Welcome to the April edition of Tablets, a prescribing newsletter produced monthly by the Medicines Management team at Midlands and Lancashire CSU.
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New Medicines
RED PITOLISANT Tablets (Wakix®▼)
The Pan Mersey Area Prescribing Committee recommends the prescribing of PITOLISANT tablets (Wakix®▼), by specialists working in a regional and national tertiary commissioned sleep service only, for the treatment of Narcolepsy with or without cataplexy in those who are contraindicated or have not tolerated other standard treatments.
https://www.panmerseyapc.nhs.uk/media/2180/pitolisant.pdf
RED SODIUM OXYBATE Oral Solution (Xyrem®)
The Pan Mersey Area Prescribing Committee recommends SODIUM OXYBATE oral solution (Xyrem®) as a treatment option for Narcolepsy with cataplexy in adult patients only when recommended by a consultant in a specialist commissioned sleep service.
https://www.panmerseyapc.nhs.uk/media/2179/sodiumoxybate.pdf
GREY ERTUGLIFLOZIN film-coated tablets (Steglatro®▼)
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of ERTUGLIFLOZIN film-coated tablets (Steglatro®▼) for use as part of a triple therapy regimen for the treatment of type 2 diabetes.
https://www.panmerseyapc.nhs.uk/media/2177/ertugliflozin_triple.pdf
GREY DEOXYCHOLIC ACID injection (Belkyra®▼)
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of DEOXYCHOLIC ACID injection (Belkyra®▼) for submental (under chin) fat.
https://www.panmerseyapc.nhs.uk/media/2151/deoxycholic.pdf
GREY TILDRAKIZUMAB solution for injection (Ilumetri®▼)
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of TILDRAKIZUMAB solution for injection (Ilumetri®▼) for the treatment of plaque psoriasis.
https://www.panmerseyapc.nhs.uk/media/2163/tildrakizumab_plaquepsoriasis.pdf
GREEN ERTUGLIFLOZIN film-coated tablets (Steglatro®▼) as monotherapy or with metformin for treating type 2 diabetes
The Pan Mersey Area Prescribing Committee recommends the prescribing of ERTUGLIFLOZIN film-coated tablets (Steglatro®▼) as monotherapy or with metformin for treating type 2 diabetes in accordance with NICE TA572.
https://www.panmerseyapc.nhs.uk/media/2176/ertugliflozin_monodual.pdf
Formulary
BLACK Ascorbic acid tablets
The Pan Mersey Area Prescribing Committee does not recommend the prescribing of ASCORBIC ACID for any indication, other than scurvy.
https://www.panmerseyapc.nhs.uk/media/2173/ascorbicacid.pdf
BLACK Lactase enzyme drops 50,000 units/g (Colief®)
The Pan-Mersey Area Prescribing Committee recommends that Lactase Enzyme Drops 50,000 units/g (Colief®) are not prescribed on the NHS. Patients are advised to purchase Colief® if they wish.
https://www.panmerseyapc.nhs.uk/media/2172/lactase.pdf
RED Drugs used in medically assisted reproduction
Clarification that use of any drug in medically assisted reproduction is designated red, even where the drug has an alternative designation for other indications.
http://formulary.panmerseyapc.nhs.uk/chaptersSub.asp?FormularySectionID=7
AMBER INITIATED Aviptadil 25micrograms + phentolamine 2mg intracavernosal injection (Invicorp®)
Additional option to alprostadil in treatment of erectile dysfunction where oral therapy unsuitable.
http://formulary.panmerseyapc.nhs.uk/searchresults.asp?SearchVar=aviptadil
AMBER INITIATED Hydrocortisone granules 0.5mg, 1mg, 2mg and 5mg (Alkindi®)
Licensed formulation for use instead of unlicensed “special”. The unlicensed “special” to be retained for children requiring dose increments of less than 0.5mg.
http://formulary.panmerseyapc.nhs.uk/chaptersSub.asp?FormularySectionID=6
GREEN Calcium carbonate 750 mg + colecalciferol 200 units caplets
Additional formulation for patients who cannot swallow/ chew higher dose formulations.
http://formulary.panmerseyapc.nhs.uk/chaptersSub.asp?FormularySectionID=9
GREEN Ibuprofen and naproxen oral formulations
The Pan Mersey Area Prescribing Committee recommends the prescribing of IBUPROFEN (low dose) and NAPROXEN (low dose) as the non-steroidal anti-inflammatory drugs (NSAIDs) of choice, if an NSAID is appropriate.
https://www.panmerseyapc.nhs.uk/media/2174/ibuprofennaproxen.pdf
GREEN Preferred choice direct – acting oral anti-coagulant (DOAC)
The Pan Mersey APC recommends, in the absence of a specific clinical reason to select a particular DOAC, that the least costly DOAC is the first line DOAC for patients with non-valvular AF. Currently this is edoxaban.
http://formulary.panmerseyapc.nhs.uk/chaptersSub.asp?FormularySectionID=2
Chapter 3 Respiratory system
Routine update of chapter.
http://formulary.panmerseyapc.nhs.uk/chaptersSub.asp?FormularySectionID=3
Chapter 12 Ear, nose and oropharynx
Routine update of chapter.
http://formulary.panmerseyapc.nhs.uk/chaptersSub.asp?FormularySectionID=12
Definitions and Criteria for the Categorisation of Medicines in Pan Mersey
Updated to reflect that specialists may be located in specifically commissioned services in community settings, as well as hospitals.
https://www.panmerseyapc.nhs.uk/media/1393/rag_criteria.pdf
Guidelines
AMBER INITIATED Insulin – criteria for transfer of prescribing to primary care
Before requesting that Primary Care take over prescribing of newly initiated insulin the specialist team must be assured that the patient is willing, competent and trained to: administer the insulin (or District Nurse arranged); if and when required amend the dose of the insulin, either with the support of their diabetes HCP or independently.
During this time prior to requesting Primary Care take over prescribing, the specialist team must maintain clinical responsibility, review the patient (either face to face or by telephone) and prescribe the insulin and administration devices for: a minimum of 4 weeks supply; OR a supply length that allows enough time for the patient to be reviewed by the specialist team, whichever of the above is the longer.
A copy of the final review must be sent to the primary care prescriber with the request for transfer of prescribing.
http://formulary.panmerseyapc.nhs.uk/chaptersSub.asp?FormularySectionID=6
Asthma guideline in primary care – adults
Updated guideline based on current BTS/SIGN British Asthma guideline in preference to NICE guideline.
https://www.panmerseyapc.nhs.uk/media/2171/asthma_adult.pdf
Paediatric chronic pain guideline
Incorporation of previously agreed restrictions on use of lidocaine plaster into the paediatric chronic pain guideline.
https://www.panmerseyapc.nhs.uk/media/2175/pain_children.pdf
Prescribing support
Hydroxychloroquine
Minor amendments to documentation to decrease in recommended maximum daily dose and emphasise that specialist is responsible for arranging and managing eye monitoring.
https://www.panmerseyapc.nhs.uk/media/2181/hydroxychloroquine_prescribing.pdf
Safety
PARAFFIN-BASED EMOLLIENTS: fire risk
The Pan Mersey Area Prescribing Committee recommends that the risk of fire should be considered when issuing paraffin-based emollient preparations.
https://www.panmerseyapc.nhs.uk/media/2170/emollient_firerisk.pdf
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Please click here for a summary of safety updates and SPC updates in March.
NIHR Signal: Medication to reduce stomach acid may increase risk of hip fractures
National Institute for Health Research Signal | 06 Mar
Expert commentary is provided for a meta-analysis of 24 observational studies (total n=2,103,800) which found that PPIs increased the risk of hip fracture by 20%. The findings don’t suggest stopping use of PPIs, but they should be used with caution, and no drug is totally safe.
https://discover.dc.nihr.ac.uk/content/signal-000743/medication-to-reduce-stomach-acid-may-increase-risk-of-hip-fractures
What is the sodium content of medicines?
Specialist Pharmacy Service | 06 Mar
This Q&A provides lists of preparations that could contain high levels of sodium, and so might be unsuitable for people with conditions associated with sodium retention (e.g hypertension, heart failure or renal impairment) or who are on a salt-restricted diet.
https://www.sps.nhs.uk/articles/what-is-the-sodium-content-of-medicines-2/
Chloramphenicol: is it safe in breastfeeding?
Central Specialist Pharmacy Service | 15 Mar
This updated Medicines Q&A discusses the safety of the antibiotic, chloramphenicol (systemic and ophthalmic), in breastfeeding women.
https://www.sps.nhs.uk/articles/chloramphenicol-is-it-safe-in-breastfeeding/
Fluoroquinolone Antibiotics: New Restrictions and Precautions Due To Very Rare Reports Of Disabling And Potentially Long-Lasting Or Irreversible Side Effects
Central Alerting System | 21 Mar
See alert for new restrictions and precautions for fluoroquinolone antibiotics (ciprofloxacin, levofloxacin, moxifloxacin, ofloxacin) following a review of disabling, long-lasting or potentially irreversible adverse reactions affecting musculoskeletal (including tendonitis and tendon rupture) and nervous systems with fluoroquinolone antibiotics.
https://www.cas.mhra.gov.uk/ViewAndAcknowledgment/viewAlert.aspx?AlertID=102852
Medicines with teratogenic potential: what is effective contraception and how often is pregnancy testing needed?
Medicines and Healthcare products Regulatory Agency | 21 Mar
MHRA has issued new guidance on contraceptive methods and frequency of pregnancy testing to reduce inadvertent exposures during pregnancy in a woman taking a medicine of teratogenic potential.
https://www.gov.uk/drug-safety-update/medicines-with-teratogenic-potential-what-is-effective-contraception-and-how-often-is-pregnancy-testing-needed
Triptans and SSRI or SNRI antidepressants - is there an interaction?
Specialist Pharmacy Service | 27 Mar
This Q&A advises that using these antidepressants together may have additive effects on the serotonin system with potential for adverse effects. Clinical experience however indicates that combined use is normally uneventful and they can be co-prescribed if clinically required.
https://www.sps.nhs.uk/articles/triptans-and-ssri-or-snri-antidepressants-is-there-an-interaction/
Direct Oral Anticoagulant (DOAC) Dosing in renal impairment
Drug and Therapeutics Bulletin | 28 Mar
In light of > 4,000 yellow card reports of DOAC-associated haemorrhagic events since their launch, the author of this editorial highlights the urgent need for national guidance to help clinicians prescribe DOACs safely, particularly for patients with declining renal function.
https://dtb.bmj.com/content/57/4/50
Valproate and the Pregnancy Prevention Programme: exceptional circumstances
British Journal of General Practice | 29 Mar
This editorial argues that there are exceptional circumstances, and personal and practical implications, that have not been adequately considered in the MHRA’s regulations on valproate prescribing.
https://bjgp.org/content/69/681/166
NICE publishes a summary of its guidance and other safety advice on valproate
National Institute for Health and Care Excellence | 29 Mar
Summary sheet brings together existing information and advice on safe prescribing from other sources (e.g. MHRA safety alerts, BNF, SPCs and information from DVLA) with NICE’s existing guideline recommendations, to produce easy to access, practical recommendations.
https://www.nice.org.uk/news/article/nice-publishes-a-summary-of-its-guidance-and-other-safety-advice-on-valproate
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NICE Guidance March 2019
There has been one guideline published in March 2019 by the National Institute for Clinical Excellence which has impact upon primary care.
The delirium: prevention, diagnosis and management guideline has been updated and published. The guideline covers diagnosing and treating delirium in people aged 18 and over in hospital and in long term residential care or a nursing home. The guideline also covers identifying people at risk of developing delirium in these settings and preventing onset. The aim is to improve the diagnosis of delirium and reduce hospital stays and complications. The update removed the recommendation of the use of olanzapine for the treatment of delirium in people who are distressed or considered a risk to themselves or others.
Clinicians should be aware of these guidelines and implement any necessary changes to their practice.
CKS Updates March 2019
During the month of March 2019, the following Clinical Knowledge Summaries were published or updated:
All the above topics have undergone reviews and minor restructures. No major changes have been made.
Clinicians can use the updated and new information when reviewing patients.
Useful Resources
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