4. Central Nervous System · 2016. 8. 15. · Antipsychotic drugs should not be used in older patients to treat mild psychotic symptoms i.e. non-distressing symptoms. Initial doses

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For further advice on mental health issues see NHS Fife website www.moodcafe.co.uk/

4.1 - Hypnotics and anxiolytics 4.1.1 Hypnotics 1st Choice Non-drug treatment e.g. sleep hygiene 2nd Choice Drug treatment 1st Choice Zopiclone 2nd Choice Temazepam Nitrazepam

Prescribing Points

Before a hypnotic is prescribed, the cause of the insomnia should be established and underlying factors be addressed. Non-drug management should be considered 1st e.g. sleep hygiene, avoiding caffeine intake close to bedtime.

A patient self help guide on sleep problems is available at http://www.moodcafe.co.uk/media/20236/tipsforbettersleep.pdf

Prescriptions for hypnotics should only be issued for short-term relief (1- 4 weeks) of severe insomnia that is disabling or causing unacceptable patient distress.

In new patients hypnotics should not be added as a repeat prescription. They should only be prescribed as ‘acutes’.

Prescribers should exercise caution when starting a patient on a benzodiazepine or ‘z’ drug as these medicines have a ‘street value’.

Relative durations of action are:

short-acting: lorazepam, temazepam, zopiclone intermediate-acting: nitrazepam long-acting: chlordiazepoxide, diazepam

Short-acting hypnotics are preferable in patients with sleep onset insomnia, when sedation the following day is undesirable or when prescribing for elderly patients.

Short-acting hypnotics have a higher potential for abuse and withdrawal phenomena are more common.

Long-acting hypnotics are indicated in patients with poor sleep maintenance (e.g. early morning waking), when an anxiolytic effect is needed during the day or when sedation the following day is acceptable.

Longer acting hypnotics can increase the risk of falls in the elderly and may cause ataxia and confusion.

Patients who have been on a benzodiazepine for many years can be switched to diazepam and the diazepam then be slowly withdrawn (See withdrawal protocol BNF section 4.1.).

The sedating antihistamine promethazine is regarded as less suitable for prescribing in the BNF. However, it is sometimes used in patients for occasional insomnia when ‘z’ drugs and benzodiazepines are considered inappropriate.

Chloral and Derivatives S - Chloral Hydrate

4. Central Nervous System

H – Hospital Use Only S – Specialist Initiation or Recommendation R – Restricted Use Fife Formulary January 2013 Last amended July 2016

http://www.moodcafe.co.uk/http://www.moodcafe.co.uk/media/20236/tipsforbettersleep.pdf

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Prescribing Points Reserved for paediatric patients.

Melatonin For further advise on the use of melatonin in children see Melatonin Guidance for the treatment of sleep-wake cycle disorders in children S – Melatonin M/R 2mg tablets (Circadin®)

Prescribing Points

Melatonin is used in treating sleep onset insomnia and also in delayed sleep phase syndrome in children in conditions such as ADHD.

Treatment with melatonin in children and adolescents should be initiated and supervised by a specialist. The need for continuing melatonin therapy should be reviewed at least every 6 months.

Circadin® is approved for use in NHS Fife for the treatment of sleep-wake cycle disorders in children (off-label use). Circadin® can be administered as whole tablet or halved to retain the slow-release profile or can be crushed and be dispersed in water to give an immediate release profile.

Other formulations and strengths of unlicensed melatonin, including liquid preparations, may be prescribed occasionally if Circadin® is considered clinically unsuitable.

Circadin® (melatonin MR 2mg tablets) has not been approved by the SMC as monotherapy for the short-term treatment of primary insomnia characterised by poor quality of sleep in patients who are aged 55 or over. Should only be prescribed if an Individual Patient Treatment Request (IPTR) has been approved.

4.1.2 Anxiolytics

For further advice on anxiety disorders see NHS Fife website http://www.moodcafe.co.uk/practitioners-resources/anxiety.aspx Acute anxiety 1st Choice Diazepam (long acting) 2nd Choice Lorazepam (short acting) Chlordiazepoxide(long acting)

Prescribing Points

Patient self help guides on anxiety problems are available at http://www.moodcafe.co.uk/practitioners-resources/anxiety.aspx

Prescriptions for anxiolytics should only be issued for short-term relief (1- 4 weeks) of severe acute anxiety that is disabling or causing unacceptable patient distress.

The use of benzodiazepines to treat short–term “mild” anxiety is inappropriate and unsuitable.

Benzodiazepines should not be used as sole treatment for chronic anxiety.

Benzodiazepines should be used at the lowest possible dose for the shortest possible time. Dependence is particularly likely in patients with a history of alcohol or drug abuse and in patients with marked personality disorders.

Patients who have been on a benzodiazepine for many years can be switched to diazepam and


http://www.fifeadtc.scot.nhs.uk/formulary/4-central-nervous-system/appendix-4i-melatonin-guidance-for-the-treatment-of-sleep-wake-cycle-disorders-in-children.aspxhttp://www.moodcafe.co.uk/practitioners-resources/anxiety.aspxhttp://www.moodcafe.co.uk/practitioners-resources/anxiety.aspx

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the diazepam then be slowly withdrawn (See withdrawal protocol BNF section 4.1.).

The most common use for chlordiazepoxide is for alcohol withdrawal.

Lorazepam acts for a shorter period and does not accumulate with repeated doses but has greater potential for withdrawal phenomena, dependence and abuse. Lorazepam is useful in patients with impaired liver function and in the elderly.

Other drugs for acute anxiety

Propranolol (standard tablets)

Prescribing Points

Used to relieve the physical symptoms of anxiety e.g. palpitations and tremor. Long acting propranolol preparations are more expensive than standard tablet formulations.

Anxiety Disorders Also see -

NICE CG 113 - Generalised Anxiety Disorder and Panic Disorder (with or without Agoraphobia), January 2011 http://www.nice.org.uk/guidance/cg113

NICE CG 31 - Obsessive-Compulsive Disorder, November 2005 http://www.nice.org.uk/guidance/CG31

NICE CG 26 - Post-Traumatic Stress Disorder, March 2005

http://www.nice.org.uk/guidance/cg26 1st Choice Citalopram

+/- psychological therapies Fluoxetine

Sertraline 2nd Choice Clomipramine

+/- psychological therapies Venlafaxine

3rd Choice R - Pregabalin

+/- psychological therapies

Prescribing Points

Psychological therapies should be considered along with pharmacological treatment in patients with anxiety disorders. Refer to NICE Clinical guidelines.

The choice of agent for the treatment of anxiety disorders will depend on licensed indications, patient preference, severity of the condition and cost. Also refer to NICE Clinical guidelines.

For further prescribing information on antidepressants see section 4.3. R - Pregabalin is approved for restricted 3rd line use. For the treatment of GAD and anxiety

associated with schizophrenia. Pregabalin is restricted to specialist initiation / specialist recommendation after failure with/intolerance to at least two different formulary SSRIs/SNRIs in patients unable to engage in or unresponsive to cognitive behavioral therapy. Treatment


http://www.nice.org.uk/guidance/cg113http://www.nice.org.uk/guidance/CG31http://www.nice.org.uk/guidance/cg26

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should be reviewed after a 12 week trial period and discontinued if found to be ineffective.

Prescribers should be alert to the misuse potential of pregabalin. All strengths of pregabalin capsules are the same cost; therefore ensure the

correct strength of capsule is prescribed i.e. 300mg rather than 2x 150mg.

4.2 - Drugs used in psychoses and related disorders Also see :-

Appendix 4A - Guidance on Drug Treatment of Schizophrenia in Patients 18 Years and Over http://www.fifeadtc.scot.nhs.uk/formulary/4-central-nervous-system/appendix-4a-treatment-of-schizophrenia-in-patients-18-years-over.aspx

NICE Clinical Guidance 82 - Schizophrenia: Core interventions in the treatment and management of schizophrenia in adults in primary and secondary care. March 2009. http://publications.nice.org.uk/schizophrenia-cg82

For prescribing in pregnancy refer to the UK Teratology Information Service http://www.uktis.org./index.html 4.2.1 Antipsychotic drugs

General Prescribing Points

Patients should receive antipsychotic drugs for a minimum of 6 weeks before the drug is deemed ineffective.

Antipsychotics should be initiated with caution in the first episode (i.e. start with a low dose).

Patients should be reviewed regularly to monitor efficacy and development of side-effects.

Specialist advice should be sought before discontinuing antipsychotics due to the risk of relapse.

Prescribing of more than one antipsychotic drug at the same time is not recommended. See NHS Fife Policy M1-P3-MH - Regular Prescription of more than one antipsychotic drug at the same time - https://intranet.fife.scot.nhs.uk/uploadfiles/publications/MH3%20-%20(M1-P3-MH)%20%20More%20than%20one%20antipsychotic%20Approved%20June%202014.pdf

Antipsychotics vary in their side effect profile and this will influence choice of therapy. See Appendix 4A - Guidance on Drug Treatment of Schizophrenia.

Antipsychotics in older people with dementia

In elderly patients with dementia, all antipsychotic drugs are associated with a small increased risk of mortality and an increased risk of stroke or transient ischaemic attack. Elderly patients are also particularly susceptible to postural hypotension and to hyper- and hypothermia in hot or cold weather. It is recommended that:

Antipsychotic drugs should not be used in older patients to treat mild psychotic symptoms i.e. non-distressing symptoms.

Initial doses of antipsychotic drugs in elderly patients should be reduced (to half the adult dose or less), taking into account factors such as the patient’s weight, co-morbidity, and concomitant medication. Doses used should be the lowest possible, titrated carefully and closely monitored.

Treatment should be reviewed regularly.

Patients/caregivers should be cautioned to immediately report signs and symptoms of


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potential cerebrovascular adverse events such as sudden weakness or numbness in the face, arms or legs, and speech or vision problems.

Antipsychotics may be prescribed with caution in the management of behavioural disorders associated with some types of dementia. It is important to remember that such behaviour can be a temporary phenomenon and that drugs should be prescribed on a short–term basis. Risperidone (for physical aggression) and olanzapine (off-label use) are the preferred antipsychotics for use in patients with dementia.

1st Choice S - Chlorpromazine S - Olanzapine S - Risperidone 2nd Choice S - Amisulpride S - Aripiprazole (Abilify®) S - Haloperidol S – Quetiapine (standard tablets)

Prescribing Points

Selection of an antipsychotic drug is influenced by relative adverse effects, the patient's susceptibility to adverse effects and variability in patient response. Choice should therefore be made jointly by the prescriber and the informed patient or carer where possible. Where more than one antipsychotic is appropriate, the drug with the lowest purchase cost should be prescribed.

In general, due to its side-effect profile chlorpromazine should not be initiated in the elderly. Chlorpromazine also has a high risk of photosensitivity.

Orodispersible formulations of olanzapine and risperidone are expensive compared to generic versions of the standards tablets. The orodispersible formulations should only be used in patients who have swallowing difficulties or when there are compliance problems with the standard tablets.

Haloperidol has a high risk of extrapyramidal side effects, especially in the elderly. The manufacturer of haloperidol recommends a baseline ECG before starting haloperidol and at regular intervals during treatment due to risk of QT prolongation /ventricular arrhythmias.

All antipsychotics can cause weight gain and can increase the risk of diabetes.

S – Clozapine (Zaponex®)

Prescribing Points

Clozapine is the only drug with evidence for use in treatment resistant schizophrenia.

Clozapine must be initiated by and prescribed under the supervision of a Consultant Psychiatrist.

The patient, supplying pharmacist and consultant must be registered with the Clozapine (Zaponex®) Patient Monitoring Service. Patients are at risk of agranulocytosis and monitoring of white cell count is mandatory.

If a patient presents with signs of fever or infection then an urgent full blood count should be undertaken.

Patients who have not taken clozapine for 48 hours will require re-titration. Seek specialist advice.


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Gastro–intestinal obstruction and paralytic ileus may also occur with clozapine. Patients should be advised to contact the prescriber if they develop abdominal pain or constipation.

Changes in smoking habit can significantly affect clozapine plasma levels increasing the risk of relapse (on starting or increasing smoking) or toxicity (on stopping or reducing smoking).

4.2.2 Antipsychotic depot injections First Generation S - Flupentixol decanoate (Depixol®) S – Fluphenazine decanoate S - Haloperidol decanoate (Haldol®) S - Pipotiazine palmitate (Piportil Depot®) S - Zuclopenthixol decanoate (Clopixol®) Second Generation S - Risperidone (Risperdal Consta®) S - Paliperidone (Xeplion®) S - Aripiprazole (Abilify Maintena®)

Prescribing Points

Depot injections should be used for the patient’s convenience or to improve concordance.

First-generation antipsychotic depot injections are administered at intervals of 1-4 weeks dependent on patient requirements and drug half-life.

The BNF recommends that for 1st generation antipsychotics a test dose of the depot injection should be given first since some side–effects can be prolonged.

There is no evidence that there is a major difference in efficacy between depot injections. However, there may be differences in tolerability that are important which may affect choice on an individual basis.

Extrapyramidal reactions occur less frequently with second generation antipsychotic depot preparations.

2nd Generation Antipsychotics

2nd generation antipsychotic depot injections are substantially more expensive than and there is no evidence of better efficacy compared to 1st generation depot injections.

They may be considered if:

Patient has experienced unacceptable side-effects with typical antipsychotic depots.

Patient has responded favourably to oral risperidone but prefers a long-acting IM injection.

Patient has responded favourably to an oral atypical but there are concerns about long-term concordance.

Risperidone depot is administered at 2-week intervals. It has a delayed response therefore administration of oral medication should be continued for at least 4 - 6 weeks.

Paliperidone can be considered as an alternative to risperidone depot in patients where the use of a monthly depot would be advantageous.

Aripiprazole (Abilify Maintena®) is a monthly injection which is approved for use in patients requiring a depot who have been stabilised on oral aripiprazole.


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The long-acting olanzapine injection (ZypAdhera®) for maintenance treatment of schizophrenia has not been accepted for use by the SMC and is non-formulary.

4.2.3 Antimanic drugs

Also see

Lithium Shared Care Protocol and Information for GPs http://www.fifeadtc.scot.nhs.uk/shared-care-protocols/scps-fife/lithium.aspx

SIGN Guideline No. 82. Bipolar Affective Disorder. May 2005. www.sign.ac.uk/pdf/sign82.pdf

SIGN Guideline 127 – Management of Perinatal Mood Disorders, March 2012 www.sign.ac.uk/guidelines/fulltext/127/index.html NICE Clinical Guideline 38 - Bipolar disorder: The management of bipolar disorder in adults, children and adolescents, in primary and secondary care, July 2006 http://publications.nice.org.uk/bipolar-disorder-cg38 For prescribing in pregnancy refer to the UK Teratology Information Service http://www.uktis.org./index.html

1st Choice S – Lithium (Prescribe by brand name only, preferred brand is Priadel®)

2nd Choice S - Semisodium valproate (Depakote®) S - Sodium valproate (off label use)

Prescribing Points

Long-term treatment of bipolar disorder should continue for at least two years from the last manic episode and up to five years if the patient has risk factors for relapse.

For acute manic episodes, oral administration of an antipsychotic drug (see section 4.2.1), lithium or semisodium valproate should be considered.

The full prophylactic effect of lithium may not occur for six to twelve months after the initiation of therapy.

Due to differences in bioavailability, lithium products are not interchangeable therefore should be prescribed by brand name. The NHS Fife preferred brand is Priadel®.

Routine serum-lithium monitoring, monitoring of renal function and thyroid function are required in patients prescribed lithium. For further information see Lithium Shared Care Protocol and Information for GPs http://www.fifeadtc.scot.nhs.uk/shared-care-protocols/scps-fife/lithium.aspx.

The need for continued lithium therapy should be assessed regularly. Patients on continuous lithium treatment should be assessed by a secondary care specialist at least every 2 years.

Abrupt discontinuation of lithium increases the risk of relapse. If lithium is to be discontinued, the dose should be reduced gradually over a period of at least 4 weeks (preferably over a period of up to 3 months).

If treatment with valproate is to be stopped, reduce the dose gradually over at least 4 weeks.

There is an increased risk of teratogenicity associated with the use of lithium and valproate preparations. Women of child bearing potential should be informed of the possible consequences and be provided with appropriate contraceptive advice. Valproate should not be


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prescribed routinely in women of child bearing potential.

4.3 - Antidepressant drugs Also see Appendix 4B: Guidance on the use of pharmacological agents for the treatment of depression

http://sign.ac.uk/guidelines/fulltext/114/index.html SIGN guideline 114, Non-pharmaceutical management of depression in adults, January 2010

SIGN Guideline 127 – Management of Perinatal Mood Disorders, March 2012 www.sign.ac.uk/guidelines/fulltext/127/index.html

http://www.nice.org.uk/guidance/cg90 NICE Clinical Guideline No. 90 Depression in Adults (Update) Oct 2009.

http://www.nice.org.uk/guidance/cg91 NICE Clinical Guideline 91 (Oct 2009) The treatment and management of depression in adults with chronic physical health problems (partial update) for further advice.

For prescribing in pregnancy refer to the UK Teratology Information Service http://www.uktis.org./index.html


Antidepressant drugs should not be used for initial treatment in mild depression as the risk-benefit ratio is poor. Psychological therapy should be considered initially; a trial of antidepressant therapy may be considered in cases refractory to psychological treatments or those associated with psychosocial or medical problems.

Ideally, patients with moderate to severe depression should be treated with psychological therapy in addition to drug therapy.

SSRIs are better tolerated and are safer in overdose than other classes of antidepressants and should generally be considered first-line for treating depression.

St John’s wort (Hypericum perforatum) should not be prescribed or recommended for depression due to its limited evidence of efficacy and because St John’s wort can interact with a number of other drugs (See BNF for further information).

Patients should be reviewed at least every 2-4 weeks at the start of antidepressant treatment. Treatment should be continued for at least 4 weeks (6 weeks in the elderly) before considering whether to switch antidepressant due to lack of efficacy. In cases of partial response, continue for a further 2-4 weeks (elderly patients may take longer to respond).

Following remission, antidepressant treatment should be continued at the same dose for at least 6 months (12 months in the elderly). Patients who have had 2 or more previous episodes of depression within the last 5 years may benefit from long-term antidepressants (at least 2 years) at therapeutic doses.

All antidepressants may be associated with a discontinuation syndrome and, if taken continuously for 6 weeks or longer, should be withdrawn gradually. The dose should preferably be reduced gradually over about 4 weeks, or longer if withdrawal symptoms emerge (6 months in patients who have been on long-term maintenance treatment). Drugs with a shorter half-life e.g. paroxetine or venlafaxine, are associated with a higher risk of withdrawal symptoms.

Hyponatraemia has been associated with all types of antidepressants, especially in the elderly, and should be considered in all patients who develop drowsiness, confusion, or convulsions while taking an antidepressant.

For Information on prescribing antidepressants during pregnancy and breastfeeding – see


http://www.fifeadtc.scot.nhs.uk/formulary/4-central-nervous-system/appendix-4b-treatment-of-depression-of-adults-(18-years-and-older).aspxhttp://sign.ac.uk/guidelines/fulltext/114/index.htmlhttp://www.sign.ac.uk/guidelines/fulltext/127/index.htmlhttp://www.nice.org.uk/guidance/cg90http://www.nice.org.uk/guidance/cg91http://www.uktis.org./index.html

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Appendix 4B: Guidance on the use of pharmacological agents for the treatment of depression.

Depressive illness in children and adolescents

The safety and efficacy of drugs used in the treatment of depression in children (under 18 years) has not been established. Long term safety information is also lacking. Depression in children should be managed by an appropriate specialist and treatment should involve psychological therapies. The CSM have issued advice on the treatment of depressive illness in children and adolescents - ‘Only fluoxetine has shown in clinical trials to be effective for treating children and adolescents but it is possible that it is associated with a small risk of self harm and suicidal thoughts. The balance of risk and benefit for the use of fluoxetine is considered favourable but careful monitoring for suicidal behaviour, self harm or hostility, particularly at the beginning of treatment should be undertaken.’

4.3.1 Tricyclic and related antidepressant drugs Amitriptyline (neuropathic pain) Clomipramine (phobia and obsessional states) Imipramine Lofepramine Nortriptyline (neuropathic pain) Trazodone

Prescribing Points

Antimuscarinic and cardiovascular side-effects are common. Dose titration is essential to avoid risk of postural hypotension. Caution with use in elderly patients and those with cardiovascular disease.

Both amitriptyline and dosulepin (dothiepin) are not recommended in the treatment of depression due to their association with ischaemic heart disease, cardiac arrhythmias and fatalities following overdose. They should only be prescribed in new patients if initiated by a specialist.

Trazodone is more sedating and has fewer cardiovascular side-effects than tricyclics. Trazodone is often used in the elderly and as a hypnotic (off-label use).

4.3.2 Monoamine-Oxidase Inhibitors (MAOIs) Initiated by specialists only 4.3.3 Selective Serotonin Re-Uptake Inhibitors (SSRIs) Citalopram Fluoxetine Sertraline

Prescribing Points

SSRIs are generally better tolerated than tricyclics. Tolerance to the main gastrointestinal side-effects usually develops within a short time. SSRIs have fewer cardiotoxic and antimuscarinic side-effects and are less sedating than the tricyclic and related antidepressants.

Due to the risk of gastrointestinal bleeding, SSRIs should be avoided if possible, or used with caution, in patients aged over 80 years, those with prior upper gastrointestinal bleeding, or in


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those also taking aspirin or another NSAID.

Citalopram has fewer drug interactions than other SSRIs, it has a relatively short half and is particularly useful in the elderly.

Due to the risk of a dose-dependent QT prolongation, citalopram should not be used in doses above 40mg a day in adults and not above 20mg a day in the elderly (>65 years) or in patients with reduced hepatic function. Citalopram is contra-indicated in patients with a known QT prolongation or congenital long QT syndrome and in patients who are taking other medicines known to prolong QT interval.

If a patient requires a dose of citalopram out with the above, an ECG should be performed and the reason for prescribing the unlicensed dose recorded in the patient’s medical notes. Possibility of switching to an alternative antidepressant should be considered.

Fluoxetine, due to its long half-life, is less likely to cause a withdrawal reaction. Beware of drug interactions when switching to alternative antidepressants.

At higher doses it is more cost-effective to prescribe fluoxetine 3x20mg capsules rather than 60mg capsules.

Fluoxetine is also available as a 20mg dispersible tablet (Olena®). The tablet can be halved in order to administer a 10mg dose. The dispersible tablet should be used in preference to fluoxetine suspension in patients who are unable to swallow the capsule formulation. The dispersible tablets should also be used in patients requiring a 10mg dose instead of ordering a specially manufactured 10mg tablet formulation (costs up to £60 per month).

Patients who have had a recent cardiovascular event should be prescribed sertraline, it has less negative effects on the QT interval.

Escitalopram is non-formulary and should only be considered when formulary options have been ineffective, not tolerated or are considered unsuitable.

Escitalopram is contra-indicated in patients with known QT interval prolongation or congenital long QT syndrome and in patients who are taking other medicines known to prolong QT interval.

4.3.4 Other Antidepressant Drugs Mirtazapine Venlafaxine(standard tablets, M/R capsules)

Prescribing Points

These drugs are considered second-line agents for use when first line antidepressants have failed.

Mirtazapine has few antimuscarinic effects, but causes sedation during initial treatment. Lower doses of mirtazapine cause more sedation than higher doses.

Mirtazapine can be used as a first line option in patients who require sedation but are unsuitable for treatment with a tricyclic.

Mirtazapine is associated with a rare risk of white blood cell dyscrasias. Patients should be advised to report any fever, sore throat, stomatitis or other signs of infection. Weight gain is also frequently reported.

Treatment with venlafaxine is associated with a higher risk of withdrawal effects compared with other antidepressants.

Venlafaxine is contraindicated in patients with an identified high risk of cardiac arrhythmia and those with uncontrolled hypertension. Use with caution in patients with established cardiac


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disease.

Blood pressure should be reviewed periodically, after initiation of treatment and after dose increases. For patients who experience a sustained increase in blood pressure while receiving venlafaxine, either dose reduction or discontinuation should be considered.

The use of duloxetine in depression is restricted to patients with co-morbidities i.e. urinary incontinence, diabetic peripheral neuropathy.

Agomelatine (Valdoxan®) is not recommended by the Scottish Medicines Consortium (SMC). Agomelatine should not be prescribed unless an Individual Patient treatment Request has been approved by NHS Fife.

4.4 - CNS Stimulants and drugs used for ADHD Also see:-

NHS Fife Shared Care Protocol - Children with Attention Deficit Hyperactivity Disorder (ADHD) - Atomoxetine, Methylphenidate http://www.fifeadtc.scot.nhs.uk/shared-care-protocols.aspx

SIGN 112 - Management of attention deficit and hyperkinetic disorders in children and young people http://www.sign.ac.uk/pdf/sign112.pdf

NICE Clinical Guidance 72 - Attention deficit hyperactivity disorder: Diagnosis and management of ADHD in children, young people and adults http://publications.nice.org.uk/attention-deficit-hyperactivity-disorder-cg72 Attention Deficit Hyperactivity disorder (ADHD)

1st Choice

S - Methylphenidate - standard tablet, M/R-M/R product should be prescribed by brand name Matoride® XL, Equasym XL®, Medikinet XL ®

2nd Choice S - Atomoxetine (Strattera®) H - Guanfacine (Intuniv®) S - Lisdexamfetamine (Elvanse®) 3rd Choice S - Dexamfetamine

Prescribing Points

Methylphenidate, atomoxetine and dexamfetamine are useful for some children with severe forms of ADHD as part of a comprehensive treatment programme when remedial measures alone prove insufficient. All 3 drugs are licensed for use in children aged 6 years and above.

Majority of children will persist with some degree of symptoms into adulthood (15-66% depending on the criteria used). Some individuals may be diagnosed with ADHD as adults, not having been diagnosed during childhood.

Use of methylphenidate, lisdexamfetamine or dexamfetamine in patients aged over 18 is an ‘off-label’ use.

Atomoxetine is licensed for initiation in adults as well as children and adolescents.

Patient selection is important and therefore initiation and titration of treatment should be carried out by a child/adolescent psychiatrist, adult psychiatry or a paediatrician working in a dedicated specialist clinic.

Before initiation of drug therapy, and then at least every 6 months thereafter, pulse, blood pressure, weight, and height should be measured. See NHS Fife Shared Care Protocols


http://www.fifeadtc.scot.nhs.uk/shared-care-protocols.aspxhttp://www.sign.ac.uk/pdf/sign112.pdfhttp://publications.nice.org.uk/attention-deficit-hyperactivity-disorder-cg72

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http://www.fifeadtc.scot.nhs.uk/shared-care-protocols.aspx.

The need to continue drug treatment for ADHD should be subject to specialist review at least annually.

Modified release preparations of methylphenidate (Matoride® XL, Equasym XL® or Medikinet XL®) can improve compliance and acceptability especially in adolescents and adults.

Matoride® XL has the same pharmacokinetic release profile as Concerta® XL. The Matoride® brand is the Formulary choice as it is more cost-effective than Concerta® XL.

Due to differences in release profiles for some methylphenidate M/R preparations, prescribe by brand.

Atomoxetine should normally be used 2nd line in patients who do not respond to methylphenidate or when methylphenidate is contraindicated or not tolerated e.g. because of significant anxiety, tic disorders or sleep difficulties. It may be used 1st line in patients where drug diversion is a concern or if substance misuse is also an issue.

Guanfacine is a non-stimulant and can be used as an alternative to atomoxetine in children and adolescents from the age of 6 years, as part of a comprehensive ADHD treatment programme. Restricted to use as monotherapy in patients where atomoxetine is ineffective, inappropriate or not tolerated. There is not an approved Shared Care Agreement in place for guanfacine so use is restricted to ADHD specialists only.

Lisdexamfetamine is recommended as a 2nd line stimulant in patients who do not respond to methylphenidate.

Dexamfetamine should normally be used 3rd line in patients where 1st and 2nd choices are unsuitable or ineffective.

Melatonin For further advise on the use of melatonin in children see Melatonin Guidance for the treatment of sleep-wake cycle disorders in children S – Melatonin M/R 2mg tablets (Circadin®)

Prescribing Points

Melatonin is used in treating sleep onset insomnia and also in delayed sleep phase syndrome in children in conditions such as ADHD.

Treatment with melatonin in children and adolescents should be initiated and supervised by a specialist. The need for continuing melatonin therapy should be reviewed at least every 6 months.

Circadin® is approved for use in NHS Fife for the treatment of sleep-wake cycle disorders in children (off-label use). Circadin® can be administered as whole tablet or halved to retain the slow-release profile or can be crushed and be dispersed in water to give an immediate release profile.

Other formulations and strengths of unlicensed melatonin, including liquid preparations, may be prescribed occasionally if Circadin® is considered clinically unsuitable.

Narcolepsy S – Modafinil (Provigil®)

Prescribing Points

Due to risk of serious side-effects modafinil is only licensed for the treatment of narcolepsy.


http://www.fifeadtc.scot.nhs.uk/shared-care-protocols.aspxhttp://www.fifeadtc.scot.nhs.uk/formulary/4-central-nervous-system/appendix-4i-melatonin-guidance-for-the-treatment-of-sleep-wake-cycle-disorders-in-children.aspx

13

Modafinil is not recommended by the MHRA for use for any other off-label use.

4.5 - Drugs used in treatment of obesity Also see

SIGN Clinical Guideline 115 - Management of Obesity www.sign.ac.uk/guidelines/fulltext/115/index.html

1st Choice Diet and lifestyle changes 2nd Choice Orlistat (Xenical®)

Prescribing Points

The main treatment for obesity is a suitable diet and increased physical activity. Orlistat should only be considered as an adjunct to lifestyle changes.

Before commencing drug therapy, patients should enter a minimum 3 month structured weight management programme to confirm that they can comply with dietary restriction.

Orlistat should be prescribed only as part of an overall plan for managing obesity in adults who meet one of the following criteria BMI ≥ 30kg/m2 or BMI ≥ 28kg/m2 plus associated risk factors e.g. type 2 diabetes, hypertension or hypercholesterolaemia.

Patients should have their body weight monitored and recorded on at least a monthly basis.

Orlistat should be discontinued after 3 months if patients fail to lose 5% of their initial body weight since starting drug treatment. (Less strict goals may be appropriate for people with type 2 diabetes.) Further courses should only be considered after a suitable period and patients should again demonstrate the ability to lose weight on a suitable diet.

Treatment should only be continued beyond 12 months after discussing potential benefits and risks with the patient. On stopping orlistat, there may be a gradual reversal of weight loss.

Patient experience of flatulence with loose stools may be limited by dietary compliance (decreased fat intake,

14

Choices for specific indications Chemotherapy Induced Highly emetogenic S - Ondansetron H - Aprepitant (Emend®) Moderately emetogenic S - Ondansetron Domperidone* Mildly emetogenic Domperidone* Motion Sickness 1st Choice OTC treatment from pharmacy 2nd Choice Cyclizine N&V in Migraine 1st Choice Metoclopramide** 2nd Choice Domperidone* Opioid Induced

1st Choice Haloperidol (also see palliative care guidance, and PONV guidance)

* For safety information regarding domperidone see prescribing note below. ** For safety information regarding metoclopramide see prescribing note below.

Prescribing Points

Anti-emetics may only be necessary for short-term management of nausea & vomiting (N&V). Patients should be reviewed regularly and treatment discontinued when appropriate.

Metoclopramide can cause acute dystonic reactions, usually in the young (especially girls and young women) and the very old. Reactions usually occur shortly after starting treatment with metoclopramide and subside within 24 hours of stopping it.

Metoclopramide is preferred when patient sedation should be avoided. Prochlorperazine may be preferred when sedation is required.

** Due to risk of neurological side-effects, metoclopramide is now only licensed for limited indications and the maximum duration of treatment is 5 days in all patients. For further advice, see http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON300404.

Prochlorperazine buccal tablets (Buccastem®) may be a suitable alternative formulation for patients who are vomiting.

Long-term use of haloperidol, levomepromazine, metoclopramide or prochlorperazine may cause tardive dyskinesia in the elderly.

Domperidone does not cross the blood brain barrier; it is less likely than metoclopramide and prochlorperazine to cause sedation or dystonic reactions. Domperidone is the preferred anti-emetic in patients with Parkinson’s disease.

*Domperidone is associated with an increased risk of serious cardiac events especially in those aged over 60 or those who take more than 30mg daily. Domperidone should be only used for the shortest duration of time (normally no longer than 7 days) and the maximum licensed oral dose in adults is now 30mg daily. Domperidone is contraindicated in patients who are taking concomitant medication known to cause QT prolongation (such as erythromycin and ketoconazole), in patients with underlying cardiovascular disease or in conditions where cardiac conduction is, or could be, impaired and also in patients with severe hepatic impairment. (For


http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON300404

15

further advice see http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON418518)

Domperidone and metoclopramide are no longer recommended as motility stimulants (See section 1.2).

Patients with prolonged N&V should be considered for administration of parenteral treatments (see palliative care guidance).

Cyclizine is the recommended 1st line agent for treatment of PONV.

Cyclizine has potential for abuse.

Cyclizine, haloperidol, levomepromazine and metoclopramide are used for management of nausea and vomiting in palliative care and can be added to morphine or diamorphine in a syringe driver for continuous subcutaneous administration (off-label use). The choice of agent will depend on the underlying cause of the nausea and vomiting.

Ondansetron is the recommended 1st line agent for chemotherapy induced N&V; it may also be used peri-operatively to prevent PONV as per the PONV Guidelines and also for constant, intractable nausea in patients with Parkinson’s disease.

Ondansetron and other 5HT3 antagonists are prescribed in the 1st week after chemotherapy but thereafter if N&V are difficult to control without use of 5HT3 antagonist, the GP should contact the hospital for further advice.

The ‘Melt’ formulation of ondansetron is relatively expensive compared to standard tablets and should only be considered when patients are continuously vomiting and are unable to take the standard tablets.

Domperidone and dexamethasone (section 6.3.2) are also routinely used in the management of cytotoxic chemotherapy-induced nausea and vomiting.

Aprepitant is restricted to use in the prevention of acute and delayed nausea and vomiting with highly emetogenic cisplatin-based chemotherapy in adults after failure with ondansetron. It is not approved for use in the prevention of nausea and vomiting associated with moderately emetogenic cancer chemotherapy.

Other Vestibular Disorders Acute treatment Cinnarizine or Prochlorperazine Maintenance Betahistine or Cinnarizine

Prescribing Points

Cinnarizine or prochlorperazine are effective for the acute treatment of vestibular disorders.

Prochlorperazine buccal tablets (Buccastem®) may be a suitable alternative for patients who are vomiting.

Prochlorperazine is best avoided in the elderly due to the risk of postural hypotension, confusion and drug-induced parkinsonism.

Long-term use of prochlorperazine is not recommended as it can hinder recovery. Betahistine or cinnarizine are preferred as maintenance therapy.

Betahistine should be reserved for prophylaxis in patients with a proven diagnosis of Ménière’s disease. Betahistine can be used to reduce the frequency and severity of attacks of hearing loss, tinnitus and vertigo.


http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON418518

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4.7 - Analgesics Also see:- Appendix 4C - Management of Chronic Non-Malignant Pain

Acute Pain Guidelines http://intranet.fife.scot.nhs.uk/atoz/index.cfm?fuseaction=service.display&objectid=67947A94-5056-8C6F-C0B9209FE8095FC2

SIGN 136 –Management of Chronic pain http://sign.ac.uk/pdf/SIGN136.pdf

SIGN 107 - Diagnosis and Management of Headache in Adults www.sign.ac.uk/guidelines/fulltext/107/index.html

British Pain Society’s Opioids for persistent pain: Good Practice www.britishpainsociety.org/book_opioid_main.pdf

4.7.1 Non- Opioid analgesics and compound analgesic preparations The WHO ladder was designed to aid cancer pain and is useful in acute pain. It was not designed for chronic pain but may give guidance to aid patients to manage symptoms whilst trying to implement self-help strategies. When considering titrating to strong opioids, refer to NHS Fife Chronic Non-Malignant Pain Strong Opioid Prescribing Guideline and the British Pain Society’s Guidance on Good Practice (see links above). The objective of treatment in all types of pain, irrespective of origin, is to achieve symptom control, and improve the patient’s quality of life. At any stage in the ladder, the addition of an appropriate Formulary NSAID can be considered for the treatment of short term exacerbation of pain or where there is an inflammatory component. Non-Opioid analgesics Paracetamol Ibuprofen (low dose

17

Paracetamol tablets or caplets are the preferred formulation not capsules.

Dispersible and effervescent formulations of paracetamol are considerably more expensive and should be restricted to patients with swallowing difficulties. Their high sodium content (the equivalence of up to 8g daily of salt) exceeds the WHO daily salt intake recommendation of 6g daily.

In patients with a low body weight (>33kg to 50kg with risk factors for hepatotoxicity the max. dose per administration is 1g (i.e 2 x 500mg ). Maximum daily dose is 3g.

Paracetamol infusion is restricted to short term treatment of moderate pain following surgery and fever, when administration by intravenous route is clinically justified and other routes are not available.

R - Nefopam is relatively expensive and is approved for restricted use only in patients intolerant of opioids. Nefopam has significant anticholinergic side-effects and should be used VERY cautiously, if at all, in frail older people especially those with cognitive impairment.

Compound analgesic preparations 1st Choice Co-codamol 30/500

Co-codamol 15/500 (restricted to patients unable to tolerate 30/500 or unable to cope with combining 30/500 with paracetamol)

2nd Choice Co-dydramol 20/500, 30/500

Prescribing Points

The use of low strength compound analgesics, e.g. co-codamol 8/500 and co-dydramol 10/500, in chronic pain is not generally encouraged. There is no evidence that they are more effective than paracetamol in relieving acute pain, they produce more side-effects and can complicate treatment of overdosage.

Co-codamol 15/500 is more expensive to prescribe than the generic co-codamol 30/500. Use of co-codamol 15/500 should be restricted to patients unable to tolerate the 30/500 strength or unable to cope with combining co-codamol 30/500 with paracetamol.

Dispersible and effervescent formulations of co-codamol are considerably more expensive and should be restricted to patients with swallowing difficulties. Their high sodium content (the equivalence of up to 8g daily of salt) exceeds the WHO daily salt intake recommendation of 6g daily.

Co-dydramol is approved for patients in whom codeine/co-codamol is ineffective and for patients who are known to be poor metabolisers of codeine (10% of the population).

4.7.2 Opioid analgesics Weak Opioids 1st Choice Codeine 2nd Choice Compound analgesic preparations (see above) 3rd Choice Tramadol oral Strong Opioids

1st Choice Morphine sulphate (including parenteral preparations) (Zomorph® is preferred M/R preparation)

2nd Choice Oxycodone (Shortec® - immediate release,


18

Longtec® M/R are preferred oral preparations)

3rd Choice S - Fentanyl patches (Matrifen®) –

Palliative care initiation only

S - Fentanyl sublingual tablets (Abstral®) -

Palliative care initiation only

S - Fentanyl nasal spray (Pecfent®) –

Palliative care initiation only Diamorphine Tramadol injection R- Oxycodone 50mg/ml inj (Oxynorm®) R- Cyclimorph® R- Pethidine

Prescribing Points

Weak opioids

Up to 10% of the population have poor or absent metabolism of codeine resulting in a reduced or absent analgesic effect. Co-dydramol or tramadol may be more effective in this patient group.

Tramadol is a Schedule 3 Controlled Drug and should be considered 3rd line after codeine and co-codamol/co-dydramol and may also be useful in patients with neuropathic pain.

Modified release tramadol preparations should only be prescribed for use in night time breakthrough pain, to aid compliance or if there are side-effects with immediate release tramadol. Modified release tramadol preparations are available as both 12-hour and 24-hour release formulations. The appropriate dose for the formulation should be prescribed. 12 hour formulations should be prescribed twice daily. 24 hour formulations once daily.

The combination product Tramacet® should not be prescribed as there is insufficient paracetamol in each tablet.

Strong opioids

In chronic non–malignant pain the long–term use of opioids has many implications. Complete analgesia is rarely achievable and then only at the expense of side-effects such as cognitive impairment. Extensive guidance is given in the NHS Fife Chronic Non-Malignant Pain Strong Opioid Prescribing Guideline and on the Pain Society website www.britishpainsociety.org/book_opioid_main.pdf.

Patients prescribed a strong opioid should also be prescribed paracetamol to be used regularly.

In cancer pain or in a palliative care setting, modified release preparations of strong opioids should be prescribed in combination with an immediate release preparation to allow treatment of breakthrough pain.

In chronic, non-malignant pain, immediate–release preparations should not be prescribed routinely and should only be considered for short-term flare-ups.

Patients prescribed a strong opioid should have access to regular prophylactic laxatives. Combination of a stimulant and softening laxative is recommended.

Post operative patients may be discharged on an appropriate short-term analgesic regimen which may include potent opioids. These should not be automatically continued beyond this


http://www.britishpainsociety.org/book_opioid_main.pdf

19

period.

Elderly patients are particularly susceptible to side effects of opioids e.g. respiratory depression and constipation.

Transdermal preparations are not suitable for acute pain or in those patients whose analgesic requirements are changing rapidly because the long time to steady state prevents rapid titration of the dose.

Care should be taken to avoid unintentional changes to brand of modified release morphine preparations or fentanyl patches.

Oxycodone is the 2nd line choice strong opioid for patients with severe non-malignant pain in whom morphine is ineffective or not tolerated.

Oxycodone preparations should always be prescribed by brand name. Shortec® is the preferred immediate release preparation and Longtec® is the preferred modified release preparation.

Targinact® (oxycodone/naloxone combination) is not currently approved for use in NHS Scotland by the SMC - an individual patient treatment request form (IPTR) should be submitted and approved before prescribing.

Fentanyl is the 3rd line choice strong opioid, it should be reserved for patients whose pain has been stabilised on oral opioids. Therapy with transdermal fentanyl is restricted to palliative care or for chronic intractable pain in patients intolerant of morphine and oxycodone.

Matrifen® is the preferred brand of fentanyl patches.

There are important differences between matrix and reservoir formulations of fentanyl patches and they are not interchangeable.

Fentanyl buccal tablets (Abstral®) or nasal spray (Pecfent®) is reserved for breakthrough pain in palliative care patients. They should only be used when immediate release morphine and oxycodone is ineffective or unsuitable. Prescribers should be aware of the differing absorption and elimination characteristics of available oral fentanyl preparations; doses are not interchangeable and should be titrated in individual patients. (See SPC’s for further information).

Transdermal buprenorphine (either as Butrans® 7 day patch or Transtec® 4 day patch) are not currently approved for use in NHS Scotland by the SMC - an individual patient treatment request form (IPTR) should be submitted and approved before prescribing.

R- Cyclimorph® and pethidine are approved for restricted use only in patients undergoing endoscopy

R- Oxycodone injection 50mg/ml is approved for restricted use in cancer patients with moderate to severe pain who are unable to tolerate morphine or diamorphine who require a high dose of oxycodone via syringe driver.

4.7.3 Neuropathic Pain/ Adjuvants See Appendix 4C: Guidance on Chronic Pain Management: Neuropathic Pain

1st Choice Amitriptyline (off label use)

Imipramine (If amitriptyline is not tolerated) (off label use)

Nortriptyline (If patient at increased risk of seretonergic syndrome) (off label use) 2nd Choice Gabapentin


http://www.fifeadtc.scot.nhs.uk/formulary/4-central-nervous-system/appendix-4c-chronic-pain-management-(overview).aspx

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3rd Choice Pregabalin Fibromyalgia 1st Choice Amitriptyline (off label use)


Nortriptyline (If patient at increased risk of seretonergic syndrome) (off label use) 2nd Choice Gabapentin (off label use) 3rd Choice S – Duloxetine (Cymbalta®) Trigeminal neuralgia 1st Choice Carbamazepine 2nd Choice Gabapentin (off label use) 3rd Choice Oxacarbazepine (off label use) Post herpatic neuralgia 1st Choice Amitriptyline (off label use)


Nortriptyline (If patient at increased risk of seretonergic syndrome) (off label use) 2nd Choice Gabapentin Diabetic peripheral neuropathic pain 1st Choice Amitriptyline (off label use)


Nortriptyline (If patient at increased risk of seretonergic syndrome) (off label use) 2nd Choice Gabapentin +/- TCA 3rd Choice S – Duloxetine (Cymbalta®) Prescribing Points

Neuropathic symptoms are characterised by a description of tingling, burning or shooting pains, there may also be allodynia (pain elicited by a non–noxious stimulus e.g. light touch) and hyperalgesia (pain that is of inappropriate severity to a noxious stimulus).

Titration should be made up to the most effective dose with consideration given to the occurrence of side effects. (See Appendix 4C).

After a minimum trial period of 6-8 weeks at maximum tolerated dose the patient should be reviewed to ascertain benefits produced. Treatment should be withdrawn gradually if ineffective.

Tricyclic Antidepressants (TCAs)

There is evidence that tricyclic antidepressants have analgesic efficacy in a variety of chronic pain syndromes and their use should be considered where conventional analgesics are proving of limited benefit in the chronic situation.


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Tricyclic antidepressants (TCAs) appear to be more effective than other classes of antidepressants. Amitriptyline has been the most studied but nortriptyline has similar benefits and may be chosen in an attempt to avoid side–effects such as sedation.

Patients should be warned of likely side–effects with TCAs and that unlike conventional analgesics, the TCAs may have to be taken regularly for 4–6 weeks before the full analgesic effect may be apparent.

The analgesic effect of amitriptyline is attained at a lower dose (

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4.7.4 Antimigraine drugs Also see SIGN 107 - Diagnosis and Management of Headache in Adults. www.sign.ac.uk/guidelines/fulltext/107/index.html 4.7.4.1 Treatment of acute migraine attack Step 1 Aspirin Ibuprofen Naproxen Paracetamol Anti-emetic 1st Choice Metoclopramide 2nd Choice Domperidone Prescribing Points

Any analgesic product used for a prolonged period of time has the potential to cause chronic overuse headache.

Treatment of a migraine attack should be guided by response to previous treatment, the severity and frequency of the attacks, other symptoms and patient preference.

An early stepped approach should be used starting with an analgesic +/- antiemetic and escalating to 5HT1 receptor antagonist (triptan) as required.

Simple oral analgesics such as aspirin, ibuprofen, naproxen or paracetamol are suitable first line agents. This medication is better taken early in the attack when absorption will be least inhibited by gastric stasis.

For rapid effect, dispersible or effervescent preparations are preferred. However, they may contain relatively large quantities of sodium chloride and are more expensive than standard preparations. They should be reserved for patients with gastric stasis or swallowing difficulties.

Suppositories may be useful for pain relief if vomiting occurs during migraine.

Opioid analgesics should not be used for acute migraine, due to the potential for development of medication overuse headache. Migraleve® products contain codeine and should not be prescribed.

Aspirin should not be given to patients under 16 years due to the risk of Reye’s syndrome, unless specifically indicated.

Metoclopramide or domperidone tablets or suppositories may be necessary to relieve nausea, and have the advantage of promoting gastric emptying and normal peristalsis.

Metoclopramide can cause acute dystonic reactions especially in the young and the very old.

Due to risk of neurological side-effects, metoclopramide is now only licensed for limited indications and the maximum duration of treatment is 5 days in all patients. For further advice, see MHRA Drug Safety Update, August 2013 www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON300404

Domperidone may be associated with an increased risk of serious ventricular arrhythmias or sudden cardiac death especially in those aged over 60 or those who take more than 30mg daily. Domperidone should be taken at the lowest effective dose, avoided in patients who are taking concomitant medication known to cause QT prolongation (such as erythromycin and ketoconazole) and used with caution in patients with underlying cardiovascular disease. (For further advice see MHRA Drug Safety Update, May 12.

www.mhra.gov.uk/home/groups/dsu/documents/publication/con152742.pdf)


http://www.sign.ac.uk/guidelines/fulltext/107/index.htmlhttp://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON300404http://www.mhra.gov.uk/home/groups/dsu/documents/publication/con152742.pdf

23

Step 2 5HT1-receptor agonists 1st Choice Sumatriptan 2nd Choice Rizatriptan Prescribing Points

Triptans should be reserved for patients resistant to simple analgesics +/- antiemetic therapy.

Ensure the diagnosis of migraine is correct as triptans are expensive and can be ineffective in other types of headache.

Patient’s characteristics and preferences vary and individual responses to a triptan cannot be predicted. Finding the most suitable therapy may involve trial and error and if the first triptan fails then switch to another. Other triptans can be used if the formulary options are not found to be effective or tolerated.

If a patient fails to responds to one triptan which has been tried for three separate migraine attacks, then an alternative triptan should be considered.

Medication should be taken as early as possible after migraine headache starts, but not during the aura phase. Headache recurrence within the first 24 hours can be treated with a second dose. If the first dose of a triptan fails to help, alternative (analgesic) medication should be considered.

Triptans are not recommended for use in those aged over 65 and are contraindicated in those with a history of cardiac disease.

Nasal zolmitriptan or subcutaneous sumatriptan should be considered in severe migraine, where vomiting precludes oral treatment or where oral triptans have been ineffective.

Overuse of triptans (more than 2 days use per week) should be discouraged due to the risk of medication overuse headache.

4.7.4.2 Prophylaxis of migraine Pizotifen Propranolol S - Sodium Valproate (off label use) S - Topiramate

Prescribing Points

The aim of prophylactic therapy is to reduce the frequency, severity and duration of attacks and improve responsiveness to treatment. Acute treatment will still be required

Prophylaxis should be considered for patients who suffer at least two attacks per month, suffer an increasing frequency of headaches, suffer significant disability despite suitable treatment for migraine attacks or cannot take suitable treatment for migraine attacks.

Evidence suggests that standard release preparations of propranolol are superior to modified release preparations.

Topiramate and sodium valproate may be effective for migraine prophylaxis if other treatments fail.

Sodium valproate should be avoided in women of child bearing potential due to its teratogenic


24

risk.

Prophylaxis should be given for 6 months, then consideration given to gradual withdrawal if there has been a good response. If symptoms recur the preventive treatment should be recommenced.

Botox® is not recommended by the Scottish Medicines Consortium (SMC) for the prophylaxis of headaches in adults with chronic migraine

4.7.4.3 Cluster headache and the trigeminal autonomic cephalalgias 1st Choice Sumatriptan injection (Imigran®) 2nd Choice Zolmitriptan nasal spray (Zomig®)(off label use)

Prescribing Points

Oral medication is usually ineffective for acute attacks.

During a cluster headache, patients may suffer more than one attack daily and require up to 2 doses of sumatriptan in a 24 hour period.

In secondary care, patients may get rapid relief of the cluster headache by the use of oxygen. Patients should receive 100% oxygen at a flow rate of 10-12 litres/min. for 15 minutes.

Prophylaxis of cluster headache can be considered if the attacks are frequent, last for more than 3 weeks, or if the attacks cannot be treated effectively. Refer for specialist advice.

4.8 - Antiepileptics

Also see SIGN 70 - Diagnosis and Management of Epilepsy in Adults www.sign.ac.uk/pdf/qrg70.pdf Also see SIGN 81 - Diagnosis and management of Epilepsies in Children and Young People www.sign.ac.uk/pdf/qrg81.pdf

Also see NICE Clinical Guidance 137 - The Epilepsies: the Diagnosis and Management of the Epilepsies in Adults and Children in Primary and Secondary Care http://www.nice.org.uk/guidance/cg137 4.8.1 Control of Epilepsies

1st Choice S - Carbamazepine - for partial seizures and secondary generalised tonic-clonic seizures

S - Lamotrigine - for primary generalised epilepsy (including absences and myoclonus), partial seizures, secondary generalised tonic–clonic seizures

S - Leviteracetam - for mycolinic seizures, focal seizures

S - Sodium Valproate- for primary generalised epilepsy (including absences and myoclonus), partial seizures, secondary generalised tonic-clonic seizures

2nd Choice (Restricted use when 1st line choices have failed or in combination with a 1st line choice):


http://www.sign.ac.uk/pdf/qrg70.pdfhttp://www.sign.ac.uk/pdf/qrg81.pdfhttp://www.nice.org.uk/guidance/cg137

25

S - Clobazam (Schedule 11 - requires ‘SLS’ endorsement on prescription) S - Eslicarbazepine S -Lacosamide S -Topiramate 3rd Choice* (Restricted use for treatment resistant seizures or as adjuncts to other therapy): S - Ethosuximide S - Oxcarbazepine S - Perampanel (Fycompa®) S - Phenobarbital S - Phenytoin S - Primidone

S – Rufinamide (Inovelon®) (Lennox-Gastaut

syndrome) S – Retigabine (Trobalt®) S – Vigabatrin (Sabril®) (infantile spasms) S – Zonisamide (Zonegran®)

*may be used earlier in certain seizure types or patient groups For appropriate prescribing of anti-epileptic drugs see section below on switching between different manufacturers’ products

Prescribing Points

All drugs for control of epilepsy should be initiated by hospital specialists only.

Antiepileptic medication should be commenced after two or more clinically definite seizures or after one seizure in a patient with a clearly epileptiform EEG or causative lesion on brain imaging. Treatment may also be considered after a single attack if the risk of a second seizure is considered to be high.

If a second seizure occurs before the patient is seen by a specialist then start an appropriate first choice agent. Phone the specialist for advice if required.

The choice of agent is determined by the epilepsy syndrome, type of seizure, other medication, co-morbidities and the age and sex of the patient.

Treatment with a single agent is preferred. A combination of drugs may be used in refractory patients.

In order to minimise side-effects It is essential to initiate anti-epileptic drugs at a low dose and titrate the dose gradually as per BNF.

When switching patients from one drug to another the dose should be reduced /increased gradually. Seek specialist advice.

Therapeutic drug monitoring should only be considered in patients where non-compliance or patient toxicity is suspected or when managing drug interactions.

In new patients, the use of M/R carbamazepine is recommended instead of standard tablets to aid compliance and minimise side-effects.

There is an increased risk of teratogenicity associated with the use of all antiepileptic drugs. This risk is increased with the use of high doses or the use of a combination of antiepileptic


26

drugs. Women taking antiepileptic drugs who may become pregnant should be informed of the possible consequences. The risk is particular high with sodium valproate especially at high doses (>800mg daily) or when used in combination with lamotrigine.

The effectiveness of hormonal contraceptives may be considerably reduced by some antiepileptics. This should be considered when discussing choice of contraception.

Switching Between Different Manufacturers’ Products for a Particular Anti-Epileptic Drug

The MHRA have divided anti-epileptic drugs into 3 categories in order to determine whether it is necessary to maintain continuity of supply of a specific manufacturer’s products.

The following categories relate only to the treatment of epilepsy, it does not apply to the use of these drugs for other indications e.g. mood stabilisation, neuropathic pain.

If a patient has to be maintained on a particular product this should be prescribed by brand name or the name of the manufacturer should be stated on the prescription.

In order to maintain continuity of supply, when a specified product is unavailable, pharmacists may dispense a product from a different manufacturer if discussed and agreed with both the prescriber and patient/carer.

Category Anti-epileptic drug

Category 1 – Ensure patient is maintained on a specific manufacturer’s product

Carbamazepine, phenobarbital, phenytoin, primidone

Category 2 – Need for continued supply of a particular manufacturer’s product should be based on clinical judgement and consultation with patient and/or carer. Taking into account factors such as seizure frequency and treatment history.

Clobazam, clonazepam, eslicarbazepine, lamotrigine, oxcarbazepine, perampanel, retigabine, rufinamide, sodium valproate, topiramate, zonisamide

Category 3 – Usually unnecessary to ensure patients are maintained on a specific manufacturer’s product unless specific patient reason e.g. patient anxiety and risk of confusion or dosing errors.

Ethosuximide, gabapentin, lacosamide, levetiracetam, pregabalin, tiagabine, vigabatrin

Neuropathic Pain

For the use of gabapentin and pregabalin in neuropathic pain refer to section 4.7.3.

4.8.2 Drugs used in status epilepticus Also see Paediatric Department Guideline on ‘Emergency Management of Status Epilepticus in Children’ - http://intranet.fife.scot.nhs.uk/uploadfiles/publications/Status%20Epilepticus.pdf

1st Choice S - Midazolam (Preferred brand Epistatus® -

buccal, intranasal- both are unlicensed routes) Alternative Choices S - Diazepam Rectal tubes

S - Paraldehyde rectal (unlicensed) H - Fosphenytoin injection H - Lorazepam Injection


http://intranet.fife.scot.nhs.uk/uploadfiles/publications/Status%20Epilepticus.pdf

27

H - Paraldehyde injection (unlicensed) H - Phenytoin injection Community setting

The preferred midazolam product in NHS Fife is Epistatus®. Patients and carers are trained on the use of this product. Alternative formulations e.g. Buccolam® pre-filled syringes should not be prescribed.

Prescribing Points

Community Setting

Where possible, treatment should be initiated in the community prior to hospital.

A possible underlying cause (e.g. hypoglycaemia, hypoxia etc) must be considered.

The first episode of status epilepticus should be treated with buccal midazolam if available, and an ambulance should be called.

Treatment should be given if convulsion lasts longer than 5 minutes. Rectal diazepam is an alternative to buccal midazolam.

Buccal midazolam should only be initiated on the advice of a specialist in accordance with agreed local guidelines and following appropriate training of the parent or carer. It may, however, be continued to be prescribed in primary care

The preferred midazolam product in NHS Fife is Epistatus®. Patients and carers are trained on the use of this product. Alternative formulations e.g. Buccolam® pre-filled syringes should not be prescribed.

In some cases, rectal paraldehyde may be administered in the community for prolonged seizures, according to individual patient protocol.

Hospital

If still fitting at 10 minutes and, if not already in hospital, call an ambulance. A second dose may be given sooner if resuscitation facilities are available.

If convulsion continues beyond 30 minutes (status epilepticus), patient will need hospitalisation and preferably admission to ITU.

Clobazam may be prescribed to prevent status epilepticus in patients with a previous history of status or who are known to be at risk if their seizures accelerate or begin to cluster. It may also be prescribed for those whose seizures occur or accelerate at certain times e.g. during menstruation or intercurrent infections. Prescriptions should be endorsed ‘SLS’.


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4.8.3 Febrile convulsions

Also see

NICE Clinical Guidance update 160 - Feverish illness in children: Assessment and initial management in children younger than 5 years http://guidance.nice.org.uk/CG160/

1st Choice Midazolam (Preferred brand Epistatus® - buccal

- unlicensed route) 2nd Choice Diazepam (rectal)

Prescribing Points

See prescribing points above under section 4.8.2

4.9 - Drugs used in parkinsonism and related disorders Also see SIGN guideline No. 113, Diagnosis and Pharmacological Management of Parkinson’s Disease www.sign.ac.uk/guidelines/fulltext/113/index.html

ALL PATIENTS WITH SUSPECTED PARKINSON’S DISEASE SHOULD BE REFERRED FOR SPECIALIST ASSESSMENT BEFORE TREATMENT IS INITIATED. (See referral pathway on the intranet public folders - parkinsons).


Therapy is usually initiated with levodopa. However in younger patients (aged

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4.9.1 Dopaminergic drugs used in parkinsonism Levodopa S - Co-beneldopa (Madopar®) S - Co-careldopa (Sinemet®)

Levodopa and carbidopa S - Co-careldopa intestinal gel (Duodopa®)

Prescribing Points

To reduce the risk of nausea, levodopa therapy should be taken with food. Patients with more advanced disease may be encouraged to take before food to aid absorption and reduce motor fluctuations. Levodopa should be initiated at a low dose and increased in small steps. Dosing intervals should be chosen to suit the needs of the individual patient.

Reduction in dose of levodopa should only occur after specialist consultation and levodopa should not be withdrawn abruptly as this may lead to potentially fatal neuroleptic type syndrome.

Levodopa may colour urine red.

Dispersible Madopar® may be useful for patients with swallowing difficulties, or where rapid absorption is desired, for example first thing in the morning.

Modified–release formulations of levodopa are not routinely recommended. They are reserved only for nocturnal immobility and rigidity.

Co-careldopa intestinal gel (Duodopa®) is recommended by the Scottish Medicines Consortium (SMC) for the treatment of advanced levodopa-responsive Parkinson’s disease with severe motor fluctuations and hyper/dyskinesia when available combinations of Parkinson medicinal products have not given satisfactory results.

Dopamine agonists Also see :-

Shared Care Protocol for Apomorphine http://www.fifeadtc.scot.nhs.uk/shared-care-protocols/scps-fife/apomorphine.aspx

S - Apomorphine S - Pramipexole S - Ropinirole S – Rotigotine (Neupro®) Prescribing Points

When prescribing pramipexole, ensure the correct dose and strength are prescribed. Pramipexole dose and strengths are stated in terms of base. See BNF.

Sudden onset of sleep can occur with dopamine-receptor agonists.

Rotigotine patches are expensive compared to tablets but may be prescribed in patients when oral therapy is unsuitable, to reduce the burden of oral medicines or when patients have significant motor fluctuations especially overnight.

Patients taking dopaminergic drugs who require an antiemetic must not be prescribed metoclopramide, prochlorperazine or cyclizine. Domperidone is the antiemetic of choice in this


http://www.fifeadtc.scot.nhs.uk/shared-care-protocols/scps-fife/apomorphine.aspxhttp://www.fifeadtc.scot.nhs.uk/shared-care-protocols/scps-fife/apomorphine.aspx

30

patient group.

Domperidone may be associated with an increased risk of serious ventricular arrhythmias or

sudden cardiac death especially in those aged over 60 or those who take more than 30mg daily. Domperidone should be taken at the lowest effective dose, avoided in patients who are taking concomitant medication known to cause QT prolongation (such as erythromycin and ketoconazole) and used with caution in patients with underlying cardiovascular disease. (For further advice see MHRA Drug Safety Update, May 12 www.mhra.gov.uk/home/groups/dsu/documents/publication/con152742.pdf).

Apomorphine is a potent dopamine-receptor agonist used in patients experiencing unpredictable ‘off’ periods with levodopa treatment or motor fluctuations. Patients on apomorphine should be co-prescribed long-term domperidone.

Other dopaminergic agents S - Selegiline S - Stalevo®

S – Entacapone (COMT inhibitor) (normally prescribed as Stalevo®, but may be used as entacapone when co-prescribed with other levodopa therapy)

S - Amantadine

Prescribing Points

These agents have complex drug interactions. Caution should be taken when co-prescribing with other drugs. See BNF.

Selegiline and entacapone are used in Parkinson’s disease to reduce ‘end-of-dose’ deterioration.

Selegiline should be administered in the morning as it may cause insomnia.

A buccal formulation of selegiline, (Zelapar®), produces less side effects but is considerably more expensive than the oral formulation. It should only be considered in patients with swallowing problems or intolerance of standard selegiline.

Entacapone must be used in combination with levodopa and both drugs must be taken at the same time. A combination product, Stalevo®, is available to aid concordance.

Stalevo® is only available in fixed component doses. When increasing the dose, multiple tablets can not be used. The strength of Stalevo® needs to be increased instead.

Amantadine may be useful for control of dyskinesia.

Restless Legs Syndrome

Treatments for restless leg syndrome should only be initiated by a Consultant Physician/Neurologist running Movement Disorder clinics. They can be considered in moderate to severe idiopathic restless legs syndrome (RLS) i.e. when symptoms result in significant disruption to sleep and impairment of daily living.

4.9.2 Antimuscarinic drugs used in parkinsonism S - Procyclidine S - Orphenadrine


http://www.mhra.gov.uk/home/groups/dsu/documents/publication/con152742.pdf

31

Prescribing Points

These drugs should not be prescribed for idiopathic Parkinson’s disease.

Antimuscarinic drugs should not be used in drug-induced parkinsonism. If possible, the offending drug should be discontinued instead.

Tardive dyskinesia is not improved by antimuscarinic drugs and may be made worse.

Procyclidine can be given parenterally and is effective emergency treatment for acute drug-induced dystonic reactions.

Abrupt withdrawal of antimuscarinics must be avoided as this can pose significant clinical risk.

4.9.3 Drugs used in essential tremour, chorea, tics and related disorders Essential Tremor 1st Choice Propranolol (standard tablets) 2nd Choice S - Primidone

Prescribing Points

Propranolol is the drug of choice for tremor associated with anxiety or thyrotoxicosis.

Primidone is a suitable alternative where a beta blocker is contraindicated or not tolerated.

Intractable Hiccups

Also see:-

NHS Fife Palliative Care Guidelines http://www.fifeadtc.scot.nhs.uk/guidance-documents/fife-wide-palliative-care.aspx

Chlorpromazine Haloperidol

Prescribing Points

Chlorpromazine has a high risk of photosensitivity

Torsion dystonias and other involuntary movements S - Botulinum A toxin (Botox®)

Prescribing Points

There are several brands of botulinum A toxin available. They are not interchangeable and doses are specific to individual preparations. The NHS Fife preferred brand is Botox®.

Botox® is not recommended by the Scottish Medicines Consortium (SMC) for the prophylaxis of headaches in adults with chronic migraine, for use in focal lower limb spasticity associated with stroke nor for the temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (glabellar lines).


http://www.fifeadtc.scot.nhs.uk/guidance-documents/fife-wide-palliative-care.aspxhttp://www.fifeadtc.scot.nhs.uk/guidance-documents/fife-wide-palliative-care.aspx

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4.10 - Drugs used in substance dependence Also see :- NHS Fife Addiction Service Guidelines http://www.fifeadtc.scot.nhs.uk/guidance-documents.aspx 4.10.1 Alcohol dependence Also see :-

SIGN 74 - Management of Harmful Drinking and Alcohol Dependence in Primary Care www.sign.ac.uk/guidelines/fulltext/74/index.html

NICE Clinical Guidance 100 - Alcohol-use disorders: Diagnosis and clinical management of alcohol-related physical complications http://publications.nice.org.uk/alcohol-use-disorders-diagnosis-and-clinical-management-of-alcohol-related-physical-complications-cg100 NICE Clinical Guidance 115 - Alcohol Dependence and Harmful Alcohol Use www.nice.org.uk/guidance/CG115

Alcohol detoxification

Also see:-

NHS Fife Guidance for the Identification, Assessment and Management of Harmful Drinking and Alcohol Dependence Chlordiazepoxide

Prescribing Points

Alcohol dependent patients exhibiting moderate to severe withdrawal features or those assessed at high risk of developing severe withdrawal symptoms should be prescribed benzodiazepines for detoxification.

Chlordiazepoxide in a tapered dosing regime over a period of 5 to 10 days is recommended (See Guideline A5).

For short term use only - there is no role for long term prescribing of chlordiazepoxide in alcohol dependence.

Benzodiazepines should not be prescribed if the patient is likely to drink alcohol concomitantly.

Vitamin Supplementation Also see:-

NHS Fife Guidance for the Identification, Assessment and Management of Harmful Drinking and Alcohol Dependence S - Pabrinex® Thiamine Prophylaxis of Wernicke–Korsakoff syndrome: Pabrinex® Treatment of patients with Wernicke–Korsakoff syndrome (hospital in–patients): Pabrinex® Poor diet in patients who are alcohol dependent but not at risk of Wernicke-Korsakoff


http://www.fifeadtc.scot.nhs.uk/guidance-documents.aspxhttp://www.sign.ac.uk/guidelines/fulltext/74/index.htmlhttp

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4. Central Nervous System · 2016. 8. 15. · Antipsychotic drugs should not be used in older patients to treat mild psychotic symptoms i.e. non-distressing symptoms. Initial doses