Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

Alogliptin Launched

Alogliptin (Vipidia®) has been launched for the treatment of type 2 diabetes. Alogliptin is a DPP-4 inhibitor in the same class of medicines as sitagliptin.

It is licensed for use in type 2 diabetes to improve glycaemic control with other glucose-lowering treatments, including insulin. It does not currently have a monotherapy license and the safety of triple therapy with metformin and a sulphonylurea has not been established. It will be available in three strengths to allow appropriate dosing in patients with renal impairment. It will also be available in a fixed dose combination with metformin at 12.5mg/1000mg strength (Vipdomet®). Summaries of Product Characteristics containing detailed prescribing information are available for Vipidia and Vipdomet.

A New Medicines Evidence Summary has already been published by NICE. This summary notes that alogliptin reduces HbA1c by around 5.5 mmol/mol compared to placebo and that no serious safety concerns have been identified to date. It is also noted that alogliptin has similar tolerability to other oral hypoglycaemic drugs. Both products have been launched at an NHS cost of £26.60 for 28 days treatment. This represents a 16% to 20% saving compared to current treatments.

As required by some regulatory agencies, a cardiovascular safety study has been conducted in more than 5,000 patients with type 2 diabetes who had recently has an acute coronary syndrome. The study found no difference between treatment with alogliptin or placebo in the rates of major adverse cardiovascular events (death from cardiovascular causes, nonfatal myocardial infarction or nonfatal stroke).

Action: Clinicians should be aware of this new drug launch. Other DPP-4 inhibitors in the class have a wider range of licensed indications for use and are also due to come off patent sooner. These factors need to be considered when choosing an appropriate drug within this class.

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Drug Safety Update - January 2014

The Medicines and Healthcare products Regulatory Agency (MHRA) has published Drug Safety Update for January 2014 (PDF).

This issue contains drug safety advice informing clinicians of new advice and recommendations for several drugs.

A recent trial aimed to assess optimal dosing time for patients undergoing percutaneous coronary intervention (PCI). Some patients were given a split loading dose before and at the time of the PCI while others were given a single loading dose at the time of the PCI. The trial found an increased risk of bleeding but no additional benefit in those who received the split loading dose. In line with the current product license, it is recommended that patients undergoing PCI are dosed at the time of the intervention to minimise the risk of bleeding.

Hepatic injury, including hepatic failure with fatal outcome, has been reported in association with temozolomide (Temodal®). Liver function testing is recommended before starting treatment and also at the mid-point between cycles. Onset may be delayed and even occur have treatment is complete.

Severe skin reactions such as Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) have been reported in association with capecitabine. This is a rare (less than 1 in 10,000) but serious occurrence with 20 cases reported in the UK between 2002 and the end of 2013. Treatment should be permanently discontinued in patients who have a severe skin reaction and the reaction should be treated promptly.

As always, serious adverse drug reactions should be reported through the Yellow Card system.

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

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NICE Guidance - January 2014

The National Institute of Health and Care Excellence (NICE) has published new guidance for the month of January 2014. This month there are two clinical guidelines and one public health guideline that impact upon primary care.

The Prostate Cancer clinical guideline updates original guidance issued in February 2008. It offers evidence-based advice on the care of men referred to secondary care with suspected or diagnosed prostate cancer, including follow-up in primary care for men with diagnosed prostate cancer.

The Head Injury clinical guideline updates original guidance issued in September 2007. It offers evidence-based advice on the care of children, young people and adults with head injury including recommendations regarding pre-hospital assessment, advice and referral to hospital.

The Behaviour Change: Individual Approaches public health guideline makes recommendations on individual-level interventions aimed at changing health-damaging behaviours related to alcohol, diet, physical activity, sex and smoking among people aged 16 or over. It includes a range of approaches, from single interventions delivered as the opportunity arises to planned, high-intensity interventions that may take place over a number of sessions.

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

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MTRAC Reviews - January 2014

MTRAC issued a new Commissioning Support review in January 2014. The review covers dapoxetine.

The dapoxetine (Priligy®) summary advises that this drug is suitable for restricted prescribing in primary care for the treatment premature ejaculation. The review notes that the evidence for this treatment is relatively strong but notes that accurate diagnosis of this condition requires referral to a specialist psychosexual health clinic.

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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SMC Update - January 2014

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

Fentanyl citrate (Breakyl®) has been rejected for the treatment of breakthrough pain (BTP) in adults with cancer who are already receiving maintenance opioid therapy for chronic cancer pain. The manufacturer failed to make a submission.

Saxagliptin / Metformin (Kombogylze®) has been accepted for use in the treatment of type 2 diabetes mellitus in adults as triple oral therapy (in combination with a sulphonylurea) to improve glycaemic control when dual therapy (with metformin and a sulphonylurea), in combination with diet and exercise, does not provide adequate glycaemic control.

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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