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Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

Swine flu vaccination advice update

The Joint Committee on Vaccination and Immunisation (JCVI) has issued updated advice (PDF) regarding the use of the H1N1 vaccine (Pandemrix®) in children aged under 10 years.

Post marketing surveillance data from the European Medicines Agency and preliminary data from a paediatric trial were considered. The former identified a higher rate of fever in children after administration of the second dose.

JCVI now advise that children aged over 6 months and below 10 years that are healthy or in the clinical at risk groups (with the exception of those who are immunocompromised) as defined previously are offered one dose (0.25ml) of the vaccine. Children who are immunocompromised in this age group should still receive two doses (both 0.25ml) of the vaccine given at least three weeks apart.

Finally, parents are advised to monitor for signs of fever and give antipyretics should one develop. Prophylactic use of antipyretics immediately prior or shortly after vaccination is not recommended due to concerns that this may make vaccines less effective.

Action: Clinicians should be aware of this change in the recommended vaccination administration. Parents should be advised about the signs of fever, the use of antipyretics and when to seek medical assistance.

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SMC December Update

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

Liraglutide (Victoza®) has been accepted for restricted use for treatment of adults with type 2 diabetes mellitus to achieve glycaemic control. It is restricted to a third line position after metformin and a sulphonylurea.

Pramipexole (Mirapexin®) in a modified release formulation has been accepted for use in the treatment of Parkinson’s disease. An economic analysis found that the once daily formulation could provide the benefit of once-daily rather than thrice-daily dosing, at an equivalent cost.

Tafluprost preservative-free eye drops (Saflutan®) have been accepted for restricted for the reduction of elevated intraocular pressure in open angle glaucoma and ocular hypertension. The product is restricted to use in those patients with a proven sensitivity to the preservative benzalkonium chloride in currently available prostaglandin preparations.

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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HbA1c for diabetes diagnosis?

The British Medical Journal has published an analysis of the recent expert committee recommendation that HbA1c be adopted for use in diagnosing type 2 diabetes.

The expert committee included members appointed by the American Diabetes Association, the European Association for the Study of Diabetes and the International Diabetes Federation. They concluded that anyone with a confirmed HbA1c greater than or equal to 6.5% (48mmol/mol) should be diagnosed as being type 2 diabetic in the absence of a glucose test.

This article goes on to discuss the advantages and disadvantages of using HbA1c. Advantages include a lesser day-to-day in-person variability in HbA1c compared to fasting glucose and the non-fasting state of the HbA1c blood test. Disadvantages include the complications introduced by blood disorders like sickle cell or iron deficiency anaemia and the effect of age and ethnicity. HbA1c is 0.4% higher in those aged over 70 compared to those aged 40 with the same glucose tolerance. A similar variability applies when comparing ethnic groups, for example HbA1c is 0.4% higher in Afro-Caribbeans compared with Europids.

The authors of this article conclude that, measuring glucose may present less of a risk of complete misdiagnosis than measuring HbA1c alone. They further state that, a move to HbA1c only diagnosis could be a step too far.

Action: Clinicians should continue to use the current WHO diagnostic criteria (PDF) for screening and diagnosing type 2 diabetes.

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Drug Safety Update – December 2009

The Medicines and Healthcare products Regulatory Agency (MHRA) has published Drug Safety Update for December 2009 (PDF).

This issue contains drug safety advice reminding clinicians that ciclosporin preparations should always be prescribed using a brand name due to the narrow therapeutic index of the drug and the variability that exists between brands. In addition, clinicians are informed of the potential risk of male breast cancer posed by finasteride. Patients taking this drug should be advised to report any changes in their breast tissue such as lumps, pain, or nipple discharge.

Readers are also informed of a future update to the prescribing information and patient information leaflets for warfarin. No new safety concerns have been identified but the information provided to clinicians and patients was found to be lacking in the following areas:

  • Timing of warfarin treatment after ischaemic stroke
  • Management of the patient before surgical or dental procedures
  • Patients at particular risk of haemorrhage
  • Interactions with herbal products, foods, and food supplements
  • Management of patients with significantly raised INR and/or haemorrhage

Finally, this issue contains the annual quiz that aims to test the knowledge of monthly readers. Answers are given at the end of the Update and sadly there are no prizes!

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

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Benzodiazepine Converter

A few years ago I wrote a spreadsheet application that calculates conversion and reduction schedules for patients reducing and stopping treatment with benzodiazepines. Recently, I started using it again and added some more options to the old version. I also wondered if this same converter could be moved to an internet environment.

The Benzodiazepine Converter is now linked in the menus above. It can transfer daily doses for a number of benzodiazepines into a daily equivalent of diazepam and produce a dose reduction schedule based on 7 or 14 days prescription intervals. I have also made the original Excel version available for stand alone use.

Disclaimer: The reduction schedules should be checked before treatment is changed and reductions should be supervised by a healthcare professional.

Action: Clinicians who supervise managed withdrawal of benzodiazepines may find these resources helpful.

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