First Line

• Preferred treatment option, either within a treatment pathway or drug class.
• In some sections a first line option is not given. This is done to draw attention to cases where either pharmacotherapy is seen as second line to some other form of therapy or if the use of a drug from a different pharmacological class is seen as the first line treatment.

Second Line

• Alternative treatment option generally used later down the treatment pathway or if the first line drugs are inappropriate or ineffective.

Specialist

• Treatments where specialist input is required for general use.
• A specialist is not exclusively a consultant, rather someone with recognised skills, for example a GP with a specialist interest, specialist nurse, or microbiology culture and sensitivity report.
• Examples of specialist input:
  • A specialist initiates treatment.
  • A specialist provides advice for a specific patient.
  • Appropriate prescribing is in accordance with specific guidelines developed either included or referenced in the formulary
• GMC prescribing guidance on responsibilities for continuing care or treatment: www.gmc-uk.org/guidance/ethical_guidance

Hospital only

• Not considered suitable for prescribing in general practice.
• The prescribing responsibility for these medicines should normally remain with the consultant or specialist clinician. These drugs should not be initiated or prescribed in general practice.
• It is recommended that the supply of hospital only drugs should be organised via the hospital pharmacy.
• GP practice prescribing systems
  • It is important that GPs are informed of the supply and use of these drugs and that they are recorded in individual patient records on the GP prescribing system and added to the patient's medication list as a hospital drug
  • Ensure that the start date is recorded, the drug appears on the repeat list, and interactions/adverse effects are flagged up by the computer when other drugs are supplied
  • Systems should be in place to ensure no hospital drugs will be issued accidentally by a GP practice if a prescription is generated for the patient in error
  • Information from secondary care should be used to keep the records updated. For example where the drug is no longer required or changed. This will reduce the potential risks associated with inaccurate records
  • Please follow the advice here for adding medicines prescribed by outside sources to GP computer systems.
• GPs should contact their local Medicines Optimisation Pharmacist for advice and support on the use of hospital only drugs.