In line with NICE

Itracranial hypertension

• Second line in Acute Otitis Externa, as per antimicrobial guidelines
   
   
  

• For COPD only

Non-adherent viscose net dressing 99% Manuka honey and 1% Manuka oil.

Type of wound product is suitable for
A primary dressing for low to moderate shallow exuding wound with light slough. Granulating or
epithelialising wounds with clinical signs of infection. Requires a secondary dressing.

Max Duration dressing remains on wound before changing
3-7 Days

Frequency of dressing change
3 to 7 days depending on exudate

Caution/contraindications (when not to use the dressing, patient groups to avoid etc.)
Known allergy to Bee Venom and Honey products
Blood sugars should be monitored in patients with diabetes
Stinging sensation may be experienced. If unacceptable for patient then discontinue.

Rationale for inclusion in formulary
For antimicrobial and de-sloughing properties
Ease of application
Can be cut to size
Easy removal in one piece
Availability of different sizes
Not found to be harmful to peri-wound skin
Malodour
Cost effective

Tracheostomy foam dressing

Type of wound product is suitable for
ActivHeal Foam Tracheostomy dressing has a fenestration, which allows the dressing to fit neatly around a tracheostomy tube. The dressing can also be used around intubation and cannula insertion procedures, external bone fixators and appropriately-sized wound drainage tubes.

Duration dressing remains on wound before changing
Dependant on clinical need and soiling

Frequency of dressing change
Up to 7 days, dependant on clinical need and soiling

Caution/contraindications (when not to use the dressing, patient groups to avoid etc.)
Do not use if reaction to any of its components

Rationale for inclusion in formulary
Specific dressing shaped and able to cut for tracheostomies.
Cost effective

Knitted viscose mesh impregnated with 100% Manuka Honey.

Type of wound product is suitable for
Creates a moist healing environment effectively eliminates odour. Provides anti-microbial action.
Debrides and de-sloughs shallow wounds where the exudate level has started to decrease. Requires secondary dressing

Max Duration dressing remains on wound before changing
Up to 4 days

Frequency of dressing change
Daily in acute infection
Up to 4 days for chronic infection depending on exudate

Caution/contraindications (when not to use the dressing, patient groups to avoid etc.)
Wounds with active blood loss
Known allergies to bee Venom and Honey products
Blood sugars should be monitored in diabetic patients
Stinging sensation may be experienced – discontinue if not tolerant.

Rationale for inclusion in formulary
Anti-microbial and de-sloughing properties for wounds with reduced levels of exudate.
Control of odours
Ease of application and removal in one piece
Can be cut to size
Available to various size
Cost effective

• Hospital only
• Biosimilar brands available:
  • Amgevita®
  • Hulio®
  • Imraldi®
  • Hyrimoz®

• The need for continued bisphosphonate treatment should be re-evaluated periodically particularly after 5 or more years of use

Alginate dressing impregnated with 100% Manuka Honey.

Type of wound product is suitable for
Primary dressing for infected, shallow cavity wounds, particularly if necrotic or malodorous with
moderate exudate. Requires secondary dressing.

Max Duration dressing remains on wound before changing
Up to 4 days for chronic infection

Frequency of dressing change
Daily for acute infection
Up to 4 days for chronic infection/depending upon exudate

Caution/contraindications (when not to use the dressing, patient groups to avoid etc.)
Wounds with active blood loss
Known allergy to be venom and honey products
Blood sugars should be monitored in diabetic patients
Stinging sensation may be experienced – discontinue if not tolerated

Rationale for inclusion in formulary
Antimicrobial and de sloughing properties
Absorbent
Malodour
Ease of application and removal in one piece
Can be cut to size
Available in various sizes
Can be shaped to wound size and depth
Cost effective

Type of wound product is suitable for
Wound management by secondary intention on acute, chronic, full thickness or partial
thickness or shallow granulating wounds including pressure ulcers, leg ulcers, diabetic foot ulcers, malignant wounds surgical wounds, malignant wounds donor sites and fungating ulcers
Can be used as a primary or secondary dressing

Duration dressing remains on wound before changing
Can stay in place up to 3-7 days

Frequency of dressing change
Dependent on exudate levels

Caution/contraindications (when not to use the dressing, patient groups to avoid etc.)
In common with all adhesive products, some cases of irritation and/or maceration of the skin may occur.
It should be noted that inappropriate use or too frequent dressing changes, particularly in patients with fragile skin, can result in skin stripping. If this occurs change to the Allevyn gentle border range.
If redness or sensitisation occur, discontinue use
Caution under compression when exudate levels are moderate to high.

Rationale for inclusion in formulary
Can be used for low to moderate exudate levels
Different sizes and shapes available
Cost effective

• Replacement for Calcium Sandoz ^® (discontinued)

Specialist initiation

• For patients who would otherwise use alprostadil injection.

• Capsules
• Syrup- for patients with swallowing difficulties

• Specialist initiation

• ££££

 Following diagnosis of AF- use in line with NICE. Initiation/ recommendation by a clinician who routinely initiates anticoagulants. 

BSSE APC Primary Care Clinical Pathway for Arial Fibrillation Detection and Management
 
  Use following Hip and Knee surgery- full course of treatment supplied on discharge. 
 
  For the treatment and secondary prevention of DVT and/or PE - use in line with NICE. Initiation/ recommendation by a clinician who routinely initiates anticoagulants. Where this is not the patient's GP, transfer to GP should be with the support of RICaD.
RICaD: Apixaban in DVT/ PE

• only PF sympathomimetic

• Infant and child: Hydrolysate formula
• Whey hydrolysate formula containing lactose. Use in infants (from birth – 6 mths) who have cow’s milk protein intolerance / allergy but no lactose intolerance. Tube or oral feed.
• Established cows' milk protein intolerance, with or without secondary lactose intolerance

Hydrofibre with silver

Type of wound product is suitable for
Management of clinically infected, sloughy, necrotic or granulating wounds with moderate to heavy exudate.
Moderate to highly exuding wounds.
Aquacel Ag Plus Extra can be used to break down biofilms
Requires a secondary dressing

Duration dressing remains on wound before changing
Dependent upon exudate 1 - 7 days

Frequency of dressing change
Dependent upon level of exudate and clinical presentation

Caution/contraindications (when not to use the dressing, patient groups to avoid etc.)
Should not be used on individuals who are sensitive to or have had an allergic reaction to the dressing or its components.
Not suitable for dry wounds.
No haemostatic properties.

Rationale for inclusion in formulary
Specialist antimicrobial product
Moderate to high exudate levels
Can be used to break down biofilms
Remains intact on wound bed and easily removable in one piece (non dispersible)

The APC's view is that, on clinical grounds, the status of antipsychotic depot injections should be amber with a framework in place in Primary Care before transfer.
HOWEVER, until the commissioning arrangements have been agreed to allow safe transfer of patient care, the status will remain RED.

• In line with NICE

Injection

• For Myaesthenia Gravis only.

• Hospital only
• In line with NICE

• Approved on formulary December 2017
• Specialist initiation.
• 3rd line after oral PDE-5 inhibitors failed and patient not responding to or intolerant of alprostadil.
• To be reviewed within 12 months to assess alprostadil supply issues and patent expiry

• 1.5 kcal/mL and 5 g (or more) protein/100 mL
• Second line choice for 200ml ready-made. If powder is not tolerated or contraindicated

• In line with food first
• Not suitable for CKD 4-5, renal pts.
• Not suitable for lactose intolerance
• Not suitable for bile acid malabsorption or fat maldigestion associated with biliary diseases/conditions
• To be made up with whole milk.
• Standard ACBS indications: Disease-related malnutrition, intractable malabsorption, pre-operative preparation of malnourished patients, dysphagia, proven inflammatory bowel disease, following total gastrectomy, short-bowel syndrome, bowel fistula . Use with caution in child 1–6 years.

Tablets 25mg, 50mg
 Maintenance of remission of acute ulcerative colitis and Crohn’s disease in adults– unlicensed but in line with national guidelines.
 
 For use in Inflammatory Bowel Disease (IBD) as per effective shared care agreement (ESCA). See link below.

Specialist use only for neurological conditions

Supported by ESCA, see link below.

• Do not prescribe azithromycin as stand-alone medication for the indication of gonorrhoea. Refer to GUM clinic for IM ceftriaxone as per current UK guidelines.

• First line for ophthalmic chlamydia

Over the counter preparation suitable for self-care/purchase if appropriate

COPD Appendix 4 - Criteria for triple therapy and for triple inhaler use in COPD

In line with NICE

Potency: potent

• High-energy supplements: fat
• 21% MCT emulsion, used orally and in cooking as an energy source for children and adults on a ketogenic diet

• Specialist Ophthalmologist Recommendation

• Specialist Ophthalmologist Recommendation

Achalasia

• Use for SWB only in endoscopy
• 100 units

• In line with NICE

• Specialist Ophthalmologist Recommendation

• Specialist Ophthalmologist Recommendation
• Third line option, after prostaglandin analogues (1st line) and beta-blocker/ prostaglandin analogue plus beta-blocker (2nd line)
• For patients in whom monotherapy provides insufficient IOP reduction.

• Initiation by Tertiary Epilepsy Specialist only.
• For adjunctive therapy in the treatment of partial-onset seizures with or without secondary generalisation in adult and adolescent patients from 16 years of age with severe refractory epilepsy warranting tertiary specialist input for patients who have tried three or more AEDs. The patient has used levetiracetam and has documentation of intolerance and patient is using a third line agent (perampanel, zonisamide, lacosamide, eslicarbazepine) which would be replaced by brivaracetam.
• Supported by an ESCA

In line with NICE

Approved January 2018. Interim measure due to supply issues with ketorolac eye drops

2mg/dose foam enema

Approved July 2018

Specialist use only.

Formulary status to be reviewed on publication of NICE TA (expected October 2019)

Hospital only- NHSE Commissioned

Over the counter preparation suitable for self-care/purchase if appropriate

• Specialist recommendation
• For delicate areas,face and flexures

• High-energy supplements: fat
• Used as a source of LCT, as an energy supplement and additive to feed to enhance energy density.
• Does not contain protein
• Also this is the only LCT fat source that can be used as a fat energy source in patients with organic acidaemias e.g. propionic acidaemia and methyl malonic acidaemia and urea cycle disorders. It may also be used as part of a modular feed or protein-free energy source. The dose and type of product should always be advised by the specialist dietitian according to the needs of the patient.
• Disease-related malnutrition, malabsorption states, or other conditions requiring fortification with a high fat (or fat and carbohydrate) supplement. Liquid supplements

• Protein, fat, and carbohydrate
• Used on dietetic advice only
• Used where hygiene concerns/infection control – single use sterile dose – where Calogen Extra bottle is not appropriate
• Used where energy, protein and micronutrients required in small volume
• Disease-related malnutrition, malabsorption states, or other conditions requiring fortification with a high fat or carbohydrate (with protein) supplement.
• Not suitable for child under 3 years; use with caution in child 3–6 years. May require dilution for child 3–5 years.

Over the counter preparation suitable for self-care/purchase if appropriate

• Only strength licensed for post-herpetic neuralgia and diabetic peripheral polyneuropathy.
  
  For other strength, see section 10.3.2
  

• High-energy supplements: fat
• 20% LCT emulsion, used as an energy source for children and adults on a ketogenic diet, may be used orally or in cooking
• For use in ketogenic diets. Long chain triglyceride liquid emulsion used as a milk replacement (when diluted) for some patients with PKU on very low protein diets who cannot tolerate other low protein milk replacements. It will help meet essential energy requirements. The dose and type of product should always be advised by the specialist dietitian according to the needs of the patient.

Only when used in line with Antimicrobial guidelines 
 
 When used outside Antimicrobial guidelines, on Specialist recommendation.

Sub compression wadding bandage to pad and shape a limb prior to compression therapy

Type of wound product is suitable for
Provides padding for larger limbs under compression.

Duration dressing remains on wound before changing
Up to 7 days

Frequency of dressing change
Daily up to weekly dependant on exudate and oedema management.

Caution/contraindications (when not to use the dressing, patient groups to avoid etc.)
Advised not to apply directly to skin as can cause irritation.

Rationale for inclusion in formulary
Cost effective for use in larger quantities when used in lymphoedema management.

Essential protein-free basic products. Necessary for children and adults with inborn errors of protein metabolism who tolerate very little natural protein. 2 regular Weetabix = 4.5g protein and this protein amount is more than the amount of protein that may be tolerated.

OTC preparation suitable for self-care/purchase if appropriate

• tablets
• syrup
• Supported by ESCA, see link below.

• via travel vaccine service

• Initiation by a respiratory specialist
• Supported by a RICaD

Specialist use only for neurological conditions

Supported by ESCA, see link below.

• Specialist Opthalmologist Initiation
• Treatment of severe vernal keratoconjunctivitis (VKC) in children from 4 years of age and adolescents

Only when used in line with Antimicrobial guidelines 
 
When used outside Antimicrobial guidelines, on Specialist recommendation.

• Off label use of eye drops
• Specialist Recommendation

• Not recommended routinely due to QT prolongation risk

Only when used in line with Antimicrobial guidelines 
 
When used outside Antimicrobial guidelines, on Specialist recommendation.

• Specialist initiation
• 12 week course

Odour absorbent charcoal dressing

Type of wound product is suitable for
Malodourous wounds such as fungating wounds

Duration dressing remains on wound before changing
Up to 7 days

Frequency of dressing change
1-7 days dependent on exudate levels

Caution/contraindications (when not to use the dressing, patient groups to avoid etc.)
Not indicated as a primary dressing in dry wounds
Store at room temperature
Exudate levels will reduce the effectiveness of the charcoal

Rationale for inclusion in formulary
Clinisorb is an activated charcoal dressing which adsorb toxins removing malodour from the wound
Can be cut to size
Cost effective

MHRA Advice
Care should be taken when switching between oral formulations. The need for continued supply of a particular manufacturer’s product should be based on clinical judgement and consultation with patient and/or carer, taking into account factors such as seizure frequency and treatment history.

• For ovulation induction
• On specialist recommendation
• Generic tablets

MHRA Advice
Care should be taken when switching between oral formulations. The need for continued supply of a particular manufacturer’s product should be based on clinical judgement and consultation with patient and/or carer, taking into account factors such as seizure frequency and treatment history.

Over the counter preparation suitable for self-care/purchase if appropriate

Only when used in line with Antimicrobial guidelines 
 
When used outside Antimicrobial guidelines, on Specialist recommendation.

Two layer compression system available in full and reduced compression (Coban Lite). Comprises of a latex free foam padding and cohesive bandage.

Type of wound product is suitable for
Treatment of venous and mixed aetiology leg ulcers

Duration dressing remains on wound before changing
1 to 7 days

Frequency of dressing change
Daily up to weekly dependant on exudate and oedema management.

Caution/contraindications (when not to use the dressing, patient groups to avoid etc.)
Arterial disease
Not to be used with other padding or wadding

Rationale for inclusion in formulary
Two layer compression kit, Once applied the two layers form a band to become a single
layer bandage.
Bandage technique can be adapted to reduce forefoot oedema (Extra training required)

• Tablets
• M/R tablets

Jaundice and Primary Biliary Cholangitis (PBC)

• See Chapter 3 for respiratory specific indications

Commissioned by NHS England for Cystic Fibrosis only

  New patients
 
   Existing patients (initiated prior to April 2013)

100 % cotton short stretch compression bandage

Type of wound product is suitable for
Venous leg ulceration
Varicosis
Management of chronic oedema
Management of primary and secondary lymphoedema
Deep venous thrombosis
Thrombophlebitis

Duration dressing remains on wound before changing
1 to 7 days

Frequency of dressing change
Dependant on exudate levels if wound present or oedema management.

Caution/contraindications (when not to use the dressing, patient groups to avoid etc.)
Advanced Peripheral arterial occlusive disease
Decompensated cardiac insufficiency
Septic phlebitis
Phlegmasia coerula doleris

Rationale for inclusion in formulary
Cotton short stretch bandage. Used by lymphoedema nurse specialists

Over the counter preparation suitable for self-care/purchase if appropriate

• Specialist Ophthalmologist Recommendation.

In line with NICE

In line with NICE

In line with NICE

See Type 2 diabetes DMMAG Guideline for the choice of oral and non-insulin antihyperglycaemic agents in adults

SLGT2 inhibitors are not to be used in primary care for type 1 diabetes until further local guidance becomes available

 for treating Type 2 diabetes in line with NICE 

 Specialist centres only for treating Type 1 diabetes as per NICE TA 597: Dapagliflozin with insulin for treating type 1 diabetes

• Commissioned by CCGs, in line with NICE
• Transfer to Primary Care supported by an ESCA. Click here
  to access

• in the treatment of hyponatraemia resulting from inappropriate secretion of antidiuretic hormone. UNLICENSED

Cream containing 25% urea
Type of wound product is suitable for
To moisturise dry skin on the soles of feet
For use on adults and children over 12 years of age
Frequency of use
Reapply daily
Caution/contraindications (when not to use the dressing, patient groups to avoid etc.)
Allergy or hypersensitivity to any of the ingredients, contains beeswax and lanolin
Not to be used on children under 12
Rationale for inclusion in formulary
Treatment of dry skin conditions of the foot. Dermatology approved

Over the counter preparation suitable for self-care/purchase if appropriate

Important protein-free foods to provide important energy, assist dietary adherence and provide variety when natural protein tolerance is very limited. Necessary for children and adults with inborn errors of protein metabolism who tolerate very little natural protein.

Please note that commissioning discussion is underway. However the present status is as follows:-

Birmingham and Solihull CCG
 
 Age 6 and over - Solihull practices.  Supported with ESCA

 Age 16 and over - Birmingham practices.  Supported with ESCA

 Age under 16 - Birmingham practices

Sandwell and West Birmingham CCG

 Age 6 and over. Supported with ESCA.  Click here for shared care document for patients seen by Black Country Partnership NHS FT 

• Protein and carbohydrate
• This is a source of essential amino acids for use in low protein diets with urea cycle disorders. The dose and type of product should always be advised by the specialist dietitian according to the needs of the patient.
• Hypoproteinaemia, chronic renal failure, wound fistula leakage with excessive protein loss, conditions requiring a controlled nitrogen intake, and haemodialysis. Not suitable for child under 6 months.

Inpatient use and prison settings only

In line with NICE

• All Strengths. Specialist Recommendation

• DHA supplement for low chain fatty acid and low protein diets
• The only ACBS prescribed DHA supplement for low protein diets. The dose and frequency of administration will be determined by the specialist dietitian.
• Nutritional supplement for the dietary management of inborn errors of metabolism for adults and children from birth.

Commissioned by NHS England for Cystic Fibrosis only

  New patients
 
  For existing patients (initiated pre April 2013)

• Specialist Ophthalmologist Recommendation

• Specialist Ophthalmologist Recommendation

Plain tablets only

 Modified release tablets are non formulary.

All spacer devices

• NOT for monotherapy

• Fat and Carbohydrate
• For renal children with fluid restriction
• Disease-related malnutrition, malabsorption states, or other conditions requiring fortification with a high fat (or fat and carbohydrate) supplement.

In line with NICE

• When finasteride has failed or is contraindicated/not tolerated

  Following diagnosis of AF- use in line with NICE. Initiation/ recommendation by a clinician who routinely initiates anticoagulants. 

BSSE APC Primary Care Clinical Pathway for Arial Fibrillation Detection and Management

 For treating and for preventing recurrent DVT and PE- use in line with NICE. Initiation/ recommendation by a clinician who routinely initiates anticoagulants. Where this is not the patient's GP, transfer to GP should be with the support of RICaD
RICaD: Edoxaban in DVT/PE

• Less than 1 kcal/mL and less than 5 g protein/100 mL
• Amino acid formula (essential and non-essential amino acids)
• Pts with IBD, multiple allergies. For tube feed and oral feeding. Alter concentration of feed to support individual patient’s nutritional needs.
• Short bowel syndrome, intractable malabsorption, proven inflammatory bowel disease, bowel fistula

• If a 40mcg or 80mcg strength required

In line with NICE

See Type 2 diabetes DMMAG Guideline for the choice of oral and non-insulin antihyperglycaemic agents in adults

SLGT2 inhibitors are not to be used in primary care for type 1 diabetes until further local guidance becomes available

For existing patients only.

• Fat and Carbohydrate
• Infant feed - Metabolic disorder pts
• Also protein-free (containing fat, carbohydrate, vitamins and minerals) powder necessary for infants with inborn errors of protein metabolism. It is the only protein-free infant feed for patients with urea cycle disorders and organic acidaemias. It is commonly used in combination with a measured amount of natural protein e.g. expressed breast milk. It will help meet essential energy and nutrient requirements. The dose and type of product should always be advised by the specialist dietitian according to the needs of the patient.
• For children requiring additional energy, vitamins, minerals, and trace elements following a protein-restricted diet

• More than 1.5 kcal/mL and 5g (or more) protein/100 mL
• High calorie vegetarian fish oil free
• Standard ACBS indications: Disease-related malnutrition, intractable malabsorption, pre-operative preparation of malnourished patients, dysphagia, proven inflammatory bowel disease, following total gastrectomy, short-bowel syndrome, bowel fistula ; also haemodialysis and CAPD

Over the counter preparation suitable for self-care/purchase if appropriate

In line with NICE

See Type 2 diabetes DMMAG Guideline for the choice of oral and non-insulin antihyperglycaemic agents in adults

SLGT2 inhibitors are not to be used in primary care for type 1 diabetes until further local guidance becomes available

• Supported by an ESCA

• Secondary care use only

• Phasic (28-day ‘Every day’ preparation)
• For Synphase failure

Ethambutol liquid 400mg in 5ml (unlicensed)

• Monophasic low strength (21-day preparation)
• For pubertal induction in adolescent patient or premature ovarian failure ONLY

• For induction of puberty in female patients who cannot tolerate or are allergic to first-line patches.
•  2 microgram- unlicensed special

•  Specialist recommendation - 10 microgram ££

MHRA Advice
When prescribing for epilepsy, the potential for clinically relevant differences to exist between different manufacturers’ products is considered to be extremely low. However, consider other patient/carer-related factors, such as negative perceptions about alternative products and/or other issues related to the patient such co-morbid autism, mental health issues, or learning disability.

• Evorel® patch 

• 2nd line to Evorel Sequi®

• for Hyperandrogenism in women (unlicensed)
  
  
• Black listed in NHS primary care

• Capsules
• Suspension- For patients with swallowing difficulties only

Adhesive, waterproof, occlusive tape impregnated with 4mg/cm2 fludroxycortide (topical steroid)
Type of wound product is suitable for
Chronic overgranulation, non acute or weeping.
Duration dressing remains on wound before changing
Cut the tape to size. Apply for 12 hours at a time, remove and discard. Apply to clean, dry skin that is shorn of any hair.
Frequency of dressing change
Apply daily for 12 hours at a time. Maximum treatment time 7 days.

Caution/contraindications (when not to use the dressing, patient groups to avoid etc.)
Chicken pox
Tuberculosis of the skin
Hypersensitivity to any components in the tape (steroid fludroxycortide)
Facial rosacea
Acne vulgaris
Perioral dermatitis
Perianal and genital pruritis
Dermatoses in infants Dermatitis napkin eruption Bacterial, viral and fungal infections
Keep away from the eyes
Avoid prolonged use on the face
Not for untreated bacterial, fungal or viral skin lesions
Rationale for inclusion in formulary
Treatment of overgranulation

Unlicensed medicine