GI - GASTROINTESTINAL

1.1.1 Antacids First choice: Magnesium trisilicate mixture: [200ml 1.01]. Dose: 10ml three times daily. Prescribing notes: Magnesium salts can have laxative effect. More potent antacid effect than alginates. Contain sodium (3mmol per 5ml). OTC. : Low sodium choice: Asilone suspension: [500ml 1.95]. Dose: 5-10ml after meals and at bedtime or when required up to four times a day. Prescribing notes: Contains the antifoaming agent simeticone which will help to relieve flatulence. OTC. : 1.1.2 Alginates First choice: Peptac suspension [500ml 1.95]. Dose: 10-20ml four times daily after meals and at bedtime. Prescribing notes: Alginates should be reserved for the treatment of gastro-oesophageal reflux disease. Peptac contain sodium (3mmol per 5ml) but is sugar free. Available as peppermint and aniseed flavours, but the majority of patients prefer peppermint. OTC. If tablet formulation required recommend OTC products initially; if this is ineffective then prescribe Gastrocote tablets (1mmol sodium per tablet). : Second choice: Acidex suspension [500ml 1.70]. Dose: 10-20ml four times daily after meals and at bedtime. Prescribing notes: Alginates should be reserved for the treatment of gastro-oesophageal reflux disease. Acidex contain sodium (3mmol per 5ml) but is sugar free. Available as peppermint and aniseed flavours, but the majority of patients prefer peppermint. OTC. If tablet formulation required recommend OTC products initially; if this is ineffective then prescribe Gastrocote tablets (1mmol sodium per tablet).

Side effects include dry mouth, hesitancy, constipation and blurred vision. : 1.3 Ulcer healing and H pylori H. Pylori Eradiation See also North Devon Joint Formulary antibiotic recommendations for primary care First choice: Lansoprazole 30mg twice daily for 7 days, plus Clarithromycin 250mg twice daily for 7 days, plus Metronidazole 400mg twice daily for 7 days. [Total cost =4.47]. Prescribing notes: Please note lower strength of clarithromycin than the regimen above. Do not use clarithromycin or metronidazole if used in the past 12 months for ANY infection, refer to BNF for an alternative regimen.

1.3.1 H2 Receptor antagonists First choice: Ranitidine tabs (G): 150mg [60tabs 1.59], 300mg [30tabs 1.58]. Dose: 150mg twice daily or 300mg at night. Prescribing notes: 1.3.5 Proton pump inhibitors Links to NICE Guidance

Dyspepsia Managing Dyspepsia in Adults

Lansoprazole caps (G): 15mg caps [28caps 1.02], 30mg caps [28caps 1.56]. Dose: 15mg to 30mg once daily. Prescribing notes: Also available as orodispersible tablet formulation 15mg [28tabs 2.99], 30mg [28tabs 5.50]. These should only be prescribed for patients with swallowing difficulties. Orodispersible tablets will be treated as a NonFormulary drug.

Omeprazole (G): 10mg caps [28caps 1.34], 20mg caps [28caps 1.36]. Dose: 20mg daily (treatment); 10mg daily (maintenance). Prescribing notes: Capsules are more cost effective than EC tablets. Dispersible tablets are only available as a branded product and do not 1.2 Drugs altering gut motility attract generic cost savings 10mg dispersible tabs Links to NICE guidance Irritable Bowel Syndrome. Clinical Guideline No. 61 [28 disp tabs 7.75], 20mg dispersible tabs [28 disp tabs 11.60]. If a dispersible tablet is required then Mebeverine tabs 135mg (G): [84 tabs 5.07]. lansprazole dispersible tablets are more cost Dose: One three times daily, 20 mins before effective. If patient on warfarin or phenytoin it is meals. preferable to prescribe lansoprazole. Hyoscine Butylbromide tabs 10mg: [224 tabs 9.00]. Dose: 20mg four times daily. Prescribing notes: Poor absorption, brief action. 1.4 Acute Diarrhoea Oral Rehydration See section 9.2.1.2. 1.4.2 Antimotility drugs

First Choice: Loperamide caps (G): 2mg [30 caps 89p]. Dose: 4mg initially followed by 2mg after each loose stool for up to 5 days. Prescribing notes: Low systemic absorption. OTC.

reduce. Prescribing notes: No stimulant laxative should be given long term as they cause atony of the colon and significant electrolyte imbalance. Senna can give a red tint to urine. OTC. Links: Constipation Guidelines: :

Second Choice: Codeine Phosphate tabs (G): 15mg [28 tabs 87p], 30mg [28 tabs 1.02], 60mg [28 tabs 1.62]. Dose: 30mg three or four times daily (range 1560mg). Prescribing notes: : 1.5 Chronic Bowel Disorders Caution: Patients receiving aminosalicylates should be advised to report any unexplained bleeding, bruising, purpura, sore throat, fever or malaise that occurs during treatment. A blood count should be performed and the drug stopped immediately if there is a suspicion of a blood dyscrasia. First Choice: Sulfasalazine EC tabs (G): 500mg [112 tabs 13.03]. Dose: 500mg four times a day (maintenance). Prescribing notes: For monitoring see Shared Care Guideline :

Second choice: Docusate caps (G): 100mg [60 caps 3.84]. Dose: up to 500mg daily in divided doses. Prescribing notes: No stimulant laxative should be given long term as they cause atony of the colon and significant electrolyte imbalance. OTC. Links: Constipation Guidelines:

1.6.4 Osmotic laxatives First choice: Macrogol 3350 compound sachets: [30 sachets 4.45]. Dose: see BNF. Prescribing notes: OTC. Links: Constipation Guidelines:

Chronic Constipation and Faecal Impaction in Children: First Choice: Movicol Paediatric Plain Sachets [20 sachets 4.45, 30 sachets 6.68]. Dose: see BNF for children. Prescribing notes: Prescription Only Medicine (POM). Second Choice: 1.6.5 Rectally administered laxatives Mesalazine EC tabs Mesalazine MR tabs Bisacodyl suppositories: [10mg supps 22p each]. (Asacol MR ): 400mg [90 (Pentasa ): 500mg Glycerin suppositories: [4g supps 10p each]. tabs 29.41], 800mg [90 [90 tabs 27.67]. Phosphates enema BP: [enema 46p each] Dose: see BNF tabs 58.81]. Sodium citrate microenema: [enema 41p each]. Dose: see BNF 1.7 Local preparations for anal and rectal Prescribing notes: Test renal function initially and disorders every 3 months for the first year then every 6 1.7.1 Soothing haemorrhoidal preparations months for the next 4 years and annually First choice: Anusol cream and ointment: [25g thereafter. tube 1.84], suppositories [15p each]. Brands are not interchangeable; patients should Dose: use rectally night and morning and after stay on the brand that stabilised their condition. each bowel movement. May stain soft contact lenses. Prescribing notes: May sensitise anal skin so they : should not be used for more than 2 weeks. OTC. 1.6 Laxatives : 1.6.1 Bulk forming laxatives 1.7.2 Compound haemorrhoidal preparations Link to NICE guidance Constipation in children and youngcorticosteroids Guideline No. 99 with people. Clinical First choice: Anusol HC ointment: [tube 3.50], First choice: Ispaghula husk sachets: [60 suppositories [21p each]. sachets 3.56]. Dose: use rectally night and morning and after Dose: 1 sachet twice daily each bowel movement. Available OTC as Anusol Prescribing notes: Fybogel sachets are now Plus HC. sugar free and gluten free. OTC. Available as Prescribing notes: Do not use for more than 7 plain, orange & lemon flavours. days. : Links: Constipation Guidelines: 1.7.4 Management of Anal Fissures 1.6.2 Stimulant laxatives First choice: Senna tabs(G): [60 tabs 1.34]. Dose: 2 to 4 tabs usually at night, then gradually First choice: Glyceryl Trinitate 0.4% rectal ointment (Rectogesic): [30g tube 34.80]. Dose: for the relief of pain associated with chronic

anal fissure, apply 2.5cm of ointment to anal canal every 12 hours until pain stops. Maximum duration of use 8 weeks. Prescribing notes: The management of anal fissures requires stool softening by increasing dietary fibre in the form of bran or by using a bulkforming laxative. Short-term use of local anaesthetic agents may help. : 1.8 Faecal Incontinence Links to NICE guidance Faecal Incontinence. Clinical Guideline No. 49

twice daily for 7-10days, [20tabs 1.30]. If there is failure to respond then refer to secondary care.

1.9 G.I.Infections Clostridium difficile Clostridium difficile should be suspected in patients with diarrhoea, especially if there are risk factors such as age over 65, co-morbidities, recent hospital admission or recent antibiotic use (particularly ciprofloxacin or other quinolones). Stop unnecessary antibiotics and/or PPIs. 70% of patients respond to Metronidazole in 5 days; 94% in 14 days Send a stool sample for toxin testing. First or second episode: Metronidazole 400mg 3 times a day for 10-14 days, [42tabs 3.06]. Third episode or severe* disease: Vancomycin 125mg 4 times a day 7 - 10 days, [40caps 174.10]. * Severe if temp above 38.5C; WCC above 15; rising creatinine or signs/symptoms of severe colitis Discuss patients with consultant microbiologist. Travellers Diarrhoea Most diarrhoea is self limiting so antibiotic treatment is not routinely indicated. Send stool sample for identification of pathogens which may indicate treatment. Please indicate time and place of travel on request. Some pathogens, eg Giardia, need 3 samples to be excluded If empiric treatment is required use ciprofloxacin 500mg bd for 5 days, [10tabs 91p]. If not settling within 48 hours seek advice as metronidazole may be indicated. Diverticulitis The diagnosis of diverticulitis can be difficult. If there is confirmed diverticulitis then first choice antibiotic therapy is co-amoxiclav 625mg three times daily for 5 days, [15tabs 1.81]. If there is failure to respond then advise refer to secondary care. Cholecystitis (Low Grade) The diagnosis of cholecystitis can be difficult. First choice antibiotic therapy is ciprofloxacin 500mg

Threadworms First Choice: Mebendazole (G): 100mg tabs [2tabs 45p], 100mg/5ml suspension [10ml 53p]. Dose: Adults and Child over 2 years, 100mg as a single dose repeat after 2 weeks if reinfection occurs. Prescribing notes: Only licensed above the age of 2 years but BNF for Children states that the dose for 6months onwards is as above. : Second Choice: Piperazine 4g with Senna 15.3mg (Pripsen): [2 sachets 1.47]. Dose: 3 months to 1 year one level 2.5ml spoonful as a single dose in the morning repeated after 14 days; 1 to 6 years one level 5ml spoonful as a single dose in the morning repeated after 14 days; above 6 years the contents of one sachet as a single dose in the morning repeated after 14 days Prescribing notes: OTC. :

CARDIOVASCULAR
2.1.1 Cardiac Glycosides First choice: Digoxin tabs (G): 62.5micrograms [28 tabs 2.67] 125micrograms [28 tabs 91p], 250micrograms [28 tabs 91p]. Dose: 62.5 to 250 micrograms daily. Prescribing notes: : Summary of antihypertensive treatment choices & treatment steps Step Age 55 years or Age over 55 less years, or any age people of AfroCaribbean origin 1 A C 2 A+C 3 A+C+D 4 Resistant hypertension: A + C + D + additional diuretic or alpha-blocker or beta-blocker. Consider seeking specialist advice A = ACE inhibitor or low cost ARB; C = calciumchannel blocker; D = thiazide-like diuretic 2.2 Diuretics 2.2.1 Thiazides and related diuretics First Choice: Indapamide tabs (G): 2.5mg [28 tabs 1.09]. Dose: 2.5mg daily. Prescribing Notes: First line diuretic in newly diagnosed patients with stage 3 hypertension or those requiring a change of therapy (see NICE 127) : Second choice: Bendroflumethiazide tabs (G): 2.5mg [28 tabs 66p]. Dose: 2.5mg in the morning (higher doses rarely necessary). Prescribing notes: Oedema, or to continue in patients with stage 3 hypertension already established and well controlled on it. : Links: Hypertension Lifestyle Measures Hypertension. Clinical Guideline No. 127. 2.2.2 Loop Diuretics First choice: Furosemide tabs (G): 20mg [28 tabs 71p], 40mg [28 tabs 70p]. Dose: 20 to 80mg daily. Prescribing notes: : Second choice: Bumetanide tabs 1mg (G):

[28tabs 91p]. Dose: 1 to 5mg daily. Prescribing notes: Bumetanide has no advantage over furosemide in the majority of cases. : 2.2.3 Potassium Sparing Diuretics First choice: Amiloride tabs 5mg (G): [28tabs 1.00] Dose: 5 to 20mg daily. Prescribing notes: On its own amiloride is a weak diuretic, best used in combination with a loop diuretic where it is more effective than potassium supplements in conserving potassium. : Second choice: Spironolactone tabs (G): 25mg [28tabs 1.33], 50mg [28tabs 2.11], 100mg [28tabs 2.30]. Dose: moderate to severe heart failure and first choice additional treatment in Stage4 hypertension, initially 25mg daily; for other indications see BNF. Prescribing notes: High doses used in oedema and ascites in cirrhosis of the liver malignant ascites etc. Low doses in heart failure. : 2.3 Anti-Arrhythmic Drugs Links to NICE guidance Dronedarone for the treatment on nonpermanent atrial fibrillation. TAG 197

Amiodarone tabs (G): 100mg [28 tabs 1.22], 200mg [28 tabs 1.68]. Dose: 100 to 200mg daily (maintenance). Prescribing notes: Needs loading dose see BNF. Liver & thyroid function tests and a chest Xray required before treatment started. Check SPC and BNF for Cautions, Contra-indications, Adverse Effects and Drug Interactions. Patients should be warned about long term side effects, to shield their skin from sunlight and to use a total sunscreen because of risk of phototoxicity. : Choice of Antihypertensive Drugs Disopyramide caps (G): 100mg [84 caps 20.37], 150mg [84 caps 27.21]. : Dose: 300 to 800mg daily in divided doses Prescribing notes: Antimuscarinic activity. Caution with glaucoma and prostatic enlargement. : Flecainide tabs (G): 50mg [60 tabs 4.35], 100mg [60 tabs 6.26] Dose: 50 to 200mg twice daily. Prescribing notes: Flecainide must only be initiated under the direction of a hospital consultant. When

prescribed for prn use in arythmia (e.g. pill in the pocket approach) the dose must be explicit, unambiguous and include a clear statement of dose frequency and the maximum daily dose to be taken. See BNF for further information. : Propafenone tabs: 150mg [90 tabs 7.37], 300mg [90 tabs 14.01] Dose: 150 to 300mg three times a day. Prescribing notes: Antimuscarinic activity. Caution with glaucoma and prostatic enlargement. : 2.4 Beta- Blockers Hypertension Angina and Arrythmias First choice: Atenolol tabs (G): 25mg [28 tabs 71p], 50mg [28 tabs 73p], 100mg [28 tabs77p]. Dose: 25 to 100mg once daily. Prescribing notes: Do not co-prescribe with verapamil. Caution with any beta-blocker in asthmatic patients. If combination of beta-blocker and diuretic is needed use atenolol and bendroflumethiazide separately. Tenoretic / Tenoret (co-tenidone) contains chlorthalidone which is longer acting and may cause nocturia. Prescribing notes: Links: Hypertension Lifestyle Measures Hypertension. Clinical Guideline No. 127. Second choice: Metoprolol tabs (G): 50mg [56 tabs 1.40], 100mg [56 tabs 3.73]. Dose: 50 to 200mg daily in one to three divided doses. Prscribing notes: Do not co-prescribe with verapamil. Caution with any beta-blocker in asthmatic patients. : Anxiety First choice: Propranolol tabs (G): 10mg [28 tabs 76p], 40mg [28 tabs 79p], 80mg [28 tabs 69p], 160mg [28 tabs 2.34]. Dose: 40mg once daily increased to three times a day if necessary Prescribing notes: Do not co-prescribe with verapamil. Caution with any beta-blocker in asthmatic patients. Chapter 4 - Anxiolytics :

Heart Failure First choice: Bisoprolol tabs (G): 1.25mg [28tabs 1.62]; 2.5mg [28tabs 1.42]; 3.75mg [28tabs 4.92]; 5mg [28 tabs 92p]; 7.5mg [28tabs 5.33]; 10mg [28 tabs 99p]. Dose: 1.25mg once daily (in the morning) for one week then, if well tolerated, increase to 2.5mg once daily for 1 week, then 3.75mg once daily for 1 week, then 5mg once daily for 4 weeks, then 7.5mg once daily for 4 weeks, then 10mg once daily.

Maximum 10mg daily. Prescribing notes: Do not co-prescribe with verapamil. Caution with any beta-blocker in asthmatic patients. : Second choice: Carvedilol tabs (G): 3.125mg [56 tabs 1.94]; 6.25mg [56 tabs 2.14]; 12.5mg [56 tabs 2.38]; 25mg [56 tabs 2.92]. Dose: initially 3.125mg twice daily (with food), dose increased at intervals of at least two weeks to 6.25mg twice daily, then to 12.5mg twice daily, then to 25mg twice daily; increase to highest dose tolerated. Maximum 25mg twice daily in patients with severe heart failure or body-weight less than 85kg and 50mg twice daily in patients over 85kg. Prescribing notes: Do not co-prescribe with verapamil. Caution with any beta-blocker in asthmatic patients. : Life-Threatening Arrhythmias First Choice: Sotalol tabs (G): 40mg [56tabs 1.29]; 80mg [56tabs 1.91]. Dose: with ECG monitoring and measurement of QT interval, arrhythmias, initially 80mg daily in one to two divided doses increasing gradually at intervals of 2 to 3 days to usual dose of 80 to 160mg twice daily. Prescribing notes: Usually only initiated in Choice of Antihypertensive Drugs The use of sotalol secondary care. CSM advice. should be limited to the treatment of ventricular : arrhythmias . It should no longer be used for angina, hypertension, thyrotoxicosis or for secondary prevention of myocardial infarction; when stopping sotalol for these indications, the dose should be gradually reduced. More cost effective to prescribe 160mg dose as 2 x 80mg tablets. : 2.5.4 Alpha-Blockers First choice: Doxazosin tabs (G): 1mg [28 tabs 82p], 2mg [28 tabs 85p], 4mg [28 tabs 1.21]. Dose: 1mg daily increasing slowly to a maximum of 16mg daily. Prescribing notes: Initiate therapy gradually. First dose on retiring to bed to avoid collapse. May be used in conjunction with a thiazide diuretic or betablocker : 2.5.5.1 ACE Inhibitors First choice: Ramipril caps (G): 1.25mg [28 caps 97p], 2.5mg [28 caps 1.04], 5mg [28 caps 1.11], 10mg [28 caps 1.23]. Dose: 1.25 to 10mg daily (hypertension), 1.25 to 10mg daily (heart failure), 2.5 to 5mg twice daily (post MI). Prescribing notes: Tablets are more expensive than capsules at all strengths. Hypertension Lifestyle Measures

Hypertension. Clinical Guideline No. 127. Second choice: Lisinopril tabs (G): 2.5mg [28 tabs 75p], 5mg [28 tabs 80p], 10mg [28 tabs 89p], 20mg [28 tabs 1.02]. Dose: 2.5 to 40mg daily (hypertension), 2.5 to 20mg daily (heart failure), 5 to 10mg daily (post MI), 2.5 to 20mg daily (diabetic nephropathy). Prescribing notes: Hypertension Lifestyle Measures Hypertension. Clinical Guideline No. 127. 2.5.5.2 Angiotensin-2 Antagonists (ARB) First choice: Losartan tabs (G): 12.5mg [28 tabs 6.61], 25mg [28 tabs 99p], 50mg [28 tabs 1.07]; 100mg [28 tabs 1.24]. Dose: HYPERTENSION: diabetic nephropathy in type 2 diabetes mellitus, usually 50mg once daily (intravascular volume depletion, initially 25mg once daily); if necessary increased after several weeks to 100mg once daily; ELDERLY over 75 years initially 25mg daily. Prescribing notes: ARBs should be reserved for those patients who cannot tolerate ACE inhibitors. Losartan is now available as a generic product. New patients who require an ARB due to true intolerance to an ACEI should be initiated on losartan for treatment of hypertension. Hypertension Lifestyle Measures Hypertension. Clinical Guideline No. 127. Second choice: Candesartan tabs: 2mg [28 tabs 14.32], 4mg [28 tabs 9.78], 8mg [28 tabs 9.89], 16mg [28 tabs 12.72], 32mg [28 tabs 16.13]. Dose: HYPERTENSION: the recommended initial dose and usual maintenance dose is 8 mg once daily. Increase to 16mg once daily after 4 weeks and 32mg once daily after a further 4 weeks. HEART FAILURE: the usual recommended initial dose is 4 mg once daily. Titrate up to the target dose of 32 mg once daily or the highest tolerated dose by doubling the dose at intervals of at least 2 weeks Prescribing notes: Angiotensin II antagonists should be reserved for those patients who cannot tolerate ACE inhibitors. Dose 4mg daily in hepatic and renal impairment. Hypertension Lifestyle Measures Hypertension. Clinical Guideline No. 127. 2.6.1 Nitrates Sublingual Preparations

First choice: Glyceryl Trinitrate 400micrograms spray: aerosol spray [180 doses 2.63, 200 doses 3.29]; pump spray [180 doses 2.63, 200 doses 3.44]. Dose: Use one or two doses under the tongue, and close mouth, at onset of angina. If pain has not subsided within five minutes, dial 999. Prescribing notes: May prove more cost effective than GTN tablets if attacks are infrequent due to short shelf life of tablets once opened. : Second choice: Glyceryl Trinitrate tabs (G): 500micrograms [100 tabs 2.77]. Dose: 1 to 2 tabs as required. Prescribing notes: Tablets must be discarded 8 weeks after opening. : Oral Preparations First choice: Isosorbide Mononitrate tabs: 10mg [56 tabs 94p], 20mg [56 tabs 1.02], 40mg [56 tabs 1.33]. Dose: 10 to 40mg twice daily, preferably asymmetrically in the morning and 2pm. Maximum 120mg daily. Prescribing notes: : Second choice: Isosorbide Mononitrate SR tabs (Monomax XL tabs): 60mg [28 tabs 5.25]. Dose: One tablet in the morning (half a tablet for the first 2 to 4 days to minimise the possibility of headache), increased if necessary to two tablets in the morning. Prescribing notes: NB please ensure the prescription states tablets as the capsules are more expensive. DO NOT prescribe SR isosorbide mononitrate generically. : 2.6.2 Calcium Channel Blockers Hypertension and Angina First Choice: Amlodipine tabs (G): 5mg [28 tabs 82p], 10mg [28 tabs 91p]. Dose: 5 to 10mg once daily. Prescribing notes: Grapefruit juice increases the bioavailability of amlodipine. Hypertension Lifestyle Measures Hypertension. Clinical Guideline No. 127. Second Choice: Diltiazem tabs (G) 60mg tabs [84 tabs 4.43]; MR caps (Slozem): 120mg MR caps [28 caps 7.00], 180mg MR caps [28 caps 7.80], 240mg MR caps [28 caps 8.20], 300mg MR caps [28 caps 8.50]. Dose: Tabs, 60 to 120mg three times a day; MR Caps, 120mg to 360mg once daily. Prescribing notes: Once daily preparations

improve concordance. They should be prescribed by brand name to avoid bioavailability differences. Other brands of diltiazem include Adizem & Tildiem but Slozem provides is the most cost effective preparation. Appropriate patients should be transferred onto Slozem. Links: Hypertension Lifestyle Measures Hypertension. Clinical Guideline No. 127. Third Choice: Nifedipine MR (Adalat LA tabs): 20mg [28 tabs 5.27], 30mg [28 tabs 6.85], 60mg [28 tabs 9.03]; (Coracten XL caps): 30mg [28caps 4.89], 60mg [28caps 7.34]. Dose: 20 to 90mg once daily. Prescribing notes: Avoid use if hepatic impairment or where there is a history of oesophageal or gastro-intestinal obstruction, decreased lumen diameter of the GI tract or inflammatory bowel disease (including Crohns disease). Grapefruit juice increases the bioavailability of nifedipine. It is recommended MR nifedipine should be prescribed by brand name to avoid bioavailability differences. Links: Hypertension Lifestyle Measures Hypertension. Clinical Guideline No. 127. Arrythmias First choice: Verapamil tabs (G): 40mg [84 tabs 1.32], 80mg [84 tabs 1.67], 120mg [84 tabs 3.96]. Dose: 40 to 120mg three times a day. Prescribing notes: : 2.6.3 Potassium Channel Activators Nicorandil tabs: 10mg [60 tabs 7.88], 20mg [60 tabs 14.44]. Dose: 10 to 30mg twice daily. Prescribing notes: : 2.8.1 Parenteral Anticoagulants Links: Enoxaparin administration record

Prescribing notes: : 2.9 Antiplatelet Drugs Acute coronary syndromes - glycoprotein IIb/IIIc inhibitors. No.47. Choice of coronary syndromes - clopidogrel. No.80. Acute Antihypertensive Drugs : Prevention of occlusive vascular events - clopidogrel and MR dipyridamole. TAG 210. AFTER ISCHAEMIC STOKE or TRANSIENT ISCHAEMIC ATTACK First Choice: Clopidogrel tabs (G): 75mg [30 tabs 1.94]. Dose: 75mg once daily. Prescribing notes: No limit on duration of treatment. Link to EPC statement. Second Choice: Aspirin dispersible tabs (G): 75mg [28 tabs 82p]. Dose: 75mg once daily. Plus Dipyridamole 200mg MR caps [60 caps 9.00]. Dose: one cap twice a day. Choice of Antihypertensive Drugs Prescribing notes: only if clopidogrel is contraindicated or not tolerated, but treatment is no : longer limited to 2 years duration. Link to EPC statement. Third Choice: Dipyridamole: 200mg MR caps: [60 caps 9.00]. Dose: one cap twice a day. Prescribing notes: MR dipyridamole alone is recommended after an ischaemic stroke only if both aspirin and clopidogrel cannot be used as above because they are contraindicated or not tolerated, again with no limit on duration of treatment. Link to EPC statement. AFTER A MYOCARDIAL INFARCTION First Choice: Aspirin dispersible tabs (G): 75mg [28 tabs 82p]. Dose: 75mg once daily. Prescribing notes: Link to EPC statement. Second Choice: Clopidogrel tabs (G): 75mg [30 tabs 1.94]. Dose: 75mg once daily. Prescribing notes: only if aspirin is contraindicated or not tolerated. This guidance should be considered alongside existing NICE guidance on clopidogrel in combination with aspirin in people with unstable angina or NSTEMI (see CG94) and those who have had an MI (see CG48). Link to EPC statement.

2.8.2 Oral Anticoagulants Oral Anticoagulation Guideline Treatment guidelines for anticoagulated patients with an INR greater than 7 First Choice: Warfarin tabs (G): 500micrograms [28tabs 1.41]; 1mg [28 tabs 75p], 3mg [28 tabs 78p], 5mg [28 tabs 81p]. Dose: As per PTT.

PERIPHERAL ARTERIAL DISEASE (PAD) OR MULTIVASCULAR DISEASE. First Choice: Clopidogrel tabs (G): 75mg [30 tabs 1.94]. Dose: 75mg once daily. Prescribing notes: . Link to EPC statement.. Second Choice: Aspirin dispersible tabs (G): 75mg [28 tabs 82p]. Dose: 75mg once daily. Prescribing notes: Although not discussed in the guidance, aspirin monotherapy would seem to be the logical choice if clopidogrel were contraindicated or not tolerated. Link to EPC statement. 2.10 Myocardial Infarction and Fibrinolysis Link to NICE guidance Alteplase for the treatment of acute ischaemic stroke No.122 Myocardial infarction thrombolysis. No.52 2.11 Antifibrinolytic Drugs and Haemostatics First Choice: Tranexamic Acid tabs (G): 500mg [60 tabs 4.56]. Dose: For menorrhagia, two to three tabs three or four times a day for 3 or 4 days, starting on first day of period. Prescribing notes: Links: Menorrhagia Guideline:

2.12 Lipid-Regulating Drugs Links NICE guidance: Cardiovascular disease statins. No.94. Ezetimibe for Hypercholesterolemia No.132 Statins First Choice: Simvastatin tabs (G): 10mg [28 tabs 72p], 20mg [28 tabs 90p], 40mg [28 tabs 1.17]; 80mg [28 tabs 1.98]. Dose: 10 to 80mg once daily at night. Prescribing notes:

Second Choice: Atorvastatin tabs: 10mg [28 tabs 13.00], 20mg [28 tabs 24.64], 40mg [28 tabs 24.64], 80mg [28 tabs 28.21]. Dose: 10 to 80mg once daily. Prescribing notes:

RESPIRATORY
Management of Chronic Asthma in Adults & Children (based on the recommendations of the British Thoracic Society and Scottish Intercollegiate Guidelines Network (updated June 2009) Adult and Child over 5 years Step 1: occasional relief bronchodilators. Inhaled short acting beta2 agonist as required (up to once daily). NOTE: Move to step 2 if needed more than twice a week (or if night-time symptoms more than once a week or if exacerbation in last 2 years). Step 2: Regular inhaled preventer therapy. Inhaled short acting beta2 agonist as required plus Regular standard-dose inhaled corticosteroid (alternatives are considerably less effective). Step 3: inhaled corticosteroids + long-acting inhaled beta2 agonist. Inhaled short acting beta2 agonist as required plus Regular standard-dose inhaled corticosteroid plus Regular inhaled long acting beta2 agonist (salmeterol or formoterol) If asthma not controlled Increase dose of inhaled corticosteroid to upper end of standard dose. and Either stop long acting beta2 agonist if of no benefit Or continue long acting beta2 agonist if of some benefit If asthma still not controlled and long acting beta2 agonist stopped add one of: leukotriene receptor antagonist modified release oral theophylline a modified release oral beta2 agonist. Step 4: high-dose inhaled corticosteroids + regular bronchodilators. Inhaled short acting beta2 agonist as required with Regular high-dose inhaled corticosteroid plus Regular inhaled long acting beta2 agonist plus In adults a six week sequential therapeutic trial of one or more of:: leukotriene receptor antagonist modified release oral theophylline modified release oral beta2 agonist.

Step 5: regular corticosteroid tablets. Inhaled short acting beta2 agonist as required with Regular high-dose inhaled corticosteroid and One or more long acting bronchodilators (see step 4) plus Regular prednisolone tablets (as a single daily dose). NOTE. In addition to regular prednisolone, continue high-dose inhaled corticosteroid (in exceptional cases may exceed licensed doses); these patients should normally be referred to an asthma clinic. Stepping down. Review treatment every 3 months; if control achieved stepwise reduction may be possible, reduce dose of inhaled corticosteroid slowly (consider reduction every 3 months, decreasing dose by approximately 50% each time). Chronic asthma: children under 5 years Step 1: occasional relief bronchodilators. Short acting beta2 agonist as required (not more than once daily). NOTE. Preferably by inhalation (less effective and more side-effects when given by mouth). Move to step 2 if needed more than twice a week, or if night-time symptoms more than once a week or if exacerbation in last 2 years. Step 2: Regular preventer therapy. Inhaled short acting beta2 agonist as required plus Either regular standard-dose inhaled corticosteroid Or (if inhaled corticosteroid cannot be used) leukotriene receptor antagonist. Step 3: add-on therapy. Child under 2 years: Refer to respiratory paediatrician. Child 2-5 years: Inhaled short acting beta2 agonist as required plus Regular inhaled corticosteroid in standard-dose plus Leukotriene receptor antagonist Step 4: persistent poor control. Refer to respiratory paediatrician. Stepping down Regularly review need for treatment. 3.1 Bronchodilators 3.1.1.1 Selective Beta-2 Agonists Short Acting First choice: Salbutamol CFC-Free Aerosol Inhaler (G): 100 mcg/dose [200 doses 1.50]. Dose: 1 or 2 puffs up to three or four times daily Prescribing notes: Beware hypokalaemia, monitor plasma potassium levels in severe asthmatics. If

more than two doses are used regularly consider inhaled steroids. In severe attacks 2 puffs, via a spacer half-hourly is as effective as nebuliser. :

Inhaler devices for older childr

Second choice: Ipratropium nebuliser solution (Atrovent): Link to NICE guidance Inhaler devices for children under 5. TAG 250mcg [20 UDVs 4.14], 500mcg [20 UDVs 4.87]. 10. Dose: 100 to 500mcg up to four times a day. Prescribing notes: Because paradoxical Inhaler devices for older children. TAG 38. bronchospasm has occurred the first dose should be inhaled under medical supervision. : Second choice: Salbutamol nebuliser solution Long Acting Bronchodilator (G): 2.5mg [20 UDVs 1.91], 5mg [20 UDVs Tiotropium inhalation capsules: 22.5mcg 3.82]. [30caps + HandiHaler 34.87, 30caps refill 31.89]. Dose: 2.5mg repeated up to four times daily; may Dose: Inhale the contents of one capsule at the be increased to 5mg if necessary. same time each day. Prescribing notes: For chronic bronchospasm Prescribing notes: Initially for 30day trial period. unresponsive to conventional therapy and severe Discontinue if no improvement. Black triangle. acute attack. : : 3.1.3 Theophylline Breath Actuated Inhaler Adults First Choice: Salamol Easi-Breathe CFC-Free First choice: Theophylline MR tabs (Uniphyllin): Aerosol Inhaler: 100 mcg/dose [200 doses 200mg [56tabs 2.95], 300mg [56tabs 4.77], 6.30]. 400mg [56tabs 5.65]. Prescribing notes: Beware hypokalaemia, monitor Dose: 200 to 400mg twice daily. plasma potassium levels in severe asthmatics. If Prescribing notes: Theophylline should be more than two doses are used regularly consider prescribed by brand name. Half life increased in inhaled steroids. heart failure and by some drugs eg cimetidine and Long Acting Beta-2 Agonist oral contraceptives and is decreased in smokers First choice: Salmeterol CFC-Free Aerosol and heavy drinkers. Oral aminophylline is no longer Inhaler: 25mcg/dose [120 doses 29.26]. recommended. Co-prescription with ciprofloxacin Dose: 50 to 100mcg twice daily. and macrolides is not recommended as they inhibit Prescribing notes: Salmeterol is licensed for its metabolism. Consider ofloxacin in these children 4 years and over. Aerosol inhalers should circumstances. be prescribed in preference to dry powder devices. : Co-prescribe a spacer if there are compliance issues. Second choice: Theophylline MR tabs (Nuelin): : 175mg [60tabs 3.19], 250mg [60tabs 4.46]. Second choice: Formoterol Turbohaler: Dose: 250 to 500mg twice daily. 6mcg/dose [60 doses 24.80], 12mcg/dose [60 Prescribing notes: Theophylline should be doses 24.80]. prescribed by brand name. Half life increased in Dose: 6 to 12mcg once or twice daily. heart failure and by some drugs eg cimetidine and Prescribing notes: Formoterol is licensed for oral contraceptives and is decreased in smokers children 6 years and over. and heavy drinkers. Oral aminophylline is no longer : recommended. Co-prescription with ciprofloxacin and macrolides is not recommended as they inhibit 3.1.2 Antimuscarinics its metabolism. Consider ofloxacin in these Short Acting Bronchodilator circumstances. First choice: Ipratropium CFC-free Aerosol : Inhaler (G): 20mcg/dose [200doses 5.05]. Children Dose: 20 to 80mcg three or four times a day. First Choice: Theophylline MR Caps (SloPrescribing notes: Ipratropium is more effective in Phyllin): 60mg [56caps 2.76], 125mg [56caps relieving bronchoconstriction associated with 3.48], 250mg [56caps 4.34]. chronic bronchitis. Aerosol inhalation slower acting Dose: 2- 6 years, 60 to 120mg every twelve hours; than salbutamol. Trial for one week before 7- 12 years, 125 to 250mg every twelve hours. prescribing long term. Paradoxical bronchospasm Prescribing notes: Swallow whole with fluid or may occur. First weeks treatment needs close swallow enclosed granules with soft food (eg medical supervision. Black triangle. yoghurt). : : Link to NICE guidance Inhaler devices for children under 5. TAG 3.1.4 Compound Bronchodilator Preparations 10. Long Acting Bronchodilator

Budesonide with Formoterol Inhaler (Symbicort): 100/6 [120 doses 33.00]; 200/6 [120 doses 38.00]; 400/12 [60 doses 38.00] Dose: see BNF, (licensed for asthma and COPD). Prescribing notes: See also Devon PCT Effective Practice Committees statement re Symbicort SMART. : Fluticasone with Salmeterol Aerosol Inhaler (Seretide 50 CFC-Free Evohaler): 50mcg/25mcg [120 doses 18.00]; (Seretide 500 Accuhaler): 500mcg/50mcg [60 doses 40.92]. Dose: asthma, 2 puffs Seretide 50 twice daily; COPD: 1 blister Seretide 500 Accuhaler twice a day. Prescribing notes: In general patients are best treated with single ingredient preparations so that the dose of each drug can be adjusted. However, for patients stabilised on this combination it is more cost effective to prescribe as Seretide 50. Aerosol inhalers should be prescribed in preference to dry powder devices. Co-prescribe a spacer if there are compliance issues. : 3.1.5 Peak flow meters and drug inhaler devices Peak Flow Meters Drug Delivery Devices

Corticosteroids for asthma in a CFC Free Beclometasone CFC-Free Inhaler (Qvar): 50mcg/dose [200doses 7.87], 100mcg/dose [200doses 17.21] Dose: 50 to 200 mcg twice a day; maximum 400mcg twice daily. Prescribing notes: Prescribe by brand name. Because of increased solubility of beclometasone in the CFC-free propellant Qvar is approximately twice as potent as standard inhalers. Newly diagnosed patients should be prescribed the CFCfree inhaler. For converting from standard beclometasone inhalers to beclometasone cfc-free inhalers see below. Not licensed in children less than 12 years old. Maximum high dose corticosteroid inhalers are associated with adrenal suppression so steroid cards should be considered and corticosteroid cover may be necessary during times of stress (eg an operation). :

Converting patients to Qvar Beclometasone Aerosol Inhalers For patients with well controlled asthma by a CFCcontaining inhaler initially prescribe 100mcg CFC-free beclometasone Link to NICE guidance Inhaler devices for children under 5. TAG (Qvar) for: 10. 200 - 250mcg CFC-containing beclometasone aerosol inhaler Inhaler devices for older children. TAG 38. 200 - 250mcg budesonide aerosol inhaler 100mcg fluticasone aerosol inhaler AeroChamber Plus: standard (blue) [4.61], For patients with poorly controlled asthma by a standard (blue) with mask [7.70], child (yellow) CFC-containing inhaler with mask [7.70], infant (orange) with mask initially prescribe 100mcg CFC-free beclometasone [7.70]. (Qvar) for: Dose: 100mcg CFC-containing beclometasone aerosol Prescribing notes: Medium volume device. For inhaler use with, Atrovent, Salbulin & Qvar inhalers. 100mcg budesonide aerosol inhaler : 100mcg fluticasone aerosol inhaler. Volumatic standard [2.86], paediatric with mask [2.86]. Beclometasone CFC-Free Inhaler (Clenil Dose: Modulite): 50mcg/dose [200doses 3.70], Prescribing notes: Large volume device. For use 100mcg/dose [200doses 7.42], 200mcg/dose with Becotide, Flixotide, Serevent, Ventolin & Clenil [200doses 16.17], 250mcg/dose [200doses inhalers. 16.29]. : Dose: The usual starting dose is 200mcg twice a day. In severe cases this may be increased to 200mcg three or four times a day. This may then Peak Flow Meter: Standard Range 60 to 800 be reduced when the patients asthma has litres/min [6.86], Low Range 30 to 400 litres/min stabilised. [6.90]. Prescribing notes: Prescribe by brand name. Dose: Clenil Modulite is equipotent with CFC- containing Prescribing notes: inhalers so dose adjustment should not be needed : on conversion. Newly diagnosed patients should be 3.2 Corticosteroids prescribed the CFC-free inhaler. Can be prescribed Link to NICE guidance Corticosteroids for asthma in children TAG less than 12 years old. Maximum high for children 131

dose corticosteroid inhalers are associated with adrenal suppression so steroid cards should be considered and corticosteroid cover may be necessary during times of stress (eg an operation). : Link to NICE guidance

Prescribing notes: OTC. : Pruritis First choice: Hydroxyzine tabs (G): 25mg [56 tabs 2.22]. Dose: initially 25mg at night increasing to 25mg Inhaler devices for children under 5. TAG times a day. three or four 10. Prescribing notes: : Inhaler devices for older children. TAG 38. 3.4.2 Allergen Immunotherapy Link to NICE guidance

Breath Actuated Inhaler First Choice: Qvar Easi-Breathe Aerosol Inhaler: 50mcg/dose [200 doses 7.74]; 100mcg/dose [200doses 16.95]. Dose: 50 to 200 mcg twice a day; maximum 400mcg twice daily. Prescribing notes: See Prescribing notes for Qvar. 3.3.2 Leukotriene Receptor Antagonists First choice: Montelukast tabs: 4mg [28 tabs 25.69]; 5mg [28 tabs 25.69]; 10mg [28 tabs 26.97]. Dose: prophylaxis of asthma: adult and child over 15years, 10mg once daily in the evening; child 6 months to 6 years, 4mg once daily in the evening; child 6 to 15 years, 5mg once daily in the evening. Prescribing notes: 4mg and 5mg strengths of tablet are chewable. : 3.4.1 Antihistamines Sedating First choice: Chlorphenamine (Chlorpheniramine) (G): 4mg tabs [112tabs 3.72], 2mg/5ml sugar free oral solution [150ml 2.49]. Dose: 4mg every four to six hours, max 24mg a day. Prescribing notes: OTC. : Second choice: Promethazine HCl (G): 25mg tabs [56tabs 4.34], 5mg/5ml sugar free oral solution [100ml 2.67]. Dose: 25mg at night, increased to 25mg twice daily. Prescribing notes: OTC. : Non-Sedating First choice: Cetirizine (G): 10mg tabs [30tabs 95p], 5mg/5ml sugar free oral solution [100ml 85p]. Dose: 10mg once daily. Prescribing notes: OTC. : Second choice: Loratadine tabs (G): 10mg [30 tabs 1.00; 5mg/5ml oral solution [100ml 2.15]. Dose: 10mg once daily.

Omalizumab for uncontrolled a

3.4.3 Allergic Emergencies First Choice: Adrenaline (Epinephrine) injection: Epipen 300mcg [26.45 each], Epipen Jr 150mcg [26.45 each]. Dose: Adult and child over 30kg, 300mcg by IM injection repeated after 15mins as necessary. Child 15 to 30kg, 10mcg/kg by intramuscular injection repeated after 10mins as necessary. 3.7 Mucolytics First choice: Carbocisteine 375mg caps (G): [120caps 17.57] Dose: Initially 2.25g daily in divided doses, then 1.5g daily in divided doses as condition improves. Prescribing notes: Also available as syrup 125mg in 5ml and 250mg in 5ml. : 3.8 Aromatic Inhalations First choice: Menthol and Eucalyptus Inhalation BP 1980: [100ml 1.01] Dose: Add one teaspoonful to a pint of hot, not boiling, water and inhale the vapour. Prescribing notes: OTC. : Second choice: Benzoin Tincture Compound BP: [100ml 2.11]. Dose: Add one teaspoonful to a pint of hot, not boiling, water and inhale the vapour. Prescribing notes: OTC. : 3.9.1 Cough Suppressants First choice: Pholcodine Linctus BP: 5mg/5ml [200ml 1.03], 5mg/5ml sugar-free [200ml 38p]. Dose: 5 to 10ml three or four times a day. Prescribing notes: Preferable to codeine linctus. : Second choice: Codeine Linctus BP: 15mg/5ml [200ml 1.56], 15mg/5ml sugar-free [200ml 76p]. Dose: 5 to 10ml three or four times a day. Prescribing notes: : 3.9.2 Expectorants First choice: Simple Linctus BP: [200ml 58p], paediatric [200ml 87p], sugar-free [200ml 78p]. Dose: 5ml three or four times a day. Prescribing notes:.

: Second choice: Ammonium and Ipecacuanha Mixture BP: [200ml 1.14]. Dose: 10 to 20ml three or four times a day. Prescribing notes:. Links:

[28tabs 3.35], 2.5mg [28tabs 5.04]. Dose: 1 to 4mg daily in divided doses. Prescribing notes: Benzodiazepines are indicated CNS for the short-term relief of severe anxiety but long term use should be avoided. Lorazepam has a 4.1.1 Hypnotics short action and as such may be more prone to NICE Guidance withdrawal symptoms. : Link to NICE guidance Insomnia - newer hypnotic drugs. TAG 77. Non-Benzodiazepines First choice: Propranolol tabs (G): 40mg [84tabs Benzodiazepines 2.37]. First choice: Temazepam tabs (G): 10mg [28tabs Dose: 40mg once daily increased to three times a 2.31], 20mg tabs [28tabs 1.65]. day if necessary. Dose: 10 to 20mg at bedtime, for a maximum of 28 Prescribing notes: Indicated for patients with days. predominantly somatic symptoms. Patients with Prescribing notes: Before a hypnotic is prescribed predominantly psychological symptoms may obtain the cause of the insomnia should be established no benefit. and, where possible, underlying factors should be : treated. Some patients have unrealistic sleep expectations, and others understate their alcohol 4.2.1 Antipsychotic Drugs consumption which is often the cause of the Link to NICE guidance Schizophrenia - Clinical Guide insomnia. Chronic insomnia is rarely benefited and is more often due to mild dependence caused by Typicals injudicious prescribing. Temazepam is short acting Phenothiazines and has little or no hangover effect. Withdrawal Chlorpromazine tabs (G): 25mg [84tabs 4.44], phenomena, however, are more common with 50mg [84tabs 4.68], 100mg [84tabs 4.65]. short-acting benzodiazepines. Dose: 25 to 100mg three times a day. : Prescribing notes: 10mg tablets no longer Non-Benzodiazepines manufactured. First choice: Zopiclone tabs (G): 3.75mg [28tabs : 1.51], 7.5mg [28tabs 1.51]. Dose: 7.5mg at bedtime, for a maximum of 28 Promazine tabs (G): 25mg [84tabs 10.40]. days. Dose: Prescribing notes: Before a hypnotic is prescribed Prescribing notes: the cause of the insomnia should be established : and, where possible, underlying factors should be treated. Some patients have unrealistic sleep Trifluoperazine tabs (G): 1mg [84tabs 6.43], expectations, and others understate their alcohol 5mg [84tabs 4.40]. consumption which is often the cause of the Dose: initially 5mg twice a day then increase insomnia. Chronic insomnia is rarely benefited and according to response, age and body-weight. is more often due to mild dependence caused by Prescribing notes: injudicious prescribing. Zopiclone is short acting : and has little or no hangover effect. Zopiclone is Butyrophenones not licensed for long-term use as there is evidence Haloperidol (G): 500micrograms [84caps 3.30], of dependence in a small number of patients. 1.5mg [84tabs 3.78], 5mg [84tabs 6.15], 10mg : [84tabs 20.94], 20mg [84tabs 49.44]. Dose: initially 1.5 to 3mg two or three times a day; 4.1.2 Anxiolytics 3 to 5mg two or three times a day in severely Link to NICE guidance Generalised anxiety disorder andaffected patients. adults panic disorder in Prescribing notes: Clinical Guideline No.113 : Benzodiazepines Thioxanthenes First choice: Diazepam tabs (G): 2mg [84tabs Flupentixol tabs: 3mg [84tabs 5.23]. 2.13], 5mg [84tabs 2.16], 10mg [84tabs 2.31]. Dose: 3 to 9mg twice daily (in psychosis). Dose: 2 to 10mg three times a day. Prescribing notes: Lower dose tabs (0.5mg & Prescribing notes: Benzodiazepines are indicated 1mg) used in depression). for the short-term relief of severe anxiety but long : term use should be avoided. Diazepam has a sustained action. Zuclopenthixol tabs: 2mg [84 tabs 2.64], 10mg : [84 tabs 4.74], 25mg [84 tabs 6.06]. Dose: initially 20 to 30mg daily in divided doses. Second choice: Lorazepam tabs (G): 1mg

Prescribing notes: : Substituted Benzamides First choice: Sulpiride tabs (G): 200mg [84tabs 20.02], 400mg [84tabs 29.29]. Dose: 200 to 400mg twice a day (in predominantly negative symptoms); may be increase to a maximum of 2.4g in mainly positive symptoms. Prescribing notes: More cost effective to prescribe 400mg dose as 2 x 200mg. : Atypicals Link to NICE guidance

days. Prescribing notes: Deep IM injection into the gluteal muscle. Also available as pre-loaded syringes. : Haloperidol Decanoate: 50mg/ml [amp 3.81], 100mg/ml [amp 5.05]. Dose: 50 to 300mg every four weeks. Prescribing notes: Deep IM injection into the gluteal muscle. : 100mg/2ml [amp 26.65]. Dose: 50 to 200mg every four weeks. Prescribing notes: Deep IM injection into the gluteal muscle. : Zuclopenthixol Decanoate: 200mg/ml [amp 1.99], 500mg/ml [amp 3.64]. Dose: 200 to 600mg repeated every 7 to 28 days. Prescribing notes: Deep IM injection into the gluteal muscle. : 4.2.3 Antimanic Drugs Link to NICE guidance

Schizophrenia - Clinical Guideline No. 82 Pipothiazine Palmitate: 50mg/ml [amp 16.29],

Risperidone tabs (G): 500micrograms [60tabs 2.40], 1mg [60tabs 1.38], 2mg [60tabs 1.74], 3mg [60tabs 2.13]; 4mg [60tabs 2.31]. Dose: 2 to 6mg in one or two divided doses. Prescribing notes: Generic products now available. 6mg tablets have been removed from formulary on cost-effectiveness grounds. : Olanzapine tabs: 2.5mg [28tabs 21.85], 5mg [28tabs 43.70], 7.5mg [28tabs 65.55], 10mg [28tabs 87.40], 15mg [28tabs 119.18]; 20mg [28tabs 158.90]. Dose: 5 to 20mg once daily. Prescribing notes: Generic products now available. : Quetiapine tabs: 25mg [60tabs 33.83], 100mg [60tabs 113.10], 150mg [60tabs 113.10], 200mg [60tabs 113.10], 300mg [60tabs 170.00]. Dose: maintenance 300mg to 450mg daily in two divided doses (max 750mg daily). Prescribing notes: : Aripirazole tabs: 5mg [28tabs 95.74], 10mg [28tabs 95.74], 15mg [28tabs 95.74], 30mg [28tabs 191.47]. Dose: 10 to 15mg once daily; maximum 30mg daily. Prescribing notes: : 4.2.2 Antipsychotic Depot Injections Flupentixol Decanoate: 20mg/1ml [amp 1.27], 40mg/2ml [amp 2.49], 50mg/0.5ml [amp 1.53], 100mg/1ml [amp 1.84], 200mg/1ml [amp 3.01]. Dose: 50 to 300mg every two weeks (max 400mg weekly). Prescribing notes: Deep IM injection into the gluteal muscle. : Fluphenazine Decanoate: 12.5mg/0.5ml [amp 1.30], 25mg/1ml [amp 2.26], 50mg/0.5ml [amp 4.47], 50mg/2ml [amp 4.44], 100mg/1ml [amp 8.79]. Dose: 12.5 to 100mg repeated every 14 to 35

Bipolar Disorder Clinical Guide

First choice: Lithium Carbonate SR tabs (Priadel): 200mg [56tabs 1.29], 400mg [56tabs 1.88]. Dose: 200 to 1200mg daily in one or two divided doses, adjusted according to serum levels. Prescribing notes: Lithium preparations should be prescribed by brand name. Lithium levels should be monitored after 4 to 7 days of starting lithium therapy or after a change in dose, then every week until dosage has remained constant for 4 weeks and every 3 months thereafter. For once daily dosage, serum lithium concentrations should fall within the range 0.7 to 1.0 mmol/litre on samples taken 12 hours after last dose, and 0.5 to 0.8 mmol/litre on samples taken 24 hours after last dose. For twice daily dosage, serum lithium concentrations should fall within the range 0.5 to 0.8 mmol/litre on samples taken 12 hours after last dose. Thyroid and kidney function should be monitored before starting treatment and yearly thereafter. Lithium is subject to a large number of drug interactions (see BNF). : Second choice: Valproate semisodium tabs (Depakote): 250mg [90tabs 12.17], 500mg [90tabs 24.29]. Dose: initially 750mg daily in 2 to 3 divided doses, increased according to response, usual dose 1 to 2 g daily.

Prescribing notes: : 4.3 Antidepressant Drugs Link to NICE guidance

10.92]. Dose: Initially 5mg once or twice a day, increased if necessary at weekly intervals by 5 to 10mg daily to a maximum of 60mg daily in divided doses. Depression in adults Clinical Guideline No.90response after 1 month, also Discontinue if no suspend periodically to assess childs condition Depression in children and young people Clinical Guideline No.28 (usually finally discontinue during or after puberty). Prescribing notes: Not recommended for children Obsessive-compulsive disorder - Clinical Guideline No.31 under the age of 6 years. : Link to NICE guidance CSM Statement on the Safety of SSRIs

Attention deficit hyperactivity d

4.3 1 Tricyclic Antidepressants First choice: Lofepramine tabs (G): 70mg [56tabs 11.55]. Dose: 140 to 210mg daily in divided doses. Prescribing notes: Less likely to cause side effects than other TCAs. Links: Antidepressant Guideline: :

Attention deficit hyperactivity d Clinical Guideline No. 72. 4.5 Anti-Obesity Drugs 4.5.1Drugs acting on GI tract Links to NICE guidance

Obesity. Clinical Guideline N

First Choice: Orlistat caps: 120mg [84caps 31.63]. Dose: 120mg taken immediately before, during or up to one hour after each main meal (maximum 4.3.3 SSRIs 360mg daily). First choice: Fluoxetine caps (G): 20mg [30caps Prescribing notes: Only to be prescribed in 90p]. accordance with the NICE guideline. If a meal is Dose: 20mg once daily. missed or contains no fat the dose of orlistat should Prescribing notes: be omitted. OTC pack available Alli. Links: Antidepressant Guideline: : 4.6 Drugs Used in Nausea and Vertigo Antihistamines First Choice: Cyclizine tabs: 50mg [84tabs Alternative choice: Citalopram tabs (G): 10mg 6.83]. [28tabs 1.47], 20mg [28tabs 1.85], 40mg [28tabs Dose: 50mg up to three times a day. 1.83]. Prescribing notes: First choice in pregnancy. Dose: 20mg once daily increasing to a maximum of : 40mg daily (max 20mg in elderly). Phenothiazines Prescribing notes: First Choice: Prochlorperazine tabs (G): 5mg Links: Antidepressant Guideline: : [84 tabs 1.74]; 3mg buccal tablets [84 tabs 9.90]. Dose: prevention 5 to 10mg two or three times a day; buccal Citalopram See also New Advice for the Safer Prescribing ofone or two tablets twice daily. Prescribing notes: Second choice in pregnancy. : Alternative choice: Sertraline tabs (G): 50mg Dopamine Antagonists [28tabs 6.60], 100mg [28tabs 13.91]. First Choice: Metoclopramide tabs (G): 10mg Dose: 50mg once daily increasing to a maximum of [84tabs 2.73]. 200mg daily. Dose: 10mg three times a day. Prescribing notes: Patent expiry due Oct 2005. Prescribing notes: Third Choice in pregnancy. Links: Antidepressant Guideline: : Avoid in patients under 20 years old especially females. 4.3.4 Third Line Antidepressants : Mirtazapine (G): 15mg [28tabs 3.08]; 30mg [28tabs 1.77]; 45mg [28tabs 5.49]. Second Choice: Domperidone tabs (G): 10mg Dose: 15 to 45mg at night. [84tabs 1.50]. Prescribing notes: Dose: 10 to 20mg every four to eight hours. Prescribing notes: Anti-nauseant of choice for Links: Antidepressant Guideline: : patients with Parkinsons Disease. OTC. : Travel Sickness 4.4 CNS Stimulants First Choice: Cinnarizine tabs (G): 15mg [10tabs Methylphenindate tabs (G) (CD): 5mg [30tabs 58p]. 3.03], 10mg [30tabs 6.46], 20mg [30tabs

Dose: 30mg two hours before travel then 15mg every eight hours during journey. Prescribing notes: OTC. : Menieres Disease First Choice: Betahistine tabs (G): 8mg [84tabs 1.78], 16mg [84tabs 1.94]. Dose: 8 to 16mg three times a day. Prescribing notes: : 4.7 Analgesics 4.7.1 Non-Opioid Analgesics First Choice: Paracetamol (G): 500mg tabs [224tabs 2.64], 500mg soluble tabs [224tabs 13.81]. Dose: One to two tabs every four to six hours when necessary (max 4g daily). Prescribing notes: Soluble paracetamol tabs are approximately five times more expensive than standard paracetamol tabs. Soluble paracetamol tabs contain 425mg of sodium per tablet. OTC. : Paracetamol 120mg/5ml sugar free paediatric solution [200ml 1.12]. Dose: 3 to 6 months, 2.5ml four times a day 6 to 24 months, 5ml four times a day 2 to 4 years, 7.5ml four times a day 4 to 6 years, 10ml four times a day. Paracetamol 250mg/5ml sugar free suspension [200ml 1.26]. Dose: 6 to 8 years, 5ml four times a day 8 to 10 years, 7.5ml four times a day 10 to 12 years, 10ml four times a day. Second Choice: Aspirin (G): tabs 300mg [224tabs 2.17], dispersible tabs 300mg [224tabs 6.07]. Dose: One to three tabs every four to six hours when necessary (max 4g daily). Prescribing notes: Dispersible aspirin tabs are approximately six times more expensive than standard aspirin tabs. OTC. : 4.7.1.1 Compound Analgesics Co-codamol 8/500 (G): tabs [224tabs 3.11]. Dose: One to two tabs every four to six hours when necessary (max 8 tabs daily) daily). Prescribing notes: OTC. BNF denotes preparation that is considered to be less suitable for prescribing : Co-codamol 30/500 (G): tabs [224tabs 6.76]. Dose: One to two tabs every four to six hours when necessary (max 8 tabs daily) daily). Prescribing notes: Co-codamol 30/500 tablets more cost effective than capsules. : Co-dydramol 10/500 tabs (G): [224tabs 3.34]. Dose: One to two tabs every four to six hours when

necessary (max 8 tabs daily) daily). Prescribing notes: BNF denotes preparation that is considered to be less suitable for prescribing. : 4.7.2 Opioid Analgesics Non-Controlled Drugs First Choice: Dihydrocodeine tabs (G): 30mg [224tabs 5.31]. Dose: 30mgevery four to six hours when necessary (max 240mg daily). Prescribing notes: Doubling the dose to 60mg may provide some additional pain relief but this may be at the cost of more nausea and vomiting. : Second Choice: Codeine Phosphate tabs (G): 15mg [224tabs 6.96], 30mg [224tabs 8.16], 60mg [112tabs 12.96]. Dose: 30 to 60mg every four hours when necessary (max 240mg daily). Prescribing notes: Codeine is effective for relief of mild to moderate pain relief but is too constipating for long-term use. : Alternative choice for patients intolerant, or unresponsive, to codeine: Tramadol capsules (G): 50mg [224 caps 3.63]. Dose: 50-100mg, not more frequently than every four hours. Prescribing notes: Daily dose greater than 400mg not usually required. : Strong Opiates Oral Preparations (tablets) First Choice: Morphine Sulphate MR tabs (MST) (CD): 5mg [60tabs 3.29], 10mg [60tabs 5.16], 15mg [60tabs 9.61], 30mg [60tabs 12.41], 60mg [60tabs 24.22], 100mg [60tabs 38.34], 200mg [60tabs 81.34]. Dose: initially 10 to 30mg twice daily, increased to 60mg twice daily then by further increments of 25 to 50% if needed. Prescribing notes: Patients should not be switched between brands without retitration, although the evidence suggests that the release characteristics of MST and Morphgesic are very similar. : Alternative Choice: Morphine Sulphate MR tabs (Morphgesic) (CD): 10mg [60tabs 3.85], 30mg [60tabs 9.24], 60mg [60tabs 18.04], 100mg [60tabs 28.54]. Dose: initially 10 to 30mg twice daily, increased to 60mg twice daily then by further increments of 25 to 50% if needed. Prescribing notes: Patients should not be switched between brands without retitration, although the evidence suggests that the release characteristics of MST and Morphgesic are very similar.

: Oral Preparations (liquids) First Choice: Morphine Sulphate Solution: 10mg in 5ml [100ml 1.78, 300ml 4.95, 500ml 7.47], 20mg/ml (CD) [30ml 4.98, 120ml 18.59]. Dose: Prescribing notes: : Parenteral Preparations First Choice: Diamorphine injection (G) (CD): 5mg [amp 2.70], 10mg [amp 3.51], 30mg [amp 3.75], 100mg [amp 9.82], 500mg [amp 43.34]. Dose: Prescribing notes: Parenteral diamorphine is approximately three times a strong as oral morphine. : Transdermal Preparations First Choice: Fentanyl Patches (Durogesic DTrans) (CD): 12micrograms/hr [patch 2.52], 25micrograms/hr [patch 3.60], 50micrograms/hr [patch 6.73], 75micrograms/hr [patch 9.40], 100micrograms/hr [patch 11.57]. Dose: 25micrograms/hr to 300micrograms/hr. Patch should be changed once every 72 hours. Prescribing notes: Prescribe by trade name not generically. Prescribing notes: Durogesic Patch 25 micrograms/hr 37 micrograms/hr 50 micrograms/hr 62 micrograms/hr

First Choice: Amitriptyline tabs (G): 10mg [56tabs 1.46], 25mg [56tabs 1.48], 50mg [56tabs 1.62]. Dose: Initially 10 to 25mg at night, increased gradually to 75mg at night. Prescribing notes: Unlicensed use. : Second Choice: Gabapentin (G): Caps 100mg [84caps 4.71], 300mg [84caps 7.03], 400mg [84caps 5.70]; Tabs 600mg [84tabs 11.58]; 800mg [84tabs 13.69]. Dose: 300mg on day 1, 300mg twice daily on day 2, 300mg three times a day on day 3. Then increase according to response in steps of 300mg daily to a maximum of 1.8g a day. Prescribing notes: : 4.7.4 Antimigraine Drugs Treatment Paracetamol soluble tabs (G): 500mg [60tabs 3.70]. Dose: Three tablets stat then two tabs every six hours if needed. Prescribing notes: OTC. Domperidone 10mg tabs can be co-prescribed for nausea and gastric stasis. :

PLUS Oral Morphine Ibuprofen tabs (G): 200mg [84tabs 1.55], 400mg <90 mg/day [84tabs 1.70]. Dose: 800mg stat then 400mg three times a day if 90 to 134 mg/day needed. Prescribing notes: OTC (200mg). 135 to 189 mg/day :

190 to 224 mg/day Prophylaxis First choice: Propranolol tabs (G): 40mg [56 75 micrograms/hr 225 to 314 mg/day tabs 1.58]. Dose: Initially 40mg two or three times a day. 100 micrograms/hr 315 to 404 mg/day Prescribing notes: : 125 micrograms/hr 405 to 494 mg/day Second Choice: Amitriptyline tabs (G): 10mg 150 micrograms/hr 495 to 584 mg/day 1.46], 25mg [56tabs 1.48], 50mg [56tabs [56tabs 1.62]. Dose: 175 micrograms/hr 585 to 674 mg/day l0mg at night increasing by l0mg every fifth night up to the recommended dose (usually l00mg). Prescribing notes: 200 micrograms/hr 675 to 764 mg/day : Triptans 225 micrograms/hr 765 to 854 mg/day Oral First 250 micrograms/hr 855 to 944 mg/day Choice: Sumatriptan tabs (G): 50mg [6tabs 1.50] , 100mg [6tabs 2.07] : Dose: 50mg (some patients may require 100mg); 4.7.3 Neuropathic Pain dose may be repeated after at least 2 hours if migraine recurs; max Link to NICE guidance Neuropathatic pain pharmacological management. 300mg in 24 hours. Patient not responding to initial dose should not take Clinical Guideline No. 96 second dose for same attack. Prescribing notes: Following reports of chest pain and tightness (coronary vasoconstriction) CSM has

emphasised that sumatriptan should not be used in ischaemic heart disease or Prinzmetals angina, and that use with ergotamine should be avoided. : Second Choice: Almotriptan tabs: 12.5mg [3 tabs 9.07] Dose: 12.5mg as soon as possible after onset repeated after 2 hours if migraine recurs (patient not responding should not take second dose for same attack); max 25mg in 24 hours. Prescribing notes: : 4.8 Antiepileptics Links to NICE guidance

phenytoin tablets cost 120.00 compared to 1.34 for 56x100mg Epanutin capsules. Ataxia, nystagmus and slurred speech especially common in the elderly. Plasma concentration for optimal response 10 to 20mg/litre (40 to 80 micromols per litre). NB 90mg phenytoin suspension = 100mg phenytoin sodium caps. :

Traditional Drugs Carbamazepine tabs (Tegretol): 100mg [84tabs 2.07], 200mg [84tabs 3.83], 400mg [84tabs 7.53]. Dose: Initially 100 to 200mg once or twice daily increasing to 400mg three times a day (in some cases up to 2g daily maybe necessary) Prescribing notes: If being used as an antiepileptic then prescribe as Tegretol. Plasma concentration for optimal response 20 to 50 micromols per litre. Double vision can occur and there are rare reports of leukopenia. Carbamazepine is also indicated for trigeminal neuralgia but avoid chronic use here. Plasma concentrations for optimum response 4 to 12 mg/litre (20 to 50 micromol/litre). NB 250mg rectal = 200mg oral. :

Sodium Valproate tabs (Epilim): 100mg [84tabs 4.70], 200mg [84tabs 6.47], 500mg [84tabs 16.17] Dose: 200mg three times a day, increasing to a max of 2.5g daily. Prescribing notes: If being used as an antiEpilepsy (adults) - newer drugs. TAGthen prescribe as Epilim. Plasma epileptic 76. valproate levels are not a good indicator of efficacy. Epilepsy (children) - newer drugs. positive urine test for ketones possible with False TAG 79. valproate. Epilepsy - Clinical Guideline No. 20 : Newer Agents Links to NICE guidance

Epilepsy (adults) - newer d

Epilepsy (children) - newer

Epilepsy - Clinical Guidelin Gabapentin (G): Caps 100mg [84caps 4.71], 300mg [84caps 7.03], 400mg [84caps 5.70]; Tabs 600mg [84tabs 11.58]; 800mg [84tabs 13.69]. Dose: 300mg on day 1, 300mg twice daily on day 2, 300mg three times a day on day 3. Then increase according to response in steps of 300mg daily to a maximum of 2.4g a day. Prescribing notes:

Phenobarbital (Phenobarbitone) tabs (G): 15mg [56tabs 3.40], 30mg [56tabs 1.70], 60mg [56tabs 1.42]. Dose: 60 to 180mg at night. Prescribing notes: Plasma concentration for optimal response 60 to 180 micromols per litre. Also available as Phenobarbitone Sodium Solution 15mg/5ml (NB Phenobarbitone Elixir BP contains 38% alcohol and is unsuitable for children). Plasma concentrations for optimum response 15 to 40 mg/litre (60 to 180 micromol/litre) : Phenytoin sodium caps (Epanutin): 25mg [56caps 1.32], 50mg [56caps 1.34], 100mg [56caps 1.89], 300mg [56caps 5.66]. Dose: 150 to 300mg daily at night or in two divided doses, max 600mg daily. Prescribing notes: Brand prescribing of phenytoin as Epanutin capsules will help ensure consistent bioavailability. Prescribing as Epanutin capsule is also more cost effective. 56x100mg generic

Lamotrigine: Tabs 25mg [56tabs 1.77], 50mg [56tabs 2.35], 100mg [56tabs 3.44], 200mg [56tabs 5.44]; Dispersible tabs 2mg [56tabs 19.51], 5mg [56tabs 3.40], 25mg [56tabs 2.41], 100mg [56tabs 4.43]. Dose: Monotherapy, initially 25mg daily for 14 days, then 50mg daily for 14 days, then increase by 50 to 100mg daily every 7 to 14 days. Usual maintenance 100 to 200mg daily in one or two divided doses but up to 500mg daily has been required. For adjunctive therapy see BNF. Prescribing notes: Dispersible tabs can be chewed. Levetiracetam tabs: 250mg [60tabs 26.86], 500mg [60tabs 47.31], 750mg [60tabs 82.10], 1000mg [60tabs 93.09]. Dose: 500mg twice a day, adjusted in increments of 1g every 2 to 4 weeks; max 3g daily in two divided doses. Prescribing notes:

RECTAL Oxcarbazepine tabs: 150mg [56tabs 16.57], 300mg [56tabs 25.69]; 600mg [56tabs 51.34]. Dose: Initially 300mg twice a day increased according to response in steps of up to 600mg daily at weekly intervals; usual dose range 0.6 to 2.4g daily in divided doses. Prescribing notes: In adjunctive therapy patients may require dose reduction of concomitant antiepileptics when using high doses of oxcarbazepine. First Choice: Diazepam Rectal tubes: 5mg [tube 1.18], 10mg [tube 1.60]. Dose: Adult and child over 10kg, 500micrograms/kg. Prescribing notes: Absorption from suppository too slow therefore rectal solution must be used. Febrile convulsions if brief need only tepid sponging and paracetamol. Those lasting more than 15mins should be treated with diazepam rectal solution. Intermittent prophylaxis with diazepam rectal solution at onset of fever may be considered in a small proportion of children. INTRAVENOUS First Choice: Lorazepam injection: 4mg/ml [amp 35p]. Dose: by slow intravenous injection 100 micrograms per kg (max 4mg) as a single dose (repeated once if initial dose ineffective). Dilute with an equal volume of sodium chloride 0.9% or water for injection; give slowly into a large vein at a rate not exceeding 50 micrograms per kg over 3 to 5 minutes. In neonates dilute intravenous injection to 100 micrograms per ml. Prescribing notes: Currently unavailable until May 2013. 4.9 Parkinsons Disease Levodopa First Choice: Co-beneldopa: Caps 62.5mg [84caps 4.17], 125mg [84caps 5.80], 250mg [84caps 9.90]; Dispersible Tabs 62.5mg [84tabs 4.96], 125mg [84tabs 8.78]; SR Caps 125mg [84caps 10.73]. Dose: Usual maintenance dose 400 to 800mg (of levodopa) daily in divided doses. Prescribing notes:

Tiagabine tabs: 5mg [56tabs 22.92], 10mg [56tabs 45.84]; 15mg [56tabs 68.76]. Dose: Adjunctive therapy, with enzyme inducing drugs, 5mg twice daily for 1 week , the increased at weekly intervals in steps of 5 to 10mg daily ; usual maintenance dose 30 to 45mg daily (doses above 30mg given in 3 divided doses). Adjunctive therapy, with non-enzyme inducing drugs initial maintenance should be 15 to 30mg daily. Prescribing notes: Topiramate tabs: 25mg [60tabs 3.60], 50mg [60tabs 2.94], 100mg [60tabs 4.11], 200mg [60tabs 7.10]. Dose: Monotherapy, initially 25mg daily at night for 1 week, then increased in steps of 25 to 50mg daily at intervals of 1 to 2 weeks taken in 2 divided doses; usual dose 100mg daily in 2 divided doses; max 400mg daily. Adjunctive therapy, 25mg daily for 1 week, then increased in steps of 25 to 50mg daily at intervals of 1 to 2 weeks taken in 2 divided doses; usual dose 200 to 400mg daily in 2 divided doses; max 800mg daily. Prescribing notes: Tabs more cost effective than capsules. If patient cannot tolerate regimen recommended above then smaller steps or longer interval between steps may be used. Vigabatrin tabs: 500mg [56tabs 17.27]. Dose: with current antiepileptic therapy, initially 1g daily in a single or 2 divided doses then increased according to response in steps of 500mg at weekly intervals; usual range 2 to 3g daily; max 3g daily. Prescribing notes: VISUAL FIELD DEFECTS. The CSM has advised that onset of symptoms varies from 1 month to several years after starting vigabatrin. In most cases visual field defects have persisted despite discontinuation. Manufacturer advises visual field testing before treatment and at 6-month intervals. Patients should be warned to report any new visual symptoms that develop and those with symptoms should be referred for an urgent ophthalmological opinion. Gradual withdrawal of vigabatrin should be considered. 4.8.2 Status Epilepticus

Second Choice: Co-carledopa: Tabs 62.5mg [84tabs 5.86], 110mg [84tabs 6.13], 125mg [84tabs 20.87], 275mg [84tabs 30.31]; SR Tabs 125mg [84tabs 16.24], 250mg [84tabs 16.24]. Dose: Usual maintenance dose 400 to 800mg (of levodopa) daily in divided doses. Prescribing notes: Dopamine Agonists (Oral) Ergot First Choice: Cabergoline tabs: 1mg [28tabs 80.99], 2mg [28tabs 97.58]. Dose: Initially 1mg daily, increased by increments of 0.5 to 1mg at 7 to 14 day intervals; usual range 2 to 3mg daily. Prescribing notes: Specialist initiation only.

Second Choice: Pergolide tabs (G):

50micrograms [84tabs 21.85], 250micrograms [84tabs 22.30], 1000micrograms [84tabs 79.80]. Dose: Building gradually to a maintenance dose of 2 to 2.5mg daily in divided doses. Prescribing notes: Specialist initiation only. Dopamine Agonists (Oral) Non-Ergot First Choice: Ropinirole tabs: 1mg [84tabs 11.39], 2mg [84tabs 19.83], 5mg [84tabs 49.74]. Dose: Building gradually to a maintenance dose of 3 to 9mg daily in divided doses. Prescribing notes: Dopamine Agonists (Parenteral) First Choice: Apomorphine injection: 20mg/2ml [amp 6.07], 50mg/5ml [amp 11.70]; Pen 30mg in 3ml [24.78 each]; prefilled syringe 50mg/10ml [14.62 each]. Dose: Max 100mg daily. Prescribing notes: Specialist initiation only. MAOB Inhibitors First Choice: Selegiline tabs (G): 5mg [60tabs 8.92], 10mg [30tabs 7.58]. Dose: 10mg daily in the morning or 5mg twice daily in the morning and midday. Prescribing notes: COMP Inhibitors First Choice: Entacapone tabs: 200mg [84tabs 48.26]. Dose: 200mg with each dose of Madopar or Sinemet, max 2g daily. Prescribing notes: Levodopa + COMP Inhibitor Combined First Choice: Stalevo tabs (levodopa/carbidopa/entacapone): 50mg/12.5mg/200mg [84 tabs 58.22]; 100mg/25mg/200mg [84tabs 58.22]; 150mg/37.5mg/200mg [84tabs 58.22]; 200mg/50mg/200mg [84tabs 58.22]. Dose: as per expert advice. Prescribing notes: Use to improve concordance in patients taking large numbers of tablets or if there is a doubt that entacapone is being taken within 20 minutes of levodopa/dopa-decarboxylase inhibitor. Other strengths have now been added to the above range see BNF. NB 2 x 50mg Stalevo tabs are NOT equivalent to 1 x 100mg tab. 4.9.2 Antimuscarinic Drugs Procyclidine tabs (G): 5mg [84tabs 6.33]. Dose: 2.5mg three times a day increase gradually to a max of 30mg daily. Prescribing notes:

Orphenadine tabs (G): 50mg [84tabs 61.67]. Dose: 50mg three times a day increase gradually to a max of 400mg daily. Prescribing notes:

4.9.3 Riluzole Link to NICE guidance

Motor Neurone disease - riluzo

http://www.northdevonhealth.nhs.uk/ndht/departme nts/clinical_support/pharmacy/FORMULARIES/PC T - Effective Practice Statements.htm 4.10 Drugs used in substance dependence 4 10.1 Nicotine Replacement Therapy Link to NICE Guidance

http://www.northdevonhealth.nhs.uk/ndht/departments/clin - ch4 main.htm

http://www.northdevonhealth.nhs.uk/ndht/departments/clin - ch4 main.htm

http://www.northdevonhealth.nhs.uk/ndht/departments/clin - ch4 main.htm

Patches Nicorette patches: 5mg [7patches 9.07], 10mg [7patches 9.07], 15mg [7patches 9.07]. Dose: Apply on waking to dry, non-hairy skin on hip, chest or upper arm, removing after approx 16 hours usually when retiring to bed, site next patch on different area (avoid using same site on consecutive days). Initially 15mg patch for 16 hours daily for 8 weeks, then if abstinence achieved, 10mg patch for 16 hours daily for 2 weeks then 5mg patch for 16 hours daily for 2 weeks. Review treatment if abstinence is not achieved in 3 months.

Prescribing notes: OTC. Links: Nicotinell patches: 10 [7patches 9.11], 20 [7patches 9.40], 30 [7patches 9.97]. Dose: Apply to dry, non-hairy skin on trunk or upper arm removing after 24 hours and siting replacement patch on a different area (avoid using the same area for several days). Individuals smoking more than 20 cigarettes daily, initially one '30' patch daily, withdraw gradually, reducing dose every three to four weeks. Review treatment if abstinence is not achieved in 3 months. Individuals smoking 20 cigarettes daily or fewer, initially one '20' patch daily. Prescribing notes: A 10 patch releases approximately 7mg of nicotine in 24 hours, a 20 14mg in 24 hours and a 30 21mg in 24hours. OTC. Links: NiQuitin CQ patches: 7mg [7patches 9.97], 14mg [7patches 9.97], 21mg [7patches 9.97]. Dose: Apply on waking to dry, non-hairy skin site, removing after 24 hours and siting replacement patch on different area (avoid using same area for 7 days). Individuals smoking 10 or more cigarettes daily, initially 21mg patch daily for 6 weeks, then 14mg patch daily for 2 weeks, then 7mg patch daily for 2 weeks. Review treatment if abstinence not achieved in 10 weeks. Individuals smoking less than 10 cigarettes daily, initially 14mg patch daily for 6 weeks, then 7mg patch daily for 2 weeks. Prescribing notes: Patients using the 21mg patch who experience excessive side-effects, which do not resolve within a few days, should change to 14mg patch for the remainder of the initial 6 weeks before switching to the 7mg patch for the final 2 weeks. OTC. Links: Gum Nicorette gum: 2mg [30pieces 3.25, 105pieces 8.89], 4mg [30pieces 3.99, 105pieces 10.83]. Dose: Individuals smoking 20 cigarettes or fewer, initially one 2mg chewed slowly for approx 30 mins when urge to smoke occurs. Individuals smoking more than 20 cigarettes or needing more than 15 pieces of 2mg gum a day may need the 4mg strength. Maximum 15 x 4mg daily. Withdraw gradually after 3 months. Prescribing notes: OTC. Links: Nicotinell gum: 2mg [24pieces 2.67, 96pieces 8.26], 4mg [24pieces 3.30, 96pieces 10.26]. Dose: Initially one 2mg piece chewed for approx 30 mins when urge to smoke occurs. Maximum 60mg daily. Withdraw gradually after 3 months. Prescribing notes: OTC. Links:

Niquitin CQ gum: 2mg [12pieces 1.71, 24pieces 3.25, 96pieces 9.97], 4mg [12pieces 1.71, 24pieces 3.25, 96pieces 9.97]. Dose: Initially one piece chewed slowly for approx 30 mins when urge to smoke occurs. Maximum 15 pieces daily. Withdraw gradually after 3 months. Prescribing notes: OTC. Links: Lozenges and Microtabs Nicotinell lozenge: 1mg [12 loz 1.71, 36 loz 4.27, 96 loz 9.12], 2mg [12 loz 1.99, 36 loz 4.95, 96 loz 10.60]. Dose: Initially one lozenge every one to two hours when urge to smoke occurs. Maximum 30mg daily. Withdraw gradually after 3 months. Maximum period of treatment should not usually exceed 6 months. Prescribing notes: OTC. Links: Niquitin CQ lozenge: 2mg [36 loz 5.12, 72 loz 9.97], 4mg [36 loz 5.12, 72 loz 9.97]. Dose: Initially one lozenge every one to two hours when urge to smoke occurs (maximum 15 lozenges daily) for 6 weeks, then one lozenge every two to four hours for 3 weeks, then one lozenge every four to eight hours for 3 weeks, withdraw gradually after 3 months. Maximum period of treatment should not exceed 6 months. Prescribing notes: OTC. Links: Nicorette sublingual microtab: 2mg [30tab starter pack 3.99, 105tab refill pack 11.12]. Dose: Individuals smoking 20 cigarettes or less daily, sublingually 2mg each hour, for patients who fail to stop smoking or have significant withdrawal symptoms, consider increasing to 4mg each hour. Individuals smoking more than 20 cigarettes, 4mg every hour. Maximum 80mg daily. Treatment should continue for at least 3 months followed by a gradual reduction in dosage. Maximum period of treatment should not exceed 6 months. Prescribing notes: OTC. Links: Inhalator and Nasal Spray Nicorette inhalator: 10mg [6 cartridges starter pack 3.99, 42 cartridges refill pack 12.81]. Dose: inhale when urge to smoke occurs; initially use between 6 and 12 cartridges daily for up to 8 weeks, then reduce the number of cartridges used by half over next 2 weeks and stop altogether at end of further 2 weeks; review treatment if abstinence not achieved in 3 months. Prescribing notes: OTC. Links: Nicorette nasal spray: 0.5mg/metered spray [200 sprays 12.26]. Dose: 1 spray into each nostril as required to a maximum of twice an hour for 16 hours daily (max

64 sprays daily) for 8 weeks, then reduce gradually over next 4 weeks (reduce by half at end of first 2 weeks), stop altogether at end of next two weeks. Maximum treatment length 3 months. Prescribing notes: OTC. Links: Bupropion Bupropion tablets: 150mg [60tabs 41.76]. Dose: initially 150mg daily for 6 days then 150mg twice daily; maximum period of treatment 7 to 9 weeks; discontinued if abstinence not achieved at 7 weeks. Consider 150mg daily throughout treatment in patients with risk factors for seizures (see CSM Advice). Prescribing notes: Adjunct to smoking cessation in combination with motivational support.

Galantamine: 8mg tabs [56tabs 68.32], 12mg tabs [56tabs 84.00]; 8mg MR caps.[28caps 51.88]; 16mg MR caps [28caps 64.90]; 24mg MR caps.[28caps 79.80]. Dose: Tablets: initially 4mg twice a day for 4 weeks, increased to 8mg twice a day for 4 weeks, maintenance 8 to 12mg twice a day; MR caps initially 8mg once daily for 4 weeks, increased to 16mg once daily for 4 weks, maintenance 16 to 24mg daily. Prescribing notes: : Rivastigmine caps: 1.5mg [56caps 66.50], 3mg [56caps 66.50], 4.5mg [56caps 66.50], 6mg [56caps 66.50]. Dose: 1.5mg twice a day increased in steps of Link to NICE Guidance Smoking cessation bupropion1.5mg twice daily at intervals of at least two weeks and nicotine replacement therapy TAG 39 according to response and tolerance. Usual range Varenicline 3 to 6mg twice daily. Varenicline tablets: 500micrograms [56tabs Prescribing notes: 54.60]; 1mg [56tabs 54.60]. : Dose: Start 1 to 2 weeks before target stop date. Initially 500micrograms once daily for 3 days, increased to 500micrograms twice daily for 4 days, INFECTIONS then 1mg twice daily for 11 weeks. Reduce to 500micrograms twice daily if not tolerated. 5.1 Antibiotics Prescribing notes: Treatment can be repeated in abstinent individuals to reduce risk of relapse. Link to NORTH DEVON JOINT FORMULARY ANT https://nww.devonpctinfo.nhs.uk/EPC/ PRIMARY CARE 4.10.2 Alcohol Dependence 4.10.3 Opiate Dependence 5.2 Antifungal Drugs Link to NICE guidance Drug misuse oral gel: 2% [15g 2.85, 80g 4.38]. Miconazole methadone & buprenorphine TAG 114 four times a day in the Dose: Adults 5 - 10ml mouth after food, retain near lesions before http://www.nice.org.uk/pdf/NiceNRT39GUIDANCE.pdf Drug misuse naltrexone TAG 115 swallowing. Neonates (oral fungal infections only) 1ml twice http://www.nice.org.uk/pdf/NiceNRT39GUIDANCE.pdf Drug misuse: psychosocial interventions. daily smeared around the mouth after feeds; Clinical guideline No. 2.5ml twice daily in the mouth 1 month to 2 years 51. after food, retain near lesions before swallowing; http://www.nice.org.uk/pdf/NiceNRT39GUIDANCE.pdf Drug misuse: opioid detoxification. mouth after food, 2 to 6 years 5ml twice daily in the Clinical guideline No. before swallowing; retain near lesions 52. 6 to 12 years 5ml four times a day in the mouth http://www.nice.org.uk/pdf/NiceNRT39GUIDANCE. after food, retain near lesions before swallowing. pdf Prescribing notes: Continue treatment until 4.11 Drugs for Dementia 48hours after lesions have resolved. Miconazole oral gel is not licensed for use in children under 4 Link to NICE guidance Dementia. months of age or during the first 5 6 months of life Clinical of an infant born pre-term. The doses quoted Guideline above for neonates are taken from the BNF forNo. 42. Children. : http://www.northdevonhealth.nhs.uk/ndht/departments/clinical_support/pharmacy/FORMULARIES/PCT Alzheimer's - ch4 NICE39 - NRT.htm disease. Nystatin oral suspension (G): 100,000 units/ml 111 TAG [30ml 19.32]. Dose: 1ml four times a day after food, usually for 7 Donepezil tabs: 5mg [28tabs 59.85], 10mg days (continue for 48 hours after lesions have [28tabs 83.89]. resolved). Dose: 5mg at night, increased if necessary after Prescribing notes: Immunosuppressed patients one month to 10mg daily. may require 500,000 units (5ml) four times a day. Prescribing notes: : :

when clearly indicated by NICE guidelines. Links: Vaginal fungal infections Oral therapy First choice: Fluconazole caps (G): 150mg [1cap 79p]. Dose: a single dose of 150mg. Prescribing notes: Avoid oral antifungals in pregnancy; topical therapy may be used. see also chapter 7.2.2 . OTC. Links: : Topical therapy First Choice: Clotrimazole (G): 1% cream [20g 1.24, 50g 3.19], 200mg pessaries [3pess 3.63], 500mg pessaries [1pess 2.78]; 10% vaginal cream [5g 5.86]. Dose: see BNF Prescribing notes: Both cream and pessaries can damage latex condoms and diaphragms. OTC. Links: : Second Choice: Miconazole: 2% intravaginal cream [78g 4.33], 1200mg vaginal capsule [1cap 2.94]. Dose: see BNF Prescribing notes: All the above products can damage latex condoms and diaphragms. see also chapter 7.2.2. Links: : 5.3 Antiviral Drugs Herpes Simplex and Zoster First Choice: Aciclovir (G): 200mg tabs [25tabs 3.70], 400mg tabs [25tabs 3.00], 800mg tabs [35tabs 8.46]; 200mg dispersible tabs [25tabs 2.06], 400mg dispersible tabs [25tabs 4.50], 800mg dispersible tabs [35tabs 9.84]. Dose: Herpes simplex, treatment 200mg five times a day for 5 days; 400mg five times a day if immunocompromised or if absorption impaired. Varicella and herpes zoster, treatment 800mg five times a day for 7 days. Prescribing notes: : Influenza Refer to the NICE guidance below. Should only be considered following advice from the Department of Health. Current advice should be sought concerning appropriate prophylaxis for various parts of the world. For treatment of malaria seek urgent specialist advice. 5.5 Anthelmintics Threadworms First Choice: Mebendazole (G): 100mg tabs [2tabs 45p], 100mg/5ml suspension [10ml 53p]. Dose: Adults and Child over 2 years, 100mg as a single dose repeat after 2 weeks if reinfection occurs. Prescribing notes: Only licensed above the age of 2 years but BNF for Children states that the dose for 6months onwards is as above. : Second Choice: Piperazine 4g with Senna 15.3mg (Pripsen): [2 sachets 1.98]. Dose: 3 months to 1 year one level 2.5ml spoonful as a single dose in the morning repeated after 14 days; 1 to 6 years one level 5ml spoonful as a single dose in the morning repeated after 14 days; above 6 years the contents of one sachet as a single dose in the morning repeated after 14 days Prescribing notes: OTC. : Zanamivir diskhaler: 5mg [pack 16.36]. Dose: by inhalation of powder, 10mg twice a day for 5 days. Prescribing notes: Should only be prescribed when clearly indicated by NICE guidelines, ie atrisk adults who present within 36 hours of the onset of an influenza like illness. Links: 5.4.1 Antimalarials

Amantadine, oseltamivir and zanamivir for the treatment of influenza No. 168 Oseltamivir, amantadine and zanamivir for the prophylaxis of influenza No. 158 Oseltamivir caps: 75mg [10caps 15.41]. Dose: Treatment, 75mg twice a day for 5 days starting within 2 days of onset of symptoms; Prevention, 75mg once daily starting within 2 days of exposure and continued for at least 7 days or up to six weeks during an epidemic. . Prescribing notes: Should only be prescribed

ENDOCRINOLOGY
6.1.1 Insulin Diabetes (types 1 & 2) - long acting insulin analogues. (TAG 53). Diabetes (type 1) - insulin pump therapy. (TAG 151). Diabetes (types 1 & 2) - patient education modules. (TAG 60). Diabetes (type 2) - glitazones. (TAG 63). Type 2 diabetes - footcare. Clinical guideline No.10. Type 1 diabetes - children and young people and adults. Clinical guideline No.15. Diabetes in Pregnancy. Clinical Guideline No.63. Diabetes Type 2 - Clinical Guideline No. 87 6.1.1.1 Short-acting insulins Actrapid insulin: 100 units/ml [10ml vial 7.48]. Humulin S insulin: 100 units/ml [10ml vial 15.68; 5 x 3ml cartridge 19.08]. Insulin aspart (NovoRapid): 100 units/ml [10ml vial 16.28; 5 x 3ml cartridge 28.31; 5 x 3ml preloaded pens 30.60]. Insulin lispro (Humalog): 100 units/ml [10ml vial 16.61; 5 x 3ml cartridge 28.31; 5 x 3ml preloaded pens 29.46]. 6.1.1.2 Intermediate and long-acting insulins Insulatard: 100 units/ml [10ml vial 7.48; 5 x 3ml cartridge 22.90; 5 x 3ml Innolet 20.40]. Humulin I: 100 units/ml [10ml vial 15.68; 5 x 3ml cartridge 19.08; 5 x 3ml preloaded Kwikpens 21.70]. Insulin glargine (Lantus): 100units/ml [10ml vial 30.68; 5 x 3ml cartridge 41.50; 5 x 3ml preloaded pens (Solostar) 41.50]. Please note the preloaded disposable pen Optiset replaced with Solostar preloaded disposable pen. Please re-usable pens Opiticlik and Optipen replaced with Clikstar re-usable pen. Biphasic Insulin Humulin M3: (30% soluble, 70% isophane) 100 units/ml [10ml vial 15.68; 5 x 3ml cartridge 19.08; 5 x 3ml preloaded Kwikpens 21.70]. Humalog Mix25: (25% insulin lispro, 75% insulin lispro protamine) 100units/ml [10ml vial 16.61; 5 x

3ml cartridge 29.46; 5 x 3ml preloaded pens 30.98]. Humalog Mix50: (50% insulin lispro, 50% insulin lispro protamine) 100units/ml [5 x 3ml cartridge 29.46; 5 x 3ml preloaded pens 30.98]. Novomix 30: (30% insulin aspart, 70% insulin aspart protamine) 100 units/ml [5 x 3ml cartridge 28.84; 5 x 3ml preloaded pens 30.98]. : 6.1.1.3 Hypodermic Equipment Needle Clipping (Chopping) Device: [137p each]. Sharpsguard: [1 litre 85p]. Sharpsafe: [1 litre 85p]. 6.1.2 Oral Antidiabetic Drugs Links to NICE guidance

Type 2 diabetes. Clinical G

6.1.2.1 Sulphonylureas Longer Duration of Action First Choice: Gliclazide tabs 80mg (G): [60 tabs 1.30]. Dose: Initially 40 to 80mg daily with breakfast, increased up to a maximum of 160mg as a single dose or 320mg daily in divided doses. Prescribing notes: Also available as MR tabs but avoid prescribing as different bioavailability may cause confusion. Oral hypoglycaemics should be used to augment the effects of diet and NOT to replace it. : Shorter Duration of Action First Choice: Tolbutamide tabs (G): 500mg [56tabs 4.42]. Dose: 500mg to 2g daily in divided doses. Prescribing notes: Large tablets may present swallowing difficulties. Oral hypoglycaemics should be used to augment the effects of diet and NOT to replace it. : 6.1.2.2 Biguanides First Choice: Metformin tabs (G): 500mg [84 tabs 1.25], 850mg [56 tabs 1.09]. Dose: 500mg daily with breakfast (week 1), 500mg twice daily with breakfast and evening meal (week 2), 500mg three times a day with breakfast, lunch and evening meal (week 3). Usual max 2g daily. Prescribing notes: Metformin may be preferred for initial treatment of severely obese patients as it does not cause weight gain. Usually used in combination when sulphonylurea alone is insufficient. Risk of lactic acidosis increases with age and in COPD. Metformin should be stopped 48 hours before elective use of IV Xray contrast media to avoid lactic acidosis. It should be restarted 48 hours after the procedure, or later if more time is needed for renal function to return to preinvestigation levels. Large tablets may present swallowing difficulties. Metformin MR: Clinical trial data for fewer gastrointestinal adverse events with Metformin MR is weak and metformin MR was substantially more

expensive than non-MR metformin. (SMC rejected use of MR formulation for this reason). Experience with non-XL metformin has shown that starting at a low dose and titrating according to an individual patients tolerance level resulted in the majority of patients being able to tolerate metformin. : 6.1.2.3 Other antidiabetic drugs Diabetes (type 2) - glitazones. TAG 63. Diabetes (type 2) Clinical Guideline No. 66 Pioglitazone tabs: 15mg [28tabs 25.19], 30mg [28tabs 35.00], 45mg [28tabs 38.56]. Dose: Initially 15 to 30mg once daily. Maximum 45mg daily. Prescribing notes: Should only be prescribed when clearly indicated by NICE guidelines, ie for patients who are inadequately controlled on a combination of metformin and a sulphonylurea or where there are contraindications or tolerability problems, in accordance with the NICE guideline. Glitazones tend to be more effective when prescribed with metformin than with a sulphonylurea. MRHA warning Rosiglitazone and Cardiovascular Risk 6.2.1 Thyroid Hormones First Choice: Levothyroxine (Thyroxine) tabs (G): 25mcg [28tabs 1.78], 50mcg [28tabs 97p], 100mcg [28tabs 92p]. Dose: Initially 50 to 100mcg daily before breakfast, adjusted in steps of 50mcg every three to four weeks until normal metabolism maintained (usually 100 to 200mcg daily). Prescribing notes: Because of long half life (7 days) full effects may not be seen for several weeks. Combination products of liothyronine (T3) and levothyroxine (T4), e.g Armathyroid, are not recommended. : 6.2.2 Antithyroid Drugs First Choice: Carbimazole tabs: 5mg [28tabs 1.08], 20mg [28tabs 3.20]. Dose: Maintenance dose, 5 to 15mg daily. Prescribing notes: CSM Warning (neutropenia and agranulocytosis). Doctors are reminded of the importance or recognising bone marrow suppression induced by carbimazole and the need to stop treatment promptly. 1. Patients should be asked to report symptoms and signs suggestive of infection, especially sore throat. 2. A white blood cell count should be performed if there is any clinical evidence of infection. 3. Carbimazole should be stopped promptly if there is clinical or laboratory evidence of neutropenia. Most patients become euthyroid in one to three

months. Lack of compliance is a significant cause of treatment failure. Carbimazole should be used in pregnancy only when propylthiouracil is not suitable. A blockingreplacement regimen of levothyroxine and carbimazole is NOT suitable during pregnancy. Propylthiouracil and carbimazole cross the placenta and appear in breast milk; both should be used at the lowest effective dose to control the hyperthyroid state. : Second Choice: Propylthiouracil tabs (G): 50mg [28tabs 20.67]. Dose: Maintenance dose, 50 to 150mg daily. Prescribing notes: Propylthiouracil should only be used in preference to carbimazole during pregnancy, for patients who are or might be breast feeding, or those who have had a reaction to carbimazole. Propylthiouracil and carbimazole cross the placenta and appear in breast milk; both should be used at the lowest effective dose to control the hyperthyroid state. : 6.3 Corticosteroids 6.3.1 Mineralocorticoid First Choice: Fludrocortisone tabs: 100mcg [28tabs 1.41]. Dose: 50 to 300mcg once daily. Prescribing notes: : 6.3.2 Glucocorticoid First Choice: Prednisolone tabs (G): 1mg [28tabs 91p], 5mg [28tabs 2.91], 25mg [28tabs 15.00], 2.5mg EC [28tabs 6.71], 5mg EC [28tabs 5.97], 5mg Soluble [28tabs 9.89]. Dose: Prescribing notes: Corticosteroid Withdrawal: Osteoporosis Prevention: :

Equivalent Strengths:

Second Choice: Dexamethasone tabs (G): 2mg [28tabs 3.43]. Dose: Prescribing notes: 500mcg tablets have been discontinued by the manufacturer. Replacement Therapy First Choice: Hydrocortisone tabs: 10mg [30tabs 43.56], 20mg [30tabs 46.06]. Dose: 10 to 30mg daily in divided doses. Prescribing notes: For the treatment of Addisons disease only 6.4.1.1 Oestrogens and HRT Oestrogen only Prescribing Note: Low strength versions of several HRT variants are available to facilitate

the tapering-off of doses when discontinuing treatment. They are not considered as formulary items because any use will only constitute a small percentage of overall HRT prescribing. First Choice: Elleste Solo tabs: 1mg [3x28tabs 5.04], 2mg [3x28tabs 5.34]. Dose: Prescribing notes: Synthetic source of oestrogens. Contains estradiol. Links: Second Choice: Premarin tabs: 625mcg [3x28tab 4.02], 1.25mcg [3x28tabs 3.58]. Dose: Prescribing notes: Animal source of oestrogens. Contains conjugated oestrogens. Links: Oestrogens with Progestogen Synthetic source of oestrogens First Choice: Elleste Duet tabs: 1mg/1mg [3x28tabs 9.17], 2mg/1mg [3x28tabs 9.72]. Dose: Prescribing notes: Contains estradiol & norethisterone. Links: Second Choice: Femoston tabs:1mg/10mg [3x28tabs 13.47], 2mg/10mg [3x28tabs 13.47]. Dose: Prescribing notes: Contains estradiol & dydrogesterone. Links: Animal source of oestrogens. Prempak C tabs: 625mcg/150mcg [3x28tab 6.25], 1.25mcg/150mcg [3x28tabs 7.40]. Dose: Prescribing notes: Contains conjugated oestrogens. & norgestrel. Links: Continuous Preparations Synthetic source of oestrogens. First Choice: Elleste Duet Conti tabs: 2mg/1mg [3x28tabs 16.95]. Dose: Prescribing notes: Contains estradiol & norethisterone. Links: Second Choice: Femoston-Conti tabs:1mg/5mg [3x28tabs 20.36]. Dose: Prescribing notes: Contains estradiol & dydrogesterone. Links: Animal source of oestrogens. Premique tabs: 625mcg/5mg [3x28tabs 10.61]. Dose: Prescribing notes: Contains conjugated oestrogens. & medroxyprogesterone. Links: 6.4.1.2 Progestogens

First Choice: Norethisterone tabs (G): 5mg [30tabs 1.81]. Dose: Prescribing notes: Although oral progestogens have been used widely for menorrhagia they are relatively ineffective compared with tranexamic acid or, particularly where dysmenorrhoea is also a factor, mefenamic acid. A Mirena coil may particularly useful for women also requiring contraception. : 6.4.2 Anti-androgens Finasteride tabs: 5mg [28tabs 1.68]. Dose: benign prostatic hyperplasia, 5mg daily, review treatment after 6 months. Prescribing notes: : 6.5.1 Gonadotrophins Human growth hormone (children). TAG 42 Human growth hormone (adults). TAG 64 6.6.2 Bisphosphonates Osteoporosis primary prevention TAG 160 Osteoporosis secondary prevention including strontium ranelate TAG 161 First Choice: Alendronic acid tabs (G): 10mg [28tabs 1.29], 70mg [4tabs 95p]. Dose: Treatment of postmenopausal osteoporosis and osteoporosis in men 70mg once weekly. Prescribing notes: Alendronic acid 70mg once weekly is the most cost effective way to prescribe a bisphosphonate. Swallow tablets whole with a full glass of water on an empty stomach at least 30 mins before breakfast (and any other oral medication); stand or sit upright for at least 30 mins and do not lie down until after eating breakfast. Do not take the tablets at bedtime or before rising. : Second Choice: Risedronate tabs: 5mg [28tabs 10.90], 35mg [4tabs 1.66]. Dose: Treatment of postmenopausal osteoporosis to reduce risk of vertebral or hip fractures 5mg daily or 35mg once weekly. Prevention of osteoporosis (including corticosteroid induced osteoporosis) in postmenopausal women, 5mg daily. Prescribing notes: Swallow tablets whole with a full glass of water on an empty stomach at least 30 mins before first food or drink of the day; stand or sit upright for at least 30 mins. Do not take the tablets at bedtime or before rising. :

OBSTETRICS, GYNAECOLOGY AND URINARY TRACT

7.1 Drugs Used in Obstetrics See : 7.2.1 Vaginal Atrophy First Choice: Estradiol 25mcg vaginal tablets in disposable applicators (Vagifem): [15 applicators 10.56]. Dose: Insert one tablet daily for 2 weeks then reduce to one tablet twice weekly; discontinue after 3 months to assess need for further treatment. Prescribing notes: No evidence of damage to latex condoms and diaphragms. : Second Choice: Estriol 0.1% intravaginal cream (Ovestin): [15g 4.45]. Dose: Insert 1 applicator-dose daily for 23 weeks, then reduce to twice a week (discontinue every 23 months for 4 weeks to assess need for further treatment); vaginal surgery, 1 applicator-dose daily for 2 weeks before surgery, resuming 2 weeks after surgery. Prescribing notes: Effect on latex condoms and diaphragms not yet known. :

pregnancy; topical therapy may be used. See also 5.2. OTC. Links: : 7.3 Contraceptives NICE recommend LARC as first line contraceptive choice, for effectiveness and cost-effectiveness reasons. Patients should be informed about these options in the first instance. Long acting reversible contraception. Clinical Guideline No. 30 Long Acting Reversible Contraceptives Parenteral Contraceptive: Medroxyprogesterone Acetate injection (DepoProvera): 150mg/ml [1ml syringe 6.01]. Dose: 150mg every 12 weeks. Prescribing notes: Prescribe by brand name to avoid confusion. : Subdermal Implant: Etonogestrel radiopaque implant (Nexplanon): 68mg [79.46] Dose: see BNF. Prescribing notes: Effective for three years but may be removed sooner. Contraceptive cover ceases upon removal of implant : Intra-uterine Device Levonorgestrel Intra-uterine System (Mirena): [88.00]. Dose: Releases 20 micrograms over 24 hours. Prescribing notes: A levonorgestel coil may particularly useful for treating menorrhagia in women also requiring contraception. Effective for 5 years. Links: Menorrhagia Guideline: :

7.2.2 Anti-Infective Drugs Vaginal fungal infections Topical therapy First Choice: Clotrimazole (G): 1% cream [20g 1.24, 50g 3.19], 200mg pessaries [3pess 3.63], 500mg pessaries [1pess 2.78]; 10% vaginal cream [5g 5.86]. Dose: Prescribing notes: Both cream and pessaries can damage latex condoms and diaphragms. See also 5.2. OTC. Links: : Second Choice: Miconazole: 2% intravaginal cream [78g 4.33], 1200mg vaginal capsule [1cap 2.94]. Dose: Prescribing notes: All the above products can damage latex condoms and diaphragms. See also 5.2. Links: : Oral therapy First choice: Fluconazole caps: 150mg [1cap 79p]. Dose: a single dose of 150mg. Prescribing notes: Avoid oral antifungals in

7.3.1 Combined Oral Contraceptives Low Strength First Choice: Loestrin 20 tabs: [3x21tabs 2.85]. Dose: Prescribing notes: Each tablet contains ethinylestradiol 20mcg & norethisterone 1mg. : Second Choice: Mercilon tabs: [3x21tabs 7.67]. Dose: Each tablet contains ethinylestradiol 20mcg & desogestrel 150mcg. Prescribing notes: : Standard Strength First Choice: Ovranette tabs: [3x21tabs 2.20]. Dose: Prescribing notes: Each tablet contains ethinylestradiol 30mcg & levonorgestrel 150mcg. Ovranette and Microgynon contain the same

active ingredients in the same doses and as such may be considered interchangeable. : OR Microgynon 30 tabs: [3x21tabs 2.82]. Dose: Prescribing notes: Each tablet contains ethinylestradiol 30mcg & levonorgestrel 150mcg. Ovranette and Microgynon contain the same active ingredients in the same doses and as such may be considered interchangeable. : Second Choice: Marvelon tabs: [3x21tabs 6.45]. Dose: Prescribing notes: Each tablet contains ethinylestradiol 30mcg & desogestrel 150mcg. Some studies have reported a greater risk of venous thromboembolism in women using preparations containing the third-generation progestogens desogestrel and gestodene. : Emergency Contraception First Choice: Levonelle 1500 tabs: [1tab 5.20]. Dose: One tablet should be taken as soon as possible, preferably within 12 hours, and no later than 72 hours after unprotected intercourse. If vomiting occurs within three hours of taking the tablet, another tablet should be taken immediately. Prescribing notes: Each tablet contains levonorgestrel 1500mcg. Levonelle One Step can be sold to women over 16 years. : 7.3.2 Progesterone-Only ContraceptivesOral Cerazette tabs: [3x28tabs 8.68]. Dose: 1 tablet daily at same time each day, starting on day 1 of cycle then continuously; if administration delayed for 12 hours or more it should be regarded as a missed pill. Prescribing notes:. Each tablet contains desogestrel 75mcg. The following advice is recommended by family planning organisations if a pill is missed. If you forget a pill , take it as soon as you remember and carry on with the next pill at the right time. If the Cerazette pill was more than 12 hours overdue you are not protected. Continue normal pill-taking but you must also use another method, such as the condom for the next 2 days. : Micronor tabs: [3x28tabs 2.11]. Dose: 1 tablet daily at same time each day, starting on day 1 of cycle then continuously; if administration delayed for 3 hours or more it should be regarded as a missed pill. Prescribing notes: Each tablet contains norethisterone 350mcg. The following advice is recommended by family planning organisations if a pill is missed. If you forget a pill , take it as soon

as you remember and carry on with the next pill at the right time. If the Micronor pill was more than 3 hours overdue you are not protected. Continue normal pill-taking but you must also use another method, such as the condom for the next 2 days. : 7.4.1 Benign Prostatic Hyperplasia First Choice: Tamsulosin MR caps (G): 400mcg [30caps 4.41]. Dose: 400mcg daily after food. Prescribing notes: MR tablets are more than twice as expensive. : 7.4.2 Urinary frequency, enuresis and incontinence Link to NICE guidance

Urinary Incontinence. Clinica

Lower urinary tract symptom First Choice: Oxybutynin tabs (G): 2.5mg [56tabs 5.78], 5mg [56tabs 5.62]; 5mg MR [30tabs 13.77], 10mg MR [30tabs 27.54]. Dose: 5mg two or three times a day increased if necessary to a max of 5mg four times a day. Elderly 2.5mg twice a day increased to 5mg twice a day according to response and tolerance. MR tabs, initially 5mg daily adjusted according to response in 5mg steps at weekly intervals; maximum 30mg daily as a single dose. The need for continuing antimuscarinic drug therapy should be review after 6 months. Prescribing notes: :: Second Choice: Tolterodine tabs: 1mg [56tabs 29.03], 2mg [56tabs 30.56]; 4mg MR caps [28caps 25.78]. Dose: 2mg twice daily, reduce to 1mg twice daily if necessary to reduce side-effects OR 4mg MR once daily (dose form not appropriate for hepatic and renal impairment). Prescribing notes: Tolterodine should only be prescribed for patients who cannot tolerate oxybutynin. Taking MR caps at night may reduce incidence of dry mouth. The need for continuing antimuscarinic drug therapy should be review after 6 months. : 7.4.5 Drugs for Erectile Dysfunction First Choice: Sildenafil tabs: 25mg [4tabs 16.59], 50mg [4tabs 21.27], 100mg [4tabs 23.50]. Dose: Initially 50mg approximately one hour before sexual activity, adjust dose according to response to 25 to 100mg as a single dose, maximum one dose in 24hours. Prescribing notes: Sildenafil (and the other phosphodiesterase type-5 inhibitors) can only be prescribed on the NHS to men who: 1. have diabetes, multiple sclerosis, Parkinsons

disease, poliomyelitis, prostate cancer, severe pelvic injury, single gene neurological disease, spina bifida or spinal cord injury; 2. are receiving dialysis for renal failure; 3. have had radical pelvic surgery, prostatectomy, or kidney transplant; 4. were receiving Caverject, Erecnos, MUSE, Viagra or Viridal for erectile dysfunction, at the expense of the NHS, on 14 September 1998; 5. are suffering severe distress as a result of impotence (prescribed in specialist centres only, see notes above). The prescription must be endorsed SLS.

EYE
11.0 Prescribing Note Preservative-free (PF) formulations Preservative intolerance should be diagnosed by an ophthalmologist. PF eye drops may be of benefit in patients needing several doses of eye drops each day, where likelihood of irritation is greater. If PF formulation is warranted, proprietary preservative-free formulations (often available as unit dose preparations) should be prescribed if at all possible. Manufactured specials are unlicensed and almost invariably cost significantly more. 11.3 Anti-Infective Eye Preparations 11.3.1 Antibacterial First Choice: Chloramphenicol (G): 0.5% eye drops [10ml 1.63], 1% eye ointment [4g 2.03]. Dose: Drops; 1 or 2 drops four times a day, Ointment; apply four times a day or just at night when used in combination with eye drops. If chloramphenicol fails, consider viral infection or user failure. For more serious infections see : Prescribing notes: OTC (for acute bacterial conjunctivitis only). Ointment is preservative free. Preservative free drops available as Minims [20 = 9.55]. : Second Choice: Gentamicin eye drops (G): 0.3% [10ml 2.13]. Dose: 1 or 2 drops up to six times a day, or more frequently if required. Prescribing notes: : 11.3.3 Antiviral First Choice: Aciclovir eye ointment: 3% [4.5g 9.34]. Dose: Apply five times a day, continue for at least 7 days after complete healing. Prescribing notes: Steroid preparations should not be used in combination with antivirals. : 11.4.1 Corticosteroids First Choice: Prednisolone eye drops: 0.5% [10ml 2.00], 1% [5ml 1.52, 10ml 3.05]. Dose: 0.5%; 1 or 2 drops every one or two hours until controlled, then reduce frequency. 1%: 1 or 2 drops two to four times a day. Prescribing notes: Topical steroids should be used with great care due to the dangers of producing steroid glaucoma or masking an underlying infection. Preservative free prednisolone 0.5% drops available as Minims [20 = 9.78]. : Second Choice: Betamethasone 0.1% eye drops: (G) [10ml 2.32]; 0.1% eye ointment: [3g 1.41].

Dose: 1 or 2 drops every one or two hours until controlled, then reduce frequency. Prescribing notes: Topical steroids should be used with great care due to the dangers of producing steroid glaucoma or masking an underlying infection. Eye ointment is frequently unavailable. : Third Choice: Dexamethasone with hypromellose eye drops (Maxidex): 0.1% [5ml 1.42, 10ml 2.80]. Dose: 1 or 2 drops every four to six hours; in severe conditions every 30 to 60 minutes until controlled then reduce frequency. Prescribing notes: Topical steroids should be used with great care due to the dangers of producing steroid glaucoma or masking an underlying infection. Preservative free dexamethasone 0.1% drops available as Minims [20 = 9.04]. : 11.4.2 Other Anti-Inflammatory Preparations First Choice: Sodium Cromoglicate eye drops (G): 2% [13.5ml 2.08]. Dose: 1 or 2 drops four times a day. Prescribing notes: OTC (10ml). : 11.6 Glaucoma Link to NICE guidance

Diagnosis and management of g

Prescribing Note: No more than one drop at a time is required to deliver the correct dose of active ingredient in glaucoma treatment products. Use of more than one drop increases likelihood of localised side effects and systemic absorption Beta-Blockers First Choice: Timolol eye drops (G): 0.25% [5ml 1.34], 0.5% [5ml 1.38]. Dose: 1 drop twice a day. Prescribing notes: : Carbonic Anhydrase Inhibitors First Choice: Dorzolamide eye drops (G): 2% [5ml 4.78]. Dose: Used alone 1 drop three times a day; with beta-blocker 1 drop twice a day. Prescribing notes: : Second Choice: Brinzolamide eye drops: 1% [5ml 6.56]. Dose: 1 drop twice a day, increase to three times a day if necessary. Prescribing notes: Reported to cause less stinging than dorzolamide. : Alpha-Blockers Brimonidine eye drops (G): 0.2% [5ml 3.49]. Dose: 1 drop twice a day.

Prescribing notes: : Prostaglandin Analogues First Choice: Latanoprost eye drops: 0.005% [2.5ml 12.48]. Dose: 1 drop once daily, preferably in the evening. Prescribing notes: Now licensed for first line use but timolol more cost effective unless beta-blockers are contra-indicated. One bottle contains 83 drops so should be sufficient for one months treatment in both eyes. Devices to aid drop administration are available. : Second Choice: Bimatoprost eye drops: 0.03% [2.5ml 10.30]. Dose: 1 drop once daily, preferably in the evening. Prescribing notes: For patients who cannot tolerate or who do not reach target intraocular pressure with latanoprost. Now licensed for first line use but timolol more cost effective unless betablockers are contra-indicated. : Beta-Blockers + Prostaglandin Analogues Combined First Choice: Xalacom eye drops (timolol 0.5% + latanoprost 0.005%): [2.5ml 14.32]. Dose: 1 drop once daily. Prescribing notes: : Beta-Blockers + Carbonic Anhydrase Inhibitors Combined First Choice: Dorzolamide 2% + timolol 0.5% eye drops (G): [5ml 4.78]. Dose: 1 drop twice a day. Prescribing notes: Previously only available as branded Cosopt but generic formulations now available. : 11.7 Eye Drop Dispensers Designed to help patients administer correct single drop dose. Arthro versions have lever function to help patients with particular dexterity problems. Opticare (for 2.5ml, 5ml, 10ml,15ml, 20ml bottles) 4.92 Opticare Arthro 5 ( for 2.5ml, 5ml bottles) 4.92, Opticare Arthro 10 (for 10ml, 15ml, 20ml bottles) 4.92 11.8.1 Tear Deficiency & Ocular Lubricants Drops First Choice: Hypromellose eye drops (G): 0.3% [10ml 1.35]. Dose: One or two drops as required depending on the need for lubrication. Prescribing notes: OTC. If PF product needed, prescribe as Minims Artificial Tears [20 = 7.48]. Generic PF hypromellose 0.3% UDVs available but costs may vary depending upon supplier and oncosts etc.

: Gels First Choice: Carbomer 980 liquid gel: 0.2% [10g 2.80], 0.2% preservative-free [30 x 0.6ml 5.42]. Dose: 1 drop three or four times a day or as required depending on the severity of the disease. Prescribing notes: OTC. Viscotears brand preserved with cetrimide, not benzalkonium chloride so may be considered where benzalkonium chloride intolerance is suspected. : Ointments First Choice: Lacri-Lube eye ointment: [3.5g 2.51, 5g 3.32]. Dose: Apply a small amount as required. Prescribing notes: OTC. Preservative free. Contains lanolin alcohols. :

ENT
12.1.Otitis Externa Steroid Only First Choice: Betamethasone ear drops: 0.1% [10ml 2.32]. Dose: 2 or 3 drops every two to three hours, reduce frequency when relief obtained. Prescribing notes: Avoid prolonged use as with all ear drops. Care with perforated eardrum. : Second Choice: Prednisolone sodium phosphate ear drops: 0.5% [10ml 2.00]. Dose: 2 or 3 drops every two to three hours, reduce frequency when relief obtained. Prescribing notes: Avoid prolonged use as with all ear drops. Care with perforated eardrum. : Steroid + Anti-Infective Agent First Choice: Locorten-Vioform ear drops: 0.2%/1% [7.5ml 1.76; 10ml 2.35]. Dose: 2 or 3 drops twice a day for up to 7 to 10 days; not recommended for children under 2 years. Prescribing notes: Limit use to about a week as excessive use may result in fungal infections which may be difficult to treat and require expert advice. Contains flumetasone and clioquinol. : Second Choice: Otomize ear spray: [5ml 3.50]. Dose: 1 spray three times a day. Prescribing notes: Limit use to about a week as excessive use may result in fungal infections which may be difficult to treat and require expert advice. Contains 0.1% dexamethasone, 3250 units/ml neomycin sulphate & 2% glacial acetic acid. : Anti-Infective Agent Only First Choice: Gentamicin ear drops (G): 0.3% [10ml 2.13]. Dose: 2 or 3 drops every three or four times a day and at night. Prescribing notes: Limit use to about a week as excessive use may result in fungal infections which may be difficult to treat and require expert advice. In view of reports of ototoxicity in patients with a perforated tympanic membrane (eardrum), the CSM has stated that treatment with a topical aminoglycoside antibiotic is contra-indicated in those with a tympanic perforation. However, many specialists do use these drops cautiously in the presence of a perforation in patients with otitis media and where other measures have failed for otitis externa. : Anti-Fungal Agent First Choice: Clotrimazole solution: 1% [20ml 2.43].

Dose: 3 or 4 drops two to three times a day for at least 14 days after the disappearance of infection. Prescribing notes: Avoid prolonged use as with all ear drops. Care with perforated eardrum. : 12.1.2 Acute Otitis Media See BNF. 12.1.3 Removal of Ear Wax First Choice: Sodium Bicarbonate ear drops (G): 5% [10ml 1.25]. Dose: 3 drops two or three times a day. Prescribing notes: Avoid prolonged use as with all ear drops. Care with perforated eardrum. OTC. : Second Choice: Olive Oil ear drops (G): [10ml 1.42]. Dose: 3 drops two or three times a day. Prescribing notes: Avoid prolonged use as with all ear drops. Care with perforated eardrum. OTC. : 12.2.1 Drugs used in Nasal Allergy Corticosteroids First Choice: Beclometasone nasal spray (G): 50microgram/spray [200doses 2.27]. Dose: 2 sprays into each nostril twice a day. Prescribing notes: 200 dose pack is least expensive pack size. OTC versions (100 & 180 doses) available for adults over 18 only. : Second Choice: Mometasone 50 microgram /pray: [140doses 7.68]. Dose: For allergic rhinitis in children over 6 years of age, one spray into each nostril once daily; for allergic rhinitis in adults children over 12 years of age, two sprays into each nostril once daily increased if necessary to a maximum of four sprays into each nostril once daily, when control is achieved reduce to one spray into each nostril once daily. For nasal polyps in adults over 18 years: 2 sprays into each nostril once daily, increased if necessary after 5 to 6 weeks to 2 sprays into each nostril twice daily (consider alternative treatment if no improvement after further 5 to 6 weeks), reduce to the lowest effective dose when control achieved. Prescribing notes: : 12.2.2 Topical Nasal Decongestants Sympathomimetics First Choice: Xylometazoline nasal drops (G): 0.05% [10ml 1.59], 0.1% [10ml 1.91], 0.1% spray [10ml 1.91]. Dose: 2 or 3 drops (or 1 spray) into each nostril two or three times a day. Prescribing notes: OTC. : Antimuscarinics First Choice: Ipratropium nasal spray: 0.03% [15ml 3.99].

Dose: 2 sprays into each nostril two or three times a day. Prescribing notes: NB for rhinorrhoea only, ipratropium is not a decongestant. : 12.2.3 Nasal Preparations for Infection First Choice: Mupirocin nasal ointment (Bactroban Nasal): 2% [3g 3.54]. Dose: For eradication of nasal carriage of staphylococci, including meticillin-resistant Staphylococcus aureus (MRSA), apply 23 times daily to the inner surface of each nostril. Prescribing notes: A nasal ointment containing mupirocin is also available; it should probably be held in reserve for resistant cases. In hospital or in care establishments, mupirocin nasal ointment should be reserved for the eradication (in both patients and staff) of nasal carriage of meticillinresistant Staphylococcus aureus (MRSA). The ointment should be applied 3 times daily for 5 days and a sample taken 2 days after treatment to confirm eradication. The course may be repeated if the sample is positive (and the throat is not colonised). To avoid the development of resistance, the treatment course should not exceed 7 days and the course should not be repeated on more than one occasion. If the MRSA strain is mupirocinresistant or does not respond after 2 courses, consider alternative products such as Naseptin cream. : Second Choice: Naseptin nasal cream: [15g 1.90]. Dose: For eradication of nasal carriage of staphylococci, apply to nostrils 4 times daily for 10 days; for preventing nasal carriage of staphylococci apply to nostrils twice daily. Prescribing notes: Contains chlorhexidine 0.1% and neomycin 3250 units/g. NB includes arachis (peanut) oil. : 12.3.1 Drugs for Oral Ulceration & Inflammation Benzydamine oral rinse: 0.15% [300ml 4.64]. Dose: Rinse or gargle with 15ml every 1 to 3 hours as required, usually for not more than 7 days. Prescribing notes: OTC. : 12.3.2 Oral Fungal Infections Miconazole oral gel: 2% [15g 2.85, 80g 4.38]. Dose: Adults 5 - 10ml four times a day in the mouth after food, retain near lesions before swallowing. Neonates (oral fungal infections only) 1ml twice daily smeared around the mouth after feeds; 1 month to 2 years 2.5ml twice daily in the mouth after food, retain near lesions before swallowing; 2 to 6 years 5ml twice daily in the mouth after food, retain near lesions before swallowing; 6 to 12 years 5ml four times a day in the mouth after food, retain near lesions before swallowing.

Prescribing notes: Continue treatment until 48hours after lesions have resolved. Miconazole oral gel is not licensed for use in children under 4 months of age or during the first 5 6 months of life of an infant born pre-term. The doses quoted above for neonates are taken from the BNF for Children. : Nystatin oral suspension (G): 100,000 units/ml [30ml 20.80]. Dose: 1ml four times a day after food, usually for 7 days (continue for 48 hours after lesions have resolved). Prescribing notes: Immunosuppressed patients may require 500,000 units (5ml) four times a day. : 12.3.4 Mouthwashes First Choice: Chlorhexidine mouthwash (G): 0.2% [300ml 3.30] Dose: 10ml rinsed around the mouth for about one minute twice a day. Prescribing notes: OTC. : 12.3.5 Treatment of Dry Mouth First Choice: Glandosane spray: [50ml 4.99]. Dose: As required. Prescribing notes: OTC. ACBS: patients suffering from dry mouth as a result of having undergone radiotherapy or having sicca syndrome. Neutral, lemon or peppermint flavour. :

SKIN
13.2.1 Emollients National Patient Safety Agency warning: Potential fire hazard with paraffin based skin products on dressings and clothing. FOR DIRECT APPLICATION TO THE SKIN Cream-like products First Choice: Diprobase Cream: [50g 1.28, 500g 6.32]. Also: E45 Cream: [50g 1.40, 350g 4.46]. Doublebase Hydrating Gel: [100g 2.65, 500g 5.83]. Cetraben Cream: [50g 1.40, 150g 3.98, 500g 5.99, 1.05kg 11.62]. Ointment-like products Liquid Paraffin and White Soft Paraffin Ointment (50:50): [500g 6.09]. Epaderm Ointment: [125g .3.69, 500g 6.26]. Diprobase Ointment: [50g 1.28]. Urea containing products Aquadrate Cream: [30g 1.64, 100g 4.37]. Calmurid Cream: [100g 5.70, 500g 27.42]. NB also contains lactic acid use sparingly. EMOILLIENT BATH & SHOWER PREPARATIONS Emulsifying Ointment BP: [500g 2.10]. Dermalo Bath Emollient: [500ml 3.44] Oilatum Emollient: [250ml 2.75, 500ml 4.57]. Aveeno Bath Oil: [250ml 4.49] Diprobath Emollient: [500ml 6.74]. Balneum Plus Bath Oil: [500ml 6.66]. Useful for itching skin. AS A SOAP SUBSTITUTE Emulsifying Ointment BP: [500g 2.10]. Aqueous Cream BP: [500g pot 1.72, 100g tube 1.25]. Prescribing notes: The constituents of all the above products may be found in the BNF or MIMS (which also has a chart of potential skin sensitisers included as ingredients in various products). Links: : 13.2.2 BARRIERS First line: Sudocrem: [30g tube 1.13] Prescribing notes: Tube has longer in-use shelf life than larger pots; a little goes a long way. Water repellent; protects skin from moisture, irritants, chafing. Reduces inflammation, weak local anaesthetic action. May be used for patients using continence pads.

Second line: Conotrane cream: [100g tube 88p] Prescribing notes: For nappy rash and pressure sores. Tube has longer in-use shelf life than pots; a little goes a long way. Water repellent, protects skin from moisture, irritants, chafing and contamination with yeasts or bacteria. Useful in urinary rash, but not suitable for use on patients with continence pads. Note: Cavilon cream [28g 3.92] and film [5x3ml 7.83] are included as part of the NHS Devon Dressings, Appliance and Stoma formulary but should not be used for routine barrier cream application.

13.3 Antipruritics First Choice: Crotamiton cream 10% [30g 2.38, 100g 4.15]. Dose: Apply two or three times a day. Prescribing notes: Although crotamiton is helpful and widely used, it may modify the appearance of scabies making subsequent diagnosis more difficult. It is important that scabies is excluded befoe use. OTC. Links: : 13.4 Topical Corticosteroids

NICE Guidance Topical corticosteroids for atopic eczema should be presc effective than once daily.) Where more than one alternative topical steroid is conside cost should be prescribed. This should take into account t Atopic dermatitis (eczema) - topical steroids. No.81. The British Association of Dermatologists suggests tha when the eczema is active followed by the use of emollien Mild Potency First Choice: Hydrocortisone 1% (G): cream [30g 1.61], ointment [30g 2.15]. Dose: Apply thinly once or twice a day. Prescribing notes: Prescribe in multiples of 30g, avoid the 50g size. Hydrocortisone Cream can be purchased from a pharmacy but it can only be sold for specific indications and excludes use on genitals, face and broken skin. Not to be sold for use by pregnant women or children under ten. Links: : Moderate Potency First Choice: Betamethasone 0.025%: cream & ointment [100g 3.15]. Dose: Apply thinly once or twice a day. Prescribing notes: Links: : Second Choice: Clobetasone 0.05%: cream & ointment [30g 1.86, 100g 5.44]. Dose: Apply thinly once or twice a day. Prescribing notes:

Links: : Potent First Choice: Betamethasone 0.1% (G): cream [30g 2.25, 100g 4.49], ointment [30g 2.83, 100g 5.46], scalp application [100ml 3.75]. Dose: Cream or Ointment, apply thinly once or twice a day. Scalp application, apply twice daily until noticeable improvement then once daily. Prescribing notes: Use betamethasone lotion if the alcoholic base of scalp application stings. Links: : Second Choice: Hydrocortisone Butyrate 0.1%: cream & ointment [30g 1.60, 100g 4.93]. Dose: Apply thinly once or twice a day. Prescribing notes: Links: : Very Potent First Choice: Clobetasol 0.05%: cream & ointment [30g 2.69, 100g 7.90]. Dose: Apply thinly once or twice a day for up to 4 weeks; maximum 50g per week. Prescribing notes: Links: : Corticosteroid plus Anti-infective Agent Corticosteroid plus Antibiotic First choice: Fucidin H cream [30g 4.99]. Dose: apply sparingly, twice daily, for one week. Prescribing notes: contains hydrocortisone acetate 1%, fusidic acid 2%. May be useful for infected eczema. Do not use for longer than one week due to risk of sensitisation and resistance. Potency: mild. Second choice: Fucibet cream [30g 5.29]. Dose: apply sparingly, twice daily, for one week. Prescribing notes: contains Betametasone valerate 0. 1%, fusidic acid 2%. May be useful for infected eczema. Do not use for longer than one week due to risk of sensitisation and resistance. Potency: potent. Corticosteroid plus Anti-Fungal Agent First Choice: Daktacort: cream [30g 2.28]; ointment [30g 2.28]. Dose: Apply thinly twice daily. Prescribing notes: Contains hydrocortisone 1% & miconazole 2%. A 15g tube is available OTC for the treatment of athletes foot and candidal intertrigo. Mild potency steroid. Links: : Second Choice: Canesten HC cream: [30g 2.42]. Dose: Apply thinly twice daily. Prescribing notes: Contains hydrocortisone 1% & clotimazole1%. A 15g tube is available OTC for the treatment of athletes foot and fungal infection of skin folds with associated inflammation. Mild potency steroid. Links: :

Corticosteroid plus Anti-Fungal Agent plus Antibiotic First Choice: Trimovate cream: [30g 3.29]. Dose: Apply to the affected area up to four times a day. Prescribing notes: Contains clobetasone 0.05% & nystatin 100,000 units/g & oxytetracycline 3%. Moderate potency steroid. Links: : 13.5.2 Psoriasis Link to NICE guidance

Psoriasis efalizumab and e

Psoriasis infliximab TAG 1

Psoriasis adalimumab TAG

Psoriatric arthritis etanerce Coal Tar Alphosyl HC cream: [100g 3.54]. Dose: Apply thinly once or twice daily. Prescribing notes: Not recommended for under 5 year olds. Links: : Polytar Emollient: [500ml 6.50]. Dose: Use 2 to 4 capfuls (15 to 30ml) in bath and soak for 20 mins. Prescribing notes: OTC. Links: : Dithranol Dithrocream: 0.1% [50g 3.77], 0.25% [50g 4.04], 0.5% [50g 4.66], 1% [50g 5.42], 2% [50g 6.79]. Dose: For application to skin or scalp; 0.1% to 0.5% cream suitable for overnight treatment, 1 and 2%cream for a maximum of one hour. Prescribing notes: OTC (0.1 to 1%). Links: : Vitamin D analogues Calcipotriol 0.005%: cream [120g 22.66]; ointment [120g 23.10]; scalp solution [60ml 12.70]. Dose: apply twice a day, max 100g per week. Scalp solution, apply to the scalp twice daily, max 60ml weekly. Prescribing notes: When preparations are used together the maximum is 5mg in any one week (eg 60g cream with 30ml scalp application). Calcipotriol should be used twice a day. However, care in the flexures as it can irritate and therefore use daily at first. Care is required on application to the face and in particular to prevent it getting in the eyes where it might irritate. Not recommended for under 6 year olds. Links: : Calcipotriol 0.005% with betamethasone 0.05% (Dovobet): ointment [60g 32.99, 120g 61.27].

Dose: Apply once daily, max 15g daily, 100g per week. Prescribing notes:. Dovobet should be applied once daily for a maximum of 4 weeks (risk of flare and rebound if continued). Usage should not exceed 100g per week. Not recommended for under 18 year olds. Links: : Calcitriol 0.003% ointment: [100g 13.87]. Dose: Apply twice a day, max 30g daily. Prescribing notes: May be less irritant. Apply twice daily, maximum 30g daily and not more than 35% of body surface. Not recommended in children. Links: : Scalp psoriasis Betamethasone 0.1% (G): scalp application [100ml 3.75]. Dose: Apply twice daily until noticeable improvement then once daily. Prescribing notes: Use betamethasone lotion if the alcoholic base of scalp application stings. Links: : Calcipotriol 0.005%: scalp solution [60ml 12.70]. Dose: Apply to the scalp twice daily, max 60ml weekly. Prescribing notes: When used together with other calcipotriol preparations the maximum is 5mg in any one week (eg 60g cream with 30ml scalp application). Care is required on application in particular preventing it getting in the eyes where it might irritate. Not recommended for under 6 year olds. Links: : Cocois Ointment: [40g 6.22, 100g 11.69]. Dose: Apply to the scalp once a week as necessary (if severe use daily for first 3 to 7 days). Shampoo off after one hour. Prescribing notes: Contains coal tar solution, salicylic acid, precipitated sulphur and coconut oil. OTC. Links: : 13.5.3 Drugs Affecting the Immune Response

and sunlamps. Do not apply other topical preparations within 2 hours of application. Links :

13.6.1 Topical Preparations for Acne Links

NHS Clinical Knowledge Summaries Acne Vulg

Topical Preparations (non-antbiotics) PanOxyl: 5% acne gel [40g 1.89], 5% cream [40g 1.89]; 10% acne gel [40g 1.99]; 2.5% Aquagel [40g 1.76], 5% Aquagel [40g 1.92], 10% Aquagel [40g 2.13]. Dose: Apply once daily. Prescribing notes: OTC. Links: : Quinoderm: 5% cream [50g 2.43], 10% cream [25g 1.58, 50g 2.55]. Dose: Apply once to three times daily. Prescribing notes: OTC. Links: : Topical Antibiotics First Choice: Clindamycin 1%: alcoholic solution [30ml 4.34], aqueous lotion [30ml 5.08]. Dose: Apply twice a day. Prescribing notes: Links: : Topical Retinoids First Choice: Tretinoin 0.01% gel [60g 5.28], 0.025% gel [60g 5.28]. Dose: Apply thinly once or twice a day. Prescribing notes: Useful for comedones and inflammatory lesions in mild to moderate acne. May cause initial redness and peeling, which ususlly settles with time.

Second Choice: Isotretinoin 0.05% gel [30g 5.24]. Dose: Apply thinly once or twice a day. Prescribing notes: Less irritating than tretinoin but twice as expensive. 13.6.2 Oral Preparations for Acne Antibiotics First Choice: Oxytetracycline tabs (G): 250mg [56tabs 2.38]. Link to NICE guidance Atopic dermatitis (eczema) - pimecrolimus and tacrolimus TAG 82. Dose: 500mg twice a day for 1 to 4 weeks then 250mg twice a day until improvement. First choice: Tacrolimus ointment: 0.03% [30g Prescribing notes: 3 months treatment initially. 19.44, 60g 35.46]; 0.1% [30g 21.60, 60g Avoid taking with food, milk, antacids, iron preps 39.40]. etc. Dose: Initially apply 0.1% ointment thinly twice Links: : daily for up to 3 weeks then reduce to 0.03% (with further reduction to once daily where appropriate) Second Choice: Lymecycline caps: 408mg until lesions clear. [28caps 7.77]. Prescribing notes: Initial prescription should be by Dose: one daily for at least 8 weeks. a specialist. Treatment can be transferred to Prescribing notes: Once daily administration may primary care. Avoid excessive exposure to sunlight aid compliance. No need to avoid food but antacids, iron and zinc containing medication

should not be taken at the same time of day. Links: Hormones First Choice: Co-Cyprindiol tabs: [3 x 21tabs 4.03]. Dose: 1 tab daily for 21 days starting on day 1 of the menstrual cycle. Prescribing notes: See MRHAs advice on the prescribing of co-cyprindiol. Contains ethinylestradiol 35mcg & cyproterone 2mg. Links: : 13.8.1 Photodamage First choice: Diclofenac sodium 3% gel: [50g 38.30]. Dose: apply thinly twice daily for 60- 90 days; max 8g per day. Prescribing Notes: superficial lesions in mild nonhypertrophic actinic keratosis. Links: : Second choice: Fluorouracil 5% cream: [40g 32.76] Dose: apply thinly to affected area twice a day, usually for 3-4 weeks at a time. Prescribing notes: No more than 500cm2 to be treated at a time (23cmx23cm). Links: : 13.10 Anti-Infective Skin Preparations 13.10.1 Topical Antibiotics Fusidic Acid 2%: cream [15g 1.92, 30g 3.57], ointment [15g 2.23, 30g 3.79]. Dose: Apply three or four times a day. Prescribing notes: Links: : Metronidazole 0.75% (Rozex): cream [40g 6.86]; gel [40g 6.86]. Dose: Apply twice daily for 3 to 4 months. Prescribing notes: For inflammatory papules, pustules and erythema of acne rosacea. Links: Metronidazole 0.8% (Metrotop): gel [15g 4.59]. Dose: Apply to clean wound once or twice daily and cover (flat wounds apply liberally; cavities, smear on paraffin gauze and pack loosely). Prescribing notes: For malodorous fungating tumours and malodorous gravitational and decubitus ulcers. Links: 13.10.1.1 MRSA Minor soft tissue infections could be treated with doxycycline 100mg twice daily. IF the isolate is sensitive to tetracyclines. Other infections may need hospital admission. Please discuss patients with consultant microbiologist. MRSA screening MRSA screens are required before most elective admissions, including elective admissions to

community hospitals. The MRSA screen consists of swabs moistened with sterile saline from the nose, axilla, perineum/ groin, any wounds, sores or eczema. Plus, if applicable, catheter specimen of urine and sputum. Links: MRSA patient information leaflet

Mupirocin 2% ointment (Bactroban): [15g 4.38]. Dose: Apply up to three times daily for up to 10 days. Prescribing notes: Reserve for MRSA infections, although Staphylococcus aureus strains with lowlevel resistance to mupirocin are emerging. To avoid the development of resistance, mupirocin should not be used for longer than 10days. Cream and ointment are not interchangeable, the prescription should specify the formulation required. Links: : 13.10.2 Topical Anti-Fungals Clotrimazole 1% cream (G): [20g 1.40]. Dose: Apply two or three times a day. Prescribing notes: OTC. Links: : Ketoconazole 2% cream: [30g 4.24]. Dose: Apply once or twice a day. Prescribing notes: Endorse all scripts SLS. 15g tube OTC for the treatment of tinea pedis, tinea cruris, and candidal intertrigo. Links: : Terbinafine cream 1% [30g 2.70]. Dose: Apply twice daily. Duration dependent on indication- see BNF. Prescribing Notes: For tinea infections, candidiasis, pityriasis versicolor. 30g pack size cheaper than 15g. Links: : Ketoconazole 2% Shampoo (G): [120ml 3.65] Dose: Seborrhoeic dermatitis; use twice a week for 2 to 4 weeks then reduce to once every 1 to 2 weeks. Pityriasis versicolor; once daily for a maximum of 5 days. Prescribing notes: OTC. Ketoconazole shampoo is the preferred treatment for seborrhoeic eczema since this is fungal. Do not use within two weeks of a topical steroid. Links: : 13.10.3 Topical Anti-Virals Aciclovir 5% cream (G): [2g 1.36, 10g 1.99]. Dose: Apply every four hours (five times a day) for 5 to 10 days, starting at first sign of attack. Prescribing notes: OTC (2g). Links: : 13.10.4 Topical Parasiticidal Preparations Link to Prevention and Treatment of Head Lice 13.11.6 Potassium Permanganate

Potassium permanganate 400mg solution tablets (Permitabs): [30 9.85]. Dose: For External Use Only, dissolve one tablet in 4 litres of water to give a 1 in 10,000 solution. Soak twice daily for 15 minutes. Stop soaks as soon as the rash has dried up - usually a few days. Prescribing notes: Potassium permanganate soaks are very useful for weeping hand and/or foot eczema. Warn patients about staining of the skin, nails, towels and the bowl. Links: : 13.13 Dressings WOUND DRESSINGS FORMULARY