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 Formulary Chapter 4: Central nervous system - Full Chapter
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04.03.04  Expand sub section  Other antidepressant drugs
 note 

These drugs are for use in patients not responding adequately to first-line treatments.

Agomelatine
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Alternatives
Green plus
  • NETAG approved for the treatment of depression only following an adequate trial of at least three alternative antidepressant drugs at maximally tolerated doses (as described by NICE and as stated in the BNF).

 

  • Prescribing and monitoring should be initiated by specialist mental health physicians. After a minimum of 12 weeks, prescribing may be transferred to primary care. 
 
Link  MHRA Drug Safety Update (Dec 2014): Agomelatine (Valdoxan): risk of liver toxicity
Link  North of Tyne, Gateshead and North Cumbria Area Prescribing Committee - Agomelatine – Prescribing and Monitoring in Adults: Information for Primary Care
 
Duloxetine
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Alternatives
Green
  • For use on advice of psychiatrists as a third-line antidepressant - but only for use in patients who cannot tolerate high-dose (>150mg daily) venlafaxine, or patients with hypertension, established CHD or other cardiovascular risk factors which would make the use of high-dose venlafaxine undesirable.
    Also approved for third-line use (after drugs such as the tricyclic antidepressants and gabapentin) in the treatment of neuropathic pain on the advice of pain specialists.
 
 
Mirtazapine
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Alternatives
Green
  • Orodispersible mirtazapine tablets should only be prescribed for use when other formulations are unsuitable (more expensive).
 
 
Reboxetine
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Alternatives
Green plus

 

    • Not licensed in the elderly

 

 
 
Venlafaxine
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Alternatives
Green
  • For patients on doses of 300mg/day or more. Green Traffic Light
  • Patients who are deemed stable on doses of up to 225mg daily of MR venlafaxine should be switched to the equivalent dose of immediate release venlafaxine.
  • MR tablets are only to be used in patients currently prescribed doses of 300mg and over and for whom there is no suitable alternative, those who have experienced discontinuation reactions (at any dose), and for patients who need to take the once daily formulation in order to facilitate care visits.
 
Link  TEWV Depression medication pathway for adults
 
Vortioxetine
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Alternatives
Green
  • Only approved for use in accordance with NICE guidance. 
 
Link  NICE TA367: Vortioxetine for treating major depressive episodes
 
 ....
Key
note Notes
Section Title Section Title (top level)
Section Title Section Title (sub level)
First Choice Item First Choice item
Non Formulary Item Non Formulary section
Restricted Drug
Restricted Drug
Unlicensed Drug
Unlicensed
Track Changes
Display tracking information
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Link to adult BNF
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Link to children's BNF
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Link to SPCs
Cytotoxic Drug
Cytotoxic Drug
CD
Controlled Drug
High Cost Medicine
High Cost Medicine
NHSE
NHS England
Homecare
Homecare
CCG
CCG

Traffic Light Status Information

Status Description

Red

Drugs for hospital use only. The responsibility for initiation and monitoring treatment should rest with an appropriate hospital clinician and the drug should be supplied through the hospital throughout the duration of treatment. In some very exceptional circumstances (e.g. due to distance from the hospital, storage, supply or mobility/transport problems) it may be appropriate for the GP to be asked to prescribe a Red drug. This should be negotiated on an individual patient basis and should only be done with the GP’s prior informed agreement where the roles of the GP and hospital services are clearly defined and agreed. The GP should not feel under pressure to prescribe in these circumstances. For all RED drugs automatically added to the formulary in response to a positive NICE TA: Prescribers need to ensure that local Trust new drug governance procedures and pharmacy processes are followed before any prescribing.  

Amber

Drugs initiated by hospital specialist, but where continuing treatment by GPs may be appropriate under a shared care arrangement. The specialist should send the GP a copy of the shared care agreement to sign. The GP should sign the shared care agreement, or indicate they do not want to be part of such an agreement, and return a copy back to the specialist. Shared care guidelines are available or are being developed for most of the drugs listed as Amber. If no shared care guideline is available, the hospital specialist should provide the patient’s GP with sufficient information and support to allow treatment to be continued and managed safely in primary care.  

Green plus

Drugs normally recommended or initiated by a specialist (hospital or GP with an extended role https://www.rcgp.org.uk/gpwer), but can be safely maintained in primary care with very little or no monitoring required. In some cases there may be a further restriction for use outlined - these will be defined in each case. Provision of additional information, or an information leaflet, may be appropriate in some cases to facilitate continuing treatment by GPs.  

Green

Drugs where prescribing by GPs is appropriate. Can be initiated and prescribed in all care settings, and if appropriate, discontinued without recourse to secondary care.  

Black

NOT APPROVED: Drugs that have been considered by NTAG or the NENC ICB Medicines Subcommittee (or other approved body) and are not approved for prescribing within the North East and North Cumbria.   

Brown

UNDER REVIEW: drugs whose current formulary status or RAG status is currently under review.  

Not Recomended

NOT REVIEWED: Drugs that haven not been reviewed yet. This usually means that an application is in progress. These drugs are not normally considered appropriate for prescribing in the North East and North Cumbria until such time that a decision is taken on their formulary status.  

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