Formulary

Positive Inotropic drugs

Digoxin 

Diuretics

Indapamide 2.5mg 
Bendroflumethiazide 2.5mg
Spironolactone

NICE NG136: Hypertension in adults: diagnosis and management

Furosemide
Eplerenone

NICE NG106: Chronic heart failure in adults: diagnosis and management 

Beta-adrenoreceptor blocking drugs 

Atenolol
Propranolol
Bisoprolol 
Carvedilol

Beta-blockers and ACE inhibitors are first line treatment for heart failure. A Beta-blocker licensed for heart failure should be used eg. Bisoprolol or Carvedilol. Dose titration is required, see below:

NICE NG106: Chronic heart failure in adults: diagnosis and management

Alpha-Adrenoreceptor Blockers

Doxazosin

Alpha-blockers only as 4th line antihypertensive agents unless there is compelling indication for their use eg. prostatism. 

NICE NG136: Hypertension in adults: diagnosis and management

Do NOT use Doxazosin XL as it is “Double Red”

Angiotensin- converting enzyme inhibitors

Ramipril
Lisinopril
Perindopril erbumine

Angiotensin-II-receptor antagonists

Losartan
Candesartan- drug of choice in heart failure if AIIRA required

NICE NG136: Hypertension in adults: diagnosis and management

Sacubitril valsartan (Entresto®)- GREEN (Specialist Initiated)

Sacubitril valsartan is recommended as an option for treating symptomatic chronic heart failure with reduced ejection fraction, only in people:
•    with New York Heart Association (NYHA) class II to IV symptoms and
•    with a left ventricular ejection fraction of 35% or less and
•    who are already taking a stable dose of angiotensin‑converting enzyme (ACE) inhibitors or ARBs. 

NICE TA388: Sacubitril valsartan for treating symptomatic chronic heart failure with reduced ejection fraction 

Nitrates, calcium-channel blockers and potassium channel activators

Glyceryl Trinitrate- Pump spray and tablets
Monomil XL® or Chemydur XL®
Isosorbide mononitrate- standard release asymmetric dosing (eg. 8am and 2pm)- prescribe generically
Amlodipine
Verapamil

Diltiazem M/R- prescribe by brand. 
Preferred brands are:
•    Slozem® - ONCE a day preparation- (Supply problem with Viazem XL® April 2025)
•    Tildiem® Retard- TWICE a day preparation 

Other anti-anginal drugs

Nicorandil
Ivabradine – GREEN (Specialist Recommended) for both angina and heart failure

NICE TA267: Ivabradine for treating chronic heart failure 

Peripheral vasodilators and related drugs

Naftidrofuryl oxalate

NICE TA223: Cilostazol, naftidrofuryl oxalate, pentoxifylline and inositol nicotinate for the treatment of intermittent claudication in people with peripheral arterial disease 

Anticoagulants

Warfarin

Generic apixaban (Most cost-effective twice a day DOAC)
Generic rivaroxaban (Most cost-effective once a day DOAC)
Generic dabigatran

Commissioning recommendations for national procurement for direct-acting oral anticoagulant(s) (DOACs)- January 2024

Apixaban and rivaroxaban are categorised as:

GREEN for stroke prevention in Atrial Fibrillation
GREEN (Specialist Initiated) for treatment and prevention of DVT and PE
RED for prevention of DVT post-knee and hip replacement

Dabigatran is categorised as:

GREEN for stroke prevention in Atrial Fibrillation 

GREEN (Specialist Initiated) for treatment and prevention of DVT and PE
RED for prevention of DVT post-knee and hip replacement

Edoxaban is categorised as:

GREEN for stroke prevention in Atrial Fibrillation
GREEN (Specialist Recommended) for treatment and prevention of DVT and PE

NICE TA355: Edoxaban for preventing stroke and systemic embolism in people with non-valvular atrial fibrillation

NICE TA275: Apixaban for preventing stroke and systemic embolism in people with nonvalvular atrial fibrillation

NICE TA249: Dabigatran etexilate for the prevention of stroke and systemic embolism in atrial fibrillation

NICE TA256: Rivaroxaban for the prevention of stroke and systemic embolism in people with atrial fibrillation

NICE TA261: Rivaroxaban for the treatment of deep vein thrombosis and prevention of recurrent deep vein thrombosis and pulmonary embolism

NICE TA287: Rivaroxaban for treating pulmonary embolism and preventing recurrent venous thromboembolism 

Antiplatelet drugs

Aspirin 75mg 
Clopidogrel 75mg
Prasugrel
Ticagrelor
Dipyridamole 200mg M/R

NICE TA210: Clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events 

Lipid-regulating drugs

NICE NG238: Cardiovascular disease: risk assessment and reduction, including lipid modification 

Atorvastatin
Rosuvastatin tablets

Pravastatin (with warfarin)

MHRA/CHM advice: Statins: very infrequent reports of myasthenia gravis (September 2023) 
There has been a very small number of reports of new-onset, or exacerbation of pre-existing, myasthenia gravis or ocular myasthenia associated with statin use, albeit very infrequent and no reported fatalities. In most cases, patients recovered after stopping statin treatment. However, a minority continued to experience symptoms, some of which recurred on rechallenge with the same, or an alternative, statin. Symptom onset ranged from a few days to 3 months after starting statin treatment.
Healthcare professionals are advised to refer patients who present with suspected new-onset myasthenia gravis symptoms, after starting a statin, to a neurologist—the statin may need to be discontinued if its risks outweigh the benefits. Healthcare professionals are also advised to counsel patients and their carers to:
•    inform their doctor, before taking a statin, if they have a history of myasthenia gravis or ocular myasthenia as it may exacerbate their symptoms;
•    continue taking their statin unless they are advised to stop;
•    inform their doctor if they experience symptoms such as weakness in the arms or legs that worsens after activity, double vision, drooping of the eyelids, difficulty swallowing, or shortness of breath;
•    seek immediate medical attention if they develop severe breathing or swallowing problems.

Ezetimibe 
Do not prescribe as Ezetrol® brand as it is “Double Red”

NICE NG238: Cardiovascular disease: risk assessment and reduction, including lipid modification

Bempedoic acid

Bempedoic acid and ezetimibe (Nustendi)

NICE TA694: Bempedoic acid with ezetimibe for treating primary hypercholesterolaemia or mixed dyslipidaemia

Inclisiran- GREEN (Specialist Recommended) 

NICE TA733: Inclisiran for treating primary hypercholesterolaemia or mixed dyslipidaemia

NHS England » Funding and supply of inclisiran (Leqvio®)

PCSK9 Inhibitors

The PCSK9 inhibitors Alirocumab and Evolocumab are “Red” (specialist prescribing in secondary care only).

NICE TA393: Alirocumab for treating primary hypercholesterolaemia and mixed dyslipidaemia

NICE TA394: Evolocumab for treating primary hypercholesterolaemia and mixed dyslipidaemia 

SGLT2 Inhibitors for heart failure

Dapagliflozin

NICE TA679: Dapagliflozin for treating chronic heart failure with reduced ejection fraction

NICE TA902: Dapagliflozin for treating chronic heart failure with preserved or mildly reduced ejection fraction

Empagliflozin

NICE TA773: Empagliflozin for treating chronic heart failure with reduced ejection fraction

NICE NG28: Type 2 diabetes in adults: management

Inhalers:

Base the choice of inhaler on:

• an assessment of correct technique
• the preference of the person receiving the treatment
• the lowest environmental impact among suitable devices
• the presence of an integral dose counter.

A spacer should usually be prescribed for use with a metered dose inhaler, particularly in children, and particularly for corticosteroid-containing inhalers. See patient decision aid on asthma inhalers and climate change [BTS/SIGN 2019, amended BTS/NICE/SIGN 2024]

Give people with asthma or COPD information on their inhaler treatments. This should include the medicines they contain, how they work, when they should be taken and the correct technique to use for each device. [BTS/SIGN 2019, amended BTS/NICE/SIGN 2024]

Observe the person using their inhaler device (and spacer if used) to check they can use it properly:

• at every asthma/COPD review, either routine or unscheduled
• at every asthma/COPD-related consultation
• when there is deterioration in asthma/COPD control
• when the inhaler device is changed
• when the person asks for it to be checked or changed.

If the person is assessed as being unable to use a device properly, find an alternative. [NICE 2017, BTS/SIGN 2019, amended BTS/NICE/SIGN 2024]

If possible, prescribe the same type of device to deliver preventer and reliever treatments where more than one inhaler is needed. Consider providing an additional metered dose short-acting beta2 agonist (SABA) inhaler plus spacer for emergency use for children under 12 years who may be unable to activate a dry powder inhaler during an acute asthma attack. [BTS/SIGN 2019, amended BTS/NICE/SIGN 2024]

Encourage people to take their used or expired inhalers to their pharmacy for disposal. [BTS/SIGN 2019]

Inhaler technique training should be kept simple.

Inhalers:

Base the choice of inhaler on:

• an assessment of correct technique
• the preference of the person receiving the treatment
• the lowest environmental impact among suitable devices
• the presence of an integral dose counter.

A spacer should usually be prescribed for use with a metered dose inhaler, particularly in children, and particularly for corticosteroid-containing inhalers. See patient decision aid on asthma inhalers and climate change [BTS/SIGN 2019, amended BTS/NICE/SIGN 2024]

Give people with asthma or COPD information on their inhaler treatments. This should include the medicines they contain, how they work, when they should be taken and the correct technique to use for each device. [BTS/SIGN 2019, amended BTS/NICE/SIGN 2024]

Observe the person using their inhaler device (and spacer if used) to check they can use it properly:

• at every asthma/COPD review, either routine or unscheduled
• at every asthma/COPD-related consultation
• when there is deterioration in asthma/COPD control
• when the inhaler device is changed
• when the person asks for it to be checked or changed.

If the person is assessed as being unable to use a device properly, find an alternative. [NICE 2017, BTS/SIGN 2019, amended BTS/NICE/SIGN 2024]

If possible, prescribe the same type of device to deliver preventer and reliever treatments where more than one inhaler is needed. Consider providing an additional metered dose short-acting beta2 agonist (SABA) inhaler plus spacer for emergency use for children under 12 years who may be unable to activate a dry powder inhaler during an acute asthma attack. [BTS/SIGN 2019, amended BTS/NICE/SIGN 2024]

Encourage people to take their used or expired inhalers to their pharmacy for disposal. [BTS/SIGN 2019]

Inhaler technique training should be kept simple. 

In brief, to achieve optimum lung deposition, the inspiratory effort should be:

• DPI (dry powder inhaler) QUICK AND DEEP
• pMDI (aerosol) SLOW AND STEADY

Videos on how to use various inhaler devices can be found on the Asthma + Lung UK website: How to use your inhaler | Asthma + Lung UK

Bronchodilators   

Selective beta2 agonists

Short-acting beta2 agonists: 

• Easyhaler Salbutamol® Dry Powder inhaler 100 microgram per inhalation (low carbon footprint) 
• Salamol® (Salbutamol) CFC-free pMDI 100microgram per inhalation (lower carbon footprint compared with generic due to lower volume propellant)
• Airomir® (Salbutamol) CFC-free pMDI 100microgram per inhalation (high carbon footprint, lower volume propellant)

Ventolin® MDI and generic salbutamol MDI is DOUBLE RED 
 
Long acting beta2 agonists: 
 
To ensure safe use, Commission on Human Medicines (CHM) has advised that for the management of chronic asthma, long-acting β2 agonists should: 

• be added only if regular use of standard-dose inhaled corticosteroids has failed to adequately control asthma 
• not be initiated in patients with rapidly deteriorating asthma 
• be introduced at a low dose and the effect properly monitored before considering dose increase 
• be discontinued in the absence of benefit 
• be reviewed as clinically appropriate - stepping down therapy should be considered when good long-term asthma control has been achieved. 
• combination inhalers should be prescribed when appropriate to aid compliance 
• Patients should report any deterioration in symptoms after they start treatment with a long-acting β2 agonist. 
   
• Formoterol Easyhaler® (low carbon footprint) 
• Olodaterol Soft Mist Inhaler (Striverdi Respimat®) – low carbon footprint 
• Formoterol pMDI (high carbon footprint) 
• Salmeterol pMDI* (high carbon footprint) or Serevent Accuhaler (low carbon footprint)

*NB Some generic salmeterol pMDIs contain soya oil 

Antimuscarinic bronchodilators

Short Acting

• Ipratropium pMDI (high carbon footprint)

Long Acting

• Tiotropium DPI (low carbon footprint):

Prescribe by brand:
1.    Acopair Neumohaler® 18microgram tiotropium (device plus inhalation powder capsules)
2.    Tiogiva® 18 microgram tiotropium (device plus inhalation powder capsules or refill pack of capsules only). Device may be used for up to 6 months before replacement but must be cleaned once a month.
3.    Tiotropium via “Respimat” device (Spiriva®) (soft mist inhaler – low carbon footprint) if unable to use dry powder inhaler.

NB: Take the risk of cardiovascular side effects into account when prescribing tiotropium to patients with certain cardiac conditions, who were excluded from clinical trials of tiotropium (including TIOSPIR) See MHRA statement Feb 2015
 
Spiriva Respimat® in asthma: LAMA add-on treatment for specialist initiation only. 

• Aclidinium (Eklira Genuair®) (low carbon footprint)

Theophylline

Modified Release Theophylline tablet – prescribe by brand

• Uniphyllin Continus®

Compound bronchodilator preparations: LAMA + LABA

Prescribe by BRAND

• Duaklir Genuair® Aclidinium bromide (LAMA) + formoterol fumarate (LABA) (low carbon footprint)
• Spiolto Respimat® Tiotropium bromide (LAMA) + olodaterol hydrochloride (LABA) (low carbon footprint)

Spacer devices

Provide a spacer that is compatible with the person's metered-dose inhaler.

• A2A spacer®
• EasyChamber®  
• Volumatic®  
• Aerochamber Plus® 

How to use a spacer: 2 techniques 

• Single breath and hold: How to use a pMDI inhaler with a spacer – single breath and hold 
• Tidal breathing/multiple breath technique: This is usually recommended if you can’t hold your breath for five seconds after using your inhaler or if you are having an asthma attack. How to use a pMDI inhaler with a spacer – tidal breathing

Advise people on spacer cleaning. Tell them: 

• not to clean the spacer more than monthly, because more frequent cleaning affects their performance (because of a build-up of static) 
• to hand wash using warm water and washing-up liquid and allow the spacer to air dry. 
• to replace with a new spacer after 12 months’ use.

Corticosteroids

High doses of inhaled corticosteroids used for prolonged periods can induce adrenal suppression.  Patients using such high doses should be given a blue “steroid card” and may need corticosteroid cover during period of stress. Steroid treatment cards should be considered at lower doses if there is concomitant use of: (i) intranasal and/or topical corticosteroids; OR (ii) medicines that inhibit the metabolism of corticosteroids (cytochrome p450 inhibiting drugs especially ritonavir, itraconazole and ketoconazole). 

The prescriber is responsible for issuing the card. Its purpose should be discussed with the patient. The prescriber should ensure that the information on the card is kept up to date and should explain the instructions on the card when issuing one to the patient. 

High doses are >800 microgram (BDP or equivalent) daily for adults and >400 microgram (BDP or equivalent) daily for children.

When switching between corticosteroid products be aware of dose inequivalence. See table for comparison: Inhaled corticosteroid doses for the BTS, NICE and SIGN asthma guideline

Single component inhaled corticosteroid products are only licensed for use in asthma, NOT COPD.

Steroid-containing pMDIs should be used with a spacer to improve lung deposition and reduce side-effects.

Monitoring of patients on inhaled corticosteroids (ICS):

• Physicians should remain vigilant for the development of pneumonia and other infections of the lower respiratory tract e.g. bronchitis in patients with COPD who are treated with inhaled drugs that contain steroids because the clinical features of such infections and exacerbation frequently overlap.  Any patient with severe COPD who has had pneumonia during treatment with inhaled drugs that contain steroids should have their treatment reconsidered. Drug Safety Update October 2007
• Psychological and behavioural side effects may occur in association with use of inhaled and intranasal formulations of corticosteroids Drug Safety Update September 2010
   

Prescribe inhaled corticosteroid inhalers by brand name to avoid differences in therapeutic equivalence between different corticosteroid molecules and between different particle-size formulations of the same molecule which lead to variations in potency. See table for equivalent doses: Inhaled corticosteroid doses for the BTS, NICE and SIGN asthma guideline

Single component inhaled corticosteroid:

products are only licensed for use in asthma, not COPD.

• Budesonide Easyhaler® – low carbon footprint 
• Soprobec® (Beclometasone dipropionate, standard particle) cfc-free pMDI (high carbon footprint) plus spacer 

Combination (LABA/ICS) inhalers:
Prescribe by brand.

Beware of dose inequivalence if switching “from” or “to” another inhaler, especially with fine-particle beclometasone products, which have a potency of 2 – 2.5 times greater than standard particle beclometasone.

pMDIs should be used with a spacer.

ICS/formoterol inhalers:
Because formoterol has an onset of action as fast as salbutamol, it can be used for relief of breathlessness. The effect sets in rapidly (within 1-3 minutes) and is still significant 12 hours after inhalation. By combining formoterol with low dose ICS, patients with asthma symptoms can address the inflammation causing their symptoms as the same time as relieving breathlessness.

MART (maintenance and reliever therapy) in asthma:
Consider using a single combination (ICS/formoterol only) inhaler as a “preventer” and “reliever” (“MART”) for patients aged 12 years and over with troublesome or on-going asthma exacerbations.
 
N.B. MART is NOT suitable for products containing salmeterol as LABA, only for LABA with fast onset of action e.g. formoterol. 

AIR (anti-inflammatory reliever) in asthma:
For patients (aged 12 years and over) with mild asthma symptoms, less than twice a month, low dose ICS/formoterol combination inhaler can be used as a reliever when required. This should replace monotherapy with short-acting beta-agonist (SABA).

Dry powder inhalers:

• Fobumix Easyhaler® (Budesonide plus formoterol DPI) (low carbon footprint)
  Licensed for asthma from 6 years (fixed dose), MART and AIR, from 12 years, and for COPD in adults. Three strengths, (equivalent to Symbicort Turbohaler range).
• WockAIR® (Budesonide plus formoterol DPI). Low carbon footprint.
• Fostair 200/6 NEXThaler® (Formoterol plus fine-particle beclomethasone DPI) (low carbon footprint)

Licensed for asthma only, in adults. High strength ICS.

Pressurised metered dose inhalers: (Use with spacer)

• Bibecfo® pMDI (fine-particle beclomethasone plus formoterol) High carbon footprint.
• Luforbec® pMDI (fine-particle beclomethasone plus formoterol) High carbon footprint.
• Proxor® pMDI (fine-particle beclomethasone plus formoterol High carbon footprint.
• Vivaire® pMDI (fine-particle beclomethasone plus formoterol) High carbon footprint.
• Symbicort® pMDI 100/3 N.B. Very high carbon footprint.

Triple therapy: ICS/LABA/LAMA
Patients with severe COPD which is not controlled on two inhaled drugs should be offered a third inhaled drug. 
 
For patients already on triple therapy using 2 devices (e.g. LAMA plus LABA/ICS) it may be cost effective to prescribe this as a single fixed dose device.

Trimbow® (Beclometasone (fine particle)/formoterol/glycopyrronium)

• NEXThaler (88/5/9 – delivered dose) COPD only.
• pMDI (87/5/9 – delivered dose). COPD, asthma.
• pMDI (172/5/9 – delivered dose). Asthma only.

The pMDI should be used with a spacer.

Cromoglicate, related therapy and leukotriene antagonists

When used in asthma offer a trial of leukotriene receptor antagonist (LTRA) and review the response to treatment in 8 to 12 weeks. 

• Montelukast (licensed from age 6 months) 

Prescribers are reminded to be alert for neuropsychiatric reactions in patients taking montelukast.

Antihistamines (purchase OTC for hayfever/seasonal allergic rhinitis)

• Cetirizine 
• Loratadine (if liquid required, loratadine more cost-effective than cetirizine)
• Chlorphenamine

Mucolytics

4 week trial; stop if no benefit seen.

• Carbocisteine 375mg capsule
• Acetylcysteine sugar free effervescent tablets 600mg if liquid or once daily preparation required (115mg Na+ per tablet = 1/20th recommended daily intake).

Hypnotics and Anxiolytics

Insomnia Newer Hypnotic Drugs
NICE TA77 – (April 2004)

• When, after due consideration of the use of non-pharmacological measures, hypnotic drug therapy is considered appropriate for the management of severe insomnia interfering with normal daily life, it is recommended that hypnotics should be prescribed for short periods of time only, in strict accordance with their licensed indications.

• It is recommended that, because of the lack of compelling evidence to distinguish between zaleplon, zolpidem, zopiclone or the shorter acting benzodiazepine hypnotics, the drug with the lowest purchase cost (taking into account daily required dose and product price per dose) should be prescribed.

• It is recommended that switching from one of these hypnotics to another should only occur if a patient experiences adverse effects considered to be directly related to a specific agent. These are the only circumstances in which the drugs with the higher acquisition costs are recommended.

• Patients who have not responded to one of these hypnotic drugs should not be prescribed any of the others.

Benzodiazepine indications

• Benzodiazepines are indicated for the short-term relief (two to four weeks only) of anxiety that is severe, disabling, or causing the patient unacceptable distress, occurring alone or in association with insomnia or short-term psychosomatic, organic, or psychotic illness.

• The use of benzodiazepines to treat short-term ‘mild’ anxiety is inappropriate.

• Benzodiazepines should be used to treat insomnia only when it is severe, disabling or causing the patient extreme distress - BNF

Diazepam (if liquid formulation required prescribe as Oral Solution SF) 
Zaleplon, zolpidem and zopiclone are non-benzodiazepine hypnotics, but they act as the benzodiazepine receptor.  They are not licensed for long-term use; dependence has been reported in a small number of patients.

Antidepressant drugs

Prescribing Guideline for Treatment of Depression in Adults in Primary Care

First prescribe an SSRI in generic form unless there are interactions with other drugs; consider using citalopram or sertraline because they have less propensity for interactions.
When prescribing antidepressants, be aware that: 
• Dosulepin should not be prescribed 
• Non-reversible monoamine oxidase inhibitors (MAOIs; for example, phenelzine), combined antidepressants and lithium augmentation of antidepressants should normally be prescribed only by specialist mental health professionals

Take into account toxicity in overdose when choosing an antidepressant for patients at significant risk of suicide. Be aware that:
• Compared with other equally effective antidepressants recommended for routine use in primary care, venlafaxine is associated with a greater risk of death from overdose
• Tricyclic antidepressants (TCAs), except for lofepramine, are associated with the greatest risk in overdose.

When prescribing antidepressants for older people:
• Prescribe at an age-appropriate dose taking into account the effect of general physical health and concomitant medication on pharmacokinetics and pharmacodynamics
• Carefully monitor for side effects

Sertraline (for patients with co-existing CHD)
Escitalopram (first line in epilepsy)
Fluoxetine (first line for <24 years of age) where capsules are unsuitable prescribe as 20mg/5ml oral solution (not SF) or 20mg dispersible tablets
Mirtazapine (sedative effect may be beneficial in sleep disturbances)

Third line options after trial of alternative first line option:
Venlafaxine (monitor BP before and during treatment)
Vortioxetine (cognitive enhancement independent of depression)
Duloxetine (if pain a predominant co-morbid symptom)

Drugs used in nausea and vertigo

Metoclopramide not recommended for patients <20 years
Prochlorperazine
Betahistine

Analgesics
Limited amount of evidence that combinations containing low doses of opioid e.g. 8 mg codeine are more effective than aspirin or paracetamol alone. Soluble products not included due to high sodium content.

Paracetamol tablets available OTC
Co-codamol tablets 8/500 available OTC

High strength
1st line - Co-codamol tablets 30/500 
2nd line - Co-codamol capsules 30/500
No longer cheaper to prescribe separately
Codeine phosphate

Drugs in terminal care
Morphine – prescribe by brand, which must stay consistent
Preferred brand – Zomorph® capsules (twice a day preparation)

Zomorph® capsules can be swallowed whole or opened and sprinkled on food.

Diamorphine
Fentanyl patches (pack of 5 only) preferred brands Matrifen®, Mezolor® and Opiodur® 
Dexamethasone
Midazolam
Cyclizine
Levomepromazine- for a 6.25mg dose, use a 25mg tablet broken into quarters

Antimigraine drugs

Simple Analgesic plus anti-emetic
Several combination products are available

Reserve triptans for patients in whom adequate doses of analgesics and anti-emetics are not effective.  Monitor patients and review if patient overusing as potential for medication overuse headache.
Sumatriptan 50mg
Naratriptan 2.5mg
Rizatriptan 10mg Orodispersible tablets SF

NICE/UKHSA Summary of antimicrobial prescribing guidance - managing common infections

See the British National Formulary (BNF) for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding.

Unnecessarily long courses of antimicrobials are one of the factors driving antimicrobial resistance and an increased risk of Clostridioides difficile infection in at-risk populations. Follow national guidance on prescribing the shortest effective course. For example, the NICE/UKHSA summary currently recommends a 5-day course when prescribing for acute sore throat, acute otitis media, sinusitis, acute cough and acute exacerbations of COPD.

Antibacterials

Penicillins:
Phenoxymethylpenicillin (Pen V)
Amoxicillin
Flucloxacillin
Co-amoxiclav - only first choice for human & animal bites, uncomplicated diverticulitis, cellulitis and erysipelas near the eyes or nose, sinusitis (only if systemically very unwell or high risk of complications), community acquired pneumonia (only if high severity in adults or severe in children) and hospital acquired pneumonia (non-severe and not higher risk of resistance).

Pivmecillinam 200mg for lower UTI only (second line).

Cephalosporins:
Cefalexin

Tetracyclines: 
Doxycycline
Lymecycline

Macrolides:
Clarithromycin (first choice macrolide)
Erythromycin (preferred for some indications in pregnancy and breast feeding  - see NICE/UKHSA Summary of antimicrobial prescribing guidance - managing common infections)

Azithromycin - Chlamydia treatment option for pregnant women

Vancomycin - see National Institute for Health and Care Excellence (NICE) guidance [NG199] for Clostridioides difficile infection: antimicrobial prescribing

Trimethoprim – nitrofurantoin is preferred for most patients especially where risk of resistance is high e.g. over 70s. Trimethoprim should only be used in over 70s only where sensitivity has been confirmed on MSU.

Metronidazole

Ciprofloxacin* only first choice for acute prostatitis (guided by susceptibilities when available). *See the MHRA January 2024 advice on restrictions and precautions for using fluoroquinolone antibiotics because of the risk of disabling and potentially long-lasting or irreversible side effects.

Nitrofurantoin 50mg capsules 

Methenamine Hippurate - Prophylaxis of recurrent urinary tract infections.

Antifungal drugs

Fluconazole
Itraconazole
Nystatin oral suspension

Treat fungal nail infections only after confirmed mycology. Topical preparations should be purchased rather than prescribed.

Terbinafine

Herpes virus infections

Aciclovir

Influenza treatment 

Oseltamivir
Zanamivir

NICE technology appraisal (TA168)
Oseltamivir and Zanamivir recommended as possible treatments for people with flu if all of the following apply:

• The person is in an ‘at risk’ group.
• The person has a ‘flu-like illness’ and can start treatment within 48 hours (36 hours for Zanamivir treatment in children) of the first sign of symptoms.
• The Department of Health and Social Care has confirmed that the flu virus is known to be circulating and it is likely that a flu-like illness has been caused by the flu virus.

To be added.

Urinary frequency, enuresis and incontinence

Antimuscarinics (systemic): Consider high anticholinergic burden

Solifenacin 5mg-10mg once daily
Tolterodine immediate-release 1mg - 2mg twice daily
Fesoterodine MR 4mg - 8mg once daily

Beta3-Adrenoceptor agonists

Mirabegron: Option only if antimuscarinic drugs are ineffective, contraindicated or not tolerated 
Overview | Mirabegron for treating symptoms of overactive bladder | Guidance | NICE

See OAB guidance - Overactive bladder prescribing pathway

Overview | Urinary incontinence and pelvic organ prolapse in women: management | Guidance | NICE

Urinary retention

Alpha-adrenoceptor blockers:

Doxazosin tablets (not m/r) 8mg prescribe as 2x4mg
Tamsulosin 400mcg m/r capsules

Contraceptives, combined

The risk of VTE in association with drospirenone-containing pills, including Yasmin, is higher than that for levonorgestrel-containing ‘second generation’ pills and may be similar to the risk for ‘third-generation’ pills that contain desogestrel or gestodene. See full MHRA warning link
If Yasmin® equivalent is still needed, please prescribe as Yacella®, or Dretine® brand (Ethinylestradiol 30mcg, Drospirenone 3mg)

Contraceptive, emergency

Ulipristal acetate 30mg 
Levonorgestrel 1500mcg 

Levonorgestrel 1500mcg: 
Available OTC as Levonelle One Step® from all pharmacies for over-16s.  
Available from many pharmacies under PGD, including for under 16s

Ulipristal acetate 30mg:
Available OTC as ellaOne® from all pharmacies

For choice of product see decision making algorithm in FSRH guideline on Emergency Contraception (link)

Contraception, oral progestogen-only

Desogestrel 75mcg Prescribe generically

Desogestrel has a 12-hour missed pill window and may be useful where poor compliance is likely.  However, it is only recommended for use in women who cannot tolerate oestrogen-containing contraceptives or in whom these preparations are contraindicated.

Erectile dysfunction

Sildenafil - “SLS” criteria no longer apply to generic sildenafil.  Max 8 tablets per month
Tadalafil 10mg, 20mg PRN (not daily) – “SLS” criteria apply.  Max 8 tablets per month

Tadalafil 5mg DAILY (5mg only; 2.5mg is double red) - “SLS” criteria apply.

Guidelines for drugs and devices used in the treatment of erectile dysfunction

Anaemias

Iron deficiency anaemia

Iron (oral): once daily (or alternate day) dosing

Vitamin Deficiency

Vitamin D

For the management of insufficiency (serum 25(OH)D 25-50nmol/L) and the routine prophylaxis of deficiency, vitamin D should be purchased OTC or, if eligible, obtained free of charge, or at a reduced cost, via the government’s “Healthy Start” scheme www.healthystart.nhs.uk This includes prevention of deficiency in pregnant women, including those with high BMI and in other at risk groups.

For the treatment of deficiency (serum 25(OH)D <25nmol/L) vitamin D may be provided via NHS prescription. 

See Vitamin D guidelines for formulary preparations Guidelines for the management of Vitamin D deficiency and insufficiency in children, adolescents and adults

Vitamin D with calcium

Calci D® chewable tablets (once daily dose) (Colecalciferol 1,000unit / Calcium carbonate 2.5g chewable tablets)

Accrete D3® film-coated tablets (swallowed whole or halved) (Colecalciferol 400unit / Calcium carbonate 1.5g tablets)

Evacal D3® chewable tablets (Colecalciferol 400unit / Calcium carbonate 1.5g chewable tablets) - if a twice daily chewable tablet is needed

Non-steroidal Anti-inflammatory Drugs

NPAG does not recommend the use of coxibs. In high GI risk patients where simple analgesics provide inadequate relief then prescribe a traditional NSAID
with Lansoprazole 15-30mg daily.

Ibuprofen available OTC 

Naproxen
Avoid M/R preparations and E/C versions as they are considerably more expensive without additional benefits.

Diclofenac
There are now concerns about the cardiovascular safety which appear to have a similar risk to coxibs

Drugs for the Relief of Soft-tissue Inflammation

NICE Guidance: Osteoporosis. Consider topical NSAID if needed and no contra-indications (particularly if hand or knee involvement)  Link

Fenbid Gel® - only prescribe for long-term conditions as available OTC
(Ibuprofen 5% gel but should prescribe as Fenbid 100g)

Anti-infective Eye Preparations

Chloramphenicol 0.5% eye drops 10ml or 1% eye ointment 4g
-Available OTC for acute bacterial conjunctivitis in adults and children over 2 years 

Fusidic Acid 1% MR eye drops 5g

Corticosteroids and Other Anti-inflammatory Preparations

Corticosteroid eye preparations

Should be prescribed on specialist recommendation

Other Anti-inflammatory Preparations

Sodium cromoglicate 2% eye drops 13.5ml
-Available OTC (10ml) for acute seasonal and perennial allergic conjunctivitis

Azelastine 0.05% eye drops 8ml

Antazoline 0.5% with xylometazoline 0.05% eye drops 8ml (Otrivine Antistin ®)
-Available OTC

Treatment of Glaucoma

Eye preparations for glaucoma should be prescribed on specialist recommendation. 

Miscellaneous Ophthalmic Preparations

Advise self-care where possible and advise patient to purchase preparations OTC
See ‘Guidance on the Use of Eye Lubricants for Dry Eye Conditions in Primary Care’ (‘Ocular Lubricant Guidelines’) 

Standard Formulations

AaproMel® Hypromellose 0.3% or 0.5% eye drops 10ml (hypromellose) one-month expiry - available OTC

Clinitas® Carbomer 0.2% eye gel 10g (carbomer 980) one-month expiry - available OTC

Eyeaze® Carmellose 0.5% preservative free eye drops 10ml (carmellose) three-month expiry - available OTC

Preservative Free Formulations (consider as detailed in Guidelines above)

Eyeaze® Carmellose 0.5% preservative free eye drops 10ml (carmellose) three-month expiry - available OTC

Hy-Opti® 0.1% 10ml (sodium hyaluronate) six-month expiry -available OTC

Eyeaze® 0.1% or Eyeaze Lyte® 0.1% (sodium hyaluronate) – three-month expiry -  available OTC

Hy-Opti® 0.2% 10ml (sodium hyaluronate) six-month expiry -available OTC

Eyeaze® 0.2% or Eyeaze Lyte® 0.2% (sodium hyaluronate) – three-month expiry -  available OTC

High Viscosity Formulations (for use at night in addition to daytime treatment)

Hylo Night® preservative free eye ointment 5g (retinol palmitate with WSP, LLP, LP, and wool fat) six-month expiry - available OTC

Xailin Night® eye ointment 5g (liquid paraffin with WSP and wool alcohols) two-month expiry - available OTC

See Northamptonshire OTC When To Prescribe 

Otitis Externa

First use aural toilet (if available) and simple analgesia

Acetic Acid 2% ear spray 5ml (Earcalm spray) (available over the counter (OTC))

Acetic Acid 2%/Dexamethasone 0.1%/Neomycin 0.5% ear spray 5ml (Otomize ear spray)

Drugs acting on the Nose

Mild to moderate hay fever/seasonal rhinitis is listed by NHS England as a condition where OTC medicines should not routinely be prescribed in primary care. Most patients should be able to relieve symptoms with OTC treatments

First line
Beclometasone 50mcg/dose aqueous nasal spray 200 sprays - available OTC for adults for prevention and treatment of allergic rhinitis in 100 and 180 spray sizes

Second line
Budesonide 64mcg/dose nasal spray 120 sprays - available OTC for adults for prevention and treatment of seasonal allergic rhinitis in 60 and 120 spray sizes

Fluticasone furoate 27.5mcg/dose 120 sprays  - available OTC for adults 

See Tablet Press Extra ‘Hay Fever Treatment Update - OTC’ 

Topical Nasal Decongestants

Sodium chloride 0.9% nasal drops 10ml - available OTC

Nasal Preparations for Infection (nasal staphylococci)

Chlorhexidine 0.1% and neomycin 0.5% nasal cream (Naseptin nasal cream)

Drugs for Oral Ulceration and Inflammation

Chlorhexidine gluconate 0.2% mouthwash 300ml - available OTC (Corsodyl mouthwash)

Benzydamine 0.15% mouthwash sugar free 300ml - available OTC (Difflam oral rinse)

Oropharyngeal Anti-infective Drugs - Fungal Infections

Miconazole 20mg/g oromucosal gel sugar free 80g (Daktarin oral gel) - available OTC in 15g size

Nystatin 100,000 units/ml oral suspension 30ml

Treatment of Dry Mouth (artificial saliva products)

Saliveze mouth spray 50ml - available OTC

Artificial Saliva Gel (Biotene Oralbalance saliva replacement gel) 50g - available OTC

See Northamptonshire OTC When To Prescribe 

Emollient and Barrier Preparations

There is no advantage in prescribing these products by generic name. Choice is largely based on patient preference.

Emollients

There is a risk of severe and fatal burns with ALL emollients. See MHRA/CHM advice (updated May 2021): Emollients: new information about risk of severe and fatal burns with paraffin-containing and paraffin-free emollients. Emollients and risk of severe and fatal burns: new resources available - GOV.UK 

Mild dry skin is listed by NHS England as a condition where OTC medicines should not routinely be prescribed in primary care. Most patients should be able to relieve symptoms with OTC treatments. Emollients can continue to be prescribed for patients with long term dermatological conditions such as eczema and psoriasis. 
Guidance on conditions for which over the counter items should not routinely be prescribed in primary care

‘Epimax’ and ‘Zero’ product ranges provide cost effective equivalents to many commonly used emollients and soap substitutes and are suitable for initial prescribing in most cases. These should be first choice. Patients already established on more expensive products should be encouraged to try the equivalent ‘Epimax’ or ‘Zero’ product. 

See Northamptonshire Emollient Guidelines 

See Northamptonshire OTC When To Prescribe

Emollients for Mild Dry Skin

Creams containing paraffin

Epimax® Moisturising Cream Flexi-dispenser 500g 

Zerocream® pump 500g

Creams/lotions containing Colloidal Oatmeal

Epimax Oatmeal Cream Flexi-dispenser 500g

Zeroveen pump 500g

Aveeno preparations are Borderline Substances and have been classed as Double Red. Aveeno preparations are available OTC if patients prefer to purchase them instead of the formulary choices.

Rich creams for mild dry skin

Zeroguent cream 500g 

Emollients for Moderately Dry Skin

Creams containing paraffin

Epimax Original Cream Flexi-dispenser 500g
Zerobase Cream Pump 500g 
Epimax Excetra Cream Flexi-dispenser 500g 

Gels containing paraffin

Epimax Isomol Gel Flexi-dispenser 500g
Zerodouble Gel 

Creams containing urea

ImuDERM Emollient 5% Urea pump 500g

Emollients for Severe Dry Skin

Ointments containing paraffin

Epimax Ointment 500g
Epimax Ointment can harm the eyes if used on the face. Do not prescribe these  ointments for use on the face. Tell patients to wash their hands and avoid touching their eyes after using these products. See MHRA advice.

Zeroderm Ointment 500g

Creams containing Urea 5% and Lauromacrogols 3%

Balneum Plus Cream 500g or 100g – use for itch if emollient alone not helped

Sprays containing paraffin

Emollin Spray 240ml - use only when unable to use other preparations or where application without touching skin is necessary. Highly flammable.

Emollients with Anti-bacterial

Dermol 500 lotion pump 500ml 
Use for washing only when infection is present or recurrent. Avoid regular use.
Use should be targeted and short term. Avoid adding to repeat prescription.
Revert to non-antimicrobial containing emollient once condition is controlled

Paraffin Free Emollient

Epimax Paraffin Free Ointment 500g 
Epimax Paraffin-Free Ointment can harm the eyes if used on the face. Do not prescribe these ointments for use on the face. Tell patients to wash their hands and avoid touching their eyes after using these products. See MHRA advice.

Soap Substitutes

ZeroAQS (does not contain sodium lauryl sulphate)
Aqueous cream (contains sodium lauryl sulphate)
Emulsifying ointment

Bath and Shower Additives 

Bath and shower additives have not been included in this formulary due to lack of evidence of efficacy. 

Any emollient (except white soft paraffin) can be used as a soap substitute. This can be applied prior to washing and directly afterwards onto damp skin. They provide greater moisturising than emollients marketed specifically as bath or shower preparations that don’t have enough contact with the skin. The use of bath emollients/oils and shower products are not routinely recommended for the majority of dermatological conditions as they are less effective than alternatives.

There is an exception where a bath additive may be beneficial to patients and should be made available:

Balneum Plus Bath Oil: can be used for managing itch that remains a problem despite optimum topical therapy. Follow the manufacturer’s instructions. 

As per NHSE recommendations prescribers in primary care should not initiate bath and shower preparations for any new patients. However, where clinically advised by a specialist and appropriate, prescribing may continue.

Barrier Creams

See Northamptonshire Dressings Formulary

Topical Corticosteroids

Hydrocortisone preparations

Prices vary considerably between pack sizes; prescribe 1% preparations as multiples of 30g, not 50g.
Hydrocortisone 2.5% is much more expensive than 1% and is ‘Double Red’. Consider clobetasone preparations if hydrocortisone 1% is not effective.

Mild potency steroids:

Hydrocortisone 1% cream/ointment - available OTC

Moderate potency steroids:

Betametasone 0.025% (Betnovate RD) cream/ointment

Clobetasone butyrate 0.05% (Eumovate) cream/ointment -15g cream available OTC

Potent steroid:

Betamethasone 0.1% (Betnovate) cream/ointment

Very potent steroid:

Clobetasol propionate 0.05% (Dermovate) cream/ointment

Mild steroids with anti-fungal:

Hydrocortisone 1%/miconazole 2% cream/ointment (Daktacort cream/ointment) -15g cream available OTC

Hydrocortisone 1%/clotrimazole1% cream (Canesten HC) -15g available OTC

Preparations for Eczema and Psoriasis

Specialist led

See Management of Psoriasis (Adults & Children) in Primary Care

Drugs affecting the Immune Response

Tacrolimus and pimecrolimus for atopic eczema NICE TA 82 (Last reviewed: 13 July 2015)
Only use when atopic eczema is not controlled by maximal topical corticosteroid treatment. Initiation by Specialist or GP with special interest and experience. 

Acne and Rosacea

For full acne guidance refer to NICE guideline NG198

Managing Acne Vulgaris

12-week course of 1 of the following first-line treatment options: 

Any acne severity:

• a fixed combination of topical adapalene with topical benzoyl peroxide 
• a fixed combination of topical tretinoin with topical clindamycin

Mild to moderate acne severity:

• a fixed combination of topical benzoyl peroxide with topical clindamycin

Moderate to severe acne severity:

• a fixed combination of topical adapalene with topical benzoyl peroxide, together with either oral lymecycline or oral doxycycline
• topical azelaic acid with either oral lymecycline or oral doxycycline

Preparations for Warts and Callouses

Warts and verrucae are listed by NHS England as a condition where OTC medicines should not routinely be prescribed in primary care. Most patients should be able to relieve symptoms with OTC treatments.

Wart and verruca preparations are ‘Double Red’ and should not be prescribed in primary care. They are available to purchase OTC.

Salicylic acid with lactic acid (Salatac gel or Salactol paint) - available OTC

Shampoos and other preparations for Scalp and Hair Conditions

Dandruff is listed by NHS England as a condition where OTC medicines should not routinely be prescribed in primary care. Most patients should be able to relieve symptoms with OTC treatments. 

Coal tar with salicylic acid and sulfur ointment (Cocois ointment) - available OTC

Ketoconazole 2% shampoo - available OTC

Antibacterial preparations

Fusidic acid 2% cream (Fucidin cream) - up to 10 days only, to prevent resistance

Metronidazole 0.75% cream or gel (as Rozex brand)

Silver sulfadiazine 1% cream (Flamazine cream) - for infection in burns wounds

Antifungal preparations

Clotrimazole 1% cream - available OTC

Miconazole 2% cream (Daktarin® cream) - available OTC

Fungal nail infections

Fungal nail infections are listed by NHS England as a condition where OTC medicines should not routinely be prescribed in primary care. Most patients should be able to relieve symptoms with OTC treatments. link

Fungal nail preparations are ‘Double Red’ drugs and should not be prescribed in Primary Care. They are available to purchase OTC.

Parasiticidal preparations

Dimeticone 4% lotion - available OTC

Malathion 0.5% liquid - available OTC

Permethrin 1% liquid - available OTC

Skin Cleansers, Antiseptics and Desloughing Agents

Alcohols and Saline

Irripod saline solution 20ml x 25

Oxidisers and Dyes

Potassium permanganate 0.1% solution diluted 1 in 10 to provide a 0.01% solution - see Guidance on the safe use of potassium permanganate soaks

Continence

Continence Appliances Prescribing Guidelines and Formulary [pdf] 188KB

Dressings

Northamptonshire Dressings Formulary [pdf] 463KB

Stoma

Formulary for Northamptonshire Stoma Care Products [pdf] 231KB