Approved: 1 Sep 2012. Last amended: 21 Jul 2020.

4.1 Hypnotics and anxiolytics

  • Anxiety and insomnia should, where possible, be managed by non-pharmaceutical means. Medication should be reserved for severe and disabling cases.
  • Benzodiazepines are indicated for the short-term relief of anxiety (2 to 4 weeks) to alleviate acute conditions. Tolerance and dependence can occur after only a few weeks.
  • Benzodiazepines should be avoided where there is a history of substance misuse including alcohol.
  • To reduce the risk of tolerance and dependence benzodiazepines should be prescribed on an 'as required' basis.
  • Refer to BNF (section 4.1) for information on benzodiazepine withdrawal
  • There are a number of “good sleep guides” available to view on the internet, which suggest how to achieve and maintain a healthy sleep cycle.

4.1.1 Hypnotics

Before a hypnotic is prescribed the underlying cause should be identified and addressed, and realistic sleep requirements should be discussed with the patient.

All hypnotics should be used for the minimum length of time due to the risks of dependence.

Patients who require short term treatment for insomnia during their hospital admission should not routinely be prescribed a hypnotic to continue following discharge.

  • Zopiclone
  • Alternative

  • Temazepam
  • Zolpidem
  • Specific Indication

  • Melatonin
    • Sleep disorder associated with learning disability. Specialist initiation only. Shared Care Guideline
    • Sleep disorder in children with neurological and/or behavioural problems. Specialist initiation only. Shared Care Guideline
    • Gloucestershire Prescribing Guidance: melatonin
  • Melatonin (Circadin® only)

    Sleep reversal associated with dementia where hypnotics are not suitable. General & Old Age Medicine Consultant only. Inpatient use only

  • 4.1.2 Anxiolytics

    Benzodiazepines should be prescribed at the lowest possible dose for the shortest possible time due to the risk of dependence.

    Diazepam should be used with caution in the elderly. Lorazepam is preferred in these patients.

    Some antidepressants are licensed for anxiety: see section 4.3

    Recommended

  • Diazepam
  • Alternative

  • Lorazepam
  • Specific Indication

  • Midazolam

    Conscious sedation for procedures. Use with caution: NPSA Rapid Response Report

  • Oxazepam

    Liver impairment

  • Propranolol

    See chapter 2.4 (Anxiety with Palpitations, Sweating, Tremors)

  • 4.1.3 Barbituates

  • None
  • 4.2 Drugs used in psychoses and related disorders

    4.2.1 Antipsychotic drugs

    GHNHSFT Local Guideline: Emergency Sedation (intranet)

    The choice of drug should be made by the patient and healthcare professional together, considering the relative potential of individual antipsychotic drugs to cause extrapyramidal side effects (including akathisia), metabolic side effects (including weight gain) and other side effects (including unpleasant subjective experiences).

    Clozapine is restricted to patients who have not responded to two or more antipsychotics (one of which should be an atypical antipsychotic), or who are intolerant of conventional antipsychotics.

    In the case of psychotic disorders occurring during the course of Parkinson's disease, olanzapine, quetiapine or sulpiride are preferable, but clozapine can be used when standard treatment has failed.

    Clozapine may only be initiated by members of the healthcare team who are registered with Clozaril Patient Monitoring Service (CPMS). The patient and supplying Pharmacist must also be registered with the CPMS.

    Full blood counts are required prior to and during clozapine treatment.

    Recommended

  • Risperidone
  • Olanzapine (standard formulation)
  • Quetiapine (standard formulation)
  • Haloperidol
  • Zuclopenthixol
  • Flupentixol
  • Alternative

  • Amisulpride
  • Sulpiride
  • Chlorpromazine and pericyazine

    occasional use

  • Specific Indication

  • Olanzapine (orodispersible)

    Swallowing problems, compliance issues

  • Quetiapine (modified release)

    Zaluron XL and Biquelle XL are the preparations of choice. Compliance issues or acute titration (after titration phase, consider whether switching to standard preparation is feasible).

  • Aripiprazole

    For patients where movement disorders, sedation or metabolic syndrome make treatment with other first- or second-generation antipsychotics unfeasible. NICE TA213

  • Clozapine

    Schizophrenia. Senior Psychiatry advice only.

  • 4.2.2 Antipsychotic long acting injections

    These preparations may only be initiated on the advice of senior medical staff working in psychiatry.

    Please refer to BNF section for advice on equivalent doses of antipsychotic drugs.

    Recommended

  • Flupentixol decanoate

    depot injection

  • Haloperidol decanoate

    depot injection

  • Zuclopenthixol decanoate

    depot injection

  • Specific Indication

  • Paliperidone

    depot injection (50mg, 75mg, 100mg) – Patients who are unable to tolerate the recommended preparations listed above

  • Risperidone

    depot injection – Patients who are unable to tolerate the recommended preparations listed above

  • 4.2.3 Antimanic drugs

    First-line options for the treatment of acute mania include atypical antipsychotics (particularly olanzepine) or valproate compounds. Occasionally, benzodiazepines are added for short-term use.

    4.2.3.1 Acute treatment

    Recommended

  • Olanzapine
  • Quetiapine
  • Risperidone
  • Sodium valproate (Episenta®) capsules/granules

    Please note that the use of valproate in females of childbearing age must be carefully considered due to the high risk of foetal abnormalities, and the Pregnancy Prevention Programme guidance followed.

    Annual Risk Acknowledgement Form

    Note: not suitable for compliance aids

  • Valproic acid (Depakote®)

    Please note that the use of valproate in females of childbearing age must be carefully considered due to the high risk of foetal abnormalities, and the Pregnancy Prevention Programme guidance followed.

    Annual Risk Acknowledgement Form

  • Specific Indication

  • Aripiprazole
    • Senior Psychiatry advice only
    • Bipolar Disorder (Children): NICE TA292
  • 4.2.3.2 Prophylaxis

    Lithium must be prescribed by brand name. Patients should remain on the same brand.

    Lithium has a narrow therapeutic / toxic ratio and should therefore not be prescribed unless facilities for monitoring serum lithium concentrations are available. Samples should be taken 12 hours after the preceding dose: sample requirements.

    Lithium Monitoring Criteria NICE guidance:

    • Lithium levels must be measured every 3 months
    • Renal function must be monitored every 6 months
    • Thyroid function must be monitored every 6 months

    A Lithium Record Booklet should be supplied to every patient at initiation.

    Recommended

  • Lithium carbonate
  • Lithium citrate liquid
  • Alternative

  • Carbamazepine
  • Sodium Valproate (Episenta®) capsules/granules)

    Please note that the use of valproate in females of childbearing age must be carefully considered due to the high risk of foetal abnormalities, and the Pregnancy Prevention Programme guidance followed.

    Annual Risk Acknowledgement Form

    Note: not suitable for compliance aids

  • Valproic acid (Depakote®)

    Please note that the use of valproate in females of childbearing age must be carefully considered due to the high risk of foetal abnormalities, and the Pregnancy Prevention Programme guidance followed.

    Annual Risk Acknowledgement Form

  • Specific Indication

  • Lamotrigine

    Senior Psychiatry advice only

  • 4.3 Antidepressant drugs

    Antidepressants have markedly different safety profiles in overdose. Where there are concerns regarding suicide risk the SSRIs are the least toxic in overdose. Of the tricyclic antidepressants, lofepramine is the least toxic.

    Antidepressants should not be withdrawn abruptly if the patient has been taken them regularly for 8 weeks or more, unless there is a serious adverse drug reaction.

    Care should be taken when switching between antidepressants. Contact Medicines Information for advice (GRH 0300 422 6108, CGH 0300 422 3030)

    SSRIs should not be prescribed in children and adolescents unless under the advice of a Child & Adolescent Mental Health Consultant.

    4.3.1 Tricyclic and related antidepressant drugs

    In general, SSRIs are the first-line choice for the treatment of depression.

    Tricyclics should not be used to treat depression in patients over 75 years old.

    Recommended

  • Lofepramine
  • Alternative

  • Amitriptyline
  • Clomipramine
  • Imipramine
  • 4.3.2 Monoamine-oxidase inhibitors

    In general, SSRIs are the first-line choice for the treatment of depression.

    Diet Restrictions with MAOIs: GHNHSFT Advice Sheet

    Specific Indication

  • Moclobemide

    Specialist use only

  • Isocarboxazid

    Specialist use only

  • Phenelzine

    Specialist use only

  • 4.3.3 Selective serotonin re-uptake inhibitors (SSRIs)

    Meta-analysis of comparative efficacy of 12 antidepressants – Bandolier comment

    Where there is mixed depression and anxiety, citalopram may be considered first line.

    SSRIs may initially increase anxiety levels and it may be necessary to ‘cover’ their initiation with a brief course of a benzodiazepine in order to encourage compliance.

    Abrupt withdrawal of SSRIs should be avoided (associated with headache, nausea, paraesthesia, dizziness and anxiety).

    Withdrawal syndrome is reported to the CSM more commonly with paroxetine than with other SSRIs.

    Recommended

  • Sertraline
  • Alternative

  • Escitalopram

    Second-line when citalopram not tolerated

  • Fluoxetine

    (long half life; may be beneficial in patients with concordance issues)

  • Specific Indication

  • Vortioxetine

    Third-line as an option for treating major depressive episodes in adults whose condition has responded inadequately to 2 antidepressants within the current episode, as per NICE TA367

  • 4.3.4 Other antidepressant drugs

    Gloucestershire Local Guideline: Venlafaxine MR versus IR (immediate release)

    Venlafaxine may be considered if a patient fails on another antidepressant or in severe depression.

    BP monitoring is advisable for doses of venlafaxine above 200mg daily.

    Mirtazapine may be useful for treating depression in patients with reduced appetite.

    Recommended

  • Venlafaxine

    (Should be prescribed as standard release tablets whenever possible – see local guidance above. If an MR formulation is required, this should only be prescribed as MR tablets)

  • Mirtazapine
  • 4.4 Central nervous system stimulants and other drugs used for attention deficit hyperactivity disorder

    Attention Deficit Hyperactivity Disorder – NICE TA98

  • Methylphenidate
    • Only to be initiated by a specialist experienced in managing ADHD. Shared Care Guideline (intranet)
    • Note: Xaggitin XL is the preferred brand of methylphenidate MR (where an 18mg, 27mg, 36mg or 54mg dose is required).
  • Atomoxetine

    only to be initiated by a specialist experienced in managing ADHD. Shared Care Guideline (intranet)

  • Lisdexamfetamine

    Consultant child and adolescent Psychiatrist prescribing only. Second line. Shared Care Guideline (intranet)

  • Dexamfetamine

    refer to BNF for indications

  • Modafinil

    narcolepsy

  • Guanfacine

    Second-line to atomoxetine where a non-stimulant option for ADHD is required but atomoxetine is not tolerated or ineffective

  • 4.5 Drugs used in the treatment of obesity

    Pharmacological management of obesity should be initiated in primary care as an adjunct to other lifestyle measures.
    Treatment must be reviewed regularly to ensure that required weight loss is being achieved. See BNF for details.

  • Orlistat
  • 4.6 Drugs used in nausea and vertigo

    4.6.1 General and post-operative nausea and vomiting (PONV)

    GHNHSFT Local Guideline: Post-operative Nausea and Vomiting (PONV) - intranet

    GHNHSFT Local Guideline: Domperidone Restrictions

    Recommended

  • Ondansetron
  • Alternative

  • Cyclizine

    note: cyclizine injection is expensive, only use where ondansetron injection is unsuitable

  • Metoclopramide
  • Prochlorperazine
  • Domperidone
  • 4.6.2 Cytotoxic chemotherapy

    GHNHSFT: Refer to OPMAS electronic prescribing system

    Recommended

  • Aprepitant
  • Cyclizine
  • Dexamethasone
  • Domperidone
  • Granisetron patch (Sancuso®)

    patients for whom there is concern about the absorption of oral medicines

  • Haloperidol
  • Levomepromazine
  • Metoclopramide
  • Nabilone
  • Ondansetron
  • Prochlorperazine
  • 4.6.3 Vestibular disorders

  • Prochlorperazine
  • Cinnarizine
  • Betahistine

    Ménières disease

  • Hyoscine hydrobromide patch

    nausea and vomiting associated with vestibular disorder and to reduce secretions in neurological conditions.

  • 4.7 Analgesics

    For NSAIDs see anti-inflammatory section: chapter 10

    4.7.1 Non-opioid analgesics and compound analgesic preparations

    Paracetamol and codeine should be prescribed separately and the dose titrated according to pain. Co-codamol may be prescribed in palliative care to reduce tablet burden.

    Low dose weak opioid combinations with paracetamol (e.g. co-proxamol, co-codamol 8/500) offer little additional pain relief compared with regular full dose paracetamol and are not recommended.

    Effervescent analgesics are not generally recommended because they are expensive and contain large amounts of sodium. Use is restricted to patients unable to swallow tablets or in the treatment of migraine attacks (see section 4.7.4.1).

    Recommended

  • Paracetamol

    Paracetamol has no demonstrable anti-inflammatory effect. If the pain has an inflammatory component then an NSAID should be considered. (see anti-inflammatory section: chapter 10)

    Intravenous paracetamol criteria

  • Alternative

  • Co-codamol 30/500

    See notes

  • 4.7.2 Opioid analgesics

    In general, the use of more than one opioid should be avoided.

    Opioid Equivalence Chart

    Caution: Some opioids accumulate in renal impairment resulting in increased and prolonged effect.

    Regular paracetamol (1g qds) may have an 'opioid-sparing' effect, thus enabling a lower opioid dose.

    Recommended

  • Codeine
  • Alternative

  • Dihydrocodeine

    Efficacy does not increase above a certain dose; however, the risks of side effects and dependence do; do not prescribe more than 30mg of Dihydrocodeine as a single dose.

  • Specific Indication

  • Tramadol

    Patients with a definite intolerance to codeine.

  • 4.7.3 Strong opioids

    GHNHSFT Local Guideline: Policy for pain management in patients with morphine allergy

    Recommended

  • Morphine
    • oral, immediate release: Oramorph® liquid
    • oral, modified release: Zomorph® capsules
    • parenteral
  • Diamorphine
    • parenteral
  • Alternative

  • Oxycodone
    • Expensive
    • Oral, immediate release: Oxynorm® liquid, Shortec® capsules
    • Oral, modified release: Longtec® tablets
    • Parenteral
  • Specific Indication

  • Buprenorphine
    • patches:
      • Bunov® (replaced weekly)
      • Transtec® (replaced every 4 days)
        Expensive: pain team / palliative care (useful in renal impairment)
        Not suitable for acute pain or unstable/worsening pain
    • oral: pain team / palliative care / substance misuse team
  • Fentanyl
    • patches (expensive): pain team / palliative care.
      Not suitable for acute pain or unstable/worsening pain.
      NOTE: in primary care, Fencino®, Mezolar® and Matrifen® are the lower cost fentanyl products of choice where a patch is definitely required.
    • sublingual tablets (Abstral®): Pain team / palliative care. Breakthrough pain relief in patients with chronic cancer pain who are opioid tolerant and for whom immediate release morphine or oxycodone preparations are unsuitable / ineffective
  • Hydromorphone

    Pain team / palliative care.

  • Methadone
    • parenteral: pain team / palliative care
    • oral: substance misuse team
  • Pethidine

    Pain team / palliative care / obstetrics (unsuitable for chronic pain due to short duration of action). The toxic metabolite nor-pethidine accumulates with repeated use and in renal impairment.

  • Tapentadol M/R

    Pain team / palliative care. 3rd line use in patients for whom Zomorph® and Longtec® are ineffective or intolerable. Prescribing may only be transferred from Secondary Care to Primary Care following prior approval, in accordance with the Criteria Based Access Policy

  • 4.7.4 Neuropathic pain

    GHNHSFT Local Guideline: Neuropathic Pain

    Recommended

  • Amitriptyline

    (unlicensed use)

  • Gabapentin

    See section 4.8.1

  • Alternative

  • Carbamazepine
  • Sodium valproate

    (Unlicensed use. See section 4.8 for preparations)

    Please note that the use of valproate in females of childbearing age must be carefully considered due to the high risk of foetal abnormalities, and the Pregnancy Prevention Programme guidance followed.

    Annual Risk Acknowledgement Form

  • Imipramine

    (Unlicensed use)

  • Nortriptyline

    (Unlicensed use)

  • Specific Indication

  • Corticosteroids

    Compression neuropathy

  • Capsaicin

    (Axsain® cream) – diabetic peripheral neuropathic pain

  • Duloxetine

    Diabetic peripheral neuropathic pain (second line to amitriptyline)

  • Ketamine

    Pain team / palliative care only

  • Clonazepam

    Palliative care only

  • Pregabalin
  • Capsaicin 179mg [8%]

    (Qutenza®) patches – Hospital only: Peripheral neuropathic pain in non-diabetic patients where recommended oral treatments are ineffective or not tolerated. Maximum of 2 patches per patient per treatment session.

  • 4.7.5 Antimigraine drugs

    4.7.5.1 Treatment of the acute migraine attack

    • Simple analgesia (e.g. paracetamol, NSAIDs) is often effective.
    • Dispersible or effervescent preparations are preferred because peristalsis is often reduced during migraine attacks.
    • Formulations such as suppositories may allow absorption
    • Concomitant anti-emetics may be required e.g. metoclopramide or domperidone tablets/suppositories (see 4.6)
    • 5HT1 agonists if simple analgesia fails:
    • If one 5HT1 agonist is ineffective patients may respond to another.
    • 5HT1 agonists should not be used for prophylaxis and they are contraindicated in ischaemic heart disease, previous MI, coronary vasospasm (including Prinzmetal’s angina), and uncontrolled hypertension.
    • Use of 5HT1 agonists with ergotamine/ergotamine-derivatives should be avoided.

    Recommended

  • Sumatriptan
  • Alternative

  • Rizatriptan

    Orodispersible tablets

  • Zolmitriptan
  • Specific Indication

  • Migril®

    Specialist use only

  • Sumatriptan

    Injection: Specialist use only

  • 4.7.5.2 Prophylaxis of migraine

    Acute treatments are still required. Prophylaxis only reduces the severity and frequency of attacks. Please note however that 5HT1 agonists must not be taken within 24hrs of methysergide.

    Recommended

  • Propranolol
  • Alternative

  • Amitriptyline

    (Unlicensed use)

  • Pizotifen
  • Sodium valproate

    (Unlicensed use: see section 4.8 for preparations)

    Please note that the use of valproate in females of childbearing age must be carefully considered due to the high risk of foetal abnormalities, and the Pregnancy Prevention Programme guidance followed.

    Annual Risk Acknowledgement Form

  • Topiramate
  • Methysergide

    Consultant Neurologist initiation only

  • Specific Indication

  • Botulinum A toxin

    Botox® for chronic migraine as per NICE TA260

  • Flunarizine

    Unlicensed

    Consultant Neurologist only. To be used when all other licensed oral options have failed or are unsuitable

  • Fremanezumab

    As per NICE TA631

  • 4.7.5.3 Cluster headache: Acute

  • Sumatriptan

    sub-cutaneous injection

  • Oxygen
  • 4.7.5.4 Cluster headache: Prophylaxis

  • Verapamil

    (unlicensed)

  • Sodium valproate

    (Unlicensed - see section 4.8 for preparations)

    Please note that the use of valproate in females of childbearing age must be carefully considered due to the high risk of foetal abnormalities, and the Pregnancy Prevention Programme guidance followed.

    Annual Risk Acknowledgement Form

  • 4.8 Antiepileptic drugs

    4.8.1 Control of the epilepsies

    The choice of antiepileptic agent will depend on the type of epilepsy

    Prescribing of Antiepileptic Drugs (AEDs):

    Prescribers should consider the MHRA guidance (summarised below) regarding the generic prescribing of AEDs.

    MHRA Summary:

    Category 1 – Phenytoin, carbamazepine, phenobarbital, primidone

    For these drugs, prescribers are advised to ensure that their patient is maintained on a specific manufacturer’s product (i.e. prescribe by brand or by using the generic drug name and name of the manufacturer / marketing authorisation holder).

    Category 2 – Valproate, lamotrigine, perampanel, rufinamide, clobazam, clonazepam, oxcarbazepine, eslicarbazepine, zonisamide, topiramate

    For these drugs the need for continued supply of a particular manufacturer’s product should be based on clinical judgement and consultation with patient and/or carer taking into account factors such as seizure frequency and treatment history.

    Category 3 - Levetiracetam, lacosamide, tiagabine, gabapentin, pregabalin, ethosuximide, vigabatrin

    For these drugs it is usually unnecessary to ensure that patients are maintained on a specific manufacturer’s product unless there are specific concerns such as patient anxiety, and risk of confusion or dosing errors.

    4.8.1.1 Sodium valproate (oral)

    Recommended

  • Episenta®

    capsules/granules – note: not suitable for compliance aids

    Please note that the use of valproate in females of childbearing age must be carefully considered due to the high risk of foetal abnormalities, and the Pregnancy Prevention Programme guidance followed.

    Annual Risk Acknowledgement Form

  • Alternative

  • Epilim®

    tablets

    Please note that the use of valproate in females of childbearing age must be carefully considered due to the high risk of foetal abnormalities, and the Pregnancy Prevention Programme guidance followed.

    Annual Risk Acknowledgement Form

  • Epilim Chrono®

    tablets

    Please note that the use of valproate in females of childbearing age must be carefully considered due to the high risk of foetal abnormalities, and the Pregnancy Prevention Programme guidance followed.

    Annual Risk Acknowledgement Form

  • Specific Indication

  • Epilim®

    liquid – patients who are unable to swallow tablets and where Episenta® is not appropriate.

    Please note that the use of valproate in females of childbearing age must be carefully considered due to the high risk of foetal abnormalities, and the Pregnancy Prevention Programme guidance followed.

    Annual Risk Acknowledgement Form

  • 4.8.1.2 Sodium valporate (parenteral)

  • Episenta®

    Injection

    Please note that the use of valproate in females of childbearing age must be carefully considered due to the high risk of foetal abnormalities, and the Pregnancy Prevention Programme guidance followed.

    Annual Risk Acknowledgement Form

  • 4.8.1.3 Others

    Agents marked with an * are indicated when symptoms have not been controlled with other antiepileptics. They may only be prescribed on the recommendation of a Specialist.

  • Carbamazepine
  • Lamotrigine
  • Phenytoin

    See information above

  • Clobazam
  • Clonazepam
  • Gabapentin
  • Acetazolamide*
  • Eslicarbazepine*
  • Ethosuximide*
  • Lacosamide*
  • Levetiracetam*
  • Oxcarbazepine*
  • Perampanel*
  • Phenobarbital*
  • Pregabalin*
  • Primidone*
  • Tiagabine*
  • Topiramate*
  • Zonisamide*
  • Specific Indication

  • Vigabatrin

    initiated & supervised by a Specialist

  • Cannabidiol (Epidyolex®)

    Dravet Syndrome NICE TA614

    Lennox-Gastaut Syndrome NICE TA615

  • 4.8.2 Drugs used in status epilepticus

    GHNHSFT Local Guideline: Management of status epilepticus - intranet

    Recommended

  • Midazolam

    buccal, out-patient use (in conjunction with an individual patient plan)

  • Diazepam

    rectal tubes

  • Lorazepam

    parenteral

  • Phenytoin

    slow i.v. injection

  • Alternative

  • Phenobarbital

    Parenteral

  • Midazolam

    injection – Use with caution: NPSA Rapid Response Report

  • Specific Indication

  • Paraldehyde

    Specialist use

  • Sodium thiopentone

    Specialist use

  • Thiamine

    (Pabrinex® IV/IM) – alcohol abuse

  • Pyridoxine

    deficiency

  • 4.8.3 Febrile convulsions

    Recommended

  • Paracetamol
  • Specific Indication

  • Diazepam

    Rectal tubes – prolonged or recurrent seizures

  • 4.9 Drugs used in parkinsonism and related disorders

    The symptoms of drug-induced parkinsonism, e.g. with antipsychotic drugs, may be suppressed with the antimuscarinic drugs. However, routine administration is not justified.

    Management of Parkinson's Disease – NICE guidelines

    4.9.1 Dopaminergic drugs used in Parkinson's disease

    4.9.1.1 Dopamine-receptor agonists

    Recommended

  • Ropinirole
  • Alternative

  • Ropinirole MR (Ipinnia® XL)

    Where once daily dosing will improve compliance significantly

  • Specific Indication

  • Rotigotine

    Patch – restricted to patients who are unable to swallow (see local guideline)

  • Apomorphine

    Severe Parkinson's disease inadequately controlled by other preparations

  • 4.9.1.2 Levodopa

    Recommended

  • Co-beneldopa
  • Co-careldopa
  • Co-careldopa with entacapone

    (Sastravi®)

  • Specific Indication

  • Duodopa®

    Intestinal gel (levodopa 20 mg/ml + carbidopa 5 mg/ml)

  • 4.9.1.3 Monoamine-oxidase-B inhibitors

  • Selegiline

    5mg, 10mg tablets

  • Rasagiline
  • 4.9.1.4 Catechol-O-methyltransferase inhibitors

    Recommended

  • Entacapone
  • Specific Indication

  • Opicapone

    Second-line where entacapone is not tolerated or where there has been a suboptimal response to entacapone

  • 4.9.1.5 Amantadine

  • Amantadine
  • 4.9.2 Antimuscarinic drugs used in parkinsonism

    Antimuscarinics can be of help with tremor, but use is limited by side effects of confusion, prostatism, dry eyes, and dry mouth especially in the elderly.

    Recommended

  • Benzatropine
  • Orphenadrine
  • Procyclidine
  • Trihexyphenidyl
  • 4.9.3 Drugs used in essential tremor, chorea, tics, and related disorders

    Recommended

  • Propranolol

    Essential tremor

  • Primidone

    Essential tremor

  • Piracetam

    Myoclonus

  • Tetrabenazine

    Huntingdon’s chorea

  • Specific Indication

  • Riluzole

    For use in the management of motor neurone disease as per NICE TA20. Shared Care Guideine (intranet)

  • 4.9.3.1 Torsion dystonias and other involuntary movements

    Specific Indication

  • Botulinum A toxin

    Xeomin® for chronic sialorrhoea, as per NICE TA605

  • 4.10 Drugs used in substance dependence

    Drug Misuse and Dependence: UK Guidelines on Clinical Management

    4.10.1 Alcohol dependence

    GHNHSFT Local Guideline: Alcohol Detoxification - intranet

    In alcohol withdrawal Pabrinex® and/or thiamine may be required.
    Facilities for treating anaphylaxis should be available when administering Pabrinex®.

    Specific Indication

  • Diazepam

    Alcohol withdrawal

  • Acamprosate

    Alcohol dependence

  • Disulfiram

    Alcohol dependence

  • Nalmefene

    Alcohol dependence, as per NICE TA325. Note: only to be prescribed in conjunction with continuous psychosocial support focused on treatment adherence and reducing alcohol consumption. Local Guidance: Nalmefene

  • 4.10.2 Cigarette smoking

    Smoking Cessation – NICE guidelines

    GHNHSFT Local Guideline: Inpatient Smoking Cessation

    Contact Gloucestershire Smoking Advice Service (GSAS) for advice or referrals (0300 422 0040)

    Recommended

  • Nicotine replacement therapy
  • Alternative

  • Varenicline
  • 4.10.3 Opioid dependence

    GHNHSFT Local Guideline – Management of Opiate Users on the Ward - intranet

    Specific Indication

  • Methadone

    Specialist advice only. Shared Care Guideline (intranet). NICE TA114

  • Buprenorphine

    Specialist advice only. Shared Care Guideline (intranet). NICE TA114

  • Suboxone®

    (buprenorphine/naloxone) – specialist advice only

  • Lofexidine

    Specialist advice only. Shared Care Guideline (intranet)

  • Naltrexone

    Specialist advice only. Opiate Dependence: Shared Care Guideline, Alcohol Dependence: Shared Care Guideline (intranet). NICE TA115

  • 4.11 Drugs for dementia

    Management of dementia: NICE guidelines

    The following drugs should be prescribed in line with NICE TA217

  • Donepezil

    Tablets

  • Galantamine

    Tablets

  • Rivastigmine
    • Capsules
    • Patches (NB patches are an expensive option, and should only be used when oral dosage forms are not suitable; if patches are necessary, prescribe as Alzest®)
  • Memantine

    Tablets

  • 4.11.1 Anxiolytics and tranquillising drugs in elderly patients and patients with dementia

    • Anxiety should be tolerated to some extent and, wherever possible, be managed by non-pharmaceutical means
    • Medication is associated with a high frequency of unwanted and sometimes serious side effects.
    • There is a clear increased risk of stroke and a small increased risk of death when antipsychotics (typical or atypical) are used in elderly people with dementia (Read more for MHRA advice)
    • Depression and additional pathologies should be specifically sought.
    • Sedation, parkinsonism and non-specific decline should be watched for.
    • Benzodiazepine use in elderly patients is associated with falls and cognitive impairment.

    Recommended

  • Risperidone

    Risk of stroke (see above)

  • Specific Indication

  • Lorazepam

    Short-term use only

  • Trazodone
  • BEST CARE FOR EVERYONE