Suffolk Drug & Therapeutics Group

East & South East England Specialist Pharmacy Services

East of England, London, South Central & South East Coast

East Anglia Medicines Information Service

Medicine Review

Traffic light decision

Comments

Julie Brache Consultant Elderly Services IHT

I do use it for patients with falls/syncope and significant orthostatic hypotension. The evidence base for treating OH is rather limited so I’ll describe how I use it. OH is very common in the frail elderly so caution has to be used not to treat a drop in BP alone, only to use it for symptomatic drop associated with a history of falls or syncope that are suggestive of a BP mediated cause. My practise is to use it 3rd line. 1st is self management advice and medication review (this is enough for a significant proportion of my patients, especially the younger ones), 2nd line is fludrocortisone.

I have been prescribing it and monitoring and changing doses in clinic, once a month until established then asking the GP to take over the prescription, I’m not currently prescribing it for anyone. I probably start less than 12 patients a year.

Sharmistha Nadi Consultant Elderly Services IHT

I would agree completely with Julie.

Duncan McNab Cardiologist IHT
I would agree with the comments below. My experience with fludrocortisone is that it is rarely a great success with neurocardiogenic syncope (although I do start with it as my first agent) and that in the small numbers of patients who do require midodrine, it can be a life-changer. I have always followed these patients up, to screen for hypertension, especially at night, whilst supine, but if there were rigorous protocols in primary care to ensure this was done, it could be continued in Primary Care.

Gerry Rayman Consultant Physician Diabetes and Endocrinology IHT
I do not have the time to sift through the document that you have sent. Basically, I have a single patient whose life is dependent on midodrine in whom I have to issue a repeat prescription every three months. This has been the case for this individual for more than 5 years. It is a pain for both me and the patient to keep corresponding re the prescription. All I want out of this is for the GP to now be able toissue the prescription. In the next few year I may have 2 or 3 more such prescription. The place in therapy this therapy in diabetic postural hypotension has been accepted by diabetologists for many years.

Andrew Owen Cardiologist IHT
I would like to be able to use this occasionally, but at present it is difficult because GP’s cant/won’t continue with the prescription. They should.

Craig ParkinsonConsultant Physician Diabetes and Endocrinology IHT
I think we should bear in mind the difficulties we sometimes face with patients who have postural orthostatic hypotension or neurocardiogenic syncope. I can think of some patients who attend hospital on a very regular basis as a consequence and others where there quality of life and ability to work has been dramatically impaired by these conditions.

In this context we should make available all options for treatment. There are in fact very few, and whilst I agree that fludrocortisone should be used first line the introduction of midodrine is quite commonly required by patients with these conditions in my experience. I believe the numbers will be higher than those suggested so far. I have picked up approximately 4 new patients this year and I know of other existing patients, and if we are all, individually seeing a handful of patients there is cumulatively a reasonable patient cohort (although not clearly defined and not likely to represent huge numbers). I am also concerned that we, as yet, have no input from the COE teams and I certainly know that Dr Lockington see’s many patients with this problem. How much use of midodrine takes place in that group of patients however is not clear to me.

I would suggest that a shared care document is developed, with the initiation being undertaken by a consultant specialist, and after 3-6/12 of dose stabilisation the ongoing prescription should be picked up by the GP. It is not a high cost drug, but these patients can be a significant challenge and as such we must have this option available.

Damian Morris Consultant Physician Diabetes and Endocrinology IHT
I agree with Paul & Duncan. Will be small numbers.

Duncan Fowler Consultant Physician Diabetes and Endocrinology IHT
I agree with Paul Venables. I use it very occasionally on patients with orthostatic hypotension resistant to other therapies. It is small numbers (I can think of just a couple of patients) and should be consultant initiated and stabilised with then transfer of prescribing to GP with their agreement (possibly under some shared care policy if they wish).

Paul Venables Consultant Cardiologist IHT
I think this has a place for shared care. I use the drug selectively for both Orthostatic Hypotension and Neurocardiogenic Syncope. I would strongly advise we include the latter as Cambridge have done. This invariably involves me prescribing the drug until I’ve seen them tolerating it well as a follow-up, then the GP could prescribe.

I did bring this up in the last round of e-mails, was it considered?

Review prepared by Sarah Cavanagh, East Anglia Medicines Information Service

May be freely copied by NHS agencies Not to be used for promotional purposes

Grids used to assist the NHS Suffolk PCT Drug & Therapeutics Committee in reaching a decision about new medications

For many years scientists have recognised two types of research:

Primary: original studies, based on observation or experimentation on subjects.

Secondary: reviews of published research, drawing together the findings of two or more primary studies.

In biomedical science there is general agreement over a hierarchy: the higher up a methodology is ranked, the more robust and closer to objective truth it is assumed to be. The orthodox hierarchy looks something like this-

Adapted from Systematic reviews, What are they and why are they useful? ScHARR 2008

To Decide if a Medication Is To Be Used In Suffolk

Prescriber’s Rating Definitions

1. Bravo! -The drug is a major therapeutic advance in an area where previously no treatment was available.
2. A real advance - The product is an important therapeutic innovation but has certain limitations.
3. Offers an advantage - The product has some value but does not fundamentally change present therapeutic practice.
4. Possibly Helpful - The product has minimal additional value, and should not change prescribing habits except in rare circumstances.
5. Judgement reserved - The Committee postpones its judgement until better data and a more thorough evaluation of the drug are available.
6. Nothing New - The product may be a new substance but is superfluous because it does not add to the clinical possibilities offered by previous products available. In most cases these are “me-too” products.
7. Not acceptable - Product without evident benefit over others but with potential or real disadvantages.

(With acknowledgement to Prescrire)

To Decide Where A Medication Is To Be Used In Suffolk

References

Jonsen A. Bentham in a box: Technology assessment and health care allocation. Law Med. Health Care. 1986;14:172-174

Suffolk Drug & Therapeutics Committee Responsibility for prescribing, Hospital Trust or GP

Review prepared by Sarah Cavanagh, East Anglia Medicines Information Service

May be freely copied by NHS agencies Not to be used for promotional purposes