Controlled Document Number: Version Number: 1.0 Controlled Document Sponsor: Controlled Document Lead: Approved By: Essential Reading for:

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1 Drug Formulary/Nurse Prescriber Drug Formulary and Pharmacy Protocol for CONTROLLED DOCUMENT CATEGORY: CLASSIFICATION: PURPOSE: Controlled Document Number: Version Number: 1.0 Controlled Document Sponsor: Controlled Document Lead: Approved By: Guideline Clinical A formulary/pharmacy protocol which covers prescribing and dispensing within Services. To contribute to a rational standard approach to prescribing across UHB resulting in safe, effective and economic use of medicines, in line with national and local policies and guidelines Aims to give prescribing guidance rather than just a list of medicines. (Guidance is usually brief) CG348 On: July 2017 Review Date: July 2019 Distribution: Essential Reading for: Clinical Service Lead for Services Lead Medicines Management Advisory Group (MMAG) All doctors, registered nurses and pharmacists. Information for: pharmacy technicians Microbiology consultant covering 1 Drug Formulary/Nurse Prescriber Formulary/Pharmacy Protocol for

2 1 Purpose 1.1 A list of products and indications for use, usually in pre-packaged form, available for dispensing in by medical and nursing staff. For non-medical prescribers (s), the prescribing of medication will only be within an individual s competence as assessed regularly by medical staff. All s who have a recognised qualification will first have the Approval to practice form completed and approved. All s will have professional accountability and clinical responsibility for prescribing practice. 2 Scope To provide guidance on the use of drugs and contraceptive products for sexual health doctors and nurses including non-medical prescribers, and information for the pharmacy team regarding where different preparations should be stocked. 2 Drug Formulary/Nurse Prescriber Formulary/Pharmacy Protocol for

3 SEXUAL HEALTH SERVICE DRUG FORMULARY AND PHARMACY PROTOCOL The following products are available in pre-packaged form for supplying by clinical staff. Drugs marked are available for inclusion in individual formularies for nurses who have been approved as non-medical prescribers. Abbreviations: BASHH BV Faculty HSV IUD/IUS LGV NGU NSU PEPSE PID PREP PV TV UPSI UTI WSC British Association for and HIV Bacterial vaginosis Faculty of Reproductive and Herpes Simplex Virus Intra-uterine Device/Intra-uterine System Lymphogranuloma venereum Non-gonococcal urethritis Non-specific urethritis Non-Medical Prescriber Post Exposure Prophylaxis after Exposure to HIV Patient Group Directives in force Pelvic Inflammatory Disease Pre Exposure Prophylaxis to HIV Per Vaginam Reproductive and Trichomonas vaginalis Unprotected Intercourse Urinary Tract Infection Whittall Street Clinic MEDICATION INDICATION(S) COMMENTS Category Stocked at Aciclovir tablets 400mg TDS orally for 5 days guidelines Aciclovir tablets 800mg TDS orally for 2 days Aciclovir tablets 400mg BD orally 28 days Aciclovir tablets 400mg TDS orally 28 days ANAPHALACTIC SHOCK PACK Yellow Boxes Contents: Adrenaline 1:1000 Aqueous cream BP (100g) To be used topically as First line: primary genital herpes HSV recurrence HSV recurrence First line: HSV suppression HSV suppression in third trimester of pregnancy Second line: HSV suppression Emergency drug use. Soap substitute in dermatitis Follow BASHH AND WSC guidelines may not initiate treatment. If not prescribed by consultant should have special clinic appointment within 3 months. Labelled: ANAPHYLAXIS Stored alongside emergency resuscitation equipment. Advise medical review if condition worsening 3 Drug Formulary/Nurse Prescriber Formulary/Pharmacy Protocol for

4 Atropine injection 0.6mg (600micrograms)/1mL injection Bradycardia during intrauterine procedures Azithromycin tablets 1g stat orally (Supply 4x 250mg tablets) Second line Chlamydia Second line NGU Contacts of chlamydia and NGU. Co treatment of Gonorrhoea (not in pregnancy) Azithromycin tablets 500mg stat followed by 250 mg OD orally for 4 days First line: Persistent NGU/mycoplasma genitalium (use with metronidazole). Unlicensed use Azithromycin 200mg/5mL suspension 1g (25mL) stat orally Benzathine benzylpenicillin injection 2.4 million units IM either as a single dose or once a week for 3 weeks Betamethasone 0.1% cream (30g) Betamethasone 0.025% cream (100g) As for Azithromycin 1g tablets. Syphilis and epidemiological treatment of contacts of syphilis Used when patient unable to swallow tablets local guideline. Unlicensed product. Frequency of administration (not in pregnancy) dependent on diagnosis Genital Dermatoses Unlicensed use Genital Dermatoses Unlicensed use Co-amoxiclav tablets 625mg TDS orally 7 days Cefixime tablets 400mg stat orally (Supply 2x 200mg tablets) Ceftriaxone injection 500mg IM stat Cefalexin capsules 500mg TDS orally 7 days Skin infections requiring anaerobic cover Second line: gonorrhoea First line: Gonorrhoea PID (with doxycycline and metronidazole) Pregnant women with UTI. Second line sensitive UTI. Co treat with azithromycin. Co treat with Azithromycin Doctor only in pregnancy 4 Drug Formulary/Nurse Prescriber Formulary/Pharmacy Protocol for

5 Ciprofloxacin tablet 500mg stat orally Dispensed from pack of 20 Alternative second line: uncomplicated gonorrhoea Clindamycin 2% cream (40g) 5gm PV nocte 7 days Clobetasol proprionate 0.05% ointment (30g) Clotrimazole 500mg pessary 500mg PV stat preferably nocte Clotrimazole cream 1% (20g) Clotrimazole HC 1% cream (30g) Bacterial vaginosis Consider special clinic if more than 3 episodes a year and symptoms persisting Genital dermatoses Unlicensed use. First line vaginal candidiasis First line: candidiasis, tinea cruris 2 nd line: Candida, balanitis / vulvitis and genital dermatosis Prescribed with 1% clotrimazole cream if vulvitis present or when prescribed for vaginal candidiasis on. In women must also prescribe 500mg pessary. Dispensed as separate items Cyclizine 50mg tablets 50mg stat orally Dermol 500 Lotion (500mL) Doublebase Gel 100g For nausea and vomiting Genital dermatoses Genital dermatoses Doxycycline capsules 100 mg BD orally 7 days First line: chlamydia, NGU Contacts of chlamydia and NGU Follow Doxycycline capsules100mg BD orally 14 days Alternative: Early syphilis 2 nd line: epididymoorchitis Follow BASSH and Doxycycline capsules 100mg BD 21 days LGV Failure of treatment of rectal Chlamydia 5 Drug Formulary/Nurse Prescriber Formulary/Pharmacy Protocol for

6 Doxycycline capsules 100mg BD orally 28 days Second line: Late syphilis local guideline Doxycycline capsules 200mg BD orally 28 days Erythromycin tablets 500mg BD orally 14 days Second line: neurosyphillis 2 nd line: Folliculitis supply 7 days only 3 rd line: Uncomplicated Chlamydia local guideline Follow BASHH guidelines (Chlamydia only) Flucloxacillin capsules 250mg QDS orally 7 days Fluconazole capsule 150mg stat orally Gentamicin injection 240mg IM stat Hepatitis A vaccine injection IM Hepatitis B vaccine injection IM First line: folliculitis/skin infections 2 nd line: genital candidiasis 3 rd line gonorrhoea If allergic to cephalosprins or history of penicillin anaphylaxis and spectinomycin not available or contraindicated First line: Hepatitis A vaccination First line: Hepatitis B vaccination Follow local guideline. Stored in refrigerator Follow local guideline. Stored in refridgerator on consultant Hydrocortisone 1% cream 15g Imiquimod cream Apply topically 3 times/week (12 sachets) Levofloxacin 500mg tablets 500mg OD orally 14 days Lidocaine 2.5% & Prilocaine 2.5% cream (EMLA ) (5g) First line: genital dermatoses Alternative 2 nd line: anogenital warts Pelvic inflammatory disease Topical anaesthesia : For maximum 1-2 week therapy. Requires specific knowledge and in-house training in genital dermatology. Follow up to be booked with doctor for review BASHH and local guidelines Prior to hyfrecation treatment of anogenital warts health 6 Drug Formulary/Nurse Prescriber Formulary/Pharmacy Protocol for

7 Lidocaine 5% ointment (15g) Lidocaine 1% injection (5mL) Metronidazole 400mg tablets 2g stat orally (Supply 5 400mg tablets) Metronidazole gel 0.75% (40gm) PV nocte 5 days Metronidazole 200mg/5mL suspension 400mg BD orally 7 days Metronidazole tablets 400mg BD orally 7 days Metronidazole tablets 400 mg BD 14 days (Monsel s) Ferric subsulfate solution (50mL) To be used as Moxifloxacin tablet 400mg OD orally 14 days Topical anaesthesia As diluent for Ceftriaxone and Benzathine benzylpenicillin. Local anaesthesia in genital dermatology clinic and for fitting / removal of implants First line: Trichomoniasis (TV) Alternative first line: Bacterial vaginosis Alternative first line BV (indications as for Metronidazole tablets) 2 nd line: Trichomonas (TV) First line: bacterial vaginosis, 2 nd line: Trichomonas (TV) Persistent/recurrent NSU With ofloxacin/levofloxacin or doxycycline and ceftriaxone for PID Genital dermatology clinic during minor surgery / skin biopsy Second line PID: Mycoplama genitalium/persistent NGU For post liquid nitrogen wart treatment or symptomatic relief of HSV Use with azithromycin Two 7days boxes dispensed Unlicensed special product Includes contacts of mycoplama genitalium Nurses administer when used as a diluent for ceftriaxone under for BV and TV Nystatin pessaries 100,000 units 1-2 PV nocte 14 days Nitrofurantoin MR capsules 100mg BD orally 3 days Resistant candidiasis First line: uncomplicated UTI in women Follow BASHH guideline Unlicensed product 7 Drug Formulary/Nurse Prescriber Formulary/Pharmacy Protocol for

8 Nitrofurantoin MR capsules 100mg BD orally 7 days Mild to moderate symptoms of UTI in men Ofloxacin tablets 400mg BD orally 7 days Ofloxacin tablets 400mg BD orally 14 days Severe symptoms of UTI suggestive of pyelonephritis in women and men. First line: PID (combined with Metronidazole) First line: epididymo-orchitis, prostatitis Paracetamol 500mg tablets 1g stat orally For use as required Single dose only PEPSE PACK Truvada (tenofovir disoproxil 245mg and emtricitabine 200mg) 1 tablet daily Raltegravir 400mg 12 hourly 5 day supply Truvada (tenofovir disoproxil 245mg and emtricitabine 200mg) 1 tablet daily 3 months (90 tablets) Permethrin 5% cream (30g) Podophyllotoxin 0.5% liquid (3.5ml) Podophyllotoxin cream 0.15% (5g) HIV post exposure prophylaxis HIV PREP Scabies Pediculosis pubis First line: (alternative to podophylotoxin cream) penile warts First line: perianal and vulval warts. Alternative treatment: Molluscum Contagiosum Unlicensed Rest of 28 day course via QEH HIV clinic Follow BASHH guideline only Relactagel Vaginal Gel (lactic acid 4.5% + glycogen 0.1%) (5mL) 1 tube each night 7 days Sodium chloride 0.9% (saline)flush Sensilube (40ml) To be used as 2 nd line prevention of recurrent bacterial vaginosis To flush butterfly if IV (intravenous) atropine administered Second line: Atrophic vaginitis use only 8 Drug Formulary/Nurse Prescriber Formulary/Pharmacy Protocol for

9 Spectinomycin injection 2g IM stat Trimethoprim tablet 200mg BD orally 3 days Alternative second line: uncomplicated gonorrhoea Second line: uncomplicated UTI (female only) Follow BASHH guideline Unlicensed product (limited availability) Trimovate Clobetasone butyrate 0.05% oxytetracycline 3%, nystatin 100,000 units/g (30g) Genital Dermatoses Unlicensed use GENITOURINARY MEDICICINE NON STOCK DRUGS ORDER FROM PHARMACY Flucytosine 5g cream OR 1g pessaries with nystatin 100,000 units Treat for 14 days Failure of first line treatments of non albicans vaginal yeast infections Short expiry date order as required. Store in refrigerator Unlicensed preparation Not kept in stock Prednisolone tablets 40-60mg TDS orally 3 days Prevention of Jarisch- Herxheimer reaction Opthalmic, neuro or cardiovascular syphilis Not kept in stock Probenecid tablets 500mg QDS orally 17 days With procaine penicillin Follow BASHH syphilis guideline. Unlicensed indication Not kept in stock Procaine penicillin injection million units IM for days Neurosyphilis. Also prescribe probenecid Follow BASHH syphilis guideline. Unlicensed product Not kept in stock Tinidazole tablets 2gm orally BD 14 days Failure of first line treatment of trichomonas Follow BASHH trichomonas guideline Unlicensed use of licensed UK product Not kept in stock Simple eye ointment To be applied to the affected eye lash(es) BD for 8-10days as Permethrin 1% lotion (59mL) To be applied to the effected eye lash(es) as (e.g. Lyclear dermal cream rinse ) First line for pubic lice on eye lashes Second line for pubic lice on eye lashes Follow BASHH pediculosis pubis and local guideline. Follow SHS pubic lice guideline (CG102). Unlicensed use of UK licensed product On consultant Not kept in stock Not kept in stock 9 Drug Formulary/Nurse Prescriber Formulary/Pharmacy Protocol for

10 CONTRACEPTION AND REPRODUCTIVE AND SEXUAL HEALTH DRUGS CONTRACEPTIVES Levonorgestrel tablet 1500mcg single dose orally (e.g. Levonelle ) Ulipristal acetate tablet 30mg single dose orally (e.g. EllaOne ) Desogestrel 75mcg (e.g. Cerezette, Cerelle, Feanolla, Zeletta ) Emergency oral Emergency Oral Contraceptives Emergency Oral Contraception including as advanced prescription/ supply Progesterone Only Contraceptives First Line oral progestogen only Bridging method or as an adjunct to Nexplanon as per FSRH guidelines Levonorgestrel 30micrograms (Norgeston ) Norethisterone 350mcg tablet (e.g. Noriday ) Levonorgestrel 13.5mg Jaydess IUS Mirena 20 micrograms/24 hours IUS Levonorgestrel 52micrograms Etonogestrel 68mg Implant (Nexplanon ) Oral Progestogen only Contraception Oral progestogen only Contraception Intra-uterine system progesterone only Intra-uterine system progesterone only Sub-dermal Contraceptive Implant Fitted on days 1-5 of cycle. At any other time excluding pregnancy. Medroxyprogesterone acetate (Depo Provera ) IM injection (150mg/1ml) Medroxyprogesterone acetate (Sayana Press ) 104mg in 0.65ml SC injection Injectable Contraception Injectable Contraception Every 12 weeks Every 13 weeks 10 Drug Formulary/Nurse Prescriber Formulary/Pharmacy Protocol for

11 Estradiol valerate (E) Dienogest (D) E3mgX2/E2mgX5/ E2mgX17/E1mgX2 D2mgX7/D3mgX19 (Qlaira ) Ethinylestradiol (E) Levonorgestrel (L) E30/L5O X6 E40/L75 X5 E30/L125 X10 (e.g. TriRegol, Logynon ) Ethinylestradiol (E) Norethisterone (N) E35mcgX21/N500mcgX7/ N1mgX9/N500mcgX5 1 month supply (e.g. SynPhase ) Ethinylestradiol 20mcg Desogestrel 150mcg (e.g. Gedarel 20/150, Lestramyl 20/150, Mercilon ) Ethinylestradiol 20mcg Gestodene 75mcgs (e.g. Millinette 20/75, Femodette ) Ethinylestradiol 30mcg Levonorgestrel 150mcg (e.g. Rigevidon, Levest, Microgynon ) Ethinylestradiol 30mcg Desogestrel 150mcg (e.g. Gedarel 30/150, Lestramyl 30/150, Marvelon ) Ethinylestradiol 30mcg Gestodene 75mcgs (e.g. Millinette 30/75 or Femodene ) Ethinylestradiol 30mcg Levonorgestrel 150mcgs Includes 7days placebo pills (Microgynon 30mcg ED ) Phasic Oral Contraceptives Phasic 28 day combined oral contraceptive Phasic 21 day combined oral contraceptive pill. Phasic 21 day combined oral contraceptive pill. Oral combined Contraception Oral combined Combined Contraceptives First line oral combined Oral combined Oral combined Oral combined use only use only use only 11 Drug Formulary/Nurse Prescriber Formulary/Pharmacy Protocol for

12 Ethinylestradiol 35mcg Norgestimate 250mcg (e.g. Cilest, Lizinna ) Ethinylestradiol 15micrograms + Etonogestrel120micrograms per 24 hours Supply 3 rings (1 original pack) NuvaRing 0.120mg/0.015 per 24 hours. Oral combined Combined contraceptive vaginal ring Stored in refrigerator between 2-8 C until dispensed. Can be stored at room temperature (less than 30 C) for 4months Must only dispense 3 months (3 rings) supply FOR UMBRELLA SHS USE ONLY Ethinylestradiol approx 33.9mcgs/Norelgestromin 203mcgs (approx 24hrs) Evra Subdermal Patches Trans-dermal combined contraceptive patches Caya diaphragm Other Contraceptive Devices Vaginal contraceptive diaphragm Barrier method as per faculty guidelines. Non-prescription item order via stores. Caya gel Vaginal spermicidal gel Use only in conjunction with Caya diaphragm. Barrier method as per faculty guidelines. Non-prescription item order via stores. Flexi-T 300 Gynefix Copper Intra-Uterine Devices Intrauterine Copper device Intrauterine Copper devices (frameless) MiniTT 380 Slimline Nova-T 380 TCu380A QuickLoad Intrauterine contraceptive devices Intrauterine contraceptive devices Intrauterine contraceptive devices 12 Drug Formulary/Nurse Prescriber Formulary/Pharmacy Protocol for

13 OTHER DRUGS Chlorhexidine wash For procedures Lidocaine 2% chlorhexidine gluconate solution 0.25% - 11mL syringe (Instillagel or Optilube Active ) To be applied as Mepivacaine 3% 2.2ml cartridge Prilocaine 3% with felypressin (octapressin) (2.2mL) injection Citanest with octapressin Xylocaine (lidocaine) 2% with adrenaline 1:200,000 injection Norethisterone 5mg tablets 5mg TDS 10 days (Supply up to 2 original packs) Topical anaesthesia IUD/IUS insertions Local anaesthesia/intracervical block Local anaesthesia for cervical blocks Removal of deep implants consultant heavy menstrual bleeding Days 5 25 of cycle consultant All complex clinic sites All complex clinic sites Cyproterone acetate 2mg Ethinylestradiol 0.035mg (e.g. Dianette, Clairette, Teragezza ) Tranexamic acid 500mg tablets 1g TDS orally for up to 4 days/cycle Mefenamic acid 500mg tablets 500mg TDS orally 28 days Contraception with acne and hirsutism Menorrhagia Dysmenorrhoea/bleeding problems Acne and hirsutism not responding to other COCs Associated with intra uterine contraceptive device Associated with contraceptive method consultant consultant consultant All complex clinic sites All complex clinic sites All complex clinic sites BASHH guidelines Faculty of Reproductive and guidelines Local guidelines (from UHB computers) Drug Formulary/Nurse Prescriber Formulary/Pharmacy Protocol for

14 Appendix 1: Changes in Drug Formulary/Nurse Prescriber Drug Formulary and Pharmacy Protocol for Changes in version Abbreviations list has been updates and expanded to ensure clear communication. 2. Anaphylaxis Shock Pack has been updated to include adrenaline only as per the local and national guidelines for the management of acute anaphylaxis. 3. Citanest with octapressin (Citanest 3 % ) has been added to the formulary for local anaesthesia associated with cervical blocks. 4. Contraceptives categorised into group class to simplify formulary structure and ease identification. 5. Ethinylestradiol with noresthisterone tablets (SynPhase ) has been added to the formulary for consultant use only as a third phasic contraceptive option. This is in line with availability on the local APC formulary. 6. Flexi-T 300 has been added to offer an addition copper inter-uterine device for those patient s with narrow cervical openings. This is in-line with the current local APC formulary. 7. Hepatitis A Vaccine has been added in response to the Public England alert relating to an increase in hepatitis A cases particularly in men who have sex with men. 8. Lidocaine 2.5% and prilocaine 2.5% cream (e.g. EMLA cream) has been added to the formulary for local anaesthesia to anogential warts prior to hyfrecation procedure 9. PREP (Pre-exposure Prophylaxis Pack) has been added to the formulary. 10. Arching spring diaphragm and flat spring diaphragm have been removed due to low usage. 11. Citanest 1% has been removed as it has now been replaced with Citanest 3%. 12. Gygel gel 2% has been removed as no longer used. 14 Drug Formulary/Nurse Prescriber Formulary/Pharmacy Protocol for