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NHCCG Prescribing Forum 23rd March 2017
What’s New?- Safety
Risk of hospital admissions for heart failure with non- steroidal anti- inflammatory drugs.
Medicines Evidence Commentary and DTB December 2016, Vol 54, Issue 12
• A European nested case-control study including 92,163 cases and 8,246,403 controls found that current use of any non-steroidal anti-inflammatory drug (NSAID) increased the risk of admission to hospital for heart failure by nearly 20% compared with past use.
• The study suggests a dose-response effect with very high doses of etoricoxib and diclofenac more than doubling the risk of admission to hospital for heart failure.
• Prescribers should continue to follow MHRA prescribing advice on use of NSAIDs, and base prescribing on assessment of a person’s individual risk factors (including cardiovascular and gastrointestinal).
• NSAIDs should be avoided in people with heart failure or those at high risk of heart failure.
• If an NSAID is needed it should be used at the lowest effective dose for the shortest possible time and reviewed regularly.
http://dtb.bmj.com/content/54/12/134
What’s New?- Safety
Adding Hospital Drugs on EMIS- reminder
Guildford & Waverley CCG News Feb 2017
When patients are prescribed medication which is only issued by a hospital or from another source it is important that there is a record of this in general practice. EMIS web has a facility which allows these medications to be recorded on the medication screen under hospital but cannot be issued.
• Add the drug as you normally would, then highlight the drug from the medication screen, click issue,
• then select change all, select record hospital no print.
• On the medication screen it will read as ‘record hospital’ on the right hand side (under last issue number/method).
• Recording these medications will increase safety and allow for a complete record of a patients medication to be easily accessible at the GP practice.
• Incidences have occurred where medications for the same indication have been co- prescribed, e.g. denosumab and alendronate.
What’s New?- Safety
Methotrexate reminder
Following a recent situation, it has come to the attention of the Medicines Management Team that there is more than one brand of methotrexate injection. It is important that the patient is familiar with the use of the device provided.
• The hospital’s clinicians have a tendency to recommend methotrexate injection generically and this is then inadvertently transcribed on to the patient’s medication record.
• Prescribers receiving requests from secondary care to prescribe methotrexate (any formulation) are reminded to check the CCG’s current shared care guidelines (available on our website). This includes information on
• what to prescribe and how, and the responsibilities for monitoring these patients.
• The scg for methotrexate clearly states that the words Metoject® must appear somewhere on the prescription for the injection, as this is the device that the hospital has been using.
• Plus the volume to be administered is not the same between the different brands- Zlatal® contains methotrexate 25mg/ml soln for inj in pre-filled syringe, compared to
Metoject® contains methotrexate 50mg/ml soln for inj in pre-filled syringe.
What’s New?- Safety
What legal and pharmaceutical issues should be considered when administering medicines covertly?
Specialist Pharmacy Service
Covert administration of medicines is a complex issue and involves disguising the administration of a medicine (e.g. in food or drink) to a patient lacking the capacity to consent to treatment. Covert administration should not be confused with disguising the administration of a medicine against a competent patient’s wishes.
This Medicines Q&A discusses some of the legal issues, pharmaceutical issues (e.g. absorption, incompatibility, interactions) and patient factors (e.g. acceptability) that need to be considered when deciding whether to administer medicines in this way.
• This article reminds that altering medicinal products (for example crushing tablets) or adding to food/drink is usually an unlicensed (off-label) activity.
• Prescribing medicines in a manner outside of the recommendations of the marketing authorisation alters (and probably increases) the prescriber’s professional responsibility and liability. This should only be conducted if the prescriber can justify, and is confident in, the use of the medicine in this manner.
What’s New?- Safety
What legal and pharmaceutical issues should be considered when administering medicines covertly? Contd.
• Additionally, nurses that are not independent prescribers are not presently allowed to authorise the use of medicines outside of their marketing authorisation. Therefore if medicines are to be administered in this way this must be authorised by a relevant prescriber.
A summary is provided:
• Covert administration of medicines is a complex issue and involves the administration of a medicine disguised in some manner (e.g. in food or drink) to a patient without their knowledge or consent. It should only be considered within the appropriate legal framework, for patients who lack capacity. It should not be undertaken without being discussed between various healthcare professionals and the family/carer of the patient.
• PrescQIPP and NICE have produced guidance on issues (including legal issues) to be considered when medicines are given covertly in care homes, although the principles would apply in other care settings.
• Pharmaceutical issues (e.g. absorption, incompatibility, interactions) and patient factors (e.g. acceptability) also need to be considered when deciding whether to administer medicines in this way.
• There may be limited pharmaceutical information on the stability of medicines hidden in food or drink.
• https://www.sps.nhs.uk/articles/what-legal-and-pharmaceutical-issues-should-be-considered-when-administering-medicines-covertly-2/
•
What’s new? MHRA Drug safety updates Jan 2017 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/584584/pdf_Jan.pdf
Direct-acting antiviral interferon-free regimens to treat chronic hepatitis C: risk of hepatitis B reactivation
This article advises that rapid reduction in hepatitis C viral load during treatment with direct-acting antiviral interferon-free regimens may lead to increased replication of hepatitis B virus in co-infected patients.
• Therefore, all patients with hepatitis C who are starting therapy with these antivirals should be screened for hepatitis B infection, and should be monitored and managed for co-infection according to current clinical guidelines
• Patients should be advised to inform their doctor or pharmacist if they have a current or previous infection with hepatitis B virus if they are prescribed direct- acting antiviral interferon- free regimens for hepatitis C (these include : daclatasvir (Daklinza▼); dasabuvir (Exviera▼); ombitasvir, paritaprevir, ritonavir (Viekirax▼); sofosbuvir (Sovaldi▼); ledipasvir with sofosbuvir (Harvoni▼); and simeprevir (Olysio▼)).
• GPs are reminded that these medications are RED LISTED and should not be prescribed in primary care but need to be recorded as hospital- ONLY do not issue.
Tbc on next slide
What’s new? MHRA Drug safety updates Jan 2017 contd.
Direct-acting antivirals to treat chronic hepatitis C: risk of interaction with vitamin K antagonists and changes in INR
• The article highlights possible changes in liver function due to treatment with direct-acting antivirals for chronic hepatitis C infection, which may result in fluctuations of INR values, in patients also taking vitamin K antagonists (e.g., warfarin).
changes in liver function secondary to hepatitis C treatment are thought to affect the efficacy of vitamin K antagonists.
• In these patients, INR should be monitored closely and, if necessary, anticoagulant therapy adjusted.
• Patients should be advised to inform their doctor or pharmacist that they are taking warfarin or other similar vitamin K antagonists used to thin the blood if they are prescribed direct- acting antivirals.
• Patients receiving vitamin K antagonists should be advised that during treatment with direct- acting antivirals for chronic hepatitis C, they may have more-regular blood tests to check how well their blood can clot.
• GPs are reminded that direct- acting antivirals are RED LISTED and should not be prescribed in primary care but need to be recorded as hospital- ONLY do not issue.
Tbc on next slide
What’s new? MHRA Drug safety updates Jan 2017 contd.
Apremilast (Otezla ▼): risk of suicidal thoughts and behaviour
Apremilast is used for the treatment of moderate to severe chronic plaque psoriasis or active psoriatic arthritis in adults who have not responded to other systemic treatments.
• It is associated with an increased risk of psychiatric symptoms, including depression, suicidal thoughts, and suicidal behaviours. These events are reported to occur uncommonly (estimated frequency of between 1 in 1000 to 10 in 1000 patients taking apremilast).
• Suicidal thoughts and behaviour, including completed suicide, have been reported in patients with or without a history of depression.
• Carefully assess the benefits and risks of starting or continuing treatment in patients with a history of psychiatric symptoms, or in those who are taking other medicines likely to cause psychiatric symptoms .
• Stop treatment if patients experience new psychiatric symptoms or if existing symptoms get worse.
• Advise patients to inform a healthcare professional if they notice changes in their mood
• GPs are reminded that this medication is RED LISTED and should not be prescribed in primary care.
What’s new? MHRA Drug safety updates Jan 2017 contd.
Summary of letters sent to healthcare professionals in December 2016
Potential for medication errors associated with overdose with liquid levetiracetam (Keppra 100mg/ml oral solution) Prescribing Snippets Issue 152 Jan 2017 (Brent CCG) & Medicines Management Matters Feb 2017 (Surrey CCGs)
• This letter highlights the potential for medication errors associated with overdose with liquid levetiracetam, particularly in children.
Levetiracetam overdose may lead to a depressed level of consciousness, respiratory depression and coma.
• There have been errors in measuring the dose with an oral syringe, due to confusion between a 1mL and 10mL syringe.
• To minimise this risk, it is recommended that the dosing directions should specify the dose appropriate for the child’s age, in milligrams and millilitres and
• patients and/or carers should be advised about how to measure the prescribed dose and the importance of using the syringe supplied with the medication.
https://www.gov.uk/drug-safety-update/letters-sent-to-healthcare-professionals-in-december-2016
What’s new? MHRA Drug safety updates Feb 2017
Hyoscine butylbromide (Buscopan) injection risk of serious adverse effects in patients with underlying cardiac disease
MHRA Drug Safety Update Vol 10, Issue 7, Feb 2017
Adverse effects can be more serious in patients with cardiac disease, such as those with heart failure, coronary heart disease, cardiac arrhythmia, or hypertension. Healthcare professionals should monitor these patients, and ensure that resuscitation equipment, and personnel who are trained how to use this equipment, are readily available.
Advice for healthcare professionals:
• hyoscine butylbromide injection can cause serious adverse effects including tachycardia, hypotension, and anaphylaxis
• these adverse effects can result in a fatal outcome in patients with underlying cardiac disease, such as those with heart failure, coronary heart disease, cardiac arrhythmia, or hypertension
• hyoscine butylbromide injection should be used with caution in patients with cardiac disease
• monitor these patients, and ensure that resuscitation equipment, and personnel who are trained how to use this equipment, are readily available
• hyoscine butylbromide injection remains contraindicated in patients with tachycardia
• https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/592989/Drug_Safety_update_-_February_2017.pdf
What’s New?- Safety
Why should the dosage of Citalopram Oral Drops 40mg/ml be prescribed in ‘drops’ instead of in ‘millilitres’?
Article taken from Derbyshire Medicines Management newsletter Vol 6, Issue 11 Feb 2017
The dose for citalopram oral drops should be stated in drops, not in millilitres to avoid confusion for patients and also for ease of administration (doses cannot accurately be prescribed or administered by volume of the liquid).
• The bottle is fitted with a dropper to facilitate this and to ensure accurate dosing.
• Also, the oral drops should be mixed with water, orange juice or apple juice before taking or administering via a feeding tube.
• The resulting solution must be drunk by the patient or administered via a feeding tube immediately.
• Citalopram Oral Drops 40mg/ml (citalopram hydrochloride, corresponding to 40 mg citalopram base) contain the following:
• (a) 1 drop = 2 mg citalopram
• (b) 1 ml = 20 drops = 40 mg citalopram
Tbc on the next 2 slides
What’s New?- Safety
Why should the dosage of Citalopram Oral Drops 40mg/ml be prescribed in ‘drops’ instead of in ‘millilitres’? contd.
• Citalopram oral drops have approximately 25% increased bioavailability compared to the tablet formulation.
• If a patient was given a dose of 0.5ml of the citalopram oral drops, according to the number of drops in 1ml, the patient would actually be receiving a dose of 10 drops which equates to an actual dose of 20mg of the oral drop solution (equivalent to 25mg of a tablet formulation)
• However, as the oral drops have an increased bioavailability compared to the tablet formulation, the dose that should be given to a patient is 16mg given as a dose of 8 drops (equivalent to 20mg given in tablet form). *Maximum dose for patients over 65yrs.
Dose of citalopram in tablet form
Equivalent dose of citalopram in ‘oral drop’ dose form
No. of drops required to deliver the required dose
10mg 8mg 4 drops
*20mg *16mg *8 drops
30mg 24mg 12 drops
40mg 32mg 16 drops
What’s New?- Safety
Why should the dosage of Citalopram Oral Drops 40mg/ml be prescribed in ‘drops’ instead of in ‘millilitres’? contd.
Prescribers are also reminded
• The maximum dose of citalopram is 40mg daily (previously a dose of up to 60mg daily was licensed).
• The maximum dose in the elderly and in patients with reduced hepatic function is 20mg daily.
• Citalopram is contraindicated in patients with known QT interval prolongation or congenital long QT syndrome.
• Use with other medicines known to prolong QT interval is contraindicated.
• Use is cautioned in patients at higher risk of developing Torsade de Pointes, including those with congestive heart failure, recent myocardial infarction, bradyarrhythmias, or a predisposition to hypokalaemia or hypomagnesaemia due to illness or drug therapy.
What’s New?- Changes
The dose of nystatin for oral candidiasis in the BNF and BNF for Children has been updated to reflect the licensed doses for generic nystatin products. RPS and Guildford & Waverley CCG News Jan 2017
Indications and dose by mouth for Oral candidiasis:
• Neonates (birth- 1m): 100,000 units (1ml) 4 times a day, to be given after feeds. Clinical studies of limited size in neonates, including preterm and babies of low weight at birth, indicate that 1 ml (100,000 U) four times daily is an effective regimen.
• Infants (1m- 2y): 200,000 units (1ml for each side of the mouth) 4 times a day
• Child (over 2y & adults): 400,000 units- 600,000 units (4- 6 ml half dose in each side of the mouth) 4 times a day
Prevention and treatment of intestinal candidiasis:
• Neonates (birth- 1m) and Infants (1m- 2y): 100,000 units- 200,000 (1ml- 2ml) four times daily administered with milk or other liquid.
• If needed, the dose can be increased, even in the neonates. Treatment should be continued for at least 48 hours after clinical cure and/or normalisation of cultures to avoid a relapse.
• Limited clinical studies in premature and low birth weight infants indicate that 1 mL four times daily is effective. Tbc on next slide
What’s New?- Changes
• The dose of nystatin for oral candidiasis in the BNF and BNF for Children has been updated to reflect the licensed doses for generic nystatin products, contd.
Prevention and treatment of intestinal candidiasis, contd.:
• Children (over 2 years) and adults: 400,000– 600,000 U (4 – 6 ml) 4 times daily. The suspension should be retained in the mouth for as long as possible (e.g., several minutes) before swallowing. If needed, the dose can be increased. Treatment should be continued for at least 48 hours after clinical cure and/or normalisation of cultures to avoid a relapse.
• Older people: No specific dosage recommendations or precautions.
• In the prevention and treatment of candidiasis, the dosage regimen for Nystan should be continued for at least 48 hours after symptoms have disappeared. If signs and symptoms worsen or persist (beyond 14 days of treatment) the patient should be re-evaluated, and an alternative therapy considered. NB: Doses for nystatin suspension produced by Sandoz have not changed.
• Though, these doses are not yet included in current UK guidelines from PHE or CKS, the latter notes that it is based on expert opinion, as there is a lack of direct evidence from randomised controlled trials to support the use of topical miconazole or nystatin, or oral fluconazole in the treatment of oral candidiasis in otherwise healthy adults.
• Some clinicians have traditionally recommended 5ml doses as they felt 1ml was insufficient to coat the inside of the mouth.
http://www.medicines.org.uk/emc/medicine/20153
What’s New?- Changes
Metformin for patients with moderately reduced kidney function.
Derbyshire Medicines Management Newsletter Vol 6 Issue 11 Feb 2017
Metformin has previously been contraindicated in this population out of concern that those with reduced kidney function would be unable to clear metformin, resulting in an increased risk of lactic acidosis – a rare but serious complication of treatment.
• However, after considering the scientific literature, clinical data, epidemiological studies and clinical guidelines, the EMA concluded that patients with moderately reduced kidney function (glomerular filtration rate [GFR] 30–59mL/min) can still benefit from metformin treatment.
• The EMA notes that clear dosing recommendations and monitoring before and during treatment can minimise any increased risk.
• The EMA's new recommendations serve both to standardise the prescribing advice for metformin and, more importantly, to make this potentially beneficial hypoglycaemic agent available to more people .
Further information can be found in DTB Jan 2017, Vol 55.
What’s New?- Guidelines
British Asthma Guideline Update
Tablets Prescribing Newsletter Jan 2017 (Midlands & Lancashire CSU) Available in a quick reference format (http://www.sign.ac.uk/pdf/QRG153.pdf) or as a full guideline (http://www.sign.ac.uk/pdf/SIGN153.pdf).
• The guideline covers diagnosis and management of asthma in adults and children.
• This update contains minor corrections and changes , apart from the change advised
to now immediately treat children under 2 years old in hospital settings with acute asthma symptoms.
• Clinicians who diagnose and treat asthma should be aware of this update and have access to this guideline.
Inhaler Prescribing Reminder
• Inhalers should be prescribed only after patients have received training in the use of the device and have demonstrated satisfactory technique.
• Generic prescribing of inhalers is discouraged as this might lead to people being given an unfamiliar inhaler device which they are not able to use properly.
• This is especially important with the number of new generic inhaled treatments coming onto the market which have various different devices available to deliver the drug, e.g. Tiotropium
Spiriva® comes in a Handihaler® or Respimat® device while Braltus® the generic tiotropium comes in the Zonda® dry powder device which is different. Important to prescribe by brand.
What’s New?- Prescription services
Unidentified Prescriber Prescription forms
City Scripts Prescribing Newsletter Jan- Mar 2017 (Brighton & Hove CCG)
NHS Prescription Services receives a substantial number of prescriptions from non-medical prescribers- these prescribers are independent or supplementary prescribers and include optometrists, pharmacists, physiotherapists, podiatrists, radiographers and dieticians.
• Where these prescribers have not been registered with NHS Prescription Services at the practice they are issuing prescriptions from, a high volume of unidentified NMP prescribing results.
• Likewise, there are doctors not registered with NHS Prescription Services at the practice they are issuing prescriptions from (e.g. locums or agency).
• This then impacts on prescribing budgets and any clinical governance arrangements you have that rely on prescribing information.
• To register NMPs and unrecognised GPs at your practice you need to notify your authorised signatory (Primary Care Support England (PCSE) and the NMP lead at the CCG (Alma Kilgarriff).
• They will submit a NMP registration form to the NHS Prescription Services and all registration requests will be added to the their database within five working days of receipt. A link to the form is available at http://www.nhsbsa.nhs.uk/PrescriptionServices/3971.aspx
• From 1 April 2017, if the NHS Prescription Services are unable to identify the NMP from the prescriber details provided because the NMP isn’t registered, they will attribute the prescribing to the lead prescriber based on the practice code and address provided.
What’s New?- Changes Quadrivalent Influenza vaccine (QIV)
Short & Sweet NH CCG Newsletter 15th March 2017
In response to queries regarding the use of Quadrivalent Inactivated Influenza Vaccines (QIV), the Medicines Management Team have highlighted the collated information circulated by PHE Wessex in Dec 2016 (available as a hyperlink in Short & Sweet).
• PHE is currently undertaking cost-effectiveness analysis for QIV compared to TIV. Findings will be shared with JCVI when available. Currently the only clinical advice regarding the use of QIV is that published in the Green Book influenza chapter:
JCVI has advised that, all other things being equal, quadrivalent inactivated vaccine is preferable to trivalent inactivated influenza vaccine. For adults in clinical risk groups a range of inactivated vaccines are available from suppliers for GPs to purchase. Because influenza B is relatively more common in children, the vaccines centrally purchased for the childhood programme in recent years have been quadrivalent preparations (Fluenz Tetra® and Fluarix Tetra®). The childhood programme should therefore contribute to better control of influenza B overall, by reducing transmission across the population.
• Nikki Osborne (PHE- Wessex) informed practices NOT to order the quadrivalent vaccine.
• The QIV are approximately 30% more expensive than that of the standard Trivalent Influenza Vaccine (TIV) used in adults (with the exception of Intanza). Fluarix Tetra® list price is currently £9.94 (excluding VAT) per dose.
• The Green Book states that “The QIV are ‘preferred’ rather than a must do”, and there is no evidence that has compared the cost-effectiveness of the trivalent and quadrivalent flu vaccines.
What’s New?- Changes
NHS prescription charges to go up from April 2017
Department of Health
The prescription charge will increase by 20 pence from £8.40 to £8.60 for each medicine or appliance dispensed.
• To ensure that those with the greatest need, including patients with long-term conditions, are protected, the DH have frozen the cost of the prescription prepayment certificates (PPCs) for another year.
• The 3 month PPC remains at £29.10 and the cost of the annual PPC will stay at £104, allowing unlimited prescriptions within a specified time period.
• Existing arrangements for prescription charge exemptions will remain in place, principally covering those with certain medical conditions like cancer, epilepsy and diabetes, pregnant women and new mothers, children under 16 and anyone over 60, and those on a low income.
• https://www.gov.uk/government/speeches/nhs-prescription-charges-from-april-2017
What’s New?- Changes
Re-named product: Haelan tape has been re-named as fludroxycortide tape.
Product Miscellany Jan 2017
This is a transparent plastic surgical tape (size available is 7.5cm x 20cm=£8.19) impregnated with fludroxycortide, which is a fluorinated, synthetic, moderately potent, topical corticosteroid.
• Therapeutic effect is primarily the result of its anti-inflammatory activity, but it offers protection and support to the affected skin.
• The tape is indicated for use as an adjuvant therapy indicated for chronic, localised recalcitrant dermatoses that may respond to topical corticosteroids, and particularly for dry scaling lesions.
Revised SPC: Caverject (alprostadil) 40 micrograms powder for solution for injection
Electronic Medicines Compendium
Myocardial ischaemia and cerebrovascular accident added as adverse effects of unknown frequency. Thereby, the SPC notes that alprostadil should be used with caution in patients with cardiovascular and cerebrovascular risk factors
• http://www.medicines.org.uk/emc/medicine/27308
What’s New?- Changes
Dermatological specials
Product Miscellany Jan 2017
The cost of specials can seem disproportionate to the item, especially when a similar product can be an effective alternative, e.g.
• Liq Paraffin 50%/Emulsifying Oint 50% at a cost of > £600 for 500g
• Alternatives may include : white soft paraffin 50%/ liquid paraffin 50% ointment (also known as 50:50 ointment) at a cost of <£5.00 for 500g.
Adcirca (tadalafil) revised SPC
Electronic Medicines Compendium
• SPC has been updated to warn that cases of sudden hearing loss have been reported after the use of tadalafil. Although other risk factors were present in some cases, patients should be advised to stop taking tadalafil and seek prompt medical attention if this occurs.
• http://www.medicines.org.uk/emc/medicine/23886
What’s New?- New Products
Chewable sildenafil preparations (Nipatra®) available for patients with swallowing difficulties
Product Miscellany Jan 2017
Prescribe this product only by exception as generic sildenafil tablets are the most cost effective preparations. However Nipatra® is more cost effective than unlicensed specials of sildenafil liquid preparations which can only be obtained at high cost in community.
Glycopyrronium bromide 2mg/5ml oral solution and oral suspension have been removed from Part VIIIB of the Drug Tariff.
This is because a licenced alternative, Glycopyrronium bromide 400mcg/1ml oral solution sugar free, is now available and has been added to Part VIIIA effective from 1st March 2017.
• Glycopyrronium bromide (Sialanar®) is an antimuscarinic (anticholinergic) medicine licensed in September 2016 for the symptomatic treatment of severe sialorrhoea (chronic pathological drooling) in children and adolescents aged 3 years and older with chronic neurological disorders.
• Sialanar® is licensed for short-term intermittent use and is only licensed in children. There is limited clinical trial evidence on the use of glycopyrronium in adults with sialorrhoea. Sialanar® 320 micrograms/ml oral solution is the first formulation of glycopyrronium bromide licensed for this indication in the UK.
What’s New? New Products
Fluoxetine- New strengths and formulations
Medicines Optimisation News Headlines Jan 2017 (WH CCG)
Although they provide a wider range of dosing some of them come at a premium price. A table showing the generic versions of these preparations and their relative costs is shown below. Formulation Cost for 28 days treatment (January 2017)
10mg daily 20mg daily 40mg daily 60mg daily Fluoxetine 10mg capsule £61.25
Fluoxetine 20mg dispersible
tablet (scored) (£1.72) £3.44
Fluoxetine 20mg capsule £0.81 £1.62 £2.44
Fluoxetine 30mg capsule £3.86
Fluoxetine 40mg capsule £1.93
Fluoxetine 60mg capsule £6.29
Fluoxetine oral solution
20mg in 5ml £2.81 £5.62
Fluoxetine sugar free
oral solution 20mg in 5ml £12.95 £25.90
Tbc on next slide
What’s New?- New Products
Fluoxetine- New strengths and formulations contd.
Recommendations: • Use fluoxetine 20mg capsules to provide best value and enable flexibility with higher doses. • In patients who require a 10mg dose, consider whether it is appropriate to use scored 20mg tablets rather than 10mg capsules. • Consider use of alternate day dosing as a better value option when reducing the dose below 20mg a day.
What’s New?- Price comparison
Prescribing mild to moderate analgesics.
£12.66
£9.58
£9.21
£8.66
£8.25
£7.25
£6.88
£3.97
£3.93
£3.85
£3.50
£3.39
£3.03
£2.97
£2.91
£2.19
Co-codamol 8mg/500mg caps
Co-codamol 15mg/500mg tabs
Paracetamol 500mg soluble tablets
Co-codamol 30mg/500mg efferv tabs SF
Co-codamol 15mg/500mg efferv tabs SF
Co-codamol 15mg/500mg caps
Co-codamol 8mg/500mg efferv tabs SF
Co-codamol 30mg/500mg tabs
Codeine 30mg tabs
Zapain 30mg/500mg caps
Co-codamol 30mg/500mg caps
Codeine 15mg tabs
Zapain 30mg/500mg tabs
Co-codamol 8mg/500mg tabs
Paracetamol 500mg caps
Paracetamol 500mg tabs
PRICE PER PACK OF 100 (drug tariff March 2017)
Review patients prescribed co-codamol 15mg/500mg tablets/capsules and consider stepping down to paracetamol 500mg tablets or switching to separate tablets of paracetamol 500mg and 15mg codeine tablets.
What’s New?- Price comparison
The ready availability of low cost generic desogestrel
The T@blet Issue 4 2017 (Doncaster CCG)
Following review of the historic recommendation to prescribe this progestogen-only-pill by brand e.g. Cerelle or Cerazette. The new recommendations are,
• There is no clinical requirement to prescribe desogestrel by brand
• For new patients – prescribe desogestrel as a generic prescription
• Do NOT switch existing patients currently prescribed Cerelle and Cerazette but review at an appropriate point and move across to a generically written prescription if appropriate.
Carbocisteine 750mg/10ml sachets Vs Carbocisteine 250mg/5ml solution
NHS listed price for carbocisteine solution £8.39 x 300ml vs carbocisteine sachets £3.85 x 15
Assuming dose of 750mg tds used for 30 days, the cost comparison of the two preparations is
• Solution £37.76 per month
• Sachets £23.10 per month
• By using sachets instead of the solution there is £14.66/month/patient potential saving to be made.
•
What’s New?- NICE guidelines
NG60 HIV testing: increasing uptake among people who may have undiagnosed HIV (Joint NICE and Public Health England guideline) Details taken from Medicines Management Matters Jan 2017 (Surrey CCG)
This guideline covers how to increase the uptake of HIV testing in primary and secondary care, specialist sexual health services and the community. It describes how to plan and deliver services that are tailored to the local prevalence of HIV, promote awareness of HIV testing and increase opportunities to offer testing to people who may have undiagnosed HIV.
https://www.nice.org.uk/guidance/ng60
NG61 End of life care for infants, children and young people with life-limiting conditions: planning and management Details taken from Medicines Management Matters Jan 2017 (Surrey CCG)
This guideline looks at the planning and management of end of life and palliative care for infants, children and young people (aged 0–17 years) with life-limiting conditions. It aims to involve children, young people and their families in decisions about their care, and improve the support that is available to them throughout their lives. It includes sections on managing distressing symptoms, hydration and nutrition.
https://www.nice.org.uk/guidance/ng61
What’s New?- NICE guidelines
NG62 Cerebral palsy in under 25s: assessment and management NICE
This guideline covers diagnosing, assessing and managing cerebral palsy in children and young people from birth up to their 25th birthday. It aims to make sure they get the care and treatment they need for the developmental and clinical comorbidities associated with cerebral palsy, so that they can be as active and independent as possible. This guideline includes recommendations on the:
•causes and recognition of cerebral palsy
•multidisciplinary care and information and support
•managing feeding and drooling problems
•support with speech, language and communication
•assessing and managing pain, discomfort, distress and sleep disturbances
•information on other comorbidities, including mental health problems
•transition to adults’ services
Recommendations relating to medicines appear in sections:
• 1.11 Managing saliva control
• 1.12 Risk factors for low bone mineral density
• 1.13 Pain, discomfort & distress and
• 1.14 Sleep disturbances.
https://www.nice.org.uk/guidance/ng62 Tbc on the next slide
What’s New?- NICE guidelines
NG63 Antimicrobial stewardship: changing risk-related behaviours in the general population
NICE
This guideline covers making people aware of how to correctly use antimicrobial medicines (including antibiotics) and the dangers associated with their overuse and misuse.
• It also includes measures to prevent and control infection that can stop people needing antimicrobials or spreading infection to others. It aims to change people’s behaviour to reduce antimicrobial resistance and the spread of resistant microbes.
• https://www.nice.org.uk/guidance/ng63
What’s New?- NICE Quality Standards
Falls in older people- updated quality standard (QS86)
Statement 1 Older people are asked about falls when they have routine assessments and reviews with health and social care practitioners, and if they present at hospital. [new 2017] Statement 2 Older people at risk of falling are offered a multifactorial falls risk assessment. [new 2017] Statement 3 Older people assessed as being at increased risk of falling have an individualised multifactorial intervention. [new 2017] Statement 4 Older people who fall during a hospital stay are checked for signs or symptoms of fracture and potential for spinal injury before they are moved. [2015] Statement 5 Older people who fall during a hospital stay and have signs or symptoms of fracture or potential for spinal injury are moved using safe manual handling methods. [2015] Statement 6 Older people who fall during a hospital stay have a medical examination. [2015] Statement 7 Older people who present for medical attention because of a fall have a multifactorial falls risk assessment. [2015] Statement 8 Older people living in the community who have a known history of recurrent falls are referred for strength and balance training. [2015] Statement 9 Older people who are admitted to hospital after having a fall are offered a home hazard assessment and safety interventions. [2015] https://www.nice.org.uk/guidance/QS86/chapter/Quality-statements
What’s New?- NICE Quality Standards
Menopause- quality standard (QS143)
This quality standard covers diagnosing and managing menopause in women, including women who have premature ovarian insufficiency (menopause before the age of 40, which can occur naturally or as a result of medical or surgical treatment). It describes high-quality care in priority areas for improvement. There are 5 quality statements: Statement 1: Women over 45 years presenting with menopausal symptoms are diagnosed with perimenopause or menopause based on their symptoms alone, without confirmatory laboratory tests. Statement 2: Women under 40 years presenting with menopausal symptoms have their levels of follicle-stimulating hormone measured. Statement 3: Women with premature ovarian insufficiency are offered hormone replacement therapy or a combined hormonal contraceptive. Statement 4: Women having treatment for menopausal symptoms have a review 3 months after starting each treatment and then at least annually. Statement 5: Women who are likely to go through menopause as a result of medical or surgical treatment are given information about menopause and fertility before they have their treatment. https://www.nice.org.uk/guidance/qs143/chapter/Quality-statements
What’s New?- NICE Quality Standards
Stable angina- quality standard (QS21)
This quality standard covers diagnosing and managing stable angina in adults (aged 18 and over). It describes high-quality care in priority areas for improvement.
In February 2017, statement 1 was updated to reflect changes to the NICE guideline on chest pain of recent onset.
Currently there are 5 quality statements:
• Statement 1. People with features of typical or atypical angina are offered 64-slice (or above) CT coronary angiography.
• Statement 2. People with stable angina are offered a short-acting nitrate and either a beta-blocker or calcium-channel blocker as first-line treatment.
• Statement 3. People with stable angina are prescribed a short-acting nitrate and 1 or 2 anti-anginal drugs as necessary before revascularisation is considered.
• Statement 4. People with stable angina who have had coronary angiography, have their treatment options discussed by a multidisciplinary team if there is left main stem disease, anatomically complex three-vessel disease or doubt about the best method of revascularisation.
• Statement 5. People with stable angina whose symptoms have not responded to treatment are offered re-evaluation of their diagnosis and treatment.
• https://www.nice.org.uk/guidance/qs21/chapter/List-of-quality-statements
What’s New- Information sources
“Lost Prescriptions”
Details taken from Medicines Management Matters Jan 2017 (Surrey CCG)
The use of EPS prevents prescriptions getting ‘lost’. When pharmacies or patients report missing prescriptions, please
• confirm they have checked the prescription tracker to identify where the EPS prescription is currently located. EPS prescriptions should not be re-issued until the tracker has been checked.
https://portal2.national.ncrs.nhs.uk/prescriptionsadmin.
Patient and professional eye information
Primary Care Talk No. 177 Nov/ Dec 2016
A range of patient information leaflets (PILs) have been developed by the Association of Optometrists (AOP) in the UK, aimed at helping patients recognise and treat eye conditions.
Conditions covered include dry eye, blepharitis, age-related macular degeneration and glaucoma.
• Leaflets can be downloaded individually; a ‘patient leaflet pack’ containing a PIL for each eye condition, as well as information on general eye care, is also available for download as a Zip file: https://www.aop.org.uk/advice-and-support/for-patients/patient-leaflets
• Clinical Knowledge Summaries (CKS) guidelines for primary care practitioners are available on a wide variety of eye conditions https://cks.nice.org.uk/#?char=A (change the character letter to B for blepharitis, G for glaucoma, etc.) including :
blepharitis, conjunctivitis, corneal injury, dry eye syndrome, glaucoma, ocular herpes simplex, red eye, retinal detachment, squint in children, styes and uveitis.
What’s New- Information sources
Clinical audit by SHFT MM Team
Medicines Matters January 2017
• A recent audit that looked at all the interventions that the SHFT Medicines Management Team made over a two week period found the following:
• 429 interventions were made over two weeks, extrapolation approximates 11,150 a year
• Estimated cost saving implication to the Trust of £1.5-3 million a year
• 86% were significant and improved patient care, 7% either prevented organ failure or were potentially lifesaving.
• A copy of the report including some selected serious interventions and a list of common interventions can be found on the medicines management section of the intranet.
http://www.southernhealth.nhs.uk/EasysiteWeb/getresource.axd?AssetID=109911&type=full&servicetype=Inline&filename=/SH01284_Medicine_Matters_-_January_2017_edition2.pdf
