Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

SMC Update - August 2016

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

Alirocumab (Praluent®) has been accepted for restricted use in adults with primary hypercholesterolaemia (heterozygous familial and non-familial) or mixed dyslipidaemia, as an adjunct to diet and other medication, if tolerated. The restriction limits use specialist lipid clinics in patients at high cardiovascular risk. This advice is also contingent upon the continuing availability of the PAS in NHS Scotland or a list price that is equivalent or lower.

Insulin degludec (Tresiba®) has been accepted for use in the treatment of diabetes mellitus in adults.

Levofloxacin (Quinsair®) has been accepted for restricted use in the management of chronic pulmonary infections due to Pseudomonas aeruginosa in adult patients with cystic fibrosis. The restriction limits use to third line after colistimethate sodium (first line) and tobramycin (second line).

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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Drug Safety Update - August 2016

The Medicines and Healthcare products Regulatory Agency (MHRA) has published Drug Safety Update for August 2016 (PDF).

Following early termination of a clinical trial it is recommended that riociguat (Adempas®) should not be used to treat patients with pulmonary hypertension associated with idiopathic interstitial pneumonias. This medication should be under specialist supervision.

There is also a summary of letters sent to healthcare professionals in July including a letter advised that posaconazole (Noxafil®) tablets and suspension are not interchangeable and that inadvertent changes between the two formulations has led to under-dosing or over-dosing.

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

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CKS Updates - July 2016

During July 2016 Clinical Knowledge Summaries were updated for the following topics:

There were no major changes other than to the Head injury topic that was updated in line with NICE guidance.

Action: Clinicians who see patients with any of these conditions may find the new and updated information useful when reviewing current clinical practice.

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Vitamin D advice issued

Public Health England has issued new advice on vitamin D based on the recommendations of the Scientific Advisory Committee on Nutrition.

The advice notes that vitamin D is made in the skin on exposure to UVB in sunlight but since this is difficult to quantify a daily dietary intake of 10 micrograms is being recommended.

It is noted that in spring and summer the majority of the population get enough vitamin D through sunlight on the skin and a healthy, balanced diet. In autumn and winter months it is difficult for people to meet the 10 microgram recommendation from consuming foods naturally containing or fortified with vitamin D so people should consider taking a daily supplement containing 10 micrograms of vitamin D.

The advice also considers people whose skin has little or no exposure to the sun, like those in institutions such as care homes, or who always cover their skin when outside and recommends that they need to take a supplement throughout the year.

Ethnic minority groups with dark skin, from African, Afro-Caribbean and South Asian backgrounds, may not get enough vitamin D from sunlight in the summer and therefore should consider taking a supplement all year round.

Recommendations are also made for children under 5. Children from birth to 1 year old who are breast feed should be given a daily supplement containing 8.5 to 10 micrograms of vitamin D. Formula fed children of this age consuming 500ml or more each day do not require a daily supplement because infant formula is fortified with vitamin D. Children aged 1 to 4 years should be given a daily supplement containing 10 micrograms of vitamin D. It is noted that low-income families can access vitamin D free of charge via Healthy Start schemes.

Action: Clinicians should be aware of this new advice. The advice consistently refers to "dietary sources" of vitamin D including foods naturally containing or fortified with vitamin D and supplements. As such prescribing of vitamin D purely for supplementation following this advice should be resisted.

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NICE Guidance - July 2016

The National Institute of Health and Care Excellence (NICE) have published new or updated guidance for the month of July 2016. This month there are seven clinical guidelines and two technology appraisals that impact upon primary care.

The Type 2 diabetes in adults clinical guideline has been updated to clarify the role of GPs in referring people for eye screening and also to add information on when this should happen.

The Type 1 diabetes in adults clinical guideline has also been updated to clarify the role of GPs in referring people for eye screening and also to add information on when this should happen.

The Non-Hodgkin’s lymphoma clinical guideline covers diagnosing and managing non-Hodgkin's lymphoma in people aged 16 years and over. It aims to improve care for people with non-Hodgkin's lymphoma by promoting the best tests for diagnosis and staging and the most effective treatments for 6 of the subtypes.

The Cardiovascular disease: risk assessment and reduction guideline covers the assessment and care of adults who are at risk of or who have cardiovascular disease. It describes the lifestyle changes people can make and how statins can be used to reduce their risk. It has been updated to clarify the advice on saturated and monounsaturated fat.

The Prophylaxis against infective endocarditis guideline has been updated to make the wording of two of the recommendations more consistent.

The Non-alcoholic fatty liver disease guideline covers how to identify the adults, young people and children with non-alcoholic fatty liver disease (NAFLD) who have advanced liver fibrosis and are most at risk of further complications. It outlines the lifestyle changes and pharmacological treatments that can manage NAFLD and advanced liver fibrosis.

The Oral health for adults in care homes guideline covers oral health, including dental health and daily mouth care, for adults in care homes. The aim is to maintain and improve their oral health and ensure timely access to dental treatment.

The Abiraterone for treating metastatic hormone-relapsed prostate cancer before chemotherapy technology appraisal has been reviewed after a change to the commercial arrangements in July 2016. It has been verified that this change does not impact cost effectiveness and supply is contingent upon the manufacturer providing abiraterone in accordance with the commercial access arrangement as agreed with NHS England.

The Abiraterone for castration-resistant metastatic prostate cancer technology appraisal has been reviewed after a change to the commercial arrangements in July 2016. It has been verified that this change does not impact cost effectiveness and supply is contingent upon the manufacturer providing abiraterone in accordance with the commercial access arrangement as agreed with NHS England.

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

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