Welcome to the January edition of Tablets, a prescribing newsletter produced monthly by the Medicines Management team at Midlands and Lancashire CSU.
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Recommendations
BLACK CO-PROXAMOL tablets
The Pan Mersey Area Prescribing Committee does not recommend the prescribing of CO-PROXAMOL tablets.
https://www.panmerseyapc.nhs.uk/media/2063/co-proxamol.pdf
BLACK OXYCODONE with NALOXONE modified release tablets (Targinact®) for adults with chronic pain
The Pan Mersey Area Prescribing Committee does not recommend the prescribing of OXYCODONE with NALOXONE modified release tablets (Targinact®) for adults with chronic pain.
https://www.panmerseyapc.nhs.uk/media/2069/oxycodonenaloxone_pain.pdf
BLACK Acetylcysteine for idiopathic pulmonary fibrosis
The Pan Mersey Area Prescribing Committee does not recommend the prescribing of oral acetylcysteine in idiopathic pulmonary fibrosis.
https://www.panmerseyapc.nhs.uk/media/2097/acetylcysteine_idp.pdf
RED TOFACITINIB film-coated tablets (Xeljanz®▼) for Psoriatic Arthritis
The Pan Mersey Area Prescribing Committee recommends the prescribing of TOFACITINIB tablets (Xeljanz®▼), by specialists only, for treating psoriatic arthritis after inadequate response to DMARDs in accordance with NICE TA543.
https://www.panmerseyapc.nhs.uk/media/2108/tofacitinib_psa.pdf
GREY RIVAROXABAN 2.5mg tablets (Xarelto®▼) for the prevention of atherothrombotic events
The Pan Mersey Area Prescribing Committee does not recommend the prescribing of RIVAROXABAN 2.5mg tablets (Xarelto®▼) for the prevention of atherothrombotic events in adult patients with coronary artery disease (CAD) or symptomatic peripheral artery disease (PAD) at high risk of ischaemic events – in combination with aspirin.
https://www.panmerseyapc.nhs.uk/media/2093/rivaroxaban_ad.pdf
AMBER RECOMMENDED Midazolam buccal solution (Epistatus® brand)
Seizures. Additional option to Buccolam brand (Epistatus smaller volume, more viscous to aid administration). £46 compared to £23 per dose, but minimal cost implication anticipated as low volume use and available as single pack rather than multi-pack.
AMBER RETAINED METHADONE tablets (Physeptone®)
The Pan Mersey Area Prescribing Committee recommends the prescribing of methadone tablets (Physeptone®) in adults following initiation by a consultant in pain medicine in a tertiary centre.
https://www.panmerseyapc.nhs.uk/media/2094/methadone.pdf
https://www.panmerseyapc.nhs.uk/media/2095/methadone_support.pdf
https://www.panmerseyapc.nhs.uk/media/2096/methadone_letter.docx
GREEN Levonorgestrel intrauterine device (Kyleena® brand)
Contraception. Additional option to maximise patient choice. Less expensive: £76 / 5 years compared to £69 / 3 years (for Jaydess® brand)
GREEN Pramipexole, ropinirole, rotigotine
Restless legs syndrome. Change of RAG designation from amber recommended as suitable for initiation in primary care for this indication (remain amber recommended in Parkinson’s disease). Minimal cost implication anticipated.
GREEN Tiotropium
Asthma. Routine update of current statement. RAG status changed from Amber Recommended following updated NICE and BTS guidance. Minimal cost implication anticipated.
https://www.panmerseyapc.nhs.uk/media/2070/tiotropium_asthma.pdf
GREEN IVERMECTIN 10mg/g Cream (Soolantra®)
The Pan Mersey Area Prescribing Committee recommends the prescribing of IVERMECTIN 10mg/g cream (Soolantra®) for second line topical treatment of moderate to severe papulopustular rosacea in adult patients.
https://www.panmerseyapc.nhs.uk/media/2092/ivermectin.pdf
Guidelines
Hypersalivation in Children and Adults
Adult patients with Parkinson’s disease, children with neurodisability, cerebral palsy, long-term ventilation with drooling, and drug-induced hypersalivation.
https://www.panmerseyapc.nhs.uk/media/2066/hypersalivation.pdf
DEMENTIA: behavioural and psychological symptoms (BPSD), use of antipsychotics
The Pan Mersey Area Prescribing Committee recommends that antipsychotics prescribed for BPSD should be initiated by a dementia specialist and reviewed in accordance with NICE/SCIE guidelines.
https://www.panmerseyapc.nhs.uk/media/2104/dementia_bpsd.pdf
GENERALISED ANXIETY DISORDER in adults
Pharmacological treatment pathway 2018
https://www.panmerseyapc.nhs.uk/media/2098/gad.pdf
NEUROPATHIC PAIN, pharmacological management in non-specialist settings
This guideline is for use in primary care for initial management, not in specialist pain service settings.
https://www.panmerseyapc.nhs.uk/media/2103/neuropathicpain.pdf
Formulary Updates
RED TERIPARATIDE for osteoporosis in males
Now commissioned by NHS England. CCGs will no longer fund for treatment in males (PBR excluded drug).
RED ITRACONAZOLE for Chronic pulmonary aspergillosis
This indication is commissioned by NHS England.
AMBER RECOMMENDED Cortiment® (budesonide m/r) for Crohn’s disease
This is now an equivalent option to Clipper® (beclomethasone m/r).
AMBER RECOMMENDED Pilocarpine tablets FOR Dry mouth caused by irradiation for head & neck cancers and Sjogren’s Syndrome
Change in RAG rating from Red to Amber Recommended to reflect that almost all the prescribing is in primary care.
GREEN Evolve HA® eye drops (sodium hyaluronate 0.2% eye drops) for Dry eyes
Additional lower-cost brand to be 1st-line option. (Evolve HA® £5.99, Hyloforte® £9.50 per 10ml). Counsel patient that container is softer than conventional container requiring less pressure to administer single drop.
GREEN GABAPENTIN AND PREGABALIN for restless legs syndrome
Additional RAG designation clarifying as suitable for initiation in primary care for this indication, 2nd line option to dopaminergic agents (off-label indication). Minimal cost implication anticipated.
Antimicrobial Prescribing
Introduction
General prescribing advice. Routine review of current chapter. Includes signposting to advice for prescribing in pregnancy and considerations when prescribing for children.
https://www.panmerseyapc.nhs.uk/media/2067/introduction.pdf
Genital Tract Infections
Chalmydia update
http://formulary.panmerseyapc.nhs.uk/chaptersSubDetails.asp?FormularySectionID=27&SubSectionRef=27.11&SubSectionID=A100&drugmatch=5571#5571
Fungal nfections
http://formulary.panmerseyapc.nhs.uk/chaptersSubDetails.asp?FormularySectionID=27&SubSectionRef=27.13&SubSectionID=A100
Miscellany
Treatment of Splenectomy Patients
http://formulary.panmerseyapc.nhs.uk/chaptersSubDetails.asp?FormularySectionID=27&SubSectionRef=27.14&SubSectionID=A100v
Outpatient Parenteral Antimicrobial Therapy (OPAT)
http://formulary.panmerseyapc.nhs.uk/chaptersSubDetails.asp?FormularySectionID=27&SubSectionRef=27.15&SubSectionID=A100
Antimicrobial Prophylaxis: Endocarditis and Malaria
http://formulary.panmerseyapc.nhs.uk/chaptersSubDetails.asp?FormularySectionID=27&SubSectionRef=27.17&SubSectionID=A100
Current statutorily notifiable diseases and food poisoning (2017) http://formulary.panmerseyapc.nhs.uk/chaptersSubDetails.asp?FormularySectionID=27&SubSectionRef=27.18&SubSectionID=A100
List of Contributors
http://formulary.panmerseyapc.nhs.uk/chaptersSubDetails.asp?FormularySectionID=27&SubSectionRef=27.19&SubSectionID=A100
Useful Contact Numbers
http://formulary.panmerseyapc.nhs.uk/chaptersSubDetails.asp?FormularySectionID=27&SubSectionRef=27.20&SubSectionID=A100
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Guidelines for Pharmacological Management of Overactive Bladder Syndrome (OAB) in Adults in Primary Care
Wirral CCG have approved and adopted the Pan Mersey overactive bladder guidance. The full guidelines can be found at:
https://www.panmerseyapc.nhs.uk/media/2036/oab_adult_201701_v0202.pdf
Main differences/additions include:
- Treatment of nocturnal symptoms – tricyclic antidepressants e.g. amitryptyline is not recommended as per NICE guidelines
- Vesomni® (solifenacin 6mg + Tamsulosin MR 400 micrograms) – Pan Mersey APC does not recommend the routine use of this drug in primary care.
Patient Led Repeat Ordering Scheme Update
Background
Prescribing is the most common patient-level intervention and it is the second highest area of spending in the NHS, after staffing costs. Repeat prescriptions represent approximately 60-75% of all prescriptions and approximately 80% of primary care prescribing costs.
On Wirral around £2.1 million of wasted medicines are disposed of every year. NHS Wirral CCG is committed to improving the overall management of repeat prescribing systems in primary care, not only to reduce costs but also to improve patients’ safety. The change to patient led repeat ordering supports these aims and focuses on improving the control of ordering by practices.
The Wirral ‘Patient Led Repeat Ordering Project’ started with a pilot led by NHS Wirral CCG in eight Wirral GP practices over a five-month period from November 2016 to March 2017. From April 2017, NHS Wirral CCG began to implement the approach across all Wirral GP practices.
Over a year on the scheme is going very well, and we have seen a reduction in prescription items which supports our aims to reduce medication waste and improve patient safety.
For further information please visit the recently updated NHS Wirral CCG website page, which contains the key messages for patients/carers/nominated family member or friend and a prescription alignment form if the repeat prescription medication needs syncing, at; https://www.wirralccg.nhs.uk/your-health-and-services/changes-to-the-way-you-order-repeat-prescriptions-in-wirral/
Patients Excluded from the ‘Patient Led Repeat Ordering’ Scheme
As part of the implementation process, practices were advised to work with their local community pharmacies to create a list of patients who they felt should be ‘excluded’ from the scheme due to a certain reason, for example, vulnerable patients, patients with dementia or patients who have no-one to support them with the ordering. It was also recommended that practices should share the initial list with the appropriate pharmacies so that they could record the exclusion in the patient records. This patient list should be regularly reviewed, for example each month, by the practice and in collaboration with the local pharmacies so that if any changes are made the pharmacy can update their records.
At the end of 2018 practices and community pharmacies were asked to action the following;
GP Practices;
- Please display the key messages for patients/carers within the GP practice via your preferred route of communication, for example, email to patients, on the practice website, in the practice newsletter, on a noticeboard in the waiting room. The prescription alignment form is also included for use within the practice if necessary.
- Please ensure that your vulnerable patients are regularly reviewed and that the appropriate community pharmacies are informed of any changes. For any queries please contact abigailcowan@nhs.net
Community Pharmacies;
- Please display the key messages for patients/carers within the community pharmacy. The prescription alignment form is available for use within the pharmacy if necessary.
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Items which should not routinely be prescribed in primary care: an update and consultation on further guidance for CCGs
In 2017, the cost of prescriptions dispensed in the community was £9.17 billion. This cost coupled with finite resources means it is important that the NHS achieves the greatest value from the money that it spends. Across England there is significant variation in what is being prescribed and to whom. Often patients are receiving medicines and products which have been proven to be ineffective or in some cases dangerous, for which there are other more effective, safer and/or cheaper alternatives.
NHS England has partnered with NHS Clinical Commissioners to support Clinical Commissioning Groups (CCGs) in ensuring that they can use their prescribing resources effectively and deliver best patient outcomes from the medicines and products that their local population uses.
The aim is that this will lead to a more equitable process for making decisions about guidance on medicines, but CCGs will need to take individual decisions on implementation locally.
In November 2017 ‘Items which should not routinely be prescribed in primary care: Guidance for CCGs’, was published and is available at; https://www.england.nhs.uk/publication/items-which-should-not-be-routinely-prescribed-in-primary-care-guidance-for-ccgs/
Following on from this, NHS England and NHS Clinical Commissioners have identified a number of further products which fall under the criteria of products with low clinical value and the addition of further guidance on rubificants.
To provide information about the proposed national guidance and to seek views about these proposals, a consultation has been set up. The consultation period runs from 28th November 2018 - 28th February 2019 and the consultation document sets out proposals for a review and update of the guidance, published in November 2017. For further information please see the consultation document at;
https://www.engage.england.nhs.uk/consultation/items-routinely-prescribed-update/user_uploads/low-priority-prescribing-consultation-guidance.pdf
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Please click here for a summary of safety updates and SPC updates in November.
Hydrochlorothiazide: risk of non-melanoma skin cancer, particularly in long-term use
Medicines and Healthcare Products Regulatory Agency | 14 November 2018
This update advises that patients taking hydrochlorothiazide-containing products should be informed of the cumulative, dose-dependent risk of non-melanoma skin cancer, particularly in long-term use, and the need to regularly check for (and report) any suspicious skin lesions or moles. Counsel patients to limit exposure to sunlight and UV rays and to use adequate sun protection.
Systemic and inhaled fluoroquinolones: small increased risk of aortic aneurysm and dissection; advice for prescribing in high-risk patients
Medicines and Healthcare Products Regulatory Agency | 14 November 2018
Owing to these reports, this advice details that in patients at risk for aortic aneurysm and dissection (e.g. family history), fluoroquinolones should only be used after careful assessment of the benefits and risks and after consideration of other therapeutic options.
European CHMP endorses suspension or restrictions of quinolone and fluoroquinolone antibiotics due to disabling and potentially permanent adverse effects
European Medicines Agency | 16 November 2018
Following a PRAC review of adverse effects involving muscles, tendons and bones and the nervous system, the CHMP has endorsed suspension of medicines containing cinoxacin, flumequine, nalidixic acid, and pipemidic acid and restrictions on use of other fluoroquinolone antibiotics.
Cannabidiol oil – potential adverse effects and drug interactions
Specialist Pharmacy Services | 30 November 2018
Due to an increasing popularity of self-administration of over-the-counter bought cannabidiol oil, doctors and pharmacists should be aware of its potential adverse effects and interactions. Available data suggests it interacts with cytochrome p450 enzymes.
Nutilis Clear Product Update – New Scoop and Mixing Instructions
Pharmaceutical Services Negotiating Committee | 30 November 2018
Thickened drinks are changing from ‘Stage 1, 2 and 3’ to IDDSI (International Dysphagia Diet Standardisation Initiative) Levels 1 – 4. To meet these changes, the scoops in tins of Nutilis Clear are changing from a purple 3g scoop to a green 1.25g scoop with new directions for use
Please click here for a summary of safety updates and SPC updates in December.
In use product safety assessment report for enoxaparin biosimilars (INHIXA and AROVI)
Specialist Pharmacy Service | 12 December 2018
This assessment on Inhixa and Arovi (enoxaparin biosimilars) describes the in-use medication safety considerations resultant from the products’ presentation or other pre-defined characteristics. Potential next steps and mitigation actions are suggested.
Emollients: new information about risk of severe and fatal burns with paraffin-containing and paraffin-free emollients
Medicines and Healthcare products Regulatory Agency | 18 December 2018
Warnings about risk of severe and fatal burns are being extended to all paraffin-based emollients regardless of paraffin concentration. Data suggest there is also a risk for paraffin-free emollients. Patients who use these products are advised not to smoke/go near naked flames.
Hydrocortisone muco-adhesive buccal tablets: should not be used off-label for adrenal insufficiency in children due to serious risks
Medicines and Healthcare products Regulatory Agency | 18 December 2018
Alert reiterates hydrocortisone muco-adhesive buccal tablets are indicated only for local use in the mouth for aphthous ulceration; and if incorrectly used for treating adrenal insufficiency, there is risk of insufficient cortisol absorption and life-threatening adrenal crisis.
Valproate medicines: are you in acting in compliance with the pregnancy prevention measures?
Medicines and Healthcare products Regulatory Agency | 18 December 2018
The MHRA has noted there is wide variation in prescribing between CCGs and women continue to report instances when they have not received patient information with their dispensed valproate (VP) medicine. All healthcare professionals must continue to identify/review all female patients on VP.
Herbal skin cream found to contain steroids
Medicines and Healthcare products Regulatory Agency | 19 December 2018
The MHRA advises that a skin cream claiming to be a natural Chinese herbal remedy for treating eczema (Zudaifu), contains a potentially harmful steroid (clobetasol) and should not be used.
What information is available on drugs in diving?
Specialist Pharmacy Service | 21 December 2018
This Q & A highlights that professional divers are required by law to undergo a medical assessment by a clinician trained in diving medicines; and the underlying condition for which medications are being taken will be one of the most important considerations.
What is the first choice antidepressant for patients with renal impairment?
Specialist Pharmacy Service | 21 December 2018
This Q & A states the majority of antidepressants can be used in renal impairment with caution; however side effects may be enhanced and extra caution may be needed when switching between antidepressants as half-lives may be extended.
What is the risk of interaction between opioids and monoamine oxidase inhibitors (MAOIs)?
Specialist Pharmacy Service | 21 December 2018
This Q & A states given widespread availability of suitable alternative drugs, the combination of dextromethorphan, methadone, tramadol, fentanyl or tapentadol with an MAOI should be avoided, including in the 14 day period following the withdrawal of an irreversible MAOI.
Which opioids can be used in renal impairment?
Specialist Pharmacy Service | 21 December 2018
This Q & A states renal impairment not only alters the clearance of the parent compound but also affects the accumulation of its metabolites; elimination may also be prolonged. Recommendations for adjustment of doses are based on pharmacokinetic studies and clinical experience.
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NICE Guidance November 2018
There have been two guidelines published in November 2018 by the National Institute for Clinical Excellence which has impact upon primary care.
The Heavy menstrual bleeding guideline has been updated. The guideline was updated to reinstate recommendations on ulipristal acetate (Esmya®) in line with the European Medicines Agency review.
The Urinary tract infection (catheter-associated): antimicrobial prescribing guideline has been published. The guideline sets out an antimicrobial prescribing strategy for catheter-associated urinary tract infection in children, young people and adults.
The following below guidelines have also been released and they aim to provide an antimicrobial prescribing strategy to optimise antibiotic use and reduce antibiotic resistance.
Clinicians should be aware of these guidelines and implement any necessary changes to their practice.
CKS Updates November 2018
During the month of November 2018, the following Clinical Knowledge Summaries were updated:
There have been minor restructures to the topics listed above. Clinicians can use the updated and new information when reviewing patients.
NICE Guidance December 2018
There have been five guidelines published in December 2018 by the National Institute for Clinical Excellence which has impact upon primary care.
The Antenatal care for uncomplicated pregnancies guideline has been updated. A link to the UK CMO’s low risk-drinking guideline has replaced the existing recommendations on alcohol consumption in pregnancy.
The Post-traumatic stress disorder guideline has been published and replaces previous guidance from 2005. The guidance sets out recognising, assessing and treating post-traumatic stress disorder (PTSD) in children, young people and adults.
The Chronic obstructive pulmonary disease in over 16s guideline replaces guidance from June 2010. The guideline sets out diagnosing and managing chronic obstructive pulmonary disease (COPD) in people aged 16 and older, which includes emphysema and chronic bronchitis.
The Chronic obstructive pulmonary disease (acute exacerbation): antimicrobial prescribing guideline has been published. The guideline sets out an antimicrobial prescribing strategy for acute exacerbations of COPD.
The Bronchiectasis (non-cystic fibrosis), acute exacerbation: antimicrobial prescribing guideline has been published. The guideline sets out an antimicrobial prescribing strategy for managing and preventing acute exacerbations of bronchiectasis (non-cystic fibrosis).
Clinicians should be aware of these guidelines and implement any necessary changes to their practice.
CKS Updates December 2018
There were no CKS updates during the month of December 2018.
Useful Resources
New online resource available for adults with Type 1 diabetes
The NHS diabetes programme have developed new content which is accessible on the NHS UK website. This has been developed in collaboration with its partners Diabetes UK and NHS Digital. Further information on how the content can be utilised has been relayed in a letter from Dr Partha Kar, NHS England Deputy Clinical Director Diabetes.
Acute Kidney Injury (AKI)
Resources to support the NHS campaign to improve the care of people at risk of, or with, Acute Kidney Injury can be accessed via the Think Kidneys website.
Practices should ensure patients at risk of AKI are identified and medication reviews are carried out. Advice should be given on measures to help prevent AKI and actions to be taken if they are unwell.
BNF App drug interactions checker
The BNF App is a free drug interaction checker which can be downloaded free of charge on smart phones and tablets via this link. This app should be utilised by all prescribers particularly when prescribing outwith the support of a prescribing support software e.g. during clinical system failure, home visit.
TARGET Antibiotics -Prescribing in Primary Care online CPD course
A new free to access online CPD course starting 28 January 2019 has been produced in collaboration between the British Society of Antimicrobial Chemotherapy and TARGET. The course is aimed at primary care healthcare professionals who are involved in the treatment of common infections. Topics will be released every week for 7 weeks, including:
- Introduction to Antimicrobial Resistance in Primary Care
- Prescribing in Urinary Tract Infections
- Assessing the Need for Antibiotics
- Managing Patient Expectations and Back up/Delayed Prescribing
- Antibiotics for Children
- Common Practice Approach
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