In line with NICE

Itracranial hypertension

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

Hospital Only

• Tablets
• Sachets- available as 200mg powder for oral solution- licensed product.
• Effervescent tablets

• 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

Supported by RICaD

• ££££

 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.

 £££- Paediatrics only
 £££- Recommended by specialist for oncology use only.

In line with NICE

Hospital only

• In line with NICE

• More than 1.5 kcal/ml and 5g (or more) protein/100ml
• Low energy per serving as a semi-solid supplement where low volume is required only.
• Standard ACBS indications: Disease-related malnutrition, intractable malabsorption, preoperative
  preparation of malnourished patients, dysphagia, proven inflammatory bowel
  disease, following total gastrectomy, short-bowel syndrome, bowel fistula Not suitable for child
  under 3 years; use with caution in child 3–6 years.

• in conjunction with prednisolone (plain tablets, not EC)
• Supported by ESCA , see link below.

• supported by ESCA, see link below

  Tablets/ suspension. When used in line with Primary care antimicrobial guidelines

   Tablets only. For COPD or bronchiectasis patients who have ≥3 exacerbations per year. Off-label use. Supported by RICaD and Guidelines on Respiratory use of long term azithromycin in adults

• 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.

• urea 5%, lauromacrogols 3%

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

Specialist initiation for severe brittle asthma/ cystic fibrosis

• Fat and Carbohydrate
• Over one year of age. Metabolic disorder pts
• Also these are the only protein free (containing fat, carbohydrate, vitamins and minerals) powders aimed at children ≥1-year-old and adults with inborn errors of protein metabolism (particularly patients with urea cycle disorders and organic acidaemias). Basecal 100 and Basecal 200 are commonly added as an energy source in low protein module tube feeds. The dose will depend on energy requirements and tolerance to natural protein. It is commonly used in combination with a controlled amount of natural protein e.g. measured dose of standard enteral tube feed. 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.

Approved April 2019

Hydrocolloid Range with film border

Type of wound product is suitable for
Lightly to moderately exuding wounds

Duration dressing remains on wound before changing
Up to 7 days

Frequency of dressing change
Only when necessary - up to 7 days

Caution/contraindications (when not to use the dressing, patient groups to avoid etc.)
Do not use on third-degree burns. Should not be used on individuals who are sensitive to or have had an allergic reaction to the dressing or its components.

Rationale for inclusion in formulary
Reduced dressing changes. More cost effective. Reduce use of more expensive foam dressings.

• Short term use only

Potency: Potent

Maximum treatment period 30 days

• Specialist Ophthalmologist Recommendation

• Specialist Ophthalmologist Recommendation

Polyurethane foam dressing with bevelled edges

Type of wound product is suitable for
Moderately exuding wounds with signs of granulation, epithelialisation or slough.
Can be used as primary or secondary

Duration dressing remains on wound before changing
1-7 days

Frequency of dressing change
Up to 7 days dependent on exudate levels

Caution/contraindications (when not to use the dressing, patient groups to avoid etc.)
Do not use with oxidising solutions such as hydrogen peroxide
Full thickness burns
Surgical implantations

Rationale for inclusion in formulary
Simple to use on the foot and digits Can be cut to shape

• Specialist Ophthalmologist Recommendation.
• 2nd line

For use in H Pylori eradication in penicillin allergy and previous clarithromycin, as per Antimicrobial guidelines.

In line with NICE

Essential protein-free basic products. Necessary for children and adults with inborn errors of protein metabolism who tolerate very little natural protein. 1 slice ordinary bread = 4g protein and is not allowed in low protein diets.

In line with NICE

• Specialist Ophthalmologist Recommendation

• Specialist Ophthalmologist Recommendation

• Specialist Ophthalmologist Recommendation
• 2nd/3rd line

• Hospital only
• In line with NICE

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

• Capsules

• Capsules
• M/R capsules
• Dispersible tablets

• Tablets

• tablets
• 25mg/5ml syrup
• Use with caution in patients aged over 65
• Contraindicated in children below the age of 12

• Supported by a RICaD (in development)

Powder

• For patients with poor compliance or absorption problems

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

• For glycogen storage disease
• Slow release CHO to prevent hypoglycaemia in GSD
• Slow release carbohydrate to prevent hypoglycaemia in all types of GSD. Cheaper than glycosade and easier to mix. Used in less severe forms of GSD. Between 1 to 2g/kg body weight is prescribed dependent on age, weight and clinical symptoms of hypoglycaemia. Doses may be given at regular intervals during the day and night or at bedtime only. The dose and frequency of dose should always be advised by the specialist dietitian according to the needs of the patient.

• Infant and child: Hydrolysate formula
• Whey hydrolysate. Use in infants who have malabsorption problems and require a peptide and MCT containing feed. Eg after gut surgery. Use as tube or oral feed
• Disaccharide and/or whole protein intolerance, or where amino acids and peptides are indicated in conjunction with medium chain triglycerides.

DACC coated dressings providing antimicrobial properties, available in a pad, gel, gel sheet, ribbon, round swab and rectangular swab

Type of wound product is suitable for
Colonised or clinically infected moist wound, suitable for any wound type

Duration dressing remains on wound before changing
1-3 days

Frequency of dressing change
1-3 days dependent on exudate levels

Caution/contraindications (when not to use the dressing, patient groups to avoid etc.)
Do not use in combination with oils and creams
Known hypersensitivity to ingredients
Not for dry wound
Not for heavily exuding wounds

Rationale for inclusion in formulary
Alternative to available antimicrobials

• To correct cysteine deficiency in homocystinuria
• The only pre-measured sachet of cysteine to correct cysteine deficiency in homocystinuria. The dose and frequency of administration will be determined by the specialist dietitian.
• Nutritional supplement for the dietary management of inborn errors of amino acid metabolism in adults and children from birth.

  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: Dabigatran in DVT / PE

Use in line with NICE

• Low protein milk for children and adults with phenylketonuria and other disorders of protein metabolism
• Low protein milk (similar energy content to cow’s milk) for children and adults with phenylketonuria and other disorders of protein metabolism.

• For hereditary angioedema (off label use)

In line with NICE

• Specialist recommendation

• First line
• Specialist recommendation
• 100 shades available
• FP10 prescriptions should be endorsed "ACBS"

specialist recommendation for epidermolysis bullosa

short term use only

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

• for post corneal implants or OSD
• Use the agent with the lowest acquisition cost

• palliative care only

• Specialist Ophthalmologist Recommendation.

Potency: very potent

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

• Specialist Ophthalmologist Recommendation

• Specialist Ophthalmologist Recommendation

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

• Supported by a RICaD

• Topical treatments should be used first line.
• Oral antibiotics should be reserved for acne, if topical treatment is not adequately effective or if it is inappropriate.
  
  Please refer to Antimicrobial guidelines

• Specialist recommendation

In line with NICE

• Consists of essential amino acids for the treatment of urea cycle disorders
• Essential amino acid supplement for use in urea cycle disorders and the cerebral creatine deficiency syndrome: guanidinoacetate methyltransferase (GAMT) deficiency. The only pre-measured sachet of essential amino acids with added vitamins and minerals for the treatment of urea cycle disorders. This is particularly important as most of our families with UCD do not speak English as their first language so require pre-measured products. Unmeasured use of essential amino acid supplements in UCD could lead to hyperammonaemia, acute brain encephalopathy and ITU admission. The dose and frequency of administration will be determined by the specialist dietitian.
• Nutritional supplement for the dietary management of disorders of protein metabolism including urea cycle disorders in children over 3 years.

Approved June 2018 to replace Flivasorb^®

• 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 allergy
• Short bowel syndrome, intractable malabsorption, proven inflammatory bowel disease, bowel fistula

• Elleste Solo® 1mg and 2mg tablets

• In line with NICE
• Specialist initiation, transfer of prescribing supported by RICaD.
• RICaD: Eluxadoline

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

In line with NICE

• Protein, fat, and carbohydrate
• First choice for patients with very high energy requirement eg cystic fibrosis
• In adults with cystic fibrosis, nutritional advice and interventions should be aimed at maintaining a BMI of 22kg/m2 in women and 23kg/m2 in men, as these are associated with better lung function (Nutritional management of CF – Consensus document – 2016)
• Disease-related malnutrition, malabsorption states, or other conditions requiring fortification with a high fat or carbohydrate (with protein) supplement. Not suitable for child under 1 year; use with caution in child 1–6 years.

• Tablets

In line with NICE

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