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 Formulary Chapter 4: Central nervous system - Full Chapter
Notes:

Opioid Resource Pack

Gabapentinoid Reduction Leaflet

 Details...
04.07  Expand sub section  Analgesics
04.07.01  Expand sub section  Non-opioid analgesics and compound analgesic preparations
04.07.01  Expand sub section  Compound analgesic preparations
Aspirin
View adult BNF View SPC online View childrens BNF
Formulary
Green

Prescribe as dispersible tablets

 
   
Nefopam
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Amber

Specialist advice only

Occasional use for patients intolerant or allergic to opioids

 
   
Paracetamol
View adult BNF View SPC online View childrens BNF
Formulary
OTC

Tablets and suspension for self-purchase in primary care unless for treatment of long term condition as per NHSE guidance

 

 
Link  NHSE OTC Guidance
   
Paracetamol and codeine (Co-codamol® 30/500)
View adult BNF View SPC online View childrens BNF
Formulary
Green

Prescribe as Zapain in Primary Care

 
   
Paracetamol and codeine (Co-codamol® 8/500)
View adult BNF View SPC online View childrens BNF
Formulary
OTC

For self-purchase in primary care

For long term use consider prescribing "when required" codeine separately

 
   
Paracetamol and dihydrocodeine (Co-dydramol®)
View adult BNF View SPC online View childrens BNF
Formulary
Green

Dihydrocodeine 10mg and Paracetamol 500mg

NB other strengths of co-dydramol now available

 
   
04.07.02  Expand sub section  Opioid analgesics
Codeine
(analgesia)
View adult BNF View SPC online View childrens BNF
First Choice
Green 1

Codeine-containing medicines should only be used in children over 12 years old to treat acute (short lived) moderate pain, and only if it cannot be relieved by other painkillers such as paracetamol or ibuprofen. Contra-indicated in any patient under 18 years old who undergoes the removal of tonsils or adenoids for the treatment of sleep apnoea. Not recommended in 12-18 yr olds with breathing problems.

MHRA advice April 2015 and July 2013 on use in children and adolescents.

Known to be misused and subject to drug seeking behaviour.

 
Controlled Drug Morphine (Zomorph®)
View adult BNF View SPC online View childrens BNF
First Choice
Green 1

First choice opioid for oral and sub-cut/syringe driver use.

Immediate release (IR) for titration and breakthrough pain

Prescribe modified release preparations by brand as good practice to ensure consistency of supply.

Zomorph® capsules may be opened and sprinkled onto food.

Prescribe 10mg in 1ml ampoules in primary care

 
Controlled Drug Morphine Salts (Oramorph®)
View adult BNF View SPC online View childrens BNF
First Choice
Green

Immediate release (IR) for titration and breakthrough pain

 

 

 
Controlled Drug Morphine Salts (Sevredol®)
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First Choice
Green

Immediate release (IR) for titration and breakthrough pain

 

 
Controlled Drug Buprenorphine (Butec® patch)
View adult BNF View SPC online View childrens BNF
Second Choice
Green 2

For patients with poor swallow who are unable to tolerate higher doses of opioids.

Prescribe as BuTec. 5mcg/hr patch approx equivalent to 12mg oral morphine. 

 
   
Dihydrocodeine
View adult BNF View SPC online View childrens BNF
Second Choice
Green 2

Known to be misused and subject to drug seeking behaviour.

 
   
Controlled Drug Fentanyl (Matrifen)
(Patch)
View adult BNF View SPC online View childrens BNF
Third Choice
Green 3

Prescribe by brand as good practice to ensure consistency of supply.

MATRIFEN is HCCG brand of choice

 
   
Controlled Drug Tramadol
View adult BNF View SPC online View childrens BNF
Third Choice
Green 3

Use capsules (standard release) first line. If MR necessary prescribe as brand Tramulief® in primary care

NOT recommended for routine use in primary care and should NOT be considered as an alternative to codeine/or stepping up to stronger opioids.

 
Link  Nociceptive Pain
   
Controlled Drug Buprenorphine (Temgesic®)
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Formulary
Green
 
   
Controlled Drug Diamorphine Hydrochloride Injection
View adult BNF View SPC online View childrens BNF
Formulary
Green
 
   
Controlled Drug Fentanyl Nasal Spray (PecFent®)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Amber

Second line use by the Palliative Care team for incident pain only. Not for routine use for breakthrough pain with fentanyl patches. 

 
   
Controlled Drug Fentanyl sublingual tablets (Abstral®)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Amber

Second line use by the Palliative Care team for incident pain only. Not for routine use for breakthrough pain with fentanyl patches. 

 
   
Controlled Drug Pethidine
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Red

Injection for maternity inpatient use only.

 

 
   
Controlled Drug Oxycodone modified release tablets
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Amber

Oral preparation

Palliative care only for those unable to tolerate morphine or in patients with renal impairment.

Prescribe by brand as good practice to ensure consistency of supply.

HCCG brand of choice LYNLOR for standard release and OXYPRO for modified release preparations and are stocked by Out Of Hours pharmacies for emergency supplies.

 

 
   
Controlled Drug Tapentadol (Palexia®)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Amber

 Specialist initiation only by pain consultant

 
   
04.07.03  Expand sub section  Neuropathic pain to top
Amitriptyline
View adult BNF View SPC online View childrens BNF
First Choice
Green 1

Off-label use . Routinely used and included in NICE (CG173) guidelines

 

 

 
Gabapentin
(Neuropathic pain)
View adult BNF View SPC online View childrens BNF
Second Choice
Green 2

Titrate slowly - see guidance

 
Link  HCCG Neuropathic Guidelines
   
Pregabalin
(Neuropathic pain)
View adult BNF View SPC online View childrens BNF
Second Choice
Green 2

Titrate slowly – see guidance

Because of price structure for pregabalin, ensure dose optimisation is carried out.
Pregabalin dose spread over two daily doses proved non-inferior to three times a day dosing: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007076.pub2/pdf

 
Link  HCCG Neuropathic Guidelines
   
Duloxetine
View adult BNF View SPC online View childrens BNF
Formulary
Green 2
 
   
Controlled Drug Ketamine oral solution
Restricted Drug Restricted
Amber

Pallative Care Use Only - See Shared Care

 

 
Link  Ketamine Shared Care
   
04.07.03  Expand sub section  Trigeminal neuralgia
04.07.03  Expand sub section  Postherpetic neuralgia
04.07.03  Expand sub section  Chronic facial pain
04.07.04  Expand sub section  Antimigraine drugs
04.07.04.01  Expand sub section  Treatment of the acute migraine attack to top
04.07.04.01  Expand sub section  Analgesics
04.07.04.01  Expand sub section  5HT1 agonists
Sumatriptan
View adult BNF View SPC online View childrens BNF
First Choice
Green 1

Generically prescribed tablets 1st line. Nasal spray for paediatrics only.

 
Zolmitriptan
View adult BNF View SPC online View childrens BNF
First Choice
Green 1

Generically prescribed tablets and dispersible tablets. 

 
04.07.04.01  Expand sub section  Ergot alkaloids
04.07.04.01  Expand sub section  Anti-emetics
04.07.04.01  Expand sub section  Other drugs for migrane to top
04.07.04.02  Expand sub section  Prophylaxis of migraine
Propranolol
View adult BNF View SPC online View childrens BNF
First Choice
Green 1
 
Amitriptyline
(Migraine prophylaxis)
View adult BNF View SPC online View childrens BNF
Second Choice
Green 2

Off label use

 
   
Pizotifen
View adult BNF View SPC online View childrens BNF
Second Choice
Green 2
 
   
04.07.04.03  Expand sub section  Cluster headache
 ....
 Non Formulary Items
Controlled Drug  Alfentanyl Sublingual Spray 5 mg in 5mL

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Almotriptan  (Almogran®)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Analgesics  (Migraleve®)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Aspirin  (Nu-Seals® Aspirin)

View adult BNF View SPC online View childrens BNF
Non Formulary

No evidence of benefit over dispersible aspirin

 

 
Aspirin + Codeine  (Co-codaprin®)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Aspirin + Metoclopramide  (MigraMax®)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Aspirin + Papaveretum  (Aspav®)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Co-proxamol

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Controlled Drug  Dihydrocodeine Tartrate  (DHC Continus®)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Controlled Drug  Dipipanone  (Diconal®)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Eletriptan  (Relpax®)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Ergotamine Tartrate  (Cafergot®)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Ergotamine Tartrate  (Migril®)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Controlled Drug  Fentanyl
(Actiq lozenges)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Controlled Drug  Fentanyl  (Effentora® buccal tablets)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Controlled Drug  Fentanyl  (Instanyl® nasal spray)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Frovatriptan

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Controlled Drug  Hydromorphone  (Palladone®)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Isometheptene Mucate  (Midrid®)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Melatonin
(Cluster headache)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Meptazinol  (Meptid®)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Methoxyflurane  (Penthrox®)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Controlled Drug  Morphine and cyclizine  (Cyclimorph®)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Controlled Drug  Morphine Salts  (MST Continus®)

View adult BNF View SPC online View childrens BNF
Non Formulary

Except 5mg tablets

 
Controlled Drug  Morphine suppositories

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Naratriptan  (Naramig®)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Controlled Drug  Papaveretum

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Controlled Drug  Papaveretum
(Papaveretum with hyoscine injection)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Paracetamol and methionine  (Pardote®)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Paracetamol and metoclopramide  (Paramax®)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Rizatriptan  (Maxalt®)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Sumatriptan  (Imigran® Radis)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Controlled Drug  Targinact (Oxycodone/Naloxone)  (Targinact®)
(Pain)

View adult BNF View SPC online View childrens BNF
Non Formulary
Not Recomended / Black

 See Herefordshire LPT Low Value Medicine 

 
Controlled Drug  Targinact (Oxycodone/Naloxone)  (Targinact®)
(Restless legs)

View adult BNF View SPC online View childrens BNF
Non Formulary
Not Recomended / Black

See Herefordshire LPT Low Value Medicine

 
Tolfenamic Acid  (Clotam®)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Controlled Drug  Tramadol Hydrochloride and paracetamol  (Tramacet®)

View adult BNF View SPC online View childrens BNF
Non Formulary

See Herefordshire LPT Low Value Medicine

 

 
  
Key
note Notes
Section Title Section Title (top level)
Section Title Section Title (sub level)
First Choice Item First Choice item
Non Formulary Item Non Formulary section
Restricted Drug
Restricted Drug
Unlicensed Drug
Unlicensed
Track Changes
Display tracking information
click to search medicines.org.uk
Link to adult BNF
click to search medicines.org.uk
Link to children's BNF
click to search medicines.org.uk
Link to SPCs
SMC
Scottish Medicines Consortium
Cytotoxic Drug
Cytotoxic Drug
CD
Controlled Drug
High Cost Medicine
High Cost Medicine
Cancer Drugs Fund
Cancer Drugs Fund
NHSE
NHS England
Homecare
Homecare
CCG
CCG

Traffic Light Status Information

Status Description

Green

Suitable for use in primary care  

Amber

Specialist initiation. Shared care in place  

Red

Red do not use..  

Advice

Some formulations restricted  

Black

NICE "Do not do"  

Green 1

1st line option  

Green 2

2nd line option  

Green 3

3rd line option only  

Not Recomended / Black

Low Value Medicine not recommended for use - see NHSE guidelines  

OTC

This preparation should be bought over the counter for self-care  

Red Amber

Check product description for traffic light status  

Red Black

Low Value Medicine  

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