This document is now maintained and updated by the Nottingham Area Prescribing
Committee (APC). The APC includes representatives from all three hospital trusts (Chair and Secretary of Drug and Therapeutics Committee), all of the Nottingham PCTs (GP prescribing
lead, prescribing advisers, nurse lead), LMC and LPC. OBJECTIVES
• The purpose of this document is to clarify the clinical and prescribing responsibility for
• Particular attention has been given where new drugs are being introduced or where
existing drugs are being used for a new clinical indication.
• Drugs will also be considered which would normally have been prescribed in secondary
care, but due to changing clinical responsibilities may now need to be considered for use
• In all classifications priority is given to the patients clinical safety and where their care is
most appropriately managed. Once clinical safety has been assured, patient convenience is considered.
The list is intended as a recommendation for prescribing only. It is divided into five
categories: Red; Amber 1; Amber 2; Green; and Grey. For your information we have also included a section on drugs of limited clinical value.
As new drugs are introduced and reviewed by the APC, they will be added to the Traffic Lights classification.
CLASSIFICATION
RED DRUGS – these are considered to be suitable for prescribing within hospital only • Drugs that have been omitted from this list are those that would clearly not be used
outside of a hospital setting (for example: anaesthetics, muscle relaxants, pulmonary surfactants and intravenous chemotherapy agents).
• Red drugs included on the list are those where specialist skills, training or expertise are
needed to handle such drugs safely, or where the need for specialist monitoring means that a general practitioner cannot meaningfully take part in the prescribing process.
• It is important to remember that the legal responsibility for a prescription lies with the
doctor who actually signs it; therefore the signing doctor must have the necessary expertise to take on the clinical responsibility associated with the prescription.
• RED drugs may be prescribed by general practitioners in exceptional circumstances, but
they are strongly advised to consider whether they are able to take on the clinical and
• Drugs that are classified as ‘Red’ within the traffic lights scheme will not normally be
eligible for contingency fund reimbursement.
• Criteria for classification of a drug as RED:
! Certain new drugs and new indications for old drugs where there is at present
no experience of use in general practice.
! Where the patient is under the care of a specialist and attends the hospital
frequently for treatment, monitoring and investigations.
! The drug is unlicensed or being used outside its licensed indications (exemption
to this are drugs for which a shared care protocol is available).
! Clinical trial drugs which are being used in secondary care.
Nottingham 'Traffic Lights' Prescribing System RED – for prescribing within hospital only AMBER 1 – governed by a Nottingham APC approved Shared Care Protocol AMBER 2 – no formal Shared Care Protocol, but should usually be recommended by a secondary care specialist before prescribing is initiated in primary care. The Trust D&T Committee will also have approved them for use GREEN – are in common use and can be prescribed within primary care with no special restrictions GREY – APC feels unable at present to commend for use or have yet to be considered by a Trust D&T Committee and are therefore not recommended for use within Nottingham Classification Comments Category
Follow osteoporosis guidelines (Fosamax and Fosamax Once Weekly)
Caverject, MUSE follow DoH recommendations
NICE does not recommend use for the treatment of influenza
Treatment of Parkinsons disease, by specialist clinic
Rosiglitazone & metformin combination tablet
Suppression of organ transplant rejection
Nottingham 'Traffic Lights' Prescribing System RED – for prescribing within hospital only AMBER 1 – governed by a Nottingham APC approved Shared Care Protocol AMBER 2 – no formal Shared Care Protocol, but should usually be recommended by a secondary care specialist before prescribing is initiated in primary care. The Trust D&T Committee will also have approved them for use GREEN – are in common use and can be prescribed within primary care with no special restrictions GREY – APC feels unable at present to commend for use or have yet to be considered by a Trust D&T Committee and are therefore not recommended for use within Nottingham Classification Comments Category
unlicensed Approved for use in Dermatolgy & Respiratory
Use in heart failure usually under hospital supervision
Follow ‘Treatment of Drug Misusers in Primary Care’ guidelines
6.7.2/8.3.4 Treatment of infertility/Treatment Prostate Ca
4.9.1/6.7 Hyperprolactinaemia, Parkinsons disease
Treatment of epilepsy & prophylaxis of bipolar disorder
Use in heart failure usually under hospital supervision
Nottingham 'Traffic Lights' Prescribing System RED – for prescribing within hospital only AMBER 1 – governed by a Nottingham APC approved Shared Care Protocol AMBER 2 – no formal Shared Care Protocol, but should usually be recommended by a secondary care specialist before prescribing is initiated in primary care. The Trust D&T Committee will also have approved them for use GREEN – are in common use and can be prescribed within primary care with no special restrictions GREY – APC feels unable at present to commend for use or have yet to be considered by a Trust D&T Committee and are therefore not recommended for use within Nottingham Classification Comments Category
Suppression of organ transplant rejection
BNF considers less suitable for prescribing
Nottingham 'Traffic Lights' Prescribing System RED – for prescribing within hospital only AMBER 1 – governed by a Nottingham APC approved Shared Care Protocol AMBER 2 – no formal Shared Care Protocol, but should usually be recommended by a secondary care specialist before prescribing is initiated in primary care. The Trust D&T Committee will also have approved them for use GREEN – are in common use and can be prescribed within primary care with no special restrictions GREY – APC feels unable at present to commend for use or have yet to be considered by a Trust D&T Committee and are therefore not recommended for use within Nottingham Classification Comments Category
Reserved for patients that satisfy CASH criteria
On recommendation from specialist clinic only
Mild to moderate pain including dysmenorroea
Hypercalcaemia, bone pain, Paget’s disease
On recommendation from specialist clinic only
Paracetamol plus Domperidone combination product
Combination products not generally recommended
No advantage over other triptans apparent
Nottingham 'Traffic Lights' Prescribing System RED – for prescribing within hospital only AMBER 1 – governed by a Nottingham APC approved Shared Care Protocol AMBER 2 – no formal Shared Care Protocol, but should usually be recommended by a secondary care specialist before prescribing is initiated in primary care. The Trust D&T Committee will also have approved them for use GREEN – are in common use and can be prescribed within primary care with no special restrictions GREY – APC feels unable at present to commend for use or have yet to be considered by a Trust D&T Committee and are therefore not recommended for use within Nottingham Classification Comments Category
Approved only for 8 week course for severe oesophagitis
Reserved for patients that satisfy CASH criteria
Advanced breast cancer in post menopausal women
Nottingham 'Traffic Lights' Prescribing System RED – for prescribing within hospital only AMBER 1 – governed by a Nottingham APC approved Shared Care Protocol AMBER 2 – no formal Shared Care Protocol, but should usually be recommended by a secondary care specialist before prescribing is initiated in primary care. The Trust D&T Committee will also have approved them for use GREEN – are in common use and can be prescribed within primary care with no special restrictions GREY – APC feels unable at present to commend for use or have yet to be considered by a Trust D&T Committee and are therefore not recommended for use within Nottingham Classification Comments Category
Approved for use in advanced breast cancer & prostate cancer
Approved for use in proven antibody deficiency
BNF recommends less suitable for prescribing
On recommendation from specialist clinic only, patients should be stable before treatment continued by GP
Nottingham 'Traffic Lights' Prescribing System RED – for prescribing within hospital only AMBER 1 – governed by a Nottingham APC approved Shared Care Protocol AMBER 2 – no formal Shared Care Protocol, but should usually be recommended by a secondary care specialist before prescribing is initiated in primary care. The Trust D&T Committee will also have approved them for use GREEN – are in common use and can be prescribed within primary care with no special restrictions GREY – APC feels unable at present to commend for use or have yet to be considered by a Trust D&T Committee and are therefore not recommended for use within Nottingham Classification Comments Category
Chronic Hepatitis B or HIV specialist clinic only
Mania and manic depression (awaiting revision of shared care protocol)
Follow ‘Treatment of Drug Misusers in Primary Care’ guidelines
No current advantage over other NSAIDs apparent
Nottingham 'Traffic Lights' Prescribing System RED – for prescribing within hospital only AMBER 1 – governed by a Nottingham APC approved Shared Care Protocol AMBER 2 – no formal Shared Care Protocol, but should usually be recommended by a secondary care specialist before prescribing is initiated in primary care. The Trust D&T Committee will also have approved them for use GREEN – are in common use and can be prescribed within primary care with no special restrictions GREY – APC feels unable at present to commend for use or have yet to be considered by a Trust D&T Committee and are therefore not recommended for use within Nottingham Classification Comments Category
Proguanil 100mg + atovaquone 250mg, in conjunction with DoH advice that malaria prophylaxis should be prescribed on private prescription
Unlicensed – secondary care specialist only
On recommendation from specialist clinic only
BNF recommends less suitable for prescribing
As antimetabolite in treatment of cancers
Nottingham 'Traffic Lights' Prescribing System RED – for prescribing within hospital only AMBER 1 – governed by a Nottingham APC approved Shared Care Protocol AMBER 2 – no formal Shared Care Protocol, but should usually be recommended by a secondary care specialist before prescribing is initiated in primary care. The Trust D&T Committee will also have approved them for use GREEN – are in common use and can be prescribed within primary care with no special restrictions GREY – APC feels unable at present to commend for use or have yet to be considered by a Trust D&T Committee and are therefore not recommended for use within Nottingham Classification Comments Category
Named patient basis for ventricular arrhythmias
BNF considers less suitable for prescribing
BNF considers less suitable for prescribing
On recommendation from specialist clinic only
Schizophrenia and related disorders and treatment of mania
BNF considers less suitable for prescribing
Nottingham 'Traffic Lights' Prescribing System RED – for prescribing within hospital only AMBER 1 – governed by a Nottingham APC approved Shared Care Protocol AMBER 2 – no formal Shared Care Protocol, but should usually be recommended by a secondary care specialist before prescribing is initiated in primary care. The Trust D&T Committee will also have approved them for use GREEN – are in common use and can be prescribed within primary care with no special restrictions GREY – APC feels unable at present to commend for use or have yet to be considered by a Trust D&T Committee and are therefore not recommended for use within Nottingham Classification Comments Category
Treatment of PCP HIV specialist clinic only
BNF considers less suitable for prescribing
BNF considers less suitable for prescribing
Schizophrenia and related disorders and treatment of mania
Nottingham 'Traffic Lights' Prescribing System RED – for prescribing within hospital only AMBER 1 – governed by a Nottingham APC approved Shared Care Protocol AMBER 2 – no formal Shared Care Protocol, but should usually be recommended by a secondary care specialist before prescribing is initiated in primary care. The Trust D&T Committee will also have approved them for use GREEN – are in common use and can be prescribed within primary care with no special restrictions GREY – APC feels unable at present to commend for use or have yet to be considered by a Trust D&T Committee and are therefore not recommended for use within Nottingham Classification Comments Category
Approved for use from specialist neurology clinic
On recommendation from lipid clinic, or 3rd line initiation in primary care
BNF considers less suitable for prescribing
Named Patient only via Nottinghamshire Healthcare NHS Trust
Hyperphosphataemia - for renal patients only
BNF recommends less suitable for prescribing
Synthetic human growth hormone for use in children
By specialist clinic only for treatment of adults
Levodopa, carbidopa, entacapone combination tablet
Nottingham 'Traffic Lights' Prescribing System RED – for prescribing within hospital only AMBER 1 – governed by a Nottingham APC approved Shared Care Protocol AMBER 2 – no formal Shared Care Protocol, but should usually be recommended by a secondary care specialist before prescribing is initiated in primary care. The Trust D&T Committee will also have approved them for use GREEN – are in common use and can be prescribed within primary care with no special restrictions GREY – APC feels unable at present to commend for use or have yet to be considered by a Trust D&T Committee and are therefore not recommended for use within Nottingham Classification Comments Category
Verapamil 180mg with trandolapril 2mg in MR capsule
Second line treatment of malignant glioma
2nd line treatment of schizophrenia under specialist supervision only
Urinary frequency, urgency and incontinence
Nottingham 'Traffic Lights' Prescribing System RED – for prescribing within hospital only AMBER 1 – governed by a Nottingham APC approved Shared Care Protocol AMBER 2 – no formal Shared Care Protocol, but should usually be recommended by a secondary care specialist before prescribing is initiated in primary care. The Trust D&T Committee will also have approved them for use GREEN – are in common use and can be prescribed within primary care with no special restrictions GREY – APC feels unable at present to commend for use or have yet to be considered by a Trust D&T Committee and are therefore not recommended for use within Nottingham Classification Comments Category
Advanced prostate cancer and endometriosis
Post-op and chemo nausea and vomiting agent
Dissolution of gallstones/ Primary biliary
Maybe effective in depressed patients who have not responded to an SSRI and/or TCAD
Third line use only in women intolerant of a 2nd and 3rd generation pill Nottingham 'Traffic Lights' Prescribing System RED – for prescribing within hospital only AMBER 1 – governed by a Nottingham APC approved Shared Care Protocol AMBER 2 – no formal Shared Care Protocol, but should usually be recommended by a secondary care specialist before prescribing is initiated in primary care. The Trust D&T Committee will also have approved them for use GREEN – are in common use and can be prescribed within primary care with no special restrictions GREY – APC feels unable at present to commend for use or have yet to be considered by a Trust D&T Committee and are therefore not recommended for use within Nottingham Classification Comments Category
** For pts already receiving prescriptions in primary care, continue. Pts from April 2000 should receive their medication from hospital. # May be appropriate for specialist GP to initiate or any GP to prescribe whilst awaiting hospital referral
AMBER 1 DRUGS – are governed by a Nottingham APC approved Shared Care Protocol (See
Guidelines for Shared Care Protocols) • A shared care protocol aims to ensure that a patient receives the best possible care and
to allow a seamless transfer of treatment between secondary and primary care.
• It should be used in situations where specialised prescribing takes place, there may be
limited experience of the drug in primary care, or it requires regular monitoring.
• A secondary care specialist should initiate treatment and clinical responsibility should be
transferred to primary care only when the patient's clinical condition is stable or
• It is the responsibility of the secondary care specialists to provide the GP with a copy of
the appropriate shared care protocol for each patient.
• As with RED drugs a GP may initiate the prescribing of an AMBER 1 drug, but are strongly
advised to carefully consider the issue of clinical and legal responsibility before so doing.
• Despite the existence of a shared care protocol, an individual practitioner may feel that
under certain circumstances it would be inappropriate to take clinical and legal prescribing responsibilities for an individual drug. General practitioners are under no
obligation to become involved in shared care if they consider it to be inappropriate.
AMBER 2 DRUGS – have no formal shared care protocol, but should usually be recommended by a secondary care specialist before prescribing is initiated in primary care. They will also have been approved for use by a Trust D&T Committee
• Brief information about the drug (such as a Summary of Product Characteristics), with
details about the cost of the drug should be sent to the GP with a request to prescribe, to
enable them to make an informed decision.
• Within the amber 2 list some classes of drugs have been noted as being appropriate for a
specialist GP to initiate or for any GP to prescribe whilst awaiting hospital referral. These
are drugs such as anti-epileptics or insulins and been annotated with comments.
GREEN DRUGS – are in common use and can be prescribed within primary care with no
special restrictions • GPs will take full clinical responsibility for prescribing green drugs.
• We have only listed those drugs where there has been some debate about their
classification or new drugs where it was felt that guidance would be appropriate.
• It was felt unnecessary to list every individual drug within a commonly used therapeutic
class (eg each ACE inhibitor, beta blocker etc).
• If you have any doubts about whether a drug falls within the green category then please
clarify this with one of the prescribing advisers.
GREY DRUGS – are those that the APC feels unable at present to commend for use or have
yet to be considered by a Trust D&T Committee • Some of these will be more expensive variants of products already in use and which offer
• In the event that a Trust Drug & Therapeutic Committee has yet to receive a request to
use a new drug (or existing drug in a new indication) then the drug will automatically be classified as Grey 1 to avoid primary care being asked to prescribe as a means to bypass
• This may include drugs for which more information is sought before classifying under the
Traffic Lights system or upon which NICE guidance is awaited.
Nottingham Prescribing Team, March 2004, Date of review December 2004
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