Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

NICE Guidance - December 2012

The National Institute of Health and Clinical Excellence (NICE) has published new guidance for the month of December 2012. This month is one clinical guideline and one public health guideline that impact upon primary care.

The Ectopic pregnancy and miscarriage guideline aims to improve the diagnosis and management of early pregnancy loss in order to reduce the incidence of the associated psychological morbidity and avoid the unnecessary deaths of women with ectopic pregnancies.

The Hepatitis B and C public health guideline aims to ensure more people at increased risk of hepatitis B and C infection are tested. The recommendations include items such as awareness-raising, contact tracing and service commissioning.

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

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MTRAC Reviews - November 2012

MTRAC issued two new Commissioning Support reviews in November 2012. The reviews cover aclidinium and glycopyrronium inhalers for COPD.

The aclidinium bromide (Eklira Genuair®) summary advises that the inhaler is suitable for prescribing in primary care but has a low place in therapy as the evidence is relatively weak. It is noted that the trials were relatively small and short in duration (12 or 24 weeks) and that there are no fully published trials comparing this treatment with other long acting bronchodilators.

The glycopyrronium bromide (Seebri Breezhaler®) summary advises that the inhaler is suitable for prescribing in primary care but has a low place in therapy. The evidence is reasonably strong and demonstrates improved lung function, reduced breathlessness and fewer hospital admissions. However, after 52 weeks of treatment there was no difference in FEV1 compared to open label tiotropium.

For both treatments it is concluded that there is insufficient evidence to support a switch in prescribing from tiotropium in patients already on treatment but they could be considered as an option when initiating treatment for a new patient.

Action: Clinicians should be aware of these reviews and compare current practice to the recommendations, making changes where appropriate.

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Drug Safety Update - December 2012

The Medicines and Healthcare products Regulatory Agency (MHRA) has published Drug Safety Update for December 2012 (PDF).

This update contains drug safety advice informing clinicians of an increased risk of serious skin reactions in patients of European descent or Japanese origin with the HLA-A*3101 allele when carbamazepine, oxcarbazepine and eslicarbazepine is used. The current data do not support pre-treatment screening but any individuals known to have this allele should only be started on these treatments after careful consideration of the benefits and risks.

This issue also contains the annual drug safety quiz that tests drug safety knowledge based on the updates published this year. Completion of the quiz may be a useful way to demonstrate continuing professional development.

Action: Clinicians will find this publication to be a useful review of current issues in drug safety.

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SMC Update - December 2012

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

Lanthanum carbonate (Fosrenol®) has been accepted for restricted use as a phosphate binding agent for use in the control of hyperphosphataemia in chronic renal failure patients on haemodialysis or continuous ambulatory peritoneal dialysis (CAPD). The restriction recommends use as a second-line agent where a non-aluminium and non-calcium phosphate binder is required.

Olmesartan / amlodipine / hydrochlorothiazide (Sevikar HCT®) has been accepted for use in adult patients whose blood pressure is not adequately controlled on the combination of olmesartan and amlodipine taken as dual-component formulation. The recommendation clarifies that "These fixed dose combinations are among many options for the treatment of hypertension, many of which are less expensive".

5-aminolaevulinic acid (Ameluz®) has been accepted for use in the treatment of actinic keratosis of mild to moderate intensity on the face and scalp.

Perampanel (Fycompa®) has been accepted for restricted use in as an adjunctive treatment of partial-onset seizures with or without secondarily generalised seizures in patients with epilepsy aged 12 years and older. The restriction recommends use as a second-line agent in refractory partial onset epilepsy and that it should only be initiated by experienced physicians.

Racecadotril (Hidrasec Infants®, Hidrasec Children®) has been rejected for us as a complementary symptomatic treatment of acute diarrhoea in infants older than three months and in children. The manufacturer failed to make a sufficiently robust clinical and economic case.

Racecadotril (Hidrasec®) has been rejected for symptomatic treatment of acute diarrhoea in adults when causal treatment is not possible. The manufacturer failed to make a submission.

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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NICE Guidance - November 2012

The National Institute of Health and Clinical Excellence (NICE) has published new guidance for the month of November 2012. This month is one technology appraisal and two public health guidelines that impact upon primary care.

The Chronic heart failure - ivabradine technology appraisal recommends ivabradine as a possible treatment for people with chronic heart failure provided the following conditions are met.

  • New York Heart Association (NYHA) class II to IV stable chronic heart failure with systolic dysfunction and
  • who are in sinus rhythm with a heart rate of 75 beats per minute or more and
  • who are given ivabradine in combination with standard therapy including beta-blocker therapy, angiotensin-converting enzyme (ACE) inhibitors and aldosterone antagonists, or when beta-blocker therapy is contraindicated or not tolerated and
  • with a left ventricular ejection fraction of 35% or less

It is also recommended that ivabradine is initiated by a specialist after a 4 week period of stabilisation on a combination of ACE inhibitors, beta-blockers and aldosterone antagonists.

The Walking and cycling public health guideline aims to encourage people to increase the amount they walk or cycle for travel or recreation purposes. It is hoped this would help meet public health goals as well as impacting on other areas such as traffic congestion, air pollution and greenhouse gas emissions.

The Obesity - working with local communities public health guideline aims to support effective, sustainable and community-wide action to prevent obesity. The recommendations cover 14 areas from strategic leadership and integrated commissioning to planning and implementing monitoring and evaluation.

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

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