INSIDE THIS ISSUE
PAGE 1: Clozapine - Information for GPs, Patient Alert - Desmopressin, Antibiotics
PAGE 2: Silver Dressings, ScriptSwitch, Prescribing codes, SEL APC Formulary
BITTER
PILL
MARCH
2016
PAGE 2: MELATONIN, APC & VITAMIN D
Clozapine – Information for GPs
Clozapine is a RED drug therefore responsibility for prescribing, monitoring,
dose adjustment and reviews rests with the specialist. However, GPs will be
involved in providing general medical care for patients on clozapine.
Some key issues for GPs prescribing other medicines or managing physical
health problems for patients on clozapine are outlined below:
1.
2.
3.
4.
Clozapine can cause agranulocytosis therefore all patients
undergo regular mandatory blood tests organised by Oxleas. If at
all possible, other medicines that can suppress the bone marrow
should be avoided in a patient who is taking clozapine; e.g.
carbamazepine.
Clozapine plasma levels are correlated with both response and
toxicity. Plasma levels can be raised by drugs that inhibit some
hepatic cytochrome enzymes and these drugs should be ideally
avoided in a patient who takes clozapine e.g. ciprofloxacin,
erythromycin and fluoxetine.
Smoking induces the metabolism of clozapine and patients who
stop smoking can become clozapine toxic (resulting in over
sedation, confusion, profound hypotension, and seizures).
Clozapine causes weight gain; this contributes to an adverse lipid
profile and increases the risk of developing type 2 diabetes. An
annual physical (BMI, BP, glucose and lipids and subsequent
cardiovascular risk assessment) should be undertaken and
remedial treatment prescribed as appropriate. Results could be
communicated to the mental health team.
For more information please visit:
http://www.practicezone.bromleyccg.nhs.uk/guidelines/clozapineinformation-for-gps/18914
Need help or advice with prescribing for mental health problems? Please
contact: Oxleas’ Medicines Information Line on 01322 625002 (Monday to
Friday 9am to 5pm) or email: [email protected]
WHAT IS TARGET?
TARGET stands for: Treat Antibiotics Responsibly, Guidance, Education,
Tools. This toolkit aims to help influence prescribers’ and patients’
personal attitudes, social norms and perceived barriers to optimal
antibiotic prescribing. It includes a range of resources that can be used to
support prescribers’ and patients’ responsible antibiotic use, helping to
fulfil CPD and revalidation requirements.
WHO IS IT FOR, AND HOW CAN IT BE USED?
Patient safety alert
Risk of severe harm or death
when desmopressin is omitted
or delayed in patients with
cranial diabetes insipidus
A patient safety alert has been issued by NHS
England to raise awareness of the risk of severe
dehydration and death caused by an omission or
delay of desmopressin in patients with cranial
diabetes insipidus.
Cranial diabetes insipidus is a rare disorder of the
pituitary gland characterised by an inability to
produce antidiuretic hormone (ADH), resulting in
the production of large volumes of dilute urine – if
left untreated this can lead to life-threatening
dehydration and hypernatraemia. Treatment is with
a synthetic form of ADH known as desmopressin,
which is considered a life sustaining medication.
Following reports of patient safety incidents caused
by an omission or delay in the provision of
desmopressin, providers of NHS care are asked to
consider if immediate action needs to be taken
locally to raise awareness and reduce the risk of
these incidents from occurring. The main themes
identified as causes include a lack of awareness of
the critical nature of desmopressin amongst
medical, pharmacy and nursing staff; and poor
availability of the medication within inpatient
clinical areas.
Using the resources in the TARGET Antibiotics Toolkit will enable primary
care organisations to demonstrate compliance with the Health and Social
Care Act 2008: Code of Practice on the prevention and control of
infections and related guidance. The Toolkit also supports
recommendations made in the recent NICE Antimicrobial stewardship
guidance published in August 2015.
To access the Antibiotic Resistance in Primary Care e-learning module,
visit: http://elearning.rcgp.org.uk/course/info.php?popup=0&id=167
The TARGET Toolkit is designed to be used by the whole primary care
To access the local antibiotic guidance for primary care, please visit:
team within the GP practice or out of hours setting. These resources can
http://www.practicezone.bromleyccg.nhs.uk/guidelines/antimicrobialbe used flexibly, either as standalone materials or as part of an integrated
guidelines-guidance8179
package. We do recommend that ALL resources are used if this is feasible.
Produced and distributed by the Bromley CCG Medicines Management Team.
Not to be used for commercial or marketing purposes. Strictly for use within the NHS
SOUTH EAST LONDON APC
FORMULARY
RED DRUGS
In 2015, Bromley spent over £77,000 on silver dressings. The average quantity
prescribed was 15 dressings per prescription. NICE state that there is no robust
clinical, or cost-effectiveness evidence for the use of antimicrobial dressings
e.g. silver, honey, iodine, over non-medicated dressings for treating chronic
wounds. Additionally, overuse of topical antimicrobial dressings should be
avoided due to concerns with bacterial resistance and toxicity.
Silver dressings are not listed in the Bromley Healthcare dressings formulary
and are not routinely used by our community nurses. They are not suitable for
wounds which require daily dressing changes.
Key messages for prescribing silver dressings:

Ensure that a silver (Ag) dressing is intended. Prescribing staff should
be aware that Ag represents silver and that silver dressings should
not be routinely requested. Unfortunately, on EMIS Web, silver (Ag)
dressings are listed before non-medicated dressings so one will need
to scroll down!

Prescribe on acute. Do not add to repeat prescriptions.

Prescribe a maximum quantity of 5 dressings. This should be
sufficient for the recommended maximum of 2 weeks treatment,
allowing for changing of dressings every 3 days.
Silver dressings should not be continued if the wound does not respond or once
the infection is controlled.
Alteplase – For the treatment of acute massive
and sub-massive pulmonary embolus.
Budesonide (Cortiment®) – For
moderate ulcerative colitis.
mild to
Dexamfetamine 5mg tablets - For narcolepsy
treatment in adults.
Methylphenidate (both immediate release and
prolonged release) tablets and dexamfetamine
5mg tablets - For idiopathic hypersomnia in
adults.
NB: RED drugs are NOT suitable for GPs to prescribe
and responsibility for prescribing, monitoring, dose
adjustment and review should remain with the
specialist.
AMBER DRUGS
Dexamfetamine 5mg tablets - For ADHD in
adults. Specialist mental health team initiation
and supply. GPs may be asked to take on
prescribing under a full shared care agreement.
Lisdexamfetamine (Elvanse Adult®) - For ADHD
in adults. Specialist mental health team
initiation and supply. GPs may be asked to take
on prescribing under a full shared care
agreement.
EMIS has recently changed the right of access to ScriptSwitch for practice staff;
non-clinical staff can now be set up as ScriptSwitch users. However, there is a
safety issue associated with activating ScriptSwitch for non-clinical staff.
Problems may arise if an offered switch is accepted in error. ScriptSwitch defaults
to the 'Accept' icon, when it offers a switch, hitting the return key will activate
the switch, this is effectively a 'clinical decision’, and should only be made by a
prescriber. All switches must be authorised by a doctor.
Duloxetine 20mg and 40mg capsules
(Yentreve®) - For stress urinary incontinence in
women. Initiation and first month’s supply is
provided from urogynaecology specialist team.
Ongoing follow up by the specialist team will be
managed on a case by case basis. However, the
GP should review long-term treatment annually
in primary care (or every 6 months for women
over 75 years old).
Where practices activate the ScriptSwitch function for non-clinical staff, e.g.
prescription clerks, it is strongly recommended that those using ScriptSwitch have
a clear understanding of how the system works and a procedure for how they
process the information they are shown.
NB: AMBER drugs may be suitable for GPs to
prescribe if they have a specialist interest or where
the division of clinical responsibilities for prescribing
and monitoring of the patient are clear.
To ensure we get the most from ScriptSwitch, check that it is loaded onto all PCs
and that all doctors, locums and nurses are activated in EMIS for ScriptSwitch.
GREY DRUGS
If you require further information on how to activate/de-activate a user please do
not hesitate to contact Shirley Brookes: [email protected]
PRESCRIBING CODES
The process of requesting a prescribing code from the BSA for new GPs
joining a practice is part of the overall Performer List (PL) procedure
which Primary Care Support Services (PCSS) undertake. This did not
change as a result of the contract award to Capita.
The PL Team for Bromley is based at PCSS Surbiton and the manager is
Helena Cooper. Her contact details are: [email protected]
Tadalafil daily dosing – For the treatment of
erectile dysfunction not responding to
maximum “when required” dosing of
sildenafil/tadalafil.
Please note that daily
dosing is not covered in the SLS criteria for
treating erectile dysfunction.
A single common pathway for the management
of erectile dysfunction is to be developed by
GSTT. The SEL APC has agreed that until this
pathway work is completed, daily tadalafil
dosing would not be supported for prescribing
in this indication across South East London.
NB: GREY drugs are not recommended for
prescribing in secondary or primary care.
Produced and distributed by the Bromley CCG Medicines Management Team.
Not to be used for commercial or marketing purposes. Strictly for use within the NHS