Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

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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Drug Safety Update - July 2016

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

This issue highlights very rare reports of calciphylaxis in patients taking warfarin. This is a very serious condition causing vascular calcification and skin necrosis most commonly observed in patients with end-stage renal disease on dialysis, or in those with known risk factors such as protein C or S deficiency, hyperphosphataemia, hypercalcaemia or hypoalbuminaemia. However, cases have been reported in patients taking warfarin, including those with normal renal function, and evidence suggests that on rare occasions warfarin use might lead to calciphylaxis.

This issue also notes the possibility of an interaction between citalopram and cocaine suggested in a Coroner's report after the death of a man due to subarachnoid haemorrhage. There are plausible mechanisms for an interaction between cocaine and citalopram that could lead to subarachnoid haemorrhage, including hypertension related to cocaine and an additive increased bleeding risk in combination with citalopram. Possible illicit drug use should be considered when making prescribing decisions and prescribers should consider enquiring about illicit drug use.

N-acetylcysteine may interfere with assays from Siemens ADVIA Chemistry and Dimension/Dimension Vista instruments, leading to false-low biochemistry test results. Local laboratories should already be aware of this issue however it may be prudent to indicate to laboratories any patients who are taking N-acetylcysteine.

Finally this month there is a summary of letters sent to healthcare professionals in June.

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

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SMC Update - July 2016

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

Brivaracetam (Briviact®) has been accepted for restricted use as adjunctive therapy in the treatment of partial-onset seizures with or without secondary generalisation in adult and adolescent patients from 16 years of age with epilepsy. The restriction limits use to patients with refractory epilepsy and treatment should be initiated by physicians who have appropriate experience in the treatment of epilepsy.

Vortioxetine (Brintellix®) has been accepted for restricted use in the treatment of major depressive episodes in adults. The restriction limits use to patients who have experienced an inadequate response (either due to lack of adequate efficacy and/or safety concerns/intolerability) to two or more previous antidepressants.

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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Shingles immunisation programme for 2016

The Department of Health has written to healthcare colleagues about the shingles immunisation programme from September 2016.

From the 1st September 2016 shingles vaccine should be offered to patients aged 70 or 78 years on the 1st September 2016. In addition, patients who have been eligible in previous years but remain unvaccinated may also be offered the vaccine. This would include anyone aged 71 to 73 or 79 on the 1st September 2016.

Anyone who reaches their 80th birthday is no longer eligible for the vaccine due to the reducing efficacy of the vaccine as age increases.

The letter also notes that by the end of March 2016 just under half of eligible 70 and 78 year olds had been vaccinated against shingles. It is noted that this is a "significant achievement
and one that we can improve on
".

Action: Clinicians should be aware of the age cohorts for the shingles immunisation programme and offer vaccination from September.

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