Specials
On this page you will find information, links and resources around prescribing special order medicines.
Prescribing
Medicines are not always available in formulations that are suitable for patients with swallowing difficulties or for patients with enteral feeding tubes. The alteration of medication formulations may therefore be necessary, such as crushing tablets or prescribing a ‘special’ liquid formulation.
Our Specials Guidance provides information on available licensed formulations, suggests options for treatment within a drug class, or advises where tablets may be crushed, or capsules opened.
Whilst there is some information with regard to administration via feeding tubes, prescribers are advised to contact the ICB Medicines Management team for full details if administration via a feeding tube is necessary.
Licensed or Unlicensed?
Any alteration in the formulation of a medicine means that the medicine is used outside its product licence. The manufacturer of the product is no longer responsible for any adverse event or treatment failure. Instead, professionals responsible for prescribing, supplying and administering the drugs, become liable for any adverse event that the patient may experience.
Medications should only be given in an unlicensed manner when a licensed alternative is not available. Licensed routes of administration should be sought first.
When prescribing alternatives (licensed/unlicensed) it is important to consider:
- Dose adjustments that need to be made with alternative liquid/ injection preparations.
- Full dose directions need to be included on the prescription (if applicable) g. ’take one tablet, disperse in water and take once in the morning’.
Somerset Specials Guidance
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Disclaimer: This document is intended as a guide only - it is subject to clinical interpretation and judgement on an individual basis and the specific needs and best interests of the individual patient should be considered. It contains a list of commonly prescribed medicines and alternative methods of administration for patients with swallowing difficulties, feeding tubes or for patients prescribed unlicensed ‘specials’ medication. It considers alternative medicines, formulations, cost, and licensing. The list of medicines is not exhaustive. Prices of medicines may fluctuate.
It is advised that while every effort will be made to keep the information in this document current and correct, errors may have occurred and data for individual drugs may have changed. Where there is any doubt or if further information is needed – prescribers should check the manufacturers’ recommendations, published literature or other specialist sources e.g. NEWT Guidelines, Handbook of Drug Administration via Enteral Feeding Tubes.
Specialist Pharmacy Service Useful Links
The Specialist Pharmacy Service (SPS) has produced a number of useful resources on using medicines safely and effectively in patients with swallowing difficulties
All SPS advice on using medicines safely and effectively in patients with swallowing difficulties:
Specialist Pharmacy Service: Swallowing difficulties
Some adults cannot safely swallow tablets or capsules. A stepwise process for choosing suitable formulations, including crushing tablets, is described.
Specialist Pharmacy Service: Choosing formulations of medicines for adults with swallowing difficulties
How to disperse tablets in water, crush tablets and open capsules safely for adults with swallowing difficulties.
Specialist Pharmacy Service: Preparing medicines for administration to adults with swallowing difficulties
A knowledge of the different types of enteral feeding tube is important when recommending options for medicines administration
Specialist Pharmacy Service: How enteral feeding tubes affect medicines
Tips for giving crushed tablets or other medicines with food or drink, for adults with swallowing difficulties
Specialist Pharmacy Service: Giving medicines safely with food or thickened fluid
Dermatology Special Medicines
Dermatology prescribing may rely significantly on unlicensed creams and ointments. The British Association of Dermatologists (BAD) has produced a list of preferred specials.
For many common dermatological diseases including psoriasis and eczema, the range of licensed medicines is limited. As a result, Dermatology prescribing may rely significantly on unlicensed creams and ointments (known as ‘Specials’) containing tars, dithranol, salicylic acid, steroids and other active constituents in a range of concentrations and bases. This is of particular concern in primary care where a lack of effective price controls and a mechanism to ensure independent scrutiny of product quality has increased costs and concern about standards. To address these concerns, and help optimise quality of care, BAD encourage adherence to the revised British Association of Dermatologists (BAD) list of preferred Specials (2018).
See also our Dermatology page.
Use of Special Order Medicines in Children
Before accepting a request for prescribing (including specials) from secondary care, a prescriber should consider if the condition is suitable for taking on in primary care, for example complex paediatrics under the care of a consultant.
Access the specials guide for information and to avoid delay in treatment and unnecessary use of unlicensed options for children. See the Somerset Formulary for further information. Medications should only be given in an unlicensed manner when a licensed alternative is not available. Licensed routes of administration should be sought first. When prescribing alternatives (licensed/ unlicensed) it is important to consider:
- Dose adjustments that need to be made with alternative liquid/ injection preparations.
- Full dose directions need to be included on the prescription (if applicable) e.g. ’take one tablet, disperse in water and take once in the morning’.
See Managing the risks of using effervescent tablets in children from Specialist Pharmacy Service.
Before accepting a request for prescribing (including specials) from secondary care, a prescriber should consider if the condition is suitable for taking on in primary care, for example complex paediatrics under the care of a consultant.
See our Medicines in Childhood page for more information on prescribing in children
Helping your child to swallow tablets – Medicines For Children
