These drugs are for use in patients not responding adequately to first-line treatments.
NETAG approved for the treatment of depression only following an adequate trial of at least three alternative antidepressant drugs at maximally tolerated doses (as described by NICE and as stated in the BNF).
Prescribing and monitoring should be initiated by specialist mental health physicians. After a minimum of 12 weeks, prescribing may be transferred to primary care.
For use on advice of psychiatrists as a third-line antidepressant - but only for use in patients who cannot tolerate high-dose (>150mg daily) venlafaxine, or patients with hypertension, established CHD or other cardiovascular risk factors which would make the use of high-dose venlafaxine undesirable. Also approved for third-line use (after drugs such as the tricyclic antidepressants and gabapentin) in the treatment of neuropathic pain on the advice of pain specialists.
Orodispersible mirtazapine tablets should only be prescribed for use when other formulations are unsuitable (more expensive).
Not licensed in the elderly
For patients on doses of 300mg/day or more.
Patients who are deemed stable on doses of up to 225mg daily of MR venlafaxine should be switched to the equivalent dose of immediate release venlafaxine.
MR tablets are only to be used in patients currently prescribed doses of 300mg and over and for whom there is no suitable alternative, those who have experienced discontinuation reactions (at any dose), and for patients who need to take the once daily formulation in order to facilitate care visits.
Drugs for hospital use only. The responsibility for initiation and monitoring treatment should rest with an appropriate hospital clinician and the drug should be supplied through the hospital throughout the duration of treatment.
In some very exceptional circumstances (e.g. due to distance from the hospital, storage, supply or mobility/transport problems) it may be appropriate for the GP to be asked to prescribe a Red drug. This should be negotiated on an individual patient basis and should only be done with the GP’s prior informed agreement where the roles of the GP and hospital services are clearly defined and agreed. The GP should not feel under pressure to prescribe in these circumstances.
Drugs initiated by hospital specialist, but where continuing treatment by GPs may be appropriate under a shared care arrangement.
The specialist should send the GP a copy of the shared care agreement to sign. The GP should sign the shared care agreement, or indicate they do not want to be part of such an agreement, and return a copy back to the specialist. Shared care guidelines are available or are being developed for most of the drugs listed as Amber.
If no shared care guideline is available, the hospital specialist should provide the patient’s GP with sufficient information and support to allow treatment to be continued and managed safely in primary care.
Drugs normally recommended or initiated by hospital specialist, but where the provision of an information leaflet may be appropriate to facilitate continuing treatment by GPs. Many of these information sheets are in the process of development.
Drugs where prescribing by GPs is appropriate. Drugs not classified as Red, Amber or Green Plus (formerly blue in North of Tyne) are generally classified as ‘Green’ by default. The Green drugs listed here include those products normally initiated by hospital specialists where there was a need for discussion and debate as to the category in which they should be placed.