NHCCG Prescribing Forum
19th January 2017
What’s New? – Safety
Points to consider when prescribing Direct Oral Anticoagulants (DOACs)
Information provided by West Hampshire CCG Medicines Optimisation news headlines Nov 2016
NOACS are now generally referred to as DOACs (Direct Oral Anticoagulants). Tamara Everington,
Consultant Haematologist, HHFT has been attending the Medicines Optimisation Groups to provide an
update on DOACs and answer some of the questions that have arisen recently.
The following re-iterates some of the important points that have originated from these meetings, or
gives a taster for those who have yet to receive the talk.
• One important point that has come out of the discussions is that a ‘one size fits all’ approach is
definitely not suitable. There are differences between the DOACs in terms of efficacy and adverse
effects and these must be considered in conjunction with an individual patient’s renal function and
risk of bleeding.
• High dose (150mg BD) dabigatran is associated with greatest efficacy in stroke prevention of AF.
However, it is not suitable for patients with reduced renal function.
• Rivaroxaban and edoxaban can cause mucosal bleeding so should be avoided in patients where
this is a risk.
• Apixaban carries the lowest risk for incidence of a gastrointestinal bleed.
• We are all aware of the possible consequences that might ensue from an overdose of anticoagulant
and may tend to err towards lower doses.
• However, there is a significant risk that use of low doses will not be sufficient to provide adequate
prophylaxis against a thromboembolic event.
Tbc next slide
What’s New? – Safety contd.
Points to consider when prescribing Direct Oral Anticoagulants (DOACs) contd.
•
Therefore, it is important to assess the patient fully to ensure that they receive an appropriate dose
of whichever DOAC is preferred.
• The evidence for efficacy is based on higher doses and lower does should only be used where there is
a definite reason to reduce the amount prescribed.
• Although creatinine clearance may be comparable to eGFR for a proportion of the population, there
can be a significant difference for those who are frail or who are at the extremes of age or weight.
Failure to calculate creatinine clearance can result in excessive under- or overdosing for these
patients.
• Interactions with warfarin are at the forefront of our minds, as any change to a medication regimen
can affect the INR and consequently flag up a possible problem. There is no such safety measure in
place with the DOACs so it is even more important to consider interactions when changes are made
to a treatment regimen (either adding a DOAC or adding to a DOAC).
 The main culprits are anticonvulsants, antifungals and verapamil (for dabigatran), but
prescribers should bear in mind that many other drugs including ‘Over The Counter’ medicines
have the potential to interact too.
• A check should be made for interactions before any changes are instigated.
• If all else is equal, then price could be a deciding factor. The current cost for 28 days treatment with a
DOAC is:
o Apixaban £53.20
o Dabigatran £47.60 o Edoxaban £51.80
o Rivaroxaban £50.40
What’s New? – Safety contd.
Ticagrelor for preventing atherothrombotic events after myocardial infarction- guidance
(TA420)
NICE
Ticagrelor 60 mg twice daily is the recommended dose when an extended treatment is required for
patients with a history of MI of at least one year and a high risk of an atherothrombotic event.
• NICE guidance supports use of ticagrelor in combination with aspirin as an option for preventing
atherothrombotic events in adults who had an MI and who are at high risk of a further event.
• Treatment with ticagrelor may be started without interruption as continuation therapy after the
initial one-year treatment with ticagrelor 90 mg or other adenosine diphosphate (ADP) receptor
inhibitor therapy in ACS patients with a high risk of an atherothrombotic event.
• Treatment can also be initiated up to 2 years from the MI, or within one year after stopping
previous ADP receptor inhibitor treatment.
• There are limited data on the efficacy and safety of ticagrelor beyond 3 years of extended
treatment.
• Treatment should be stopped when clinically indicated or at a maximum of 3 years.
• http://www.medicinesresources.nhs.uk/en/Medicines-Awareness/Guidance-and-Advice/Drugbest-practice-guidance/Ticagrelor-for-preventing-atherothrombotic-events-after-myocardialinfarction--guidance-TA420/
What’s New? – Drug Safety Update Dec 2016
Cobicistat, ritonavir and coadminsitration with a steroid: risk of systemic
corticosteroid adverse effects
Drug Safety Update Dec 2016
• Clinicians who may prescribe or administer steroids to patients with HIV should be aware
that concomitant use of a corticosteroid metabolised by cytochrome P450 3A (CYP3A) and
a HIV-treatment-boosting agent (ritonavir, cobicistat) may increase the risk of systemic
corticosteroid adverse effects.
• Co-administration of these medicines is not recommended unless the potential benefit to
the patient outweighs the risk, in which case patients should be monitored for systemic
corticosteroid-related adverse reactions (e.g., Cushing’s syndrome, adrenal insufficiency).
• Although these reactions are rarely reported, there is potential for this interaction to occur
even with non-systemically administered steroid formulations, including intranasal, inhaled,
and intra-articular routes
• If co-administration is necessary, use of beclomethasone should be considered where
possible—particularly for long-term use. Beclomethasone is less dependent on CYP3A
metabolism and, although the risk of an interaction leading to adverse corticosteroid
effects may not be completely removed, it may be lower
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/577417/pdf_
Dec.pdf
•
What’s New? – Drug Safety Update Dec 2016 contd.
Spironolactone and renin-angiotensin system drugs in heart failure: risk of
potentially fatal hyperkalaemia—clarification
Prescribing Snippets Issue 151 Nov- Dec 2016 (Brent CCG)
Advice issued in Drug Safety Update February 2016 regarding the concomitant use of
spironolactone with an angiotensin converting enzyme inhibitor (ACEi) or an angiotensin
receptor blocker (ARB) has been re-issued to clarify that the combination must be used with
caution (consistent with clinical guidelines for both chronic and acute heart failure).
• This update is a result of feedback from the initial advice, which indicated that some
readers of the Drug & Safety update had interpreted that advice to mean that the
combination must not be used.
• Concomitant use of spironolactone with ACEi or ARB increases the risk of severe
hyperkalaemia, particularly in patients with marked renal impairment, and should be used
with caution.
• The article now also clarifies that the same advice applies for concomitant use of the
aldosterone antagonist eplerenone with ACEi or ARB in heart failure. The full article can be
accessed here:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/577417/pdf_
Dec.pdf
What’s New? – Safety contd.
Which opioids can be used in renal impairment?
Specialist Pharmacy Service (previously known as UKMi)
• Opioids are used in a wide variety of clinical settings and are well established for the treatment
of both acute and chronic pain.
• Renal impairment (RI) not only alters the clearance of the parent compound but also affects the
accumulation of its metabolites. Elimination may be prolonged.
• This Q&A notes absolute recommendations on reductions of opioid doses are difficult as clear
relationship between renal function and removal of opioid metabolites has yet to be identified.
• Recommendations for dose are based on pharmacokinetic studies and clinical experience.
https://www.sps.nhs.uk/articles/which-opioids-can-be-used-in-renal-impairment/
Helicobacter pylori in dyspepsia: test and treat.
Public Health England
• These updated documents aim to provide a simple, effective, economical and empirical
approach for testing and treatment of Helicobacter pylori and to minimise the emergence of
antibiotic resistance in the community.
• Of particular use is the summary table which can be accessed along with the other documents
from:
• https://www.gov.uk/government/publications/helicobacter-pylori-diagnosis-and-treatment
What’s New? – Safety contd.
What is the most appropriate antidepressant to use in patients with epilepsy?
Published 16th October 2014, updated 22nd December 2016 · UKMi
This updated Medicines Q&A evaluates the published information available on the most
appropriate choice of antidepressant for patients with epilepsy.
• The first consideration should always be to check the patients’ anticonvulsant regimen for
potential drug-induced depression. It may be that the patient would benefit from changing the
anticonvulsant to another agent with a more favourable effect on mood rather than adding in
an antidepressant.
• The risk of seizures with most antidepressants is low, but is probably not zero for any of them,
and patients should be made aware of this when prescribing. The risk of seizures increases
with increasing doses.
• Selective Serotonin Reuptake Inhibitors (SSRIs) are considered the first line antidepressant
option in patients with epilepsy. Sertraline may be considered the better option due to safety
data and reduced interaction potential with the anticonvulsants. Fluoxetine is not the best
choice due to its long half-life, a possibly greater incidence of seizures and an increased risk of
drug interactions.
• Moclobemide is a good alternative, as it has a low incidence of seizures but due to limited data
it should be reserved as a second choice to SSRIs.
Tbc next slide
What’s New? – Safety contd.
What is the most appropriate antidepressant to use in patients with epilepsy? Contd.
•
Tricyclic antidepressants (TCAs) should be used cautiously in patients with epilepsy and
reserved for patients who poorly respond to or are intolerant of other antidepressants. Where
a TCA is needed, doxepin is possibly of lowest risk and therefore the agent of choice within this
group.
• Clinicians should be aware of the possibility of interactions between antidepressants and
anticonvulsants and should monitor carefully patients with epilepsy who are prescribed
antidepressants.
• Introducing the antidepressant gradually, starting with a low dose, and not exceeding the
maximum recommended doses may reduce the risk of a seizure.
• If seizures occur or if the incidence of seizures increases, the antidepressant should be
discontinued.
• Check for pharmacokinetic & pharmacodynamic drug interactions between antidepressants and
antiepileptic drugs prior to prescribing.
https://www.sps.nhs.uk/articles/what-is-the-most-appropriate-antidepressant-to-use-in-patientswith-epilepsy/
What’s New? – Safety contd.
Emollients containing antimicrobials- reminder
The BNF recommends when to use emollients containing an antibacterial and as such, preparations
e.g. Dermol® & Eczmol®, containing an antibacterial should be avoided unless infection is present or is a
frequent complication https://www.medicinescomplete.com/mc/bnf/current/PHP7459-emollients.htm.
• Children with atopic eczema are known to carry a higher staph. colony so the use of these products
can be useful in stopping the growth of bacteria, but should be used for short periods of time.
• In all situations the use of antimicrobial- containing emollients should be reviewed regularly. Incorrect
use of antiseptics can irritate the skin and make eczema worse.
• Therefore, prescribe these medications where clinically appropriate to avoid sensitization and the
development of microbial resistance, and at the same time make substantial cost- savings (all of these
products are more expensive than antimicrobial- free emollients of similar lipid content).
• The CCGs emollient spend for the 6 month period, May 2016- Nov 2016 (ePACT) was
£204,134.11 = 34,255 items
of this the prescribing of antimicrobial- containing emollients accounted for
£29,114.31 (14% of the total cost) = 4,550 items (13% of the total items)
• If we could switch 60% of these preparations to another antimicrobial- free emollient of similar lipid
content the CCG could potentially reduce the spend on antibacterial- containing emollients by
£17,468.59 per annum (based on average cost per item).
What’s New? – Safety contd.
Patient safety incident involving Entresto® (sacubitril and valsartan)
Medicines Matters Winter 2016 PCPA Newsletter
A CCG has reported that Entresto® was prescribed by a hospital doctor who failed to tell the
patient to stop taking losartan.
The hospital pharmacy never asked about the
• patient’s other medicines so the error wasn’t picked up until the patient was reviewed some
weeks later in the local heart failure clinic —
• by when his blood pressure had fallen and creatinine had risen.
Raising awareness of MDS (blisterpack) patients
Medicines Matters Winter 2016 PCPA Newsletter
It is recommended that all GP practice staff, including locum doctors, be aware when a patient
uses a blisterpack so that the dispensing pharmacy can be notified when medicines changes are
made- add notes to patient records.
What’s New? – Safety contd.
Galantamine Monitoring
Prescribers are reminded to check renal & hepatic function in patients prescribed galantamine.
• Galantamine is contraindicated in severe renal and hepatic impairment and metabolic disorders
of galactose metabolism.
• Reduce the dose of galantamine in moderate hepatic impairment
• Eclipse has identified that there are at least 20 patients - 9 have not had LFTs for >12months and
6 have not had creatinine levels done for >12 months.
Galantamine - Total Items Issued Nov15 -Oct16
90
80
70
60
50
40
30
20
10
0
Total Items
What’s New? – Safety contd.
Sertraline use in the first trimester and risk of congenital anomalies: a systemic review
and meta-analysis of cohort studies
British Journal of Clinical Pharmacology
• Review of 12 studies (total 6,468,241 pregnancies) found that those who used sertraline in the
first trimester had an increased risk of infant cardiovascular related malformations (OR 1.36,
95%CI 1.06-1.74) as well as atrial and/or ventricular septal defects (1.26, 1.06-1.76).
• Meanwhile, nonsignificant associations between sertraline use and other congenital anomalies
were found.
• More cohort studies are warranted to provide detailed results of other congenital anomalies.
http://onlinelibrary.wiley.com/doi/10.1111/bcp.13161/full
What is serotonin syndrome and which medicines cause it?
Specialist Pharmacy Service
• This Medicines Q&A outlines causes and symptoms of serotonin syndrome, which results in
certain symptoms consisting of triad of features: alteration of mental status, neuromuscular
abnormalities and autonomic hyperactivity. It also lists medicines with the potential to cause it.
https://www.sps.nhs.uk/articles/what-is-serotonin-syndrome-and-which-medicines-cause-it-2/
What’s New? – Safety contd.
Alaris® syringe pumps (all models) – risk of uncontrolled bolus of medicine with nonrecommended syringes
MHRA
Alaris syringe pumps are manufactured by CareFusion. This alert warns that using nonrecommended syringes in Alaris syringe pumps that have a broken spring in the plunger assembly
may cause unintended bolus of medication.
https://www.cas.dh.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=102562
Access to Immunisation PGDs
Medicines Optimisation news headlines Sept 2016 West Hampshire CCG
• The associated Patient Group Direction (PGD) documents for the routine immunisation
schedule for 2016/17 have now been updated by NHS England for both standard childhood
immunisations and annual immunisation programmes such as influenza.
• It is important that all practices have up to date and signed copies of these PGDs in place.
• The documents can be easily accessed through the NHS England website.
What’s New? – Seasonal
DH permits use of antiviral medicines against influenza
PSNC News
• Due to increasing flu levels in the community, the Department of Health (DH) has issued a letter
advising that GPs and other prescribers working in primary care in England may now prescribe
antiviral medicines for the prophylaxis and treatment of flu at NHS expense.
• Prescribers may prescribe for patients in ‘clinical at-risk’ groups as well as those who are at risk of
severe illness and/or compilations from flu if not treated (including people with morbid obesity), in
accordance with NICE’s guidance and the Selected List Scheme (SLS) in Part XVIIIB of the England and
Wales Drug Tariff.
• It is important that oseltamivir for adults and children (aged 1 year or over) and zanamivir for adults
are taken within 48 hours of onset of symptoms. Children 5 years and over and under 13 years of age
should start taking zanamivir within 36 hours of onset of symptoms, to obtain maximum benefit.
• There is also an extension of the national childhood influenza immunisation programme to include
children of appropriate age for school years 1, 2, and 3.
• Information on the available vaccines and the management of children and adults with egg allergy
has been updated in line with the chapter on Influenza in the Public Health England (PHE) document
Immunisation against infectious disease (The Green Book).
• Community pharmacy teams who receive FP10 NHS prescriptions – written generically or by brand –
for oseltamivir (Tamiflu) or zanamivir (Relenza) must be endorsed "SLS" by the prescriber. If the SLS
endorsement is missing, the prescription will not be dispensed, as it will not be passed for payment.
Find out more, and read the letter in full, at:
https://www.cas.dh.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=102560
What’s New? – Seasonal contd.
Guidelines for malaria prevention in travellers from the UK: 2016
Updated guidance reflects recognition that world malaria situation has improved significantly in
some regions in recent years and finding from WHO report 2015 that 88% global cases originate in
Africa- practitioners should engage as much as possible with those planning trip there.
What’s New? – Revised SPCs
Revised SPC: Flagyl (metronidazole) - all presentations
Electronic Medicines Compendium
• SPC has been revised to include the following new adverse effects: fixed drug eruption and hearing
impairment and sensorineural deafness.
• Dosages of metronidazole vary according to the indication.
http://www.medicines.org.uk/emc/medicine/26716
Metronidazole dose changes for acute ulcerative gingivitis and acute oral infections
BNF
Acute ulcerative gingivitis by mouth:
• Child 1–2 years 50 mg every 8 hours for 3 days. Child 3–6 years 100 mg every 12 hours for 3 days.
Child 7–9 years 100 mg every 8 hours for 3 days. Child 10–17 years 200–250 mg every 8 hours for 3
days.
• Adult 400 mg every 8 hours for 3 days.
Acute oral infections by mouth:
• Child 1–2 years 50 mg every 8 hours for 3–7 days. Child 3–6 years 100 mg every 12 hours for 3–7
days. Child 7–9 years 100 mg every 8 hours for 3–7 days. Child 10–17 years 200–250 mg every
8 hours for 3–7 days.
• Adult 400 mg every 8 hours for 3–7 days.
What’s New? – Revised SPCs contd.
Revised SPC: Klaricid (clarithromycin) Paed Susp 125mg & 250mgh/5ml
Electronic Medicines Compendium
• The SPC has been updated with information on the contraindicated use of clarithromycin with
ergot alkaloids, and with oral midazolam due to interactions.
• Mania and ventricular fibrillation have also been added as undesirable effects of unknown
frequency.
http://www.medicines.org.uk/emc/medicine/45
Revised SPC: Sustanon 250, 250mg/ml solution for injection (testosterone propionate,
testosterone phenylpropionate, testosterone isocaproate, testosterone decanoate)
Electronic Medicines Compendium
• Section 4.4 now advises that testosterone should be used with caution in patients with
thrombophilia, as there have been post-marketing studies and reports of thrombotic events in
these patients during testosterone therapy.
http://www.medicines.org.uk/emc/medicine/28840
What’s New? – Revised SPCs contd.
Revised SPC: Dermovate ointment (clobetasol propionate)
Electronic Medicines Compendium
• SPC has been revised to bring it in line with the SPC for the cream and now includes advice on
using with caution in infants and children under 12 years.
• Long-term continuous topical corticosteroid therapy should be avoided where possible, as
adrenal suppression can occur.
https://www.medicines.org.uk/emc/medicine/730
Revised SPC: Eumovate (clobetasone) preparations
Electronic Medicines Compendium
• SPC now states children are more likely to develop local and systemic adverse reactions from
local corticosteroids because of a higher surface area to body mass ratio.
• Long term use in <12yr olds to be avoided where possible as adrenal and growth suppression is
more likely.
http://www.medicines.org.uk/emc/medicine/2606
What’s New? – Revised SPCs contd.
Revised SPCs: Adalat, Adalat 5, Adalat retard 10mg and 20mg modified-release tablets
(nifedipine)
Electronic Medicines Compendium
• The SPCs have been updated with information that nifedipine should be used with caution in
severe hepatic impairment. However, careful monitoring and dose reduction may be required
with any severity of liver impairment:
http://www.medicines.org.uk/emc/medicine/20901
Revised SPCs: Losec (omeprazole) 10mg, 20mg and 40mg capsules
Electronic Medicines Compendium
• The SPC has been updated with information regarding the risk of clostridium difficile with
omeprazole due to the reduction of acid in the gastrointestinal tract.
http://www.medicines.org.uk/emc/medicine/7275
What’s New? – Revised SPCs contd.
Revised SPC: Havrix and Havrix Junior (hepatitis A [inactivated] vaccine [adsorbed])
preparations
Electronic Medicines Compendium
• SPC updated to clarify the list of vaccines that can be co-administered with Havrix Monodose
and Havrix Junior Monodose vaccines (monovalent and combination vaccines comprised of
measles, mumps, rubella and varicella).
https://www.medicines.org.uk/emc/medicine/2041
https://www.medicines.org.uk/emc/medicine/2040
Revised SPC: Lariam (mefloquine) 250 mg Tablets
Electronic Medicines Compendium
• SPC now explicitly states that the recommended chemoprophylactic dose of mefloquine is
~ 5 mg/kg bodyweight once weekly.
• Also the recommended total therapeutic dose for curative treatment is now the same for all
patients irrespective of immune status (20 – 25 mg/kg).
https://www.medicines.org.uk/emc/medicine/1701
What’s New? – Revised SPCs contd.
Revised SPC: Cardura (doxazosin) preparations
Electronic Medicines Compendium
• SPC now highlights that prostate cancer should be ruled out before initiating therapy. Priapism
has been added as a rare adverse event. Gastrointestinal obstruction has also been added as a
rare adverse effect for the modified release preparations only.
http://www.medicines.org.uk/emc/medicine/30615
What’s New? – Storage enquiry
Prednisolone 5mg/5ml oral solution unit (Dompe® Prednisolone)
This product is currently more cost effective than using prednisolone 5mg soluble tablets.
Each 10 single- dose containers = £11.41
Medicines Management received an enquiry as to whether 9 out of 10 of the unit dose vials could
be dispensed:
The SPC Section 6.5 Nature and Contents of Container states:
• ‘Single-dose polyethylene containers containing 5 ml of oral solution, grouped in strips of five
containers. All opened units should be discarded once the required dose is removed. Each strip
is packaged in a PET/Al/PE over-pouch. Each unit carton contains two over-pouches (ten singledoses), a patient leaflet and a measuring spoon (dosing 3.75 ml, 2.5 ml and 1.25 ml,
corresponding to partial doses).’
• Please note, in the case of administration partial doses, the opened single-dose container must
be discarded once the required dose is removed.
• The packs may be split (i.e. where less than a full pack is prescribed), provided the product is
not exposed to light and is stored below 30°C.
• For endorsing and reimbursement purposes, Prednisolone Dompé 1mg/ml Oral Solution has a
special container status. Special container rules are automatically applied and contractors will
be reimbursed for the nearest pack or combination of packs.
https://www.medicines.org.uk/emc/medicine/30037
What’s New? – Savings
Medicines Optimisation Prescribing Hints and Tips
×

Paroxetine tablets 2x 20mg
Paroxetine tablets 40mg
Paroxetine tablets 0.5 x 20mg
Paroxetine tablets 10mg
Aripiprazole tablets 2 x 15mg
Aripiprazole tablets 30mg
Butec Patches (7- day) 5mcg/hr, 10mcg/hr, & 20mcg/hr
BuTrans® Patches(7- day) 5mcg/hr, 10mcg/hr, & 20mcg/hr
Paracetamol oral solution
Paracetamol oral suspension
Levetiracetam 100mg/ml SF oral solution
Keppra® 100mg/ml oral solution (cat 3 for AEDs)
Risperidone oral solution 1mg/ml SF oral solution
Risperidone all strengths orodispesible tablets
Cefalexin capsules 250mg & 500mg
Cefalexin tablets 250mg & 500mg
Paracetamol SF oral suspension 250mg/5ml
Paracetamol oral suspension 250mg/5ml or Paracetamol SF oral
suspension 500mg/5ml or Paracetamol SF oral solution
500mg/5ml
What’s New? – Savings contd.
Paracetamol caplets and tablets on EMIS:
Paracetamol Caplets are listed on the EMIS medication list but it is NOT DMD mapped so CAN NOT
be prescribed via an EPS prescription. The prices listed are as follows:
•
16 = £0.43 Wockhardt - IN BOLD on EMIS
•
32 = £2.11 Teva / 0.82p Wockhardt / 0.42p Actavis
•
100 = £1.82 Teva / £2.56 Wockhardt / 0.92p Actavis / 0.76p Zentiva
Paracetamol Tablets are listed on the EMIS medication list and ARE DMD mapped so CAN be
prescribed via an EPS prescription. The prices listed are as follows:
•
16 =
•
32 = 0.72p Drug Tariff - IN BOLD on EMIS / £1.24 Teva / 0.82p Wockhardt /0.20p M&A
Pharmchem
•
100 = £2.28 Drug Tariff / £2.10 Actavis / £1.62 Ecogen
0.37p Alliance / 0.16p AAH / 0.14p Wockhardt
What’s New? – Savings contd.
Iron preparations
Derbyshire Medicines Management Newsletter Vol 6 Issue 9 Dec 2016
•
•
•
The choice of iron preparations is based on cost and incidence of side effect. There is little difference
in efficiency of absorption of iron between the different salts.
Modified release preparations have no therapeutic advantage and the low incidence of side effects
are related to the lower absorption of iron.
Iron Preparation
Ferrous Iron
Content
Cost
Therapeutic Dose
28 day cost of
therapeutic dose
Ferrous fumarate
305mg caps
100mg
£2.33 per 100
1 cap Twice daily
£1.30
Ferrous fumarate
322mg tabs
100mg
£1.00 per 28
1 tab Twice daily
£2.00
Ferrous fumarate
210mg tabs
65mg- 70mg
£3.50 per 84
1 tab Two to Three
times a day
£2.33- £3.50
Ferrous sulphate
200mg tabs
65mg
£1.84 per 28
1 tab Three times a
day
£5.52
Ferrous fumarate 305mg is the preferred oral iron product. Iron salts should be given orally until
haemoglobin has reached reference range and then maintained for 3 months, to replenish iron stores
before stopping.
What’s New? – New products
Braltus® (Tiotropium) 10mcg Inhalation Powder
Derbyshire Medicines Management Newsletter Vol 6 Issue 9 Dec 2016
Braltus is licensed as a maintenance bronchodilator treatment to relieve symptoms in patients with
chronic obstructive pulmonary disease.
• The Zonda inhaler is especially designed for use with Braltus capsules to deliver the same dose of
tiotropium as Spiriva HandiHaler for patients with COPD.


•
•
Spiriva capsules for inhalation contain 18 microgram of tiotropium, but the delivered dose is 10
microgram of tiotropium.
Braltus capsules for inhalation contain 13 microgram of tiotropium, but the delivered dose is 10
microgram of tiotropium.
However note the tiotropium devices are not interchangeable.
Before a product is prescribed, patients should have an inhaler technique assessment and be able to
demonstrate that they are able to use the chosen device effectively. The device should not be
changed without a full review of technique.
Drug name
Dose
Cost
Braltus (tiotropium 13mcg hard caps) One inhalation daily £25.80 x 30 caps (& zonda inhaler)
Spiriva (tiotropium 18mcg caps)
One inhalation daily £34.87 x 30 (& handihaler)
• It is estimated that a like for like switch from the Spiriva inhaler to Braltus would save NH CCG £24K
over 3 months.
https://www.medicines.org.uk/emc/medicine/32634
What’s New? – New products
Noqdirna® (desmospressin acetate) 25mcg and 50mcg oral lyophilisate
Electronic medicines compendium
This treatment is licensed for symptomatic treatment of nocturia due to idiopathic nocturnal
polyuria in adults.
• The dose is 25 microgram daily for women and 50microgram daily for men.
• Costs : 30 tablets both strengths are £15.16
https://www.medicines.org.uk/emc/medicine/32493
5 litre sharps bin available
Medicines Matters Winter 2016 PCPA Newsletter
• Sharpsguard now produce a 5 litre sharps bin that can be
• prescribed on FP10. The 5L bin costs £1.20 compared with
• the 1L bin that costs 78p.
What’s New? – New products contd.
Licensed equivalents now available
Hints & Tips Prescription Information Services 01/2017 (NHSBsa)
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)
What’s New? – Withdrawals/ shortages
Napratec® (naproxen/ misoprostol) tablets were discontinued Nov 2016.
Anugesic- HC® preparations discontinued Nov 2016.
Fentazin® (perphenazine) preparations discontinued Nov 2016.
Qvar® (beclomethasone 250mcg/ dose) Easibreathe has been discontinued - only the 50 and 100
are now listed in MIMS.
Matrifen® (fentanyl) patch 50micrograms per hour in short supply
Vensir XL® m/r capsules 150mg in short supply
What’s New? – Strategies & Guidelines
GOLD 2017: Global Strategy for the Diagnosis, Management and Prevention of
COPD
Much has changed in the 10 years since the first GOLD report, Global Strategy for the Diagnosis,
Management, and Prevention of COPD, was published.
This major revision builds on the strengths from the original recommendations and incorporates
new knowledge. It reflects new data relating to pathophysiology, diagnosis, assessment and
approaches to the management of COPD.
Access to this document can be found using http://goldcopd.org
Healthcare Waste collection referral forms
For collections by the Council for healthcare waste e.g. filled sharps bins, the healthcare
professional needs to complete a referral form and fax to the appropriate Hampshire Local
Authority Contact:
Basingstoke Contact Centre 01256- 844844 (phone) or 01256- 845200 (fax).
What’s New? – Strategies & Guidelines contd.
Is there a calcium and vitamin D preparation which is suitable for a vegetarian or
vegan?
UKMi Q & A (SPS)
There are a number of branded calcium and vitamin D preparations listed in the BNF, which all
contain colecalciferol as vitamin D component. This updated medicines Q&A includes a table of
calcium and vitamin D preparations and their suitability for use by vegetarians and vegans.
https://www.sps.nhs.uk/articles/is-there-a-calcium-and-vitamin-d-preparation-which-issuitable-for-a-vegetarian-or-vegan/
What’s New? – NICE Clinical Guidelines
Chest pain of recent onset: assessment and diagnosis [CG95]
Prescribing Snippets Issue 151 Nov- Dec 2016 (Brent CCG)
This guideline covers assessing and diagnosing recent chest pain in people aged 18 and over and managing
symptoms while a diagnosis is being made.
• In November 2016, NICE reviewed the evidence for high-sensitivity troponin tests, non-invasive imaging
and exercise ECG for adults with acute chest pain, and diagnostic testing for adults with stable chest
pain.
• Some changes and additions have been made to the sections in this guidance relating to the
assessment and management of patients presenting with acute chest pain and patients presenting with
stable chest pain.
Spasticity in under 19s: management [CG145]
Prescribing Snippets Issue 151 Nov- Dec 2016 (Brent CCG)
This clinical guideline covers managing spasticity and co-existing motor disorders and their early
musculoskeletal complications in children and young people (from birth up to their 19th birthday) with nonprogressive brain disorders.
• It aims to reduce variation in practice and help healthcare professionals to select and use appropriate
treatments.
• This guidance has been amended to update information on the World Health Organization’s
International Classification of Functioning, Disability and Health (ICF) and the domains it covers.
What’s New? – NICE Clinical Guidelines contd.
Hypertension in adults: diagnosis and management [CG127]
Prescribing Snippets Issue 151 Nov- Dec 2016 (Brent CCG)
This guideline covers identifying and treating primary hypertension (high blood pressure) in
people aged 18 and over.
• It aims to reduce the risk of cardiovascular problems such as heart attacks and strokes by
helping healthcare professionals to diagnose hypertension accurately and treat it effectively.
• It also aims to reduce unnecessary treatment by improving the way blood pressure is
measured.
• This guidance has been updated to include footnotes relating to the MHRA alerts:

ACE inhibitors and angiotensin II receptor antagonists: not for use in pregnancy which states 'Use in
women who are planning pregnancy should be avoided unless absolutely necessary, in which case
the potential risks and benefits should be discussed'.
https://www.gov.uk/drug-safety-update/ace-inhibitors-and-angiotensin-ii-receptor-antagonists-not-for-usein-pregnancy
 ACE inhibitors and angiotensin II receptor antagonists: use during breast feeding and related clarification:
ACE inhibitors and angiotensin II receptor antagonists, which states that although ACE inhibitors and
angiotensin II receptor antagonists are generally not recommended for use by breastfeeding mothers,
they are not absolutely contraindicated.
https://www.gov.uk/drug-safety-update/clarification-ace-inhibitors-and-angiotensin-ii-receptor-antagonists
What’s New? – NICE Technical Appraisal Guidance
Apremilast for treating moderate to severe plaque psoriasis [TA419] - “Red- Listed”
Apremilast is recommended as an option for treating chronic plaque psoriasis in adults whose
disease has not responded to other systemic therapies, including ciclosporin, methotrexate and
PUVA (psoralen and ultraviolet-A light), or when these treatments are contraindicated or not
tolerated, only if:
• the disease is severe, as defined by a total Psoriasis Area Severity Index (PASI) of 10 or more
and a Dermatology Life Quality Index (DLQI) of more than 10
• treatment is stopped if the psoriasis has not responded adequately at 16 weeks
• Clinicians should note that Apremilast is “Red- Listed” on the CCG’s Formulary.
What’s New? – NICE Guidelines
Diabetes (type 1 and type 2) in children and young people: diagnosis and
management [NG18]
This guideline covers the diagnosis and management of type 1 and type 2 diabetes in children
and young people aged under 18.
• The guideline recommends strict targets for blood glucose control to reduce the long-term
risks associated with diabetes.
In November 2016, recommendations 1.2.115 and 1.3.52 were amended to add information on
when eye screening should begin and referral for eye screening should happen.
https://www.nice.org.uk/guidance/ng18?unlid=101943720420162266160
NICE Bites Oct/Nov 2016 Mental health problems in people with learning
disabilities NICE NG54; 2016
City Scripts Nov- Dec 2016 Prescribing Newsletter Brighton & Hove CCG & High Weald Lewes
Havens CCG
This guideline covers preventing, assessing and managing mental health problems in people
with learning disabilities in all settings and should be used in conjunction with NICE guidelines
on specific mental health problems.
https://pathways.nice.org.uk/pathways/mental-health-problems-in-people-with-learningdisabilities
What’s New? – NICE Guidelines contd.
Low back pain and sciatica in over 16s: assessment and management [NG59]
Prescribing Snippets Issue 151 Nov- Dec 2016 (Brent CCG)
• This guideline covers assessing and managing low back pain and sciatica in people aged 16 and
over. It outlines physical, psychological, pharmacological and surgical treatments to help
people manage their low back pain and sciatica in their daily life. The guideline aims to
improve people’s quality of life by promoting the most effective forms of care for low back
pain and sciatica.
• The guidance advises clinicians to refer to NICE's guideline on neuropathic pain in adults for
recommendations on the pharmacological management of sciatica.
• The guidance also makes the following recommendations:

Consider oral non-steroidal anti-inflammatory drugs (NSAIDs) for managing low back pain, taking into
account potential differences in gastrointestinal, liver and cardio-renal toxicity, and the person's risk
factors, including age.
Tbc next slide
What’s New? – NICE Guidelines contd.
Low back pain and sciatica in over 16s: assessment and management [NG59] contd.
 When prescribing oral NSAIDs for low back pain, think about appropriate clinical assessment,
ongoing monitoring of risk factors, and the use of gastroprotective treatment.
 Prescribe oral NSAIDs for low back pain at the lowest effective dose for the shortest possible
period of time.
 Consider weak opioids (with or without paracetamol) for managing acute low back pain only if an
NSAID is contraindicated, not tolerated or has been ineffective.
 Do not offer paracetamol alone for managing low back pain.
 Do not routinely offer opioids for managing acute low back pain
 Do not offer opioids for managing chronic low back pain.
 Do not offer selective serotonin reuptake inhibitors, serotonin–norepinephrine reuptake
inhibitors or tricyclic antidepressants for managing low back pain.
 Do not offer anticonvulsants for managing low back pain.