Riluzole

• Tablets 50mg (£337.43 = 56 tablets)
• Oral suspension sugar free 25mg/5ml (£100.00 = 300ml bottle)

Indications

• To extend life in patients with amyotrophic lateral sclerosis, initiated by a neurological specialist with expertise in the management of motor neurone disease

Dose

• 50mg twice daily

Notes

1. Refer to Devon wide shared care prescribing guideline.
2. Due to its higher acquisition cost, oral suspension should be reserved for patients with swallowing difficulties or requiring administration via enteral feeding tube.
3. NICE TA20: Riluzole (Rilutek) is recommended for the treatment of individuals with the amyotrophic lateral sclerosis (ALS) form of Motor Neurone Disease (MND) (January 2001).

Tetrabenazine

• Tablets 25mg (£152.08 = 112 tablets)

Indications and dose

• Movement disorders due to Huntington's chorea, hemiballismus, senile chorea, and related neurological conditions, initially 25mg 3 times daily, increased by 25mg every 3–4 days as tolerated to maximum 200mg daily
• Moderate to severe tardive dyskinesia, initially 12.5mg daily, gradually increased according to response

Notes

1. Tetrabenazine has a useful action for movement disorders, only in the latter stage of the disease.
2. Tetrabenazine may cause depression and excessive sedation. It may also precipitate extrapyramidal side effects. It is therefore important to initiate treatment on the minimum effective dose and increase dosage no more frequently than on a weekly basis.

Botulinum Toxin Type A

• Botox powder for solution for injection 50unit, 100unit, 200unit vials
• Dysport powder for solution for injection 300unit, 500unit vials
• Xeomin powder for solution for injection 50unit, 100unit, 200unit vials

Indications

• Blepharospasm
• Chronic anal fissure
• Focal hyperhidrosis
• Hemifacial spasm
• Urinary incontinence due to detrusor overactivity
• Prophylaxis of headaches in adults with chronic migraine
• Chronic sialorrhoea caused by neurological conditions in adults

Notes

1. Prescribe by brand. Botulinum toxin type A units are not interchangeable from one product to another, please consult Summary of Product Characteristics (SPCs) and BNF for details of cautions, specific side effects, contraindications, and differences in licensed indications.
2. Botulinum toxin type A should only be administered by appropriately trained specialists.
3. The routine commissioning of botulinum toxin type A injection is accepted in Devon for the management of blepharospasm only when specified criteria are met (see Commissioning Policy for more details).
4. The routine commissioning of botulinum toxin type A injection is accepted in Devon for the treatment of chronic anal fissure in adults following failure of conservative management and topical treatments (to include GTN and diltiazem) and where surgery is considered the only other option (see Commissioning Policy for more details).
5. The routine commissioning of botulinum toxin type A injection is accepted in Devon for the management of focal hyperhidrosis only when specified criteria are met (see Commissioning Policy for more details).
6. The routine commissioning of botulinum toxin A is accepted in Devon for the management of hemifacial spasm when the condition causes the patient to be affected to at least a moderate degree by one or more of the criteria specified in the policy (see Commissioning Policy for more details).
7. The routine commissioning of bladder wall botulinum toxin injection for use in adult male and female patients with urinary incontinence due to detrusor overactivity is accepted in Devon, when used in accordance with the relevant NICE clinical guideline (see Commissioning Policy for more details).
8. NICE TA260: Botulinum toxin type A (Botox) is recommended as an option for the prophylaxis of headaches in adults with chronic migraine (defined as headaches on at least 15 days per month of which at least 8 days are with migraine) (June 2012):
   1. that has not responded to at least three prior pharmacological prophylaxis therapies and
   2. whose condition is appropriately managed for medication overuse.
9. NICE TA605: Botulinum neurotoxin type A (Xeomin) is recommended as an option for treating chronic sialorrhoea caused by neurological conditions in adults (October 2019).
10. Botulinum toxin type A is included in both NICE CG145: Spasticity in under 19s (July 2012) and NICE CG148: Urinary incontinence in neurological disease (August 2012).

Mexiletine

• Namuscla capsules 167mg
• Capsules 50mg, 100mg (unlicensed special)

Indication

• Non-dystrophic myotonic disorders (NHS England commissioned)

Notes

1. Mexiletine hydrochloride 100mg is approximately equivalent to mexiletine 83.1mg
   1. Namuscla contains mexiletine hydrochloride; doses are expressed as mexiletine base.
2. NICE TA748: Mexiletine (Namuscla) is recommended, within its marketing authorisation, as an option for treating the symptoms of myotonia in adults with non-dystrophic myotonic disorders (December 2021)
   1. It is recommended only if the company provides mexiletine according to the commercial arrangement.