GASTRO-INTESTINAL SYSTEM · Web viewContents 1. Gastro-intestinal system Antacids Antispasmodics...

Liverpool Heart and Chest Hospital NHS Foundation TrustDrug Formulary

Contents

1. Gastro-intestinal system Antacids Antispasmodics Motility stimulants Ulcer healing drugs

- H 2 antagonists- Proton pump inhibitors

Antidiarrhoeals Chronic Bowel Disorders Laxatives

- Bulk forming - Stimulant - Faecal softeners - Osmotic laxatives - Bowel cleansing solutions - Laxative policy - Management of impacted faeces

Haemorrhoid preparations Intestinal secretions 2. Cardiovascular System Positive inotropesDiuretics

- Thiazides - Loop diuretics - Potassium sparing diuretics - Combination diuretics - Osmotic diuretics

Anti-arrhythmicsBeta-blockersDrugs affecting the renin-angiotensin system and other antihypertensives

- Vasodilator antihypertensives - Centrally acting antihypertensives - Alpha-blockers - ACE inhibitors - Angiotensin II receptor antagonists

NitratesCalcium channel blockersIvabradinePotassium channel activatorsSympathomimeticsAnticoagulantsAntiplatelet drugs

- Clopidogrel prescribing guidelines

Fibrinolytic drugsAntifibrinolytic drugs Lipid lowering drugs

- Anion-exchange resins - Fibrates

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- Statins - Guidelines for prescribing cholesterol lowering agents - Fish oils - Other agents

3. Respiratory System

Bronchodilators Selective Beta2 agonist antimuscarinics2 Theophylline Combination bronchodilators Inhaler devices

Inhaled CorticosteroidsLeukotriene receptor antagonistsManagement of acute severe asthma in adults

Management of COPD:pharmacological therapy of stable COPD and Hospital management of severe exacerbations of COPDSolutions for nebulisationAntihistamines Respiratory stimulantsOxygenMucolyticsAromatic InhalationsCough preparations

4. Central Nervous SystemHypnotics and anxiolyticsDrugs used in psychosesAntidepressant drugsNausea and vertigo

- Algorithm for the management of post-operative nausea and vomiting

Analgesics- Pain Ladder – ‘Please refer to before prescribing’.- Non-opioid analgesics - Opioid analgesics - Prophylaxis of migraine

Antiepileptics Parkinsonism and related disorders

- Dopaminergics - Antimuscarinics - Relief of intractable hiccup

Drugs used in substance dependenceManagement of alcohol withdrawal

5. Infections - Refer to Antimicrobial Policy

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http://ctcnt20/policy/81/Antimicrobial%20Current%20February%202010.pdf


6. Endocrine systemDrugs used in diabetes

- Insulins - Oral antidiabetic drugs

- Hypoglycaemia

Thyroid and antithyroid drugsCorticosteroids

Pituitary hormonesDrugs affecting bone metabolism

7. Urinary tract disordersVaginal anti-infective drugsGenito-urinary disorders

8. Malignant disease and immunosupressionCytotoxic drugsImmunosupressantsSex hormones and hormone antagonists

9. Nutrition and bloodAnaemiasFluids and electrolytesIntravenous nutritionEnteral nutritionMineralsVitamins

10. Musculoskeletal and joint diseasesDrugs used in rheumatic diseases and gout

- NSAIDS - Corticosteroid injections - Drugs used in gout

Neuromuscular disorders- Drugs which enhance neuromuscular transmission - Skeletal muscle relaxants - Nocturnal leg cramps

Topical antirheumatics

11. Drugs acting on the eyeAnti-infective preparationsCorticosteroidsMydriaticsTreatment of glaucomaMiscellaneous

- Tear deficiency

12. Ear, nose and oropharynxDrugs acting on the ear

- Anti-inflammatory and anti-infective preparations 3


- Removal of ear wax Drugs acting on the nose

- Nasal allergy - Nasal staphylococci

Drugs acting on the oropharynx- Ulceration and inflammation - Fungal infections - Oral hygiene

- Dry mouth

13. SkinEmollient and barrier preparationsTopical antipruriticsTopical corticosteroidsSunscreensScalp preparationsAnti-infective skin preparations

- Antibacterials - Antifungals - Antivirals - Scabies and lice

Disinfectants and cleansersWound management

14. Immunological products and vaccines

15. AnaesthesiaIntravenous anaesthesiaInhalation anaesthesia AntimuscarinicsSedative and analgesic peri-operative drugs

- Anxiolytics and neuroleptics - Non-opioid analgesics - Opioid analgesics

Muscle relaxants AnticholinesterasesAntagonists for central and respiratory depressionMalignant hyperthermiaLocal anaesthetics

Appendix 8. Wound management – refer to Wound formulary

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http://nww.staffintranet.lhch.nhs.uk/library/departments/support_services/pharmacy/woundcareformulary/wound%20dressing%20formulary%20july%202011.xls


1. GASTRO-INTESTINAL SYSTEM

1.1 Antacids

Magnesium trisilicate mixtureGaviscon

1.2 Antispasmodics

MebeverineHyoscine butylbromidePeppermint water

Motility stimulants

Metoclopramide (Maximum of 5 days treatment only as per MHRA restrictions)Domperidone (Restricted to Cystic Fibrosis and Palliative Care use only)Erythromycin (unlicensed indication. IV and oral)

1.3 Ulcer healing drugs

H2 antagonists

Ranitidine

Proton pump inhibitors

Lansoprazole (see below for dosing and duration of therapy)

Indication Dose of Lansoprazole Duration of

TherapySurgical prophylaxis

30mg daily (unlicensed indication) 4 weeks

NSAID GI prophylaxis

30mg daily (unlicensed indication) http://www.npc.nhs.uk/merec/pain/musculo/merec_extra_no30.php#GIR

Duration of NSAID therapy

Benign gastric ulcer

30mg daily 8 weeks

Duodenal ulcer

30mg daily for 4 weeks then 15mg maintenance therapy

Continuous (15mg daily)

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http://www.npc.nhs.uk/merec/pain/musculo/merec_extra_no30.php#GIR

http://www.npc.nhs.uk/merec/pain/musculo/merec_extra_no30.php#GIR

https://www.cas.dh.gov.uk/ViewandAcknowledgment/ViewAttachment.aspx?Attachment_id=101896

https://www.cas.dh.gov.uk/ViewandAcknowledgment/ViewAttachment.aspx?Attachment_id=101896

http://www.mhra.gov.uk/PrintPreview/DSUArticlePage/CON300404?DynamicListQuery=dDocType%20%3Cmatches%3E%20%60Publication%60%20%20%3CAND%3E%20%20xSecondLevel%20%3Cmatches%3E%20%60Safety%20Guidance%60%20%20%3CAND%3E%20%20xThirdLevel%20%3Cmatches%3E%20%60Medicines%60%20%20%3CAND%3E%20%20xFourthLevel%20%3Cmatches%3E%20%60Drug%20Safety%20Update%60%20%3Cand%3E%20%20xNHSNetOnly%20%3Cmatches%3E%20%60No%60



GORD 30mg daily for 4 weeks, continued for a further 4 weeks if not fully healed then maintenance dose of 15-30mg daily

Continuous

NSAID associated duodenal or gastric ulcer

As for GORD above Continuous

Zollinger-Ellison syndrome

60mg daily adjusted according to response (up to 120 mg in divided doses).

Continuous

Eradication of H Pylori

Consult antimicrobial guidelines 1 week

Cough associated with GORD

15-30mg twice a day before meals (unlicensed dose) http://www.brit-thoracic.org.uk/Portals/0/Guidelines/Cough/Guidelines/coughguidelinesaugust06.pdf

8 weeks and then review

Omeprazole (IV only) for use Where IV therapy is required at a dose of 40mg daily Prophylaxis of acid aspiration during general anaesthesia at a

dose of 40mg on the evening before surgery then 40mg 2-6 hours before surgery.

Dose should be converted to oral lansoprazole if therapy at earliest opportunity if treatment is to continue

Discharge prescriptions MUST state duration of therapy for Proton Pump inhibitors. Consideration should be given to the possible long term side effects of proton pump inhibitors including hypomagnesaemiahttp://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON149774 and hip fracture risk http://www.bmj.com/content/344/bmj.e372.pdf%2Bhtml.

1.4 Antidiarrhoeals

Codeine PhosphateLoperamide

1.5 Chronic bowel disorders

Consult gastroenterologist

1.6 Laxatives

Bulk forming Fybogel

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http://www.bmj.com/content/344/bmj.e372.pdf%2Bhtml

http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON149774

http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON149774

http://www.brit-thoracic.org.uk/Portals/0/Guidelines/Cough/Guidelines/coughguidelinesaugust06.pdf




Stimulant Senna Glycerine suppositories Docusate sodium Dantron (present in co-danthramer capsules and suspension) Terminal

care only.

Faecal softeners Arachis oil enema

Osmotic laxatives Lactulose Gastrografin (CF use only – unlicensed) Macrogol ‘3350’ sachets Sodium Citrate enema Phosphate enema

Bowel cleansing solutions Klean Prep Picolax

5HT4 Receptor AgonistsPrucalopride 2mg tablets – for use in chronic constipation in CF unresponsive to other treatments.(For CF consultant use only). NICE TA211 Chronic constipation in women

Laxative Guidelines

Surgical Treatment/Prophylaxis in patients on opioids:

Senna 15mg at nightLactulose 15ml bd initially and adjusted according to response

Consider changing lactulose to Macrogol ‘3350’ One sachet bd where lactulose is ineffective or a more rapid response is required

Other points to considerConsider increasing fluid intake and mobility and reviewing other potentially constipating medication (e.g. NSAIDs) in all cases where possible.

All laxatives are contraindicated in bowel obstruction.

Lactulose may take up to 48 hours to have an effect and is therefore not suitable for ‘prn’ administration or short term use.

7

http://www.nice.org.uk/nicemedia/live/13284/52078/52078.pdf



Distal Intestinal Obstruction Syndrome in CF (See policy - Nursing a patient with DIOS in CF)

Initially give oral Gastrografin 100ml prn up to 500ml (unlicensed) with adequate fluid intake (1 litre of fluid is recommended per 100ml dose)

If this fails to resolve blockage then commence Klean-Prep - one sachet in 1 litre of water every hour orally or via naso-gastric/PEG tube until blockage has resolved (unlicensed) plus Metoclopramide IV 10mg tds. Consider IV paracetamol 1g qds for pain relief (avoid opioid analgesia)

1.7 Haemorrhoid preparations

Anusol (suppositories or cream)

1.9 Intestinal secretions

Ursodeoxycholic acid Creon Pancrease

CARDIOVASCULAR SYSTEM

2.1 Positive inotropes

DigoxinEnoximone

2.2 Diuretics

ThiazidesIndapamideChlortalidone

Bendroflumethiazide Metolazone (unlicensed). Consider using bendroflumethiazide instead.

Patients requiring metoloazone for discharge will need to obtain on going supplies from LHCH pharmacy (typically as an outpatient)

Loop diureticsFurosemideBumetanide

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Potassium sparing diureticsAmiloride Aldosterone antagonists/Mineralocorticoid receptor antagonists (MRA)Spironolactone

Eplerenone Consultant use only for:Patients intolerant of spironolactone in heart failure NYHA II and LVEFless than 30% or Heart failure post MI with LVEF less than 40%

Combination diureticsCo-amilofruse

Osmotic diuretics Mannitol

2.3 Anti-arrhythmicsAdenosineAmiodarone DisopyramideFlecainideLidocaineMexiletine (unlicensed use) PropafenoneQuinidine (unlicensed use)Verapamil

Dronedarone ( Dronedarone for the treatment of non-permanent atrial fibrillation NICE TA197

2.4 Beta blockers

Indication Preferred drug Other optionsSecondary prevention after myocardial infarction

bisoprolol propanolol, metoprolol

Angina bisoprolol atenolol, metoprolol, propanolol

Hypertension (uncomplicated)

Not indicated for first line use. In combination therapy: atenolol, bisoprolol, propanolol. For intravenous treatment after aortic dissection use labetolol

Heart failure bisoprolol carvedilol, metoprolol, nebivolol

Treatment of SVT metoprolol esmololProphylaxis of SVT metoprolol propanolol, bisoprolol

(unlicensed

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indication), atenolol, sotalol (seek consultant advice)

Life-threatening arrhythmias/ Recurrent ICD shocks

Bisoprolol (unlicensed indication)

Esmolol (unlicensed indication)

Prophylaxis of AF post CABG

bisoprolol

Treatment of AF post CABG

Amiodarone 1st line (this should be reviewed at OPD and if patient still in AF consider alternative treatment options due to adverse side effect profile)Sotalol 80mg BD

See also Chronic Heart Failure guidelines on Trust Intranet

2.5 Drugs affecting the renin-angiotensin system and other antihypertensives

Vasodilator antihypertensivesSodium nitroprussideHydralazineDiazoxide

SildenafilPatients with pulmonary arterial hypertension should normally be referred to the regional specialist centre (Sheffield). Any intention to treat a patient locally should be discussed with the chief pharmacist/cardiology pharmacist. This drug is outside of tariff and therefore agreement for recharge must be obtained from the relevant CCG before prescribing.

Centrally acting antihypertensivesMethyldopaMoxonidine

Alpha blockersDoxazosinPhentolaminePhenoxybenzamine

Angiotensin Converting Enzyme (ACE) inhibitorsRamiprilPerindopril

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http://nww.staffintranet.lhch.nhs.uk/Library/Corporate/policies_procedures/Heart%20Failure%20Guideline%20Current%20March%202009.pdf


Angiotensin II receptor antagonists

Indication Preferred Drug Other DrugsHypertension Telmisartan Losartan ,

CandesartanLeft Ventricular dysfunction (when ACE-inhibitor not tolerated because of cough)

Candesartan

Left Ventricular Function ( in addition to ACE-inhibitor)*

Candesartan (Seek consultant advice)

*Recent ESC guidance suggests mineralocorticoid receptor antagonist (MRA) should be added to an ACE-inhibitor not an angiotensin II receptor antagonist (ARA). Dual use of ACEi/ARA should be reserved for patients intolerant to MRAs.

Renin InhibitorsAliskiren (Treatment of essential hypertension as a 3 or 4th line agent)

2.6 NitratesIsosorbide mononitrate (10mg tabs, 20mg tabs, 60mg slow releasepreparations only)Glyceryl trinitrate (Buccal preparation is unlicensed)

2.6.2 Calcium channel blockers AmlodipineDiltiazem (as Tildiem LA capsules)Verapamil

2.6.3 Ivabradine). Antianginal- for the treatment of stable angina pectoris for patients in sinus rhythm who have contraindication or intolerance of beta blockersHeart failure (Ivabradine for treating chronic heart failure NICE TA267)

2.6.3 Other anti-anginal drugs NicorandilRanolazine (consultant use only for the treatment of stable angina pectoris)

2.7 SympathomimeticsAdrenalineDobutamineDopamineDopexamine (Consultant anaesthetists only)Isoprenaline (unlicensed use)NoradrenalinePhenylephrine

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2.8 Anticoagulants (oral) – See Anticoagulation Policy and EP anticoagulation policy

WarfarinAcenocoumarolPhenindioneDabigatran (Dabigatran etexilate for stroke prevention in atrial fibrillation NICE

TA249)Rivaroxaban (Rivaroxaban for stroke prevention in atrial fibrillation NICE TA256) (Rivaroxaban for treatment and prevention of venous thromboembolism NICE TA261)Apixaban (Apixaban for stroke prevention in atrial fibrillation NICE TA275 )

2.9 2.8.1 Anticoagulants (parenteral) See Anticoagulation Policy and EP anticoagulation policy

Heparin (unfractionated) Enoxaparin (Low Molecular Weight Heparin)Danaparoid Sodium (in place of heparin where heparin induced

thrombocytopenia suspected-refer to Trust HITT policy) Bivalirudin For patients undergoing primary PCI for ST-elevation Myocardial Infarction

(Bivalirudin for the treatment of Myocardial Infarction (persistent ST-segment elevation) NICE TA230)

2.10 Antiplatelet drugsAspirinClopidogrel (see below)Prasugrel (Prasugrel for the treatment of acute coronary syndrome NICE TA182).

This appraisal was based on a health economic model using Plavix®. Subsequently, generic clopidogrel has become available at a substantially lower acquisition cost. The cost effectiveness of prasugrel relative to generic clopidogrel is now uncertain. A review of this guidance is currently being undertaken by NICE. The Trust will review accordingly.

Ticagrelor Ticagrelor for the treatment of acute coronary syndromes NICE TA236

For more detailed information on antiplatelet use:

In NSTEMI refer to CMSCN guidelines-http://www.cmcsn.nhs.uk//fileuploads/NSTEACS_Guidelines.pdf

In STEMI refer to LHCH PPCI protocol-

Abciximab12

http://www.cmcsn.nhs.uk//fileuploads/NSTEACS_Guidelines.pdf

http://www.cmcsn.nhs.uk//fileuploads/NSTEACS_Guidelines.pdf







http://nww.staffintranet.lhch.nhs.uk/Library/Corporate/policies_procedures/EP%20Anticoagulation%20Guidelines%20Mar%202013.pdf

http://nww.staffintranet.lhch.nhs.uk/Library/Corporate/policies_procedures/Anticoagulation%20Policy%20Version%205%200%20Mar%202013.pdf







http://nww.staffintranet.lhch.nhs.uk/Library/Corporate/policies_procedures/EP%20Anticoagulation%20Guidelines%20Mar%202013.pdf

http://nww.staffintranet.lhch.nhs.uk/Library/Corporate/policies_procedures/Anticoagulation%20Policy%20Version%205%200%20Mar%202013.pdf


EptifibatideTirofiban

The current guidelines for the use of clopidogrel within the Trust are as follows

a) 75mg once daily post PCI with stent insertion.. Treatment for one year is generally recommended, but may be reduced, at the operators discretion, in patients treated with bare-metal stents for stable angina (e.g. to 4 weeks) or in ACS patients with a higher bleeding risk dependant on stent type And/or concurrent anticoagulant therapy

b) Antiplatelet treatment indicated, but definite proven allergy to aspirinc) Gastrointestinal intolerance of aspirin where symptoms persist in spite

of the use of low dose (75mg) aspirin and H2 antagonists or Proton-pump-inhibitors.

d) 75mg once daily for one month following percutaneous closure of PFO, ASD and VSD (+ aspirin 300mg daily for 6 months)

e) In combination with aspirin following CABG f) Medical management following acute myocardial infarction (STEMI) in

combination with aspirin, for at least 4 weeksg) Option to prevent occlusive vascular events (clopidogrel and modified-

release dipyridamole for the prevention of occlusive vascular events NICE TA210)

2.11 Fibrinolytic drugsTenecteplase (TNK-tpa)

Administer over 5-10 seconds according to weight;

Weight (kg) Dose (mL) <60 660-69 7 70-79 880-89 9 90+ 10

Co-therapy: IV heparin (minimum of 48hrs)Weight <67 kg -4000 IU bolus then 800 IU/hr infusion (0.8ml/h of 1000 units/ml)Weight > 67kg -5000 IU bolus then 1000 IU/hr infusion (1ml/h of 1000 units/ml)

Target APTT: 50-75s (1.5-2.5 times control)

Alteplase (reserved use for pulmonary embolism only)

Please note alteplase is recommended by NICE in acute ischaemic stroke (NICE TA 264). Alteplase is not approved for use for this indication at LHCH as all patients presenting with acute ischaemic stroke must be transferred to their local specialist centre for thrombolysis

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2.12 Antifibrinolytic drugsAprotininEtamsylateTranexamic acid NB. IV is unlicensed

2.13 Lipid lowering drugsAnion-exchange resinsColestyramine

FibratesBezafibrate MRFenofibrate

StatinsSimvastatinAtorvastatinRosuvastatin (consultant/SpR use only)

Guidance removed pending review

Fish oilsOmega-3-acid ethyl esters (Omacor®)

Other agentsEzetimibe (consultant/SpR use only)

3. RESPIRATORY SYSTEM

3.1 Bronchodilators

3.1.1 Selective beta2 agonists

Short acting beta2 agonistsDrug Formulation Strength Usual dose

AsthmaUsual dose COPD

Salbutamol Generic CFC free MDIVentolin AccuhalerSalamol Easibreathe breath activated MDI

Salbutamol easyhaler

Salbutamol nebules

100mcg

200mcg100mcg

200mcg

2.5mg, 5mg

200mcg prn

2.5-5mg qds

200mcg qds and prn

2.5-5mg qds

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Salbutamol injection 500mcg/ml Consult chest physician

Consult chest physician

Terbutaline Bricanyl turbohaler

Bricanyl nebules

Bricanyl injection

500mcg

5 mg

500mcg/ml

500mcg prn

5-10mg qds


500mcg qds and prn

5-10mg qds


Long acting beta2 agonists (see also combination steroid inhalers)Drug Formulation Strength Usual dose


Salmeterol Salmeterol CFC free MDISerevent Accuhaler

25mcg

50mcg

50mcg bd (only in combination with steroid inhaler)

50mcg bd

Formeterol Oxis Turbohaler 6mg, 12mg 12mcg bd (only in combination with steroid inhaler)

12mcg bd

Indacaterol Onbrez Breezhaler 150mcg, 300mcg

Unlicensed 150-300mcg od

Oral beta2 agonistsDrug Formulation Strength Usual dose


Bambuterol Tablets 10mg Consult chest physician


3.1.2 Antimuscarinics (anticholinergics)Drug Formulation Strength Usual dose


Ipratropium Atrovent MDI

Ipratropium nebules

20mcg

250mcg, 500mcg

Not routinely used

250-500mcg qds

20-40mcg qds

250-500mcg qds

Tiotropium Spiriva handihaler plus inhalant capsule

Spiriva Respimat metered inhaler

18mcg

2.5mg

Not licensed for treatment of asthma

18mcg od

5mg od

Aclidinium Bromide (Eklira

Inhalation Powder 400mcg 400mcg inhaled TWICE

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Genuair®) daily.

For maintenance treatment of chronic obstructive pulmonary disease.

Glycopyrronium Bromide (Seebri Breeshaler®)

Inhalation powder, hard capsule.

50mcg 50mcg ONCE daily.

Second line maintenance treatment of chronic obstructive pulmonary disease.

3.1.3 TheophyllineDrug Formulation Strength Usual dose


Theophylline

Aminophylline(multiply by 0.8 for equivalent theophylline dose)

Uniphyllin continus M/R tablets

Injection for IV infusion

Phyllocontin tablets

200mg, 300mg, 400mg

25mg/ml

225mg

200-400mg bd

See notes below

225-450mg bd

200-400mg bd

See notes below

225-450mg bd

Dose of Aminophylline intravenous infusion: Loading dose (only if not previously treated with oral theophylline):

250-500mg (5mg/kg) over 20 minutes Maintenance dose (if on oral theophylline check levels first)

0.5mg/kg/hr adjusted according to plasma concentration Higher doses may be used in Cystic Fibrosis

Therapeutic drug level monitoring of theophylline/aminophyline:- Therapeutic range: 10-20mg/l Time to steady state: Usually 24-48 hrs (unless loading dose given or

previously on oral). Levels should not be taken before 48hours unless

an IV loading dose has been given or previously on oral in which case 24hours is sufficient.

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Oral theophylline levels (usual range 10-20mg/l) should be monitored 4 to 7 days after starting therapy. Levels should ideally be taken immediately before the next dose.

The theophylline dose should be reduced if macrolide or fluroquinolone antibiotics (or other drugs known to interact) are prescribed for an exacerbation (contact pharmacy for advice)

3.1.4 Combination bronchodilators (To aid compliance only)Drug Formulation Strength Usual dose


Ipratropium and salbutamol nebules

Combivent nebules 500mcg/2.5mg

Not licensed for treatment of asthma

One nebule qds

3.1.5 Inhaler devices

Both Volumatic (for use with Flixotide, Seretide and salbutamol MDIs) and Aerochamber (for use with all MDI inhalers) spacer devices are available from pharmacy to assist drug delivery. Patients should be advised to clean their spacer monthly with detergent and allow to air dry. Spacers should be replaced at least every 12 months.Haleraids are available from pharmacy for patients who have impaired hand strength and are prescribed an MDI. These patients should initially be assessed by the respiratory specialist nurse to ensure that an MDI is the most appropriate device.

3.2 Inhaled Corticosteroids (prescribe by brand)Drug Formulation Strength Usual dose


Beclometasone Qvar CFC free MDIQvar CFC free autohaler

Qvar 50mcg is equivalent to 100mcg Clenil CFC free MDI (non formulary)

50mcg, 100mcg, 250mcg

100-400mcg bd Not normally used.

Fluticasone Flixotide evohaler (MDI)

Flixotide accuhaler


50mcg, 100mcg, 250mcg, 500mcg

100-1000mcg bd

See Seretide

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Budesonide Pulmicort turbohaler

Pulmicort MDI

Easyhaler


200mcg

200mcg

100-800mcg bd See Symbicort

Patients receiving high dose inhaled steroids (800mcg of beclometasone or equivalent) via a metered dose inhaler should also be prescribed an appropriate spacer device (Volumatic/aerochamber) to prevent oropharyngeal side effects. Consult the respiratory specialist nurse or pharmacy for advice on appropriate inhaler devices for individual patients.

Combination steroid plus long acting beta2 agonist inhalers (prescribe by brand)Drug Formulation Strength Usual dose


Fluticasone plus salmeterol

Budesonide plus formeterol

Beclometasone plus formeterol

Seretide CFC free evohaler (MDI)

Seretide Accuhaler

Symbicort turbohaler

Fostair MDI

50/25mcg, 125/25mcg,

100/50mcg, 250/50mcg, 500/50mcg

100/6, 200/6, 400/12

100/6

2 puffs bd

One blister bd

100/6 bd to 800/24 bd

1-4 puffs bd

Not licensed in COPD

500/50 (one blister) bd

400/12 bd


Seretide 250/25mcg evohaler has been removed from the hospital formulary as it is expensive and not licensed in COPD. Any new prescriptions for this will be queried by pharmacy and only supplied if there is no other device the patient can tolerate as determined by the respiratory specialist nurse.

Equivalent doses of inhaled steroids (adapted from British Thoracic Society Asthma Guidelines May 2011)Corticosteroid Equivalent dose to non-formulary

Clenil 400mcg (beclomethasone)Beclometasone Qvar MDI/Autohaler Fostair MDI

200-300mcg200mcg

Budesonide Pulmicort MDI/turbohaler Easyhaler Symbicort turbohaler

400mcg400mcg400mcg

Fluticasone

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Flixotide evohaler/Accuhaler Seretide evohaler/Accuhaler

200mcg200mcg

3.3 Leukotriene Receptor Antagonists

Drug Formulation Strength Usual dose Asthma

Usual dose COPD

Montelukast tablets 10mg 10mg in the evening


MANAGEMENT OF ACUTE SEVERE ASTHMA IN ADULTS

Patients with acute severe asthma will not normally present at LHCH. If further guidance is required please refer to the BNF.

STEPWISE MANAGEMENT OF CHRONIC ASTHMA IN ADULTS(Adapted from British Thoracic Society Guidelines, Thorax 2008 revised May

2011 www.brit-thoracic.org.uk)Start at the step most appropriate to initial severity of disease. Check compliance and inhaler technique prior to stepping up therapy.

19

http://www.brit-thoracic.org.uk/


STEP ONEMild Intermittent Asthma

Inhaled short acting ß2 agonist as required (up to once daily)Move to step 2 if ß2 agonist needed more than once daily

STEP TWO

Regular Preventer Therapy

Add regular inhaled steroid (200-800*mcg/day of beclometasone dipropionate [BDP] or equivalent)Start at dose of inhaled steroid appropriate to severity of disease. A dose of 400mcg/day is appropriate for most patients.

STEP THREE

Add on Therapy

1. Add regular inhaled long acting ß2 agonist (LABA)2. Assess asthma control:

Good response to LABA – continue Benefit from LABA but control still

inadequate – continue LABA and increase dose of inhaled steroid (up to 800mcg/day BDP or equivalent).

No response to LABA – stop LABA, increase dose of inhaled steroid as above. If control still inadequate, trial of other therapies eg leukotriene receptor antagonist or slow release theophylline

NB Addition of anticholinergics is generally of no value

STEP FOUR

Persistent Poor Control

Consider trials of Increase dose of inhaled steroid (up to

2000micrograms/day* BDP or equivalent)Addition of fourth drug e.g. leukotriene receptor antagonist, slow release theophylline or slow release oral ß2 agonist. If trial is of no benefit then stop the drug or in the case of inhaled steroid, reduce to the original dose.

STEP FIVEContinuous or frequent use of oral steroids

Use oral steroid once daily in the lowest dose possible to provide adequate control.Maintain high dose inhaled steroids.Consider other treatments to minimize dose of oral steroids.

STEPPING DOWNOnce asthma is controlled then stepping down of treatment is recommended. When deciding which drug to step down first consider benefits of treatment, side effects and patient preferences.Inhaled steroids should be maintained at the lowest possible dose. The dose should be reduced slowly at a rate of approximately 25-50% every three months.

*Doses of BDP refer to the BDP-HFA product Clenil which is non formulary. When prescribing Qvar these dosages shold be halved. See table in section 3.2 : Equivalent doses of inhaled steroids (adapted from

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British Thoracic Society Asthma Guidelines May 2011) to determine the equivalent doses for other inhaled steroids.

Prescribers should note the contents of NICE TA138 Inhaled corticosteroids for the treatment of chronic asthma in adults and children over 12 years before prescribing

Pharmacological therapy of stable COPD

Adapted from NICE Guidelines June 2010 www.nice.org.uk

Smoking

All COPD patients still smoking should be referred to the Smoking Cessation Advisor for appropriate support and advice regarding quitting. Nicotine replacement therapies and varenicline are available for prescribing. NICE TA123

Inhaled bronchodilator therapy (from NICE COPD Guidelines June 2010)

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_ Choose a drug based on the person’s symptomatic response and preference, the drug’s side effects,potential to reduce exacerbations and cost._ Do not use oral corticosteroid reversibility tests to identify patients who will benefit from inhaledcorticosteroids._ Be aware of the potential risk of developing side effects (including non-fatal pneumonia) in peoplewith COPD treated with inhaled corticosteroids and be prepared to discuss this with patients.

SABA = Short Acting Beta2 AgonistsSAMA = Short Acting Muscarinic Antagonist (Antimuscarinics/anticholinergics)LABA = Long Acting Beta2 AgonistsLAMA = Long Acting Muscarinic Antagonist (Antimuscarinics/anticholinergics)

Nebulised bronchodilator therapy in stable COPDNebulised bronchodilator therapy should only be considered in patients with distressing or disabling breathlessness despite maximal inhaler therapy and should not be continued unless there is a perceived benefit. Assess individual and/or carer’s ability to use the nebuliser before prescribing. Patients should be referred to the respiratory specialist nurses for further support. Patients commencing ipratropium nebules should have all anticholinergic inhaler therapy (eg tiotropium) stopped since there is no additional benefit.

Oral corticosteroidsMaintenance oral corticosteroid therapy is not normally recommended and should only be prescribed in advanced COPD in patients whose treatment cannot be stopped after an exacerbation. The dose should be kept as low as possible and osteoporosis prophylaxis therapy considered.

TheophyllineOnly offer after trials of short- and long-acting bronchodilators or to patients who cannot use inhaled therapy (see section 3.1.3)

MucolyticsMucolytics (Carbocisteine) can be considered for patients with chronic productive cough

RoflumilastRoflumilast is not currently recommended for use at LHCH. NICE TA244 COPD – Roflumilast recommends roflumilast for use in severe COPD in the context of a clinical trial and at present no trials are available at LHCH. Should a clinical trial become available the use of roflumilast will be reconsidered.

Hospital Management of Severe Exacerbations of COPD

Assess severity of symptoms (x-ray, blood gases, ECG, FBC, U & Es, sputum microscopy and culture if purulent).

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Check theophylline level if on theophylline therapy on admission Administer controlled oxygen therapy if necessary - see below. (Repeat

blood gases after 30 minutes). Oxygen must be prescribed on EPMA and the paper the drug chart.

Bronchodilators- Increase dose or frequency consider giving via

nebuliser (air driven if the patient is hypercapnic (PaCO2

> 6.0Kpa))- Combine ß2-agonists and anticholinergics.- Consider adding IV aminophylline if inadequate

response to nebulised bronchodilators. Monitor levels within 24 hours of starting therapy

Add oral corticosteroids – prednisolone 30mg daily for 7-14 days (if NBM consider IV hydrocortisone 100mg BD ).

Give antibiotics if sputum purulent or clinical signs of pneumonia (see Trust Antimicrobial policy)

Consider non-invasive mechanical ventilation. At all times: - Monitor fluid balance and nutrition.

- Consider subcutaneous low molecular weight heparin (enoxaparin 40mg od).

- Identify and treat associated conditions (eg heart failure, arrhythmias).

- Closely monitor condition of the patient. Change nebulisers back to handheld inhalers as soon as their condition

has stabilised.SOLUTIONS FOR NEBULISATION

Patients with COPD and carbon dioxide retention (PaCO2 > 6.0Kpa) should have their nebuliser therapy driven via an air cylinder or a nebuliser compressor. If the hypercapnic patient is so hypoxic that they need continuous oxygen then this should be administered via nasal cannula and the nebuliser driven from an air cylinder or compressor concurrently. Patients without CO2 retention can use either air or oxygen safely (unless the patient has acute asthma in which case oxygen must be used) but oxygen as a driving gas should be discontinued immediately after medication is nebulised. (See nebulisation guidelines for further information on preparations and administration)Patients not previously using nebulised therapy should only be discharged on such treatment on the advice of a respiratory physician or the Respiratory Nurse Specialist.

3.4 Antihistamines

Drug Formulation Strength DoseChlorphenamine

Cetirizine

TabletsOral solution

Tablets

4mg2mg/5ml

10mg

4mg 4-6hourly. Max 24mg in 24 hours

10mg daily

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3.5 Respiratory stimulants

Doxapram - Consult SPC for dosing details. For use on consultant recommendation only.

3.6 Oxygen

Oxygen is one of the most widely used drugs and as such must be prescribed on an inpatient prescription chart. Oxygen should be signed for by nursing staff on the drug chart initially. On subsequent drug rounds it is the responsibility of the nursing staff to ensure that the prescription is still correct and should be crossed off once oxygen is discontinued.

Oxygen therapy will be adjusted to achieve target saturations rather than giving a fixed dose to all patients with the same disease in accordance with the new Emergency Oxygen Guideline (2008), which can be reviewed on the British Thoracic Society website.

In general, oxygen should be prescribed to achieve a target saturation of 94 - 98 % for most acutely unwell patients or 88 – 93 % for those at risk of hypercapnic respiratory failure.

If the patient is critically ill / peri arrest situation

Commence treatment with reservoir mask (non rebreath mask) at 15L/mt. Seek urgent medical advice. Once the patient is stable reduce the oxygen dose and aim for target saturations of 94 – 98 %. Patients with COPD and other risk factors for hypercapnia (see below for risk factors of hypercapnia) who develop critical illness should have the same initial target saturations as other critically ill patients pending results of urgent blood gas measurements after which patients may need controlled oxygen therapy or supported ventilation (NIV or IPPV)

For hypoxemic patients who are not at risk of hypercapnic respiratory failureInitial oxygen therapy is nasal cannula at 2 – 6 L/mt or Venturi mask 28 % to up to 60 % and aim oxygen saturations of 94 – 98 %. Obtain ABG. If the oxygen saturation is less than 85 % use reservoir mask at 15 L/mt and seek urgent medical advice.

For hypoxemic patients who are at risk of hypercapnic respiratory failure (moderate or severe COPD, moderate or severe bronchiectasis, those on long term oxygen therapy, morbid obesity, chest wall deformities or neuromuscular disorders)Aim for target saturations of 88 – 92 %, start with 24 – 28 % Venturi mask or nasal cannula at 1- 2 L/mt. Obtain ABG and consult respiratory physician for further advice. Any increase in oxygen therapy must be followed by repeat ABG in 30 – 60 minutes or sooner if conscious level deteriorates.

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3.7 Mucolytics

Drug Formulation Strength DoseDornase Alfa

Sodium Chloride

Carbocisteine

Mannitol

Erdosteine

Pulmozyme nebulisation solutionNebusalnebules

CapsulesSyrup

Inhalation powder,hard capsules

Capsules

2.5mg

7%

375mg250mg/5ml

40mg

300mg

2.5mg daily (Cystic Fibrosis only)

4mL up to twice daily

375-750mg tds

400mg twice daily (Cystic Fibrosis only)NICE TAG 266 Mannitol dry powder for inhalation for treating cystic fibrosis

300mg TWICE daily for up to 10 days.

3.8 Aromatic inhalations

Menthol and eucalyptus inhalation

3.9 Cough preparations

Simple linctusCodeine 15mg/5ml linctus

4. CENTRAL NERVOUS SYSTEM

4.1 Hypnotics and anxiolytics

Benzodiazepines and other hypnotics should not be routinely prescribed for anxiety or night sedation. If treatment is considered necessary then they should be prescribed on a ‘prn’ basis only and be reviewed regularly. Owing to the possibility of addiction, patients not previously taking benzodiazepines prior to admission should not receive them on discharge.

HypnoticsZopiclone - licensed for short term use only. Follow advice as for

benzodiazepines aboveTemazepam (controlled drug)

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AnxiolyticsDiazepamLorazepamChlordiazepoxide (alcohol withdrawal – see below)

4.2 Drugs used in psychoses

Antipsychotic drugs Consult appropriate psychiatric specialist Antimanic drugs Lithium (Priadel) (Click here to view Lithium therapy policy)

4.3 Antidepressants

AmitriptylineFluoxetineSertraline

General Guidance for Management of Depression at LHCH

In accordance with NICE recommendations, patients with significant physical illness causing disability e.g. Heart failure, COPD should be screened for depression.

Screening for depression should include the use of at least two questions concerning mood and interest, such as: “During the last month, have you often been bothered by feeling down, depressed or hopeless?” and “During the last month, have you often been bothered by having little interest or pleasure in doing things?” Severity must be assessed using the ICD-10 definitions as described below.

Patients should be referred to their G.P. for management in all cases of mild depression and where symptoms are diagnosed in the outpatient setting.

In-patients diagnosed with depression will most likely be categorised as moderately depressed due to co-morbidities. In moderate depression, antidepressant medication should be routinely offered to all patients before psychological interventions.

A selective serotonin reuptake inhibitor (SSRI) should be considered first line therapy. When initiating treatment in a patient with a recent myocardial infarction or unstable angina, sertraline is the treatment of choice as it has the most evidence for safe use in this situation. Sertraline is a well-tolerated SSRI but is more likely to be associated with upwards dosage titration during treatment than the other SSRIs. In most other circumstances, fluoxetine is a reasonable choice because it is associated with fewer continuation/withdrawal

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symptoms than other SSRIs. However, it has a high propensity for drug interactions through hepatic enzyme inhibition. Sertraline is less problematic in this regard although enzyme inhibition is dose-related. Where there are concerns regarding drug interactions with SSRIs, pharmacy should be consulted for further advice.

All patients commenced on antidepressants at LHCH should be referred back to their GP within 2 weeks of commencing treatment for continued care and dosage titration (particularly sertraline) if necessary.

All healthcare professionals actively screening and treating depression at LHCH must familiarise themselves with NICE guidelines for the Management of Depression.

ICD-10 Definitions

A. Look for key Symptoms: Persistent sadness or low mood; and/or Loss of interests or pleasureFatigue or low energy. At least one of these, most days, most of the time for at least 2 weeks.

B. If any of above present, ask about associated symptoms: • Disturbed sleep • Poor concentration or indecisiveness • Low self-confidence • Poor or increased appetite • Suicidal thoughts or acts • Agitation or slowing of movements• Guilt or self-blame.

C. Then ask about past, family history, associated disability and availability of social support

1. Factors that favour general advice and watchful waiting: • Four or fewer of the above symptoms • No past or family history • Social support available • Symptoms intermittent, or less than 2 weeks duration • Not actively suicidal • Little associated disability.2. Factors that favour more active treatment: • Five or more symptoms • Past history or family history of depression • Low social support • Suicidal thoughts • Associated social disability. 3. Factors that favour referral to mental health professionals: • Poor or incomplete response to two interventions

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• Recurrent episode within 1 year of last one • Patient or relatives request referral • Self-neglect. 4. Factors that favour urgent referral to a psychiatrist: • Actively suicidal ideas or plans • Psychotic symptoms • Severe agitation accompanying severe (more than 10) symptoms• Severe self-neglect.

ICD-10 definitions

Mild depression: four symptoms Moderate depression: five or six symptoms

Severe depression: seven or more symptoms, with or without psychotic features

Adapted from NICE Guidelines for the Management of Depression in Primary and Secondary Care (Amended). April 2007

4.6 Nausea and vertigo

Metoclopramide (Maximum of 5 days treatment only as per MHRA restrictions)CyclizineProchlorperazineBetahistineOndansetron (limited indications, post-operative nausea and vomiting only)

Consult the following algorithm for the management of post-operative nausea and vomiting

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Algorithm for the management of post-operative nausea and vomiting

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POST OPERATIVE NAUSEA and VOMITING (PONV) ALGORITHM

ASSESSMENT PONV:0 – No nausea or vomiting1- Mild nausea/occasional vomiting2- Moderate nausea and/or occasional vomiting3- Severe nausea and/or frequent vomiting

PONV : GENERAL ADVICE:Ensure adequate hydration.Do not discontinue PCA if patient in pain:-Administer anti-emetics as prescribed.Anti-emetics are more effective if used in combination.

SATISFACTORY RESPONSE

Continue cyclizine 25-50mg 8hrly IV

PONV Score greater than 1:Give cyclizine 50 mg IV (reduce dose to 25 mg if over 70 yrs)

Re-assess in one hour

PONV Score greater than 1

Administer single dose Ondansetron 4 mg IV

Re assess in one hour PONV Score greater than 1

Administer Dexamethasone 8 mg IV as single dose and re-assess in one hour

Seek advice from pain nurse specialist or on-call anaesthetist

KM/JC review date 02/11


4.7 Analgesics – Also see Acute Pain Protocol

Compound oral analgesics, such as paracetamol plus an opioid, should not be prescribed because of the inflexibility in the dosage of such products. Combinations with low doses of opioid have not been proven to provide more effective analgesia than paracetamol alone, yet still have opioid side effects. Combinations with higher doses of opioid result in dosage inflexibility and a greater incidence of side effects. If an opioid analgesic is considered necessary then a single ingredient preparation should be used, such as dihydrocodeine or codeine phosphate tablets.

Consult the following ‘ Pain Ladder’ before prescribing

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http://ctcnt20/policy/81/Acute%20Pain%20Current%20June%202011.pdf


Non-opioid analgesicsParacetamol

Opioid analgesicsCodeine phosphateDihydrocodeineDiamorphineMorphineFentanyl patch (palliative care)Tramadol (Consultant use only)Oxycodone (Anaesthetist use only and in accordance with cardiac surgery analgesia algorithm below)

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Prophylaxis of migrainePizotifen

4.8 Antiepileptics

CarbamazepinePhenytoinSodium valproate

Status epilepticusDiazepamPhenytoin

4.9 Parkinsonism and related disorders

Contact appropriate specialist in the management of Parkinson’s disease and related disorders

Relief of intractable hiccupChlorpromazineHaloperidol

4.10 Drugs used in substance dependence

Methadone (Addicts must be registered with the Home Office)Nicotine (Various preparations available. Refer to smoking advisor)Varenicline NICE TA123

Management of alcohol withdrawal

Step Dose of chlordiazepoxide (mg)

Time of administration10:00 14:00 18:00 22:00

1 25 25 25 252 25 20 20 253 20 20 20 204 20 20 205 20 10 106 10 10 107 10 108 109 5

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The severity of withdrawal symptoms will determine the initial dose of chlordiazepoxide.

Steps 1 and 2 are usually reserved for patients with severe withdrawal symptoms such as confusion, seizures and hallucinations.

Oxazepam may be used in place of chlordiazepoxide if there is severe liver failure.

If the oral route is not available then use:- diazepam 10-20mg IV every 6 hours or lorazepam 4mg IV every 4 hours

Thiamine deficiency

Thiamine tablets 100mg bdplus

Multivitamins one or two daily

If neurological signs are present then - Vitamins B and C injection – 2-3 pairs of ampoules IV every eight hours for up to two days. Then one pair daily for 5-7 days.

5. INFECTIONS

Please refer to the Antimicrobial Policy and NICE TA158 Oseltamivir, amantadine (review) and zanamivir for the prophylaxis of influenza and TA168Amantadine, oseltamivir and zanamivir for the treatment of influenza

6. ENDOCRINE SYSTEM

6.1 Drugs used in diabetes

6.1.1 Insulins

Type Drug Brand NotesShort acting insulins

Soluble Insulin Actrapid For use in management of acutely ill or peri-procedural diabetic/non-diabetic patients requiring insulin only.

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http://www.nice.org.uk/nicemedia/pdf/TA168fullguidance.pdf

http://www.nice.org.uk/nicemedia/pdf/TA168fullguidance.pdf



http://nww.staffintranet.lhch.nhs.uk/Library/Corporate/policies_procedures/Antimicrobial%20Policy%203.1%20April%202012.pdf


Insulin AspartInsulin GlulisineInsulin Lispro

NovorapidApidraHumalog

For use in CF or Diabetes Specialist Nurse advice only

Long acting insulins

Insulin DetemirInsulin GlargineNICE TA53

LevemirLantus


Intermediate acting insulins

Biphasic Insulin Aspart

Biphasic Insulin Lispro

NovoMix 30

Humalog Mix 25


6.1.2 Oral Diabetic Drugs

Type Drugs AvailableSulfonylureas Gliclazide

Biguanides MetforminMetformin oral SolutionMetformin M/R

Dipeptidylpeptidope – 4 inhibitors Sitagliptin

6.1.2.3 Other Antidiabetic Drugs

Exenatide M/R 2mg s/c injection NICE TA 248 Exenatide modified- release for the treatment of type 2 diabetes mellitus

Liraglutide 6mg/mL s/c injection – NICE TAG-TA203 Liraglutide for the treatment of type 2 diabetes mellitus

For further information on the management of type 2 diabetes please consult NICE guidelines –NICE clinical Guideline 87

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HypoglycaemiaGlucagon

6.2 Thyroid and anti-thyroid drugs

Thyroid hormonesLevothyroxine (thyroxine)Liothyronine

Antithyroid drugsCarbimazolePropylthiouracil

6.3 Corticosteroids

Prednisolone (not enteric coated*) DexamethasoneHydrocortisoneMethylprednisolone

* There is currently no evidence to indicate that enteric coated prednisolone is less likely than uncoated prednisolone to cause peptic ulceration. The evidence that enteric coating is less likely to cause dyspepsia is unsatisfactory and there is no robust evidence to suggest that enteric coating of prednisolone confers gastrointestinal protection. There is however, evidence to suggest lack of disease control for some conditions in those taking enteric coated compared to uncoated prednisolone particularly in cystic fibrosis. Patients should not be commenced enteric coated prednisolone and those currently taking enteric coated should be advised to switch to ordinary tablet. The Pan Mersey Medicines Management committee does not support the use of enteric coated prednisolone in primary care.

6.5 Pituitary hormones

TetracosactideVasopressin Terlipressin

6.6Drugs affecting bone metabolismDisodium etidronateDisodium pamidronate

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7. URINARY TRACT DISORDERS

7.2 Vaginal anti-infective drugs

Clotrimazole 500mg pessary

7.4 Genito-urinary disorders

Urinary retentionIndoraminTamsulosin

Urinary frequencyOxybutynin

Urological painPotassium citrate mixture

8. MALIGNANT DISEASE AND IMMUNOSUPPRESSION

8.1 Cytotoxic drugs

Bleomycin

8.2 Immunosuppresants

AzathioprineCiclosporin (Neoral)

8.3 Sex hormones and hormone antagonists

ProgestogensMedroxyprogesterone acetateMegestrol acetate

Hormone antagonistsTamoxifenOctreotide

9. NUTRITION AND BLOOD

9.1 Anaemias

Ferrous sulphateFerrous glycine sulphate syrup

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Ferrous Fumarate syrupFolic acidHydroxocobalaminErythropoetin beta (Neo-Recormon®) (consultant only)

9.2 Fluids and electrolytes

Oral potassiumPotassium effervescent (12mmol of K+) Potassium chloride syrup (1mmol/ml of K+)Potassium chloride MR* (8mmol of K+)

*N.B. Absorption of MR is poor and should only be used where the patient cannot tolerate syrup or effervescent tablets

Potassium removalCalcium Resonium®

Resonium A®

Oral sodiumSodium chloride MR (10mmol each of Na+and Cl-)

Oral bicarbonateSodium bicarbonate 600mg tablets

Intravenous fluids and electrolytes Contact Pharmacy for availability of various solutions

Plasma substitutesPentastarch® 10%Gelofusin®

Voluven®

9.3 Intravenous nutrition

Contact Pharmacy for advice

9.4 Enteral nutrition

Contact dietitian for advice

9.5 Minerals

CalciumCalcium carbonateCalcium gluconate injection

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Calcium chloride injection

MagnesiumMagnesium sulphate injection 50%

PhosphatePhosphate-Sandoz®

Potassium acid phosphate injection

ZincZinc sulphate effervescent tabs

9.6 Vitamins

Vitamin BThiamine (B1)Pyridoxine (Isoniazid neuropathy prophylaxis only)Vitamin B compound strongVitamin B and C injection (Pabrinex®)

Vitamin CAscorbic acid tablets

Vitamin DCalcium and vitamin D tabletsAlfacalcidol capsules

Colecalciferol 50,000units capsules (unlicensed)- for CF patients only

Vitamin E Vitamin E capsules 400 IU

Vitamin KMenadiol (water soluble for use in fat malabsorption states)Phytomenadione

Multivitamin preparationsMultivitamins tabs/caps

10. MUSCULOSKELETAL AND JOINT DISEASES

10.1 Drugs used in rheumatic diseases and gout

Non-steroidal anti-inflammatory drugsIbuprofenDiclofenac (PR only)

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NICE guidance (cyclo-oxygenase-2 selective inhibitors). NICE has recommended that cyclo-oxygenase-2 selective inhibitors (celecoxib, etodolac and meloxicam) should:• not be used routinely in the management of patients with rheumatoid arthritis or osteoarthritis;• be used in preference to standard NSAIDs only when clearly indicated (and

in accordance with UK licensing), for patients with a history of gastroduodenal ulcer or perforation or gastro-intestinal bleeding—in these patients even the use of cyclo-oxygenase-2 selective inhibitors should be considered very carefully; they should also be used in preference to standard NSAIDs for other patients at high risk of developing serious gastro-intestinal side-effects (e.g. those aged over 65 years, those who are taking other medicines which increase the risk of gastro-intestinal effects, those who are debilitated or those receiving long-term treatment with maximal doses of standard NSAIDs);• not be used routinely in preference to standard NSAIDs for patients with cardiovascular disease; the benefit of cyclo-oxygenase-2 selective inhibitors is reduced in patients taking concomitant low-dose aspirin and this combination is not justified.

There is no evidence to justify the simultaneous use of gastro-protective drugs with cyclo-oxygenase-2 selective inhibitors as a means of further reducing potential gastro-intestinal side-effects.

Local corticosteroid injectionsMethylprednisolone

Drugs used in goutColchicine (acute attacks if need to avoid fluid retention)Allopurinol (long term control)

10.2 Neuromuscular disorders

Drugs which enhance neuromuscular transmissionPyridostigmineEdrophonium

Skeletal muscle relaxantsDantroleneBaclofenDiazepam

Nocturnal leg crampsQuinine sulphate 300mg tablets

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10.3 Topical antirheumatics

Benzydamine

11. DRUGS ACTING ON THE EYE

11.3 Anti-infective preparations

AntibacterialsChloramphenicol (drops and ointment)

AntiviralsAciclovir ointment

11.4 Corticosteroids

Betamethasone dropsPrednisolone drops

11.5 Mydriatics

Tropicamide drops

11.6 Treatment of glaucoma

Contact Pharmacy for availability of specific treatments

11.8 Miscellaneous

Tear deficiencyHypromellose drops

12. EAR, NOSE AND OROPHARYNX

12.1 Drugs acting on the ear

Anti-inflammatory and anti-infective preparationsBetamethasone dropsGentamicin drops

Removal of ear waxSodium bicarbonate drops

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12.2 Drugs acting on the nose

Nasal allergyBeclometasone nasal spray (Beconase®)Fluticasone nasal spray (Flixonase®)

Nasal staphylococciMupirocin Naseptin®

12.3 Drugs acting on the oropharynx

Ulceration and inflammationBenzydamine mouthwash/spray (Difflam®)Triamcinolone (Adcortyl) in OrabaseCholine salicylate gel (Bonjela®)

Fungal infectionsNystatin

Oral hygieneThymol (mouthwash tablets)Chlorhexidine gluconate

Dry mouthGlandosane® spray (Restricted use. Severe cases only)

13. SKIN

See NPSA alert regarding fire hazard with products containing 100g or more of paraffin http://www.nrls.npsa.nhs.uk/resources/?entryid45=59876

EmollientsWhite soft paraffinHydromol ointmentOilatum bath additive

MoisturisersE45 creamDiprobase

Barrier preparationsMetanium ointmentCavilon barrier cream and film spray

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Topical antipruriticsCrotamiton cream (Eurax)

Topical corticosteroidsHydrocortisone 1%Fucibet creamFucidin H cream

Sunscreens

Uvistat factor 30

Anti-infective skin preparations

Antibacterials Mupirocin Silver sulfadiazine Metronidazole gel

AntifungalsClotrimazole

AntiviralsAciclovir

Scabies and liceMalathion

Disinfectants and cleansers

ChlorhexidinePovidone iodineAlcoholic iodine solutionHydrogen peroxide

A8 WOUND MANAGEMENT

See wound care formulary and guidelines

14. IMMUNOLOGICAL PRODUCTS AND VACCINES

Tuberculin PPD (100units/ml)Hepatitis B vaccineInfluenza vaccinePneumococcal vaccineTetanus Vaccine Adsorbed

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http://nww.staffintranet.lhch.nhs.uk/library/departments/support_services/pharmacy/wound_dressing_formulary_march_09.doc


Tetanus immunoglobulinNormal immunoglobulin for IV use

15. ANAESTHESIA

15.1.1 Intravenous anaesthesia

ThiopentalEtomidatePropofolKetamine

15.1.2 Inhalational anaesthesia

EnfluraneSevofluraneIsoflurane

15.1.3 Antimuscarinics

AtropineGlycopyrroniumHyoscine hydrobromide

15.1.4 Sedative and analgesic peri-operative drugs

Anxiolytics and neurolepticsDiazepamLorazepamMidazolam

Non-opioid analgesicsKetorolacDexmedetomidine (use only for post operative sedation/analgesia supplementation for patients after thoracoabdominal aortic aneurysm surgery)

Opioid analgesicsAlfentanilFentanylRemifentanil

15.1.5 Muscle relaxantsAtracuriumMivacuriumPancuronium

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RocuroniumSuxamethoniumVecuronium

15.1.6 Anticholinesterases

NeostigmineEdrophonium

15.1.6.1 Other drugs for reversal of neuromuscular blockade

Sugammadex

15.1.7 Antagonists for central and respiratory depression

DoxapramFlumazanilNaloxone

15.1.8 Malignant hyperthermia

Dantrolene

15.2 Local anaesthetics

Lidocaine (lignocaine) Bupivacaine Cocaine Emla cream

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