l BREAST FEEDING Manufacturer advises avoid.
l HEPATIC IMPAIRMENT Manufacturer advises caution (risk
of increased plasma concentrations).
Manufacturer advises for modified-release tablets,
initially 50 mg daily, increased daily in steps of 50 mg.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension, oral
CAUTIONARY AND ADVISORY LABELS 2, 23, 25
▶ Atrolak XL (Accord Healthcare Ltd)
Quetiapine (as Quetiapine fumarate) 50 mg Atrolak XL 50mg
tablets | 60 tablet P £67.65 DT = £67.66
Quetiapine (as Quetiapine fumarate) 150 mg Atrolak XL 150mg
tablets | 60 tablet P £107.45 DT = £113.10
Quetiapine (as Quetiapine fumarate) 200 mg Atrolak XL 200mg
tablets | 60 tablet P £113.09 DT = £113.10
Quetiapine (as Quetiapine fumarate) 300 mg Atrolak XL 300mg
tablets | 60 tablet P £169.99 DT = £170.00
Quetiapine (as Quetiapine fumarate) 400 mg Atrolak XL 400mg
tablets | 60 tablet P £226.19 DT = £226.20
▶ Biquelle XL (Aspire Pharma Ltd)
Quetiapine (as Quetiapine fumarate) 50 mg Biquelle XL 50mg
tablets | 60 tablet P £29.45 DT = £67.66
Quetiapine (as Quetiapine fumarate) 150 mg Biquelle XL 150mg
tablets | 60 tablet P £49.45 DT = £113.10
Quetiapine (as Quetiapine fumarate) 200 mg Biquelle XL 200mg
tablets | 60 tablet P £49.45 DT = £113.10
Quetiapine (as Quetiapine fumarate) 300 mg Biquelle XL 300mg
tablets | 60 tablet P £74.45 DT = £170.00
Quetiapine (as Quetiapine fumarate) 400 mg Biquelle XL 400mg
tablets | 60 tablet P £98.95 DT = £226.20
Quetiapine (as Quetiapine fumarate) 50 mg Brancico XL 50mg
tablets | 60 tablet P £12.00 DT = £67.66
Quetiapine (as Quetiapine fumarate) 150 mg Brancico XL 150mg
tablets | 60 tablet P £26.00 DT = £113.10
Quetiapine (as Quetiapine fumarate) 200 mg Brancico XL 200mg
tablets | 60 tablet P £26.00 DT = £113.10
Quetiapine (as Quetiapine fumarate) 300 mg Brancico XL 300mg
tablets | 60 tablet P £45.00 DT = £170.00
Quetiapine (as Quetiapine fumarate) 400 mg Brancico XL 400mg
tablets | 60 tablet P £60.00 DT = £226.20
▶ Mintreleq XL (Aristo Pharma Ltd)
Quetiapine (as Quetiapine fumarate) 50 mg Mintreleq XL 50mg
tablets | 60 tablet P £14.99 DT = £67.66
Quetiapine (as Quetiapine fumarate) 150 mg Mintreleq XL 150mg
tablets | 60 tablet P £29.99 DT = £113.10
Quetiapine (as Quetiapine fumarate) 200 mg Mintreleq XL 200mg
tablets | 60 tablet P £29.99 DT = £113.10
Quetiapine (as Quetiapine fumarate) 300 mg Mintreleq XL 300mg
tablets | 60 tablet P £49.99 DT = £170.00
Quetiapine (as Quetiapine fumarate) 400 mg Mintreleq XL 400mg
tablets | 60 tablet P £64.99 DT = £226.20
▶ Seroquel XL (AstraZeneca UK Ltd)
Quetiapine (as Quetiapine fumarate) 50 mg Seroquel XL 50mg
tablets | 60 tablet P £67.66 DT = £67.66
Quetiapine (as Quetiapine fumarate) 150 mg Seroquel XL 150mg
tablets | 60 tablet P £113.10 DT = £113.10
Quetiapine (as Quetiapine fumarate) 200 mg Seroquel XL 200mg
tablets | 60 tablet P £113.10 DT = £113.10
Quetiapine (as Quetiapine fumarate) 300 mg Seroquel XL 300mg
tablets | 60 tablet P £170.00 DT = £170.00
Quetiapine (as Quetiapine fumarate) 400 mg Seroquel XL 400mg
tablets | 60 tablet P £226.20 DT = £226.20
Quetiapine (as Quetiapine fumarate) 50 mg Sondate XL 50mg
tablets | 60 tablet P £11.99 DT = £67.66
Quetiapine (as Quetiapine fumarate) 150 mg Sondate XL 150mg
tablets | 60 tablet P £25.99 DT = £113.10
Quetiapine (as Quetiapine fumarate) 200 mg Sondate XL 200mg
tablets | 60 tablet P £25.99 DT = £113.10
Quetiapine (as Quetiapine fumarate) 300 mg Sondate XL 300mg
tablets | 60 tablet P £44.99 DT = £170.00
Quetiapine (as Quetiapine fumarate) 400 mg Sondate XL 400mg
tablets | 60 tablet P £59.99 DT = £226.20
▶ Zaluron XL (Fontus Health Ltd)
Quetiapine (as Quetiapine fumarate) 50 mg Zaluron XL 50mg
tablets | 60 tablet P £27.96 DT = £67.66
Quetiapine (as Quetiapine fumarate) 150 mg Zaluron XL 150mg
tablets | 60 tablet P £46.96 DT = £113.10
Quetiapine (as Quetiapine fumarate) 200 mg Zaluron XL 200mg
tablets | 60 tablet P £46.96 DT = £113.10
Quetiapine (as Quetiapine fumarate) 300 mg Zaluron XL 300mg
tablets | 60 tablet P £70.71 DT = £170.00
Quetiapine (as Quetiapine fumarate) 400 mg Zaluron XL 400mg
tablets | 60 tablet P £93.98 DT = £226.20
CAUTIONARY AND ADVISORY LABELS 2
▶ Quetiapine (Non-proprietary)
Quetiapine (as Quetiapine fumarate) 25 mg Quetiapine 25mg
tablets | 60 tablet P £38.05 DT = £1.70
Quetiapine (as Quetiapine fumarate) 100 mg Quetiapine 100mg
tablets | 60 tablet P £113.10 DT = £3.46
Quetiapine (as Quetiapine fumarate) 150 mg Quetiapine 150mg
tablets | 60 tablet P £113.10 DT = £4.45
Quetiapine (as Quetiapine fumarate) 200 mg Quetiapine 200mg
tablets | 60 tablet P £133.10 DT = £5.68
Quetiapine (as Quetiapine fumarate) 300 mg Quetiapine 300mg
tablets | 60 tablet P £170.00 DT = £6.66
▶ Seroquel (AstraZeneca UK Ltd)
Quetiapine (as Quetiapine fumarate) 25 mg Seroquel 25mg tablets
| 60 tablet P £48.60 DT = £1.70
Quetiapine (as Quetiapine fumarate) 100 mg Seroquel 100mg
tablets | 60 tablet P £135.72 DT = £3.46
Quetiapine (as Quetiapine fumarate) 200 mg Seroquel 200mg
tablets | 60 tablet P £135.72 DT = £5.68
Quetiapine (as Quetiapine fumarate) 300 mg Seroquel 300mg
tablets | 60 tablet P £204.00 DT = £6.66
CAUTIONARY AND ADVISORY LABELS 2
▶ Quetiapine (Non-proprietary)
Quetiapine (as Quetiapine fumarate) 20 mg per 1 ml Quetiapine
20mg/ml oral suspension sugar free sugar-free | 150 ml P £95.00
l DRUG ACTION Risperidone is a dopamine D2, 5-HT2A,
alpha1-adrenoceptor, and histamine-1 receptor
Schizophrenia and other psychoses in patients tolerant to
risperidone by mouth and taking oral risperidone up to
▶ BY DEEP INTRAMUSCULAR INJECTION
▶ Adult: Initially 25 mg every 2 weeks, to be administered
into the deltoid or gluteal muscle, adjusted in steps of
12.5 mg (max. per dose 50 mg every 2 weeks) at
intervals of at least 4 weeks, during initiation
402 Mental health disorders BNF 78
risperidone by mouth may need to be continued for
4–6 weeks; risperidone by mouth may also be used
during dose adjustment of depot injection
Schizophrenia and other psychoses in patients tolerant to
risperidone by mouth and taking oral risperidone over
▶ BY DEEP INTRAMUSCULAR INJECTION
▶ Adult: Initially 37.5 mg every 2 weeks, adjusted in steps
of 12.5 mg (max. per dose 50 mg every 2 weeks) at
intervals of at least 4 weeks, during initiation
risperidone by mouth may need to be continued for
4–6 weeks; risperidone by mouth may also be used
during dose adjustment of depot injection
▶ Adult: 2 mg daily in 1–2 divided doses for day 1, then
4 mg daily in 1–2 divided doses for day 2, slower
titration is appropriate in some patients, usual dose
4–6 mg daily, doses above 10 mg daily only if benefit
considered to outweigh risk; maximum 16 mg per day
▶ Elderly: Initially 500 micrograms twice daily, then
increased in steps of 500 micrograms twice daily,
increased to 1–2 mg twice daily
▶ Adult: Initially 2 mg once daily, then increased in steps
of 1 mg daily if required; usual dose 1–6 mg daily
▶ Elderly: Initially 500 micrograms twice daily, then
increased in steps of 500 micrograms twice daily,
increased to 1–2 mg twice daily
Short-term treatment (up to 6 weeks) of persistent
aggression in patients with moderate to severe
Alzheimer’s dementia unresponsive to nonpharmacological interventions and when there is a risk
▶ Adult: Initially 250 micrograms twice daily, then
increased in steps of 250 micrograms twice a day on
alternate days, adjusted according to response; usual
dose 500 micrograms twice daily (max. per dose 1 mg
Risperidone has been confused with ropinirole; care
must be taken to ensure the correct drug is prescribed
syndrome). dehydration . dementia with Lewy bodies . prolactin-dependent tumours
▶ With intramuscular use when transferring from oral to depot
therapy, the dose by mouth should be reduced gradually
l INTERACTIONS → Appendix 1: risperidone
▶ Common or very common Anaemia . anxiety . appetite
congestion . nausea . oedema . oral disorders . pain . sexual
dysfunction . skin reactions . sleep disorders . urinary
disorders . vision disorders . weight decreased
▶ Uncommon Alopecia . breast abnormalities . cardiac
consciousness impaired . cystitis . diabetes mellitus . dry
eye . dysarthria . dysphagia . dysphonia . ear pain . eye
▶ Rare or very rare Angioedema . dandruff. diabetic
▶ Frequency not known Cardiac arrest
l PREGNANCY Use only if potential benefit outweighs risk.
l BREAST FEEDING Use only if potential benefit outweighs
risk—small amount present in milk.
l HEPATIC IMPAIRMENT Manufacturer advises caution.
Dose adjustments ▶ With intramuscular use Manufacturer
advises if an oral dose of at least 2 mg daily tolerated,
25 mg as a depot injection can be given every 2 weeks (no
▶ With oral use Manufacturer advises dose reduction to half
the usual dose, and slower dose titration.
Dose adjustments Initial and subsequent oral doses should
▶ With intramuscular use Treatment requires careful
monitoring for optimum effect.
l DIRECTIONS FOR ADMINISTRATION
▶ With oral use Orodispersible tablets should be placed on the
tongue, allowed to dissolve and swallowed. Oral liquid may
be diluted with any non-alcoholic drink, except tea.
▶ With intramuscular use Correct injection technique
(including the use of z-track technique) and rotation of
injection sites are essential.
▶ With oral use Patients or carers should be given advice on
how to administer risperidone orodispersible tablets and
oral liquid (counselling on use of dose syringe advised).
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral solution
CAUTIONARY AND ADVISORY LABELS 2
▶ Risperidone (Non-proprietary)
Risperidone 500 microgram Risperidone 500microgram tablets | 20 tablet P £6.95 DT = £2.76
Risperidone 1 mg Risperidone 1mg tablets | 20 tablet P £10.16
DT = £4.02 | 60 tablet P £1.56–£19.75
Risperidone 2 mg Risperidone 2mg tablets | 60 tablet P £60.10
Risperidone 3 mg Risperidone 3mg tablets | 60 tablet P £88.38
Risperidone 4 mg Risperidone 4mg tablets | 60 tablet P £116.67 DT = £32.74
Risperidone 6 mg Risperidone 6mg tablets | 28 tablet P £50.91
▶ Risperdal (Janssen-Cilag Ltd)
Risperidone 500 microgram Risperdal 500microgram tablets |
Risperidone 1 mg Risperdal 1mg tablets | 20 tablet P £8.36 DT
Risperidone 2 mg Risperdal 2mg tablets | 60 tablet P £34.62 DT
Risperidone 3 mg Risperdal 3mg tablets | 60 tablet P £50.91 DT
Risperidone 4 mg Risperdal 4mg tablets | 60 tablet P £67.20 DT
Risperidone 6 mg Risperdal 6mg tablets | 28 tablet P £67.88 DT
BNF 78 Psychoses and schizophrenia 403
CAUTIONARY AND ADVISORY LABELS 2
▶ Risperidone (Non-proprietary)
Risperidone 1 mg per 1 ml Risperidone 1mg/ml oral solution sugar
free sugar-free | 100 ml P £58.22 DT = £3.43
▶ Risperdal (Janssen-Cilag Ltd)
Risperidone 1 mg per 1 ml Risperdal 1mg/ml oral solution sugarfree | 100 ml P £37.01 DT = £3.43
Powder and solvent for suspension for injection
▶ Risperdal Consta (Janssen-Cilag Ltd)
Risperidone 25 mg Risperdal Consta 25mg powder and solvent for
suspension for injection vials | 1 vial P £79.69 DT = £79.69
Risperidone 37.5 mg Risperdal Consta 37.5mg powder and solvent
for suspension for injection vials | 1 vial P £111.32 DT = £111.32
Risperidone 50 mg Risperdal Consta 50mg powder and solvent for
suspension for injection vials | 1 vial P £142.76 DT = £142.76
CAUTIONARY AND ADVISORY LABELS 2
EXCIPIENTS: May contain Aspartame
▶ Risperidone (Non-proprietary)
Risperidone 500 microgram Risperidone 500microgram
orodispersible tablets sugar free sugar-free | 28 tablet P £18.64
Risperidone 1 mg Risperidone 1mg orodispersible tablets sugar free
sugar-free | 28 tablet P £21.66 DT = £21.66
Risperidone 2 mg Risperidone 2mg orodispersible tablets sugar free
sugar-free | 28 tablet P £39.65 DT = £39.59
Risperidone 3 mg Risperidone 3mg orodispersible tablets sugar free
sugar-free | 28 tablet P £43.50 DT = £43.50
Risperidone 4 mg Risperidone 4mg orodispersible tablets sugar free
sugar-free | 28 tablet P £50.27 DT = £50.27
ANTIPSYCHOTICS › SECONDGENERATION (DEPOT INJECTIONS) eiiiF 384i
Maintenance in schizophrenia in patients tolerant to
olanzapine by mouth (patients taking 10 mg oral
▶ BY DEEP INTRAMUSCULAR INJECTION
▶ Adult 18–75 years: Initially 210 mg every 2 weeks,
alternatively initially 405 mg every 4 weeks, then
maintenance 150 mg every 2 weeks, alternatively
maintenance 300 mg every 4 weeks, maintenance dose
to be started after 2 months of initial treatment, dose
to be administered into the gluteal muscle, consult
product literature if supplementation with oral
Maintenance in schizophrenia in patients tolerant to
olanzapine by mouth (patients taking 15 mg oral
▶ BY DEEP INTRAMUSCULAR INJECTION
▶ Adult 18–75 years: Initially 300 mg every 2 weeks, then
maintenance 210 mg every 2 weeks, alternatively
maintenance 405 mg every 4 weeks, maintenance dose
to be started after 2 months of initial treatment, dose
to be administered into the gluteal muscle, consult
product literature if supplementation with oral
Maintenance in schizophrenia in patients tolerant to
olanzapine by mouth (patients taking 20 mg oral
▶ BY DEEP INTRAMUSCULAR INJECTION
▶ Adult: Initially 300 mg every 2 weeks, then
maintenance 300 mg every 2 weeks (max. per dose
300 mg every 2 weeks), adjusted according to response,
dose to be administered into the gluteal muscle,
consult product literature if supplementation with oral
When prescribing, dispensing or administering, check
that this is the correct preparation—this preparation is
used for maintenance treatment and should not be used
for the rapid control of an acute episode.
l CAUTIONS Bone-marrow depression . hypereosinophilic
transferring from oral to depot therapy, the dose by mouth
l INTERACTIONS → Appendix 1: olanzapine
▶ Uncommon Abdominal distension . alopecia . breast
▶ Rare or very rare Drug reaction with eosinophilia and
▶ Frequency not known Erythema . gait abnormal . increased
risk of fall . pneumonia . visual hallucinations
SIDE-EFFECTS, FURTHER INFORMATION Side-effects may
persist until the drug has been cleared from its depot site.
Overdose Post-injection reactions have been reported
leading to signs and symptoms of overdose.
l PREGNANCY Use only if potential benefit outweighs risk;
neonatal lethargy, tremor, and hypertonia reported when
l BREAST FEEDING Avoid—present in milk.
l HEPATIC IMPAIRMENT Manufacturer advises caution.
Dose adjustments Manufacturer advises consider initial
Dose adjustments Initially 150 mg every 4 weeks.
▶ Observe patient for at least 3 hours after injection.
▶ Treatment requires careful monitoring for optimum effect.
▶ Blood lipids and weight should be measured at baseline, at
3 months (weight should be measured at frequent intervals
during the first 3 months), and then yearly with
antipsychotic drugs. Patients taking olanzapine require
more frequent monitoring of these parameters: every
3 months for the first year, then yearly.
▶ Fasting blood glucose should be measured at baseline, at
4–6 months, and then yearly. Patients taking olanzapine
should have fasting blood glucose tested at baseline, after
one months’ treatment, then every 4–6 months.
l DIRECTIONS FOR ADMINISTRATION Correct injection
technique (including use of z-track technique) and
rotation of injection sites are essential.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Powder and solvent for suspension for injection
▶ Zypadhera (Eli Lilly and Company Ltd)
Olanzapine (as Olanzapine embonate monohydrate)
210 mg Zypadhera 210mg powder and solvent for suspension for
injection vials | 1 vial P £142.76 DT = £142.76
Olanzapine (as Olanzapine embonate monohydrate)
300 mg Zypadhera 300mg powder and solvent for suspension for
injection vials | 1 vial P £222.64 DT = £222.64
404 Mental health disorders BNF 78
Olanzapine (as Olanzapine embonate monohydrate)
405 mg Zypadhera 405mg powder and solvent for suspension for
injection vials | 1 vial P £285.52 DT = £285.52
Motor neurone disease 17-May-2017
Motor neurone disease is a neurodegenerative condition
affecting the brain and spinal cord. Degeneration of motor
neurones leads to progressive muscle weakness; resulting
symptoms include muscle cramps, wasting and stiffness, loss
of dexterity, reduced respiratory function and cognitive
dysfunction. The most common form is amyotrophic lateral
g Patients suspected of having developed motor
neurone disease should be referred to a neurologist without
As there is no cure, treatment focuses on maintaining
functional ability and managing symptoms.
Non-drug treatment includes nutrition, psychosocial
support, physiotherapy, exercise programmes and use of
special equipment or mobility aids.
g Quinine p. 619 [unlicensed indication] is recommended
as first line treatment for muscle cramps. If quinine is
ineffective, not tolerated or contra-indicated, baclofen
p. 1128 [unlicensed indication] should be considered as
second line treatment. Subsequent treatment options
include tizanidine p. 1129 [unlicensed indication],
dantrolene sodium p. 1346 [unlicensed indication] or
gabapentin p. 315 [unlicensed indication].
Symptoms of muscle stiffness, spasticity or increased tone
can be managed with baclofen, tizanidine, dantrolene
sodium or gabapentin [unlicensed indication]. Treatment of
severe spasticity may require specialist referral. h
g A trial of an antimuscarinic drug [unlicensed
indication] can be considered for excessive drooling of saliva.
Glycopyrronium bromide p. 1335 is recommended in
patients who have cognitive impairment as it has fewer
central nervous system side-effects. If initial treatment is
ineffective, not tolerated or contra-indicated, referral for
specialist administration of botulinum toxin type A p. 407
[unlicensed indication] may be required.
Humidification, nebulisers and carbocisteine p. 291 can be
used to treat patients with thick, tenacious saliva. h
g Reversible causes of worsening respiratory impairment
(such as respiratory tract infections or secretion problems)
should be treated before considering other options.
Patients experiencing breathlessness can be treated with
opioids [unlicensed indication], or benzodiazepines
[unlicensed indication] if the patient’s symptoms are
exacerbated by anxiety. Non-invasive ventilation should be
considered in patients with respiratory impairment. h
Riluzole p. 1123 is licensed for use in patients with
amyotrophic lateral sclerosis to extend life or to extend the
time to mechanical ventilation—see National funding/access
Motor neurone disease: assessment and management.
National Institute for Health and Care Excellence. Clinical
guideline NG42. February 2016.
Essential tremor, chorea, tics, and
Drugs used in essential tremor, chorea, tics, and
Tetrabenazine p. 406 is mainly used to control movement
disorders in Huntington’s chorea and related disorders.
Tetrabenazine can also be prescribed for the treatment of
tardive dyskinesia if switching or withdrawing the causative
antipsychotic drug is not effective. It acts by depleting nerve
endings of dopamine. It is effective in only a proportion of
patients and its use may be limited by the development of
Haloperidol p. 386 [unlicensed indication], olanzapine
p. 398 [unlicensed indication], risperidone p. 402 [unlicensed
indication], and quetiapine p. 401 [unlicensed indication],
can also be used to suppress chorea in Huntington’s disease.
Haloperidol can also improve motor tics and symptoms of
Tourette syndrome and related choreas. Other treatments
for Tourette syndrome include pimozide p. 388 [unlicensed
indication] (important: ECG monitoring required), clonidine
hydrochloride p. 145 [unlicensed indication], and sulpiride
p. 390 [unlicensed indication]. Trihexyphenidyl
hydrochloride p. 412 in high dosage can also improve some
movement disorders; it is sometimes necessary to build the
dose up over many weeks. Chlorpromazine hydrochloride
p. 384 and haloperidol are used to relieve intractable hiccup.
Propranolol hydrochloride p. 150 or another betaadrenoceptor blocking drug may be useful in treating
essential tremor or tremors associated with anxiety or
Primidone p. 336 in some cases provides relief from benign
essential tremor; the dose is increased slowly to reduce sideeffects.
Piracetam p. 406 is used as an adjunctive treatment for
myoclonus of cortical origin. After an acute episode,
attempts should be made every 6 months to decrease or
Riluzole p. 1123 is used to extend life in patients with
motor neurone disease who have amyotrophic lateral
Torsion dystonia and other involuntary movements
Treatment with botulinum toxin type A p. 407 can be
considered after an acquired non-progressive brain injury if
rapid-onset spasticity causes postural or functional
Other drugs used for Dystonias and other involuntary
hydrochloride, p. 411 . Ropinirole, p. 424 . Rotigotine, p. 426 . Trifluoperazine, p. 390
BNF 78 Dystonias and other involuntary movements 405
ANTIPSYCHOTICS › FIRST-GENERATION
Short-term adjunctive management of psychomotor
▶ Adult: 100–200 mg 4 times a day
Agitation and restlessness in elderly
▶ Elderly: 25–50 mg 4 times a day
l CONTRA-INDICATIONS CNS depression . comatose states . phaeochromocytoma
l CAUTIONS Cerebral arteriosclerosis
l INTERACTIONS → Appendix 1: phenothiazines
l SIDE-EFFECTS Apathy . autonomic dysfunction . cardiac
arrest. cardiovascular effects . confusion . consciousness
disorder. muscle rigidity . nasal congestion . photosensitivity reaction . skin reactions . urinary
hesitation . vision blurred . withdrawal syndrome
l HEPATIC IMPAIRMENT Manufacturer advises caution.
Dose adjustments Start with small doses in severe renal
impairment because of increased cerebral sensitivity.
l LESS SUITABLE FOR PRESCRIBING Promazine
hydrochloride is less suitable for prescribing.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension, oral
CAUTIONARY AND ADVISORY LABELS 2
▶ Promazine hydrochloride (Non-proprietary)
Promazine hydrochloride 5 mg per 1 ml Promazine 25mg/5ml
syrup | 150 ml P £15.00 DT = £15.00
Promazine 25mg/5ml oral solution | 150 ml P £15.00 DT = £15.00
Promazine hydrochloride 10 mg per 1 ml Promazine 50mg/5ml
syrup | 150 ml P £17.00 DT = £17.00
Promazine 50mg/5ml oral solution | 150 ml P £17.00 DT = £17.00
CAUTIONARY AND ADVISORY LABELS 2
▶ Promazine hydrochloride (Non-proprietary)
Promazine hydrochloride 25 mg Promazine 25mg tablets | 100 tablet P £49.99 DT = £45.34
Promazine hydrochloride 50 mg Promazine 50mg tablets |
100 tablet P £76.49 DT = £76.18
Adjunctive treatment of cortical myoclonus
▶ Adult: Initially 7.2 g daily in 2–3 divided doses, then
increased in steps of 4.8 g every 3–4 days, adjusted
according to response, subsequently, attempts should
be made to reduce dose of concurrent therapy;
l CONTRA-INDICATIONS Cerebral haemorrhage . Huntington’s chorea
▶ Common or very common Anxiety . movement disorders . weight increased
▶ Uncommon Asthenia . depression . drowsiness
l HEPATIC IMPAIRMENT Manufacturer advises caution in
combined hepatic and renal impairment.
Dose adjustments Manufacturer advises dose reduction in
combined hepatic and renal impairment.
l RENAL IMPAIRMENT Avoid if eGFR less than
Dose adjustments Use two-thirds of normal dose if eGFR
; use one-third of normal dose in
2 divided doses if eGFR 30–50 mL/minute/1.73 m2
one-sixth of normal dose as a single dose if eGFR
l TREATMENT CESSATION Avoid abrupt withdrawal.
l DIRECTIONS FOR ADMINISTRATION Follow the oral
solution with a glass of water (or soft drink) to reduce
l PRESCRIBING AND DISPENSING INFORMATION Piracetam
has been used in children 16 years and over as adjunctive
treatment for cortical myoclonus.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 3
Piracetam 333.3 mg per 1 ml Nootropil 33% oral solution sugar-free
CAUTIONARY AND ADVISORY LABELS 3
Piracetam 800 mg Nootropil 800mg tablets | 90 tablet P £11.75 DT = £11.75
Piracetam 1.2 gram Nootropil 1200mg tablets | 60 tablet P £10.97 DT = £10.97
Movement disorders due to Huntington’s chorea,
hemiballismus, senile chorea, and related neurological
▶ Adult: Initially 25 mg 3 times a day, then increased, if
tolerated, in steps of 25 mg every 3–4 days; maximum
▶ Elderly: Lower initial dose may be necessary
Moderate to severe tardive dyskinesia
▶ Adult: Initially 12.5 mg daily, dose to be gradually
increased according to response
l CONTRA-INDICATIONS Depression . parkinsonism . phaeochromocytoma . prolactin-dependent tumours
l CAUTIONS Susceptibility to QT-interval prolongation
l INTERACTIONS → Appendix 1: tetrabenazine
▶ Uncommon Consciousness impaired . hyperthermia
▶ Rare or very rare Neuroleptic malignant syndrome . skeletal muscle damage
▶ Frequency not known Bradycardia . dizziness . dry mouth . epigastric pain . suicidal ideation
l PREGNANCY Avoid unless essential—toxicity in animal
l HEPATIC IMPAIRMENT Manufacturer advises caution
(increased risk of exposure), particularly in severe
impairment (no information available).
Dose adjustments Manufacturer advises initial dose
reduction of 50% and slower dose titration in mild to
l RENAL IMPAIRMENT Use with caution.
l TREATMENT CESSATION Avoid abrupt withdrawal.
Driving and skilled tasks May affect performance of skilled
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: oral suspension
CAUTIONARY AND ADVISORY LABELS 2
▶ Tetrabenazine (Non-proprietary)
Tetrabenazine 25 mg Tetrabenazine 25mg tablets | 112 tablet P £107.69 DT = £107.69
▶ Tardiben (AOP Orphan Pharmaceuticals AG)
Tetrabenazine 25 mg Tardiben 25mg tablets | 112 tablet P £100.00 DT = £107.69
▶ Xenazine (Alliance Pharmaceuticals Ltd)
Tetrabenazine 25 mg Xenazine 25 tablets | 112 tablet P £100.00 DT = £107.69
MUSCLE RELAXANTS › PERIPHERALLY ACTING ›
NEUROTOXINS (BOTULINUM TOXINS)
Botulinum toxin type A 24-Apr-2017
Treatment of focal spasticity (including hand and wrist
disability associated with stroke) (specialist use only)|
Blepharospasm (specialist use only)| Hemifacial spasm
(specialist use only)| Spasmodic torticollis (specialist
use only)| Severe hyperhidrosis of the axillae (specialist
use only)| Prophylaxis of headaches in adults with
chronic migraine (specialist use only)| Temporary
improvement of moderate to severe wrinkles between
the eyebrows in adults under 65 years (specialist use
only)| Ankle disability due to lower limb spasticity
associated with stroke (specialist use only)|
Management of bladder dysfunctions (specialist use
only)| Temporary improvement of moderate to severe
crow’s feet (specialist use only)
▶ BY SUBCUTANEOUS INJECTION, OR BY INTRADERMAL
INJECTION, OR BY INTRAMUSCULAR INJECTION
▶ Adult: (consult product literature)
DOSE EQUIVALENCE AND CONVERSION
▶ Important: information is specific to each individual
l CONTRA-INDICATIONS Acute urinary retention (specific to
use in bladder disorders only). catheterisation difficulties
(specific to use in bladder disorders only). generalised
use in bladder disorders only). urinary tract infection
(specific to use in bladder disorders only)
GENERAL CAUTIONS Atrophy in target muscle . chronic
respiratory disorder. elderly . excessive weakness in target
▶ When used for blepharospasm or hemifacial spasm Risk of
CAUTIONS, FURTHER INFORMATION Neuromuscular or
neurological disorders can lead to increased sensitivity and
exaggerated muscle weakness including dysphagia and
▶ Blepharospasm or hemifacial spasm When used for
blepharospasm and hemifacial spasm, reduced blinking
can lead to corneal exposure, persistent epithelial defect
and corneal ulceration (especially in those with VIIth
nerve disorders)—careful testing of corneal sensation in
previously operated eyes, avoidance of injection in lower
lid area to avoid ectropion, and vigorous treatment of
l INTERACTIONS → Appendix 1: botulinum toxin type A
▶ Common or very common Alopecia . asthenia . autonomic
abnormal . haematuria . headaches . hot flush . increased
risk of infection . influenza like illness . insomnia . joint
paraesthesia . photosensitivity reaction . postural
▶ Frequency not known Abdominal pain . angioedema . angle
disorders .respiratory disorders . seizure . syncope . tinnitus . vomiting
l CONCEPTION AND CONTRACEPTION Avoid in women of
child-bearing age unless using effective contraception.
l PREGNANCY Avoid unless essential—toxicity in animal
studies (manufacturer of Botox ® advise avoid).
l BREAST FEEDING Low risk of systemic absorption but
l PRESCRIBING AND DISPENSING INFORMATION
Preparations are not interchangeable.
l PATIENT AND CARER ADVICE Patients and carers should be
warned of the signs and symptoms of toxin spread, such as
muscle weakness and breathing difficulties; they should be
advised to seek immediate medical attention if swallowing,
speech or breathing difficulties occur.
l NATIONAL FUNDING/ACCESS DECISIONS
▶ Botulinum toxin type A for the prevention of headaches in
adults with chronic migraine (June 2012) NICE TA260
Botulinum toxin type A is recommended as an option for
the prophylaxis of headaches in adults with chronic
migraine, (defined as headaches on at least 15 days per
BNF 78 Dystonias and other involuntary movements 407
month, of which at least 8 days are with migraine), that
has not responded to at least three prior pharmacological
prophylaxis therapies and whose condition is
appropriately managed for medication overuse.
Scottish Medicines Consortium (SMC) decisions
The Scottish Medicines Consortium has advised that
Azzalure ® and Vistabel ® (December 2010), and Bocouture ®
(February 2011) are not recommended for use within NHS
The Scottish Medicines Consortium has advised (February
2017) that botulinum toxin type A (Botox ®) is accepted for
restricted use within NHS Scotland for the prophylaxis of
headaches in adults with chronic migraine, (defined as
headaches on at least 15 days per month, of which at least
8 days are with migraine), that has not responded to at
least three prior oral pharmacological prophylaxis
therapies and whose condition is appropriately managed
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Powder for solution for injection
▶ Azzalure (Galderma (UK) Ltd)
Botulinum toxin type A 125 unit Azzalure 125unit powder for
solution for injection vials | 1 vial P £64.00 | 2 vial P £128.00
▶ Bocouture (Merz Pharma UK Ltd)
Botulinum toxin type A 50 unit Bocouture 50unit powder for
solution for injection vials | 1 vial P £72.00
Botulinum toxin type A 100 unit Bocouture 100unit powder for
solution for injection vials | 1 vial P £229.90
Botulinum toxin type A 50 unit Botox 50unit powder for solution
for injection vials | 1 vial P £77.50
Botulinum toxin type A 100 unit Botox 100unit powder for solution
for injection vials | 1 vial P £138.20
Botulinum toxin type A 200 unit Botox 200unit powder for solution
for injection vials | 1 vial P £276.40
Botulinum toxin type A 300 unit Dysport 300unit powder for
solution for injection vials | 1 vial P £92.40
Botulinum toxin type A 500 unit Dysport 500unit powder for
solution for injection vials | 2 vial P £308.00
Botulinum toxin type A 50 unit Xeomin 50unit powder for solution
for injection vials | 1 vial P £72.00
Botulinum toxin type A 100 unit Xeomin 100unit powder for
solution for injection vials | 1 vial P £129.90
Botulinum toxin type A 200 unit Xeomin 200unit powder for
solution for injection vials | 1 vial P £259.80 (Hospital only)
Spasmodic torticollis (cervical dystonia) (specialist use
▶ Adult: Initially 5000–10 000 units, adjusted according
to response, dose to be divided between 2–4 most
DOSE EQUIVALENCE AND CONVERSION
▶ Important: information specific to each individual
l CONTRA-INDICATIONS Neuromuscular disorders . neuromuscular junctional disorders
l CAUTIONS History of dysphagia or aspiration . off-label
use (risk of toxin spread).tolerance may occur
l INTERACTIONS → Appendix 1: botulinum toxin type B
weakness . neck pain .taste altered . vision disorders
l PREGNANCY Low risk of systemic absorption but avoid
l BREAST FEEDING Low risk of systemic absorption but
l DIRECTIONS FOR ADMINISTRATION Injection may be
diluted with sodium chloride 0.9%.
l PRESCRIBING AND DISPENSING INFORMATION Important:
not interchangeable with other botulinum toxin
l PATIENT AND CARER ADVICE Patients should be warned of
the signs and symptoms of toxin spread, such as muscle
weakness and breathing difficulties; they should be
advised to seek immediate medical attention if swallowing,
speech or breathing difficulties occur.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ NeuroBloc (Sloan Pharma Sarl)
Botulinum toxin type B 5000 unit per 1 ml NeuroBloc
5,000units/1ml solution for injection vials | 1 vial P £148.27
NeuroBloc 10,000units/2ml solution for injection vials | 1 vial P £197.69 (Hospital only)
NeuroBloc 2,500units/0.5ml solution for injection vials | 1 vial P £111.20 (Hospital only)
l DRUG ACTION Inotersen is an antisense oligonucleotide
inhibitor which inhibits transthyretin production.
Stage 1 or stage 2 polyneuropathy in patients with
hereditary transthyretin amyloidosis (hATTR) (initiated
▶ Adult: 284 mg once weekly, for dose adjustments due
to side-effects and information on Vitamin A
supplementation—consult product literature
l CONTRA-INDICATIONS Patients undergoing liver
transplantation (no information available). platelet count
/litre before starting treatment. urine
protein to creatinine ratio (UPCR) greater than or equal to
113 mg/mmol before starting treatment
l CAUTIONS Concomitant administration with nephrotoxic
drugs . elderly . history of major bleeding
l INTERACTIONS → Appendix 1: inotersen
▶ Frequency not known Intracranial haemorrhage . vitamin A
l CONCEPTION AND CONTRACEPTION Manufacturer advises
women of childbearing potential should use effective
contraception during treatment; if conception is planned,
inotersen and vitamin A supplementation should be
stopped and vitamin A levels monitored—consult product
l PREGNANCY Manufacturer advises avoid unless essential
(limited information available)—potential teratogenic risk
due to unbalanced vitamin A levels, consult product
l BREAST FEEDING Manufacturer advises avoid—present in
l HEPATIC IMPAIRMENT Manufacturer advises avoid in
severe impairment (no information available).
l RENAL IMPAIRMENT Manufacturer advises avoid if eGFR
less than 45 mL/minute/1.73 m2
l PRE-TREATMENT SCREENING Manufacturer advises plasma
vitamin A levels below the lower limit of normal should be
corrected and any ocular symptoms or signs of vitamin A
deficiency should have resolved before starting treatment.
▶ Manufacturer advises monitor platelet count before
starting treatment, every 2 weeks during treatment, and
for 8 weeks after stopping treatment—consult product
▶ Manufacturer advises monitor UPCR and eGFR before
starting treatment, every 3 months or more frequently as
clinically indicated during treatment, and for 8 weeks after
stopping treatment—consult product literature.
▶ Manufacturer advises monitor hepatic enzymes before
starting treatment, then 4 months after starting
treatment, and annually thereafter or more frequently as
l DIRECTIONS FOR ADMINISTRATION Manufacturer advises
to take the syringe out of the refrigerator at least
subcutaneous injection technique.
l HANDLING AND STORAGE Manufacturer advises store in a
refrigerator (2–8°C) and protect from light—consult
product literature for further information regarding
l PATIENT AND CARER ADVICE Manufacturer advises
patients should immediately report any signs of unusual or
prolonged bleeding, neck stiffness, or atypical severe
Self-administration Manufacturer advises patients and
carers should be given training in subcutaneous injection
Missed doses If a dose is missed, the next dose should be
administered as soon as possible, unless the next
scheduled dose is within 2 days, in which case the missed
dose should not be taken and the next dose should be
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Tegsedi (Akcea Therapeutics UK Ltd) A
Inotersen (as Inotersen sodium) 189.33 mg per 1 ml Tegsedi
284mg/1.5ml solution for injection pre-filled syringes | 1 pre-filled
disposable injection P £5,925.00
Treatment of transthyretin familial amyloid
polyneuropathy (TTR-FAP) in patients with stage 1
symptomatic polyneuropathy to delay peripheral
neurological impairment (initiated under specialist
▶ Common or very common Abdominal pain upper. diarrhoea . increased risk of infection
l CONCEPTION AND CONTRACEPTION Exclude pregnancy
before treatment and ensure effective contraception
during and for one month after stopping treatment.
l PREGNANCY Avoid (toxicity in animal studies).
l BREAST FEEDING Avoid—present in milk in animal studies.
l HEPATIC IMPAIRMENT Manufacturer advises caution in
severe impairment (no information available).
l PRESCRIBING AND DISPENSING INFORMATION Tafamidis
should be prescribed in addition to standard treatment,
but before liver transplantation; it should be discontinued
in patients who undergo liver transplantation.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 25
Tafamidis 20 mg Vyndaqel 20mg capsules | 30 capsule P £10,685.00 (Hospital only)
Parkinson’s disease 14-Sep-2018
Parkinson’s disease is a progressive neurodegenerative
condition resulting from the death of dopaminergic cells of
the substantia nigra in the brain.
Patients with Parkinson’s disease classically present with
motor-symptoms including hypokinesia, bradykinesia,
rigidity, rest tremor, and postural instability.
Non-motor symptoms include dementia, depression, sleep
disturbances, bladder and bowel dysfunction, speech and
language changes, swallowing problems and weight loss.
g Patients with suspected Parkinson’s disease should
be referred to a specialist and reviewed every 6 to 12 months.
When Parkinson’s disease diagnosis is confirmed, patients
should be advised to inform the DVLA and their car insurer.
Parkinson’s disease is an incurable progressive condition,
and the aim of treatment is to control the symptoms and to
improve the patient’s quality of life.
g Parkinson’s disease patients should be offered
physiotherapy if balance or motor function problems are
present, speech and language therapy if they develop
communication, swallowing or saliva problems, and
occupational therapy if they experience difficulties with their
daily activities. Dietitian referral should be considered. h
Drug management of motor symptoms in Parkinson’s disease
g In early stages of Parkinson’s disease, patients whose
motor symptoms decrease their quality of life should be
offered levodopa combined with carbidopa (co-careldopa
p. 415) or benserazide (co-beneldopa p. 414).
Parkinson’s disease patients whose motor symptoms do
not affect their quality of life, could be prescribed a choice of
levodopa, non-ergot-derived dopamine-receptor agonists
(pramipexole p. 422, ropinirole p. 424 or rotigotine p. 426) or
monoamine-oxidase-B inhibitors (rasagiline p. 427 or
selegiline hydrochloride p. 428).
BNF 78 Parkinson’s disease 409
Before starting antiparkinsonian treatment, the patient’s
individual circumstances, including symptoms,
comorbidities and preferences, should be discussed together
with the potential benefits and harms from the different
Patients and their carers should be informed about the risk
of adverse reactions from antiparkinsonian drugs, including
psychotic symptoms, excessive sleepiness and sudden onset
of sleep with dopamine-receptor agonists, and impulse
control disorders with all dopaminergic therapy (especially
dopamine-receptor agonists). For further information see
Levodopa treatment is associated with motor
complications, including response fluctuations and
dyskinesias. Response fluctuations are characterised by large
variations in motor performance, with normal function
during the ‘on’ period, and weakness and restricted mobility
during the ‘off’ period. ‘End-of-dose’ deterioration with
progressively shorter duration of benefit can also occur.
Modified-release preparations may help with ‘end-of-dose’
deterioration or nocturnal immobility.
The overall improvement in motor performance is more
noticeable with levodopa than with dopamine-receptor
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