NMHC DRUG FORMULARY

The Norfolk & Waveney Mental Health Partnership NHS Trust formulary has been compiled by the NMHC Pharmacotherapy Advisory Committee in conjunction with prescribers and users throughout the Trust.
HYPNOTICS

Please note:

Non-drug management is preferable e.g. proper sleep hygiene etc (see separate section). All hypnotics have some addictive or abuse potential

If drugs necessary, restrict to "when required" use, and possibly add "only after 12 midnight" or similar

Avoid including on discharge prescriptions where at all possible.

First choice;-

Other sedative drugs given at night

Zopiclone (although recent evidence suggests a real addictive potential)

Alternatives;-

Chloral betaine (some addictive potential)

Zolpidem (some addictive potential)

Nitrazepam (long half-life)

Promazine (longer-term use not recommended)

Promethazine (limited potency)

Temazepam (with caution in potential misusers)

Non-formulary;-

Flunitrazepam (use temazepam - has similar characteristics)

Loprazolam (use temazepam - has similar characteristics)

Other "Black-listed" benzodiazepine

Clomethiazole (not recommended for routine use as hypnotic)

ACUTE PSYCHIATRIC EMERGENCY (see protocol)

First choice;-

Haloperidol

Diazepam, lorazepam or clonazepam

Alternatives;-

Zuclopenthixol acetate ("Acuphase")

Chlorpromazine (use only with great care in the elderly)

Droperidol (IV only)

ANXIOLYTICS

There is no real first choice drug as all have problems associated with their use. With symptomatic anxiety, treatment of the underlying disorder is essential. Non-drug treatments are preferable in the longer-term.

First choice:

Thioridazine (low dose)

Propranolol (low dose, for physical symptoms)

Diazepam (for short-term episodes, using BNF and Trust prescribing guidelines)

Alternatives;-

Chlordiazepoxide

Lorazepam (continuation of psychiatric therapy only)

Buspirone

SSRIs or tricyclics

Flupenthixol (low dose)

Non-formulary;-

Clobazam (use in epilepsy only)

Other Black-listed benzodiazepines

Chlormezanone (not recommended - use a first choice drug)

ANTIPSYCHOTICS

or NEUROLEPTICS

First choice:

Phenothiazines:

Chlorpromazine

Thioridazine

Trifluoperazine

Butyrophenones:

Haloperidol

Thioxanthenes:

Zuclopenthixol

Others:

Sulpiride

Risperidone

Depot injections:

Fluphenazine decanoate

Flupenthixol decanoate ("Depixol")
Zuclopenthixol decanoate ("Clopixol")

Alternatives:

Perphenazine

Methotrimeprazine (levomepromazine)

Droperidol (IV use only)

Pimozide (CSM advises care)
Haloperidol decanoate ("Haldol Decanoate")

Fluspirilene ("Redeptin")

Clozapine (see protocol and algorithm, assess initially and at 3 months)

Olanzapine (see algorithm, assess initially and at 3 months)

Sertindole (see algorithm, assess initially and at 3 months)

Quetiapine (see algorithm, assess initially and at 3 months)

Non-formulary;-

Droperidol (orally)

Amisulpride (no proven advantage over sulpiride, relatively expensive)

Pipothiazine palmitate ("Piportil") (expensive phenothiazine - use Modecate as an equivalent)

Prochlorperazine (not for psychiatric use - use another phenothiazine)

Benperidol (very expensive, no evidence for specific anti-sexual activity. Use haloperidol)

Loxapine (expensive and of limited potency)

MOOD STABILISING DRUGS

Lithium carbonate ("Camcolit-250", "Camcolit-400" and "Priadel 200mg", lithium citrate syrup as "Priadel")

Carbamazepine (plain tablets and syrup. "Tegretol Retard" for where side effects on higher dose therapy occurs)

Sodium valproate (unlicensed)

Non-formulary;-
"Priadel-400" (use Camcolit 400)

"Phasal" (variable bioequivalence & should not be used. Change to another preparation but check lithium levels carefully)

"Liskonum" 450mg (use Camcolit 400)

Lithium citrate ("Litarex")

ANTIDEPRESSANTS

First choice;-

Amitriptyline (not S/R preps)

Clomipramine (not S/R preps)

Dothiepin

Imipramine

Lofepramine

SSRIs;-

Citalopram (cheapest in community)

Fluoxetine (joint second cheapest, at 20mg/d)

Paroxetine (joint second cheapest, at 20mg/d)

MAOIs;-

Phenelzine

Others;-

Trazodone

Alternatives;-

Tricyclics;-

Amoxapine (Consultant Only)

Doxepin

Nortriptyline (Consultant Only)

Trimipramine

MAOIs;-

Isocarboxazid

Tranylcypromine

RIMAs;-

Moclobemide

SSRIs;-

Sertraline (most expensive in community)

Others;-

Mirtazapine

Reboxetine (not in over 65's, not in combination with SSRIs - if combination considered necessary, use venlafaxine instead)

Tryptophan (named patient basis only)

Flupenthixol

Venlafaxine

Non-formulary;-

Amitriptyline S/R preps (e.g. "Lentizol" - use plain tablets)

Clomipramine S/R preps (use plain capsules)

Fluvoxamine (high incidence of nausea - use another SSRI)

Maprotiline (very toxic in overdose - use a less toxic tricyclic or other antidepressant)

Mianserin (note also CSM warnings).

Nefazodone ("Dutonin") - use trazodone

Protriptyline (use another tricyclic)

Viloxazine (limited potency - use a tricyclic, mianserin or any other antidepressant)

STATUS EPILEPTICUS

First choice;-

Benzodiazepine;-

Diazepam rectal tubules

Diazepam IV

Alternatives;-

Benzodiazepine;-

Clonazepam

Others;-

Phenytoin IV (with cardiac monitoring)

ANTICHOLINERGICS

Please note that long-term treatment is rarely needed and so continuous treatment should be regularly assessed. There is little, if anything, to choose between the different agents

First choice;-

Procyclidine

Alternatives;-

Benzhexol/trihexyphenidyl

Benztropine

Non-formulary;-

Orphenadrine (due to toxicity in overdose)

MISCELLANEOUS

Stocked;-

Dexamfetamine (for Narcolepsy - Consultant only)

Disulfiram

Lofexidine

Methadone

Methylphenidate

Naloxone

Naltrexone

Propranolol

Tetrabenazine

Non-formulary;-

Acamprosate (Campral)

Donepezil (ENHA guidelines)

OTHER PRESCRIBING INFORMATION:

Antibiotic courses will be assumed to be for five days unless otherwise stated.

Prescriptions for omeprazole (Losec) will be therapeutically substituted with lansoprazole (Zoton), unless "Do not substitute" is written on, and pharmacy informed of the clinically significant reason.

Omeprazole 10mg/d to lansoprazole 15mg/d

Omeprazole 20mg/d to lansoprazole 30mg/d

Omeprazole 40mg/d to lansoprazole 30mg/d

Omeprazole 20mg bd to lansoprazole 30mg/d

This substitution is purely on cost grounds, there being no effect on efficacy. Omeprazole is now significantly more expensive than lansoprazole.

Last update 27.7.99

This site is based on original work by Steve Bazire and Sarah Branch, and developed in 2007-8 by a collaboration between Mick Collins, Maureen Ng, Rowan Purdy and Steve Bazire through NWMHFT, CSIP, ABPI, UEA, and NIMH-E

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Information here is based on published data. References include the UK British National Formulary (BNF, published by the British Medical Association and Royal Pharmaceutical Society of Great Britain), Martindale (the extra pharmacopoea, published by RPSGB Pharmaceutical Press), Psychotropic Drug Directory (latest edition), Data Sheet Compendium (UK Manufacturers Data Sheets, published by the Association of British Pharmaceutical Industry), MicroMedex (an independent and extensive CD-ROM based drug information source), UK Psychiatric Pharmacy Group leaflets, Royal College of Psychiatrists advice and guidelines and the current medical literature. Thanks also to all those people who left e-mail comments, suggestions and requests, who have helped shape the site.