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Specialist Drug Traffic Light List

Requests for RED or Non-Formulary products

You may occassional receive requests from Speciailst Teams to prescribe a medication which you know is a RED category drug, or you feel is not appropriate for primary care prescribing, or at least until further information is made available to you by the Specialist Team. This Non-Formulary Feedback form is intended to be used by primary care prescribing teams to easily communicate with the specialist team, and can be found here.

Please remember to never send patient identifiable information to the CCG, so alway remove any PID before sending to the Medicines Optimisation Team.

THE TRAFFIC LIGHT SYSTEM (scroll down)

 

NB It is not obligatory for GPs to prescribe “Amber” medications purely because we have an agreed Shared Care Guideline. Clinical responsibility is with the prescriber and therefore individual GPs need to decide on whether it is appropriate for them to accept this responsibility for a particular drug in a particular patient. If this situation occurs timely communication with the specialist is essential so that alternative arrangements can be implemented.

Guidelines for the transfer of prescribing responsibility between primary and secondary care in Gloucestershire and the Traffic_Light_System

Shared Care Guideline template - download this template to start a new SCG.

 

Category Information  (NB Greater detail within Guidelines above)

RED - Hospital / Specialist initiation and  continued prescribing only
AMBER - Hospital / Specialist recommendation OR Hospital / Specialist initiation and prescribing, with requested transfer of prescribing to GP upon agreement once patient is stabilised
GREEN - Green listed items have been removed from the Traffic Light List since they had no particular restrictions. Any associated prescribing guidance is now listed under Prescribing Guidance in the Medicines Management section on CCG LIVE. 
Specialist Drug Traffic Light List
Drug name Category Condition listed / Notes Link to Shared care Guideline
Acapella Choice Amber No SCG required. Mucous clearing device (e.g. cystic fibrosis). For specialist initiation and specialised patient training required. Prescribing in primary care if patient benefit shown.  
Adalimumab (Humira™) Red Crohn's Disease  
Alirocumab Red Primary hypercholesterolemia and mixed dyslipidaemia (as per NICE TA393 and TA394)  
Alitretinion (Toctino™) Red Hand Eczema  
Amiodarone Amber Cardiac rhythm disorders SCG
Apomorphine (Apo-Go™) Amber Parkinson's Disease- now provided directly via Homecare SCG (includes homecare)
Atomoxetine (Strattera™) Adult Amber Attention Deficit Hyperactivity Disorder (ADHD) in Adults SCG
Azathioprine (Imuran™) Amber

Inflammatory Bowel Disease

 SCG

Azathioprine (Imuran™) Amber

Prevention of rejection transplant. Bechet’s syndrome, chronic active hepatitis, Idiopathic thrombocytopenic purpura, interstitial lung disease, myasthenia gravis, Polymyositis, Rheumatoid arthritis, sarcoidosis, scleritis and uveitis, SLE, vasculitic syndromes, eczema, pemphigoid and psoriasis.

SCG in development
Azathioprine (Imuran™) Amber Severe Uveitis SCG
Bicalutamide Amber Management of Prostate Cancer SCG
Buprenorphine ™ Amber Opioid withdrawal. CGL primarily prescribe medications for substance misuse. They will now routinely prescribe Espranor™, a rapidly dissolving orolyophilisate for mucosal absorption. Bioavailability differs so should not be interchanged with standard sublingual tablets.  
Buserelin (Suprefact™, Suprecur™) Amber Prostate cancer  
Cannabinoids (Sativex™) Red

Multiple Sclerosis

 
Cannabis Derived Medicines (including Cannabis oil) Red

Following the recent legislative review relating to legal prescribing of cannabis, please see the following NHS England Bulletin.

Prescribing will be limited to “specialists” in the areas associated with its potential use, and that GPs should NOT prescribe cannabis products.
Referrals- NHS choices further elaborates the limited areas of specialist review where legislation has been amended, namely a certain rare epilepsy, MS spasticity, and nausea or vomiting from chemotherapy. NB this does not include chronic pain.
Therefore please only refer appropriate patients in line with the approved treatable conditions.

When licensed products become available, which could take a while dependent on the licencing processes, this current prescribing position will be reviewed. Therefore, cannabis products are classed on the Gloucestershire traffic light system as ‘red’ drugs.

NHS England Guideline Oct 2018

CCG Medicinal Cannabis  Briefing

NHS Choices Website- useful to print out for patients- clearly advises them of the specifics of who can prescribe, and for what conditions.

NHS England have recently produced a guide for prescribers

RCGP Cannabis based medicine desk top guide

CAPD (Continuous Ambulatory Peritoneal Dialysis fluids) Red    
Chorionic Gonadotrophin (Profasi™, Pregnyl™, Choragon™) Red Infertility. Refer to Items not Normally Funded (INNF)  
Ciclosporin (Neoral™, Sandimmun™, SangCya™) Amber Rheumatoid Arthritis  
Ciclosporin (Capimune™, Neoral™, Deximune™ ) Amber Psoriasis. Dermatologists will prescribe by brand, using Capimune™ as the first line choice SCG
Ciclosporin (Neoral™, Sandimmun™) Amber Renal transplant SCG
Ciclosporin (Neoral™, Sandimmun™, SangCya™) Red Ulcerative Colitis  
Ciclosporin (Capimune™) Amber Severe Uveitis SCG
Ciclosporin (Ikervis™) eye drops Red Severe keratitis unresponsive to other agents. See Joint Formulary  
Cinacalcet (Mimpara™) Red Secondary Hyperparathyroidism in patients with end-stage renal disease on maintenance therapy  
Clozapine (Clozaril™) Red Atypical antipsychotic NICE June 2002.   
Degarelix Red    

Denosumab (Prolia™)

Amber Osteoporosis in women and men where biphosphonates not appropriate. Specialist initiation, then shared care. Recorded reasons for preference over alternatives be noted. SCG
Denosumab (XGEVA™) Amber prevention of skeletal related events in adults with bone metastases from solid tumours. SCG
Desferrioxamine (Desferal™) Red Elimination of excess iron. Specialist use only  
Dexamfetamine Amber ADHD refractory to methylphenidate and/or atomoxetine, under specialist supervision (Adult) SCG
Disodium Pamidronate (Aredia™) Red For use in management of multiple myeloma  
Donepezil (Aricept™) Green G-Care holds local supporting guidance for GPs Downgraded Sep 2018
Dornase Alfa (Pulmozyme™) Red Cystic Fibrosis. For patients currently receiving this in primary care, the GP should contact the Specialist Team and arrange a repatriation time. Until repatriated, prescribing may continue under the previous SCG, but this shoudl be temporary. SCG only whilst repatriation is being arranged.
Dronederone (Multaq™) Red Atrial Fibrillation (AF) - see SPC for full details  
Eltrombopag Red Chronic idiopathic thrombocytopenic purpura  
Entacapone (Comtess™) Amber Parkinson's Disease  
Eplerenone (Inspra™) Green Heart failure post MI. Classified green on 26/11/19, only where spironolctone is not appropriate.  
Epoprostenol (Flolan™) Red Primary pulmonary hypertension. Hospital Trusts are responsible for making the necessary arrangements for patients to receive intravenous treatment at home  
Erythropoiesis Stimulating Agents (darbepoietin alfa, Methoxy polyethylene glycol Epoietin beta) Amber Pre-dialysis, dialysis and renal transplant SCG
Etanercept (Enbrel™) Red As per NICE guidelines March 02.
Recommended for rheumatoid arthritis in patients who meet certain criteria (including non response to at least 2 DMARDs to include methotrexate if not contra-indicated).
Also recommended for juvenile idiopathic arthritis where methotrexate has failed.
 
Evolucumab Red Primary hypercholesterolemia and mixed dyslipidaemia (as per NICE TA393 and TA394)  
Fampridine (Fampyra™) Red Use in multiple sclerosis - specialist use only  
Filgastrim Amber Neutropenia  
Flutamide (Drogenil™) Amber Management of Prostate cancer  
Follitropin alfa and beta (Gonal F™ and Puregon™) Red Infertility Items Not Normally Funded (INNF)  
Galantamine  Green  Recommended for the treatment of Alzheimer’s disease. Changed to green in January 2019  
Gold (Auranofin™, Myocrisin™) Amber Rheumatoid and juvenile arthritis  
Gonadorelins Amber Prostate cancer A shared SCG
Gosorelin Amber Prostate Cancer Part of a shared SCG
Growth Hormone in Adults Amber As per NICE guideline  
Growth Hormone in children Amber As per NICE guideline. For use in short stature due to growth hormone deficiency, Turner Syndrome and chronic renal insufficiency SCG
Hydroxicarbamide Amber
Several uses-
  • Myeloproliferative neoplasms such as Essential Thrombocythaemia and Polycythaemia Rubra Vera
  • Sickle cell disease
  • Initial cytoreductive therapy for Chronic Myeloid Leukaemia with high counts
  • Palliative therapy in Acute Leukaemia
SCG
Hydroxychloroquine (Plaquenil™) Amber Rheumatoid Arthritis  
Infliximab (Remicade™) Red As per NICE guidelines April 02.
Recommended for the treatment of severe crohns disease where certain criteria are met.
 
Infliximab (Remicade™) Red As per NICE guidelines March 02.
Recommended in combination with methotrexate for rheumatoid arthritis in patients who meet certain criteria (including non response to at least 2 DMARDs).
 
Interferon alfa (Intron A™, Roferon A™, Viraferon™, Wellferon™) Red As per NICE guidelines Oct 00.
For use in combination with ribavirin in the management of moderate to severe hepatitis C.
For chronic myeloid leukaemia.
 
Intravenous / nebulised antibiotics Amber Cystic Fibrosis  
Intravenous Cancer Drugs Red Hospital Trusts are responsible for making the necessary arrangements for patients to receive intravenous treatment at home  
Intravenous immunoglobulins (Alphaglobin, Octagam, Sandoglobulin, Vigam) Red Hospital Trusts are responsible for making the necessary arrangements for patients to receive intravenous treatment at home  
Isotretinoin (Roaccutane™) Red Acne, side-effects require specialist supervision  
Lanreotide (Somatuline™) Amber Third-line treatment for acromegaly (second line if patient is unfit for surgery) Now found within the SCG with Octreotide
Leflunomide (Arava™) Amber For third-line use in patients with active rheumatoid arthritis when treatment with sulphasalazine and methotrexate is contra-indicated or has been found to be ineffective or not tolerated  
Lenograstim Amber Neutropenia  
Leuprorelin Amber Prostate Cancer Part of a shared SCG
Liraglutide Red Anti-diabetic agent (at 1.8mg dose). Also no longer joint formulary choice- see joint formulary here  
Lisdexamfetamine (Elvanse™) Child Amber ADHD refractory to methylphenidate and/or atomoxetine, under specialist supervision (Child) SCG
Lisdexamfetamine (Elvanse™) Adult Amber ADHD refractory to methylphenidate and/or atomoxetine, under specialist supervision (Adult) SCG
Lofexidine Amber Opioid withdrawal SCG
Lurasidone Amber Schizophrenia, commenced by secondary care after alternative anti-psychotics have been tried and found unsuitable. SCG
Melatonin Amber Sleep disturbances in neurological or behavioural problems. Circadin is preferred, and can be crushed to provide an immediate release characteristic (unlicensed). Patient leaflet SCG expired- under review
Melatonin Amber Sleep disorders in people with learning disabilities. Circadin is preferred, and can be crushed to provide an immediate release characteristic (unlicensed). Patient leaflet SCG expired- under review
Melatonin Red Sleep reversal associated with dementia (hospital only)  
Memantine Green Alzheimer’s Disease (now also includes the treating agitation in dementia pathway)

Downgraded Sep 2018

SCG (maybe useful for agitation advice)

Mercaptopurine Amber Treatment of Inflammatory Bowel Disease SCG
Methadone Amber

Opioid withdrawal
Not to be prescribed in primary care
Countywide LES

SCG
Methotrexate Amber

Covers use when providing tablets or injections for Juvenile Idiopathic Arthritis, Rheumatological conditions and Uveitis

(Reflects dosing orally or by subcutaneous injection).

NB since publication, the availability of sharps bins in different sizes has improved, and larger bins are now available on FP10 prescription. See p3 of our newsletter for further information.

SCG

GP Info (most relevant to adult patients using tablets)
Patient Info (most relevant to adult patients using tablets)

Methylphenidate Amber As per NICE guidelines Oct 00 it is recommended for use as part of a comprehensive treatment programme for children with ADHD  
Methylphenidate (Adult) Amber ADHD (Adult) under specialist supervision SCG
Metolazone Amber

Severe heart failure and diuretic resistance – it is significantly more potent than bendroflumethiazide and will cause profound diuresis in combination with loop diuretics. Careful monitoring is required to avoid electrolyte disturbance and dehydration. Sometimes prescribed as a twice or three times weekly dose.

Joint Formulary
Midodrine Amber Hypotension. Secondary care initiated. SCG
Mucositis Oral Gels Amber Should only be used on NHS under recommendation of a specialist. Used to treat the discomfort of oral mucositis during or following radiotherapy or chemotherapy for the oral cavity. Two products available, either Gelclair oral gel (TM) or Episil oral spray (TM)

Gelclair SCG

Episil SCG

Mycophenolate Mofetil (CellCept™) Amber Prophylaxis of rejection in transplant  
Mycophenolate Mofetil (generic) Amber Severe Uveitis SCG
N-Acetylcysteine Red For prescribing by Respiratory specialists only  
Naloxegol Green Resistant Constipation when use strictly under the G-Care Pathway G-Care Link
Naltrexone (Nalorex™) Amber Prevention of relapse in detoxified opium dependency, and also Alcohol Dependence SCG
Octreotide (Sandostatin LAR™) Amber Acromegaly and the relief of symptoms associated with neuroendocrine (particularly carcinoid) tumours. Second line treatment for patients intolerant of lanreotide (Somatuline Autogel) Now found within the SCG with Lanreotide
Omalizumab (Xolair™) Red    
Penicillamine (Distamine™) Amber Second-line choice in rheumatoid arthritis.  
Perampanel (Fycompa™) Amber Seizure treatment. Specialist use. SCG
Pergolide (Celance™) Amber Parkinson’s Disease  
Phenelzine Red    
Pirfenidone Red Idiopathic pulmonary fibrosis  
Pramipexole (Mirapexin™) Amber Parkinson’s Disease  
Prucalopride Green Constipation in line with the G-Care pathway G-Care link
Ranolazine (Ranexa™) Amber Anti-Anginal drug- specialist initiation only SCG
Ribavirin (Rebetol™) Red

As per NICE guidelines Oct 00.For use in combination with interferon alfa in the management of moderate to severe hepatitis C.

 
Rifaximin Amber

Gastroenterology / Hepatology Consultant initiation. Hepatic encephalopathy (not associated with gastrointestinal bleeding, medication, or neurological injury) that has not responded to optimal lactulose therapy. If shows continued benefit after 6 months of consultant prescribing, can be considered for shared care.

SCG
Riluzole(Rilutek™) Amber As per NICE guidelines Jan 01.Recommended for use in the  amyotrophic lateral sclerosis form of Motor Neurone Disease  
Rivastigmine Patches (PS prescribe as Alzest where possible) Amber

Mild to Moderately Severe Alzheimers dementia for NEW patients only, in line with NICE TAG.

SCG
Rivastigmine Capsules Green Changed to green January 2019  
Roflumilast (Daxas™) Amber COPD patients with chronic bronchitis SCG being develoepd
Ropinirole Amber Parkinson’s Disease. no SCG currently. Formulary product choice for MR is Ipinnia™ 
Sacubitril / Valsartan (Entresto™) Amber Symptomatic chronic heart failure with reduced ejection fraction SCG
Sativex™ (Cannabinoids) Red Multiple Sclerosis- Specialist use only  
Sevelamer (Renagel™) Amber For hyperphosphataemia in haemodialysis patients  
Sodium Clodronate (Bonefos™, Loron™) Amber Osteolytic lesions, hypercalcaemia and bone pain with bone metastases with breast cancer or myeloma.  
Somatropin Amber See Growth Hormone  
Strontium Ranelate Amber Treatment of severe Osteoporosis, if all other treatments are not suitable SCG
Sulfasalazine Amber Rheumatoid Arthritis (and other inflammatory arthritis) SCG
Tacrolimus (Adoport™ and Prograf™) Amber Prevention of rejection in liver and kidney transplant. SCG
Tacrolimus (Adoport™) Amber Severe Uveitis SCG
Tapentadol Red Use within Pain clinic only Link to Criteria Based Access Policy which can also be found within the Joint Formulary
Teriparatide (Forsteo™) Red Osteoporosis. Now supplied via GHT Homecare route.  
Tizanidine (Zanaflex™) Amber Spasticity with Multiple Sclerosis or spinal cord injury or disease.  
Tolvaptan Red Posterior Pituitary hormone  
Totalparenteral nutrition (TPN) Red Hospital Trusts are responsible for making the necessary arrangements for TPN.  
Tretinoin Cream (Pigmanorm cream (a special order)) Red See joint formulary skin chapter   

Triptorelin (De-capeptyl SR™)

Amber Endometriosis. No, as not anticipated to be used

Triptorelin (De-capeptyl SR™)

Amber Prostate cancer. Part of a shared SCG
Vortioxetine Amber Third-line as an option for treating major depressive episodes in adults whose condition has responded inadequately to 2 antidepressants within the current episode, as per NICE TA367 Specialist Initiated