Commissioned by NHS England for:

• Juvenile idiopathic arthritis in line with NICE TA373.
• Paediatric indications where an adult NICE TA is available.

 Commissioned by CCG for the treatment of rheumatoid arthritis in line with NICE TA195 and TA375.

For paediatrics, to be initiated in hospital

Gel, benzoyl peroxide 5% in an aqueous gel basis
Excipients include propylene glycol

For use within acne guideline when required in combination with antibiotics

Not RBCH

Self Care Medicine

Available as 8g or 15g

Commissioned by CCG for psoriasis in accordance with NICE TA146.

 Commissioned by NHS England via specialist centres only for treating moderate to severe hidradenitis suppurativa in accordance with NICE TA392.

Pre-filled syringe - various brands available. Injection technique is device specific. To ensure patients receive the auto-injector device that they have been trained to use, prescribers should normally prescribe by brand.

First line spacer option.

Commissioned by NHS England in line with NICE TA310.

Commissioned by NHSE in line with NICE TA536 recommendations.

Commissioned by NHS England for treatment multiple sclerosis in accordance with NICE TA312.

Commissioned for two treatment courses only as per marketing authorisation. Any subsequent courses by IFR only.

RED, Initiation by lipid specialist – this can be by written or verbal approval to other secondary care consultant clinicians. A copy of any letters should be forwarded to the patient’s GP.

Commissioned by CCG in accordance with NICE TA 393 for primary non-familial hypercholesterolaemia or mixed dyslipidaemia and primary heterozygous familial hypercholesterolaemia.

Commissioned by NHS England via specialist centres only for homozygous familial hypercholesterolaemia.

Alternative option for cow’s milk protein allergy 

NICE CG32 Nutrition support in adults

Should be prescribed only after nutrition screening has taken place using a validated tool e.g. MUST (Malnutrition Universal Screening Tool) 

Restrict use to those patients with increased protein requirement. Use only under direction of dietitian. Not to be used for those with renal insufficiency

Not first line with regard to depression, as per the Dorset Primary Care Protocol for Depression (see link above)

Commissioned by NHS England for the treatment of Adult-Onset Still’s Disease refractory to second-line therapy in line with clinical commissioning policy 170056P via specilaist centres only.

Commissioned by NHS England in Cryopyrin Assoicated Periodic Syndrome via specilaist centres only in line with highly specialised criteria.

Restrict to patients in exceptional circumstances, this is a  Self Care Medicine

Solution (= application), aluminium chloride hexahydrate 20% in an alcoholic basis

 Self Care Medicine for primary care.

Red for in-patient use as unable to purchase OTC. 

Tablets.

• For prevention of stroke or systemic embolism in patients with AF within NICE TA275 and local guidance, as per licensed indications.

Prophylaxis in Superficial Thrombophlebitis - refer to Anticoagulation policy. 6 week course  Unlicensed

Alternative option for cow's milk protein allergy

Cream, emulsifying ointment 30%, (1)phenoxyethanol 1% in freshly boiled and cooled purified water

Excipients include cetostearyl alcohol

Do not use soap or bubble baths etc when you wash as they can dry out the skin and make it more prone to irritation. 

Use a leave-on emollient as a soap substitute and continue with standard eczema management, including regular leave-on emollients and topical corticosteroids when required

Enema.

• Contains peanut oil. DO NOT give to patients with PEANUT ALLERGY.

Tablets, Orodispersible tablets.

Use in accordance with NICE CG178 recommendations for the use of atypical antipsychotic drugs for the treatment of schizophrenia and local shared care guidelines.

See guidance on the use of antipsychotics in conditions other than schizophrenia (NICE CG 82)

To be initiated on specialist advice only for:
-schizophrenia.
-the treatment of moderate to severe manic episodes in Bipolar I Disorder.
-the prevention of a new manic episode in patients who experienced predominantly manic episodes and whose manic episodes responded to aripiprazole treatment.

Solution shouldn't be used routinely as is very expensive (30mg = ~£600 per month)

Option based on NICE guidance and licence.

For the maintenance of adult patients with schizophrenia who have responded to oral aripiprazole but who are non-compliant.

see guidelines for the use of aripiprazole long acting injections

Indicated for the management of exuding partial to full thickness wounds, stage I -IV pressure sores, venous ulcers, second degree burns and donor sites. It is indicated for external use only and may be used in the management of infected wounds under medical supervision at the discretion of the physician.

Sterile dressing consisting of two layers:

• an absorbent polyurethane foam layer which provides for the absorption of wound exudate.
• an ionic silver alginate matrix which provides for broad anti-microbial effectiveness and helps prevent contamination from external bacteria.

Tablets, suppositories.

Dispersible tablets are considered 2nd Line 

Reserved for patients with severe eczema and infants under the age of 1 year. 

Bath oil, colloidal oatmeal, white oat fraction in emollient basis

Excipients include beeswax, fragrance

Do not use soap or bubble baths etc when you wash as they can dry out the skin and make it more prone to irritation.

Use a leave-on emollient as a soap substitute and continue with standard eczema management, including regular leave-on emollients and topical corticosteroids when required

Commissioned by CDF in line with CDF criteria at commissioned CAR-T treatment centres only.

Commissioned centres include:

• University College London Hospital NHS Foundation Trust
• King’s College Hospital NHS Foundation Trust
• University Hospitals Bristol NHS Trust

NICE CG32 (Feb 2006) Nutrition support in adults www.nice.org.uk/page.aspx?o=cg032niceguideline

Should be prescribed only after nutrition screening has taken place using a validated tool e.g. MUST (Malnutrition Universal Screening Tool)

Adult sip feeds containing 1kcal/ml (Fresubin Original, Ensure, Fortimel, Clinutren ISO) should not be prescribed as they are less cost effective compared to 1.5kcal/ml sip feeds

for Sexual Health indications in Primary Care - see Sexual Health Dorset Guidelines below. Liquid preparation is green for use in children who are allergic to penicillin.

with Shared Care Guideline: For bronchiectasis, in line with local shared care guideline

For COPD or other indications.

Consultant microbiologist or specialist use only.

Size: 4mm/32g
Size: 5mm/31g

Pack Size : 90

For use within its licensed indication for COPD

Commissioned by NHS England in line with TA216 and NHSE clinical commissioning policies (see below).

Commissioned by CDF for the treatment of relapsed multiple myeloma in lince with CDF criteria.

Unlicensed

 RBCH: Approved for Eye specialist use in the following indications where there is no licensed product available:

• Iris/drainage angle neovascularization - single injection
• Pre-operative use to reduce the risk of vitreous hemorrhage during vitreoretinal surgery - single injection
• Treatment of choroidal neovascularisation non-age related macular degeneration (AMD) or myopic CNV causes - repeated injection up to maximum frequency of monthly according to condition.
• Treatment of choroidal neovascularisation due to age related macular degeneration where clinical benefit is present but patient falls outside the criteria for licensed drug treatment i.e. better than 6/12

All sizes 

Biatain^® Silicone Lite is a thin and ultra flexible foam dressing with gentle silicone adhesive. It can be used on a wide range of exuding wounds and is to be used whenever a thin foam dressing is needed. Biatain^® Silicone Lite combines superior absorption and increased mobility.

0.01% is only strength on formulary

Choline salicylate dental gel

In accordance with NICE TA (TA129, TA228, TA311) or CDF policy.

Commissioned by NHS England in line with NICE TA401.

Cream, benzoyl peroxide 4% in an aqueous basis
Excipients include cetyl alcohol, fragrance, stearyl alcohol

For use within acne guideline when required in combination with antibioticsFor use within acne guideline when required in combination with antibiotics

Self Care Medicine

Not RBCH

*prescribe by brand to ensure the patient receives the same inhaler at each dispensing*

If generic prescription - patients should be supplied with the combination inhaler they have been using or trained in 

March 2018: Non Formulary for new initiations

Sublingual tablets.

Red for substance misuse as per DMAG March 2018

Cabometyx^®:

• Commissioned by NHSE in accordance with NICE TA463 and TA542 for the treatment of previously treated advanced renal cell carcinoma and untreated locally advanced or metastatic renal cell carcinoma respectively.
• Patients initiated on the Named Patient Programme should remain on free of charge stock for the duration of their treatment.

Cometriq^®:

• Commissioned in accordance with NICE TA516 for the first line treatment of medullary thyroid cancer.

One gram of cutaneous foam contains 50 micrograms of calcipotriol (as monohydrate) and 0.5 mg of betamethasone (as dipropionate).

Not stocked at RBCH

2nd line option at RBCH for patients intolerat of Adcal D3

Sizes: 5cmx5cm, 7.5cmx12cm, 10cmx20cm, 15cmx25cm

Energy supplement.

Calogen and Calogen extra contain some vitamins & minerals

To be used under direction of dietitian only.

Paediatric patients: not suitable in children under the age of 3, use with caution in children aged 3-6 years. 

Generally use as a second choice to 1.5kcal/ml sip feeds as not nutritionally complete. However these supplements do provide more calories per ml approx. 600kcal in 250ml so useful for those with very high calorie needs (when reconstituted with whole milk) e.g. CF Patients

Generic drug should be used where possible

For microbiology or haematology use only.

Commissioned by NHS England for fungal infection according to agreed Trust Guidelines.

Restrict to where moderate to severe skin condition requires it

Shampoo, cetrimide 10%, undecenoic acid 1%

Self Care Medicine

Approved at RBCH and PHT only when recommended by a Consultant Microbiologist

Commissioned by NHS England in line with NICE TA395 and TA500.

Emollient cream; white soft paraffin 13.2%, light liquid paraffin 10.5%
Excipients include cetostearyl alcohol
Hydroxybenzoates (parabens) are no longer included as an excipient as per up to date SPC from manufacturer - BNF in the process of being updated.

Self Care Medicine - to be purchased when part of routine skin care in the absence of a moderate to severe skin condition.

For use in line with NICE TA recommendations.

PGH: For use as part of the paediatric sedation guideline only.

For rheumatoid arthritis in accordance with NICE recommendations (CG79).

Ointment, suppositories

Brands include Proctosedyl® and Uniroid®

ENT use only: Treatent of ear infection

1st line - use licensed ear drops 1st line in ear.

2nd line - use eye drops in the ear - Off label use (UNLICENSED ROUTE)

Excipients include benzyl alcohol, cetostearyl alcohol, polysorbates, propylene glycol
May damage latex condoms and diaphragms

Tubular bandage for fixation/retention and wet and dry wrapping

Red Line 3.5cm x 1m

Green Line 5cm x 1m / 3m / 5m

Blue Line 7.5cm x 1m / 3m / 5m

Yellow Line 10.75 x 1m / 3m / 5m

Beige Line 17.5cm x 1m

Odour control via activated charcoal

CliniSorb is indicated for the management of malodorous wounds. It can be used on fungating wounds and a variety of other chronic wounds with good results.

• CliniSorb can be cut to size if necessary
• CliniSorb can be applied either side down
• A secondary dressing can be applied on top of CliniSorb if appropriate
• CliniSorb can be secured in place using adhesive tape or in a manner appropriate for the indication
• Change when necessary

Tablets.

• In accordance with NICE recommendations for the use of clopidogrel in the treatment of non-ST-segment-elevation in ACS (TA80), clopidogrel should be used for up to 12 months.

• Post stent insertion (unless follows acute coronary syndrome, see above):
  - clopidogrel should be used for 1 month following insertion of non-drug eluting stent.
  - clopidogrel should be used for 12 months following insertion of a drug-eluting stent.

• In accordance with NICE TA210 (Prevention of acute vascular events).
• <a href="http://www.dorsetccg.nhs.uk/Downloads/aboutus/medicines-management/Other%20Guidelines/Generic_clopidogrel_statement%20nov%2009.pdf" target=”_blank”

• Update from the Cardiology Working Group July 2017 : The interaction of omeprazole on the antiplatelet efficacy of clopidogrel is no longer considered clinically significant.

Prescribers should use a LICENSED product (e.g.  Fultium D3^®, Invita D3^®;Desunin^®)

In accordance with local guidance for the management of vitamin D deficiency and insufficiency in adults.

Not at DCHFT and RBCH.

Commissioned by NHS England for use in CF as per policy A01/P/b and NICE TA276.

Adult patients: specialist centre only (University Hospital Southampton)

Paediatric patients: PHFT use in line with network arrangements with UHS.

Not at DCH or RBCH.

The calories are based on a sachet made up with 200ml of full cream milk and contain approx. 385 kcals.

If your patient likes milky drinks prescribe as a supplement to diet 1-2 servings/day.

Not suitable for patient with cow’s milk intolerance or galactosaemia. Not nutritionally complete.

If your patient dislikes milky drinks choose from the juice style supplements instead.

• Protects wound margins and peri-wound skin from external factors including wound exudate, incontinence and friction, caused by urinary and/or faecal incontinence
• Preserves and maintains intact or irritated skin by building a moisture barrier with good permeability to oxygen and water vapour
• Prevention of incontinence dermatitis
• Prevents maceration by providing up to 96 hours of moisture barrier action
• Effective adjunctive skin therapy during treatment of chronic wounds  e.g. venous or arterial, diabetic foot or pressure ulcers, or whenever skin requires a protective shield

Cutimed Sorbact gel dressings reduce bacterial load in a wound by combining Cutimed Sorbact swab with an amorphous hydrogel to support moist wound healing in lower exuding or sloughy wounds. 

Available as 7.5cm x 15cm and 7.5cm x 7.5cm

All sizes approved for addition to the Joint Wound Formulary April 2018

• In accordance with NICE TA for prevention of VTE in patients undergoing hip or knee replacement surgery, as per licensed indications.
  • Note routine 1st line option at RBCH and DCH is LMWH

• For prevention of stroke or systemic embolism in patients with AF within NICE TA and local guidance, as per licensed indications.
• For the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism in accordance with NICE TA. 

PHFT: 

For treatment of cellulitis when approved by microbiology

For treatment of bone and joint infections (including spinal abscess, discitis, osteomyelitis and septic arthritis) when approved by microbiology and who are suitable for discharge and:

• Compliance with daily IV or oral antibiotics is likely to be an issue and are therefore at risk of treatment failure and readmission
• Discharge with an IV cannula is likely to be a risk e.g. IVDU
• Is likely to decline treatment / self-discharge and therefore likely to have repeated readmissions
• Are identified as suitable for early discharge in which oral antibiotics would not be appropriate and were not requiring any other medical/therapy interventions.

for DVT in patients who are intravenous drug users.

Specialist initiation:

Please use in accordance with the relevant local shared care guidance.

for specialist indications, e.g. prevention of clotting in the extracorporeal circuit during haemodialysis, not listed above

• RBCH and PGH.
• DCHFT: Dalteparin not routinely used.

 When used with oral hyperglycaemics in patients with Type 2 Diabetes
 
  When used with insulin in patients with Type 2 Diabetes

Commissioned by NHS England (for dialysis-induced anaemia including via outpatients and only as per NICE CG114) and Trust Guidelines.

Treatment of hepatitis C commissioned in line with latest rate card from NHS England.

Commissioned by NHS England for iron chelation in thalassaemia and sickle cell - policy in progress.

Nov 18: Approved for use at RBCH as 2nd line agent - application for Green status is pending DMAG approval. 

An alternative to Flexitol® with 25% Urea content

Lotion, benzalkonium chloride 0.1%, chlorhexidine hydrochloride 0.1%, liquid paraffin 2.5%, isopropyl myristate 2.5%

Excipients include cetostearyl alcohol

Injections.

Stock update (5mg and 10mg injections) 14/8/2018

Accord are still out of stock of diamorphine 5mg and 10mg injection, but have advised that new stock of both strengths will be available during the w/c 27th August. There are further deliveries scheduled for both strengths through September, October and the coming months. Wockhardt still have supplies available, but as previously advised they cannot support the full demand for primary and secondary care.

Therefore, it is expected that this supply issue should hopefully be resolved by early September. Until this time therefore please continue with the management plan as previously stated – primary care and drug misuse centres will be able to continue to order diamorphine in line with historical demand.

Recommended local action - primary care - Although you will be able to access diamorphine as per historical demand, we would encourage prescribers to be aware of the supply issues and reduce prescribing where appropriate. Please order responsibly during this time, in line with historical demand and do not stock pile to avoid lengthening the stock shortage. In the case that diamorphine cannot be accessed, please refer to the clinical guidance issued by UKMI which provides more information on suggested alternatives to diamorphine.

15/6/17
The medicines team has been made aware of shortages of some strengths of Diamorphine ampoules, in some areas. 

In order that patients are able to access essential palliative care medicines, it is recommended that prescribers and palliative care staff check availability with local pharmacies before sending patients or relatives to collect prescriptions.
Where possible and appropriate, prescriptions should be written to order the strengths that are available. Prescribers may need to amend prescriptions accordingly. The diamorphine prescription may need to be written on a separate prescription to other palliative care medicines. 

Nurses and carers are reminded to carefully check ampoule strengths if doses need to be made up from smaller amps, or where wastage of parts of larger amps needs to occur, following best practice when wasting part amps.

If diamorphine is unavailable, then prescribers are advised to convert to Morphine, using the conversion tables in the front of the BNF or on bnf.org
Seek the advice of local pharmacies and the listed palliative care pharmacies in the out of hours period. 

Tablets, syrup.

Commissioned by NHSE in line with NICE TA538 at or under shared care with a neuro-oncology centre.

Cream, cetomacrogol 2.25%, cetostearyl alcohol 7.2%, liquid paraffin 6%, white soft paraffin 15%
Ointment, liquid paraffin 5%, white soft paraffin 95%,
Excipients include cetostearyl alcohol, chlorocresol

DCHFT: Ointment not stocked.

Self Care Medicine - to be purchased when part of routine skin care in the absence of a moderate to severe skin condition. 

Restrict to patients in exceptional circumstances, this is a  Self Care Medicine

Application, aluminium chloride hexahydrate 20% in an alcoholic basis

Not stocked at RBCH

RBCH :  Consultant Anaesthetist only in Recovery areas for Intractable PONV.

For treating moderate to severe atopic dermatitis, in accordance with NICE TA534

Paediatric and adult patients.

If patient dislikes or does not tolerate Modulen IBD then trial of Elemental 028 extra can be considered

Available in 2 flavours or the unflavoured one can be made more palatable using the flavour modjuls

Use liquid E028 for patients who need to take product away from home or who dislike the taste of powdered E028

Short bowel syndrome, intractable malabsorption, inflammatory bowel disease, bowel fistulae.

To be prescribed by specialist metabolic centres only in accordance with NICE HSTG 5 and NHS England Commissioning criteria. 

Approved specialist adult metabolic centres are:
„h Addenbrookes
„h University Hospital Birmingham
„h Salford Royal
„h UCLH
„h Royal Free Hospital

In accordance with NICE TA

 When used with oral hyperglycaemics in patients with Type 2 Diabetes
 
  When used with insulin in patients with Type 2 Diabetes

Ointment, emulsifying wax 30%, white soft paraffin 50%, liquid paraffin 20%

Excipients include cetostearyl alcohol

Self Care Medicine - to be purchased when part of routine skin care in the absence of a moderate to severe skin condition.

Pre-thickened feed for use in severe gastro-oesophageal reflux. 

Generally use as a second choice to 1.5kcal/ml sip feeds as not nutritionally complete. However these supplements do provide more calories per ml approx. 600kcal in 250ml so useful for those with very high calorie needs (when reconstituted with whole milk) e.g. CF Patients

NICE CG32 (Feb 2006) Nutrition support in adults www.nice.org.uk/page.aspx?o=cg032niceguideline

Should be prescribed only after nutrition screening has taken place using a validated tool e.g. MUST (Malnutrition Universal Screening Tool)

Adult sip feeds containing 1kcal/ml (Fresubin Original, Ensure, Fortimel, Clinutren ISO) should not be prescribed as they are less cost effective compared to 1.5kcal/ml sip feeds

NICE CG32 Nutrition support in adults

Should be prescribed only after nutrition screening has taken place using a validated tool e.g. MUST (Malnutrition Universal Screening Tool) 

Restrict use to those patients with bowel problems as slightly more expensive than 1.5kcal.ml sips without fibre.

NICE CG32 (Feb 2006) Nutrition support in adults www.nice.org.uk/page.aspx?o=cg032niceguideline

Should be prescribed only after nutrition screening has taken place using a validated tool e.g. MUST (Malnutrition Universal Screening Tool)

Adult sip feeds containing 1kcal/ml (Fresubin Original, Ensure, Fortimel, Clinutren ISO) should not be prescribed as they are less cost effective compared to 1.5kcal/ml sip feeds

Calories are based on a sachet made up with 200ml of full cream milk and contains approx 385 kcals.

If patient likes milky drinks, prescribe as a supplement to diet 1-2 servings/day.

Not suitable for patients with cow's milk intolerance or galactosaemia.

Not nutritionally complete.

If patient dislikes milk drinks, choose from the juice style supplements instead.

Cream, yellow soft paraffin 15%, liquid paraffin 10%, emulsifying wax 5%
Excipients include cetostearyl alcohol, chlorocresol

Ointment, emulsifying wax 30%, yellow soft paraffin 30%, liquid paraffin 40%
Excipients include cetostearyl alcohol

Not stocked at RBCH: use Hydromol ointment

Self Care Medicine - to be purchased when part of routine skin care in the absence of a moderate to severe skin condition.

Capsules.

• For use in Barrett's oesophagus only.

GPs should consider discontinuing PPIs in patient with unexplained eGFR decline or substituting them with ranitidine if indicated.

Such patients should be referred for specialist advice as per CKD NICE guidance i.e.

• eGFR less than 30 ml/min/1.73m2
• sustained decrease in eGFR of 25% or more within 12 months
• sustained decrease in eGFR of 15 ml/min/1.73m2 or more within 12 months

Alternatively, patients with AKI as defined in the AKI NICE guidance should be discussed with a nephrologist if interstitial nephritis is suspected, as soon as it is possible i.e. within 24 hours.�

All products should be prescribed by brand. Biosimilar should be used where possible.

 Commissioned by CCG for:

• Rheumatoid arthritis in accordance with NICE TA 375 and local pathway.
• Ankylosing spondylitis in accordance with NICE TA383 and local pathway
• Plaque psoriasis in accordance with NICE TA103
• Psoriatic arthritis in accordance with NICE TA199 and local pathway

 Commissioned by NHS England for:

• Juvenile idiopathic arthritis in line with NICE TA373.
• Paediatric patients in line with adult NICE TAs.

  DCHFT renal consultants only.

Commissioned by NHS England in line with NICE TA448 for treating secondary hyperparathyroidism via specialist centres only.

Treatment must have prior approval on Blueteq^®.

Commissioned by NHS England in line with NICE TA recommendations.

Restrict to where moderate to severe skin condition requires it

Lotion, coal tar solution 5% in an emollient basis

Excipients include hydroxybenzoates (parabens)

Self Care Medicine

RBCH & PHT: Approved as a treatment option for patients with recurrent C. difficile infections that have failed to respond to antibiotics and other treatments on recommendation of Consultant Microbiologist and Gastroenterologist. 

For the management of hyperuricaemia in people with gout, in accordance with NICE TA 164 as a secondline treatment to allopurinol

Please ensure all prescribing is by brand to ensure matrix patches are issued to patients. Currently, the most cost-effective matrix patch is: Matrifen.  

Pain team/palliative care initiation, where morphine is contra-indicated or not tolerated or where there is specific need for a non-oral route. For non-cancer pain, 75mcg/hour should be the maximum dose, if ineffective other causes for lack of response should be considered. 

NB: fentanyl reservoir patches are non-formulary due to increased risk of abuse and diversion.

Choice should be based on selecting the most cost-effective option.

alginate with glucose oxidase and lactoperoxidase, for moderately to heavily exuding wounds,