Transcript the pink one - current publication

the Pink One
Number 111, October-November 2014
Including the Formulary Update (back page)
Article removed pending further discussion
Will you become an antibiotic guardian?
European Antibiotic Awareness Day is
on 18 November. Antibiotic resistance
is a public health priority for everyone:
patients and healthcare professionals
alike. Raising awareness to conserve
this precious resource is paramount.
Visit www.antibioticguardian.com for
useful patient resources including
information leaflets, quizzes and
About the Pink One
The Pink One is published by NHS Highland Pharmacy
Services. It is circulated to all GPs, hospital medical
staff, pharmacists in primary and secondary care,
nurse prescribers, charge nurses and to local service
managers and directorate managers for onward
dissemination to other nursing staff. Views expressed
are those of one or more of the editors/contributors.
The Pink One, Pharmacy Services, John Dewar
crosswords. For clinical teams, there
are toolkits and checklists to support
targeted prescribing.
Building, Highlander Way, Inverness IV2 7GE.
e-mail: [email protected]
Available on the intranet at: http://intranet.nhsh.scot.
nhs.uk/Clinical/Formulary/Pages/Default.aspx
Editorial team:
General editor: Clare Morrison, Lead Pharmacist
(North), North and West Highland Operational Unit
Formulary editor: Evelyn Cromarty, Formulary
Pharmacist, NHS Highland
Primary care editor: Findlay Hickey, Lead Pharmacist
In this issue of the Pink One
• Page 1: antibiotic guardians
• Page 2: combination inhalers, new
oral anticoagulants
• Page 3: antibiotics, generics,
clopidogrel,
dexamethasone,
antimicrobial policy, GSK creams,
nitrofurantoin
• Page 4: Formulary update
(West), North and West Highland Operational Unit
Secondary care editor: Mairi Dunbar, Senior Clinical
Pharmacist, Raigmore Hospital
Articles in this issue were also contributed by:
Alison MacDonald, Area Antimicrobial Pharmacist
Jo Craig, Consultant Haematogist, Raigmore
Thomas Ross, Lead Pharmacist, and Fiona Nicholas,
Prescribing Support Pharmacist, South and Mid
Operational Unit
Alison MacRobbie, Palliative and Community Care
Pharmacist
Asthma and COPD: which combination inhaler?
The respiratory section of the Highland Formulary has been updated to
provide clearer advice on which combination inhalers should be prescribed
in asthma and chronic obstructive
pulmonary disease (COPD), when
a combination inhaler is indicated. It
also now includes prices as an aid to
cost-effective prescribing.
This article highlights key points for
the use of combination inhalers. The
new first choice combination inhalers
for asthma and COPD are shown in
Figure 1. Seretide is no longer a preferred preparation. It will remain within
the Formulary for now but will no longer be recommended by the respiratory
physicians or nurse specialists.
Asthma
For the treatment of asthma, combination inhalers should be used when an
inhaled corticosteroid and a long-acting beta2 agonist (LABA) are indicated. There is no difference in efficacy
in giving the inhaled steroid and LABA
Asthma
COPD
First Choice:
Symbicort Turbohaler
Second Choice: Fostair Nexthaler
Third Choice:
Relvar Ellipta
First Choice: Relvar Ellipta 92/22
Figure 1: Updated Highland Formulary preferred combination inhaler choices
in combination or in separate devices
but there are risks associated with
patients receiving a LABA on its own.
Symbicort Turbohaler is the recommended first-line inhaler. Alternative,
easy to use, cost-effective options are
Fostair Nexthaler and Relvar Ellipta. If
a metered dose inhaler is preferred,
consider Flutiform or Fostair.
Patients should be maintained at
the lowest possible dose of steroid;
stepping down therapy once asthma is controlled is recommended.
Reduction in the steroid dose should
be slow as patients deteriorate at different rates. A dose reduction should
be considered every three months,
decreasing the dose by approximately
25 to 50% each time.
Combination inhaler for COPD
Dose
Cost
Relvar Ellipta 92/22
Fostair inhaler 100/6
Symbicort Turbohaler 400/12
Seretide Accuhaler 500/50
1 inhalation daily
4 inhalations daily
2 inhalations daily
2 inhalations daily
£27.80
£29.32
£38.00
£40.92
Figure 2: Comparison of costs for 30 days’ treatment using combination
inhalers licensed for COPD
Consider pitfalls of the new oral anticoagulants
NHS Highland’s haematology department is reminding prescribers that
the new oral anticoagulants have
particular pitfalls and should not be
assumed to be a safer alternative to
warfarin.
Rivaroxaban, apixaban (factor Xa
inhibitors) and dabigatran (direct
thrombin inhibitor) are collectively
termed as novel oral anticoagulants
(NOACs). These drugs have been
shown to be equivalent to traditional
anticoagulant therapies, eg, warfarin,
for the management and prevention
of venous thromboembolism, and prevention of stroke in atrial fibrillation.
NOACs have several benefits,
most notably their oral administration at fixed doses and because the
anticoagulant effect does not need
to be regularly monitored. However
they are not suitable for those with
poor adherence to taking medication
regularly or for those with significant
renal impairment. Regardless of the
baseline blood results, patients on
long term NOACs should have their
renal function measured every six to
12 months.
It is important to review potential
drug interactions. Several drugs enhance or reduce the anticoagulant effects of NOACs but, unlike with warfarin and INR monitoring, there is no
way to accurately measure this. There
are currently no specific antidotes
available for those who have bleeding
complications on NOACs but guidance on how to manage such bleeding
is available in the Highland Formulary.
Guidance on managing patients who
are due to have invasive procedures
is available from the relevant specialty
or the medicine’s summary of product
characteristics. If in doubt, prescribers
should contact haematology.
Doubling the dose in an exacerbation is of unproven value and is no
longer recommended.
COPD
Inhaled corticosteroids, in combination with a long-acting bronchodilator,
should be prescribed for patients with
an FEV 50% or less of predicted, who
are having two or more exacerbations
requiring treatment with antibiotics
or oral corticosteroids in a 12 month
period.
The need for inhaled steroids in
patients with COPD should be reviewed if an episode of pneumonia
has occurred. High doses of inhaled
corticosteroid have been associated
with lower respiratory tract infections,
including pneumonia, in older patients
with COPD.
Relvar Ellipta 92/22 is cost-effective
and offers the advantage of oncedaily dosing. This is now the first
choice preparation for this indication.
Comparative costs with other combination inhalers licensed treatment of
COPD are shown in Figure 2.
New practical advice issued
Practical advice on the use of oral
anticoagulants has recently been
published by the UK Medicines
Information network (UKMi).
It covers both old and new oral
anticoagulants, and includes answers to the following questions:
• How do anticoagulants work?
• What
are
their
main
contraindications?
• When should specific oral
anticoagulants be avoided?
• What pre-testing and monitoring
are necessary?
• How should dose be adjusted in
renal impairment?
• What are the common side
effects?
• Does the risk of a bleed vary
between anticoagulants?
• How do you switch between
anticoagulants?
Antibiotic prescribing: how to say “no” nicely!
Generic prescribing tool
Winter brings an increased focus on
appropriate antibiotic prescribing.
Antibiotics should be carefully targeted but how should patient expectation
for antibiotics be dealt with?
Relating resistance on a more personal, individual patient level can be
more informative than global messages. For example, we know how effective antibiotics are against pathogenic
organisms but did you know that the
effect on commensal flora (including
resistant strains) can persist for up
to one year after a course of therapy? Previous Pink One articles have
detailed side effects such as QT prolongation (macrolides & quinolones),
drug interactions with warfarin and
pulmonary toxicity from nitrofurantoin.
Add in photosensitivity (doxycycline)
and rash (beta lactams) to the well
known diarrhoea, thrush and alcohol
interaction and you wonder why anyone would take these medicines!
NHS Highland has recently asked all
prescribers to ensure that they prescribe all medicines generically, unless there is a valid clinical reason for
prescribing by brand (see Pink One).
Primary care prescribers who use
the GP software Vision may find the
“switch to generic” button a useful
tool to assist with this. It can be found
above the drug name box in the prescribing screen. This is shown in the
screenshot above.
News in brief
Shortages of GSK creams
Due to manufacturing problems,
there are currently shortages of a
number of GSK topical products.
GSK is advising that it will be the
end of January 2015 before normal
supplies resume. Affected products include: Betnovate, Trimovate,
Eumovate, Dermovate and Bactroban. Information on alternative
options was circulated by email
in September. Generic versions
of Bactroban cream, Betnovate,
Dermovate and Eumovate may
be available so the first option is to
prescribe generically (see above).
Nitrofurantoin: renal function
Updated guidance from the MHRA
on the use of nitrofurantoin in
patients with reduced renal function states that it can be used for
lower urinary tract infection in patients with eGFR of 45ml/min or
above. Although contra-indicated,
prescribers can consider using
nitrofurantoin with caution at eGFR
of 30ml/min but only if there are
no other suitable oral drugs and
clinical improvement is monitored.
Nitrofurantoin does not penetrate
tissues to any great extent, therefore, is unsuitable for upper UTI or
as oral step down for urosepsis.
Good sources of patient information
are available from patient.co.uk and
NHS inform which help explain the infection course, including management
of self-limiting conditions. For parents,
the “When should I worry?” booklet is
a validated tool that can help reduce
re-consultation rates. Other resources
include www.treatyourselfbetter.co.uk
and for children www.e-bug.eu.
Improvements in GP prescribing
GP practices in NHS Highland are
commended on reducing the number
of prescriptions for antibiotics written,
resulting in 43 practices now at or below the national “total antibiotic prescribing” indicator. A further 18 practices have made an acceptable shift
towards the target, with NHS Highland
now ranking third of the 14 boards in
Scotland. However, at 35 practices
antibiotic prescribing rates have increased.
Clopidogrel associated with acquired haemophilia
Prescribers are advised to be vigilant
for symptoms or signs suggestive of
acquired haemophilia in patients taking clopidogrel.
The number of cases reported is
small overall but there have been two
suspected cases in NHS Highland in
recent years, and the risk was highlighted by the MHRA last year.
The presenting symptoms are usu-
ally unexplained easy bruising or soft
tissue bleeding. This can often be
attributed to the antiplatelet effect of
clopidogrel but if symptoms are particularly severe or persistent, a coagulation screen should be performed.
If you suspect a patient has developed acquired haemophilia due to
clopidogrel therapy, please discuss urgently with the on-call haematologist.
Dexamethasone dose caution Restricted antimicrobial policy
Particular care is needed when prescribing and administering dexamethasone
parenterally, following the discontinuation of the 4mg/ml preparation in September. The alternatives currently available are a 3.3mg/ml injection (Hameln
or Hospira brands, Formulary choice)
and a 3.8mg/ml injection (Aspen brand).
Safety points to consider include:
• Ensure doses are prescribed
accurately and the correct product
is selected.
• Check concentrations carefully.
• Check dose calculations, especially
when using decimal points.
• Check brand availability when patient
moves between care settings.
• Check storage conditions: the Aspen
brand requires refridgeration.
Detailed advice is available from specialist departments, including palliative care and oncology.
NHS Highland has introduced a
restricted antimicrobial prescribing
protocol for hospital prescribers (not
for Argyll & Bute).
The protocol aims to ensure all
broad spectrum antibiotics are targeted effectively. Initially, the focus will be
in acute hospital prescribing but it may
occasionally be relevant to the community hospital setting.
Prescribers should obtain an authorisation code from a consultant
microbiologist or infectious disease
physician prior to prescribing certain
anti-infective agents or within 24 hours
of initiation of others as detailed in the
protocol. This supports appropriate
timely treatment of severe infections
(meningitis, necrotising fasciitis) using
broad spectrum agents and facilitates
early review of therapy. See the policies page of the intranet.
Highland Formulary news and updates: October 2014
Changes agreed in October 2014 to the Highland Formulary are shown below. The Highland Formulary document has been updated with these
changes and is available on NHS Highland Intranet at http://intranet.nhsh.scot.nhs.uk/Clinical/Formulary/Pages/Default.aspx and website at www.
nhshighland.scot.nhs.uk. Highland Formulary decisions on recent SMC advice are also available on NHS Highland intranet and website.
Stroke review
Stroke protocols for acute treatment
of ischaemic stroke and secondary
prevention post-TIA or ischaemic
stroke have been updated.
Flumetasone & clioquinol ear drops
The Locorten-Vioform brand name has
been discontinued by the manufacturer
but the product is still available under
the generic name ‘Flumetasone and
Clioquinol’.
Dry eye
Several additional products for the
treatment of dry eye have been added
to the Formulary. These should be
used in accordance with the new
‘Dry eye syndrome’ shared clinical
guideline on the intranet.
Antacid tablets
Gastrocote
tablets
have
been
discontinued. Gaviscon Advance
chewable tablets have been added
to the Formulary as a suitable
alternative.
Estriol intravaginal cream 0.01%
The Gynest brand of estriol intravaginal
cream 0.01% has been discontinued
but a generic version is available.
Minor Ailments Formulary
The Community Pharmacy Minor
Ailments Service Formulary has been
updated in accordance with changes
to products and guidance within the
Highland Formulary. A copy has been
provided to all community pharmacies
and the summary list is available in
Appendix 4 of the Formulary.
User Survey
Thank you to those of you who have
completed and returned the Highland
Formulary user survey questionnaire.
This will inform future development of
the Highland Formulary.
List of changes to the Highland Formulary agreed in October 2014
The full cumulative list of changes to the
Highland Formulary 5th edition is provided
in the e-Pink One document, available on
NHS Highland Intranet and website.
Chapters and sections reviewed
Chapter 3 Respiratory system
Chapter 5 Infections
Chapter 11 Eye
Chapter 12 Ear, nose and oropharynx
Chapter 13 Skin
Appendix 6 Palliative care guidelines
(introduction)
Guidance reviewed
‘Protocol for acute treatment of ischaemic
stroke (day 1-14 post-ischaemic stroke)’
‘Protocol for secondary prevention post-TIA
or ischaemic stroke (starting 2 weeks postischaemic stroke or immediately post-TIA)’
‘Adverse reactions to topical therapy’
‘Use of emollients’
‘Incontinence dermatitis’
‘Management of pruritus’
‘Use of topical corticosteroids’
‘Management of eczema/dermatitis’
‘Management of psoriasis’
‘Management of acne’
‘Management of chronic urticaria and
angioedema’
Addition of medicines
Chapter 1 Gastrointestinal system
Gaviscon Advance chewable tablets
Chapter 3 Respiratory system
Budesonide dry powder for inhalation
(Easyhaler) 100 micrograms, 200
micrograms, 400 micrograms
Fostair NEXThaler 100/6 in micrograms
inhaler
Chapter 5 Infections
Daclatasvir tablets 30mg, 60mg
Zanamivir dry powder for inhalation, disks
containing 4 blisters of zanamivir 5mg/
blister
Chapter 8 Malignant disease and
immunosuppression
Aflibercept concentrate for intravenous
infusion 25mg/mL
Chapter 9 Nutrition and blood
Gelaspan infusion
Chapter 11 Eye
Ocriplasmin intravitreal injection 500
micrograms/0·2mL
Olopatadine eye drops 5mg/5mL
Antazoline 0·5% and xylometazoline 0·05%
eye drops (Otrivine-Antistin)
Lodoxamide eye drops 0·1%
Apraclonidine eye drops 0·5%,
preservative-free single-use eye drops 1%
Bimatoprost 300 micrograms/mL eye drops,
preservative-free single-use eye drops
Bimatoprost 300 micrograms/mL and timolol
5mg/mL eye drops, preservative-free singleuse eye drops
Sodium hyaluronate eye drops 0·15%
(Oxyal), 0·2% (Blink Intensive Tears),
preservative-free eye drops 0·1% (Hylo
Tears), 0·18% (Vismed Multi), 0·2% (Hylo
Forte), 0·4% (Clinitas)
Ranibizumab 1·65mg/0·165mL pre-filled
syringe
Brinzolamide with brimonidine (brinzolamide
10mg/mL, bromonidine 2mg/mL) eye drops
Systane (polyethylene glycol 400 0·4%,
propylene glycol 0·3%, hydroxypropyl guar,
sorbitol) eye drops and preservative-free
eye drops
Carbomers preservative free eye gel 0.2%
(Xailin Gel)
Chapter 12 Ear, nose and oropharynx
Acetic acid ear spray 2%
Chapter 13 Skin
Adapalene 0·1% and benzoyl peroxide
2·5% gel (Epiduo)
Benzoyl peroxide 10% gel
Chapter 14 Immunological products and
vaccines
Boostrix-IPV
Deletion of medicines
Chapter 1 Gastrointestinal system
Gastrocote tablets
Chapter 4 Central nervous system
Carbamazepine chewable tablets 100mg,
200mg
Chapter 5 Infections
Azithromycin capsules 250mg
Chapter 6 Endocrine system
Dexamethasone injection 4mg/mL
Chapter 9 Nutrition and blood
Gelofusine infusion
Chapter 11 Eye
Mydricaine subconjunctival injection No1,
No 2 [unlicensed]
Chapter 13 Skin
Dithranol in Lassar’s Paste 0·25%
Coal tar in yellow soft paraffin 20%
Coal tar ointment in base of 15% zinc oxide
in yellow soft paraffin
Tretinoin gel 0·01% (Retin-A)
HIGHLAND FORMULARY
Fifth edition: cumulative index of changes October 2014
Please keep this cumulative list for reference. Preparations in bold and italics indicate new additions or deletions agreed at
the meeting of the Formulary Subgroup on 28.10.14. For more information please see Formulary webpage on NHS Highland
intranet at http://intranet.nhsh.scot.nhs.uk/Clinical/Formulary/Pages/Default.aspx.
Chapters and sections reviewed
Chapter 4 Central nervous system
Chapter 3 Respiratory system
Chapter 5 Infections
Chapter 6 Endocrine system
Chapter 7 Obstetrics, gynaecology
Chapter 8 Malignant disease
Chapter 9 Nutrition and blood
Chapter 10 Musculoskeletal and joint
disease
Chapter 11 Eye
Chapter 12 Ear, nose and oropharynx
Chapter 13 Skin
Chapter 14 Immunological products and
vaccines
Chapter 15 Anaesthesia
Appendix 2 ‘Good prescription writing
guidelines’
Appendix 3 ‘ Emergency treatment of
poisoning’
Appendix 6 Palliative care guidelines
(introduction)
Guidance reviewed
‘Acute pain - adult oral and rectal analgesic
stepladder’
‘Smoking cessation interventions
‘Guidelines for administration of Pabrinex/
thiamine in alcohol detoxification’
‘Prescribing guidelines for the management
of opioid misuse: using methadone’
‘Orlistat in the management of obesity’’
‘Urinary tract infections’
‘Intra-abdominal infections
‘Hormone replacement therapy’
‘Missed oral contraceptive pills’
‘Emergency contraception’
‘Summary of guidelines for the inpatient
treatment of low electrolytes’
‘Non-steroidal anti-inflammatory drugs’
‘Step up management of essential
hypertension’
‘Anxiety spectrum disorders’
‘Generalised anxiety disorder (GAD):
Treatment guidance
‘Antispychotics - relative side-effects’
‘Guidelines for the use of psychotropics in
older adults’
‘Schedule for physical monitoring for people
with bipolar disorder’
‘Antidepressant guidance’
‘Antidepressant selection’
‘Antidepressant switching’
‘NHS Highland policy for treatment of
infective endocarditis’
‘Meningitis’
‘Respiratory-tract infections’
‘Parasitic infestations’
‘Genital-tract infections’
‘Viral infections’
‘Bone and joint infections’
‘Catheter patency solutions for long-term
indwelling urinary catheters’
‘Protocol for acute treatment of
ischaemic stroke (day 1-14 postischaemic stroke)’
‘Protocol for secondary prevention
post-TIA or ischaemic stroke (starting
2 weeks post-ischaemic stroke or
immediately post-TIA)’
‘Chlordiazepoxide: symptom trigger
scoring sheet for use in alcohol
withdrawal only’
‘Diazepam: symptom trigger scoring
sheet for use in alcohol withdrawal only’
‘Fixed-dose protocol for
chlordiazepoxide’
Additions
Chapter 1 Gastrointestinal system
Gaviscon Advance chewable tablets
Chapter 2 Cardiovascular
Urokinase injection 100 000 units
Nonacog alfa, factor IX fraction, dried
(Replenine VF Factor IX fraction)
Factor VIII fraction, dried (Fanhdi Factor
VIII)
Chapter 3 Respiratory system
Fostair (beclometasone dipropionate
100 micrograms/formoterol fumarate 6
micrograms/metered inhalation)
Fluticasone furoate/vilanterol dry powder
for inhalation 92/22, 184/22 (micrograms)
(Relvar Ellipta)
Pirfenidone capsules 267mg
Aclidinium inhalation powder 322
micrograms/inhalation
Budesonide dry powder for inhalation
(Easyhaler) 100 micrograms, 200
micrograms, 400 micrograms
Fostair NEXThaler 100/6 in micrograms
inhaler
Chapter 4 Central nervous system
Trifluoperazine syrup 1mg/5mL
Clozapine suspension 50mg/1mL
Clonazepam oral solution 500
micrograms/5mL
Lisdexamfetamine capsules 30mg, 50mg,
70mg
Tramadol m/r tablets 50mg
Nicotine orodispersible film 2·5mg (NiQuitin
Strips)
Nicotine inhalator 15mg/cartridge
Nalmefene tablets 18mg
Aripiprazole 400mg powder and solvent for
prolonged release suspension for injection
Chapter 5 Infections
Nitrofurantoin capsules 50mg
Tobramycin dry powder for inhalation (Tobi
Podhaler) 28mg/capsule
Sofosbuvir tablets 400mg
Posaconazole tablets 100mg
Simeprevir 150mg capsules
Daclatasvir tablets 30mg, 60mg
Zanamivir dry powder for inhalation,
disks containing 4 blisters of zanamivir
5mg/blister
Chapter 6 Endocrine system
Contour NEXT blood glucose test strips
Desmopressin nasal spray 150 micrograms/
metered spray (Octim)
Chapter 7 Obstetrics and gynaecology
and urinary-tract disorders
Tolterodine tablets 2mg
Chapter 8 Malignant disease and
immunosuppression
Tacrolimus granules for oral suspension
(Modigraf) 200 micrograms, 1mg
Vemurafenib tablets 240mg
Ipilimumab concentrate for intravenous
infusion 5mg/mL
Trastuzumab 600mg/5mL solution for
subcutaneous injection
Axitinib tablets 1mg, 5mg
Teriflunomide tablets 14mg
Dimethyl fumarate capsules 120mg, 240mg
Alemtuzumab, 12mg, concentrate for
solution for infusion
Aflibercept concentrate for intravenous
infusion 25mg/mL
Chapter 9 Nutrition and blood
Glucose intravenous infusion 20%
Albumin solution 5%
Renavit tablets
Fortisip Compact Fibre
Fortisip Compact Protein
Fresubin Juicy Drink
Nutriflex Peri 1250mL, 2500mL
Nutriflex Plus 1875mL, 2500mL
Nutriflex Special 1875mL
Nutriflex Special EF 2500mL
Nutilis Fruit Stage 3
Magnesium hydroxide 7mmol in 5mL
Colecalciferol capsules 3200 units
Colecalciferol oral solution 25 000 units/1mL
Gelaspan infusion
Chapter 10 Musculoskeletal and joint
disease
Abatacept injection, pre-filled syringe
125mg, intravenous infusion, powder for
reconstitution, 250mg
Ustekinumab solution for injection
45mg/0·5mL
Baclofen intrathecal injection 10mg/5mL
Tocilizumab solution for injection 162mg
(RoActemra)
Methotrexate injection, pre-filled autoinjector pen 7·5mg/0·15mL, 10mg/0·2mL,
12·5mg/0·25mL, 15mg/0·3mL,
17·5mg/0·35mL, 20mg/0·4mL,
22·5mg/0·45mL, 25mg/0·5mL
Chapter 11 Eye
Latanoprost preservative-free single-dose
eye drops 50 micrograms/mL
Ocriplasmin intravitreal injection 500
micrograms/0·2mL
Olopatadine eye drops (as
hydrochloride) 5mg/5mL
Antazoline 0·5% and xylometazoline
0·05% eye drops
Lodoxamide eye drops 0·1%
Apraclonidine eye drops 0·5%,
preservative-free single-use eye drops
1%
Bimatoprost 300 micrograms/mL eye
drops
Bimatoprost 300 micrograms/mL
preservative-free single-use eye drops
Bimatoprost 300 micrograms/mL and
timolol 5mg/mL eye drops
Bimatoprost 300 micrograms/mL and
timolol 5mg/mL preservative-free singleuse eye drops
Sodium hyaluronate eye drops 0·15%
(Oxyal), 0·2% (Blink Intensive Tears)
Sodium hyaluronate eye drops 0·3%
(preservative-free), 0·1% (Hylo Tears),
0·18% (Vismed Multi), 0·2% (Hylo Forte),
0·3% (Vismed Gel), 0·4% (Clinitas)
Carbomers preservative-free eye tel
0·2% (Xailin Gel multidose unit)
Ranibizumab 1·65mg/0·165mL pre-filled
syringe
Brinzolamide with brimonidine
(brinzolamide 10mg/mL, bromonidine
2mg/mL)
Systane (polyethylene glycol 400 0·4%,
propylene glycol 0·3%, hydroxypropyl
guar, sorbitol) eye drops and
preservative-free eye drops
Chapter 12 Ear, nose and oropharynx
Clove Oil BP 100% v/v
Acetic acid spray 2%
Chapter 13 Skin
Hydromol ointment
Adapalene 0·1% and benzoyl peroxide
2·5% gel (Epiduo)
Benzoyl peroxide 10% gel
Chapter14 Immunological products and
vaccines
Fluenz
Bexsero
Infanrix IPV + Hib
Boostrix-IPV
Chapter 15 Anaesthesia
Sugammadex injection 200mg/2mL
Prilocaine hydrochloride 2% hyperbaric
solution for injection (Prilotekal)
Appendix 3 Emergency treatment of
poisoning
Fomepizole injection 1gram/mL [unlicensed]
Deletions
Chapter 1 Gastrointestinal system
Domperidone suppositories 30mg
Gastrocote tablets
Chapter 4 Central nervous system
Memantine tablets 5mg/15mg
Clonazepam injection 1mg/1mL
Nicotine inhalator 10mg/cartridge
Nicotine transdermal patch 5mg/16 hours
Domperidone suppositories 30mg
Carbamazepine chewable tablets 100mg,
200mg
Chapter 5 Infections
Piperazine 2 dose sachet pack (piperazine
4 grams, sennosides 15·3mg/sachet)
Azithromycin capsules 250mg
Chapter 6 Endocrine system
Metformin oral powder sachets 500mg, 1
gram
Dexamethasone injection 4mg/mL
Chapter 9 Nutrition and blood
Albumin solution 4%
Volulyte infusion
Voluven infusion
Epoetin beta multidose injection 50 000
units
Fortisip Fruit Dessert
Oliclinomel N4-720E, N5-800E, N6-900E,
N7-1000E
Provide Xtra Juice Drink
Gelofusine infusion
Chapter 10 Musculoskeletal and joint
disease
Methotrexate injection, prefilled syringe 7·5mg/0·15mL,
10mg/0·2mL,12·5mg/0·25mL, 15mg/0·3mL,
17·5mg/0·35mL, 20mg/0·4mL,
22·5mg/0·45mL, 25mg/0·5mL
Chapter 11 Eye
Proxymetacaine 0·5% with fluorescein
0·25% single-use eye drops
Mydricaine subconjunctival injection No
1, No 2 [unlicensed]
Chapter 12 Ear, nose and oropharynx
Miconazole oral gel 24mg/mL
Chapter 13 Skin
Dithranol in Lassar’s Paste 0·25%
Coal tar in yellow soft paraffin 20%
Coal tar ointment in base of 15% zinc
oxide in yellow soft paraffin
Tretinoin gel 0·01% (Retin-A)
Chapter 15 Anaesthesia
Etomidate injection 20mg/10mL
Appendix 3 Emergency treatment of
poisoning
Potassium iodate tablets 85mg
Methionine tablets 500mg