NHCCG Prescribing Forum
17th November 2016
What’s New? – Safety
A UKMi Medicines Q&A considers the risks of medication errors with buprenorphine
patches, available as high and low strengths with different indications and
administration schedules, and how to minimise those risks.
Primary Care Talk No. 176 Oct 2016
• Transdermal buprenorphine patches are widely prescribed and available from a variety of
manufacturers. A number of patient safety incidents have occurred in the use of transdermal
opiate patches and concerns have been raised nationally about errors seen with these
products.
• There are two groups of buprenorphine patches, lower strength and higher strength and
there are at least 8 different brands and 21 individual preparations in each of the low
and high strength categories.
• This Q&A aims to cover a number of topics in order to improve the safety of buprenorphine
patch prescribing and administration, as well as highlighting some of the concerns.
• This Q&A does not compare the costs of the various transdermal buprenorphine products.
https://www.sps.nhs.uk/wp-content/uploads/2016/10/UKMI-QA431-1-buprenorphine-patches2016-final.doc
• Do NOT prescribe buprenorphine patches generically.
What’s New? – Safety contd.
A UKMi Medicines Q&A considers the risks of medication errors with buprenorphine
patches, available as high and low strengths with different indications and administration
schedules, and how to minimise those risks. Contd.
Bupeaze (buprenorphine) transdermal patches have been launched
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For the treatment of moderate to severe cancer pain and severe pain which does not respond to
non-opioid analgesics.
The dose should be adapted to the condition of the individual patient; the lowest possible dose
providing adequate pain relief should be given.
Patches should be changed twice a week at regular intervals, and last a maximum of 96 hours (4
days).
Cost for 4 patches: 35mcg/hour, £11.85; 52.5 mcg/hour, £17.78; 70 mcg/hour, £23.70
Panitaz (buprenorphine) transdermal patches have been launched
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For the treatment of non-malignant pain of moderate intensity when an opioid is necessary for
obtaining adequate analgesia.
The lowest strength patch should be used as the initial dose; consideration should be given to
previous opioid history and the current general condition and medical status of the patient. Patches
are applied every 7 days.
Cost for 4 patches: 5 mcg/hour, £9.86; 10 mcg/hour, £17.67; 20 mcg/hour, £32.18.
What’s New? – Safety contd.
RCGP sepsis toolkit to support GPs with sepsis identification and treatment
Brighton & Hove CCG City Scripts Newsletter Sept- Oct 2016
The RCGP, in partnership with Health Education England and NHS England, has launched a new
toolkit to support GPs and healthcare professionals assessing people in the community with acute
infection, to identify and manage sepsis.
• The RCGP’s Sepsis toolkit is designed to help GPs better identify possible sepsis, and provide
education resources for healthcare professionals and patients alike.
• The toolkit contains a series of educational materials, up-to-date guidance and training
resources, as well as information for patients, carers and parents, including
• an adult and child sepsis ‘symptom checker’, to illustrate the signs and symptoms to look for
when concerned about a sudden deterioration in a person’s health in the presence of infection.
http://www.rcgp.org.uk/news/2016/september/new-sepsis-toolkit-designed-to-support-gps-withsepsis-identification-and-treatment.aspx.
What’s New? – Safety contd.
New warfarin administration time at UHS
Southampton City CCG Antidote Issue 161 Oct 2016
At University Hospital Southampton (UHS) NHS Foundation Trust, the warfarin dosage time will change to
2pm (from 6pm). This change will be in effect across the trust as of 19th of October 2016.
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The primary aim for this change is to prevent missed doses, by allowing all prescriptions of warfarin to
occur within core hours.
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This will prevent out of hours doctors having to prescribe warfarin for patients that they are unfamiliar
with.
 Warfarin which requires a review will be addressed during the usual team’s working
hours.
 Upon discharge, the paperwork will state that the patient will have received warfarin at
2pm whilst an inpatient at UHS.
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This change is being instigated at UHS only and do not expect other trusts to mirror this.
All patients are advised on the discharge paperwork that they are to revert to their usual dosage time
for warfarin (likely to be 6pm in most cases).
Toolkit on the risks of valproate medicines in female patients
Medicines and Healthcare products Regulatory Agency
MHRA has worked with industry, healthcare professionals and patient groups on a toolkit to ensure female
patients are better informed about the risks of taking valproate medicines during pregnancy, including a
learning video for GPs.
https://www.gov.uk/government/publications/toolkit-on-the-risks-of-valproate-medicines-in-femalepatients
What’s New? – Safety contd.
BTS/SIGN asthma guidance updated
Primary Care Talk No. 175 Sept 2016
The BTS/SIGN guideline on the diagnosis and management of asthma has been updated.
• Treatment stages for chronic management are no longer referred to as numbered steps. A table shows
recommended doses of inhaled steroids for each inhaler by brand.
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Doses are expressed as very low (generally paediatric dose), low (generally starting dose for adults),
medium and high.
• The full guideline, quick reference guide and supporting material are available from the SIGN
http://www.sign.ac.uk/guidelines/fulltext/153/index.html
Specials (unlicensed) items containing coal tar
There is evidence that prescribing and dispensing errors for specials products (unlicensed products)
containing coal tar can result in some patients receiving an inappropriate product. This leads to a risk of
significant harm.
• The British Association of Dermatologists’ List of Preferred Specials, lists products containing coal in
terms of the % of one of the official coal tar preparations. There are three of these:
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Coal Tar BP, Coal Tar Solution BP, and • Coal Tar Solution Strong BP.
An important factor contributing to the errors appears to be confusion as to which of these
preparations is needed. Prescribers should therefore ensure that prescribed orders for specials items
containing coal tar clearly specify the coal tar preparation.
The Royal Pharmaceutical Society has published updated guidance for the procurement and supply of
specials and guidance for the prescribers of specials: http://www.rpharms.com/unsecure-supportresources/specials-resources.asp.
What’s New? – Seasonal contd.
Prescribing for patients going on holiday
Midlands & Lancashire CSU Tablets Medicines Management News, Issue 28 July 2016
Under NHS legislation, the NHS ceases to have responsibility for people when they leave the UK.
However, to ensure good patient care the following guidance is offered:
• To ensure continuity of care for patients on a stable medication regime it is reasonable to provide
a routine repeat prescription usually for one but no more than three months.
• GPs are not responsible for prescribing items required for conditions which may arise while
travelling e.g. travel sickness and diarrhoea. Patients should be advised to purchase these items
locally prior to travel.
• Countries have different rules and regulations about the types and quantity of medicine they
allow to be taken into the country. Patients should check the rules for all the countries they are
going to, including countries that they just pass through.
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The gov.uk/travel website has a full list of foreign embassies in the UK with whom the patients can make
contact. ( https://www.gov.uk/foreign-travel-advice )
Patients entering or leaving the UK for three months or more with personal medication containing
a controlled drug must get a licence.
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Online applications must be made on the Home Office website at least ten working days before travel
date. Travel arrangements should not be made until the licence has been received.
(https://www.gov.uk/guidance/controlled-drugs-licences-fees-and-returns)
What’s New? – Seasonal contd.
Prescribing for patients going on holiday contd.
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Patients entering or leaving the UK for less than three months do not need a licence but should
have a letter from their doctor with the following information:
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patient’s name, patient’s travel itinerary, a list of prescribed controlled drugs being carried, dosages and
total amounts for each drug.
Medicines for the prevention of malaria (except for Malarone, mefloquine and doxycycline) are
available for purchase “over the counter” at community pharmacies.
Malarone, mefloquine and doxycycline are prescription only medicines and should be prescribed
on private prescription.
Community pharmacies have access to up to date advice about appropriate prophylactic
regimens and can advise travellers accordingly.
Useful links and websites:
http://www.fitfortravel.nhs.uk/home.aspx
http://www.who.int/ith/en/
http://travelhealthpro.org.uk/
http://nathnac.net
What’s New? – Seasonal contd.
Can Doxycycline Be Used For Malaria Prophylaxis in a Patient with Raised Liver Function Tests?
Midlands & Lancashire CSU Tablets Medicines Management News, Issue 28 July 2016
• The manufacturer of doxycycline advises caution when using in a patient with hepatic
impairment. They also state that doxycycline can rarely cause abnormal hepatic function.
• The UK malaria prophylaxis guidelines note this caution
(https://www.gov.uk/government/publications/malaria-prevention-guidelines-for-travellersfrom-the-uk), and provide the following recommendations about choice of drug in patients with
liver disease:• Most antimalarial drugs are excreted or metabolised by the liver. Thus, there is a risk of drug
accumulation in severe liver impairment.
• In severe liver disease: A CDC (Centers for Disease Control and Prevention) expert meeting
concluded that the dose of doxycycline does not have to be adjusted in patients with impaired
hepatic function since it is excreted as an inactive chelated product via a process of back diffusion
in the small bowel.
• Note to prescribers: The BNF states that tetracyclines should be avoided or used with caution in
patients with hepatic impairment. The manufacturer of an atovaquone-proguanil combination
preparation states that although no pharmacokinetic studies have been conducted in severe
hepatic impairment, no special precautions or dosage adjustment are anticipated (SPC).
What’s New? – Seasonal contd.
Can Doxycycline Be Used For Malaria Prophylaxis in a Patient with Raised Liver
Function Tests? contd.
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In moderate liver impairment: doxycycline and proguanil, alone or in combination, or mefloquine
may be used.
• In mild impairment: chloroquine, or proguanil, alone or in combination, combined atovaquoneproguanil or mefloquine, or doxycycline may be used.
• The choice of chemoprophylaxis should be made after discussion with the patient’s specialist,
who will be able to assess their degree of hepatic impairment.
• The Child-Pugh classification is often used for grading liver function and can be found at:
http://www.liverpoolmedics.co.uk/clinicalcalculator/childpugh.php?valid=[ss11].
or
http://www.hepatitis.va.gov/provider/tools/child-pugh-calculator.asp.
What’s New? – Safety contd.
Yellow Card iDAPs
Primary Care Talk No. 176 Oct 2016
• Interactive Drug Analysis Profiles (iDAPs) are a new way to display data from the Yellow Card
Scheme. They replace Drug Analysis Prints (DAPs) that provided information on the number of
reports received for a drug.
• Each iDAP provides an overview of all UK spontaneous suspected adverse drug reactions
reported through the Yellow Card Scheme. Reports are of reactions suspected of being
medicine-related; a causal association may not have been confirmed.
• The number of reports can be viewed according to factors such as patient age or sex, or by year
of report.
• Suspected reactions are listed by system organ class. The list is expandable into smaller
divisions, allowing the user to see the number of reports for specific reactions.
• Each iDAP contains essential guidance (at the bottom of the report) that explains the context of
the data available.
• To view, go the Yellow Card website and click on “Drug Analysis profiles” towards the top of the
screen. Use the A-Z list to select the drug you want. Medicines are listed alphabetically by the
name of the active ingredient. iDAPs are not available for combination drugs; individual iDAPS
include a column showing the number of reports for medicines containing ‘multiple active
constituents’.
What’s New? – Savings
Medicines Optimisation Prescribing Hints and Tips
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Fluoxetine capsules 3 x 20mg
Fluoxetine capsules 1 x 60mg
Azithromycin tablets 250mg
Azithromycin capsules 250mg
Paracetamol tablets 500mg
Paracetamol capsules and caplets 500mg
Zapain® tablets 30mg + 500mg
Co- Codamol (codeine 30mg + paracetamol 500mg) tablets
Omeprazole gastro- resistant capsules 20mg
Omeprazole gastro- resistant tablets 20mg
Zaluron ® XL tablets 50mg, 150mg, 200mg, 300mg & 400mg
Quetiapine m/r tablet 50mg, 150mg, 200mg, 300mg & 400mg
Oronac® tablets 600mg
Acetylcysteine tablets 600mg
Nitromin® pump spray 400mcg/ dose
Glyceryl trinitrate pump spray 400mcg/ dose
Tramulief SR® tablets 50mg, 100mg, 150mg,2 & 00mg
Tramadol m/r capsules 50mg,100mg, 150mg & 200mg
Testosterone Undecanoate Oily injection 1000mg/ 4ml
Nebido® oily injection1000mg/4ml
What’s New? – Savings contd.
Centrally supplied vaccines
Brighton & Hove CCG City Scripts Newsletter Sept- Oct 2016
This is a reminder to practices that where vaccines have been centrally procured through Public
Health England, they should not make a claim under personal administration arrangements to NHS
Prescription Services on form FP34D/PD Appendix or FP10.
• An FP34D/PD Appendix or FP10 form should only be submitted for payment to cover the
dispensing of a vaccine by personal administration where the vaccine has been purchased by
the practice.
• Recently NHS Prescription Services has conducted an exercise to recover payments for
Meningococcal vaccines claimed by GP practices where they had been centrally supplied and
payment had been claimed under personal administration arrangements.
What’s New? – New products
A pharmacist must supply a product with a marketing authorization
Product Miscellany Sept- Oct 2016
There is a professional requirement that where a product is ordered on a prescription, a pharmacist
must supply a product with a marketing authorization, where such a product exists and is available,
in preference to an unlicensed medicine:
• Glycopyrronium Bromide 1 mg/5 ml Oral Solution
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Diazepam 2mg/5ml oral suspension (Special Order) has been discontinued.
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Quantum Pharmaceuticals have launched a licenced glycopyrronium bromide 1mg/5ml oral solution for
use in adults as an add-on therapy in the treatment of peptic ulcer.
There are currently 3 licensed oral glycopyrronium bromide preparations :
Glycopyrronium bromide 1mg/5ml 150ml=£91.00
Glycopyrronium bromide 2mg 30 tabs=£229.20
Glycopyrronium bromide 1mg 30 tabs=£206.63.
A licensed option Diazepam 2mg/5ml oral suspension is available from Sandoz Ltd.
Cost- 100ml=£31.75.
Ergocalciferol 50 000 IU Capsules
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This new product is licensed for the treatment of vitamin D deficiency and the maintenance of vitamin
D levels in adults and the elderly.
What’s New? – New products contd.
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Polyvinyl alcohol 1.4% eye drops and Polyvinyl alcohol 1.4% eye drops0.4ml unit dose
preservative free are classified as medical devices
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These products are no longer being manufactured as licensed medicines.
The medical devices containing polyvinyl alcohol that have been approved as appliances are
listed in Part IXA of the Drug Tariff in the eye products category.
The products in Part IX are listed by proprietary name or generic name + supplier.
Prescribers may wish to consider whether a patient would be able to use one of the unit
dose preservative free products as an alternative to prescribing Polyvinyl alcohol 1.4%
eye drops preservative free (‘ a special’) which may also be prescribed and sourced from
a manufacturer holding a MHRA specials licence.
Newly licensed fluoxetine preparations:
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fluoxetine dispersible 20mg tabs 28=£3.44
fluoxetine oral solution 20mg/5ml 70ml=£3.06
fluoxetine 10mg caps 30=£55.00
(consider prescribing oral solution 10mg dose = 11p and 1 x 10mg caps = £1.83)
fluoxetine 20mg caps 30=93p fluoxetine 30mg caps 30=£1.80
fluoxetine 40mg caps 30=£1.80 fluoxetine 60mg caps 30=£9.98
(prescribe 3 x 20mg caps = £2.79 instead of 1 x 60mg caps = £9.98 for 30 units)