Wirral University Teaching Hospital Foundation Trust Non ... · PDF fileSystem Medicine...

Wirral University Teaching Hospital Foundation Trust Non Medical Prescribing Personal Formulary

Principal Author: C Herring, Lead Pharmacist Medicines Management, WUTH Version Number 2

Approved by: WUTH Non Medical Prescribing Committee March 2013

Review date: March 2015

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Guidance notes on completing this document

1. Not all medicines can be listed in the “groups” section of this document. Medicines that are exempted are:

a. Chemotherapy (list as individual drugs in section 2) b. Antimicrobial agents (list as individual drugs in section 3) c. Unlicensed medicines (including the use of licensed medicines in an off label manner, list as individual drugs in section 4)

2. You will only be able to prescribe medicines that appear in the Wirral Wide Formulary (providing that they are not restricted to certain groups of staff, i.e consultant cardiologists, or anaesthetists only) or medicines that appear in a Trust approved Clinical Guideline.

3. If you wish to prescribe a medicine that is not listed in the Wirral Wide Formulary or a Clinical Guideline, or in a dose, patient group, or for an indication not listed in these documents then please seek advice from the Secretary of the Non Medical Prescribing Committee.

4. You do not have to fill in every section. If you do not prescribe antibiotics, or wish to prescribe specific medicines rather than classes then do not fill in that section.

5. If you wish to prescribe dressings then fill in dressings as per wound formulary. You will not be able to prescribe dressings that are restricted in the wound formulary.

6. Detail the drug class as per the BNF does. i.e Laxatives is section 1.6, however there are 7 different classes of laxatives. If you want them all then list them.

7. List the classes in the order that they appear in the BNF. 8. When completing one of the sections, all columns (except the comments/remarks section) need to be completed. The application will not be considered

unless this is complete. 9. Please ensure that you have completed the necessary training to allow you to prescribe these medicines before you come to the Committee. They are:

a) Antimicrobial training (for antibiotics, antivirals and antifungal agents). Arranged via Lin Miller ([email protected]) b) Insulin http://www.diabetes.nhs.uk/safety/safe_use_of_insulin_elearning_module/elearning_course c) Unlicensed (and off label) medicines. Arranged via Lin Miller ([email protected]) d) Injectable medicines http://learning.bmj.com/learning/search-result.html?moduleId=10009161 e) Nicotine Replacement Therapy http://learning.bmj.com/learning/module-intro/smoking-cessation.html?moduleId=5004316

Drugs for Personal Formulary must be in the Hospital Formulary (Medicines Guide) or Trust approved Clinical Guideline. All independent prescribers are accountable and responsible for assessment, as well as ongoing

monitoring and review of all patients for whom they prescribe.

http://learning.bmj.com/learning/search-result.html?moduleId=10009161

http://learning.bmj.com/learning/module-intro/smoking-cessation.html?moduleId=5004316





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Drugs for Personal Formulary must be in the Hospital Formulary (Medicines Guide) or Trust approved Clinical Guideline Name: Kate Jones Date: September 2013 Designation: Medical Division Advance Nurse Practitioner Review date: September 2015 SECTION 1. MEDICINES BY CLASS Version: 4

System Medicine Class/group Indication Route () Comments/ remarks

Oral S/C I.M I.V

Other

Gastrointestinal system

Antacids 1.1.1 Dyspepsia x

Compound Alginates and indigestion preparations 1.1.2

Acid reflux x

Anti-spasmodics 1.2 IBS, diverticular disease x x x

H2 – receptor antagonists 1.3.1

Gastro-oesophageal reflux

x

Proton pump inhibitors 1.3.5 Gastro-oesophageal reflux/ peptic ulcer disease

x x

Anti-motility drugs 1.4.2 Acute diarrhoea chronic bowel disorders

x

Aminosalicylates 1.5.1 Ulcerative colitis x PR

Corticosteroids 1.5.2 Inflammatory bowel disease alcoholic hepatitis

x x

Bulk forming laxatives 1.6.1 Constipation x

Stimulant laxatives 1.6.2 Constipation x

Osmotic laxatives 1.6.4 Constipation hepatic encephalopathy

x

Bowel cleansing preparations 1.6.5

Pre-procedural preparation

x





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Oral S/C I.M I.V

Other

Compound haemorrhoidal preparations with corticosteroids 1.7.2

Haemorrhoids Topical

Drugs affecting intestinal secretions 1.9.1

Primary biliary cirrhosis x On consultant advice

Bile acid sequestrants 1.9.2 Pruritis x

Pancreatin 1.9.4 pancreatic insufficiency x

Cardiovascular Cardiac glycosides 2.1.1 Supraventricular arrhythmias and heart failure

x

Thiazides and related diuretics 2.2.1

Heart failure and hypertension

x

Loop diuretics 2.2.2 Pulmonary oedema Hypertension

x x

Potassium sparing diuretics & aldosterone antagonists 2.2.3

Potassium sparing diuretic effect Hypertension

x

Drugs for arrhythmias 2.3.2 Arrhythmias x

Beta-adrenorecoptor blocking drugs 2.4

Hypertension, arrhythmias, angina, heart failure, anxiety, oesophageal varices

x

Alpha-adrenoreceptor blocking drugs 2.5.4

Hypertension x

Angiotension converting enzyme inhibitors 2.5.5.1

Heart failure, hypertension

x

Angiotensin II receptor antagonists 2.5.5.2

Heart failure, hypertension

x





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Oral S/C I.M I.V

Other

Nitrates 2.6.1 Angina x

Calcium channel blockers 2.6.2

Hypertension, angina prophylaxis

x

Other anti-anginal drugs 2.6.3

Angina x

Low molecular weight heparin 2.8.1

Treatment and prophylaxis of VTE

x

Oral anti-coagulants 2.8.2 AF, treatment of VTE x Ensure ABCD complete. Competency assessment required

Anti-platelet drugs 2.9 Inhibition of thrombus formation, cerebral and cardiac

x Consider PPI

Lipid regulating drugs 2.12 CVD prevention, hypercholesterolemia

x

Respiratory System

Bronchodilators 3.1 COPD/ Asthma x x x NICE guidelines

Magnesium Sulphate 9.5.1.3

Asthma x x BTS guidelines

Theophylline 3.1.3 COPD/ Asthma x x

Corticosteroids 3.2 COPD/ Asthma x x x x

Leukotriene receptor antagonists 3.3.2

Asthma x BTS guidelines

Antihistamines 3.4.1 COPD/ Asthma/ Allergy/ Anaphylaxis

x x

Allergic emergencies: Anaphylaxis & angioedema 3.4.3

Anaphylaxis x x





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Oral S/C I.M I.V

Other

Oxygen 3.6 Hypoxemia x BTS guidelines

Mucolytics 3.7 Sputum retention x

Cough suppressants 3.9.1 Cough x

Demulcent cough preparations 3.9.2

Cough x

CNS Hypnotics 4.1.1 Insomnia x

Anxiolytics 4.1.2 Anxiety x Chlordiazepoxide in alcohol withdrawal Lorazepam in status epilepticus

Drugs for nausea & vomiting 4.6

Nausea & vomiting, vertigo, labyrinth disorders

x x x Prochloperazine- buccal

Antiepileptic drugs 4.8.1 Control of epilepsy x

Nicotine dependence (section 4.10.2 in BNF 64)

Smoking cessation Inhaled, nasal spray, trans dermal patches

Excluding the oral agents bupropion and varenicline Competency assessment required

Drugs for dementia 4.11 Treatment for dementia x Amendments on specialist advice only

CNS (Analgesics)

Non-opioid analgesics and compound analgesic preparations 4.7.1

Pain x x x x Competency assessment required





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Oral S/C I.M I.V

Other

Opioid analgesics 4.7.2 Pain x x x x Exclusion: Methadone and Diamorphine

Competency assessment required

Benzodiazepines 4.1.1 Agitation, anti-epileptic, anxiolytic, alcohol withdrawal

x x x x Sublingual, rectal

On specialist advice unless for alcohol withdrawal. Exclusion: temazepam

Neuropathic analgesics 4.7.3

Neuropathic pain x

Endocrine Short acting insulin 6.1.1.1 Diabetes mellitus

x Competency assessment required On specialist advice

Intermediate & long acting insulin 6.1.1.2

x

Sulfonylureas 6.1.2.1 x

Biguanides 6.1.2.2 x

Other anti-diabetic drugs 6.1.2.3

x On specialist advice

Treatment of hypoglycaemia 6.1.4

Hypoglycaemia x x x

Thyroid hormones 6.2.1 Hypothyroidism x On specialist advice Anti-thyroid drugs 6.2.2 Hyperthyroidism x





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Oral S/C I.M I.V

Other

Glucocorticoid therapy 6.3.2 Suppression of inflammatory/allergic disorders, cerebral oedema associated with malignancy, nausea and vomiting

x x x x

Bisphosphonates 6.6.2 Prophylaxis and treatment of osteoporosis. Hypocalcaemia in malignancy

x x

Gynaecology and urinary tract disorders

Drugs for urinary retention 7.4.1

Chronic urine retention x

Drugs for urinary frequency, enuresis and incontinence 7.4.2

Urinary incontinence x

Anaemia and nutrition

Oral iron 9.1.1.1 Iron deficiency anaemia x

Megaloblastic anaemia 9.1.2

Vitamin B12 deficiency x x On Consultant/SpR advice

Potassium 9.2.1.1 Hypokalaemia x

Parenteral preparations for fluid and electrolyte imbalance 9.2.2.1

Fluid and electrolyte imbalance

x

Calcium supplements 9.5.1.1

Hypocalcaemia and osteoporosis

x x

Magnesium supplements 9.5.1.3

Hypomagnesaemia x x

Phosphate supplements 9.5.2.1

Hypophosphatemia x x

Vitamin B group 9.6.2 Alcohol excess x x x





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Oral S/C I.M I.V

Other

Vitamin D group 9.6.4 Osteoporosis x

Vitamin K 9.6.6 Reverse INR x x

Multivitamins 9.6.7 Vitamin deficiencies x

Nutritional supplements A2.2.1.1

Nutritional support x

High Energy Supplements A2.4.1.1

Nutritional support x

Feed thickeners & pre-thickened drinks A2.5.2

Pre thickening of fluids x

Musculoskeletal System

Non-Steroidal anti-inflammatory drugs (NSAID)10.1.1

Pain and inflammation x x PR

Drugs that suppress the rheumatic disease process 10.1.3

Rheumatoid/ crohns/ Ulcerative colitis

x Continuation therapy/ asked to commence by Consultant

Gout 10.1.4 Acute and prophylactic treatment of gout

x

Skeletal muscle relaxants 10.2.2

Muscle spasm/ muscle spasticity/ leg cramps

x

Topical NSAID's 10.3.2 Pain relief Topical

Eye All treatment of glaucoma 11.6

Glaucoma Drops/ ointments

Continuation therapy

All ophthalmic corticosteroids and anti-inflammatory agents 11.4

Drops/ ointments


Ear, nose and oropharynx

Drugs acting on the ear 12.1

Drops/ ointments





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Oral S/C I.M I.V

Other

Drugs acting on the nose 12.2

Drops/ ointments


Drugs acting on the oropharynx 12.3

Drops/ ointments

Skin Emollients 13.2.1 Dry skin Eczematous disorders

Topical

Barrier preparations 13.2.2 Skin protection Topical

Topical local anaesthetics and antipruritic 13.3

Pruritis Topical

Topical corticosteroids 13.4 Inflammatory skin conditions

Topical Continuation therapy or on advice of dermatologist

Preparations for eczema 13.5.1

Eczema Topical Continuation therapy or on advice of dermatologist

Preparations for psoriasis 13.5.2

Psoriasis Topical Continuation therapy or on advice of dermatologist

Wound management

Hydrogel dressings Dry sloughy wounds

Topical

Hydrocolloid dressings Mild to moderately exudative wounds.

Topical

Alginate dressings Exudative wounds Topical

Odour absorbent dressings To absorb odour from wounds

Topical

Antimicrobial dressings Local wound infections Topical

Silver dressings Infected wounds Topical





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Oral S/C I.M I.V

Other

Honey Acute of chronic wounds

Topical

Poisoning Acetylcysteine Paracetamol overdose x After discussion with Senior Medical staff

Naloxone hydrochloride Opiate overdose x x After discussion with Senior Medical staff

Flumazenil Benzodiazepine overdose

x After discussion with Senior Medical staff

EXTRA GROUPS PREVIOUSLY APPROVED – July 2013


Oral S/C I.M I.V

Other

Skin Antifungal preparations 13.10.2

Localised fungal infections

x Topical

Antiviral preparations 13.10.3

Herpes simplex infections

x Topical

Parasitical infections 13.10.4

Scabies Head lice

Topical

Eye All anti-infective eye preparations 11.3

Eye infections Drops/ ointment

(Please insert all drugs in BNF order and detail down to the same level as per BNF, i.e ACE inhibitors 2.5.5.1 in BNF 64 )

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Name: Kate Jones Date: September 2013 Designation: Medical Division Advance Nurse Practitioner Review date: September 2015 Version: 4 SECTION 2. SPECIFIC MEDICINES BY NAME (i.e Chemotherapy, or if you do not wish to list as classes)

Medicine Indications Route () Comments/ Remarks

Oral S/C I.M I.V

Other

Atropine Excessive bradycardia IV

Azathioprine Rheumatoid Arthritis Oral

Bactroban MRSA eradication Ointment

Citalopram Anxiety / Depression Oral

Diazepam Status epilepticus Palliative care

Oral IV Rectal Continuation for patients admitted to palliative care.

Digoxin Heart failure, arrhythmias particularly AF Oral IV

Fluoxetine Anxiety / depression Oral

Fondaparinux Acute coronary syndrome and MI S/C If creatinine clearance <20 use enoxaparin

Glycopyrronium Treatment of excessive respiratory secretions in palliative care,

S/C

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Oral S/C I.M I.V

Other

Haloperidol Prevention of opioid induced nausea and vomiting when treating chronic pain. Short term treatment of agitation and restlessness in the elderly.

Antipsychotic should be used with caution in patients with hepatic and renal impairment, cardiovascular disease, Parkinson’s disease (may be exacerbated). Epilepsy. Caution is also required in severer respiratory disease. Caution is also required in subarachnoid haemorrhage, hypokalaemia and hypo- magnesia

Human albumin solution 20% 9.2.2.2

Post paracentesis Spontaneous bacterial peritonitis

x According to protocol

Levomepromazine Specialist Palliative Care Team (SPCT) Liverpool Care Pathway for the Dying (LCP)

S/C Syringe driver

For use as PRN S/C injections or in syringe driver in the palliative care setting.

Lidocaine 1% & 2% Local anaesthesia S/C IM

Lorazepam Palliation of dyspnoea in end stage respiratory disease

Sub-lingual

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Oral S/C I.M I.V

Other

Magnesium Hypomagnesaemia, Arrhythmias Asthma

Oral IV

Sodium Chloride 0.9% Nebulised Diluent Neb

Tetracosactide Test adrenocortical function

(Please insert all drugs in alphabetical order) References: Wirral formulary: http://www.whnt.nhs.uk/staff/divisions/ds/pharmacy/medicinesmanagement/Medicines_Management.html Wirral antibiotic formulary: http://www.whnt.nhs.uk/staff/formulary/

BSG Guidelines on the Management of Ascites in Cirrhosis www.bsg.org.uk/.../guidelines-on-the-management-of-ascites-in-cirrhosis.html BSG Guidleines on the Management of Inflammatory Bowel Disease www.bsg.org.uk/...guidelines/ibd/guidelines-for-the-management-of-inflammatory-bowel-disease.html BNF December 64: http://www.bnf.org/bnf/index.htm NICE Craft clinical guideline- opioids in palliative care: http://www.nice.org.uk/nicemedia/live/12953/57394/57394.pdf NICE CG101 COPD: http://guidance.nice.org.uk/CG101/Guidance/pdf/English BTS/ SIGN National Asthma Guideline: http://www.brit-thoracic.org.uk/Portals/0/Guidelines/AsthmaGuidelines/sign101%20Jan%202012.pdf BTS Pleural Disease Guidelines: http://www.brit-thoracic.org.uk/Guidelines/Pleural-Disease-Guidelines-2010.aspx

http://www.brit-thoracic.org.uk/Guidelines/Pleural-Disease-Guidelines-2010.aspx

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Name: Kate Jones Date: September 2013 Designation: Medical Division Advance Nurse Practitioner Review date: September 2015 Version: 4

SECTION 3: ANTIMICROBIALS

Medicine Indications Route () Remarks

Oral S/C I.M I.V other

Aciclovir Herpes simplex and varicella-zoster

Topical

Caution in renal impairment

Amoxicillin Second line choice for exca copd (unless already had a course in last 4 weeks or recurrent exacerbations)

Oral Do not use in penicillin allergy Caution in renal and hepatic impairment dose may need adjusting

Cefalexin Treatment of UTI in pregnancy

Oral Do not use with patients that have had anaphylaxis or urticurial reaction to penicillin based drugs Renal impairment

Clarithromycin Macrolide treatment for community acquired pneumonia Medical Microbiology advice

PO IV Doses may need adjusting in renal or hepatic impairment Only IV if unable to take orally Freshly expectorated sputum, before administration of antibiotics if possible

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Co amoxiclav infections due to beta-lactamase-producing strains Medical Microbiology advice

PO IV Contraindicated in Penicillin Hypersensitivity Doses may need adjusting in renal or hepatic impairment Freshly expectorated sputum/ MSSU before administration of antibiotics if possible

Clotrimazole – Pessaries and cream

Treatment of genital and skin fungal infections

Topical and PV

Chloramphenicol 0.5%

Acute bacterial conjunctivitis Eye drops

Doxycycline Tetracycline use for COPD/ acute or chronic bronchitis Penicillin allergic cellulitis Medical Microbiology advice

PO If the patient has already received a 5 day course of co-amoxiclav for the treatment of this episode of bronchitis prior to admission Freshly expectorated sputum/ swabs before administration of antibiotics if possible

Flucloxacillin Cellulitis – NOT associated with ulcers, pressure sores, surgical site or lymphoedema Medical Microbiology advice

PO Contraindicated in Penicillin Hypersensitivity

Fluconazole Oropharyngeal fungal infections

IV Fluconazole should be used orally if the infection does not respond to topical treatment.

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Gentamicin Septicaemia (according to probable source) Medical Microbiology advice ERCP Prophylaxis

IV Stat dose to start treatment, but need to refer to pharmacy for maintenance dosing. Createnine clearance: doses may need adjusting in renal or hepatic impairment Weight Microbiology advice Pharmacy dept/ Therapeutic drug monitoring

Levofloxacin Quinolone therapy used for Penicillin allergic patients Medical Microbiology advice

PO IV Caution - Levofloxacin induced tendonitis Caution in Epilepsy – can lower seizure threshold Only IV if unable to tolerate orally as same bio-availability Freshly expectorated sputum, before administration of antibiotics if possible

Meropenem Consultant Microbiologist advice Aerobic and anaerobic Gram-positive and Gram-negative infections

IV Blood for culture Freshly expectorated sputum, before administration of antibiotics if possible Caution in renal impairment; monitor bilirubin and transaminase

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Metronidazole Proven Clostridium difficile infection (Antibiotic associated diarrhoea Medical Microbiology advice

PO IV Confirmed stool sample testing positive to Clostridium difficile Involve Infection Control Team

Nystatin Candidiasis, oral infection

PO Nystatin suspension is not absorbed from the gastro-intestinal tract and is suitable for treating local infections

Octenisan MRSA eradication Solution

Piperacillin with

tazobactam

Hospital acquired pneumonia (pneumonia occurring at least 48 hours after admission) Medical Microbiology advice

IV Contraindicated in Penicillin Hypersensitivity Blood for culture Freshly expectorated sputum, before administration of antibiotics if possible

Trimethoprim Treatment naïve non catheterised patients Medical Microbiology advice

PO Midstream specimen of urine (MSSU) clean-voided first thing in the morning if possible

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Vancomycin Septicaemia (according to

probable source)

Medical Microbiology advice

IV Dose to start treatment, but need to refer to pharmacy for maintenance dosing. Creatinine clearance: doses may need adjusting in renal or hepatic impairment Weight Microbiology advice Pharmacy dept/ Therapeutic drug monitoring

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Name: Kate Jones Approved date: September 2013 Designation: Advanced Nurse Practitioner – Medicine Review date: September 2016 Version: 4 SECTION 4: UNLICENSED MEDICINES

Medicine Indications Route () Guidelines Available?

e.g. NICE, Medicines Guide

Remarks


Sterile Talc

Used in Talc pleurodesis unlicensed medicine

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