Medicines Management

Chapter 1 - Gastro-intestinal system

BNF chapter/
section
Drug group First line choices Second line choices
1.1 Dyspepsia and GORD Co-magaldrox (prescribe as Mucogel®).Peptac® Liquid (alternative to Gaviscon® and Gavscon® Advance).  
 1.2 Antispasmodics and other drugs altering gut motility Mebeverine (prescribe generically)  Hyoscine butylbromide.Peppermint oil gastro resistant capsules.Alverine (Spasmonal).
1.3.1 H2 receptor antagonists  Ranitidine   
1.3.2 Proton pump inhibitors Omeprazole capsulesLansoprazole capsules Pantoprazole tablets.Lansoprazole (orodispersible tablets) FasTabs® and Losec® MUPS® (dispersible tablets)-for patients with swallowing difficulties only.
1.4 Acute diarrhoea  Loperamide capsules (capsules more cost effective than tablets) Codeine Phosphate
1.5 Chronic bowel disorders Sulphasalazine EC-prescribe as Salazopyrin® EN-Tabs®Mesalazine-prescribe by brand name. Octasa® MR is our first line brand of oral mesalazine It is recommended that mesalazine is prescribed by brand name-if 400mg tablets are required Octasa® MR tablets are recommended as they are considered to be bioequivalent to Asacol® MR tablets but more cost effective. It is more cost effective to prescribe 800mg dose as 2 x 400mg Octasa® MR tablets.
1.6.1 Bulk forming laxatives  Ispaghula (prescribe as Fybogel®)  
1.6.2 Stimulant laxatives SennaDocusate sodium  
1.6.4 Osmotic laxatives Laxido® Orange oral powder (compound macrogol oral powder)-please note Laxido® is not recommended for children under 12 years  Lactulose
1.7 Local preparations for anal and rectal disorders Anusol-HC® (ointment).Uniroid HC suppositories.Glyceryl trinitrate 0.4% ointment (Rectogesic®)- only licensed strength for anal fissure.  

Formulary

Constipation Management in Adults

Chapter 2 - Cardiovascular system

BNF chapter/
section
Drug group First line choices Second line choices
2.1 Cardiac glycosides Digoxin   
2.2.1  Thiazide diuretics  Indapamide.Chlortalidone (NICE CG Hypertension).  
2.2.2  Loop diuretics  Furosemide   
2.2.3  Aldosterone antagonist  Spironolactone   
2.3  Anti-arrhythmic drugs  Specialist initiated and usually continued in primary care  
2.4  Beta-adrenoceptor blocking drugs  Atenolol.Propranolol.Bisoprolol (heart failure only).  
2.5.4  Alpha-adrenoceptor blocking drugs  Doxazosin - prescribe as standard release tablets   
2.5.5.1  Angiotensin converting enzyme inhibitors  Ramipril-prescribe as capsules (not tablets). Lisinopril.Perindopril Erbumine (not arginine).   
2.5.5.2  Angiotensin-II receptor antagonists  Losartan.Candesartan  Irbesartan.Valsartan-prescribe as capsules (not tablets) and generically. 
2.6.1  Nitrates  GTN spray-pump spray prescribe as Nitromin®. It is more cost effective to prescribe as 200 dose pack.Isosorbide mononitrate-prescribe as standard release first line 10mg and 20mg tablets (as ISMO® 10 or ISMO® 20).Isosorbide mononitrate MR for patients that can’t comply with standard release:-60mg MR tablets/capsules-Monomil XL® tablets-40mg MR tablets/capsules-Isotard® 40XL tablets-25mg MR tablets/capsules-Elantan LA®25 capsules-50mg MR tablets/capsules-Elantan LA®50 capsulesGTN patches-prescribe as Nitro-Dur®  Standard tablets are more cost effective than MR formulations. Note asymmetric dosing regime. The second dose should be 8hrs after the first e.g. 8am and 4pm to allow for a nitrate free period. 
2.6.2  Calcium-channel blockers  Amlodipine  Diltiazem-branded diltiazem MR preparations are not interchangeable. Angitil SR® is the most cost effective twice daily brand and Zemtard® XL is the most cost effective once daily brandNifedipine- branded nifedipine MR preparations are not interchangeable. Coracten SR® is the most cost effective twice daily brand and Adipine® XL is the most cost effective once daily brand 
2.6.3 Other anti-anginal drugs Nicorandil  
2.6.8 Anticoagulants and protamine Warfarin Phenindione-specialist recommendation.Acenocoumarol-specialist recommendation.Rivaroxaban-specialist initiation, then shared care.Dabigatran-specialist initiation, then shared care.Apixaban-specialist initiation, then shared care.
2.9 Antiplatelet drugs  Aspirin-prescribe as standard not EC tablets.Clopidogrel (generic) (please ensure stop date in ACS).  Prasugrel-specialist initiation (please ensure stop date).Ticagrelor-specialist initiation (please ensure stop date).
2.12  Lipid regulating drugs  Simvastatin  Pravastatin (consider if side effects or intolerance with simvastatin).Atorvastatin

Formulary

Apixaban

Dabigatran

Rivaroxaban

BBCCG DVT Pathway

Entresto Prescribing Information

Chapter 3 - Respiratory system

BNF chapter/
section
Drug group First line choices Second line choices
3.1.1.1 Selective beta2 agonists  Short acting-salbutamol.Longer acting-formoterol. Short acting-terbutaline.Longer acting-salmeterol.
3.1.2 Antimuscarinic bronchodilators Ipratropium Bromide Tiotropium-prescribe as Spiriva HandiHaler®.Tiotropium Spiriva Respimat® is not recommended due to safety concerns-see MHRA guidance 
3.1.3  Theophylline Theophylline and aminophylline MR.Bioequivalence of different brands of oral theophylline/aminophylline cannot be guaranteed-prescribe by brand name   
3.2 Corticosteroids Beclometasone, Clenil Modulite®, Qvar® (twice as potent as Clenil Modulite®)-prescribe by brand name.Fostair® MDI (beclometasone/formoterol). Budesonide.Symbicort Turbohaler® (DPI) (budesonide/formoterol).Fluticasone.Seretide Evohaler® and Accuhaler® (fluticasone/salmeterol)-COPD.
3.3.2 Leukotriene receptor antagonists Montelukast (generic)   
3.4.1 Antihistamines Chlorphenamine.Loratadine.Cetirizine. Hydroxyzine.Fexofenadine.
3.7 Mucolytics Carbocisteine   

Formulary

Adult Asthma Management

Guidelines for the Management of COPD

COPD Patient Passport

Pulmonary Rehabilitation Course leaflet

Chapter 4 - Nervous System

BNF chapter/
section
Drug group First line choices Second line choices
4.1.1 Hypnotics Zopiclone Temazepam
4.1.2  Anxiolytics  Diazepam   
4.2.1 Antipsychotic drugs First line typical-haloperidolFirst line atypical-risperidone Please refer to the SEPT formulary and prescribing guidelines - section 2: treatment of psychosis
4.2.3 Anti-manic drugs Please refer to the SEPT formulary and prescribing guidelines-section 3: treatment of bipolar affective disorder  
4.3 Antidepressant drugs Fluoxetine-1st line SSRI.Fluoxetine and paroxetine have a higher propensity fordrug interactions.It may be appropriate to consider sertraline and citalopram in patients with chronic health problems, as these have a lower propensity for drug interactions. Please refer to the SEPT formulary and prescribing guidelines-section 1: treatment of depression
4.4 CNS stimulant and drugs for ADHD Methylphenidate, dexamfetamine and atomoxetine-under shared care following specialist initiation. Please refer to the SEPT formulary and prescribing guidelines-section 6: treatment of ADHD 
4.5.1 Anti-obesity drugs Orlistat To be used in conjunction with other lifestyle measures and in line with NICE guidance
4.6  Drugs used in nausea  Prochlorperazine.Choice of agent may depend on cause of nausea and vomiting. Domperidone.Metoclopramide.
4.7.1 Non-opoid analgesics and compound analgesics Paracetamol.Co-codamol (30/500 strength prescribed as Zapain tablets).  
4.7.2 Opoid analgesics Weak: codeine, dihydrocodeine Stronger: morphine, fentanyl patches (as the brand name Fencino®).
4.7.3 Neuropathic pain Amitriptyline Gabapentrin.Pregabalin (prescribed as BD dosing).
4.7.4.1 Antimigraine drugs - acute treatment Aspirin or ibuprofen.Metoclopramide, domperidone, prochlorperazine. First line triptan: sumatriptan (generic)
4.7.4.2 Prophylaxis od migraine Propranolol.Amitriptyline. Topiramate - specialist initiation.Sodium valproate - specialist initiation.
4.8 Antiepileptic drugs Management/initiation in secondary care  
4.9 Drugs used in parkinsonism and related disorders Management/initiation in secondary care  
4.10 Drugs used in substance dependence    
4.11 Drugs for dementia Donepezil - under shared care following specialist initiation Galantamine.Rivastigmine patches - used if excessive GI side-effects and dizziness with oral preparation.Memantine (moderate to severe dementia).Under shared care following specialist initiation.

Formulary

Melatonin

SEPT formulary and shared care guidelines

Taramadol review guidance

Chapter 5 - Infection

Chapter 6 - Endocrine system

BNF chapter/
section
Drug group First line choices Second line choices
6.1 Drugs used in diabetes Please refer to Pharmacological Management of Type 2 Diabetes (excluding insulin) and Pharmacological Management of Diabetes-Insulin Therapy.
6.2.1 Thyroid hormones Levothyroxine  

Formulary

Denosumab

Interim Guidance - Pharmacological treatment of type 2 diabetes in adults

Guideline for Self-monitoring of Blood Glucose in Adults and children 

Insulin Therapy

Chapter 7 - Genito-Urinary System

BNF chapter/
section
Drug group First line choices Second line choices
7.2.1 Preparations for vaginal and vulval changes Estriol 0.01% (Gynest®) intravaginal cream.Estriol 500mcg (Ortho-Gynest®) pessaries. Estriol 0.1% (Ovestin®) intravaginal cream
7.2.2 Vaginal and vulval infections Clotrimazole 500mg pessary plus clotrimazole 1% cream Oral fluconazole 150mg if treatment failure
7.3.1 Combined hormonal contraceptives: prescribe by brand name  
Type of preparation Formulary brand name
Monophasic low strength  Loestrin 20®.Gedarel® 20/150 (same active ingredients as Mercilon®).  
Monophasic standard strength   Rigevidon® (same active ingredients as Microgynon 30®, Levest® and Ovranette®).Gedarel® 30/150 (same active ingredients as Marvelon®).Millinette® 30/75 (same active ingredients as Femodene® and Katya 30/75®).  
7.3.2.1  Oral progestogen-only contraceptives  Micronor®  Desogestrel (as the brand name Zelleta® or Nacrez®
7.3.2.2 Parenteral progestogen-only contraceptives Depo-Provera® injection  Nexplanon® implant 
7.3.2.3 Intra-uterine progestogen-only device Mirena®   
7.3.5 Emergency contraception Levonorgestrel (as the brand name Levonelle® 1500). Do not prescribe as Levonelle® One Step, as it is significantly more costly.  Ulipristal acetate (ellaOne®). Emergency contraceptive from 72-120 hours post unprotected intercourse. 
7.4.1 Drugs for urinary retention Tamsulosin MR-prescribe as capsules (not tablets)   
7.4.2 Drugs for urinary frequency, enuresis, and incontinence Oxybutynin immediate release tablets (not suitable for frail older women). Ditropan® (oxybutynin) 2.5mg/5ml elixir if patient unable to swallow tablets.  Tolterodine immediate release tablets.Darifenacin (Emselex®) modified release tablets-3rd line.Mirabegron (Betmiga®) sustained release tablets-4th line, unless there is a contra-indication to antimuscarinic agents. 
7.4.5 Drugs for erectile dysfunction Sildenafil (prescribe generically)  

Formulary

OAB medicines pathway

Chapter 8 - Malignant disease

BNF chapter/
section
Drug group First line choices Second line choices
8.3 Sex hormones and hormone antagonists in malignant disease Specialist initiation  

Formulary

Gonadorelin Analogues in prostatic carcinoma

Chapter 9 - Nutrition and blood

BNF chapter/
section
Drug group First line choices Second line choices
9.1.1 Oral iron Ferrous fumarate (ferrous fumarate 210mg (68mg iron) and dried ferrous sulphate 20mmg (65mg iron) considered interchangeable)  
9.1.2 Drugs used in megaloblastic anaemia Folate deficiency anaemia: folic acid.Vitamin B12 deficiency: hydroxocobalamin.   
9.4 Oral nutrition Please refer to Guidelines for the appropriate use of oral nutritional supplements (ONS) in primary care
9.6.4 Vitamin D (with calcium) Calceos tablets chewable (calcium carbonate 1.25g and colecalciferol 10mcg (400units) per tablet)  Higher dose vitamin D preparations may be needed for the treatment of deficiency/insufficiency-please refer to local vitamin D guidelines. 

Formulary

Gluten-free foods on prescription

Infant formula prescribing guidelines

Quick reference guide to prescribing infant formula

Supporting papers for CMPA

Adult Oral Nutritional Supplements Prescribing Guidelines

Quick reference guide to ONS prescribing in adults

Guide to prescribing thickeners for adults with dysphagia

Vitamin D Guidelines

Policy Statement for Vitamin D

Chapter 10 - Musculoskeletal System

BNF chapter/
section
Drug group First line choices Second line choices
10.1.1 Non-steroidal anti-inflammatory drugs Ibuprofen.Naproxen (prescribe as standard tablets, ec tablets are not recommended).  
10.1.2 Corticosteroids Prednisolone (prescribe as standard tablets, ec tablets are not recommended)  Local injections? 
10.1.3 Drugs that suppress the rheumatic disease process Specialist initiation/recommendation  
10.1.4 Gout and cytotoxic-induced hyperuricaemia Acute attacks of gout: colchicine.Prophylaxis: allopurinol.  Febuxostat is an option when allopurinol is not tolerated at an effective dose or for whom allopurinol is contra-indicated. 
10.2.2 Skeletal muscle relaxants Baclofen  Diazepam
10.3.2 Topical NSAIDs, capsaicin Ibuprofen 5% gel (prescribe as brand name Fenbid® gel-100g container is most cost effective)  

Formulary

Rheumatology methotrexate shared care guidelines

Chapter 11 - Eye

BNF chapter/
section
Drug group First line choices Second line choices
11.3.1 Anti-infective eye preparations-antibacterials Chloramphenicol eye drops 0.5% and eye ointment 1% Fusidic acid modified release eye drops 1%
11.3.3 Anti-infective eye preparations-antivirals Aciclovir eye ointment 3%  
11.4 Corticosteroids and other anti-inflammatory preparations Specialist recommendation and supervision  
11.4.2 Other anti-inflammatory preparations Sodium cromoglicate eye drops 2%  
11.6 Treatment of glaucoma Specialist recommendation   
11.8.1 Tear deficiency, ocular lubricants, and astringents Hypromellose 0.3% eye drops.Clinitas Gel® (carbomer 980 0.2%-most cost effective brand name).  Tear-Lac® if preservative free preparation required

Formulary

Chapter 12 - Ear, Nose and Oropharynx

BNF chapter/
section
Drug group First line choices Second line choices
12.1.1 Otitis externa    
12.1.2 Otitis media Please refer to the South West Essex Antimicrobial Prescribing Guidance For Primary Care  
12.2.1 Drugs used in nasal allergy Beclometasone aqueous nasal spray 50micrograms/actuation   

Formulary

Chapter 13 - Skin

End of Life Formulary

Wound Care Formulary

Traffic light list for prescribing

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