Central nervous system

4.1.1 Hypnotics

First line: temazepam (short term use only)
Alternatives: zopiclone, clomethiazole

• Benzodiazepine prescribing support pack

 

4.1.2 Anxiolytics

First line: diazepam, lorazepam
For alcohol withdrawal: chlordiazepoxide

For rapid tranquilisation: lorazepam (im or iv)

For convulsive status epilepticus: lorazepam (slow iv)

• primary care protocol for anxiety disorders 

 

4.2.1 Antipsychotic drugs

Hospital initiated, option based on NICE guidance and licence: amisulpiride, aripiprazole, chlorpromazine, flupentixol, haloperidol, olanzapine, quetiapine, risperidone, sulpiride

For oncology/palliative care use: levomepromazine

For hospital use only: clozapine

• shared care guideline for atypical antipsychotics in schizophrenia and related psychoses
• guidance on the use of antipsychotics in conditions other than schizophrenia
• shared care guideline for the use of risperidone in children

 

4.2.2 Antipsychotic depot injections

Hospital initiated, option based on NICE guidance and licence: flupentixol decanoate, fluphenazine decanoate, haloperidol decanoate, pipothiazine palmitate, zuclopenthixol decanoate.

For hospital use only: olanzapine embonate, risperidone

 

4.2.3 Antimanic drugs

For hospital initiation: carbamazepine, sodium valproate, valproic acid, lithium carbonate, lithium citrate liquid, lamotrigine, olanzapine, quetiapine, risperidone

• shared care guideline for lithium

Prescribers should be aware of the brand and form of lithium each patient is taking and ensure all prescribing is branded. Local practice, prescribing guidance and formulary restrictions should be considered when initiating lithium.

 

4.3.1 Tricyclic and related antidepressant drugs

First line option: amitriptyline, lofepramine, trazadone

For perinatal care only: imipramine, nortriptyline

 

4.3.2 Monoamine-oxidase inhibitors

Moclobemide

 

4.3.3 Selective serotonin re-uptake inhibitors

First line options: citalopram, fluoxetine, sertraline

 

4.3.4 Other antidepressant drugs

First line options: duloxetine, mirtazapine, venlafaxine

For hospital use only: tryptophan

• primary care protocol for depression

 

4.4 CNS stimulants and drugs used for attention deficit-hyperactivity disorder

First line options: atomoxetine, dexamfetamine, methylphenidate

• pharmacological intervention in ADHD 
• shared care guidelines for methylphenidate in children and adolescents
• shared care guideline for atomoxetine in children and adolescents
• shared care guideline for methylphenidate in adults
• shared care guideline for atomoxetine in adults
• shared care guideline for dexamfetamine

For tertiary care initiation only: modafinil

 

4.5.1 Anti-obesity drugs acting on the gastro-intestinal tract

Orlistat

 

4.6 Drugs used in nausea and vertigo

Antihistamine options: cinnarizine, cyclizine, promethazine
Phenothiazine options: prochlorperazine
Domperidone, metoclopramide
For Meniere's disease: betahistine

For hypersalivation: hyoscine

For palliative care use: chlorpromazine, haloperidol

For hospital use only: ondansetron, aprepitant, palonosetron

 

4.7.1 Non-opioid analgesics

First line options: aspirin, paracetamol, co-codamol, co-dydramol

guideline for paracetamol use RBCH

 

4.7.2 Opioid analgesics

First line: codeine phosphate
Short term use only: dihydrocodeine tartrate, tramadol
Second line: morphine, diamorphine hydrochloride

Second line: tapentadol

shared care guideline for tapentadol

For pain team or palliative care initiation: fentanyl, oxycodone

For hospital use only: pethidine

 

4.7.3 Neuropathic pain

First line options: amitriptyline, gabapentin
Alternatives: duloxetine, pregabalin
For trigeminal neuralgia: carbamazepine

 

4.7.4.1 Treatment of acute migraine

First line: sumatriptan
Alternatives: almotriptan, zolmitriptan

 

4.7.4.2 Prophylaxis of migraine

First line: pizotifen

 

4.8.1 Control of epilepsy

Options based on licence
First line options: carbamazepine, clonazepam, ethosuximide, lamotrigine, phenytoin, sodium valproate
Second line options: clobazam, gabapentin, lacosamide, levetiracetam, phenobarbital, pregabalin, primidone, retigabine, topirimate, vigabatrin, zonisamide

 

4.8.2 Drugs used in status epilepticus

First line option: diazepam rectal solution

For hospital initiation: midazolam buccal liquid

shared care guideline for buccal midazolam(adults)

shared care guideline for buccal midazolam (paediatrics)

For hospital use only: clonazepam iv, diazepam iv, paraldehyde, phenytoin iv, midazolam iv - NB unlicensed, lorazepam iv for status epilepticus

 

4.9.1 Dopaminergic drugs used in Parkinson's disease

• pharmacological management of Parkinson's Disease

Dopamine receptor agonists:

 first line options: pramipexole, ropinirole, rotigotine (standard release preparations)
second line options: cabergoline, pergolide

for hospital use only: apomorphine injection

• shared care guideline for dopamine agonists

Levodopa:

first line option: co-beneldopa, co-careldopa

for hospital use only following individual patient funding approval: co-careldopa intestinal gel

Monoamine oxidase inhibitors:

first line option: selegiline

• shared care guideline for selegiline

Catechol-O-methyl transferase inhibitors

first line option: entacapone

for hospital use only: tolcapone

• shared care guideline for entacapone

Amantadine

• shared care guideline for amantadine

 

 

4.9.2 Antimuscarinic drugs used in Parkinsonism

First line options: orphenadrine, procyclidine, trihexyphenidyl

 

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

For patients with MND: riluzole

• shared care guideline for riluzole

  

For patients with movement disorders or tardive dyskinesias: tetrabenazine

For spasticity associated with stroke or cerebral palsy, or for axillary hyperhidrosis: botulinum toxin

 

4.10 Drugs used in substance dependence

Alcohol dependence

acamprosate, disulfiram

• shared care guideline for acamprosate

 

Smoking cessation

bupropion, nicotine, varenicline

 

Opioid dependence

First line options: buprenorphine, methadone hydrochloride

For specialist initiation: naltrexone

• shared care guideline for naltrexone

 

4.11 Drugs for dementia

For specialist initiation first line for mild-moderate Alzheimer's Disease: donepezil film-coated tablets 

Alternatives: donepezil orodispersible tablets, galantamine, rivastigmine

• shared care guideline for ACH inhibitors

 

For specialist initiation for moderate to severe Alzheimer's Disease: memantine

• shared care guideline for memantine