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OUTPATIENTS FORMULARY LIST September 2021
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Page 1: Out-Patients Formulary List

OUTPATIENTS FORMULARY LIST

September 2021

Page 2: Out-Patients Formulary List

V3.0 September 2021

2

Contents How to use the formulary ............................................................... 3

The Schedule V Chronic Conditions ................................................. 5

Dispensing ...................................................................................... 7

1. Gastro-Intestinal System ............................................................. 11

2. Cardiovascular System ................................................................ 21

3. Respiratory System ...................................................................... 35

4. Central Nervous System .............................................................. 43

5. Infections ..................................................................................... 73

6. Endocrine System ........................................................................ 99

7. Obstetrics, Gynaecology, and Urinary-tract Disorders ............. 110

8. Malignant disease and immunosuppression ............................ 112

9. Nutrition and Blood ................................................................... 124

10. Musculoskeletal and Joint Diseases ........................................ 136

11. Eye ........................................................................................... 142

12. Ear, Nose and Oropharynx ...................................................... 145

13. Skin .......................................................................................... 147

14. Anaesthesia ............................................................................. 157

15. Consumables ........................................................................... 159

A1 Borderline Substances ............................................................. 163

Index .......................................................................................... 168

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V3.0 September 2021

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How to use the formularyNote:

▪ This formulary lists medicinal products that are available within the

National Health Scheme for Out-Patients use.

▪ Medicinal products listed can be issued via a Schedule V Card (Yellow

Card) once Schedule V entitlement is in place or to Pink Card holders if

the respective item is Pink Card Positive.

▪ Certain medicinal products are protocol regulated and will be supplied

only against the relevant approval in addition to the Schedule V Card.

▪ After hours, the Resident Specialist on duty can endorse approval of

protocol-regulated drugs, provided that it is then endorsed by its

respective consultant on the next day.

Prescriber Criteria:

All Medical Practitioners, i.e. doctors working within the National Health

Services and private doctors, can change the dose of treatment for the

following conditions when an item is marked on the formulary as ‘Medical

Practitioners’ or ‘Consultant’. This includes also protocol-regulated items.

(Medicines that require permit/approval)

1. Hypertension

2. Diabetes Mellitus

3. Chronic Heart Failure

4. Asthma

5. Chronic Obstructive Pulmonary Disease

6. Treatment for hypercholesterolaemia under the respective

Schedule V conditions

7. Chronic Mood Disorders

8. Chronic Neurotic Disorders

Abbreviations

A Acute

AG Antimicrobial Guidelines

ATC Anatomical Therapeutic Chemical Classification System

B Both Acute and Chronic

C Chronic

DM Pink Card for Diabetes Mellitus Only

FPOP only From Psychiatric Out-patients Only

HU Hospital Use

MAS Medicines Approval Section

MDHP Mater Dei Hospital Pharmacy

MHCs Mental Health Clinics

MP Medicinal Protocol

N/A Not Applicable

PHCD Primary Health Care Department

SAMOCP Sir Anthony Mamo Oncology Centre Pharmacy

SPBHP Sir Paul Boffa Hospital Pharmacy

SVPRP St Vincent De Paul Residence Pharmacy

TBDF To be dispensed from

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1. ATC Code - The Anatomical Therapeutic Chemical (ATC) classification system.

2. Active Ingredient - The substance in the medicinal product that is pharmaceutically active.

3. Dosage Form and Strength - Describes the physical form and the amount of the active ingredient in the medicinal product.

4. Schedule V Prescriber Criteria - The category of medical practitioners allowed initiating treatment of a particular medicinal product for Schedule V Card entitlement.

5. Protocol - Certain medicinal products are further regulated with a medicinal protocol (patient requires MAS permit). These are marked with a number e.g. MP 177

6. Dispensing Policy - Certain medicinal products can only be dispensed from certain entities.

7. Pink Card - Medicinal products which can be issued to patients in possession of a Pink Card (Schedule II). Pink positive items are marked with ‘A’, ‘B’ or ‘C’.

8. Diabetes Mellitus - Medicinal products which can be issued to patients in possession of a Pink Card for Diabetes Mellitus only.

9. Pink Card Prescriber Criteria - The category of medical practitioners allowed prescribing a particular medicinal product for Pink Card entitlement.

10. Schedule V Entitlement - The Schedule V condition/s for which the medicinal product can be issued via Schedule V entitlement.

11. Formulary Version - The version number is changed with every minor formulary amendment.

12. Formulary Edition - The formulary edition is changed after major amendments (usually twice a year or more).

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The Schedule V Chronic Conditions

The Fifth Schedule of the Social Security Act lists the diseases and conditions

in respect of which free medicines are provided irrespective of financial

position. These are as follows:

1. Malignant Diseases

2. Cardiovascular Diseases:

(a) Chronic Heart Failure

(b) Hypertension

(c) Ischaemic Heart Disease

(d) Cardiac Arrhythmias

(e) Peripheral Vascular Disease

(f) Cerebrovascular Disease

(g) Genetic Dyslipidaemia

3. Respiratory Diseases:

(a) Chronic Respiratory Failure

(b) Cystic Fibrosis

(c) Chronic Obstructive Pulmonary Disease

(d) Chronic Asthma

4. Digestive System Diseases:

(a) Gastro – Oesophageal Reflux Disease

(b) Gastric/Duodenal Ulcers

(c) Inflammatory Bowel Disease

(d) Coeliac Disease

(e) Diverticular Disease requiring Stoma Care

(f) Hirschsprung’s Disease

(g) Imperforate Anus

(h) Small Intestinal Failure

5. Liver Diseases:

(a) Chronic Liver Disease

6. Haematological Diseases:

(a) Inherited Bleeding Disorders

(b) Inherited Haemoglobinopathies

7. Nervous System Diseases:

(a) Epilepsy

(b) Parkinson’s disease

(c) Myasthenia Gravis

(d) Multiple Sclerosis

(e) Motor Neurone Disease

(f) Trigeminal Neuralgia

(g) Huntington’s Chorea

(h) Dementia

(i) Schizophrenia

(j) Psychosis

(k) Chronic Mood Disorders

(l) Chronic Neurotic Disorders

(m) Addiction Disorders

(n) Chronic Psychiatric Disorders starting in Childhood

(o) Chronic Eating Disorders

(p) Cerebral Palsy

(q) Narcolepsy

(r) Spinal Cord Pathologies

(s) Congenital indifference to pain

(t) Neuromyelitis Optica

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8. Renal Diseases:

(a) Chronic Kidney Disease

9. Endocrine Diseases:

(a) Diabetes Mellitus

(b) Addison’s Disease

(c) Precocious Puberty

(d) Hypoparathyroidism

(e) Hypopituitarism

(f) Hypogonadism

(g) Enzyme Disorders

(h) Endometriosis and Adenomyosis

(i) Pituitary Adenomas

(j) Benign Prostatic Enlargement

10. Skin Diseases:

(a) Psoriasis

(b) Chronic Immunobullous Disorders

(c) Congenital Ichthyosis

(d) Hidradenitis Suppurativa

(e) Severe Refractory Atopic Dermatitis

(f) Severe Chronic Urticaria

11. Infectious Diseases:

(a) HIV/AIDS and HIV Related Diseases

(b) Hepatitis B & C

(c) Tuberculosis

(d) Hospital Acquired Infections

(e) Leprosy

(f) Polio and Post-Polio Syndrome

(g) Chronic Osteomyelitis

12. Rheumatic Diseases:

(a) Rheumatoid Arthritis

(b) Paget’s Disease

(c) Lupus Erythematosus

(d) Systemic Sclerosis

(e) Dermatomyositis/Polymyositis

(f) Polyarteritis Nodosa

(g) Spondyloarthritis

(h) Crystal Deposition Disease

(i) Polymyalgia Rheumatica

(j) Myalgic Encephalomyelitis

(k) Fibromyalgia

13. Metabolic Disorders:

a) Inborn errors of Metabolism

14. Eye Diseases:

(a) Glaucoma

(b) Vascular Disease of the Retina

15. Immunodeficiency:

(a) Primary Immunodeficiency Disorder

(b) Secondary Immunodeficiency Disorder

16. Chromosome Disorders:

(a) Down Syndrome

(b) Turner Syndrome

(c) Prader-Willi Syndrome

17. Gender Identity & Sex Characteristics Related Conditions

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Dispensing

When dispensing a formulary item, patient should present:

▪ Valid Schedule V card

▪ Prescription (white prescription [DH 46] and/or green prescription [DH

129] + Control card [DH680i])

▪ Patient’s ID card and ID card of person who comes to collect the

medicines on the patient’s behalf

When dispensing a protocol regulated item, patient should present:

▪ Approval form

▪ Valid Schedule V card

▪ Prescription (white form [DH 46] and/or green form [DH 129] + Control

card [DH680i])

▪ Patient’s ID card and ID card of person who comes to collect the

medicines on the patient’s behalf

If an item is added to the Schedule V card in ink and endorsed by the

Consultant, the patient should be directed to the Medicines Approval

Section (POYC), St Luke’s Hospital in order to have the necessary

amendments made to their entitlement documents and POYC records. The

necessary medicinal supplies will be sent to the respective community

pharmacy at the earliest possible. This does not apply to particularly

vulnerable patient groups and conditions requiring urgent treatment e. g.

Malignancy

If a Schedule V card is valid and there is no more space to log in dispensing

entries, patients should not be sent to the Medicines Approval Section

(POYC) [Formerly known as the Schedule V office] for a Continuation

Sheet/Card. Instead, a Continuation Sheet/Card is attached to the Schedule

V card, by the dispenser. The Continuation Sheet/Card is only valid if

attached to the valid issued Schedule V card. Dispensers are to make sure

that they have Continuation Sheets readily available.

If the Schedule V card is expired, the dispenser should dispense the items

once and instruct the patient to fix an appointment with the Consultant for

the renewal. The endorsed Schedule V request can then be left at Mater

Dei Hospital Pharmacy or sent to the Medicines Approval Section (POYC).

If a Schedule V Card Application with the relevant prescriptions is

presented, the dispenser should dispense the items once and instruct the

patient to leave the application at Mater Dei Hospital Pharmacy or send it

to the Medicines Approval Section (POYC).

Protocol Regulated Drugs

The requests for these drugs should be sent to the Medicines Approval

Section (POYC) to be reviewed accordingly. The approval is given according

to the individual protocols and approved for a stated duration (in months

or years) depending on the specific item.

If the approval is expired, the dispenser should dispense the item once and

instruct the patient to fix an appointment with the Consultant for the

renewal requests endorsement. The endorsed request should be left at

Mater Dei Hospital Pharmacy or sent to the Medicines Approval Section

(POYC).

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If a request for a protocol regulated drug with the relevant prescription is

presented, the dispenser may dispense items for one month only if the

item is according to protocol.

Schedule V Cards with Codes Instead of Patient’s Name

Certain Schedule V cards are issued with a code instead of the patient’s

name. The treatment covered by these Schedule V cards should be

dispensed from hospitals only.

Pink Positive Drugs (Drugs available for Schedule II holders)

Pink card positive drugs were classified into acute (A), chronic (C) and both

acute and chronic use (B).

(A) – Items for Acute Use

Medicines are classified as (A) for conditions where treatment should have

a rapid onset and is of short duration.

(C) – Items for Chronic Use

Medicines are classified as being for chronic use if they are utilized for the

treatment of an ongoing or recurring condition.

(B) – Items for Both Acute and Chronic use

Medicines which can be used both for short a duration of use and for an

ongoing or recurrent condition.

Genitourinary (GU) Clinic Entitlement

A legal notice (LN 188/2009) was issued containing a list of medicines that

can be dispensed by the consultant from the GU Clinic.

The legal notice entitled ‘Provision of Medicinal Products through the

Genitourinary Clinic within the Government Health Services Rules’ states

that:

The medicinal products listed in the Schedule shall only be provided by the

consultant to patients attending or who have been referred to the clinic.

The consultant shall:

a. Provide the medicinal products referred to in the Schedule, directly to

patients attending the clinic, and he shall keep a record thereof;

b. Dispense only those amounts which are needed for the period

specified therein;

c. Immediately notify the Authority of any amendment needed in the

Schedule;

d. Inform the Authority of the address of the clinic and of any changes in

such an address;

e. Be responsible for all duties and obligations relating to the provision of

medicinal products to patients under the Act and any regulations or

rules made thereunder, and for standards and conditions issued by the

Authority from time to time in relation to dispensing;

f. Keep such amount of medicinal products as per internal arrangements

with the hospital pharmacy in order to ensure continuation of service

at the clinic;

g. Take all reasonable precautions to ensure appropriate storage and

dispensing of medicinal products;

h. Keep updated, written, and agreed procedures with the hospital

pharmacy supplying the medicinal products.

Page 9: Out-Patients Formulary List

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List of medicinal products authorized for the purpose of these rules

1. Doxycycline 100mg bd for 7 days. (Occasionally for 14 days in

epididymitis and rarely for 28 days in LGV and Latent Syphilis)

2. Erythromycin 250mg - two tablets daily for 7 days

3. Metronidazole 200mg tablets - 2 tablets daily for 7 days

4. Ceftriaxone 500mg IM injections and 1% lignocaine injection for

dilution to be given as stat dose

5. Spectinomycin 2g IM stat

6. Benzathine Penicillin 1.2 million units IM injections and 1% lignocaine

injection for dilution to be given as stat dose of 2.4 million units.

7. Clotrimazole 100mg pessaries

8. Podophyllotoxin 0.15% cream

9. Podophyllotoxin 0.5% topical solution

10. Aciclovir 200mg to be given as 400mg tds for 7 days for acute episodes

11. Prednisolone 5mg to be given as 20mg tds for 3

12. Amoxicillin 250mg to be given as 500mg tds for 5 days

13. Azithromycin 250mg and 500mg

When dispensing one of the above mentioned drugs, a patient needs only

to present a prescription from GU consultant; there is no need of a

Schedule II card (Pink Card) or a Schedule V card. This applies for the 13

drugs mentioned in the Legal Notice only.

Renewals by Specialists in Family Medicine Working in the Private Sector

Specialists in Family Medicine working in the private sector can apply for

the renewal of Schedule V cards for dyslipidaemia and hypertension

medicines using the Medicines Approval Section (MAS) Application forms.

Renewals will be for patients suffering from Hypertension and/or

Dyslipidaemia as per table below:

Patients with co-morbid conditions (other than hypertension and

dyslipidaemia) necessitating other treatment should still be referred to the

relevant specialist medical professionals as usual. MAS Applications for the

renewal of multiple conditions will not be accepted.

Antibiotics for Treatment of Diabetes Related Infections

The following antibiotics can be prescribed for Diabetes Mellitus Type 1 or

Type 2 by doctors in the community. Prescriptions cannot exceed ten (10)

days duration and the number of episodes should not exceed three per

calendar year. If longer courses are believed to be required, advice from

respective caring physician should be sought. The antibiotics include:

a. Amoxicillin Capsules 250mg, Syrup 125mg/5mL

b. Amoxicillin + Clavulanic Acid Tablets 250mg + 125mg

c. Cefalaxin Capsules 250mg, Syrup 125mg/5mL

d. Doxycycline Capsules 100mg

e. Erythromycin Capsules/Tablets 250mg, Syrup 125mg/5mL

f. Flucloxacillin Capsules 250mg, Syrup 125mg/5mL

g. Metronidazole Tablets 200mg, Suspension 200mg/5mL

h. Nitrofurantoin Tablets 50mg, Syrup 25mg/5mL

Condition Medicines which can be Renewed by Specialists in

Family Medicine Working in the Private Sector

Hypertension Anti-Hypertensive Medicines

Dyslipidaemia Atorvastatin, Bezafibrate, Fenofibrate, Simvastatin,

Rosuvastatin

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Dispensing of Oral Antimalarials to Out-Patients

Oral antimalarials are given free of charge to the following:

1. Persons undertaking missionary service or humanitarian aid abroad.

Claims in this category must be accompanied by:

- A letter by the Head of the organisation explaining the nature

of the mission abroad

- Registration number of the voluntary organisation on the

National VO Register

- Country/countries to be visited during the course of the mission

- Start and end dates of the mission abroad

- Beneficiaries of the project to be undertaken

- Contact details of host person/organisation in country where

mission is to be carried out

2. Adoptive and foster parents who are to travel abroad to adopt or foster

a child.

3. All sportsmen/women representing Malta in official International

Competitions

4. The President of Malta and his Office, the Chief Justice, the Prime

Minister and Parliamentary delegations.

Other Information

Formulary Management

Website: www.pharmaceuticalaffairs.gov.mt

Email: [email protected]

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11 1. Gastro-Intestinal System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

1. Gastro-Intestinal System 1.1 Dyspepsia and gastro-oesophageal reflux disease

1.1.1 Antacids and simeticone A02AX Magnesium

Hydroxide + Aluminium Hydroxide + Simeticone

Oral Liquid Consultants A Medical Practitioners Gastro-Oesophageal Reflux Disease, Malignant Diseases

A02AX Antacid Chewable Tablets

Consultants A Medical Practitioners Gastro-Oesophageal Reflux Disease

1.2 Antispasmodics and other drugs altering gut motility A03BA01 Atropine

Sulphate Tablets 0.5mg Consultant Neurologists,

Consultant Geriatricians, Consultant Paediatricians

MP 13 Cerebral Palsy, Motor Neuron Disease, Myasthenia Gravis

A03BB01 Hyoscine Butylbromide

Injections 20mg

Consultant Palliative Care TBDF Hospitals

only

Malignant Diseases

A03BB01 Hyoscine Butylbromide

Tablets 10mg Consultants A Medical Practitioners Inflammatory Bowel Disease, Malignant Diseases

A03AA04 Mebeverine

Hydrochloride*

Tablets 135mg Consultants C Medical Practitioners Inflammatory Bowel Disease, Malignant Diseases

* Availability temporarily suspended due to problematic sourcing.

Page 12: Out-Patients Formulary List

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12 1. Gastro-Intestinal System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

1.3 Antisecretory drugs and mucosal protectants 1.3.1 H2-Receptor antagonists

A02BA02 Ranitidine Syrup

75mg/5mL#

Consultant Gastroenterologists, Consultant Geriatricians, Consultant Oncologists, Consultant Paediatric Oncologist, Consultant Paediatricians, Consultant Palliative Care

Spinal Cord Pathologies, Gastric/Duodenal

Ulcers, Gastro-Oesophageal Reflux Disease, Chronic Liver Disease, Malignant Diseases

EXTEMP13

Ranitidine Syrup 75mg/5mL (Extemp - Alcohol free)*

Consultant Paediatricians Spinal Cord Pathologies, Gastric/Duodenal Ulcers, Gastro-Oesophageal Reflux Disease, Chronic Liver Disease, Malignant Diseases

A02BA02 Ranitidine Tablets 150mg*

Consultants B Medical Practitioners Spinal Cord Pathologies, Gastric/Duodenal Ulcers, Gastro-Oesophageal Reflux Disease, Chronic Liver Disease, Malignant Diseases, Lupus Erythematosus, Polyartritis Nodosa, Polymyalgia Rheumatica, Rheumatoid Arthritis, Spondyloarthritis, Systemic Sclerosis

1.3.2 Chelates and complexes A02BX02 Sucralfate Oral Liquid

1g/5mL Consultants C Consultants Gastric/Duodenal Ulcers, Gastro-Oesophageal

Reflux Disease

Availability temporarily suspended due to the current shortage. # Omeprazole MUPS tablets are currently available instead of ranitidine syrup. Omeprazole MUPS tablets should only be used as per SPC.

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13 1. Gastro-Intestinal System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

1.3.3 Prostaglandin analogues A02BB01 Misoprostol Tablets

200mcg Consultant Rheumatologists, Consultant Gastroenterologists, Consultant Obstetrics & Gynaecology, Consultant Cardiologists, Consultant Cardiac Surgeons

MP 132 Ischaemic Heart Disease

1.3.4 Proton pump inhibitors A02BC01 Omeprazole Capsules

20mg Consultants B Medical Practitioners Spinal Cord Pathologies, Gastric/Duodenal

Ulcers, Gastro-Oesophageal Reflux Disease, Chronic Liver Disease, Malignant Diseases, Crystal Deposition Disease, Lupus Erythematosus, Paget's Disease, Polyartritis Nodosa, Polymyalgia Rheumatica, Rheumatoid Arthritis, Spondyloarthritis, Systemic Sclerosis

1.4 Acute diarrhoea 1.4.1 Antimotility drugs

R05DA04 Codeine Phosphate

Tablets 30mg Consultants Motor Neuron Disease, Spinal Cord Pathologies, Trigeminal Neuralgia, Inflammatory Bowel Disease, Inherited Bleeding Disorders, Malignant Diseases, Rheumatoid Arthritis, Spondyloarthritis

A07DA03 Loperamide Hydrochloride

Capsules 2mg Consultants A Medical Practitioners Inflammatory Bowel Disease, Small Intestinal Failure, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Malignant Diseases

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14 1. Gastro-Intestinal System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

1.5 Chronic bowel disorders 1.5.1 Aminosalicylates

A07EC02 Mesalazine Foam/ Retention Enema 1g

Consultant Gastroenterologists, Consultant Paediatricians, Consultant Surgeons

Inflammatory Bowel Disease

A07EC02 Mesalazine Suppositories 500mg

Consultant Gastroenterologists, Consultant Paediatricians, Consultant Surgeons

Inflammatory Bowel Disease

A07EC02 Mesalazine (e.g.

Pentacol®, Asacol®, Octasa®, Asacolon®)

Tablets 400mg Consultant Gastroenterologists, Consultant Paediatricians, Consultant Surgeons

C Consultant Gastroenterologists, Consultant Paediatricians, Consultant Surgeons

Inflammatory Bowel Disease

A07EC02 Mesalazine (Active Ingredient Released at pH

≥7)

Tablets 400mg Consultant Gastroenterologists, Consultant Paediatricians, Consultant Surgeons

MP 124 C Consultant Gastroenterologists, Consultant Paediatricians, Consultant Surgeons

Inflammatory Bowel Disease

A07EC02 Mesalazine (Active Ingredient Released from Duodenum to Rectum)

Slow Release Tablets 500mg

Consultant Gastroenterologists, Consultant Paediatricians, Consultant Surgeons

MP 125 Inflammatory Bowel Disease

A07EC02 Sulfasalazine Oral Liquid 250mg/5mL

Consultant Gastroenterologists, Consultant Paediatricians, Consultant Surgeons

MP 186 Inflammatory Bowel Disease

Availability temporarily suspended.

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15 1. Gastro-Intestinal System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

A07EC01 Sulfasalazine Suppositories 500mg

Consultant Gastroenterologists

MP 185 Inflammatory Bowel Disease

A07EC01 Sulfasalazine Tablets 500mg Consultant Gastroenterologists, Consultant Paediatricians, Consultant Surgeons, Consultant Rheumatologists

Inflammatory Bowel Disease, Rheumatoid Arthritis, Spondyloarthritis

1.5.2 Corticosteroids A07EA06 Budesonide Controlled

Release Capsules 3mg

Consultant Gastroenterologists, Consultant Paediatricians, Consultant Surgeons

MP 23 Inflammatory Bowel Disease

A07EA06 Budesonide Enema 2mg/100mL

Consultant Gastroenterologists, Consultant Paediatricians, Consultant Surgeons

MP 24 Inflammatory Bowel Disease

A07EA02 Hydrocortisone Foam Enema 10%

Consultant Gastroenterologists, Consultant Surgeons, Consultant Paediatricians, Consultant Oncologists, Consultant Palliative Care

C Consultant Gastroenterologists, Consultant Surgeons, Consultant Paediatricians, Consultant Oncologists, Consultant Palliative Care

Inflammatory Bowel Disease

Availability temporarily suspended due to problematic sourcing.

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16 1. Gastro-Intestinal System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

A07EA01 Prednisolone Retention Enema 20mg/100mL

Consultant Gastroenterologists, Consultant Surgeons, Consultant Paediatricians, Consultant Oncologists, Consultant Palliative Care

C Consultant Gastroenterologists, Consultant Surgeons, Consultant Paediatricians, Consultant Oncologists, Consultant Palliative Care

Inflammatory Bowel Disease, Malignant Diseases

1.5.3 Drugs affecting the immune response L04AB04 Adalimumab Solution for

Injection in Pre-filled Syringes 40mg

Consultant Dermatologists, Consultant Gastroenterologists, Consultant Paediatrician, Consultant Rheumatologists

MP 307 Hidradenitis Suppurativa, Inflammatory Bowel Disease, Psoriasis, Rheumatoid Arthritis, Spondyloarthritis

L04AX01 Azathioprine Tablets 50mg Consultants Myasthenia Gravis, Inflammatory Bowel Disease, Secondary Immunodeficiency Disorder, Chronic Liver Disease, Malignant Diseases, Chronic Kidney Disease, Chronic Respiratory Failure, Dermatomyositis/ Polymyositis, Lupus Erythematosus, Polyartritis Nodosa, Rheumatoid Arthritis, Severe Refractory Atopic Dermatitis, Spondyloarthritis, Systemic Sclerosis, Chronic Immunobullous Disorders, Psoriasis, Neuromyelitis Optica

L04AD01 Ciclosporin (Cyclosporin)

Capsules 100mg

Consultants MP 46 Inflammatory Bowel Disease, Secondary Immunodeficiency Disorder, Chronic Kidney Disease, Chronic Liver Disease, Malignant Diseases, Rheumatoid Arthritis, Severe Chronic Urticaria, Severe Refractory Atopic Dermatitis, Spondyloarthritis, Psoriasis

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17 1. Gastro-Intestinal System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

L04AD01 Ciclosporin (Cyclosporin)

Capsules 25mg

Consultants MP 46 Inflammatory Bowel Disease, Secondary Immunodeficiency Disorder, Chronic Kidney Disease, Chronic Liver Disease, Malignant Diseases, Rheumatoid Arthritis, Severe Chronic Urticaria, Severe Refractory Atopic Dermatitis, Spondyloarthritis, Psoriasis

L04AD01 Ciclosporin (Cyclosporin)

Oral Solution 100mg/mL

Consultants MP 47 Secondary Immunodeficiency Disorder, Chronic Kidney Disease, Chronic Liver Disease, Rheumatoid Arthritis, Severe Chronic Urticaria, Severe Refractory Atopic Dermatitis, Psoriasis, Malignant Diseases

L01BB02 Mercaptopurine Tablets 50mg Consultants Inflammatory Bowel Disease, Secondary Immunodeficiency Disorder, Chronic Liver Disease, Malignant Diseases, Chronic Kidney Disease

L01BA01/ L04AX03

Methotrexate Tablets 2.5mg Consultants Inflammatory Bowel Disease, Secondary Immunodeficiency Disorder, Chronic Liver Disease, Malignant Diseases, Chronic Kidney Disease, Dermatomyositis/ Polymyositis, Lupus Erythematosus, Polyartritis Nodosa, Polymyalgia Rheumatica, Rheumatoid Arthritis, Severe Refractory Atopic Dermatitis, Spondyloarthritis, Systemic Sclerosis, Psoriasis

1.6 Laxatives 1.6.1 Bulk-forming laxatives

A06AC01 Ispaghula Husk Powder Consultants B Medical Practitioners Motor Neuron Disease, Parkinson's Disease, Spinal Cord Pathologies, Diverticular Disease requiring Stoma Care, Hirschsprung's Disease, Imperforate Anus, Inflammatory Bowel Disease, Polio and Post-Polio Syndrome, Malignant Diseases

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18 1. Gastro-Intestinal System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

1.6.2 Stimulant laxatives A06AB02 Bisacodyl Suppositories

10mg Consultants A Medical Practitioners Multiple Sclerosis, Spinal Cord Pathologies,

Down Syndrome, Hirschsprung's Disease, Polio and Post-Polio Syndrome, Malignant Diseases, Chronic Kidney Disease

A06AB02 Bisacodyl Tablets 5mg Consultants A Medical Practitioners Multiple Sclerosis, Spinal Cord Pathologies, Down Syndrome, Hirschsprung's Disease, Polio and Post-Polio Syndrome, Malignant Diseases, Chronic Kidney Disease

A06AB53 Co-Danthramer Suspension 75/1000 in 5mL

Consultant Haematologists, Consultant Oncologists, Consultant Paediatricians, Consultant Palliative Care

MP 43 Malignant Diseases

A06AA02 Docusate Sodium Tablets 100mg Consultant Oncologist, Consultant Palliative Care

MP 54 Malignant Diseases

A06AX01 Glycerol Adult Suppositories 4g

Consultants A Medical Practitioners Cerebral Palsy, Motor Neuron Disease, Multiple Sclerosis, Parkinson's Disease, Spinal Cord Pathologies, Down Syndrome, Hirschsprung's Disease, Polio and Post-Polio Syndrome, Malignant Diseases, Chronic Kidney Disease

A06AX01 Glycerol Infant Suppositories 1g

Consultants A Medical Practitioners Cerebral Palsy, Motor Neuron Disease, Spinal Cord Pathology, Down Syndrome, Hirschsprung's Disease, Polio and Post-Polio Syndrome, Malignant Diseases, Chronic Kidney Disease

A06AB06 Senna Tablets 7.5mg Consultants A Medical Practitioners Multiple Sclerosis, Spinal Cord Pathologies, Down Syndrome, Hirschsprung's Disease, Imperforate Anus, Polio and Post-Polio Syndrome, Malignant Diseases, Chronic Kidney Disease

Page 19: Out-Patients Formulary List

V3.0 September 2021

19 1. Gastro-Intestinal System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

1.6.3 Osmotic laxatives A06AD11 Lactulose Syrup

3.35g/5mL Consultants Cerebral Palsy, Chronic Mood Disorders,

Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Cystic Fibrosis, Huntington's Chorea, Motor Neuron Disease, Multiple Sclerosis, Parkinson's Disease, Psychosis, Schizophrenia, Spinal Cord Pathologies, Down Syndrome, Hirschsprung's Disease, Imperforate Anus, Polio and Post-Polio Syndrome, Chronic Liver Disease, Malignant Diseases, Chronic Kidney Disease

A06AD Osmotic Laxative for Constipation (Currently macrogol 3350 with potassium chloride, sodium bicarbonate and sodium chloride)

Oral Liquid Consultants A Medical Practitioners Malignant Diseases, Spinal Cord Pathologies

A06AG11 Micro-Enemas (Currently Sodium Citrate Compound)

Micro-Enema Consultant Oncologists MP 130 TBDF SAMOC P only

Malignant Diseases

A06AG01 Phosphate Enema Consultants A Medical Practitioners Cerebral Palsy, Motor Neuron Disease, Multiple Sclerosis, Parkinson's Disease, Spinal Cord Pathologies, Imperforate Anus, Malignant Diseases

Page 20: Out-Patients Formulary List

V3.0 September 2021

20 1. Gastro-Intestinal System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

1.7 Drugs affecting intestinal secretions 1.7.1 Drugs affecting biliary composition and flow

A05AA02 Ursodeoxycholic Acid

Tablets 150mg Consultant Gastroenterologists, Consultant Oncologists, Consultant Paediatricians

Chronic Liver Disease, Malignant Diseases

A05AA02 Ursodeoxycholic Acid

Capsules 250mg

Consultant Gastroenterologists, Consultant Oncologists, Consultant Paediatricians

Chronic Liver Disease, Malignant Diseases

1.7.2 Bile acid sequestrants C10AC01 Colestyramine Powder Consultants C Medical Practitioners Chronic Liver Disease, Genetic Dyslipidaemia,

Ischaemic Heart Disease, Inflammatory Bowel Disease, Malignant Diseases

1.7.3 Pancreatin A09AA02 Pancreatin Capsules

(Creon 10,000U)

Consultants Enzyme Disorders, Malignant Diseases, Cystic Fibrosis

A09AA02 Pancreatin Capsules (Creon 25,000U)

Consultants Enzyme Disorders, Malignant Diseases, Cystic Fibrosis

Page 21: Out-Patients Formulary List

V3.0 September 2021

21 2. Cardiovascular System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

2. Cardiovascular System 2.1 Positive inotropic drugs

2.1.1 Cardiac glycosides C01AA05 Digoxin Oral Solution

0.05mg/mL Consultants C Consultants Chronic Heart Failure

C01AA05 Digoxin Tablets 0.0625mg

Consultants C Medical Practitioners Cardiac Arrhythmias, Chronic Heart Failure

C01AA05 Digoxin Tablets 0.25mg

Consultants C Medical Practitioners Cardiac Arrhythmias, Chronic Heart Failure

2.2 Diuretics 2.2.1 Thiazides and related diuretics

C03AA01 Bendroflumethiazide (Bendrofluazide)

Tablets 2.5mg Consultants, Specialist Family Medicine PHCD [Hypertension Only]

C Medical Practitioners Chronic Heart Failure, Hypertension, Chronic Kidney Disease

C03AA01 Bendroflumethiazide (Bendrofluazide)

Tablets 5mg Consultants, Specialist Family Medicine PHCD [Hypertension Only]

C Medical Practitioners Chronic Heart Failure, Hypertension, Chronic Kidney Disease

C03BA08 Metolazone Tartrate

Tablets 5mg Consultant Cardiac Surgeons, Consultant Physicians

MP 128

Chronic Heart Failure, Hypertension, Chronic Kidney Disease

2.2.2 Loop diuretics C03CA02 Bumetanide Tablets 1mg Consultants, Specialist

Family Medicine PHCD [Hypertension Only]

C Medical Practitioners Chronic Heart Failure, Hypertension, Chronic Liver Disease, Malignant Diseases, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure

Page 22: Out-Patients Formulary List

V3.0 September 2021

22 2. Cardiovascular System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

C03CA02 Bumetanide Tablets 5mg Consultants, Specialist Family Medicine PHCD [Hypertension Only]

C Medical Practitioners Chronic Heart Failure, Hypertension, Chronic Liver Disease, Malignant Diseases, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure

C03CA01 Furosemide Syrup 1mg/mL Consultants

Chronic Heart Failure, Chronic Liver Disease, Malignant Diseases, Chronic Kidney Disease, Chronic Respiratory Failure

C03CA01 Furosemide Tablets 40mg Consultants, Specialist Family Medicine PHCD [Hypertension Only]

C Medical Practitioners Chronic Heart Failure, Hypertension, Chronic Liver Disease, Malignant Diseases, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure

2.2.3 Potassium-sparing diuretics and aldosterone antagonists C03DA01 Spironolactone Tablets 25mg Consultants, Specialist

Family Medicine PHCD [Hypertension Only], Consultants Endocrinology (Transgender MDT)

C Medical Practitioners Chronic Heart Failure, Chronic Kidney Disease, Chronic Liver Disease, Gender Identity & Sex Characteristics Related Conditions, Hidradenitis Suppurativa, Hypertension, Malignant Diseases

C03DA01 Spironolactone Tablets 100mg Consultants, Specialist Family Medicine PHCD [Hypertension Only], Consultants Endocrinology (Transgender MDT)

Chronic Heart Failure, Chronic Kidney Disease, Chronic Liver Disease, Gender Identity & Sex Characteristics Related Conditions, Hidradenitis Suppurativa, Hypertension, Malignant Diseases

2.2.4 Potassium-sparing diuretics with other diuretics C03EA01 Amiloride +

Hydrochlorothiazide Tablets 5mg + 50mg

Consultants, Specialist Family Medicine PHCD [Hypertension Only]

C Medical Practitioners Chronic Heart Failure, Hypertension, Malignant Diseases, Chronic Kidney Disease

Page 23: Out-Patients Formulary List

V3.0 September 2021

23 2. Cardiovascular System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

C03EB01 Co-amilofruse (Amiloride + Furosemide

[Frusemide])

Tablets 5mg + 40mg

Consultant Cardiologists, Consultant Cardiac Surgeons

MP 82

Chronic Heart Failure

2.3 Anti-arrhythmic drugs C01BD01 Amiodarone HCl Tablets 200mg Consultants Cardiac Arrhythmias, Chronic Heart Failure

C01BA03 Disopyramide Tablets 100mg Consultants C Consultants Cardiac Arrhythmias

C01BC04 Flecainide Tablets 100mg Consultants Cardiac Arrhythmias

C01BB02 Mexiletine Capsules 200mg

Consultant Cardiologists MP 142

Cardiac Arrhythmias

C01BC03 Propafenone Tablets 150mg Consultant Physicians, Consultant Cardiologists

MP 169

Cardiac Arrhythmias

2.4 Beta-adrenoceptor blocking drugs C07AB03 Atenolol Tablets 25mg

or Scored Tablets 50mg

Consultants, Specialist Family Medicine PHCD [Hypertension Only]

C Medical Practitioners Cardiac Arrhythmias, Chronic Kidney Disease, Chronic Neurotic Disorders, Hypertension, Ischaemic Heart Disease, Malignant Diseases

C07AB03 Atenolol Tablets 100mg Consultants, Specialist Family Medicine PHCD [Hypertension Only]

C Medical Practitioners Cardiac Arrhythmias, Chronic Kidney Disease, Chronic Neurotic Disorders, Hypertension, Ischaemic Heart Disease, Malignant Diseases

C07AG02 Carvedilol Tablets 6.25mg

Consultants

Chronic Heart Failure, Hypertension, Ischaemic Heart Disease, Chronic Kidney Disease

C07AG02 Carvedilol Tablets 25mg Consultants

Chronic Heart Failure, Hypertension, Ischaemic Heart Disease, Chronic Kidney Disease

C07AG01 Labetalol Hydrochloride

Tablets 100mg Consultants, Specialist Family Medicine PHCD [Hypertension Only]

C Hospital Doctors Hypertension, Ischaemic Heart Disease, Chronic Kidney Disease

Officially deleted. Available until stocks last.

Page 24: Out-Patients Formulary List

V3.0 September 2021

24 2. Cardiovascular System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

C07AG01 Labetalol Hydrochloride

Tablets 200mg Consultants, Specialist Family Medicine PHCD [Hypertension Only]

C Hospital Doctors Hypertension, Ischaemic Heart Disease, Chronic Kidney Disease

C07AB02 Metoprolol Tartrate

Scored Tablets 100mg

Consultants

Cardiac Arrhythmias, Hypertension, Ischaemic Heart Disease, Chronic Psychiatric Disorders Starting in Childhood, Chronic Kidney Disease

C07AA05 Propranolol Hydrochloride

Oral Solution 1mg/mL

Consultant Paediatricians, Consultant Psychiatrists

Cardiac Arrhythmias, Chronic Psychiatric Disorders Starting in Childhood, Chronic Liver Disease

C07AA05 Propranolol Hydrochloride

Tablets 10mg Consultants, Specialist Family Medicine PHCD [Hypertension Only]

C Medical Practitioners Addiction Disorders, Cardiac Arrhythmias, Chronic Kidney Disease, Chronic Liver Disease, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Down Syndrome, Hypertension, Hypopituitarism, Ischaemic Heart Disease, Malignant Diseases, Psychosis, Schizophrenia, Turner Syndrome

C07AA05 Propranolol Hydrochloride

Tablets 40mg Consultants, Specialist Family Medicine PHCD [Hypertension Only]

C Medical Practitioners Addiction Disorders, Cardiac Arrhythmias, Chronic Kidney Disease, Chronic Liver Disease, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Down Syndrome, Hypertension, Hypopituitarism, Ischaemic Heart Disease, Malignant Diseases, Psychosis, Schizophrenia, Turner Syndrome

C07AA07 Sotalol Tablets 80mg Consultants Cardiac Arrhythmias

Page 25: Out-Patients Formulary List

V3.0 September 2021

25 2. Cardiovascular System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

2.5 Hypertension and heart failure 2.5.1 Vasodilator antihypertensive drugs

L04AX04 Sildenafil Tablets 20mg Consultant Respiratory Physicians, Consultant Cardiologists, Consultant Paediatricians, Consultant Rheumatologists

MP 181 Chronic Heart Failure, Chronic Respiratory Failure, Systemic Sclerosis

C02DB02 Hydralazine Tablets 25mg Consultants, Specialist Family Medicine PHCD [Hypertension Only]

C Medical Practitioners Chronic Heart Failure, Hypertension

2.5.2 Centrally acting antihypertensive drugs C02AC01 Clonidine

Hydrochloride Tablets 100mcg

Consultants C Consultants Addiction Disorders, Hypertension, Chronic Psychiatric Disorders Starting in Childhood

C02AB Methyldopa Tablets 250mg Consultants, Specialist Family Medicine PHCD [Hypertension Only]

C Medical Practitioners Hypertension

2.5.3 Alpha-adrenoceptor blocking drugs C02CA04 Doxazosin Tablets 1mg Consultants, Specialist

Family Medicine PHCD

Hypertension

C02CA04 Doxazosin Tablets 2mg Consultants [Hypertension Only], Specialist Family Medicine PHCD [Hypertension Only], Consultant Urologists

C Consultant Urologist Hypertension, Benign Prostatic Enlargement

C02CA04 Doxazosin Tablets 4mg Consultants, Specialist Family Medicine PHCD

Hypertension

Page 26: Out-Patients Formulary List

V3.0 September 2021

26 2. Cardiovascular System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

C04AX02 Phenoxybenzamine Capsules 10mg

Consultant Anaesthetists, Consultants Endocrinology & Diabetes, Consultant Intensivists, Consultant Oncologists

MP 238

Chronic Kidney Disease, Malignant Diseases

C02CA01 Prazosin Hydrochloride

Tablets 1mg Consultant Physicians, Consultant Cardiologists, Consultant Cardiac Surgeons

MP 166

Chronic Heart Failure

2.5.4 Drugs affecting the renin-angiotensin system 2.5.4.1 Angiotensin-converting enzyme inhibitors

C09AA01 Captopril Tablets 25mg Consultants C Medical Practitioners Chronic Heart Failure, Hypertension, Ischaemic Heart Disease, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Chronic Kidney Disease

C09AA02 Enalapril Tablets 5mg Consultants, Specialist Family Medicine PHCD [Hypertension Only]

C Medical Practitioners Chronic Heart Failure, Hypertension, Ischaemic Heart Disease, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Chronic Kidney Disease

C09AA02 Enalapril Tablets 20mg Consultants, Specialist Family Medicine PHCD [Hypertension Only]

C Medical Practitioners Chronic Heart Failure, Hypertension, Ischaemic Heart Disease, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Chronic Kidney Disease

C09AA03 Lisinopril Tablets 5mg Consultants, Specialist Family Medicine PHCD [Hypertension Only]

Chronic Heart Failure, Hypertension, Ischaemic Heart Disease, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Chronic Kidney Disease

C09AA03 Lisinopril Tablets 10mg Consultants, Specialist Family Medicine PHCD [Hypertension Only]

Chronic Heart Failure, Hypertension, Ischaemic Heart Disease, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Chronic Kidney Disease

Page 27: Out-Patients Formulary List

V3.0 September 2021

27 2. Cardiovascular System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

C09AA04 Perindopril Tablets 4mg Consultants, Specialist Family Medicine PHCD [Hypertension Only]

Chronic Heart Failure, Hypertension, Ischaemic Heart Disease, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Malignant Diseases, Chronic Kidney Disease

2.5.4.2 Angiotensin-II receptor antagonists C09CA03 Angiotensin-II

Receptor Anatagonists (Currently Valsartan)

Tablets Consultant Physicians, Consultant Cardiologists, Consultant Cardiac Surgeons, Specialist Family Medicine PHCD [Hypertension Only]

MP 9

Chronic Heart Failure, Hypertension, Ischaemic Heart Disease, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Chronic Kidney Disease

2.6 Nitrates, calcium-channel blockers, and other antianginal drugs 2.6.1 Nitrates

C01DA02 Glyceryl Trinitrate

Sublingual tablets 500mcg

Consultants C Medical Practitioners Ischaemic Heart Disease

C01DA02 Glyceryl Trinitrate

Transdermal Patches 5mg/24hrs

Consultant Physicians, Consultant Cardiologists, Consultant Cardiac Surgeons

Ischaemic Heart Disease

C01DA02 Glyceryl Trinitrate

Transdermal Patches 10mg/24hrs

Consultant Physicians, Consultant Cardiologists, Consultant Cardiac Surgeons

Ischaemic Heart Disease

C01DA08 Isosorbide Dinitrate

Tablets 10mg Consultants C Medical Practitioners Chronic Heart Failure, Ischaemic Heart Disease, Chronic Liver Disease

C01DA14 Isosorbide Mononitrate

Tablets 20mg Consultant Physicians, Consultant Cardiologists, Consultant Cardiac Surgeons, Consultant Gastroenterologists

Chronic Heart Failure, Ischaemic Heart Disease, Chronic Liver Disease

Page 28: Out-Patients Formulary List

V3.0 September 2021

28 2. Cardiovascular System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

C01DA14 Isosorbide Mononitrate

Tablets SR 60mg

Consultant Physicians, Consultant Cardiologists, Consultant Cardiac Surgeons

Chronic Heart Failure, Ischaemic Heart Disease

2.6.2 Calcium-channel blockers C08CA01 Amlodipine Tablets 5mg Consultants, Specialist

Family Medicine PHCD [Hypertension Only]

Hypertension, Ischaemic Heart Disease, Malignant Diseases, Chronic Kidney Disease, Lupus Erythematosus, Systemic Sclerosis

C08CA01 Amlodipine Tablets 10mg Consultants, Specialist Family Medicine PHCD [Hypertension Only]

Hypertension, Ischaemic Heart Disease, Malignant Diseases, Chronic Kidney Disease, Lupus Erythematosus, Systemic Sclerosis

C08DB01 Diltiazem Tablets 60mg Consultants, Specialist Family Medicine PHCD [Hypertension Only]

Cardiac Arrhythmias, Hypertension, Ischaemic Heart Disease, Chronic Kidney Disease, Systemic Sclerosis

C08CA05 Nifedipine Modified Release Tablets 10mg

Consultants, Specialist Family Medicine PHCD [Hypertension Only]

Hypertension, Chronic Kidney Disease

C08CA05 Nifedipine Tablets/ Capsules 10mg#

Consultants

Chronic Kidney Disease, Lupus Erythematosus, Systemic Sclerosis

C08DA01 Verapamil Slow-Release Tablets 240mg

Consultant Physicians, Consultant Cardiologists, Consultant Cardiac Surgeons

Cardiac Arrhythmias

C08DA01 Verapamil Tablets 40mg Consultants, Specialist Family Medicine PHCD [Hypertension Only]

C Medical Practitioners Cardiac Arrhythmias, Hypertension, Ischaemic Heart Disease, Chronic Kidney Disease

# Officially deleted. Available until stocks last.

Page 29: Out-Patients Formulary List

V3.0 September 2021

29 2. Cardiovascular System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

2.6.3 Other antianginal drugs C01DX16 Nicorandil Tablets 10mg Consultant Physicians,

Consultant Cardiologists MP 144

Ischaemic Heart Disease

2.6.4 Peripheral vasodilators and related drugs C04AD03 Pentoxifylline

(Oxypentifylline) Tablets 400mg Consultant Cardiologists,

Consultant Cardiac Surgeons, Consultant Vascular Surgeons, Consultant Rheumatologists

Peripheral Vascular Disease, Lupus Erythematosus, Systemic Sclerosis

2.6.5 3-KAT inhibitors C01EB15 Trimetazidine

Hydrochloride Tablets 20mg Consultant Physicians,

Consultant Cardiologists, Consultant Cardiac Surgeons

Ischaemic Heart Disease

2.7 Anticoagulants and protamine 2.7.1 Parenteral anticoagulants

B01AB01 Heparin Sodium in Sodium Chloride

Flushing Solution 10 IU/mL in 5mL

Consultants TBDF Hospitals only (TPN

patients only)

Small Intestinal Failure

B01AB05 Enoxaparin Sodium

Pre-filled syringe 20mg (2,000 IU)

Consultants MP 204

Enzyme Disorders, Malignant Diseases, Thromboprophylaxis in pregnancy

B01AB05 Enoxaparin Sodium

Pre-filled syringe 40mg (4,000 IU)

Consultants MP 204

Enzyme Disorders, Malignant Diseases, Thromboprophylaxis in pregnancy

Availability temporarily suspended due to problematic sourcing.

Page 30: Out-Patients Formulary List

V3.0 September 2021

30 2. Cardiovascular System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

B01AB05 Enoxaparin Sodium

Pre-filled syringe 60mg (6,000 IU)

Consultants MP 204

Enzyme Disorders, Malignant Diseases, Thromboprophylaxis in pregnancy

B01AB05 Enoxaparin Sodium

Pre-filled syringe 80mg (8,000 IU)

Consultants MP 204

Enzyme Disorders, Malignant Diseases, Thromboprophylaxis in pregnancy

B01AB05 Enoxaparin Sodium

Pre-filled syringe 100mg (10,000 IU)

Consultants MP 204

Enzyme Disorders, Malignant Diseases, Thromboprophylaxis in pregnancy

2.7.2 Oral anticoagulants B01AA03 Warfarin Tablets 1mg Consultants C Medical Practitioners Cardiac Arrhythmias, Cerebrovascular Disease,

Chronic Heart Failure, Chronic Liver Disease, Ischaemic Heart Disease, Lupus Erythematosus, Malignant Diseases, Peripheral Vascular Disease

B01AA03 Warfarin Tablets 3mg Consultants C Medical Practitioners Cardiac Arrhythmias, Cerebrovascular Disease, Chronic Heart Failure, Chronic Liver Disease, Ischaemic Heart Disease, Lupus Erythematosus, Malignant Diseases, Peripheral Vascular Disease

B01AA03 Warfarin Tablets 5mg Consultants C Medical Practitioners Cardiac Arrhythmias, Cerebrovascular Disease, Chronic Heart Failure, Chronic Liver Disease, Ischaemic Heart Disease, Lupus Erythematosus, Malignant Diseases, Peripheral Vascular Disease

Page 31: Out-Patients Formulary List

V3.0 September 2021

31 2. Cardiovascular System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

2.8 Antiplatelet drugs B01AC06 Aspirin Tablets 75mg Consultants, Specialist

Family Medicine PHCD [Hypertension Only]

C Medical Practitioners Cardiac Arrhythmias, Cerebrovascular Disease, Hypertension, Ischaemic Heart Disease, Peripheral Vascular Disease, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Inherited Haemoglobinopathies, Malignant Diseases, Systemic Sclerosis

B01AC04 Clopidogrel Tablets 75mg Consultant Physicians MP 276 Ischaemic Heart Disease

B01AC07 Dipyridamole Tablets 25mg Consultants C Medical Practitioners Cerebrovascular Disease, Chronic Heart Failure, Ischaemic Heart Disease, Peripheral Vascular Disease, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Systemic Sclerosis

B01AC07 Dipyridamole Tablets 100mg Consultants C Medical Practitioners Cerebrovascular Disease, Chronic Heart Failure, Ischaemic Heart Disease, Peripheral Vascular Disease, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Systemic Sclerosis

2.9 Antifibrinolytic drugs and heamostatics B02BD02 Anti-Haemophilic

Factor VIII (stand-by)

Infusion 500IU Consultant Haematologists, Consultant Paediatricians, Consultant Infectious Diseases Physician

TBDF Hospitals

only

Inherited Bleeding Disorders

B02BD02 Anti-Haemophilic Factor VIII (stand-by)

Infusion 1000IU

Consultant Haematologists, Consultant Paediatricians, Consultant Infectious Diseases Physician

TBDF Hospitals

only

Inherited Bleeding Disorders

Page 32: Out-Patients Formulary List

V3.0 September 2021

32 2. Cardiovascular System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

B02BD06 Anti-Heamophilic Factor VIII Intermediate

Injection IV 500IU

Consultant Haematologists, Consultant Paediatricians, Consultant Infectious Diseases Physicians

TBDF Hospitals

only

Inherited Bleeding Disorders

B02BD03 Anti-Haemophilic Factor VIII inhibitor bypassing activity/fraction

Injection IV 500U or 1000U

Consultant Haematologists, Consultant Paediatricians, Consultant Infectious Diseases Physicians

TBDF Hospitals

only

Inherited Bleeding Disorders

B02BD04 Anti-Haemophilic Factor IX

Infusion 500IU Consultant Haematologists, Consultant Paediatricians, Consultant Infectious Diseases Physicians

TBDF Hospitals

only

Inherited Bleeding Disorders

B02BD08 Eptacog Alfa (Recombinant Factor VIIa) (stand-by)

Vials Consultant Anaesthetists, Consultant Haematologists

TBDF Hospitals

only

Inherited Bleeding Disorders

B02BB01 Fibrinogen Concentrate

Vials Consultants Haematologists

MP 212 TBDF

MDHP only

Inherited Bleeding Disorders

B02BD07 Factor XIII Concentrate

Vials Consultant Haematologists MP 211 TBDF

Hospitals only

Inherited Bleeding Disorders

B02AA02 Tranexamic Acid Tablets 500mg Consultants

Inherited Bleeding Disorders, Malignant Diseases

Page 33: Out-Patients Formulary List

V3.0 September 2021

33 2. Cardiovascular System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

2.10 Lipid-regulating drugs C10AA05 Atorvastatin Tablets 10mg Consultants, Specialist

Family Medicine PHCD

DM Consultants Cerebrovascular Disease, Genetic

Dyslipidaemia, Hypertension, Ischaemic Heart Disease, Peripheral Vascular Disease, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Chronic Kidney Disease

C10AA05 Atorvastatin Tablets 20mg Consultants, Specialist Family Medicine PHCD

DM Consultants Cerebrovascular Disease, Genetic Dyslipidaemia, Hypertension, Ischaemic Heart Disease, Peripheral Vascular Disease, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Chronic Kidney Disease

C10AA05 Atorvastatin Tablets 40mg Consultants, Specialist Family Medicine PHCD

DM Consultants Cerebrovascular Disease, Genetic Dyslipidaemia, Hypertension, Ischaemic Heart Disease, Peripheral Vascular Disease, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Chronic Kidney Disease

C10AB02 Bezafibrate Modified Release Tablets 400mg

Consultants, Specialist Family Medicine PHCD

DM Consultants Genetic Dyslipidaemia, Hypertension, Ischaemic Heart Disease, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2

C10AC01 Colestyramine Powder Consultants C Medical Practitioners Chronic Liver Disease, Genetic Dyslipidaemia, Ischaemic Heart Disease, Inflammatory Bowel Disease, Malignant Diseases

C10AB05 Fenofibrate Micronised 200mg Capsules or Nanocrystal 145mg Tablets

Consultants, Specialist Family Medicine PHCD

DM Consultants Genetic Dyslipidaemia, Hypertension, Ischaemic Heart Disease, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2

C10AB05 Fenofibrate Micronised 67mg Capsules

Consultants, Specialist Family Medicine PHCD

DM Consultants Genetic Dyslipidaemia, Hypertension, Ischaemic Heart Disease, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2

Page 34: Out-Patients Formulary List

V3.0 September 2021

34 2. Cardiovascular System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

C10AA07 Rosuvastatin Tablets 20mg Consultants, Specialist Family Medicine PHCD

MP 177 DM Consultants Cerebrovascular Disease, Genetic Dyslipidaemia, Hypertension, Ischaemic Heart Disease, Peripheral Vascular Disease, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Chronic Kidney Disease

C10AA07 Rosuvastatin Tablets 40mg Consultants, Specialist Family Medicine PHCD

MP 177 DM Consultants Cerebrovascular Disease, Genetic Dyslipidaemia, Hypertension, Ischaemic Heart Disease, Peripheral Vascular Disease, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Chronic Kidney Disease

C10AA01 Simvastatin Tablets 10mg Consultants, Specialist Family Medicine PHCD

DM Consultants Cerebrovascular Disease, Genetic Dyslipidaemia, Hypertension, Ischaemic Heart Disease, Peripheral Vascular Disease, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Chronic Kidney Disease

C10AA01 Simvastatin Tablets 20mg Consultants, Specialist Family Medicine PHCD

DM Consultants Cerebrovascular Disease, Genetic Dyslipidaemia, Hypertension, Ischaemic Heart Disease, Peripheral Vascular Disease, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Chronic Kidney Disease

C10AA01 Simvastatin Tablets 40mg Consultants, Specialist Family Medicine PHCD

DM Consultants Cerebrovascular Disease, Genetic Dyslipidaemia, Hypertension, Ischaemic Heart Disease, Peripheral Vascular Disease, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Chronic Kidney Disease

Page 35: Out-Patients Formulary List

V3.0 September 2021

35 3. Respiratory System

ATC Code Active Ingredient

Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

3. Respiratory System 3.1 Bronchodilators

H02AB06 Prednisolone Soluble Tablets 5mg

Consultant Paediatricians

Addison's Disease, Chronic Asthma, Chronic Kidney Disease, Chronic Respiratory Failure, Cystic Fibrosis, Dermatomyositis/ Polymyositis, Epilepsy, Hypopituitarism, Inflammatory Bowel Disease, Lupus Erythematosus, Malignant Diseases, Myasthenia Gravis, Polymyalgia Rheumatica, Rheumatoid Arthritis, Spondyloarthritis

H02AB06 Prednisolone Tablets 1mg Consultants B Medical Practitioners Addison's Disease, Chronic Asthma, Chronic Kidney Disease, Chronic Liver Disease, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Cystic Fibrosis, Dermatomyositis/ Polymyositis, Enzyme Disorders, Epilepsy, HIV/AIDS and HIV Related Diseases, Hypopituitarism, Inflammatory Bowel Disease, Leprosy, Lupus Erythematosus, Malignant Diseases, Multiple Sclerosis, Myasthenia Gravis,Neuromyelitis Optica, Polyartritis Nodosa, Polymyalgia Rheumatica, Rheumatoid Arthritis, Secondary Immunodeficiency Disorder, Spondyloarthritis, Systemic Sclerosis

Page 36: Out-Patients Formulary List

V3.0 September 2021

36 3. Respiratory System

ATC Code Active Ingredient

Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

H02AB06 Prednisolone Tablets 5mg Consultants GU Clinic Entitlement: GU Clinic Consultant

B Medical Practitioners,

Addison's Disease, Chronic Asthma, Chronic Immunobullous Disorders, Chronic Kidney Disease, Chronic Liver Disease, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Cystic Fibrosis, Dermatomyositis/ Polymyositis, Enzyme Disorders, Epilepsy, HIV/AIDS and HIV Related Diseases, Hypopituitarism, Inflammatory Bowel Disease, Leprosy, Lupus Erythematosus, Malignant Diseases, Multiple Sclerosis, Myasthenia Gravis, Neuromyelitis Optica, Polyartritis Nodosa, Polymyalgia Rheumatica, Rheumatoid Arthritis, Secondary Immunodeficiency Disorder, Spondyloarthritis, Systemic Sclerosis

H02AB06 Prednisolone Tablets enteric-coated 5mg

Consultants B Medical Practitioners Addison's Disease, Chronic Asthma, Chronic Immunobullous Disorders, Chronic Kidney Disease, Chronic Liver Disease, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Cystic Fibrosis, Dermatomyositis/ Polymyositis, Enzyme Disorders, Epilepsy, HIV/AIDS and HIV Related Diseases, Hypopituitarism, Inflammatory Bowel Disease, Leprosy, Lupus Erythematosus, Malignant Diseases, Multiple Sclerosis, Myasthenia Gravis, Neuromyelitis Optica, Polyartritis Nodosa, Polymyalgia Rheumatica, Rheumatoid Arthritis, Secondary Immunodeficiency Disorder, Spondyloarthritis, Systemic Sclerosis

Page 37: Out-Patients Formulary List

V3.0 September 2021

37 3. Respiratory System

ATC Code Active Ingredient

Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

3.1.1 Adrenoceptor agonists 3.1.1.1 Selective beta2 agonists

R03AC12/ R03AC13

Long Acting Beta2-Agonist for children aged 4-12 years (Formoterol or Salmeterol)

Inhaler Consultant Respiratory Physicians, Consultant Paediatricians, Specialist Respiratory Medicine Consultants

MP 270

Chronic Asthma, Chronic Respiratory Failure, Cystic Fibrosis

R03AC12/ R03AC13

Long Acting Beta2-Agonist for patients over 12 years (Formoterol or Salmeterol)

Inhaler Consultant Respiratory Physicians, Consultant Paediatricians, Specialist Respiratory Medicine Consultants, Consultant Geriatricians

MP 271

Chronic Asthma, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Cystic Fibrosis

R03AC02 Salbutamol Inhaler 100mcg/puff

Consultants B Medical Practitioners Malignant Diseases, Chronic Asthma, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Cystic Fibrosis

R03AC02 Salbutamol Respiratory Solution 5mg/mL

Consultants C Medical Practitioners Malignant Diseases, Chronic Asthma, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Cystic Fibrosis

R03AC02 Salbutamol Syrup 2mg/5mL Consultants B Medical Practitioners Malignant Diseases, Chronic Asthma

R03AC02 Salbutamol Tablets 4mg Consultants B Medical Practitioners Malignant Diseases

R03AC03 Terbutaline Dry Powder Inhaler 500mcg

Consultant Respiratory Physicians, Consultant Paediatricians, Specialist Respiratory Medicine Consultants

MP 206

Chronic Asthma, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Cystic Fibrosis

Page 38: Out-Patients Formulary List

V3.0 September 2021

38 3. Respiratory System

ATC Code Active Ingredient

Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

3.1.2 Antimuscarinic bronchodilators R03BB01 Ipratropium Inhaler

20mcg/dose Consultants

Malignant Diseases, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Cystic Fibrosis

R03BB01 Ipratropium Nebuliser Solution 250mcg/mL

Consultants

Malignant Diseases, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Cystic Fibrosis

R03BB07 Umeclidinium Dry Powder Inhaler 55mcg/dose

Consultant Respiratory Physicians

MP 111

Chronic Obstructive Pulmonary Disease

3.1.3 Theophylline R03DA04 Theophylline Prolonged

Release Tablets 200mg

Consultant Respiratory Physicians, Specialist Respiratory Medicine Consultants

Chronic Asthma, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure

3.2 Corticosteroids R03BA01 Beclometasone

Dipropionate Inhaler 50mcg Consultants B Medical Practitioners Malignant Diseases, Chronic Asthma, Chronic

Respiratory Failure, Cystic Fibrosis

R03BA01 Beclometasone Dipropionate

Inhaler 250mcg Consultants

Malignant Diseases, Chronic Asthma, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Cystic Fibrosis

R03BA02 Budesonide Dry Powder Metered Dose Inhaler 100mcg/ Dose

Consultant Respiratory Physicians, Consultant Paediatricians, Specialist Respiratory Medicine Consultants

MP 27

Chronic Asthma, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Cystic Fibrosis

R03BA02 Budesonide Inhaler 200mcg/ Dose

Consultants MP 26

Chronic Asthma, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Cystic Fibrosis

Page 39: Out-Patients Formulary List

V3.0 September 2021

39 3. Respiratory System

ATC Code Active Ingredient

Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

R03BA02 Budesonide Nebuliser Solution Ampoules 0.25mg/mL

Consultant Respiratory Physicians, Consultant Paediatricians, Consultant Oncologists, Specialist Respiratory Medicine Consultants

MP 28

Chronic Asthma, Chronic Respiratory Failure, Cystic Fibrosis

R03BA02 Budesonide Nebuliser Solution Ampoules 0.5mg/mL

Consultant Respiratory Physicians, Consultant Paediatricians, Consultant Oncologists, Specialist Respiratory Medicine Consultants

MP 28

Chronic Asthma, Chronic Respiratory Failure, Cystic Fibrosis

R03BA05 Fluticasone Inhaler 50mcg Consultant Respiratory Physicians, Consultant Paediatricians, Specialist Respiratory Medicine Consultants

MP 77

Chronic Asthma, Chronic Respiratory Failure, Cystic Fibrosis

R03BA05 Fluticasone Inhaler 250mcg Consultant Respiratory Physicians, Consultant Paediatricians, Specialist Respiratory Medicine Consultants

MP 78

Chronic Asthma, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Cystic Fibrosis

3.3 Cromoglicate and related therapy, leukotriene receptor antagonists, and phosphodiesterase type-4 inhibitors 3.3.1 Leukotriene Receptor Antagonists

R03DC03 Montelukast Chewable Tablets 4mg

Consultant Respiratory Physicians, Consultant Paediatricians

MP 295

Chronic Asthma

Page 40: Out-Patients Formulary List

V3.0 September 2021

40 3. Respiratory System

ATC Code Active Ingredient

Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

R03DC03 Montelukast Chewable Tablets 5mg

Consultant Respiratory Physicians, Consultant Paediatricians

MP 295

Chronic Asthma

R03DC03 Montelukast Tablets 10mg Consultant Respiratory Physicians, Consultant Paediatricians

MP 295

Chronic Asthma

3.4 Antihistamines, hyposensitisation, and allergic emergencies 3.4.1 Antihistamines

N05BB01 Hydroxyzine Hydrochloride

Tablets 25mg Consultants B Medical Practitioners Addiction Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Chronic Liver Disease, Malignant Diseases, Severe Refractory Atopic Dermatitis

R06AD02 Promethazine Hydrochloride

Syrup 5mg/5mL Consultants A Medical Practitioners Addiction Disorders, Dermatomyositis/ Polymyositis, Malignant Diseases, Severe Refractory Atopic Dermatitis

R06AD02 Promethazine Hydrochloride

Tablets 10mg Consultants B Medical Practitioners Addiction Disorders, Dermatomyositis/ Polymyositis, Malignant Diseases, Severe Refractory Atopic Dermatitis

R06AD02 Promethazine Hydrochloride

Tablets 25mg Consultants B Medical Practitioners Addiction Disorders, Dermatomyositis/ Polymyositis, Malignant Diseases, Severe Refractory Atopic Dermatitis

3.4.2 Allergen Immunotherapy R03DX05 Omalizumab Injections

150mg Consultant Respiratory Physicians, Consultant Paediatricians

MP 294 TBDF

Hospitals only

Chronic Asthma

Page 41: Out-Patients Formulary List

V3.0 September 2021

41 3. Respiratory System

ATC Code Active Ingredient

Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

3.5 Oxygen V03AN01 Medical Oxygen

1.5m³ Gas Medical Practitioners

Chronic Obstructive Pulmonary Disease

3.6 Mucolytics R05CB02 Bromhexine Syrup 4mg/5mL Consultants A Medical Practitioners Malignant Diseases, Chronic Respiratory Failure

R05CB13 Dornase Alfa Nebuliser Solution 1000units/mL (2.5mg)

Consultant Paediatricians, Consultant Respiratory Physicians

MP 52

Cystic Fibrosis

R07AX02 Ivacaftor Tablets 150mg Consultant Paediatric Respiratory Medicine, Consultant Respiratory Physician

MP 308

Cystic Fibrosis

R07AX30 Ivacaftor + Lumacaftor

Granules 188mg + 150mg

Consultant Paediatric Respiratory Medicine

MP 309

Cystic Fibrosis

R07AX31 Ivacaftor + Tezacaftor

Tablets 150mg + 100mg

Consultant Paediatric Respiratory Medicine, Consultant Respiratory Physician

MP 310

Cystic Fibrosis

R07AX32 Ivacaftor + Tezacaftor + Elexacaftor

Tablets 75mg + 50mg + 100mg

Consultant Paediatric Respiratory Medicine, Consultant Respiratory Physician

MP 311

Cystic Fibrosis

V03AB23, R05CB01

N-Acetylcysteine Tablets 600mg Consultant Surgeons, Consultant Physicians, Consultant Respiratory Physicians

MP 252 TBDF

MDHP only

Chronic Respiratory Failure

Page 42: Out-Patients Formulary List

V3.0 September 2021

42 3. Respiratory System

ATC Code Active Ingredient

Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

3.7 Aromatic inhalations

R01AX10 Benzoin Tincture Tincture 50mL N/A A Medical Practitioners No Schedule V Entitlement

3.8 Cough preparations 3.8.1 Cough suppressants

R05DA04 Codeine Phosphate

Suspension 15mg/5mL

Consultants B Medical Practitioners Inherited Bleeding Disorders, Malignant Diseases, Chronic Respiratory Failure, Rheumatoid Arthritis

3.8.2 Expectorant and demulcent cough preparations R06AA52 Diphenhydramine

Containing Preparation for Chesty Cough

Oral Liquid Consultants A Medical Practitioners Malignant Diseases

Page 43: Out-Patients Formulary List

V3.0 September 2021

43 4. Central Nervous System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

4. Central Nervous System 4.1 Hypnotics and anxiolytics

4.1.1 Hypnotics N05BA01 Diazepam Syrup

2mg/5mL Consultants A Medical Practitioners Addiction Disorders, Cerebral Palsy, Chronic

Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Motor Neuron Disease, Multiple Sclerosis, Psychosis, Schizophrenia, Malignant Diseases

N05BA01 Diazepam Tablets 2mg Consultants A Medical Practitioners Addiction Disorders, Cerebral Palsy, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Motor Neuron Disease, Multiple Sclerosis, Psychosis, Schizophrenia, Malignant Diseases

N05BA01 Diazepam Tablets 5mg Consultants A Medical Practitioners Addiction Disorders, Cerebral Palsy, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Motor Neuron Disease, Multiple Sclerosis, Psychosis, Schizophrenia, Malignant Diseases

N05CD02 Nitrazepam Tablets 5mg Consultants B Medical Practitioners Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Psychosis, Schizophrenia

Page 44: Out-Patients Formulary List

V3.0 September 2021

44 4. Central Nervous System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

N06AD02 Promethazine Hydrochloride

Syrup 5mg/5mL

Consultants A Medical Practitioners Addiction Disorders, Dermatomyositis/ Polymyositis, Malignant Diseases, Severe Refractory Atopic Dermatitis

N06AD02 Promethazine Hydrochloride

Tablets 10mg Consultants B Medical Practitioners Addiction Disorders, Dermatomyositis/ Polymyositis, Malignant Diseases, Severe Refractory Atopic Dermatitis

N06AD02 Promethazine Hydrochloride

Tablets 25mg Consultants B Medical Practitioners Addiction Disorders, Dermatomyositis/ Polymyositis, Malignant Diseases, Severe Refractory Atopic Dermatitis

4.1.2 Anxiolytics N05BA08 Bromazepam Tablets 1.5mg Consultants A Medical Practitioners Addiction Disorders, Chronic Mood Disorders,

Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Psychosis, Schizophrenia

N05BA08 Bromazepam Tablets 3mg Consultants A Medical Practitioners Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Psychosis, Schizophrenia

N05BA08 Bromazepam Tablets 6mg Consultants A Medical Practitioners Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Psychosis, Schizophrenia

N05BE01 Buspirone Hydrochloride

Tablets 10mg Consultants

Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood

N05BA01 Diazepam Rectal Tubes 5mg/2.5mL

Consultants B Medical Practitioners Cerebral Palsy, Epilepsy, Malignant Diseases

N05BA01 Diazepam Rectal Tubes 10mg/2.5mL

Consultants B Medical Practitioners Cerebral Palsy, Epilepsy, Malignant Diseases

Page 45: Out-Patients Formulary List

V3.0 September 2021

45 4. Central Nervous System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

N05BA01 Diazepam Syrup 2mg/5mL

Consultants A Medical Practitioners Addiction Disorders, Cerebral Palsy, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Motor Neuron Disease, Multiple Sclerosis, Psychosis, Schizophrenia, Malignant Diseases

N05BA01 Diazepam Tablets 2mg Consultants A Medical Practitioners Addiction Disorders, Cerebral Palsy, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Motor Neuron Disease, Multiple Sclerosis, Psychosis, Schizophrenia, Malignant Diseases

N05BA01 Diazepam Tablets 5mg Consultants A Medical Practitioners Addiction Disorders, Cerebral Palsy, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Motor Neuron Disease, Multiple Sclerosis, Psychosis, Schizophrenia, Malignant Diseases

N05BA06 Lorazepam Tablets 1mg Consultants A Medical Practitioners Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Psychosis, Schizophrenia, Malignant Diseases

N05BA06 Lorazepam Tablets 2mg Consultants A Medical Practitioners Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Psychosis, Schizophrenia, Malignant Diseases

Page 46: Out-Patients Formulary List

V3.0 September 2021

46 4. Central Nervous System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

4.2 Drugs used in psychoses and related disorders 4.2.1 Antipsychotic drugs

N05AA01 Chlorpromazine Hydrochloride

Tablets 25mg Consultants C Medical Practitioners Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Psychosis, Schizophrenia, Malignant Diseases

N05AA01 Chlorpromazine Hydrochloride

Tablets 100mg Consultants C Medical Practitioners Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Psychosis, Schizophrenia, Malignant Diseases

N05AH02 Clozapine Tablets 25mg Consultant Psychiatrists MP 42 TBDF

Hospitals only

Chronic Mood Disorders, Psychosis, Schizophrenia

N05AH02 Clozapine Tablets 100mg Consultant Psychiatrists MP 42 TBDF

Hospitals only

Chronic Mood Disorders, Psychosis, Schizophrenia

N05AF01 Flupentixol Dihydrochloride

Tablets 0.5mg Consultant Psychiatrists

Addiction Disorders, Chronic Mood Disorders, Psychosis, Schizophrenia

N05AD01 Haloperidol Capsules 0.5mg

Consultant Geriatricians, Consultant Haematologists, Consultant Oncologists, Consultant Palliative Care, Consultant Psychiatrists

C Consultant Geriatricians, Consultant Haematologists, Consultant Oncologists, Consultant Palliative Care, Consultant Psychiatrists

Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Psychosis, Schizophrenia, Malignant Diseases

Page 47: Out-Patients Formulary List

V3.0 September 2021

47 4. Central Nervous System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

N05AD01 Haloperidol Injections 5mg Consultant Haematologists, Consultant Oncologists, Consultant Palliative Care, Consultant Psychiatrists

Addiction Disorders, Chronic Psychiatric Disorders Starting in Childhood, Psychosis, Schizophrenia, Malignant Diseases

N05AD01 Haloperidol Oral Solution 2mg/mL

Consultant Geriatricians, Consultant Haematologists, Consultant Oncologists, Consultant Palliative Care, Consultant Psychiatrists

C Consultant Geriatricians, Consultant Haematologists, Consultant Oncologists, Consultant Palliative Care, Consultant Psychiatrists

Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Psychosis, Schizophrenia, Malignant Diseases

N05AD01 Haloperidol Tablets 1.5mg Consultant Geriatricians, Consultant Haematologists, Consultant Oncologists, Consultant Palliative Care, Consultant Psychiatrists

C Consultant Geriatricians, Consultant Haematologists, Consultant Oncologists, Consultant Palliative Care, Consultant Psychiatrists

Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Psychosis, Schizophrenia, Malignant Diseases

Page 48: Out-Patients Formulary List

V3.0 September 2021

48 4. Central Nervous System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

N05AD01 Haloperidol Tablets 5mg Consultant Geriatricians, Consultant Haematologists, Consultant Oncologists, Consultant Palliative Care, Consultant Psychiatrists

C Consultant Geriatricians, Consultant Haematologists, Consultant Oncologists, Consultant Palliative Care, Consultant Psychiatrists

Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Psychosis, Schizophrenia, Malignant Diseases

N05AA02 Levomepromazine Tablets 25mg Consultant Haematologists, Consultant Oncologists, Consultant Paediatric Oncologists, Consultant Paediatricians, Consultant Palliative Care

MP 287

Malignant Diseases

N05AH03 Olanzapine Coated Tablets 10mg

Consultant Geriatricians, Consultant Psychiatrists

Addiction Disorders, Chronic Eating Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Psychosis, Schizophrenia

N05AH03 Olanzapine Coated Tablets 5mg

Consultant Geriatricians, Consultant Psychiatrists

Addiction Disorders, Chronic Eating Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Psychosis, Schizophrenia

N05AG02 Pimozide Scored Tablets 4mg

Consultant Psychiatrists MP 163

Psychosis, Schizophrenia

N05AB04 Prochlorperazine Tablets 5mg Consultants A Medical Practitioners Addiction Disorders, Psychosis, Schizophrenia, Malignant Diseases

Page 49: Out-Patients Formulary List

V3.0 September 2021

49 4. Central Nervous System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

N05AH04 Quetiapine Tablets 25mg Consultant Geriatricians, Consultant Psychiatrists

Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Psychosis, Schizophrenia

N05AH04 Quetiapine Tablets 100mg Consultant Geriatricians, Consultant Psychiatrists

Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Psychosis, Schizophrenia

N05AH04 Quetiapine Tablets 200mg Consultant Geriatricians, Consultant Psychiatrists

Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Psychosis, Schizophrenia

N05AX08 Risperidone Syrup 1mg/mL Consultant Geriatricians, Consultant Psychiatrists

MP 175

Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Psychosis, Schizophrenia

N05AX08 Risperidone Tablets 1mg Consultant Geriatricians, Consultant Psychiatrists

C Consultant Psychiatrists

Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Psychosis, Schizophrenia

N05AX08 Risperidone Tablets 2mg Consultant Geriatricians, Consultant Psychiatrists

C Consultant Psychiatrists

Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Psychosis, Schizophrenia

N05AL01 Sulpiride Capsules 50mg

Consultant Psychiatrists

Addiction Disorders, Chronic Mood Disorders, Chronic Psychiatric Disorders Starting in Childhood, Psychosis, Schizophrenia

N05AL01 Sulpiride Suspension 40mg/mL

Consultant Psychiatrists

Addiction Disorders, Chronic Mood Disorders, Chronic Psychiatric Disorders Starting in Childhood Psychosis, Schizophrenia

Page 50: Out-Patients Formulary List

V3.0 September 2021

50 4. Central Nervous System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

N05AL01 Sulpiride Tablets 200mg Consultant Psychiatrists

Addiction Disorders, Chronic Mood Disorders, Chronic Psychiatric Disorders Starting in Childhood, Psychosis, Schizophrenia

N05AB06 Trifluoperazine Tablets 5mg Consultants C Medical Practitioners Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Psychosis, Schizophrenia

N05AF05 Zuclopenthixol Acetate

Oily injection 50mg

Consultant Psychiatrists

Chronic Mood Disorders, Psychosis, Schizophrenia

N05AF05 Zuclopenthixol Dihydrochloride

Tablets 2mg Consultant Psychiatrists

Addiction Disorders, Chronic Mood Disorders, Psychosis, Schizophrenia

N05AF05 Zuclopenthixol Dihydrochloride

Tablets 10mg Consultant Psychiatrists

Addiction Disorders, Chronic Mood Disorders, Psychosis, Schizophrenia

N05AF05 Zuclopenthixol Dihydrochloride

Tablets 25mg Consultant Psychiatrists

Addiction Disorders, Chronic Mood Disorders, Psychosis, Schizophrenia

4.2.2 Antipsychotic depo injections N05AF01 Flupentixol

Decanoate Injection 20mg/mL

Consultant Psychiatrists

Addiction Disorders, Chronic Mood Disorders, Psychosis, Schizophrenia

N05AF01 Flupentixol Decanoate

Injection 100mg/mL

Consultant Psychiatrists

Addiction Disorders, Chronic Mood Disorders, Psychosis, Schizophrenia

N05AB02 Fluphenazine Decanoate

Injection 25mg

Consultant Psychiatrists

Chronic Mood Disorders, Chronic Psychiatric Disorders Starting in Childhood, Psychosis, Schizophrenia

N05AB02 Fluphenazine Decanoate

Injection 100mg

Consultant Psychiatrists

Chronic Mood Disorders, Chronic Psychiatric Disorders Starting in Childhood, Psychosis, Schizophrenia

N05AD01 Haloperidol Decanoate

Injection 50mg

Consultant Psychiatrists

Chronic Mood Disorders, Chronic Psychiatric Disorders Starting in Childhood, Psychosis, Schizophrenia

Page 51: Out-Patients Formulary List

V3.0 September 2021

51 4. Central Nervous System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

N05AD01 Haloperidol Decanoate

Injection 100mg

Consultant Psychiatrists

Chronic Mood Disorders, Chronic Psychiatric Disorders Starting in Childhood, Psychosis, Schizophrenia

N05AX08 Risperidone Depot Injection 25mg

Consultant Psychiatrists MP 291 FPOP & MHCs only

Psychosis, Schizophrenia

N05AX08 Risperidone Depot Injection 37.5mg

Consultant Psychiatrists MP 291 FPOP & MHCs only

Psychosis, Schizophrenia

N05AX08 Risperidone Depot Injection 50mg

Consultant Psychiatrists MP 291 FPOP & MHCs only

Psychosis, Schizophrenia

N05AF05 Zuclopenthixol Decanoate

Injection 200mg

Consultant Psychiatrists

Schizophrenia

4.2.3 Antimanic drugs N05AN01 Lithium

Carbonate Tablets 400mg Consultants C Medical Practitioners Chronic Mood Disorders, Chronic Neurotic

Disorders, Chronic Psychiatric Disorders Starting in Childhood, Psychosis, Schizophrenia

N05AN01 Lithium Citrate Tetrahydrate

Syrup 520mg/5mL (equivalent to 200mg Lithium Carbonate)

Consultant Psychiatrists MP 120

Chronic Mood Disorders, Psychosis

Page 52: Out-Patients Formulary List

V3.0 September 2021

52 4. Central Nervous System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

4.3 Antidepressant drugs 4.3.1 Tricyclic and related antidepressant drugs

N06AA09 Amitriptyline Tablets 10mg Consultants B Medical Practitioners Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Fibromyalgia, Malignant Diseases, Motor Neuron Disease, Multiple Sclerosis, Myalgic Encephalomyelitis, Polio and Post-Polio Syndrome, Psychosis, Schizophrenia, Spinal Cord Pathologies, Trigeminal Neuralgia

N06AA09 Amitriptyline Tablets 25mg Consultants B Medical Practitioners Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Fibromyalgia, Malignant Diseases, Motor Neuron Disease, Multiple Sclerosis, Myalgic Encephalomyelitis, Polio and Post-Polio Syndrome, Psychosis, Schizophrenia, Spinal Cord Pathologies, Trigeminal Neuralgia

N06AA04 Clomipramine Hydrochloride

Tablets 10mg Consultants C Medical Practitioners Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Malignant Diseases, Narcolepsy, Psychosis, Schizophrenia

N06AA04 Clomipramine Hydrochloride

Tablets 25mg Consultants C Medical Practitioners Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Malignant Diseases, Narcolepsy, Psychosis, Schizophrenia

Page 53: Out-Patients Formulary List

V3.0 September 2021

53 4. Central Nervous System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

N06AA02 Imipramine Hydrochloride

Tablets 10mg Consultants C Medical Practitioners Addiction Disorders, Chronic Eating Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Malignant Diseases, Psychosis, Schizophrenia

N06AA02 Imipramine Hydrochloride

Tablets 25mg Consultants C Medical Practitioners Addiction Disorders, Chronic Eating Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Malignant Diseases, Psychosis, Schizophrenia

N06AA21 Maprotiline Hydrochloride

Tablets 25mg Consultants

Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders

N06AX03 Mianserin Hydrochloride

Tablets 10mg Consultants C Medical Practitioners Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders

N06AX03 Mianserin Hydrochloride

Tablets 30mg Consultants C Medical Practitioners Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders

N06AA09 Nortriptyline Tablets 10mg Consultants C Medical Practitioners Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Malignant Diseases, Multiple Sclerosis, Psychosis, Schizophrenia, Spinal Cord Pathologies

N06AA09 Nortriptyline Tablets 25mg Consultants C Medical Practitioners Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Malignant Diseases, Multiple Sclerosis, Psychosis, Schizophrenia, Spinal Cord Pathologies

Page 54: Out-Patients Formulary List

V3.0 September 2021

54 4. Central Nervous System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

4.3.2 Monoamine-oxidase inhibitors N06AG02 Moclobemide Tablets 150mg Consultant Psychiatrists MP 134

Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Psychosis

4.3.3 Selective serotonin re-uptake inhibitors N06AB03 Fluoxetine Capsules

20mg Consultant Geriatricians, Consultant Psychiatrists

C Consultant Psychiatrists

Addiction Disorders, Chronic Eating Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Psychosis, Schizophrenia

N06AB08 Fluvoxamine Maleate

Tablets 100mg Consultant Geriatricians, Consultant Psychiatrists

Addiction Disorders, Chronic Eating Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Psychosis, Schizophrenia

N06AB05 Paroxetine Tablets 20mg Consultant Geriatricians, Consultant Oncologists, Consultant Psychiatrists, Consultant Palliative Care

C Consultant Psychiatrists, Consultant Palliative Care

Addiction Disorders, Chronic Eating Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Malignant Diseases, Psychosis, Schizophrenia

4.3.4 Other antidepressant drugs N05AF01 Flupentixol

Dihydrochloride Tablets 0.5mg Consultant Psychiatrists

Addiction Disorders, Chronic Mood Disorders, Psychosis, Schizophrenia

N06AX16 Venlafaxine Modified Release Capsules 75mg

Consultant Geriatricians, Consultant Psychiatrists

Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Psychosis

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55 4. Central Nervous System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

4.4 CNS stimulants and drugs used in attention deficit hyperactivity disorder N06BA09 Atomoxetine Capsules

18mg Consultant Paediatricians (Community Paediatrics), Consultant Paediatricians (Paediatric Neurology and Neurodisability), Consultant Psychiatrists

MP 4

Chronic Psychiatric Disorders Starting in Childhood

N06BA09 Atomoxetine Capsules 25mg

Consultant Paediatricians (Community Paediatrics), Consultant Paediatricians (Paediatric Neurology and Neurodisability), Consultant Psychiatrists

MP 4

Chronic Psychiatric Disorders Starting in Childhood

N06BA09 Atomoxetine Capsules 40mg

Consultant Paediatricians (Community Paediatrics), Consultant Paediatricians (Paediatric Neurology and Neurodisability), Consultant Psychiatrists

MP 4

Chronic Psychiatric Disorders Starting in Childhood

N06BA02 Dexamfetamine Sulphate

Tablets 5mg Consultants

Chronic Psychiatric Disorders Starting in Childhood

N06BA04 Methylphenidate Hydrochloride

Tablets 10mg Consultant Paediatricians, Consultant Psychiatrists

C Consultant Paediatricians, Consultant Psychiatrists

Chronic Psychiatric Disorders Starting in Childhood, Narcolepsy

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V3.0 September 2021

56 4. Central Nervous System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

N06BA04 Methylphenidate Hydrochloride

Prolonged Release Tablets 18mg

Consultant Paediatricians (Community Paediatrics), Consultant Paediatricians (Paediatric Neurology and Neurodisability), Consultant Psychiatrists

MP 126

Chronic Psychiatric Disorders Starting in Childhood

N06BA04 Methylphenidate Hydrochloride

Prolonged Release Tablets 36mg

Consultant Paediatricians (Community Paediatrics), Consultant Paediatricians (Paediatric Neurology and Neurodisability), Consultant Psychiatrists

MP 126

Chronic Psychiatric Disorders Starting in Childhood

4.5 Drugs used in nausea and vertigo A04AD12 Aprepitant Capsules

80mg Consultant Heamatologists, Consultant Oncologists, Consultant Paediatric Oncologists, Consultant Palliative Care

MP 269

Malignant Diseases

A04AD12 Aprepitant Capsules 125mg

Consultant Heamatologists, Consultant Oncologists, Consultant Paediatric Oncologists, Consultant Palliative Care

MP 269

Malignant Diseases

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V3.0 September 2021

57 4. Central Nervous System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

R06AE03 Cyclizine Ampoules 50mg/mL

Consultant Anaesthetists, Consultant Haematologists, Consultant Obstetrics and Gynaecology, Consultant Oncologists, Consultant Paediatric Oncologists, Consultant Palliative Care

MP 267

Malignant Diseases

R06AE03 Cyclizine Tablets 50mg Consultants A Hospital Doctors Malignant Diseases

A03FA03 Domperidone Suspension 1mg/mL

Consultants MP 57 C Consultants Malignant Diseases

A03FA03 Domperidone Tablets 10mg Consultants

C Consultants Malignant Diseases

A03FA01 Metoclopramide Ampoules 10mg/2mL

Consultant Oncologists, Consultant Palliative Care

HU/TBDF Hospitals

only

Malignant Diseases

A03FA01 Metoclopramide Tablets 10mg Consultants Malignant Diseases

A04AA01 Ondansetron Syrup 4mg/5mL

Consultant Haematologists, Consultant Oncologists, Consultant Paediatric Surgeons, Consultant Paediatricians, Consultant Palliative Care

MP 153

Malignant Diseases

A04AA01 Ondansetron Tablets 4mg Consultants MP 154 Malignant Diseases

A04AA01 Ondansetron Tablets 8mg Consultants MP 154 Malignant Diseases

N05AB04 Prochlorperazine Tablets 5mg Consultants A Medical Practitioners Addiction Disorders, Psychosis, Schizophrenia, Malignant Diseases

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V3.0 September 2021

58 4. Central Nervous System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

4.6 Analgesics 4.6.1 Non-opioid analgesics

N02BA01 Aspirin Effervescent Tablets 300mg

Consultants B Medical Practitioners Malignant Diseases

N02BA01 Aspirin Tablets 300mg

B Medical Practitioners No Schedule V Entitlement

N02BE01 Paracetamol Suppositories 100mg or 125mg

Consultants A Medical Practitioners Motor Neuron Disease, Spinal Cord Pathologies, Malignant Diseases

N02BE01 Paracetamol Suppositories 250mg

Consultants A Medical Practitioners Motor Neuron Disease, Spinal Cord Pathologies, Malignant Diseases

N02BE01 Paracetamol Suppositories 500mg

Consultants A Medical Practitioners Motor Neuron Disease, Spinal Cord Pathologies, Malignant Diseases, Rheumatoid Arthritis

N02BE01 Paracetamol Syrup 120mg/5mL

Consultants A Medical Practitioners Motor Neuron Disease, Malignant Diseases, Rheumatoid Arthritis, Spondyloarthritis

N02BE01 Paracetamol Tablets 500mg Consultants B Medical Practitioners Motor Neuron Disease, Spinal Cord Pathologies, Inherited Bleeding Disorders, Polio and Post-Polio Syndrome, Malignant Diseases

4.6.2 Opioid analgesics R05DA04 Codeine

Phosphate Tablets 30mg Consultants

Motor Neuron Disease, Spinal Cord Pathologies, Trigeminal Neuralgia, Inflammatory Bowel Disease, Inherited Bleeding Disorders, Malignant Diseases, Rheumatoid Arthritis, Spondyloarthritis

N02AA08 Dihydrocodeine Tartrate

Tablets 30mg Consultants

Trigeminal Neuralgia, Malignant Diseases

Page 59: Out-Patients Formulary List

V3.0 September 2021

59 4. Central Nervous System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

N02AB03 Fentanyl Transdermal Patches 25mcg

Consultant Anaesthetists (Pain Clinic), Consultant Haematologists, Consultant Oncologists, Consultant Paediatric Oncologists, Consultant Palliative Care

MP 67

Malignant Diseases

N02AB03 Fentanyl Transdermal Patches 50mcg

Consultant Anaesthetists (Pain Clinic), Consultant Haematologists, Consultant Oncologists, Consultant Paediatric Oncologists, Consultant Palliative Care

MP 67

Malignant Diseases

N02AA01 Morphine Sulphate/ Hydrochloride (for Paediatric Use – Currently Mercury Pharma)

Injection 10mg/mL

Consultants

Spinal Cord Pathologies, Trigeminal Neuralgia, Malignant Diseases

N02AA01 Morphine Sulphate/ Hydrochloride (Currently Wockhardt)

Injection 10mg/mL

Consultants

Spinal Cord Pathologies, Trigeminal Neuralgia, Malignant Diseases

N02AA01 Morphine Sulphate/ Hydrochloride

Injection 15mg/mL

Consultants

Spinal Cord Pathologies, Trigeminal Neuralgia, Malignant Diseases

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V3.0 September 2021

60 4. Central Nervous System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

N02AA01 Morphine Sulphate/ Hydrochloride

Injection 20mg/mL

Consultants

Spinal Cord Pathologies, Trigeminal Neuralgia, Malignant Diseases

N02AA01 Morphine Sulphate

Injection 30mg/mL

Consultants

Spinal Cord Pathologies, Trigeminal Neuralgia, Malignant Diseases

N02AA01 Morphine Sulphate

Solution 10mg/5mL

Consultants

Motor Neuron Disease, Spinal Cord Pathologies, Trigeminal Neuralgia, Malignant Diseases

N02AA01 Morphine Sulphate

Slow-Release Tablets 10mg

Consultants

Motor Neuron Disease, Spinal Cord Pathologies, Trigeminal Neuralgia, Malignant Diseases

N02AA01 Morphine Sulphate

Slow-Release Tablets 30mg

Consultants

Motor Neuron Disease, Spinal Cord Pathologies, Trigeminal Neuralgia, Malignant Diseases

N02AA01 Morphine Sulphate

Slow-Release Tablets 60mg

Consultants

Motor Neuron Disease, Spinal Cord Pathologies, Trigeminal Neuralgia, Malignant Diseases

N02AA01 Morphine Sulphate

Slow-Release Tablets 100mg

Consultants

Motor Neuron Disease, Spinal Cord Pathologies, Trigeminal Neuralgia, Malignant Diseases

N02AD01 Pentazocine Tablets 25mg Consultants Motor Neuron Disease, Trigeminal Neuralgia

N02AX02 Tramadol Capsules 50mg

Consultant Physicians, Consultant Surgeons, Consultant Anaesthetists, Consultant Palliative Care, Consultants Oncologists, Pain Clinic Specialists, Consultant Neurologists

MP 192

Motor Neuron Disease, Spinal Cord Pathologies, Trigeminal Neuralgia, Malignant Diseases, Fibromyalgia, Myalgic Encephalomyelitis

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V3.0 September 2021

61 4. Central Nervous System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

4.6.3 Neuropathic pain N06AA09 Amitriptyline Tablets 10mg Consultants B Medical Practitioners Addiction Disorders, Chronic Mood Disorders,

Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Fibromyalgia, Malignant Diseases, Motor Neuron Disease, Multiple Sclerosis, Myalgic Encephalomyelitis, Polio and Post-Polio Syndrome, Psychosis, Schizophrenia, Spinal Cord Pathologies, Trigeminal Neuralgia

N06AA09 Amitriptyline Tablets 25mg Consultants B Medical Practitioners Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Fibromyalgia, Malignant Diseases, Motor Neuron Disease, Multiple Sclerosis, Myalgic Encephalomyelitis, Polio and Post-Polio Syndrome, Psychosis, Schizophrenia, Spinal Cord Pathologies, Trigeminal Neuralgia

N06AA10 Nortriptyline Tablets 10mg Consultants C Medical Practitioners Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Malignant Diseases, Multiple Sclerosis, Psychosis, Schizophrenia, Spinal Cord Pathologies

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V3.0 September 2021

62 4. Central Nervous System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

N06AA10 Nortriptyline Tablets 25mg Consultants C Medical Practitioners Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Malignant Diseases, Multiple Sclerosis, Psychosis, Schizophrenia, Spinal Cord Pathologies

N03AX16 Pregabalin Capsules 75mg

Consultant Anaesthetists, Consultant Geriatricians, Consultant Neurologists, Consultant Oncologists, Consultant Palliative Care, Consultant Psychiatrists, Pain Clinic Specialists, Consultant Haematologists

MP 160

Epilepsy, Trigeminal Neuralgia, Malignant Diseases

N03AX16 Pregabalin Capsules 150mg

Consultant Anaesthetists, Consultant Geriatricians, Consultant Neurologists, Consultant Oncologists, Consultant Palliative Care, Consultant Psychiatrists, Pain Clinic Specialists, Consultant Haematologists

MP 160

Epilepsy, Trigeminal Neuralgia, Malignant Diseases

Page 63: Out-Patients Formulary List

V3.0 September 2021

63 4. Central Nervous System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

N03AX16 Pregabalin Capsules 300mg

Consultant Anaesthetists, Consultant Geriatricians, Consultant Neurologists, Consultant Oncologists, Consultant Palliative Care, Consultant Psychiatrists, Pain Clinic Specialists, Consultant Haematologists

MP 160

Epilepsy, Trigeminal Neuralgia, Malignant Diseases

4.6.4 Antimigraine drugs

4.6.4.1 Prophylaxis Treatment of acute migraine C02AC01 Clonidine

Hydrochloride Tablets 100mcg

Consultants C Consultants Addiction Disorders, Hypertension, Chronic Psychiatric Disorders Starting in Childhood

4.7 Antiepileptic drugs 4.7.1 Control of epilepsy

S01EC01 Acetazolamide Tablets 250mg Consultants Epilepsy, Glaucoma

N03AF01 Carbamazepine Controlled Release Tablets 200mg

Consultant Paediatricians, Consultant Neurologists, Consultant Psychiatrists, Consultant Geriatricians

Addiction Disorders, Chronic Mood Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Epilepsy, Multiple Sclerosis, Psychosis, Schizophrenia, Spinal Cord Pathologies, Trigeminal Neuralgia, Malignant Diseases

N03AF01 Carbamazepine Controlled Release Tablets 400mg

Consultant Paediatricians, Consultant Neurologists, Consultant Psychiatrists, Consultant Geriatricians

Addiction Disorders, Chronic Mood Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Epilepsy, Multiple Sclerosis, Psychosis, Schizophrenia, Spinal Cord Pathologies, Trigeminal Neuralgia, Malignant Diseases

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V3.0 September 2021

64 4. Central Nervous System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

N03AF01 Carbamazepine Syrup 100mg/5mL

Consultants C Medical Practitioners Addiction Disorders, Chronic Mood Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Epilepsy, Multiple Sclerosis, Psychosis, Schizophrenia, Spinal Cord Pathologies, Trigeminal Neuralgia, Malignant Diseases

N03AF01 Carbamazepine Tablets 200mg Consultants C Medical Practitioners Addiction Disorders, Chronic Mood Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Epilepsy, Multiple Sclerosis, Psychosis, Schizophrenia, Spinal Cord Pathologies, Trigeminal Neuralgia, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Malignant Diseases

N05BA09 Clobazam Tablets 10mg Consultant Neurologists, Consultant Paediatricians

Epilepsy

N03AE01 Clonazepam Tablets 0.5mg Consultants

Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Epilepsy, Psychosis, Schizophrenia

N03AE01 Clonazepam Tablets 2mg Consultants

Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Epilepsy, Psychosis, Schizophrenia

N03AD01 Ethosuximide Syrup 250mg/5mL

Consultants

Epilepsy

N03AD01 Ethosuximide Capsules 250mg

Consultants

Epilepsy

N03AX12 Gabapentin Tablets 100mg Consultant Neurologists, Consultant Paediatricians

MP 83

Epilepsy

Page 65: Out-Patients Formulary List

V3.0 September 2021

65 4. Central Nervous System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

N03AX12 Gabapentin Tablets 300mg Consultant Neurologists, Consultant Paediatricians

MP 83

Epilepsy

N03AX09 Lamotrigine Dispersible Tablets 5mg

Consultant Paediatricians, Consultant Neurologists, Consultant Psychiatrists

Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Epilepsy

N03AX09 Lamotrigine Dispersible Tablets 25mg

Consultant Paediatricians, Consultant Neurologists, Consultant Psychiatrists

Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Epilepsy

N03AX09 Lamotrigine Tablets 25mg Consultant Paediatricians, Consultant Neurologists, Consultant Psychiatrists

Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Epilepsy

N03AX09 Lamotrigine Tablets 50mg Consultant Paediatricians, Consultant Neurologists, Consultant Psychiatrists

Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Epilepsy

N03AX09 Lamotrigine Tablets 100mg Consultant Paediatricians, Consultant Neurologists, Consultant Psychiatrists

Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Epilepsy

N03AX14 Levetiracetam Syrup 100mg/mL

Consultant Paediatricians, Consultant Palliative Care, Consultant Neurologists

MP 116

Epilepsy

N03AX14 Levetiracetam Tablets 500mg Consultant Paediatricians, Consultant Palliative Care, Consultant Neurologists

MP 115

Epilepsy

N03AX14 Levetiracetam Tablets 1000mg

Consultant Paediatricians, Consultant Palliative Care, Consultant Neurologists

MP 115

Epilepsy

N03AA02 Phenobarbital (Phenobarbitone)

Powder Consultants

Chronic Liver Disease, Epilepsy

N03AA02 Phenobarbital (Phenobarbitone)

Tablets 15mg or 30mg

Consultants B Medical Practitioners Epilepsy

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V3.0 September 2021

66 4. Central Nervous System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

N03AB02 Phenytoin Sodium

Capsules 50mg

Consultants

Epilepsy, Malignant Diseases

N03AB02 Phenytoin Sodium

Capsules 100mg

Consultants

Epilepsy, Malignant Diseases

N03AB02 Phenytoin Sodium

Syrup 30mg/5mL

Consultants

Epilepsy, Malignant Diseases

N03AX16 Pregabalin Capsules 75mg

Consultant Anaesthetists, Consultant Geriatricians, Consultant Neurologists, Consultant Oncologists, Consultant Palliative Care, Consultant Psychiatrists, Pain Clinic Specialists, Consultant Haematologists

MP 160

Epilepsy, Trigeminal Neuralgia, Malignant Diseases

N03AX16 Pregabalin Capsules 150mg

Consultant Anaesthetists, Consultant Geriatricians, Consultant Neurologists, Consultant Oncologists, Consultant Palliative Care, Consultant Psychiatrists, Pain Clinic Specialists, Consultant Haematologists

MP 160

Epilepsy, Trigeminal Neuralgia, Malignant Diseases

N03AX16 Pregabalin Capsules 300mg

Consultant Anaesthetists, Consultant Geriatricians, Consultant Neurologists, Consultant Oncologists, Consultant Palliative Care, Consultant Psychiatrists, Pain Clinic Specialists, Consultant Haematologists

MP 160

Epilepsy, Trigeminal Neuralgia, Malignant Diseases

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V3.0 September 2021

67 4. Central Nervous System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

N03AA03 Primidone Tablets 250mg Consultants C Medical Practitioners Epilepsy

N03AF03 Rufinamide Tablets 200mg Consultant Neurologist, Consultant Paediatrician

MP 293

Epilepsy

N03AG01 Sodium Valproate

Controlled Release Tablets 200mg

Consultants

Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Epilepsy, Malignant Diseases

N03AG01 Sodium Valproate

Controlled Release Tablets 500mg

Consultants

Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Epilepsy, Malignant Diseases

N03AG01 Sodium Valproate

Oral Solution 200mg/5mL

Consultant Geriatricians, Consultant Haematologists, Consultant Neurologists, Consultant Oncologists, Consultant Paediatricians, Consultant Psychiatrists

Chronic Psychiatric Disorders Starting in Childhood, Epilepsy, Malignant Diseases

N03AX11 Topiramate Tablets 25mg Consultant Neurologists, Consultant Paediatricians

MP 191

Epilepsy

N03AX11 Topiramate Tablets 50mg Consultant Neurologists, Consultant Paediatricians

MP 191

Epilepsy

N03AX11 Topiramate Tablets 100mg Consultant Neurologists, Consultant Paediatricians

MP 191

Epilepsy

N03AX11 Topiramate Tablets 200mg Consultant Neurologists, Consultant Paediatricians

MP 191

Epilepsy

N03AG04 Vigabatrin Sachets 500mg

Consultant Paediatricians, Consultant Neurologists

MP 198

Epilepsy

N03AG04 Vigabatrin Tablets 500mg Consultant Paediatricians, Consultant Neurologists

MP 197

Epilepsy

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V3.0 September 2021

68 4. Central Nervous System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

4.7.2 Drugs used in status epilepticus N05BA01 Diazepam Rectal Tubes

5mg/2.5mL Consultants B Medical Practitioners Cerebral Palsy, Epilepsy, Malignant Diseases

N05BA01 Diazepam Rectal Tubes 10mg/2.5mL

Consultants B Medical Practitioners Cerebral Palsy, Epilepsy, Malignant Diseases

4.8 Drugs used in parkinsonism and related disorders 4.8.1 Dopaminergic drugs used in parkinsonism

N04BB01 Amantadine Tablets 100mg Consultants

Huntington's Chorea, Multiple Sclerosis, Parkinson's Disease

G02CB01/ N04BC01

Bromocriptine Mesylate

Tablets 2.5mg Consultants

Addiction Disorders, Chronic Mood Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Huntington's Chorea, Parkinson's Disease, Hypopituitarism, Pituitary Adenomas, Malignant Diseases, Psychosis, Schizophrenia

N04BA02 Levodopa + Benserazide Hydrochloride

Dispersible Tablets 100mg + 25mg

Consultant Geriatricians, Consultant Neurologists

MP 118

Parkinson's Disease

N04BA02 Levodopa + Benserazide Hydrochloride

Tablets 50mg + 12.5mg

Consultants C Medical Practitioners Parkinson's Disease

N04BA02 Levodopa + Benserazide Hydrochloride

Tablets 100mg + 25mg

Consultants C Medical Practitioners Parkinson's Disease

N04BA02 Levodopa + Benserazide Hydrochloride

Tablets 200mg + 50mg

Consultants C Medical Practitioners Parkinson's Disease

N04BA02 Levodopa + Carbidopa

Tablets 100mg + 10mg

Consultants C Medical Practitioners Cerebral Palsy, Parkinson's Disease

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V3.0 September 2021

69 4. Central Nervous System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

N04BA03 Levodopa + Carbidopa + Entacapone

Tablets 100mg + 25mg + 200mg

Consultant Geriatricians, Consultant Neurologists

MP 216

Parkinson's Disease

N04BC04 Ropinirole Tablets 250mcg

Consultant Geriatricians, Consultant Neurologists

MP 215

Parkinson's Disease

N04BC04 Ropinirole Tablets 1mg Consultant Geriatricians, Consultant Neurologists

MP 215

Parkinson's Disease

N04BC04 Ropinirole Tablets 5mg Consultant Geriatricians, Consultant Neurologists

MP 215

Parkinson's Disease

N04BD02 Rasagiline Tablets 1mg Consultant Neurologists, Consultant Geriatricians

MP 268

Parkinson's Disease

N04BD01 Selegiline Tablets 5mg Consultants C Medical Practitioners Parkinson's Disease

4.8.2 Antimuscarinic drugs used in parkinsonism N04AB02 Orphenadrine

Hydrochloride Tablets 50mg Consultants

Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Parkinson's Disease, Malignant Diseases, Psychosis, Schizophrenia

N04AA04 Procyclidine Injection IM/IV 10mg/2mL

Consultant Geriatricians, Consultant Neurologists, Consultant Psychiatrists

Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Parkinson's Disease, Psychosis, Schizophrenia

N04AA04 Procyclidine Syrup 5mg/5mL

Consultant Geriatricians, Consultant Neurologists, Consultant Psychiatrists

MP 168

Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Parkinson's Disease, Psychosis, Schizophrenia

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70 4. Central Nervous System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

N04AA04 Procyclidine Tablets 5mg Consultant Geriatricians, Consultant Neurologists, Consultant Psychiatrists

Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Parkinson's Disease, Psychosis, Schizophrenia

N04AA01 Trihexyphenidyl Hydrochloride (Benzhexol Hydrochloride)

Tablets 2mg Consultants C Medical Practitioners Cerebral Palsy, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Huntington's Chorea, Motor Neuron Disease, Parkinson's Disease, Psychosis, Schizophrenia, Malignant Diseases

4.8.3 Drugs used in tremor, chorea, tics and related disorders N05AD01 Haloperidol Capsules

0.5mg Consultant Geriatricians, Consultant Haematologists, Consultant Oncologists, Consultant Palliative Care, Consultant Psychiatrists

C Consultant Geriatricians, Consultant Haematologists, Consultant Oncologists, Consultant Palliative Care, Consultant Psychiatrists

Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Psychosis, Schizophrenia, Malignant Diseases

N05AD01 Haloperidol Injections 5mg Consultant Haematologists, Consultant Oncologists, Consultant Palliative Care, Consultant Psychiatrists

Addiction Disorders, Chronic Psychiatric Disorders Starting in Childhood, Psychosis, Schizophrenia, Malignant Diseases

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V3.0 September 2021

71 4. Central Nervous System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

N05AD01 Haloperidol Oral Solution 2mg/mL

Consultant Geriatricians, Consultant Haematologists, Consultant Oncologists, Consultant Palliative Care, Consultant Psychiatrists

C Consultant Geriatricians, Consultant Haematologists, Consultant Oncologists, Consultant Palliative Care, Consultant Psychiatrists

Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Psychosis, Schizophrenia, Malignant Diseases

N05AD01 Haloperidol Tablets 1.5mg Consultant Geriatricians, Consultant Haematologists, Consultant Oncologists, Consultant Palliative Care, Consultant Psychiatrists

C Consultant Geriatricians, Consultant Haematologists, Consultant Oncologists, Consultant Palliative Care, Consultant Psychiatrists

Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Psychosis, Schizophrenia, Malignant Diseases

N05AD01 Haloperidol Tablets 5mg Consultant Geriatricians, Consultant Haematologists, Consultant Oncologists, Consultant Palliative Care, Consultant Psychiatrists

C Consultant Geriatricians, Consultant Haematologists, Consultant Oncologists, Consultant Palliative Care, Consultant Psychiatrists

Addiction Disorders, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Psychosis, Schizophrenia, Malignant Diseases

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72 4. Central Nervous System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

N07XX06 Tetrabenazine Tablets 25mg Consultants C Consultants Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Huntington's Chorea, Parkinson's Disease, Psychosis, Schizophrenia, Malignant Diseases

4.9 Drugs used in substance dependence N07BB01 Disulfiram Tablets 200mg Consultants C Hospital Doctors Addiction Disorders

N07BB04 Naltrexone Hydrochloride

Tablets 50mg Consultant Psychiatrists

Addiction Disorders, Chronic Psychiatric Disorders Starting in Childhood

4.10 Drugs for dementia N06DA02 Donepezil

Hydrochloride Tablets 5mg Consultant Geriatricians,

Consultant Neurologists, Consultant Psychiatrists

MP 58

Dementia

N06DA02 Donepezil Hydrochloride

Tablets 10mg Consultant Geriatricians, Consultant Neurologists, Consultant Psychiatrists

MP 58

Dementia

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V3.0 September 2021

73 5. Infections

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

5. Infections 5.1 Antibacterial drugs

5.1.1 Penicillins J01CA04 Amoxicillin Capsules

250mg Consultants GU Clinic Entitlement: GU Clinic Consultants

A Medical Practitioners Chronic Kidney Disease, Chronic Liver Disease, Chronic Obstructive Pulmonary Disease, Chronic Osteomyelitis, Chronic Respiratory Failure, Congenital Indifference to Pain, Cystic Fibrosis, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Down Syndrome, Gastric/Duodenal Ulcers, HIV/AIDS and HIV Related Diseases, Hospital Acquired Infections, Imperforate Anus, Malignant Diseases, Peripheral Vascular Disease, Primary Immunodeficiency Disorder, Secondary Immunodeficiency Disorder, Spinal Cord Pathologies

J01CA04 Amoxicillin Injection 250mg

Consultants A Medical Practitioners Malignant Diseases, Peripheral Vascular Disease

J01CA04 Amoxicillin Injection 500mg

Consultants A Medical Practitioners Malignant Diseases, Peripheral Vascular Disease

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74 5. Infections

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

J01CA04 Amoxicillin Oral Suspension 125mg/5mL

Consultants A Medical Practitioners Chronic Kidney Disease, Chronic Liver Disease, Chronic Obstructive Pulmonary Disease, Chronic Osteomyelitis, Chronic Respiratory Failure, Congenital Indifference to Pain, Cystic Fibrosis, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Down Syndrome, Gastric/Duodenal Ulcers, HIV/AIDS and HIV Related Diseases, Hospital Acquired Infections, Imperforate Anus, Malignant Diseases, Peripheral Vascular Disease, Primary Immunodeficiency Disorder, Secondary Immunodeficiency Disorder, Spinal Cord Pathologies

J01CR02 Amoxicillin + Clavulanic Acid

Oral Suspension 156mg/5mg

Consultants A Medical Practitioners Chronic Kidney Disease, Chronic Liver Disease, Chronic Obstructive Pulmonary Disease, Chronic Osteomyelitis, Chronic Respiratory Failure, Congenital Indifference to Pain, Cystic Fibrosis, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Down Syndrome, HIV/AIDS and HIV Related Diseases, Hospital Acquired Infections, Malignant Diseases, Peripheral Vascular Disease, Primary Immunodeficiency Disorder, Secondary Immunodeficiency Disorder, Spinal Cord Pathologies

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V3.0 September 2021

75 5. Infections

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

J01CR02 Amoxicillin + Clavulanic Acid

Tablets 250mg + 125mg

Consultants A Medical Practitioners Chronic Kidney Disease, Chronic Liver Disease, Chronic Obstructive Pulmonary Disease, Chronic Osteomyelitis, Chronic Respiratory Failure, Congenital Indifference to Pain, Cystic Fibrosis, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Down Syndrome, HIV/AIDS and HIV Related Diseases, Hospital Acquired Infections, Malignant Diseases, Peripheral Vascular Disease, Primary Immunodeficiency Disorder, Secondary Immunodeficiency Disorder, Spinal Cord Pathologies

J01CE01 Benzylpenicillin Injection 600mg

Consultants A Medical Practitioners Congenital Indifference to Pain, Chronic Osteomyelitis, Hospital Acquired Infections, Malignant Diseases, Peripheral Vascular Disease, Spinal Cord Pathologies

J01CF05 Flucloxacillin Capsules 250mg

Consultants A Medical Practitioners Chronic Immunobullous Disorders, Chronic

Osteomyelitis, Congenital Ichthyosis,

Congenital Indifference to Pain, Cystic Fibrosis,

Diabetes Mellitus Type 1, Diabetes Mellitus

Type 2, HIV/AIDS and HIV Related Diseases,

Hospital Acquired Infections, Malignant

Diseases, Peripheral Vascular Disease, Spinal

Cord Pathologies

J01CF05 Flucloxacillin Injection 250mg

Consultants A Medical Practitioners Congenital Indifference to Pain, Chronic Osteomyelitis, Hospital Acquired Infections, Malignant Diseases, Peripheral Vascular Disease, Spinal Cord Pathologies

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V3.0 September 2021

76 5. Infections

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

J01CF05 Flucloxacillin Syrup 125mg/5mL

Consultants A Medical Practitioners Chronic Immunobullous Disorders, Chronic Osteomyelitis, Congenital Ichthyosis, Congenital Indifference to Pain, Cystic Fibrosis, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, HIV/AIDS and HIV Related Diseases, Hospital Acquired Infections, Malignant Diseases, Peripheral Vascular Disease, Spinal Cord Pathologies

J01CE02 Phenoxymethylpenicillin (Penicillin

V)

Solution 125mg/5mL

Consultants C Medical Practitioners Chronic Kidney Disease, Chronic Osteomyelitis, Congenital Indifference to Pain, Hospital Acquired Infections, Inherited Haemoglobinopathies, Malignant Diseases, Peripheral Vascular Disease, Secondary Immunodeficiency Disorder, Spinal Cord Pathologies

J01CE02 Phenoxymethylpenicillin (penicillin

V)

Tablets 250mg Consultants C Medical Practitioners Chronic Kidney Disease, Chronic Osteomyelitis, Congenital Indifference to Pain, Hospital Acquired Infections, Inherited Haemoglobinopathies, Malignant Diseases, Peripheral Vascular Disease, Secondary Immunodeficiency Disorder, Spinal Cord Pathologies

5.1.2 Cephalosporins J01DB01 Cefalexin Capsules

250mg Consultants A Medical Practitioners Chronic Immunobullous Disorders, Chronic

Osteomyelitis, Congenital Ichthyosis, Congenital Indifference to Pain, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Hospital Acquired Infections, Malignant Diseases, Peripheral Vascular Disease, Spinal Cord Pathologies

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V3.0 September 2021

77 5. Infections

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

J01DB01 Cefalexin Syrup 125mg/5mL

Consultants A Medical Practitioners Chronic Immunobullous Disorders, Chronic Osteomyelitis, Congenital Ichthyosis, Congenital Indifference to Pain, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Hospital Acquired Infections, Malignant Diseases, Peripheral Vascular Disease, Spinal Cord Pathologies

J01DC02 Cefuroxime Axetil Suspension 125mg/5mL

Consultants A Medical Practitioners Chronic Osteomyelitis, Congenital Indifference to Pain, Down Syndrome, Hospital Acquired Infections, Malignant Diseases, Peripheral Vascular Disease, Spinal Cord Pathologies

J01DC02 Cefuroxime Axetil Tablets 250mg Consultants A Medical Practitioners Chronic Osteomyelitis, Congenital Indifference to Pain, Down Syndrome, HIV/AIDS and HIV Related Diseases, Hospital Acquired Infections, Malignant Diseases, Peripheral Vascular Disease, Spinal Cord Pathologies

5.1.3 Tetracyclines J01AA02 Doxycycline Capsules

100mg Consultants GU Clinic Entitlement: GU Clinic Consultants

DM Medical Practitioners Chronic Immunobullous Disorders, Chronic Obstructive Pulmonary Disease, Chronic Osteomyelitis, Chronic Respiratory Failure, Congenital Indifference to Pain, Cystic Fibrosis, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Hidradenitis Suppurativa, HIV/AIDS and HIV Related Diseases, Hospital Acquired Infections, Malignant Diseases, Peripheral Vascular Disease, Spinal Cord Pathologies

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V3.0 September 2021

78 5. Infections

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

J01AA07 Tetracycline Capsules 250mg

Consultants A Medical Practitioners Chronic Immunobullous Disorders, Chronic Osteomyelitis, Congenital Indifference to Pain, Gastric/Duodenal Ulcers, Hospital Acquired Infections, Malignant Diseases, Peripheral Vascular Disease, Spinal Cord Pathologies

5.1.4 Aminoglycosides J01GB03 Gentamicin Injection

80mg (to be inhaled in cystic fibrosis)

Consultants TBDF MDHP only

Cystic Fibrosis

5.1.5 Macrolides J01FA10 Azithromycin

Capsules 250mg

Consultant Paediatricians, Infectious Disease Consultants, Consultant Respiratory Physicians, Mater Dei Hospital Antibiotic Team Consultants GU Clinic Entitlement: GU Clinic Consultants

MP 11

Primary Immunodeficiency Disorder, Secondary Immunodeficiency Disorder, Cystic Fibrosis

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V3.0 September 2021

79 5. Infections

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

J01FA10 Azithromycin Capsules 500mg

Consultant Paediatricians, Infectious Disease Consultants, Consultant Respiratory Physicians, Mater Dei Hospital Antibiotic Team Consultants GU Clinic Entitlement: GU Clinic Consultants

MP 11

Primary Immunodeficiency Disorder, Secondary Immunodeficiency Disorder, Cystic Fibrosis

J01FA10 Azithromycin Suspension 200mg/5mL

Consultant Paediatricians, Infectious Disease Consultants, Consultant Respiratory Physicians, Mater Dei Hospital Antibiotic Team Consultants GU Clinic Entitlement: GU Clinic Consultants

MP 11

Primary Immunodeficiency Disorder, Secondary Immunodeficiency Disorder, Cystic Fibrosis

J01FA09 Clarithromycin Syrup 125mg/5mL

Consultant Paediatricians

Down Syndrome, Congenital Indifference to Pain, Gastric/Duodenal Ulcers, Chronic Osteomyelitis, HIV/AIDS and HIV Related Diseases, Hospital Acquired Infections, Chronic Respiratory Failure

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V3.0 September 2021

80 5. Infections

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

J01FA09 Clarithromycin Tablets 250mg Consultants A Consultants Chronic Obstructive Pulmonary Disease, Chronic Osteomyelitis, Chronic Respiratory Failure, Congenital Indifference to Pain, Down Syndrome, Gastric/Duodenal Ulcers, HIV/AIDS and HIV Related Diseases, Hospital Acquired Infections, Malignant Diseases, Peripheral Vascular Disease, Spinal Cord Pathologies

J01FA01 Erythromycin Syrup 125mg/5mL

Consultants B Medical Practitioners Chronic Kidney Disease, Chronic Osteomyelitis, Congenital Indifference to Pain, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, HIV/AIDS and HIV Related Diseases, Hospital Acquired Infections, Malignant Diseases, Peripheral Vascular Disease, Secondary Immunodeficiency Disorder, Spinal Cord Pathologies

J01FA01 Erythromycin Capsules/ Tablets 250mg

Consultants GU Clinic Entitlement: GU Clinic Consultants

B Medical Practitioners Chronic Kidney Disease, Chronic Osteomyelitis, Congenital Indifference to Pain, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, HIV/AIDS and HIV Related Diseases, Hospital Acquired Infections, Malignant Diseases, Peripheral Vascular Disease, Secondary Immunodeficiency Disorder, Spinal Cord Pathologies

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V3.0 September 2021

81 5. Infections

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

5.1.6 Clindamycin J01FF01 Clindamycin Capsules

150mg Consultants A Consultants Chronic Osteomyelitis, Congenital Indifference

to Pain, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Hidradenitis Suppurativa, HIV/AIDS and HIV Related Diseases, Hospital Acquired Infections, Malignant Diseases, Peripheral Vascular Disease, Spinal Cord Pathologies

5.1.7 Some other antibacterials J01BA01 Chloramphenicol Capsules

250mg Consultants A Consultants Chronic Osteomyelitis, Congenital Indifference

to Pain, HIV/AIDS and HIV Related Diseases, Hospital Acquired Infections, Malignant Diseases, Spinal Cord Pathologies

J01XB01 Colistimethate Sodium (Colistin Sulphomethate Sodium)

Injection 1 MU (for inhalation in cystic fibrosis)

Consultant Infectious Diseases Physicians, Consultant Paediatricians, Consultant Respiratory Physicians

MP 44

Chronic Respiratory Failure, Cystic Fibrosis

J01XC01 Fusidate Sodium Tablets 250mg Consultants A Consultants Chronic Osteomyelitis, Congenital Indifference to Pain, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, HIV/AIDS and HIV Related Diseases, Hospital Acquired Infections, Malignant Diseases, Peripheral Vascular Disease, Spinal Cord Pathologies

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V3.0 September 2021

82 5. Infections

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

J01XC01 Fusidic Acid Oral Suspension

250mg/5mL

Consultants A Consultants Chronic Osteomyelitis, Congenital Indifference to Pain, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, HIV/AIDS and HIV Related Diseases, Hospital Acquired Infections, Malignant Diseases, Peripheral Vascular Disease, Spinal Cord Pathologies

5.1.8 Sulphonamides and trimethoprim J01EE01 Co-Trimoxazole Syrup Adult

480mg/5mL Consultants B Medical Practitioners Chronic Immunobullous Disorders, Chronic

Kidney Disease, Chronic Osteomyelitis, Chronic Respiratory Failure, Congenital Ichthyosis, Congenital Indifference to Pain, Cystic Fibrosis, HIV/AIDS and HIV Related Diseases, Hospital Acquired Infections, Imperforate Anus, Inflammatory Bowel Disease, Malignant Diseases, Peripheral Vascular Disease, Primary Immunodeficiency Disorder, Secondary Immunodeficiency Disorder, Spinal Cord Pathologies

Officially deleted. Available until stocks last.

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V3.0 September 2021

83 5. Infections

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

J01EE01 Co-Trimoxazole Syrup Paediatric 240mg/5mL

Consultants B Medical Practitioners Chronic Immunobullous Disorders, Chronic Kidney Disease, Chronic Osteomyelitis, Chronic Respiratory Failure, Congenital Ichthyosis, Congenital Indifference to Pain, Cystic Fibrosis, HIV/AIDS and HIV Related Diseases, Hospital Acquired Infections, Imperforate Anus, Inflammatory Bowel Disease, Malignant Diseases, Peripheral Vascular Disease, Primary Immunodeficiency Disorder, Secondary Immunodeficiency Disorder, Spinal Cord Pathologies

J01EE01 Co-Trimoxazole Tablets 400mg + 80mg

Consultants B Medical Practitioners Chronic Immunobullous Disorders, Chronic Kidney Disease, Chronic Osteomyelitis, Chronic Respiratory Failure, Congenital Ichthyosis, Congenital Indifference to Pain, Cystic Fibrosis, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, HIV/AIDS and HIV Related Diseases, Hospital Acquired Infections, Imperforate Anus, Inflammatory Bowel Disease, Malignant Diseases, Peripheral Vascular Disease, Primary Immunodeficiency Disorder, Secondary Immunodeficiency Disorder, Spinal Cord Pathologies

J01EC02 Sulfadiazine Tablets 500mg Consultants

Chronic Osteomyelitis, Congenital Indifference to Pain, HIV/AIDS and HIV Related Diseases, Hospital Acquired Infections, Malignant Diseases, Peripheral Vascular Disease, Spinal Cord Pathologies

Page 84: Out-Patients Formulary List

V3.0 September 2021

84 5. Infections

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

J01EA01 Trimethoprim Tablets 100mg Consultants A Medical Practitioners Chronic Kidney Disease, Chronic Osteomyelitis, Congenital Indifference to Pain, Hospital Acquired Infections, Imperforate Anus, Malignant Diseases, Peripheral Vascular Disease, Spinal Cord Pathologies

5.1.9 Antituberculosis drugs J04AB01 Cycloserine Tablets 250mg Consultant Infectious

Diseases Physicians, Paediatric Infectious Diseases Clinic Physicians, Consultant Respiratory Physicians, Chest Clinic Physicians

TBDF Hospitals

only

Tuberculosis

J04AK02 Ethambutol Tablets 100mg Consultant Infectious Diseases Physicians, Paediatric Infectious Diseases Clinic Physicians, Consultant Respiratory Physicians, Chest Clinic Physicians

As per AG TBDF

Hospitals only

Tuberculosis

J04AK02 Ethambutol Tablets 400mg Consultant Infectious Diseases Physicians, Paediatric Infectious Diseases Clinic Physicians, Consultant Respiratory Physicians, Chest Clinic Physicians

TBDF Hospitals

only

Tuberculosis

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V3.0 September 2021

85 5. Infections

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

J04AD03 Ethionamide Tablets 250mg Consultant Infectious Diseases Physicians, Chest Clinic Physicians

MP 255 TBDF

Hospitals only

Tuberculosis

J04AC01 Isoniazid Tablets 100mg Consultant Infectious Diseases Physicians, Paediatric Infectious Diseases Clinic Physicians, Consultant Respiratory Physicians, Chest Clinic Physicians

TBDF Hospitals

only

Tuberculosis

J04AM02 Isoniazid + Rifampicin

Tablets 100mg + 150mg

Consultant Infectious Diseases Physicians, Paediatric Infectious Diseases Clinic Physicians, Consultant Respiratory Physicians, Chest Clinic Physicians

TBDF Hospitals

only

Tuberculosis

J04AM02 Isoniazid + Rifampicin

Tablets 150mg + 300mg

Consultant Infectious Diseases Physicians, Paediatric Infectious Diseases Clinic Physicians, Consultant Respiratory Physicians, Chest Clinic Physicians

TBDF Hospitals

only

Tuberculosis

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V3.0 September 2021

86 5. Infections

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

J04AK01 Pyrazinamide Tablets 500mg Consultant Infectious Diseases Physicians, Paediatric Infectious Diseases Clinic Physicians, Consultant Respiratory Physicians, Chest Clinic Physicians

TBDF Hospitals

only

Tuberculosis

J04AB04 Rifabutin Capsules 150mg

Consultant Infectious Diseases Physicians, Chest Clinic Physicians

MP 259 TBDF

Hospitals only

Tuberculosis

J04AB02 Rifampicin Capsules 300mg

Consultants, Consultant Dermatologists

MP 174 TB

patients to collect item from Hospitals

only

Hidradenitis Suppurativa, Hospital Acquired Infections, Leprosy, Tuberculosis, Malignant Diseases

J04AB02 Rifampicin Oral Suspension 100mg/5mL

Consultants, Consultant Dermatologists

MP 174 TB

patients to collect item from Hospitals

only

Hidradenitis Suppurativa, Hospital Acquired Infections, Leprosy, Tuberculosis, Malignant Diseases

5.1.10 Antileprotic drugs J04BA01 Clofazimine Capsules/

Tablets 50mg Consultants

Leprosy, Malignant Diseases

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V3.0 September 2021

87 5. Infections

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

J04BA02 Dapsone Tablets 50mg Consultants

Chronic Immunobullous Disorders, Dermatomyositis/ Polymyositis, Hidradenitis Suppurativa, HIV/AIDS and HIV Related Diseases, Leprosy, Lupus Erythematosus, Malignant Diseases, Severe Chronic Urticaria, Other Schedule V conditions as determined by a member of the Antibiotic Team

J04BA02 Dapsone Tablets 100mg Consultants

Chronic Immunobullous Disorders, Dermatomyositis/ Polymyositis, Hidradenitis Suppurativa, HIV/AIDS and HIV Related Diseases, Leprosy, Lupus Erythematosus, Malignant Diseases, Severe Chronic Urticaria, Other Schedule V conditions as determined by a member of the Antibiotic Team

L04AX02 Thalidomide Capsules/ Tablets 50mg

Consultant Rheumatologists, Consultant Dermatologists, Consultant Haematologists, Consultant Infectious Disease Physicians, Consultant Oncologists

MP 189 TBDF

Hospitals only

Leprosy, Malignant Diseases, Lupus Erythematosus

5.1.11 Metronidazole P01AB01 Metronidazole Suppositories

500mg Consultants A Medical Practitioners Gastric/Duodenal Ulcers, Hirschsprung's

Disease, Inflammatory Bowel Disease, Peripheral Vascular Disease, Spinal Cord Pathologies

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V3.0 September 2021

88 5. Infections

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

P01AB01 Metronidazole Suspension 200mg/5mL

Consultants A Medical Practitioners Chronic Kidney Disease, Chronic Osteomyelitis, Congenital Indifference to Pain, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Gastric/Duodenal Ulcers, Hirschsprung's Disease, HIV/AIDS and HIV Related Diseases, Hospital Acquired Infections, Inflammatory Bowel Disease, Malignant Diseases, Peripheral Vascular Disease, Primary Immunodeficiency Disorder, Secondary Immunodeficiency Disorder, Spinal Cord Pathologies

P01AB01 Metronidazole Tablets 200mg Consultants GU Clinic Entitlement: GU Clinic Consultants

A Medical Practitioners Chronic Kidney Disease, Chronic Osteomyelitis, Congenital Indifference to Pain, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Gastric/Duodenal Ulcers, Hirschsprung's Disease, HIV/AIDS and HIV Related Diseases, Hospital Acquired Infections, Inflammatory Bowel Disease, Malignant Diseases, Peripheral Vascular Disease, Primary Immunodeficiency Disorder, Secondary Immunodeficiency Disorder, Spinal Cord Pathologies

5.1.12 Quinolones J01MA02 Ciprofloxacin Suspension

250mg/5mL Consultants MP 38

Cystic Fibrosis

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V3.0 September 2021

89 5. Infections

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

J01MA02 Ciprofloxacin Tablets 250mg Consultants A Hospital Doctors Chronic Kidney Disease, Chronic Liver Disease, Chronic Osteomyelitis, Chronic Respiratory Failure, Congenital Indifference to Pain, Cystic Fibrosis, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, HIV/AIDS and HIV Related Diseases, Hospital Acquired Infections, Inflammatory Bowel Disease, Malignant Diseases, Peripheral Vascular Disease, Primary Immunodeficiency Disorder, Secondary Immunodeficiency Disorder, Spinal Cord Pathologies

J01MA12 Levofloxacin Tablets 500mg Mater Dei Hospital Antibiotic Team Consultants

MP173

Hospital Acquired Infections

J01MA14 Moxifloxacin Tablets 400mg Consultant Infectious Diseases Physicians

MP 250 TBDF

Hospitals only

Tuberculosis

J01MA06 Norfloxacin Tablets 400mg Consultants A Consultants Chronic Kidney Disease, Chronic Liver Disease, Chronic Osteomyelitis, Congenital Indifference to Pain, Hospital Acquired Infections, Peripheral Vascular Disease, Spinal Cord Pathologies

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V3.0 September 2021

90 5. Infections

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

5.1.13 Urinary tract infections J01XE01 Nitrofurantoin Syrup

25mg/5mL Consultants A Medical Practitioners Chronic Kidney Disease, Congenital

Indifference to Pain, Imperforate Anus, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Chronic Osteomyelitis, HIV/AIDS and HIV Related Diseases, Hospital Acquired Infections, Malignant Diseases, Peripheral Vascular Disease, Spinal Cord Pathologies

J01XE01 Nitrofurantoin Tablets 50mg Consultants A Medical Practitioners Chronic Kidney Disease, Congenital Indifference to Pain, Imperforate Anus, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Chronic Osteomyelitis, HIV/AIDS and HIV Related Diseases, Hospital Acquired Infections, Malignant Diseases, Peripheral Vascular Disease, Spinal Cord Pathologies

5.2 Antifungal drugs J02AC01 Fluconazole Capsules

50mg Consultants MP 72

Primary Immunodeficiency Disorder, Secondary Immunodeficiency Disorder, HIV/AIDS and HIV Related Diseases, Malignant Diseases, Chronic Kidney Disease

J02AC01 Fluconazole Capsules 150mg

Consultants MP 72

Primary Immunodeficiency Disorder, Secondary Immunodeficiency Disorder, HIV/AIDS and HIV Related Diseases, Malignant Diseases, Chronic Kidney Disease

J02AC01 Fluconazole Suspension 50mg/5mL

Consultants MP 73

Primary Immunodeficiency Disorder, Secondary Immunodeficiency Disorder, HIV/AIDS and HIV Related Diseases, Malignant Diseases, Chronic Kidney Disease

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V3.0 September 2021

91 5. Infections

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

D01BA01 Griseofulvin Tablets 125mg Consultants A Hospital Doctors Congenital Indifference to Pain, Chronic Osteomyelitis, Hospital Acquired Infections, Malignant Diseases

J02AC02 Itraconazole Capsules 100mg

Consultant Paediatricians, Consultant Infectious Diseases Physicians, Consultant Oncologists, Consultant Haematologists, Microbiologists

MP 108

Primary Immunodeficiency Disorder, Secondary Immunodeficiency Disorder, HIV/AIDS and HIV Related Diseases, Malignant Diseases, Chronic Kidney Disease, Cystic Fibrosis

J02AC02 Itraconazole Syrup 10mg/mL

Consultant Paediatricians, Consultant Oncologists, Consultant Haematologists, Consultant Infectious Diseases Physicians

MP 107

Primary Immunodeficiency Disorder, Secondary Immunodeficiency Disorder, HIV/AIDS and HIV Related Diseases, Malignant Diseases, Chronic Kidney Disease, Cystic Fibrosis

A07AA02 Nystatin Syrup 100000 IU

Consultants A Medical Practitioners Congenital Indifference to Pain, Primary Immunodeficiency Disorder, Secondary Immunodeficiency Disorder, Chronic Osteomyelitis, HIV/AIDS and HIV Related Diseases, Hospital Acquired Infections, Malignant Diseases, Chronic Kidney Disease, Chronic Immunobullous Disorders

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V3.0 September 2021

92 5. Infections

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

J02AC04 Posaconazole Oral Suspension 40mg/mL

Consultant Infectious Diseases Physicians, Consultant Infectious Diseases Paediatricians, Consultant Haematologists, Consultant Oncologists, Mater Dei Hospital Antibiotic Team Consultants

MP 164 Chronic Kidney Disease, Cystic Fibrosis, HIV/AIDS and HIV Related Diseases, Malignant Diseases, Primary Immunodeficiency Disorder, Secondary Immunodeficiency Disorder

J02AC03 Voriconazole Tablets 200mg Consultant Haematologists, Consultant Infectious Diseases Paediatricians, Consultant Infectious Diseases Physicians, Consultant Intensivists, Consultant Microbiologists, Consultant Oncologists, Mater Dei Hospital Antibiotic Team Consultants

MP 305 Chronic Kidney Disease, Cystic Fibrosis, HIV/AIDS and HIV Related Diseases, Malignant Diseases, Primary Immunodeficiency Disorder, Secondary Immunodeficiency Disorder

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V3.0 September 2021

93 5. Infections

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

5.3 Antivirals 5.3.1 HIV infection

5.3.1.1 Nucleoside reverse transcriptase inhibitors J05AR02 Abacavir +

Lamivudine Tablets 600mg + 300mg

Consultant Infectious Diseases Physicians, Consultant Hospital Infection Control Physicians

MP 292 TBDF

Hospitals only

HIV/AIDS and HIV Related Diseases

J05AF05 Lamivudine Oral Solution 10mg/mL

Consultant Paediatricians, Consultant Infectious Diseases Physicians

MP 256 TBDF

Hospitals only

HIV/AIDS and HIV Related Diseases

J05AF05 Lamivudine Tablets 100mg Consultant Gastroenterologists, Consultant Infectious Diseases Physicians

MP 110

Hepatitis B and C

J05AF05 Lamivudine Tablets 150mg Consultant Infectious Diseases Physicians, Consultant Hospital Infection Control

MP 99 TBDF

Hospitals only

HIV/AIDS and HIV Related Diseases

J05AF07 Tenofovir Disoproxil

Tablets 245mg Consultant Infectious Diseases Physicians, Consultant Gastroenterologists

MP 187

Hepatitis B and C, HIV/AIDS and HIV Related Diseases

J05AF01 Zidovudine (Azidothymidine)

Capsules 100mg

Consultant Infectious Diseases Physicians, Hospital Infection Control

MP 203 TBDF

Hospitals only

HIV/AIDS and HIV Related Diseases

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V3.0 September 2021

94 5. Infections

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

J05AF01 Zidovudine (Azidothymidine) (stand-by)

Oral Solution 100mg/10mL

Consultant Paediatricians, Consultant Infectious Diseases Physicians, Paediatric Infectious Diseases Clinic Physician

MP 202 TBDF

Hospitals only

HIV/AIDS and HIV Related Diseases

J05AR01 Zidovudine+ Lamivudine

Tablets 300mg + 150mg

Consultant Infectious Diseases Physicians, Consultant Hospital Infection Control Physicians

MP 209 TBDF

Hospitals only

HIV/AIDS and HIV Related Diseases

5.3.1.2 Protease inhibitors

J05AR10 Lopinavir/ Ritonavir

Oral Solution 80mg + 20mg per mL

Consultant Infectious Diseases Physicians, Consultant Paediatricians

MP 257 TBDF

Hospitals only

HIV/AIDS and HIV Related Diseases

J05AR10 Lopinavir/ Ritonavir

Tablets 200mg + 50mg

Consultant Infectious Diseases Physicians, Consultant Hospital Infection Control

MP 221 TBDF

Hospitals only

HIV/AIDS and HIV Related Diseases

J05AE03 Ritonavir Capsules 100mg

Consultant Infectious Diseases Physicians

MP 176 TBDF

Hospitals only

HIV/AIDS and HIV Related Diseases

J05AE01 Saquinavir Capsules 500mg

Consultant Infectious Diseases Physicians

MP 178 TBDF

Hospitals only

HIV/AIDS and HIV Related Diseases

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V3.0 September 2021

95 5. Infections

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

5.3.1.3 Non-nucleoside reverse transcriptase inhibitors J05AG03 Efavirenz Capsules

200mg Consultant Infectious Diseases Physicians

MP 208 TBDF

Hospitals only

HIV/AIDS and HIV Related Diseases

J05AG03 Efavirenz Tablets 600mg Consultant Infectious Diseases Physicians

MP 222 TBDF

Hospitals only

HIV/AIDS and HIV Related Diseases

J05AG01 Nevirapine Oral suspension 50mg/5mL

Consultant Paediatricians, Consultant Infectious Diseases Physicians

MP 258 TBDF

Hospitals only

HIV/AIDS and HIV Related Diseases

J05AG01 Nevirapine Tablets 200mg Consultant Infectious Diseases Physicians

MP 143 TBDF

Hospitals only

HIV/AIDS and HIV Related Diseases

5.3.1.4 Other antiretrovirals J05AX09 Maraviroc Tablets 300mg Consultant Infectious

Diseases Physicians MP 121

TBDF Hospitals

only

HIV/AIDS and HIV Related Diseases

5.3.2 Herpesvirus infections

5.3.2.1 Herpes simplex and varicella-zoster infection J05AB01 Aciclovir

(Acyclovir) Suspension 200mg/5mL

Consultants MP 3 A Consultant Dermatologists

Primary Immunodeficiency Disorder, Secondary Immunodeficiency Disorder, HIV/AIDS and HIV Related Diseases, Malignant Diseases, Chronic Kidney Disease

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96 5. Infections

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

J05AB01 Aciclovir (Acyclovir)

Tablets 200mg Consultants GU Clinic Entitlement: GU Clinic Consultants

MP 2 A Consultant Dermatologists

Primary Immunodeficiency Disorder, Secondary Immunodeficiency Disorder, HIV/AIDS and HIV Related Diseases, Malignant Diseases, Chronic Kidney Disease

J05AB01 Aciclovir (Acyclovir)

Tablets 800mg Consultants MP 2 A Consultant Dermatologists

Primary Immunodeficiency Disorder, Secondary Immunodeficiency Disorder, HIV/AIDS and HIV Related Diseases, Malignant Diseases, Chronic Kidney Disease

5.3.2.2 Cytomegalovirus infection J05AB14 Valganciclovir Tablets 450mg Consultant Infectious

Diseases Physicians, Consultant Nephrologists, Consultant Cardiac Surgeons, Consultant Gastroenterologists

MP 247 TBDF

Hospitals only

Chronic Kidney Disease, Chronic Liver Disease, HIV/AIDS and HIV Related Diseases, Secondary Immunodeficiency Disorder

5.3.3 Viral Hepatitis 5.3.3.1 Chronic hepatitis C

J05AP51 Ledipasvir + Sofosbuvir

90mg + 400mg Tablets

Consultant Gastroenterologist (HCV Patient Management Committee), Consultant Infectious Disease Physician (HCV Patient Management Committee)

MP 112 TBDF

Hospitals Only

Hepatitis B and C

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97 5. Infections

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

J05AB04 Ribavirin 200mg Capsules/ Tablets

Consultant Gastroenterologist (HCV Patient Management Committee), Consultant Infectious Disease Physician (HCV Patient Management Committee)

MP 171 TBDF

Hospitals Only

Hepatitis B and C

5.4 Antiprotozoal drugs 5.4.1 Antimalarials

P01BA01 Chloroquine Syrup 50mg/5mL

No Schedule V Entitlement. Can be prescribed by Medical Practitioners as per ‘Dispensing of Oral Antimalarials to Out-Patients’ (refer to page 10), or against payment.

P01BA01 Chloroquine Syrup 150mg base/5mL

No Schedule V Entitlement. Can be prescribed by Medical Practitioners as per ‘Dispensing of Oral Antimalarials to Out-Patients’ (refer to page 10), or against payment.

P01BA01 Chloroquine Tablets 250mg

No Schedule V Entitlement. Can be prescribed by Medical Practitioners as per ‘Dispensing of Oral Antimalarials to Out-Patients’ (refer to page 10), or against payment.

P01BC02 Mefloquine Tablets 250mg

No Schedule V Entitlement. Can be prescribed by Medical Practitioners as per ‘Dispensing of Oral Antimalarials to Out-Patients’ (refer to page 10), or against payment.

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98 5. Infections

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

P01BB51 Proguanil Hydrochloride + Atovaquone

Tablets 100mg + 250mg

No Schedule V Entitlement. Can be prescribed by Medical Practitioners as per ‘Dispensing of Oral Antimalarials to Out-Patients’ (refer to page 10), or against payment.

P01BD01 Pyrimethamine (stand-by)

Tablets 25mg Consultants TBDF Hospitals

only

HIV/AIDS and HIV Related Diseases

5.4.2 Antigiardial drugs P01AX05 Mepacrine

Hydrochloride Tablets 100mg Consultant Physicians MP 123

TBDF Hospitals

only

Lupus Erythematosus

5.5 Antihelmintics 5.5.1 Drugs for tapeworm infections

P02BA01 Praziquantel Tablets 500mg N/A A Consultant Infectious Diseases Physicians

No Schedule V Entitlement

5.5.3 Schistosomides (Bilharzias) P02BA01 Praziquantel Tablets 500mg N/A A Consultant Infectious

Diseases Physicians No Schedule V Entitlement

5.5.4 Filaricides P02CF01 Ivermectin Tablets 3mg N/A A Consultants, Senior

Public Health Physicians

No Schedule V Entitlement

5.5.5 Drugs for cutaneous larva migrans P02CF01 Ivermectin Tablets 3mg N/A A Consultants, Senior

Public Health Physicians

No Schedule V Entitlement

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99 6. Endocrine System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

6. Endocrine System 6.1 Drugs used in diabetes

6.1.1 Insulins

6.1.1.1 Short-acting insulins A10AB05 Insulin Aspart Cartridge

100IU/mL in 3mL

Consultants Endocrinology & Diabetes

MP 207 DM Consultants Endocrinology & Diabetes

Diabetes Mellitus Type 1

A10AB01 Insulin Neutral (Soluble Insulin)

Cartridge 100units/mL in 3mL

Consultants Endocrinology & Diabetes, Consultant Geriatricians, Consultant Paediatricians

MP 100 DM Consultants Endocrinology & Diabetes

Diabetes Mellitus Type 1, Diabetes Mellitus Type 2

A10AB01 Insulin Neutral (Soluble Insulin)

Injection SC 100IU/mL in 10mL

Consultants Endocrinology & Diabetes, Consultant Geriatricians, Consultant Paediatricians

DM Consultants Endocrinology & Diabetes

Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Gestational Diabetes

6.1.1.2 Intermediate- and long-acting insulins A10AD01 Insulin Biphasic

Isophane (Isophane + Neutral)

Cartridges (70%. 30%) 100IU/mL

Consultants Endocrinology & Diabetes, Consultant Geriatricians, Consultant Paediatricians

MP 100 DM Consultants Endocrinology & Diabetes

Diabetes Mellitus Type 1, Diabetes Mellitus Type 2

A10AD01 Insulin Biphasic Isophane (Isophane + Neutral)

Injection 100IU/mL

Consultants Endocrinology & Diabetes, Consultant Geriatricians, Consultant Paediatricians

DM Consultants Endocrinology & Diabetes

Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Gestational Diabetes

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100 6. Endocrine System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

A10AE04 Insulin Glargine Cartridge 100IU/mL

Consultants Endocrinology & Diabetes

MP 101 DM Consultants Endocrinology & Diabetes

Diabetes Mellitus Type 1, Diabetes Mellitus Type 2

A10AC01 Insulin Isophane Cartridge 100 units/mL in 3mL

Consultants Endocrinology & Diabetes, Consultant Geriatricians, Consultant Paediatricians

MP 100 DM Consultants Endocrinology & Diabetes

Diabetes Mellitus Type 1, Diabetes Mellitus Type 2

A10AC01 Insulin Isophane Injection 100 IU/mL in 10mL

Consultants Endocrinology & Diabetes, Consultant Geriatricians, Consultant Paediatricians

DM Consultants Endocrinology & Diabetes

Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Gestational Diabetes

6.1.2 Antidiabetic drugs

6.1.2.1 Sulphonylureas A10BB01 Glibenclamide Tablets 5mg Consultants DM Consultants

Endocrinology & Diabetes

Diabetes Mellitus Type 2, Gestational Diabetes, Malignant Diseases

A10BB09 Gliclazide Tablets 80mg Consultants DM Consultants Endocrinology & Diabetes

Diabetes Mellitus Type 2, Gestational Diabetes, Malignant Diseases

6.1.2.2 Biguanides A10BA02 Metformin Tablets

500mg Consultants, Specialist Family Medicine PHCD

DM Consultants Endocrinology & Diabetes

Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Gestational Diabetes, Hidradenitis Suppurativa, Malignant Diseases

6.1.2.3 Other Antidiabetic Drugs A10BH01 DPP-4 Inhibitors

[Gliptins] (Currently Vildagliptin)

Tablets 50mg Consultants Endocrinology & Diabetes

MP 89

Diabetes Mellitus Type 2

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101 6. Endocrine System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

A10BX02 Repaglinide Tablets 0.5mg

Consultants Endocrinology & Diabetes

Diabetes Mellitus Type 2

A10BX02 Repaglinide Tablets 2mg Consultants Endocrinology & Diabetes

Diabetes Mellitus Type 2

A10BK03 SGLT2 inhibitor (currently Empagliflozin)

Tablets 10mg Consultants Endocrinology & Diabetes

MP 182 Diabetes Mellitus Type 2

A10BK03 SGLT2 inhibitor (currently Empagliflozin)

Tablets 25mg

Consultants Endocrinology & Diabetes

MP 182 Diabetes Mellitus Type 2

6.1.3 Treatment of hypoglycaemia H04AA01 Glucagon Injection 1mg Consultants Endocrinology

& Diabetes DM Consultants

Endocrinology & Diabetes

Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Gestational Diabetes

6.2 Thyroid and antithyroid drugs 6.2.1 Thyroid hormones

H03AA01 Levothyroxine (Thyroxine)

Tablets 25mcg

Consultants C Medical Practitioners Chronic Mood Disorders, Down Syndrome, Turner Syndrome, Hypopituitarism, Malignant Diseases

H03AA01 Levothyroxine (Thyroxine)

Tablets 100mcg

Consultants C Medical Practitioners Chronic Mood Disorders, Down Syndrome, Turner Syndrome, Hypopituitarism, Malignant Diseases

H03AA02 Liothyronine Sodium (L-Tri-iodothyronine)

Tablets 25mcg

Consultants MP 242

Down Syndrome, Turner Syndrome, Hypopituitarism, Malignant Diseases

6.2.2 Antithyroid drugs H03BB01 Carbimazole Tablets 5mg Consultants C Medical Practitioners Malignant Diseases

H03BA02 Propylthiouracil Tablets 50mg Consultants C Medical Practitioners Malignant Diseases

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102 6. Endocrine System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

6.3 Corticosteroids 6.3.1 Replacement therapy

H02AA02 Fludrocortisone Acetate

Tablets 0.1mg

Consultants

Addison's Disease, Hypopituitarism, Secondary Immunodeficiency Disorder, Malignant Diseases, Chronic Kidney Disease

6.3.2 Glucocorticoid therapy H02AB02 Dexamethasone Tablets

0.5mg Consultants C Medical Practitioners Addison's Disease, Enzyme Disorders,

Hypopituitarism, Malignant Diseases

H02AB02 Dexamethasone Tablets 2mg Consultants

Addison's Disease, Enzyme Disorders, Hypopituitarism, Malignant Diseases

H02AB09 Hydrocortisone Tablets 5mg (Half Scored) or Tablets 10mg (Quarter Scored)

Consultant Paediatricians, Consultant Physicians

Addison's Disease, Enzyme Disorders, Epilepsy, Hypopituitarism, Malignant Diseases

H02AB09 Hydrocortisone Tablets 20mg Consultants C Consultants Addison's Disease, Enzyme Disorders, Epilepsy, Hypopituitarism, Malignant Diseases

H02AB09 Hydrocortisone Sodium Succinate

Injection 100mg

Consultants TBDF Hospitals

only

Addison's Disease, Hypopituitarism, Inherited Haemoglobinopathies, Malignant Diseases, Lupus Erythematosus

H02AB04 Methylprednisolone Tablets 4mg Consultant Dermatologists

Addison's Disease, Hypopituitarism, Malignant Diseases, Dermatomyositis/ Polymyositis, Lupus Erythematosus

H02AB04 Methylprednisolone Acetate

Injection IM 40mg/mL

Consultants

Myasthenia Gravis, Malignant Diseases, Rheumatoid Arthritis, Spondyloarthritis, Chronic Immunobullous Disorders

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V3.0 September 2021

103 6. Endocrine System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

H02AB04 Methylprednisolone (as Sodium Succinate or Hemisuccinate/ Hydrogen Succinate)

Injection 500mg

Consultants

Malignant Diseases, Neuromyelitis Optica

H02AB04 Methylprednisolone (as Sodium Succinate or Hemisuccinate/ Hydrogen Succinate)

Injection IM/IV 40mg

Consultants

Myasthenia Gravis, Chronic Immunobullous Disorders

H02AB06 Prednisolone Tablets 1mg Consultants B Medical Practitioners Addison's Disease, Chronic Asthma, Chronic Kidney Disease, Chronic Liver Disease, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Cystic Fibrosis, Dermatomyositis/ Polymyositis, Enzyme Disorders, Epilepsy, HIV/AIDS and HIV Related Diseases, Hypopituitarism, Inflammatory Bowel Disease, Leprosy, Lupus Erythematosus, Malignant Diseases, Multiple Sclerosis, Myasthenia Gravis,Neuromyelitis Optica, Polyartritis Nodosa, Polymyalgia Rheumatica, Rheumatoid Arthritis, Secondary Immunodeficiency Disorder, Spondyloarthritis, Systemic Sclerosis

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V3.0 September 2021

104 6. Endocrine System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

H02AB06 Prednisolone Tablets 5mg Consultants GU Clinic Entitlement: GU Clinic Consultants

B Medical Practitioners Addison's Disease, Chronic Asthma, Chronic Immunobullous Disorders, Chronic Kidney Disease, Chronic Liver Disease, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Cystic Fibrosis, Dermatomyositis/ Polymyositis, Enzyme Disorders, Epilepsy, HIV/AIDS and HIV Related Diseases, Hypopituitarism, Inflammatory Bowel Disease, Leprosy, Lupus Erythematosus, Malignant Diseases, Multiple Sclerosis, Myasthenia Gravis, Neuromyelitis Optica, Polyartritis Nodosa, Polymyalgia Rheumatica, Rheumatoid Arthritis, Secondary Immunodeficiency Disorder, Spondyloarthritis, Systemic Sclerosis

H02AB06 Prednisolone Tablets enteric-coated 5mg

Consultants B Medical Practitioners Addison's Disease, Chronic Asthma, Chronic Immunobullous Disorders, Chronic Kidney Disease, Chronic Liver Disease, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Cystic Fibrosis, Dermatomyositis/ Polymyositis, Enzyme Disorders, Epilepsy, HIV/AIDS and HIV Related Diseases, Hypopituitarism, Inflammatory Bowel Disease, Leprosy, Lupus Erythematosus, Malignant Diseases, Multiple Sclerosis, Myasthenia Gravis, Neuromyelitis Optica, Polyartritis Nodosa, Polymyalgia Rheumatica, Rheumatoid Arthritis, Secondary Immunodeficiency Disorder, Spondyloarthritis, Systemic Sclerosis

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V3.0 September 2021

105 6. Endocrine System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

6.4 Sex hormones 6.4.1 Female sex hormones 6.4.1.1 Estrogens and HRT

G03CA57 Conjugated Estrogens (Equine)

Tablets 0.625mg

Consultants C Consultants Hypogonadism

G03CA57 Conjugated Estrogens (Equine)

Tablets 1.25mg

Consultants C Consultants Hypogonadism

G03CA03 Estradiol Tablets 1mg Consultants Obstetrics & Gynaecology, Consultants Endocrinology & Diabetes, Consultants Endocrinology (Transgender MDT)

C Consultants Obstetrics & Gynaecology

Turner Syndrome, Hypogonadism, Gender Identity & Sex Characteristics Related Conditions

G03FA10 Estradiol (as hemihydrate) + Dydrogesterone

Tablets 2mg + 10mg

Consultants Endocrinology & Diabetes, Consultant Oncologists, Consultant Haematologists

MP 234

Hypopituitarism, Malignant Diseases

G03CA01 Ethinylestradiol Tablets 10mcg

Consultant Paediatricians, Consultants Endocrinology & Diabetes, Consultants Endocrinology (Transgender MDT)

MP 235

Hypogonadism, Hypopituitarism, Malignant Diseases, Turner Syndrome, Gender Identity & Sex Characteristics Related Conditions

6.4.1.2 Progesterone G03DB01 Dydrogesterone Tablets 10mg N/A B Consultants No Schedule V Entitlement

G03DA02 Medroxyprogesterone Acetate

Tablets 5mg Consultants, Consultants Endocrinology (Transgender MDT)

Endometriosis/Adenomyosis, Hypogonadism, Malignant Diseases, Gender Identity & Sex Characteristics Related Conditions

G03DC02 Norethisterone Tablets 5mg Consultants B Hospital Doctors Turner Syndrome, Hypogonadism, Hypopituitarism, Malignant Diseases

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V3.0 September 2021

106 6. Endocrine System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

6.4.2 Male sex hormones and antagonists G03BA03 Testosterone Oily Injection

250mg Consultant Paediatricians, Consultants Endocrinology & Diabetes, Consultant Oncologists, Consultants Endocrinology (Transgender MDT)

MP 188

Hypogonadism, Hypopituitarism, Malignant Diseases, Gender Identity & Sex Characteristics Related Conditions

G03BA03 Testosterone Undecanoate

Injection 1000mg/4mL

Consultants Endocrinology & Diabetes, Consultants Endocrinology (Transgender MDT)

MP 279

Hypogonadism, Gender Identity & Sex Characteristics Related Conditions

G04CB01 Finasteride Tablets 5mg Consultant Dermatologists, Consultant Urologists, Consultants Endocrinology (Transgender MDT)

C Consultant Urologists Benign Prostatic Enlargement, Gender Identity & Sex Characteristics Related Conditions, Hidradenitis Suppurativa, Malignant Diseases

6.5 Hypothalamic and pituitary hormones and anti-estrogens 6.5.1 Hypothalamic and anterior pituitary hormones and anti-estrogens

G03GA01 Chorionic Gonadotrophin (HCG)

Injection 1000 IU

Consultants

Hypogonadism, Hypopituitarism

G03GA01 Chorionic Gonadotrophin (HCG)

Injection 5000 IU

Consultants

Hypogonadism, Hypopituitarism

H01AC01 Growth Hormone Recombinant (Somatropin)

Injection Consultant Paediatricians, Consultants Endocrinology & Diabetes

MP 88

Prader Willi Syndrome, Turner Syndrome, Hypopituitarism

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107 6. Endocrine System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

6.5.2 Posterior pituitary hormones and antagonists J01AA01 Demeclocycline

Hydrochloride Capsules 150mg

Consultant Physicians MP 49

Malignant Diseases

H01BA02 Desmopressin Nasal Spray 10mcg

Consultants Endocrinology & Diabetes, Consultant Paediatricians, Consultant Nephrologists, Consultant Oncologists

MP 50

Hypopituitarism, Malignant Diseases

H01BA02 Desmopressin Tablets 0.1mg

Consultants Endocrinology & Diabetes, Consultant Paediatricians, Consultant Nephrologists, Consultant Oncologists

MP 51

Hypopituitarism, Malignant Diseases

6.6 Drugs affecting bone metabolism 6.6.1 Calcitonin

H05BA01 Calcitonin (Salmon Synthetic)

Injection 100IU/mL

Consultants C Consultants Malignant Diseases, Paget's Disease

H05AA02 Teriparatide Pre-Filled Pen 20mcg/ 80mcL

Consultant Rheumatologists, Consultant Endocrinologists

MP 190

Multiple Sclerosis, Myasthenia Gravis, Inflammatory Bowel Disease, Chronic Liver Disease, Malignant Diseases, Chronic Kidney Disease, Chronic Asthma, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Cystic Fibrosis, Dermatomyositis/ Polymyositis, Lupus Erythematosus, Polyartritis Nodosa, Polymyalgia Rheumatica, Rheumatoid Arthritis, Spondyloarthritis, Systemic Sclerosis

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108 6. Endocrine System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

6.6.2 Bisphosphonates and other drugs affecting bone metabolism M05BA02 Sodium

Clodronate Tablets 400mg

Consultant Oncologists, Consultant Haematologists

MP 41

Malignant Diseases

6.7 Other endocrine drugs 6.7.1 Bromocriptine and other dopaminergic drugs

G02CB01/ N04BC01

Bromocriptine Mesylate

Tablets 2.5mg

Consultants

Addiction Disorders, Chronic Mood Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Huntington's Chorea, Parkinson's Disease, Hypopituitarism, Pituitary Adenomas, Malignant Diseases, Psychosis, Schizophrenia

G02CB03/ N04BC06

Cabergoline Tablets 0.5mg

Consultant Physicians MP 29

Pituitary Adenomas, Malignant Diseases

6.7.2 Drugs affecting gonadotrophins L02AE03 Goserelin Implants

3.6mg Consultant Obstetrics & Gynaecology, Consultant Oncologists, Consultants Endocrinology (Transgender MDT)

MP 86

Endometriosis/Adenomyosis, Malignant Diseases, Gender Identity & Sex Characteristics Related Conditions

L02AE03 Goserelin Implants 10.8mg

Consultant Oncologists, Consultant Urologists, Consultants Endocrinology (Transgender MDT)

MP 87

Malignant Diseases, Gender Identity & Sex Characteristics Related Conditions

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109 6. Endocrine System

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

L02AE02 Leuprorelin Injections 3.75mg

Consultant Paediatricians, Consultants Endocrinology & Diabetes, Consultants Endocrinology (Transgender MDT)

MP 114

Precocious Puberty, Gender Identity & Sex Characteristics Related Conditions

Page 110: Out-Patients Formulary List

V3.0 September 2021

110 7. Obstetrics, Gyaecology, and Urinary-tract Disorders

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

7. Obstetrics, Gynaecology, and Urinary-tract Disorders 7.1 Treatment of vaginal and vulval conditions

7.1.1 Vaginal and vulval infections D01AC01 Clotrimazole Cream 1% Consultants A Medical Practitioners Down Syndrome, Congenital Indifference to

Pain

G01AF02 Clotrimazole Pessaries 100mg

GU Clinic Entitlement: GU Clinic Consultants

A Medical Practitioners No Schedule V Entitlement

G01AF05 Econazole Pessaries 150mg

N/A A Consultants No Schedule V Entitlement

7.2 Drugs for Genitor-urinary disorders 7.2.1 Drugs for urinary retention

G04CA01 Alfuzosin Prolonged Release Tablets 10mg

Consultant Urologists Benign Prostatic Enlargement

C02CA04 Doxazosin Tablets 2mg Consultants [Hypertension Only], Specialist Family Medicine PHCD [Hypertension Only], Consultant Urologists

C Consultant Urologist Hypertension, Benign Prostatic Enlargement

G04CB02 Dutasteride Tablets 0.5mg Consultant Urologists Benign Prostatic Enlargement

7.2.2 Drugs for urinary frequency, enuresis and incontinence G04BD04 Oxybutynin

Hydrochloride Tablets 5mg Consultants C Consultants Multiple Sclerosis, Parkinson's Disease,

Spinal Cord Pathologies, Malignant Diseases, Neuromyelitis Optica

Page 111: Out-Patients Formulary List

V3.0 September 2021

111 7. Obstetrics, Gyaecology, and Urinary-tract Disorders

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

7.2.3 Drugs used in urological pain A12BA02 Potassium Citrate Mixture

1.5g/5mL Consultant Nephrologists, Consultant Urologists, Consultant Paediatricians

Inborn Errors of Metabolism

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V3.0 September 2021

112 8. Malignant Disease and Immunosuppresion

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

8. Malignant disease and immunosuppression 8.1 Cytotoxic drugs

V03AF03 Calcium Folinate (Leucovorin/ Folinic Acid)

Tablets 15mg Consultants TBDF Hospitals

only in Malignant Diseases

Enzyme Disorders, Malignant Diseases, Inborn Errors of Metabolism

8.1.1 Alkylating drugs L01AB01 Busulfan Tablets 2mg Consultant Oncologists,

Consultant Haematologists, Consultant Paediatricians

TBDF Hospitals

only

Malignant Diseases

L01AA02 Chlorambucil Tablets 2mg Consultants Malignant Diseases

L01AA01 Cyclophosphamide Tablets 50mg Consultants

Secondary Immunodeficiency Disorder, Malignant Diseases, Chronic Kidney Disease, Chronic Respiratory Failure, Dermatomyositis/ Polymyositis, Lupus Erythematosus, Polyartritis Nodosa, Rheumatoid Arthritis, Systemic Sclerosis

L01AD02 Lomustine Capsules 40mg

Consultant Haematologists, Consultant Oncologists, Consultant Paediatric Oncologists, Consultant Paediatricians

TBDF Hospitals

only

Malignant Diseases

L01AA03 Melphalan Tablets 2mg Consultants Malignant Diseases

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113 8. Malignant Disease and Immunosuppresion

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

8.1.2 Antimetabolites L01BC06 Capecitabine Tablets 150mg Consultant Oncologists MP 31

TBDF Hospitals

only

Malignant Diseases

L01BC06 Capecitabine Tablets 500mg Consultant Oncologists MP 31 TBDF

Hospitals only

Malignant Diseases

L01BB05 Fludarabine Tablets 10mg Consultant Oncologists, Consultant Haematologists, Consultant Paediatricians

TBDF Hospitals

only

Malignant Diseases

L01BC02 Fluorouracil Cream 5% Consultant Dermatologists, Consultant Oncologists

Malignant Diseases

L01BB02 Mercaptopurine Tablets 50mg Consultants

Inflammatory Bowel Disease, Secondary Immunodeficiency Disorder, Chronic Liver Disease, Malignant Diseases, Chronic Kidney Disease

L01BA01/ L04AX03

Methotrexate Tablets 2.5mg Consultants

Inflammatory Bowel Disease, Secondary Immunodeficiency Disorder, Chronic Liver Disease, Malignant Diseases, Chronic Kidney Disease, Dermatomyositis/ Polymyositis, Lupus Erythematosus, Polyartritis Nodosa, Polymyalgia Rheumatica, Rheumatoid Arthritis, Severe Refractory Atopic Dermatitis, Spondyloarthritis, Systemic Sclerosis, Psoriasis

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114 8. Malignant Disease and Immunosuppresion

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

L01BB03 Tioguanine Tablets 40mg Consultant Oncologists, Consultant Haematologists, Consultant Paediatricians

Malignant Diseases

8.1.3 Etoposide L01CB01 Etoposide Capsules

50mg Consultant Oncologists, Consultant Haematologists, Consultant Paediatricians

TBDF Hospitals

only

Malignant Diseases

8.1.4 Other antineoplastic drugs L01XX25 Bexarotene Capsules

75mg Consultant Haematologists, Consultant Oncologists

MP 18 TBDF

Hospitals only

Malignant Diseases

L01XE23 Dabrafenib Capsules 75mg

Consultant Oncologists MP 303

Malignant Diseases

L01XE03 Erlotinib Capsules/ Tablets 150mg

Consultant Oncologists MP 262 TBDF

Hospitals only

Malignant Diseases

L04AA18 Everolimus Tablets 0.25mg

Consultant Nephrologists MP 71 Chronic Kidney Disease

L04AA18 Everolimus Tablets 0.75mg

Consultant Nephrologists MP 71

Chronic Kidney Disease

L01XE10 Everolimus Tablets 5mg Consultant Oncologists MP 302 TBDF

Hospitals only

Malignant Diseases

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115 8. Malignant Disease and Immunosuppresion

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

L01XE10 Everolimus Tablets 10mg Consultant Oncologists MP 302 TBDF

Hospitals only

Malignant Diseases

L01XX05 Hydroxycarbamide (Hydroxyurea)

Capsules 500mg

Consultant Oncologists, Consultant Haematologists, Consultant Paediatricians, Thalassaemia Clinic Consultants

C Consultant Oncologists, Consultant Haematologists, Consultant Paediatricians, Thalassaemia Clinic Consultants

Inherited Haemoglobinopathies, Malignant Diseases

L01XE01 Imatinib Capsules/ Tablets 100mg

Consultant Oncologists, Consultant Haematologists, Consultant Paediatricians

MP 95 TBDF

Hospitals only

Malignant Diseases

L01XE01 Lapatinib Tablets 250mg Consultant Oncologists MP 109 Malignant Diseases

L01XE08 Nilotinib Capsules 200mg

Consultant Haematologists MP 213

Malignant Diseases

L01XB01 Procarbazine Capsules 50mg

Consultants

Malignant Diseases

L01XE04 Sunitinib Capsules 12.5mg

Consultant Oncologists MP 264 TBDF

Hospitals only

Malignant Diseases

L01XE04 Sunitinib Capsules 25mg

Consultant Oncologists MP 264 TBDF

Hospitals only

Malignant Diseases

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116 8. Malignant Disease and Immunosuppresion

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

L01XE04 Sunitinib Capsules 50mg

Consultant Oncologists MP 264 TBDF

Hospitals only

Malignant Diseases

L01AX03 Temozolomide Capsules 5mg Consultant Oncologists, Consultant Paediatric Oncologists

TBDF Hospitals

only

Malignant Diseases

L01AX03 Temozolomide Capsules 20mg

Consultant Oncologists, Consultant Paediatric Oncologists

TBDF Hospitals

only

Malignant Diseases

L01AX03 Temozolomide Capsules 100mg

Consultant Oncologists, Consultant Paediatric Oncologists

TBDF Hospitals

only

Malignant Diseases

L01AX03 Temozolomide Capsules 140mg

Consultant Oncologists, Consultant Paediatric Oncologists

TBDF Hospitals

only

Malignant Diseases

L01XE25 Trametinib Tablets 2mg Consultant Oncologists MP 304 Malignant Diseases

L01XX14 Tretinoin Capsules 10mg

Consultant Haematologists, Consultant Oncologists, Consultant Paediatric Oncologists

Malignant Diseases

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117 8. Malignant Disease and Immunosuppresion

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

8.2 Drugs affecting the immune response 8.2.1 Antiproliferative immunosuppressants

L04AX01 Azathioprine Tablets 50mg Consultants

Myasthenia Gravis, Inflammatory Bowel Disease, Secondary Immunodeficiency Disorder, Chronic Liver Disease, Malignant Diseases, Chronic Kidney Disease, Chronic Respiratory Failure, Dermatomyositis/ Polymyositis, Lupus Erythematosus, Polyartritis Nodosa, Rheumatoid Arthritis, Severe Refractory Atopic Dermatitis, Spondyloarthritis, Systemic Sclerosis, Chronic Immunobullous Disorders, Psoriasis, Neuromyelitis Optica

L04AA06 Mycophenolate Mofetil

Oral Suspension 1g/5mL

Consultant Cardiac Surgeons, Consultant Gastroenterologists, Consultant Nephrologists, Consultant Paediatricians

MP 141

Chronic Kidney Disease, Chronic Liver Disease, Lupus Erythematosus, Secondary Immunodeficiency Disorder

L04AA06 Mycophenolate Mofetil

Capsules 250mg

Consultant Cardiac Surgeons, Consultant Gastroenterologists, Consultant Nephrologists, Consultant Paediatricians, Consultant Rheumatologists

MP 145

Chronic Kidney Disease, Chronic Liver Disease, Lupus Erythematosus, Myasthenia Gravis, Secondary Immunodeficiency Disorder

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V3.0 September 2021

118 8. Malignant Disease and Immunosuppresion

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

L04AA06 Mycophenolate Mofetil

Tablets 500mg Consultant Cardiac Surgeons, Consultant Gastroenterologists, Consultant Nephrologists, Consultant Paediatricians, Consultant Rheumatologists

MP 145

Chronic Kidney Disease, Chronic Liver Disease, Lupus Erythematosus, Myasthenia Gravis, Secondary Immunodeficiency Disorder

L04AA06 Mycophenolate Sodium

Gastro-Resistant Tablets 180mg

Consultant Nephrologists, Consultant Paediatricians (Paediatric Nephrology)

MP 140

Chronic Kidney Disease

L04AA06 Mycophenolate Sodium

Gastro-Resistant Tablets 360mg

Consultant Nephrologists, Consultant Paediatricians (Paediatric Nephrology)

MP 140

Chronic Kidney Disease

8.2.2 Corticosteroids and other immunosuppressants L04AD01 Ciclosporin

(Cyclosporin) Capsules 25mg

Consultants MP 46

Inflammatory Bowel Disease, Secondary Immunodeficiency Disorder, Chronic Kidney Disease, Chronic Liver Disease, Malignant Diseases, Rheumatoid Arthritis, Severe Chronic Urticaria, Severe Refractory Atopic Dermatitis, Spondyloarthritis, Psoriasis

L04AD01 Ciclosporin (Cyclosporin)

Capsules 100mg

Consultants MP 46

Inflammatory Bowel Disease, Secondary Immunodeficiency Disorder, Chronic Kidney Disease, Chronic Liver Disease, Malignant Diseases, Rheumatoid Arthritis, Severe Chronic Urticaria, Severe Refractory Atopic Dermatitis, Spondyloarthritis, Psoriasis

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119 8. Malignant Disease and Immunosuppresion

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

L04AD01 Ciclosporin (Cyclosporin)

Oral Solution 100mg/mL

Consultants MP 47

Secondary Immunodeficiency Disorder, Chronic Kidney Disease, Chronic Liver Disease, Rheumatoid Arthritis, Severe Chronic Urticaria, Severe Refractory Atopic Dermatitis, Psoriasis, Malignant Diseases

L04AA06 Sirolimus Tablets 1mg Consultant Nephrologists MP 231 Chronic Kidney Disease

L04AD02 Tacrolimus Capsules 0.5mg

Consultant Gastroenterologists, Consultant Paediatricians, Consultant Nephrologists

MP 210

Chronic Kidney Disease, Chronic Liver Disease

L04AD02 Tacrolimus Capsules 1mg Consultant Gastroenterologists, Consultant Paediatricians, Consultant Nephrologists

MP 210

Chronic Kidney Disease, Chronic Liver Disease

L04AD02 Tacrolimus Capsules 5mg Consultant Gastroenterologists, Consultant Paediatricians, Consultant Nephrologists

MP 210

Chronic Kidney Disease, Chronic Liver Disease

8.2.3 Other immunomodulating drugs N07XX09 Dimethyl

Fumarate Gastro-Resistant Hard Capsules 120mg

Consultant Neurologists MP 60

Multiple Sclerosis

N07XX09 Dimethyl Fumarate

Gastro-Resistant Hard Capsules 240mg

Consultant Neurologists MP 60

Multiple Sclerosis

L04AA27 Fingolimod Capsules 0.5mg

Consultant Neurologists MP 70

Multiple Sclerosis

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V3.0 September 2021

120 8. Malignant Disease and Immunosuppresion

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

L03AB11 Peg-Interferon Alfa 2a

Pre-filled Syringe 180mcg

Consultant Gastroenterologists, Consultant Haematologists, Consultant Infectious Diseases Physicians, Consultant Oncologists

MP 102

Hepatitis B and C, Malignant Diseases

L03AB07 Interferon Beta 1a

Injection 30mcg (6M IU)

Consultant Neurologists

Multiple Sclerosis

L03AB08 Interferon Beta 1b

Injection 9.6M IU

Consultant Neurologists

Multiple Sclerosis

L03AB03 Interferon Gamma

Injection 100mcg

Consultant Paediatricians, Consultant Respiratory Physicians, Consultant Infectious Diseases Physicians

MP 104 TBDF

Hospitals only

Primary Immunodeficiency Disorder

L04AX04 Lenalidomide Capsules 5mg Consultant Oncologists, Consultant Haematologists

MP 263 TBDF

Hospitals only

Malignant Diseases

L04AX04 Lenalidomide Capsules 10mg

Consultant Oncologists, Consultant Haematologists

MP 263 TBDF

Hospitals only

Malignant Diseases

L04AX04 Lenalidomide Capsules 15mg

Consultant Oncologists, Consultant Haematologists

MP 263 TBDF

Hospitals only

Malignant Diseases

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V3.0 September 2021

121 8. Malignant Disease and Immunosuppresion

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

L04AX04 Lenalidomide Capsules 25mg

Consultant Oncologists, Consultant Haematologists

MP 263 TBDF

Hospitals only

Malignant Diseases

L04AA31 Teriflunomide Tablets 14mg Consultant Neurologists MP 195 Multiple Sclerosis

L04AX02 Thalidomide Capsules/ Tablets 50mg

Consultant Rheumatologists, Consultant Dermatologists, Consultant Haematologists, Consultant Infectious Disease Physicians, Consultant Oncologists

MP 189 TBDF

Hospitals only

Leprosy, Malignant Diseases, Lupus Erythematosus

8.3 Sex hormones and hormone antagonists in malignant diseases 8.3.1 Estrogens

G03CB02/ L02AA01

Diethylstilbestrol (Stilboestrol)

Tablets 1mg Consultants C Consultants Malignant Diseases

G03CA01 Ethinylestradiol Tablets 10mcg Consultant Paediatricians, Consultants Endocrinology & Diabetes, Consultants Endocrinology (Transgender MDT)

MP 235

Turner Syndrome, Hypopituitarism, Malignant Diseases, Gender Identity & Sex Characteristics Related Conditions

8.3.2 Progestogens L02AB02 Medroxyprogester

one Acetate Tablets 100mg Consultants, Consultants

Endocrinology (Transgender MDT)

Malignant Diseases, Gender Identity & Sex Characteristics Related Conditions

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V3.0 September 2021

122 8. Malignant Disease and Immunosuppresion

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

8.3.3 Hormone antagonists 8.3.3.1 Breast cancer

L02BG03 Anastrozole Tablets 1mg Consultant Oncologists

Malignant Diseases

L02BG06 Exemestane Tablets 25mg Consultant Oncologists MP 64 TBDF

Hospitals only

Malignant Diseases

L02AE03 Goserelin Implants 3.6mg

Consultant Obstetrics & Gynaecology, Consultant Oncologists, Consultants Endocrinology (Transgender MDT)

MP 86

Endometriosis/Adenomyosis, Malignant Diseases, Gender Identity & Sex Characteristics Related Conditions

L02BG03 Letrozole Tablets 2.5mg Consultant Oncologists

Malignant Diseases

L02BA01 Tamoxifen Tablets 20mg Consultants C Medical Practitioners Malignant Diseases

8.3.3.2 Prostate cancer L02BX03 Abiraterone Tablets 500mg Consultant Oncologists MP 8 Malignant Diseases

L02BB03 Bicalutamide Tablets 50mg Consultant Urologists, Consultant Oncologists

MP 19

Malignant Diseases

G03HA01 Cyproterone Acetate

Tablets 50mg Consultants, Consultants Endocrinology (Transgender MDT)

Precocious Puberty, Malignant Diseases, Gender Identity & Sex Characteristics Related Conditions

L02BB04 Enzalutamide Capsules 40mg

Consultant Oncologists MP 300

Malignant Diseases

L02BB01 Flutamide Tablets 250mg Consultant Oncologists, Consultant Urologists

Malignant Diseases

L02AE03 Goserelin Implants 10.8mg

Consultant Oncologists, Consultant Urologists, Consultants Endocrinology (Transgender MDT)

MP 87

Malignant Diseases, Gender Identity & Sex Characteristics Related Conditions

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123 8. Malignant Disease and Immunosuppresion

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

8.3.3.3 Somatostatin analogues H01CB02 Octreotide Injection

200mcg/mL (multidose)

Consultants Endocrinology & Diabetes, Consultant Gastroenterologists, Consultant Oncologists, Consultant Surgeons, Consultant Palliative Care

MP 147 TBDF

Hospitals only

Pituitary Adenomas, Malignant Diseases

H01CB02 Octreotide Long Acting (stand-by)

Injection IM 10mg

Consultants Endocrinology & Diabetes, Consultant Gastroenterologists, Consultant Oncologists, Consultant Surgeons

MP 149 TBDF

Hospitals only

Cardiac Arrythmias, Chronic Heart Failure, Ischaemic Heart Disease, Malignant Diseases, Pituitary Adenomas

H01CB02 Octreotide Long Acting

Injection IM 20mg

Consultants Endocrinology & Diabetes, Consultant Gastroenterologists, Consultant Oncologists, Consultant Surgeons

MP 149 TBDF

Hospitals only

Cardiac Arrythmias, Chronic Heart Failure, Ischaemic Heart Disease, Malignant Diseases, Pituitary Adenomas

H01CB02 Octreotide Long Acting

Injection IM 30mg

Consultants Endocrinology & Diabetes, Consultant Gastroenterologists, Consultant Oncologists, Consultant Surgeons

MP 149 TBDF

Hospitals only

Cardiac Arrythmias, Chronic Heart Failure, Ischaemic Heart Disease, Malignant Diseases, Pituitary Adenomas

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V3.0 September 2021

124 9. Nutrition and Blood

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

9. Nutrition and Blood 9.1 Anaemias and some other blood disorders

9.1.1 Iron-deficiency anaemias

9.1.1.1 Oral iron B03AD02 Iron + folic acid Tablets/

Capsules Consultants B Medical Practitioners Inflammatory Bowel Disease, Secondary

Immunodeficiency Disorder, Malignant Diseases, Chronic Kidney Disease

B03AA02 Oral Iron (Currently Ferrous Fumarate 200mg [65mg elemental iron])

Tablets/ Capsules

Consultants B Medical Practitioners Inflammatory Bowel Disease, Secondary Immunodeficiency Disorder, Malignant Diseases, Chronic Kidney Disease, Cystic Fibrosis

B03AB03 Sodium Feredetate (oral

iron)

Solution 190mg/5mL equivalent to 27.5mg iron

Consultants B Medical Practitioners Inflammatory Bowel Disease, Secondary Immunodeficiency Disorder, Malignant Diseases, Chronic Kidney Disease, Cystic Fibrosis

9.1.2 Drugs used in megaloblastic anaemias B03BB01 Folic Acid Oral solution

2.5mg/5mL Consultant Paediatricians, Consultant Rheumatologists

MP 80

Secondary Immunodeficiency Disorder, Dermatomyositis/ Polymyositis, Lupus Erythematosus, Rheumatoid Arthritis, Spondyloarthritis

Page 125: Out-Patients Formulary List

V3.0 September 2021

125 9. Nutrition and Blood

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

B03BB01 Folic Acid Tablets 5mg Consultants B Medical Practitioners Inflammatory Bowel Disease, Inherited Haemoglobinopathies, Secondary Immunodeficiency Disorder, Chronic Liver Disease, Malignant Diseases, Inborn Errors of Metabolism, Chronic Kidney Disease, Dermatomyositis/ Polymyositis, Lupus Erythematosus, Polymyalgia Rheumatica, Polyartritis Nodosa, Rheumatoid Arthritis, Spondyloarthritis, Systemic Sclerosis, Psoriasis

B03BA03 Hydroxocobalamin (Vitamin B12)

Injection 1mg Consultants C Medical Practitioners Inflammatory Bowel Disease, Enzyme Disorders, Secondary Immunodeficiency Disorder, Malignant Diseases, Inborn Errors of Metabolism, Chronic Kidney Disease

9.1.3 Drugs used in hypoplastic, haemolytic, and renal anaemias V03AC03 Deferasirox Film-coated

tablets 180mg Thalassaemia Clinic Consultants, Consultant Haematologists

MP 277

Inherited Haemoglobinopathies, Malignant Diseases

V03AC03 Deferasirox Film-coated tablets 360mg

Thalassaemia Clinic Consultants, Consultant Haematologists

MP 277

Inherited Haemoglobinopathies, Malignant Diseases

B03XA01 Recombinant Human Erythropoietin

Pre-filled syringe 2000 IU

Consultant Gastroenterologists, Consultant Haematologists, Consultant Nephrologists, Consultant Paediatricians

MP 65

Chronic Kidney Disease, Malignant Diseases

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V3.0 September 2021

126 9. Nutrition and Blood

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

B03XA01 Recombinant Human Erythropoietin

Pre-filled syringe 3000 IU

Consultant Gastroenterologists, Consultant Haematologists, Consultant Nephrologists, Consultant Paediatricians

MP 65

Chronic Kidney Disease, Malignant Diseases

B03XA01 Recombinant Human Erythropoietin

Pre-filled syringe 4000 IU

Consultant Gastroenterologists, Consultant Haematologists, Consultant Nephrologists, Consultant Paediatricians

MP 65 Chronic Kidney Disease, Malignant Diseases

9.1.4 Drugs used in neutropenia L03AA02 Filgrastim (Rec.

Human G-CSF) Injection 30 MIU

Consultant Oncologists, Consultant Haematologists, Consultant Paediatricians, Consultant Infectious Diseases Physician

MP 69 HU/ TBDF Hospitals

only

HIV/AIDS and HIV Related Diseases, Malignant Diseases, Primary Immunodeficiency Disorder

9.2 Fluids and electrolytes 9.2.1 Oral preparations for fluid and electrolyte imbalance

9.2.1.1 Oral potassium V03AE01 Polystyrene

Sulfonate (e.g.

Calcium Resonium®)

Powder Consultants

Secondary Immunodeficiency Disorder, Malignant Diseases, Chronic Kidney Disease

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V3.0 September 2021

127 9. Nutrition and Blood

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

A12BA01 Potassium Chloride

Syrup 1mmol/mL (7.5%)

Consultants C Medical Practitioners Chronic Heart Failure, Hypertension, Secondary Immunodeficiency Disorder, Malignant Diseases, Chronic Kidney Disease, Chronic Liver Disease

A12BA30 Potassium Supplement

Effervescent Tablets

Consultants, Specialist Family Medicine PHCD [Hypertension Only]

C Medical Practitioners Chronic Heart Failure, Hypertension, Secondary Immunodeficiency Disorder, Malignant Diseases, Chronic Kidney Disease, Chronic Liver Disease

9.2.1.2 Oral sodium and water A07CA Oral Rehydration Powder Consultants A Medical Practitioners Malignant Diseases

9.2.1.3 Oral bicarbonate A02AH Sodium

Bicarbonate Tablets 500/600mg

Consultants C Hospital Doctors Enzyme Disorders, Secondary Immunodeficiency Disorder, Chronic Kidney Disease

9.2.2 Parenteral preparations for fluid and electrolyte imbalance 9.2.2.1 Electrolytes and water

B05XA03 Sodium Chloride Injection IV 0.9% in 10mL Pack

Consultants

Malignant Diseases For nebulisation in Chronic Asthma, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Cystic Fibrosis or Malignant Diseases

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V3.0 September 2021

128 9. Nutrition and Blood

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

V07AB Water for injection

Ampoule 5mL Consultants

With Colistimethate sodium or Gentamicin injections (for nebulisation) in Chronic Respiratory Failure or Cystic Fibrosis With catheters in the following conditions: Cerebral Palsy, Cerebrovascular Disease, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Congenital Indifference to Pain, Cystic Fibrosis, Dementia, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Diverticular Disease requiring Stoma Care, Enzyme Disorders, Huntington's Chorea, Malignant Diseases, Motor Neuron Disease, Parkinson's Disease, Peripheral Vascular Disease, Spinal Cord Pathologies

V07AB Water for injection

Ampoule 10mL

Consultants

Malignant Diseases

9.3 Intravenous nutrition 9.3.1 Proprietary infusion fluids for parenteral feeding

B05BA Total Parenteral Nutrition (Adult)

Intravenous Nutrition

Consultants TBDF Hospitals only (TPN

patients only)

Small Intestinal Failure

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V3.0 September 2021

129 9. Nutrition and Blood

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

B05BA02 Parenteral Fat Emulsion LCT

Emulsion for Intravenous Infusion 20% in 500mL

Consultants TBDF Hospitals only (TPN

patients only)

Small Intestinal Failure

9.3.2 Supplementary preparations

B05XA31 Trace Elements + Electrolytes

Infusion (Adults)

Consultants TBDF Hospitals only (TPN

patients only)

Small Intestinal Failure

A11BA Multivitamins (Cernevit®) for TPN for Adults and Children Over 11 Years

Infusion Consultants TBDF Hospitals only (TPN

patients only)

Small Intestinal Failure

9.4 Minerals 9.4.1 Calcium and magnesium

9.4.1.1 Calcium supplements A12AA04 Calcium Tablets

Effervescent 400-500mg

Consultant Paediatricians, Consultant Physicians

MP 30

Enzyme Disorders, Hypoparathyroidism, Secondary Immunodeficiency Disorder, Chronic Kidney Disease

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V3.0 September 2021

130 9. Nutrition and Blood

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

A12AA04 Calcium Carbonate

Chewable Tablets or Tablets 1250mg (equivalent to 500mg elemental calcium)

Consultants

Inflammatory Bowel Disease, Enzyme Disorders, Hypoparathyroidism, Secondary Immunodeficiency Disorder, Chronic Liver Disease, Malignant Diseases, Chronic Kidney Disease, Paget's Disease, Rheumatoid Arthritis, Spondyloarthritis, Chronic Immunobullous Disorders

A12AA05 Calcium Lactate Tablets 300mg (equivalent to 39mg elemental calcium)

Consultants C Medical Practitioners Inflammatory Bowel Disease, Enzyme Disorders, Hypoparathyroidism, Secondary Immunodeficiency Disorder, Chronic Liver Disease, Malignant Diseases, Chronic Kidney Disease, Chronic Immunobullous Disorders

9.4.1.2 Hypercalcaemia and hypercalciuria

H05BX01 Cinacalcet Tablets 30mg Consultant Nephrologists, Consultant Oncologists, Consultant Endocrinologists

MP 48 Chronic Kindey Disease, Malignant Diseases

9.4.1.2 Magnesium A12CC Magnesium

Glycerophosphate Tablets 97.2mg (4mmol)

Consultant Gastroenterologists, Consultant Haematologists, Consultant Nephrologists, Consultant Oncologists, Consultant Paediatricians

MP 122 TBDF

Hospitals only

Chronic Kidney Disease, Chronic Liver Disease, Inborn Errors of Metabolism, Malignant Diseases, Secondary Immunodeficiency Disorders

Page 131: Out-Patients Formulary List

V3.0 September 2021

131 9. Nutrition and Blood

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

9.4.2 Phosphorus 9.4.2.1 Phosphate supplements

A12CX Phosphate Supplement

Tablets Effervescent

Consultant Paediatricians, Consultant Physicians

MP 165

Enzyme Disorders, Secondary Immunodeficiency Disorder, Malignant Diseases, Chronic Kidney Disease

9.4.2.2 Phosphate-Binding agents V03AE03 Lanthanum Chewable

tablets 750mg Consultant Nephrologists MP 273

Chronic Kidney Disease

9.5 Vitamins 9.5.1 Vitamin A

A11CA01 Vitamin A (Retinol)

Tablets 25,000 IU or 50,000 IU

Consultants

Chronic Liver Disease, Cystic Fibrosis

A11CB Vitamin A + D Tablets 4000 IU + 400 IU

N/A A Medical Practitioners No Schedule V Entitlement

9.5.2 Vitamin B group A11HA01 Nicotinamide Tablets 250mg Consultant Dermatologists

Chronic Immunobullous Disorders

A11HA02 Pyridoxine (Vitamin B6)

Tablets 10mg or 20mg

Consultants TB patients to collect item from Hospitals

only

C Medical Practitioners Enzyme Disorders, HIV/AIDS and HIV Related Diseases, Tuberculosis, Inborn Errors of Metabolism

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V3.0 September 2021

132 9. Nutrition and Blood

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

A11HA02 Pyridoxine (Vitamin B6)

Tablets 50mg Consultants TB patients to collect item from Hospitals

only

C Medical Practitioners Enzyme Disorders, HIV/AIDS and HIV Related Diseases, Tuberculosis, Inborn Errors of Metabolism, Malignant Diseases

A11DA01 Thiamine (Vitamin

B1) Tablets 50mg Consultants C Medical Practitioners Addiction Disorders, Enzyme Disorders,

Chronic Liver Disease, Inborn Errors of Metabolism

A11EA Vitamin B Compound Strong (Nicotinamide+ Pyridoxine + Riboflavin +

Thiamine) *

Tablets 20mg + 2mg + 2mg + 5mg

Consultants B Medical Practitioners Chronic Liver Disease

9.5.3 Vitamin C A11GA01 Ascorbic Acid Tablets Consultants B Medical Practitioners Inborn Errors of Metabolism

9.5.4 Vitamin D A11CC03 Alfacalcidol

(1-α Hydroxyvitamin D3)

Tablets 0.25mcg

Consultants C Consultants Inflammatory Bowel Disease, Enzyme Disorders, Hypoparathyroidism, Secondary Immunodeficiency Disorder, Chronic Liver Disease, Malignant Diseases, Chronic Kidney Disease, Cystic Fibrosis, Chronic Immunobullous Disorders

* Preparation temporarily available instead of Vitamin B Complex (Nicotinamide 15mg, Riboflavin 1mg, Thiamine 1mg)

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V3.0 September 2021

133 9. Nutrition and Blood

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

A11CC03 Alfacalcidol (1-α Hydroxyvitamin D3)

Tablets 1mcg Consultants

Inflammatory Bowel Disease, Enzyme Disorders, Hypoparathyroidism, Secondary Immunodeficiency Disorder, Chronic Liver Disease, Malignant Diseases, Chronic Kidney Disease, Cystic Fibrosis, Chronic Immunobullous Disorders

A11CC03 Alfacalcidol (1-α Hydroxyvitamin

D3)

Oral Drops 2mcg/mL

Consultants MP 5

Chronic Liver Disease, Enzyme Disorders, Hypoparathyroidism, Inflammatory Bowel Disease, Secondary Immunodeficiency Disorder, Malignant Diseases, Chronic Kidney Disease, Cystic Fibrosis, Chronic Immunobullous Disorders

9.5.5 Vitamin E A11HA03 Vitamin E (Alpha

Tocopheryl) Suspension 100mg/mL

Consultant Paediatricians, Consultant Gastroenterologists, Consultant Respiratory Physicians, Consultants Endocrinology & Diabetes

MP 199

Small Intestinal Failure, Enzyme Disorders, Chronic Liver Disease, Inborn Errors of Metabolism, Cystic Fibrosis

A11HA03 Vitamin E (dl-

Alpha Tocopheryl Acetate or d-Alpha Tocopherol)

Capsules/ Tablets 100mg-200mg (dl-Alpha Tocopheryl Acetate) OR 67mg-135mg (d-Alpha Tocopherol)

Consultant Paediatricians, Consultant Gastroenterologists, Consultant Respiratory Physicians, Consultants Endocrinology & Diabetes

MP 200

Small Intestinal Failure, Enzyme Disorders, Chronic Liver Disease, Inborn Errors of Metabolism, Cystic Fibrosis

Page 134: Out-Patients Formulary List

V3.0 September 2021

134 9. Nutrition and Blood

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

A11HA03 Vitamin E (Alpha

Tocopheryl) Capsules 670mg (1000 IU)

Consultant Paediatricians, Consultant Gastroenterologists, Consultant Respiratory Physicians, Consultants Endocrinology & Diabetes

MP 200

Small Intestinal Failure, Chronic Liver Disease, Inborn Errors of Metabolism, Cystic Fibrosis

9.5.6 Vitamin K B02BA02 Menadiol Sodium

Phosphate*

Tablets 10mg Consultants

Cystic Fibrosis

B02BA01 Phytomenadione (Vitamin K1)

Injection 10mg/mL in 1mL

Consultants HU/TBDF Hospitals only for oral use

Chronic Liver Disease, Cystic Fibrosis, Malignant Diseases

B02BA01 Phytomenadione (Vitamin K1)

Injection 10mg/mL in 0.2mL

Consultants HU/TBDF Hospitals only for oral use

Chronic Liver Disease, Cystic Fibrosis, Malignant Diseases

9.5.7 Multivitamin preparations A11BA Multivitamins

(Abidec®) Drops Consultant Paediatricians MP 135

Cystic Fibrosis

A11AA03 Multivitamins + mineral preparation (Ketovite®)

Syrup Consultant Paediatricians, Consultant Physicians, Consultant Gastroenterologists

MP 137

Inborn Errors of Metabolism

* Availability temporarily suspended due to problematic sourcing.

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135 9. Nutrition and Blood

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

A11AA03 Multivitamins + mineral preparation (Ketovite®)

Tablets Consultant Paediatricians, Consultant Physicians, Consultant Gastroenterologists

MP 136

Inborn Errors of Metabolism

9.6 Metabolic disorders

9.6.1 Drugs uses in metabolic disorders

G04BX16 Tiopronin Tablets 250mg Consultant Nephrologists, Consultant Paediatric Nephrologists, Consultant Urologists

MP 193

Chronic Kidney Disease

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136 10. Musculoskeletal and Joint Diseases

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

10. Musculoskeletal and Joint Diseases 10.1 Drugs used in rheumatic diseases and gout

10.1.1 Non-Steroidal anti-inflammatory drugs M01AB05 Diclofenac Sodium Suppositories

12.5mg Consultant Paediatricians

A Consultant Paediatricians

Spinal Cord Pathologies, Congenital Indifference to Pain, Lupus Erythematosus, Rheumatoid Arthritis, Spondyloarthritis, Systemic Sclerosis

M01AB05 Diclofenac Sodium Suppositories 100mg

Consultants A Medical Practitioners

Spinal Cord Pathologies, Congenital Indifference to Pain, Malignant Diseases

M01AB05 Diclofenac Sodium Tablets 25mg Consultants B Medical Practitioners

Spinal Cord Pathologies, Congenital Indifference to Pain, Polio and Post-Polio Syndrome, Malignant Diseases, Lupus Erythematosus, Rheumatoid Arthritis, Spondyloarthritis, Systemic Sclerosis

M01AE01 Ibuprofen

Oral Suspension 100mg/5mL

Consultant Oncologists, Consultant Paediatric Oncologists, Consultant Paediatric Surgeons, Consultant Paediatricians, Consultant Palliative Care, Consultant Rheumatologists

MP 92

Chronic Kidney Disease, Malignant Diseases, Lupus Erythematosus, Rheumatoid Arthritis, Spondyloarthritis

M01AE01 Ibuprofen Tablets 200mg Consultants B Medical Practitioners

Spinal Cord Pathologies, Congenital Indifference to Pain, Polio and Post-Polio Syndrome, Malignant Diseases, Lupus Erythematosus, Systemic Sclerosis

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137 10. Musculoskeletal and Joint Diseases

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

M01AB01 Indometacin Capsules 25mg

Consultants B Medical Practitioners

Congenital Indifference to Pain, Malignant Diseases

M01AG01 Mefenamic Acid Capsules 250mg

Consultants B Medical Practitioners

Congenital Indifference to Pain, Polio and Post-Polio Syndrome, Malignant Diseases

M01AC06 Meloxicam Tablets 7.5mg Consultant Rheumatologists, Consultant Palliative Care, Consultant Oncologists, Consultant Geriatricians

MP 45

Malignant Diseases, Rheumatoid Arthritis, Spondyloarthritis

M01AE02 Naproxen Tablets 250mg Consultants B Medical Practitioners

Congenital Indifference to Pain, Malignant Diseases, Lupus Erythematosus, Paget's Disease, Rheumatoid Arthritis, Spondyloarthritis, Systemic Sclerosis

10.1.2 Corticosteroids

10.1.2.1 Local corticosteroids injections H02AB04 Methylprednisolon

e Acetate Injection IM 40mg/mL

Consultants

Myasthenia Gravis, Malignant Diseases, Rheumatoid Arthritis, Spondyloarthritis, Chronic Immunobullous Disorders

10.1.3 Drugs that suppress the rheumatic disease process L04AB04 Adalimumab Solution for

Injection in Pre-filled Syringes 40mg

Consultant Dermatologists, Consultant Gastroenterologists, Consultant Paediatrician, Consultant Rheumatologists

MP 307 Hidradenitis Suppurativa, Inflammatory Bowel Disease, Psoriasis, Rheumatoid Arthritis, Spondyloarthritis

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138 10. Musculoskeletal and Joint Diseases

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

L04AX01 Azathioprine Tablets 50mg Consultants

Myasthenia Gravis, Inflammatory Bowel Disease, Secondary Immunodeficiency Disorder, Chronic Liver Disease, Malignant Diseases, Chronic Kidney Disease, Chronic Respiratory Failure, Dermatomyositis/ Polymyositis, Lupus Erythematosus, Polyartritis Nodosa, Rheumatoid Arthritis, Severe Refractory Atopic Dermatitis, Spondyloarthritis, Systemic Sclerosis, Chronic Immunobullous Disorders, Psoriasis, Neuromyelitis Optica

L04AD01 Ciclosporin (Cyclosporin)

Capsules 25mg

Consultants MP 46

Inflammatory Bowel Disease, Secondary Immunodeficiency Disorder, Chronic Kidney Disease, Chronic Liver Disease, Malignant Diseases, Rheumatoid Arthritis, Severe Chronic Urticaria, Severe Refractory Atopic Dermatitis, Spondyloarthritis, Psoriasis

L04AD01 Ciclosporin (Cyclosporin)

Capsules 100mg

Consultants MP 46

Inflammatory Bowel Disease, Secondary Immunodeficiency Disorder, Chronic Kidney Disease, Chronic Liver Disease, Malignant Diseases, Rheumatoid Arthritis, Severe Chronic Urticaria, Severe Refractory Atopic Dermatitis, Spondyloarthritis, Psoriasis

L04AD01 Ciclosporin (Cyclosporin)

Oral Solution 100mg/mL

Consultants MP 47

Secondary Immunodeficiency Disorder, Chronic Kidney Disease, Chronic Liver Disease, Rheumatoid Arthritis, Severe Chronic Urticaria, Severe Refractory Atopic Dermatitis, Psoriasis, Malignant Diseases

L04AB01 Etanercept (Enbrel®)

Injection 25mg

Consultant Dermatologists, Consultant Rheumatologists

MP 66

Psoriasis, Rheumatoid Arthritis

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139 10. Musculoskeletal and Joint Diseases

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

L04AB01 Etanercept (Benepali®)

Pre-filled Pen 50mg

Consultant Dermatologists, Consultant Rheumatologists

MP 66

Psoriasis, Rheumatoid Arthritis

L04AB01 Etanercept (Currently Erelzi®)

Pre-filled Pen 50mg

Consultant Dermatologists, Consultant Rheumatologists

MP 66

Psoriasis, Rheumatoid Arthritis

P01BA02 Hydroxychloroquine Sulphate

Tablets 200mg Consultants

Dermatomyositis/ Polymyositis, Lupus Erythematosus, Rheumatoid Arthritis, Spondyloarthritis

L04AA13 Leflunomide Tablets 10mg, 20mg

Consultant Rheumatologists

MP 113

Rheumatoid Arthritis, Spondyloarthritis

L01BA01/ L04AX03

Methotrexate Tablets 2.5mg Consultants

Inflammatory Bowel Disease, Secondary Immunodeficiency Disorder, Chronic Liver Disease, Malignant Diseases, Chronic Kidney Disease, Dermatomyositis/ Polymyositis, Lupus Erythematosus, Polyartritis Nodosa, Polymyalgia Rheumatica, Rheumatoid Arthritis, Severe Refractory Atopic Dermatitis, Spondyloarthritis, Systemic Sclerosis, Psoriasis

M01CC01 Penicillamine Tablets 250mg Consultants C Consultants Chronic Liver Disease

A07EC01 Sulfasalazine Tablets 500mg Consultant Gastroenterologists, Consultant Paediatricians, Consultant Surgeons, Consultant Rheumatologists

Inflammatory Bowel Disease, Rheumatoid Arthritis, Spondyloarthritis

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140 10. Musculoskeletal and Joint Diseases

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

10.1.4 Gout and cytotoxic induced hyperuricaemia M04AA01 Allopurinol Tablets 100mg Consultants C Medical

Practitioners Enzyme Disorders, Malignant Diseases, Inborn Errors of Metabolism, Crystal Deposition Disease

M04AA01 Allopurinol Tablets 300mg Consultants C Medical Practitioners

Enzyme Disorders, Malignant Diseases, Inborn Errors of Metabolism, Crystal Deposition Disease

M04AC01 Colchicine Tablets 500mcg

Consultants C Medical Practitioners

Chronic Immunobullous Disorders, Crystal Deposition Disease, Enzyme Disorders, Hidradenitis Suppurativa

10.2 Drugs used in neuromuscular disorders 10.2.1 Drugs that enhance neuromuscular transmission

N07AA02 Pyridostigmine Bromide

Tablets 60mg Consultants

Myasthenia Gravis

10.2.2 Skeletal muscle relaxants M03BX01 Baclofen Syrup

5mg/5mL Consultant Paediatricians, Consultant Neurologists, Consultant Palliative Care, Consultant Oncologists, Consultant Geriatricians, Consultant Anaesthetists, Pain Clinic Specialists

MP 14

Cerebrovascular Disease, Cerebral Palsy, Huntington's Chorea, Motor Neuron Disease, Multiple Sclerosis, Spinal Cord Pathologies, Malignant Diseases

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141 10. Musculoskeletal and Joint Diseases

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

M03BX01 Baclofen Tablets 10mg Consultants

Cerebrovascular Disease, Cerebral Palsy, Huntington's Chorea, Motor Neuron Disease, Multiple Sclerosis, Spinal Cord Pathologies, Trigeminal Neuralgia, Malignant Diseases, Neuromyelitis Optica

M03CA01 Dantrolene Sodium Capsules 25mg

Consultants

Cerebral Palsy, Motor Neuron Disease, Multiple Sclerosis, Spinal Cord Pathologies

N05BA01 Diazepam Syrup 2mg/5mL

Consultants A Medical Practitioners

Addiction Disorders, Cerebral Palsy, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Motor Neuron Disease, Multiple Sclerosis, Psychosis, Schizophrenia, Malignant Diseases

N05BA01 Diazepam Tablets 2mg Consultants A Medical Practitioners

Addiction Disorders, Cerebral Palsy, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Motor Neuron Disease, Multiple Sclerosis, Psychosis, Schizophrenia, Malignant Diseases

N05BA01 Diazepam Tablets 5mg Consultants A Medical Practitioners

Addiction Disorders, Cerebral Palsy, Chronic Mood Disorders, Chronic Neurotic Disorders, Chronic Psychiatric Disorders Starting in Childhood, Dementia, Motor Neuron Disease, Multiple Sclerosis, Psychosis, Schizophrenia, Malignant Diseases

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142 11. Eye

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

11. Eye 11.1 Anti-infective eye preparations

11.1.1 Antibacterials S01AA01 Chloramphenicol Eye Drops

0.5% Consultants A Medical Practitioners HIV/AIDS and HIV Related Diseases

S01AA01 Chloramphenicol Eye Ointment 1%

Consultants A Medical Practitioners HIV/AIDS and HIV Related Diseases

S03AA06 Dexamethasone+ Framycetin + Gramicidin

Ear/Eye Drops 0.05% + 0.5% + 0.005%

A Medical Practitioners No Entitlement

11.1.2 Antivirals S01AD03 Aciclovir (Acyclovir) Eye Ointment

3% N/A A Consultant

Ophthalmologists No Schedule V Entitlement

11.2 Corticosteroids and anti-inflammatory preparations 11.2.1 Corticosteroids

S01BA01 Dexamethasone Eye Drops 0.1%

Consultants A Medical Practitioners Vascular Disease of the Retina, Malignant Diseases

11.2.2 Other anti-inflammatory preparations S01XG01 Sodium

Cromoglicate Eye Drops 2% N/A A Medical Practitioners No Schedule V Entitlement

11.3 Mydriatics and cycoplegics S01FA01 Atropine Sulphate Eye Drops 1% Consultants

Vascular Disease of the Retina, Malignant Diseases

S01FA04 Cyclopentolate Hydrochloride

Unit Dose Eye Drops 1%

Consultant Ophthalmologists

C Consultant Ophthalmologists

Vascular Disease of the Retina

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143 11. Eye

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

S01FA06 Tropicamide Unit Dose Eye Drops 0.5%

Consultant Ophthalmologists

Vascular Disease of the Retina

11.4 Treatment of glaucoma S01EC01 Acetazolamide Tablets 250mg Consultants Epilepsy, Glaucoma

S01ED02 Betaxolol Hydrochloride

Eye Drops Suspension 0.25% or Eye Drops Solution 0.5%

Consultant Ophthalmologists

Glaucoma

S01EA05 Brimonidine Tartrate

Eye drops 0.2%

Consultant Ophthalmologists

Glaucoma

S01EC04 Brinzolamide Eye drops 10mg/mL

Consultant Ophthalmologists

Glaucoma

S01ED01, S01ED02, S01ED03

Beta-Blocker preservative free (Timolol, Betaxolol or Levobunolol)

Eye Drops Consultant Ophthalmologists

MP 127

Glaucoma

S01EB01 Pilocarpine Hydrochloride

Eye drops 1% Consultants C Medical Practitioners Glaucoma, Malignant Diseases

S01EB01 Pilocarpine Hydrochloride

Eye drops 2% Consultants C Medical Practitioners Glaucoma, Malignant Diseases

S01EB01 Pilocarpine Hydrochloride

Eye drops 4% Consultants C Medical Practitioners Glaucoma, Malignant Diseases

S01EE01, S01EE04

Prostaglandin Analogues (Currently Latanoprost)

Eye drops Consultant Ophthalmologists

Glaucoma

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144 11. Eye

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

S01EE04 Travoprost (Benzalkonium Free)

Eye drops Consultant Ophthalmologists

MP 194

Glaucoma

S01ED01 Timolol Maleate Eye Drops 0.25%

Consultants C Medical Practitioners Glaucoma

S01ED01 Timolol Maleate Eye Drops 0.5%

Consultants C Medical Practitioners Glaucoma

11.5 Miscellaneous ophthalmic preparations 11.5.1 Tear deficiency, ocular lubricants, and astringents

S01KA02 Hypromellose Eye Drops 0.3% - 0.5%

Consultants B Medical Practitioners Malignant Diseases

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145 12. Ear, Nose and Oropharynx

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

12. Ear, Nose and Oropharynx 12.1 Drugs acting on the ears

12.1.1 Otitis externa S03CA01 Dexamethasone+

Framycetin + Gramicidin

Ear/Eye Drops 0.05% + 0.5% + 0.005%

N/A A Medical Practitioners No Schedule V Entitlement

S03AA06 Gentamicin Ear/Eye Drops 0.3%

N/A A Medical Practitioners No Schedule V Entitlement

12.2 Drugs acting on the nose 12.2.1 Drugs used in nasal allergy

R01AD01 Beclometasone Dipropionate

Nasal Spray 50mcg

Consultants B Consultants Malignant Diseases

12.2.2 Topical nasal decongestants R01AA07 Xylomethazoline

Hydrochloride Nasal Drops 0.05%

N/A A Medical Practitioners No Schedule V Entitlement

R01AA07 Xylomethazoline Hydrochloride

Nasal Drops 0.1%

N/A A Medical Practitioners No Schedule V Entitlement

12.3 Drugs acting on the oropharynx 12.3.1 Mouthwashes, gargles, and dentifrices

A01AB03 Chlorhexidine Gluconate

Mouthwash 0.2%

Consultants A Dentists, Hospital Doctors

Down Syndrome, Congenital Indifference to Pain, Malignant Diseases, Chronic Immunobullous Disorders

A01AB02/ D08AX01

Hydrogen Peroxide

Solution 6% Consultants A Medical Practitioners Congenital Indifference to Pain, Malignant Diseases, Chronic Immunobullous Disorders

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146 12. Ear, Nose and Oropharynx

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

12.3.2 Treatment of dry mouth A01AD11 Artificial Saliva Solution Designate ENT

Consultants, Consultant Heamatologists, Consultant Oncologists, Consultant Palliative Care

Malignant Diseases

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V3.0 September 2021

147 13. Skin

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

13. Skin 13.1 Emollient and barrier preparations

13.1.1 Emollients D02AX Aqueous Cream Cream Consultants B Medical Practitioners Congenital Ichthyosis, Diabetes Mellitus Type

1, Diabetes Mellitus Type 2, Down Syndrome, Malignant Diseases, Psoriasis, Severe Refractory Atopic Dermatitis

D02AX Compound Emollient Preparation (Currently Lipobase®)

Cream Consultant Dermatologists

Congenital Ichthyosis, Malignant Diseases, Psoriasis, Severe Refractory Atopic Dermatitis

D02AX Emulsifying Ointment

Ointment Consultant Dermatologists

Congenital Ichthyosis, Psoriasis

D02AC White Soft Paraffin

Ointment Consultants

Congenital Ichthyosis, Malignant Diseases, Psoriasis

D02AE51 Urea Cream/ Lotion 10%

Consultant Dermatologists

Congenital Ichthyosis

13.1.1.1 Emollient bath additives D02AX Emollient Bath or

Shower Preparation

Solution Consultant Dermatologists

B Consultant Dermatologists

Congenital Ichthyosis, Malignant Diseases, Psoriasis, Severe Refractory Atopic Dermatitis

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148 13. Skin

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

13.1.2 Barrier preparations D02AB Zinc Based

Barrier Cream/ Ointment

Cream/ Ointment

Consultants B Medical Practitioners Malignant Diseases

13.2 Topical corticosteroids D07AC01 Betamethasone

Dipropionate [Potency: potent]

Cream 0.05% Consultant Dermatologists

C Consultant Dermatologists

Chronic Immunobullous Disorders, Congenital Ichthyosis, Dermatomyositis/ Polymyositis, Lupus Erythematosus, Malignant Diseases, Psoriasis, Severe Refractory Atopic Dermatitis

D07AC01 Betamethasone Valerate [Potency: potent]

Cream 0.1% Consultants B Medical Practitioners Chronic Immunobullous Disorders, Congenital Ichthyosis, Dermatomyositis/ Polymyositis, Lupus Erythematosus, Malignant Diseases, Psoriasis, Severe Refractory Atopic Dermatitis, Systemic Sclerosis

D07AC01 Betamethasone Valerate [Potency: moderate]

Ointment 0.025%

Consultant Dermatologists

Chronic Immunobullous Disorders, Congenital Ichthyosis, Dermatomyositis/ Polymyositis, Lupus Erythematosus, Malignant Diseases, Psoriasis, Severe Refractory Atopic Dermatitis, Systemic Sclerosis

D07AC01 Betamethasone Valerate [Potency: potent]

Ointment 0.1%

Consultants B Medical Practitioners Chronic Immunobullous Disorders, Congenital Ichthyosis, Dermatomyositis/ Polymyositis, Lupus Erythematosus, Malignant Diseases, Psoriasis, Severe Refractory Atopic Dermatitis, Systemic Sclerosis

D07AC01 Betamethasone Valerate [Potency: potent]

Scalp Application 0.1%

Consultants B Hospital Doctors Chronic Immunobullous Disorders, Congenital Ichthyosis, Dermatomyositis/ Polymyositis, Lupus Erythematosus, Psoriasis, Severe Refractory Atopic Dermatitis

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149 13. Skin

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

D07AD01 Clobetasol Propionate [Potency: very potent]

Cream 0.05% Consultant Dermatologists

B Consultant Dermatologists

Chronic Immunobullous Disorders, Congenital Ichthyosis, Dermatomyositis/ Polymyositis, Lupus Erythematosus, Malignant Diseases, Psoriasis, Severe Refractory Atopic Dermatitis, Systemic Sclerosis

D07AD01 Clobetasol Propionate [Potency: very potent]

Ointment 0.05%

Consultant Dermatologists

B Consultant Dermatologists

Chronic Immunobullous Disorders, Congenital Ichthyosis, Dermatomyositis/ Polymyositis, Lupus Erythematosus, Malignant Diseases, Psoriasis, Severe Refractory Atopic Dermatitis, Systemic Sclerosis

D07AD01 Clobetasol Propionate [Potency: very potent]

Scalp Application 0.05%

Consultant Dermatologists

B Consultant Dermatologists

Chronic Immunobullous Disorders, Congenital Ichthyosis, Dermatomyositis/ Polymyositis, Lupus Erythematosus, Psoriasis, Severe Refractory Atopic Dermatitis, Systemic Sclerosis

D07AA02 Hydrocortisone [Potency: mild]

Cream 1% Consultants A Medical Practitioners Chronic Immunobullous Disorders, Congenital Ichthyosis, Dermatomyositis/ Polymyositis, Down Syndrome, Malignant Diseases, Psoriasis, Severe Refractory Atopic Dermatitis

D07AA02 Hydrocortisone [Potency: mild]

Ointment 1% Consultants A Medical Practitioners Chronic Immunobullous Disorders, Congenital Ichthyosis, Dermatomyositis/ Polymyositis, Down Syndrome, Malignant Diseases, Psoriasis, Severe Refractory Atopic Dermatitis

D07AB02 Hydrocortisone Butyrate [Potency: potent]

Cream 0.1% Consultants B Medical Practitioners Chronic Immunobullous Disorders, Congenital Ichthyosis, Dermatomyositis/ Polymyositis, Lupus Erythematosus, Malignant Diseases, Psoriasis, Severe Refractory Atopic Dermatitis, Systemic Sclerosis

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150 13. Skin

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

D07AB02 Hydrocortisone Butyrate [Potency: potent]

Cream Fatty Base

Consultants B Medical Practitioners Chronic Immunobullous Disorders, Congenital Ichthyosis, Dermatomyositis/ Polymyositis, Lupus Erythematosus, Malignant Diseases, Psoriasis, Severe Refractory Atopic Dermatitis, Systemic Sclerosis

D01AC52/ D07XA01

Miconazole + Hydrocortisone [Potency: mild]

Cream 2% + 1%

Consultant Dermatologists

Congenital Ichthyosis, Psoriasis

D07AC13 Mometasone Furoate [Potency: potent]

Cream 0.1% Consultant Dermatologists

Chronic Immunobullous Disorders, Congenital Ichthyosis, Dermatomyositis/ Polymyositis, Lupus Erythematosus, Malignant Diseases, Psoriasis, Severe Refractory Atopic Dermatitis

D07AC13 Mometasone Furoate [Potency: potent]

Ointment 0.1%

Consultant Dermatologists

Chronic Immunobullous Disorders, Congenital Ichthyosis, Dermatomyositis/ Polymyositis, Lupus Erythematosus, Malignant Diseases, Psoriasis, Severe Refractory Atopic Dermatitis

D07XC01 Salicylic Acid + Betamethasone [Potency: potent]

Ointment 3% + 0.05%

Consultant Dermatologists

C Consultant Dermatologists

Chronic Immunobullous Disorders, Congenital Ichthyosis, Psoriasis

D07XC01 Salicylic Acid + Betamethasone [Potency:

potent]

Scalp Application 2% + 0.05%

Consultant Dermatologists

Chronic Immunobullous Disorders, Congenital Ichthyosis, Psoriasis

Officially deleted. Available until stocks last.

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151 13. Skin

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

13.3 Preparations for eczema and psoriasis 13.3.1 Preparations for psoriasis

D05BB02 Acitretin Capsules 10mg

Consultant Dermatologists

Congenital Ichthyosis, Hidradenitis Suppurativa, Lupus Erythematosus, Malignant Diseases, Psoriasis

D05BB02 Acitretin Capsules 25mg

Consultant Dermatologists

Congenital Ichthyosis, Hidradenitis Suppurativa, Lupus Erythematosus, Malignant Diseases, Psoriasis

D05AX02 Calcipotriol Ointment 50mcg/g

Consultant Dermatologists

Psoriasis

D05AX52 Calcipotriol + Betamethasone [Potency: potent]

Ointment or Cutaneous Foam 50mcg/g + 500mcg/g

Consultant Dermatologists

Psoriasis

D05AA Coal Tar* Shampoo Consultants B Medical Practitioners Congenital Ichthyosis, Psoriasis

EXTEMP2 Miconazole + Hydrocortisone Butyrate

Cream 1:1 Consultant Dermatologists

TBDF Hospitals

only

Psoriasis

EXTEMP3 Salicylic Acid + Betamethasone

Cream 5% Consultant Dermatologists

TBDF Hospitals

only

Psoriasis

EXTEMP4 Salicylic Acid + Betamethasone

Cream 10% Consultant Dermatologists

TBDF Hospitals

only

Psoriasis

* Availability temporarily suspended due to problematic sourcing.

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152 13. Skin

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

EXTEMP5 Salicylic Acid + Betamethasone

Ointment 5% Consultant Dermatologists

TBDF Hospitals

only

Psoriasis

EXTEMP6 Salicylic Acid + Betamethasone

Ointment 10%

Consultant Dermatologists

TBDF Hospitals

only

Psoriasis

EXTEMP7 Salicylic Acid + Clobetasol

Cream 5% Consultant Dermatologists

TBDF Hospitals

only

Psoriasis

EXTEMP8 Salicylic Acid + Clobetasol

Cream 10% Consultant Dermatologists

TBDF Hospitals

only

Psoriasis

EXTEMP9 Salicylic Acid + Clobetasol

Ointment 5% Consultant Dermatologists

TBDF Hospitals

only

Psoriasis

EXTEMP10 Salicylic Acid + Clobetasol

Ointment 10%

Consultant Dermatologists

TBDF Hospitals

only

Psoriasis

EXTEMP11 Salicylic Acid + Hydrocortisone butyrate

Cream 5% Consultant Dermatologists

TBDF Hospitals

only

Psoriasis

EXTEMP12 Salicylic Acid + Hydrocortisone butyrate

Cream 10% Consultant Dermatologists

TBDF Hospitals

only

Psoriasis

EXTEMP1 Menthol + Aqueous Cream

Cream Consultant Dermatologists

TBDF Hospitals

only

Psoriasis

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153 13. Skin

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

13.3.2 Drugs affecting the immune response L04AB04 Adalimumab Solution for

Injection in Pre-filled Syringes 40mg

Consultant Dermatologists, Consultant Gastroenterologists, Consultant Paediatrician, Consultant Rheumatologists

MP 307 Hidradenitis Suppurativa, Inflammatory Bowel Disease, Psoriasis, Rheumatoid Arthritis, Spondyloarthritis

L04AD01 Ciclosporin (Cyclosporin)

Capsules 25mg

Consultants MP 46

Inflammatory Bowel Disease, Secondary Immunodeficiency Disorder, Chronic Kidney Disease, Chronic Liver Disease, Malignant Diseases, Rheumatoid Arthritis, Severe Chronic Urticaria, Severe Refractory Atopic Dermatitis, Spondyloarthritis, Psoriasis

L04AD01 Ciclosporin (Cyclosporin)

Capsules 100mg

Consultants MP 46

Inflammatory Bowel Disease, Secondary Immunodeficiency Disorder, Chronic Kidney Disease, Chronic Liver Disease, Malignant Diseases, Rheumatoid Arthritis, Severe Chronic Urticaria, Severe Refractory Atopic Dermatitis, Spondyloarthritis, Psoriasis

L04AD01 Ciclosporin (Cyclosporin)

Oral Solution 100mg/mL

Consultants MP 47

Secondary Immunodeficiency Disorder, Chronic Kidney Disease, Chronic Liver Disease, Rheumatoid Arthritis, Severe Chronic Urticaria, Severe Refractory Atopic Dermatitis, Psoriasis, Malignant Diseases

L04AB01 Etanercept (Enbrel®)

Injection 25mg

Consultant Dermatologists, Consultant Rheumatologists

MP 66

Psoriasis, Rheumatoid Arthritis

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154 13. Skin

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

L04AB01 Etanercept (Benepali®)

Pre-filled Pen 50mg

Consultant Dermatologists, Consultant Rheumatologists

MP 66

Psoriasis, Rheumatoid Arthritis

L04AB01 Etanercept (Currently Erelzi®)

Pre-filled Pen 50mg

Consultant Dermatologists, Consultant Rheumatologists

MP 66

Psoriasis, Rheumatoid Arthritis

L01BA01/ L04AX03

Methotrexate Tablets 2.5mg

Consultants

Inflammatory Bowel Disease, Secondary Immunodeficiency Disorder, Chronic Liver Disease, Malignant Diseases, Chronic Kidney Disease, Dermatomyositis/ Polymyositis, Lupus Erythematosus, Polyartritis Nodosa, Polymyalgia Rheumatica, Rheumatoid Arthritis, Severe Refractory Atopic Dermatitis, Spondyloarthritis, Systemic Sclerosis, Psoriasis

13.4 Acne 13.4.1 Oral preparations for acne

D10BA01 Isotretinoin Capsules 20mg

Consultant Dermatologists

C Consultant Dermatologists

Congenital Ichthyosis

13.6 Anti-infective skin preparations 13.6.1 Antibacterial preparations

13.6.1.1 Antibacterial preparations also used systemically D06BX01 Metronidazole Gel 0.75% Consultant Oncologists,

Consultant Palliative Care, Consultant Dermatologists

MP 129

Malignant Diseases

Page 155: Out-Patients Formulary List

V3.0 September 2021

155 13. Skin

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

13.6.2 Antifungal preparations D01AC01 Clotrimazole Cream 1% Consultants A Medical Practitioners Down Syndrome, Congenital Indifference to

Pain

D01AC02 Miconazole Cream 2% Consultants A Medical Practitioners Down Syndrome, Congenital Indifference to Pain

13.6.3 Antiviral preparations D06BB03 Aciclovir

(Acyclovir) Cream 5% N/A A Consultant

Dermatologists No Schedule V Entitlement

13.6.4 Parasiticidal preparations P03AX03 Malathion Liquid 0.5%

w/w N/A A Medical Practitioners No Schedule V Entitlement

P03AC04 Permethrin Preparation for Treatment of Head Lice and Nits 1% w/w

N/A A Medical Practitioners No Schedule V Entitlement

P02CF01 Ivermectin Tablets 3mg N/A A Consultants, Senior Public Health Physicians

No Schedule V Entitlement

13.6.5 Preparations for minor cuts and abrasions D11AX05 Magnesium

Sulphate Paste Consultants A Medical Practitioners Malignant Diseases

Page 156: Out-Patients Formulary List

V3.0 September 2021

156 13. Skin

ATC Code Active Ingredient Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

13.7 Skin cleansers and antiseptics 13.7.1 Chlorhexidine salts

D08AC52 Chlorhexidine Gluconate in Isopropyl Alcohol

Solution (Hand Cleansing)

Consultants MP 37 TBDF

Hospitals only (TPN patients

only)

Small Intestinal Failure

13.7.3 Oxidisers and dyes A01AB02/D08AX01

Hydrogen Peroxide

Solution 6% Consultants A Medical Practitioners Congenital Indifference to Pain, Malignant Diseases, Chronic Immunobullous Disorders

13.7.4 Preparations for promotion of wound healing Wound Dressing

Emulsion (Currently Trolamine [Biafine®])

Emulsion Consultant Dermatologists, Consultant Oncologists, Consultant Surgeons

MP 201

Malignant Diseases

13.8 Sunscreen preparations D02BA Sunscreen SPF

50+ Milk or Lotion

Consultant Dermatologists, Consultant Rheumatologists

MP 180

Lupus Erythematosus, Psoriasis

Page 157: Out-Patients Formulary List

V3.0 September 2021

157 14. Anaesthesia

TC Code Active Ingredient

Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

14. Anaesthesia 14.1 General anaesthesia 14.1.1 Antimuscarinic Drugs

A03AB02 Glycopyrrolate (Glycopyrronium) (stand-by)

Injections 0.6mg

Consultants TBDF MDHP only

Cerebral Palsy, Epilepsy, Motor Neuron Disease, Malignant Diseases

A04AD01, N05CM05

Hyoscine Hydrobromide

Injections 400mcg

Consultant Palliative Care TBDF Hospitals

only

Malignant Diseases

14.1 Local anaesthesia D04AB01 Lidocaine

Hydrochloride (Lignocaine Hydrochloride)

Gel 2% Consultants C (Cathe

teri-sation)

Hospital Doctors With catheters in the following conditions: Cerebral Palsy, Cerebrovascular Disease, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Congenital Indifference to Pain, Cystic Fibrosis, Dementia, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Diverticular Disease requiring Stoma Care, Enzyme Disorders, Hirschsprung's Disease, Huntington's Chorea, Malignant Diseases, Motor Neuron Disease, Parkinson's Disease, Peripheral Vascular Disease, Spinal Cord Pathologies

Page 158: Out-Patients Formulary List

V3.0 September 2021

158 14. Anaesthesia

TC Code Active Ingredient

Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

14.2 Topical local anaesthetics and antipruritics D04AX Calamine Lotion Cream/

Lotion N/A A Medical Practitioners No Schedule V Entitlement

D04AX Crotamiton Cream Consultants A Medical Practitioners Dermatomyositis/ Polymyositis

Page 159: Out-Patients Formulary List

V3.0 September 2021

159 14. Anaesthesia

ATC Code Active Ingredient

Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

15. Consumables STOMA Stoma and

Related Consumables

Consultants

Chronic Kidney Disease, Diverticular Disease requiring Stoma Care, Hirschsprung's Disease, Imperforate Anus, Inflammatory Bowel Disease, Small Intestinal Failure, Malignant Diseases

STOMA Adhesive Remover

Consultants

Chronic Kidney Disease, Diverticular Disease requiring Stoma Care, Hirschsprung's Disease, Imperforate Anus, Inflammatory Bowel Disease, Small Intestinal Failure, Malignant Diseases

STOMA Deodorizing Agent

Consultants

Chronic Kidney Disease, Diverticular Disease requiring Stoma Care, Hirschsprung's Disease, Imperforate Anus, Inflammatory Bowel Disease, Small Intestinal Failure, Malignant Diseases

Page 160: Out-Patients Formulary List

V3.0 September 2021

160 15. Consumables

ATC Code Active Ingredient

Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

STOMA

Flanges Wafer Consultants

Chronic Kidney Disease, Diverticular Disease requiring Stoma Care, Hirschsprung's Disease, Imperforate Anus, Inflammatory Bowel Disease, Small Intestinal Failure, Malignant Diseases

STOMA

Gauze (non-sterile)

Consultants

Chronic Kidney Disease, Diverticular Disease requiring Stoma Care, Hirschsprung's Disease, Imperforate Anus, Inflammatory Bowel Disease, Small Intestinal Failure, Malignant Diseases

STOMA Pouches Closed

Consultants Chronic Kidney Disease, Diverticular Disease requiring Stoma Care, Hirschsprung's Disease, Imperforate Anus, Inflammatory Bowel Disease, Small Intestinal Failure, Malignant Diseases

Page 161: Out-Patients Formulary List

V3.0 September 2021

161 15. Consumables

ATC Code Active Ingredient

Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

Equipment related to the condition and/or treatment of that condition

Consultants

Cerebral Palsy, Cerebrovascular Disease, Chronic Immunobullous Disorders, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Chronic Osteomyelitis, Chronic Respiratory Failure, Congenital Indifference to Pain, Cystic Fibrosis, Dementia, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Diverticular Disease requiring Stoma Care, Enzyme Disorders, Epilepsy, Gastro-Oesophageal Reflux Disease, Hirschsprung's Disease, Hospital Acquired Infections, Huntington's Chorea, Imperforate Anus, Inflammatory Bowel Disease, Inherited Bleeding Disorders, Leprosy, Malignant Diseases, Motor Neuron Disease, Multiple Sclerosis, Parkinson's Disease, Peripheral Vascular Disease, Primary Immunodeficiency Disorder, Small Intestinal Failure, Spinal Cord Pathologies

Page 162: Out-Patients Formulary List

V3.0 September 2021

162 15. Consumables

ATC Code Active Ingredient

Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

V07AY Lubricating Jelly Consultants

With catheters in the following conditions: Cerebral Palsy, Cerebrovascular Disease, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Congenital Indifference to Pain, Cystic Fibrosis, Dementia, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Diverticular Disease requiring Stoma Care, Enzyme Disorders, Hirschsprung's Disease, Huntington's Chorea, Malignant Diseases, Motor Neuron Disease, Parkinson's Disease, Peripheral Vascular Disease, Spinal Cord Pathologies

Page 163: Out-Patients Formulary List

V3.0 September 2021

163 A1 Borderline Substances

ATC Code Active Ingredient

Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

A1 Borderline Substances A1.1 Enteral feeds (non-disease specific)

A1.1.1 Enteral feeds (non-disease specific): less than 5g protein/100mL A1.1.1.1 Enteral feeds: 1kcal/mL and less than 5g protein/100mL

V06 Complete Nutritional Preparation (e.g. Nutrison®, Nutricomp® Standard)

Liquid 500mL Consultants C Medical Practitioners Cerebrovascular Disease, Cerebral Palsy, Dementia, Epilepsy, Huntington's Chorea, Motor Neuron Disease, Multiple Sclerosis, Parkinson's Disease, Down Syndrome, Small Intestinal Failure, Malignant Diseases

A1.1.2 Enteral feeds (non-disease specific): 5g (or more) protein/100mL

A1.1.2.1 Enteral feeds: 1.5kcal/mL and 5g (or more) protein/100mL V06 Complete

Nutritional Preparation (e.g. Resource Energy®, formerly known as Ensure®, Clinutren®)

Liquid 200mL Consultants C Medical Practitioners Cerebrovascular Disease, Cerebral Palsy, Dementia, Epilepsy, Huntington's Chorea, Motor Neuron Disease, Multiple Sclerosis, Parkinson's Disease, Down Syndrome, Small Intestinal Failure, Malignant Diseases

A1.1.2.2 Enteral feeds: less than 1kcal/mL and less than 5g protein/100mL V06 Elemental

Formulas (e.g.

Elemental 028® Extra)

Powder Consultant Paediatricians, Consultant Gastroenterologists

MP 61

Gastro-Oesophageal Reflux Disease, Inflammatory Bowel Disease, Small intestinal Failure, Malignant Diseases

Page 164: Out-Patients Formulary List

V3.0 September 2021

164 A1 Borderline Substances

ATC Code Active Ingredient

Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

A1.1.3 Enteral feeds (non-disease specific): Child under 12 years A1.1.3.1 Enteral feeds, Child: 1kcal/mL and less than 4g protein/100mL

V06 Paediatric Liquid Food Preparation (e.g.

Paediasure®)

Liquid Consultant Paediatricians MP 158

Chronic Heart Failure, Cerebral Palsy, Down Syndrome, Gastro-Oesophageal Reflux Disease, Small Intestinal Failure, Malignant Diseases

A1.2 Nutritional supplements (non-disease specific) A1.2.1 Nutritional supplements: 5g (or more) protein/100mL

A1.2.2.2 Nutritional supplements: More than 1.5kcal/mL and 5g (or more) protein/100mL V06 Diet

Supplementation (e.g. FoodLink®, Sustagen®)

Powder

C Hospital Doctors No Schedule V Entitlement

A1.3 Specialised formulas A1.3.1 Specialised formulas: Infant and child – Amino acid-based formula

V06 Elemental Infant Formula (e.g. Neocate® LCP or Alfamino®)

Powder Consultant Paediatricians MP 62

Gastro-Oesophageal Reflux Disease, Small intestinal Failure, Inborn Errors of Metabolism

A1.3.2 Specialised formulas: Infant and child – Hydrolysate formula V06DF Milk Substitute

(e.g. Pregestimil®)

Powder Consultants

Enzyme Disorders, Inborn Errors of Metabolism

Page 165: Out-Patients Formulary List

V3.0 September 2021

165 A1 Borderline Substances

ATC Code Active Ingredient

Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

A1.3.3 Specialised formulas: Infant and child – Soya-based formula V06DF Milk Substitute

[Soya Based] (e.g. SMA ® Wysoy)

Powder Consultants

Enzyme Disorders, Inborn Errors of Metabolism

A1.4 Feed supplements A1.4.1 High-energy supplements

A1.4.1.1 High-energy supplements: carbohydrate V06DC Carbohydrate

Source Supplement (e.g. Maxijul®)

Powder Consultants MP 32

Chronic Heart Failure, Cerebral Palsy, Motor Neuron Disease, Multiple Sclerosis, Parkinson's Disease, Down Syndrome, Enzyme Disorders, Malignant Diseases

A1.4.1.2 High-energy supplements: fat V06 Fat and

Carbohydrate Food Supplement (e.g. Duocal®)

Powder Consultant Paediatricians MP 68

Chronic Heart Failure, Cerebral Palsy, Down Syndrome, Enzyme Disorders

A1.4.1.3 High-energy supplements: protein V06B Protein (e.g.

Forceval®) Powder Consultants

Epilepsy, Motor Neuron Disease

V06B Protein (e.g.

Casilan®, Promod®, Protifar®)

Powder 70-90% (high)

Consultants

Cerebral Palsy, Epilepsy, Motor Neuron Disease, Multiple Sclerosis, Parkinson's Disease, Malignant Diseases

Page 166: Out-Patients Formulary List

V3.0 September 2021

166 A1 Borderline Substances

ATC Code Active Ingredient

Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

A1.5 Feed additives A1.5.1 Feed thickeners and pre-thickened food

V07A Fluid thickener Powder Consultants C Consultants Cerebrovascular Disease, Cerebral Palsy, Dementia, Epilepsy, Huntington's Chorea, Motor Neuron Disease, Multiple Sclerosis, Parkinson's Disease, Down Syndrome, Polio and Post-Polio Syndrome, Malignant Diseases

A1.5.2 Flavouring preparations Flavour Sachets

(to be added with SHS products)

Sachets Consultant Paediatricians, Consultant Gastroenterologists, Dieticians

MP 232

Inflammatory Bowel Disease, Small intestinal Failure, Enzyme Disorders, Malignant Diseases

A1.6 Foods for special diets A1.6.1 Gluten-free foods

V06 Gluten Free Dietary Items

Voucher Scheme for Coeliac Patients

Consultant Gastroenterologists, Consultant Paediatricians, Consultant Surgeons

MP 85

Coeliac Disease

A1.6.2 Low-protein foods V06 Low-protein

bread Consultants

Chronic Kidney Disease

V06 Low-protein cracker bread

Consultants

Chronic Kidney Disease

V06 Low-protein flavoured biscuits

Consultants

Chronic Kidney Disease

Page 167: Out-Patients Formulary List

V3.0 September 2021

167 A1 Borderline Substances

ATC Code Active Ingredient

Dosage Form and Strength

Schedule V Prescriber Criteria

Protocol Pink Card

Pink Card Prescriber Criteria

Schedule V Entitlement

V06 Low-protein flour

Consultants

Chronic Kidney Disease

V06 Low-protein pasta

Consultants

Chronic Kidney Disease

V06 Low-protein plain biscuits

200g Consultants

Chronic Kidney Disease

Page 168: Out-Patients Formulary List

V3.0 September 2021

168 Index

Index

A

Abacavir + Lamivudine, 93

Abidec®, 134

Abiraterone, 122

Acetazolamide, 63, 143

Aciclovir (Acyclovir), 95, 96, 142, 155

Acitretin, 151

Adalimumab, 16, 137, 153

Alfacalcidol, 132, 133

Alfuzosin, 110

Allopurinol, 140

Alpha Tocopheryl (Vitamin E), 133, 134

Amantadine, 68

Amiloride + Hydrochlorothiazide, 22

Amiodarone HCl, 23

Amitriptyline, 52, 61

Amlodipine, 28

Amoxicillin, 73, 74

Amoxicillin + Clavulanic Acid, 74, 75

Anastrozole, 122

Angiotensin-II Receptor Anatagonists, 27

Antacid Compound Preparation, 11

Anti-Haemophilic Factor IX, 32

Anti-Haemophilic Factor VIII (stand-by), 31

Anti-Haemophilic Factor VIII inhibitor bypassing activity,

32

Anti-Heamophilic Factor VIII Intermediate, 32

Aprepitant, 56

Aqueous Cream, 147

Artificial Saliva, 146

Ascorbic Acid, 132

Aspirin, 31, 58

Atenolol, 23

Atomoxetine, 55

Atorvastatin, 33

Atropine Sulphate, 11, 142

Azathioprine, 16, 117, 138

Azidothymidine, 93, 94

Azithromycin, 78, 79

B

Baclofen, 140, 141

Beclometasone Dipropionate, 38, 145

Bendroflumethiazide (Bendrofluazide), 21

Benzhexol Hydrochloride, 70

Benzoin Tincture, 42

Benzylpenicillin, 75

Beta-Blocker preservative free, 143

Betamethasone Dipropionate, 148

Betamethasone Valerate, 148

Betaxolol, 143

Betaxolol Hydrochloride, 143

Bexarotene, 114

Bezafibrate, 33

Bicalutamide, 122

Bisacodyl, 18

Brimonidine Tartrate, 143

Brinzolamide, 143

Bromazepam, 44

Bromhexine, 41

Bromocriptine Mesylate, 68, 108

Budesonide, 15, 38, 39

Bumetanide, 21, 22

Buspirone Hydrochloride, 44

Busulfan, 112

C

Cabergoline, 108

Calamine Lotion, 158

Calcipotriol, 151

Calcipotriol+ Betamethasone, 151

Calcitonin (Salmon Synthetic), 107

Calcium, 28, 112, 129, 130

Calcium Carbonate, 130

Calcium Folinate, 112

Calcium Lactate, 130

Capecitabine, 113

Captopril, 26

Carbamazepine, 63, 64

Carbimazole, 101

Carbohydrate Source Supplement (Maxijul®), 165

Carvedilol, 23

Cefalexin, 76, 77

Cefuroxime Axetil, 77

Cernevit™-12, 129

Chlorambucil, 112

Chloramphenicol, 81, 142

Chlorhexidine Gluconate, 145

Chlorhexidine Gluconate in Isopropyl Alcohol, 156

Chloroquine, 97

Chlorpromazine Hydrochloride, 46

Chorionic Gonadotrophin (HCG), 106

Ciclosporin (Cyclosporin), 16, 17, 118, 119, 138, 153

Cinacalcet, 130

Ciprofloxacin, 88, 89

Page 169: Out-Patients Formulary List

V3.0 September 2021

169 Index

Clarithromycin, 79, 80

Clindamycin, 81

Clobazam, 64

Clobetasol Propionate, 149

Clofazimine, 86

Clomipramine Hydrochloride, 52

Clonazepam, 64

Clonidine Hydrochloride, 25, 63

Clopidogrel, 31

Clotrimazole, 110, 155

Clozapine, 46

Coal Tar, 151

Co-amilofruse (Amiloride + Furosemide [Frusemide]), 23

Co-Danthramer, 18

Codeine Phosphate, 13, 42, 58

Colchicine, 140

Colestyramine, 20, 33

Colistimethate Sodium, 81

Colistin Sulphomethate Sodium, 81

Complete Nutritional Preparation, 163

Compound Emollient Preparation (Currently Lipobase®),

147

Conjugated Estrogens, 105

Consumables, 159

Co-Trimoxazole, 82, 83

Crotamiton, 158

Cyclizine, 57

Cyclopentolate Hydrochloride, 142

Cyclophosphamide, 112

Cycloserine, 84

Cyproterone Acetate, 122

D

Dabrafenib, 114

Dantrolene Sodium, 141

Dapsone, 87

Deferasirox, 125

Demeclocycline Hydrochloride, 107

Desmopressin, 107

Dexamethasone, 102, 142

Dexamethasone+ Framycetin + Gramicidin, 142, 145

Dexamfetamine Sulphate, 55

Diazepam, 43, 44, 45, 68, 141

Diclofenac Sodium, 136

Diet Supplementation, 164

Diethylstilbestrol (Stilboestrol), 121

Digoxin, 21

Dihydrocodeine Tartrate, 58

Diltiazem, 28

Dimethyl Fumarate, 119

Diphenhydramine Citrate + Menthol, 42

Dipyridamole, 31

Disopyramide, 23

Disulfiram, 72

Docusate Sodium, 18

Domperidone, 57

Donepezil, 72

Dornase Alfa, 41

Doxazosin, 25, 110

Doxycycline, 77

DPP-4 Inhibitors, 100

Duocal®, 165

Dutasteride, 110

Dydrogesterone, 105

E

Econazole, 110

Efavirenz, 95

Elemental 028® Extra, 163

Elemental Formulas, 163

Elemental Infant Formula, 164

Emollient Bath or Shower Preparation, 147

Empagliflozin, 101

Emulsifying Ointment BP, 147

Enalapril, 26

Enoxaparin Sodium, 29, 30

Enzalutamide, 122

Eptacog Alfa (Recombinant Factor VIIa) (stand-by), 32

Erlotinib, 114

Erythromycin, 80

Estradiol, 105

Estradiol (as hemihydrate) + Dydrogesterone, 105

Etanercept, 138, 139, 153, 154

Ethambutol, 84

Ethinylestradiol, 105, 121

Ethionamide, 85

Ethosuximide, 64

Etoposide, 114

Everolimus, 114, 115

Exemestane, 122

F

Factor XIII Concentrate, 32

Fat and Carbohydrate Food Supplement, 165

Fenofibrate, 33

Fentanyl, 59

Ferrous Gluconate, 124

Fibrinogen Concentrate (stand-by), 32

Filgrastim (Rec. Human G-CSF), 126

Finasteride, 106

Fingolimod, 119

Flavour Sachets, 166

Flecainide, 23

Flucloxacillin, 75, 76

Fluconazole, 90

Fludarabine, 113

Fludrocortisone Acetate, 102

Fluid thickener, 166

Fluorouracil, 113

Fluoxetine, 54

Flupentixol Decanoate, 50

Page 170: Out-Patients Formulary List

V3.0 September 2021

170 Index

Flupentixol Dihydrochloride, 46, 54

Fluphenazine Decanoate, 50

Flutamide, 122

Fluticasone, 39

Fluvoxamine Maleate, 54

Folic Acid, 124, 125

Folinic Acid, 112

FoodLink®, 164

Furosemide, 22

Fusidate Sodium, 81

Fusidic Acid, 82

G

Gabapentin, 64, 65

Gentamicin, 78, 128, 145

Glibenclamide, 100

Gliclazide, 100

Gliptins, 100

Glucagon, 101

Gluten Free Dietary Items, 166

Glycerol, 18

Glyceryl Trinitrate, 27

Glycopyrolate (Glycopyrronium) (stand-by), 123

Glycopyrrolate (Glycopyrronium) (stand-by), 157

Goserelin, 108, 122

Griseofulvin, 91

Growth Hormone Recombinant, 106

H

Haloperidol, 46, 47, 48, 70, 71

Haloperidol Decanoate, 50, 51

HCG, 106

Heparin Sodium in Sodium Chloride, 29

Hydralazine, 25

Hydrocortisone, 15, 102, 149

Hydrocortisone Butyrate, 149, 150

Hydrocortisone Sodium Succinate, 102

Hydrogen Peroxide, 145, 156

Hydroxocobalamin, 125

Hydroxycarbamide, 115

Hydroxychloroquine Sulphate, 139

Hydroxyurea, 115

Hydroxyzine Hydrochloride, 40

Hyoscine Butylbromide, 11

Hyoscine Hydrobromide, 157

Hypromellose, 144

I

Ibuprofen, 136

Imatinib, 115

Imipramine Hydrochloride, 53

Indometacin, 137

Insulin Aspart, 99

Insulin Biphasic Isophane (Isophane + Neutral), 99

Insulin Glargine, 100

Insulin Isophane, 100

Insulin Neutral (Soluble Insulin, 99

Interferon Beta 1a, 120

Interferon Beta 1b, 120

Interferon Gamma, 120

Ipratropium, 38

Iron + folic acid, 124

Isoniazid, 85

Isoniazid + Rifampicin, 85

Isosorbide Dinitrate, 27

Isosorbide Mononitrate, 27, 28

Isotretinoin, 154

Ispaghula Husk, 17

Itraconazole, 91

Ivacaftor, 41

Ivacaftor + Lumacaftor, 41

Ivacaftor + Tezacaftor, 41

Ivacaftor + Tezacaftor + Elexacaftor, 41

Ivermectin, 98, 155

K

Ketovite®, 134

L

Labetalol Hydrochloride, 23, 24

Lactulose, 19

Lamivudine, 93

Lamotrigine, 65

Lanthanum, 131

Lapatinib, 115

Latanoprost, 143

Ledipasvir + Sofosbuvir, 96

Leflunomide, 139

Lenalidomide, 120, 121

Letrozole, 122

Leucovorin, 112

Leuprorelin, 109

Levetiracetam, 65

Levobunolol, 143

Levodopa + Benserazide Hydrochloride, 68

Levodopa + Carbidopa, 68

Levodopa + Carbidopa + Entacapone, 69

Levofloxacin, 89

Levomepromazine, 48

Levothyroxine (Thyroxine), 101

Lidocaine Hydrochloride, 157

Liothyronine Sodium (L-Tri-iodothyronine), 101

Lisinopril, 26

Lithium Carbonate, 51

Lithium Citrate, 51

Lomustine, 112

Long Acting Beta2-Agonist, 37

Loperamide, 13

Lopinavir/Ritonavir, 94

Page 171: Out-Patients Formulary List

V3.0 September 2021

171 Index

Lorazepam, 45

Low-protein bread, 166

Low-protein cracker bread, 166

Low-protein flavoured biscuits, 166

Low-protein flour, 167

Low-protein pasta, 167

Low-protein plain biscuits, 167

Lubricating Jelly, 162

M

Magnesium Glycerophosphate, 130

Magnesium Hydroxide + Aluminium Hydroxide +

Simeticone, 11

Magnesium Sulphate, 155

Malathion, 155

Maprotiline Hydrochloride, 53

Maraviroc, 95

Maxijul®, 165

Mebeverine Hydrochloride, 11

Medical Oxygen, 41

Medroxyprogesterone Acetate, 105, 121

Mefenamic Acid, 137

Mefloquine, 97

Meloxicam, 137

Melphalan, 112

Menadiol Sodium Phosphate, 134

Menthol + Aqueous Cream, 152

Mepacrine Hydrochloride, 98

Mercaptopurine, 17, 113

Mesalazine, 14

Mesalazine, 14

Metformin, 100

Methotrexate, 17, 113, 139, 154

Methyldopa, 25

Methylphenidate Hydrochloride, 55, 56

Methylprednisolone, 102

Methylprednisolone (as Sodium Succinate or

Hemisuccinate/ Hydrogen Succinate), 103

Methylprednisolone (as Sodium Succinate or

Hemisuccinate/ Hydrogen Succinate), 103

Methylprednisolone Acetate, 102, 137

Metoclopramide, 57

Metolazone Tartrate, 21

Metoprolol Tartrate, 24

Metronidazole, 87, 88, 154

Mexiletine, 23

Mianserin Hydrochloride, 53

Miconazole, 150, 151, 155

Miconazole + Hydrocortisone, 150

Miconazole + Hydrocortisone Butyrate, 151

Micro-Enemas, 19

Milk Substitute (Pregestimil®), 164

Milk Substitute [Soya Based] (SMA ® Wysoy), 165

Misoprostol, 13

Moclobemide, 54

Mometasone Furoate, 150

Montelukast, 39, 40

Morphine, 59, 60

Moxifloxacin, 89

Multivitamins, 129, 134

Multivitamins + mineral preparation, 135

Mycophenolate Mofetil, 117, 118

Mycophenolate Sodium, 118

N

Naltrexone Hydrochloride, 72

Naproxen, 137

Neocate®, 164

Nevirapine, 95

Nicorandil, 29

Nicotinamide, 131

Nifedipine, 28

Nilotinib, 115

Nitrazepam, 43

Nitrofurantoin, 90

Norethisterone, 105

Norfloxacin, 89

Nortriptyline, 53, 61, 62

Nutrini®, 164

Nutrison® or Nutricomp® Standard, 14, 163

Nystatin, 91

O

Octreotide, 123

Octreotide Long Acting, 123

Olanzapine, 48

Omalizumab, 40

Omeprazole, 13

Ondansetron, 57

Oral Iron, 124

Oral Rehydration, 127

Orphenadrine Hydrochloride, 69

Osmotic Laxative for Constipation, 19

Oxybutynin Hydrochloride, 110

P

Paediasure®, 164

Paediatric Liquid Food Preparation, 164

Pancreatin, 20

Paracetamol, 58

Paraffin White Soft, 147

Parenteral Fat Emulsion LCT, 129

Paroxetine, 54

Peg-Interferon Alfa 2a, 120

Penicillamine, 139

Penicillin V, 76

Pentazocine, 60

Pentoxifylline (Oxypentifylline), 29

Perindopril, 27

Page 172: Out-Patients Formulary List

V3.0 September 2021

172 Index

Permethrin, 155

Phenobarbital (Phenobarbitone), 65

Phenoxybenzamine, 26

Phenoxymethylpenicillin, 76

Phenytoin Sodium, 66

Phosphate, 19, 131

Phosphate Supplement, 131

Phytomenadione (Vitamin K1), 134

Pilocarpine Hydrochloride, 143

Pimozide, 48

Polystyrene Sulfonate (e.g. Calcium Resonium®), 126

Posaconazole, 92

Potassium Chloride, 127

Potassium Citrate, 111

Potassium Supplement, 127

Praziquantel, 98

Prazosin Hydrochloride, 26

Prednisolone, 16, 35, 36, 103, 104

Pregabalin, 62, 63, 66

Primidone, 67

Procarbazine, 115

Prochlorperazine, 48, 57

Procyclidine, 69, 70

Proguanil Hydrochloride + Atovaquone (stand-by), 98

Promethazine Hydrochloride, 40, 44

Propafenone, 23

Propranolol Hydrochloride, 24

Propylthiouracil, 101

Prostaglandin Analogues, 143

Protein (Casilan®, Promod®, Protifar®), 165

Protein (Forceval®), 165

Pyrazinamide, 86

Pyridostigmine Bromide, 140

Pyridoxine (Vitamin B6), 131, 132

Pyrimethamine (stand-by, 98

Q

Quetiapine, 49

R

Ranitidine, 12

Rasagiline, 69

Recombinant Human Erythropoietin, 125, 126

Repaglinide, 101

Resource Energy®,, 163

Ribavirin, 97

Rifabutin, 86

Rifampicin, 86

Risperidone, 49, 51

Ritonavir, 94

Ropinirole, 69

Rosuvastatin, 34

Rufinamide, 67

S

Salbutamol, 37

Salicylic Acid + Betamethasone, 150, 151, 152

Salicylic Acid + Clobetasol, 152

Salicylic Acid + Hydrocortisone butyrate, 152

Salmeterol, 37

Saquinavir, 94

Selegiline, 69

Senna, 18

SGLT2 inhibitor, 101

Sildenafil, 25

Simvastatin, 34

Sirolimus, 119

Sodium Bicarbonate, 127

Sodium Clodronate, 108

Sodium Cromoglicate, 142

Sodium Feredetate (oral iron), 124

Sodium Valproate, 67

Somatropin, 106

Sotalol, 24

Spironolactone, 22

Stoma and Related Consumables, 159

Sucralfate, 12

Sulfadiazine, 83

Sulfasalazine, 14, 15, 139

Sulpiride, 49, 50

Sunitinib, 115, 116

Sunscreen SPF 50+, 156

Sustagen®, 164

T

Tacrolimus, 119

Tamoxifen, 122

Temozolomide, 116

Tenofovir, 93

Terbutaline, 37

Teriflunomide, 121

Teriparatide, 107

Testosterone Undecanoate, 106

Tetrabenazine, 72

Tetracycline, 78

Thalidomide, 87, 121

Theophylline, 38

Thiamine (Vitamin B1), 132

Thyroxine, 101

Timolol, 143

Timolol Maleate, 144

Tioguanine, 114

Tiopronin, 135

Topiramate, 67

Total Parenteral Nutrition (Adult), 128

Trace Elements + Electrolytes, 129

Tramadol, 60

Trametinib, 116

Page 173: Out-Patients Formulary List

V3.0 September 2021

173 Index

Tranexamic Acid, 32

Travoprost, 144

Tretinoin, 116

Trifluoperazine, 50

Trihexyphenidyl Hydrochloride, 70

Trimetazidine Hydrochloride, 29

Trimethoprim, 84

Tropicamide, 143

U

Umeclidinium, 38

Urea, 147

Ursodeoxycholic Acid, 20

V

Valganciclovir, 96

Valsartan, 27

Venlafaxine, 54

Verapamil, 28

Vigabatrin, 67

Vitamin A (Retinol), 131

Vitamin A + D, 131

Vitamin B Complex (Nicotinamide+ Riboflavin +

Thiamine), 132

Vitamin B1, 132

Vitamin B12, 125

Vitamin B6, 131

Vitamin E, 133, 134

Vitamin K1, 134

Voriconazole, 92

W

Warfarin, 30

Water for injection, 128

Wound Dressing Emulsion (Currently Trolamine

[Biafine®]), 156

X

Xylomethazoline Hydrochloride, 145

Z

Zidovudine, 93, 94

Zidovudine+ Lamivudine, 94

Zinc Based Barrier Cream/Ointment, 148

Zuclopenthixol Acetate, 50

Zuclopenthixol Decanoate, 51

Zuclopenthixol Dihydrochloride, 50


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