Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

NICE Guidance - September 2014

The National Institute of Health and Care Excellence (NICE) has published new guidance for the month of September 2014. This month there is three clinical guidelines that impact upon primary care.

The Long-acting reversible contraception guideline has been re-issued with an addendum which updates the recommendations on progestogen-only subdermal implants. The new advice relates to information provided to women about these implants.

The Drug allergy guideline offers evidence-based advice on the diagnosis and management of drug allergy in adults, children and young people.

The Dyspepsia and gastro‑oesophageal reflux disease guideline offers evidence-based advice on the care and treatment of adults (aged 18 and over) with symptoms of dyspepsia, symptoms suggestive of gastro-oesophageal reflux disease (GORD), or both. It replaces CG17 that was published in August 2004 and contains new recommendations about investigation and referral, Helicobacter pylori eradication therapy, specialist management, and surveillance of Barrett’s oesophagus in people with dyspepsia.

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

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Domperidone Now Prescription Only

The Medicines and Healthcare products Regulatory Agency (MHRA) has announced that domperidone will no longer be available to purchase from pharmacies with effect from the 4th September 2014.

The Drug Safety Update from May 2014 warned of the risk of cardiac side effects especially in those with existing cardiac conduction conditions, impaired liver function or taking medication that may interact with domperidone.

It was noted that while community pharmacists are able to manage the majority of risks identified with this medicine, they would not routinely have access to a patient’s full medical history and would not quickly and accurately be able to assess which patients were at risk of cardiac side effects.

Action: Clinicians should be aware of this over the counter (OTC) drug withdrawal. Patients may present to GPs to enable continued access to this medication on prescription.

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NICE Guidance - July 2014

The National Institute of Health and Care Excellence (NICE) has published new guidance for the month of July 2014. This month there is one clinical guideline that impacts upon primary care.

The Lipid Modification guideline offers evidence-based advice on the care and treatment of people at risk of cardiovascular disease and people who have had previous cardiovascular disease. It includes new and updated recommendations on risk assessment, lifestyle modifications and the use of lipid-lowering drugs. In particular the following changes are noted:

  • The QRISK2 risk assessment tool is recommended to assess CVD risk
  • Lipid-lowering drugs are now recommended in people with a QRISK of 10% when the management of all other modifiable CVD risk factors has been optimised
  • Atorvstatin 20mg daily is the recommended treatment for primary prevention and 80mg daily is recommended for secondary prevention

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

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BNF for Children 2014-2015

The hard copy of the British National Formulary for Children 2014-2015 has been updated and published. Electronic versions are updated monthly.

Hard copies can be ordered from the publishers however many NHS clinicians should receive a free hard copy through usual channels and can also access the online version.

Significant changes in this revision include:

  • Revised dose and monitoring requirements for gentamicin in neonatal sepsis
  • Safety restrictions on the use of codeine, domperidone, and metoclopramide
  • Significant dose changes to amoxicillin, ampicillin, paracetamol, metronidazole, and naloxone
  • New advice on switching between different manufacturers’ products of an antiepileptic drug
  • Updated advice on the use of ototoxic ear drops in children with perforated tympanic membrane or patent grommet
  • Changes to recommendations on interchangeability of oral mesalazine preparations
  • Updated guidance on prevention of pertussis
  • Rotavirus vaccine included on immunisation schedule, and changes to schedule for meningococcal group C conjugate vaccine
  • New safety information on serious hypersensitivity reactions with intravenous iron

Action: BNFC is the primary source of prescribing information when prescribing to all children up to the age of 18 years.

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NICE Guidance - June 2014 [updated]

The National Institute of Health and Care Excellence (NICE) has published new guidance for the month of June 2014. This month there is one clinical guideline and one technology appraisal that impacts upon primary care.

The Atrial fibrillation clinical guideline is an updated to guidance issued in June 2006 and it offers evidence-based advice on the care and treatment of people with atrial fibrillation. New recommendations have been added for a personalised package of care and information, referral for specialised management, stroke prevention, rate and rhythm control and the management of acute atrial fibrillation.

Additionally, this guideline recommends using CHA2DS2-VASc score to assess stroke risk and the HAS-BLED score to assess bleeding risk. Stroke prevention therapy is not recommended at low levels of stroke risk (CHA2DS2-VASc 0 for men and 1 for women).

Anticoagulation should be considered in men with a CHA2DS2-VASc risk score of 1 and offered to everyone with a risk score of 2 and above. Anticoagulation may be with apixaban, dabigatran and rivaroxaban or a vitamin K antagonist. Recommendations for the newer agents are adopted from existing technology appraisals. If a vitamin K antagonist is used, time in therapeutic range (TTR) should be calculated regularly and used with INR results to assess anticoagulation control. If control is poor and remains poor despite addressing factors that may contribute to poor control (cognitive function, adherence, illness, drug interactions, lifestyle) the risks and benefits of alternative stroke prevention strategies should be evaluated and discussed with the patient.

The Type 2 diabetes - Canagliflozin technology appraisal recommends this treatment as an option in dual therapy with metformin in patients who cannot take a sulphonylurea or is at risk of hypoglycaemia. It can also be used in triple therapy with metformin with a sulphonylurea or a glitazone. Finally, it can be used in combination with insulin, with or without antidiabetic drugs.

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

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