Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

Evorel range supply interruption

The manufacturer of the Evorel® range of HRT patches has written healthcare professionals advising of an imminent supply shortage.

An increase in demand for the products is cited as one of the reasons for the shortage with the entire product range affected - Evorel®, Evorel® Sequi and Evorel® Conti. It is anticipated that supplies will be restored in mid-2020.

Alternative patches are available to switch from Evorel®, but alternatives to the Sequi and Conti products are going to be more complex, perhaps involving supply of oestrogen patches and progestogen tablets or a switch to tablet versions.

Action: Clinicians should be aware of this supply interruption and be prepared to supply appropriate alternatives.

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SMC Update - August 2019

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

Empagliflozin and linagliptin (Glyxambi®) has been accepted for restricted use in adults aged 18 years and older with type 2 diabetes mellitus:

  • To improve glycaemic control when metformin and/or sulphonylurea (SU) and one of the monocomponents of Glyxambi do not provide adequate glycaemic control
  • When already being treated with the free combination of empagliflozin and linagliptin

The restriction limits use in line with the previous SMC advice on empagliflozin and linagliptin.

Perampanel suspension (Fycompa®) has been accepted for restricted use for the adjunctive treatment of partial-onset seizures with or without secondarily generalised seizures in adult and adolescent patients from 12 years of age with epilepsy. The restriction limits use to second-line adjunctive treatment in patients with refractory partial onset epilepsy who are unable to swallow perampanel tablets. Treatment should be initiated only by physicians who have appropriate experience in the treatment of epilepsy.

Perampanel suspension (Fycompa®) has been rejected for the adjunctive treatment of primary generalised tonic-clonic seizures in adult and adolescent patients from 12 years of age with idiopathic generalised epilepsy. The manufacturer failed to make a submission for this indication.

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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CKS Updates - July 2019

During July 2019 Clinical Knowledge Summaries were published or updated in the following areas.

The Autism in adults and Cerebral palsy topics are new. The Cholesteatoma and Gallstones topics have undergone reviews and minor restructures.

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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NICE Guidance - July 2019

The National Institute of Health and Care Excellence (NICE) have published new or updated guidance for the month of July 2019. This month there are four guidelines that impact upon primary care.

The Suspected neurological conditions guideline has been updated. It covers the initial assessment of symptoms and signs that might indicate a neurological condition. It helps non-specialist healthcare professionals to identify people who should be offered referral for specialist investigation. The update changed the timing of referral from urgent to immediate for adults with sudden-onset speech or language disturbance and children under 4 years with a change in head circumference and signs or symptoms of raised intracranial pressure following user feedback.

The Long-acting reversible contraception guideline has been updated. It covers long-acting reversible contraception. It aims to increase the use of long-action reversible contraception by improving the information given to women about their contraceptive choices. The update notes the wider range of LARC products now available and recognises the different ways contraceptive services are commissioned and provided in England.

The Neuropathic pain in adults: pharmacological management in non-specialist settings guideline has been updated. It covers managing neuropathic pain with pharmacological treatments in adults in non-specialist settings. It aims to improve quality of life for people with conditions such as neuralgia, shingles and diabetic neuropathy by reducing pain and promoting increased participation in all aspects of daily living. The guideline sets out how drug treatments for neuropathic pain differ from traditional pain management. The update has amended footnotes reflecting the legal status of gabapentin and pregabalin.

The Motor neurone disease: assessment and management guideline has been updated. It covers assessing and managing motor neurone disease (MND). It aims to improve care from the time of diagnosis, and covers information and support, organisation of care, managing symptoms and preparing for end of life care. The update has amended footnotes reflecting the legal status of gabapentin and pregabalin.

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 2019

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

This issue advises that febuxostat should be avoided, unless no other therapy options are appropriate, in patients with pre-existing major cardiovascular disease due to an increased risks observed in a clinical trial. The study (CARES) found a higher risk for cardiovascular-related death and for all-cause mortality in patients assigned to febuxostat than in those assigned to allopurinol.

This issue also advises that tocilizumab (RoActemra®) has been linked with rare risk of serious liver injury including cases requiring transplantation. It is recommended that alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels should be measured before starting treatment with tocilizumab and monitored every 4–8 weeks for the first 6 months of treatment followed by every 12 weeks thereafter. Some areas may arrange monitoring under shared care.

There is also a reminder that rivaroxaban (Xarelto®) 15 mg and 20 mg tablets should be taken with food. There have been reports of reduced efficacy when taken on an empty stomach. The lower strengths can be taken with or without food.

Finally this month, the summary of letters to healthcare professionals includes a letter regarding the risk of teratogenicity and neuropsychiatric disorders with retinoids and the pregnancy prevention programme launched last month. There is also a link to a letter regarding the febuxostat advice mentioned above.

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

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