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BNSSG Adult Joint Formulary

4.3 Movement disorders

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Last edited: 25-07-2024

4.3.1 Dystonias and other involuntary movements

First line drugs

Second line drugs

Specialist drugs

Secondary care drugs

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)

As a second line option if Entacapone is ineffective or not tolerated

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

Foslevodopa–foscarbidopa (TLS Red)

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

Dopamine Receptor Agonists

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

Also Formulary for the treatment of fatigue in multiple sclerosis (Unlicensed)

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)

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

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