Issue 6, June/ July 2014
Pan Mersey APC 1
News 3
Travel Health 5
Drug Tariff 7
Safety 8
Pan Mersey APC - Halton CCG Approved
RECOMMENDATIONS
ALENDRONIC ACID and RISEDRONATE SODIUM tablets
The Pan Mersey Area Prescribing Committee recommends ALENDRONIC ACID and RISEDRONATE SODIUM tablets are prescribed generically in line with the recommendations below.
http://www.panmerseyapc.nhs.uk/recommendations/documents/PS56.pdf
ESTRADIOL VALERATE with DIENOGEST (Qlaira®▼) for Heavy Menstrual Bleeding
The Pan Mersey Area Prescribing Committee recommends the prescribing of Estradiol Valerate and Dienogest (Qlaira®) for the treatment of heavy menstrual bleeding in women without organic pathology who desire oral contraception.
http://www.panmerseyapc.nhs.uk/recommendations/documents/PS52.pdf
PRUCALOPRIDE tablets (Resolor®)
The Pan Mersey Area Prescribing Committee recommends the prescribing of prucalopride (Resolor®) for the symptomatic treatment of chronic constipation in women in accordance with NICE TA211.
http://www.panmerseyapc.nhs.uk/recommendations/documents/PS50.pdf
ESCITALOPRAM (Cipralex®▼)
The Pan Mersey Area Prescribing Committee recommends the initiation of ESCITALOPRAM for DEPRESSION or ANXIETY only with a recommendation from a mental health specialist.
http://www.panmerseyapc.nhs.uk/recommendations/documents/PS58.pdf
ESOMEPRAZOLE capsules/tablets/sachets
The Pan Mersey Area Prescribing Committee recommends the restricted prescribing of ESOMEPRAZOLE capsules/tablets/sachets as specified for adults and children.
http://www.panmerseyapc.nhs.uk/recommendations/documents/PS53.pdf
SODIUM OXYBATE oral solution (Xyrem®)
The Pan Mersey Area Prescribing Committee recommends Sodium Oxybate Oral Solution (Xyrem®) as a treatment option for narcolepsy with cataplexy only when recommended by a consultant in a specialist commissioned sleep service.
http://www.panmerseyapc.nhs.uk/recommendations/documents/PS55.pdf
BRIMONIDINE gel (Mirvaso®▼)
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of BRIMONIDINE Gel (Mirvaso®▼) for facial erythema of rosacea.
http://www.panmerseyapc.nhs.uk/recommendations/documents/PS48.pdf
INSULINS, BIOSIMILAR
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of any biosimilar insulin.
http://www.panmerseyapc.nhs.uk/recommendations/documents/PS57.pdf
SOLIFENACIN WITH TAMSULOSIN modified release tablets (Vesomni®)
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of SOLIFENACIN WITH TAMSULOSIN Modified-Release Tablets (Vesomni®) for the treatment of moderate to severe storage symptoms and voiding symptoms associated with benign prostatic hyperplasia (BPH).
http://www.panmerseyapc.nhs.uk/recommendations/documents/PS49.pdf
FLUTICASONE FUROATE with VILANTEROL Inhaler (Relvar Ellipta®▼) - Asthma & COPD
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of FLUTICASONE FUROATE with VILANTEROL Inhaler (Relvar Ellipta®▼) for the treatment of asthma or Chronic Obstructive Airways Disease (COPD).
http://www.panmerseyapc.nhs.uk/recommendations/documents/PS31.pdf
ESTRADIOL VALERATE with DIENOGEST (Qlaira®) for Oral Contraception
The Pan Mersey Area Prescribing Committee does not recommend the prescribing of Estradiol Valerate and Dienogest (Qlaira®) for use solely as an oral contraceptive
http://www.panmerseyapc.nhs.uk/recommendations/documents/PS51.pdf
RABEPRAZOLE tablets
The Pan Mersey Area Prescribing Committee does not recommend the prescribing of RABEPRAZOLE tablets
http://www.panmerseyapc.nhs.uk/recommendations/documents/PS54.pdf
ANTIEPILEPTIC DRUGS (AEDs)– EPILEPSY
The Pan-Mersey Area Prescribing Committee recommends that CHM advice (that some anti-epileptic drugs – AEDs, may be prescribed without specifying brand, branded generic or specific generic by manufacturer) is not implemented in Pan-Mersey, pending the outcome of national discussions between expert clinician groups and the MHRA about concerns with this advice. Formulary to be amended to clarify that despite CHM advice, that locally AEDs currently should continue to be prescribed by brand, branded generic or specific manufacturer generic to ensure patients stay on same preparation.
Gluten-free foods statement
The Pan Mersey Area Prescribing Committee recommends only the supply of ‘basic’ gluten free foods and in quantities described in the statement for indications approved by the Advisory Committee on Borderline Substances.
The Pan Mersey Area Prescribing Committee does NOT recommend the supply of the following gluten free (GF) foods on the NHS: Cakes, cake mixes or sweet biscuits in the interests of promoting healthy eating. Patients who wish to include these products in their diet should be advised to purchase them from supermarkets, health food shops or pharmacies.
The Pan Mersey Area Prescribing Committee recommends that each supply of GF foods should be for ONE month only, where possible. Generally fresh GF bread is available in cases of 8 x 400g and due to its short shelf life; patients should be advised to freeze surplus quantities as the bread deteriorates rapidly if stored at room temperature. Flour can also be used to make bread, where fresh bread is preferred.
Patients should be reminded that prescribed foods are for their own use only and not for family or friends.
http://www.panmerseyapc.nhs.uk/guidelines/documents/G10.pdf
PRESCRIBING OF SPECIAL-ORDER PRODUCTS (“Specials”)
The Pan Mersey Area Prescribing Committee does not recommend the routine prescribing of Specials, although there may be situations where a Special is the most appropriate, or the only product available, to meet an individual patient’s specific needs.
http://www.panmerseyapc.nhs.uk/guidelines/documents/G7.pdf
SAFETY
Adrenaline pens
Recommending one particular brand potentially leads to supply problems as has been demonstrated with Jext® (although this is now back in stock) therefore it was agreed to leave choice of pen to prescriber. Discussion with NW Regional Allergy Group determined it was not in future pursuing a single device of choice. Pan Mersey APC guidance has been updated in line with this.
The priority is that the patient knows how to use the pen they have.
May 2014 Drug Safety update included updated guidance with regards to use of these pens:
People who have been prescribed an adrenaline auto-injector because of the risk of anaphylaxis should carry two with them at all times for emergency, on-the-spot use. After every use of an adrenaline auto-injector, an ambulance should be called (even if symptoms are improving), the individual should lie down with their legs raised and, if at all possible, should not be left alone.
http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON418520
Estates and Facilities alert on e-cigarettes, batteries and chargers
A Department of Health alert reported a number of incidences involving e-cigarettes that have exploded or ignited whilst recharging or in use in an oxygen-rich environment, including a case involving a patient receiving oxygen therapy in hospital.
http://www.dhsspsni.gov.uk/efa-2014-002.pdf
News
MHRA Medical Device Alert MDA/2014/021: Accu-Chek® Mobile meter and Accu-Chek® Mobile test cassette. Issued 10 June 2014
This Alert warns that Accu-Chek® home blood glucose meters, manufactured by Roche, may give falsely high blood glucose readings. As a consequence, patients might take an inappropriately high dose of insulin.
The Accu-Chek® meter uses strip-free technology and patients need to follow specific procedures when testing blood glucose levels, which are different to standard meters and strips.
Actions for healthcare personnel managing patients who use Accu-Chek® mobile devices:-
· Identify patients who use these meters and advise them to follow the correct testing procedure, details of which have been provided in the Field Safety Notice from Roche : http://www.mhra.gov.uk/home/groups/fsn/documents/fieldsafetynotice/con418501.pdf
· Ensure that patients can continue to monitor their blood glucose
· If patients are concerned about their blood glucose readings when using this meter, advise them to contact their healthcare professional.
Enhanced patient instructions for use of the Accu-Chek® meter are available via the internet link above. Patients can contact the Roche Accu-Chek® Careline on telephone number 0800 701 000 if they have further questions.
Reclassification of zopiclone and zaleplon as Schedule 4 Controlled Drugs
From Tuesday 10 June 2014, legislative changes came into force to classify zopiclone and zaleplon as Schedule 4 Controlled Drugs. This means prescriptions for zopiclone and zaleplon will only be valid for 28 days and the quantity prescribed should not exceed 30 days’ supply. Please note that these medications are licensed for short-term use and only following review of the patient should a repeat prescription be issued. Community pharmacies will need to implement the controlled drug destruction requirements applicable to this classification of controlled drugs.
The changes are in light of reported harms from zopiclone and zaleplon misuse, including the risk of coma, respiratory depression and death associated with use of excess doses of these drugs in combination with alcohol or other similar depressants.
Metoject® syringe changing to pen device
Metoject® syringes will be changing to a pen device this month. The company have provided information (A5 leaflet and patient booklets) to:
1. Nurse specialists at hospitals.
2. Community pharmacists.
3. Home care providers.
Information regarding the switch, including patient administration guides and a video regarding administration is available at: www.metoject.co.uk.
Please ensure patients are aware of the change, have access to the patient guides, and are happy with administration via a pen device rather than a syringe.
query corner
Which medicines can be used to treat hay fever in pregnancy?
Pregnant women suffering from hay fever can be treated with some medicines without increasing the risk of an adverse pregnancy outcome. The decision to treat should always be based on a risk versus benefit assessment of each case.
UKMI have provided the following advice:
· Avoid / minimise precipitating allergens, if known and if practical.
· Assess risk and benefits – particularly in relation to trimester.
· The preferred treatment for allergic rhinitis in pregnancy is the application of topical preparations as these have increased local activity and lower systemic exposure, therefore reducing the risk posed to the foetus.
· If nasal congestion predominates, intranasal corticosteroids are the treatments of choice during pregnancy. Sodium cromoglicate nasal spray is also suitable for use during pregnancy, however this requires frequent application.
· If an intranasal preparation does not fully relieve symptoms or is not tolerated, consider an oral antihistamine. Chlorphenamine has traditionally been the antihistamine of choice but can cause sedation. Loratadine or cetirizine are the antihistamines now recommended for use during pregnancy.
· Intranasal decongestants are of limited benefit in Intermittent Allergic Rhinitis and are generally only recommended for relieving nasal congestion prior to the use of topical corticosteroids.
· Any medication prescribed during pregnancy should be at the lowest effective dose for the shortest time necessary.
If eye symptoms persist even if a patient is using an antihistamine or nasal spray, consideration can be given to adding sodium cromoglycate eye drops.
The full Q&A document from UKMI can be accessed from the link below:
http://www.medicinesresources.nhs.uk/upload/documents/Evidence/Medicines%20Q%20&%20A/2014-2015/QA29_6_Hayfever_and_Pregnancy_final.doc
Travel Health
DVT PREVENTION for AIR TRAVELLERS
It's official – the holiday travel season is upon us. With the airports full of people jetting off to exotic locations, we felt it might be an opportune time to summarise the guidance available on the risk of deep vein thrombosis (DVT) resulting from air travel, and its prevention. Although often referred to as ‘economy-class syndrome,’ travel-related DVT is also seen in travellers in first and business class, and is not restricted to plane journeys1.
What’s the risk?
Studies have shown that the relative risk of DVT is increased by long distance travel2. However, the absolute risk of travel-related DVT in healthy individuals is extremely low. Based on a cohort of healthy individuals, the absolute risk was calculated to be2:
For flights lasting less than 4 hours — one event per 106,667 flights.
For flights lasting over 4 hours — one event per 4656 flights.
For flights lasting 16 hours or more — one event per 1264 flights.
Prevention
The table below outlines the latest advice from NICE CKS guidance3.
Risk / Relevant risk factors / Suggested prophylaxis/ adviceLow risk / · No history of DVT or pulmonary embolism (PE), and
· Not undergone surgery in the previous 4weeks, and
· No other risk factors to indicate moderate or high risk. / · Provide advice on general measures to reduce the risk of travel-related DVT:
Ø Avoid periods of prolonged immobility.
Ø Maintain normal fluid intake and avoid excessive alcohol.
· Seek urgent medical advice if they develop the following after the trip: Swollen, painful legs, especially where one is more affected than the other, and/or breathing difficulties (suggesting pulmonary embolism).
· Reassure the person that no specific treatment is required
Moderate risk / · Has previous history of DVT or PE. (However, people with a recent DVT or PE who are on anticoagulant treatment are considered to be at low risk)
· Has undergone surgery under general anaesthesia lasting more than 30minutes in the previous 2months but not in the last 4weeks.
· Is pregnant or postpartum.
· Has clinically evident cardiac disease
· Is taking combined oral contraceptives or hormone replacement therapy.
· Is obese
· Has varicose veins with phlebitis.
· Has a family history of venous thromboembolism in a first degree relative.
· Has polycythaemia.
· Has a lower-limb fracture in plaster.
(multiple risk factors will increase risk.) / · Provide the advice above on general measures to reduce the risk of travel-related DVT.
· Advise the use of graduated compression stockings. Class 1 stockings or proprietary flight socks are generally sufficient.
· Measure the ankle-brachial pressure index (ABPI) if the person has symptoms of arterial disease. If the ABPI is less than 0.5, compression stockings should not be worn.
High risk / · Has undergone surgery under general anaesthesia lasting more than 30minutes in the previous 4weeks.
· Has known thrombophilia.
· Has cancer — untreated or currently on treatment / Assess the person's suitability for long distance travel. If appropriate:
· Consider seeking specialist advice or recommend delaying or cancelling the trip (for example people should postpone long-haul flights for 3months after a hip or knee replacement).
If travelling is unavoidable and involves continuous travel lasting more than 6hours:
· Provide advice on general measures to reduce the risk of travel-related DVT.
· Advise the use of graduated compression stockings as for moderate risk.
· Seek specialist advice from a haematologist regarding whether the use of low molecular weight heparin is indicated.
Should compression stockings be prescribed for travel?