Reasoning Tool · Everything around the prescription pad

Prescribing Hub — write it, get the admin right, keep it safe when they're ill

One place for the three jobs that surround a prescription: grab a ready-made regimen (dose, duration, counselling, EMIS copy-paste), settle the prescribing admin (free-prescription eligibility, a valid FP10, what not to prescribe, the traffic-light RAG), and apply the sick-day rules that keep long-term medicines safe in acute illness.

Last reviewed June 2026 · NICE CKS / NG · BNF · NHSBSA · NHS England · GMMMG · Society for Endocrinology · MHRA

Filterable grid of fully-formed prescription bundles. Each opens to the full plan — indication · contraindications · drug table (dose · freq · route · duration) · alternative regimens · counselling · follow-up · red flags · copy-paste text for EMIS / SystmOne · NICE CKS source links.

Who gets free NHS prescriptions (England)

Prescriptions are free for everyone in Wales, Scotland and Northern Ireland. In England a charge applies (around £9.90 per item, 2025/26 — verify current) unless the patient falls into an exemption below, or holds a prepayment certificate.

🎂 Age

Under 16
16–18 and in full-time education
60 or over

🤰 Maternity (MatEx)

Pregnant, or have had a baby in the last 12 months, with a valid maternity exemption certificate (MatEx).

🏥 Medical exemption (MedEx — apply via FP92A)

A defined, fixed list of conditions. Valid 5 years. The qualifying conditions are:

A permanent fistula needing dressing/appliance
Hypoadrenalism (e.g. Addison's) and other conditions needing specific replacement therapy — hypoparathyroidism, hypopituitarism, diabetes insipidus
Diabetes mellitus — except where treated by diet alone
Myxoedema (hypothyroidism needing thyroid hormone replacement)
Myasthenia gravis
Epilepsy needing continuous anticonvulsant therapy
A continuing physical disability that prevents leaving home without help
Cancer — treatment of cancer, the effects of cancer, or the effects of cancer treatment

💷 Low income & benefits

Income Support, income-based JSA, income-related ESA, Pension Credit Guarantee Credit
Universal Credit — if earnings are below the set threshold in the relevant assessment period
NHS Tax Credit Exemption Certificate, or an HC2 certificate (NHS Low Income Scheme — HC3 gives partial help)
Named on a valid war pension exemption certificate (for the accepted disability)

Not exempt but on regular meds? A Prescription Prepayment Certificate (PPC) caps the cost — a 3-month or 12-month PPC pays for itself after roughly 4+ items in 3 months or 12+ a year. There is also a separate, cheaper HRT PPC covering most HRT items for 12 months.

Check, don't assume. Patients self-declare exemption on the back of the FP10 — the NHSBSA runs checks and issues penalty charges for wrongful claims. If unsure, advise the patient to confirm eligibility before ticking the box.

Writing a legally valid FP10

The FP10 is the NHS prescription form (now mostly issued electronically via EPS). Whether printed or electronic, a valid prescription must carry all of the following — a missing element means the pharmacist cannot legally dispense it.

✅ Every prescription must have

✓Patient details — full name and address; age/date of birth is a legal requirement for children under 12 (best practice for all).
✓Date the prescription was signed.
✓Drug — name (use the generic/approved name unless brand is needed, e.g. modified-release, biologics, lithium), form, strength, dose and directions.
✓Quantity or duration to supply (e.g. "28 tablets" or "28 days").
✓Prescriber's signature (in ink, or a valid digital signature for EPS) plus name and practice address.

⚠️ Controlled drugs (Sch 2 & 3) — extra legal rules

Total quantity in both words and figures.
Form and strength stated; a clearly specified dose ("as directed" is not enough).
Prescriber's details and signature; computer-generated is acceptable but the signature must be valid.
Valid for 28 days from the appropriate date.
Good practice: limit to 30 days' supply (not a strict legal limit, but expected).

🎨 Common FP10 variants

Form	Use
FP10NC / FP10SS	Standard GP prescription (green).
FP10MDA	Instalment ("blue") — supervised opioid substitution (e.g. methadone).
FP10D	Dental prescriptions.
FP10PN / FP10CN	Nurse / non-medical prescriber forms.

EPS is the norm. Most prescriptions are signed digitally and sent to the patient's nominated pharmacy. The same legal elements apply — the smartcard digital signature replaces the ink one.

Items GPs are asked not to prescribe

NHS England guidance asks prescribers to stop routinely prescribing two groups: cheap over-the-counter (OTC) items for self-limiting conditions, and a list of low clinical-value medicines. Plus a clinical group: drugs that should be started and managed by secondary care.

🛒 The 35 conditions — OTC items not to routinely prescribe

NHS England (March 2018) lists 35 minor, short-term conditions that are either self-limiting (clear on their own) or suitable for self-care (treatable with items bought over the counter), plus probiotics, vitamins & minerals as items of limited clinical effectiveness. Each shows the related OTC item(s) a patient should normally buy rather than be prescribed.

Self-limiting conditions (8)

Acute sore throat lozenges, anaesthetic/analgesic throat sprays, paracetamol/ibuprofen
Infrequent cold sores of the lip aciclovir 5% cream
Conjunctivitis chloramphenicol eye drops/ointment, lubricants
Coughs, colds & nasal congestion cough linctus/expectorants, decongestants, paracetamol, vapour rubs
Cradle cap (seborrhoeic dermatitis — infants) emollients, soft brushing, baby shampoo
Haemorrhoids topical soothing/anaesthetic creams & suppositories (e.g. Anusol)
Infant colic simeticone drops, lactase drops, gripe water
Mild cystitis potassium/sodium citrate sachets, paracetamol/ibuprofen

Conditions suitable for self-care (27)

Mild irritant dermatitis emollients, mild hydrocortisone 1% cream
Dandruff antifungal/ketoconazole or coal-tar shampoos
Diarrhoea (adults) oral rehydration salts, loperamide
Dry / sore tired eyes ocular lubricants / artificial tears
Earwax olive oil, sodium bicarbonate or urea-hydrogen-peroxide drops
Excessive sweating (hyperhidrosis) aluminium chloride antiperspirants (e.g. Driclor)
Head lice dimeticone 4% lotion, wet-combing, malathion
Indigestion & heartburn antacids, alginates (Gaviscon), low-dose H2/PPI
Infrequent constipation bulk-forming, osmotic or stimulant laxatives
Infrequent migraine paracetamol, ibuprofen/aspirin, sumatriptan OTC
Insect bites & stings antihistamines, mild hydrocortisone, crotamiton
Mild acne benzoyl peroxide, topical washes
Mild dry skin emollients / moisturisers
Sunburn (excessive sun exposure) after-sun, emollients, paracetamol/ibuprofen
Sun protection sunscreens (except ACBS photodermatoses)
Mild–moderate hayfever / seasonal rhinitis oral antihistamines, intranasal steroids, sodium cromoglicate eye drops
Minor burns & scalds dressings, paracetamol/ibuprofen
Minor pain, discomfort &/or fever (aches, sprains, headache, period pain, back pain) paracetamol, ibuprofen (oral/topical), aspirin
Mouth ulcers antiseptic/anaesthetic gels & mouthwashes (e.g. Bonjela, chlorhexidine)
Nappy rash barrier creams, mild antifungal where needed
Oral thrush miconazole oral gel, nystatin
Prevention of dental caries fluoride toothpaste / mouthwash
Ringworm / athlete's foot topical antifungals (clotrimazole, terbinafine, miconazole)
Teething / mild toothache teething gels, paracetamol/ibuprofen
Threadworms mebendazole (+ household hygiene)
Travel sickness hyoscine, cinnarizine, antihistamines
Warts & verrucae salicylic acid preparations, cryotherapy

Plus — limited clinical effectiveness

Probiotics
Vitamins & minerals (not as dietary supplements or a "pick-me-up")

📉 Low clinical-value medicines

Liothyronine; lidocaine 5% plasters (outside licensed use)
Glucosamine & chondroitin; omega-3 fatty acids; rubefacients
Homeopathy; herbal treatments; lutein & antioxidants
Co-proxamol; immediate-release fentanyl (non-cancer); dosulepin; trimipramine
Perindopril arginine, prolonged-release doxazosin, once-daily tadalafil, paracetamol+tramadol combination, oxycodone+naloxone, aliskiren — prescribe the cheaper equivalent or alternative

✅ When OTC prescribing IS still appropriate

Treating a long-term condition (e.g. regular paracetamol for persistent pain)
Patient can't self-manage / buy (safeguarding, severe social vulnerability)
Symptom of a more serious condition, or where OTC isn't clinically suitable
Prescriber's clinical judgement always overrides the default.

Secondary-care / "red" drugs: some medicines should never be initiated in primary care (see the Traffic-light tab). Don't take on prescribing of a hospital-initiated drug without a clear shared-care agreement and the monitoring it specifies.

The traffic-light (RAG) system — who prescribes what

Area Prescribing Committees classify drugs by where prescribing responsibility sits. The list below uses the Greater Manchester (GMMMG) RAG classification as the worked example, grouped by system. The full GMMMG list runs to many hundreds of items — this is the GP-relevant subset.

📍

Not in Greater Manchester? Follow your local list

RAG status varies between areas — a drug that's green in one ICB may be amber (shared care) in another. This GMMMG list is illustrative. Always check your own Area Prescribing Committee / ICB formulary RAG classification and shared-care agreements before prescribing.

Your area: Not set — showing GMMMG as the example.

GREEN

Suitable for GP prescribing and initiation in primary care, within competence.

AMBER

Specialist initiates; GP continues under a shared-care agreement with defined monitoring.

RED

Hospital / specialist only. Not for GP prescribing or routine repeat in primary care.

GREY / not recommended

Insufficient evidence or value — do not routinely prescribe.

Shared care is a two-way agreement. For amber drugs, only take on prescribing once you have the specialist's shared-care request, are competent to monitor, and have capacity to do so safely — you can decline if those aren't met.

Acute intercurrent illness — fever, vomiting, diarrhoea, dehydration, infection — destabilises many long-term conditions. Some drugs must be increased (steroids), some paused to protect the kidneys (SAD MANS), some are time-critical and must never be stopped (insulin, levodopa, anti-epileptics), and several need extra monitoring or dose review (lithium, digoxin, DOACs, warfarin).

🚨

Adrenal crisis is a medical emergency

Vomiting, severe illness, drowsiness or collapse in a steroid-dependent patient → 100 mg IM hydrocortisone immediately and call 999. Never withhold steroid in a sick adrenal-insufficient patient because of a missing diagnosis. When in doubt, give hydrocortisone.

👥 Who needs steroid sick-day rules

Primary adrenal insufficiency — Addison's disease.
Secondary adrenal insufficiency — pituitary disease, or long-term exogenous steroids suppressing the axis.
Anyone on oral prednisolone ≥5 mg/day (or equivalent) for ≥4 weeks, recently stopped long-term steroids, or on regular high-dose inhaled/topical/intra-articular steroids.
Congenital adrenal hyperplasia; post-bilateral adrenalectomy.

Every such patient should hold a NHS Steroid Emergency Card and ideally a hydrocortisone injection kit with training.

🤒 Moderate illness (oral rules)

Fever/infection needing antibiotics, or feeling significantly unwell.
Double the usual oral glucocorticoid dose until recovered (usually 24–72 h after the fever settles), then return to normal.
Minor illness without fever (e.g. common cold): usually no change needed.

Major surgery / serious infection: usually IV hydrocortisone 100 mg then 50 mg QDS or 200 mg/24 h infusion — secondary-care managed.

🤮 Can't keep tablets down → inject

Vomiting or diarrhoea = oral steroid not absorbed. Don't wait.
Give 100 mg hydrocortisone IM (adult) and seek urgent medical help / call 999.
Patient/carer should be trained to self-administer the emergency injection.

Paediatric IM hydrocortisone: <1 yr 25 mg · 1–5 yr 50 mg · >5 yr 100 mg (check local/specialist guidance).

📋 Patient advice — copy into the record / message

"You have a condition where your body can't make extra steroid when you're ill, so you must do it yourself. If you have a fever or infection, double your steroid dose until you're better. If you are vomiting or have diarrhoea, or feel very unwell, use your emergency hydrocortisone injection and call 999 — don't wait. Always carry your Steroid Emergency Card and tell any healthcare professional you are steroid-dependent."

🚨

The golden rule: never stop insulin

In type 1 diabetes, insulin must never be stopped during illness — even if not eating. Stress hormones push glucose and ketones up, and stopping insulin precipitates diabetic ketoacidosis. Illness usually means the patient needs the same or more insulin, not less.

🩸 Core diabetes sick-day rules (insulin or hypo-causing drugs)

Keep taking insulin — never omit basal insulin; correction doses are often needed.
Test glucose more often — at least every 2–4 hours, including overnight if unwell.
Check ketones (blood ketone meter preferred) if type 1, or if glucose is persistently >15 mmol/L / the patient is unwell.
Maintain hydration & carbohydrate — aim ~3 L of sugar-free fluid; if not eating, replace meals with carb-containing drinks (milk, fruit juice, sugary drinks).
Treat the underlying illness and rest.

Ketone-guided correction (type 1, rapid-acting insulin): blood ketones <0.6 usually fine · 0.6–1.5 extra correction + recheck · 1.5–3.0 significant ketosis — give correction, push fluids, seek advice · >3.0 treat as impending DKA — urgent help. Follow the patient's own specialist plan where they have one.

⏸️ Drugs to hold in diabetes during dehydrating illness

SGLT2 inhibitors ("-flozin") — stop; risk of euglycaemic DKA.
Metformin — stop if dehydrated (lactic-acidosis / AKI risk).
Sulfonylureas (gliclazide) & GLP-1 agonists — review/reduce if not eating (hypo / nausea).

📞 When to escalate

Persistent vomiting — can't keep fluids/carbs down.
Ketones rising or >3.0, or glucose uncontrolled despite correction.
Drowsy, abdominal pain, deep/laboured breathing, fruity breath → ?DKA, 999.
Unable to follow the plan / lives alone and deteriorating.

📋 Patient advice — copy into the record / message

"When you're ill, keep taking your insulin — never stop it, even if you're not eating. Test your blood sugar every 2–4 hours and check ketones if you have a meter. Drink plenty of sugar-free fluids; if you can't eat, take sugary drinks instead of meals. Stop your '-flozin' (e.g. dapagliflozin) and metformin while you're dehydrated. Get urgent help if you keep vomiting, your ketones are high, you feel drowsy, or you have tummy pain or fast breathing — this can be a diabetic emergency."

⏸️

Pause during acute dehydrating illness

During vomiting, diarrhoea, or fevers/sweats/shaking severe enough to cause dehydration, temporarily stop the drugs below to reduce the risk of acute kidney injury, DKA (SGLT2 inhibitors) and metformin-associated lactic acidosis. Restart when eating and drinking normally for 24–48 h. This is for short-term illness — not a reason to stop chronic therapy.

🔤 The "SAD MANS" drugs to hold

Sulfonylureas

gliclazide, glimepiride — hypo risk if not eating

ACE inhibitors

ramipril, lisinopril, perindopril

Diuretics

furosemide, bendroflumethiazide, spironolactone

Metformin

lactic acidosis risk if dehydrated/AKI

ARBs

losartan, candesartan, irbesartan

NSAIDs

ibuprofen, naproxen, diclofenac

SGLT2 inhibitors

dapagliflozin, empagliflozin — DKA risk

⚠ Special caution — SGLT2 inhibitors

Stop the "-flozin" during any acute illness, dehydration, or before surgery.
Risk of euglycaemic DKA — ketones can be high with near-normal glucose.
Advise: check ketones if able, seek help if unwell, vomiting, abdominal pain or breathless.

🩸 Don't stop these

Insulin — never stop in type 1 diabetes; follow diabetes sick-day rules (more frequent monitoring, correction doses, ketone testing).
Most other regular medicines continue unless advised otherwise.

📋 Patient advice — copy into the record / message

"While you are unwell with vomiting, diarrhoea or a high fever, stop these tablets until you are eating and drinking normally again for a couple of days: [list the patient's relevant SAD MANS drugs]. This protects your kidneys. Keep taking your insulin if you use it. Restart your usual tablets once you've recovered. If you can't keep fluids down, are getting more unwell, passing little urine, or feel drowsy, contact us or call 111/999."

Restart rule: resume the held medicines once the patient has been eating and drinking normally for 24–48 hours. Consider a U&E check if the illness was significant or they're high-risk.

⛔

Time-critical medicines — do not stop or delay

Some drugs cause serious harm if missed, delayed or abruptly stopped during illness. If the patient can't swallow or is vomiting, find an alternative route — don't just omit them. These are the medicines hospitals flag as "critical" / "must be given on time".

🧠 Parkinson's — levodopa & PD drugs

Must be given on time (NICE NG71, Parkinson's UK "Get It On Time"). Late/missed doses cause severe immobility, swallowing/breathing problems.
Never stop abruptly — risk of an akinetic crisis / neuroleptic-malignant-like syndrome.
If nil-by-mouth or vomiting: use dispersible levodopa, a rotigotine patch, or an NG tube — get specialist/Parkinson's nurse advice for dose conversion.
For nausea use domperidone / ondansetron — avoid metoclopramide & prochlorperazine (worsen Parkinson's).

⚡ Epilepsy — anti-epileptic drugs

Don't miss doses — abrupt withdrawal risks breakthrough seizures / status epilepticus.
If vomiting: re-dose if vomited within ~1 hour; consider buccal/rectal or alternative route; seek advice for IV equivalents.
Fever/illness lowers the seizure threshold — counsel on rescue medication (e.g. buccal midazolam) and the patient's seizure plan.

💉 Insulin & steroids

Insulin — never stop in type 1 (see Diabetes tab); illness needs the same or more.
Glucocorticoids / adrenal replacement — never stop; increase in illness (see Steroids tab).

🩸 Anticoagulants & others

Anticoagulants (DOAC / warfarin) — don't simply stop; balance clot vs bleed and review renal function/INR (see Monitor tab).
Immunosuppression / biologics, antiretrovirals (HIV), anti-rejection (tacrolimus, ciclosporin) — continue unless a specialist advises otherwise; seek advice early.
Long-term opioids, baclofen, clonidine, beta-blockers — abrupt withdrawal causes harm; don't stop suddenly.

🔬

Narrow-therapeutic-index drugs — review dose & monitor

These drugs aren't simply held or doubled — dehydration, AKI, fever and interacting antibiotics shift their levels, so they need extra monitoring or a dose review during illness.

🧂 Lithium

Dehydration (D&V, fever, sweats) and reduced intake raise lithium levels → toxicity.
Maintain salt & fluid intake; check a lithium level if significantly unwell; consider holding during marked dehydration on specialist advice.
Watch the SAD MANS interactions — NSAIDs, ACEi/ARBs, thiazides all raise levels.
Toxicity: coarse tremor, ataxia, slurred speech, vomiting, confusion → check level urgently.

❤️ Digoxin

AKI and dehydration reduce clearance; hypokalaemia (D&V or diuretics) potentiates toxicity.
Check U&E and consider a digoxin level if unwell; watch nausea, visual changes, arrhythmia.

🩸 DOACs & warfarin

DOACs are renally cleared (especially dabigatran) — AKI causes accumulation and bleeding risk; reassess renal function and dose.
Warfarin — acute illness, reduced intake, liver involvement and many antibiotics raise the INR; check INR during significant illness or new antibiotics.

💊 Other level-sensitive drugs

Methotrexate — hold during serious infection/sepsis; avoid trimethoprim/co-trimoxazole (folate antagonism → marrow toxicity).
Theophylline/aminophylline — fever and macrolides/ciprofloxacin reduce clearance → toxicity.
Phenytoin, ciclosporin, tacrolimus, aminoglycosides — monitor levels/renal function in significant illness.

🚨

Sore throat, mouth ulcers, fever or flu-like illness on these drugs = possible agranulocytosis

Several drugs can cause sudden neutropenia / agranulocytosis. In a patient on one of them, a sore throat, mouth ulcers, fever, chills or other infection is an emergency until excluded: stop the drug and arrange an urgent (same-day) FBC. Counsel every patient to recognise these symptoms when you start the drug.

🦋 Antithyroid drugs — carbimazole / propylthiouracil

Sore throat, mouth ulcers, fever, flu-like illness → stop immediately and get an urgent FBC the same day (MHRA warning).
Do not restart until agranulocytosis is excluded; if confirmed, the drug is permanently contraindicated.
Carbimazole also carries acute pancreatitis risk — stop if severe upper abdominal pain.

🧠 Clozapine

Mandatory FBC monitoring scheme; any fever/infection → check FBC and consider sepsis.
Infection & reduced intake can also raise clozapine levels (toxicity) — review dose; smoking cessation during illness raises levels too.
Fever in the first weeks may be benign clozapine-induced, but always exclude neutropenia, myocarditis and sepsis.

💊 Immunosuppressants & DMARDs — hold during significant infection, seek advice

Methotrexate, azathioprine, leflunomide, mycophenolate, sulfasalazine, ciclosporin, tacrolimus — usually pause during a serious/febrile infection; check FBC (neutropenia/marrow suppression); restart on specialist advice once recovered.
Biologics (anti-TNF — adalimumab, etanercept, infliximab; rituximab, tocilizumab, ustekinumab) and JAK inhibitors (tofacitinib, baricitinib) — withhold during active infection; infection signs may be blunted, threshold for investigation/treatment is lower.
Avoid trimethoprim/co-trimoxazole with methotrexate (folate antagonism → marrow toxicity).
High-dose / long-term corticosteroids are immunosuppressive — fever may be masked; also remember steroid sick-day rules (Steroids tab).
Live vaccines are contraindicated; consider PJP/atypical infection in the unwell immunosuppressed patient.

⚠ Other drugs that can cause agranulocytosis

Carbamazepine, mirtazapine, sulfasalazine, sulfonamides/co-trimoxazole, deferiprone, dapsone, penicillamine, ganciclovir.
Same rule: fever / sore throat / mouth ulcers → consider an urgent FBC and stop pending results.

🩸 Don't forget

Neutropenic sepsis in a patient on chemotherapy or recent immunosuppression is a medical emergency → 999 / acute oncology, do not wait for tests.
Fever also affects level-sensitive drugs (theophylline, phenytoin) — see Monitor tab.

📋 Patient advice — copy into the record / message

"While you take this medicine, a sore throat, mouth ulcers, high temperature, chills or feeling flu-like could be a sign your white blood cells have dropped. If that happens, stop the medicine and contact us urgently (the same day) for a blood test — don't wait. If you feel very unwell, shivery or can't get hold of us, call 111 or 999. Always tell any healthcare professional which medicine you're on."

🫁

Condition flare / self-management plans

Beyond individual drugs, several long-term conditions have NICE-backed self-management actions for when the patient is unwell. Make sure each has a written personalised plan and (where relevant) a rescue pack.

🌬️ Asthma

Follow the personalised asthma action plan; step up reliever / preventer per the plan.
Oral prednisolone rescue (e.g. 40 mg OD) for an acute attack as planned; seek help if reliever lasts <4 h or no better.
Red flags: too breathless to talk, blue lips, exhausted → 999.

🫁 COPD

Rescue pack: prednisolone for increased breathlessness; antibiotics if sputum is more purulent (Anthonisen criteria).
Increase short-acting bronchodilator; use the written self-management plan; seek help if not improving in 48 h.

❤️ Heart failure

Pause diuretics & ACEi/ARB during D&V/dehydration (SAD MANS) — but watch for fluid overload on recovery.
Daily weights; restart and review when eating/drinking normally; recheck U&E.

🩹 Other plans

Addison's / adrenal — steroid sick-day rules + emergency injection (see Steroids tab).
IBD — flare plans; don't stop maintenance; steroid rescue per gastro plan.
Epilepsy — rescue medication & seizure plan (see Never-stop tab).

Educational use only. Steroid replacement and sick-day guidance follow the Society for Endocrinology / NHS Steroid Emergency Card guidance; diabetes sick-day rules follow Diabetes UK / TREND-UK; medicines-to-pause guidance follows NICE CKS and Think Kidneys / local AKI pathways; time-critical medicines (Parkinson's NICE NG71 / "Get It On Time", anti-epileptics, insulin) must not be omitted; narrow-therapeutic-index monitoring follows the BNF; agranulocytosis advice (antithyroid drugs, clozapine) follows the MHRA / BNF and the drug monitoring schemes. Doses are illustrative for adults unless stated — verify against the BNF/BNFc, the patient's specialist plan, and local policy.

Reduced eGFR changes how renally-cleared drugs are handled — some need dose reduction, some should be avoided, and several must be temporarily held during acute illness (the sick-day "SAD MANS" rules) to prevent AKI. Always dose against the patient's eGFR / CrCl (use Cockcroft–Gault for narrow-therapeutic-index and DOAC dosing), and recheck renal function after any change.

Drugs to avoid or stop as eGFR falls

These either accumulate to toxicity, are ineffective, or directly worsen renal function at low eGFR.

Drug / class	Threshold	Why & action
NSAIDs	Avoid <30; caution <60	Reduce renal perfusion → AKI & CKD progression; hyperkalaemia. Avoid in CKD, especially with ACEi/ARB + diuretic ("triple whammy").
Metformin	Review <45; stop <30	Lactic-acidosis risk. Max 1 g/day if eGFR 30–45; stop if <30 or during acute illness/contrast.
Nitrofurantoin	Avoid <45 (short course 30–44 only if needed)	Inadequate urinary concentration → ineffective + neuropathy risk.
SGLT2 inhibitors	Don't start <15–20 (drug-specific)	Glucose-lowering effect attenuated at low eGFR; continue for cardiorenal benefit per product licence. Hold during acute illness (DKA/AKI risk).
Potassium-sparing diuretics / MRAs	Caution <45; avoid if K⁺ high	Hyperkalaemia — monitor U&E closely with ACEi/ARB.
Spironolactone / amiloride	Avoid eGFR <30	Severe hyperkalaemia risk.
Bisphosphonates	Avoid <35 (drug-specific)	Alendronate/risedronate contraindicated below threshold.
Lithium	Nephrotoxic — specialist	Narrow index; reduce/specialist review as eGFR falls; hold when dehydrated.
Potassium supplements / high-K⁺ salt substitutes	Caution all stages	Hyperkalaemia.

Contrast & nephrotoxins: review the need for IV contrast, aminoglycosides and other nephrotoxins; hydrate and recheck renal function.

Drugs that need dose reduction by eGFR

Renally-cleared drugs accumulate as eGFR falls — reduce dose or lengthen the interval. Doses below are a guide; confirm against the BNF / renal-drug handbook and use CrCl (Cockcroft–Gault) for DOACs and narrow-index drugs.

Drug	Adjustment	Note
Apixaban	2.5 mg BD if 2 of: age ≥80, ≤60 kg, creat ≥133; avoid CrCl <15	Use CrCl, not eGFR.
Rivaroxaban	Caution CrCl 15–50; avoid <15	AF dose 15 mg if CrCl 15–49.
Dabigatran / edoxaban	Reduce / avoid per CrCl	Dabigatran avoid <30.
DOAC dosing	Recheck renal function ≥annually (6-monthly if CrCl <60 or elderly)	—
Allopurinol	Start 50–100 mg; titrate to urate & eGFR	Lower start in CKD (hypersensitivity).
Gabapentin / pregabalin	Reduce dose by eGFR band	Accumulate → sedation, falls.
Opioids (morphine, codeine, tramadol)	Reduce / avoid <30; prefer oxycodone (low eGFR) / alfentanil, buprenorphine	Active metabolites accumulate → toxicity.
Digoxin	Reduce dose; monitor level & K⁺	Renally cleared, narrow index.
Many antibiotics	Reduce (e.g. co-amoxiclav, trimethoprim, aciclovir, gentamicin)	Dose & interval per CrCl.
Methotrexate	Reduce / avoid in significant CKD	Renally cleared — toxicity.
Atenolol / sotalol	Reduce (renally cleared)	Bisoprolol less affected.

🧯 S A D — M A N S

Sulfonylureas — hypoglycaemia if not eating.
ACE inhibitors — ramipril, lisinopril, perindopril.
Diuretics — furosemide, bendroflumethiazide, indapamide.
Metformin — lactic acidosis if AKI.
ARBs — losartan, candesartan, valsartan.
NSAIDs — ibuprofen, naproxen, diclofenac.
SGLT2 inhibitors — dapagliflozin, empagliflozin (DKA/AKI risk).

⚠️ Practical points

Restart once eating/drinking normally for 24–48 h — don't leave essential cardio-renal drugs stopped indefinitely.
Insulin must never be stopped in type 1 diabetes — adjust, don't omit (see Sick-day rules tab).
Recheck U&E after a significant illness, and after restarting ACEi/ARB/diuretic.
Avoid nephrotoxins and review contrast exposure during illness.

Reinforces the dedicated Sick-day rules section — the SAD MANS "pause" list there is the same drugs viewed from the AKI-prevention angle.

eGFR stage thresholds & what changes

CKD is staged by eGFR (G1–G5) and albuminuria (A1–A3). Prescribing thresholds that matter in primary care:

Stage (eGFR)	Key prescribing changes
G1–G2 (≥60)	Normal/mild — review nephrotoxins; offer ACEi/ARB if albuminuria/diabetes/hypertension. SGLT2i for cardiorenal protection where indicated.
G3a (45–59)	Review metformin (max 1 g/day), nitrofurantoin (avoid), NSAIDs (avoid). Start statin for CVD risk. Recheck DOAC dose.
G3b (30–44)	Stop nitrofurantoin; reduce gabapentinoids/opioids; caution MRAs; reassess all renally-cleared drugs.
G4 (15–29)	Stop metformin; avoid NSAIDs, spironolactone, many antibiotics need reduction; specialist/nephrology input; review DOAC suitability.
G5 (<15)	Established kidney failure — specialist-led; most renally-cleared drugs need major adjustment or avoidance.

Always: annual (or more frequent) U&E in CKD; recheck within 1–2 weeks of starting/increasing ACEi/ARB (accept ≤25% creatinine rise / ≤30% eGFR fall), and after any acute illness.

Common CKD prescribing problems

The scenarios that actually come up in clinic — what to do.

📉 "eGFR has dropped a stage"

First exclude an acute drop (AKI) vs true CKD progression — recheck, look for dehydration/illness/new nephrotoxin.
If genuine: re-dose renally-cleared drugs to the new band, stop nitrofurantoin if <45, review metformin (<45 reduce, <30 stop), recheck DOAC dose by CrCl.
Recheck U&E and consider nephrology if rapid decline (>15% drop or sustained fall).

💊 "Started ACEi/ARB — creatinine rose"

A creatinine rise up to 30% (eGFR fall ≤25%) is acceptable and expected — continue and recheck.
Recheck U&E 1–2 weeks after starting/up-titrating.
Stop & investigate if rise >30%, hyperkalaemia (K⁺ >6), or symptomatic — consider renal artery stenosis.

🩻 "Needs a CT with contrast"

Check eGFR; hold metformin at the time of contrast if eGFR <60 (or any AKI risk) and for 48 h after, recheck renal function before restarting.
Ensure good hydration; review other nephrotoxins around the scan.

🦠 "UTI in CKD"

Nitrofurantoin avoid if eGFR <45 (ineffective + neuropathy) — a short course at 30–44 only if no alternative and benefit outweighs risk.
Alternatives: trimethoprim (avoid 1st-tri pregnancy; watch K⁺ with ACEi/ARB), pivmecillinam, cefalexin (dose-reduce in severe CKD).

😣 "Needs pain relief in CKD"

Avoid NSAIDs. Paracetamol is first-line.
Opioids: morphine/codeine metabolites accumulate <30 → prefer low-dose oxycodone (and alfentanil/buprenorphine in advanced CKD); start low, titrate slowly.
Gabapentinoids accumulate — reduce dose by eGFR, watch sedation/falls.

🩺 "When to refer to nephrology"

eGFR <30 (G4–G5), sustained ACR ≥70, rapid progression, refractory hyperkalaemia/hypertension, or genetic/uncertain cause.
Heart failure + CKD: SGLT2i offer cardiorenal protection — don't withhold purely for a modest eGFR dip after starting.

Few drugs are formally "licensed" in pregnancy, but many are well-established as safe, and several are clearly harmful. Treating the mother's condition matters — untreated illness (epilepsy, asthma, severe mental illness, infection) often poses more risk than the drug. Always check the individual drug, and counsel using a shared decision.

Known or likely teratogens — avoid / stop

These carry recognised fetal risk. Where the underlying condition still needs treatment, switch to a safer alternative pre-conception or as early as possible.

Drug / class	Risk	Action
ACE inhibitors / ARBs	Renal dysgenesis, oligohydramnios, skull defects (2nd/3rd tri)	Stop pre-conception; switch to labetalol / nifedipine / methyldopa.
Sodium valproate	Neural-tube & major malformations, neurodevelopmental harm	Contraindicated in women of childbearing potential unless PPP; switch with specialist (e.g. lamotrigine/levetiracetam).
Warfarin	Embryopathy, fetal bleeding	Switch to LMWH pre-conception / early pregnancy.
Methotrexate / mycophenolate	Highly teratogenic, abortifacient	Stop well before conception (MTX ≥3 months); contraception essential.
Retinoids (isotretinoin, acitretin)	Severe malformations	Pregnancy Prevention Programme; avoid.
Statins	Theoretical fetal harm	Stop in pregnancy (and when planning).
Tetracyclines (doxycycline)	Dental/bone staining (2nd/3rd tri)	Avoid; use alternative antibiotic.
Trimethoprim (1st tri)	Folate antagonist — NTD risk	Avoid 1st trimester; give folic acid; use nitrofurantoin (not at term).
NSAIDs (3rd tri)	Premature ductus closure, oligohydramnios	Avoid esp. after 30 weeks.
Sodium valproate / topiramate / carbamazepine / phenytoin	AED teratogenicity (valproate worst)	Specialist pre-conception planning; high-dose folic acid 5 mg.

Common switch scenarios

🫀 Hypertension

Stop ACEi/ARB → labetalol (1st-line), nifedipine MR, or methyldopa.
Offer aspirin 75–150 mg from 12 weeks if pre-eclampsia risk.

🧠 Epilepsy

Never stop AEDs abruptly. Specialist pre-conception review; avoid valproate.
Folic acid 5 mg daily pre-conception & 1st trimester.

😔 Depression

Many SSRIs continued if needed — sertraline commonly preferred; avoid paroxetine (1st tri) where possible.
Weigh relapse risk vs drug risk; shared decision.

🩸 Diabetes

Stop non-insulin agents (except metformin, which is continued); optimise with insulin.
Folic acid 5 mg; tight pre-conception control.

🫁 Asthma

Continue inhalers (ICS, SABA, LABA) — uncontrolled asthma is more dangerous than the drugs.

🦠 Infection / UTI

1st tri: avoid trimethoprim → nitrofurantoin (not at term) or cephalexin.
Avoid tetracyclines & quinolones.

🩹 Anticoagulation / VTE

Warfarin/DOAC → LMWH in pregnancy.

🦴 Thyroid

Continue levothyroxine (often needs dose increase ~25–30%).
Hyperthyroid: propylthiouracil 1st trimester, carbimazole later (specialist).

Folic acid: 400 micrograms pre-conception–12 weeks for all; 5 mg if diabetes, BMI ≥30, on AEDs, previous NTD, sickle cell/thalassaemia, or coeliac.

Generally well-established options

Widely used and considered acceptable in pregnancy when indicated (still confirm per UKTIS/bumps):

💊 Symptom relief

Paracetamol — analgesic/antipyretic of choice.
Penicillins, cephalosporins, nitrofurantoin (not at term), erythromycin.
Antacids/alginates; omeprazole/ranitidine alternatives for reflux.

🤢 Nausea / common

Cyclizine, promethazine, prochlorperazine for nausea/vomiting of pregnancy.
Loratadine/cetirizine for allergy; chlorphenamine.
Topical steroids/emollients for skin.

"No evidence of harm" is not the same as "proven safe" — counsel honestly, document the discussion, and use the lowest effective dose for the shortest time.

Prescribing while breastfeeding

Most drugs pass into breast milk only in tiny amounts. Prefer drugs with low oral bioavailability/short half-life, dose after a feed, and watch the infant for drowsiness/poor feeding. Check LactMed / Breastfeeding Network / UKDILAS.

⛔ Avoid / caution

Codeine — variable metabolism → infant opioid toxicity (avoid; use alternative analgesia).
Aspirin (analgesic doses) — Reye's risk.
Lithium — significant transfer; specialist only.
Cytotoxics, retinoids, amiodarone, high-dose iodine.
Combined oral contraceptive in the first 6 weeks (VTE + may reduce milk) — use POP/implant.

✅ Usually compatible

Paracetamol, ibuprofen — analgesics of choice.
Most penicillins/cephalosporins/macrolides.
Sertraline / paroxetine — preferred SSRIs in lactation.
Levothyroxine, insulin, inhalers, most antihypertensives (enalapril; avoid high-dose diuretics — may suppress milk).
Progestogen-only contraception.

Common pregnancy/lactation problems

Frequent real consultations — what to advise.

😱 "I took X before I knew I was pregnant"

Don't panic the patient — most single exposures are low-risk. Check the specific drug on UKTIS / bumps.
Stop a teratogen now (ACEi/ARB, valproate, retinoid, methotrexate) and switch; arrange specialist/early scan if a known teratogen.
Give folic acid 5 mg and document the discussion.

🤢 Nausea & vomiting / hyperemesis

First-line antiemetics: cyclizine, promethazine or prochlorperazine; 2nd-line ondansetron (counsel small cleft-palate signal, 1st tri) / metoclopramide.
Hyperemesis (weight loss, ketones, dehydration) → admit/IV fluids; thiamine.

🤕 Headache / pain

Paracetamol is the analgesic of choice throughout.
Avoid NSAIDs (esp. after 30 weeks — ductus closure); avoid codeine near term/in labour.
New severe headache + ≥20 weeks → check BP/pre-eclampsia.

🦠 UTI in pregnancy

Always treat (incl. asymptomatic bacteriuria) — send MSU.
1st tri: avoid trimethoprim (folate antagonist) → nitrofurantoin; avoid nitrofurantoin at term (neonatal haemolysis) → cefalexin.
Group B strep / pyelonephritis → escalate.

🤧 Reflux / hay-fever / constipation

Reflux: lifestyle, antacid/alginate; omeprazole if needed.
Allergy: loratadine/cetirizine or chlorphenamine.
Constipation: increase fibre/fluids; bulk-forming then lactulose/macrogol.

🧠 Mental health in pregnancy

Don't stop antidepressants reflexively — relapse risk is real. Sertraline often preferred; perinatal mental-health input for severe illness.
Never stop antiepileptics/lithium without specialist advice.

👶 Planning a pregnancy on regular meds

Pre-conception review: switch ACEi/ARB, statins, valproate, methotrexate, warfarin before conception.
Optimise: folic acid (5 mg if diabetes/BMI≥30/AED/NTD/sickle), control diabetes/thyroid/epilepsy.

A structured medication review (NICE NG5 / "structured medication review", and the STOPP/START criteria) checks every drug is still needed, effective, safe and wanted — and screens for the dangerous interactions and high-risk drugs that cause most avoidable harm in primary care.

Common interactions to catch

High-yield, frequently-missed interactions in everyday GP prescribing — grouped by mechanism. Always check the specific pair in the BNF (Appendix 1 / interactions checker); this is a primary-care prompt list.

💊 Clopidogrel + omeprazole / esomeprazole

Omeprazole/esomeprazole inhibit CYP2C19, which clopidogrel needs to become active → reduced antiplatelet effect (theoretical ↑ cardiovascular risk).
Action: if a PPI is needed (e.g. with DAPT), use lansoprazole or pantoprazole; or an H₂-blocker (famotidine) — not cimetidine.

💊 Simvastatin + clarithromycin / erythromycin

Macrolides inhibit CYP3A4 → simvastatin levels soar → myopathy / rhabdomyolysis.
Action: stop simvastatin during the macrolide course (and a few days after), or use a non-interacting antibiotic; atorvastatin is less affected but still caution. Avoid simvastatin entirely with itraconazole/ketoconazole.

🫘 The "triple whammy" → AKI

ACEi/ARB + diuretic + NSAID (especially with intercurrent dehydration) → acute kidney injury.
Action: avoid adding an NSAID to this combination; if unavoidable, shortest course, check U&E, and give sick-day rules.

🩸 Methotrexate + trimethoprim

Both are antifolates → synergistic bone-marrow suppression (can be fatal). Also applies to co-trimoxazole.
Action: avoid — choose a different antibiotic for the UTI/chest infection (e.g. nitrofurantoin/amoxicillin).

🧂 Hyperkalaemia stack

ACEi/ARB + spironolactone/eplerenone + trimethoprim (or K⁺ supplements / NSAIDs) → dangerous hyperkalaemia.
Action: check U&E before and ~5–7 days after starting; avoid trimethoprim in this group where possible.

🧠 Serotonin stacking

SSRI/SNRI + tramadol / triptan / linezolid / St John's Wort → serotonin syndrome (agitation, clonus, hyperthermia).
Action: avoid stacking; counsel; review OTC/herbal use.

Bleeding risk

Combination	Effect	Action
Warfarin + macrolide / metronidazole / fluconazole / ciprofloxacin	↑ INR → bleeding (enzyme inhibition)	Avoid or check INR a few days in; counsel on bleeding.
Warfarin + NSAID / aspirin	↑ GI bleeding (additive + mucosal)	Avoid; if essential, PPI cover + INR monitoring.
Warfarin + miconazole oral gel	Marked ↑ INR (often missed — it's "just a gel")	Avoid; use nystatin instead.
DOAC + NSAID / antiplatelet / SSRI	↑ bleeding	Review need; gastroprotection; avoid triple therapy unless specialist-directed.
DOAC + strong CYP3A4/P-gp inhibitor (azoles, ritonavir) or inducer (rifampicin, carbamazepine, St John's Wort)	↑ bleeding / ↓ efficacy	Avoid combinations; check BNF for the specific DOAC.
SSRI/SNRI + NSAID	↑ GI bleeding	Add PPI or avoid; consider the bleeding risk in elderly.
SSRI + aspirin / anticoagulant	↑ bleeding (platelet effect)	Gastroprotection; review necessity.

Enzyme inhibition / induction (CYP)

Combination	Effect	Action
Simvastatin/atorvastatin + amlodipine / diltiazem / verapamil	↑ statin → myopathy	Cap simvastatin 20 mg with amlodipine; avoid with diltiazem/verapamil; consider rosuvastatin/pravastatin.
Statin + grapefruit juice (simvastatin)	↑ statin levels	Counsel to avoid large quantities.
Clopidogrel + omeprazole / esomeprazole / cimetidine / fluconazole	↓ clopidogrel activation (CYP2C19)	Use lansoprazole/pantoprazole or famotidine.
Enzyme inducers (rifampicin, carbamazepine, phenytoin, St John's Wort) + COC / DOAC / warfarin / many drugs	↓ levels → contraceptive/treatment failure	Use alternative contraception; review affected drugs; check BNF.
Macrolides / azole antifungals + many CYP3A4 substrates (statins, some DOACs, calcium-channel blockers, midazolam)	↑ substrate levels	Avoid or dose-adjust; choose non-interacting alternative.
Allopurinol + azathioprine / mercaptopurine	Azathioprine toxicity (xanthine oxidase inhibition)	Major dose reduction / avoid — specialist only.

Renal & electrolytes

Combination	Effect	Action
"Triple whammy": ACEi/ARB + diuretic + NSAID	AKI (esp. with dehydration)	Avoid NSAID; sick-day rules; check U&E.
ACEi/ARB + spironolactone/eplerenone / K⁺ supplement / trimethoprim	Hyperkalaemia	Monitor U&E/K⁺; avoid trimethoprim; counsel on salt substitutes (high K⁺).
Lithium + NSAID / ACEi/ARB / thiazide / dehydration	↑ lithium → toxicity	Avoid new NSAID; check level; sick-day advice.
Digoxin + diuretic-induced hypokalaemia / amiodarone / verapamil	↑ digoxin toxicity	Monitor K⁺ & digoxin level; reduce dose with amiodarone.
Metformin + iodinated contrast (if eGFR low / AKI)	Lactic acidosis	Hold around contrast; recheck renal function before restarting.
Drugs that lower sodium (SSRI + thiazide + carbamazepine)	Hyponatraemia (SIADH)	Check Na⁺; review the combination, esp. in elderly.

Cardiac (rate, rhythm & QT)

Combination	Effect	Action
Beta-blocker + verapamil / diltiazem	Bradycardia, heart block, asystole	Avoid the combination.
QT-prolongers stacked (citalopram/escitalopram + macrolide + antipsychotic + ondansetron + amiodarone)	↑ QT → torsades	Avoid stacking; respect citalopram dose caps (elderly ≤20 mg); ECG if needed.
Amiodarone + warfarin / digoxin / statin	↑ levels of each	Reduce warfarin/digoxin dose; cap/avoid simvastatin; monitor.
Sildenafil/tadalafil + nitrates / nicorandil	Profound hypotension	Contraindicated — never co-prescribe.

CNS & sedation

Combination	Effect	Action
Opioid + benzodiazepine / gabapentinoid / "Z"-drug	Respiratory depression, sedation, overdose death	Avoid combining; if unavoidable, lowest doses, counsel, review.
SSRI/SNRI + tramadol / triptan / linezolid / St John's Wort	Serotonin syndrome	Avoid stacking; counsel on symptoms.
MAOI + SSRI / sympathomimetics / pethidine	Serotonin syndrome / hypertensive crisis	Avoid; observe washout periods.
Anticholinergic burden stacking (TCA + oxybutynin + sedating antihistamine)	Confusion, falls, retention	Minimise total ACB — see STOPP/START tab.

Contraception & other key pairs

Combination	Effect	Action
Combined / progestogen pill + enzyme-inducer (rifampicin, some AEDs, St John's Wort)	↓ contraceptive efficacy → unintended pregnancy	Use a reliable alternative/additional method; LARC (IUD) unaffected.
Lamotrigine + COC / valproate	COC ↓ lamotrigine (seizures); valproate ↑ lamotrigine (rash/toxicity)	Specialist dose adjustment around starting/stopping.
Levothyroxine + calcium / iron / PPI / soya	↓ levothyroxine absorption	Separate doses by ≥4 h; recheck TFTs.
Bisphosphonate + calcium / iron / antacids	↓ bisphosphonate absorption	Take on empty stomach, separate from other drugs.
Quinolone/tetracycline + calcium / iron / antacids / dairy	↓ antibiotic absorption (chelation)	Separate doses by ≥2–4 h.

Always check the specific pair in the BNF interactions checker — severity and action depend on dose, indication and patient factors. See the Drug monitoring, Prescribing in CKD and Sick-day rules tabs for related safety.

The 7-step medication review

A structured framework (NHS Scotland Polypharmacy / NICE) for a shared, patient-centred review.

1
Aims — what matters to the patient? Establish their goals and understanding.
2
Need — identify essential drugs and those for unnecessary/duplicate/expired indications.
3
Effectiveness — are therapeutic goals being achieved? Stop ineffective drugs.
4
Safety — screen for ADRs, interactions, and high-risk drugs (STOPP); check adherence-limiting side effects.
5
Cost-effectiveness — is there a more cost-effective equivalent (without compromising care)?
6
Patient-centred — is the patient willing/able to take the medicines as intended? Agree changes together.
7
Plan & monitor — document changes, deprescribing plan, and follow-up/monitoring.

Who to prioritise: ≥10 regular medicines, care-home residents, frailty, recent admission/falls, high-risk drugs (anticoagulants, insulin, lithium, methotrexate, opioids), or eGFR decline.

STOPP / START — deprescribe & optimise in older people

Evidence-based criteria (STOPP/START, based on v3, 2023) for reviewing medicines in people ≥65. STOPP = potentially inappropriate medicines to consider stopping; START = potential prescribing omissions to consider adding. Always individualise to the patient's goals, frailty and life expectancy — apply alongside the 7-step review.

General / overarching

Consider stopping	When / why
Any drug with no evidence-based clinical indication	No valid indication, or prescribed beyond the recommended duration.
Duplicate drugs from the same class	e.g. two NSAIDs, two ACEi/ARB, two opioids, two SSRIs — optimise monotherapy first.
Any drug beyond its recommended duration	Where treatment duration is well defined (e.g. PPI, bisphosphonate review at 3–5 yr).
Drugs prescribed to treat a side-effect of another drug	"Prescribing cascade" — review whether the first drug can be stopped instead.

Cardiovascular

Consider stopping	When / why
Digoxin for heart failure with preserved systolic function	No clear benefit; toxicity risk.
Digoxin long-term at dose >125 microgram/day if eGFR <30	Accumulation → toxicity; reduce dose / monitor level.
Loop diuretic for dependent ankle oedema without heart failure	No evidence of HF — elevation/compression more appropriate.
Loop diuretic first-line for hypertension	Safer alternatives exist (CCB, ACEi/ARB, thiazide-like).
Thiazide with current/past significant hypokalaemia, hyponatraemia, hypercalcaemia or gout	May precipitate these.
Beta-blocker with bradycardia (<50), type II/III heart block	Risk of complete heart block, asystole.
Beta-blocker + verapamil/diltiazem	Risk of heart block.
Aspirin/antiplatelet for primary prevention (no established CVD)	Bleeding risk outweighs benefit.
Aspirin + anticoagulant for AF without a clear indication	Anticoagulant alone usually sufficient; bleeding risk.
Aspirin dose >160 mg/day	Increased bleeding, no added benefit.

CNS & psychotropics

Consider stopping	When / why
Benzodiazepines / Z-drugs ≥4 weeks	Sedation, falls, fractures, confusion — taper, don't stop abruptly.
Antipsychotics in dementia (BPSD)	Increased stroke/death; reserve for severe distress/risk, review regularly.
Antipsychotics as long-term hypnotics	No indication; anticholinergic/EPSE/falls risk.
TCAs with dementia, glaucoma, prostatism, or prior falls	Anticholinergic burden, falls, urinary retention.
SSRIs with current/recent hyponatraemia	SIADH — check sodium; consider alternative.
Anticholinergics for antipsychotic EPSE	Add to anticholinergic burden; review the antipsychotic.
Antipsychotics in those with parkinsonism / Lewy body dementia	Severe sensitivity reactions.

GI, renal & analgesia

Consider stopping	When / why
PPI at full dose >8 weeks for uncomplicated reflux/PUD	Step down to lowest effective dose or stop/on-demand.
NSAID with eGFR <50	Risk of renal deterioration.
NSAID with heart failure	Fluid retention, decompensation.
NSAID + anticoagulant/antiplatelet without PPI	GI bleeding risk.
NSAID long-term (>3 months) for mild OA pain	Paracetamol/topical preferred; GI/renal/CV risk.
Long-term opioids for chronic non-cancer pain without benefit	Review function; taper if not helping.
Opioids without laxative	Predictable constipation — co-prescribe.
Prochlorperazine / metoclopramide with parkinsonism	Worsens EPSE.
Metoclopramide long-term (>5 days)	Tardive dyskinesia / EPSE risk.

Endocrine & urinary

Consider stopping	When / why
Long-acting sulfonylureas (glibenclamide) in older people	Prolonged hypoglycaemia — use shorter-acting/safer agents.
Sulfonylurea / insulin aiming for tight HbA1c in frail older people	Relax targets; hypoglycaemia risk outweighs benefit.
Systemic oestrogen without progestogen (intact uterus)	Endometrial cancer risk.
Antimuscarinics for OAB with dementia, glaucoma, chronic constipation or prostatism	Worsens cognition, retention, constipation.
Alpha-blocker in those with symptomatic orthostatic hypotension / recurrent falls	Postural drop, falls.

Respiratory

Consider stopping	When / why
Theophylline as monotherapy for COPD	Narrow therapeutic index; safer/more effective inhaled options.
Systemic corticosteroid (not inhaled) for maintenance COPD	Long-term systemic steroid harms outweigh benefit — use inhaled.
Nebulised ipratropium with glaucoma	Can worsen glaucoma — protect the eyes / review.
Benzodiazepine with acute/chronic respiratory failure	Respiratory depression — avoid.
Long-acting beta-agonist alone in asthma	LABA must be combined with an inhaled corticosteroid.

Musculoskeletal

Consider stopping	When / why
Long-term oral NSAID/colchicine for chronic gout	Where no contraindication to a urate-lowering drug (allopurinol/febuxostat) — treat the cause.
Oral bisphosphonate with current/recent upper-GI disease	Dysphagia, oesophagitis, known stricture — reconsider/route.
Systemic corticosteroid (not NSAID) for OA monotherapy	No proven benefit; systemic steroid harms.
Long-term NSAID/oral steroid without bone & gastric protection	Add gastroprotection; bone protection if steroid ≥7.5 mg ≥3 months.
Long-term oral NSAID with hypertension / heart failure / CKD	Worsens all three — review need, use lowest dose/shortest course.

Cardiovascular

Consider adding	When indicated
Anticoagulant (DOAC/warfarin)	AF with CHA₂DS₂-VASc score qualifying — unless contraindicated.
Antihypertensive therapy	Persistent BP >140/90 (or per individualised target in frailty).
Statin	Established coronary/cerebral/peripheral vascular disease (and high-risk primary prevention) where life expectancy >5 yr.
ACEi (or ARB)	Heart failure with reduced EF; post-MI; diabetes with albuminuria.
Beta-blocker	Stable systolic heart failure; post-MI.
Antiplatelet	Established coronary/cerebral/peripheral arterial disease (secondary prevention).
SGLT2 inhibitor	Heart failure / CKD / type 2 diabetes for cardiorenal protection where indicated.

Bone, endocrine & metabolic

Consider adding	When indicated
Bone-protective therapy (bisphosphonate ± Ca/vit D)	Osteoporosis (prior fragility fracture, T-score ≤ −2.5, or high FRAX).
Vitamin D ± calcium	Housebound/falls/known osteoporosis or deficiency.
Bone protection with long-term oral steroids	Prednisolone ≥7.5 mg/day for ≥3 months.
Metformin	Type 2 diabetes (first-line) if eGFR adequate.
ACEi/ARB	Diabetes with albuminuria/diabetic nephropathy.

Respiratory, CNS & other

Consider adding	When indicated
Inhaled regular bronchodilator/steroid	Per stepwise COPD/asthma management with documented disease.
Levodopa / dopamine agonist	Idiopathic Parkinson's disease with functional impairment.
Antidepressant	Persistent moderate–severe depression.
Laxative	With regular opioids (prevent constipation).
Seasonal influenza / pneumococcal / shingles vaccine	Per national schedule for older adults.
PPI	Gastroprotection with high GI-bleed risk (NSAID/antiplatelet/anticoagulant combinations).

Drugs that increase falls risk — review in fallers

Class	Why & action
Benzodiazepines / Z-drugs	Sedation, balance impairment — taper and stop.
Antipsychotics	Sedation, postural hypotension, parkinsonism.
TCAs & sedating antihistamines	Anticholinergic, sedation, postural drop.
Opioids & gabapentinoids	Sedation, dizziness — review need, taper.
Antihypertensives / nitrates / alpha-blockers	Postural hypotension — check lying/standing BP, review.
Hypoglycaemic agents (sulfonylureas, insulin)	Hypoglycaemia → falls; relax targets in frailty.

Anticholinergic burden — minimise the total load

High cumulative anticholinergic burden (ACB) is linked to falls, confusion, constipation, urinary retention and dementia risk. Common culprits to review/replace:

🧠 High ACB (score 3)

Amitriptyline, nortriptyline (TCAs)
Oxybutynin, tolterodine, solifenacin
Chlorphenamine, promethazine, hydroxyzine, cyclizine
Hyoscine, procyclidine
Olanzapine, quetiapine, chlorpromazine

↔️ Lower-burden swaps

Depression → SSRI (sertraline) instead of TCA.
OAB → mirabegron, or bladder training, instead of antimuscarinic.
Allergy → non-sedating antihistamine (loratadine/cetirizine).
Nausea → review need; lower-ACB antiemetic where possible.

Tip: use an ACB calculator to total the burden at review; each additional point adds measurable cognitive and falls risk in older people.

Tapering schedules — practical primary-care guide

Drug class	Why taper	Suggested approach
Benzodiazepines / Z-drugs	Withdrawal: anxiety, insomnia, seizures.	Switch to equivalent diazepam; reduce by ~⅛ (up to 10%) of dose every 1–2 weeks; slower near the end. Total taper often weeks–months.
Opioids	Withdrawal, rebound pain.	Reduce by 10% of total daily dose every 1–4 weeks; slow to 10% per month near the end. Pause/slow if withdrawal symptoms.
PPIs	Rebound acid hypersecretion.	Halve dose for 2–4 weeks → stop, or step to alternate-day; use on-demand/antacid for breakthrough. No taper needed if short course.
Antidepressants (SSRI/SNRI)	Discontinuation syndrome (esp. paroxetine, venlafaxine).	Reduce gradually over ≥4 weeks (longer for short-half-life drugs); proportionate "hyperbolic" smaller steps at low doses. Fluoxetine self-tapers.
Gabapentinoids	Withdrawal, seizures.	Reduce slowly (e.g. ~10–25% per week, slower if long-term/high-dose); individualise.
Oral corticosteroids	Adrenal suppression if ≥3 weeks or repeated courses.	If <3 weeks & low dose → stop abruptly. Otherwise taper (e.g. by 2.5–5 mg prednisolone every 1–4 weeks) to physiological dose, then slower; give a steroid card.
Beta-blockers	Rebound tachycardia/angina/hypertension.	Reduce gradually over 1–2 weeks (longer in IHD) — avoid abrupt cessation.
Clonidine	Severe rebound hypertension.	Reduce slowly over days–weeks; never stop suddenly.
Antipsychotics	Withdrawal dyskinesia, relapse.	Reduce gradually over weeks–months with monitoring for relapse; in dementia, trial withdrawal with review.

Document: the reason for stopping, the schedule agreed, what to expect, and a clear review/safety-net ("contact us if…"). Stop/taper one drug at a time so any effect is attributable.

Drug monitoring recommendations

Baseline and routine monitoring for commonly-prescribed drugs that need it, grouped by system. Frequencies are a primary-care guide — follow any shared-care agreement and the current BNF/SPC.

Gastrointestinal

Drug	Baseline	Routine	Comments
Mesalazine / balsalazide	FBC, U&E, LFTs	U&E, LFTs	3-monthly for year 1, then 6-monthly for 4 years, then 12-monthly. FBC/WCC only if blood dyscrasia suspected (sore throat, fever, bruising → stop, urgent FBC).

Cardiovascular

Drug	Baseline	Routine	Comments
ACEi / ARB	U&E, BP	U&E, BP	U&E + BP 1–2 weeks after initiation/dose change, then 12-monthly. More often if on diuretics, renal impairment or unstable HF. Accept ≤30% eGFR fall / ≤25% creatinine rise.
Sacubitril/valsartan	U&E, BP, LFTs	U&E, BP	Don't initiate if SBP <100, K⁺ >5.4, or ACEi/ARB-naïve; lower start if SBP 100–110 or eGFR 30–60. Consider stopping if K⁺ >5.4.
Amiodarone	TSH, fT3, fT4, LFTs, U&E, CXR, ECG, thyroid ab	TFTs + LFTs 6-monthly (incl. 12 months after stopping)	CXR if pulmonary toxicity suspected; new dyspnoea/cough may signal lung toxicity.
Dronedarone	LFTs, ECG	LFTs + U&E	LFTs & U&E at 1 week, repeat U&E after 7 days if creatinine rises; LFTs monthly ×6, then 3-monthly ×6, then annually — stop if ALT >3× ULN twice. ECG + pulmonary review 6-monthly.
Digoxin	U&E	U&E	Routine levels not needed; check if toxicity suspected, significant weight loss, hypokalaemia or hypothyroidism — sample ≥6 h (ideally 8–12 h) post-dose.
Ivabradine	HR	HR	Don't initiate if resting HR <70 (<75 in HF); reduce/stop if persistently <50 bpm.
Thiazide / related diuretics	U&E	U&E, HbA1c	U&E at 4–6 weeks & after dose change, then 6–12-monthly — stop if eGFR <30. HbA1c 12-monthly (or per diabetes review).
Eplerenone	U&E	U&E	U&E at 1 week, then monthly ×3, then 6-monthly; plus at 1 & 4 weeks after any dose increase.
Spironolactone	U&E	U&E	Severe HF (NYHA III–IV): U&E after 1 week & any dose increase, then monthly ×3, 3-monthly ×1 yr, then 6-monthly. Other: U&E at 1 month, monthly ×3, 3-monthly ×1 yr, then 6-monthly.
Loop diuretics	U&E	U&E	U&E 1–2 weeks after initiation/dose increase (after 5–7 days if renal impairment or on ACEi/ARB/MRA; within 5 days then 5–14-daily if loop + thiazide). Monitor weight/hydration; 6-monthly once stable.
Fibrates	LFTs, CK, lipids, U&E	LFTs, U&E, lipids	LFTs 3-monthly year 1 then annually; U&E (fenofibrate) first 3 months then annually; lipids — stop if inadequate at 3 months; CK only if myopathy suspected; gemfibrozil → FBC 3-monthly year 1.
Statins	LFTs, U&E, lipids (CK only if persistent unexplained muscle pain)	Lipids, LFTs	Aim ≥40% non-HDL-C reduction; LFTs at 3 & 12 months (no re-measure unless symptoms of hepatotoxicity). CK before starting: if >5× ULN, recheck after 7 days & don't start if still >5×.
Warfarin	INR, FBC, U&E, LFTs, BP	INR	INR ≥ every 12 weeks once stable; more often if health/medication changes. BP for HAS-BLED.
DOACs (apixaban, rivaroxaban, dabigatran, edoxaban)	U&E & CrCl, LFTs, FBC, weight, BP (HAS-BLED)	U&E, LFTs, FBC	Use Cockcroft–Gault CrCl, not eGFR: <75 yrs & CrCl >60 → annual U&E; ≥75 yrs or CrCl 30–60 → 6-monthly; CrCl 15–30 → 3-monthly. Recalculate with any acute illness. Annual LFTs & FBC.

Respiratory

Drug	Baseline	Routine	Comments
Theophylline	U&E, LFTs, smoking status	Drug level, U&E	Plasma level 2–6 weeks after dose change & once maintenance reached, or if toxicity suspected. Range 10–20 mg/L; sample 4–6 h post-dose. Dose changes if starting/stopping smoking.

Infections

Drug	Baseline	Routine	Comments
Nitrofurantoin	U&E	—	Contraindicated if eGFR <45 (short course with caution 30–44). Prophylaxis ≤6 months under urology; watch pulmonary fibrosis (esp. elderly); BNF advises 6-monthly LFTs on long-term use.
Minocycline	LFTs	FBC + LFTs	3-monthly. Watch hepatotoxicity, SLE-like reaction, pigmentation. Not a preferred option.
Terbinafine (oral)	LFTs	LFTs	Recheck LFTs 4–6 weeks after initiation.

Endocrine & diabetes

Drug	Baseline	Routine	Comments
Levothyroxine	TSH, T4, ECG	TSH	Recheck 6–8 weeks after a dose change, then 12-monthly once stable.
Carbimazole / propylthiouracil	TFTs, FBC, LFTs	TFTs; FBC; LFTs	TFTs every 1–3 months until stable then 12-monthly (6-monthly if block-and-replace). FBC immediately if infection signs (sore throat, mouth ulcers, bruising, fever). PTU LFTs at 3 & 6 months then annually.
Metformin	U&E	U&E	12-monthly (6-monthly if elderly/worsening renal function). Max 1 g/day if eGFR 30–45; stop <30 or during acute illness/contrast.
Pioglitazone	LFTs, weight	LFTs	Advise to report nausea/vomiting/abdominal pain/dark urine; stop if jaundice. Monitor weight for heart-failure signs.
Gliptins	U&E, LFTs, HbA1c	LFTs, HbA1c, U&E	Vildagliptin LFTs 3-monthly year 1 then annually. HbA1c 2–6-monthly; stop if not reduced ≥5.5 mmol/mol within 6 months. U&E 6-monthly.
GLP-1 (dulaglutide, exenatide, liraglutide, etc.)	Weight, HbA1c	Weight, HbA1c	3-monthly. Discontinue if HbA1c not reduced ≥11 mmol/mol and ≥3% weight loss not achieved at 6 months.
Insulin / sulfonylurea	HbA1c, U&E	HbA1c	Hypoglycaemia review; sick-day plan (don't omit insulin in T1DM); DVLA advice.
Ulipristal (Esmya, fibroids)	LFTs (before each course)	LFTs	Do not initiate if ALT/AST >2× ULN. Monitor monthly during the first 2 treatment courses, and thereafter if clinically indicated; repeat 2–4 weeks after stopping. Test immediately in current/recent users with signs of liver injury; stop if ALT/AST >3× ULN.

Musculoskeletal & immunosuppression

Drug	Baseline	Routine	Comments
Methotrexate	FBC, LFTs, U&E	FBC, LFTs, U&E	Per shared-care (typically 2–3-monthly once stable). Folic acid co-prescribed; never with trimethoprim/co-trimoxazole (marrow suppression).
DMARDs / immunosuppressants	FBC, LFTs, U&E	FBC, LFTs, U&E	Per CDDFT/shared-care monitoring schedule; infection vigilance; avoid live vaccines.
NSAIDs	U&E, BP	U&E, BP	Monitor renal function in renal, cardiac or hepatic impairment; gastroprotection where indicated; avoid in CKD <30 and the "triple whammy".
Bisphosphonates	U&E, calcium, vit D	—	Correct calcium/vit D first; review need at 3–5 years (drug holiday). Avoid if eGFR <35 (drug-specific).

CNS / psychotropics

Drug	Baseline	Routine	Comments
Lithium	U&E, TFTs, calcium, weight, ECG if cardiac risk	Level; TFTs + U&E + calcium	Level 3-monthly (12 h post-dose); TFTs, U&E & calcium 6-monthly. Avoid dehydration/NSAIDs; narrow therapeutic index.
Valproate	FBC, LFTs	LFTs	LFTs in first 6 months. Pregnancy Prevention Programme — contraindicated in women of childbearing potential unless PPP conditions met.
Antipsychotics	FBC, U&E, LFTs, lipids, HbA1c, weight, ECG, prolactin	Weight, HbA1c/glucose, lipids	Metabolic monitoring at 12 weeks, annually (weight more often early). Follow local psychotropic monitoring guide.

DOAC dosing in renal impairment — see the Prescribing in CKD tab for the full CrCl-based dose table (apixaban, rivaroxaban, dabigatran, edoxaban).

See the Sick-day rules and Prescribing in CKD tabs for how these drugs interact with acute illness and falling eGFR.

Who gets free NHS prescriptions (England)

🎂 Age

🤰 Maternity (MatEx)

🏥 Medical exemption (MedEx — apply via FP92A)

💷 Low income & benefits

Writing a legally valid FP10

✅ Every prescription must have

⚠️ Controlled drugs (Sch 2 & 3) — extra legal rules

🎨 Common FP10 variants

Items GPs are asked not to prescribe

🛒 The 35 conditions — OTC items not to routinely prescribe

📉 Low clinical-value medicines

✅ When OTC prescribing IS still appropriate

The traffic-light (RAG) system — who prescribes what

Not in Greater Manchester? Follow your local list

GREEN

AMBER

RED

GREY / not recommended

Adrenal crisis is a medical emergency

👥 Who needs steroid sick-day rules

🤒 Moderate illness (oral rules)

🤮 Can't keep tablets down → inject

📋 Patient advice — copy into the record / message

The golden rule: never stop insulin

🩸 Core diabetes sick-day rules (insulin or hypo-causing drugs)

⏸️ Drugs to hold in diabetes during dehydrating illness

📞 When to escalate

📋 Patient advice — copy into the record / message

Pause during acute dehydrating illness

🔤 The "SAD MANS" drugs to hold

Sulfonylureas

ACE inhibitors

Diuretics

Metformin

ARBs

NSAIDs

SGLT2 inhibitors

⚠ Special caution — SGLT2 inhibitors

🩸 Don't stop these

📋 Patient advice — copy into the record / message

Time-critical medicines — do not stop or delay

🧠 Parkinson's — levodopa & PD drugs

⚡ Epilepsy — anti-epileptic drugs

💉 Insulin & steroids

🩸 Anticoagulants & others

Narrow-therapeutic-index drugs — review dose & monitor

🧂 Lithium

❤️ Digoxin

🩸 DOACs & warfarin

💊 Other level-sensitive drugs

Sore throat, mouth ulcers, fever or flu-like illness on these drugs = possible agranulocytosis

🦋 Antithyroid drugs — carbimazole / propylthiouracil

🧠 Clozapine

💊 Immunosuppressants & DMARDs — hold during significant infection, seek advice

⚠ Other drugs that can cause agranulocytosis

🩸 Don't forget

📋 Patient advice — copy into the record / message

Condition flare / self-management plans

🌬️ Asthma

🫁 COPD

❤️ Heart failure

🩹 Other plans

Drugs to avoid or stop as eGFR falls

Drugs that need dose reduction by eGFR

Sick-day rules to prevent AKI — "SAD MANS"

🧯 S A D — M A N S

⚠️ Practical points

eGFR stage thresholds & what changes

Common CKD prescribing problems

📉 "eGFR has dropped a stage"

💊 "Started ACEi/ARB — creatinine rose"

🩻 "Needs a CT with contrast"

🦠 "UTI in CKD"

😣 "Needs pain relief in CKD"

🩺 "When to refer to nephrology"

Check every drug against a specialist source

Known or likely teratogens — avoid / stop

Common switch scenarios

🫀 Hypertension