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Nottingham Traffic Lights System of Prescribing

DEVELOPMENT

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

Source: http://www.kegworthdb.co.uk/Data/Guidelines/DrugMonitor/TrafficLight/traffic.pdf

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