Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

Mucodyne Paediatric Liquid to be discontinued

The manufacturer of carbocisteine 125mg/5ml oral solution (Mucodyne® Paediatric) has written to healthcare professionals advising that this product has been discontinued due to manufacturing difficulties and will no longer be available from April 2015.

The 250mg/5ml solution remains available and may be an appropriate alternative if the required dose can be measured and delivered. An oral medicines syringe may be required. It should be noted however that the Summary of Product Characteristics advises that the product is not suitable for children and that the paediatric product should be used!

The normal daily dosage is 20 mg/kg bodyweight in divided doses. The previously recommended doses for the 125mg/5ml paediatric oral solution were:

  • Children 5 - 12 years: 10 ml three times daily
  • Children 2 - 5 years: 2.5 - 5 ml four times daily

Action: Clinicians should be aware of this product being discontinued. It may be prudent to run clinical system searches to identify any patients who are currently prescribed this product to allow a review and an alternative to be arranged.

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Drug Safety Update - January 2015

The Medicines and Healthcare products Regulatory Agency (MHRA) has published Drug Safety Update for January 2015. This month there are six updates.

There is new information and strengthened warnings related to safety of medicines containing valproate derivatives (sodium valproate, valproic acid and valproate semisodium), following completion of a Europe-wide review. It is noted that children exposed in utero to valproate are at a high risk of serious developmental disorders (in up to 30-40% of cases) and/or congenital malformations (in approximately 10% of cases). It is recommended that valproate should not be prescribed to female children, female adolescents, women of childbearing potential or pregnant women unless other treatments are ineffective or not tolerated. It is also recommended that treatment is started and supervised by a specialist and that all female patients are informed of and understand the risks.

Ustekinumab (Stelara®) has been associated with exfoliative dermatitis. Clinicians are advised to be alert for signs and symptoms of exfoliative dermatitis. If exfoliative dermatitis is suspected to have been caused by an adverse drug reaction to ustekinumab treatment must be stopped.

Mycophenolate has been linked with an increased risk of hypogammaglobulinaemia and bronchiectasis. Clinicians are advised to measure serum immunoglobulin levels if recurrent infections develop and to consider bronchiectasis or pulmonary fibrosis if patients develop persistent respiratory symptoms, such as cough and dyspnoea.

Oral diclofenac is now no longer available without prescription due to an increased risk of cardiovascular side effects.

Prescribing advice for aceclofenac (Preservex®) has been updated in line with diclofenac and COX-2 inhibitors. It is now contraindicated in people with vascular disease and heart disease. Patients with these conditions who are prescribed aceclofenac should be switched to a safer alternative as their next routine appointment.

Lastly readers are advised that the Yellow Card scheme has been extended to include devices, counterfeits and defective medicines. Previously there were separate reporting systems in place for such instances. The reporting systems have now been simplified.

Action: Clinicians should be aware of this month's new guidance and implement any necessary changes to practice.

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NICE Guidance - January 2015

The National Institute of Health and Care Excellence (NICE) has published new guidance for the month of January 2015. This month there is one clinical guideline that impacts upon primary care.

The Gastro-oesophageal reflux disease: recognition, diagnosis and management in children and young people clinical guideline offers evidence-based advice on the recognition, diagnosis and management of gastro-oesophageal reflux disease in children and young people. This is also the first guideline issued in a new number system introduce this year.

This guidance notes that that reflux is very common in well infants and does not require treatment, but that clinicians should be alert to red flag symptoms which may suggest GORD or other disorders.

Action: Clinicians should be aware of this month's new guidance and implement any necessary changes to practice.

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Key therapeutic topics 2015

The Medicines and Prescribing Centre at NICE has published the 2015 update to Key therapeutic topics - Medicines management options for local implementation (PDF).

This publication summarises key therapeutic areas where there are potential opportunities for maintaining or improving quality and improving value.

This update has retained the previous 14 therapeutic topics. All the topics have been reviewed and updated in the light of new guidance and important new evidence. Changes include:

  • KTT2: Renin-angiotensin system drugs. The addition of a table summarising NICE recommendations on the use of renin-angiotensin system drugs in various indications
  • KTT3: Lipid-modifying drugs. Updated to reflect recommendations in the NICE guideline on lipid modification, published in July 2014
  • KTT4: Omega 3 fatty acid supplements. Updated to reflect recommendations in the NICE guideline on MI – secondary prevention, published in November 2013 and the NICE guideline on lipid modification, published in July 2014
  • KTT9: Antibiotic prescribing – especially broad spectrum antibiotics. Updated in line with Public Health England guidance on managing common infections, which was updated in November 2014
  • KTT10: Three-day courses of antibiotics for uncomplicated urinary tract infection. Updated in line with Public Health England guidance on managing common infections, which was updated in November 2014

Action: Clinicians and Commissioners should be aware of this document. The key topic areas can be reviewed and prioritised based upon local need and current performance.

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SMC Update - January 2015

The Scottish Medicines Consortium (SMC) has issued its monthly advice on newly licensed medicines.

Aztreonam lysine (Cayston®) has been accepted for restricted as suppressive therapy of chronic pulmonary infections due to Pseudomonas aeruginosa in patients with cystic fibrosis aged six years and older. Use is limited to cases where inhaled colistimethate sodium and inhaled tobramycin are not tolerated or providing an unsatisfactory therapeutic benefit. It is also contingent on the continued availability of a Patient Access Scheme (PAS) that improves the cost effectiveness.

Brimonidine (Mirvaso®) has been accepted for restricted use in the symptomatic treatment of facial erythema of rosacea in adult patients. The restriction limits use to patients with moderate to severe persistent facial erythema associated with rosacea.

Canagliflozin plus metformin (Vokanamet®) has been accepted for restricted use in type 2 diabetes mellitus as an adjunct to diet and exercise to improve glycaemic control. The restriction limits use of this product to patients where combination of canagliflozin and metformin is an appropriate choice of therapy.

Olodaterol (Striverdi®) has been accepted for use as maintenance bronchodilator treatment in patients with chronic obstructive pulmonary disease.

Action: Clinicians should be aware of the recommendations of the SMC. Routine use of rejected and restricted medicines should be avoided.

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