Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

SMC Update - January 2019

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

Tiotropium (Spiriva Respimat®) has been accepted for use as add-on maintenance bronchodilator treatment in patients aged 6 years and older with severe asthma who experienced one or more severe asthma exacerbations in the preceding year.

Ertugliflozin (Steglatro®) has been accepted for restricted use in adults aged 18 years and older with type 2 diabetes mellitus as an adjunct to diet and exercise to improve glycaemic control:

  • As monotherapy in patients for whom the use of metformin is considered inappropriate due to intolerance or contraindication.
  • In addition to other medicinal products for the treatment of diabetes

The restriction limits use as monotherapy to patients who would otherwise receive a dipeptidyl peptidase-4 inhibitor and in whom a sulphonylurea or pioglitazone is not appropriate.

Semaglutide (Ozempic®) has been accepted for restricted use in the treatment of adults with insufficiently controlled type 2 diabetes mellitus (T2DM) as an adjunct to diet and exercise when used in addition to other medicinal products for the treatment of diabetes. The restriction limits this drug to add on use only as the submission from the manufacturer did not relate to use as monotherapy when metformin is considered inappropriate.

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 - January 2019

The Medicines and Healthcare products Regulatory Agency (MHRA) has published Drug Safety Update for January 2019 (PDF).

This issue advises clinicians that tapentadol (Palexia®) may increase seizure risk in patients taking other medicines that lower seizure threshold. It is recommended to use with care in patients with a history of seizure disorders or epilepsy. Serotonin syndrome has also been reported when tapentadol is used in combination with serotoninergic antidepressants.

Readers are also advised that the Yellow Card App has been updated to make it easier to use and new features have been added, such as the ability to receive updates via the app.

Finally this month, the summary of letters to healthcare professionals includes notification that aciclovir eye ointment (Zovirax®) is being discontinued globally due to challenges in guaranteeing a sustainable product supply. It is expected current supplies will last until around June 2019. There is no generic direct alternative but ganciclovir has been recommended as an appropriate first-line alternative.

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

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Antiviral Medicines Authorised for Influenza Season 2018/19

The Department of Health has written to healthcare professionals via the Central Alerting System (PDF) to advise that antiviral medicines may now be prescribed at NHS expense due to rising levels in reporting of influenza-like illness.

Surveillance data indicates an increase in influenza cases in the community and as such GPs and other prescribers working in primary care may now prescribe antiviral medicines for the prophylaxis and treatment of influenza. Doses and treatment schedules are contained in existing Public Health England guidance.

Clinicians should remember to endorse the prescription with 'SLS' to ensure that it can be dispensed in community pharmacies without undue delay.

Action: Clinicians should be aware of this letter and familiarise themselves with the current prescribing guidance.

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Drug Safety Update - December 2018

The Medicines and Healthcare products Regulatory Agency (MHRA) has published Drug Safety Update for December 2018 (PDF).

This issue notes that oral lidocaine-containing products for infant teething are now only to be available under the supervision of a pharmacist. This is to ensure that appropriate guidance about managing infant teething symptoms can be given and lidocaine-containing products only be used when simple measures have failed to provide sufficient relief.

This issue also reports that compliance with the new valproate measures for pregnancy prevention currently appears to be variable by CCG. All healthcare professionals must continue to identify and review all female patients on valproate and provide them with the patient information materials every time they attend their appointments or receive their medicines.

Readers are also advised the packaging and patient information leaflets for emollients will soon be updated warning about the risk of severe and fatal burns. These warnings are being are being extended to all paraffin-based emollients regardless of paraffin concentration and also for paraffin-free emollients where there is still a risk.

This issue also notes that direct-acting antivirals for chronic hepatitis C have been associated with an increased risk of hypoglycaemia in patients with diabetes. It is suggested the glucose levels are monitored more closely, particularly in the first 3 months of treatment, with diabetic treatment adjusted accordingly.

Also, this issue advises that hydrocortisone muco-adhesive buccal tablets should not be used off-label for adrenal insufficiency in children. This is due to serious risks of insufficient cortisol absorption and life-threatening adrenal crisis. Licensed hydrocortisone products for adrenal replacement therapy are available and should be used.

Finally this month, the summary of letters to healthcare professionals includes a letter circulated about the risk of aortic aneurysm and dissection, particularly on older patients, using fluoroquinolones and notification that Quadrivalent Influenza Vaccine (under the brand name VaxigripTetra®▼) intended for export to Europe has been authorised for use in the UK to satisfy higher than expected demand.

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

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NICE Guidance - December 2018

The National Institute of Health and Care Excellence (NICE) have published new or updated guidance for the month of December 2018. This month there are five guidelines that impact upon primary care.

The Antenatal care for uncomplicated pregnancies guideline has been updated. The recommendations on alcohol consumption in pregnancy have been removed and replaced by a link to the UK CMOs' low-risk drinking guidelines.

The Post-traumatic stress disorder guideline has been published and replaces prior guidance from 2005. It covers recognising, assessing and treating post-traumatic stress disorder (PTSD) in children, young people and adults. It aims to improve quality of life by reducing symptoms of PTSD such as anxiety, sleep problems and difficulties with concentration. Recommendations also aim to raise awareness of the condition and improve coordination of care.

The Chronic obstructive pulmonary disease in over 16s guideline has been published and replaces prior guidance from June 2010. It covers diagnosing and managing chronic obstructive pulmonary disease (COPD) in people aged 16 and older, which includes emphysema and chronic bronchitis. It aims to help people with COPD to receive a diagnosis earlier so that they can benefit from treatments to reduce symptoms, improve quality of life and keep them healthy for longer.

The Chronic obstructive pulmonary disease (acute exacerbation): antimicrobial prescribing guideline has been published. It sets out an antimicrobial prescribing strategy for acute exacerbations of chronic obstructive pulmonary disease (COPD). It aims to optimise antibiotic use and reduce antibiotic resistance.

The Bronchiectasis (non-cystic fibrosis), acute exacerbation: antimicrobial prescribing guideline has been published. It sets out an antimicrobial prescribing strategy for managing and preventing acute exacerbations of bronchiectasis (non-cystic fibrosis). It aims to optimise antibiotic use and reduce antibiotic resistance.

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

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