nhs forth valley formulary 11 - Community Pharmacy

NHS FORTH VALLEYFORMULARY11 th Edition v6 December 2012Date of First Issue 31/07/2012Approved 30/08/2012Current Issue Date 24/12/2012Review Date After each ADTC New Drug Sub Group MeetingVersion Version 6EQIANOAuthor / Contact Heather Wilson, Prescribing Support Pharmacy TechnicianGroup Committee –Final ApprovalADTC New Drugs Sub GroupArea DTCThis document can, on request, be made available in alternative formatsVersion 6.00 December 24 th 2012UNCONTROLLED WHEN PRINTED

Consultation and Change Record – for ALL documentsContributingAuthors:ConsultationProcess:Distribution:NHS Forth Valley Acute & Primary Care StaffApproval by ADTC New Drugs Sub GroupAcute Specialist ServicesForth Valley Doctors and ConsultantsForth Valley GPs, Practice Managers, Nurse PrescribersForth Valley Pharmacy StaffForth Valley Community Pharmacy ContractorsChange RecordDate Author Change Version24/12/2012 HeatherWilsonTigagrelor - additional wording in comment box ‘orcontinuation of treatment in line with recommendation fromthe initiating Health Board’Drug Added to FormularyRe-SubmissionsDysport® - SMC Restriction – for focal spasticity inconjunction with physiotherapyProduct UpdateSildenafil 20mg film-coated tablets and 10mg/mlpowder for oral solution (Revatio®) - Accepted forrestricted use for treatment of paediatric patients aged 1year to 17 years old with pulmonary arterial hypertension.Restricted to use on the advice of specialists in theScottish Pulmonary Vascular unit and from the ScottishAdult Congenital Cardiac Services. Continuation oftreatment from tertiary centres.Drug Addition to FormularyGastroenterology review –Loperamide – note to be added to say ‘high doses ofloperamide used in short bowel patients’Ferric CarboxymaltoseAcidexBalsalzide6.00Version 6.00 December 24 th 2012UNCONTROLLED WHEN PRINTED

InfliximabAdalimumab – consultant gastroenterologist initiationonlyPrednisolone suppositoriesAzathioprine, methotrexateCiclosporinMercaptopurineBisacodylMoviprepColestipolColestyramineDrug Removal from FormularyIron IsomaltosideDicylomineColifoamOlsalazineKlean-prep05/12/2012 HW Drug Addition to Formulary5.00Fluticasone propionate and formoterol fumarate(Flutiform®)11/10/2012 H W Drug Addition to Formulary4.00Abiraterone AcetateRestricted Use West of Scotland Cancer Network27/9/2012 HW Drug Addition to Formulary3.00TicagrelorFor ‘clopidogrel intolerant patients and for patients whohave had stent thrombosis’.Initiation by cardiologist only, but continued in primary careVersion 6.00 December 24 th 2012

30/8/2012 H W Drug Additon to Formulary2.00Colecalciferol 800 iu (equiv. to 20 micrograms vitamin D3)Capsules [Fultium-D3®]Fingolimod 0.5mg hard capsules (Gilenya®)(Restricted specialist use)Indapamide – as per Hypertension GuidanceRivaroxaban prescribing in Atrial Fibrilation – Forpatients who fulfill the criteria for the prescribing ofrivaroxaban in AF, it is no longer necessary to seek theapproval of a consultant haematologist - .refer to -Rivaroxaban for Stroke Prevention in Atrial Fibrillation--------------------------------------------------Drug Removal from FormularyGemeprost--------------------------------------------------Following drugs are now prescribable for initiationacross Primary Care & Mental HealthSpecialitiesHaelan Tape, Elocon, Betnovate C, Alphosyl HC,Dovobet, Exorex, Zineryt, Isotrex Gel, Isotrexin Gel,Adapalene, Metronidazole gel/cream, Ketoconazole(Nizoral)Version 6.00 December 24 th 2012

Contact numbersPrimary Care PharmacyPrescribing Support TeamPrimary Care Pharmacy OfficeEuro House, Wellgreen PlaceStirlingFK8 2DJDirector of Pharmacy Page 0796301824 01786 431200Prescribing Support Team 01786 431200Clinical and Community Services Office(Mental Health, Learning Disabilities & Vaccines) 01324 566728 &Pharmacy Department 01324 566729Forth Valley Royal HospitalStirling RoadLarbertFK5 4WROn-call service contact Switchboard 01324 566000Acute Services PharmacyOpening hours - 8.30 am – 5.00 pm Monday to Friday10.00 am – 4:30 pm Saturday10.00 am – 2.30 pm SundayOn-call service out-with these hours - Contact the pharmacist through the unit page holder.Forth Valley Royal Hospital 01324 566000Stores & Distribution 01324 566702Dispensary 01324 566701 / 700Aseptic Office 01324 566709 / 710 / 711Medicines Information 01324 566725Kirsty Peacock (CD Inspection Officer) 01324 566725Page 1

ContentsIntroduction 5Aims and objectives 5Using the Formulary 5Formulary Management 6Scottish Medicines Consortium (SMC) 6NICE Guidance 7Paediatric Declaration 7Web-Site 8Formulary Status 8Appeals 8Non-formulary drug supply 9Guidance on prescribing 9Unlicensed Medicine 10Therapeutic drug monitoring 10Advice 10Feedback 10Chapter 1: Gastro-intestinal System 111.1 Dyspepsia and Gasto-oesophageal Reflux Disease 111.2 Antispasmodics and other drugs altering gut motility 111.3 Ulcer-healing Drugs 111.4 Antidiarrhoeal Drugs 111.5 Treatment of Chronic Diarrhoeas and IBS 121.6 Laxatives 121.7 Preparation for Haemorrhoids 121.8 Stoma Care 121.9 Drugs affecting intestinal secretions 13Chapter 2: Cardiovascular System 142.1 Positive inotropic drugs 142.2 Diuretics 142.3 Antiarrhythmic Drugs 142.4 Beta-Blockers 142.5 Drugs affecting the renin-angiotensin system and 15some other antihypertensive drugs2.6 Nitrates, Calcium-channel blockers and Potassiumchannel15activators2.7 Sympathomimetics 162.8 Anticoagulants and Protamine 162.9 Antiplatelet Drugs 162.10 Fibrinolytics 162.11 Antifibrinolytics 162.12 Lipid-regulating Drugs 16Chapter 3: Respiratory System 173.1 Bronchodilators 173.2 Corticosteroids 173.3 Cromoglicate, related therapy and leukotriene18antagonists3.4 Allergic Disorders 183.5 Respiratory Stimulants and Pulmonary Surfactants 183.6 Oxygen 183.7 Mucolytics 18Chapter 4: Central Nervous System 194.1 Hypnotics & Anxiolytics 194.2 Drugs in psychoses and related disorders 194.3 Antidepressants 204.4 Central Nervous System Stimulants 204.5 Drugs Used in the Treatment of Obesity 204.6 Drugs used in Nausea & Vertigo 214.7 Analgesics 214.8 Antiepileptics 224.9 Drugs used in Parkinsonism and related disorders 224.10 Drugs used in Substance Dependence 234.11 Drugs for Dementia 23Page 2

ContentsChapter 5: Infections 245.1 Antibacterial drugs 245.2 Antifungal drugs 255.3 Antiviral drugs 255.4 Antiprotozoal drugs 265.5 Anthelmintics 26Chapter 6: Endocrine System 276.1 Drugs used in Diabetes 276.2 Thyroid and Antithyroid Drugs 276.3 Corticosteroids 276.4 Sex Hormones 286.5 Hypothalamic and pituitary hormones and antioestrogens286.6 Drugs affecting bone metabolism 286.7 Other endocrine drugs 29Chapter 7: Obstetrics, Gynaecology, and Urinary-Tract Disorders 307.1 Drugs used in obstetrics 307.2 Treatment of vaginal and vulval conditions 307.3 Contraceptives 307.4 Drugs for genito-urinary disorders 31Chapter 8: Malignant Disease and Immunosuppression 328.1 Cytotoxic drugs 328.2 Drugs affecting the immune response 338.3 Sex hormones and hormone antagonists in malignant 34diseaseChapter 9: Nutrition and Blood 349.1 Anaemias and some other blood disorders 349.2 Fluids and electrolytes 359.4 Oral Nutrition 359.5 Minerals 359.6 Vitamins 359.8 Metabolic Disorders 36Chapter 10: Musculoskeletal and Joint Diseases 3710.1 Drugs used in rheumatic diseases and gout 3710.2 Drugs used for neuromuscular disorders 3810.3 Drugs for the relief of soft-tissue inflammation 38Chapter 11: Eye 3811.3 Anti-infective eye preparations 3811.4 Corticosteroids and other anti-inflammatory38preparations11.5 Mydriatics and cycloplegics 3911.6 Treatment of glaucoma 3911.7 Local anaesthetics 3911.8 Miscellaneous ophthalmic preparations 40Chapter 12: Ear, Nose and Oropharynx 4112.1 Drugs acting on the ear 4112.2 Drugs acting on the nose 4112.3 Drugs acting on the oropharynx 41Chapter 13: Skin 4213.2 Emollient and barrier preparations 4213.3 Topical local anaesthetics and antipruritics 4213.4 Topical corticosteroids 4213.5 Preparations for eczema and psoriasis 4313.6 Acne and rosacea 4313.7 Preparations for warts and callouses 4413.8 Sunscreens and camouflagers 4413.9 Shampoos and other scalp preparations 4413.10 Anti-infective skin preparations 4413.11 Disinfectants and cleansers 4513.12 Antiperspirants 45Page 3

ContentsChapter 14: Immunological products and vaccines 4614.4 Vaccines and antisera 4614.5 Immunoglobulins 46Chapter 15: Anaesthesia 4715.1 General anaesthesia 4715.2 Local anaesthesia 48Appendices 491 NHS FV Prescribing of New Medicine Flowchart 502 Non Formulary Request Form (Acute Hospital) 513 Treatment Algorithm for Dyspepsia Guidance 524 Guidelines for The Prevention of Constipation in Adults 535 Lipid Lowering Guidelines 556 Guidance on Issuing Steroid Cards 647 The Use of Oral Analgesics for Pain in Primary Care 658 Neuropathic Pain Guideline 689 FVAH Acute Pain Stepladder 6910 Acute Services Phenytoin Guidelines 7011 Stop Smoking Guidance 7212 Therapeutic Drug Monitoring Guidelines 7913 Genito-Urinary Medicine List 8014 Recommendations for Blood Glucose Monitoring 8115 Blood Glucose Meters-Formulary Choices 8216 Beatson West of Scotland Cancer Centre 8317 Patients Receiving Chemotherapy Who Become Unwell – 84Guidance for Community Healthcare Practitioners18 Suspected Neutropenic Sepsis 8619 Hypercalcaemia of Malignancy Treatment Guideline 8820 Suspected Hypercalcaemia of Malignancy Guideline for 89Primary Care21 Superior Vena Cava Obstruction Treatment Guidance for 90Acute Services-Patients with known Malignancy22 Superior Vena Cava Obstruction Guidance for Primary 92Care23 Malignant Spinal Cord Compression Guideline (Secondary 93Care)24 Malignant Spinal Cord Compression Guideline (Primary 95Care)25 Hypomagnesaemia In Adults 9626 Hypophosphataemia In Adults 9827 Forth Valley Wound Management Formulary 100Index 102Page 4

IntroductionThe formulary is produced by the New Drugs Sub Group of the Forth Valley Area Drugand Therapeutics Committee (ADTC), and the contents reflect wide consultation with arange of practitioners in medicine and pharmacy.Aims and objectivesThe main aim of this formulary is to promote rational, safe, clinical- and cost-effectiveprescribing in both Primary and Secondary Care. The BNF contains several thousandmedicines and is designed to be comprehensive. The Forth Valley Formulary is a listcontaining fewer medicines, which provide appropriate treatment for the vast majority ofpatients, are approved for use in hospital and general practice. The modest size of the listshould enhance the quality of prescribing as familiarity with the limited range ofmedicines will be readily acquired. Clinical units, Community Health Partnerships (CHPs)and general medical practices may wish to use the complete Forth Valley Formulary ormay restrict the number of items further to suit local circumstances.Using the FormularyMedicines are presented according to the BNF classification. This enables the formularyto be used in conjunction with the current BNF, which prescribers are asked to use as theirprimary reference source for information regarding dosages, contra-indications andadverse reactions. Generally, formulations and strengths of preparations have beenomitted to allow flexibility of prescribing, except when a particular formulation is notapproved. Drugs are referred to throughout by generic name, with some exceptions.Where proprietary names are given, this indicates either a compound product or a productwith unique characteristics and no substitutions should be made. Some brief prescribingpoints have been added and have been reviewed by general practitioners and specialistsworking together.Page 5

Formulary ManagementThe printed version of the formulary will be updated annually at the start of August torespond to the outcome of the Scottish Medicines Consortium assessment of new drugsand local requirements, as discussed and reviewed by the New Drugs Sub Group of theADTC following assessment by the SMC. The formulary is also available on the NHSForth Valley intranet and this electronic version will be updated after each New DrugsMeeting.The formulary process is quite separate from any licensing restriction which might apply,details of which can be found in the BNF or Summary of Product Characteristics. The finaldecision on the formulary status of a new drug is made by the ADTC. Throughout theyear, ADTC decisions of formulary amendments will be routinely communicated to Drugand Therapeutics Committees and Prescribing Groups, CHPs and general practitioners viaADTC News bulletin.There is an area wide process for requesting drugs for inclusion in the Forth ValleyFormulary. This involves the requestor completing a New Drugs Proforma availablewithin electronic versions of the Formulary at the following link.http://intranet.fv.scot.nhs.uk/web/FILES/Pharmacyfiles/requestorproforma2002.docCompleted forms for Primary Care to be submitted to Primary Care Pharmacy Services,Euro House, Stirling and Acute forms submitted to Medicines Information, Forth ValleyRoyal Hospital.Scottish Medicines Consortium (SMC)The remit of the Scottish Medicines Consortium (SMC) is to provide advice to the NHSBoards and their Area Drug and Therapeutics Committees (ADTCs) across Scotland aboutthe status of all newly licensed medicines, all new formulations of existing medicines andany major new indications for established products. Locally the process for consideringSMC recommendations has been finalised and a summary can be found in Appendix 2.Prescribers will be updated via the ADTC News bulletin and the formulary web site.The ADTC advises prescribers not to prescribe any drug that has been rejected by SMCor has not been considered by SMC unless there is evidence to justify prescribing in thelight of particular circumstances of an individual patient.Where a medicine is not recommended for use by the Scottish Medicines Consortium(SMC) for use in NHS Scotland, including those medicines not recommended due to nonsubmission,this will be noted by the Area Drug and Therapeutics Committee New DrugSub Group and the medicine will not be added to the NHS Forth Valley Joint Formulary.Where a medicine that has not been accepted by the SMC or NHS HIS following theirappraisal on clinical and cost-effectiveness, there is a Individual Patient TreatmentRequest (IPTR) process which provides an opportunity for clinicians i.e. hospitalConsultants or General Practitioners to pursue approval for prescribing, on a “case bycase” basis for individual patientsA copy of this policy can be found at the Pharmacy page on the Intranet on the followinglink:http://intranet.fv.scot.nhs.uk/home/Depts/PrimaryPharmacy/Pharm_Primary_Intro.aspFull details of all drugs that have been considered by the SMC can be found on theirwebsite http://www.scottishmedicines.org.uk/Page 6

NICE guidanceNHS Quality Improvement Scotland (NHS QIS) reviews NICE (National Institute forHealth and Clinical Excellence) Multiple Technology Appraisal (MTA) and decideswhether the recommendations should apply in Scotland.Where NHS QIS decides that an MTA should apply in Scotland, the NICE guidancesupersedes SMC advice. Unlike the SMC process, MTAs examine a disease area or a classof drugs and usually contain new evidence gathered after the launch of drugs or neweconomic modelling.SMC is the source of advice for Scotland on new drug therapies and the NICE Singletechnology Appraisal (STA) process therefore has no status in Scotland. If a NICE STAendorses a drug that was not recommended by the SMC, it is open to the manufacturers toresubmit the drug to SMC with new evidence.This information is reviewed by the New Drugs Sub Group on a routine basis.Paediatric DeclarationChildren, and in particular neonates, differ from adults in their response to drugs.Pharmacokinetic changes in childhood are important and have a significant influence ondrug absorption, distribution, metabolism and elimination and need to be considered whenchoosing an appropriate dosing regimen for a child. Where possible, children and neonatalmedications should be prescribed within the terms of the product licence (marketauthorisation). However, many children may require medicines not specifically licensedfor paediatric use.Recommendations have been drawn up by the Standing Committee on Medicines, a jointcommittee of the RCPCH and the Neonatal and Paediatric Pharmacists Group on the useof medicines outwith their product licence. The recommendations are:• Those who prescribe for a child should choose the medicine which offers the bestprospect of benefit for that child, with due regard to cost• The informed use of some unlicensed medicines or licensed medicines for unlicensedapplications is necessary in paediatric practice• Health professionals should have ready access to sound information on any medicinethey prescribe, dispense or administer, and its availability• In general, it is not necessary to take additional steps, beyond those taken whenprescribing licensed medicines, to obtain the consent of parents, carers and childpatients to prescribe or administer unlicensed medicines or licensed medicines forunlicensed applications• NHS Forth Valley and Health Authorities should support therapeutic practices thatare advocated by a respectable, responsible body of professional opinionForth Valley Formulary should not be used in isolation when prescribing medications forchildren/neonates. It is recommended that Medicines for Children (a Royal College ofPaediatric & Child Health Publication) is used where possible or the Childrens BNF orBNF. For neonates e.g. in SCBU, the relevant formularies available on the ward should beused. Many of the drugs stated in the formulary will be used in paediatrics but not at thedosages stated.In addition sugar free medicines should be used as much as possible when prescribing inchildren/neonates.Page 7

WebsiteAn Adobe® Acrobat® version of the formulary can be found on the Forth ValleyPharmacy Pharmacy Services intranet site at the following address:http://intranet.fv.scot.nhs.uk/home/Depts/PrimaryPharmacy/Pharm_Primary_Intro.aspThe web-based version of the formulary will be updated after each ADTC meeting andwill represent the most up to date version at any point in time.Formulary StatusThe formulary is intended for use across both primary and secondary care. The key for usehas been agreed as follows:- Initiate and continue- Continue where appropriateGPs should not normally be expected to prescribe non-formulary drugs on therecommendation of hospital specialists unless sound clinical reasons are given in writing.If this does not happen, the GP can contact the specialist concerned. This requirement alsoextends to patients attending outpatient clinics.AppealsIf a drug has been omitted from the formulary, and a consultant or GP maintains that suchan omission could compromise patient care, the case for formulary inclusion can bereconsidered. Appeals against any formulary decisions should be made with fullsupporting evidence to the New Drugs Sub Group via the Medicines Informationdepartment at Forth Valley Royal Hospital. Final decisions on appeals are taken by theADTC.Page 8

Non-formulary drug supplyIn exceptional clinical circumstances a non-formulary medicine may be required for aparticular patient. For certain non-formulary drugs which are being continuouslymonitored and for recent non-formulary decision this will require completion of a nonformularyrequest form by the consultant or clinical pharmacist for all hospital initiatednon-formulary drugs.Within primary care, it would be expected that the majority of prescribing would be fromformulary choices.Non-formulary drug use is reviewed by Drug and Therapeutics Committees, and thereafterby the ADTC.An example of the Non-formulary request form has been included (Appendix 2). This isavailable within the electronic version of the Formulary at the following linkhttp://intranet.fv.scot.nhs.uk/home/Depts/PrimaryPharmacy/Pharm_Joint_Formulary/pharm_formulary.aspGuidance on prescribingLocal and National GuidanceThe appendices of this formulary include Primary Care, Secondary Care and area-wideForth Valley Guidelines. Where national guidance is applicable references to webaddresses have been included (as links in the electronic version). Prescribers are remindedthat the electronic document is a dynamic document, which will be updated after eachNew Drugs Sub Group meeting. Similarly local and national guidance is continuallyupdated and may influence prescribing. Some useful web addresses are included below toprovide access to the latest national guidelines:British Hypertension SocietyBritish Thoracic SocietyNational Institute for Health and Clinical ExcellenceScottish Intercollegiate Guidelines NetworkIn hospitalshttp://www.bhsoc.org/http://www.brit-thoracic.org.uk/http://www.nice.org.uk/http://www.sign.ac.uk/A Medicines Code of Practice is in existence within Forth Valley Royal Hospital that givesguidance on the writing of prescriptions and the safe and secure handling of medicines.Combination productsPlease note: Whenever possible prescribe individual drug components rather than a fixedratio combination as it allows flexibility of dosing and is usually more cost effective.Page 9

Unlicensed MedicinesThe New Drugs Sub Group is aware of several preparations being used out-with theirlicences, and some of these have been included within the formulary. Prescribers can stillobtain unlicensed preparations in the same manner as they did prior to the launch of theFormulary.In primary care, prescribers should note that if prescribing a preparation for an unlicensedindication, the liability for its use lies with the prescriber.Therapeutic drug monitoringGuidelines on therapeutic drug monitoring for antibiotics and other drugs can be found inAppendix 12.AdviceInformation and advice on medicine use is available from your local communitypharmacist, Medicine Information Centre, Prescribing Support Team, practice or clinicalpharmacist.FeedbackThe success of the formulary depends on feedback from the users and is most welcome.The formulary will be updated regularly.Page 10

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialtiesServices1 Gastro-intestinal System1.1 Dyspepsia and Gastro-oesophageal Reflux DiseaseComment Forth Valley Dyspepsia Management Guidelines. (Appendix 3)1.1.1 Aluminium and Magnesium containing antacidsCo-magaldrox Comment Maalox® is the contract product for supply in Secondary Care. Mucogel® has the sameformulation and is more cost-effective in Primary care.1.1.2 Other drugs for dyspepsia and GORDAcidex® Gaviscon Advance® (2 nd Line) Peptac® (1 st Line) Infant Gaviscon® 1.2 Antispasmodics and other drugs altering gut motilityMebeverine (not MR preparation) (1 st Line) Hyoscine Butylbromide (2 nd Line) Peppermint Oil Metoclopramide Domperidone 1.3 Ulcer-healing Drugs1.3.1 H2-receptor antagonistsRanitidine 1.3.3 Chelates and complexesSucralfate 1.3.5 Proton pump inhibitorsOmeprazole Capsules (1 st Line) Lansoprazole Capsules (2 nd Line) Esomeprazole (Restricted to specialist recommendation only within FV guideline)Esomeprazole (I.V.) [Nexium I.V.®]Pantoprazole (I.V.)1.4 Antidiarrhoeal Drugs1.4.1 Methylcellulose Tablets (see section 1.6.1)1.4.2 Antimotility drugsCodeine Phosphate Loperamide (High doses used in short bowel patients)Comment Prevention of electrolyte depletion and replacement of electorlyte is 1st line treatment in acutediarrhoea. Oral rehydration therapy is listed in section 9.2. Codeine recommended only in shorttermuse due to CNS side effects and dependence.Page 11

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialtiesServices1.5 Chronic Bowel Disorders1.5.1 AminosalicylatesBalsalazide Sodium Mesalazine Comment Mesalazine MR product - prescribe by brand and do not interchangeSulfasalazine [Sulphasalazine] Comment Biologic therapies can only be prescribed by consultant gastroenterologist1.5.2 CorticosteroidsPrednisolone (Predfoam®/Predenema®/Predsol®)1.5.3 Drugs affecting the immune responseAzathioprine Ciclosporin Mercaptopurine MethotrexateAdalimumab Infliximab Comment1.6 LaxativesConsultant Gastroenterologist initiation onlyComment Please refer to the relevant Constipation Management GuidelinesAppendix 4 – Acute Services guidelines for Management and Prevention of Constipation in Adults.1.6.1 Bulk-forming laxativesIspaghula Husk (2 nd Line) Methylcellulose Tablets (use in diarrhoea)1.6.2 Stimulant laxativesBisacodyl Docusate (Norgalax Micro-enema®) - For midwife initiation onlyGlycerol Senna Co-danthramer (terminal care only) 1.6.4 Osmotic LaxativesLaxido® Comment Prolonged use is not recommended.Lactulose (1 st Line) Comment Lactulose may take up to 48 hours to act and is therefore unsuitable for relief of acute symptoms andfor "prn" prescribing.Phosphate enema Sodium Citrate Enema (Micralax®) 1.6.5 Bowel cleansing solutionsMoviprep®Picolax®1.7 Preparation for HaemorrhoidsAnusol® Cream Anusol® Suppositories Anusol HC® Ointment Anusol HC® Suppositories For midwife initiation onlyUniroid – HC® Ointment Uniroid – HC® Suppositories Comment Uniroid - HC ® 1 st line if steroid containing preparation with anaethetic required, but steroidpreparations are not 1 st line and should only be used for a few days.Page 12

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialtiesServicesXyloproct® Ointment Lidocaine [lignocaine] Gel (see section 15.2)1.8 Stoma CareComment Specialist advice - contact Stoma Care Nurse.1.9 Drugs affecting intestinal secretions1.9.1 Drugs acting on the gall bladderUrsodeoxycholic Acid 1.9.2 Bile acid sequestrantsColestyramine Colestipol 1.9.4 PancreatinPancrex® Pancrex V® Creon® Comment Specialist Consultant recommendation.Page 13

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialtiesServices2 Cardiovascular SystemComment For Hypertension guidance, Please refer to NICE Hypertension Guidancehttp://guidance.nice.org.uk/CG127 and the British Hypertension Society www.bhsoc.org2.1 Positive inotropic drugsDigoxin Digibind®2.2 Diuretics2.2.1 Thiazides and related diureticsBendroflumethiazide [Bendrofluazide]Indapamide Metolazone 2.2.2 Loop DiureticsFurosemide [Frusemide] (1 st Line) Bumetanide (2 nd Line) Comment Although the efficacy of bumetanide is the same as furosemide, it is much more expensive toprescribe in Primary Care. It should therefore be used 2nd line.2.2.3 Potassium-sparing diureticsAmiloride Spironolactone (1 st Line) Eplerenone (2 nd Line) 2.2.4 Potassium-sparing diuretics with other diureticsCo-amilofruse Comment Please specify strength of Co-amilofruse.2.2.5 Osmotic DiureticsMannitolCommentDiuretics should be prescribed separately except for patients with poor compliance,where combination products may be indicated.Potassium containing diuretic combinations: The majority of patients do not require potassiumsupplementation. For those patients who may require potassium supplements, potassium-sparingdiuretics should be used. Potassium containing diuretics do not contain adequate amounts ofpotassium to match the patients' requirements and are therefore not advised for use.2.3 Anti-arrhythmic DrugsVerapamil (see section 2.6)Cardiology recommendationAmiodaroneCardiology recommendationDronedarone (Multaq®)Cardiology recommendationPropafenoneCardiology recommendationLidocaine [Lignocaine]DisopyramideCardiology recommendationAdenosineFlecainideCardiology recommendation2.4 Beta-BlockersBisoprolol (1 st Line) Nebivolol (2 nd Line)Cardiology RecommendationPropranolol (see section 4.1.2) Atenolol CarvedilolCardiology RecommendationEsmolol (I.V. for arrythmia)LabetalolCardiology RecommendationMetoprolol Page 14

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialtiesServices2.5 Drugs affecting the renin-angiotensin system and some otherantihypertensive drugs2.5.1 Vasodilator antihypertensive drugsHydralazine Sildenafil (Revatio®) – (Paediatrics - Continuation of treatment from tertiary centres)2.5.2 Centrally acting antihypertensivedrugsMethyldopa 2.5.4 Alpha-adrenoceptor blocking drugsDoxazosin (Not M/R) 2.5.5.1 Angiotensin-converting enzyme inhibitorsLisinopril Ramipril Perindopril 2.5.5.2 Angiotensin-II receptor antagonistsCandesartan (2 nd Line) Irbesartan Losartan (1 st Line) Valsartan Comment Evidence base is changing in this area and will be kept under review.2.6 Nitrates, Calcium channel blockers, and Potassium-channel activatorsComment Products marked with an * are available as both standard release and sustained releasepreparations.Sustained release preparations may be produced by many different manufacturers and may nothave the same bioavailabilities, therefore, these products should be prescribed by brand name(the locally recommended brands are specified). Standard release preparations may be prescribedgenerically.2.6.1 NitratesGlyceryl Trinitrate Comment Patches not recommended due to tolerance problemsIsosorbide Mononitrate 2.6.2 Calcium-channel blockersDiltiazem * (Tildiem LA® & Retard®) Nifedipine * (Coracten®)Cardiology RecommendationComment Only use generic Nifedipine in Raynaud's. Not to be used sublinguallyVerapamil * Amlodipine (1 st Line) Felodipine (2 nd Line) 2.6.3 Potassium-channel activatorsIvabradine (3 rd line after betablockers & diltiazem)Nicorandil 2.6.4.1 Peripheral vasodilatorsNaftidrofuryl Comment Use as per SIGN Guideline 89Page 15

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialtiesServices2.7 Sympathomimetics2.7.1 Inotropic SympathomimeticsDobutamineDopamineDopexamine2.7.2 Vasoconstrictor sympathomimeticsNoradrenaline [Norepinephrine]2.7.3 Cardiopulmonary resuscitationAdrenaline[Epinephrine] 2.8 Anticoagulants and Protamine2.8.1 Parenteral anticoagulantsHeparinEnoxaparinFondaparinux sodium inj. (to be used with guidance)2.8.2 Oral anticoagulantsWarfarin PhenindioneRivaroxaban – refer to full guidance Rivaroxaban for Stroke Prevention in Atrial Fibrillation2.8.3 Protamine 2.9 Antiplatelet DrugsAspirin Clopidogrel Dipyridamole Retard (Persantin Retard®)EptafibatideTicagrelor - Specialist initiation only Comment Ticagrelor - For clopidogrel intolerant patients and patients who have had stent thromobsis orcontinuation of treatment in line with recommendation from the initiating Health BoardTirofiban2.10 FibrinolyticsStreptokinase (For Life ThreateningP.E. )Alteplase ( For Ischaemic Stroke)Tenecteplase ( For ST Elevation M.I. )2.11 AntifibrinolyticsTranexamic Acid Etamsylate [Ethamsylate]2.12 Lipid-regulating DrugsCommentCommentEnsure that statins and ezetimibe are prescribed in accordance with Forth Valley Lipid LoweringGuidelines (Appendix 5)Bezafibrate Fenofibrate (Lipantil®) Atorvastatin (2 nd Line) Chewable Atorvastatin tablets not to be prescribedPravastatin Rosuvastatin Simvastatin (1 st Line) Ezetimibe (limited indications, see Forth Valley Guideline Appendix 5)Omacor® Page 16

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialties3 Respiratory SystemComment Local guidance is available from the Forth Valley Asthma Online Resource with links tonational guidance at http://www.qifv.scot.nhs.uk/3.1 BronchodilatorsServices3.1.1 Adrenoceptor stimulantsSalbutamol (1 st Line) Terbutaline (2 nd Line) Salmeterol 3.1.2 Antimuscarinic bronchodilatorsTiotropium (1 st Line) Ipratropium Bromide (2 nd Line) 3.1.3 TheophyllineAminophylline InjectionUniphyllin® Comment Different brands of theophylline modified release preparations have different bioavailabilities.As the products are NOT INTERCHANGEABLE, prescribers should specify the brand on which apatient is stabilised.3.1.4 Combination bronchodilator preparationsCombivent® 3.1.5 Peak flow meters, inhaler devices and nebulisersPeak Flow Meter (Mini-Wright® Adult & Paediatric)Inhaler spacer device CommentCommentSpacer devices are recommended in preference to dry powder or breath actuated inhalersparticularly in young children.Emergency DrugsAdrenaline [Epinephrine] Specialist ProductsCaffeine CitrateCaffeine Citrate is the oral xanthine of choice in neonates.3.2 CorticosteroidsBeclometasone Dipropionate (Clenil Modulite®1st line)Budesonide (2 nd Line) Fluticasone Fluticasone propionate and formoterol fumarate (Flutiform®)Hydrocortisone IV (See section 6.3.2)Prednisolone Oral (See section 6.3.2)Other Compound PreparationsSeretide® (Seretide 500 accuhalerlicensed for COPD and cheaper thanMDI which is unlicensed for COPD)Symbicort® Fostair® Comment Refer to Guidance on Issuing Steroid Cards (Appendix 6).Page 17

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialtiesServices3.3 Cromoglicate, related therapy and leukotriene antagonists3.3.2 Leukotriene receptor antagonistsMontelukast 3.4 Allergic Disorders3.4.1 AntihistaminesCetirizine (1 st Line) Loratadine (2 nd Line) Alimemazine [Trimeprazine](Paediatrics)Chlorphenamine [Chlorpheniramine]Promethazine (Paediatrics) Comment For drugs acting on the nose see section 12.2.3.4.2 Allergen ImmunotherapyOmalizumabRespiratory Consultant Only3.4.3 Allergic emergenciesEpipen® Icatibant Injection (Firazyr®)3.5 Respiratory Stimulants and Pulmonary Surfactants3.5.2 Pulmonary SurfactantsCaffeine base 5mg/ml Sol’n for injectionPoractant alfa3.6 OxygenCylinders Piped3.7 MucolyticsCarbocisteine (1 st Line) Mecysteine Hydrochloride (2 nd Line) Page 18

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialtiesServices4 Central Nervous System4.1 Hypnotics & AnxiolyticsComment All sedative hypnotics and anxiolytic products are licensed for short term use only and should bereserved for short courses to alleviate acute conditions after causal factors have been established.Refer to Guidance on Benzodiazepine Prescribing: Management of Dependence in Primary Care4.1.1 HypnoticsZopiclone (1 st Line) Temazepam (2 nd Line) 4.1.2 AnxiolyticsDiazepam (1 st Line) Chlordiazepoxide (use in alcohol detoxification)Comment Refer to Alcohol Dependence -In-patient Management of Alcohol Withdrawal ,Alcohol Dependence-Community Management of Alcohol Withdrawal &Alcohol Dependence- Maintenance of AbstinenceCommentLorazepam Lorazepam - Short term use only.Shorter acting compounds may be preferred in patients with hepatic impairment but they carry agreater risk of withdrawal symptoms.Propranolol (see section 2.4) 4.2 Drugs in psychoses and related disorders4.2.1 Antipsychotic DrugsComment:Refer to Prescribing Guidelines• Emergency Sedation Prescribing Guideline• Monitoring Guidance for Patients Receiving Atypical Antipsychotic Therapy• Integrated Care Pathway for SchizophreniaChlorpromazine (1 st Line in Primary Care)Haloperidol ( Baseline ECG Required ) Levomepromazine [Methotrimeprazine] (Palliative Care)Trifluoperazine Zuclopenthixol Dihydrochloride (Clopixol® tabs)Zuclopenthixol Acetate (Clopixol Acuphase®)Amisulpride Aripiprazole Clozapine Comment Clozapine used for treatment resistant schizophrenia only.Quetiapine Risperidone 4.2.2 Antipsychotic Depot InjectionsFlupentixol Decanoate Inj Fluphenazine Decanoate Inj Haloperidol Decanoate Inj Olanzapine (See protocol for IM use) Paliperidone Inj Pipotiazine Palmitate Inj Risperidone Zuclopenthixol Decanoate Inj Page 19

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialtiesServices4.2.3 Antimanic DrugsComment Refer to Integrated Care Pathway for Bipolar DisorderCarbamazepine Valproate Semisodium (Depakote®) CommentCommentValproate Semisodium (Depakote®) is licensed for the treatment of manic episodes associated withbipolar disorder but is not currently licensed for the maintenance treatment of bipolar affectivedisorder. It has been agreed by the Forth Valley New Drugs Sub Group that if prophylaxis is needed,following stabilisation of the episode of acute mania with Depakote® and prior to discharge, sodiumvalproate should be substituted.Lithium Lithium products Priadel® and Camcolit® have different bioavailabilities, therefore brand must bespecified when prescribing. Liquid preparations Priadel® and Li-Liquid® also have differentbioavailabilities.Refer to Guideline for the Management of Patients on Lithium4.3 AntidepressantsComment Refer to Guidance for Mangement for Depression4.3.1 Tricyclic and related Antidepressant DrugsAmitriptyline Clomipramine Lofepramine Trazodone 4.3.2 Monoamine-oxidase InhibitorsPhenelzine (dietary / interaction advice required)Moclobemide 4.3.3 Selective Serotonin Re-uptake InhibitorsCitalopram (1 st Line for 18 to 65 years) Fluoxetine Sertraline 4.3.4 Other Antidepressant DrugsMirtazapine Venlafaxine 4.4 Central nervous system stimulantsAtomoxetine Dexamfetamine (Not first line) Methylphenidate Comment Refer to SMC recommendation on sustained release methylphenidate and Atomoxetinepreparations.http://www.scottishmedicines.org.uk/4.5 Drugs used in the treatment of obesityOrlistat Comment To be prescribed in conjunction with NICE guidelines.Page 20

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcutePage 21CHPsMentalHealthSpecialtiesServices4.6 Drugs used in Nausea & VertigoHaloperidol (palliative care) (see section 4.2) Levomepromazine [Methotrimeprazine] (palliative care) (see section 4.2)Cinnarizine Cyclizine Inj ( oral use in paediatrics and adolescents in acute trust)Prochlorperazine (2 nd Line) Domperidone (1 st Line) Metoclopramide Ondansetron (Restricted – oncology & anaesthetics)Fosaprepitant (Ivemend®) Restricted use West of Scotland Cancer NetworkHyoscine Hydrobromide Betahistine4.7 AnalgesicsComment Refer to Primary Care Guidance on Use of Oral Analgesics (Appendix 7) and also to Forth ValleyPalliative Care Guidelines and Specialist FormularyRefer to Guidance on Pain Management in a Person with a Substance Misuse Problem (In-Patient)4.7.1 Non-opioid AnalgesicsParacetamol (1 st Line) Co-codamol 8/500Co-codamol 30/500 Comment N.B. increased opioid side-effects and risk of dependence with co-codamol.Also, effervescent preparations of compound analgesics may contain high levels of sodium.For patients requiring low sodium intake please refer to individual Summary of Product Characteristics.Refer also to Primary Care Guidance on Use of Oral Analgesics (Appendix 7) andAcute Pain Service Guideline for In-patient Acute Pain (Appendix 9)4.7.2 Opioid AnalgesicsDihydrocodeine Morphine Diamorphine Comment Morphine to be used first line over DiamorphineCyclimorph® Fentanyl Patch–(Prescribe by brand–Matrifen®) Fentanyl [Fentanyl Injection for Acute Services refer to section 15.1.4.3]Comment Fentanyl indicated if unacceptable toxicity from morphine.Fentanyl Patch indicated for patient with severe pain with swallowing difficulties or intractable nauseaand vomiting. (SIGN 106 – Control of Pain in Adults withCancer)Refer to manufacturers information for oral morphine to transdermal route conversion –conversion ratios vary, so should be used only as an initial approximate guide.Oxycodone (Palliative care and specialist pain management only)Comment To convert oral morphine to oral oxycodone divide total 24 hours dose of morphine by 2 to determinethe total dose of oxycodone in 24 hours4.7.3 Neuropathic PainAmitriptyline [see section 4.8] (1st Line) Gabapentin [see section 4.8] (2 nd Line) Comment Refer to Local Neuropathic Pain Guidelines (Appendix 8)Carbamazepine (see section 4.8) Epilim® (see section 4.8) 4.7.4 Antimigraine DrugsSumatriptan (1 st Line) Rizatriptan Pizotifen

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialtiesServices4.8 AntiepilepticsComment Refer to NICE guideline No 76 “Newer Drugs for Epilepsy in Adults” and No 79 “Newer Drugs forEpilepsy in Children” for guidance on the use of oxcarbazepine, levetiracetam, tiagabine andtopiramate and SIGN guideline No 70 “Diagnosis and Management of Epilepsy in Adults”4.8.1 Control of EpilepsyCarbamazepine Gabapentin Pregabalin Lamotrigine (1 st Line in women ofchild bearing potential)Levetiracetam (2 nd Line) Phenobarbital [Phenobarbitone](Paediatrics)Phenytoin Retigabine (for specialist use only) Rufinamide (for specialist use only) Zonisamide (for specialist use only) Lacosamide (for specialist use only) Topiramate (under specialist supervision) Sodium Valproate (1 st Line) Clobazam Clonazepam Comment Many antiepileptic products are available as generic products which may vary in bioavailability,therefore, are not interchangeable. It is recommended that prescribing should be by brand name toensure continuity of supply.4.8.2 Drugs used in Status EpilepticusDiazepam (rectal) Diazemuls® Lorazepam I.V. (1 st Line)CommentMidazolam,oromucosal sol’n (Buccolam®) (Prescribe by brand)While Buccolam® is only licensed in paediatrics, the New Drugs Group supports the use of thisproduct in all new patients including adults.Phenytoin I.V. (2 nd Line)Comment Refer to Acute Services Phenytoin Loading Guidelines for Status Epilepticus & MaintenanceTherapy (Appendix 10)4.9 Drugs used in Parkinsonism and related disorders4.9.1 Dopaminergic Drugs used in ParkinsonismApomorphineRefer to Clinic for Specialist Consultant RecommendationEntacaponeRefer to Clinic for Specialist Consultant RecommendationMadopar®Refer to Clinic for Specialist Consultant RecommendationPramipexolRefer to Clinic for Specialist Consultant RecommendationRopiniroleRefer to Clinic for Specialist Consultant RecommendationRotigotine PatchSpecialist Initiation OnlySinemet® Selegiline Stalevo® Comment Ideally patients should be referred to a specialist clinic untreated with any dopaminergic drug.4.9.2 Antimuscarinic Drugs used in ParkinsonismOrphenadrine Procyclidine Comment Anticholinergics should only be initiated in Parkinson’s Disease on specialist recommendationPage 22

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialties4.9.3 Drugs used in Essential Tremor, Chorea, Tics and Related DisordersServicesPropranolol (see section 2.4) Primidone (on specialist recommendation) Xeomin® InjectionDysport®4.10 Drugs used in Substance DependenceComment See Section 4.1.2 and Refer to linksAlcohol Dependence -In-patient Management of Alcohol WithdrawalAlcohol Dependence-Community Management of Alcohol Withdrawal &Alcohol Dependence – Maintenance of AbstinenceAcamprosate Nicotine Products Varenicline Bupropion Comment Refer to FV Smoking Cessation Flow Charts (Appendix 11)Disulfiram Buprenorphine (Substance Misuse Prescribing Services)Buprenorphine/naloxone (Substance Misuse Prescribing Services)Suboxone®Methadone (Substance Misuse Prescribing Services)Comment Refer to following linksMethadone Assisted Treatment ProgrammeBuprenorphine Assisted Treatment ProgrammeGuidance on the Management of Opioid Dependence: Buprenorphine detoxificationNaltrexone (Substance MisusePrescribing Services)4.11 Drugs for DementiaComment Refer toIntegrated Care Pathway for DementiaGuideline for the use of Cognitive Enhancing Drugs DonepezilGalantamineMemantine RivastigminePage 23

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcutePage 24CHPsMentalHealthSpecialtiesServices5 InfectionsComment Please refer to appropriate guidelines for specific indications• Primary Care Management of Infection Guidance• Forth Valley GUM List (Appendix 13)• Patients receiving Chemotherapy Who Become Unwell –Guidance for Community Healthcare Practitioners(Appendix 17)• British Lymphology Society – Consensus Document on the Management of Cellulitis in Lymphoedemahttp://www.lymphoedema.org/lsn5.1 Antibacterial drugs5.1.1 PenicillinsBenzylpenicillin Penicillin V Flucloxacillin Amoxicillin Co-amoxiclav (Generally not 1 st line in Primary Care)Piperacillin and tazobactam (Tazocin®)Comment Tazocin® only to be used following microbiological advice.5.1.2 Cephalosporins, cephamycins and other beta-lactamsCefalexin (for UTI) Cefotaxime (I.V.) Comment Cefotaxime I.V restricted for paediatrics / neonates. Use in Primary Care for Treatment ofInvasive Meningococcal disease in children and young people – SIGN 102CeftazidimeCeftriaxoneMeropenem- (Restricted use, seek microbiology advice)Comment Aztreonam used only following microbiological advice in Cystic Fibrosis.5.1.3 TetracyclinesDoxycycline Lymecycline (2nd line in acne) Oxytetracycline Tetracycline Comment Oral Tetracycline in combination with other agents for MRSA infection only.Tetracycline Injection is an unlicensed preparation5.1.4 AminoglycosidesGentamicinNeomycinTobramycin (Paediatric Cystic Fibrosis only) Comment Tobramycin restricted to use in Cystic Fibrosis only.5.1.5 MacrolidesErythromycin Azithromycin (For use in PrimaryCare for Chlamydia)Clarithromycin 5.1.6 ClindamycinClindamycin5.1.7 Some other antibacterialsChloramphenicolColistimethate [Colistin ] (Cystic Fibrosis only) Linezolid (Restricted use, seek microbiology advice)Sodium fusidate Vancomycin Teicoplanin (Restricted use–Haematology or on Microbiology advice) Comment Sections 5.1.6 & 5.1.7 - Above products only to be used following microbiological advice.

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialtiesServices5.1.8 Sulphonamides and trimethoprimTrimethoprim Co-Trimoxazole Comment Co-trimoxazole to be restricted for treatment and prophylaxis of Pneumocystis Pneumonia,Stenotrophomonas multiphilia or following microbiological advice5.1.9 Antituberculous drugsEthambutol Hydrochloride Isoniazid Pyrazinamide Rifampicin Rifater® Rifinah® 150 & 300 Streptomycin Amikacin (see section 5.1.4) Ciprofloxacin (see section 5.1.12) 5.1.10 Antileprotic drugsDapsone 5.1.11 Metronidazole and tinidazoleMetronidazole 5.1.12 QuinolonesCiprofloxacin (1 st line use only in acute pyelonephritis & prostatitis)MoxifloxacinNorfloxacin (Spontaneous Bacterial Peritonitis prophylaxis)OfloxacinComment Moxifloxacin restricted to 2nd line treatment in Community Acquired Pneumonia and inexacerbations of COPD in penicillin allergic patients.Ofloxacin restricted to Orchitis, prostatitis and Pelvic Inflammatory Disease only.Norfloxacin for prostatitis and prophylaxis of infection in ascites.5.1.13 Urinary-tract infectionsNitrofurantoin 5.2 Antifungal drugsAmphotericin (I.V.)Fluconazole (IV & Oral) Comment Fluconazole capsules 1st line in oral thrush in adults. ( 50mg daily for 7 – 14 days )Nystatin oral suspension for Orophanyngeal fungal infections in children (see section 13.3.2)Flucytosine (IV)Itraconazole Nystatin Terbinafine Voriconazole (IV & Oral)Comment Voriconazole should only be used following microbiological advice5.3 Antiviral drugs5.3.1 HIV InfectionComment See F.V. GUM list (Appendix 13)5.3.2 Herpes virus infectionsAciclovir (1st line) Famciclovir (2nd line if compliance is a problem) Page 25

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialtiesServices5.3.3 Viral HepatitisAdefovir dipivoxil (Restricted use Follow West of ScotlandGuidelines)Tenofovir (Viread®) (for specialist use only) Boceprevir (Victrelis®) (for specialist use only) 5.3.5 Ribavarin (Rebetol®) 200mg Capsules- (In combination withViraferon & Intron A)5.4 Antiprotozoal drugs5.4.1 AntimalarialsComment Treatment of Malaria is prescribable on the NHS. Prophylaxis is not prescribable at NHS expensebut private prescriptions can be provided.Chloroquine Primaquine Proguanil Hydrochloride Pyrimethamine with Sulfadoxine (Fansidar®)Pyrimethamine with Dapsone (Maloprim®)Quinine Sulphate Hydroxychloroquine Sulphate (see section 10.1.3)Comment Prescribe following discussion with Infectious Diseases.5.4.2 AmoebicidesDiloxanide Furoate Metronidazole Comment Prescribe following discussion with Infectious Diseases.5.5 AnthelminticsMebendazole Piperazine Page 26

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialtiesServices6 Endocrine SystemComment Please Refer to Forth Valley Management Programme for Diabetes Mellitus,Recommendations for Blood Glucose Monitoring (Appendix 14)Blood Glucose Meters- Formulary Choices (Appendix 15)6.1 Drugs used in Diabetes6.1.1 Insulins (Recommendation by Practitioner experienced in management ofdiabetes)6.1.2 Oral Antidiabetic Drugs6.1.2.1 SulphonylureasGliclazide (1 st Line) Glimepiride (only if problems with compliance or polypharmacy) (2 nd Line)6.1.2.2 BiguanidesMetformin 6.1.2.3 Other AntidiabeticsExenatide Liraglutide Comment Liraglutide restricted to secondary care initiation only.Recommended maintenance dose of 1.2mgPioglitazone Saxagliptin Sitagliptin (1 st Line) Comment Sitagliptin, Saxagliptin and Exenatide restricted to prescribers experienced in themanagement of diabetes.6.1.4 Treatment of HypoglycaemiaGlucagon Glucogel Glucose 50% 6.2 Thyroid and Antithyroid Drugs6.2.1 Thyroid HormonesLevothyroxine [Thyroxine] Sodium (1 st Line) Liothyronine Sodium 6.2.2 Antithyroid DrugsCarbimazole (1 st Line) Propylthiouracil Potassium iodidePropranolol 6.3 Corticosteroids6.3.1 Replacement TherapyFludrocortisone Acetate 6.3.2 Glucocorticoid TherapyHydrocortisone Tablets Hydrocortisone Injection Dexamethasone Methylprednisolone Prednisolone Comment Consider osteoporosis prevention treatment if corticosteroids used long term.Please refer to Forth Valley Osteoporosis GuidelinesPage 27

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialtiesServices6.4 Sex Hormones6.4.1 Female Sex Hormones6.4.1.1 Oestrogens and HRTTibolone With Premique® (Includes low dose) uterus Prempak-C® Femoston® FemSeven Conti® FemSeven Sequi® Elleste Duet® Evorel (includes Conti) Elleste Duet Conti® Kliovance® Without Premarin® uterus Elleste Solo® Estraderm MX® Oestrogel® 6.4.1.2 ProgestogensProgesterone (Cyclogest® for subfertility)Dydrogesterone Medroxyprogesterone Norethisterone 6.4.2 Male Sex Hormones & AntagonistsTestosterone Cyproterone Acetate Finasteride 6.5 Hypothalamic and pituitary hormones and anti-oestrogens6.5.1 Hypothalamic and anterior pituitary hormones and anti-oestrogensClomifene CitrateChorionic Gonadotrophin (HCG)Follicle Stimulating Hormone (FSH)Gonadorelin (LH-RH)Tetracosactrin (Synacthen®)(Synthetic Human Growth Hormone)Comment Specific recommendation from Dr McQueen. All products for assisted conception are fundedcentrally and GPs should not prescribe.6.5.2 Posterior Pituitary Hormones and AntagonistsDesmopressin Terlipressin (oesophageal varices)6.6 Drugs affecting bone metabolism6.6.1 CalcitoninParathyroid hormone 100mcg powderfor injectionSalcatonin Nasal SprayTeriparatideComment Teriparatide -restricted use refer to SMC GuidancePage 28

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialtiesServices6.6.2 BisphosphonatesComment Please refer to Hypercalcaemia of Malignancy Treatment Guideline (Appendix 19) & SuspectedHypercalcaemia of Malignancy Guideline for Primary Care (Appendix 20)Alendronic Acid (1 st Line) (prophylaxis and treatment in men and women)Risedronate Sodium (prophylaxis and treatment in women only) (2 nd Line inpatients with G.I. problems)Comment Risedronate 2 nd Line if GI intolerance of alendronic acid. Recommended in G.I problems. Caution ensurecorrect strength is prescribed for indication.Disodium Pamidronate(I.V.)- (1 st Line for hypercalcaemia)Zoledronic Acid Sol’n (2 nd line)Ibandronic Acid-(3 rd Line) Denosumab (Restricted to specialist recommendation in secondary care in women only)Strontium ranelate (Protelos®) Comment Strontium ranelate 2 nd Line to bisphosphonates for patients who cannot tolerate bisphosphonatesRaloxifene Comment Rafoxifene may be used for patients where bisphosphonates and Stontium are contra indicated or nottolerated6.7 Other endocrine drugs6.7.1 Bromocriptine and other dopamine-receptor stimulantsBromocriptine Cabergoline Quinagolide 6.7.2 Drugs affecting gonadotrophinsDanazol Naferelin Page 29

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialties7 Obstetrics, gynaecology and urinary tract disorders7.1 Drugs used in obstetrics7.1.1 Prostaglandins and oxytocicsCarboprostDinoprostoneErgometrine MaleateSyntometrine®Oxytocin7.1.1.1 Ductus arteriosusAlprostadil (restricted to paediatrics)7.1.2 MifepristoneMifepristoneMisoprostol (NB. Unlicensed indication)7.1.3 Myometrial RelaxantsAtosibanTerbutaline7.2 Treatment of vaginal and vulval conditionsServicesComment See also Forth Valley GUM List (Appendix 13)7.2.1 Preparations for vaginal and vulval changesConjugated oestrogens (Premarin® cream)Estradiol [Oestradiol] (Vagifem®, Estring®)Estriol [Oestriol] (Ovestin®) Relactagel 7.2.2 Vaginal and vulval infectionsClotrimazole Miconazole ClindamycinPovidone Iodine (Betadine®) 7.3 Contraceptives7.3.1 Combined hormonal contraceptivesLoestrin20® Logynon® Tri-Regol® Microgynon30® Rigevidon® Marvelon® Gedarel® 30/150 Mercilon® Gedarel® 20/150 Femodene® Millinette® 30/75 Femodette® Millinette® 20/75 Cilest® Evra® Patch Page 30

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialtiesServices7.3.2.1 Oral Progestogen-only contraceptivesCerazette® (use 2 nd line-follow SMC advice)Femulen® Norethisterone 7.3.2.2 Parenteral Progestogen-only contraceptivesMedroxyprogesterone acetate (Depo-provera®) Nexplanon® 7.3.2.3 Intra-uterine progestogen-only contaceptiveMirena® (not 1st line) 7.3.4 Contraceptive devicesNova-T ® 380 Multiload ® Cu375 T-Safe® CU 380A 7.3.5 Emergency contraceptionLevonelle®1500 CommentCommentLevonelle® 1500 only effective if taken within 72 hours. Taking the dose as soon aspossible increases efficacy.EllaOne® EllaOne® not to be used 1 st line unless patient presents after 72 hours.7.4 Drugs for genito-urinary disorders7.4.1 Drugs for urinary retentionTamsulosin Alfuzosin Comment Alfuzosin is available as both standard release and M/R formulations. If prescribing M/R preparation,please prescribe by brand.7.4.2 Drugs for urinary frequency, enuresis and incontinenceDarifenacin Duloxetine (restricted use refer to SMC Guidance) Fesoterodine fumarate Oxybutynin – m/r or patch only Propiverine Solifenacin Succinate (Vesicare®) Tolterodine Trospium chloride Comment See FV Guideline for the Initial Management of Urinary Incontinence - http://www.qifv.scot.nhs.uk/Tolterodine IR (immediate-release tablets) should be tried first. If this is effective, but thepatient experiences side-effects, try Tolterodine MR.If Tolterodine is ineffective a trial of Solifenacin would be advocated.Desmopressin (see section 6.5.2) Comment Desmopressin Spray is no longer indicated for nocturnal enuresis unlesstreatment is associated with multiple sclerosis7.4.3 Drugs used in urological painPotassium citrate (Effercitrate®) 7.4.4 Bladder instillations and urological surgerySodium chloride Dimethyl sulphoxideMitomycin-CEpirubicinPage 31

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcutePage 32CHPsMentalHealthSpecialtiesServices7.4.5 Drugs for impotenceComment National guidance for prescribing drugs for erectile dysfunction (and other schedule 11 drugs) isavailable at the following web link http://www.show.scot.nhs.uk/sehd/pca/pca1999(m)9(p)3.htmAlprostadil (Caverject®, Muse®) Sildenafil Tadalafil Vardenafil 8 Malignant disease and immunosuppressionComment Please refer to Superior Vena Cava Obstruction Treatment Guideline for Acute Services (Appendix 21),Superior Vena Cava Obstruction Guideline for Primary Care (Appendix 22),Malignant Spinal Cord Compression Guideline for Seconday Care (Appendix 23) &Malignant Spinal Cord Compression Guideline for Primary Care (Appendix 24)8.1 Cytotoxic drugs8.1.1 Alkylating drugsChlorambucilCyclophosphamide IfosfamideMelphalanBendamustine Hydrochloride (Levact®) Restricted use West of Scotland Cancer NetworkBusulfanTo be prescribed only by West of Scotland haemopoieticstem cell transplant team with HSCT protocolsMesna (urothelial toxicity)Treosulfan8.1.2 Cytotoxic antibioticsBleomycinDoxorubicinEpirubicinIdarubicinMitomycin-CMitozantroneDaunorubicin8.1.3 AntimetabolitesCapecitabineCladribineRestricted use West of Scotland Haematology ProtocolCytarabineFludarabine Phosphate5-Fluorouracil (cream - in liaison with Dermatologist) Gemcitabine 200mg and 1g powder Restricted use West of Scotland Cancer Networkfor infustion (Gemzar®)Methotrexate NelarabineRestricted use West of Scotland Cancer NetworkPemetrexedRestricted use West of Scotland Cancer NetworkTegafur with Gimeracil and Oteracil Restricted use West of Scotland Cancer Network(Teysuno®)Comment For patients, who are receiving S/C Methotrexate for Rheumatoid Arthritis, administer in liaison withAcute Pharmacy Services.MercaptopurineThioguanineFolinic acid (Folate rescue)8.1.4 Vinca alkaloids and etoposideEtoposideVinblastineVincristineVinorelbine

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcutePage 33CHPsMentalHealthSpecialtiesServices8.1.5 Other antineoplastic drugsBortezomibCarboplatinCisplatin8.1.5 Amsacrine BoretezomibDacarbazineTemozolomide 5, 20,100 and 250mgRestricted Use West of ScotlandCapsules (Temodal®)Cancer NetworkHydroxyurea Oxaliplatin 50mg,100mg powderRestricted Use West of ScotlandFor IV Infusion (Eloxatin®)Cancer NetworkProcarbazineDasatinibRestricted Use West of ScotlandCancer NetworkErlotinib 25, 100 and 150 f/c tabletsRestricted Use West of Scotland(Tarceva®)Cancer NetworkEverolimus (Afinitor®)Restricted Use West of ScotlandCancer NetworkImatinib (Glivec®)Restricted Use West of ScotlandCancer NetworkNilotinibRestricted Use West of ScotlandCancer NetworkSunitinibRestricted Use West of ScotlandCancer NetworkDocetaxelRestricted Use West of ScotlandCancer NetworkTopotecanRestricted Use West of ScotlandCancer NetworkTrastuzumab 150mg vial (Herceptin®)Restricted Use West of ScotlandCancer Network8.2 Drugs affecting the immune response8.2.1 Antiproliferative immunosuppressantsAzathioprine Mycophenolic acid 8.2.2 Corticosteroids and other immunosuppressantsCiclosporin [Cyclosporin] Prednisolone Methylprednisolone Tacrolimus 8.2.3 Rituximab and alemtuzumabAlemtuzumab 30mg/ml Sol’nRestricted use West of Scotlandfor IV infusionCancer NetworkRituximab 10mg/ml Concentrate for infusion (MabThera®)8.2.4 Other immunomodulating drugsInterferon-alfa (Haematology use only) Peginterferon Alfa (Pegasys®)Viraferon® (Hepatitis B)Interferon alfa 2b (Viraferon & Intron A) 18 million IU. Solution For injection, multidose pen in Combination with ribavarin (Rebetol®) capsules 200mgFingolimod (Gilenya®) (Restricted Specialist Use)Lenalidomide (Revlimid®)Specialist initiated only as per West of Scotland protocolThalidomide (Restricted to Consultant Neurologist use only)Natalizumab (Specialist Initiation)OthersBCG bladder instillation

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialtiesServices8.3 Sex hormones and hormone antagonists in malignant disease8.3.1 OestrogensEthinylestradiol [Ethinyloestradiol] 8.3.2 ProgestogensMedroxyprogesterone acetate Megestrol acetate Norethisterone 8.3.4 Hormone antagonistsTamoxifen AnastrozoleRestricted use West of ScotlandCancer NetworkLetrozole Cyproterone acetate Flutamide Bicalutamide Goserelin Leuprorelin ExemestaneRestricted Use West of ScotlandCancer NetworkTriptorelin (Decapeptyl SR ®)- (1 st Line for prostate cancer)Abiraterone AcetateRestricted use West of ScotlandCancer NetworkOctreotide 9 Nutrition and Blood9.1 Anaemias and some other blood disorders9.1.1 Iron-deficiency anaemias9.1.1.1 Oral IronFerrous sulphate Ferrous fumarate (Fersamal) (1 st Line) Pregaday® For midwife initiation onlyFerrous gluconate Sodium feredetate 9.1.1.2 Parenteral IronFerric CarboxymaltoseIron Sucrose (Venofer®)9.1.2 Drugs used in megaloblastic anaemiasFolic Acid Hydroxocobalamin Comment Giving vitamin B12 without further investigation, due to macrocytic anaemia, can preventsubsequent accurate diagnosis. Intrinsic factor antibody test cannot be interpreted in thepresence of high levels of B12 (serum B12 levels are not relevant after B12 has beengiven). If there is clinical suspicion of sub-acute combined degeneration, treatmentshould be initiated immediately after generous samples for analysis are taken.9.1.3 Drugs used in hypoplastic, haemolytic, and renal anaemiasDarbepoetin alfa Epoetin delta Epoetin alfa Epoetin beta Epoetin zeta Comment Epoetin for renal unit/shared care use only.Page 34

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcutePage 35CHPsMentalHealthSpecialtiesServices9.1.4 Drugs used in platelet disordersAnagrelideRestricted use West of Scotland Cancer Network9.1.6 Drugs used in neutropeniaFilgrastim (restricted - haematology/oncology use only)9.1.7 Drugs used to mobilise stem cellsPlerixafor (Mozobil®) [for use upon Tertiary Recommendation]9.2 Fluids and electrolytes9.2.1 Oral preparations for fluid and electrolyte imbalancePotassium chloride (Sando-K®, Kay-Cee- L syrup®)Calcium polystyrene sulphonate (Calcium resonium®)Sodium polystyrene sulphonate (Resonium A®)Oral rehydration salts Sodium bicarbonate 9.2.2 Parenteral preparations for fluid and electrolyte imbalance9.2.2.1 Electrolytes and waterSodium chloride Sodium chloride/glucoseSodium chloride with Potassium Glucose Glucose with Potassium Potassium chloride strong solutionSodium bicarbonate9.2.2.2 Plasma and plasma substitutesVolulyte®9.4 Oral NutritionDietetic recommendation9.5 MineralsComment Refer to Hypomagnesaemia in Adults Guideline (Appendix 25) and Hypophosphataemia in AdultsGuideline (Appendix 26).9.5.1 Calcium and magnesiumSandocal® Calcium-Sandoz® syrup Calcium Gluconate InjectionMagnesuim sulphate injection9.5.2 Phosphorus9.5.2.2 Phosphate binding agentsAluminium hydroxideCalcium Salts (1 st Line) Lanthanum Sevelamer (2 nd Line) 9.5.4 ZincZinc sulphate (Solvazinc®)9.6 Vitamins9.6.1 Vitamin AVitamins A and D Vitamins A C and D 9.6.2 Vitamin BThiamine (Vit B1) Pyridoxine (Vit B6) Nicotinamide Vitamins B and C IV/HP (Pabrinex®) 9.6.3 Vitamin CAscorbic acid

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialtiesServices9.6.4 Vitamin DErgocalciferol (readily available as calcium and ergocalciferol)Alfacalcidol Calcium and colecalciferol (Adcal-D3® & Calfovit D3®)Colecalciferol (800iu equiv. to 20 micrograms vitamin D 3 ) [Fultium-D3 ® ]9.6.6 Vitamin KPhytomenadione Menadiol sodiumphosphateKonakion MM® Konakion MM Paediatric® 9.6.7 Multivitamin preparationsVitamin A, B group, C,and D (Abidec® & Dalivit®)Forceval ®(+/-junior) Capsules Vitamin Capsules BPC 9.8 Metabolic disorders9.8.1 Betaine anhydrous oral powder (Cystadane®) (restricted use-specialistInitiation only)Page 36

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialtiesServices10 Musculoskeletal and joint diseases10.1 Drugs used in rheumatic diseases and gout10.1.1 Non-steroidal anti-inflammatory drugsIbuprofen Diclofenac sodium (not M/R product) Diclofenac 75mg/2ml Sol’n for intravenous injection (Dyloject®)(Restricted use for post operative pain)Naproxen Celecoxib (not 1st line) Etoricoxib (Alternative to Celecoxib) 10.1.2 CorticosteroidsTriamcinolone hexacetanide Methylprednisolone acetate Hydrocortisone acetate 10.1.3 Drugs which suppress the rheumatic disease processSodium aurothiomalate Auranofin Penicillamine Hydroxychloroquine sulphate Cyclophosphamide Methotrexate Azathioprine Sulphasalazine (EC formulation) AdalimumabCiclosporin (Prescribe by brand) Comment Due to differences in bioavailability ciclosporin brand should be specified.MycophenylateSpecialist recommendation by Rheumatologyexpert for SLE onlyLeflunomideRheumatology recommendation onlyAdalimumabRheumatology recommendation onlyEtanerceptRheumatology recommendation onlyInfliximabRheumatology recommendation onlyRituximabRheumatology recommendation onlyTocilizumab (RoActemra®) [Not 1 st Line]10.1.4 Drugs for treatment of goutColchicine (acute attack) CommentCaution with course length/total dose of colchicine - refer to BNF.Allopurinol (prophylaxis) Febuxostat (Adenuric®) (Restricted tospecialist recommendation only) Page 37

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialtiesServices10.2 Drugs used for neuromuscular disorders10.2.1 Drugs which enhance neuromuscular transmissionNeostigmine Distigmine (see section 7.4.1) Edrophonium chloride Pyridostigmine bromide 10.2.2 Skeletal muscle relaxantsBaclofen Dantrolene Diazepam (short term use) Quinine Sulphate (300mg) 10.3 Drugs for the relief of soft-tissue inflammationHyaluronidasePiroxicam GelAlgesal®11 Eye11.3 Anti-infective eye preparations11.3.1 AntibacterialsChloramphenicol Comment Chloramphenicol eye drops are well tolerated and the recommendation that they shouldbe avoided because of increased risk of aplastic anaemia is not well founded.Fusidic acid Gentamicin Ofloxacin Levofloxacin (drops and preservative free)Brolene® & ChlorhexidineOphthalmologist use only(for acanthamoeba)11.3.3 AntiviralsAciclovir (on advice from secondary care)11.4 Corticosteroids and other anti-infalmmatory preparations11.4.1 CorticosteroidsComment Ophthalmologist recommendations - GPs should not initiate corticosteroids without advice.Betamethasone (Betnesol® Drops & Oint, Betnesol-N® Drops)Dexamethasone (Maxidex® Drops & Maxitrol® Oint.)Dexamethasone Minims®Ophthalmologist use onlyFluorometholoneOphthalmologist use onlyPrednisolone (Minims®) Prednisolone 0.1% & 0.03%Ophthalmologist use onlyRimexoloneDexamethasone (Ozudrex®)Ophthalmologist use onlyPage 38

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialtiesServices11.4.2 Other anti-inflammatory preparationsOlopatadine Antazoline (Otrivine-Antistin®) Comment Otrivine-Antistin® also contains the sympathomimetic xylometazoline. It should be avoided inangle-closure glaucoma.Azelastine Lodoxamide Nedocromil (2nd line) Sodium Cromoglicate 11.5 Mydriatics and cycloplegicsAtropine 1% (Drops & Minims®) Cyclopentolate (Drops & Minims®) Tropicamide 1% (Drops & Minims®) Phenylephrine (10% Drops, 2.5% & 10% Minims®)11.6 Treatment of glaucomaPilocarpine 0.5%, 1% & 2% Brimonidine Betaxolol Timolol Timolol 0.5% preservative free CommentCommentPlease refer to CSM guidance on Beta-blocker use. Combination products can be prescribed whereappropriate if both constituents are on the formulary.Acetazolamide Acetazolamide can be initiated in Primary Care under ophthalmologist adviceBrinzolamide Dorzolamide (drops & preservative free)Bimatoprost LatanoprostTafluprost (if proven sensitivity to benzalkonium chloride)Travoprost 11.7 Local anaestheticsProxymetacaine Minims® (lessstinging than others)Proxymetacaine and Fluorescein Minims®Oxybupricaine Minims®Tetracaine [Amethocaine] 1% Minims®Cocaine 4% drops & 10% pastePage 39

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthServicesSpecialties11.8 Miscellaneous ophthalmic preparations11.8.1 Tear deficiency, ocular lubricants and astringentsAcetylcysteine Carbomer 980 (polyacrylic acid) 0.2% (Viscotears® including preservative free)(1 st Line)Carmellose sodium 0.5% (drops & preservative free)Hydroxyethylcellulose Comment Preservative free for use in patients with allergy to preservatives or patients receivingmore than 4 doses of preservative per day.Hydroxypropyl guar (drops & preservative free)Hypromellose 0.3% (drops & preservative free)Liquid paraffin (Lacri-Lube®) Sodium hyaluronate (0.1% & 0.2% drops and 0.2% preservative free)Clerz® Eye drops11.8.2 Ocular diagnostic and peri-operative preparations and photodynamic treatmentCommentCommentFluorescein sodium (Minims®) Fluorescein sodium (Strips) AcetylcholineApraclonidine (0.5% drops & 1% preservative free)Diclofenac Sodium 0.1%Flurbiprofen 0.3%Ketorolac 0.5%Severe corneal infection (keratitis) should be managed with ofloxacin initially pendingmicrobiology sensitivities.Cefuroxime 5% eye drops (severe keratitis)Penicillin 0.3% eye drops (severe keratitis)Gentamicin 1.5% eye drops (severe keratitis)Natamycin (fungal keratitis)Severe intraocular infection (endophthalmitis) should be managed as per Royal College ofOphthalmologist guidelines and following discussion with the local Vitreoretinal unit.http://www.reophth.ac.uk/docs/scientific/IVTRevisionfinal2009.pdfhttp://www.mrcophth.com/focus1/endophthalmitis.htmlVancomycin (endophthalmitis)Amikacin (endophthalmitis)Ceftazidime (endophthalmitis)Amphoteracin B (endophthalmitis)Ranibizumab (Specialist Use Only according to SMC Restriction)OthersCiclosporin 2% eye dropsDexamethasone sodium injection preservative freeDisodium edetate (EDTA) 0.37% eye drops(corneal burns)Fluorescein IV 20%Hyaluronidase 1500 unitsHydroxyamphetamine eye drops (for pupil testing)Potassium ascorbate (ascorbic acid 10%)Povidone-iodine 5%Trifluorothimidine eye drops (2 nd line after Aciclovir)Page 40

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialtiesServices12 Ear, Nose and Oropharynx12.1 Drugs acting on the ear12.1.1 Otitis externaBetamethasone sodium phosphate (Betnesol®) Betnesol-N® Flumetasone Pivalate (Locorten-Vioform®) Gentisone HC® Prednisolone (Predsol®) Predsol-N® Gentamicin (Genticin®, Garamycin®) Gentisone HC® Triadcortyl-Otic®12.1.3 Removal of ear waxCerumol® Sodium bicarbonate 5% 12.2 Drugs acting on the nose12.2.1 Drugs used in nasal allergyAzelastine Hydrochloride (Rhinalast®) Beclometasone Dipropionate (1 st Line) Betamethasone sodium phosphate (Betnesol®) Budesonide Fluticasone Comment Avamys is the most cost-effective fluticasone–containing option for prohylaxis and treatment ofallergic rhinitis. Flixonase Nasule 1 st Line for nasal polypsMometasone Furoate (Nasonex®) (2nd line) Sodium Cromoglicate 12.2.2 Topical nasal decongestantsEphedrine Hydrochloride (under 12 year olds) Sodium Chloride 0.9% (for infants) Xylometazoline Hydrochloride Ipratropium Bromide (Rinatec®) 12.2.3 Nasal preparations for infection and epistaxisMupirocin (Bactoban Nasal®) Naseptin® 12.3 Drugs acting on the oropharynx12.3.1 Drugs for oral ulceration and inflammationBenzydamine Hydrochloride Adcortyl in Orabase® Hydrocortisone pellets (Corlan®) Choline salicylate dental gel BP (Bonjela®, Teejel®)12.3.2 Orophanyngeal anti-infective drugsAmphotericin Miconazole Nystatin (1 st Line) 12.3.3 Lozenges and spraysBenzalkonium chloride (Bradosol®) 12.3.4 Mouthwashes, gargles and dentifricesChlorhexidine gluconate Povidone-Iodine Thymol 12.3.5 Treatment of dry mouthAS Saliva Orthana®Glandosane® Page 41

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialtiesServicesOralbalance Gel® Comment General Practitioners with special interest (GPSIs) are based in primary care but may prescribe ormake recommendations on behalf of Acute Services13 Skin13.2 Emollient and barrier preparationsComment Please refer to Forth Valley Dermatology Guidelines13.2.1 EmollientsAqueous Cream Emulsifying Ointment White soft paraffin 50:50 Ointment (Liq paraffin/White soft paraffin)Cetraben® (2 nd line – alternative for patients unable to use an oily product)Diprobase® cream Doublebase® E45® (2nd line) Epaderm® Oilatum® Hydromol® Cream & Ointment Oilatum Plus® Calmurid® cream (2 nd line) Balneum Plus® (1 st line) Dermol ® (Menthol in Aqueous Cream) Eucerin® cream and lotion 10% 13.2.2 Barrier preparationsMetanium® (2 nd line) Comment Barrier preparations are not appropriate for use in the treatment ofeczemaConotrane 13.3 Topical local anaesthetics and antipruriticsCalamine oily lotion Comment The oily lotion gives a more prolonged effect, but contains peanut oil.Crotamiton (Eurax®) Doxepin Hydrochloride 13.4 Topical corticosteroidsHydrocortisone - cream/oint Nystaform-HC ® (peri-oral use ) Betnovate® - cream/oint Betacap® Betamousse® Clobetasol Propionate Clobetasol with neomycin & nystatin Eumovate® - cream/oint Diprosone® - cream/oint (2 nd line) Diprosalic® - oint/scalp application Lotriderm ® (2 nd line) Nerisone Forte® (2 nd line ) Page 42

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialtiesServices13.4 Haelan ® Tape Elocon® (Once daily application) Synalar® gel - for scalp use Trimovate® Canesten HC® Daktacort® Fucibet® Fucidin H® Timodine® Betnovate C® 13.5 Preparations for eczema and psoriasisComment Extemporaneous preparations of "nostrums" containing Ichthammol, Coal Tar orSalicylic acid are no longer "cheap" options. It is highly likely that these will requireto be produced by a "Specials" manufacturer at very high cost (upwards of 10 timesthe expected cost). Therefore, wherever possible prescribe proprietary preparationswhich correspond the closest to the formulation and strength required.13.5.1 Preparations for eczemaIchthammol ointment Zinc paste and ichthammol bandage Alitretinoin (Restricted use consultant dermatologists only)13.5.2 Preparations for psoriasisCalcipotriol Calcitriol Ointment Coal tar (Extemporaneous coal tar products Acute Service use only)Carbo-Dome® Alphosyl HC® Exorex® - lotion (2 nd line) Dovobet® (follow SMC guidance) Dithranol Salicylic acid (as part of extemporaneous preparation) (see comments above)AcitretinCiclosporin Methotrexate Comment Ciclosporin and Methotrexate – Near patient testing under supervision of consultant dermatologist13.5.3 Drugs affecting the immune responseTacrolimus - ointment (in accordance with SMC guidance)Etanercept (Enbrel®)Ustekinumab (Stelara®)Adalimumab (Humira®)13.6 Acne and rosacea13.6.1 Topical preparations for acneBenzoyl peroxide (Panoxyl®) Benzoyl peroxide and clindamycin gel (Duac®)Benzoyl peroxide and erythromycin gel (Benzamycin®)Azelaic acid (2 nd line) Clindamycin Page 43

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialtiesServices13.6.1 Erythromycin (Topical) Zineryt® lotion (in guidance with Forth Valley Dermatology Guidelines)Adapalene (Differin®) (less irritant than tretinoin)Isotrex® gel Isotrexin® gel 13.6.2 Oral preparations for acneIsotretinoin (specialist use only)Co-cyprindiol 2000/35 13.7 Preparations for warts and callousesSalicylic acid (Salactol®, Occlusal®) (Verrugon® - for plantar warts only)Imiquimod Comment Imiquimod - Where surgery is not appropriate or in patients unresponsive to conventional therapyPodophyllotoxin - Cream & Solution (Warticon®) 13.8 Sunscreens and camouflagers13.8.1 SunscreensSunsense® Ultra SpectraBan® Uvistat® SPF30 Solaraze® Efudix® Actikerall® 13.9 Shampoos and other scalp preparationsCapasal® Dermax® Ketoconazole shampoo (Nizoral®) Polytar® Sebco® T/Gel® Vaniqa® (Restricted as per SMC Guidance) 13.10 Anti-infective skin preparations13.10.1 Antibacterial preparationsMupirocin (Bactroban®)- restrict for MRSASilver sulfadiazine (for burns) Fusidic acid Metronidazole 13.10.2 Antifungal preparationsAmorolfine (for fungal nail infections) Clotrimazole Ketoconazole cream (Nizoral®) Comment Nizoral® cream is only prescribable for seborrhoeic dermatitis and pityriasis versicolor and must beendorsed "SLS".Terbinafine 13.10.3 Antiviral preparationsAciclovir Penciclovir (2nd line in cold sores) 13.10.4 Paracitical preparationsMalathion (Derbac M®) Dimeticone Lotion (Hedrin®) Comment Refer to Forth Valley Headlice PolicyPage 44

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialtiesServices13.10.5 Preparations for minor cuts and abrasionsHistoacryl® 13.11 Disinfectants and cleansers13.11.1 Alcohols and salineIndustrial Methylated Spirit Sodium Chloride 0.9% 13.11.2 Chlorhexidine saltsChlorhexidine 13.11.4 Chlorine and iodinePovidone-iodine 13.11.5 PhenolicsTriclosan 13.11.6 Oxidisers and dyesCrystacide® (2 nd line, only for use if resistance develops)Potassium permanganate 13.12 AntiperspirantsAluminium SaltsPage 45

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialties14 Immunological products and vaccinesComment Refer to Forth Valley Vaccine Handling GuidelinesThese include a down-loadable temperature recording chart for refrigeratorsServices14.4 Vaccines and antiseraBCG vaccines intradermalTuberculin PPD RT 23 SSI 2T.U/0.1mlSolution for InjectionTuberculin PPD RT 23 SSI 10T.U/0.1mlSoution for InjectionOral Cholera Vaccine Diphtheria, Tetanus, Pertussis, Polio, Hib (Pediacel)Diphtheria, Tetanus, Pertussis Polio (Repevax®, Infanrix IPV®)Menitorix® (combined Hib & MenC) Hepatitis A vaccineHepatitis A/B vaccine (Twinrix®)Hepatitis A and Typhoid vaccineHepatitis B vaccine Human Papilloma Virus Vaccine(Gardasil®, Cervarix® )Comment Gardasil® first line unless completing a course already started with Cervarix®Influenza vaccine MMR vaccine Meningococcal Group C Conjugate VaccineMeningococcal Polysaccharide A, C, W135 and Y vaccineMeningococcal group A,C,W,135 and Y Conjugate vaccinePneumococcal Polysaccharide (23- valent) VaccinePneumococcal Polysaccharide (13- valent) Conjugated Vaccine(Prevenar13)Rabies vaccineDiphtheria (low dose), Tetanus and Inactivated Poliomyelitis Vaccine(Revaxis®)Typhoid vaccineYellow Fever vaccineVaricella – zoster vaccineBotulinum A Toxin (Haemagglutanin complex see BNFsection 4.9.3)14.5 ImmunoglobulinsPlease contact the Consultant HaematologistPage 46

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcutePage 47CHPsMentalHealthSpecialtiesServices15 Anaesthesia15.1 General anaesthesia15.1.1 Intravenous anaestheticsThiopental SodiumEtomidateKetaminePropofol 15.1.2 Inhalational anaestheticsDesfluraneEnfluraneHalothaneIsofluraneSevofluraneNitrous oxideEntonox®/Equanox®Oxygen (refer to section 3.6)15.1.3 Antimuscarinic drugsAtropine sulphateGlycopyronium bromide15.1.4 Sedative and analgesic peri-operative drugs15.1.4.1 Anxiolytics and neurolepticsDiazepamMidazolamTemazepamAlimemazine [Trimeprazine] (see section 3.4.1)15.1.4.2 Non-opioid analgesicsDiclofenac (See section 10.1)Ibuprofen (See section 10.1)Tenoxicam Injection (See section 10.1)Co-codamol (see section 4.7.1)15.1.4.3 Opioid analgesicAlfentanilFentanylRemifentanil15.1.4.4 Other drugs for sedationDexmedetomidine (Dexdor®)15.1.5 Muscle relaxantsAtracurium besilateCisatracuriumMivacuriumRocuronium bromideVercuronium bromideSuxamethonium chloride15.1.6 Anticholinesterases used in anaesthesiaEdrophonium chlorideNeostigmine metilsulfateRobinul-Neostigmine®Sugammadex15.1.7 Antagonists for central and respiratory depressionDoxapram hydrochlorideFlumazenilNaloxone hydrochloride15.1.8 Drugs for malignant hyperthermiaDantrolene sodium

Forth Valley Formulary Eleventh Edition 2012/13Chapter/Section/Drug Primary Care AcuteCHPsMentalHealthSpecialtiesServices15.2 Local anaesthesiaLidocaine [Lignocaine] HClLidocaine [Lignocaine] andEpinephrine [Adrenaline]Lidocaine [Lignocaine] andPrilocaine (Emla®)Bupivacaine HClBupivacaine and GlucoseBupivacaine and Epinephrine [Adrenaline]Bupivacaine and FentanylLevobupivacainePrilocaine HClRopivacaine HClTetracaine [Amethocaine]Page 48

Forth Valley Formulary Eleventh Edition 2012/13Appendices1 NHS FV Prescribing of New Medicine Flowchart 502 Non Formulary Request Form (Acute Hospitals) 513 Treatment Algorithm for Dyspepsia Guidance 524 Guidelines for The Prevention of Constipation in Adults 535 Lipid Lowering Guidelines 556 Guidance on Issuing Steroid Cards 647 The Use of Oral Analgesics for Pain in Primary Care 658 Neuropathic Pain Guideline 689 FVAH Acute Pain Stepladder 6910 Acute Services Phenytoin Guidelines 7011 Stop Smoking Guidance 7212 Therapeutic Drug Monitoring Guidelines 7913 Genito-Urinary Medicine List 8014 Recommendations for Blood Glucose Monitoring 8115 Blood Glucose Meters-Formulary Choices 8216 Beatson West of Scotland Cancer Centre 8317 Patients Receiving Chemotherapy Who Become Unwell – 84Guidance for Community Healthcare Practitioners18 Suspected Neutropenic Sepsis 8619 Hypercalcaemia of Malignancy Treatment Guideline 8820 Suspected Hypercalcaemia of Malignancy Guideline for 89Primary Care21 Superior Vena Cava Obstruction Treatment Guidance for 90Acute Services-Patients with known Malignancy22 Superior Vena Cava Obstruction Guidance for Primary 92Care23 Malignant Spinal Cord Compression Guideline (Secondary 93Care)24 Malignant Spinal Cord Compression Guideline (Primary 95Care)25 Hypomagnesaemia In Adults 9626 Hypophosphataemia In Adults 9827 Forth Valley Wound Management Formulary 100Page 49

Forth Valley Formulary Eleventh Edition 2012/13Appendix 2NHS FORTH VALLEY PRESCRIBING OF NEW MEDICINEFLOWCHARTThis flowchart outlines the NHS Forth Valley process for the prescribing of newmedicines. This follows guidance from the Scottish Government for the managedintroduction and availability of newly licensed medicines in NHS ScotlandIs this medicine licensed for theindication?YesIs the medicine approved bySMC?NoNoUse Unlicensed Medicine Form(acute services)In Primary Care the use will be atthe discretion of the GP anddocumented in the patient’s notesRefer to IPTR (Individual PatientTreatment Request) policyYesIs the medicine on the localformulary?PrescribeYESNOIs the prescription for a ‘one-off’ use or do you requireto use this medication on a regular basis?‘one-off’regular basisRefer to nonformulary processNew Medicine proforma to becompleted for medicines to beadded to formularyAuthor: Katrina Kilpatrick / Christine RussellPage 50

Forth Valley Formulary Eleventh Edition 2012/13Appendix 2FORTH VALLEY ACUTE HOSPITALSPHARMACY SERVICESREQUEST FOR A NON-FORMULARY DRUGWS-S-712IssueDate:May11ReviewDate:May 2013This form should be completed by the PRESCRIBER for initiation of a non-formulary drug if the drugis prescribed for this patient for the first time in this hospital.The form should then be forwarded to the responsible CONSULTANT for counter signature.The completed form should then be returned to the clinical ward pharmacist who will retain thedocument in the pharmacy department.These forms will be monitored and audited on a regular basis.Part A: Patient DetailsPatient Name/Details:Reason for admission:Consultant:Ward:Clinical pharmacist:Name(generic and proprietary):Part B : Drug DetailsForm: Strength: Dose:Indication:No equivalent Drug:Part C : Reason Formulary Product is not suitableNo equivalent Form of Administration:MoreEffective:Less Side Effects, Specifically………………….Other:Prescriber (printed):………………………………….Signature:………………………………Date:………………….Consultant (printed):………………………………….Signature:………………………………Date:………………….Part D: Pharmacy UsePrice (include VAT) - per packsize:- per daily doseComment:Clinical Pharmacist (printed):Signature:Page 51

Forth Valley Formulary Eleventh Edition 2012/13Appendix 3Treatment Algorithm for Dyspepsia GuidanceThis algorithm should be used in conjunction with written guidance. Forth Valley Guidelines onmanagement of patients with Dyspepsia and GORD are available athttp://www.sign.ac.uk/pdf/qrg68.pdf"INDIGESTION"Consider• Heart• Liver• GallBladder• Pancreas• Bowel• NSAIDsetcNODYSPEPSIAPREDOMINANTHEARTBURNYESMANAGE ASGORDYESREFER TOHOSPITALSPECIALISTALARM FEATURES• Dysphagia• Evidence of GI blood loss• Persistent vomiting• Unexplained weight loss• Upper abdominal mass• (See also GP referral for UpperG-I Endoscopy)NOUNCOMPLICATED DYSPEPSIACONSIDER• Lifestyle• Antacids/H²RAPersistent / recurrent symptomsHp Test + veHp testHp Test -veEradicate HpPersistent / recurrent symptomsdespite confirmed eradicationAgeAsymptomaticManage as functionaldyspepsia55Consider referral to hospitalspecialist**If a patient is causing concern but does not fit into this treament algorithm, orfurther advice is necessary, please contact on call gastroenterologistof the week (0:900 to 17:00 Mon-Fri) via the GI unit secretaries.Pharmacist Lead:Pauline MorrisonPage 52

Forth Valley Formulary Eleventh Edition 2012/13Appendix 4Forth Valley Acute Hospitals ServicesGuidelines For The Prevention Of Constipation In AdultsReassureDetermine normal pattern of bowel movements for individual.Identify the causeThe following factors may be responsible for the development of constipation:• poor diet/change in diet• underlying disease e.g. hypothyroidism, hypercalcaemia• change of environment• immobility• pregnancyMedication reviewThe following drugs may exacerbate constipation. Where possible these drugs should bereviewed if constipation develops.• Opioid analgesics• Antacids containing aluminium• Anticholinergics e.g. oxybutinin, procyclidine• Antihistamines e.g. chlorpheniramine• Calcium channel blockers e.g. verapamil• Diuretics• Iron salts• Antidepressants and antipsychoticsEducateAdvise patient on the following:• adequate dietary fibre intake e.g. Weetabix®, pulses, fruit - refer to Dietician ifnecessary• adequate fluid intake - 8 to 10 cups per day• increase mobility - refer to physiotherapist if necessaryIf necessary - prescribe a laxativePage 53

Forth Valley Formulary Eleventh Edition 2012/13Appendix 4Forth Valley Acute Hospitals ServicesGuidelines For The Management Of Constipation In AdultsMode of action Preparation/Dose Time toeffectAcute constipationHard impaction Osmotic Micro-enema1 at nightOsmoticPhosphate enema1 in the morningOsmotic Laxido® 8 sachets in 1litre water over 6hoursStimulantSodium picosulphate (Picolax)Half to one sachet as requiredSoft impaction Stimulant Senna2-4 tablets at night Max 3 times a weekChronic constipation Bulk former Fybogel1 sachet twice a dayOpioid-inducedconstipationStimulantOsmoticOsmoticSoftener andstimulantStimulantSenna2-4 tablets at night Max 3 times a weekLaxido®1 sachet 2-3 times a day(elderly once daily)Lactulose10mls BDCo-danthramersuspension 5-10ml at nightSenna2-4 tablets at nightPage 54Price perday(£)15-30mins 0.41 Step 115-30mins 0.46 Step 2Additional info.1.85 Elderly pts.Max 3 days therapy3 hours 1.98 Stat dose to restore normal bowelfunction.Repeat as necessary8-12 hours 0.03-0.06 7 day course to restore normalbowel functionAvoid in Abdominal obstruction,acute surgical abdo, acute IBD andsevere dehydration1 -2 days 0.14 Mix with 1/4 pint of water and takeafter meals.Avoid in immobile, chronically ill anddisabled patientsCaution in atonic bowel, impactionand intestinal obstruction8-12 hours 0.03-0.06 Adjust to response.Avoid in Abdominal obstruction,acute surgical abdo, acute IBD andsevere dehydration0.47-0.70 Patients unable to tolerateFybogel/sennaReview after 2 weeks treatment. Canbe continued in resistant cases.Maintenance dose: 1sachet per dayor alternate days.24-48 hours 0.286-12 hours 0.19-0.38 Palliative care patients only8-12 hours 0.03-0.06 Non-palliative care patientsAvoid in Abdominal obstruction,acute surgical abdo, acute IBD andsevere dehydrationRefer to specialist in cases of chronic unresponsive constipation. Pharmaicst Lead: Pauline Morrison

Forth Valley Formulary Eleventh Edition 2012/13Appendix 5Forth Valley Lipid Lowering Guidelines v4 May 2010This guideline applies to people over 16 years of age. This guideline is not intended to serveas a standard of medical care or be applicable in every situation. Decisions regarding thetreatment of individual patients must be made by the clinician in light of that patient’spresenting clinical condition and with reference to current good medical practice.Date May 2010Date of Review May 2012AuthorL CruickshankFalkirk Community Health PartnershipAcute HeadquartersWestburn AvenueFalkirk FK1 5SDTel. (01324) 614651Page 55

Forth Valley Formulary Eleventh Edition 2012/13Appendix 5PRIMARY PREVENTION OF CARDIOVASCULAR DISEASE1. WITH NO DIABETESAll adults from 40 years onward should have their cholesterol measuredas part of an opportunistic CVD risk assessment in Primary Care.Measure random non-fasting totalcholesterol and HDL-cholesterolas part of a CVD risk assessmentTotal CVD risk * > or =20%Measure fasting lipid profileand LFTsTotal CVD risk* < 20% andno cardiovascular complications andno diabetesTotal CVD risk * > or =20%Lifestyle advice,Initiate sim vastatin 40m g ** daily.See BNF for cautions and contraindications.Treat and forget strategy.Check LFTs in 8 weeks.Lifestyle advice and follow up, ideallywithin 5 years, to repeatcardiovascular risk assessment*Assess CVD risk using the ASSIGN score.Consider secondary and familial hyperlipidaemia if cholesterol > 8.0mmol/L.Discuss with lipid clinic if in doubt.**In case of side effects with simvastatin 40mg daily try pravastatin 40mg daily(see BNF for cautions and contraindications).PREVENTION OF ATHEROSCLEROTIC ARTERIAL DISEASE REQUIRES CONTROL OFALL RISK FACTORS. NO SINGLE RISK FACTOR, INCLUDING CHOLESTEROL, SHOULDBE VIEWED IN ISOLATION.• All other risk factors (e.g. smoking, hypertension) should be addressed.• Dietary and other lifestyle advice (e.g. alcohol, obesity, physical activity) should begiven.Certain individuals are at higher risk than CVD risk charts predict.Higher risk occurs in:• Familial dyslipidaemia (e.g. hypercholesterolaemia, familial combinedhyperlididaemia, or other inherited dyslipidaemia)• People with raised triglyceride levels (>1.7mmol/fasting)• Those who are not yet diabetic, but have impaired fasting glucose (6.1-6.9 mmol/l)or impaired glucose tolerance (7.8-11mmol/l).• Women with premature menopause• People of south Asian descent, i.e. originating from the Indian subcontinent• People with central obesity (waist circumference >102cm in men and >88cm inwomen)Page 56

Forth Valley Formulary Eleventh Edition 2012/13Appendix 52. WITH DIABETESSIGN 116 recommends:• Lipid lowering therapy with simvastatin 40mg for primary prevention in patientswith type 2 diabetes aged > 40 years regardless of baseline cholesterol.• Lipid lowering therapy with simvastatin 40mg should be considered for primaryprevention in patients with type 1 diabetes aged > 40 years.• Patients < 40 years with type 1 or type 2 diabetes and other important risk factors*should be considered for primary prevention lipid lowering therapy with simvastatin40mg.*Further risk factors• Retinopathy (preproliferative, proliferative, maculopathy)• Nephropathy, including persistent microalbuminuria• Poor glycaemic control (HbA1c>9%)• Features of metabolic syndrome (central obesity; fasting triglycerides >1.7 mmol/l[non-fasting >2.0 mmol/l] and/or HDL cholesterol

Forth Valley Formulary Eleventh Edition 2012/13Appendix 5SECONDARY PREVENTION OF CARDIOVASCULAR DISEASEEstablished occlusive arterial disease- Coronary heart disease- Cerebrovascular disease- Peripheral vascular diseaseTreat all patients with statins regardless of baseline cholesterolconcentration.See treatment flowchartAll patients should have LFTs performed prior to statin treatmentATHEROSCLEROTIC ARTERIAL DISEASE IS OF MULTIFACTORIAL ORIGIN.NO SINGLE RISK FACTOR, INCLUDING CHOLESTEROL CONCENTRATION,SHOULD BE VIEWED IN ISOLATION.• Encourage smoking cessation (consider nicotine replacement therapy)• All other risk factors hypertension, diabetic control, should be addressed (see separate guidelines)• An antiplatelet agent (see separate guideline) should be taken by all those with occlusive arterialdisease in the absence of contraindications (active peptic ulceration, a bleeding disorder, or truehypersensitivity)• Treat with ACE-inhibitors unless contraindicated• Consider β-blockers, and ensure attendance at a rehabilitation programme, for patients after MI• Dietary and other lifestyle advice e.g. alcohol, obesity, physical activity, should be given.Goals of TreatmentFor secondary prevention, the ideal target is total cholesterol concentration of < 4 mmol/L.NICE recommends an audit target of total cholesterol of

Forth Valley Formulary Eleventh Edition 2012/13Appendix 5TREATMENT FLOWCHARTTreatment necessaryLifestyle advice + Simvastatin 40mg dailySee BNF for cautions and contra-indications. Note potentialinteractions (Box 1, page 7)Check LFTs before starting simvastatin.Re-test at 2 monthsRandom non-fasting total cholesterol +LFT'sCholesterol goals not achievedDiscuss concordance.Change to Atorvastatin 40mg daily.See BNF for cautions and contra-indicationsCholesterol GoalsAchievedAnnual review to ensurecontinued controlCholesterol goals not achievedDiscuss concordance.Change to Atorvastatin 80mg daily.See BNF for cautions andcontra-indicationsIf total cholesterol remains >5mmol/L* Consider addition of ezetimibe 10mg* Consider referral for specialist advicePage 59

Forth Valley Formulary Eleventh Edition 2012/13Appendix 5Acute Coronary SyndromeAll Forth Valley patients suffering acute coronary syndrome, who have no contraindication, willbe commenced on or changed to atorvastatin 80mg daily whilst an inpatient. For those nottolerating 80mg atorvastatin two possible pathways are suggested.• Reduce atorvastatin to maximum tolerated dose and add ezetemibe, if required toattain target.Or• Substitue rosuvastatin for atorvastatin. All patients must start on an initial dose ofno more than 10mg rosuvastatin daily (5mg in those > 70 years and those of Asianancestry).Please note: there is not evidence to recommend changing all those with previous acutecoronary syndrome to atorvastatin 80mg daily. Initiation of this dose without followingthe treatment flowchart should only be at the time of acute coronary syndrome.DiabetesPrevious versions of the Forth Valley Lipid Lowering Guideline have recommended treatmentof diabetes as an equivalent to established vascular disease i.e. secondary prevention. SIGN116 outlines the lack of evidence base for this approach and recommends that lipid loweringmanagement in people with diabetes is divided to primary and secondary prevention on thebasis of established vascular disease. The following recommendations are included withinSIGN guideline:• Grade A evidence. “Lipid lowering drug therapy with simvastatin 40mg isrecommended for primary prevention in patients with type 2 diabetes aged > 40years regardless of baseline cholesterol.” No treatment target is recommended bySIGN. QOF DM17 recommends a total cholesterol target in patients with diabetesof 40years.”• Grade A evidence “Consider intensive lipid lowering therapy with atorvastatin80mg for patients with diabetes and acute coronary syndrome, objective evidenceof coronary heart disease and angiography of following coronary revascularisationprocedures.”Cytochrome P450 InteractionsSimvastatin and atorvastatin are metabolized by cytochrome P450 CYP3A4 and coadministrationof potent inhibitors of this enzyme increases the risk of side effects includingrhabdomyolysis.Page 60

Forth Valley Formulary Eleventh Edition 2012/13Appendix 5MHRA gives the following advice:Interacting DrugPotent cytochrome P450 CYP3A4 inhibitors:HIV protease inhibitorsItraconazoleKetoconazoleErythromycinClarithromycinTelithromycinCiclosporinDanazolOther fibrates (except fenofibrate)Niacin (>1g/day)GemfibrozilVerapamil, amiodaroneDiltiazemGrapefruit juicePrescribing AdviceAvoid SimvastatinDo not exceed 10mg simvastatinAvoid but if necessary, do not exceed10mg simvastatin dailyDo not exceed 20mg simvastatinDo not exceed 40mg simvastatinAvoid grapefruit juice when takingsimvastatinPlease note – The FV antimicrobial guideline gives further advice on alternatives to macrolideantibiotics for various clinical indications. If an interacting drug, which would resultin MHRA advice to avoid simvastatin is deemed essential, an assessment shouldbe made of the individual’s immediate cardiac risk. The PRISM trial suggests thatstopping a statin in those suffering an acute coronary syndrome is associated witha significantly increased risk of death and non-fatal myocardial infarction within thefirst 30 days. In case of doubt seek specialist advice.WarfarinCare is needed when prescriging some statins to patients taking warfarin – pleasecheck the specific product information for further advice on possible interactions.Statin Side EffectsIn cases of possible statin side effects with either simvastatin or atorvastatin, astatin of different solubility should be tried. In primary prevention, pravastatin(hydrophilic) should be substituted for simvastatin (lipophilic). In secondaryprevention, rosuvastatin (hydrophilic) should be substituted for simvastatin oratorvastatin (lipophilic). Prescribing a statin of different solubility may improvetreatment and is recommended over alternative therapies.Page 61

Forth Valley Formulary Eleventh Edition 2012/13Appendix 5Liver Function Tests (LFTs)Statins should be used with caution in those with a history of liver disease or with a highalcohol intake. Use should be avoided in active liver disease.Baseline liver enzymes should be measured before starting a statin. Liver function(transaminases) should be measured 8 weks after starting treatment or dose changes (NICErecommends within 3 months) and at 12 months, but not again unless clinically indicate.If transaminase concentrations reach 3 times the upper limit of normal, levels should berechecked after a minimum 2 week period (a large percentage will return to normal with nointervention). If still elevated, reduce or stop statin. When transaminases return to normal astatin from a different class may be tried i.e. rosuvastatin (hydrophilc) if previously onsimvastatin / atorvastatin (lipophilic).Myopathy and RhabdomyolysisThe CSM advises that myopathy and rhabdomyolysis are rare but clinically important adverseeffects of statins. The exact mechanism by which statins cause rhabdomyolysis remainsunclear, but the risk appears to be dose related. Risk factors include:••Underlying muscle disorders, renal impairment, untreated hypothyroidism, alcohol abuseand age >70 years.Concomitant use of other lipid lowering agents i.e. gemfibrozil, fenofibrate, other fibratesor nicotinic acid.••A history of myopathy with any lipid-lowering treatment.Interactions (e.g. drugs inhibiting cytochrome P450 CYP3A4) see table above.Prescribers are reminded of the need to adjust doses of statins in accordance with therecommendations of each Summary of Product Characteristics.Patients receiving any statin should be asked to report muscle pain, weakness or crampsimmediately. If symptoms are severe or if creatine kinase is greater than 5 times the upperlimit of normal, treatment should be withheld.EzetimibeEzetimibe is a cholesterol absorption inhibitor with moderate cholesterol lowering affect.Ezetimibe has no cardiovascular outcome data to show that its cholesterol lowering effectreduces cardiovascular morbidity or mortality.• Strategies utilising the addition of ezetimibe to lower dose statins are expensive,not evidence based and not recommended.• Ezetimibe is not recommended for primary prevention.• Ezetimibe is not recommended for monotherapy. Every attempt should be made toimprove concordance with a statin by changing to a statin of different solubility inthe case of side effects.RosuvastatinAll patients must start on an initial dose of no more than 10mg rosuvastatin once daily (5mg inthose aged >70 years and those of Asian ancestry. Rosuvastatin should only be titrated to20mg if considered necessary after a 4-week trial of 10mg daily.The 40mg dose is contraindicated in patients with predisposing risk factors for musculartoxicity and specialist supervision is recommended if the 40mg dose is initiated.Page 62

Forth Valley Formulary Eleventh Edition 2012/13Appendix 5Omega – 3 Fatty Acid CompoundsNICE clinical guideline 67 advises that there is insufficient evidence to recommend omega 3fatty acid supplementation in patients with angina, peripheral arterial disease or stroke. Use inprimary prevention is also not recommended.FibratesFibrates act mainly by decreasing serum triglycerides; they have variable effects oncholesterol. All can cause a myositis-like syndrome, especially in those with impaired renalfunction. Combining a fibrate with a statin increases the risk of muscle effects (especiallyrhabdomyolysis) and should be used with caution and after specialist advice. Bezafibrate andfenofibrate are current FV formulary choice fibrates.The routine use of additional lipid-lowering treatment is not recommended withoutspecialist advice.Page 63

Forth Valley Formulary Eleventh Edition 2012/13Appendix 6Pharmacy ServicesGuidance on Issuing Steroid CardsThis advice has been produced by the Forth Valley Airways GroupInhaled SteroidsSteroid Cards should be issued to the following patients 1,2,3Inhaled Steroid Threshold Dose (per day)Adults Beclometasone Dose > 1000mcg 4Budesonide Dose > 800mcg 4Fluticasone Dose > 500mcg 4Mometasone (Non Dose > 800mcg 4– Formulary)Ciclesonide (Non – Dose > 320mcg 4 Unlicensed doseFormulary)Children Beclometasone Dose > 400mcg 1 (age not stated)Budesonide Dose > 800mcg 1 (12 years and under)Fluticasone Dose > 400mcg 1 (4-16 years)Mometasone (Non Dose > 800mcg 1 (12-16 years)– Formulary)Ciclesonide (Non –Formulary)Dose > 320mcg 4 (12-16 years)Unlicensed doseSystemic SteroidsSteroid Cards should be issued to the following patients 1,2,3Adults• Receiving repeated courses, 2-3 courses per year (particularly if takenfor longer than 3 weeks)• Taking a short course within 1 year of stopping long-term therapy• Receiving more than 40mg prednisolone daily (or equivalent)• Receiving repeated doses in the evening• Receiving more than 3 weeks treatment• Patients with other possible causes of adrenal suppressionChildren• As above except 5 :- Receiving more than 20mg prednisolone daily for children < 5years- Receiving more than 30mg prednisolone daily for children > 5yearsThese patients are at risk of disease relapse and/or hypoadrenalism if treatment is withdrawn rapidly 2Chemotherapy Patients – Acute Pharmacy ServicesPharmacists providing clinical check on chemotherapy prescriptions will endorse any prescription thatrequires a steroid card to be givenReferences:1. CSM. Current problem in pharmacovigilance. May 2006; 31:5 2. Scottish Executive. Steroid treatment cards. SEHD/CMO(2006) 10. 26 th July 2006 3. BNF 52. BMJ/RPS. September 2006 4. GINA Guideline 2006 5. Personal correspondance. Dr. McFadyen.Consultant Paediatrician. Stirling Royal Infirmary. 27.10.2006. Lead Pharmacsit Clare Colligan Review August 2014Page 64

Forth Valley Formulary Eleventh Edition 2012/13Appendix 7The Use Of Oral Analgesics For Pain In Primary CareThe World Health Organisation’s three-step analgesic ladder for cancer pain (see below) mayalso be used for non-malignant chronic or acute nociceptive pain. Analgesics should bestarted at the ‘step’ most appropriate to the patient’s level of pain. Decision on analgesicchoice depends on the type of pain, patient factors and supporting clinical evidence. For painthat is present constantly, analgesia should be prescribed regularly and not on an “as required”basis. For more detailed guidance on the management of pain in palliative care- Please refer tothe Forth Valley Palliative Care guidelines and specialist formulary.STEP 2 MILD TO MODERATE PAINOpioid (for mild to moderate pain)e.g Dihydrocodeine, Co-codamol 30/500(Note 2)+/- Non Opioid+/- Adjuvant*STEP 3 MODERATE TO SEVERE PAINOpioid (for moderate to severe pain)e.g Morphine, pethidine (Note 3)+/- Non Opioid+/- Adjuvant*STEP 1 MILD PAINNon Opioide.g Paracetamol, co-codamol 8/500 (Note 1), NSAIDSe.g Ibuprofen, diclofenac sodium, naproxen+/- Adjuvant**AdjuvantAnti-inflammatory- NSAIDs eg ibuprofen, diclofenacsodium, naproxenNeuropathic pain- See Appendix 13 FV Guideline forTreatment of Neuropathic PainTrigeminal Neuralgia- carbamazepine-see BNF fordosage titration (licensed indication)NOTE 1:Compound analgesics containing a low dose of opioid (e.g 8mg of codeine phosphate per tablet) are commonly used, but theadvantages have not been substantiated. Effervescent preparations of compound analgesics may contain high levels of sodium. Forpatients requiring low sodium intake please refer to individual Summary of Product Characteristics.NOTE 2:Prescribe regular laxatives when opioids are being taken regularlyNOTE 3 : Advice regarding strong opioidsUse oral route first, start with normal release oral morphine eg 5-10mg every 4 hours and as required for breakthrough pain.A 2.5mg dose may be enough in the elderly or those with renal impairment. Consider alternative opioids ony if experiencing sideeffects to morphine or can no longer manage oral routeEvery patient on regular opioid should have access to breakthrough analgesia (equivalent to 1/6th total dose oralmorphine).Reserve use of pethidine for short term use- eg changing of painful dressings. Start regular laxative and prophylactic antemeticas required for 7-10 daysDate of Approval June 2006Review Date June 2007References BNF March 2006,Relief of Pain and Related Symptoms – The Role of Drug Therapy - ScottishPartnership AgencyPharmacist Lead: Moira BailliePage 65

Forth Valley Formulary Eleventh Edition 2012/13Appendix 7General Advice on Pain ManagementAccurate assessment should be undertaken to determine the cause, type and severity ofpain and effect on patient (anxiety/depression, neuropathic, mechanical, psychosocial).Non-pharmacological interventionsConsideration should be given at all stages to utilising non-pharmacological interventionseg TENS, acupuncture, physiotherapy, weight loss, exercise, stress managementcounselling, pain management programmes (Pain Association Scotland) and selfmanagement.1. Optimise non-opioid (ie paracetamol and/or NSAID) or opioid treatment• Titrate doses to achieve optimal balance between analgesic benefit,side effects and functional improvement• For continuous pain, ensure maximum tolerated dose is prescribedon a regular basis, by the clock, not ‘prn’.2. Add in adjuvant• Consider adjuvant drugs (any drug that has a primary indicationother than for pain management but is analgesic in some painfulconditions) and choose the class of drug according to yourassessment of type of pain (see shaded box on the WHO analgesicladder) (1) .• Adjuvants can provide greater pain relief and less toxicity withlower doses of each drug given. Start low and go slow (for TCA’sand anticonvulsants)• Topical NSAIDs are recommended for short term usage (up to 6weeks) for small joint pain – wrist, elbow, knees and ankles (2)3. Give adequate length of trial• neuropathic / inflammatory pain – 2-4 weeks to take effect andcontinue for 8 weeks, if tolerated, then assess• non-opioid / opioid – 1 month at regular, maximal doses4. Assess regularly (ask the patient to rate their pain on a score of 1 to 10)and STOP if not effective5. If pain treatment effective, consider withdrawal of treatment aftersignificant improvement every 6 months with careful review (3)6. If pain management still uncontrolled, refer to pain clinicPage 66

Forth Valley Formulary Eleventh Edition 2012/13Appendix 7TramadolIf co-codamol 30/500 + adjuvant drug therapies are ineffective or side-effects are nottolerated, tramadol could be considered. Tramadol should not be co-prescribedwith co-codamol and should not be considered as first line therapy.Tramadol is licensed for moderate to severe pain and is approximately twice aspotent as codeine (3) . It is promoted as between WHO step 2 analgesics for moderatepain (eg codeine) and WHO step 3 analgesics (morphine) BUT there is no evidenceof improved efficacy of safety over other drugs at step 2. Hallucinations,confusion and convulsions as well as drug dependence and withdrawal are reportedat therapeutic doses.Ref1.SIGN 106. Control of pain in adults with cancer November 20082.NICE Osteorthritis February 20083. MeReC Briefing. Issue 22, 2003.The use of strong opioids in palliative carePage 67

Forth Valley Formulary Eleventh Edition 2012/13Appendix 8Forth Valley Guideline for Treatment of Neuropathic Pain*This guidance EXCLUDES Trigeminal Neuralgia (use Carbamazepine first line)STEP ONEConfirm diagnosis by clinical criteriaand exclude reversible causesSTEP TWOAMITRIPTYLINE 10mg nocte(£11.76 per year)AVOID if history of cardiac arryhthmias or troublesome urinary retention - move to step 3and STOP if side effects are troublesome (see BNF for full details)If tolerated increase weekly until effective.Reassess after 4 weeks or maximal dose.(maximal dose 75mg = £23.64 per year)Discontinue if inadequate response after 2 months.In patients with purely diabetic neuropathy consider Duloxetine 60mg once daily. (£332.64 per year)STEP THREEAdd in GABAPENTIN capsules300mg once daily for 4 - 7 daysthen 300mg BD for 4 - 7 daysthen 300mg TID (£115.61 per year)Can titrate slower with low dose 100mg if clinicallyappropriate eg elderly, renal impariment (see BNF) anddifficulty in taking medicinesAssess regularly - if required increase to MAX 600mgTID by slow titration eg 300mg added weeklyNote: always use capsules rather than tabletsIf troublesomeside effectsOR noresponse tomaximal dosegabapentinSTEP FOURReduce Gabapentin gradually and stop, thenstart Pregabalin75mg once daily for 3 - 7 days75mg BD for 3 - 7 days then150mg BD (£772.80 per year)Assess benefit / side effectsCan titrate slower or with lower dose if clinicallyappropriate eg elderly, renal impairment (seeBNF) and difficulty in taking medicinesIf appropriate may titrate gradually to max of300mg BDSTOP IF INSUFFICIENT BENEFIT WITHIN 8WEEKSSMC accepted ONLY for 3rd line treatment inperipheral neuropathic painNote: always prescribe in BD doses andoptimise dose/caps strength to alllow singlecapsule per dose where possible eg. 150mgcaps BD (£772.80 per year)2 x 75mg caps BD (£1,545.60 per year)STEP FIVEIf pain remains uncontrolled or deterioration then...Reconsider diagnosisConsider referral to FV Chronic Pain Service (see SID)Neuropathic Pain* - Pain cause by a lesion or disease of the somatosensory nervous system (International Associationfor the Study of Pain July 2011)Ref: BNF, NICE, SIGN 116. Prices based on MIMS November 2011and Scottish Drug Tariff November 2011 Version 4 30/11/11Page 68

Forth Valley Formulary Eleventh Edition 2012/13Appendix 9Acute Pain Service Guidelines for inpatient acute painAcute Pain StepladderSEVERE PAINMorphine sulphate solution (10mg/5ml) 10mg PRN orRegional analgesia e.g. epidural analgesia orMorphine PCA or s/c protocolhttp://www.qifv.scot.nhs.uk/CE_Guidance.asp?topic=Pain%20Managementplus NSAID (if tolerated)plus paracetamol 1g QDS regularlyMODERATE PAINDihydrocodeine 30-60mg 4 hourly (max 240mg daily)plus NSAID (if tolerated)plus paracetamol 1g 6hrly regularlyMILD PAINparacetamol 1g 6hourlyplus NSAID (if tolerated)• It is advisable not to give dihydrocodeine or tramadol with other opiate based products.• NSAID = Ibuprofen 400mg TID (second line = Diclofenac 50mg TID)• NSAID’s should not be prescribed for more than one week in the first instance.• Do not prescribe NSAID’s in the presence or renal impairment, dehydration or ahistory of peptic ulceration.• Pregnancy/breast feeding – refer to BNF• All analgesia MUST be reassessed prior to discharge.APS is available for advice on page 100 during normal working hoursSr Baggott / Dr E JackPharmacist Lead:Peter BucknerPage 69

Forth Valley Formulary Eleventh Edition 2012/13Appendix 10Acute ServicesPhenytoin Loading Guidelines For Status EpilepticusParenteral Phenytoin is an antiepileptic used for the control of status epilepticus and seizuresdue to head trauma. These guidelines apply to adults only.Drug Presentation:Phenytoin is available as a 50mg/ml (250mg/5ml) injection. If the injection or infusion hasprecipitated or is hazy it should be discarded.• Continuous ECG monitoring is mandatory when administering this drug.• For administration on designated areas only - A&E, Intensive Care areas, AcuteAdmissions Unit.Status Epilepticus-Loading Dose1. For patients not previously receiving phenytoin : 18mg/kgPreparation:Dilute with sodium chloride 0.9% to a maximum concentration of 10mg/ml e.g. 1000mg in100ml.forThe solution must be given immediately.Administration:DO NOT ADMINISTER INTRAMUSCULARLYIntravenous Bolus:Rate should NOT exceed 50mg/min (e.g. 20 minutes for a 1000mg dose). Administer intoa large vein via a large gauge needle or IV catheter.Intravenous Infusion:Rate should NOT exceed 50mg/min. The infusion must be completed within one hour.Administer via an in-line filter (0.22-0.5micron) which is available on the ward. Sterile salineshould be administered prior to and following phenytoin administration through the sameaccess site to avoid local irritation and to ensure adequate venous flow.Important Side-effects:CNS and cardiac depression, hypotension, local tissue irritation, arrhythmias. Cardiacresuscitation equipment should be available.Monitoring:ECG, blood pressure, signs of respiratory depression.Blood levels should only be taken if the patient shows signs of toxicity or is uncontrolled.This should be taken immediately prior to the next dose and levels of 10-20mg/litre aimedfor.References:1. British National Formulary2. Manufacturers Datasheet Compendium 2010.3. Handbook of Clinical Drug Data, 8th Edition, 1997-98.4. A Thomson, Clinical Pharmacokinetics Unit, Glasgow, November 1995Page 70

Forth Valley Formulary Eleventh Edition 2012/13Appendix 10Acute ServicesPhenytoin Guidelines For Maintenance therapyMaintenance Dose : 5mg/kg/day (IV or oral as appropriate)Monitoring ConcentrationsTarget Range : 10 – 20 mg/LSampling Time : predose not criticalIdeally samples should be taken after at least 5 days of maintenance therapy but may be takenearlier if toxicity is suspected or if a patient fails to respond. Steady state may not be reacheduntil 2-3 weeks treatment at a constant dose.Dose AdjustmentThe relationship between phenytoin dose and steady state concentration is non-linear i.e.when the dose is doubled the concentration will increase disproportionately. The followingguidelines may be useful if a dosage adjustment is clinically indicated.Concentration (mg/L) Dose Dose Increase

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Forth Valley Formulary Eleventh Edition 2012/13Appendix 12Therapeutic Drug Monitoring GuidelinesDrugTime tosteady stateDRUGSIdeal Sampling time Target range CommentsCarbamazepine2-3 weeks(newtherapy)2-4 days(dosechange)7-10 days(depends onrenalfunction)Pre dose (not critical) 4 – 12 mg/L Metabolised bythe liver,autoinductionSee BNF forinteractionsDigoxin> 6 hours post dose 0.5 – 2.0μg/L Mainly renalexcretionSee BNF forinteractionsLithium 5-7 days 12 hours post dose 0.4-1.0 mmol/L Renal excretionPhenytoin 2-3 weeks Pre dose (not critical) 10-20 mg/L Metabolised inliver. Non linearincrease inconc with dose.Theophylline 2-3 days 8-12 hours 10-20 mg/L Metabolised inpost dosethe liver.Valproic acid 3 days Pre dose 40-100 mg/L Metabolised inthe liver. Levelsdo not correlatewell withtherapeuticeffectPage 79

Forth Valley Formulary Eleventh Edition 2012/13Appendix 13Genito-Urinary Medicine ListThe following products are not included in the Formulary but are available for restricted useby GUM Clinics:-AntimicrobialsErythromycin capsulesProcaine Benzylpenicillin[Procaine penicillin] injection (UNLICENSEDPRODUCT)Spectinomycin injection (UNLICENSED PRODUCT)Benzathine penicillin (UNLICENSED PRODUCT)AntiretroviralsNucleoside Reverse Transcriptase Inhibitors (NRTIs)AbacavirDidanosineEmtricitabineLamivudineStavudineTenofovirZidovudineCombined NRTIsEmtricitabine/Tenofovir (Truvada®)Abacavir / Lamivudine (Kivexa®)Abacavir / Lamivudine / Zidovudine (Trizivir®)Lamivudine / Zidovudine (Combivir®)Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)EfavirenzEtravirineNevirapineRilpivirine (Edurant®)NRTI & NNRTI Combination ProductEfavirenz/emtricitabine/tenofovir (Atripla®)Emtricitabine/Tenofovir/Rilpivirine (Eviplera®)Protease Inhibitors (PIs)AtazanavirFosamprenavirLopinavir / Ritonavir (Kaletra®)RitonavirSaquinavirTipranavirDarunavirOther AntiretroviralsRaltegravir (As per SMC Guidance)MaravirocTopical preparationsClindamycin 2% creamEconazole 1% creamImiquimod 5% creamUnguentum M creamPharmacist Lead :Isabel MarwickPage 80

Forth Valley Formulary Eleventh Edition 2012/13Appendix 14Recommendations for Blood Glucose MonitoringType 1 diabetesAll patients with Type 1 diabetes need to be able to self-monitor blood glucose –the extent to which they do this will reflect how useful they find the information it.Driving legislation states that patients with type 1 diabetes should test beforedriving every time, and every 2 hours during long car journeys.Type 2 diabetesPatients on insulin or sulphonylurea medication are at risk of hypoglycaemia andshould be able to monitor blood glucose to identify this. The driving rules alsoapply to patients with type 2 diabetes who use insulin.Patients who combine nocturnal insulin with oral hypoglycaemic agents will needto test fasting blood glucose in order to dose-titrate.Some patients who manage their diabetes with diet or on metformin and aretherefore not at risk of hypoglycaemia, will nonetheless find it helpful to be able totest their blood glucose periodically, e.g. to confirm a stable level of glycaemiccontrol or during a period of ill-health. Those who periodically are treated withsteroids may find it useful to be able to test at these times – some patients usesulphonylureas or even insulin during a course of prednisolone, reverting to dietalone afterwards.If there is a suspicion that a patient with Type 2 diabetes is likely to becomeinsulin-requiring it is prudent to ensure they are able to blood glucose monitor.However in patients at no risk of hypoglycaemia who would not gain any benefitfrom self blood-glucose monitoring, regular HbA1c checks is an acceptable way ofassessing glycaemic control.Target blood glucose levelsTarget blood glucose levels should be individualised.Textbook values would be 4-7 mmols fasting, 7-8 mmols pre-meals and less than9 mmols post-prandially. However, whilst we recognise an HbA1c < 48mmol/molgreatly reduces the risk of microvascular complications, it increases the risk ofhypoglycaemia. Those with a short life expectancy, impaired awareness ofhypoglycaemia, mobility or visual problems may benefit from a higher target bloodglucose range. Furthermore introduction of very tight glycaemic control mayincrease morbidity and mortality in those at risk of ischemic heart disease.Lead Dr. Alison MacKenzie /Dr. Linda BuchananPage 81

Forth Valley Formulary Eleventh Edition 2012/13Appendix 15Blood Glucose Meters – Formulary ChoicesMeter Name Insulinx Advantage Expert Optium Exceed FreestyleFreedom LiteFreestyle LiteOneTouchUltra 2One TouchUltraeasyiBGStarManufacturer Abbott Roche Abbott Abbott Abbott Lifescan Lifescan SanofiAventisStrip Name Freestyle Lite Aviva Freestyle Optium Freestyle Lite Freestyle Lite OneTouchUltraAdvantagesCalculates correction andhas bolus advisorWill not acceptbatch or out ofdate test stripsCan also be usedby T1 patients totest bloodketonesNo codingrequired. Largewindowdisplaying resultsNo codingrequired. Backlight for use inpoor lightLargewindowdisplayCost of Strips £15.16 for 50 £15.15 for 50 £15.06 for 50 £15.16 for 50 £15.16 for 50 £15.00for 50One TouchUltraSmall insize.Variouscolours£15.00 for50BG StarConnects toiPod touch &iPhone forinstantdownload£14.73 for 50PossibleDisadvantagesHave to have only onemeter on the go as usesactive insulin forcalculationRequires codingby chipStrips can bedifficult to openButtons are smallSingleCode 25nowCareline 0500 467466 0800 701000 0500 467466 0500 467466 0500 467466 0800121200BLOOD GLUCOSE METERS RECOMMENDATIONSForth Valley Diabetes Specialist Nurse Group Review DateAugust 2011Single Code25 now0800121200Must bebought inBoots – notgiven out.Cost £40 (vatexempt)0800 352525Page 82

Forth Valley Formulary Eleventh Edition 2012/13Appendix 16Medical Communication with theBeatson West of Scotland Cancer CentreThe Beatson West of Scotland Cancer Centre treats patients from all over theWest of Scotland and sometimes beyond. They are aware that sometimes thereare difficulties with communication and therefore have issued the followingadvice on how to get in touch:Out of Hours: Contact Oncology SpR on-call via Beatson switchboard on 0141301 7000. They will be able to answer most questions immediately. If specificpatient information is required they will endeavour to phone you back within 30minutes. Through their internal records system they will at least have access tothe last letter on the patient. This should be sufficient to allow for executivedecision making. Consultant staff at the Beatson have also indicated that theywould be happy to answer specific questions about their own patients.Switchboard at the Beatson have the relevant contact numbers. Normally thiscontact would be consultant to consultant.Normal working hours: SpR on call has page 3277 and will endeavour to get areply on all queries within 30 minutes. SpR’s may pass on the request to aspecific team for action but you will not be asked to transfer or hold.Protocols: Common oncological emergencies policies have been developed inForth Valley for both primary and acute care, in line with Beatsonrecommendations. These are designed to facilitate the urgent care measuresrequired in these situations. It is expected that such patients will then bediscussed and management arrangements agreed with the Beatson consultantstaff.Referrals: The “Clinic Finder” on the Beatson website(http://www.beatson.scot.nhs.uk) allows referring staff to explore the mostappropriate route to refer an individual patient to a member of the site specificteam that serves that geographical catchment area. Click on the ‘For CancerProfessionals’ tab to locate the Clinic Finder on the left of the screen.Page 83

Forth Valley Formulary Eleventh Edition 2012/13Appendix 17Patients Receiving Chemotherapy Who Become UnwellGuidance for Community Healthcare PractitionersPolicy StatementCancer patients receiving chemotherapy are at risk of infection because bothdisease and treatment can compromise the host defenses. The risk of infection isdirectly related to the depth and duration of neutropenia. Patients most at risk arethose with a prolonged (>48 hours) neutrophil count of

Forth Valley Formulary Eleventh Edition 2012/13Appendix 17Neutropenic sepsis is a life-threatening medical emergencyManagement of Unwell Patients Receiving ChemotherapyPatient complains of feeling unwellALL PATIENTS WITHIN 28 DAYS OF CHEMOTHERAPY SHOULD HAVE A PHYSICALASSESSMENT UNLESS SITUATION CONSIDERED IMMEDIATELY LIFE-THREATENINGYES2 OR MORE OF THE FOLLOWING PRESENT?• Temp>38ºC OR 20BPM• Altered Mental StatusNoTemperatureYES >38ºC? NOCheck UrgentFBC*Manage as ClinicallyAppropriateRefer toAcuteMedicalReceivingTeam,FVRHNeutrophils< 1 x 10 9 /L* See guidance on obtaining urgent FBCNeutrophils>1 x 10 9 /LReview and repeat FBC dailyuntil clinical improvement. Ifsubsequent neutrophil < 1 andstill unwell arrange admissionunder acute medical receivingteamObtaining an urgent FBC after the last lab van collection1.Call FVRH switchboard on 01324 566000 and request that switchboard organisesa contract taxi to collect an urgent blood sample, giving the address of thepick-up point and making sure the sample goes to FVRH. (Switchboard has beengiven financial code V79110-4640 to cover the taxi cost).2.Contact the on-call haematology technician (through FVRH switchboard 01324566000) to inform them that an urgent sample is on its way and giveinstructions on who to call with the result.3.Ensure that the details of who to phone with the result are also clearly marked on the lab form.4. If the result is to be given to the out of hours service, please phone the out of hours hub after 5.30 pm on01324 616138 to warn them to expect the result.5. Ensure that relevant clinical details are also posted on ‘Taycare’ special notes.Written April 2010. Reviewed by Paul Baughan, Marie Hughes, Joanne Robinson, Vicky Chisolm, Fiona Galbraith,Sheila Kowalczyk, Duncan Lamont, Mary Orzel, Karen MacLure. Updated June 2011. Review June 2013Page 85

Forth Valley Formulary Eleventh Edition 2012/13Appendix 18SUSPECTED NEUTROPENIC SEPSISNEUTROPENIC SEPSIS CAN BE FATAL IF NOT TREATED PROMPTLY.PATIENTS WITH SUSPECTED NEUTROPENIC SEPSIS MUST BE ASSESSED, CULTURES TAKEN ANDANTIBIOTIC THERAPY STARTED WITHIN 1 HOUR OF ADMISSION (or onset of fever if already an inpatient).NEUTROPENIC SEPSIS SHOULD BE CONSIDERED A POSSIBILITY IN ANY PATIENT WHO HAS HADCHEMOTHERAPY WITHIN PREVIOUS 28 DAYS.PATIENTS SHOULD BE ADMITTED UNDER THE MEDICAL RECEIVING TEAM.Definition of Neutropenic sepsis:• Neutrophils 38 o C on one occasion or clear history of persistent pyrexia measured by patientprior to admissionOR• Clinical signs of septicaemia (tachycardia, hypotension, increased respiratory rate, rigor, alteredmental status, hypothermia)MANAGEMENTWITHIN 1 HOUR• Take brief history to establish potential for neutropenic sepsis and identify any drug allergies• Record baseline observations on Early Intervention Score Sheet• Establish venous access• Take peripheral blood cultures (and central line blood cultures if line present)• Take FBC, U+E, LFTs and CRP• Start IV fluids - 0.9% saline. Minimum rate 125ml/hr• Start accurate fluid balance monitoring. Patient may require urinary catheterisation for this to beaccurate.• Give first dose of antibiotics as per FV neutropenic sepsis antibiotic policyDO NOT WAIT UNTIL BLOOD RESULTS ARE BACKWITHIN 4 HOURS -Subsequent management presumes confirmation of neutropenia• Complete full history and examination. If the patient is being treated by a Beatson Oncologist furtherinformation can be obtained by contacting the on-call Specialist Registrar via Beatson Oncologyswitchboard on 0141 301 7000• Carry out full infection screen (MSSU, line swab, wound swab, throat swab, sputum sample, stool forC+S where appropriate)• Review blood results and ensure subsequent doses of antibiotics are prescribed and at correct dosefor renal function• CXR- if any respiratory symptoms or signs eg. cough, purulent sputum, decreased O2 saturation on air• Continue to record observations at minimum intervals of 4 hours or more frequently if clinicallyindicatedWITHIN 24 HOURS• Consultant should review patient within 24 hours of admission.• Repeat blood cultures if fresh temperature spike9• Identify single room and reverse barrier nurse until neutrophils >1.0 x 10 /LWritten by Dr. Marie Hughes, Consultant Haematologist, March 2010Review date: March 2012Page 86

Forth Valley Formulary Eleventh Edition 2012/13Appendix 18SUBSEQUENT HOURS• Check FBC and U+E daily• Monitor gentamicin levels• Assess daily for signs of localised infection• Inform Specialist Oncology Nurses or patient’s Haematology/Oncology Consultant of admission• If patient in clinical trial inform Clinical Trials Nurse of admission (Ex. 6223)• Discuss transfer of care with duty Consultant Haematologist• Consider use of GCSF if patient has factors predictive of poor outcome: neutrophils 10days, uncontrolled primary disease, hypotensionnot responding to fluid challenge, multiorgan dysfunction or invasive fungal disease• Review blood culture results and clinical condition at 48-72 hours. Decide if antibiotics can berationalised or if switch to 2 nd line antibiotics indicated – see FV neutropenic sepsis antibioticpolicyDURATION OF ANTIBIOTICS• Patients with neutrophil count >0.5 x 10 9 /L and risingStop antibiotics if patient has been apyrexial for 72 hours and:i. blood cultures are negativeii. all sites of infection have resolvediii. patient clinically welliv. CRP fallingIf organism/source of infection identified switch to appropriate oral antibiotic for total treatmentduration of 7 days, taking into account duration of IV treatment• Patients with neutrophil count 0.5 x 10 9 /L and rising, antibiotics eitherdiscontinued or switched from IV to oral and patient well.Written by Dr. Marie Hughes, Consultant Haematologist, March 2010 Review date: March 2012Page 87

Forth Valley Formulary Eleventh Edition 2012/13Appendix 19HYPERCALCAEMIA of MALIGNANCY TREATMENT GUIDELINECorrected Calcium levelMild2.7 – 3.0 mmol/LModerate3.1 – 3.3 mmol/LSe vere>3.3 mmol/LHypercalcaemia most commonly occurs in patients with myeloma and bone metastases ie tumour induced,but it may also occur in non-malignant conditions eg hyperparathyroidism, sarcoidosis, thyrotoxicosis.Symptoms: (usually occur with corrected calcium >3mmol/L)• Dehydration • Nausea/vomiting • Lethargy • Confusion • Abdominal pain• Weakness • Weight loss • Constipation • Anorexia • Hypertension• Polyuria • Polydipsia • Depression • Renal failure • Cardiac arrestTreatment:1. All patients should be started on IV Sodium Chloride 0.9%, 2-6L/24 hours (as tolerated) to endureadequate hydration. Once patient is hydrated consider using IV Furosemide along with fluids toincrease urine output and promote renal calcium excretion. Avoid thiazides as they reduce calciumexcretion. For patients with mild hypercalcaemia fluids alone may be sufficient to reduce the calciumlevel and no further treatment may be required. If the calcium has not normalized after 24 hours, go tostep 2.2. IV Pamidronate should be prescribed according to the calcium level (See dosing chart below). If thepatient is particularly symptomatic this should be started at the same time as the fluid hydration. Thedose should be made up in the appropriate volume of Sodium Chloride 0.9% (see table). In patientswith hypercalcaemia of malignancy, the maximum rate of administration of Pamidronate is22.5mg/hour.Serum Calcium (mmol/L)(corrected or uncorrected)Pamidronate Dose(Single IV dose)Minimum volume ofdilutionUp to 3 15-30mg 250ml3.0 – 3.5 30-60mg 250ml3.5 – 4.0 60-90mg 500ml>4.0 90mg 500ml3. Pamidronate is not recommended in patients with a creatinine clearance of less than 30ml/min unlessin case of life-threatening tumour induced hypercalcaemia where the benefit outweighs the potentialrisk. In such cases contact your clinical pharmacist for advice on appropriate doses.4. The patient’s electrolytes, calcium, phosphate and renal function should be monitored daily.5. Pamidronate has a delayed effect and should start to reduce the calcium level in 2-3 days withmaximal effect within 7 days.6. If corrected serum calcium continues to rise or has not returned to the reference range within 5 daysof giving the Pamidronate, zoledronic acid may be used. 4mg Zoledronic Acid should be prescribedfor all patients with a serum calcium of >3mmol/L. It is not recommended in patients with a serumcreatinine > 400 μmol/l due to lack of safety data. The dose of Zoledronic Acid should be diluted with100ml Sodium Chloride 0.9% or Glucose 5% and given over 15 minutes.7. Adverse effects are usually mild and transient. Most common adverse effects are fever (within 48hours of dose), influenza-like symptoms, hypocalcaemia and hypophosphataemia.8. Duration of response to bisphosphonates is usually 3-4 weeks. The hypercalcaemia will almostcertainly recur if there is no treatment of the underlying cause. Bisphosphonates can be repeatedwhenever hypercalcaemia recurs, however evidence suggests that the effect may diminish withrepeated doses.Please note that this guidance relates to treatment of hypercalcaemia of malignancy only,bisphoshonates may be given to prevent skeletal events/bone pain in certain tumour types, regardlessof calcium level. If in doubt, contact haematologist or oncologist (as appropriate) for advice.Version 5 June 2011 Review June 2013 Written by J Robinson. Reviewed by Dr. HughesReferences: WoSCAN Guidelines on the Use of Bisphosphonates (2005)Stewart AF. Hypercalcaemia Associated with Cancer. NEJM 2005;352(4):373-379Page 88

Forth Valley Formulary Eleventh Edition 2012/13Appendix 20SUSPECTED HYPERCALCAEMIA of MALIGNANCY GUIDELINEfor Primary CareDefinition: Elevated blood calcium levelCorrected Calcium levelMild2.7 – 3.0 mmol/LModerate3.1 – 3.3 mmol/LSevere>3.3 mmol/LCause: Hypercalcaemia most commonly occurs in patients with myeloma or bonemetastases ie tumour induced, but it may also occur in non-malignant conditions eghyperparathyroidism, sarcoidosis, thyrotoxicosis.Clinical Presentation: (symptoms usually occur with corrected calcium >3mmol/L)• Dehydration • Nausea/vomiting • Lethargy • Confusion• Weakness • Weight loss • Constipation • Anorexia• Polyuria • Polydipsia • Depression • Renal failure• Abdo pain • Hypertension • Cardiac arrestManagement:1 If you suspect that a patient is hypercalcaemic but their symptoms do not require urgent admission tohospital, obtain an urgent calcium level. If the patient is symptomatic and hypercalcaemic arrangeadmission to Forth Valley Royal Hospital combined clinical assessment unit, under the medical receivingteam. If the patient has mild hypercalcaemia and you are unsure as to whether admission is requiredcontact the patients known consultant haematologist/oncologist for advice.2 Patients who are acutely unwell should be admitted urgently to hospital. Do not delay admission bywaiting for a calcium level.3 As dehydration can worsen symptoms, encourage the patient to drink fluids until admission can bearranged.4 After discharge from hospital:a. If there has been no treatment of the underlying cause the patients calcium levels shouldbe monitored in the community every 2 weeks and appropriate action taken. If they remainstable for several months reduce monitoring to monthly.b. If the patient has received treatment for the cause of hypercalcaemia the calcium levelshould be monitored every 2 weeks initially. If the calcium remains normal for 4 weeksthen frequency of monitoring can be reduced to monthly.Further Information: Treatment will usually involve hydration of the patient and administration of a bisphosphonate.The underlying cause will be investigated and treated (if appropriate). Without treatment of the underlying cause thehypercalcaemia is likely to recur.Contact numbers On-call Consultant haematologist via FVRH switchboard 01324 566000West of Scotland Beatson Cancer Centre 0141 301 7000.Version 3 June 2011 Written by J. RobinsonReviewed by Dr Paul Baughan and members of the Forth Valley Haematology and Oncology teamsReview date June 2013Page 89

Forth Valley Formulary Eleventh Edition 2012/13Appendix 21SUPERIOR VENA CAVA OBSTRUCTION (SVCO) TREATMENT GUIDELINEfor ACUTE SERVICES–Patients with known malignancyBACKGROUND Superior vena cava obstruction results from the compression of the superior vena cava(SVC) by either tumour arising in the right main or upper lobe bronchus or mediastinal lymphadenopathy(usually right paratracheal or precarinal). This gradual, insidious or acute compression/obstruction of the SVCcauses a reduction of blood flow from the head, neck and upper extremities to the heart. Because the SVC issurrounded by rigid structures, it is relatively easy to compress. The low intravascular pressure also allows forthe possibility of thrombus formation, such as catheter-induced thrombus. Although the syndrome can be lifethreatening, its presentation is often associated with a gradual increase in symptoms. Over 90% of cases areassociated with malignancy and 80% of these are associated with lung cancer.CLINICAL PRESENTATION In the early clinical course, few, if any, signs or symptoms of superior vena cavasyndrome (SVCS) may be manifested. Typically, symptoms accelerate as the underlying malignancyincreases in size and/or invasiveness. Note: Symptoms may begin suddenly or gradually, and may worsenwhen bending over or lying down.•Dyspnoea•Neck, trunk or extremitydistension.•Facial swelling, includingperiorbital swelling•Orthopnoea•Redness of the faceor cheeks•Engorged collateral veins•Cough•Headache•Nasal stuffiness•Conjunctival redness•Vision changesINVESTIGATIONSThe diagnosis of superior vena cava syndrome (SVCS) is often made on clinical grounds alone, combiningclinical presentation +/- history of thoracic malignancy.• Plain chest xray and CT scans are often helpful, showing a mediastinal mass in the majority ofpatients.• Remember that the histological diagnosis is importandt when initiating therapy.TREATMENT The treatment of superior vena cava syndrome (SVCS) depends on the etiology of theobstruction, the severity of symptoms and patient prognosis. Radiation therapy or chemotherapy should bewithheld until the aetiology of the obstruction is clear. See Treatment/Referral flow chart.Steroids – Used to decrease the inflammatory response to tumour invasion and oedema surrounding thetumour mass, reducing pressure on the SVC. Recommended drug/dose: Dexamethasone 8mg twice daily(8am and 2 pm) orally (or IV if oral route contraindicated). Consider use of a gastroprotective agent if used incombination with NSAID’s or if patient has a peptic history. Steroids should be continued at high dose for 48-72 hours, if symptoms improve gradually reduce the dose. If there is no improvement – stop.Interventional radiology – It may be possible to place a stent to relieve symptoms associated with SVCO,particulary in patients with tumours that are not chemo-sensitive. Symptom relief may be more rapid than withchemotherapy or radiotherapy in lung tumours 1 . Consider use of low molecular weight heparin in patientswith a thrombus present at time of stenting. Patients who have had a stent inserted should be able todiscontinue steroids.Chemotherapy – Treatment of choice for chemo-sensitive tumours eg lymphoma and small cell lung cancers.Radiotherapy – used to treat tumours that are not chemo-sensitive. Choice between radiotherapy andstenting will depend on various factors including patient’s previous treatment and should be discussed with anoncologist.Thrombectomy – May be used where there is a documented thrombus in the SVC causing obstruction.Thrombolytic agents may be used.Reference: 1 Cochrane Review 2006. Steroids, radiotherapy, chemotherapy and stents for superior vena caval obstruction incarcinoma of the bronchus http://www.cochrane.org//reviews/en/ab001316.htmlSVCO Guideline Version 4 Review date June 2011. Review June 2013. Written by J Robinson Reviewed by Dr.WrightPage 90

Forth Valley Formulary Eleventh Edition 2012/13Appendix 21Treatment / Referral Pathway for Suspected Superior Vena Cava ObstructionFor patients with known malignancyPrimaryCarePatient presents with symptoms consistent with superiorvena cava obstruction eg facial redness/oedema, dyspnoea,distended veins in neck and thorax, orthopnoea.Exercise high level of suspicion in patients with small celllung cancer, thoracic lymphoma or patients with centralvenous cathetersAcute CareArrange admission to Combined AssessmentUnit, Forth Valley Royal Hospital, undermedical receiving team(FVRH switchboard 01324 566000)Clinical assessment of the patient shouldinclude physical examination and chest x-ray.CT scan may be required.Start patient on Dexamethasone 8mg bd+/-gastroprotectionContact patient’s knownoncologist/haematologist urgently for adviceon further treatment (usually interventionalradiology, chemotherapy or radiotherapy)Haematologists – contact via FVRHswitchboardOncologists – Within working hourscontact patient’s consultant and outwithnormal hours (or where consultant cannotbe reached) contact the on-call registrar atthe West of Scotland Beastson CancerCentre. Switchboard number 0141 301 7000Patient can be made more comfortable bygiving oxygen, keeping their head elevated,advising them to avoid bending over andcoughing, loosening upper clothing andsupporting upper arms on pillows. Prescribeanalgesia if required.Reference: 1 Cochrane Review 2006. Steroids, radiotherapy, chemotherapy and stents for superior vena caval obstruction in carcinoma of the bronchushttp://www.cochrane.org//reviews/en/ab001316.htmlSVCO Guideline Version 4 Review date June 2011. Review June 2013. Written by J Robinson Reviewed by Dr.WrightPage 91

Forth Valley Formulary Eleventh Edition 2012/13Appendix 22SUPERIOR VENA CAVA OBSTRUCTION (SVCO) GUIDELINEfor PRIMARY CAREDEFINITION Narrowing or blockage of the superior vena cavaCAUSE Superior vena cava obstruction results from the compression of the superior vena cava (SVC) by either tumourarising in the right main or upper lobe bronchus or mediastinal lymphadenopathy (usually right paratracheal orprecarinal). This gradual, insidious or acute compression/obstruction of the SVC causes a reduction of blood flow fromthe head, neck and upper extremities to the heart. Because the SVC is surrounded by rigid structures, it is relatively easyto compress. The low intravascular pressure also allows for the possibility of thrombus formation, such as catheterinducedthrombus. Although the syndrome can be life threatening, its presentation is often associated with a gradualincrease in symptoms. Over 90% of cases are associated with malignancy and 80% of these are associated with lungcancer.CLINICAL PRESENTATION In the early clinical course, few, if any, signs or symptoms of superior vena cavasyndrome (SVCS) may be manifested. Typically, symptoms accelerate as the underlying malignancy increases in sizeand/or invasiveness. Note: Symptoms may begin suddenly or gradually, and may worsen when bending over or lyingdown.• Dyspnoea • Redness of the face orcheeks• Nasal stuffiness• Neck, trunk orextremity distension.• Engorged collateralveins• Conjunctival redness• Facial swelling,including periorbitalswelling• Cough • Vision changes• Orthopnoea • HeadacheMANAGEMENT If a patient presents with symptoms consistent with superior vena cava obstruction eg facialredness/oedema, dyspnoea, distended veins in neck and thorax, orthopnoea :ADMIT TO COMBINED ASSESSMENT UNIT, FORTH VALLEY ROYAL HOSPITAL, UNDER MEDICALRECEIVING TEAM (contact bed manager via FVRH switchboard 01324 566000)Exercise high level of suspicion in patients with small cell lung cancer, thoracic lymphoma, tumours at right hilum, orpatients with central venous catheters. In some patients SVCO may be the first presenting symptom of cancer.Patient can be made more comfortable by giving oxygen, keeping their head elevated, advising them to avoid bendingover and coughing, loosening upper clothing and supporting upper arms on pillows.FURTHER INFORMATION The diagnosis of superior vena cava syndrome (SVCS) is usually made on clinicalgrounds alone, combining clinical presentation +/- history of thoracic malignancy. Plain chest xray and CT scans areoften helpful, showing a mediastinal mass in the majority of patients. These scans will be done on admission to hospital.The treatment of superior vena cava syndrome depends on the etiology of the obstruction, the rate of progression, theseverity of symptoms and patient prognosis. Steroids should be commenced as soon as the diagnosis is made(Dexamethasone 8mg twice daily (8am and 2pm) orally (or IV if oral route contraindicated). A gastroprotective agentshould also be considered. Stenting of the SVC can bring rapid relief and allow time to make a histological diagnosis, ifnot known. Further treatment ie radiotherapy or chemotherapy can then be discussed with onlcology.Reference: Cochrane Review 2006. Steroids, radiotherapy, chemotherapy and stents for superior vena cavaobstruction in carcinoma of the bronchus www.cochrane.org//reviews/en/ab001316.htmlVersion 4 June 2011 Written by J. Robinson Reviewed by Oncology/Respiratory/Haematology/Radiology Review date June 2013Page 92

Forth Valley Formulary Eleventh Edition 2012/13Appendix 23MALIGNANT SPINAL CORD COMPRESSION GUIDELINESSpinal cord compression (SCC) should be treated as a medical emergency and there should be a highindex of suspicion in all patients with a diagnosis of malignancyEarly detection of initial symptoms is key as any delay in diagnosis can lead to paralysis and canadversely affect life expectancyDefinition:• Compression of the spinal cord and nerve roots (including cauda equina nerve roots)Cause: • Bone metastases – usually in body of vertebra(e), often multiple levels• Soft tissue disease eg lymphoma in spinal canal• Most commonly affects patients with cancer of the lung, prostate, breast (account for 50% of cases)but can affect patients with all tumour types and at any time during diseaseClinicalPresentation:Early PresentationBack pain – often progressing over several weeks. The patientmay have an increased use of breakthrough analgesia.Radicular pain is a particular cause for concern, oftendescribed as a tight band around the chest or abdomen or nervelikepain in upper thighs. Radicular pain is exacerbated byactivities involving the valsalva manoeuvre, such as: coughing,sneezing, straining, straight leg raising and neck flexion. Mayworsen on lying down and relieved on sitting and is typicallyworse at night. There may be thoracic or anterior thighdistribution.There may be significant change in the nature of longstandingpain (unremitting, feelings of despair).Late PresentationSensory or motor change –especially if bilateral egmuscle weakness, loss ofcoordination, paralysis,parasthesia, loss of sensationAutonomic dysfunction egConstipation/urineretention/recentcatheterisation, newfaecal/urinary incontinenceReduced mobility - ‘off legs’, falls, heavy or stiff limbs, newdifficulty with ‘getting up stairs’Unexplained ‘taking to bed’ or needing a catheter, even in the absence of pain should raise thepossibility of spinal cord compressionDiagnosis:• have a high index of suspicion in all patients with malignancy as any delay indiagnosis can lead to paralysis and can adversely affect life expectancy• MRI scan of whole spine within 24-48 hours• Multi-detector row CT (MDCT) (16 slice or more) is now considered an acceptable alternative ifMRI is not availableManagement: • Dexamethasone 8mg bd (8am and 2pm) +/- proton pump inhibitor (if not already prescribed)• Analgesia – often strong opioids +/- NSAIDSSee flow• A telephone discussion with the on-call oncologist or neurosurgical registrar is advised onceclinical and radiological assessment has been performed.chartoverleaf• In general a patient presenting with the following criteria should be initially referred toNeurosurgery• A solitary lesion.• Radioresistant tumours (eg renal)• Ambulant.• A life expectancy of > 3 months.• A patient with the following criteria should be initially referred to Oncology, usually forradiotherapy• Multiple levels of cord compression.• Radiosensitive cancer(such as lymphoma,breast).• Preferably ambulant but definitely with an established paralysis of 4 weeks• Patients with late presentation consider best supportive care locally• Advanced signs of compression eg complete paralysis for >72 hours• Life expectancy of 2 prior to paralysis• If the Specialist Palliative Care Team (SPCT) are not already involved referral could be madeto maximise the multi-disciplinary team (MDT) management of the patient, and their family.The patient may have quite complex physical needs depending on the level of compression, inaddition to any psychological, social and spiritual needs.Version 3 June 2011. Written by J Robinson, reviewed by members of the oncology and palliative care teams. Review date June2013To be read in conjunction with West of Scotland Guidelines for Malignant Spinal Cord Compression February 2007Page 93

Forth Valley Formulary Eleventh Edition 2012/13Appendix 23Management of Spinal Cord Compression (SCC)GP will admit patient with suspected SCC toCAU under medical receiving teamDoes the patient have signs or symptoms of SCC or Cauda Equina compression?Prescribe Dexamethasone 8mg bd po (8am and 2pm) +/- proton pump inhibitor (if not already prescribed)Advise patient to lie flatAssess need for analgesia and start pain chartArrange URGENT full spine MRI scan to confirm diagnosis (if MRI unavailable consider MDCT)Confirmed spinal cord/Cauda equina compression syndromeDoes the patient have a cancer diagnosis?NoUrgent –phone the oncallneurosurgical team with view to urgenttransfer to Western General Hospital,Edinburgh (0131 537 1000) or SouthernGeneral Glasgow (0141 201 1100)Yes·One area of cordcompression·Radio-resistantcancer (eg renal)·Ambulant·Life expectancy >6months?·Physically fit forsurgery Urgent – phoneand discuss patientwith neurosurgeonand oncologistDexamethasonereduction/discontinuationwill be directed byneurosurgeon/oncologist·Multiple levels of cordcompression·Radiosensitive cancer (egbreast)·Preferably ambulant orestablished completeparalysis for 4 weeks. Urgent – phone on-callregistrar at West of ScotlandCentre, Glasgow to discusstransfer for urgent radiotherapytreatment.Dexamethasonereduction/discontinuationwill be directed byoncologist-Establish completeparalysis for > 72 hours.-Life expectancy < 4weeks Neurological recoverunlikely.-Refer to specialist palliativecare service (if not alreadyinvolved).- Consider best supportivecare locally-Patient positioning andmobilisation will be determinedby the patients pain and anyneurological deterioration-If pain is not responding toconventional analgesiacontactthe oncologist forconsideration of non urgentradiotherapy. Neurosurgical registrar at Western General Hospital, Edinburgh - 0131 537 1000 Neurosurgical registrar at Southern General Hospital, Glasgow-0141 201 1100Clinical Oncology registrar at Beatson West of Scotland Cancer Centre-0141 301 7000Contact the patients established oncologist within working hours, ringing theconsultant’s secretary at the Beatson 0141 301 7000Version 3 June 2011. Written by J Robinson, reviewed by members of the oncology andpalliative care teams. Review date June 2013 . To be read in conjunction with West ofScotland Guidelines for Malignant Spinal Cord Compression February 2007Discontinuedexamethasonewithin 5 days if noneurologicalimprovement.Reduce graduallyif improvementseen.Page 94Discontinue dexamwithin 5 days if noimprovement. Redimprovement seen

Forth Valley Formulary Eleventh Edition 2012/13Appendix 24MALIGNANT SPINAL CORD COMPRESSION GUIDELINESPrimary CareSpinal cord compression (SCC) should be treated as a medical emergency and there should be a high indexof suspicion in all patients with a diagnosis of malignancyEarly detection of initial symptoms is key as any delay in diagnosis can lead to paralysis and can adverselyaffect life expectancyDefinition: • Compression of the spinal cord and nerve roots (including cauda equina nerve roots)Cause:• Bone metastases – usually in body of vertebra(e), often multiple levels• Soft tissue disease eg lymphoma in spinal canal• Most commonly affects patients with cancer of the lung, prostate, breast (accountfor 50% of cases) but can affect patients with all tumour types and at any timeduring diseaseClinicalPresentationEarly PresentationLate PresentationBack pain – often progressing over several weeks. Thepatient may have an increased use of breakthroughanalgesia. Radicular pain is a particular cause forconcern, often described as a tight band around the chestor abdomen or nerve-like pain in upper thighs. Radicularpain is exacerbated by activities involving the valsalvamanoeuvre as well as coughing, sneezing, straining,straight leg raising and neck flexion. May worsen on lyingdown and relieved on sitting and is typically worse at night.There may be thoracic or anterior thigh distribution.There may be significant change in the nature oflongstanding pain (unremitting, feelings of despair).Reduced mobility - ‘off legs’, falls, heavy or stiff limbs,new difficulty with ‘getting up stairs’Sensory or motor change –especially if bilateral eg muscleweakness, loss of coordination,paralysis, parasthesia, loss ofsensationAutonomic dysfunction egConstipation/urineretention/recent catheterisationNew faecal / urinary incontinenceUnexplained ‘taking to bed’ or needing a catheter, even in the absence of pain should raise the possibility of spinalcord compressionMANAGEMENTEarly Presentation (see above)New/different spinal pain (particularly thoracic)“tight band around chest”Nerve like pain in upper thighsNew difficulty climbing stairsLate Presentation (see above)Condition deteriorating dailyParalysis for >72 hoursSphincter disturbanceLife expectancy < 4 weeksCommence 8mg Dexamethasone bd (or 50mg Prednisolone)Twice daily ( 8am &2pm) +/- PPI coverPatient should be advised to lie flatArrange admission to CAU at FORTH VALLEY ROYAL HOSPITALunder medical receiving teamArrange for patient to be transferred to hospital via2-man ambulance with stretcherDiscuss with oncology/palliative medicine teaminvolved. Discuss immediate care options withpatient and family. Patient positioning andmobilisation will be determined by patients painand any neurological deterioration, flat bedrestis not required. Where the level and type ofsupport is not available at home, admission tohospital or hospice may be necessary. A trial ofsteroids (Dexamethasone 8mg bd) may besuggested, but if no improvement identifiedwithin five days these should be discontinued.• MSCC section of Scottish Referral Guidelines for Suspected CancerFurther• RCGP RED FLAGS for Possible Serious Spinal PathologyInformation: • West of Scotland Guidelines for Malignant Spinal Cord Compression(available on the Forth Valley Intranet)• This guideline refers to patients with an existing cancer diagnosis but bear in mind that inapproximately 20% of patients with MSCC, cord compression is the first indication of them havingcancer.Version 4 May 2011 Writen by JRobinson Reviewed by members of the Oncology and Palliative Care TeamReview Date May 2013Page 95

Forth Valley Formulary Eleventh Edition 2012/13Appendix 25FORTH VALLEY ACUTE HOSPITALSPRESCRIBING GUIDELINES PHARMACY DEPARTMENTHYPOMAGNESAEMIA in ADULTSThis guideline does not cover:Acute deficiency states e.g. acute arrhythmia, seizures, eclampsia/pre-eclampsia, acute asthma. Refer tocurrent Medical Unit Prescribing Protocols.Hypomagnesaemia may be due to drugs, GI losses, pancreatitis, alcoholism, malnutrition, re-feeding syndromeor metabolic acidosisHypomagnesaemia can also induce hypokalaemia and hypocalcaemia. Intracellular potassium cannot beretained in the presence of significant hypomagnesaemia. Serum magnesium should be in the normal rangebefore potassium can be replaced effectively.Significant hypoalbuminaemia may falsely lower serum magnesium levelsIV dosage and administration (indicated if patient is symptomatic, magnesium < 0.3mmol/L or patientcannot take/tolerate oral supplements)Magnesium sulphate injection BP 50% w/v: Contains 20mmol magnesium in 10ml. (2mmol/ml)No other drugs should be added to a magnesium infusion. There is limited data available for y-sitecompatibility-contact clinical pharmacist for advice.Dose: Recent deficiency states• 20mmol Mg IV over 6 hours.Give centrally or peripherally in a minimum of 100mls of glucose 5% (or sodium chloride 0.9%). Higherconcentrations may cause peripheral vein irritation. Faster rates will exceed the renal threshold resulting inpoor retention of magnesium.Recheck level after 24 and 48 hours and repeat as required. Up to 5 days treatment may be required inlong term deficiency states.It takes about 36 to 48 hours for the magnesium to distribute fully to the body tissues.Oral magnesium replacement (for treatment mild deficiency in asymptomatic patients)Magnesium salts are poorly absorbed from the GI tract and may cause diarrhoea, with the possibility of moremagnesium being lost than was administered.Oral magnesium may be given to prevent recurrence of magnesium deficiency, and should only be usedwhen magnesium has been replaced and corrected by IV infusion, or in proven slow-losers of magnesium.The recommended maximum oral daily dose is 24mmol magnesium in divided doses. The oral magnesiumpreparations of choice in order of preference are:1. magnesium aspartate 10mmol sachets; 1 sachet once or twice daily2. magnesium glycerophosphate 4mmol tablets; 1-2 tabs three times daily3. magnesium oxide 160mg (4mmol) tablets; 1-2 tabs three times dailyMagnesium oxide and magnesium glycerophosphate are available as unlicensed medicines whereasmagnesium aspartate is a licensed food supplement. Patients who cannot tolerate first choice preparationsdue to diarrhoea can be considered for second and third line preparations.For further information or to arrange supplies please page your clinical pharmacist.Page 96

Forth Valley Formulary Eleventh Edition 2012/13Appendix 25Important adverse drug reactions and side effects• Nausea, vomiting, thirst, arrythmias, drowsiness, confusion, muscle weakness, diplopia, respiratorydepression, coma• Hypermagnesaemia is reversible with IV calcium gluconate 2.5-5mmol plus fluid support.• Flushing, sweating, hypotension, mild bradycardia may occur with rapid IV administration.• Diarrhoea with oral preparations.Contra-indications or precautionsIV replacement• Renal impairment (use half dose)• Recurrent renal stone formation• Severe bradycardia/ AV block• Respiratory insufficiency• Myasthenia gravis• Hepatic comaOral replacement• Renal impairment (use half dose)• Dehydration• Recurrent renal stone formation• DiarrhoeaMonitoring• Serum magnesium levels above 2.0mmol/L can lead to symptoms of hypermagnesaemia, thereforedaily monitoring of patients on IV magnesium infusions is necessary. Serum levels should be checkedbefore next dose is given. Blood pressure, respiratory rate, urine output should be monitored.References1. British National Formulary. 63 rd Ed. March 2012.2. Martindale the Extra Pharmacopoeia. 37 th Ed. 2001.3. Injectable Medicines Guide. Magnesium sulphate 50% injection. Nov 2011. Available atwww.injguide.nhs.uk (accessed June 2012)4. SmPC for magnesium sulphate injection 50% (Aurum Pharmaceuticals Ltd). Sept 2010. Available atwww.medicines.org.uk (accessed June 2012)5. Applied Therapeutics: The Clinical Use of Drugs. Young L, Koda-Kimble M. 9th Ed. 2008.Pharmacist Lead: Peter BucknerPage 97

Forth Valley Formulary Eleventh Edition 2012/13Appendix 26FORTH VALLEY ACUTE HOSPITALSPRESCRIBING GUIDELINES PHARMACY DEPARTMENTHYPOPHOSPHATAEMIA in ADULTSRisk factors for hypophosphataemia include critical illness, a period of starvation prior to nutritional support,malnutrition, alcoholism, and respiratory alkalosis.Phosphate supplementation should be considered where there is evidence of phosphate deficiency. Serumphosphate does not always correlate to total body stores as most phosphate is stored intracellularly. Theonset and severity of symptoms will determine the need for and type of treatmentDrug Presentation:Addiphos® 20ml vial containing : phosphate 40 mmol (2mmol phosphate /ml)potassium 30 mmoland sodium 30 mmolNo other drugs should be added to a phosphate infusion.No other drugs should be co administered at a Y site with phosphate.Caution should be used if the patient has renal impairment.Mild to moderate deficiency : usually associated with levels of 0.3-0.6mmol/l and is usuallyasymptomaticSevere deficiency:usually associated with levels less than 0.3mmol/l, especially ifsymptomatic.Drugs and AdministrationINTRAVENOUS:In acute deficiency, or when a clinical difference to serum phosphate needs to be assuredquickly.• 20mmols phosphate (10mls Addiphos) over 6 hours in 100mls 0.9% N Saline through a central line, or20mmols phosphate (10mls Addiphos) in 500mls 0.9% N Saline over12 hours through a peripheral line.• In cases where the hypophosphataemia is symptomatic, or if prolonged phosphate wastage hasoccurred, then the dosage may be repeated within 12 hours and a level obtained several hours afterthe end of the infusionOral – see notes on diarrhoea before contemplating oral replacement• 1-2 Phosphate Sandoz ® tablets (see BNF) three times a day (provides 48 - 96mmol phosphate, 60-120mmol sodium and 9-18mmol potassium per day)• Continued therapy may be required depending on clinical response/adverse effects.• Oral phosphate is slow to effect and should be used in slow-losers of phosphate only, and not when arapid response is required.Page 98

Forth Valley Formulary Eleventh Edition 2012/13Appendix 26Important side effects²HyperphosphataemiaSymptoms may be those of resultant hypocalcaemianamely, muscle cramps, tetany and convulsion andmetastatic calcification.HyperkalaemiaHypernatraemiaandAs a result of infusion of these elements along withphosphateHyperphosphataemiaHypotensionHypocalcaemiaHigh dose rapid infusions of phosphate.Excessive doses of phosphates may causehypocalcaemia and metastatic calcification; it isessential to monitor closely plasma concentrations ofcalcium, phosphate, potassium and other electrolytes.Treatment of adverse effects involves withdrawal ofphosphate infusion, general supportive measures andcorrection of serum electrolyte concentrations,especially calcium.Diarrhoea with oraltherapyOral phosphate is poorly absorbed from the gut andmay cause diarrhoea, with the potential to exacerbatelosses of Magnesium, Sodium, Potassium and water..PrecautionsIn renal impairment, Addisons disease and where restricted sodium or potassium intake is required e.g..cardiac failure, hypertension, hyperkalaemia, severe oedema. Care should be taken when replacingphosphate to minimise electrolyte disturbances and the biochemist should be contacted for advice.MonitoringBlood pressure monitoring is advisedCalcium, magnesium, phosphate, potassium and other electrolyte monitoring is essential. Phosphate levelsshould be checked at least 6 hours after the end of the infusion 3AcknowledgementsJane SillarsMark HollidaySenior DietitianConsultant BiochemistReferences June 2012-1. Walmsley RN, Guerin MD. Disorders of fluid and electrolyte balance. Bristol 1984. Wrightpublishing2. Thatte L, Oster J et al. Review of literature: Severe Hyperphosphataemia. Am J Med Sciences1995; 310(4):167-1743. Bugg NC, Jones A Hypophosphataemia. Anaesthesia 1998;53:895-902Note: June 2012 This guideline is currently under reviewPharmacist Lead: Peter BucknerPage 99

Forth Valley Formulary Eleventh Edition 2012/13Appendix 27Forth Valley Wound Management FormularyPage 100

Forth Valley Formulary Eleventh Edition 2012/13Appendix 27Page 101

Forth Valley Formulary Eleventh Edition 2012/1350:50 Ointment (Liq paraffin/White softparaffin), 425-Fluorouracil (cream - in liaison withDermatologist), 32Abiraterone Acetate, 34Acamprosate, 23Acetazolamide, 39Acetylcholine, 40Acetylcysteine, 40Aciclovir, 44Aciclovir (1st line), 25Aciclovir (on advice from secondarycare), 38Acidex®,11Acitretin, 43Actikerall®, 44Acute Pain Stepladder, 69Adalimumab, 12, 37Adalimumab (Humira®), 43Adapalene (Differin®), 44Adcortyl in Orabase®, 41Adefovir dipivoxil (Restricted use FollowWest of Scotland Guidelines), 26Adenosine, 14Adrenaline [Epinephrine], 17Adrenaline[Epinephrine], 16Alemtuzumab 30mg/ml Sol’nRestricted use West of Scotland, 33Alendronic Acid (1 st Line) (prophylaxisand treatment in men and women),29Alfacalcidol, 36Alfentanil, 47Alfuzosin, 31Algesal®, 38Alimemazine [Trimeprazine](Paediatrics), 18Alimemazine [Trimeprazine] (see section3.4.1), 47Alitretinoin, 43Allopurinol (prophylaxis), 37Alphosyl HC®, 43Alprostadil (restricted to paediatrics), 30Alteplase ( For Ischaemic Stroke), 16Aluminium Chloride, 45Aluminium hydroxide, 35Amikacin, 25Amikacin (endophthalmitis), 40Amiloride, 14Aminophylline Injection, 17Amiodarone, 14Amisulpride, 19Amitriptyline, 20Amitriptyline [see section 4.8], 21Amlodipine (1 st Line), 15Amorolfine, 44Amoxicillin, 24Amphoteracin B (endophthalmitis), 40Amphotericin, 41Amphotericin (I.V.), 25Amsacrine, 33Anagrelide, 35Analgesics For Pain In Primary Care,65Anastrozole, 34Antazoline (Otrivine-Antistin®), 39Anusol HC® Ointment, 12Anusol HC® Suppositories, 12Anusol® Cream, 12Anusol® Suppositories, 12Apomorphine, 22Apraclonidine (0.5% drops & 1%preservative free), 40Aqueous Cream, 42Aripiprazole, 19AS Saliva Orthana®, 41Ascorbic acid, 35Aspirin, 16Atenolol, 14Atomoxetine, 20Atorvastatin (2 nd Line), 16Atosiban, 30Atracurium besilate, 47Atropine 1% (Drops & Minims®), 39Atropine sulphate, 47Auranofin, 37Azaelastine, 39Azathioprine,12, 33, 37Azelaic acid 2nd line, 43Azelastine Hydrochloride (Rhinalast®),41Azithromycin, 24Balsalzide.12Baclofen, 38Balneum Plus® (1st line), 42BCG bladder instillation, 33BCG vaccines intradermal, 46Beatson West of Scotland CancerCentre, 83Beclometasone Dipropionate (1st lineClenil Modulite®), 17Beclometasone Dipropionate (1 st Line),41Bendamustine Hydrochloride (Levact®),32Bendroflumethiazide [Bendrofluazide],14Benzalkonium chloride (Bradsol®), 41Benzoyl peroxide (Panoxyl®), 43Benzoyl peroxide and clindamycin gel(Duac®), 43Benzoyl peroxide and erythromycin gel(Benzamycin®), 43Benzydamine Hydrochloride, 41Benzylpenicillin, 24Betacap®, 42Betahistine, 21Betaine, 36Betamethasone (Betnesol® Drops &Oint, Betnesol-N® Drops), 38Page 102

Forth Valley Formulary Eleventh Edition 2012/13Betamethasone sodium phosphate(Betnesol®), 41Betamousse®, 42Betaxolol, 39Betnesol-N®, 41Betnovate C®, 43Betnovate® - cream/oint, 42Bezafibrate, 16Bicalutamide, 34Bimatoprost, 39Bisacodyl, 12Bisoprolol (1 st Line), 14Bleomycin, 32Blood Glucose Meters – FormularyChoices, 82Blood Glucose Monitoring, 81Boceprevir (Victrelis®), 26Boretezomib, 33Bortezomib, 33Botulinum A Toxin (Haemagglutanincomplex see BNF, 46Brimonidine, 39Brinzolamide, 39Brolene® & Chlorhexidine, 38Bromocriptine, 29Budesonide, 41Budesonide (2 nd Line), 17Bumetanide (2 nd Line), 14Bupivacaine and Epinephrine[Adrenaline], 48Bupivacaine and Fentanyl, 48Bupivacaine and Glucose, 48Bupivacaine HCl, 48Buprenorphine (CADS, FV-TOX &GPwSP), 23Buprenorphine/naloxone (CADS + FV-TOX) Suboxone®, 23Bupropion, 23Busulfan, 32Cabergoline, 29Caffeine base 5mg/ml Sol’n for injection,18Caffeine Citrate, 17Calamine oily lotion, 42Calcipotriol, 43Calcitriol Ointment, 43Calcium and colecalciferol (Adcal-D3® &Calfovit D3®), 36Calcium Gluconate Injection, 35Calcium polystyrene sulphonate(Calcium resonium®), 35Calcium Salts (1 st Line), 35Calcium-Sandoz® syrup, 35Calmurid® cream (2 nd line), 42Canesten HC®, 43Capasal®, 44Capecitabine, 32Carbamazepine, 20Carbamazepine (1 st Line), 22Carbamazepine (see section 4.8), 21Carbimazole (1 st Line), 27Carbocisteine (1 st Line), 18Carbo-Dome®, 43Carbomer 980 (polyacrylic acid) 0.2%(Viscotears® including preservativefree), 40Carboplatin, 33Carboprost, 30Carmellose sodium 0.5% (drops &preservative free), 40Carvedilol, 14Cefalexin (for UTI), 24Cefotaxime (I.V.), 24Ceftazidime, 24Ceftazidime (endophthalmitis), 40Ceftriaxone, 24Cefuroxime 5% eye drops (severekeratitis), 40Celecoxib (not 1st line), 37Cerazette® (use 2 nd line-follow SMCadvice), 31Cerumol®, 41Cetirizine (1 st Line), 18Cetraben®, 42Chlorambucil, 32Chloramphenicol, 24, 38Chlordiazepoxide (use in alcoholaddiction), 19Chlorhexidine, 45Chlorhexidine gluconate, 41Chloroquine, 26Chlorphenamine [Chlorpheniramine], 18Chlorpromazine (1 st Line), 19Choline salicylate dental gel BP(Bonjela®, Teejel®), 41Chorionic Gonadotrophin (HCG), 28Ciclosporin, 12, 37, 43Ciclosporin [Cyclosporin], 33Ciclosporin 2% eye drops, 40Cilest®, 30Cinnarizine, 21Ciprofloxacin, 25Cisatracurium, 47Cisplatin, 33Cladribine, 32Clarithromycin, 24Clerz® Eye drops, 40Clindamycin, 24, 30, 43Clobazam, 22Clobetasol Propionate, 42Clobetasol with neomycin & nystatin, 42Clomifene Citrate, 28Clomipramine, 20Clonazepam, 22Clopidogrel, 16Clotrimazole, 30, 44Clozapine, 19Coal tar, 43Co-amilofruse’, 14Co-amoxiclav, 24Cocaine 4% drops & 10% paste, 39Co-codamol (see section 4.7.1), 47Co-codamol 30/500, 21Page 103

Forth Valley Formulary Eleventh Edition 2012/13Co-codamol 8/500, 21Co-cyprindiol 2000/35, 44Co-danthramer (terminal care only), 12Codeine Phosphate, 11Colchicine (acute attack), 37Colestipol, 13Colestyramine, 13Colecalciferol (800iu equiv. to 20micrograms vitamin D 3 ) [Fultium-D3 ® ],36Colestyramine [Cholestyramine], 12Colifoam®, 12Colistimethate [Colistin ] - (CysticFibrosis only), 24Co-magaldrox, 11Combivent®, 17Conjugated oestrogens (Premarin®cream), 30Conotrane, 42Constipation In Adults, 53Co-Trimoxzole, 25Creon®, 13Crotamiton (Eurax®), 42Crystacide® (2 nd line, only for use ifresistance developes), 45Cyclimorph®, 21Cyclizine Inj ( oral use in paediatrics andadolescents in acute trust), 21Cyclopentolate (Drops & Minims®), 39Cyclophosphamide, 32, 37Cyproterone acetate, 34Cyproterone Acetate, 28Cytarabine, 32Dacarbazine, 33Daktacort®, 43Danazol, 29Dantrolene, 38Dantrolene sodium, 47Dapsone, 25Darbepoetin alfa, 34Darifenacin, 31Dasatinib, 33Daunorubicin, 32Denosumab, 29Dermax®, 44Dermol ® (2 nd Line), 42Desflurane, 47Desmopressin, 28, 31Dexamethasone, 27Dexamethasone (Maxidex® Drops &Maxitrol® Oint, 38Dexamethasone Minims®, 38Dexamethasone (Ozudrex®), 38Dexamethasone sodium injectionpreservative free, 40Dexamfetamine (Not first line), 20Dexmedetomidine (Dexdor®) ,47Diamorphine, 21Diazemuls®, 22Diazepam, 47Diazepam (1 st Line), 19Diazepam (rectal), 22Diazepam (short term use), 38Diclofenac (See section 10.1), 47Diclofenac 75mg/2ml Sol’n forintravenous injection (Dyloject) -Restricted use for post operativepain, 37Diclofenac sodium (not M/R product), 37Diclofenac Sodium 0.1%, 40Digibind®, 14Digoxin, 14Dihydrocodeine, 21Dihydrogesterone, 28Diloxanide Furoate, 26Diltiazem * (Tildiem LA® & Retard®), 15Dimethyl sulphoxide, 31Dimeticone Lotion (Hedrin®), 44Dinoprostone, 30Diphtheria (low dose), Tetanus andInactivated Poliomyelitis Vaccine(Revaxis®), 46Diphtheria, Tetanus, Pertussis Polio(Repevax®, Infanrix IPV®), 46Diphtheria, Tetanus, Pertussis, Polio,Hib, Pediacel, 46Diprobase® cream, 42Diprosalic® - oint/scalp application, 42Diprosone® - cream/oint (2nd line), 42Dipyridamole Retard (PersantinRetard®), 16Disodium edetate (EDTA) 0.37% eyedrops, 40Disodium Pamidronate(I.V.)- (1 st Linefor hypercalcaemia), 29Disopyramide, 14Distigmine (see section 7.4.1), 38Disulfiram, 23Dithranol, 43Dobutamine, 16Docetaxel, 33Docusate (Norgalax Micro-enema®),12Domperidone, 11Domperidone (1 st Line), 21Donepezil, 23Dopamine, 16Dopexamine, 16Dorzolamide (drops & preservative free),39Doublebase®, 42Dovobet® ( Use in accordance withSMC guidance), 43Doxapram hydrochloride, 47Doxazosin (not M/R), 15Doxepin Hydrochloride, 42Doxorubicin, 32Doxycycline, 24Dronedarone (Multaq®), 14Duloxetine (restricted use refer to SMCGuidance), 31Dyspepsia Guidance, 52Dysport®,23E45® (2nd line), 42Page 104

Forth Valley Formulary Eleventh Edition 2012/13Edrophonium chloride, 38, 47Efudix®, 44EllaOne®, 31Elleste Duet Conti®, 28Elleste Duet®, 28Elleste Solo®, 28Elocon® (Once daily application), 43Emulsifying Ointment, 42Enflurane, 47Enoxaparin, 16Entacapone, 22Entonox®/Equanox®, 47Epaderm®, 42Ephedrine Hydrochloride (under 12s), 41Epilim® (see section 4.8), 21Epipen®, 18Epirubicin, 31, 32Eplerenone (2 nd Line), 14Epoetin alfa, 34Epoetin beta, 34Epoetin delta, 34Epoetin zeta, 34Eptafibatide, 16Ergocalciferol (readily available ascalcium and ergocalciferol, 36Ergometrine Maleate, 30Erlotinib, 33Erythromycin, 24Erythromycin (Topical), 44Esmolol (I.V. for arrythmia), 14Esomeprazole (I.V.) [Nexium I.V.®], 11Esomeprazole 10mg, 11Estraderm MX®, 28Estradiol [Oestradiol] (Vagifem®,Estring®), 30Estriol [Oestriol] (Ovestin®), 30Etanercept, 37Etanercept (Enbrel®), 43Ethambutol Hydrochloride, 25Ethamsylate, 16Ethinylestradiol [Ethinyloestradiol], 34Etomidate, 47Etoposide, 32Etoricoxib (Alternative to Celeboxib), 37Eucerin® cream and lotion 10%, 42Eumovate® - cream/oint, 42Everolimus (Afinitor®), 33Evorel (includes Conti), 28Evra® Patch, 30Exemestane, 34Exenatide, 27Exorex® - lotion (2nd line), 43Ezetimibe, 16Famciclovir (2nd line if compliance is aproblem), 25Febuxostat (Adenuric®), 37Felodipine (2 nd Line), 15Femodene®, 30Femodette®, 30Femoston®, 28FemSeven Conti®, 28FemSeven Sequi®, 28Femulen®, 31Fenofibrate (Lipantil®), 16Fentanyl, 21, 47Ferrous fumarate (Fersamal) (1 st Line),34Ferrous gluconate, 34Ferrous sulphate, 34Fesoterodine fumarate, 31Fingolimod (Gilenya®) (RestrictedSpecialist Use), 33Filgrastim (restricted -haematology/oncology use only), 35Finasteride, 28Flecainide, 14Flucloxacillin, 24Fluconazole, 25Fluconazole Caps (Not 1st line in oralthrush), 25Flucytosine (IV), 25Fludarabine Phosphate, 32Fludrocortisone Acetate, 27Flumazenil, 47Flumetasone Pivalate (Locorten-Vioform®), 41Fluorescein IV 20%, 40Fluorescein sodium (Minims®), 40Fluorescein sodium (Strips), 40Fluorometholone, 38Fluoxetine, 20Flupentixol Decanoate Inj, 19Fluphenazine Decanoate Inj, 19Flurbiprofen 0.3%, 40Flutamide, 34Fluticasone, 17, 41Fluticasone propionate and formoterolfumarate ( Flutiform®),17Folic Acid, 34Folinic acid (Folate rescue), 32Follicle Stimulating Hormone (FSH), 28Fondaparinux sodium inj. (to be usedwith guidance), 16Forceval ®(+/-junior) Capsules, 36Fosaprepitant (Ivemend®), 21Fostair®, 17Fucibet®, 43Fucidin H®, 43Furosemide [Frusemide] (1 st Line), 14Fusidic acid, 38, 44Gabapentin, 22Gabapentin [see section 4.8], 21Galantamine, 23Gaviscon Advance®, 11Gedarel® 20/150, 30Gedarel® 30/150, 30Gemcitabine, 32Genito-Urinary Medicine List, 80Gentamicin, 24, 38Gentamicin (Genticin®, Garamycin®), 41Gentamycin 1.5% eye drops(severekeratitis), 40Gentisone HC®, 41Glandosane®, 41Page 105

Forth Valley Formulary Eleventh Edition 2012/13Gliclazide (1 st Line), 27Glimepiride, 27Glucagon, 27Glucogel, 27Glucose, 35Glucose 50%, 27Glucose with Potassium, 35Glycerol, 12Glyceryl Trinitrate, 15Glycopyronium bromide, 47Gonadorelin (LH-RH), 28Goserelin, 34Guidance on Issuing Steroid Cards,64Haelan ® Tape, 43Haloperidol (Baseline ECG Required),19Haloperidol (palliative care) (seesection 4.2), 21Haloperidol Decanoate Inj, 19Halothane, 47Heparin, 16Hepatitis A and Typhoid vaccine(Hepatyrix®), 46Hepatitis A vaccine, 46Hepatitis A/B vaccine (Twinrix®), 46Hepatitis B vaccine, 46Histoacryl®, 45Human Papilloma Virus Vaccine(Gardasil®, Cervarix®), 46Hyaluronidase, 38Hyaluronidase 1500 units, 40Hydralazine, 15Hydrocortisone - cream/oint, 42Hydrocortisone acetate, 37Hydrocortisone Injection, 27Hydrocortisone IV, 17Hydrocortisone pellets (Corlan®), 41Hydrocortisone Tablets, 27Hydromol® Cream & Ointment, 42Hydroxocobalamin, 34Hydroxyamphetamine eye drops (forpupil testing), 40Hydroxychloroquine sulphate, 37Hydroxychloroquine Sulphate (seesection 10.1.3), 26Hydroxyethylcellulose, 40Hydroxypropyl guar (drops &preservative free), 40Hydroxyurea, 33Hyoscine Butylbromide (2 nd Line), 11Hyoscine Hydrobromide, 21HYPERCALCAEMIA of MALIGNANCYTREATMENT GUIDELINE, 88HYPOMAGNESAEMIA in ADULTS, 96HYPOPHOSPHATAEMIA in ADULTS,98Hypromellose 0.3% (drops &preservative free), 40Ibandronic Acid-(3 rd Line), 29Ibuprofen, 37Ibuprofen (See section 10.1), 47Icatibant Injection (Firazyr®), 18Ichthammol ointment, 43Idarubicin, 32Ifosfamide, 32Imatinib (Glivec®), 33Imiquimod, 44Indapamide, 14Industrial Methylated Spirit, 45Infant Gaviscon, 11Infliximab, ,12 , 37Influenza vaccine, 46Inhaler spacer device, 17Insulins (Recommendatiion bypractitioner experienced inmanagement of diabetes), 27Interferon alfa 2b (Viraferon &, 33Interferon-alfa (Haematology use only),33Ipratropium Bromide (2 nd Line), 17Ipratropium Bromide (Rinatec®), 41Irbesartan, 15Ferric Carboxymaltose, 34Iron Sucrose (Venofer®), 34Isoflurane, 47Isoniazid, 25Isosorbide Mononitrate *, 15Isotretinoin (specialist use only), 44Isotrex® gel, 44Isotrexin® gel, 44Ispaghula Husk (2 nd Line), 12Itraconazole, 25Ivabradine, 15Ketamine, 47Ketoconazole cream (Nizoral®), 44Ketoconazole shampoo (Nizoral®), 44Ketoprofen®, 38Ketorolac 0.5%, 40Kliovance®, 28Konakion MM Paediatric®, 36Konakion MM®, 36Labetalol, 14Lacosamide, 22Lactulose (1 st Line), 12Lamotrigine, 22Lansoprazole Capsules (2 nd Line), 11Lanthanum, 35Latanoprost, 39Laxido®, 12Leflunomide, 37Lenalidomide (Revlimid®), 33Letrozole, 34Leuprorelin, 34Levetiracetam, 22Levobupivacaine, 48Levofloxacin, 38Levomepromazine [Methotrimeprazine](Palliative Care), 19Levomepromazine [Methotrimeprazine](palliative care) (see section 4.2),21Levonelle®1500, 31Lidocaine [Lignocaine], 14Page 106

Forth Valley Formulary Eleventh Edition 2012/13Lidocaine [Lignocaine] and Epinephrine[Adrenaline], 48Lidocaine [Lignocaine] and Prilocaine(Emla®), 48Lidocaine [lignocaine] Gel, 13Lidocaine [Lignocaine] HCl, 48Linezolid –Restricted use seekmicrobiology advice, 24Liothyronine Sodium, 27Lipid Lowering Guidelines, 55Liquid paraffin (Lacri-Lube®), 40Liraglutide, 27Lisinopril, 15Lithium, 20Lodoxamide, 39Loestrin20®, 30Lofepramine, 20Logynon®, 30Loperamide, 11Loratadine (2 nd Line), 18Lorazepam, 19Lorazepam I.V., 22Losartan (1 st Line), 15Lotriderm (2 nd line), 42Lymecycline (2nd line in acne), 24Madopar®, 22Magnesuim sulphate injection, 35Malathion (Derbac M®), 44MALIGNANT SPINAL CORDCOMPRESSION GUIDELINES, 93,95Mannitol, 14Marvelon®, 30Mebendazole, 26Mebeverine (not MR preparation) (1 stLine), 11Mecysteine Hydrochloride (2 nd Line), 18Medroxyprogesterone, 28Medroxyprogesterone acetate, 34Medroxyprogesterone acetate (Depoprovera®),31Megestrol acetate, 34Melphalan, 32Memantine, 23Menadiol sodium, 36Meningococcal group A,C,W,135 and YConjugate vaccine, 46Meningococcal Group C ConjugateVaccine, 46Meningococcal Polysaccharide A, C,W135 and Y vaccine, 46Menitorix® (combined Hib & MenC), 46Mercaptopurine, 12, 32Mercilon®, 30Meropenem-Restricted use, seekmicrobiology advice, 24Mesalazine ,12Mesna (urothelial toxicity), 32Metanium® (2 nd line), 42Metformin, 27Methadone (CADS + GPPS), 23Methotrexate, 12, 32, 37, 43Methylcellulose Tablets, 11Methylcellulose Tablets (use indiarrhoea), 12Methyldopa, 15Methylphenidate, 20Methylprednisolone, 27, 33Methylprednisolone acetate, 37Metoclopramide, 11, 21Metolazone, 14Metoprolol, 14Metronidazole, 25, 26, 44Miconazole, 30, 41Microgynon30®, 30Midazolam, 47Midazolam,oromucosal sol’n(Buccolam®), 22Mifepristone, 30Millinette® 20/75, 30Millinette® 30/75, 30Mirena® (not 1st line), 31Mirtazapine, 20Misoprostol (NB. Unlicensed indication),30Mitomycin-C, 31, 32Mitozantrone, 32Mivacurium, 47MMR vaccine, 46Moclobemide, 20Mometasone Furoate (Nasonex®) (2ndline), 41Montelukast, 18Morphine, 21Moviprep®,12Moxifloxacin, 25Multiload ® Cu375, 31Mupirocin (Bactoban Nasal®), 41Mupirocin (Bactroban®) - restrict forMRSA, 44Mycophenolic acid, 33Mycophenylate, 37Naferelin, 29Naftidrofuryl, 15Naloxone hydrochloride, 47Naltrexone (CADS & FV-TOX), 23Naproxen, 37Naseptin®, 41Natalizumab (Specialist Initiation), 33Natamycin (fungal keratitis), 40Nebivolol (2 nd Line), 14Nedocromil (2nd line), 39Nelarabine, 32Neomycin, 24Neostigmine, 38Neostigmine metilsulfate, 47Nerisone Forte® (2 nd line ), 42Neuropathic Pain Guideline, 49Nexplanon®, 31NHS FORTH VALLEY PRESCRIBINGOF NEW MEDICINE FLOWCHART,50Nicorandil, 15Nicotinamide, 35Page 107

Forth Valley Formulary Eleventh Edition 2012/13Nicotine Products, 23Nifedipine * (Coracten®), 15Nilotinib, 33Nitrofurantoin, 25Nitrous oxide, 47Noradrenaline [Norepinephrine], 16Norethisterone, 31, 34Norfloxacin, 25Nova-T ® 380, 31Nystaform-HC (peri-oral use ), 42Nystatin, 25, 41Octreotide, 34Oestrogel®, 28Ofloxacin, 25, 38Oilatum Plus®, 42Oilatum®, 42Olanzapine (See protocol for IM use), 19Olopatadine, 39Omacor, 16Omalizumab, 18Omeprazole Capsules(1 st line), 11Ondansetron (Restricted – oncology &anaesthetics), 21Oral Cholera Vaccine, 46Oral rehydration salts, 35Oralbalance Gel®, 42Orlistat, 20Orphenadrine, 22Oxaliplatin, 33Oxybupricaine Minims®, 39Oxybutynin – m/r or patch only, 31Oxygen, 18Oxygen (refer to section 3.6), 47Oxytetracycline, 24Oxytocin, 30Paliperidone Inj, 19Pancrex V®, 13Pancrex®, 13Pantoprazole (I.V.), 11Paracetamol (1 st Line), 21Parathyroid hormone 100mcg powder forinjection, 28Patients Receiving ChemotherapyWho Become Unwell, 84Peak Flow Meter (Mini-Wright® Adult &Paediatric), 17Peginterferon Alfa (Pegasys®), 33Pemetrexed, 32Penciclovir (2nd line in cold sores), 44Penicillamine, 37Penicillin 0.3% eye drops (severekeratitis), 40Penicillin V, 24Peppermint Oil, 11Peptac® (1 st Line), 11Perindopril, 15Phenelzine (dietary / interaction advicerequired), 20Phenindione, 16Phenobarbital [Phenobarbitone](Paediatrics), 22Phenylephrine (10% Drops, 2.5% & 10%Minims®), 39Phenytoin, 22Phenytoin I.V., 22Phenytoin Loading Guidelines ForStatus Epilepticus, 70Phosphate enema, 12Phytomenadione, 36Picolax®, 12Pilocarpine 0.5%, 1% & 2%, 39Pioglitazone, 27Piperacillin and tazobactam (Tazocin®),24Piperazine, 26Pipotiazine Palmitate Inj, 19Piroxicam Gel, 38Pizotifen, 21Plerixafor (Mozobil®) [for use uponTertiary Recommendation], 35Pneumococcal Polysaccharide (13-valent) Conjugated Vaccine(Prevenar13), 46Pneumococcal Polysaccharide (23-valent) Vaccine, 46Podophyllotoxin, 44Polytar®, 44Poractant alfa, 18Potassium ascorbate (ascorbic acid10%), 40Potassium chloride, 35Potassium chloride strong solution, 35Potassium citrate (Effercitrate®), 31Potassium iodide, 27Potassium permanganate, 45Povidone Iodine (Betadine®), 30Povidone-iodine, 45Povidone-Iodine, 41Povidone-iodine 5%, 40Pramipexol, 22Pravastatin, 16Prednisolone, 27, 33Prednisolone (Minims®), 38Prednisolone (Predfoam®/Predenema®(Predsol®), 12Prednisolone (Predsol®), 41Prednisolone 0.1% & 0.03%, 38Prednisolone Oral, 17Predsol-N®, 41Pregabalin, 22Pregaday®, 34Premarin®, 28Premique® (Includes low dose), 28Prempak-C®, 28Prilocaine HCl, 48Primaquine, 26Primidone, 23Procarbazine, 33Prochlorperazine (2 nd Line), 21Procyclidine, 22Progesterone (Cyclogest® forsubfertility), 28Proguanil Hydrochloride, 26Page 108

Forth Valley Formulary Eleventh Edition 2012/13Promethazine (Paediatrics), 18Propafenone, 14Propiverine, 31Propofol, 47Propranolol, 27Propranolol (see section 2.4), 19, 23Propranolol (see section 4.1.2), 14Propylthiouracil, 27Protamine, 16Proxymetacaine and FluoresceinMinims®, 39Proxymetacaine Minims® (less stingingthan others), 39Pyrazinamide, 25Pyridostigmine bromide, 38Pyridoxine (Vit B6), 35Pyrimethamine with Dapsone(Maloprim®), 26Pyrimethamine with Sulfadoxine(Fansidar®), 26Quetiapine, 19Quinagolide, 29Quinine Sulphate, 26Quinine Sulphate (300mg), 38Rabies vaccine, 46Raloxifene, 29Ramipril, 15Ranibizumab (Specialist Use Onlyaccording to SMC Restriction), 40Ranitidine, 11Relactagel, 30Remifentanil, 47REQUEST FOR A NON-FORMULARYDRUG, 51Retigabine (for specialist use only), 22Ribavarin (Rebetol®) 200mg Capsules-(In combination with Viraferon &Intron A), 26Rifampicin, 25Rifater®, 25Rifinah® 150 & 300, 25Rigevidon®, 30Rimexolone, 38Risedronate Sodium (prophylaxis andtreatment in women only), 29Risperidone, 19Rituximab, 37Rituximab 10mg/ml Concentrate forinfusion (MabThera®), 33Rivaroxaban, 16Rivastigmine, 23Rizatriptan, 21Robinul-Neostigmine®, 47Rocuronium bromide, 47Ropinirole ), 22Ropivacaine HCl, 48Rosuvastatin, 16Rotigotine Patch, 22Rufinamide, 22Salbutamol (1 st Line), 17Salcatonin Nasal Spray, 28Salicylic acid, 44Salicylic acid (as part of extemporaneouspreparation), 43Salmeterol, 17Sandocal®, 35Saxagliptin, 27Sebco®, 44Selegiline, 22Senna, 12Seretide® (Seretide 500 accuhalerlicensedfor COPD and cheaper thanMDI which is unlicensed for COPD),17Sertraline, 20Sevelamer (2 nd Line), 35Sevoflurane, 47Sildenafil (Revatio®), 15Silver sulfadiazine (for burns), 44Simvastatin (1 st Line), 16Sinemet®, 22Sitagliptin, 27Sodium aurothiomalate, 37Sodium bicarbonate, 35Sodium bicarbonate 5%, 41Sodium chloride, 31, 35Sodium Chloride 0.9%, 45Sodium Chloride 0.9% (for infants), 41Sodium chloride with Potassium, 35Sodium chloride/glucose, 35Sodium Citrate Enema (Micralax®), 12Sodium Cromoglicate, 39, 41Sodium Feredetate, 34Sodium fusidate, 24Sodium hyaluronate (0.1% & 0.2% dropsand 0.2% preservative free), 40Sodium polystyrene sulphonate(Resonium A®), 35Sodium Valproate (2 nd Line), 22Solaraze®, 44Solifenacin Succinate (Vesicare®), 31Somatropin (Synthetic Human GrowthHormone), 28SpectraBan®, 44Spironolactone (1 st Line), 14Stalevo®, 22Strontium ranelate (Protelos®), 29Streptokinase (For Life ThreateningP.E. ), 16Stop Smoking Guidance,72Streptomycin, 25Sucralfate, 11Sugammadex, 47Sulfasalazine [Sulphasalazine], 12Sulphasalazine (EC formulation), 37Sumatriptan (1 st Line), 21Sunitinib, 33Sunsense® Ultra, 44SUPERIOR VENA CAVAOBSTRUCTION (SVCO)GUIDELINE, 92SUPERIOR VENA CAVAOBSTRUCTION (SVCO)Page 109

Forth Valley Formulary Eleventh Edition 2012/13TREATMENT GUIDELINE forACUTE SERVICES, 90SUSPECTED HYPERCALCAEMIA ofMALIGNANCY GUIDELINE, 89SUSPECTED NEUTROPENIC SEPSIS,86Suxamethonium chloride, 47Symbicort®, 17Synalar® gel - for scalp use, 43Syntometrine®, 30T/Gel®, 44Tacrolimus, 33Tacrolimus - ointment (in accordancewith SMC guidance) , 43Tadalafil, 32Tafluprost (if proven sensitivity tobenzalkonium chloride), 39Tegafur with Gimeracil and Oteracil(Teysuno®), 32Tamoxifen, 34Tamsulosin, 31Teicoplanin ( Restricted use –Haematology or on microbiologyadvice), 24Temazepam, 47Temazepam (2 nd Line), 19Temozolomide, 33Tenecteplase ( For ST Elevation M.I. ),16Tenofovir (Viread®) (for specialist useonly), 26Tenoxicam Injection (See section 10.1),47Terbinafine, 25, 44Terbutaline, 30Terbutaline (2 nd Line), 17Teriparatide, 28Terlipressin (oesophageal varicies), 28Testosterone, 28Tetracaine [Amethocaine] 1% Minims®,39Tetracaine[Amethocaine], 48Tetracosactrin (‘Synacthen®’), 28Tetracycline, 24Tetracyclines, 24Thalidomide (Restricted to ConsultantNeurologist use only), 33Therapeutic Drug MonitoringGuidelines, 79Thiamine (Vit B1), 35Thioguanine, 32Thiopental Sodium, 47Thymol, 41Tibolone, 28Ticagrelor, 16Timodine®, 43Timolol, 39Timolol 0.5% preservative free, 39Tiotropium (1 st Line), 17Tirofiban, 16Tobramycin- (Paediatric Cystic Fibrosisonly), 24Tocilizumab (RoActemra®) [Not 1 st Line],37Tolterodine, 31Topiramate (under specialistsupervision), 22Topotecan, 33Tranexamic Acid, 16Trastuzumab, 33Travoprost, 39Trazodone, 20Treosulfan, 32Triadcortyl-Otic®, 41Triamcinolone hexacetanide, 37Triclosan, 45Trifluoperazine, 19Trifluorothimidine eye drops (2 nd lineafter Aciclovir), 40Trimethoprim, 25Trimovate®, 43Triptorelin ( Decapeptyl SR ®), 34Tri-Regol®, 30Tropicamide 1% (Drops & Minims®), 39Trospium chloride, 31T-Safe® CU 380A, 31Tuberculin PPD RT 23 SSI 10T.U/0.1ml,46Tuberculin PPD RT 23 SSI 2T.U/0.1ml,46Typhoid vaccine, 46Uniphyllin®, 17Uniroid – HC Ointment (1 st Line), 12Uniroid – HC Suppositories, 12Ursodeoxycholic Acid, 13Ustekinumab (Stelara®), 43Uvistat® SPF30, 44Vaccines, 46Valproate Semisodium (Depakote®), 20Valsartan, 15Vancomicin (endophthalmitis), 40Vancomycin, 24Vaniqa®, 44Vardenafil, 32Varenicline, 23Varicella – zoster vaccine, 46Venlafaxine, 20Verapamil (see section 2.6), 14Verapamil *, 15Vercuronium bromide, 47Viaferon® (Hepatitis B), 33Vinblastine, 32Vincristine, 32Vinorelbine, 32Vitamin A, B group, C,and D (Abidec® &Dalivit®), 36Vitamin Capsules BPC, 36Vitamins A C and D, 35Vitamins A and D, 35Vitamins B and C IV/HP (Pabrinex®), 35Volulyte®, 35Voriconazole (IV & Oral), 25Warfarin, 16White soft paraffin, 42Page 110

Forth Valley Formulary Eleventh Edition 2012/13Xeomin® Injection, 23Xylometazoline Hydrochloride, 41Xyloproct® Ointment, 13Yellow Fever vaccine, 46Zinc paste and ichthammol bandage, 43Zinc sulphate (Solvazinc®), 35Zineryt® lotion, 44Zoledronic Acid Sol’n (2 nd line), 29Zonisamide (for specialist use only), 22Zopiclone (1 st Line), 19Zuclopenthixol Acetate (Clopixol®Acuphase), 19Zuclopenthixol Decanoate Inj, 19Zuclopenthixol Dihydrochloride(Clopixol® tabs), 19Page 111

Publications in Alternative FormatsNHS Forth Valley is happy to consider requests for publications in other language orformats such as large print.To request another language for a patient, please contact 01786 434784.For other formats contact 01324 590886,text 07990 690605,fax 01324 590867 ore-mail - fv-uhb.nhsfv-alternativeformats@nhs.netVersion 6.00 December 24 th 2012UNCONTROLLED WHEN PRINTED