Informer
May 2017
Pregabalin switch to Alzain brand
Over the next few months you will see prescriptions from Doncaster GP practices for generic Pregabalin
capsules switched to the brand Alzain.
Key Information:
 Alzain is bioequivalent to Lyrica. 1
 Patient cohort – pain in adults. Note: may include existing off-label indications.
 Exclusions - epilepsy, generalised anxiety disorder, patented indications.
 Opportunity will be taken to optimise to twice daily dosing.
 Supply – Dr Reddy’s have provided assurance they can meet demand.
Pharmacy staff may wish to review their stock levels of generic Pregabalin and Alzain to avoid over/ under
stocking.
Electronic Repeat Dispensing
Update to nystatin dose in BNF and BNF for Children
Electronic Repeat Dispensing (ERD)
continues to roll out across Doncaster GP
practices. Pharmacies have been very
helpful during this implementation phase
and can continue to support ERD by
nominating and reminding patients to
request a new prescription at their second
to last and last ERD prescriptions.
Nystatin dose for oral candidiasis in BNF has historically reflected
posology recommendations (PRs) in Nystan® SPC. Following
discussions with MHRA, the dose has been updated (live in digital
versions of BNF from March 2017) and now reflects current PRs
for generic nystatin products.
https://www.medicinescomplete.com/mc/bnf/current/PHP7390nystatin.htm?q=nystatin&t=search&ss=text&tot=37&p=6#_hit
Canagliflozin may increase the risk of lower-limb amputation
Canagliflozin may increase the risk of lower-limb amputation (mainly toes) in patients with type 2 diabetes. Evidence
does not show an increased risk for dapagliflozin and empagliflozin, but the risk may be a class effect.
Pharmacists should continue to provide advice to patients with diabetes on the importance of preventive foot care
and refer patients to prescribers where required.
Advice for healthcare professionals:
 carefully monitor patients receiving canagliflozin who have risk factors for amputation, such as poor control
of diabetes and problems with the heart and blood vessels
 consider stopping canagliflozin if patients develop foot complications such as infection, skin ulcers,
osteomyelitis, or gangrene
 advise patients receiving any sodium-glucose co-transporter 2 (SGLT2) inhibitor about the importance of
routine preventive foot care and adequate hydration
 continue to follow standard treatment guidelines for routine preventive foot care for people with diabetes
 report any suspected side effect with SGLT2 inhibitors or any other medicine on a Yellow Card
https://www.gov.uk/drug-safety-update/sglt2-inhibitors-updated-advice-on-increased-risk-of-lower-limbamputation-mainly-toes
How to minimise the risks of medication
errors with rivastigmine patches
This Q&A aims to raise awareness on
the types of medication errors reported
with rivastigmine patches, as well as
highlighting strategies to improve
medication safety on the prescribing
and administration of these patches.
https://www.sps.nhs.uk/articles/how-tominimise-the-risks-of-medication-errorswith-rivastigmine-patches/
What should people do if they miss a dose of their medicine?
As pharmacy staff are very aware, sometimes patients forget to
take their medicines at the normal time. This may cause a problem
because missing a dose may make the medicine less effective, but
taking doses too close together may increase the risk of side effects.
It is very difficult to give general guidance on what to do in these
situations. Each situation needs to be looked at individually.
However, this Medicines Q&A offers some general guidance, which
may help patients who occasionally forget or delay a dose. It does
not apply to patients who frequently miss doses.
https://www.sps.nhs.uk/articles/what-should-people-do-if-they-miss-adose-of-their-medicine/
What legal and pharmaceutical issues should be considered when administering medicines covertly?
Specialist
Pharmacy
Service
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.
https://www.sps.nhs.uk/articles/what-legal-and-pharmaceutical-issues-should-be-considered-when-administering-medicines-covertly-2/
Resources to support the safety of girls and women who are being treated with valproate
It is vital where valproate is prescribed & dispensed to girls and women of childbearing potential that they
are made aware of the risks of taking the medication in pregnancy. The need for effective contraception
planning must also be emphasised, along with the requirement for specialist oversight to safely change
their medication if planning a pregnancy.
MHRA have updated its valproate toolkit, providing a range of resources to support providers, staff and
patients in the safe use of valproate. This alert asks all providers to undertake systematic identification of
girls and women who are taking valproate, and to ensure the MHRA resources are used to support them to
make informed choices. The guidance asks dispensing pharmacists:
 Whenever you dispense a medicine containing valproate (brand names Epilim,
Depakote, Episenta) to a girl or woman of childbearing age, give her a Patient
Card, unless she confirms that she already has one.
 Encourage her to read the card and enter her name and date to reinforce her own
accountability to consider the information it contains.
 If you manage dispensing services in your organisation, ensure that processes
are in place to allow these requirements to be met.
www.gov.uk/government/publications/toolkit-on-the-risks-of-valproate-medicines-in-female-patients
https://www.cas.dh.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=102582
Mucodyne Paediatric Syrup 250 mg/5 mL (carbocisteine oral liquid) - new double-strength presentation
Sanofi have launched a double strength Mucodyne Paediatric Syrup which has double the concentration of the active
ingredient carbocisteine per mL compared with the previous formulation. The letter available via the link below
warns healthcare professionals to ensure correct dosing.
https://assets.publishing.service.gov.uk/media/58fa19a7ed915d06b00001a2/MucodynePaediatricReformulation_October_2016.pdf
Hyoscine butylbromide (Buscopan) injection: risk of serious adverse effects in patients with
underlying cardiac disease
Hyoscine butylbromide (Buscopan), given intravenously or intramuscularly, is indicated in acute
muscular spasm, as in renal or biliary colic; in radiology for differential diagnosis of obstruction and to
reduce spasm and pain in pyelography; and in other diagnostic procedures where spasm may be a
problem (e.g. gastroduodenal endoscopy).
Prescribing information has been updated to help to minimise the risk of serious adverse reactions in
patients with cardiac disease.
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
Pharmacists should refer to the prescriber if they have any concerns over the prescribing of hyoscine
butylbromide.
https://www.gov.uk/drug-safety-update/hyoscine-butylbromide-buscopan-injection-risk-of-serious-adverse-effectsin-patients-with-underlying-cardiac-disease
Shortage of Hyoscine Hydrobromide (Kwells) 150 and 300
microgram tablets
Bayer is currently facing some technical issues relating to
the manufacturing of, hyoscine hydrobromide and is thus
not able to supply further stock for at least 6 months. This
memo advises on alternative treatment options in the
interim, with a focus on its off-label use for hypersalivation.
https://www.sps.nhs.uk/articles/shortage-of-hyoscine-hydrobromidekwells-150-and-300-microgram-tablets/
Launch of RightBreathe internet resource
This internet resource is designed
specifically to help with the selection,
prescribing, and on-going use of inhalers. It
covers each and every inhaler and spacer
device licensed in the UK for treating
asthma and COPD.
https://www.rightbreathe.com/
Apremilast (Otezla ▼): risk of suicidal thoughts and behaviour
Apremilast (Otezla▼) is a phosphodiesterase-type-4 inhibitor for the treatment of moderate to severe
chronic plaque psoriasis or active psoriatic arthritis in adults who have not responded to other systemic
treatments. There is an increased risk that some patients may experience psychiatric symptoms with
apremilast, including depression and suicidal thoughts.
Advice for healthcare professionals:
 apremilast is associated with an increased risk of psychiatric symptoms, including depression, suicidal
thoughts, and suicidal behaviours
 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
Pharmacists should advise patients of the possible side effects and refer to the prescriber if any of these
symptoms are reported.
https://www.gov.uk/drug-safety-update/apremilast-otezla-risk-of-suicidal-thoughts-and-behaviour
Glucose content of Lucozade Energy drinks to be
reduced by 50% from April 2017
Pharmacy Guidance on Smoking
& Mental Disorder
The sugar and carbohydrate content levels of
Lucozade Ribena Suntory drinks will be reduced by
approximately 50%. Pharmacists advising people
with diabetes to consume Lucozade Energy for the
treatment of hypoglycaemia should advise that they
check the label of any product purchased to ensure
that they are aware of the correct quantity to
consume.
This guide from the Royal College of Psychiatrists,
endorsed by the Royal Pharmaceutical Society,
outlines how pharmacists can help reduce or stop
smoking in people with mental health disorders as well
as facilitating appropriate changes of medication
doses.
http://www.rcpsych.ac.uk/pdf/Pharmacy%20guidance%20smoking%20a
nd%20mental%20health%202017%20update%20FINAL.pdf
Launch of pilot reporting scheme for harms associated with illicit drugs, particularly new psychoactive substances
MHRA is launching a pilot for healthcare professionals in UK to report suspected adverse reactions to illicit drugs
(IDs), particularly new psychoactive substances. This will aid closer collaboration with Public Health England on
safety issues affecting licensed medicines and IDs.
New psychoactive substances (previously known as ‘legal highs’) pose potentially serious risks to public health. The
number of new substances identified in recent years has increased rapidly, with greater availability over the
internet.
The pilot reporting website, the Report Illicit Drug Reaction form, will be available for 1 year for healthcare
professionals across the UK who come into contact with patients experiencing harm associated with use of illicit
drugs, particularly new psychoactive substances. The pilot aims to better collect data on harms from illicit drug use,
to support provision of clinical guidance to professionals.
The form is intended to be used by health professionals who work in emergency departments, general practice, drug
treatment services, sexual health services, mental health services, and any other services who come into contact
with people who have developed acute or chronic problems associated with use of new psychoactive substances.
https://report-illicit-drug-reaction.phe.gov.uk/
Levetiracetam containing products 100 mg/mL oral solution presentations:
Risk of medication errors associated with overdose
Pharmacy staff should be aware of the following safety concern issued by UCB Pharma Limited in agreement with
the European Medicines Agency and the MHRA:
Summary
 Cases of an up to 10‐fold accidental overdose with Keppra (levetiracetam) oral solution have been reported. The
majority of cases occurred in children aged between 6 months and 11 years. The use of an inadequate dosing device
(e.g. confusion between a 1mL and a 10mL syringe, resulting in a 10‐fold overdose) was identified as an important
cause.
 Physicians should always prescribe the dose in mg with mL equivalence based on the correct age.
 Pharmacists should ensure that the appropriate presentation of levetiracetam oral solution is dispensed.
 With every prescription, physicians and pharmacists should advise the patient and/or caregiver on how to measure
the prescribed dose.
 With every prescription, physicians and pharmacists should remind patients or caregivers to use only the syringe
delivered with the medicine. Once the bottle is empty the syringe should be discarded and not kept.
https://assets.publishing.service.gov.uk/media/587f5894e5274a130300016c/Levetiracetam.pdf
Safeguarding children and vulnerable adults: a guide for the pharmacy team CPPE e-learning
The programme covers recognising types of abuse to identify victims for onward referral, who to contact for advice
and how to report and record information.
The aim of this learning resource is to give you the skills, knowledge and confidence to deal professionally with
any safeguarding issues that may arise in the course of your practice.
Completion of the programme and the associated Level 2 assessment will fulfil the safeguarding requirements at
level 2 for pharmacists and pharmacy technicians as required for the Quality Payment Scheme and by the
Intercollegiate Document: Safeguarding children and young people.
Completion of the programme and the associated Level 1 assessment (available February 2017) will allow
pharmacy support staff to prove their competence at Level 1 as required by the Intercollegiate Document:
Safeguarding children and young people.
https://www.cppe.ac.uk/programmes/l/safegrding-e-02
Licensed equivalents now available
Instead of using Metformin 850mg/5ml oral solution and Metformin 1g/5ml oral
solution, the following products which are licensed should ideally be considered:
• Metformin 850mg/5ml oral solution sugar free (Colonis Pharma Ltd)
• Metformin 1g/5ml oral solution sugar free (Colonis Pharma Ltd)
The following special order products have all been discontinued:
• Hydromorphone 10mg/1ml solution for injection ampoules (Special Order)
• Hydromorphone 20mg/1ml solution for injection ampoules (Special Order)
• Hydromorphone 50mg/1ml solution for injection ampoules (Special Order)
Instead of using these, the following licensed options, available from Napp
Pharmaceuticals Ltd, should ideally be considered:
• Palladone 10mg/1ml solution for injection ampoules (Napp Pharmaceuticals Ltd)
• Palladone 20mg/1ml solution for injection ampoules (Napp Pharmaceuticals Ltd)
• Palladone 50mg/1ml solution for injection ampoules (Napp Pharmaceuticals Ltd)
Is there an interaction
between erythromycin
and statins?
This updated Medicines
Q&A evaluates the
evidence for an
interaction between
erythromycin and
statins. It concludes that
if co-prescription with a
drug that increases
systemic exposure to
statins is unavoidable, it
is particularly important
to start on the lowest
statin dose.
https://www.sps.nhs.uk/article
s/is-there-an-interactionbetween-erythromycin-andstatins-2/
Glycopyrronium bromide 2mg/5ml oral solution
& oral suspension has been removed from
Part VIIIB of the March Drug Tariff
Is there an interaction between bisphosphonates
and proton pump inhibitors?
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.
This updated Medicines Q&A from the Specialist
Pharmacy Service (SPS) concludes that whilst there is
not a recognised interaction between
bisphosphonates (B) and PPIs, a common side effect
of bisphosphonates is gastro-intestinal disturbance.
Additionally the SPCs for B and PPIs highlight an
increased risk of fractures
The electronic Drug Tariff can be viewed here
https://www.sps.nhs.uk/articles/is-there-an-interactionbetween-bisphosphonates-and-proton-pump-inhibitors-2/
Managing asthma in children: A booklet
for parents, carers and family members
Scottish Intercollegiate Guidelines Network have
developed an information booklet which explains
the recommendations in the SIGN/BTS clinical
guideline for asthma. It details the medications
used as treatment and gives advice on how
parents and carers can help control their child’s
asthma.
http://www.sign.ac.uk/pdf/PAT153_Children.pdf
Specialist Pharmacy Service
Medicines Use and Safety Updates
This report addresses the progress and
activities of the Medicines Use and Safety
Division of the Specialist Pharmacy Service. It
includes links to recent resources, collaborative
audits, and publications.
https://www.sps.nhs.uk/wpcontent/uploads/2017/01/Medicines_Use_and_Safety_Update
_-Mar_2017.pdf
Be Clear on Cancer campaign resources available to order
Community pharmacy teams can now pre-order their free campaign resources from Public Health England
pharmacy order line for the Be Clear on Cancer Respiratory Symptoms campaign which launches on 18th May
2017. A toolkit has been created for pharmacies to support the campaign.
https://campaignresources.phe.gov.uk/resources/campaigns/46/resources/1747
Controlled Drug Update
CD Incident - Fraudulent Computer Generated Prescription
A fraudulent computer generated prescription was recently identified by a Doncaster pharmacy. The
prescription for Co-Codamol 30/50mg tablets and Zimovane 7.5mg did not look suspicious and was
only identified when the pharmacist queried the number of tablets as he felt 56 days was excessive.
On liaison with the GP practice it was confirmed that the practice had not issued the prescription. It is
not yet known if there could be further fraudulent prescriptions, South Yorkshire Police are currently
investigating the incident. Pharmacy staff should continue to be vigilant and contact the prescriber if
they have any concerns regarding excessive quantities or validity of any prescriptions. Staff should
report any prescriptions known or suspected to be fraudulent to the Police and NHS Protect, online via
the link https://www.reportnhsfraud.nhs.uk/ or call the Fraud & Corruption Reporting Line
Tel: 0800 028 40 60
Authorisation of CD Destruction Witnesses
Pharmacies can now apply to the NHS
England CD Accountable Officer to have
staff authorised as witnesses for CD
destructions. Requests for authorisation
should be emailed to
[email protected]
Alternatively if you require an authorised
witness to visit your pharmacy please email
medicinesmanagementadmin@doncastercc
g.nhs.uk or Tel: 01302 566229 for further
information.
Controlled Drug Incident Reporting
The Controlled Drug Accountable Officer for NHS
England Yorkshire & Humber is Gazala Khan.
The Medicines Management Team continue to
support the CD AO through delegated authority to
implement the Controlled Drugs (Supervision of
Management and Use) Regulations 2013.
All CD incidents must be reported to NHS England
by completing the incident form below
& submitting via: Email:
[email protected]
NHS E CD Incident
or by fax to 0113 245 1594
Form