GREATER GLASGOw AND CLYDE FORmULARY - NHS Greater ...

2009The Greater Glasgowand Clyde FormularyThird editionAugust 2009

IntroductionGastro-intestinal system1Cardiovascular system2Respiratory system3Central nervous system4Infections5Endocrine system6Obstetrics, gynaecology and urinary-tract disorders7Malignant disease and immunosuppression8Nutrition and blood9Musculoskeletal and joint diseases10Eye11Ear, nose and oropharynx12Skin13Total Formulary medicinesIndex

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Third edition August 2009 3IntroductionBackgroundThe British National Formulary (BNF) contains a comprehensive list ofmedicines. The NHS Greater Glasgow and Clyde (NHSGGC) Formulary is alimited list of medicines approved for local use in hospitals and primarycare. The choice of Formulary medicines has been made on the basis ofclinical effectiveness, cost-effectiveness, comparative safety and patientacceptability. The NHSGGC Formulary covers all prescribers.Structure of the NHSGGC FormularyMany of the medicines in the Formulary are more suitable for use by and onthe recommendation of specialists, so in order to help the generalist prescriberchoose the appropriate medicine, a two-tier Formulary system hasbeen adopted, where the Preferred List is a subset of the Total Formulary:Preferred List: This is defined as: A Preferred List of cost-effective Formularymedicines covering most common conditions and which are appropriatefor initiation in general practice and by those prescribing outwiththeir specialty areas. The Preferred List consists of approximately 350medicines, and in many cases where there are several drugs in a class, thefavoured first line agent is highlighted. The Preferred List is printed on anannual basis.Total Formulary: All other Formulary medicines, including those that arenot included in the Preferred List are included in the Total Formulary.(Printed annually as an appendix to the Preferred List.)All other medicines including new medicines not yet considered by theSMC and Area Drug and Therapeutics Committee (ADTC) are non-Formulary.Using the FormularyPreferred List medicines are generally presented according to the BNF classification.The vast majority of entries are based on generic name, whichshould be used in most cases of prescribing, with exceptions noted in theprescribing notes of the Formulary entry. For most medicines, formulationsand strengths of preparations have been omitted to allow flexibility inprescribing, except when a particular formulation is not approved or whena particular preparation is considered the most cost-effective.Each entry contains relevant Formulary information about the medicine,such as restrictions on use, place in therapy or prescribing guidance notes.In most cases, adult doses are included in the Formulary entry. The BNFshould be consulted for further product information, with reference to theSummary of Product Characteristics if required (www.medicines.org.uk).

8 The Greater Glasgow and Clyde FormularyMr D Thomson, Deputy Lead, Community Pharmacy Development, Queens ParkHouse, Victoria InfirmaryMr J Wallace, Lead Directorate Pharmacist, Royal Hospital for Sick ChildrenDr M Walters, Clinical Pharmacologist, Western InfirmaryMrs J Watt, Principal Pharmacist, Area Medicines Information Centre, Glasgow RoyalInfirmaryDr B West, Medical Secretary, General Practitioner Sub-Committee, GlasgowProfessor D Wray, Clinical Director, Glasgow Dental Hospital & SchoolAttendeesDr I Wallace, Medical Director, Royal Hospital for Sick ChildrenObserversDr P Beardon, Pharmacy Advisor, Dumfries & Galloway NHS BoardMs J Davison, Principal Pharmacist, Stirling Royal InfirmaryMs C Kerr, Senior Prescribing Advisor, Ayrshire & ArranFormulary and New Drugs Sub-committeeDr J Gravil (Co-chairperson), Consultant Physician, Royal Alexandra HospitalDr G J A MacPhee (Co-chairperson), Consultant Physician, Southern General HospitalDr J Burns, Consultant Geriatrician, Glasgow Royal InfirmaryMs J Camp, Non-medical Prescribing Lead, Queens Park House, Victoria InfirmaryMrs A Campbell, Public Health Pharmacist, NHSGGCDr S Davidson, Consultant Physician, Southern General HospitalMr R Foot, Lead Pharmacist, Formulary and Prescribing Interface, Glasgow RoyalInfirmaryDr G Forrest, General Practitioner, JohnstoneDr A Power, Medical Prescribing Advisor, Queens Park House, Victoria InfirmaryMrs J Watt, Principal Pharmacist, Area Medicines Information Centre, Glasgow RoyalInfirmaryMedicines Utilisation and Prescribing Education Sub-committeeDr K Beard, (Chairperson) Hospital Prescribing Advisor to NHSGGC, Victoria InfirmaryDr D Brown, Consultant Psychiatrist, Community Elderly TeamMrs A Campbell, Public Health Pharmacist, NHSGGCMr R Foot, Formulary Development Pharmacist, Glasgow Royal InfirmaryMs A K Greschner, Formulary Support Pharmacist, Glasgow Royal InfirmaryDr H MacDonald, General Practitioner, Port GlasgowMs L McGovern, Specialist in Pharmaceutical Public Health, NHSGGCDr D Marshall, Consultant Rheumatologist, Inverclyde Royal HospitalMs E McIvor, Medicines Education Pharmacist, Glasgow Royal InfirmaryMr P Mulholland, Senior Pharmacy Manager, Southern General HospitalDr K O’Neill, General Practitioner, GlasgowMs F Qureshi, Senior Medicines Information Pharmacist, Prescribing Guidance,Southern General Hospital

Third edition August 2009 9Mrs Y Semple, Principal Pharmacist, Clinical Effectiveness, Glasgow Royal InfirmaryDr G Simpson, Consultant, Care of the Elderly, Royal Alexandra HospitalMs J Stirton, Lead Clinical Pharmacist, Stobhill HospitalMr J Stuart, Head of Nursing (Regional Services), Southern General HospitalMrs J Watt, Principal Pharmacist, Area Medicines Information Centre, Glasgow RoyalInfirmaryNon-medical Prescribing Sub-committeeMs J Camp (Chairperson), Non-medical Prescribing Lead, Queens Park House,Victoria InfirmaryMr A Best, Podiatrist, NHSGGCMrs C Byrne, Lead Pharmacist Policies and Practice, Queens Park House, VictoriaInfirmaryMs B Campbell, Primary Care Support NurseMs E Clark, Senior Nurse, Mental Health PartnershipMs D Connolly, Practice NurseMr M Cooper, A&E Nurse PractitionerMs N Downes, Lead for Prescribing and Clinical Pharmacy, South West Glasgow CHCPMs L Forster, Head of Nursing, Sandyford InitiativeDr M Haughney, General Practitioner, NHSGGCMs M McLoone, Clinical Effectiveness Administrator, NHSGGCMs L McGovern, Specialist in Pharmaceutical Public Health, NHSGGCMs C McKay, Directorate Nurse Lead, Surgery and Anaesthetics DirectorateDr P Munro, A&E Consultant, Southern General HospitalMrs M Ryan, Lead for Prescribing Governance and Development, Queens Park House,Victoria InfirmaryMr J Stuart, Head of Nursing (Regional Services), Southern General HospitalMs L Watret, Tissue Viability Nurse, Community CareSafer Use of Medicines Sub-committeeMr A Crawford (Chairperson), Head of Clinical Governance, Southern General HospitalDr G Gordon, Consultant, Surgery and Anaesthetics, Victoria InfirmaryDr R Hardman, General Practitioner, GlasgowMs K Hazard, PA, Regional Services, Southern General HospitalMs L Langan, Clinical Risk Manager, Royal Hospital for Sick ChildrenMr A Maclaren, Lead Pharmacist for Clinical Governance, Victoria InfirmaryMs C McKay, Clinical Co-ordinator, Surgery and Anaesthetics, Royal AlexandraHospitalMs C McLaughlin, Lead Pharmacist, Risk Management, Victoria InfirmaryMs J McQueen, Clinical Risk Manager, Glasgow Royal InfirmaryMrs F Needleman, Lead Pharmacist Medication Safety, Southern General HospitalMrs L Rankine, Risk Management Pharmacist, Glasgow Royal InfirmaryDr. I Reeves, Consultant, Medicines for the Elderly, Southern General HospitalMr S Nicol, Lead Pharmacist, Preparative Services, Victoria Infirmary

10 The Greater Glasgow and Clyde FormularyDr E Spilg, Consultant Geriatrician, Gartnavel General HospitalMr J Stuart, Head of Nursing, Regional Services Directorate, Southern GeneralHospitalMr A Walker, Lead Clinical Pharmacist, Mental Health South Clyde, Dykebar HospitalDr I Wallace, Medical Director, Royal Hospital for Sick ChildrenMr F Westerduin, A&E Consultant, Royal Alexandra HospitalCommunications Sub-committeeMrs A Thompson (Chairperson), Lead Pharmacist Controlled Drugs Governance,Queens Park House, Victoria InfirmaryMrs A Campbell, Public Health Pharmacist, NHSGGCDr D Gaffney, General Practitioner, GlasgowMrs S Galbraith, Prescribing Adviser, Queens Park House, Victoria InfirmaryMs A K Greschner, Formulary Support Pharmacist, Glasgow Royal InfirmaryMs V Holloway, Nurse Prescriber, Western InfirmaryDr H Hopkinson, Consultant Physician, Victoria InfirmaryMrs P MacIntyre, Lead Clinical Pharmacist, West Dunbartonshire CHPMrs E McIvor, Medicines Education Pharmacist, Glasgow Royal InfirmaryMs A McMaster, Nurse Prescriber, Mansionhouse Unit, Victoria InfirmaryDr A Power, Medical Prescribing Advisor, Queens Park House, Victoria InfirmaryMr I Speirits, Prescribing Support Pharmacist, East Glasgow CHCPMrs J Watt, Principal Pharmacist, Area Medicines Information Centre, Glasgow RoyalInfirmaryAntimicrobial Utilisation Sub-committeeMr S Bryson (Chairman), Pharmaceutical Advisor, NHSGGCDr E Biggs, Consultant Microbiologist, Inverclyde Royal HospitalDr S Binning, ICU & Anaesthetics Specialist, Glasgow Royal InfirmaryDr R Boulton-Jones, Consultant Physician, Gastroenterology, Southern GeneralHospitalDr A Bowman, Consultant Physician, Medicines for the Elderly, Stobhill HospitalDr M Cotton, Consultant Physician, Acute & Respiratory Medicine, Glasgow RoyalInfirmaryMrs S Galbraith, Primary Care Prescribing Advisor, Queens Park House, VictoriaInfirmaryMs Y Gourley, Lead Pharmacist, Antimicrobials,Gartnavel General HospitalMs R Hague, Consultant in Paediatric Infectious Diseases & Immunology, RoyalHospital for Sick ChildrenMr B Jones, Microbiologist, Glasgow Royal InfirmaryMr B Jones, Consultant Surgeon, Orthopaedics, Glasgow Royal InfirmaryDr A M Karcher, Consultant Microbiologist, Western Infirmary GlasgowMs L McGovern, Specialist in Pharmaceutical Public Health, NHSGGCMs C McLaughlin, Lead Pharmacist Risk Management, Victoria InfirmaryMs S McNamee, Nurse Consultant, Infection Control, NHSGGC

Third edition August 2009 11Ms L Meikle, Head of Nursing, Surgery & Anaesthetics Directorate, Southern GeneralHospitalMs A Parker, Consultant Haematologist, West of Scotland Cancer CentreDr A Seaton, Consultant Physician, Infectious Diseases, Gartnavel General HospitalMrs Y Semple, Principle Pharmacist, Clinical Effectiveness, Glasgow Royal InfirmaryMr J Stuart, Head of Nursing, Regional Services Directorate, Southern GeneralHospitalMr T Walsh, Infection Control Manager, NHSGGCDr B Weinhardt, Consultant Microbiologist, Royal Alexandra HospitalDr S Whitehead, Consultant Microbiologist, Southern General HospitalMrs M Whittle, Nominee of the (PPSU) Pharmaceutical Care Committee, GlasgowRoyal InfirmaryObserversDr K Beard, Hospital Prescribing Advisor to NHSGGC, Victoria InfirmaryMs A Eastaway, Team Leader, AMC Resistance Surveillance, Health ProtectionScotlandDr C Williams, Consultant Microbiologist, Royal Hospital for Sick Children

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Third edition August 2009 131 Gastro-intestinal system1.1 Dyspepsia and gastro-oesophageal reflux diseaseSIGN 68 and NICE CG17 provides guidance on the management of dyspepsiain adults in the community.1.1.1 AntacidsA mixture of aluminium hydroxide and magnesium hydroxide balances thetendency of aluminium to constipate against that of magnesium to causediarrhoea.Co-magaldroxDose: 10-20ml after meals and at bedtime, or when required.1.1.2 Compound alginates and compound indigestion preparationsFor adults:Peptac ®Peptac ® has the same active ingredient as Gaviscon ® Liquid, whichhas been discontinued. It is high in sodium and should be used withcare when salt restriction is important (heart disease, hepatic or renalimpairment, pregnancy).Dose: 10-20ml after meals and at bedtime.For infants:Gaviscon ® Infant SachetsOne dose is equivalent to half a dual-sachet.Dose: (infant >4.5 kg – 2 years) 2 doses mixed with feeds when required(max six times in 24 hours).11.2 Antispasmodics and other drugs altering gut motilityOther than in the early phase of irritable bowel disease, the place in therapyof antispasmodics is questionable. Reassurance, diet, fluids, exercise,bulking agents and lifestyle modifications achieve best results.MebeverineRestrictions: Excludes MR preparations.Dose: 135mg three times a day 20-30 minutes before meals.DomperidoneSee section 4.6 for details.

14 The Greater Glasgow and Clyde Formulary11.3 Ulcer-healing drugsHelicobacter pylori infectionOne week triple therapy regimens containing a proton pump inhibitor andtwo antibiotics are recommended for the eradication of H pylori. Recommendedregimens for NHSGGC are shown below.Triple therapy regimen 1: Continue for one week (14 days in relapse)Omeprazole capsulesDose: 20mg twice dailyor Lansoprazole capsulesDose: 30mg twice dailyClarithromycinDose: 500mg twice dailyAmoxicillinDose: 1000mg twice dailyor for penicillin allergic patients:TetracyclineDose: 500mg twice dailyTriple therapy regimen 2: Continue for one week (14 days in relapse)Omeprazole capsulesDose: 20mg twice dailyor Lansoprazole capsulesDose: 30mg twice dailyMetronidazoleDose: 400mg twice dailyAmoxicillinDose: 1000mg twice dailyor for penicillin allergic patients:TetracyclineDose: 500mg twice dailyPractice point: In patients with active ulcers, continue the proton pumpinhibitor alone for one further week in duodenal ulcer or three weeksin gastric ulcer. Patient education is vital to maximise the likelihood ofsuccess. Prescribers and pharmacists should ensure that patients arecounselled appropriately.1.3.1 H2-receptor antagonistsRanitidineDose: Orally, 150mg twice a day or 300mg at night. See BNF for furtherprescribing information.

Third edition August 2009 171.9 Drugs affecting intestinal secretions1.9.1 Drugs affecting biliary composition and flowS Ursodeoxycholic acidDose: Dissolution of gallstones, 8-12mg/kg daily as a single dose atbedtime (see BNF for further details). Primary biliary cirrhosis, 10-15mg/kg daily in two to four divided doses.1.9.2 Bile acid sequestrantsColestyramine sachets (Cholestyramine)Dose: Pruritis 4-8g daily (see BNF for other indications).1.9.4 PancreatinThere is great variation in patient response to these products. Fat malabsorptionhas the most bearing on the clinical picture. Theoretically,60,000 BPU of lipase should enable a completely achylic patient to digestthe fat in a normal meal; the quantity of protease and amylase that comesfrom this dose of lipase is more than sufficient to digest the protein andcarbohydrate.For details of the CSM warning for use in children, refer to the BNF or BNFfor Children.Creon ®All strengths.Dose: See BNF for dosing information.1

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Third edition August 2009 192 Cardiovascular system2.1 Positive inotropic drugs2.1.1 Cardiac glycosidesThe management of persistent atrial fibrillation is the subject of aNHSGGC guideline (available on the ADTC home page www.ggcformulary.scot.nhs.uk or on the Clinical Info section of StaffNet www.staffnet.ggc.scot.nhs.uk/Clinical+Info/default.htm).DigoxinDose: Maintenance dose 62.5 - 500 micrograms depending on renalfunction and response.22.2 Diuretics2.2.1 Thiazide and related diureticsThe choice of therapeutic class for the management of hypertensionis dependent on individual patient parameters. See the NHSGGCguidelines for the Management of Hypertension for details (available onthe ADTC home page www.ggcformulary.scot.nhs.uk or on the ClinicalInfo section of StaffNet www.staffnet.ggc.scot.nhs.uk/Clinical+Info/default.htm).Bendroflumethiazide (Bendrofluazide)Dose: Hypertension, 2.5mg daily.2.2.2 Loop diureticsFurosemide (Frusemide)Dose: (Oral) Initially 40mg once daily. See BNF for further dosinginformation.2.2.3 Potassium-sparing diuretics and aldosterone antagonistsPotassium-sparing diureticsAmilorideDose: 5-10mg daily (usually morning).Aldosterone antagonistsSpironolactoneUsed in heart failure and in Conn’s syndrome or decompensated liverdiseases (ascites). Combination with ACE inhibitors, angiotensin-IIreceptor antagonists (AIIRAs) or potassium supplements may result inhyperkalaemia (monitor).Dose: Symptomatic heart failure despite optimal treatment with anACE inhibitor or AIIRA and a beta-blocker, 25mg daily. See NHSGGCguidelines on the management of left ventricular systolic dysfunctionfor further details. For doses for other indications, please refer to BNF.

20 The Greater Glasgow and Clyde Formulary22.4 Beta-adrenoceptor blocking drugsThe CSM has advised that beta-blockers, including those considered to becardioselective, should not be given to patients with a history of asthma orbronchospasm. However, in rare situations where there is no alternative acardioselective beta-blocker may be given to these patients with extremecaution and under specialist supervision.Combination products containing a beta-blocker and a diuretic are notrecommended as fixed dose preparations lack flexibility and may not beavailable in dose combinations appropriate for individual patients.Beta-blockers used for angina and hypertensionAtenololDose: Hypertension, 25-50mg daily. Angina, 100mg daily (1 or 2 divideddoses).Beta-blockers used for heart failure1 BisoprololFirst line beta-blocker for patients with heart failure.Restrictions: The initiation and initial supervision of bisoprololin confirmed cases of chronic cardiac failure is restricted toprescribers working with specialised heart failure teams in line withagreed protocols.Dose: Stable moderate to severe heart failure, titrated from 1.25mgdaily up to 10mg daily (See BNF or local protocols for titration details).CarvedilolRestrictions: The initiation and initial supervision of carvedilolin confirmed cases of chronic cardiac failure is restricted toprescribers working with specialised heart failure teams in line withagreed protocols. Not approved for hypertension or angina.Dose: See BNF for full dosing information.Beta-blockers used primarily for other indicationsPropranololOnly beta-blocker licensed for anxiety with symptoms such aspalpitation, sweating and tremor. It is not included in the Preferred Listfor hypertension, angina and heart failure.Dose: See BNF for full dosing information.2.5 Hypertension and heart failureThe choice of therapeutic class for the management of hypertension isdependent on individual patient parameters. See the NHSGGC Guidelinesfor the Management of Hypertension for details (available on theADTC home page www.ggcformulary.scot.nhs.uk). A NHSGGC guidelinefor the management of left ventricular systolic dysfunction (LVSD) alsoexists (available on the ADTC home page www.ggcformulary.scot.nhs.uk

Third edition August 2009 21or on the Clinical Info section of StaffNet www.staffnet.ggc.scot.nhs.uk/Clinical+Info/default.htm).2.5.4 Alpha-adrenoceptor blocking drugsDoxazosinRestrictions: Excluding MR preparations.Dose: Hypertension, 1mg daily, increased after 1-2 weeks to 2mg daily,and then 4mg daily if necessary. See BNF for further dosing information.22.5.5 Drugs affecting the renin-angiotensin systemThe choice of therapeutic class for the management of hypertensionis dependent on individual patient parameters. See the NHSGGCGuidelines for the Management of Hypertension for details (available onthe ADTC home page www.ggcformulary.scot.nhs.uk or on the ClinicalInfo section of StaffNet www.staffnet.ggc.scot.nhs.uk/Clinical+Info/default.htm).Any ACE inhibitor or Angiotensin-II receptor antagonist may cause deteriorationin renal function. Urea and electrolytes should be checked beforeinitiation and within 7 days of commencing therapy or a change in dose.2.5.5.1 Angiotensin-converting enzyme inhibitorsRamiprilRestrictions: Excluding combination products.Dose: Hypertension, 1.25mg daily increased every 1-2 weeks to a usualmaintenance dose of 2.5-5mg daily.Heart failure, initially 1.25mg daily (under supervision), increasedincrementally every 1-2 weeks if tolerated up to 5mg BD (see NHSGGCguidelines on the management of left ventricular systolic dysfunction(LVSD) for further details).LisinoprilRestrictions: Excluding combination products.Dose: Hypertension, initially 10mg daily (see BNF for details) with ausual maintenance dose of 20mg daily.Heart failure, initially 2.5mg daily (under supervision), increase incrementallyup to 30-35mg daily or maximum tolerated dose (see NHSGGLVSD guidelines for further information).2.5.5.2 Angiotensin-II receptor antagonistsThere are no indications where angiotensin-II receptor antagonists (oftenreferred to as AIIRAs or ARBs) should be used as first line therapy andthey should only be used as second line agents in patients who develop asignificant cough with ACE inhibitors. Angiotensin-II receptor antagonistsare generally more expensive than ACE inhibitors.

22 The Greater Glasgow and Clyde Formulary2CandesartanRestrictions: Candesartan should only be used as a second line agentin patients who develop a significant cough with ACE inhibitors. Use asadd-on therapy with ACE inhibitors for heart failure and left ventricularsystolic dysfunction is restricted to initiation by specialists.Dose: 4-16mg daily (see BNF for details). For use in heart failure, referto the NHSGGC guidelines on left ventricular systolic dysfunction.LosartanRestrictions: Losartan should only be used as a second line agent inpatients who develop a significant cough with ACE inhibitors.Dose: 50-100mg daily (see BNF for details).For use in heart failure, refer to the NHSGGC guidelines on leftventricular systolic dysfunction.2.6 Nitrates, calcium-channel blockers, and other antianginal drugs2.6.1 NitratesLong acting nitratesIsosorbide mononitrate (standard-release tablets)Restrictions: Modified-release preparations, which are restricted topatients who fail to comply with standard-release tablets, can be foundin the Total Formulary.Isosorbide mononitrate should be prescribed as asymmetric dosesof standard-release products (e.g. 20mg at 8am and 20mg at 2pm).Nitrate-free periods (usually at night) are recommended to avoid thedevelopment of tolerance.Dose: 10-40mg twice daily.Short acting nitratesGlyceryl trinitrateThe patient should be fully aware of how to use a GTN sprayprophylactically before angina-inducing activities. If symptoms persistfollowing two uses of the spray within a 15 minute period, the patientshould seek medical help.Dose: Sublingual spray, 1-2 doses under the tongue when required forchest pain.2.6.2 Calcium-channel blockersThe choice of therapeutic class for the management of hypertension isdependent on individual patient parameters. See the NHSGGC Guidelinesfor the Management of Hypertension for details (available on the ADTChome page www.ggcformulary.scot.nhs.uk or on the Clinical Info sectionof StaffNet www.staffnet.ggc.scot.nhs.uk/Clinical+Info/default.htm).Calcium-channel blockers differ in their possible sites of action; thereforetheir therapeutic effects are disparate, with much greater variation than

Third edition August 2009 23those of beta-blockers. There are important differences between verapamil/diltiazemand the dihydropyridine group of nifedipine/amlodipine.Within the dihydropyridine group, the efficacy and side effect profiles aresimilar, except that amlodipine has a much longer half-life.Non-rate limiting calcium-channel blockersAmlodipineRestrictions: Excludes combination productsDose: 5-10mg daily.NifedipinePrescribe by brand name.Restrictions: Short-acting formulations are not recommended forangina and hypertension.Dose: 30-60mg daily (based on Adalat LA ® ). For further dosing information,see BNF.Rate limiting calcium-channel blockersDiltiazemPrescribe by brand name. Diltiazem should not be prescribedin conjunction with beta-blockers because of the risk of severebradycardia.Dose: See BNF for dosing information of products.22.8 Anticoagulants2.8.2 Oral anticoagulantsWarfarinDose: Dosing should be adjusted to maintain INR within target basedon reason for anticoagulation.2.9 Antiplatelet drugsSee the NHSGGC Antiplatelet Guidelines for appropriate use of the followingmedicines (available on the ADTC website: www.ggcformulary.scot.nhs.uk or on the Clinical Info section of StaffNet www.staffnet.ggc.scot.nhs.uk/Clinical+Info/default.htm).1 Aspirin dispersibleAspirin enteric coated (EC) is not included in the Formulary and shouldnot be used as the formulation does not reduce GI symptoms.If the patient experiences new gastro-intestinal symptoms, considerother contributory factors (e.g. alcohol intake or NSAID use) and thenconsider gastro-protection (e.g. omeprazole or lansoprazole).Dose: 75-150mg daily (See NHSGGC Antiplatelet Guidelines).

24 The Greater Glasgow and Clyde Formulary2ClopidogrelRestrictions: Restricted to patients contraindicated to aspirin orintolerant of aspirin despite the addition of a PPI.Use in combination with aspirin post ST segment elevation acutemyocardial infarction (STEMI) is restricted to specialist initiation forduration of 4 weeks.For prevention of atherothrombotic events in acute coronary syndrome,clopidogrel, in combination with aspirin, should be used in accordancewith the current NHSGGC Antiplatelet Guideline for the appropriateduration.Dose: 75mg daily. See BNF for full dosing information.Dipyridamole MRRestrictions: Dipyridamole retard is restricted to patients requiringstroke/TIA secondary prevention where an event has occurred despitetreatment with aspirin.The addition of dipyridamole to aspirin reduces recurrent stroke and TIAbut not the risk of other vascular events. Refer to NHSGGC Guideline forSecondary Prevention for Stroke and TIA patients.Dose: 200mg twice daily (retard preparations).2.11 Antifibrinolytic drugs and haemostaticsTranexamic acidDose: Menorrhagia, 1g three times a day for up to four days. See BNFfor full dosing information.2.12 Lipid-regulating drugsSee NHSGGC Guidelines for the Secondary Prevention of Coronary HeartDisease and Stroke. They are available in the guideline store on the ADTCwebsite: www.ggcformulary.scot.nhs.uk.Statins1 SimvastatinDose: Recommended guideline starting dose, 40mg at night. Cautionin renal impairment (see BNF for details).AtorvastatinRestrictions: Atorvastatin 80mg is only to be initiated by consultantsin patients who have definite coronary artery disease and presentwith an acute coronary syndrome (confirmed by elevated troponinconcentration). In patients who fail to meet goals for cholesterolreduction on simvastatin 40mg, the dose of atorvastatin may be uptitratedup to 80mg (see below).In preference to increasing the dose of simvastatin, patients should beswitched to an appropriate dose of atorvastatin, 20mg followed by uptitrationif required, through 40mg to 80mg.

Third edition August 2009 25Use in children aged over 10 years is restricted to initiation bypaediatricians or physicians specialising in the management of lipiddisorders.Dose: 20-80mg at night (depending on indication and cholesterollevels).Other lipid-regulating drugsS EzetimibeRestrictions: Excluding combination preparations.Restricted to initiation by specialists when cholesterol targets are notreached on the maximum tolerated and optimised statin therapy.Dose: 10mg daily.2

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Third edition August 2009 273 Respiratory systemThe British Thoracic Society and the Scottish Intercollegiate GuidelinesNetwork jointly produced a British Guideline on the Management ofAsthma in May 2004, with an update in November 2005 (SIGN 63). Theguideline is due for revision.CFC-free containing medicines will be phased out in the near future withinhaled medicines being reformulated in hydrofluoroalkane. Where possible,CFC-free formulations should be prescribed for new patients.The choice of device should be based on patient ability and lifestyle.Metered dose inhalers (MDIs) are the most popular devices and are consideredthe most cost-effective. Patients who experience problems usingtheir MDI should either try using it in conjunction with a spacer device orchanging to a breath activated MDI or dry powder device. When changingdevices, differences in recommended doses and inhaler technique make itadvisable to adjust the dose on an individual basis to control symptoms.33.1 Bronchodilators3.1.1 Adrenoceptor agonists3.1.1.1 Selective Beta 2 agonistsShort-acting beta 2 agonistsSalbutamolSalbutamol inhalers generally should not be prescribed to be usedregularly, but should be used on a when required basis.Dose: Inhaled, 200 micrograms (2 doses based on 100 microgramsMDI) when required. See BNF for full dosing information.TerbutalineDose: Inhaled, 500 micrograms (1 dose) up to four times daily (basedon Turbohaler ® ). See BNF for full dosing information.Long-acting beta 2 agonistsSalmeterolDose: Inhaled, 50 micrograms twice daily.FormoterolAt step 3 in the BTS/SIGN guidelines inhaled long-acting beta 2 agonistsare recommended as first line add-on therapy.Dose: Dependent on device. See BNF for full dosing information.

28 The Greater Glasgow and Clyde Formulary33.1.2 Anticholinergic bronchodilatorsIpratropium bromideDose: MDI inhaler, 20-40 micrograms three or four times daily.TiotropiumUsed in the maintenance treatment of chronic obstructive pulmonarydisease (COPD).Restrictions: Spiriva-Respimat ® is restricted to patients with poormanual dexterity who have difficulty using the Handihaler ® device.Dose: Handihaler ® device, 18 micrograms daily. Respimat ® device,5 micrograms daily.3.1.3 TheophyllineTheophyllinePrescribe by brand name.Dose: See BNF for dosing information.AminophyllinePrescribe by brand name.Dose: Oral, 225-450mg twice daily. See BNF for further dosing information.3.2 CorticosteroidsPatients receiving ≥1000 micrograms of beclometasone daily (or equivalente.g. fluticasone 500 micrograms or budesonide 800 micrograms)should be issued with a steroid card.1 Beclometasone (beclomethasone)Clenil Modulite ® is the preferred CFC-free aerosol device.Different brands of beclometasone CFC-free inhalers are not equipotentand should be prescribed by brand name for safety reasons.Dose: See BNF for full dosing information.BudesonideRestrictions: Budesonide Respules ® are restricted to hospitalinpatient treatment of croup only.Dose: See BNF for dosing information.FluticasoneFluticasone provides equal clinical activity to regular beclometasoneand budesonide at half the dosage. Nebuliser solution remains non-Formulary.Dose: See BNF for dosing information.Combination preparationsPatients on combination inhalers or high dose inhaled steroids, shouldbe reviewed regularly and stepped down if appropriate. Patients receiving≥1000 micrograms of beclometasone daily (or equivalent e.g. fluticasone500 micrograms or budesonide 800 micrograms) should be issued with asteroid card.

Third edition August 2009 29Budesonide and formoterolRestrictions: restricted for use in patients on step 3 or above of theBTS/SIGN asthma guidelines or for patients with COPD in accordance tocurrent NHSGGC COPD Guidelines.Dose: See BNF or product literature for dosing information.Fluticasone and salmeterolRestrictions: Restricted for use in patients on step 3 or above of theBTS/SIGN asthma guidelines or for patients with COPD in accordance tocurrent NHSGGC COPD Guidelines.Dose: See BNF for dosing information.Beclometasone and formoterolRestrictions: restricted for use in patients on step 3 or above of theBTS/SIGN asthma guidelines.Dose: See BNF or product literature for dosing information. Beclometasonedose may not be equipotent to other beclometasone containinginhalers.33.3 Cromoglicate and related therapy and leukotriene receptorantagonists3.3.2 Leukotriene receptor antagonistsMontelukastRestrictions: Restricted to clinicians experienced in treating asthma.Use for seasonal allergic rhinitis is non-Formulary. Use in asthma inchildren aged 2 to 14 years is restricted to initiation by specialists inpaediatric asthma care.Dose: 10mg in the evening.3.4 Antihistamines, hyposensitisation and allergic emergencies3.4.1 AntihistaminesNon-sedating antihistamines1 CetirizineDose: 10mg daily.LoratadineDose: 10mg daily.Sedating antihistaminesChlorphenamineDose: 4mg every four to six hours, max 24mg daily.

30 The Greater Glasgow and Clyde Formulary3.4.3 Allergic emergenciesAdrenalineIncludes autoinjector devices.Dose: See BNF for dosing information.33.7 MucolyticsCarbocisteineDose: Initially 750mg three times daily, then 1.5g daily in divideddoses as condition improves.3.9 Cough preparationsSugar-free cough preparations should be prescribed where possible.3.9.1 Cough suppressantsPholcodine linctusDose: 5-10ml three to four times daily.3.9.2 Expectorant and demulcent cough preparationsSimple linctus (Citric acid)Dose: 5ml three to four times daily.

Third edition August 2009 314 Central nervous system4.1 Hypnotics and anxiolytics4.1.1 HypnoticsBefore a hypnotic is prescribed, the cause of the insomnia should beestablished and underlying factors should be addressed and non-drugmanagement, such as sleep hygeine considered. If a hypnotic is essential,it should be prescribed as a the lowest effective dose as a short course(preferably one week) and the choice of agent based on the patient’smedication and medical history and evaluation of the consequences ofsupplying a potential drug of abuse.TemazepamDose: 10-20mg at night.44.1.2 AnxiolyticsDiazepamDose: Anxiety, 2mg three times daily increased if necessary to 15-30mg daily in divided doses.ChlordiazepoxideDose: Anxiety, 10mg three times daily.Alcohol withdrawal, 10-30mg four times daily reduced gradually over7-14 days.4.2 Drugs used in psychoses and related disorders4.2.1 Antipsychotic drugsThe initiation of antipsychotics would usually be under the guidance of aspecialist who may base selection on a wide range of factors.For adult patients 65 years of ageHaloperidolIf haloperidol is not considered appropriate, other antipsychotics fromthe Total Formulary may be considered.Dose: Dependent on indication, see BNF for full prescribing information.

32 The Greater Glasgow and Clyde Formulary4.3 Antidepressant drugsFor drug choice in depression, see the NHSGGC Antidepressant Guideline,available on the ADTC website (www.ggcformulary.scot.nhs.uk).4.3.1 Tricyclic and related antidepressantsLofepramineDose: 140-210mg daily in divided doses.44.3.3 Selective serotonin re-uptake inhibitors1 FluoxetineDose: Depression, 20mg once daily increased after 3 weeks if necessary.Usual dose 20-60mg daily (20-40mg in the elderly).1 CitalopramDose: Depression, 20mg once daily increased if necessary to a maximumof 60mg daily.4.3.4 Other antidepressant drugsMirtazapineRestrictions: Restricted to second line therapy.Dose: Depression, initially 15mg at night increased within 2-4 weeksdepending on response (maximum 45mg daily).4.5 Drugs used in the treatment of obesitySee NICE guidance on the management of obesity (NICE CG43).4.5.1 Anti-obesity drugs acting on the gastro-intestinal tracOrlistatRestrictions: Restricted to use for patients with BMI >30 with relevantco-morbidities and BMI >35 without co-morbidities. Other conditionsfor prescribing should be in accordance with NICE CG43. It shouldbe prescribed only on the advice of the Glasgow and Clyde WeightManagement Service.Dose: 120mg directly before, with or just after main meals (maximum360mg daily).4.5.2 Centrally acting appetite suppressantsSibutramineRestrictions: Restricted to use for patients with BMI >30 with relevantco-morbidities and BMI >35 without co-morbidities. Other conditionsfor prescribing should be in accordance with NICE CG43. It shouldbe prescribed only on the advice of the Glasgow and Clyde WeightManagement Service.Dose: Initially 10mg in the morning, increased to 15mg daily if weightloss at 4 weeks is less than 2kg. See BNF for further dosing information.

Third edition August 2009 334.6 Drugs used in nausea and vertigoAntihistaminesCinnarizineDose: Vestibular disorders, 30mg three times daily.Motion sickness, 30mg two hours before travel then 15mg every eighthours during journey if necessary.Phenothiazines and related drugsProchlorperazineDose: Nausea and vomiting (acute attack), 20mg initially then 10mgafter two hours.Post-operative nausea and vomiting, oral 5-10mg two to three timesdaily.Labyrinthine disorders, 5mg three times daily increased if necessary to30mg daily in divided doses.Domperidone and metoclopramideDomperidoneDose: Oral, 10-20mg three to four times daily.MetoclopramideMetoclopramide causes more frequent extra-pyramidal side effectsthan domperidone and is not indicated in patients less than 20 years ofage except for limited indications when the dose should be determinedon the basis of body weight.Dose: Nausea and vomiting, 10mg three times daily. See BNF for fulldosing information.5HT3 antagonistsS OndansetronRestrictions: In the management of post-operative nausea andvomiting, ondansetron is restricted to use in patients refractory toroutine antiemetics or with a substantial history of post-operativenausea and vomiting.Dose: Dependent of formulation and indication. See BNF for dosinginformation.Other drugs for Ménière’s diseaseBetahistineDose: Initially 16mg three times daily. Maintenance dose 24-48mgdaily in divided doses.4

34 The Greater Glasgow and Clyde Formulary4.7 Analgesics44.7.1 Non-opioid analgesicsAnalgesics such as paracetamol are often much more effective at relievingchronic pain when taken regularly rather than ‘as required’.ParacetamolRestrictions: Dispersible and effervescent formulations are considerablymore expensive and should be restricted to patients with swallowingdifficulties. Their high sodium content (up to 8g daily) exceeds the WHOdaily salt intake recommendation of 6g daily and may compromise thetreatment of hypertension, heart failure and renal diseaseDose: Oral, 1g every four to six hours when required (up to a maximumof 4g in 24 hours). See BNF for children for paediatric doses.IbuprofenSee section 10.1.Co-codamol (8/500 and 30/500 tablets)There is no evidence that the 8/500 strength is any more effective thanparacetamol alone.Restrictions: Dispersible and effervescent formulations are considerablymore expensive and should be restricted to patients with swallowingdifficulties. Their high sodium content (up to 8g daily) exceeds the WHOdaily salt intake recommendation of 6g daily and may compromise thetreatment of hypertension, heart failure and renal disease.Dose: (8/500 or 30/500 strength) 1-2 tablets every four to six hourswhen required (maximum of 8 tablets in 24 hours).4.7.2 Opioid analgesicsCodeine phosphateDose: 30-60mg every four to six hours when required up to a maximumof 240mg in 24 hours.DihydrocodeineRestrictions: Excludes DF118 Forte ® , Remedeine ® , and RemedeineForte ® .Dihydrocodeine is generally not an effective analgesic for postoperativepain except in neurosurgical procedures where NSAIDs arecontraindicated when it avoids undue sedation and confusion whichmight interfere with neurological appraisal.Dose: 30mg every four to six hours when required.MorphineModified-release preparations should be prescribed by brand nameDose: Dependent on indication, route and formulation. See BNF fordosing information.

Third edition August 2009 35OxycodoneModified-release preparations should be prescribed by brand nameRestrictions: Use is restricted to patients in whom morphine isineffective or not tolerated. The injection is restricted to initiation byspecialists in palliative care and oncology for use in patients for whommorphine/diamorphine is ineffective or not tolerated. Oxycodoneinjection is non-Formulary for post-operative use. Excludes thecombination product of oxycodone and naloxone (Targinact ® ).Dose: Oral (normal release), initially 5mg (sometimes lower) every fourto six hours increased if necessary according to severity of pain. SeeBNF for further dosing information.DiamorphineDose: Dependent on indication and route of administration. See BNFfor dosing information.4.7.3 Neuropathic painSee NHSGGC Chronic Pain guidelines (available on the ADTC home pagewww.ggcformulary.scot.nhs.uk).AmitriptylineUse in the treatment of neuropathic pain is an unlicensed indication ofamitriptyline.Dose: Initially 10mg in the evening, increased gradually in accordanceto response and tolerance to 100mg daily (see guidelines for furtherdosing information).CarbamazepineSee NHSGGC primary care pain guidelines.Dose: Neuropathic pain, initially 100mg at night (see guidelines andBNF for further dosing information).GabapentinSee NHSGGC primary care pain guidelines.Dose: Neuropathic pain, initially 100mg three times daily (see guidelinesand BNF for further dosing information).4.7.4 Antimigraine drugs4.7.4.1 Treatment of acute migraineAnalgesicsMigraleve pink ®Migraleve yellow ® is excluded as it is equivalent to co-codamol 8/500,but much more expensive.Dose: 2 pink tablets at onset of attack.5HT1 agonistsSumatriptan tabletsDose: Acute migraine (oral), 50mg at onset. Dose may be repeated atleast two hours later if attack recurs. See BNF for full dosing information.4

36 The Greater Glasgow and Clyde Formulary4.7.4.2 Prophylaxis of migraineAlso consider propranolol (section 2.4).PizotifenDose: 1.5mg at night or 500 micrograms three times daily adjusted toresponse. See BNF for further dosing information.4.8 Antiepileptics44.8.1 Control of epilepsyThe SIGN Guideline for the Diagnosis and Management of Epilepsy inAdults (SIGN 70) and the equivalent guideline for children (SIGN 81) statethat the diagnosis of epilepsy should be made by a neurologist or epilepsyspecialist and that any decision to start antiepileptic drugs should bemade by the patient together with an epilepsy specialist.4.8.2 Drugs used for prolonged seizuresDiazepamRectal tubes.Dose: Status epilepticus, adult and child >10kg, 500 micrograms/kg(max 30mg). See BNF for further dosing information .S Buccal midazolamAvailable as an unlicensed liquid for buccal administration.Restrictions: Buccal midazolam should only be initiated on theadvice of a specialist in accordance with agreed local guidelines andfollowing appropriate training of the parent or carer. It may, however,be continued to be prescribed in primary care.4.9 Drugs used in parkinsonism and related disorders4.9.1 Dopaminergic drugs used in parkinsonismCo-careldopaRestrictions: Excludes intestinal gel.The BNF notes that the total daily dose of the carbidopa proportion ofthese products should be at least 70mg.Dose: Dependent on preparation, see BNF for information.Co-beneldopaDose: Dependent on preparation, see BNF for information.4.9.2 Antimuscarinic drugs used in parkinsonismProcyclidineThis medicine commonly causes confusion and is best avoided(especially in the elderly).Dose: 2.5mg three times daily, increased gradually if necessary. Usualmaximum dose, 30mg daily.

Third edition August 2009 374.10 Drugs used in substance dependenceCigarette smokingSelected community pharmacies are authorised to prescribe nicotinereplacement therapy on the NHS via the Smoke Free programme.Further information is available from the Smoke Free website(www.nhsggc.org.uk/cphi).Nicotine replacement therapy should be prescribed according to local protocolfor acute withdrawal from smoking or as part of the overall NHSGGCsmoking cessation programme.1 Nicorette ® patchNicorette ® patches are the Nicotine replacement formulation of choice.Dose: See BNF and product literature for dosing information.Nicorette ® product rangeIf Nicorette ® patches are unsuitable, other products from the rangeshould be considered as second line.4Opioid dependenceMethadone 1mg/ml solutionRestrictions: Excludes Eptadone ® .Information on the prescribing of methadone can be found in theGuidelines for Safe Methadone Prescribing in Glasgow or from GlasgowAddiction Services.

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Third edition August 2009 395 InfectionsGuidance on antimicrobial prescribing can be found in the NHSGGC PrimaryCare Adult infection Management Guidelines and the Infection ManagementGuidelines for use within the acute sector. Both these can be foundon the ADTC homepage (www.ggcformulary.scot.nhs.uk) or the ClinicalInfo section of StaffNet (www.staffnet.ggc.scot.nhs.uk/Clinical+Info/default.htm). The use of certain antibiotics e.g. co-amoxiclav, quinolones(such as ciprofloxacin), clindamycin and cephalosporins is inappropriatewhen standard and less broad spectrum antibiotics remain effective. Useof these antibiotics is associated with an increased risk of Clostridium difficile,MRSA and multi-resistant UTIs. Antibiotics not listed in the text mayoccasionally be prescribed on the advice of a microbiologist or infectiousdisease physician. For information on converting IV to oral preparationsrefer to Iocal IVOST protocol or guideline for step down recommendation.55.1 Antibacterial drugs5.1.1 Penicillins5.1.1.1 Benzylpenicillin and phenoxymethylpenicillinPhenoxymethylpenicillin (penicillin V)Used widely in bacterial tonsillitis, otitis media and cellulitis.Dose: Usual adult dose, 500-1000mg every six hours before food (fourtimes daily). See BNF for further dosing information.BenzylpenicillinGenerally given by slow IV injection and use in primary care will belimited.Dose: Normal adult doses range from 600-1200mg every six hours, butlarger doses can be used. See BNF and local guidelines for further dosinginformation. Bacterial meningitis, 2.4g every four hours by slow IVinjection or IV infusion.5.1.1.2 Penicillinase-resistant penicillinsFlucloxacillinPenicillinase-resistant penicillin used widely in cellulitis, otitis externaand impetigo.Dose: Generally, oral adult doses are between 250-500mg every sixhours before food (four times daily) dependent on indication. See BNFfor further information.

40 The Greater Glasgow and Clyde Formulary55.1.1.3 Broad spectrum penicillinsAmoxicillinBroad spectrum penicillin with a wide range of indications includingchest infections, otitis media, urinary tract infections and prophylaxisof endocarditis.Dose: Generally, adult doses are between 250-1000mg every eighthours (three times daily) dependent on indication. See BNF for details.Co-amoxiclavRestrictions: Excludes Augmentin Duo ® .Inappropriate use of co-amoxiclav is associated with an increased risk ofinfections such as Clostridium difficile and MRSA. The risk of cholestaticjaundice with co-amoxiclav is six times that seen with amoxicillin andis more common in men and the over 65s. Therefore, co-amoxiclavshould be reserved for infections suspected of being due to amoxicillinresistant beta-lactamase producing strains. Duration of therapy shouldnot normally exceed 14 days. See Primary Care and Acute infectionguidelines for appropriate uses in adults. Co-amoxiclav is a mixtureof amoxicillin and clavulanic acid. Care should be taken as to whichproduct should be used in paediatric patients due to the differentamounts of clavulanic acid. Consult the BNF for Children for details.Dose: Usual adult dose is 1 x 375mg tablet or 1 x 625mg tablet everyeight hours (three times daily). See BNF for further dosing information.5.1.2 Cephalosporins and other beta-lactamsApproximately 10% of patients with hypersensitivity to penicillins will alsobe allergic to cephalosporins. Inappropriate use of cephalosporins isassociated with an increased risk of infections such as Clostridium difficileand MRSA. See Primary Care and Acute infection guidelines for appropriateuses in adults.CefalexinDose: Oral, 250mg every six hours or 500mg every eight to twelve hours,with higher doses for severe infections. See BNF for further dosinginformation.Cefuroxime injectionDose: 750mg by IV injection or infusion every six to eight hours (1.5g insevere infections). See BNF and NHSGGC Infection guidance for furtherdosing information.CefotaximeDose: IV, 1g every 12 hours increased to 2g four times daily in severeinfections (e.g. meningitis). See BNF for further dosing information.CeftriaxoneThis can be given by deep IM injection or IV injection/infusion.Dose: 1g daily with higher doses being used in severe infections. SeeBNF for further dosing information.

Third edition August 2009 415.1.3 Tetracyclines1 OxytetracyclineFor use in acne and rosacea, see section 13.6.Dose: Usual dose in most infections, 250-500mg every six hours (fourtimes daily). See 13.6 for dose in acne.DoxycyclineDoxycycline is no more effective than oxytetracycline and is several timesmore expensive. Uses include sinusitis and pelvic inflammatory disease.Dose: Most infections, 200mg on first day, then 100mg daily. Pelvicinflammatory disease, 100mg twice daily for 14 days. See local guidelinesand BNF for further dosing information.5.1.4 AminoglycosidesS GentamicinGentamicin should be prescribed in line with local guidelines and issubject to dose adjustment in line with therapeutic drug monitoring.Dose: Refer to local guidelines.5.1.5 MacrolidesErythromycinErythromycin has a spectrum of activity similar to penicillin, which makesit a useful alternative for penicillin allergic patients for many infections.Dose: Oral, 250-500mg every six hours (four times daily) with largerdoses (up to 4g daily) for severe infections.ClarithromycinRestrictions: Excludes Clarosip ® .Dose: Oral 250-500mg twice daily. See BNF for further dosing information.5.1.8 Sulphonamides and trimethoprimTrimethoprimUsed primarily for urinary tract infections (see 5.1.13).Dose: Acute infections, 200mg twice daily.5.1.11 MetronidazoleMetronidazoleA useful antibiotic for anaerobic infections. Patients should becounselled to avoid alcohol whilst taking this medicine because of thepotential disulfiram-like reaction.Dose: Usual oral dose 400mg two to three times daily dependent onindication. See BNF for further information.5

42 The Greater Glasgow and Clyde Formulary55.1.12 QuinolonesCiprofloxacinCiprofloxacin should be prescribed by mouth in preference to IV wherepossible, as oral dosing gives similar concentrations to IV administration.The exception is when the oral route is compromised (e.g. nil bymouth, reduced absorption, unconsciousness, vomiting or mechanicalswallowing disorder). Ciprofloxacin is active against many Gram positiveand Gram negative bacteria and is a useful second or third line agent forurinary tract infections and infections of the GI tract, though it should notbe used empirically. The NHSGGC Infection Management guidelines canprovide advice on when use is appropriate. CSM advice for quinoloneshas been issued. Refer to BNF for further details.Dose: See BNF or product literature for further dosing information.Ciprofloxacin is not the most appropriate quinolone for communityacquiredpneumonia (CAP). In cases of CAP where a quinolone isrecommended, other Total Formulary alternatives should be considered.5.1.13 Urinary-tract infectionsSIGN 88 Management of Suspected Bacterial Urinary Tract Infections inAdults suggest uncomplicated lower UTIs should be treated with threedays of trimethoprim or nitrofurantoin.1 TrimethoprimTrimethoprim should be considered the first line choice foruncomplicated UTIs.Dose: Uncomplicated UTI, 200mg twice daily for 3 days. Prophylaxisfor recurrent UTIs, 100mg at night.NitrofurantoinMacrodantin ® causes fewer gastro-intestinal side effects than otherformulations of nitrofurantoin. Macrobid ® offers twice daily dosing.Dose: Uncomplicated UTI, 50mg every six hours with food for 7 days.For further dosing information, see BNF.5.2 Antifungal drugsFluconazoleDose: Dependent on indication. See BNF for further dosing information.NystatinFor nystatin in oral infection, see section 12.3, for skin infections, seesection 13.10.TerbinafineTerbinafine is particularly useful for systemic treatment of skin and nailfungal infections.Dose: 250mg daily, with the duration of treatment dependent on indication.See BNF for further dosing information.

Third edition August 2009 435.3 Antiviral drugs5.3.2 Herpesvirus infections5.3.2.1 Herpes simplex and varicella-zoster infectionAciclovirAciclovir and other antiviral agents are only useful in varicella andherpes zoster if started within 48 hours of the appearance of rash, withthe exception of ophthalmic shingles where the use may be justified upto 7 days after the development of rash.Dose: Oral, herpes simplex treatment, 200mg five times daily for 5days. Immunocompromised patients may need 400mg. Varicella andherpes zoster, 800mg five times daily for 7 days. See BNF for otherindications and for further dosing information.5

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Third edition August 2009 456 Endocrine system6.1 Drugs used in diabetesFor guidance on the management of diabetes, refer to SIGN 55.6.1.1 Insulins6.1.1.1 Short-acting insulinsSoluble insulin (brands include: Actrapid ® , Humulin S ® , InsumanRapid ® )Dose: Dose according to requirements.Insulin aspart (NovoRapid ® )Dose: Immediately before meals according to response.Insulin lispro (Humalog ® )Dose: Shortly before meals according to requirements.6.1.1.2 Intermediate and long-acting insulinsIsophane insulin (Insulatard ® )Dose: Dose according to requirements.Isophane insulin (Humulin I ® )Dose: Dose according to requirements.S Insulin glargine (Lantus ® )Restrictions: Restricted to initiation by consultant diabetologistsin patients with severe/frequent nocturnal hypoglycaemia. Not forroutine use in type 2 diabetes unless patients suffer from recurrenthypoglycaemia or require assistance with their insulin injections.Dose: Dose according to requirements.Biphasic insulinsBiphasic isophane insulin (Mixtard ® 30)Dose: Dose according to requirements.Biphasic isophane insulin (Humulin M3 ® )Dose: Dose according to requirements.Biphasic insulin aspart (Novomix ® 30)Dose: Dose according to requirements.Biphasic insulin lispro (Humalog ® Mix 25, Mix 50)Dose: Dose according to requirements.6

46 The Greater Glasgow and Clyde Formulary66.1.2 Oral antidiabetic drugs6.1.2.1 SulphonylureasGliclazideDose for normal release preparations: Initially, 40-80mg daily, adjustedaccording to response. Up to 160mg as a single dose with breakfast,with higher doses being divided, maximum daily dose 320mg.6.1.2.2 BiguanidesMetforminRestrictions: Excludes Metformin SR, which has not been accepted bythe SMC.Metformin is the antidiabetic drug of choice in both overweight andnormal weight patients. It is contraindicated in patients with renalfailure or dysfunction (creatinine clearance of

Third edition August 2009 476.2 Thyroid and antithyroid drugs6.2.1 Thyroid hormonesLevothyroxine (thyroxine)Dose: Hypothyroidism, initially 50-100 micrograms (50 micrograms forthose >50 years) daily, before breakfast, adjusted in steps of 50 microgramsevery three to four weeks until metabolism normalised (usually100-200 micrograms daily). For patients with cardiac disease, see BNFfor dosing information.6.2.2 Antithyroid drugsCarbimazoleDose: Usual dose is between 15-40mg daily. See BNF for further dosinginformation.6.3 CorticosteroidsThe CSM has issued a warning that all patients receiving oral or parenteralcorticosteroids for purposes other than replacement should be consideredat high risk of severe chickenpox (unless they have had chickenpox).66.3.1 Replacement therapyFludrocortisoneUsed in adrenocortical insufficiency and occasionally is used for theunlicensed indication of postural hypotension.Dose: 50-300 micrograms daily.6.3.2 Glucocorticoid therapyPrednisoloneUsed in many inflammatory and allergic disorders.Dose: Dependent on condition and route of administration – see BNFfor dosing information.HydrocortisoneUsed in adrenocortical insufficiency, shock and hypersensitivityreactions.Dose: Replacement therapy (oral), 20-30mg daily in divided doses.DexamethasoneUses include suppression of inflammatory and allergic disorders,cerebral oedema associated with malignancy, croup and chemotherapyinducednausea and vomiting.Dose: Orally, usual range in adults 0.5-10mg daily. See BNF for furtherdosing information.

48 The Greater Glasgow and Clyde Formulary6.4 Sex hormones66.4.1 Female sex hormones6.4.1.1 Oestrogens and HRTThe choice of HRT preparation depends on many factors. Patient preference,contributing risk factors for adverse events and the patient’s physicalcondition are just some that may need to be considered.Women with an intact uterus normally need a preparation with oestrogenand progestogen. Those women who have only recently stopped menstruating(within the last year) should consider a cyclical preparation. Theyshould not receive a combined continuous preparation or tibolone.Women without a uterus may receive oestrogen alone, though there aresome circumstances when the addition of progestogen is required.Transdermal routes of administration should be considered in thosewomen who are not appropriate, or cannot tolerate oral preparations.Oral oestrogen replacement1 Elleste -Solo ®Estradiol 1mg.Dose: 1 tablet (1mg) daily continuously. See BNF and product literaturefor further details.Climaval ®Estradiol valerate 1mg.Dose: 1 tablet (1mg) daily continuously. See BNF and product literaturefor further details.Topical oestrogen replacementEvorel ®Transdermal patch containing estradiol. Available in 25, 50, 75 and 100micrograms/24hour strengths.Dose: 1 patch to be applied twice weekly. See BNF and product literaturefor further dosing information.Local oestrogen therapyOnly for patients with symptoms of vaginal atrophy. See section 7.2.1.Cyclical oral HRTElleste-Duet ®Available as estradiol 1mg or 2mg with norethisterone 1mg.Dose: See BNF or product literature for further dosing information.Femoston ®Available as 1/10 and 2/10 strengths. Contains estradiol anddydrogesterone,Dose: See BNF or product literature for further dosing information.

Third edition August 2009 49Cyclical topical HRTEvorel ® SequiCombination of Evorel ® 50 patches (containing estradiol) and Evorel ®Conti patches (estradiol and norethisterone acetate).Dose: 1 Evorel 50 patch to be applied twice a week for two weeks followedby 1 Evorel Conti patch to be applied twice a week for two weeks.See BNF and product literature for further dosing information.Combined continuous oral HRTKliovance ®Estradiol and norethisterone acetate.Dose: 1 tablet daily. See BNF and product literature for further dosinginformation.Elleste-Duet ® ContiEstradiol and norethisterone acetate.Dose: 1 tablet daily. See BNF and product literature for further dosinginformation.Femoston ® -ContiEstradiol and dydrogesterone.Dose: 1 tablet daily. See BNF and product literature for further dosinginformation.Combined continuous topical HRTEvorel ® ContiEstradiol and norethisterone acetate.Dose: 1 patch to be applied twice a week. See BNF and product literaturefor further dosing information.TiboloneTiboloneUsed for the short-term treatment of symptoms of oestrogen deficiency,tibolone is not suitable for use in the pre-menopausal stage or within12 months of the last menstrual period (unless being treated withgonadotrophin releasing hormone analogues).Dose: 2.5mg daily.66.4.1.2 ProgestogensNorethisteroneDose: Dependent on indication. See BNF for dosing information.DydrogesteroneDose: Dependent on indication. See BNF for dosing information.

50 The Greater Glasgow and Clyde Formulary6.5 Hypothalamic and pituitary hormones and anti-oestrogens6.5.1 Hypothalamic and anterior pituitary hormones and anti-oestrogensClomifene citrateDose: 50mg daily for 5 days, starting within about 5 days of onset ofmenstruation (preferably 2nd day) or at any time if cycles have ceased.See BNF for further dosing information.66.5.2 Posterior pituitary hormones and antagonistsDesmopressinUsed for treatment of diabetes insipidus, primary nocturnal enuresisand postoperative polyuria or polydipsia. Due to the high level ofadverse reactions, desmopressin nasal spray is no longer indicated forprimary nocturnal enuresis. Oral formulations should be considered asan alternative.Restrictions: Desmopressin tablets are restricted to use in patientsunable to use intramuscular preparations. Intravenous desmopressin isrestricted to use in specialist haemophilia centres.Dose: Dependent on indication and preparation. See BNF for dosinginformation.6.6 Drugs affecting bone metabolismSee the Scottish Intercollegiate Guideline Network (SIGN) guideline on theManagement of Osteoporosis SIGN 71.6.6.2 Bisphosphonates and other drugs affecting bone metabolism1 Alendronic acidFirst line bisphosphonate for osteoporosis. The 70mg once a weekpreparation is the preferred formulation (except in men, where only thedaily 10mg preparation is licensed).Dose: Postmenopausal osteoporosis, 70mg once a week on an emptystomach (at least 30 minutes before breakfast and other medicineswhilst sitting or standing). See BNF for further information.Risedronate sodiumRisedronate is the second line bisphosphonate for osteoporosis andshould only be used in patients who fail to tolerate alendronic acidbecause of gastrointestinal side effects, despite the addition of aproton pump inhibitor. Treatment of osteoporosis in men at high risk offractures remains non-Formulary.Dose: Postmenopausal osteoporosis, 35mg once a week (at least 30minutes before breakfast and other medicines whilst sitting or standing).See BNF for further information.

Third edition August 2009 517 Obstetrics, gynaecology and urinary-tract disorders7.2 Treatment of vaginal and vulval conditions7.2.1 Preparations for vaginal atrophyLocal oestrogen therapyEstradiol vaginal tablets (Vagifem ® )Dose: Insert 1 tablet daily for two weeks then reduce to 1 tablet twiceweekly. Discontinue after 3 months to assess need for further treatment.See BNF and product literature for further dosing information.Estriol 0.01% intravaginal cream (Ortho-Gynest ® )This preparation contains arachis (peanut) oil and is not suitablefor patient with peanut allergy. This preparation also damages latexcondoms.Dose: Insert 1 applicatorful daily, preferably in the evening, reduced to1 applicatorful twice a week. Attempts to reduce or discontinue shouldbe made at 3-6 month intervals with examination. See BNF and productliterature for further dosing information.7.2.2 Vaginal and vulval infectionsFungal infections are treated primarily with pessaries and/or cream.ClotrimazoleClotrimazole 1% cream and 500mg pessary.Dose: Candidal vulvitis, apply 1% cream to affected area two to threetimes daily and insert one 500mg pessary at night as a single dose.See BNF for further dosing information.77.3 ContraceptivesWomen requiring contraception should be given information about andoffered a choice of all methods, including long-acting reversible contraception(LARC) methods. See the NHSGGC Guideline for ContraceptivePrescribing in Primary Care for more detail (available on the ADTC website,www.ggcformulary.scot.nhs.uk). Also see NICE CG30 which offers furtherguidance on prescribing long-acting reversible contraception.7.3.1 Combined hormonal contraceptivesStandard strength 2nd generationMicrogynon ® 30Dose: 1 tablet daily for 21 days, subsequent courses repeated after a7-day tablet-free interval.Loestrin ® 30Dose: 1 tablet daily for 21 days, subsequent courses repeated after a7-day tablet-free interval.

52 The Greater Glasgow and Clyde Formulary7Standard strength 3rd generationMarvelon ®Dose: 1 tablet daily for 21 days, subsequent courses repeated after a7-day tablet-free interval.Cilest ®Dose: 1 tablet daily for 21 days, subsequent courses repeated after a7-day tablet-free interval.Low strength 2nd generationLoestrin ® 20Dose: 1 tablet daily for 21 days, subsequent courses repeated after a7-day tablet-free interval.Low strength 3rd generationMercilon ®Dose: 1 tablet daily for 21 days, subsequent courses repeated after a7-day tablet-free interval.Co-cyprindiol (Dianette ® ) is licensed for the treatment of severe acneand hirsutism, but not as a contraceptive. It is occasionally used as acontraceptive (unlicensed indication) when acne is present. CSM advicerelating to co-cyprindiol and the risk of venous thromboembolismexists (see BNF). Formulary indications for co-cyprindiol can befound in section 13.6. For current advice about interactions betweencontraceptives and other medicines, refer to BNF.Emergency hormonal contraceptionLevonorgestrel (Levonelle ® 1500)Dose: 1.5mg as a single dose as soon as possible following intercourse(preferably within 12 hours, but no later than 72 hours).7.3.2 Progestogen-only contraceptives7.3.2.1 Oral progestogen-only contraceptivesMicronor ®Dose: 1 tablet daily at the same time each day, starting on day 1 ofcycle then continuously.Cerazette ®Cerazette ® may have advantages in women with a history of poorcompliance with a traditional progestogen-only contraceptive; however,it is significantly more expensive.Restrictions: Restricted to use in patients in whom oestrogencontaining contraceptives are not tolerated or are contra-indicated.Dose: 1 tablet daily at the same time each day, starting on day 1 ofcycle then continuously.Femulen ®Dose: 1 tablet daily at the same time each day, starting on day 1 ofcycle then continuously.

Third edition August 2009 537.3.2.2 Parenteral progestogen-only contraceptivesInjectable preparationsMedroxyprogesterone acetate (Depo-Provera ® )Dose: 150mg by deep IM injection within the first 5 days of cycle, repeatedevery 12 weeks. See BNF for further dosing information.ImplantsImplanon ®Dose: See BNF for full dosing information.7.3.2.3 Intra-uterine progestogen-only deviceMirena ®Dose: See BNF for full dosing information.7.3.4 Contraceptive devices (copper-based IUDs)1 TT 380 Slimline ®First choice device – device can be left in place for up to 10 years.Nova-T 380 ®Device must be replaced after 5 years.7.4 Drugs used for genito-urinary disorders7.4.1 Drugs for urinary retentionAlpha blockers1 Tamsulosin MR capsulesDose: MR capsules, 400 micrograms daily as a single dose (usually inthe morning).5α-reductase InhibitorsFinasterideUsed for benign prostatic hyperplasia, often in combination with analpha blocker.Dose: 5mg daily. Review treatment after 6 months. See BNF for furtherinformation.7.4.2 Drugs for urinary frequency, enuresis and incontinenceRefer to SIGN Guideline no. 79 (updated September 2005) for the Managementof Urinary Incontinence in Primary Care and NICE Clinical Guideline 40:The Management of Urinary Incontinence in Women (October 2006).Oxybutynin (standard release)Available as standard release tablets and elixir.Dose: Initially 2.5-5mg two to three times daily, increased if necessaryto a maximum of 5mg four times a day.If the patient cannot tolerate standard release oxybutynin, further TotalFormulary options should be considered as second line alternatives.Refer to BNF for dosing information.7

54 The Greater Glasgow and Clyde Formulary7Treatment options for stress incontinencePelvic floor exercises should be considered first line treatment for stressincontinence in line with NHSGGC protocol.DuloxetineFor moderate to severe stress urinary incontinence in addition to pelvicfloor exercises.Restrictions: Duloxetine should only be used as part of an overallmanagement strategy for stress urinary incontinence in addition topelvic floor muscle training and subject to use according to NHSGGCprotocol.Dose: 40mg twice daily, assessed after 2-4 weeks. See BNF for furtherdosing information.7.4.5 Drugs for erectile dysfunctionSildenafilRestrictions: Available for hospital and community prescribing butNHS prescribing by GPs is limited to nationally determined patientgroups and schedule 11 restrictions. Prescribing for patients withsevere distress must remain with the hospital specialist. Consultproduct literature for drug interactions prior to prescribing.Dose: Initially 50mg approximately 1 hour before sexual activity. Subsequentdoses adjusted to response (25-100mg as a single dose asneeded). Maximum 1 dose in 24 hours.

Third edition August 2009 559 Nutrition and blood9.1 Anaemias and some other blood disorders9.1.1 Iron-deficiency anaemias9.1.1.1 Oral ironFerrous fumarateDose: Prophylactic, 322mg daily or 210mg three times daily. Therapeutic,322mg twice daily or 210-420mg three times daily. See BNF forfurther details and other preparations.Ferrous sulphateDose: Prophylactic, 200mg daily. Therapeutic, 200mg two to threetimes daily. See BNF for further details.Sodium feredetateLiquid preparation previously known as sodium ironedetate.Dose: 5ml increasing gradually to 10ml three times daily. See BNF forfurther dosing information.9.1.2 Drugs used in megaloblastic anaemiasFolic acidUsed for folate deficiency and prophylaxis for the prevention of neuraltube defects in pregnancy. To prevent first occurrence of neural tubedefects, women planning a pregnancy should take folic acid 400micrograms daily before conception and during the first 12 weeks ofpregnancy. Women, who suspect they are pregnant but have not beentaking folic acid, should start at once and continue until the 12th weekof pregnancy. Women with a previous pregnancy affected by a neuraltube defect should take folic acid 5mg daily. Women taking antiepilepticdrugs may also be advised to take higher doses of folic acid.Dose: Folate deficiency, initially 5mg daily for 4 months. Pregnancy,400 micrograms daily for the first 12 weeks of pregnancy (but seenotes above). See BNF for full dosing information.HydroxocobalaminIntramuscular injection for vitamin B12 deficiency.Dose: Dependent on indication. See BNF for information.9

56 The Greater Glasgow and Clyde Formulary9.2 Fluids and electrolytes9.2.1 Oral preparations for fluid and electrolyte imbalancePotassium chlorideAvailable in several formulations:uueffervescent tablets (Sando-K ® ), each containing 12mmol of K+.uusyrup (Kay-Cee-L ® ) containing 1mmol K+ in 1ml.uuMR tablets (Slow-K ® ), each containing 8mmol of K+.A potassium-sparing diuretic and potassium supplements should notbe used concomitantly because of the risk of hyperkalaemia.Restrictions: Due to the risk of oesophagitis, Slow K ® should only beused in patients unable to tolerate liquid or effervescent preparations.Dose: Dependent on indication and preparation. See BNF for details.Rapolyte ®Oral rehydration salts.Dose: According to fluid loss, see BNF for further details.9.4 Oral nutrition9.4.1 Foods for special dietsFor prescribable gluten-free, see gluten-free products in the BorderlineSubstance section (Part XV) of the English Drug Tariff (available at www.ppa.org.uk). A prescribing guideline for gluten-free products can beobtained from the prescriptions link within the Healthcare Professionalssection of Coeliac UK’s website (available at www.coeliac.org.uk).99.4.2 Enteral nutritionThese are normally supplementary to food and should be taken betweenmeals evenly spread over the day. An effective dose is 1-2 bottles dailyfor a maximum of 2-3 months. Patients should be assessed regularly forcompliance and continued need. ACBS guidelines apply.Fortisip ® BottleA milk based supplement (200ml).Fortifresh ®A yoghurt style supplement (200ml).Fortijuce ®A juice based supplement.May not be suitable for patients with diabetes (200ml).Fortisip ® Multi-FibreA milk based supplement with added fibre.Patients prescribed a fibre containing supplement may need theirlaxative requirement reviewed. See NHSGGC primary care prescribingguidelines (200ml).

Third edition August 2009 579.5 Minerals9.5.1 Calcium and magnesium9.5.1.1 Calcium supplementsDifferent calcium preparations have different uses. Oral preparations aregenerally utilised when dietary intake is deficient, calcium chloride injectionis often used in emergency situations to temporarily reduce the toxiceffects of hyperkalaemia and calcium gluconate injection is often used inhypocalcaemic tetany.For calcium and vitamin D preparations, see section 9.6.4.Calcium carbonateUsed as a dietary calcium supplement.Dose: See BNF for dosing information.9.5.2 PhosphorusCalcium chlorideInjectable calcium preparation.Dose: Dependent on use, see BNF for dosing information.Calcium gluconateInjectable calcium preparation.Dose: Dependent on use, see BNF for dosing information.9.5.2.1 Phosphate supplementsS Phosphate -Sandoz ®Oral phosphate supplement used in vitamin D-resistant rickets andhypercalcaemia.Dose: 4-6 tablets daily. See BNF for full dosing information.9.5.2.2 Phosphate-binding agentsS Calcium acetateRestrictions: Initiation should be on the advice of a specialist.Used as a phosphate binder and taken with meals.Dose: According to patient requirements. See BNF for further information.99.6 Vitamins9.6.2 Vitamin B groupThiamineDose: Mild chronic deficiency, 10-25mg daily. See BNF for further dosinginformation.Pabrinex ®Parenteral vitamins B and C for rapid correction of severe depletion ormalabsorption.Dose: See BNF for dosing information.

58 The Greater Glasgow and Clyde Formulary9.6.3 Vitamin CAscorbic acidUsed in the prevention and treatment of scurvy.Dose: Prophylaxis, 25-75mg daily. Treatment, not less than 250mgdaily in divided doses.9.6.4 Vitamin DAlfacalcidolUsed for vitamin D therapy in those patients with severe renalimpairment.Dose: Initially 1 microgram daily (500 nanograms in the elderly) adjustedto avoid hypercalcaemia. See BNF for further information.9Calcium and vitamin D preparationsAdcal D3 ®Calcium and vitamin D preparation (equivalent to 600mg calcium and400 units of vitamin D). Adcal D3 ® Dissolve should only be used inpatients who cannot tolerate other calcium and vitamin D preparations.Dose: 1 tablet once or twice a day. See BNF for further dosing information.Calcichew D3 Forte ®Calcium and vitamin D preparation (equivalent to 500mg calcium and400 units of vitamin D).Dose: 1 tablet once or twice a day. See BNF for further dosing information.Calceos ®Calcium and vitamin D preparation (equivalent to 500mg calcium and400 units of vitamin D).Dose: 1 tablet once or twice a day. See BNF for further dosing information.Calcium and ergocalciferolEquivalent to 97mg calcium and 400 units of vitamin D. Due to lowamounts of calcium, this preparation is only useful in patients whorequire vitamin D substitution, but do not require additional calcium.Dose: See BNF for dosing information.9.6.5 Vitamin ES Alpha tocopheryl acetateAvailable as a 500mg/5ml suspension.Dose: Malabsorption in cystic fibrosis, 100-200mg daily. See BNF forfurther dosing information.9.6.6 Vitamin KMenadiol sodium phosphateA water soluble oral preparation to prevent vitamin K deficiency inmalabsorption syndromes. Contraindicated in late pregnancy.Dose: 10mg daily. See BNF for further dosing information.

Third edition August 2009 59PhytomenadioneUsed for the prophylaxis and treatment of vitamin K deficiencybleeding and for the reversal of the anticoagulant effect of warfarin. It isavailable as tablets and as injection.Dose: See BNF for dosing information.9.6.7 Multivitamin preparationsVitamin capsules BPCDose: Usually 1 capsule daily.Abidec ®Contains vitamin groups A, B, C and D.Dose: Dependent on age of child. See BNF for further dosing information.9

960 The Greater Glasgow and Clyde Formulary

Third edition August 2009 6110 Musculoskeletal and joint diseases10.1 Drugs used in rheumatic diseases and gout10.1.1 Non-steroidal anti-inflammatory drugsThe differences in anti-inflammatory activity between NSAIDs are small,but there is considerable variation in individual patient response. About60% of patients respond to any NSAID with an analgesic response withina week and an anti-inflammatory response within three weeks. The maindifference between NSAIDs is in the incidence and type of side effects.In osteoarthritis, there is only a minor inflammatory component, andparacetamol (4g daily) has been shown to be effective in many patients.NSAIDs should only be used when there is an inflammatory flare up.Traditional NSAIDsThe CSM advise that to minimise the risk to cardiovascular safety associatedwith some NSAIDs, the lowest effective dose should be prescribed forthe shortest necessary duration.1 IbuprofenRestrictions: Use of MR preparations is restricted (see notes below).Dose: 400mg-600mg three times daily with or after food. See BNF forfurther dosing information.1 DiclofenacRestrictions: Use of MR preparations is restricted (see notes below).Dose: Orally, 75-150mg daily in 2-3 divided doses. See BNF for furtherdosing information.IndometacinRestrictions: Acute attacks of gout.Dose: Gout, 150-200mg daily in divided doses (with or after food).NaproxenThere is a significant cost difference between the tablets and theenteric coated tablets.Dose: Acute musculoskeletal disorders, 500mg initially then 250mgevery six to eight hours as required. Rheumatic disease, 500mg-1gdaily in 1-2 divided doses. For further dosing information, see BNF.Modified-release preparations of any NSAID should be restricted topatients with early morning stiffness or compliance problems as theyencourage regular/higher doses of NSAIDs and do not afford flexibility inreducing the dose.10

62 The Greater Glasgow and Clyde FormularySelective COX-2 inhibitorsIn light of recent concerns regarding cardiovascular safety, selectiveCox-2 inhibitors should only be considered for use in patients with a highrisk of GI bleeding and perforation after an assessment of the patient’scardiac risk (see BNF for details). The CSM has also advised that selectiveCox-2 inhibitors should not be prescribed for patients with existing IHD orcerebrovascular disease (see BNF for details). For patients who require aproton pump inhibitor, a traditional NSAID should be used in preference toa selective Cox-2.EtodolacDose: 600mg daily in 1-2 divided doses.CelecoxibRestrictions: Use in ankylosing spondylitis remains non-FormularyDose: Osteoarthritis, 200mg daily in 1-2 divided doses.10.1.2 CorticosteroidsFor oral preparations, see section 6.3.MethylprednisoloneDose: Dependent on site, preparation and indication. See BNF andproduct literature for dosing information.1010.1.3 Drugs which suppress the rheumatic disease processSulfasalazineThe CSM has advised that patients should be advised to report anyunexplained bleeding, bruising, purpura, sore throat, fever or malaise(potential signs of blood dyscrasia).Dose: On specialist advice as EC tablets, 500mg daily increased by500mg at intervals of 1 week to a maximum of 2-3g daily in divideddoses. See BNF for further dosing information.S HydroxychloroquineDose: On specialist advice, initially 400mg daily in divided doses,maintenance 200-400mg daily. See BNF for further dosing information.S MethotrexateOral methotrexate should only be prescribed as 2.5mg tablets toavoid patient confusion. The dose should be clearly specified on thedispensing label. In view of reports of blood dyscrasias (includingfatalities) and liver cirrhosis with low-dose methotrexate, the CSM hasadvised:uufull blood count and renal and liver function tests before starting treatmentand repeated weekly until therapy stabilised, thereafter patientsshould be monitored every 2-3 months.uuthat patients should be advised to report all symptoms and signs suggestiveof infection, especially sore throat.

Third edition August 2009 63Dose: Moderate to severe rheumatoid arthritis, orally 7.5mg once aweek adjusted according to response (max weekly dose 20mg). SeeBNF for further dosing information.10.1.4 Gout and cytotoxic-induced hyperuricaemiaAcute attacks of goutAcute attacks of gout are generally treated with high doses of NSAIDs (seesection 10.1.1).ColchicineDose: Treatment of gout, initially 1mg, then 500 micrograms no morefrequently than every 4 hours until pain relieved or vomiting or diarrhoeaoccur, maximum 6mg per course and courses should not berepeated within 3 days. See BNF for further dosing information.Long-term control of goutAllopurinolAllopurinol alone should not be initiated during the acute phase as itmay precipitate further attacks or make the gout worse.Dose: Initially 100mg daily after food. See BNF for further dosinginformation.10.2 Drugs used in neuromuscular disorders10.2.1 Drugs which enhance neuromuscular transmissionS Pyridostigmine bromideUsed for myasthenia gravis.Dose: Orally, 30-120mg at suitable intervals throughout the day, totaldaily dose 300mg-1.2g. See BNF for full dosing information.10.2.2 Skeletal muscle relaxantsBaclofenRestrictions: Baclofen injection is restricted to use in specialistunits only. Slow withdrawal of baclofen over one to two weeks isrecommended.Dose: Orally, 5mg three times a day, with or after food, graduallyincreased to a maximum of 100mg daily and discontinued if no benefitseen within 6 weeks. See BNF for further information.QuinineAvailable as quinine sulphate and quinine bisulphate tablets, oralquinine is used primarily for nocturnal leg cramps. Patients should bereviewed regularly to establish benefit.Dose: 200-300mg at bedtime. See BNF for further dosing information.10

64 The Greater Glasgow and Clyde Formulary10.3 Drugs used for the relief of soft-tissue inflammation10.3.2 Rubefacients and other topical antirheumaticsMovelat ®Rubefacients act by counter-irritation, so pain is relieved by producingother irritation to distract away from the pain.Dose: Apply to the affected areas four times daily. See product literaturefor further information.10

Third edition August 2009 6511 EyeMany of the preparations listed are available in preservative-free formulations.These formulations should be restricted to patients who haveproven sensitivity to preservatives.11.3 Anti-infective eye preparations11.3.1 Antibacterials1 ChloramphenicolAvailable as 0.5% drops (which must be stored in a fridge), and 1% eyeointment.Dose: Eye drops, apply 1 drop every two hours initially then reducefrequency as infection is controlled and continue for 48 hours afterhealing. Eye ointment, apply either at night (if eye drops used duringthe day) or three to four times daily (if eye ointment used alone). SeeBNF for further dosing information.Fusidic acidAvailable as modified-release 1% viscous eye drops. Fusidic acidshould only be used for staphylococcal infections such as blepharitis,not bacterial conjunctivitis.Dose: Apply 1 drop to the affected eye(s) twice daily. See BNF for furtherdosing information.GentamicinAvailable as 0.3% eye drops.Dose: 1 or 2 drops up to six times a day, or more frequently if required.See BNF and product literature for further dosing information.11.3.3 AntiviralsAciclovirAvailable as 3% eye ointment.Dose: Apply five times daily and continue for at least 3 days after completehealing. See BNF for further dosing information.11.4 Corticosteroids and other anti-inflammatory preparations11.4.1 CorticosteroidsUsed for local short-term treatment of inflammation, corticosteroid eyedrops should only usually be initiated under expert supervision.11.4.2 Other anti-inflammatory preparationsSodium cromoglicateUsed primarily for allergic conjunctivitis.Dose: Apply 1 drop to the affected eye(s) four times daily. See BNF forfurther dosing information.11

66 The Greater Glasgow and Clyde Formulary11.5 Mydriatics and cycloplegicsAntimuscarinicsCyclopentolateUsed to dilate the pupil to facilitate examination.Dose: For dosing information, see BNF or product literature.TropicamideUsed to facilitate fundoscopy.Dose: For dosing information, see BNF or product literature.11.6 Treatment of glaucomaMedicines for the treatment of glaucoma should only be initiated by, oron the advice of ophthalmologists or similar specialists. It is appropriatethough for General Practitioners and other prescribers to continue therepeat prescribing of these medicines under the guidance of a specialist.11.8 Miscellaneous ophthalmic preparations11.8.1 Tear deficiency, ocular lubricants and astringents1 HypromelloseHypromellose 0.3% is considered the first line treatment option forpatients complaining of ‘dry eyes’ or tear deficiency.Dose: 1 drop into the affected eye(s) when required. See BNF for furtherdosing information.Viscotears ®Dose: Apply three to four times daily as required.Lacri-Lube ®Dose: See BNF and product literature for dosing information.11

Third edition August 2009 6712 Ear, nose and oropharynx12.1 Drugs acting on the ear12.1.1 Otitis externaBetamethasone sodium phosphate0.1% drops that can be used in ear, eye or nose.Dose: For otitis externa, apply 2-3 drops every two to three hours,reducing frequency when relief obtained. See BNF for further dosinginformation.Betnesol-N ®A combination of betamethasone and neomycin. Drops can be used inear, eye or nose.Dose: Apply 2-3 drops into the affected ear(s) three to four times daily.See BNF for further dosing information.Gentisone HC ®A combination of hydrocortisone and gentamicin.Dose: 2-3 drops into the affected ear(s) three to four times daily and atnight.Otomize ®Ear spray containing dexamethasone and neomycin.Dose: 1 spray into affected ear(s) three times a day.12.1.3 Removal of ear waxIn most cases, simple remedies such as sodium bicarbonate or olive oilare effective and less likely to cause irritation. See the BNF for furtheradvice about the use of these remedies.Sodium bicarbonateEar drops 5%.Dose: See BNF for dosing information.Olive oilEar drops (olive oil in a suitable container).Dose: See BNF for dosing information.Cerumol ®Dose: See BNF or summary of product literature for dosing information. 12

68 The Greater Glasgow and Clyde Formulary12.2 Drugs acting on the nose12.2.1 Drugs used in nasal allergyBeclometasone diproprionateNasal spray, 50 micrograms/spray.Dose: 2 sprays into each nostril twice daily. When symptoms controlled,reduce dose to 1 spray in each nostril twice daily. See BNF forfurther dosing information.BudesonideNasal spray, 100 micrograms/spray or 64 micrograms/spray.Dose: Dependent on preparation, see BNF or product literature for dosinginformation.12.2.2 Topical nasal decongestantsXylometazoline hydrochlorideAvailable as 0.1% nasal drops and a 0.1% nasal spray. Maximum durationfor treatment is 7 days as further use can cause rebound congestion.Dose: Drops, 2-3 drops into each nostril two to three times daily whenrequired. Spray, 1 spray into each nostril two to three times daily whenrequired.12.2.3 Nasal preparations for infectionNaseptin ®Cream containing chlorhexidine and neomycin.Dose: For eradication of nasal staphylococci, apply to nostrils fourtimes a day for 10 days. For prevention, apply twice daily. See BNF forfurther dosing information.Mupirocin (Bactroban Nasal ® )Dose: For eradication of staphylococci (including MRSA), apply twoto three times daily to the inner surface of each nostril. See BNF forfurther dosing information.12.3 Drugs acting on the oropharynx1212.3.1 Drugs for oral ulceration and inflammationBenzydamine hydrochlorideUsed for painful inflammatory conditions of the mouth and throat.Available as oral rinse and spray.Dose: Oral rinse: 15ml (diluted with water if stinging occurs) every1½ to 3 hours as required, usually for not more than 7 days. For otherpreparations and further dosing information, see BNF.Adcortyl in Orabase ®Corticosteroid preparation for oral lesions.Dose: Apply a thin layer two to four times daily. See BNF for furtherdosing information.

Third edition August 2009 6912.3.2 Oropharyngeal anti-infective drugsNystatinDose: Suspension, 100,000 units (equivalent to 1ml) four times dailyafter food, usually for 7 days. See BNF for further dosing information.MiconazoleOral gel. The muco-adhesive buccal tablets are non-FormularyDose: Dependent on use. Oral fungal infections, place 5-10ml in mouthafter food four times daily, continued for 48 hours after lesions havehealed. See BNF for further dosing information.12.3.4 Mouthwashes, gargles and dentifricesChlorhexidine gluconateDose: Dependent on preparation. 0.2% mouthwash, for oral hygieneand plaque inhibition, rinse with 10ml for about 1 minute twice daily.See BNF for further dosing information.12

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Third edition August 2009 7113 SkinNon-proprietary products required for extemporaneous preparation forindividual patients historically are not included in the Formulary.13.2 Emollient and barrier preparations13.2.1 EmollientsDiprobase ®Dose: Apply to affected area when required.Epaderm ®Dose: Apply to affected area when required.Aqueous creamOften also used as a soap substitute.Dose: Apply to affected area when required.13.2.1.1 Emollient bath additivesHydromol Emollient ®Dose: Add to bath as directed. See BNF and product literature forfurther dosing information.Oilatum ® PlusDose: Add to bath as directed. See BNF and product literature forfurther dosing information.13.2.2 Barrier preparationsSudocrem ®Useful for nappy rash and pressure sores.Dose: Apply a thin layer to the affected area as necessary. See BNF andproduct literature for further dosing information.13.3 Topical local anaesthetics and antipruriticsCrotamiton (Eurax ® )Dose: For pruritus, apply two to three times daily.13.4 Topical corticosteroidsTopical corticosteroids can be classified according to their potency. Forguidance on quantities to prescribe, refer to the BNF. Prolonged use ofsteroids should generally be avoided, and if long-term use is necessary,regular review of treatment should be carried out. See BNF for furtherinformation.Mildly potentHydrocortisoneDose: Apply thinly to the affected area once or twice a day.13

72 The Greater Glasgow and Clyde FormularyModerately potent1 Clobetasone butyrate (Eumovate ® )Dose: Apply thinly to the affected area once or twice a day.Alclometasone diproprionate (Modrasone ® )Dose: Apply thinly to the affected area once or twice a day.PotentBetamethasone valerate (Betnovate ® )Dose: Apply thinly to the affected area once or twice a day.Very potentVery potent topical steroids should only be initiated on the advice of adermatologist.Mildly potent with anti-infective agentsDaktacort ®Hydrocortisone and miconazole.Dose: Apply thinly to the affected area once or twice a day. See BNFand product literature for further dosing information.Moderately potent with anti-infective agentsTrimovate ®Clobetasone butyrate, oxytetracycline and nystatin.Dose: Apply to the affected area up to four times a day. See BNF andproduct literature for further dosing information.Potent with anti-infective agentsBetnovate-C ®Betamethasone valerate and clioquinol.Dose: Apply to the affected area two to three times daily until improvementoccurs, then reduce frequency. See BNF and product literature forfurther dosing information.13.5 Preparations for eczema and psoriasis1313.5.1 Preparations for eczemaIchthammol ointment BPDose: Apply one to three times daily.Zinc paste and ichthammol bandage BPDose: Use as directed. See BNF for further information.13.5.2 Preparations for psoriasisAlphosyl HC ®Contains coal tar and hydrocortisone.Dose: Apply thinly once or twice daily.

Third edition August 2009 73CalcipotriolDose: Apply to the affected areas once or twice daily up to a maximumof 100g weekly. See BNF for further dosing information.Coal tar, salicylic acid and sulphurBrands available: Cocois ® or Sebco ®Used for psoriasis of the scalp.Dose: Apply to the scalp once weekly (daily in severe cases) and shampoooff after 1 hour. See BNF and individual product preparations forfurther information.Calcipotriol and betamethasone (Dovobet ® )Restrictions: Use is restricted to physicians experienced in treatinginflammatory skin disease. The duration of treatment should notexceed 4 weeks.Dose: Apply once daily to up to 30% of body surface for 4 weeks maximum.See BNF and product literature for further dosing information.13.5.3 Drugs affecting the immune responseS MethotrexateRestrictions: Restricted to use under specialist dermatologicalsupervision.Dose: Usual dose of methotrexate when used for treatment of psoriasisis 10 to 25mg once weekly by mouth, adjusted to response. See BNFfor further dosing information.S Ciclosporin (Cyclosporin)Can be used for severe atopic dermatitis or severe psoriasis whenconventional therapy has failed.Restrictions: Restricted to use under specialist dermatologicalsupervision.Dose: Dependent on indication. See BNF for dosing information.13.6 Acne and rosaceaInflammatory lesions associated with rosacea may be responsive to oraltherapy or topical metronidazole (section 13.10.1.2).13.6.1 Topical preparations for acneBenzoyl peroxideBrands include PanOxyl ® .Dose: Dependent on product, but generally applied once or twice dailyafter washing. Lower-strength preparations should be used initially.ClindamycinAvailable as a 1% topical solution or lotion (Dalacin T ® ).Dose: Apply twice daily.13

74 The Greater Glasgow and Clyde FormularyZineryt ®Contains erythromycin and zinc acetate.Dose: Apply twice daily.ErythromycinStiemycin ® is a 2% solution.Dose: Apply twice daily.13.6.2 Oral preparations for acneLymecyclineDose: 408mg daily for at least 8 weeks.ErythromycinSee section 5.1.5.Dose: Acne, 500mg twice daily. See BNF for further dosing information.Co-cyprindiolBrands include Dianette ® .Contains a mixture of cyproterone acetate and ethinylestradiol in a2000:35 part ratio.CSM advice (see BNF for full advice): Prescribers are reminded thatthe risk of venous thromboembolism is higher in women taking cocyprindiolthan those taking a low-dose combined oral contraceptive. Itis licensed for severe acne and moderately severe hirsutism and shouldnot be used solely for contraception. It is contraindicated in those witha personal or close family history of venous thromboembolism.Dose: 1 tablet daily for 21 days starting on day 1 of the menstrual cycleand repeated after a 7-day interval. See BNF for further dosing information.OxytetracyclineDose: 500mg twice daily. If no improvement after 3 months change toa different antibacterial agent.13.7 Preparations for warts and callusesOcclusal ®Dose: Apply to the wart/verruca daily.13.8 Sunscreens and camouflagers1313.8.1 Sunscreen preparationsOnly sunblocks of factor 15 and over are prescribable on a GP10. ACBSguidelines apply.Sunsense ® UltraSPF 60. ACBS restrictions apply to prescribing. See BNF for details.Dose: Apply as a sunscreen as directed. See product literature forfurther information.

Third edition August 2009 7513.8.2 CamouflagersVeil ®Available as a cover cream and finishing powder.ACBS restrictions apply to prescribing. See BNF for details.13.9 Shampoos and other preparations for scalp and hair conditionsCapasal ®Dose: Scaly scalp disorders, including psoriasis, seborrhoeic dermatitis,dandruff and cradle cap, apply daily as necessary.Coal tar, salicylic acid and sulphurBrands available: Cocois ® or Sebco ® .See section 13.5.2.Polytar ®Dose: Apply one to two times a week. See BNF for further dosinginformation.13.10 Anti-infective skin preparations13.10.1 Antibacterial preparations13.10.1.1 Antibacterial preparations only used topicallyMupirocin (Bactroban ® )For nasal preparations, see section 12.2.3.Dose: Apply up to three times daily for up to 3 days.Silver sulfadiazine (Flamazine ® )Dose: Burns, apply daily or more frequently if very exudative. Legulcers and pressure sores, apply daily or on alternate days. Finger tipinjuries, apply every two to three days. See BNF and product literaturefor further dosing information.13.10.1.2 Antibacterial preparations also used systemicallyFusidic acid (Fucidin ® )For oral preparations, see section 5.1.7.Dose: Apply 3-4 times daily.MetronidazoleFor oral preparations, see section 5.1.11.Metronidazole is available in a range of topical preparations, someof which are licensed for acne rosacea. Consult BNF for furtherinformation.Dose: Based on 0.75% gel, acute exacerbations of acne rosacea, applythinly twice daily for 8 weeks (See BNF and individual preparationliterature for further dosing information).13

76 The Greater Glasgow and Clyde Formulary13.10.2 Antifungal preparationsClotrimazole 1%Dose: Apply two to three times daily.Miconazole 2% (Daktarin ® )Restrictions: Excludes Daktarin ® powderDose: Apply twice daily continuing for 10 days after lesions havehealed. Nail infections; Apply one to two times daily.13.10.3 Antiviral preparationsAciclovirFor oral preparations, see 5.3.2.1 and for eye ointment, see 11.3.3.Dose: Apply to lesions every four hours (five times daily) for 5-10 daysstarting at first sign of attack.13.10.4 Parasiticidal preparationsThe Greater Glasgow and Clyde Head Lice Project guidance notes wereupdated in September 2006. The project allows community pharmaciststo supply selected medicines for head lice management on the NHS for eligiblepatients. See www.nhsggc.org.uk/cphi for further information. Thecurrent policy recommends the following preparations as first line agentsfor head lice.MalathionPrioderm ® is the preferred malathion preparation except in those witheczema, asthma or young children when Derbac M ® should be used.Dose: Dependent on indication. See BNF and product literature fordetails.PhenothrinFull Marks ® liquid is the preferred phenothrin preparation.Dose: Dependent on indication. See BNF and product literature fordetails.Dimeticone 4% lotion (Hedrin ® )Hedrin ® does not contain a chemical insecticide, but works byencapsulating the head lice, preventing them from functioning.Dose: Rub into hair and scalp and allow to dry naturally, shampoo aftera minimum of 8 hours (or overnight) and repeat application after 7days. See BNF and product literature for further information.1313.10.5 Preparations for minor cuts and abrasionsMagnesium sulphate paste BPDose: Apply under dressing.

Third edition August 2009 7713.11 Skin cleansers and antiseptics13.11.1 Alcohols and salineIndustrial methylated spirit BPUsed for skin preparation prior to injection.Sodium chlorideSterile sodium chloride 0.9% is often used as an irrigation fluid forwounds and ulcers.13.11.2 Chlorhexidine saltsChlorhexidine gluconateBrands include: Hibiscrub ® , Hibisol ® , Hydrex ® and Unisept ® .See individual preparation literature for appropriate uses anddirections.Chlorhexidine/cetrimide (Tisept ® )Used for general skin disinfection and wound cleansing.13.11.4 IodinePovidone-iodineBrands include: Savlon Dry Antiseptic ® .See individual preparation literature for appropriate uses and directions.13.11.5 PhenolicsTriclosanAvailable as a hand rub and bath concentrate.Used for disinfection and pre-operative hand preparation. Seeindividual preparation literature for appropriate uses and directions.13.11.6 Oxidisers and dyesHydrogen peroxide BPThe 6% solution should be used for skin disinfection, particularlycleaning and deodorising of wounds and ulcers.Potassium permanganateAvailable as 0.1% solution, which should be diluted 1 in 10, and asPermitabs ® , where 1 tablet dissolved in 4 litres of water provides a0.01% solution. See BNF and product literature for further information.13.12 AntiperspirantsAluminium chloride hexahydrateBrands include Driclor ® and Anhydrol Forte ® .Dose: See BNF and product literature for dosing information. 13

78 The Greater Glasgow and Clyde Formulary

Third edition August 2009 79Total Formulary medicinesMedicines in the following list may be subject to Formulary restrictions oruses for specific indications only (indicated in the restriction column).The full formulary status of the below medicines can be found on the ADTCwebsite: www.ggcformulary.scot.nhs.uk.11.1.1 Aluminium hydroxideCo-magaldroxAsilone ®Infacol ®1.1.2 Gastrocote ®Gaviscon ® Infant Dual SachetsPeptac ®1.2 DicycloverinePropanthelineMebeverineExcluding mebeverine MR.s Hyoscine butylbromideinjectionPeppermint oil capsulesDomperidoneMetoclopramide1.3.1 CimetidineRanitidine1.3.3 Sucralfate1.3.4 Misoprostol1.3.5 Omeprazole capsuless Omeprazole orodispersibleRestricted for specialist initiation inpatients with narrow-bore feedingtubes.Lansoprazole capsuless Lansoprazole orodispersibleRestricted for specialist initiation inpatients with narrow-bore feedingtubes.1.4.2 Codeine phosphateCo-phenotropeLoperamide1.5 MesalazineDelivery characteristics of ECpreparations vary and should not beconsidered as interchangeable.OlsalazineSulfasalazineHydrocortisone foams MercaptopurineOral mercaptapurine for use ininflammatory bowel disease(unlicensed indication) is restrictedto specialist initiation for patientsunable to tolerate azathoprine. Incases where GPs continue theprescribing, associated monitoringwill continue to be the responsibilityof the acute sector.PrednisoloneS InfliximabUse in Crohn’s disease is subjectto NHSGGC protocol and does notinclude the maintenance treatmentof severe active, or fistulating activeCrohn’s, which have not beenaccepted by SMC. However, use in thetreatment of severe, active Crohn’sdisease in paediatric patients aged6 to 17 years of age is restrictedto specialist use in patients whohave not responded to conventionaltherapy. Use in the treatment ofmoderate to severe active ulcerativecolitis has not been accepted by SMCand is non-Formulary.1.6.1 Ispaghula husk

80 The Greater Glasgow and Clyde Formulary1.6.2 BisacodylCo-danthramerRestricted to constipation in theterminally ill.Co-danthrusateRestricted to constipation in theterminally ill.Docusate sodiumGlyceryl suppositoriesSenna1.6.3 Arachis oil enema1.6.4 Phosphate enemaLactuloseMicralax Micro-enema ®Movicol ®S Magnesium sulfate1.6.5 s Fleet Phospho-Soda ®Restricted to use as alternative toPicolax ® and Klean-Prep ® when theyare unavailable.s Klean -Prep ®s Sodium picosulfate1.7.1 Anusol ®Lasonil ®Lidocaine1.7.2 Anusol HC ®Anugesic HC ®HydrocortisoneScheriproct ®1.7.3 S Oily phenol1.8 Stoma careFor advice, contact local stoma nurse.1.9.4 Creon Micro ®Restricted to use in young cysticfibrosis sufferers who are unable toswallow capsules.Creon ®Nutrizym ®Pancrease ®Pancrex ®s Nutrizym 22 ®s Pancrease HL ®1.9.1 Ursodeoxycholic acidFor primary biliary cirrhosis,ursodeoxycholic acid is restrictedto use on the advice of consultantgastroenterologists.1.9.2 Colestyramine

Third edition August 2009 8122.1.1 DigoxinS Digibind ®2.1.2 s Enoximones Milrinone2.2.1 Bendroflumethiazides Metolazone2.2.2 FurosemideBumetanide2.2.3 AmilorideSpironolactones EplerenoneOnly to be initiated in patients withleft ventricular systolic dysfunctionaccompanied by evidence of heartfailure, both manifesting within3-14 days of myocardial infarction.Consultant signature required.2.2.4 Co-amilofruse2.2.5 S Mannitol2.3.2 VerapamilS Adenosines Amiodarones Disopyramides Flecainides Propafenones SotalolS Lidocaine2.4 AtenololBisoprololThe initiation and initial supervisionof bisoprolol in confirmed cases ofchronic cardiac failure is restrictedto prescribers experienced in thetreatment of heart failure in line withagreed protocols.CarvedilolThe initiation and initial supervisionof carvedilol in confirmed cases ofchronic cardiac failure is restrictedto prescribers experienced in thetreatment of heart failure in line withagreed protocols.PropranololSustained-release formulations offerno advantage for the majority ofpatients.S Esmolols LabetololMetoprolols NebivololRestricted to initiation in patients overthe age of 70 years with confirmedchronic cardiac failure who fail totolerate bisoprolol and carvedilol.2.5.1 S AmbrisentanRestricted to initiation and prescribingby specialists in the ScottishPulmonary Vascular Unit and theScottish Adult Congenital CardiacService.HydralazineS BosentanRestricted to initiation andprescribing by specialists in theScottish Pulmonary Vascular Unitand the Scottish Adult CongenitalCardiac Service. Use in the reductionof the number of digital ulcers inpatients with systemic sclerosis andongoing digital ulcer disease and forpulmonary arterial hypertension WHOclass II is non-Formulary.S IloprostIloprost nebules are restricted to useas an alternative in patients receivingother forms of prostacyclin treatmentand to use by specialists in theScottish Pulmonary Vascular Unit.S MinoxidilS Sildenafil citrateRestricted to specialists working inthe Scottish Pulmonary Vascular Unit

82 The Greater Glasgow and Clyde Formularyand by physicians experienced in themanagement of pulmonary vasculardisease.S Sodium nitroprussideS SitaxentanRestricted to initiation and prescribingby specialists in the ScottishPulmonary Vascular Unit.2.5.2 s Methyldopas MoxonidineRestricted to clinicians experienced intreating hypertension.2.5.4 DoxazosinExcluding MR preparation2.5.5 CaptoprilExcludes combination products.EnalaprilExcludes combination products.LisinoprilExcludes combination products.Perindopril erbumine (tertbutylamine)Excludes combination products.RamiprilExcludes combination products.CandesartanRestricted to second line use inpatients with a significant coughon an ACE inhibitor. Use as add-ontherapy with ACE inhibitors for heartfailure and left ventricular systolicdysfunction is restricted to specialistinitiation.IrbesartanExcludes combination products.Restricted to second line use inpatients with a significant cough onan ACE inhibitor.LosartanExcludes combination products.Restricted to second line use inpatients with a significant cough onan ACE inhibitor.TelmisartanRestricted to second line use inpatients with a significant coughon an ACE inhibitor. Excludescombination products.ValsartanExcludes combination products.Restricted to second line use inpatients with a significant cough onan ACE inhibitor. Restricted to secondline alternative in patients followingmyocardial infarction with evidenceof left ventricular systolic dysfunctionwho cannot tolerate ACE inhibitors.2.6.1 Isosorbide mononitrateStandard-release tablets arepreferred formulation. Sustainedreleasepreparations should onlybe considered in patients for whomcompliance is a problem.Glyceryl trinitrateTransdermal nitrate preparations aresignificantly more expensive than oralformulations.2.6.2 AmlodipineNifedipinePrescribe by brand name. Short actingcapsules are no longer recommendedfor angina and hypertension; their usemay be associated with variations inblood pressure and reflex tachycardia.DiltiazemPrescribe by brand name.VerapamilPrescribe by brand name.

Third edition August 2009 83s NimodipineOnly licensed for the prevention andtreatment of ischaemic neurologicaldeficits following aneurysmalsubarachnoid haemorrhage.2.6.3 s IvabradineRestricted to symptomatic treatmentof chronic stable angina pectoris inpatients with normal sinus rhythm forwhom heart rate control is desirableand who have a contra-indication orintolerance for beta-blockers and ratelimitingcalcium-channel blockersNicorandilNifedipineNaftidofuryl oxalateRefer to SIGN 89 for the diagnosisand management of PVD. Treatmentshould be reassessed after threemonths and discontinued if of nobenefit. There is poor evidencesupporting vasodilator treatment andit is important that contributory riskfactor treatments (such as antiplateletand cholesterol-lowering therapies)are considered.2.7.1 S DobutamineS DopamineS DopexamineS Isoprenaline2.7.2 S EphedrineS Noradrenaline2.7.3 Adrenaline2.8.1 HeparinS Epoprostenols FondaparinuxRestricted to use for the treatment ofunstable angina or non-ST segmentelevation myocardial infarction(NSTEMI) or ST segment elevationmyocardial infarction (STEMI) inaccordance with agreed local protocols.S LepirudinDanaparoid sodiumRestricted to use in accordance withlocal protocolss Dalteparins Enoxaparins Tinzaparin2.8.2 WarfarinS RivaroxabanRestricted to use in VTE prophylaxisin orthopaedic surgery in accordancewith local protocol2.8.3 S Protamine2.9 Aspirin dispersibleExcluding EC formulations.ClopidogrelRestricted to patients contraindicatedto aspirin or intolerant of aspirindespite the addition of a PPI. Forprevention of atherothromboticevents in acute coronary syndrome,clopidogrel, in combination withaspirin should be used in accordancewith the current NHSGGC AntiplateletGuideline.DipyridamoleExcluding Asasantin Retard ® .Dipyridamole retard is restrictedto patients requiring stroke/TIAsecondary prevention where an eventhas occurred despite treatment withaspirin.S AbciximabRestricted to use by consultantcardiologists in high risk and unstablepatients undergoing a variety ofpercutaneous coronary interventions.S TirofibanRestricted to use by consultantcardiologists.

84 The Greater Glasgow and Clyde Formulary2.10.2 S AlteplaseFor fibrinolytic treatment of acuteischaemic stroke alteplase isrestricted to specialist centres withadequate resources and appropriateexpertise and in accordance withdetailed protocols.S ReteplaseS StreptokinaseS Tenecteplase2.11 Tranexamic acidS Drotrecogin alfaRestricted to specialist use only forpatients in Intensive Care Units withsevere sepsis that has resulted inmultiple organ failure in line with NICEGuidance no. 84.2.12 SimvastatinRecommended starting dose is 40mgdaily.AtorvastatinAtorvastatin 80mg is only to beinitiated by consultants in patientswho have definite coronary arterydisease and present with an acutecoronary syndrome (confirmed byelevated troponin concentration).In patients who fail to meet goals forcholesterol reduction on simvastatin40mg, the dose of atorvastatin maybe up-titrated up to 80mg (see below).In preference to increasing the doseof simvastatin, patients should beswitched to an appropriate doseof atorvastatin, 20mg followed byup-titration if required through 40mgto 80mg. Use in children aged over10 years is restricted to initiationby paediatricians or physiciansspecialising in the management oflipid disorders.RosuvastatinRestricted to use in patients whofail to reach target lipid levels inaccordance with NHSGGC LipidLowering Guidelines or for patientswho are intolerant to simvastatin oratorvastatin. Doses in excess of 40mgshould only be inititated by, or on theadvice of a specialist.ColestyramineBezafibrateFenofibrates EzetimibeExcludes combination preparations ofezetimibe and simvastatin. Restrictedto initiation by specialists whencholesterol targets are not reachedon the maximum tolerated andoptimised statin therapy.2.13 S Sodium tetradecyl sulfate

Third edition August 2009 8533.1.1.1 SalbutamolTerbutalineSalmeterolSeretide 500 accuhaler® is notrecommended by SMC for patientswith COPD with an FEV1 of less than 60percentFormoterol3.1.2 Ipratropium bromideTiotropiumSpiriva-Respimat ® is restricted topatients with poor manual dexteritywho have difficulty using theHandihaler ® device3.1.3 AminophyllinePrescribe by brand name.TheophyllinePrescribe by brand name.3.2 BeclometasoneCFC-free beclometasone inhalers maynot all be of an equivalent dose toregular beclometasone inhalers andthe BNF should be consulted whenprescribing.BudesonideBudesonide respules are restricted tohospital inpatient treatment of acutecroup only.HydrocortisoneFluticasoneExcludes nebuliser solution. Seretide500 accuhaler ® is not recommendedby SMC for patients with COPD withan FEV1 of less than 60%. Fluticasoneprovides equal clinical activity tobeclometasone and budesonide athalf the dosage.PrednisoloneBudesonide and formoterolCombination inhalers are restrictedfor use in patients on step 3 or aboveof the BTS/ SIGN asthma guidelines orfor patients with COPD in accordanceto current NHSGGC COPD Guidelines.Fluticasone and salmeterolCombination inhalers are restrictedfor use in patients on step 3 or aboveof the BTS/ SIGN asthma guidelines orfor patients with COPD in accordanceto current NHSGGC COPD Guidelines.Beclometasone and formoterolCombination inhalers are restricted foruse in patients on step 3 or above ofthe BTS/SIGN asthma guidelines.3.3.1 Cromoglicate sodium3.3.2 MontelukastRestricted to clinicians experiencedin treating asthma. Use for seasonalallergic rhinitis is non-Formulary.3.4.1 CetirizineChlorphenamineFexofenadineLoratadineAlimemazineHydroxyzinePromethazineOmalizumabTo be used according to local protocoland SMC restrictions.3.4.3 AdrenalineChlorphenamineHydrocortisone3.5.1 S DoxapramS Caffeine baseRestricted to use on the advice ofspecialists in neonatal paediatrics3.5.2 S PoractantRestricted to specialist use inneonatal respiratory distresssyndrome by consultant paediatriciansand specialist registrars.

86 The Greater Glasgow and Clyde Formulary3.7 Carbocisteine3.8 Benzoin tincture compound3.9 PholcodineSimple linctus44.1.1 DiazepamNitrazepamTemazepamZopicloneRestricted to use only in patients whorequire pharmacological treatmentwhere temazepam is not tolerated orappropriate.Chloral hydrateClomethiazole4.1.2 ChlordiazepoxideDiazepamOxazepams Lorazepams BuspironePropranolol4.2.1 s QuetiapineRestricted to initiation by consultantpsychiatristRisperidoneThe Quicklet ® formulation is restrictedfor use in patients with swallowingdifficulties where orodispersibleis an appropriate formulation. TheCSM have advised that there is anincreased risk of stroke in elderlypatients with dementia treated withrisperidone.s AmisulprideRestricted to initiation by a consultantpsychiatrist.s AripiprazoleRestricted to initiation by a consultantpsychiatrist with the injection beingfurther restricted to use by consultantpsychiatrists only. The treatment ofmoderate to severe manic episodes inbipolar 1 disorder and the preventionof a new manic episode in patientswho experienced predominantlymanic episodes is non-Formulary.

Third edition August 2009 87S ClozapineConsultant only. Patients must beregistered with a Clozapine patientmonitoring scheme.s OlanzapineCSM have advised that there is anincreased risk of stroke in elderlypatients with dementia treated witholanzapine. Restricted to initiation byconsultant psychiatrist. The injectionis restricted to use when oral therapyis not suitable.ChlorpromazineIM chlorpromazine is notrecommended for rapidtranquillisation.HaloperidolLevomepromazines Flupentixols Sulpirides Trifluoperazines Zuclopenthixol4.2.2 s Flupentixol decanoates Fluphenazine decanoates Haloperidol decanoates Pipotiazine palmitates RisperidoneRestricted to use under the overallsupervision of a psychiatrist andsubject to NHSGGC protocol.s Zuclopenthixol decanoate4.2.3 CarbamazepineLithiumPrescribe by brand name. Plasmaconcentrations should be monitoredby sampling at least 12 hours afterpreceding dose and should bechecked every 3 months in stabilisedpatients.LofepramineTrazodone4.3.2 PhenelzineRestricted to patients who havefailed to respond to first lineantidepressants.s TranylcypromineSpecialist initiation. Restricted topatients who have failed to respond tofirst line antidepressants.MoclobemideRestricted to patients who havefailed to respond to first lineantidepressants.4.3.3 FluoxetineCitalopramParoxetineSertraline4.3.4 s DuloxetineRestricted to psychiatrist initiationonly as a third line therapy for majordepressive episodes. The SMC has notrecommended its use for generalisedanxiety disorders.MirtazapineRestricted to use as a second lineagent for depression.VenlafaxineRestricted to use as a third lineagent for depression. See NHSGGCdepression guidelines. The CSM haveadvised that venlafaxine should notbe used in children and adolescentsunder 18 years of age. The treatmentof moderate to severe generalisedsocial anxiety disorder/social phobiahas not been accepted for use by SMCand is non-Formulary.4.3.1 Amitriptylines ClomipramineImipramine

88 The Greater Glasgow and Clyde Formulary4.4 s AtomoxetineRestricted to initiation by specialistswith appropriate knowledge andexpertise in treating ADHD in childrenover 6 years and adolescents who donot respond to stimulants or in whomstimulants are contraindicated or nottolerated.s DexamphetamineRestricted to second line therapy forthe treatment of ADHD and initiationby child or adolescent psychiatrists orpaediatricians with expertise in ADHD.s MethylphenidateRestricted to initiation by childor adolescent psychiatrists orpaediatricians with expertise in ADHD.The modified-release preparationsare restricted to second line therapywhere there is evidence of complianceproblems or where clear evidence thatadministration of a midday dose isproblematic or inappropriate.s ModafinilVery few indications - specialist advicerequired. Modafinil is not approvedfor excessive daytime sleepinessassociated with obstructive sleepapnoea/hypopnoea syndrome or shiftwork sleep disorder.4.5.1 OrlistatRestricted to use for patients with BMI>30 with relevant co-morbidities andBMI >35 without co-morbidities. Otherconditions for prescribing should be inaccordance with NICE TA22. It shouldbe prescribed only on the adviceof the Glasgow and Clyde WeightManagement Service.s MethylcelluloseSibutramineRestricted to use for patients withBMI >30 with relevant co-morbiditiesand BMI >35 without co-morbidities.Other prescribing conditions inaccordance with NICE TA31. Itshould be prescribedon the adviceof the Glasgow and Clyde WeightManagement Service.4.6 Cinnarizines Cyclizines Promethazines ChlorpromazineProchlorperazineDomperidoneMetoclopramideMetoclopramide causes more frequentextra-pyramidal side effects thandomperidone and is not indicatedin patients less than 20 years of ageexcept for limited indications whenthe dose should be determined on thebasis of body weight.s GranisetronIn the management of post-operativenausea and vomiting (PONV),restricted to use in patients refractoryto routine antiemetics or with asubstantial history of PONV. Prolongeduse can cause severe constipation androutine laxatives should be considered.s OndansetronIn the management of post-operativenausea and vomiting (PONV),restricted to use in patients refractoryto routine antiemetics or with asubstantial history of PONV. Prolongeduse can cause severe constipationand routine laxatives should beconsidered.Not on the Formulary for themanagement of PONV.

Third edition August 2009 89s NabiloneBetahistine4.7.1 ParacetamolThe infusion should be only be usedwhen the IV route can be clinicallyjustified over other routes ofadministration.IbuprofenCo-codamolDispersible formulations areconsiderably more expensive andshould be restricted to patients withswallowing difficulties. Their highsodium content (up to 8g daily) exceedsWHO recommendations and maycompromise antihypertensive therapy.Co-dydramol4.7.2 Codeine phosphateCyclimorph ®DiamorphineDihydrocodeineExcludes DF118 Forte ® , Remedeine ®and Remedeine Forte ® .Morphine sulphateModified-release preparations shouldbe prescribed by brand nameExcludes Morcap SR ® , Moraxen ® andDepodur ®OxycodoneModified-release preparations shouldbe prescribed by brand nameOxycodone is restricted use inpatients where morphine is ineffectiveor not tolerated. The injection isrestricted to initiation by specialistsin palliative care and oncology foruse in patients for whom morphine/diamorphine is ineffective or nottolerated. Oxycodone injection isnon-Formulary for post-operative use.Excludes the combination product ofoxycodone and naloxone (Targinact ® ).Pethidines Fentanyl citrate lozengesRestricted to initiation by hospitalpalliative care and cancer specialists.s Fentanyl transdermal patchesRestricted to use on specialist advicein palliative care and to second lineuse in patients with intractable, nonmalignantpain which is relativelystable and has been controlled byoral therapy. It should be reserved forpatients with swallowing difficultiesor who have problems with opiateconstipation.s MethadoneExcludes Eptadone ®Tramadol capsulesRestricted to use when simpleanalgesia has failed or is not tolerated.Excludes modified-release andcombination preparations.s Tramadol injection4.7.3 AmitriptylineCarbamazepineGabapentins PhenytoinPregabalinRestricted to use for peripheralneuropathic pain in adults whohave not responded to or toleratedconventional first and second linetreatments. Treatment should bediscontinued if the patient has notshown sufficient benefit within 8weeks of reaching the maximallytolerated therapeutic dose.s DuloxetineRestricted to specialist initiation assecond or third line therapy.

90 The Greater Glasgow and Clyde Formulary4.7.4.1 AspirinIbuprofenMigraleve ®Migraleve ® yellow is equivalent toco-codamol 8/500, but much moreexpensive.ParacetamolParamax ®Contains metoclopramide. Notindicated in patients less than20 years of age except for limitedindications when the dose should bedetermined by body weight.RizatriptanPlasma concentrations may beincreased by concomitant use ofpropranolol, therefore the 5mg doseof rizatriptan should be used.ZolmitriptanExcluding nasal spray.FrovatriptanSumatriptanThe rapid-disintegrating tablets arerestricted to second line treatment forpatients for whom standard tabletsare not appropriate.4.7.4.2 PizotifenPropranolols TopiramateUse in the prophylaxis of migraine isrestricted to initiation by specialistsand treatment should be managedunder specialist supervision or sharedcare arrangements in patients whohave not responded to prophylactictreatment with at least one otheragent.4.8.1 s CarbamazepinePrescribe by brand name.s LacosamideRestricted to patients with refractoryepilepsy.s Phenobarbitals PhenytoinPrescribe by brand name.s Rufinamides Sodium valproatePrescribe by brand name.s Semisodium vaproateRestricted to specialist initiation for thetreatment of mania in bipolar disorder.s Acetazolamides Clobazams Clonazepams Ethosuximides Fosphenytoins Gabapentins Lamotrigines LevetiracetamMonotherapy for partial onsetseizures (with or without secondarygeneralisation) in newly diagnosedpatients is further restricted to secondline treatment when usual first linetreatment are ineffective or nottolerated. The infusion is restricted tospecialist use only.s OxcarbazepineExcluding liquid.s PregabalinRestricted to initiation only byphysicians who have appropriateexperience in the treatment ofepilepsy and should be usedprincipally in patients who have notbenefited from treatment with olderanti-convulsants or for whom thesedrugs are unsuitable because ofcontraindications, interactions or poortolerance. Pregabalin has not beenaccepted by the SMC for use in thetreatment of central neuropathic painand generalised anxiety disorder andis non-Formulary for these indications.

Third edition August 2009 91s Primidones Tiagabines Topiramates Vigabatrins ZonisamideRestricted to initiation by physicianswho have appropriate experience inthe treatment of epilepsy for use inpatients who have not responded toestablished anticonvulsants or forwhom these drugs are unsuitable ornot tolerated.4.8.2 DiazepamLorazepams Clonazepams Fosphenytoins Midazolam (buccal)Buccal midazolam should only beinitiated on the advice of a specialistin accordance with agreed localguidelines and following appropriatetraining of the parent or carer. Itmay, however, be continued to beprescribed in primary care.s Paraldehydes Phenytoin4.8.3 ParacetamolThe infusion should be only be usedwhen the IV route can be clinicallyjustified over other routes ofadministration.Diazepam4.9.1 Co-beneldopaCo-careldopaExcludes intestinal gel.Levodopa/carbidopa/entacapones ApomorphineApomorphine is restricted to usein patients with mid/late stageParkinson’s disease under consultantsupervision only. Its use is subject toa shared care protocol.BromocriptineCabergolinePergolidePramipexolePramipexole dosing can be expressedas either base or salt and thisshould be clearly documented whenprescribing. Restricted to use on theadvice of consultants with a specialinterest in Parkinson’s disease ormovement disorders. The use ofpramipexole in restless legs syndrome(RLS) is restricted to those patientswith severe RLS (symptoms resultingin significant disruption to sleep andimpairment of daily living.RopiniroleRestricted to use on the advice ofconsultants with a special interestin Parkinson’s disease or movementdisorders. Use in restless legssyndrome is restricted to thosepatients with severe RLS (symptomsresulting in significant disruption tosleep and impairment of daily living.s Rotigotine transdermal patchRestricted to specialist initiation forpatient where the transdermal routewould facilitate treatmentEntacapones SelegilineExcludes selegiline melt.s Amantadine4.9.2 TrihexyphenidylOrphenadrineProcyclidine4.9.3 Propranolols Chlorpromazines Haloperidols Pimozides Primidone

92 The Greater Glasgow and Clyde Formularys RiluzoleUse is subject to a shared careprotocol.s Sulpirides TetrabenazineS Botulinum A toxinNot recommended for focal spasticity,including the treatment of wrist andhand disability due to upper limbspasticity associated with strokein adults. Three brands available(Dysport ® , Xeomin ® and Botox ® ). Thedoses are specific to the preparationsand they are not interchangeable.Treatment of focal spasticity withDysport ® in conjunction withphysiotherapy has not been acceptedby SMC.S Botulinum B toxin4.10 s AcamprosateUse is subject to a shared careprotocol.S DisulfiramOnly to be used under specialistsupervision.Nicorette ® patchBupropionVareniclineRestricted to use according to localprotocol which includes: Patientsmust have had a previous attempt toquit smoking on the NHS more thansix months previously; The patientmust have attempted to quit usingNRT for at least a four-week period;Patients must be linked to one of therecognised smoking cessation supportprogrammes.Methadone 1mg/ml oral solutions Buprenorphine (Subutex ® )Restricted to specialist services(Alcohol and Drug directorate andGlasgow Addictions Services).s LofexidineRestricted to specialist services(Alcohol and Drug directorate andGlasgow Addictions Services).s Buprenorphine and naloxone(Suboxone ® )Restricted to specialist services(Alcohol and Drug directorate andGlasgow Addictions Services) forthose patients in whom methadoneis not suitable and for whom theuse of buprenorphine is consideredappropriate.4.11 s DonepezilUse subject to a Shared CareProtocol. Orodispersible tablets arerestricted to patients with swallowingdifficulties.s GalantamineUse subject to a Shared Care Protocol.s RivastigmineRestricted to use according to localprotocol. Use of the transdermal patchis further restricted to patients forwhom rivastigmine is an appropriatechoice and in whom a transdermalpatch is an appropriate choice offormulation.

Third edition August 2009 9355.1.1.1 BenzylpenicillinPhenoxymethylpenicillin5.1.1.2 Flucloxacillin5.1.1.3 AmoxicillinCo-amoxiclavExcludes Augmentin Duo ® .5.1.1.4 s Tazocin ®Recommended for use on the adviceof a microbiologist or an infectiousdisease physician as second linetherapy in severely ill patients withmulti-resistant organisms.5.1.2 CefalexinCefaclors Cefotaximes CefradineAvoid using oral cephalosporins as astep down following IV use.s Ceftazidimes CefuroximeAvoid using oral cephalosporins as astep down following IV use.s AztreonamRestricted to use on microbiologicaland infectious disease physicianadvice only.S DoripenemRestricted to use on the advice oflocal microbiologists or specialists ininfectious diseases for the treatmentof nosocomial pneumonia andas second or third line treatmentof complicated intra-abdominalinfections resistant to currentconventional treatment.s ErtapenemRestricted to second or third linetreatment of community-acquiredintra-abdominal infections resistantto current conventional treatments.Treatment of diabetic foot infections ofthe skin and soft tissue is restrictedto use by specialists managingdiabetic foot infection on the adviceof a microbiologist. The indication ofprophylaxis of surgical site infectionfollowing elective colorectal surgery inadults remains non-Formulary.s Imipenem with cilastinRestricted to use on microbiologicaland infectious disease physicianadvice only.s MeropenemRestricted to use on microbiologicaland infectious disease physicianadvice only.5.1.3 DoxycyclineMinocyclineOxytetracyclineTetracyclines TigecyclineRestricted to second or third lineuse under the advice of localmicrobiologists or specialists ininfectious diseases.5.1.4 s AmikacinRestricted to use on microbiologicaland infectious disease physicianadvice only.s Gentamicins Neomycins NetilmicinRestricted to use on microbiologicaland infectious disease physicianadvice only.s Tobramycin5.1.5 AzithromycinOnly Formulary for indications whichrequire its powerful anti-chlamydialeffect.

94 The Greater Glasgow and Clyde FormularyClarithromycinExcluding Clarosip ® .Erythromycin5.1.6 s ClindamycinExcludes vaginal cream.5.1.7 s Chloramphenicols ColistinRestricted to use on microbiologicaland infectious disease physicianadvice only.s DaptomycinRestricted to use in patients notresponding to or intolerant of aglycopeptide. Use for for VRE, VISAand VRSA2 or known or suspectedMRSA infection is restricted to theadvice of a microbiologist or specialistin infectious diseases.S LinezolidRestricted to hospital-based useon the advice of a microbiologistor infectious disease physician.Prolonged use (>2 weeks) must beavoided.s Quinupristin-dalfopristinRestricted to use on the adviceof consultant microbiologist formanagement of infection due tovancomycin resistant organisms.s Sodium fusidates TeicoplaninRestricted to use on microbiologicaland infectious disease physicianadvice only. Vancomycin is the firstline glycopeptide.s VancomycinRestricted to use on microbiologicaland infectious disease physicianadvice only. Vancomycin is the firstline glycopeptide.5.1.8 Trimethoprims Co-trimoxazoleThe CSM has recommended thatco-trimoxazole be restricted to usein Pneumocystis carinii pneumonia,toxoplasmosis and nocardiasis. Itshould only be used in urinary orrespiratory tract infections wherethere is bacterial evidence ofsensitivity and good reason to preferthe combination to a single antibiotic.5.1.9 RifampicinRecommended for the prevention ofsecondary cases of meningococcalmeningitis and Haemophilusinfluenza type B infection.s Ethambutols Isoniazids RifabutinRestricted to patients withmycobacterial infections resistant toconventional anti-tuberculosis drugs.s Rifater ®s Rifinah ®s Streptomycin5.1.10 s Dapsone5.1.11 Metronidazole5.1.12 CiprofloxacinExcluding eye drops and 100mgtablets for uncomplicated UTI. Oralciprofloxacin has good bioavailabilityand should be prescribed inpreference to IV whenever possible.s OfloxacinRestricted to patients with pelvicinflammatory disease.s LevofloxacinRestricted to second line use byhospital specialists for penicillinallergic patients with communityacquired pneumonia or for cysticfibrosis patients intolerant of

Third edition August 2009 95ciprofloxacin where a quinolone isrequired.s MoxifloxacinRestricted to second line use byhospital specialists for penicillinallergic patients with communityacquired pneumonia or for cysticfibrosis patients intolerant ofciprofloxacin where a quinolone isrequired.s NorfloxacinRestricted to prophylactic use onlyfor spontaneous bacterial peritonitisin line with the GGC managementof decompensated liver diseaseguidelines5.1.13 TrimethoprimFirst line choice for uncomplicated UTIs.Nitrofurantoin5.2 FluconazoleGriseofulvinItraconazoleNot approved for fungal nail infections.TerbinafineS AnidulafunginThe treatment of invasive candidasisin adult non-neutropenic patient isrestricted to use on the advice of aconsultant microbiologist where othertreatment options are unsuccessful orinappropriate.S AmphotericinAbelcet ® , AmBisome ® and Amphocil ®are restricted to use in systemicmycoses when toxicity (especiallynephrotoxicity) precludes the useof conventional amphotericin.AmBisome ® is not approved for theempirical treatment of fungal infectionsin the febrile neutropenic patient.S CaspofunginCaspofungin is restricted to adult andpaediatric patients with fluconazoleresistantCandida infectionunresponsive to or who cannottolerate amphotericin B therapy. Itis not recommended by SMC forinvasive aspergillosis. Restricted forempirical therapy for presumed fungalinfections in febrile, neutropenic adultand paediatric patients on the adviceof microbiologists or specialists ininfectious diseases.s Flucytosines KetoconazoleNystatinS PosaconazoleUse for the prophylaxis ofinvasive fungal infections inimmunocompromised patients isrestricted to patients in whom there isa specific risk of aspergillus infectionor where fluconazole or itraconazoleare not tolerated in accordance withlocal protocol.S VoriconazoleRestricted to use in secondary careon the advice of microbiologist/haematologist primarily in immunocompromisedpatients withprogressive, possibly life-threateninginfections. Treatment of candidaemiain non-neutropenic patients isrestricted to those who cannottolerate amphotericin B therapy orwho are at an increased risk of seriousside effects with amphotericin.5.3.1 S AbacavirRestricted to use by HIV specialists.S Trizivir ®Restricted to use by HIV specialists.

96 The Greater Glasgow and Clyde FormularyS Kivexa ®Restricted to use by HIV specialists.S DidanosineRestricted to use by HIV specialists.S EmtricitabineRestricted to use by HIV specialists.S LamivudineRestricted to use by HIV specialists.S StavudineRestricted to use by HIV specialists.S TenofovirRestricted to use by HIV specialists.Treatment of hepatitis B is restrictedto use according to Hepatitis MCNprotocol.S Truvada ®Restricted to use by HIV specialists.S Atripla ®Restricted to use by HIV specialists.S ZidovudineRestricted to use by HIV specialists.S Combivir ®Restricted to use by HIV specialists.S AtazanavirRestricted to use by HIV specialistsonly. Use in naïve HIV-1 infectedadults in combination with otherantiretrovirals is further restrictedto when other treatments are nottolerated or inappropriate.S DarunavirRestricted to use by HIV specialists.S FosamprenovirRestricted to use by HIV specialists.Treatment of infected adolescents andchildren of 6 years and above remainsnon-Formulary.S IndinavirRestricted to use by HIV specialists.S NelfinavirRestricted to use by HIV specialists.S RitonavirRestricted to use by HIV specialists.S Kaletra ®Restricted to use by HIV specialists.S SaquinavirRestricted to use by HIV specialists.S EfavirenzRestricted to use by HIV specialists.S NevirapineRestricted to use by HIV specialists.Potentially fatal liver toxicity and skinreactions.S EnfuvirtideRestricted to use by HIV specialists.S RaltegravirRestricted to use by HIV specialistsonly in patients with triple-classresistant HIV-1 infection.5.3.2.1 AciclovirFamciclovirNot approved for genital herpes.ValaciclovirNot approved for prevention ofrecurrent herpes.5.3.2.2 S CidofovirRestricted to use by HIV specialists.S FoscarnetRestricted to use by HIV specialists.S GanciclovirRestricted to use by HIV specialists.S ValganciclovirRestricted to use by HIV specialists.5.3.3 S Adefovir dipivoxilRestricted for use subject to localprotocol by Hepatitis MCN.

Third edition August 2009 97s EntecavirRestricted to specialist initiation inline with Hepatitis MCN protocol.S LamivudineRestricted to recommendation byconsultants treating hepatitis B.S RibavirinUse subject to Hepatitis MCN protocolwith pegylated interferon alfa inhepatitis C.s TelbivudineRestricted to specialist initiation inline with the Hepatitis MCN protocol.S TenofovirTreatment of hepatitis B is restrictedto use according to Hepatitis MCNprotocol.5.3.4 OseltamivirOseltamivir use in the prophylaxis ofinfluenza is subject to NICE TA158 andthe treatment of influenza is subjectto NICE TA168 .ZanamivirZanamivir use in the prophylaxis ofinfluenza is subject to NICE TA158 andthe treatment of influenza is subjectto NICE TA168 .Proguanils HalofantrineIt is restricted for use in specialistcentres, for quinine resistance.s QuinineQuinine IV should be administeredwith caution under the supervision ofa specialist in infectious diseases.5.4.8 s Co-trimoxazoleUse on advice of specialist ininfectious diseases.s PentamidineUse on advice of specialist ininfectious diseases.s AtovaquoneUse on advice of specialist ininfectious diseases.5.5.1 MebendazolePripsen ®5.3.5 s PalivizumabRestricted to use as indicated in Westof Scotland protocol.s Ribavirins TipranavirRestricted to specialist initiationin line with Hepatitis MCN protocolRestricted to patients with a tipranavirmutation score of less than 4.5.4.1 ChloroquineMefloquine

98 The Greater Glasgow and Clyde Formulary66.1.1 InsulinSee BNF, noting additional restrictionsbelow. Inhaled insulin is excludedfrom the Formulary.s Insulin glargineInsulin glargine is restricted toinitiation by consultant diabetologistsin patients with severe/ frequentnocturnal hypoglycaemia. Notfor routine use in type 2 diabetesunless patients suffer from recurrentepisodes of hypoglycaemia orrequire assistance with their insulininjections.s Insulin detemirInsulin detemir (Levemir ® ) isrestricted to initiation by consultantdiabetologists in children, adolescentand adult patients with severe/frequent nocturnal hypoglycaemia.Not for routine use in type 2 diabetesunless patients suffers from recurrentepisodes of hypoglycaemia.Insulin glulisineRestricted to use in patients whereregular human soluble insulin isinappropriate.6.1.2.1 GliclazideGlipizideGlibenclamideGlibenclamide should be avoided inthe elderly due to the high incidenceof hypoglycaemia.6.1.2.2 Metformin (excluding SRpreparations)Metformin is the antidiabetic drug ofchoice in both overweight and normalweight patients. It is contra-indicatedin patients with renal failure ordysfunction (creatinine clearance

Third edition August 2009 99cannot be treated or controlled witha sulphonylurea in combination withmetformin.s Rosiglitazone and metforminRestricted to initiation by or on theadvice of a consultant diabetologist.Rosiglitazone and metformin(Avandamet ® ) may offer advantagesfor concordance in some patients.Restricted to the 2mg/1000mg and4mg/1000mg formulations.Use intriple therapy is restricted to use inpatients who cannot be controlledwith a sulphonylurea in combinationwith metformin.s ExenatideRestricted to specialists initiation asan alternative for patients who havefailed treatment on metformin and/ or sulphonylureas and in whominsulin would be the next treatmentoption.s SitagliptinRestricted to specialist initiationwhen used in combination with asulphonylurea when metformin iscontraindicated or not tolerated orin combination with a sulphonylureaand metformin. In primary care, it isexpected that initiation would followinteraction between the GP/DiabeticSpecialist Nurse and the consultantcontact within the acute sector.s VildagliptinRestricted to use in combination withmetformin only when the addition ofa sulphonylurea is not appropriate forpatients with insufficient glycaemiccontrol despite maximum tolerateddose of monotherapy with metformin.In primary care it is expected thatinitiation would follow interactionbetween the GP/Diabetic SpecialistNurse and the consultant contactwithin the acute sector.s Vildagliptin and metforminRestricted to specialist initiation onlywhen the addition of a sulphonylureais not appropriate for patientswith insufficient glycaemic controldespite maximum tolerated doseof monotherapy with metformin. Inprimary care it is expected thatinitiation would follow interactionbetween the GP/ Diabetic SpecialistNurse and the consultant contactwithin acute care.6.1.4 GlucoseGlucagon6.2.1 LevothyroxineS Liothyronine6.2.2 CarbimazoleS Aqueous iodines Propylthiouracil6.3.1 FludrocortisoneHydrocortisone6.3.2 DexamethasoneHydrocortisonePrednisolones Betametasones Cortisones Methylprednisolones Triamcinolone6.4.1.1 See BNF, excludes Angeliq ®Oestradiol 0.6% gel (Oestrogel ® )Restricted to patients who fail totolerate oral or patch preparations.s Raloxifene hydrochlorideRestricted to use in patients for whombisphosphonates are contraindicatedor not appropriate.

100 The Greater Glasgow and Clyde Formulary6.4.2 s TestosteroneExcludes Intrinsa ® injection whichhas not been accepted for use bySMC and remains non-Formulary.Testosterone gel and transdermalpatches are restricted to use onthe recommendation of consultantendocrinologists, urologistsand oncologists. Testosteronemucoadhesive buccal prolongedreleasetablets (Striant SR ® ) arerestricted to use in patients who wouldbenefit particularly from this mode ofadministration where intramusculartreatment is not suitable.Cyproterones Dutasterides Finasteride6.4.3 S Nandrolone decanoate6.5.1 Clomifene (clomiphene)s Tetracosactides Choriogonadotropin alfa(Ovitrelle ® )s Chorionic gonadotrophins Human menopausalgonadotrophinsLutropin alfas SomatropinSomatropin for use in adults withgrowth hormone deficiency isrestricted to initiation by consultantendocrinologists and subject to ashared care protocol. The treatment ofgrowth disturbance in short childrenborn small for gestational age andwho have failed to show catch-upgrowth by 4 years of age or later isrestricted to initiation and monitoringby a paediatrician with expertise inmanaging childhood growth disordersand growth hormone therapy.s Gonadorelins Protirelin6.5.2 S TerlipressinDesmopressinDesmopressin tablets are restrictedto use in patients unable to useintramuscular preparations.Intravenous desmopressin isrestricted to specialist use inhaemophilia centres.s Demeclocycline6.6.1 S Parathyroid Hormone (PTH-184,Preotact ® )Restricted to specialist use for thetreatment of osteoporosis accordingto local prescribing protocol followingassessment of fracture risk includingmeasurement of bone mineral density.S Teriparatide (PTH 1-34,Forsteo ® )Restricted to specialist use for thetreatment of osteoporosis only forthose patients for whom parathyroidhormone (PTH 1-84) is not licensedor not tolerated. The treatmentof osteoporosis associated withglucocorticoid therapy in women andmen at increased risk of fracture isnon-Formulary.6.6.2 Alendronic acidRisedronateExcludes the treatment of osteoporosisin men at high risk of fractures as notrecommended by SMC.Strontium ranelateRestricted for the treatment ofpostmenopausal osteoporosis inwomen of 75 years or over withprevious fracture and T-score

Third edition August 2009 101s Ibandronic acid (excludingBonviva ® tablets)The use of the injection forosteoporosis is restricted to use inpatients who are unsuitable for orunable to tolerate oral treatmentoptions for osteoporosis. Treatmentinitiation should be under specialistsupervision. Restricted to secondline use by specialist oncologistsfor prevention of skeletal eventsin patients with breast cancer andmetastatic bone cancer and toconsultants treating tumour inducedhypercalcaemia.s Tiludronic acidS Zoledronic acidRestricted to prescribing byconsultants treating tumour-inducedhypercalcaemia and by specialistoncologists for the prevention ofskeletal related events in patientswith breast cancer and multiplemyeloma. It is not approved for usefor the prevention of skeletal relatedevents in prostate or non-small celllung cancer. Treatment of Paget’sdisease is restricted to specialist useonly. The treatment for osteoporosisin post-menopausal women isrestricted to specialist use in patientswho are unsuitable for or unable totolerate oral treatment options. Thetreatment of men at inceased riskof fracture, including those with arecent low-trauma hip fracture, is notrecommended by SMC.with pulmonary, retroperitoneal andpericardial fibrotic reactions. Refer toBNF for details.s CabergolineRestricted to use on therecommendation of a specialistendocrinologist or gynaecologist. TheCSM has advised that bromocriptineand cabergoline have been associatedwith pulmonary, retroperitoneal andpericardial fibrotic reactions. Refer toBNF for details.s Quinagolide6.7.2 BuserelinDanazols Cetrorelixs GanirelixGoserelinLeuprorelinNafarelinTriptorelinConsidered 1st choice gonadorelinanalogue for treatment of advancedprostate cancer6.7.3 s Metyrapones Trilostane6.7.1 s BromocriptineRestricted to use on therecommendation of a specialistendocrinologist or gynaecologist. TheCSM has advised that bromocriptineand cabergoline have been associated

102 The Greater Glasgow and Clyde Formulary77.1.1 ErgometrineSyntometrines Carboprosts Dinoprostones Gemeprosts Oxytocin7.1.1.1 s AlprostadilS IndometacinS Ibuprofen injection7.1.2 S Mifepristone7.1.3 s Ritodrine7.2.1 Estring ®Estradot ®Ortho-Gynest ®Ovestin ®Vagifem ®7.2.2 ClotrimazoleMiconazoleNystatinAci-Jel ®Metronidazole 0.75% vaginal gelMetronidazole gel is restricted topatients unable to tolerate or complywith oral metronidazole therapy.Povidone-iodineSultrin7.3 See BNF (excludes Yasmin ® )Cerazette ®Restricted to patients in whomoestrogen containing contraceptivesare not tolerated or are contraindicated.Evra ®Restricted to use in women with poorcompliance on the combined oralcontraceptive.Mirena ®7.4.1 AlfuzosinTerazosinTamsulosinExcludes modified-release tablets.s DutasterideOnly suitable for patient withenlargement of the prostate.s FinasterideOnly suitable for patient withenlargement of the prostate.7.4.2 DarifenacinRestricted to use in patients fail torespond to or tolerate normal-releaseoxybutynin.DuloxetineRestricted for use only as part of anoverall management strategy forstress urinary incontinence in additionto pelvic floor muscle training andsubject to use by NHSGGC protocol.OxybutyninOxybutynin patches are restrictedto patients who derive benefit fromoral oxybutynin but who experienceintolerable anticholinergic side effects.TolterodineTrospiumSolifenacinRestricted to use in patients fail torespond to or tolerate normal-releaseoxybutynin.7.4.3 Potassium citrates Sodium bicarbonate7.4.4 Chlorhexidines Dimethyl sulfoxides Glycines Noxythiolin7.4.5 SildenafilAvailable for hospital and communityprescribing but NHS prescribingby GPs is limited to nationallydetermined patient groups andschedule 11 restrictions. Prescribingfor patients with severe distress mustremain with the hospital specialist.

Third edition August 2009 103Consult Summary of ProductCharacteristics on drug interactionsprior to prescribing.TadalafilAvailable for hospital and communityprescribing but NHS prescribingby GPs is limited to nationallydetermined patient groups andschedule 11 restrictions. Prescribingfor patients with severe distress mustremain with the hospital specialist.Consult Summary of ProductCharacteristics on drug interactionsprior to prescribing.VardenafilAvailable for hospital and communityprescribing but NHS prescribingby GPs is limited to nationallydetermined patient groups andschedule 11 restrictions. Prescribingfor patients with severe distress mustremain with the hospital specialist.Consult Summary of ProductCharacteristics on drug interactionsprior to prescribing.s Alprostadil8Many of the medicines within this chapterare subject to use in accordance withregional protocol. These will always bein line with SMC advice or other nationalguidance where available.8.1 S Calcium folinateS Calcium levofolinateS Mesna8.1.1 S BusulfanS CarmustineExcluding carmustine implantsS ChlorambucilS CyclophosphamideS IfosfamideS LomustineS MelphalanS ThiotepaS Treosulfan8.1.2 S BleomycinS DactinomycinS DoxorubicinS Doxorubicin pegylatedliposomalUse in the treatment of ovarian canceris restricted to use in accordance withregional protocol. It is not approvedfor the treatment of HIV-relatedKaposi’s sarcoma, metastatic breastcancer or second line treatment forprogressive multiple myeloma.S EpirubicinS MitomycinS Mitoxantrone8.1.3 S CapecitabineRestricted to use in accordance withregional protocolsS CladribineS Cytarabine (excludesliposomal)

104 The Greater Glasgow and Clyde FormularyS FludarabineRestricted to use for treatment of CLLin accordance with regional protocol.S FluorouracilS GemcitabineRestricted to use only for bladder,pancreatic or lung cancer inaccordance with regional protocols.S MercaptopurineUse in oncology is restricted tospecialist use only. Oral use inthe unlicensed indications ofinflammatory bowel disease (seesection 1.5) and autoimmune hepatitisis restricted to specialist initiationonly in patients who fail to tolerateazathioprine.s MethotrexateUse in the treatment of cancer isrestricted to specialist use only,other indications require specialistinitiation, but may be suitable forcontinuation by the GP.S NelarabineRestricted to specialist use inaccordance to regional protocol.S PemetrexedRestricted to specialist use for thetreatment of chemotherapy-naïvepatients with stage III/IV unresectablemalignant pleural mesothelioma. Usein the second line monotherapy ofnon-small cell lung cancer (NSCLC) isrestricted to use according to regionalprotocol. First line treatment of locallyadvanced or metastatic NSCLC, otherthan predominantly squamouscell histology, in combination withcisplatin is non-Formulary.S Tioguanine8.1.4 S EtoposideExcludes Etopophos ®S VinblastineS VincristineS VindesineS VinorelbineRestricted to use in accordance withregional protocols.8.1.5 S AmsacrineS BortezomibRestricted to use according to regionalprotocols. Use in the treatment ofmultiple myeloma is restricted to 3rdline and subsequent use only.S CarboplatinS CetuximabUse for head and neck cancer isrestricted to use in accordance withregional protocol. Not approved foruse in colorectal cancer.S CisplatinS Crisantaspase (asparaginase)S DacarbazineS DasatinibRestricted to use in the chronic phaseof CML in accordance with regionalprotocol. All other indication are non-Formulary.S DocetaxelUse for adjuvant and metastatic breastcancer, metastatic prostate cancer,non-small cell lung cancer and cancerof the head and neck is restrictedto use in accordance with regionalprotocols. The use of docetaxel inmetastatic gastric adenocarcinomahas not been accepted by SMC andremains non-Formulary.S HydroxycarbamideS ImatinibRestricted to use in the treatmentof CML and GIST in accordancewith regional protocols. All otherindications remain non-Formulary.

Third edition August 2009 105S IrinotecanRestricted to use in the treatment ofcolorectal cancer in accordance withregional protocol.S OxaliplatinRestricted to use in accordance withregional protocols.S NilotinibRestricted to specialist use inaccordance with regional protocol.S PaclitaxelRestricted to use in the treatmentof lung cancer, ovarian cancer andmetastatic breast cancer only inaccordance with regional protocols.Use in the treatment of AIDS relatedKaposi’s sarcoma is non-Formulary.S PentostatinRestricted to use by specialists inhaematological oncology for patientswith hairy cell leukaemia.S ProcarbazineS TemozolomideSpecialist use only in accordance withregional protocol.S TopotecanRestricted to use in the treatementof ovarian and cervical cancer inaccordance with regional protocols.Treatment of patients with relapsedsmall cell lung cancer has not beenaccepted by SMC and is non-Formulary.S TrastuzumabUse in the treatment of HER2 postiveearly breast cancer and metastaticbreast cancer is restricted to use inaccordance with regional protocol.S TretinoinRestricted to use in accordance withregional protocols.S ErlotinibUse for non-small cell lung cancer isrestricted to use in accordance withregional protocol. The treatment ofpatients with metastatic pancreaticcancer remains non-Formulary8.2.1 s AzathioprineAzathioprine should only be usedinstead of mycophenolic acid forrenal transplantation if there is a lowperceived immunological risk.S Mycophenolate mofetilMycophenolate mofetil is restrictedto specialist use in selected patientswho are at high risk of organtransplant rejection. Mycophenolatemofetil injection is restricted to use onspecialist advice in exceptional casese.g. patients who are nil by mouth.S Mycophenolic acidRestricted to use by transplantspecialists as part of animmunosuppressive regimen.8.2.2 CiclosporinFormulations should not besubstituted in individual patients dueto varying bioavailability.PrednisoloneS BasiliximabRestricted to specialist use in selectedpatients who are at high risk of renaltransplant rejection or for kidneysexpected to have significant ischaemicdamage.S SirolimusRestricted to specialist use inspecific patients with intolerance tocalcineurin inhibitors.

106 The Greater Glasgow and Clyde Formularys TacrolimusRestricted to specialist initiation.Tacrolimus preparations should beprescribed by brand name.8.2.3 S AlemtuzumabUse for treatment of B-cell chroniclymphontic leukaemia is restrictedaccording to regional protocolS RituximabUse in haematology is restrictedto use in accordance with regionalprotocols.8.2.4 S Interferon alfaNot approved for non-Hodgkin’slymphoma or malignant melanoma.S Pegylated interferon alfaRestricted to specialist use only inadults for the treatment of hepatitis Cin combination with ribavirin.S Pegylated interferon alfa 2bRestricted to use for chronic hepatitisC in combination with ribavirincapsules in accordance with HepatitisMCN protocol.S Interferon betaRestricted to use under the provisionof the ‘Risk Sharing Scheme’ betweenthe Scottish Executive HealthDepartment and the manufacturers(NHS HDL (2002)6). Treatment of asingle demyelinating event with anactive inflammatory process has notbeen accepted by SMC and is non-Formulary.S Glatiramer acetateRestricted to use under the provisionof the ‘Risk Sharing Scheme’ betweenthe Scottish Executive HealthDepartment and the manufacturers(NHS HDL (2002)6).S Bacillus Calmette-GuerinRestricted to use by consultanturologists.S NatalizumabRestricted to specialist use inaccordance with agreed local protocoland SMC restrictions.8.3.1 s Diethylstilbestrol8.3.2 Norethisterones Medroxyprogesterones Megestrol8.3.4.1 s AnastrozoleRestricted to use on the adviceof breast cancer specialists inaccordance with regional protocols.s ExemestaneRestricted to use on the adviceof breast cancer specialists inaccordance with regional protocols.GoserelinFor the management of advancedbreast cancer (in pre- and perimenopausalwomen), goserelin (butnot Zoladex LA ® ) is approved whereother treatments have failed.s LetrozoleRestricted to use on the adviceof breast cancer specialists inaccordance with regional protocols.s TamoxifenExcluding tamoxifen liquid.8.3.4.2 s TriptorelinDecapeptyl SR ® 11.25mg is restrictedfor treatment of advanced prostatecancer in patients for whom the useof triptorelin is appropriate andwould benefit from reduced frequencyof administration compared withDecapeptyl SR ® 3mg. GonapeptylDepot ® is restricted to initiationby paediatricians only. It has not

Third edition August 2009 107been recommended by SMC for thetreatment of advanced prostatecancer or endometriosis. Treatmentof precocious puberty is restricted tospecialist initiation.s Aminoglutethimides Bicalutamides CyproteroneOwing to the risk of hepatotoxicity,cyproterone should be used forlong-term treatment only where othertreatments are not tolerated.s Flutamides Goserelins Leuprorelin8.3.4.4 s Octreotides Lanreotide AutogelThe use in the treatment ofthyrotrophic adenomas is non-Formulary.99.1.1.1 Ferrous fumarateFerrous gluconateFerrous sulphateSodium feredetatePregaday ®9.1.1.2 s Iron (III) hydroxide sucrosecomplexs Iron dextran9.1.2 Folic acidHydroxocobalamin9.1.3 s Darbepoetin alfaApproved in NHSGGC only for anaemiaassociated with renal failure. This isthe preferred Formulary agent for thisindication.s Epoetin alfaApproved in NHSGGC only for anaemiaassociated with renal failure.s Epoetin betaApproved in NHSGGC only for anaemiaassociated with renal failure.s Epoetin deltaApproved in NHSGGC only for anaemiaassociated with renal failure.s Methoxy Polyethylene GlycolepoetinbetaApproved in NHSGGC only for anaemiaassociated with renal failure.S DesferrioxamineS DeferasiroxRestricted to specialist use only. It isnot recommended by SMC for patientswith myelodysplastic syndromes.9.1.4 S Anagrelide9.1.6 S FilgrastimOnly to be prescribed by specialists.S LenograstimOnly to be prescribed by specialists.

108 The Greater Glasgow and Clyde Formulary9.2.1.1 Potassium chlorideS Calcium polystyrenesulphonateS Sodium polystyrenesulphonate9.2.1.2 s Sodium bicarbonates Sodium chlorideRapolyte ®9.2.1.3 s Sodium bicarbonate9.2.2 s See BNF9.2.2.2 s Dextran 70s Gelofusine ®s Haemaccel ®9.3 s Intravenous nutritionUse only on specialist advice.9.4.1 s Foods for special dietsUse only on specialist/dietetic advice.9.4.2 Fortisip ® BottleFortisip ® Yoghurt StyleFortijuce ®Fortisip ® Multi FibreCalshake ®Scandishake ®s Enteral tube feedsSpecialist/dietetic advice should besought.9.5.1.1 Calcium carbonateCalcium chlorideCalcium gluconateCalcium-Sandoz ®Sandocal ®9.5.1.2 s CinacalcetUse in the treatment of secondaryhyperparathyroidism in end stagerenal disease is restricted tospecialist initiation in accordancewith local protocol. The SMC has notrecommended its use for reduction ofhypercalcamia inpatients with primaryhyperparathyroidism for whomparathyroidectomy would be indicatedbut not clinically appropriate or iscontraindicated.Also see section 6.6.9.5.1.3 s Magnesium hydroxides Magnesium sulphates Co-magaldrox9.5.2.1 s Phosphate Sandoz ®9.5.2.2 s Aluminium hydroxides Calcium acetates Calcium carbonates SevelamerRestricted to second line therapy onthe recommendation of consultantnephrologists. Excludes the controlof hyperphosphataemia in adultsreceiving peritoneal dialysis.s Lanthanum carbonateRestricted to use as a secondline agent in patients where anon-aluminium, non- calciumphosphate binder is required onthe recommendation of a consultantnephrologist.9.5.3 s Sodium fluoride9.5.4 Zinc sulphateFor treatment of proven zinc deficiencyonly.9.6.1 No products recommended9.6.2 ThiaminePabrinex ®Pyridoxine9.6.3 Ascorbic acid9.6.4 AlfacalcidolCalciferolCalcitriolNot approved for use in osteoporosisand excluding Calcijex ® .Adcal D3 ®Calfovit D3 ®Calcichew D3 Forte ®

Third edition August 2009 109Calceos ®Calcium with ergocalciferol9.6.5 s Alpha tocopheryl acetate9.6.6 Menadiol sodium phosphatePhytomenadionePhytomenadione can causeanaphylactic reactions when givenIV and therefore the mixed micelleformulation is preferable.9.6.7 Abidec ®Vitamins capsules BPCs Ketovite ®9.8.1 s Penicillamines L-carnitine1010.1.1 DiclofenacExcluding Voltarol Rapid ® ,Voltarol GelPatch ® and Dyloject ®IbuprofenIndometacinKetoprofen 2.5% gelMefenamic acidRestricted to gynaecologicalindications only.NaproxenPiroxicam 0.5%gelCelecoxibUse in ankylosing spondylitis was notaccepted by SMC and remains non-Formulary.EtodolacMeloxicamDiclofenac and misoprostol(Arthrotec 75 ® )EtoricoxibRestricted to use in acute gout only.10.1.2.2 HydrocortisoneMethylprednisoloneTriamcinolone10.1.3 SulfasalazineEnteric coated sulfasalazine is theonly formulation licensed for use inrheumatoid arthritisS AdalimumabUse for ankylosing spondylitis isrestricted to use in accordance withthe British Society for Rheumatologyguidelines of July 2004. Treatment ofchronic plaque psoriasis is restrictedto specialist use in patients withsevere disease as defined by a totalPsoriasis Area Severity Index (PASI)score of ≥10 and a Dermatology LifeQuality Index (DLQI) of >10. Use foractive polyarticular idiopathic arthritisin adolescents aged 13-17 years is

110 The Greater Glasgow and Clyde Formularyrestricted to those who have aninadequate response to one or moreDMARDs. Use in severe, active Crohn’sdisease has not been accepted by SMCand remains non-Formulary.s Auranofins Azathioprines CiclosporinRestricted to specialist use forrefractory patients.S EtanerceptIn adults, etanercept is restrictedto initiation by consultantrheumatologists. In children,etanercept is restricted to thetreatment of juvenile idiopathicarthritis by paediatric rheumatologists.Etanercept is restricted to useaccording to SMC and localimplementation protocols. Its usein treating ankylosing spondylitis isrestricted to use in accordance withthe British Society for Rheumatology(BSR) guidelines of July 2004.s HydroxychloroquineS InfliximabIn adults, infliximab is restrictedto initiation by consultantrheumatologists. Infliximab for thetreatment of ankylosing spondylitisis non-Formulary in accordance withNICE TA143. Use in the treatmentof psoriatic arthritis is restricted tocriteria set out in NICE TechnologyAppraisal 104.s LeflunomideIn adults, leflunomide is restrictedto initiation by consultantrheumatologists.s Methotrexates MinocyclineThis is an unlicensed indicationof minocycline and is restrictedto initiation by consultantrheumatologists for use in patientswho could not be successfully treatedwith other DMARDs or anti-TNFtherapy because of sepsis.s Penicillamines Sodium aurothiomalateS RituximabUse in rheumatoid arthritis isrestricted to specialist use inaccordance with local protocol.10.1.4 AzapropazoneEtoricoxibEtoricoxib is restricted to use in acutegout in high risk patients. See section10.1.1 in preferred list for CSM advice.IndometacinColchicineAllopurinolUse for hyperuricaemia associatedwith cytotoxic drugs is restricted tospecialist initiation.S RasburicaseRestricted to use under thesupervision of haematologists andoncologists and subject to NHSGGCprotocol for adults and children.10.2.1 S Edrophoniums Neostigmines Pyridostigmine10.2.2 BaclofenInjection is restricted to use inspecialist units only. Slow withdrawalof baclofen over 1-2 weeks isrecommended.DiazepamQuinines Dantrolenes TizanidineRestricted to recommendation bydesignated specialists.

Third edition August 2009 11110.3.1 S HyaluronidaseAlgesal ®Movelat ®Transvasin ®CapsaicinFor advice on treatment, see NHSGGCprimary care pain guidelines.Kaolin poultice1111.3.1 ChloramphenicolFusidic acidGentamicinPolyfax ®Polytrim ®Propamidines Framycetins Neosporin ®s Ofloxacin11.3.2 See BNF11.3.3 Aciclovir11.4.1 BetametasoneMaxidex ®Prednisolone sodium phosphates Betnesol-N ®s Clobetasones Fluorometholones Hydrocortisones Prednisolone acetate11.4.2 EmedastineOlopatadineSodium cromoglicate11.5 CyclopentolateTropicamides Atropines Homatropines Phenylephrine11.6 s Betaxolols Carteolols Levobunolols Metipranolols Timolols Bimatoprosts Latanoprosts Travaprosts Brimonidines Bimatoprost and timolols Latanoprost and timolols Dipivefrine

112 The Greater Glasgow and Clyde Formularys Acetazolamides Brinzolamides Dorzolamides Dorzolamide and timololPreservative-free unit dose eye dropsare restricted to patients in whom acombination of these two agents isappropriate and who have provensensitivity to benzalkonium chloride.s Brimonidine and timolols Travaprost and timolols Pilocarpine11.7 ProxymetacaineTetracaineS CocaineS LidocaineS Proxymetacaine andfluoresceinS Oxybuprocaine11.8.1 CarmelloseHydroxyethylcelluloseHypotears ®HypromelloseIlube ®Lacri-Lube ®Polyacrylic acidPolyvinyl alcoholSimple eye ointmentSodium chloride11.8.2 Fluoresceins Rose bengals ApraclonidineApraclonidine 0.5% eye drops arerestricted to use on specialist adviceonly for short term adjunctive therapyof chronic glaucoma.S DiclofenacS FlurbiprofenS KetorolacS MiocholS Sodium hyaluronateS VerteporfinS PegaptanibRestricted to specialist use in patientswith visual acuity between 6/12 to6/60 (inclusive). It should be stoppedif visual acuity falls below 6/60 duringtreatment or where severe visual lossis experienced.S RanibizumabRestricted to specialist use inaccordance with local protocol.11.9 See BNF

Third edition August 2009 1131212.1.1 Aluminium acetateBetametasoneClotrimazoleBetnesol-N ®Gentisone HC ®The CSM has advised that topicalaminoglycosides are contra-indicatedin tympanic membrane perforationdue to increased risk of ototoxicity.Locorten-Vioform ®Otomize ®Otosporin ®Tri-Adcortyl Otic ®12.1.2 Chloramphenicol12.1.3 Cerumol ®Sodium bicarbonate12.2.1 AzelastineBeclometasoneBetamethasoneBudesonideNot approved for nasal polyps.s FluticasoneExcluding Nasules ® . Fluticasonenasal sprays should be reserved forpatients in whom beclometasone andbudesonide have been ineffective ornot tolerated.s Fluticasone furoateRestricted to allergic rhinitis patientsin whom beclomethasone andbudesonide have been ineffective ornot tolerated.MometasoneMometasone nasal sprays shouldbe reserved for patients in whombeclometasone and budesonide havebeen ineffective or not tolerated.Sodium cromoglicate12.2.2 EphedrineIpratropiumXylometazoline12.2.3 MupirocinNaseptin ®12.3.1 Adcortyl in Orabase ®BenzydamineCholine salicylateHydrocortisone pellets12.3.2 AmphotericinMiconazoleMuco-adhesive buccal tablets are notrecommended by SMC and are non-Formulary.Nystatin12.3.3 Not recommended.12.3.4 ChlorhexidineHydrogen peroxideSodium chloride12.3.5 Artificial salivaSome artificial saliva products canonly be prescribed by GPs in line withACBS approval, i.e. for dry mouthassociated only with radiotherapy orsicca syndrome. See BNF for furtherdetails.

114 The Greater Glasgow and Clyde Formulary1313.2.1 Aqueous creamDermol 500 ®Diprobase ®E45 ®Epaderm ®Hydromol ®Liquid and white soft paraffinointment NPFUnguentum-M ®13.2.1.1 Alpha-Keri ®Balneum ®Diprobath ®Hydromol Emollient ®Oilatum Emollient ®Oilatum Plus ®13.2.2 DimeticoneSudocrem ®13.3 CalamineCrotamiton13.4 Eurax-hydrocortisone ®Hydrocortisone base or acetate(0.1-2.5%)Alclometasone diproprionate(Modrasone ® )Betamethasone dipropionate(Diprosone ® )Alphaderm ®Betamethasone valerate(Betnovate RD ® )Clobetasone butyrate(Eumovate ® )Beclometasone dipropionate(Propaderm ® )Betamethasone valerate(Betnovate ® )Diprosalic ®Fluticasone (Cutivate ® )Hydrocortisone butyrate(Locoid ® )Mometasone (Elocon ® )Clobetasol propionateCanesten HC ®Daktacort ®Fucidin H ®Nystaform HC ®Timodine ®Vioform Hydrocortisone ®Trimovate ®Betnovate-C ®FuciBet ®13.5.1 IchthammolS AlitretinoinTo be prescribed and dispensed viahospital.13.5.2 Alphosyl HC ®CalcipotriolCalcipotriol and betamethasonedipropionateRestricted to physicians experiencedin treating inflammatory skin disease.The duration of treatment should notexceed 4 weeks.CalcitriolCoal tarCocois ®DithranolSalicylic acidSulphurS AcitretinRestricted to hospital use underspecialist dermatological supervision.13.5.3 s CiclosporinRestricted to use under specialistdermatological supervision.s MethotrexateRestricted to use under specialistdermatological supervision.s Pimecrolimus creamRestricted to initiation by physiciansexperienced in the managementof eczema. It is restricted to the

Third edition August 2009 115management of moderate eczema onthe face and neck of children agedbetween 2 years and 16 years that hasnot been controlled by topical steroidsor where there is serious risk ofimportant adverse effects from furthertopical steroid use, particularlyirreversible skin atrophy.s Tacrolimus creamTopical tacrolimus is restricted toinitiation and supervision by adermatologist.S EtanerceptUse in psoriasis is restricted toinitiation and supervision only byspecialist physicians in accordancewith NICE Technology Appraisal 103.S InfliximabTreatment of severe plaque psoriasisin adults is restricted to specialistuse in patients who failed to respondto, or who have a contraindicationto, or are intolerant of other systemictherapy including ciclosporin,methotrexate or psoralen ultravioletA (PUVA) and in accordance with thelocal approved protocol.13.6.1 Benzoyl peroxideClindamycinExcluding vaginal cream.Clindamycin/benzoyl peroxidegel (Duac ® )ErythromycinIsotretinoin gelQuinoderm ®TretinoinAzelaic acidZineryt ®13.6.2 Co-cyprindiolDoxycyclineErythromycinLymecyclineMinocyclineMinocycline is reserved for patientswho have failed on oxytetracyclineand tetracycline therapy.OxytetracyclineTetracyclineS IsotretinoinRestricted to use in hospitals, underspecialist dermatological supervision.13.7 Occlusal ®Posalfilin ®Salatac ®Salactol ®PodophyllinPodophyllotoxin13.8.1 Sunsense ® UltraUvistat ® (UVB-SPF 30)S Imiquimod cream (Aldara ® )Imiquimod cream is restrictedto second line use by specialistdermatologists for the topicaltreatment of small superficial basalcell carcinoma in adults wherestandard treatment with surgery orcryotherapy is contraindicated andfluorouracil is not appropriate. It isalso restricted to specialist use forthe treatment of clinically typical,nonhyperkeratotic, nonhypertrophicactinic keratoses on the face or scalpin immunocompetent adult patients.S Methylaminolevulinate cream(Metvix ® )Restricted to use by specialistdermatologists when other treatmentsare inappropriate or contra-indicated.13.8.2 Veil ®

116 The Greater Glasgow and Clyde Formulary13.9 Alphosyl 2 in 1 ®Capasal ®Ceanel concentrate ®Coal tarCocois ®KetoconazolePolytar ®Salicylic acidSelenium sulphideEflornithineRestricted for the treatment offacial hirsutism in women for whomalternative drug therapy is ineffective,contraindicated or consideredinappropriate.13.10.1.1 MupirocinSilver sulfadiazide13.10.1.2 Metronidazole13.10.2 ClotrimazoleMiconazole (excludes Daktarin ®powder)Nystaform ®NystatinTerbinafine13.10.3 AciclovirPenciclovir13.10.4 Benzyl benzoateCarbarylDimeticone 4% (Hedrin ® )MalathionPermethrinPhenothrin13.10.5 Magnesium sulphate13.11.1 Industrial methylated spiritsSodium chlorideSurgical spirit13.11.2 ChlorhexidineChlorhexidine/cetrimide13.11.3 See BNF13.11.4 Povidone-iodine13.11.5 See BNF13.11.6 Hydrogen peroxidePotassium permanganateZinc sulphate13.11.7 Aserbine ®13.12 Aluminium chloride hexahydrate13.13 See BNF

Third edition August 2009 1171414.4 See BNFExcluding diphtheria-tetanusacellularpertussis vaccine (Infanrix ® ),oral typhoid vaccine (Vivotif ® ),Alphaglobulin ® or Vigam-S ® .1515.1.1 S EtomidateS KetamineS PropofolS Thiopental15.1.2 S DesfluraneS EntonoxS IsofluraneS Nitrous oxideS Sevoflurane15.1.3 S AtropineS GlycopyrroniumS Hyoscine hydrobromideinjection15.1.4.1 s Chlorpromazines Diazepams Lorazepams Midazolams Temazepam tabletss Alimemazine15.1.4.2 s Diclofenacs Ketorolac injection15.1.4.3 S AlfentanilS Fentanyl injections Morphine (excludesDepodur ® )s Papaveretums PethidineS RemifentanilRestricted to use under directsupervision of a consultantanaesthetist.15.1.5 S AtracuriumS CisatracuriumS MivacuriumS PancuroniumS RocuroniumS VecuroniumS Suxamethonium

118 The Greater Glasgow and Clyde Formulary15.1.6 S EdrophoniumS NeostigmineS Robinul-Neostigmine ®S SugammadexRestricted to use in the immediatereversal of rocuronium-inducedneuromuscular blockade in adultsonly according to protocol. A registerof use is to be maintained byspecialists.15.1.7 S Doxaprams Flumazenils NaloxoneExcludes the combination product ofoxycodone and naloxone (Targinact ® ).15.1.8 S Dantrolene15.2 s Tetracaine gels Bupivacaines Cocaine (excluding spray)s Levobupivacaines Lidocaine 5% medicatedplaster (Versatis ® )Restricted to patients who areintolerant of first line therapies forpost-herpetic neuralgia or wherethese therapies have been ineffective.Use for other indications remain non-Formulary.s Lidocaine and phenylephrines Emla ®s Lidocaines Phenols Prilocaines Procaine1616.1 s Ipecacuanhas Activated charcoalExcluding Charcodote ® .16.2 S Acetylcysteines MethionineNaloxoneS DesferrioxamineS Dicobalt edentateS Sodium nitriteS Sodium thiosulphate.s Fuller’s earthS DimercaprolS PenicillamineS Sodium calcium edentateOrphan productsOrphan 2.11s Human protein COrphan 8.1.5s BexaroteneOrphan 9.8.1s Mercaptamines Sodium phenylbutyrateOrphan 9.8.2S Carglumic acidRestricted to use by experts providingthe supraregional specialist servicefor N-acetylglutamate synthasedeficiency.

Third edition August 2009 119IndexIndex entries/page numbers in colour refer to the Preferred List.AAbacavir 95Abciximab 83Abelcet ® see amphotericinAbidec ® 59, 109Acamprosate 92Acarbose 98Acetazolamide 90, 112Acetylcysteine 118Aciclovir 43, 65, 76, 96, 111, 116Acitretin 114Activated charcoal 118Actrapid ® see insulinAdalimumab 109Adcal D3 ® 58, 108Adcortyl in Orabase ® 68, 113Adefovir dipivoxil 96Adenosine 81Adrenaline 30, 83, 85Alclometasone diproprionate 72, 114Alemtuzumab 106Alendronic acid 50, 100Alfacalcidol 58, 108Alfentanil 117Alfuzosin 102Algesal ® 111Alimemazine 85, 117Allopurinol 63, 110Alphaderm ® 114Alpha-Keri ® 114Alpha tocopheryl acetate 58, 109Alphosyl 2 in 1 ® 116Alphosyl HC ® 72, 114Alprostadil 102, 103Alteplase 84Aluminium acetate 113Aluminium chloride hexahydrate 77,116Aluminium hydroxide 79, 108Amantadine 91AmBisome ® see amphotericinAmbrisentan 81Amikacin 93Amiloride 19, 81Aminoglutethimide 107Aminophylline 28, 85Amiodarone 81Amisulpride 86Amitriptyline 35, 87Amlodipine 23, 82Amoxicillin 14, 40, 93Amphocil ® see amphotericinAmphotericin 95, 113Amsacrine 104Anagrelide 107Anastrozole 106Anhydrol Forte ® see aluminiumchloride hexahydrateAnusol ® 16, 80Anusol HC ® 16, 80Apomorphine 91Apraclonidine 112Aqueous cream 71, 114Aqueous iodine 99Arachis oil enema 80Aripiprazole 86Arthrotec 75 ® see diclofenac andmisoprostolArtificial saliva 113Ascorbic acid 58, 108Aserbine ® 116Asilone ® 79Aspirin 23, 83, 90Atazanavir 96Atenolol 20, 81Atomoxetine 88Atorvastatin 24, 84Atovaquone 97Atracurium 117Atropine 111, 117Auranofin 110

120 The Greater Glasgow and Clyde FormularyAzapropazone 110Azathioprine 105, 110Azelaic acid 115Azelastine 113Azithromycin 93Aztreonam 93BBacillus Calmette-Guerin 106Baclofen 63, 110Bactroban ® see mupirocinBactroban Nasal ® see mupirocinBalneum ® 114Basiliximab 105Beclometasone 28, 85, 113Beclometasone and formoterol 29, 85Beclometasone diproprionate 68Beclomethasone see beclometasoneBendrofluazide seebendroflumethiazideBendroflumethiazide 19, 81Benzoin tincture compound 86Benzoyl peroxide 73, 115Benzydamine 113Benzydamine hydrochloride 68Benzyl benzoate 116Benzylpenicillin 39, 93Betahistine 33, 89Betametasone 99, 111, 113Betamethasone 113Betamethasone dipropionate 114Betamethasone sodium phosphate 67Betamethasone valerate 72, 114Betaxolol 111Betnesol-N ® 67, 111, 113Betnovate ® see betamethasonevalerateBetnovate-C ® 72, 114Betnovate ® see betamethasonevalerateBetnovate RD ® see betamethasonevalerateBexarotene 118Bezafibrate 84Bicalutamide 107Bimatoprost 111Bimatoprost and timolol 111Biphasic insulin aspart 45Biphasic insulin lispro 45Biphasic isophane insulin 45Bisacodyl 80Bisoprolol 20, 81Bleomycin 103Bortezomib 104Bosentan 81Botulinum A toxin 92Botulinum B toxin 92Brimonidine 111Brimonidine and timolol 112Brinzolamide 112Bromocriptine 91, 101Budesonide 28, 68, 85, 113Budesonide and formoterol 29, 85Bumetanide 81Bupivacaine 118Buprenorphine 92Buprenorphine and naloxone 92Bupropion 92Buserelin 101Buspirone 86Busulfan 103CCabergoline 91, 101Caffeine 85Calamine 114Calceos ® 58, 109Calcichew D3 Forte ® 58, 108Calciferol 108Calcipotriol 73, 114Calcipotriol and betamethasone 73Calcipotriol and betamethasonedipropionate 114Calcitriol 108, 114Calcium acetate 57, 108Calcium and ergocalciferol 58Calcium carbonate 57, 108Calcium chloride 57, 108

Third edition August 2009 121Calcium folinate 103Calcium gluconate 57, 108Calcium levofolinate 103Calcium polystyrene sulphonate 108Calcium-Sandoz ® 108Calcium with ergocalciferol 109Calfovit D3 ® 108Calshake ® 108Candesartan 22, 82Canesten HC ® 114Capasal ® 75, 116Capecitabine 103Capsaicin 111Captopril 82Carbamazepine 35, 87, 89, 90Carbaryl 116Carbimazole 47, 99Carbocisteine 30, 86Carboplatin 104Carboprost 102Carglumic acid 118Carmellose 112Carmustine 103Carteolol 111Carvedilol 20, 81Caspofungin 95Ceanel concentrate ® 116Cefaclor 93Cefalexin 40, 93Cefotaxime 40, 93Cefradine 93Ceftazidime 93Ceftriaxone 40Cefuroxime 40, 93Celecoxib 62, 109Cerazette ® 52, 102Cerumol ® 67, 113Cetirizine 29, 85Cetrorelix 101Cetuximab 104Chloral hydrate 86Chlorambucil 103Chloramphenicol 65, 94, 111, 113Chlordiazepoxide 31, 86Chlorhexidine 102, 113, 116Chlorhexidine/cetrimide 77, 116Chlorhexidine gluconate 69, 77Chloroquine 97Chlorphenamine 29, 85Chlorpromazine 87, 88, 91, 117Cholestyramine see colestyramineCholine salicylate 113Choriogonadotropin alfa 100Chorionic gonadotrophin 100Ciclosporin 73, 105, 110, 114Cidofovir 96Cilest ® 52Cimetidine 79Cinacalcet 108Cinnarizine 33, 88Ciprofloxacin 42, 94Cisatracurium 117Cisplatin 104Citalopram 32, 87Citric acid see simple linctusCladribine 103Clarelux ® see clobetasol propionateClarithromycin 14, 41, 94Clenil Modulite ® see beclometasoneClimaval ® 48Clindamycin 73, 94, 115Clobazam 90Clobetasol propionate 114Clobetasone 111Clobetasone butyrate 72, 114Clodronate 100Clomethiazole 86Clomifene 100Clomifene citrate 50Clomipramine 87Clonazepam 90, 91Clopidogrel 24, 83Clotrimazole 51, 76, 102, 113, 116Clozapine 87Coal tar 114, 116Coal tar, salicylic acid and sulphur 73,75Co-amilofruse 81

122 The Greater Glasgow and Clyde FormularyCo-amoxiclav 40, 93Co-beneldopa 36, 91Cocaine 112, 118Co-careldopa 36, 91Co-codamol 34, 89Cocois ® 114, 116Co-cyprindiol 52, 74, 115Co-danthramer 16, 80Co-danthrusate 80Codeine phosphate 34, 79, 89Co-dydramol 89Colchicine 63, 110Colestyramine 17, 80, 84Colifoam ® see hydrocortisone foamColistin 94Co-magaldrox 13, 79, 108Combivir ® 96Co-phenotrope 79Cortisone 99Co-trimoxazole 94, 97Cocois ® see coal tar, salicylic acid andsulphurColifoam ® see hydrocortisone foamCreon ® 17, 80Creon Micro ® 80Crisantaspase 104Cromoglicate sodium 85Crotamiton 71, 114Cutivate ® 114Cyclimorph ® 89Cyclizine 88Cyclopentolate 66, 111Cyclophosphamide 103Cyclosporin see ciclosporinCyproterone 100, 107Cytarabine 103DDacarbazine 104Dactinomycin 103Daktacort ® 72, 114Daktarin ® see miconazoleDalteparin 83Danazol 101Dantrolene 110, 118Dapsone 94Daptomycin 94Darbepoetin alfa 107Darifenacin 102Darunavir 96Dasatinib 104Decapeptyl SR 106Deferasirox 107Demeclocycline 100Depo-Provera ® see medroxyprogesteroneacetateDerbac M ® see malathionDermol 500 ® 114Desferrioxamine 107, 118Desflurane 117Desmopressin 50, 100Dexamethasone 47, 99Dexamphetamine 88Dextran 70 108Diamorphine 35, 89Dianette ® see co-cyprindiolDiazepam 31, 36, 86, 91, 110, 117Diclofenac 61, 109, 112, 117Diclofenac and misoprostol 109Dicobalt edentate 118Dicycloverine 79Didanosine 96Diethylstilbestrol 106Digibind ® 81Digoxin 19, 81Dihydrocodeine 34, 89Diltiazem 23, 82Dimercaprol 118Dimethyl sulfoxide 102Dimeticone 76, 114Dimeticone 4% 116Dinoprostone 102Dipivefrine 111Diprobase ® 71, 114Diprobath ® 114Diprosalic ® 114

Third edition August 2009 123Diprosone ® see betamethasonedipropionateDipyridamole 83Dipyridamole MR 24Disopyramide 81Disulfiram 92Dithranol 114Dobutamine 83Docetaxel 104Docusate sodium 16, 80Domperidone 13, 33, 79, 88Donepezil 92Dopamine 83Dopexamine 83Doripenem 93Dorzolamide 112Dorzolamide and timolol 112Dovobet ® see calcipotriol andbetamethasoneDoxapram 85, 118Doxazosin 21, 82Doxorubicin 103Doxorubicin pegylated liposomal 103Doxycycline 41, 93, 115Driclor ® see aluminium chloridehexahydrateDrotrecogin alfa 84Duac ® 115Duloxetine 54, 87, 89, 102Dutasteride 100, 102Dydrogesterone 49EE45 ® 114Edrophonium 110, 118Efavirenz 96Eflornithine 116Elleste-Duet ® 48Elleste-Duet ® Conti 49Elleste-Solo ® 48Elocon ® 114Emedastine 111Emla ® 118Emtricitabine 96Enalapril 82Enfuvirtide 96Enoxaparin 83Enoximone 81Entacapone 91Entecavir 97Entonox 117Epaderm ® 71, 114Ephedrine 83, 113Epirubicin 103Eplerenone 81Epoetin alfa 107Epoetin beta 107Epoetin delta 107Epoprostenol 83Ergometrine 102Erlotinib 105Ertapenem 93Erythromycin 41, 74, 94, 115Esmolol 81Estradiol vaginal tablets 51Estradot ® 102Estring ® 102Estriol 0.01% intravaginal cream 51Etanercept 110, 115Ethambutol 94Ethosuximide 90Etodolac 62, 109Etomidate 117Etoposide 104Etoricoxib 109, 110Eumovate ® see clobetasone butyrateEurax ® see crotamitonEurax-hydrocortisone ® 114Evorel ® 48Evorel ® Conti 49Evorel ® Sequi 49Evra ® 102Exemestane 106Exenatide 99Ezetimibe 25, 84

124 The Greater Glasgow and Clyde FormularyFFamciclovir 96Femoston ® 48Femoston ® -Conti 49Femulen ® 52Fenofibrate 84Fentanyl 89, 117Fentanyl citrate 89Ferrous fumarate 55, 107Ferrous gluconate 107Ferrous sulphate 55, 107Fexofenadine 85Filgrastim 107Finasteride 53, 100, 102Flamazine ® see silver sulfadiazineFlecainide 81Fleet Phospho-Soda ® 80Flucloxacillin 39, 93Fluconazole 42, 95Flucytosine 95Fludarabine 104Fludrocortisone 47, 99Flumazenil 118Fluorescein 112Fluorometholone 111Fluorouracil 104Fluoxetine 32, 87Flupentixol 87Flupentixol decanoate 87Fluphenazine decanoate 87Flurbiprofen 112Flutamide 107Fluticasone 28, 85, 113, 114Fluticasone and salmeterol 29, 85Folic acid 55, 107Fondaparinux 83Formoterol 27, 85Forsteo ® see teriparatideFortifresh ® 56, 108Fortijuce ® 56, 108Fortisip ® Bottle 56Fortisip ® Multi-Fibre 56Fortisip Multi Fibre ® 108Fosamprenovir 96Foscarnet 96Fosphenytoin 90, 91Framycetin 111Frovatriptan 90Frusemide see furosemideFuciBet ® 114Fucidin ® see fusidic acidFucidin H ® 114Fuller’s earth 118Full Marks ® see phenothrinFurosemide 19, 81Fusidic acid 65, 75, 111GGabapentin 35, 89, 90Galantamine 92Ganciclovir 96Ganirelix 101Gastrocote ® 79Gaviscon ® Infant Dual Sachets 79Gaviscon ® Infant Sachets 13Gelofusine ® 108Gemcitabine 104Gemeprost 102Gentamicin 41, 65, 93, 111Gentisone HC ® 67, 113Glatiramer acetate 106Glibenclamide 98Gliclazide 46, 98Glipizide 98GlucaGen ® HypoKit see glucagonGlucagon 46, 99Glucose 46, 99Glyceryl suppositories 80Glyceryl trinitrate 22, 82Glycine 102Glycopyrronium 117Gonadorelin 100Gonapeptyl Depot 106Goserelin 101, 106, 107Granisetron 88Griseofulvin 95

Third edition August 2009 125HHaemaccel ® 108Halofantrine 97Haloperidol 31, 87, 91Haloperidol decanoate 87Hedrin ® see dimeticoneHedrin ® see dimeticone 4%Heparin 83Homatropine 111HRT 48Humalog ® see insulin lisproHumalog ® Mix 25 see biphasic insulinlisproHuman menopausal gonadotrophins100Human protein C 118Humulin I ® see isophane insulinHumulin M3 ® see bisphasic isophaneinsulinHumulin S ® see insulinHyaluronidase 111Hydralazine 81Hydrocortisone 47, 71, 79, 80, 85, 99,109, 111, 114Hydrocortisone butyrate 114Hydrocortisone foam 15Hydrocortisone pellets 113Hydrogen peroxide 113, 116Hydrogen peroxide BP 77Hydromol ® 114Hydromol Emollient ® 71, 114Hydroxocobalamin 55, 107Hydroxycarbamide 104Hydroxychloroquine 62, 110Hydroxyethylcellulose 112Hydroxyzine 85Hyoscine butylbromide 79Hyoscine hydrobromide 117Hypotears ® 112Hypromellose 66, 112IIbandronic acid 101Ibuprofen 34, 61, 89, 90, 109Ibuprofen injection 102Ichthammol 114Ichthammol ointment BP 72Ifosfamide 103Iloprost 81Ilube ® 112Imatinib 104Imipenem with cilastin 93Imipramine 87Imiquimod 115Implanon ® 53Indinavir 96Indometacin 61, 102, 109, 110Industrial methylated spirit BP 77Industrial methylated spirits 116Infacol ® 79Infliximab 79, 110, 115Insulan Rapid ® see insulinInsulatard ® see isophane insulinInsulin 45, 98Insulin aspart 45Insulin detemir 98Insulin glargine 45, 98Insulin glulisine 98Insulin lispro 45Interferon alfa 106Interferon beta 106Ipecacuanha 118Ipratropium 113Ipratropium bromide 28, 85Irbesartan 82Irinotecan 105Iron dextran 107Iron (III) hydroxide sucrose complex107Isoflurane 117Isophane insulin 45Isoprenaline 83Isosorbide mononitrate 22, 82Isotretinoin 115Ispaghula husk 15, 79Itraconazole 95IUDs 53Ivabradine 83

126 The Greater Glasgow and Clyde FormularyKKaletra ® 96Kaolin poultice 111Kay-Cee-L ® see potassium chlorideKetamine 117Ketoconazole 95, 116Ketoprofen gel 109Ketorolac 112, 117Ketovite ® 109Kivexa ® 96Klean-Prep ® 80Kliovance ® 49LLabetolol 81Lacosamide 90Lacri-Lube ® 66, 112Lactulose 16, 80Lamivudine 96, 97Lamotrigine 90Lanreotide Autogel 107Lansoprazole 14, 15, 79Lanthanum carbonate 108Lasonil ® 80Latanoprost 111Latanoprost and timolol 111L-carnitine 109Lantus ® see insulin glargineLeflunomide 110Lenograstim 107Lepirudin 83Letrozole 106Leuprorelin 101, 107Levemir ® see insulin detemirLevetiracetam 90Levobunolol 111Levobupivacaine 118Levodopa/carbidopa/entacapone 91Levofloxacin 94Levomepromazine 87Levonelle 1500 ® see levonorgestrelLevonorgestrel 52Levothyroxine 47, 99Lidocaine 80, 81, 112, 118Lidocaine and phenylephrine 118Lidocaine plaster 118Linezolid 94Liothyronine 99Liquid and white soft paraffin ointmentNPF 114Lisinopril 21, 82Lithium 87Locoid ® see hydrocortisone butyrateLocorten-Vioform ® 113Loestrin ® 20 52Loestrin ® 30 51Lofepramine 32, 87Lofexidine 92Lomustine 103Loperamide 15, 79Loratadine 29, 85Lorazepam 86, 91, 117Losartan 22, 82Lutropin alfa 100Lymecycline 74, 115MMagnesium hydroxide 108Magnesium sulfate 80Magnesium sulphate 108Magnesium sulphate paste BP 76Malathion 76, 116Mannitol 81Marvelon ® 52Maxidex ® 111Mebendazole 97Mebeverine 13, 79Medroxyprogesterone 106Medroxyprogesterone acetate 53Mefenamic acid 109Mefloquine 97Megestrol 106Meloxicam 109Melphalan 103Menadiol sodium phosphate 58, 109Mercaptamine 118Mercaptopurine 79, 104Mercilon ® 52

Third edition August 2009 127Meropenem 93Mesalazine 15, 79Mesna 103Metformin 46, 98Methadone 37, 89, 92Methionine 118Methotrexate 62, 73, 110, 114Methoxy Polyethylene Glycol-epoetinbeta 107Methylaminolevulinate 115Methylcellulose 88Methyldopa 82Methylphenidate 88Methylprednisolone 62, 99, 109Metipranolol 111Metoclopramide 33, 79, 88Metolazone 81Metoprolol 81Metronidazole 14, 41, 75, 94, 116Metronidazole 0.75% vaginal gel 102Metyrapone 101Miconazole 69, 76, 102, 113, 116Micralax Micro-enema ® 80Microgynon ® 30 51Micronor ® 52Midazolam 36, 91, 117Mifepristone 102Migraleve ® 90Migraleve pink ® 35Milrinone 81Minocycline 93, 110, 115Minoxidil 81Miochol 112Mirena ® 53, 102Mirtazapine 32, 87Misoprostol 79Mitomycin 103Mitoxantrone 103Mivacurium 117Mixtard ® 30 see biphasic isophaneinsulinMoclobemide 87Modafinil 88Modrasone ® see alclometasonedipropionateMometasone 113, 114Montelukast 29, 85Morphine 34, 117Movelat ® 64, 111Movicol ® 80Moxifloxacin 95Moxonidine 82Mupirocin 68, 75, 113, 116Mycophenolate mofetil 105Mycophenolic acid 105NNabilone 89Nafarelin 101Naftidofuryl oxalate 83Naloxone 118Nandrolone decanoate 100Naproxen 61, 109Naseptin ® 68, 113Natalizumab 106Nebivolol 81Nelarabine 104Nelfinavir 96Neomycin 93Neosporin ® 111Neostigmine 110, 118Netilmicin 93Nevirapine 96Nicorandil 83Nicorette ® patch 37, 92Nicorette ® product range 37Nicotine replacement therapy 37Nifedipine 23, 82Nimodipine 83Nitrazepam 86Nitrofurantoin 42, 95Nitrous oxide 117Noradrenaline 83Norethisterone 49, 106Norfloxacin 95Nova-T 380 ® 53

128 The Greater Glasgow and Clyde FormularyNovomix ® 30 see biphasic insulin aspartNovoRapid ® see insulin aspartNoxythiolin 102Nutrizym 22 ® 80Nutrizym ® 80Nystaform ® 116Nystaform HC ® 114Nystatin 42, 69, 95, 102, 113, 116OOcclusal ® 74, 115Octreotide 107Oestradiol 99Oestrogel ® see oestradiolOfloxacin 94, 111Oilatum Emollient ® 114Oilatum Plus ® 71, 114Oily phenol 80Olanzapine 87Olive oil 67Olopatadine 111Olsalazine 79Omalizumab 85Omeprazole 14, 15, 79Ondansetron 33, 88Orlistat 32, 88Orphenadrine 91Ortho-Gynest ® see estriol 0.01%intravaginal creamOseltamivir 97Otomize ® 67, 113Otosporin ® 113Ovestin ® 102Oxaliplatin 105Oxazepam 86Oxcarbazepine 90Oxybuprocaine 112Oxybutynin 53, 102Oxycodone 35, 89Oxytetracycline 41, 74, 93, 115Oxytocin 102PPabrinex ® 57, 108Paclitaxel 105Palivizumab 97Pamidronate 100Pancrease ® 80Pancrease HL ® 80Pancrex ® 80Pancuronium 117PanOxyl ® see benzoyl peroxidePapaveretum 117Paracetamol 34, 89, 90, 91Paraldehyde 91Paramax ® 90Parathyroid Hormone 100Paroxetine 87Pegaptanib 112Pegylated interferon alfa 106Pemetrexed 104Penciclovir 116Penicillamine 109, 110, 118Penicillin V see phenoxymethylpenicillinPentamidine 97Pentostatin 105Peppermint oil 79Peptac ® 13, 79Pergolide 91Perindopril erbumine 82Permethrin 116Pethidine 89, 117Phenelzine 87Phenobarbital 90Phenol 118Phenothrin 76, 116Phenoxymethylpenicillin 39, 93Phenylephrine 111Phenytoin 89, 90, 91Pholcodine 86Pholcodine linctus 30Phosphate enema 80Phosphate Sandoz ® 108Phosphate-Sandoz ® 57Phytomenadione 59, 109Picolax ® see sodium picosulfate

Third edition August 2009 129Pilocarpine 112Pimecrolimus cream 114Pimozide 91Pioglitazone 46, 98Pioglitazone and metformin 98Pipotiazine palmitate 87Piroxicam gel 109Pizotifen 36, 90Podophyllin 115Podophyllotoxin 115Polyacrylic acid 112Polyfax ® 111Polytar ® 75, 116Polytrim ® 111Polyvinyl alcohol 112Poractant 85Posaconazole 95Posalfilin ® 115Potassium chloride 56, 108Potassium citrate 102Potassium permanganate 77, 116Povidone-iodine 77, 102, 116Pramipexole 91Prednisolone 47, 79, 85, 99, 105Prednisolone acetate 111Prednisolone sodium phosphate 111Pregabalin 89, 90Pregaday ® 107Preotact ® see parathyroid hormonePrilocaine 118Primidone 91Prioderm ® see malathionPripsen ® 97Procaine 118Procarbazine 105Prochlorperazine 33, 88Procyclidine 36, 91Proguanil 97Promethazine 85, 88Propaderm ® see beclometasonedipropionatePropafenone 81Propamidine 111Propantheline 79Propofol 117Propranolol 20, 36, 81, 86, 90Propylthiouracil 99Protamine 83Protirelin 100Proxymetacaine 112Proxymetacaine and fluorescein 112Pyridostigmine 110Pyridostigmine bromide 63Pyridoxine 108QQuetiapine 86Quinagolide 101Quinine 63, 97, 110Quinoderm ® 115Quinupristin-dalfopristin 94RRaloxifene hydrochloride 99Raltegravir 96Ramipril 21, 82Ranibizumab 112Ranitidine 14, 79Rapolyte ® 56, 108Rasburicase 110Remifentanil 117Reteplase 84Ribavirin 97Rifabutin 94Rifampicin 94Rifater ® 94Rifinah ® 94Riluzole 92Risedronate 100Risedronate sodium 50Risperidone 31, 86, 87Ritodrine 102Ritonavir 96Rituximab 106, 110Rivaroxaban 83Rivastigmine 92Rizatriptan 90Robinul-Neostigmine ® 118

130 The Greater Glasgow and Clyde FormularyRocuronium 117Ropinirole 91Rose bengal 112Rosiglitazone 98Rosiglitazone and metformin 99Rosuvastatin 84Rotigotine 91Rufinamide 90SSalactol ® 115Salatac ® 115Salbutamol 27, 85Salicylic acid 114, 116Salmeterol 27, 85Sandocal ® 108Sando-K ® see potassium chlorideSaquinavir 96Scandishake ® 108Scheriproct ® 80Sebco ® see coal tar, salicylic acid andsulphurSelegiline 91Selenium sulphide 116Semisodium vaproate 90Senna 16, 80Sertraline 87Sevelamer 108Sevoflurane 117Sibutramine 32, 88Sildenafil 54, 102Sildenafil citrate 81Silver sulfadiazide 116Silver sulfadiazine 75Simple eye ointment 112Simple linctus 30, 86Simvastatin 24, 84Sirolimus 105Sitagliptin 99Sitaxentan 82Slow-K ® see potassium chlorideSodium aurothiomalate 110Sodium bicarbonate 67, 102, 108, 113Sodium calcium edentate 118Sodium chloride 77, 108, 112, 113, 116Sodium cromoglicate 65, 111, 113Sodium feredetate 55, 107Sodium fluoride 108Sodium fusidate 94Sodium hyaluronate 112Sodium nitrite 118Sodium nitroprusside 82Sodium phenylbutyrate 118Sodium picosulfate 16, 80Sodium polystyrene sulphonate 108Sodium tetradecyl sulfate 84Sodium thiosulphate 118Sodium valproate 90Solifenacin 102Somatropin 100soniazid 94Sotalol 81Spironolactone 19, 81Stavudine 96Stiemycin ® see erythromycinStreptokinase 84Streptomycin 94Strontium ranelate 100Suboxone ® see buprenorphine andnaloxoneSubutex ® see buprenorphineSucralfate 79Sudocrem ® 71, 114Sugammadex 118Sulfasalazine 79, 109Sulphasalazine 62Sulphur 114Sulpiride 87, 92Sultrin 102Sumatriptan 35, 90Sunsense ® Ultra 74, 115Surgical spirit 116Suxamethonium 117Syntometrine 102TTacrolimus 106Tacrolimus cream 115

Third edition August 2009 131Tadalafil 103Tamoxifen 106Tamsulosin 53Tazocin ® 93Teicoplanin 94Telbivudine 97Telmisartan 82Temazepam 31, 86, 117Temozolomide 105Tenecteplase 84Tenofovir 96, 97Terazosin 102Terbinafine 42, 95, 116Terbutaline 27, 85Teriparatide 100Terlipressin 100Testosterone 100Tetrabenazine 92Tetracaine 112, 118Tetracosactide 100Tetracycline 14, 93, 115Theophylline 28, 85Thiamine 57, 108Thiopental 117Thiotepa 103Thyroxine see levothyroxineTiagabine 91Tibolone 49Tigecycline 93Tiludronic acid 101Timodine ® 114Timolol 111Tinzaparin 83Tioguanine 104Tiotropium 28, 85Tipranavir 97Tirofiban 83Tisept ® see chlorhexidine/cetrimideTizanidine 110Tobramycin 93Tolterodine 102Topiramate 90, 91Topotecan 105Tramadol 89Tranexamic acid 24, 84Transvasin ® 111Tranylcypromine 87Trastuzumab 105Travaprost 111Travaprost and timolol 112Trazodone 87Treosulfan 103Tretinoin 105, 115Tri-Adcortyl Otic ® 113Triamcinolone 99, 109Trifluoperazine 87Trihexyphenidyl 91Trilostane 101Trimethoprim 41, 42, 94, 95Trimovate ® 72, 114Triptorelin 101Trizivir ® 95Tropicamide 66, 111Trospium 102Truvada ® 96TT 380 Slimline ® 53UUnguentum-M ® 114Ursodeoxycholic acid 17, 80Uvistat ® 115VVagifem ® see estradiol vaginal tabletsValaciclovir 96Valganciclovir 96Valsartan 82Vancomycin 94Vardenafil 103Varenicline 92Vecuronium 117Veil ® 75, 115Velosulin ® see insulinVenlafaxine 87Verapamil 81, 82Versatis ® see lidocaine plasterVerteporfin 112Vigabatrin 91

132 The Greater Glasgow and Clyde FormularyVildagliptin 99Vildagliptin and metformin 99Vinblastine 104Vincristine 104Vindesine 104Vinorelbine 104Vioform Hydrocortisone ® 114Viscotears ® 66Vitamin capsules BPC 59Vitamins capsules BPC 109Voriconazole 95WWarfarin 23, 83XXylometazoline 113Xylometazoline hydrochloride 68ZZanamivir 97Zidovudine 96Zinc paste and Ichthammol bandageBP 72Zinc sulphate 108, 116Zineryt ® 74, 115Zoledronic acid 101Zolmitriptan 90Zonisamide 91Zopiclone 86Zuclopenthixol 87Zuclopenthixol decanoate 87

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www.ggcformulary.scot.nhs.ukGreater Glasgow and Clyde AreaDrugs and Therapeutics Committee