Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

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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MTRAC Reviews - December 2014

MTRAC issued an updated Commissioning Support guidance in December 2014. The review covers fluticasone / formoterol inhaler.

The fluticasone / formoterol inhaler (Flutiform®) summary advises that this combination inhaled corticosteroid / long-acting beta agonist inhaler is suitable for prescribing in primary care for the treatment of asthma. It is noted that in two 12-week RCTs, flutiform was found to be non-inferior to a fluticasone / salmeterol inhaler (Seretide®), and a budesonide / formoterol inhaler (Symbicort®) respectively for the primary outcome of change in pre-dose FEV1 from baseline.

Action: Clinicians should be aware of these reviews and use the recommendations to guide appropriate use of these medicines in current practice.

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Drug Safety Update - December 2014

The Medicines and Healthcare products Regulatory Agency (MHRA) has published Drug Safety Update for December 2014 (PDF).

The drug safety section in this issue contains new advice for healthcare professionals when using ivabradine (Procoralan®) in the treatment of symptomatic angina. This medication has been linked with bradycardia, atrial fibrillation and other cardiovascular risks and the following new recommendations have been made.

  • Only start ivabradine if the resting heart rate is at least 70 beats per minute
  • Do not prescribe ivabradine with other medicines that cause bradycardia, such as verapamil, diltiazem or strong CYP3A4 inhibitors
  • Monitor patients regularly for atrial fibrillation. If atrial fibrillation occurs, carefully reconsider whether the benefits of continuing ivabradine treatment outweigh the risks
  • Consider stopping ivabradine if there is no or only limited symptom improvement after 3 months

This section also reminds clinicians of the risk of psychiatric disorders with isotretinoin (Roaccutane®). Clinicians are reminded that this medicine should only be prescribed under specialist supervision and that the patients and their family should be warned that the treatment might cause psychiatric disorders such as depression, anxiety, and in rare cases suicidal thoughts. Reporting of such symptoms should be encouraged and appropriate action taken if they arise; simply stopping isotretinoin may not be enough to alleviate symptoms.

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

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