supp List auto-injector EPIPEN JR AUTO- allergy clinics: non-referable. History C01CA 5.1 0,15mg/ 0,3ml Specialist paediatrician (junior) 125 (Junior) INJECTOR of severe allergic reaction or anaphylaxis. adrenaline B.P. C01CA 7.1.2 1 A P 1:1000 1mg/ml injection ADRENALINE For: Suppl List - Children under two years of age albendazole P02CA 13 1 A P 200mg tablet ZENTEL 119/121 - Neurocysticercosis, hydatid cysts, tape worm, sandworm For: Suppl List - Children under two years of age albendazole P02CA 13 1 A P 400mg tablet ZENTEL 119/121 - Neurocysticercosis, hydatid cysts, tape worm, sandworm albumin, normal serum B05AA Ø P 0.2 infusion Specialist paediatrician Restricted to patients with DEXA T- score ≤ -2,5 plus proven history of Supp List alendronate M05BA 4.7.1 A 10mg tablets OSTEOBON Specialist initiated osteoporotic fracture (i.e. secondary 125 prevention only).. Prescriptions to be endorsed with these criteria. Specialist physicians and alfacalcidol A11CC 20.1 P 0,25µg capsule ONE-ALPHA paediatricians initiated Specialist physicians and alfacalcidol A11CC 20.1 P 1µg capsule ONE-ALPHA paediatricians initiated alfentanil N01AH 2.1.2 A 1mg/2ml injection RAPIFEN Specialist alfentanil N01AH 2.1.2 A 5mg/10ml injection RAPIFEN Specialist Cheapest uro-selective alpha-blocker on tender to be coded. For BPH and/or LUTS: with referral to a urologist within 6 months for those patients who have alfuzosin G04CA 7.3.2 SL 129 10mg tablets XATRAL Specialist initiated not previously been on an alpha- blocker (i.e. referral within 6 months for patients initiated on an alpha-blocker for BPH / LUTS). LUTS = Lower Urinary Tract Symptoms in males. allergen-skin prick tests Supp List ALLERGEN SKIN Allergy clinics for allergy 124 PRICK TESTS allopurinol M04AA 4.2 A P 100mg tablet ZYLOPRIM; PURICOS allopurinol M04AA 4.2 300mg tablet ZYLOPRIM Page 3 alprostadil C01EA 7.5 0,5mg/ml injection PROSTIN VR Specialist: paediatrician Urology. Erectile dysfunction. Central Hospitals alprostadil G04BE 17.5.2 20µg/ml injection CAVERJECT Maximum of 4 doses. Specialist: urologist Patient name basis. For acute arterial occlusion and deep alteplase B01AD 8.3 50mg injection ACTILYSE Specialist vein thrombosis. aluminium hydrox. + A02AD 12.4 1 A 250mg + 500mg tablet GELUSIL magnesium trisil. aluminium hydrox.+ For radio-oncology patients only, non- Supp List 291mg + 98mg + magnesium hydrox. + A02AD 12.4.1 suspension MUCAINE Specialist oncologist referable. 124 10mg/5ml oxethazaine Maximum dose 10ml 4 times daily. aluminium hydroxide A02AB 12.4 A 300mg/5ml suspension AMPHOGEL Specialist initiated SYMMETREL; amantadine HCl N04BB 1.7.1 100mg capsule Specialist: neurologist ANTADINE amethocaine HCl D04AB 2.2.1 0.01 cream ANETHAINE amethopterin: See methotrexate Amiloride HCl + Specialist – central hospitals, Suppl List hydrochlorothiazide C03DB 16.1 5mg + 50mg tablets MODURETIC Specialist hypertension clinic only, non-referable 128 amikacin J01GB 18.3 A P 100mg injection AMIKIN; KACINTH-A Specialist amikacin J01GB 18.3 P 250mg injection AMIKIN Specialist amikacin J01GB 18.3 A 500mg injection AMIKIN Specialist aminocaproic acid B02AA 8.1 A 250mg/ml injection AMICAR aminophylline I.V. R03DA 10.2.2 1 A P 250mg/10ml injection PETERPHYLLIN Genreal code: cardiovascular General amiodarone HCl C01BD 7.2 A 150mg/3ml injection CORDARONE X resuscitation Specialist Specialist physician physician: other indications amiodarone HCl C01BD 7.2 A 200mg tablet CORDARONE X Specialist physician For patients who have not responded to or experienced intolerable side Specialist psychiatrist Suppl List effects with other coded anti- amisulpiride N05AL 1.5.3 50mg tablet SOLIAN initiated with annual 116 psychotics. review with psychiatrist To be used in line with the Mental Health protocol For patients who have not responded to or experienced intolerable side Specialist psychiatrist Suppl List effects with other coded anti- amisulpiride N05AL 1.5.3 200mg tablet SOLIAN initiated with annual 116 psychotics. review with psychiatrist To be used in line with the Mental Health protocol TRYPTANOL; amitriptyline N06AA 1.4.1 1 A P 10mg tablet TREPILINE amitriptyline N06AA 1.4.1 1 A P 25mg tablet TRYPTANOL Supp List amlodipine C08CA 7.3.7 114 and 1 A 5mg tablet NORVASC 119 Supp List NORVASC; amlodipine C08CA 7.3.7 1 A 10mg tablet 120 AMIODAC 10 Page 4 amoxycillin J01CA 18.1.1 1 A P 250mg capsule AMOXIL; MOXYPEN amoxycillin J01CA 18.1.1 1 A 500mg capsule AMOXIL To use cheapest pack size on tender. amoxycillin J01CA 18.1.1 1 P 125mg/5ml suspension AMOXIL amoxycillin J01CA 18.1.1 1 P 250mg/5ml suspension AMOXIL amoxycillin + clavulanic acid: see co-amoxyclav amphotericin-B J02AA 18.8 A P 50mg injection FUNGIZONE PETERCILLIN; ampicillin J01CA 18.1.1 P 250mg injection AMPIPEN ampicillin J01CA 18.1.1 A P 500mg injection PETERCILLIN Specialist oncologist For second line treatment for anastrazole L02BG 19.8 SL127 1mg tablets ARIMIDEX, STRADEXA initiated Tamoxifen intolerant patients. Maximum one bottle per patient per antazoline + 0,05% + month. S01GA 15.4 eye drops SPERSALLERG tetrahydrozoline 0,04% ALTERNATIVE: Item Above. Cheapest on tender will be used. 500 000 iu/50ml aprotinin B02AB 27 1 000 000 injection TRASYLOL Central hospitals only, not referable. iu/100ml aqueous cream D02AC Ø 1 B.P. cream AQUEOUS CREAM aqueous cream D02AC Ø B.P. cream AQUEOUS CREAM artemether + Supp List P01BE 18.11 1 20mg / 120mg tablets COARTEM lumefantrine 120 ascorbic acid: See Vitamin C Supp List 1 Not repeatable for acute conditions aspirin soluble N02BA 3.2 300mg tablet DISPRIN 115 A (short course) Supp list As per Health Programmes protocol - atazanavir J05AE 18.12 150mg capsule REYATAZ 126 refer to circular H148/2011 Supp list As per Health Programmes protocol - atazanavir J05AE 18.12 150mg capsule REYATAZ 126 refer to circular H148/2011 atenolol C07AB 7.4 A 5mg/10ml injection TENORMIN Specialist atenolol C07AB 7.4 1 A P 50mg tablet TENORMIN; ATEROL General: ARV clinics only, according to Health Programmes' algorithm for the management of dyslipidaemia General - ARV clinics Specialist physician initiated: Familial Supp List only atorvastatin C10AA 7.7.2 10mg tablet LIPITOR heterozygous hypercholesterols and 116/124 Specialist physician familial homozygous initiated hypercholesterolemia patients who do not tolerate simvastatin. 3) Familial homozygous hypercholesterolemia (doses of 40mg and higher) Page 5 1) For HIV/AIDS patients. 2) Familial heterozygous hypercholesterols and familial homozygous Supp List Specialist physician atorvastatin C10AA 7.7.2 20mg tablet LIPITOR hypercholesterolemia patients who do 116/124 initiated not tolerate simvastatin. 3) Familial homozygous hypercholesterolemia (doses of 40mg and higher) Supp List Specialist physician atorvastatin C10AA 7.7.2 40mg tablet LIPITOR As above 116/124 initiated Supp List Specialist physician atorvastatin C10AA 7.7.2 80mg tablet LIPITOR As above 116/124 initiated atropine sulphate A03BA 5.4 1 A P 0,5mg/ml injection SABAX ATROPINE atropine