| Formulary Chapter 4: Central nervous system - Full Chapter
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| Chapter Links... |
 Administration of depot antipsychotic injections during COVID-19 in stable adult patients |
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| 04.07 |
Analgesics |
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| 04.07.01 |
Non-opioid analgesics and compound analgesic preparations |
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| 04.07.01 |
Compound analgesic preparations |
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Aspirin
(300mg dispersible tablets)
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Formulary
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For gargling - topical analgesia
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Paracetamol
(Oral)
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Formulary
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Tablets
SF suspension
500mg soluble tablets - high sodium content. Only for patients with swallowing difficulties
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UKMI Q&A: Can breastfeeding mothers take paracetamol?
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Paracetamol
(Suppositories)
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Formulary
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Paracetamol (Perfal®)
(Intravenous infusion)
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Formulary
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Paracetamol and codeine (Co-codamol 15/500)
(tablets and capsules)
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Formulary
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£££££
Limited evidence
For elderly community who would not tolerate separate ingredients and to support a step down review
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Paracetamol and codeine (Co-codamol ®15/500)
(Effervescent tablets)
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Formulary
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£££££
Limited evidence
Only for patients with swallowing difficulties
For elderly community who would not tolerate separate ingredients and to support a step down review
High sodium content
Tablets and capsules more cost effective
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Paracetamol and codeine (Co-codamol 30/500)
(Tablets and Capsules)
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Formulary
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Use with caution in patients over 65s
Contraindicated in children below the age of 12
Use in chronic pain only
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Paracetamol and codeine (Co-codamol 30/500)
(Effervescent tablets)
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Formulary
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£££££
High sodium content
Only for use in patients with swallowing difficulties
Tablets and capsules more cost effective
For use in chronic pain
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| 04.07.02 |
Opioid analgesics |
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Buprenorphine Patch
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Formulary
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ONCE A WEEK patch (7-day patch)
For specialist initiation: specialist pain clinics, palliative care and for patients with swallowing difficulties
Patches should be prescribed by BRAND
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Buprenorphine Patch (Transtec®)
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Formulary
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TWICE WEEKLY patch
For specialist initiation: specialist pain clinics, palliative care and for patients with swallowing difficulties
Patches should be prescribed by BRAND
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Buprenorphine sublingual tablet
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Formulary
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Specialist use only
For use in opioid dependence, see section 4.10.3
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Codeine Phosphate
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Formulary
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Tablets
25mg/5ml syrup
Use with caution in patients aged over 65
Contraindicated in children below the age of 12
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Codeine phosphate
(60mg/mL Injection)
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Formulary
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Diamorphine salts
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Formulary
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Dihydrocodeine
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Formulary
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Tablets
Oral solution for patients with swallowing difficulties
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Fentanyl
(Patches)
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Formulary
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For patients with swallowing difficulties on stable doses of opiates or on pain team specialist advice when morphine is not suitable.
Prescribe by brand.
Follow Optimise Rx advice for most cost effective brand
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Fentanyl
(lozenges)
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Formulary
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Palliative care use only
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 Patient Information: Changes to immediate-release fentanyl prescribing
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Fentanyl
(nasal spray)
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Formulary
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Patient Information: Changes to immediate-release fentanyl prescribing
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Fentanyl
(sublingual tablets)
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Formulary
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Palliative care use only
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Patient Information: Changes to immediate-release fentanyl prescribing
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Meptazinol (Meptid®)
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Formulary
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Methadone
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Formulary
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For use in opiod dependence, see section 4.10.3
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Morphine
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Formulary
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 Tablets
M/R tablets
M/R capsules
Oral solution
Injection
 Suppositories
100mg/100ml PCA
5mg/5ml intrathecal injection
pre-filled syringe
Specialist initiation- pain clinic
Modified release(MR) preparation should be used for regular dosing. Immediate release preparations may be associated with tolerance and problem drug use.
Follow Optimise Rx advice for most cost effective brand / formulation
Injectable formulations for palliative care only
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Oxycodone
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Formulary
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Capsules
M/R tablets
SF solution
For patients who do not tolerate morphine
Specialist initiation
Pain clinic and palliative care use only
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Oxycodone
(Injection)
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Formulary
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Pethidine
(injection)
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Formulary
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Tapentadol (Palexia®)
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Formulary
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Tramadol
(capsules)
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Formulary
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Third line after morphine and codeine
Please note modified release preparations are non-formulary
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 UKMI Q&A: risk of developing Serotonin Syndrome following concomitant use of tramadol with selective serotonin reuptake inhibitors (SSRIs)
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Tramadol
(soluble tablets)
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Formulary
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Third line after morphine and codeine
Only for patients with swallowing difficulties
Capsules more cost effective
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| 04.07.02 |
Weak opioids |
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Strong opioids |
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Breakthrough pain |
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Injectable |
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Other |
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| 04.07.03 |
Neuropathic pain |
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Amitriptyline
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Formulary
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1st line
Low abuse potential, low cost
Off label use
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NICE CG173: Neuropathic pain - pharmacological management in non-specialist settings
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Gabapentin
(tablets and capsules)
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Formulary
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2nd line
Be aware of abuse and addiction potential associated with this class of agent
Due to the risk of adverse effects associated with Gabapentin,start with the lowest effective dose and titrate up to the minimum effective dose. Educate patient on titration
At follow up, check patient's tolerance of treatment and understanding of dose titration
See Gabapentin leave sheet for dose titration information
Reduce dose in renal impairment
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NHS England: (Schedule 3 Controlled Drugs) Patient Leaflet; Are you taking gabapentin or pregabalin? (Lyrica, Alzain, Neurontin)
NHS England: Advice for prescribers on the risk of the misuse of pregabalin and gabapentin
UKMI Q&A: Gabapentin and pregabalin - are they safe whilst breast feeding?
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Duloxetine (Cymbalta®)
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Formulary
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Third line after gabapentin
 On advice of specilaist - initiate at 30 mg OD for 1 month, then 60 mg OD
More cost effective options available
NICE suggests 1st line for Diabetic neuropathy
Low abuse potential , high cost £££££
Not licensed for use in children
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Pregabalin
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Formulary
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4th line after duloxetine
On the advice of a specialist where duloxetine is unsuitable
Please be aware of abuse potential associated with this class of agent
From 17th July 2017, clinicians can now return to normal practice when prescribing pregabalin and no longer need to specify a brand name when prescribing for neuropathic pain
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NHS England: (Schedule 3 Controlled Drugs) Patient Leaflet; Are you taking gabapentin or pregabalin? (Lyrica, Alzain, Neurontin)
NHS England: Advice for prescribers on the risk of the misuse of pregabalin and gabapentin
UKMI Q&A: Gabapentin and pregabalin - are they safe whilst breast feeding?
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| 04.07.03 |
Trigeminal neuralgia |
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Carbamazepine
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Formulary
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For the treatment of trigeminal neuralgia only
Baseline LFTs,FBC and U & Es- then 6 monthly
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| 04.07.03 |
Postherpetic neuralgia |
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Capsaicin
(cream 0.075%)
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Formulary
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For local neuropthic pain
ONLY strength licensed for post-herpetic neualgia and diabetic peripheral polyneuropathy
For other strength, see section 10.3.2
Please note that capsaicin 8% patches are non-formulary
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Lidocaine 5% patch (Versatis®)
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Formulary
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Approved only in patients who have been treated in line with NICE CG173: Neuropathic pain in adults: pharmacological management in non-specialist settings but are still experiencing neuropathic pain associated with previous hepes zoster infection (post-herpetic neuralgia)
Following the policy - Items which should not routinely be prescribed in Primary Care. There is an exception for lidocaine for treatment of neuropathic pain in adults.
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Link to Chapter 15
Patient Information: Changes to lidocaine plaster prescribing
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| 04.07.03 |
Chronic facial pain |
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| 04.07.04 |
Antimigraine drugs |
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Migraleve ® pink
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Formulary
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| 04.07.04.01 |
Treatment of the acute migraine attack |
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| 04.07.04.01 |
Analgesics |
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Analgesics (Migraleve Pink®)
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Formulary
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| 04.07.04.01 |
5HT1 agonists |
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Rizatriptan
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Formulary
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 Tablets
Orodispersible tablets SF-reserved for patients who are vomiting due to migraine
 Wafer/oral lyophilisates SF £££££
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Sumatriptan
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Formulary
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Tablets (prescribe as generic)
Nasal spray £££££
Injection £££££
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Zolmitriptan
(Tablets)
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Formulary
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| 04.07.04.02 |
Prophylaxis of migraine |
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Amitriptyline
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Formulary
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Erenumab (Aimovig®)
(Solution for injection)
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Formulary
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In line with NICE
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NICE TA682: Erenumab for preventing migraine
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Fremanezumab (Ajovy®)
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Formulary
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In line with NICE
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NICE TA764: Fremanezumab for preventing migraine
NICE TA631: Fremanezumab for preventing migraine
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Galcanezumab (Emgality®)
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Formulary
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In line with NICE
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NICE TA659: Galcanezumab for preventing migraine
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Botulinum Toxin Type A
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Formulary
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For hospital use only
Use in line with NICE
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NICE TA260: Botox for migraine prophylaxis
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Pizotifen
(tablets & elixir)
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Formulary
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Propranolol
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Formulary
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Topiramate
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Formulary
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For migraine prophylaxis as per guidance
On specialist recommendation
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Flunarizine
(Tablets)
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Formulary
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Unlicensed medicine
Specialist use only
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| 04.07.04.03 |
Cluster headache |
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| Non Formulary Items |
Alfentanyl Sublingual Spray 5 mg in 5mL
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Non Formulary
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Almotriptan (Almogran®)
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Non Formulary
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Aspirin (Caprin®, Nu-Seals® Aspirin)
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Non Formulary
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Aspirin and codeine (Co-codaprin®)
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Non Formulary
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Aspirin and metoclopramide (MigraMax®)
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Non Formulary
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Aspirin and papaveretum (Aspav®)
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Non Formulary
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Capsaicin
(8% Patch)
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Non Formulary
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Codeine phosphate 60 mg/1 ml injection
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Non Formulary
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Co-proxamol
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Non Formulary
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In line with NHS England's Guidance for CCGs: Items which should not routinely be prescribed in primary care (Dec 2017)
Click here to access guidance |
Patient Information - Changes to co-proxamol prescribing
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Dextromoramide
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Non Formulary
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Dihydrocodeine Tartrate (DF118 Forte®, DHC Continus®)
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Non Formulary
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Dipipanone (Diconal®)
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Non Formulary
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Eletriptan (Relpax®)
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Non Formulary
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Fentanyl buccal tablets lozenges and films (Breakyl®)
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Non Formulary
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Patient Information Leaflet
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Frovatriptan
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Non Formulary
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Hydromorphone (Palladone®)
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Non Formulary
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Hydromorphone Hydrochloride (Palladone® SR)
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Non Formulary
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Isometheptene Mucate (Midrid®)
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Non Formulary
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Ketamine oral solution
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Non Formulary
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Melatonin
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Non Formulary
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Methysergide (Deseril®)
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Non Formulary
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Morphine and cyclizine (Cyclimorph®)
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Non Formulary
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Naratriptan
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Non Formulary
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Removed from formulary May 2017 following 6-fold price increase. More cost-effective options available on formulary. |
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Nefopam
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Non Formulary
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Nefopam (Acupan®)
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Non Formulary
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Papaveretum
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Non Formulary
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Paracetamol (Panadol OA®)
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Non Formulary
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Paracetamol and codeine (Co-codamol® 8/500)
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Non Formulary
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Paracetamol and dihydrocodeine (Co-dydramol®)
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Non Formulary
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Paracetamol and dihydrocodeine (Remedeine®)
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Non Formulary
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Paracetamol and methionine (Pardote®)
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Non Formulary
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Paracetamol and metoclopramide (Paramax®)
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Non Formulary
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Pentazocine
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Non Formulary
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Pethidine
(Tablets)
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Non Formulary
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Pethidine Hydrochloride and promethazine (Pamergan® P100)
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Non Formulary
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Phenytoin
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Non Formulary
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Pregabalin
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Non Formulary
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NHS England: (Schedule 3 Controlled Drugs) Patient Leaflet; Are you taking gabapentin or pregabalin? (Lyrica, Alzain, Neurontin)
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Sodium valproate
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Non Formulary
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Sumatriptan (Imigran® Radis)
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Non Formulary
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Tapentadol (Palexia SR®)
(M/R tablets)
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Non Formulary
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Targinact (Oxycodone/Naloxone) (Targinact®)
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Non Formulary
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In line with NHS England's Guidance for CCGs: Items which should not routinely be prescribed in primary care (Dec 2017)
Click here to access guidance |
Patient Information Leaflet: Changes to Targinact prescribing
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Tolfenamic Acid (Clotam®)
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Non Formulary
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Topiramate
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Non Formulary
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Tramadol Hydrochloride and paracetamol (Tramacet®)
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Non Formulary
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In line with NHS England's Guidance for CCGs: Items which should not routinely be prescribed in primary care (Dec 2017)
Click here to access guidance |
Patient Information Leaflet: Changes to Tramacet prescribing
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Tramadol MR capsules
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Non Formulary
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Tramadol oral drops
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Non Formulary
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Key |
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Restricted Drug |
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Unlicensed |
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Link to adult BNF
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Link to children's BNF
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Link to SPCs
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Cytotoxic Drug |
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Controlled Drug |
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High Cost Medicine |
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Cancer Drugs Fund |
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NHS England |
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Homecare |
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ICB |
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Low carbon footprint |
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Medium carbon footprint |
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High carbon footprint |
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| Status |
Description |
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All Settings
Suitable for initiation, ongoing prescribing, and discontinuation in both primary and secondary care settings. They are generally familiar, frequently used therapies that can be started within their licensed indications without specialist oversight. |
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Specialist only
Designated for initiation, ongoing prescribing, monitoring, exclusively by a specialists either in a hospital or as part of a specialist service (to note this could be in a non-hospital setting). Primary care should neither start nor continue these treatments except as part of a specialist service. A specialist could be either a medical or non-medical prescriber. |
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Specialist advice
Prescribers in primary care should seek advice and a recommendation from a specialists prior to initiating a medicine. Once agreed with a specialist, medicines can be initiated, prescribed and monitored in primary care without a formal shared-care agreement. |
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Specialist initiation
Medicines in this category require a specialist to start therapy, titrate dosage, and assess initial efficacy or tolerability. Once stabilised, prescribing responsibility may transfer to primary care without the need for a formal shared-care agreement. |
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Shared care agreement
Prescribing responsibility can be shared across health settings and between specialists and GPs only when formal shared care arrangement has been made. For example, there may be extensive and complex monitoring requirements or significant safety concerns (note would need a national policy on this to define the criteria for requiring a formal SCA), this will be produced once nationally. |
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Do not prescribe
Not approved for routine prescribing in primary or secondary care. For example, because they are agents classified in the BNF as “not NHS” or “Drugs of Low Clinical Value”, or they are products on NICE’s “do not do” list or NHS England’s “should not routinely prescribe” list. |
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Self Care
Not for routine prescribed in primary or secondary care unless as part of care for a long term condition. Instead, patients should be encouraged to self care with support from community pharmacy. |
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Medicines which are suitable for initiation and maintenance prescribing by primary and secondary care clinicians. These medicines should be initiated and prescribed within their licensed indications |
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Amber Specialist Initiation: Initiation and maintenance of prescribing by Specialists and transfer to Primary Care prescribing when appropriate. This may be supported by a RICaD, annotated within the formulary entry. |
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Amber Shared Care: Initiation and maintenance of prescribing by Specialists and transfer to Primary Care prescribing, in accordance with an ESCA, annotated within the formulary entry. |
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Amber Specialist Recommendation: Initiation and maintenance of prescribing in Primary Care following recommendation from a specialist. |
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Medicines for initiation and maintenance prescribing by Specialists (hospital or GPs with Special Interest) only |
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Positive NICE TA and /or awaiting local clarification on place in therapy; Please contact your Medicines Optimisation team for more information. |
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Non-formulary Medicines which APC/Trust DTC has actively reviewed and do not recommend for use. |
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