Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

MTRAC Reviews - November 2013

MTRAC issued two new Commissioning Support reviews in November 2013. The reviews cover melatonin and nalmefene.

The melatonin (Circadin®) summary advises that this drug is suitable for prescribing in primary care for the treatment of primary insomnia. The review notes that this medication reduces sleep latency but had no effect on total sleep time. It was also noted that there are no studies against active treatments for insomnia so this treatment is given a lower place in therapy.

The nalmefene (Selincro®) summary advises that this drug is suitable for restricted prescribing in primary care for the treatment of alcohol dependence in conjunction with continuous psychosocial support. The review notes that this treatment is most effective in a subgroup of patients with a high drinking risk level who fail to reduce their intake before commencing treatment. It is therefore assessed as having a lower place in therapy with relatively weak evidence.

Action: Clinicians should be aware of these reviews and use the recommendations to guide appropriate use of these medicines in current practice.

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NICE Guidance - November 2013

The National Institute of Health and Care Excellence (NICE) has published new guidance for the month of November 2013. This month there are two clinical guidelines that impact upon primary care.

The Myocardial infarction - secondary prevention clinical guideline updates and replaces NICE clinical guideline 48 originally published in May 2007. It offers evidence-based advice on secondary prevention for patients in primary and secondary care after an MI. It includes new and updated recommendations on cardiac rehabilitation, lifestyle changes and drug therapy.

The Neuropathic pain - pharmacological management clinical guideline updates and replaces NICE clinical guideline 96 originally published in March 2010. It offers evidence-based advice on the pharmacological management of neuropathic pain in non-specialist settings.

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 - November 2013

The Medicines and Healthcare products Regulatory Agency (MHRA) has published Drug Safety Update for November 2013 (PDF).

This issue contains drug safety advice reminding clinicians of the new advice on switching between different manufacturers’ products of antiepileptic drugs and about the strengthened warnings on neuropsychiatric side effects associated with mefloquine.

Additionally, this update advises that there is new evidence on neurodevelopmental delay in children following maternal use of sodium valproate. A review is in progress but in the meantime clinicians are reminded that sodium valproate must not be used during pregnancy unless there is no effective alternative.

Finally, clinicians are warned that there have been cases of intraoperative floppy iris syndrome (IFIS) during cataract surgery have been reported in patients taking the atypical antipsychotics risperidone or paliperidone. Complications can arise during or after surgery and it is recommended that use of these drugs is notified on referrals for cataract surgery.

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

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Switching Antiepileptic Drugs

The Medicines and Healthcare products Regulatory Agency (MHRA) has written to healthcare professionals to provide information about switching between different manufacturers’ products of antiepileptic drugs (AEDs). This includes switching between branded products and generic products, and between different generic products of a particular drug.

Following a review of the available evidence and consideration of the bioavailability and pharmacokinetic characteristics of the different drugs it has been suggested that they could be classified into three categories:

  • Category 1 (Phenytoin, carbamazepine, phenobarbital, primidone). For these drugs, doctors are advised to ensure that their patient is maintained on a specific manufacturer’s product.
  • Category 2 (Valproate, lamotrigine, perampanel, retigabine, rufinamide, clobazam, clonazepam, oxcarbazepine, eslicarbazepine, zonisamide, topiramate). For these drugs the need for continued supply of a particular manufacturer’s product should be based on clinical judgement and consultation with patient and/or carer taking into account factors such as seizure frequency and treatment history.
  • Category 3 (Levetiracetam, lacosamide, tiagabine, gabapentin, pregabalin, ethosuximide, vigabatrin). For these drugs it is usually unnecessary to ensure that patients are maintained on a specific manufacturer’s product unless there are specific concerns such as patient anxiety, and risk of confusion or dosing errors.

A patient information leaflet has been prepared and provides a summary of what these changes means.

Action: Clinicians will already be aware of the need to prescribe by brand for the specified medicines. This document is helpful in indicating where more flexible prescribing can be considered.

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SMC Update - November 2013

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

Atomoxetine (Strattera®) has been accepted for use in the treatment of attention-deficit/hyperactivity disorder (ADHD) in adults as part of a comprehensive treatment programme. They recommend that the presence of symptoms that were pre-existing in childhood should be confirmed.

Ondansetron orodispersible films (Setofilm®) have been accepted for restricted use in nausea and vomiting associated with emetogenic chemotherapy and post-operative nausea and vomiting (PONV). The review notes that generic preparations of ondansetron are available at a lower cost than the proprietary products.

Sodium phenylbutyrate granules (Pheburane®) have been accepted for use as an adjunctive therapy in the chronic management of urea cycle disorders. It is noted that this product provides an alternative to sodium phenylbutyrate tablets at no additional cost but is more expensive than an existing brand of sodium phenylbutyrate granules.

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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