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					                              Central Nervous System


4.1: Hypnotics and Anxiolytics

     Hypnotics                Notes           Form              Dose
     First Choice             Datasheets are not necessarily the brand kept
     Temazepam                CD schedule 3 10mg tabs           10-20mg at
     Datasheet                Second choice 10mg/5ml            bedtime
                              on NEPFT        liquid
                              formulary
     Second choice
     Zopiclone                First choice for     3.75mg and            7.5mg at bed
     Datasheet                NEPFT                7.5mg tabs            time
                              formulary                                  elderly initially
                                                                         3.75mg at
                                                                         bedtime,
                                                                         increased to
                                                                         7.5mg if
                                                                         necessary
     Lorazepam                                     5mg tablets           Refer to BNF
     Chloral hydrate                               200mg/5ml             Refer to BNF
                                                   elixir
                                                   500mg/5ml
                                                   mixture
     Cloral betaine                                707 mg tabs           1-2 tabs with
                                                                         water or milk
                                                                         before bedtime

Hypnotics should only be prescribed for short periods e.g. 2-4 weeks
maximum as advised by CSM.
All hypnotics should be prescribed/ labelled “only when necessary for sleep”.
Hypnotics should not be dispensed in a compliance aid or MDS to discourage
regular use.
Patients who have not previously been prescribed a hypnotic, should not
receive a hypnotic on discharge from inpatient care.




Further details or advice for the treatment of insomnia can be found in
NEPFT guidance for management of insomnia.

See NICE TA insomnia – newer hypnotic drugs

Melatonin              Off-label use             2mg MR tabs               Refer to continuing
                       See NEPFT                                           care guidelines
                       continuing care           (all other
                       guidelines for sleep      formulations are
                       disorders in              unlicensed in the UK)
                       children




                                          4.1
First        Second           Hospital       Primary          Specialist           Specialist
choice       choice           only           care only        shared care          initialisation
                            Central Nervous System


 Anxiolytics        Notes                         Form               Dose
 Diazepam                                         2mg,5mg and
 Datasheet                                        10mg tabs
                                                  2mg/5ml and
                                                  5mg/5ml liquid
                                                  2.5mg, 5mg
                                                  and 10mg
                                                  rectal solutions

                                                  10mg/2ml
                                                  emulsion
                                                  injection

 Lorazepam          Notes: Beware that this is the most addictive of
                    benzodiazepines. A person who is already addicted to it
                    will be unaffected by even quite high doses, and it may
                    make the person more aggressive, unreasonable and
                    difficult to handle so something else should then be used
                    (promethazine or an antipsychotic haloperidol or
                    Olanzapine)
                    The injection should be       1mg tab            See memo for
                    stored in a fridge and be     4mg/ml             alternatives in
                    given via an IV route.        injection          case of
                    If IV access not possible,                       lorazepam
                    may be given IM but must                         injection stock
                    be diluted with an equal                         shortage
                    volume of WFI.

 Chlordiazepoxide For alcohol detoxification      See
 Datasheet        only.                           “Guidelines for
                  Primary care contact            the best
                  “changes”. Secondary care       practice
                  refer to hospital policy.       treatment of
                  See MEAPC guidance on           Substance
                  discharge of patients on        Misuse” by
                  chlordiazepoxide                Essex DAT
 Oxazepam                                         10mg and           Refer to BNF
                                                  15mg tablets
 Buspirone          Response to treatment         5mg and 10mg       Refer to BNF
 Datasheet          may take up to two weeks.     tablets
                    Licensed for short term use
                    only.
 Promethazine                                     10mg, 25mg
                                                  tablets, 25mg
                                                  injection,
                                                  5mg/5ml liquid




                                       4.2
First          Second       Hospital      Primary       Specialist       Specialist
choice         choice       only          care only     shared care      initialisation
                            Central Nervous System


4.2: Drugs used in Psychosis and Related Disorders

                        Notes              Form                    Dose
 Chlorpromazine         Owing to the       25mg, 50mg and          Refer to BNF
 Datasheet              risk of contact    100mg tabs
                        sensitisation      100mg/5ml liquid
                        direct contact     25mg/5ml suspension
                        with
                        chlorpromazine
                        should be
                        avoided by the
                        person
                        administering
                        the drug.
                        Tablets should
                        not be crushed
                        and solution
                        should be
                        handled with
                        care.
 Benperidol                                250mcg tabs             0.25mg-1.5mg
                                                                   daily in divided
                                                                   doses and
                                                                   adjusted
                                                                   according to
                                                                   response.
                                                                   Elderly initially
                                                                   half adult
                                                                   dose.
 Flupentixol                               3mg tabs                3-9mg bd.
 Datasheet                                                         Max 18mg
                                                                   daily.
                                                                   Elderly initially
                                                                   quarter to half
                                                                   adult dose
 Haloperidol                               500mcg, 1.5mg, 5mg      Refer to BNF
 Datasheet                                 and 10mg tabs
                                           1mg/ml and 2mg/ml
                                           liquid
                                           5mg/ml injection
 Levomepromazine                           25mg tabs               Refer to BNF
 Datasheet                                 25mg/ml injection


  Refer to BNF section 4.2 for RCP advice on doses above BNF upper limit.

See NICE guidelines on antisocial personality disorders and personality
disorder - borderline


                                          4.3


First          Second       Hospital        Primary      Specialist    Specialist
choice         choice       only            care only    shared care   initialisation
                             Central Nervous System



   Please read antipsychotic bulletin for prescribing and administration advice
                             Notes             Form                  Dose
  Sulpiride                                    200mg, 400mg tabs     Refer to BNF
  Datasheet                                    200mg/5ml liquid
  Trifluoperazine                              1mg and 5mg tabs      Refer to BNF
  Datasheet                                    1mg/5ml syrup
                                               5mg/5ml liquid
  Zuclopenthixol                               2mg, 10mg and         Refer to BNF
  dihydrochloride                              25mg tabs
  Datasheet                                    50mg/ml and
  Zuclopenthixol acetate                       100mg/2ml injection
                                               as zuclopenthixol
                                               acetate for acute
                                               treatment.
  Risperidone                See CSM           0.5mg, 1mg, 2mg,      Refer to BNF
  Datasheet                  advice            3mg and 4mg tabs
                             regarding risk    1mg, 2mg and 4mg
                             of stroke in      orodispersible tabs
                             elderly with      1mg/ml liquid
                             dementia          Risperidone consta
                                               injection 25mg,
                                               37.5mg and 50mg
                                               vials - LINK
  Olanzapine                 See CSM           2.5mg, 5mg, 7.5mg,    Refer to BNF
  Datasheet                  advice            10mg and 15mg
                             regarding risk    tabs
                             of stroke in      5mg, 10mg and
                             elderly with      15mg orodispersible
                             dementia          tabs.
                                               10mg injection

                    Notes                 Form                       Dose
Quetiapine                                25mg, 100mg, 150mg         Refer to BNF
Datasheet                                 200mg and 300mg tabs
                                          and 50mg, 200mg,
                                          300mg & 400mg XL
Amisulpiride                              50mg and 200mg tabs        Refer to BNF
Datasheet
Aripiprazole                              5mg, 10mg, 15mg and        Refer to BNF
Datasheet                                 30mg tabs
Clozapine           Monitor leukocytes    25mg and 100mg tabs        Refer to BNF
Datasheet           and differential      MH specialist care or
                    blood counts          for LD, specialist care
                                          or individual shared
                                          care only.
Pericyazine                               2.5mg and 10mg tabs
Datasheet                                 10mg/5ml liquid


 See NICE guidelines for schizophrenia

                                         4.4
 First          Second       Hospital         Primary     Specialist     Specialist
 choice         choice       only             care only   shared care    initialisation
                                Central Nervous System


Antipsychotic Depot               Notes              Form                   Dose
injections
Flupentixol decanoate                                20mg/ml,               Refer to BNF
                                  CAUTION            50mg/0.5ml,
                                  PRODUCTS           100mg/ml and
                                  WITH               200mg/ml
                                  SIMILAR            injections
Fluphenazine decanoate            NAMES -            12.5mg/0.5ml,          Refer to BNF
Datasheet                         FREQUENTLY         25mg/ml and
                                  CONFUSED           100mg/ml
                                                     injections
Haloperidol decanoate                                50mg/ml and            Refer to BNF
Datasheet                                            100mg/ml
                                                     injections
Risperidone                       Risperdal          25mg, 37.5mg,          Refer to BNF
Datasheet                         consta             50mg vials
Zuclopenthixol decanoate                             200mg/ml and           Refer to BNF
Datasheet                                            500mg/ml
                                                     injections

Equivalent doses of oral antipsychotics   These equivalences are intended as an
LINK                                      approximate guide only. Individual dosage
                                          instructions should also be checked, patients
                                          should be carefully monitored after any dose
                                          change.
Antipsychotic drug                        Daily dose
Chlorpromazine                            100mg
Clozapine                                 50mg
Haloperidol                               2-3mg
Pimozide                                  2mg
Risperidone                               0.5-1mg
Sulpiride                                 200mg
Trifluoperazine                           5mg
Important – These equivalences must NOT be extrapolated beyond the maximum
dose for the drug. Higher doses require careful titration in specialist units and the
equivalences shown here may not be appropriate.

Equivalent doses of depot       These equivalences are intended as an approximate guide
antipsychotics                  only. Individual dosage instructions should also be checked,
LINK                            patients should be carefully monitored after any dose
                                change.
Antipsychotic drug              dose                               interval
Flupentixol decanoate           40mg                               2 weeks
Fluphenazine decanoate          25mg                               2 weeks
Haloperidol decanoate           100mg                              4 weeks
Pipotiazine palmitate           50mg                               4 weeks
Zuclopenthixol                  200mg                              2 weeks
decanoate
Important – These equivalences must NOT be extrapolated beyond the maximum
dose for the drug.
                                            4.5


First          Second          Hospital        Primary       Specialist        Specialist
choice         choice          only            care only     shared care       initialisation
                                Central Nervous System


4.2.3
Antimanic drugs             Notes                       Form                    Dose
Different lithium brands differ in their bioavailability. Patients should receive the same
brand at all times.
Olanzapine, amisulpride, quetiapine, risperidone Lamotrigine – unlicensed, but
recommended in the NICE guidelines
Lithium carbonate           Priadel is preferred        200mg S/Rand            Refer to BNF
(priadel)                   brand for patients          400mg S/R tabs
Datasheet                   starting on lithium.        520mg/5ml liquid (Li
                            Monitoring required.        5.4mmol/5ml
Lithium cards available                                 approx)
form pharmacy
Lithium citrate             Lithium carbonate           509mg/5ml               Refer to BNF
                            200mg tablets =             (5.4mmol/5ml lithium
Datasheet                   lithium citrate 509mg approx)
                            approx
Valproate semi sodium Specialist initiation             250mg and 500mg         Refer to BNF
(depakote)                                              tablets
Datasheet
Please refer to - CG38 Bipolar disorder: NICE guideline

4.3: Antidepressant drugs

It is not intended to change patients stabilised on non-formulary
antidepressants to formulary choice. The following choices are recommended
for new patients and when considering an alternative treatment.

Antidepressant prescribing advice:

Please refer to NICE clinical guidelines for anxiety and depression and OCD.

Dose: always aim for a therapeutic dose. If the patient can not tolerate the
antidepressant at this dose, change to a different antidepressant. Do not use
sub-therapeutic doses.

Duration: Antidepressants should be continued for at least six months after a
complete recovery is achieved. This should be at the same dose required to
achieve recovery.

Stopping antidepressants reduce dose of antidepressant in stop over at least
four weeks to avoid discontinuation symptoms. If abrupt withdrawal is
necessary, symptoms rarely last more than one to two weeks.

Paroxetine reduce dose by 10mg weekly or even more slowly if problematic.
Reduce dose to 5mg daily (liquid) and then stop.

Fluoxetine, can be stopped abruptly at 20mg daily dose, but interactions are
still possible for up to 5 weeks after stopping.


                                            4.6
First          Second          Hospital        Primary       Specialist       Specialist
choice         choice          only            care only     shared care      initialisation
                                         Central Nervous System


                                        Switching antidepressants

               Ref: The South London and Maudsley NHS foundation trust, Oxleas NHS
                          foundation Trust prescribing guidelines 9th edition

Swap from              To                                  Advice
MAOIs                  Any other drug                      Withdraw and await two weeks
Tricyclic              Other TCA                           Cross taper cautiously
antidepressants        SSRIs                               Halve dose add SSRI and withdraw slowly
(TCA)                  Venlafaxine                         Cross taper cautiously. Start with Venlafaxine
                                                           37.5mg ON
                       Mirtazapine                         Cross taper cautiously
                       MAOIs                               Withdraw and await one week
Citalopram             MAOIs                               Withdraw and wait for 1 week
                       TCA                                 Cross taper cautiously with low dose TCA
                       Venlafaxine                         Cross taper cautiously start Venlafaxine
                                                           37.5mg ON and increase very slowly
                       Fluoxetine                          Withdraw then start fluoxetine 10mg/day
                       Paroxetine                          Withdraw then start paroxetine 10mg/day
                       Setraline                           Withdraw then start sertraline 25mg/day
                       Mirtazapine                         Cross taper cautiously
Paroxetine             MAOIs                               Withdraw and wait for 2 weeks
                       TCAs                                Cross taper cautiously with very low dose
                                                           TCAs
                       Venlafaxine                         Cross taper cautiously, start venlafaxine
                                                           37.5mg/day and increase very slowly
                       Fluoxetine                          Withdraw then start fluoxetine
                       Citalopram                          Withdraw and start citalopram
                       Mirtazapine                         Cross taper cautiously
Fluoxetine             MAOIs                               Withdraw and wait 5-6 weeks
                       TCA                                 Stop fluoxetine. Wait 4-7 days. Start TCA at
                                                           very low dose and increase very slowly
                       Venlafaxine                         Withdraw, start venlafaxine 37.5mg ON and
                                                           increase very slowly
                       Citalopram                          Stop fluoxetine, wait 4-7 days , start
                                                           citalopram at 10mg/day increase slowly
                       Paroxetine                          Stop fluoxetine, wait 4-7 days , start
                                                           paroxetine at 10mg/day
                       Mirtazapine                         Cross taper cautiously
Sertraline             MAOIs                               Withdraw and await two weeks
                       TCA                                 Cross taper cautiously with low dose TCA
                       Venlafaxine                         Cross taper cautiously, start venlafaxine
                                                           37.5mg/day and increase very slowly
                       Mirtazapine                         Cross taper cautiously
Duloxetine             MAOIs                               Withdraw and await one week
                       TCA                                 Cross taper cautiously with very low dose
                                                           TCA
                       Venlafaxine                         Withdraw then start venlafaxine
                       Mirtazapine                         Withdraw then start mirtazapine
Venlafaxine            MAOIs                               Withdraw and wait at least one week
                       TCA and SSRIs                       Cross taper cautiously with very low doses
                       Mirtazapine                         Withdraw before starting Mirtazapine
                                                           cautiously
Mirtazapine            MAOIs                               Withdraw and wait for at least two weeks
                       TCAs, SSRIs and Venlafaxine         Withdraw and start alternative drug




                                                     4.7
             First       Second          Hospital      Primary        Specialist          Specialist
             choice      choice          only          care only      shared care         initialisation
                              Central Nervous System


Discontinuation symptoms:

What are discontinuation symptoms?

        At least one third of patients experience these symptoms after stopping
         antidepressants.
        Onset varies from 12 hours to 5 days after the last dose (or missed
         dose) determined by half life of a drug.
        Occasionally experience after dose reduction.
        Usually mild and self limiting, but can be severe and prolonged.

Common: (All)

        Anxiety, irritability, aggression, agitation, low mood and tearfulness
        Excitation, hyperactivity, impulsive behaviour, impairment of
         concentration
        Insomnia, excessive/ vivid dreaming and nightmares
        Lethargy, malaise, fatigue, weakness, myalgia
        Nausea, anorexia, abdominal discomfort, diarrhoea, vomiting

Common: (particularly SSRIs)

        Dizziness, giddiness, light head-headedness, vertigo
        Unco-ordination, unsteadiness
        Paraesthesia, numbness, „shock-like‟ sensations
        Rhinorrhoea, salivation, tremulousness, sweating, tension,
         restlessness

Uncommon: (Rare)

        Cardiovascular changes
        Withdrawal related delirium or mania
        Movement disorders, akathesia, bradykinesia, dyskinesia, dystonia,
         tremor

Risk factors

        Antidepressants with short half life
        Taking an antidepressant for 8 weeks or longer.
        Those who developed anxiety symptoms at the beginning of
         antidepressant therapy ( especially with SSRIs).
        Children and adolescents.

How to treat

If symptoms are mild: Reassure
If symptoms are severe: Reintroduce the original antidepressant and
gradually taper the dose.
                                    4.8
First          Second        Hospital       Primary     Specialist     Specialist
choice         choice        only           care only   shared care    initialisation
                             Central Nervous System

How to avoid:

Wherever possible antidepressants should be discontinued over at least 4
weeks. The shorter the half life the more important this is.

Serotonin syndrome:

        Serotonin syndrome results from serotonin hyperstimulation.
        Symptoms are usually mild and can be managed by drug withdrawal.
        Sever cases can lead to multiple organ failure and death.

        Symptoms include:
Restlessness, diaphoresis, tremor, shivering, myoclonus, confusion and
convulsions

        Onset is usually soon after starting and changing dose




                                        4.9
First          Second        Hospital     Primary     Specialist    Specialist
choice         choice        only         care only   shared care   initialisation
                                            Central Nervous System


                         Antidepressant prescribing in special situations
      Ref: Psychotropic drug directory 2009 by Stephen Bazire


Special situation          Lower risk                   Moderate risk                Higher risk
Breast feeding             Tryptophan                   Mianserin                    Reboxetine
                           Flupentixol LD               Mirtazapine                  Venlafaxine
                           Moclobemide                  SSRIs                        Doxepin
                           TCAs (most)                  Trazodone                    Duloxetine
                                                                                     MAOIs
Cardiovascular             Mirtazapine                  Moclobemide                  TCAs (especially
disease                    Duloxetine                   Reboxetine                   dosulepin)
                           Mianserin                    Venlafaxine
                           SSRIs                        MAOIs
                           Trazodone
                           Tryptophan
Diabetes                   Moclobemide                  Fluoxetine                   MAOIs
                           Duloxetine                   Mirtazapine
                           Tryptophan                   Mianserin
                           Reboxetine                   TCAs
                           SSRIs
                           Trazodone
                           Venlafaxine
Epilepsy                   Moclobemide                  Mirtazapine
                           MAOIs                        Duloxetine
                           Reboxetine                   Mianserin
                           SSRIs                        Trazodone
                           Tryptophan                   TCAs (most)
                                                        Venlafaxine
Narrow angle               Flupentixol                  SSRIs                        TCAs
glaucoma                   MAOIs                        Mirtazapine
                           Moclobemide                  Duloxetine
                           Trazodone                    Venlafaxine
                           Tryptophan
Liver disease              Mianserin                    Duloxetine                   Lofepramine
                           Paroxetine                   Mirtazapine                  MAOIs
                           Tryptophan                   Moclobemide
                                                        Reboxetine
                                                        SSRIs
                                                        Trazodone
                                                        TCAs
                                                        Venlafaxine




                                                           4.10

      First             Second              Hospital            Primary     Specialist    Specialist
      choice            choice              only                care only   shared care   initialisation
                                            Central Nervous System


                         Antidepressant prescribing in special situations
      Ref: Psychotropic drug directory 2009 by Stephen Bazire




Special situation          Lower risk                   Moderate risk                Higher risk
Old age                    Duloxetine                   MAOIs                        TCAs (most)
                           Lofepramine                  Mianserin
                           Mirtazapine                  Nortripyline
                           Moclobemide                  Trazodone
                           SSRIs                        Reboxetine
                           Tryptophan
                           Venlafaxine
Pregnancy                  Flupentixol                  Duloxetine                   Paroxetine
                           Tryptophan                   MAOIs                        Reboxetine
                                                        Mianserin
                                                        Mirtazapine
                                                        Moclobemide
                                                        SSRIs (except paroxetine)
                                                        Trazodone
                                                        TCAs
                                                        Venlafaxine
Renal disease              Mianserin                    Duloxetine                   Fluoxetine
                           Moclobemide                  MAOIs                        Venlafaxine
                           Trazodone                    Mirtazapine
                           TCAs                         Reboxetine
                           Tryptophan                   SSRIs




                                                           4.11

      First             Second              Hospital            Primary     Specialist    Specialist
      choice            choice              only                care only   shared care   initialisation
                            Central Nervous System



SSRIs are recommended as first choice in NICE guidelines.
Agitated and anxious people respond best to sedative antidepressants.

    Tricyclic and related Notes                  Form            Dose
    drugs
    Weight gain can be significant with TCAs.
    If patient drive, always counsel patient about sedation and slower reaction
    times.
    Arrhythmias and heart block occasionally follows the use of TCAs,
    particularly Amitriptyline, and may be a factor in the sudden death of
    patients with cardiac disease.
    Renal impairment, TCAs are excreted by kidneys, therefore start with low
    dose and increase slowly. Accumulation may occur causing adverse drug
    reactions. Dividing total daily dose into 2-3 doses may be helpful.
    Myocardial infarction, avoid TCAs if previous MI. Trazodone may be used
    but try to avoid any antidepressant therapy for two weeks post MI if
    possible.
    Elderly and dementia, Avoid TCA in dementia or where significant
    cognitive impairment present.
    Amitriptyline            Limited number 10mg, 25mg           Refer to BNF
    Datasheet                of TCA should       and 50mg tabs
                             be prescribed at 25mg/5ml
                             any one time,       liquid
                             due to danger in
                             over dose.
                             Frequently used
                             off-license to
                             treat pain.
    Lofepramine              Less sedating       70mg tabs       140-210mg
    Datasheet                and considered      70mg/5ml        daily in divided
                             safer in an over suspension         doses
                             dose
    Trazodone                                    50mg and        Refer to BNF
    Datasheet                                    100mg
                                                 capsules
                                                 150mg tabs
                                                 50mg/5ml
                                                 liquid
    Clomipramine                                 10mg, 25mg      Refer to BNF
    Datasheet                                    and 50mg
                                                 caps
                                                 75mg MR caps
    Imipramine                                   10mg and        Refer to BNF
    Datasheet                                    25mg tabs
    Doxepin                                      10mg, 25mg,     Refer to BNF
    Datasheet                                    50mg and
                                                 75mg caps
    Nortriptyline                                10mg and        Refer to BNF
    Datasheet                                    25mg tabs


                                        4.12
First        Second         Hospital        Primary      Specialist      Specialist
choice       choice         only            care only    shared care     initialisation
                            Central Nervous System


When prescribing SSRIs for depression:
        If no or poor response is achieved with an SSRI for optimal effect
         switch between classes rather than within a class.
        SSRIs may exacerbate sleep disturbance and cause symptoms such
         as anxiety, restlessness and agitation initially.
        Advise patients to take their SSRI in the morning as nocte
         administration may increase sleep disturbances.
        SSRIs have fewer anticholinergic and cardio toxic effect than TCAs.
        Sexual dysfunction can be complication of treatment with SSR
         antidepressants.
        SSRIs are the treatment of choice in depression post CVA or
         depression following acquired brain injury.
        SSRIs should be used with caution in Parkinson‟s disease as there are
         no controlled trials available and they have been cases of Fluoxetine
         and Paroxetine exacerbating motor symptoms.
        SSRIs are preferred over TCAs if post MI. SSRIs are antidepressant of
         choice with history of arrhythmias.
        Hepatic impairment restrict doses to lower end of dose range, avoid in
         severe liver disease.

 SSRIs             Notes                    Form                    Dose
 See CSM advice regarding SSRIs for major depressive disorder in children and
 adolescence. See CSM advice regarding hyponatraemia and SSRIs
 Risk of GI bleeding increased if used in combination with Aspirin and other
 NSAIDs, if patient over 80 yrs of age or have a history of GI bleeding.
 Caution in epilepsy.
 Citalopram        Mix drops with water, 10mg, 20mg and             Refer to BNF
 Datasheet         orange juice or apple 40mg tabs
                   juice before taking.     40mg/ml drops 8mg
                                            for drops may be
                                            considered to be
                                            equivalent to 10mg
                                            tabs.
 Fluoxetine        Long half-life.          20mg and 60mg           Refer to BNF
 Datasheet         If there is no           caps
                   response to              20mg/5ml liquid
                   Fluoxetine at lower
                   doses, increasing the
                   dose is unlikely to
                   produce additional
                   benefit but side
                   effects would be
                   expected to increase.
 Sertraline                                 50mg and 100mg          Refer to BNF
 Datasheet                                  tabs
 Paroxetine                                 20 and 30mg tabs        Refer to BNF
 Datasheet                                  10mg/5ml liquid
 Fluvoxamine                                50mg, 100mg tablets Refer to BNF
 Datasheet

                                       4.13

First          Second       Hospital       Primary     Specialist      Specialist
choice         choice       only           care only   shared care     initialisation
                            Central Nervous System


Other             Notes                    Form                           Dose
antidepressant
Mirtazapine       Appears to be safe in    15mg, 30mg and 45mg            Refer to
Datasheet         over dose.               orodispersible tabs            BNF
                  Weight gain may be       30mg tabs
                  significant.
                  See BNF for info on
                  blood disorders and
                  withdrawal
Venlafaxine       BP monitoring            37.5mg, 75mg tabs              Refer to
Datasheet         advisable, if dose       75mg and 150mg SR caps         BNF
                  exceeds 200mg daily.     Doses above 300mg are to
                                           be specialist initiated
                                           Continuing Care guidance
Reboxetine                                 4mg tabs                       Refer to
Datasheet                                                                 BNF
Duloxetine                                 30mg and 60mg tablets

4.3.2
MAOIs                      Notes               Form             Dose
Patients should avoid consuming large amounts of tyramine rich food, such as
mature cheddar, yeast extract, red wine and fermented soya bean products.
Patients should be advised to take the last dose before 3pm in order to minimise
sleep disturbance.
Phenelzine                 Fridge item         15mg tabs        Refer to BNF

Moclobemide                Specialist         150mg and        Refer to BNF
Datasheet                  initiation         300mg tabs

4.4: Central Nervous System Stimulants
See Continuing Care guidance
                  Notes                   Form                   Dose
Methylphenidate   Continuing care         5mg, 10mg and          Refer to BNF
Datasheet                                 20mg tabs (Ritalin     Equasym – contents of
                                                                 capsule may be
                                          and also 30mg          sprinkled onto a tbsp of
                                          Equasym)               apple sauce then
                                          18mg and 36mg SR       swallowed immediately
                                          tabs (Concerta XL)     without chewing.
Atomoxetine    Continuing care for        10mg, 18mg, 25mg,      Refer to BNF
Datasheet      ADHD                       40mg and 60mg
               See CSM advice,            caps
               following rare reports
               of hepatic disorders
Dexamphetamine Continuing care for        5mg tabs               Refer to BNF
Datasheet      ADHD and
               Narcolepsy
               CD schedule 2
               Monitor height and
               weight as growth
               retardation may
               occur during
               prolonged therapy.
Modafinil                                 100mg and 200mg        Refer to BNF
First         Second        Hospital       Primary     Specialist       Specialist
choice        choice        only           care only   shared care      initialisation
                            Central Nervous System


Datasheet                                 tabs
                                  4.14
4.5: Drugs Used in the treatment of obesity

                          Notes              Form             Dose
     For Primary Care use only - guidelines See NICE guidelines for obesity
     Orlistat             NICE has           120mg caps       120mg tds,
     Datasheet            recommended
                          that treatment
                          with Orlistat
                          should be
                          continued
                          beyond six
                          months only if at
                          least 10%
                          weight has been
                          lost since the
                          start of
                          treatment

4.6: Drugs used in nausea and vertigo

Anti-emetics should only be prescribed when the cause of vomiting is known.
For the management of chemotherapy induced nausea and vomiting refer to
flowchart.
  Class of anti-emetic      Anti-emetic           Useful for vomiting
                                                  caused by
  Anticholinergics          Hyoscine              Motion sickness

 Antihistamine                Cyclizine                 Motion sickness
                              Promethazine              Post-operative vomiting
                                                        Pregnancy
 Dopamine antagonist          Metoclopramide            Migraine
                              Domperidone               Pregnancy
                                                        Cytotoxic therapy
                                                        GI stasis
                              Prochlorperazine          Labyrinthitis
                                                        Migraine
                                                        Post-operative vomiting
                                                        Pregnancy
 Histamine analogue           Betahistine               Labyrinthitis

 5HT3 antagonist              Granisetron               Cytotoxic therapy
                              Ondansetron


                                       4.15
     Antiemetics           Notes         Form                  Dose
     First Choice          Datasheets are not necessarily the brand kept
     Metoclopramide        Caution in    10mg tabs             Refer to BNF
First        Second        Hospital         Primary     Specialist    Specialist
choice       choice        only             care only   shared care   initialisation
                            Central Nervous System


    Datasheet              elderly,       5mg/5ml liquid
                           young adults   10mg/2ml and
                           and children   100mg/20ml inj
                           - EPSE
    Second choice
    Prochlorperazine                      5mg and 25mg        Refer to BNF
    Datasheet                             tabs, 3mg buccal
                                          5mg/5ml syrup
                                          5mg and 25mg
                                          Supp
                                          12.5mg/ml inj
    Cyclizine                             50mg tabs           Refer to BNF
    Datasheet                             50mg/ml inj
    Domperidone                           10mg tabs           Refer to BNF
    Datasheet                             5mg/5ml
                                          suspension
                                          30mg Supp
    Promethazine                          10mg and 25mg       Refer to BNF
    Datasheet                             tabs
                                          5mg/5ml syrup
                                          25mg/1ml inj
    Haloperidol                           500mcg caps         Refer to BNF
    Datasheet                             1.5mg, 5mg and
                                          10mg tabs
                                          1mg/1ml and
                                          2mg/ml liquid

    Hyoscine                              300mcg sublingual   Refer to BNF
    hydrobromide                          tabs
    Datasheet                             400-600mcg
                                          injection

Specialist use only

    Anti-emetics           Notes             Form              Dose
    First Choice           Datasheets are not necessarily the brand kept
    Granisetron                              1mg tabs          Refer to BNF
    Datasheet                                3mg/3ml inj
    Second choice
    Ondansetron                              4mg/8mg          Refer to BNF
    Datasheet                                tabs/melt tabs
                                             4mg/5ml liquid
                                             4mg/2ml and
                                             8mg/4ml inj
    Palonosetron                             50microgm/ml     Refer to BNF




                                      4.16
    Drugs used in          Notes             Form             Dose
    vestibular disorders
    First Choice           Datasheets are not necessarily the brand kept
First        Second        Hospital       Primary     Specialist      Specialist
choice       choice        only           care only   shared care     initialisation
                           Central Nervous System


     Betahistine                             8mg and 16mg    Refer to BNF
     Datasheet                               tabs
     Second choice
     Cinnarizine                             15mg tabs       Refer to BNF
     Datasheet
     Prochlorperazine                        5mg and 25mg    Refer to BNF
     Datasheet                               tabs
                                             5mg/5ml syrup
                                             5mg and 25mg
                                             Supp
                                             12.5mg/ml inj


 Complementary methods effective in nausea and vomiting:
 Seabands: not prescribable on NHS but may be purchased.
 Carbonated drinks and ginger may be effective.


4.7: Analgesics

Pain control must be reviewed frequently.
It is important that analgesics are given regularly for chronic pain as they are
more effective in preventing the development of pain and relieving established
pain.
Specific dosage in instructions should be written on a prescription, i.e. “X to
be taken X hourly when required for pain” rather than simply prn.
Analgesic efficacy
Refer to the Oxford internet pain site which can be accessed at
http://www.jr2.ox.ac.uk//bandolier

Analgesic ladder


Adults



Analgesic ladder


Children

See NICE guidelines for feverish illness in children
See NPSA rapid response report regarding reducing dosing errors with opioid
 ;
medicines


                                      4.17
   Non-opioid analgesics    Notes              Form              Dose
   First Choice             Taking 8 tablets per day of soluble paracetamol
                            may increase sodium chloride by 8g daily
First        Second        Hospital      Primary     Specialist      Specialist
choice       choice        only          care only   shared care     initialisation
                                Central Nervous System


   Paracetamol                                      500mg            Refer to BNF
   Datasheet                                        tabs/soluble
                                                    tabs
                                                    120mg/5ml
                                                    and 250mg/5m
                                                    suspension
                                                    125mg and
                                                    500mg Supp
                                                    1g/100ml
                                                    infusion
   Second choice                 Datasheets are not necessarily the brand kept
   Aspirin                       Gastric irritation 300mg            Refer to BNF
   Datasheet                     may be a           tab/soluble
                                 problem            tabs
                                 EC aspirin is not 300mg Supp
                                 recommended
                                 (DTB Jan 1997
                                 page 7-8) GI
                                 side effects are
                                 caused
                                 systemically.

    Compound analgesics         Notes              Form              Dose
    First Choice                Taking 8 tablets per day of soluble co-codamol may
                                increase sodium chloride by 8g daily.
    Co-codamol                  Codeine and        8/500mg and       Refer to BNF
                                paracetamol        30/500mg tabs
                                When co-
                                codamol is
                                prescribed and
                                no strength is
                                stated the 8/500
                                will be
                                dispensed.
    Second choice
    Co-dydramol                 Dihydrocodeine       10/500mg tabs       Refer to BNF
                                and
                                paracetamol

Co-proxamol has little more analgesic effect than paracetamol alone in acute pain. See
MHRA advice about withdrawal of Co-proxamol and interim prescribing advice.
It is associated with dependence, sedation and increased risk of falls and at recommended
doses provides sub-optimal therapeutic dose of paracetamol.
Co-proxamol is dangerous in over dose and reports show that fatal over doses due to co-
proxamol are the second most frequent means of suicide with prescribed drugs in England
and Wales. Cancellation of licences for Co-Proxamol will be at the end of 2007. All patients
currently on therapy should be switched.




                                     4.18
Patient controlled analgesia (PCA) are available via Broomfield Hospital
pharmacy aseptic department – 01245 516188

First          Second           Hospital         Primary       Specialist       Specialist
choice         choice           only             care only     shared care      initialisation
                            Central Nervous System


    Opioid              Notes                 Form             Dose
    analgesics
    First Choice        Datasheets are not necessarily the brand kept
    Codeine             Caution – causes     15mg and          Refer to BNF
                        constipation         30mg tabs         Max dose
                                             25mg/5ml          240mg daily
                                             syrup
                                             60mg/ml inj
                                             (CD)
    Morphine            For 5mg dose         (Zomorph          Refer to BNF
    Datasheet           prescribe MST        preferred
                        For break through    brand)
                        pain use sevredol or
                        Oramorph
                        CDS2
    Diamorphine         CDS2                 5mg and 10mg Refer to BNF
    Datasheet                                inj
                                             30mg, 100mg
                                             and 500mg for
                                             continuous
                                             infusion
    Alfentanil          CDS2                 1mg/2ml and       Refer to BNF
                                             5mg/1ml inj
    Fentanyl            CDS2                 100mcg/2ml        Refer to BNF
    Datasheet           Apply patches to     and               Patches are
                        dry, non irritated,  500mcg/10ml       not licensed
                        non irradiated, non  25mcg,            for acute pain
                        hairy skin on torso  50mcg. 75mcg Due to long
                        or upper arm,        and 100mcg        duration of
                        removing after 72    patches           action monitor
                        hrs and siting new   200mcg,           patient for 24
                        patch on a different 400mcg,           hours post
                        area.                600mcg,           removal if
                        Allow 24hrs before   800mcg,           suffering side
                        evaluating effect.   1.2mg and         effects.
                        Loz is for morphine  1.6mg Loz
                        intolerant patients
                        only.




                                       4.19
    Opioid analgesics      Notes             Form              Dose
    Second Choice          Datasheets are not necessarily the brand kept
    Dihydrocodeine                           30mg tabs         Refer to BNF
    Datasheet                                10mg/5ml
First        Second         Hospital       Primary     Specialist     Specialist
choice       choice         only           care only   shared care    initialisation
                           Central Nervous System


                                              liquid
                                              50mg/ml inj
                                              (CD)
    Oxycodone             CDS2                5mg,            Refer to BNF
    Datasheet             Oxynorm is non-     10mg,20mg
                          modified release    caps
                          preparation.        10mg/ml and
                          Oxycontin is the    5mg/5ml
                          MR preparation      solution
                                              5mg, 10mg,
                                              20mg and
                                              40mg MR tabs
    Pethidine             CDS2                50mg tab        Refer to BNF
    Datasheet                                 50mg/ml,
                                              50mg/5ml and
                                              100mg/2ml inj

    Buprenorphine         CD                  200mcg SL       Refer to BNF
    Datasheet             Patches are         tabs
                          used in             35mcg
                          oncology,           52.5mcg and
                          palliative care     70mcg
                          and by the          patches
                          chronic pain
                          team
    Third Choice
    Tramadol              CSM has             50mg            Refer to BNF
    Datasheet             cautioned its       dispersible     Max 400mg
                          use I patients      tabs, 50mg      daily
                          with a history of   caps
                          epilepsy as         50mg, 100mg
                          there may be an     ,150mg,200mg
                          increased risk of   SR tabs/caps
                          convulsions.




                                       4.20
Neuropathic Pain

                          Notes             Form              Dose
    First line            Refer to Neuropathic pain guidelines

First            Second   Hospital          Primary     Specialist    Specialist
choice           choice   only              care only   shared care   initialisation
                           Central Nervous System


     Amitriptyline        Unlicensed –      10mg, 25mg        Refer to BNF
     Datasheet            see policy        and 50mg tabs
                                            25mg/5ml
                                            liquid
     Second line          Datasheets are not necessarily the brand kept
     Imipramine           Unlicensed –      10mg, 25mg        Refer to BNF
     Datasheet            see policy        tablets
     Nortriptyline        Unlicensed- see 10mg & 25mg         Refer to BNF
                          policy            tablets
     Gabapentin                             100mg,            Refer to BNF
     Datasheet                              300mg,
                                            400mg, 600mg
                                            and 800mg
                                            caps
     Third line
     Pregabalin           To be initiated in   25mg, 50mg,    Refer to BNF
     Datasheet            accordance with      75mg, 100mg,
                          local                150mg, 200mg
                          neuropathic pain     and 300mg
                          guidelines           caps
     Fourth line
     Lidocaine plasters   Initiation by pain   5% plasters    Upto 3 plasters
                          team in                             may be
                          secondary care                      applied for
                          in accordance                       large areas.
                          with guidelines                     Need 12 hour
                                                              plaster-free
                                                              period

Trigeminal neuralgia

Phenytoin and TCAs have also been used to treat trigeminal neuralgia

                          Notes                Form           Dose
     Carbamazepine        Plasma               100mg and      Refer to BNF
     Datasheet            concentration        200mg tabs     125mg Supp is
                          monitoring s         200mg and      considered
                          advised.             400mg MR       equivalent to
                                               tabs           100mg oral
                                               100mg/5ml      preparation.
                                               liquid
                                               125mg and
                                               250mg Supp




                                       4.21
Anti-Migraine Drugs

Where migraine attacks are frequent consideration should be given to the
avoidance of trigger factors such as stress or diet (cheese, chocolate etc.)


First         Second       Hospital        Primary     Specialist    Specialist
choice        choice       only            care only   shared care   initialisation
                            Central Nervous System



                             Notes             Form              Dose
    First Choice
    Since peristalsis is often reduced in migraine attacks, dispersible
    preparations are preferred.
    Migraleve pink           For yellow        Paracetamol       2 tabs at the
                             migraleve use     500mg,            onset.
                             Co-codamol        Codeine 8mg       Max 2 in 24
                             8/500             and buclizine     hrs
                                               6.25mg tabs
    Pizotifen                Can cause         500mcg and        Refer to BNF
    (prophylaxis)            weight gain and 1.5mg tabs
    Datasheet                sedation          250/5ml elixir
    Second choice            Datasheets are not necessarily the brand kept
    Rizatriptan              Half dose in      5mg and 10mg Refer to BNF
    Datasheet                patients taking   tabs              Max 20mg in
                             Propranolol.      10mg melt         24hrs
                             Not to be taken   tabs
                             within 2 hrs of
                             Propranolol.

    Sumatriptan            The tablet and     50mg and          Refer to BNF
    Datasheet              nasal spray        100mg tabs
                           preparations are   10mg nasal
                           for primary care   spray
                           use only.          6mg/0.5ml inj
    Beta-blockers          See section 2.4
    (prophylaxis)
    Topiramate                                25mg, 50mg,
    (prophylaxis)                             100mg &
                                              200mg tablets




                                       4.22
4.8 Antiepileptics

Refer to NICE guidelines regarding newer drugs in adults and children. Refer
to full NICE guidance in epilepsy.

First       Second         Hospital        Primary      Specialist      Specialist
choice      choice         only            care only    shared care     initialisation
                          Central Nervous System


Young children metabolise anti-epileptic drugs more rapidly than adults and
therefore require more frequent doses and a higher amount per Kg body
weight.

Anti-epileptic drugs (AED) should be prescribed by brand name where
appropriate.

Combination therapy enhances toxicity and drug interactions may occur. A list
of interactions can be found in the BNF chapter 4.8.1.

Abrupt withdrawal should be avoided as this may precipitate severe rebound
seizures.

Advice on therapeutic drug monitoring regarding sampling times and
monitoring levels can be sought from pharmacy or pathology.

Management of epilepsy in pregnancy:
   All women of childbearing age should be offered folic acid 5mg daily
     with AED treatment
   Doses of AEDs should not be increased routinely in pregnancy but
     should only be adjusted on clinical grounds. The usual oral dose of
     AED should be continued during labour and post-natally.

CSM advice has been issued for suicidal behaviour and antiepileptic drugs




                                     4.23
    Tonic/Clonic         Notes              Form            Dose
    seizures
    First Choice         Datasheets are not necessarily the brand kept
    Carbamazepine        Plasma            100mg and         Refer to BNF
    Datasheet            concentration     200mg tabs
First       Second        Hospital      Primary     Specialist     Specialist
choice      choice        only          care only   shared care    initialisation
                           Central Nervous System


                          monitoring is      200mg and         125mg Supp is
                          advised            400mg MR          considered
                                             tabs              equivalent to
                                             100mg/5ml         100mg oral
                                             liquid            preparation.
                                             125mg and
                                             250mg Supp
     Phenytoin sodium     On the basis of    25mg, 50mg        Refer to BNF
     Datasheet            single dose        and 100mg
                          tests there are    capsules
                          no clinically      50mg and
                          relevant           100mg tab
                          differences in     90mg/15ml liq
                          bioavailability    (90mg liquid is
                          between            approximately
                          phenytoin          equivalent to
                          sodium tablets     100mg solid
                          and capsules       dose)
                          but there may      250mg/5ml inj
                          be a               50mg
                          pharmacokinetic    chewable
                          basis for          tablets
                          maintaining the
                          same brand of
                          phenytoin in
                          some patients




If phenytoin suspension is co-administered with enteral tube feeding, there is
likely to be a significant reduction in the absorption of phenytoin.
To minimise ant interaction the following regimen is recommended.
     Phenytoin should be given as a single daily dose
     The feed is stopped for 2 hrs before the administration of phenytoin
        and the tube is flushed with 100mls of water.
     Dose of phenytoin is administered
     The tube is immediately flushed with 100mls of water.
     2 hrs after administering the phenytoin the feed is restarted.
Even using this regimen poor absorption of phenytoin may result. It is
therefore recommended the serum phenytoin levels are measured.




                                      4.24
     Absence/ myoclonic   Notes              Form              Dose
     seizures
     First Choice         Datasheets are not necessarily the brand kept
     Valproate sodium     IV dose is the    200mg and         Refer to BNF
     Datasheet            same as oral      500mg tabs
First        Second       Hospital        Primary     Specialist      Specialist
choice       choice       only            care only   shared care     initialisation
                                Central Nervous System


                               dose               100mg
                                                  crushable tabs
                                                  200mg, 300mg
                                                  and 500mg
                                                  chrono tabs
                                                  200mg/5ml
                                                  liquid
                                                  400mg inj
    Second line
    Clonazepam                                    500mcg and        Refer to BNF
    Datasheet                                     2mg tabs
                                                  1mg/2ml inj


    Simple/ complex            Notes              Form              Dose
    partial seizures
    First Choice
    Carbamazepine              Plasma             100mg and         Refer to BNF
    Datasheet                  concentration      200mg tabs
                               monitoring is      200mg and         125mg Supp is
                               advised            400mg MR          considered
                                                  tabs              equivalent to
                                                  100mg/5ml         100mg oral
                                                  liquid            preparation.
                                                  125mg and
                                                  250mg Supp
    Phenytoin sodium           On the basis of    25mg, 50mg        Refer to BNF
    Datasheet                  single dose        and 100mg
                               tests there are    capsules
                               no clinically      50mg and
                               relevant           100mg tab
                               differences in     90mg/15ml liq
                               bioavailability    (90mg liquid is
                               between            approximately
                               phenytoin          equivalent to
                               sodium tablets     100mg solid
                               and capsules       dose)
                               but there may      250mg/5ml inj
                               be a               50mg
                               pharmacokinetic    chewable
                               basis for          tablets
                               maintaining the
                               same brand of
                               phenytoin in
                               some patients


                                          4.25
 Specialist use        Notes                   Form                        Dose
 only
 Lamotrigine           MHRA consider           25mg, 50mg, 100mg and       Refer to
 Datasheet             generic                 200mg tabs                  BNF
                       Lamotrigine             2mg, 5mg, 25mg and

First        Second            Hospital        Primary     Specialist       Specialist
choice       choice            only            care only   shared care      initialisation
                              Central Nervous System


                    bioequivalent to        100mg dispersible tabs
                    branded.
 Gabapentin                                 100mg, 300mg, 400mg,          Refer to
 Datasheet                                  600mg and 800mg tabs          BNF
 Pregabalin                                 25mg, 50mg, 75mg,
                                            100mg, 150mg, 200mg,
                                            300mg capsules
 Levetiracetam      For adjunct             250mg and 500mg tabs          Refer to
 Datasheet          treatment of partial                                  BNF
                    seizures
 Topiramate         Caps can be             25mg, 50mg, 100mg and         Refer to
 Datasheet          opened and              200mg tabs                    BNF
                    sprinkled onto soft
                    food.
 Clobazam           For adjunct             10mg tablets                  Refer to
                    treatment in                                          BNF
                    children
 Phenobarbital      Schedule 3              15mg, 30mg, 60mg tabs,        Refer to
                                            15mg/5ml liquid               BNF
 Lacosamide                                 50mg, 100mg, 150mg,
                                            200mg tablets &
                                            15mg/ml syrup &
                                            10mg/ml infusion


    Febrile convulsions      Notes                Form            Dose
    Diazepam                 Diazepam             10mg/2ml        Refer to BNF
    Datasheet                emulsion inj         emulsion inj
                             should be used       10mg/2ml inj
                             for IV injection     2.5mg, 5mg
                             as it is less        and 10mg
                             irritant             rectal tubes




                                         4.26
    Status                Notes                   Form            Dose
    epilepticus
    First Choice          Specialist use only
    Diazepam              Diazepam                10mg/2ml        Refer to BNF
    Datasheet             emulsion inj should     emulsion inj
First         Second         Hospital           Primary     Specialist     Specialist
choice        choice         only               care only   shared care    initialisation
                         Central Nervous System


                     be used for IV         10mg/2ml inj
                     injection as it is     2.5mg, 5mg
                     less irritant          and 10mg
                                            rectal tubes
    Phenytoin        Phenytoin injection    250mg/5ml inj     Refer to BNF
    Datasheet        should only be
                     used when oral
                     route is not
                     available. When
                     used it should be
                     given into a large
                     vein (the solution
                     has a PH of 12)
                     and at a rate not
                     grater than 50mg
                     per minute with
                     cardiac monitoring
    Fosphenytoin     Pro-Epanutin to be     75mg/ml inj       Refer to BNF
    Datasheet        prescribed as                            Monitoring
                     fosphenytoin and                         instructions in
                     phenytoin sodium                         BNF
                     equivalents (PE)
                     e.g.1mg phenytoin
                     sodium equivalent
                     to 1.5mg
                     fosphenytoin
    Clonazepam                              1mg/1ml inj       Refer to BNF
    Datasheet
    Midazolam        Unlicensed             10mg/ml           Refer to BNF
    Datasheet                               buccal solution
    Lorazepam        Fridge item            1mg/ml inj        Refer to BNF
    Datasheet
    Paraldehyde      Is an unlicensed       5ml inj           Refer to BNF
    Datasheet        product available      Paraldehyde in
                     on named patient       oil enema
                     basis. Paraldehyde
                     may adversely
                     affect plastics.
                     Administer using a
                     glass syringe or a
                     plastic syringe and
                     give immediately.




                                  4.27
         4.9: Drugs used in Parkinsonism and related disorders
                See NICE guidelines on Parkinson‟s disease

Dopaminergic drugs

First      Second        Hospital         Primary     Specialist      Specialist
choice     choice        only             care only   shared care     initialisation
                                Central Nervous System


   Co-beneldopa          Dispense in original container
   Brand Name            Levodopa content Benserazide               Form
                                              content
   Madopar 62.5          50mg                 12.5mg                Caps/ dispersible
                                                                    tabs
   Madopar 125           100mg                 25mg                 Caps/ dispersible
                                                                    tabs
   Madopar CR            100mg                 25mg                 MR caps
   Madopar 250           200mg                 50mg                 Caps


   Co-careldopa
   Brand Name            Levodopa content      careldopa content    Form
   Sinemet 62.5          50mg                  12.5mg               tabs
   Sinemet 110           100mg                 10mg                 tabs
   Sinemet plus          100mg                 25mg                 tabs
   Sinemet 275           250mg                 25mg                 tabs
   Half-sinemet CR       100mg                 25mg                 MR tabs
   Sinemet CR            200mg                 50mg                 MR tabs


       The recommended daily dose of carbidopa is 70-100mg daily if necessary
        to achieve full inhibition of peripheral dopa-decarboxylase.
       Normal preparation of Sinemet can be dispersed in water immediately
        before administration.




                                           4.28
Specialist use only   Notes                                Form            Dose
Bromocriptine                                              1mg and 2.4mg   Refer to BNF
Datasheet                                                  tabs
                                                           10mg caps
Selegiline            If taken twice daily. Take second    5mg tabs        Refer to BNF

   First         Second         Hospital       Primary      Specialist     Specialist
   choice        choice         only           care only    shared care    initialisation
                               Central Nervous System


Datasheet           dose at no later than midday.          10mg/5ml
                    Concurrent levodopa doses may          liquid
                    need to be reduced by 10-50%.
Pergolide           During pergolide titration             50mcg, 250mg    Refer to BNF
Datasheet           levodopa dose may be reduced           and 1mg tabs
                    cautiously.
Ropinirole          When administered as adjunct to        1mg, 2mg and    Refer to BNF
Datasheet           levodopa concurrent dose of            5mg tabs and    Also used in
                                                                           moderate/severe
                    levodopa may be reduced by             starter pack    restless legs
                    Approx 20%                                             syndrome
Cabergoline         Concurrent dose of levodopa            1mg, 2mg and    Refer to BNF
Datasheet           may decrease gradually while the       4mg tabs
                    dose of cabergoline is increased.
                    Dispense in original container.
Apomorphine         Hospital admission and at least        20mg/2ml and    Refer to
Datasheet           two days of pre-treatment with         50mg/5ml inj    Guidance and
                    domperidone for nausea and             10mg/ml Apo-    Refer to BNF
                    vomiting is required for initiation.   go 3ml pen
Entacapone          Concurrent levodopa dose may           200mg tabs      200mg with
Datasheet           need to be reduced by about 10-                        each dose of
                    30%.                                                   levodopa with
                                                                           dopa-
                                                                           decarboxylase
                                                                           inhibitor.
                                                                           Max 2g daily
Pramipexole         88mcg base is approximately            88mcg and 180   Refer to BNF
Datasheet           equivalent to 125mcg salt and          mcg tabs
                    180mcg base is approximately
                    equivalent to 250mcg of salt.
                    During pramipexole titration
                    levodopa may be reduced.
Stalevo             Levodopa/Carbidopa/Entacapone          30 and 100      Refer to BNF
Datasheet           50mg/12.5mg/200mg                      tablet packs
                    100mg/25mg/200mg
                    150mg/37.5mg/200mg
Rotigotine          Neupro patches                         Packs of 28     Refer to BNF
Datasheet           Treatment initiation pack,
                    2mg/24hrs, 4mg/24hrs,
                    6mg/24hrs, 8mg/24hrs
                    STORE IN A FRIDGE




                                    4.29
  Anticholinergic drugs used in Parkinsonism

                              Notes             Form              Dose
        First Choice          Datasheets are not necessarily the brand kept
        Trihexphenidyl                          2mg and 5mg       Refer to BNF
  First         Second        Hospital         Primary      Specialist     Specialist
  choice        choice        only             care only    shared care    initialisation
                            Central Nervous System


    Datasheet                                   tabs
                                                5mg/5ml liquid
    Second choice
    Procyclidine                                5mg tabs         Refer to BNF
    Datasheet                                   5mg/5ml liquid
                                                5mg/ml inj
    Orphenadrine                                50mg tabs        150mg daily in
    Datasheet                                   25mg/5ml         divided doses,
                                                liquid           increase
                                                                 gradually. Max
                                                                 400mg daily

Drugs used in essential tremor, chorea, tics and related disorders

                        Notes           Form                     Dose
  First Choice          Datasheets are not necessarily the brand kept
  Tetrabenazine                         25mg tabs                Refer to BNF
  Datasheet
  Second choice
  Haloperidol                            500mcg, 1.5mg, 5mg        Refer to BNF
  Datasheet                              and 10mg tabs
                                         1mg/ml and 2mg/ml
                                         liquid
                                         50mg/ml injection
  Trihexphenidyl                         2mg and 5mg tabs          Refer to BNF
  Datasheet                              5mg/5ml liquid
  Clonidine                              25mcg tabs                Refer to BNF
  Datasheet
  Sulpiride                              200mg and 400mg           Refer to BNF
  Datasheet                              tabs
                                         200mg/5ml
                                         suspension
  Beta-blockers                          See section 2.4           Refer to BNF
  Specialist use only
  Piracetam                              800mg and 1.2g tabs
  Datasheet                              333.3mg/ml liq
  Riluzole              See NICE         50mg tabs                 Refer to BNF
  Datasheet
  Torsion dystonias &   Specialist use only
  other involuntary
  movement
  Botulinum A toxin                      100units/vial             Refer to BNF
  Datasheet




                                 4.30
4.10: Drug used in substance dependence
See NICE – drug misuse methadone & buprenorphine and smoking cessation
And drug misuse – opiod detox
                        Notes                     Form           Dose
 Alcohol withdrawal     Datasheets are not necessarily the brand kept

First        Second        Hospital           Primary     Specialist    Specialist
choice       choice        only               care only   shared care   initialisation
                             Central Nervous System


 Chlordiazepoxide        Drug of choice with         5mg and     Refer to BNF
 Datasheet               alcohol withdrawal.         10mg
                         See discharge checklist     tab/caps
 Specialist initiation
 Disulfiram              Patients should not         200mg
 Datasheet               ingest alcohol at all and   tabs
                         should be warned of
                         possible presence of
                         alcohol In liquid
                         medicines, foods and
                         even in toiletries
 Acamprosate             Recommended treatment       333mg       Refer to BNF
 Datasheet               period one year.            tabs
 Opioid dependence
 Methadone                                           Mixture     Refer to BNF
 Datasheet                                           1mg/ml SF
 Buprenorphine           For those receiving         400mcg,     Refer to BNF
 Datasheet               methadone, dose should      2mg and
                         be reduced to max 30mg      8mg SL
                         daily before starting       tabs
                         Buprenorphine.              (subutex)
 Naltrexone              See NICE                    50mg tabs   Refer to BNF
 Datasheet
 Lofexidine                                          200mg       Refer to BNF
 Datasheet                                           tabs
 Cigarette smoking       See NICE guidelines
 Bupropion               Primary care                150mg       Refer to BNF
 Datasheet                                           tabs
 NRT                                                 Refer to    Refer to BNF
                                                     BNF
 Varenicline             Primary care                NICE        Refer to BNF

4.11 Drugs for dementia
See Continuing Care guidance
                            Notes           Form                Dose
    First Choice            Specialist use only. Refer to NICE guidance.
    Rivastigmine                            1.5mg, 3mg,         Refer to BNF
    Datasheet                               4.5mg and 6mg
                                            caps
    Donepezil                               5mg and 10mg        Refer to BNF
    Datasheet                               tabs
    Galantamine                             4mg, 8mg and        Refer to BNF
    Datasheet                               12mg caps
                                            4mg/ml liquid


                                        4.31




First          Second       Hospital       Primary      Specialist    Specialist
choice         choice       only           care only    shared care   initialisation

				
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