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 Formulary Chapter 4: Central nervous system - Full Chapter
04.07  Expand sub section  Analgesics
04.07.01  Expand sub section  Non-opioid analgesics and compound analgesic preparations
Paracetamol
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First Choice Tablets
Soluble tablets
Oral suspension
Suppositories
IV infusion
 
Nefopam
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Formulary
Grey
Tablets

Only to be used in those patients with moderate to severe chronic liver disease who require analgesia stronger than paracetamol in whom NSAIDS and moderate strength opiates are contraindicated
 
   
04.07.01  Expand sub section  Compound analgesic preparations
 note  The advantages of analgesic preparations containing paracetamol with a low dose of an opioid have not been substantiated. The low dose of the opioid may be enough to cause opioid side-effects, yet may not provide significant additional relief of pain.
Paracetamol and codeine (Co-codamol® 8/500)
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Formulary Tablets
Effervescent tablets 
   
Paracetamol and codeine (Co-codamol® 30/500)
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Formulary Tablets
Effervescent tablets 
   
Paracetamol and dihydrocodeine (Co-dydramol® 10/500)
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Formulary Tablets 
   
04.07.02  Expand sub section  Opioid analgesics
Codeine Phosphate
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First Choice Tablets
Oral liquid 
Controlled Drug Morphine
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First Choice Oral solution:
  • 10mg/5mL
  • 100micrograms/mL (unlicensedunlicensed)

    Concentrated oral solution:
  • 100mg/5mL

    Tablets

    M/R 12-hourly oral preparations:
  • Zomorph® capsules
  • MST® tablets

    M/R 24-hourly oral preparations:
  • MXL® capsules

    Suppositories

    Injection

    PCA syringe (unlicensedunlicensed)

     
  • Controlled Drug Tapentadol (Palexia®)
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    Third Choice
    Grey

    Prolonged-release tablets


    Tablets


    Oral solution



    • Third or fourth line option in those patients who have failed other therapies and are intolerant to oxycodone.

    • To be prescribed or initiated under the advice of a specialist in pain management only.

      Grey Traffic Light Use of this agent should be restricted to those patients requiring treatment of severe chronic pain which CANNNOT be managed with more established opioid therapies.

     
    Link  GMMMG recommendation: Tapentadol for treatment of severe pain
    Link  MHRA Safety Alert: risk of seizures and reports of serotonin syndrome
       
    Controlled Drug Buprenorphine
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    Formulary Patches (BuTrans® or Transtec®)
    S/L tablets (Temgesic®
       
    Controlled Drug Diamorphine
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    Formulary Injection 
       
    Dihydrocodeine
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    Formulary Tablets
    M/R tablets 
       
    Controlled Drug Fentanyl
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    Formulary Patches
    Restricted Item Buccal tablets (Effentora®) Palliative care only
    Restricted Item Nasal spray (PecFent®) Palliative care only
     
    Link  GMMMG IPNTS Recommendation: Fentanyl preparations
    Link  MHRA Safety Alert: Transdermal fentanyl patches: life-threatening and fatal opioid toxicity from accidental exposure
       
    Controlled Drug Oxycodone
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    Formulary Immediate-release preparations (OxyNorm®):
  • Oral solution 5mg/5mL
  • Concentration oral solution 10mg/mL
  • Capsules
  • Injection

    M/R preparations (OxyContin®):
  • Tablets 
  •    
    Controlled Drug Pethidine
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    Formulary Tablets
    Injection 
       
    Controlled Drug Tramadol
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    Formulary Capsules
    Soluble tablets
    M/R tablets or capsules
    Injection 
    Link  UKMI Q&A: risk of developing Serotonin Syndrome following concomitant use of tramadol with SSRIs
       
    04.07.03  Expand sub section  Neuropathic pain to top
    Gabapentin
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    First Choice Capsules
    Oral solution 
    Amitriptyline
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    First Choice Tablets
    Oral solution 
    Pregabalin
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    Formulary
    Green 1
    Capsules

    note A trial of pregabalin may be considered in patients who cannot tolerate gabapentin, or who have not responded fully despite an adequate trial. 
       
    Duloxetine (Cymbalta®)
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    Formulary Capsules

    noteDuloxetine may be considered as an option where other treatments have failed, or for a clear diagnosis of diabetic neuropathy. 
       
    Imipramine
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    Formulary Tablets
    Oral solution 
       
    Ketamine oral solution
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    Restricted Drug Restricted
    Red

    Specialist initiation by pain team or palliative care only
    unlicensed Unlicensed

     
       
    04.07.03  Expand sub section  Trigeminal neuralgia
    Carbamazepine
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    First Choice Tablets
    M/R tablets
    Liquid
    Suppositories
     
    Gabapentin
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    Second Choice Capsules
    Oral solution 
    Link  MHRA Safety Update: Risk of severe respiratory depression
       
    04.07.04  Expand sub section  Antimigraine drugs
    04.07.04.01  Expand sub section  Treatment of the acute migraine attack
    04.07.04.01  Expand sub section  Analgesics
    Migraleve®
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    Formulary "Pink" tablets (buclizine 6.25mg, paracetamol 500mg, codeine phosphate 8mg)
    "Yellow" tablets (paracetamol 500mg, codeine phosphate 8mg)
     
       
    04.07.04.01  Expand sub section  5HT1 agonists to top
    Sumatriptan
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    Formulary Tablets
    Injection 
       
    04.07.04.01  Expand sub section  Anti-emetics
     note  Antiemetics such as metoclopramide, domperidone, or phenothiazine and antihistamine antiemetics, relieve the nausea associated with migraine. See section 4.6.
    04.07.04.02  Expand sub section  Prophylaxis of migraine
    Propranolol
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    First Choice Tablets
    M/R capsules
    Oral solution 
    Topiramate
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    Second Choice Tablets
    Sprinkle® capsules

    Grey Traffic Light Topiramate hard capsules are expensive and should not be prescribed. For those patients unable to swallow topiramate tablets “sprinkle capsules” may be considered  
       
    Pizotifen
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    Formulary Tablets 
       
    04.07.04.03  Expand sub section  Cluster headache
    Sumatriptan
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    Formulary Injection 
       
     ....
     Non Formulary Items
    Almotriptan  (Almogran®)

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    Non Formulary
     
    Aspirin and metoclopramide  (MigraMax®)

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    Non Formulary
     
    Botulinum Toxin Type A  (botox®)

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    Non Formulary
    Link  NICE TA260: Botox for migraine prophylaxis
     
    Clonidine Hydrochloride

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    Non Formulary
     
    Eletriptan  (Relpax®)

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    Non Formulary
     
    Controlled Drug  Fentanyl  (Actiq®)

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    Non Formulary
     
    Controlled Drug  Fentanyl  (Instanyl® nasal spray)

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    Non Formulary
     
    Controlled Drug  Fentanyl sublingual tablets  (Abstral®)

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    Non Formulary
     
    Frovatriptan

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    Non Formulary
     
    Controlled Drug  Hydromorphone  (Palladone®)

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    Non Formulary
     
    Melatonin

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    Non Formulary
    Link  UKMI Q&A: review of effectiveness in cluster headache
     
    Meptazinol  (Meptid®)

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    Non Formulary
     
    Controlled Drug  Morphine and cyclizine  (Cyclimorph®)

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    Non Formulary
     
    Naratriptan  (Naramig®)

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    Non Formulary
     
    Controlled Drug  Papaveretum

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    Non Formulary
     
    Paracetamol and metoclopramide  (Paramax®)

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    Non Formulary
     
    Controlled Drug  Pentazocine

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    Non Formulary
     
    Controlled Drug  Pethidine Hydrochloride and promethazine  (Pamergan® P100)

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    Non Formulary
     
    Rizatriptan  (Maxalt®)

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    Non Formulary
     
    Sodium valproate

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    Non Formulary
     
    Controlled Drug  Targinact® (Oxycodone/Naloxone)

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    Non Formulary
    Link  GMMMG Recommendation: Targinact
     
    Tolfenamic Acid  (Clotam®)

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    Non Formulary
     
    Tramadol Hydrochloride and paracetamol  (Tramacet®)

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    Non Formulary
     
    Zolmitriptan

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

    Traffic Light Status Information

    Status Description

    Amber

    Drugs designated amber are suitable for shared care arrangements under a shared care protocol. Prescribing may be transferred from secondary to primary care once the patient is stabilised and agreed shared care arrangements have been established. Alternatively primary care may initiate under the supervision of secondary care if this option is given in the shared care document. It is recommended that shared care arrangements should be drawn up following local discussion and agreement by prescribing parties.   

    Black

    These products have been reviewed by the GM Joint Formulary Group and have been deemed not suitable for prescribing for adults in primary or secondary care within Greater Manchester. These decisions have been made on the basis of safety, efficacy and cost-effectiveness of the products.  

    Green

    Not used   

    Green 1

    Drugs designated green1 are suitable for initiation and ongoing prescribing within primary care.   

    Green 2

    Drugs designated green2 can be initiated by primary care following written or verbal advice from a specialist and then be subsequently safely prescribed in primary care with little or no monitoring required.  

    Green 3

    Drugs designated green3 are suitable for on-going prescribing within primary care after specialist initiation and an initial review (unless specified) in secondary care. Little or no monitoring is required.  

    Grey

    Not suitable for routine prescribing but may be suitable for a defined patient population. Whilst prescribers should think very carefully before prescribing or recommending any of the products on the grey list, there may be exceptional instances when the use of one of these products is necessary for a particular patient.   

    Red

    Drugs designated red are considered to be specialist medicines and prescribing responsibility for these medicines should normally remain with the consultant or specialist clinician. These drugs should not be initiated or prescribed in primary care. It is recommended that the supply of these specialist medicines should be organised via the hospital pharmacy, this may include arranging for supply via a home care company.   

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