4.3 Movement disorders

4.3.1 Dystonias and other involuntary movements

CNS Stimulants

Specific indication (TLS Blue):

Piracetam

• Myoclonus

Propranolol

• Essential tremor

Primidone

• Essential tremor

Monoamine Depleting Drugs

Tetrabenazine (TLS Amber Specialist Initiated)

• Huntington's chorea

Neuroprotective Agents

Riluzole (TLS Amber 3 months) (SCP click here)

• For Motor Neurone Disease as per NICE TA20
• Riluzole liquid available for those patients with MND patients where all of the following criteria are met:
  • Those with Motor Neurone Disease who meet the criteria as described in NICE Technology Appraisal 20
  • Those with dysphagia having been assessed by SLT as needing a diet with stage II thickened fluids. This is in line with product characteristics.
  • For those where crushing tablets is not appropriate and use of this licensed liquid would be preferable to prevent PEG/RIG complications or where a PEG/RIG has been declined. 
  • Riluzole liquid will be initiated by a consultant, registrar or specialist nurse who is involved in the care of patients with Motor Neurone Disease 

Neurotoxins (Botulinum Toxins)

Botulinum toxin type A (Botox^®, Dysport^®, Xeomin^®) (TLS Red)

• Treatment of focal spasticity as per SPC. See Pathway Document.
• Symptomatic relief of blepharospasm, hemifacial spasm and idiopathic cervical dystonia (spasmodic torticollis)
• Botox^® for use in migraine (chronic) according to NICE guidance TA260

Botulinum toxin type B (Neurobloc^®) (TLS Red)

Note:

• Botulinum toxin preparations are not directly interchangeable
• Botulinum toxin is not approved for treatment for hyperhidrosis. For this indication exceptional funding should be sought on a case by case basis
• To minimise the risk of errors botulinum toxin should be prescribed by brand name
• Botulinum toxin type B is reserved for use in patients that have become tolerant to botulinum toxin type A

4.3.2 Parkinson's disease

Antimuscarinics

Specific indication: (TLS Blue)

Benztropine

• tablets are available on a named patient basis from IDIS

Orphenadrine

Procyclidine

Trihexyphenidyl

Catechol-O-Methyltransferase Inhibitors

Entacapone (TLS Amber Specialist Recommended)

Levodopa / Carbidopa / Entacapone (TLS Amber Specialist Recommended)

• Brands include Stalevo^®, Sastravi^® and Stanek^®

Opicapone (TLS Amber Specialist Initiated)

• Second line to entacapone if it is ineffective, not tolerated or not suitable

Tolcapone (TLS Red)

• In combination with levodopa/benserazide or levodopa/carbidopa for use in patients with levodopa-responsive idiopathic Parkinson's disease and motor fluctuations who have failed to respond to or are intolerant of other catechol-O-methyltransferase (COMT) inhibitors (i.e. entacapone) (TLS Red)

Dopamine Precursors

Recommended: (TLS Green)

Co-beneldopa (Madopar^®)

Co-careldopa (Sinemet^®)

• For untreated patients starting medication a dopamine agonist is usually recommended as first-line treatment - seek the advice of a specialist.

Co-careldopa + levodopa intestinal gel (Duodopa^®) (TLS Red)

See NHS England Clinical Commissioning Policy: Levodopa-Carbidopa Intestinal Gel (LCIG) D04/P/e and NHSE SSC 2684 (Update to include Levodopa-Carbidopa-Entacapone Intestinal Gel (LECIG))

Foslevodopa–foscarbidopa (TLS Red)

• NICE TA934 Foslevodopa–foscarbidopa for treating advanced Parkinson’s with motor symptoms

Dopamine Receptor Agonists

Amantadine (TLS Amber Specialist Initiated)

Apomorphine (TLS Red)

Bromocriptine (TLS Blue)

• Established patients only

Cabergoline (TLS Amber Specialist Initiated)

• Existing patients only

Pramipexole (including modified-release) (TLS Amber Specialist Initiated)  

• Parkinson's disease
• Annual vision test should be completed by Optometrist

Pramipexole (TLS Green)

• Restless Legs Syndrome

Ropinirole (including modified-release & starter pack) (TLS Amber Specialist Initiated) 

• Parkinson's disease

Ropinirole (TLS Blue)

• Restless Legs Syndrome

Rotigotine (TLS Amber Specialist Recommended)

• Can be started on advice of specialist - specialist may be Elderly Care/Neurology Consultant or Parkinson's' Disease Nurse Specialist. First prescription can come from GP.

Monoamine-oxidase B Inhibitors

Rasagiline (TLS Amber Specialist Initiated) 

• Initiation by Consultant in Neurology and Care of the Elderly only

Selegiline (TLS Amber Specialist Initiated) 

Safinamide (TLS Amber 3 months) (SCP click here)

4.3.3 Other

Methotrexate (TLS Amber 3 months) (SCP click here)

• For a variety of neurological conditions such as Myasthenia Gravis and CIDP (unlicensed)

Mexiletine (NaMuscla^®) (TLS Red)

• NICE TA748 Mexiletine for treating the symptoms of myotonia in non-dystrophic myotonic disorders

Infliximab (intravenous & subcutaneous) (TLS Red)

• Infliximab for Refractory or Progressive Neurosarcoidosis as per NHSE Clinical Commissioning Policy

Amantadine (TLS Amber Specialist Initiated)

• For the treatment of fatigue in multiple sclerosis (Unlicensed)

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