Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

Bricanyl Turbohaler Supplies Low

The manufacturer of Bricanyl® Turbohaler has written to healthcare professionals, and also informed Asthma UK, advising that supplies of this inhaler are very low in the UK.

The reason behind this shortage is being investigated and it is currently expected that this issue will persist until the end of January 2019. Asthma UK is advising patients to check their inhalers and ensure they have adequate supply; it is also recommended to seek advice from a healthcare professional for a suitable alternative before their current inhaler runs out.

Switching to an alternative will require a change to salbutamol. Consideration should be given to the range of devices available including pressurised metered dose inhalers, breath actuated aerosols and dry powder inhalers. Provision of a spacer device may also be appropriate.

Action: Clinicians should be aware of this product supply shortage. It would be prudent to run clinical system searches to identify any patients who are currently prescribed this product to allow a review and arrangements made to identify a suitable alternative.

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NICE Guidance - November 2018

The National Institute of Health and Care Excellence (NICE) have published new or updated guidance for the month of November 2018. This month there are two guidelines that impact upon primary care.

The Heavy menstrual bleeding guideline has been updated. The update reinstates recommendations on ulipristal acetate (Esmya®) following a European Medicines Agency review. Information on shared decision making and monitoring for side effects has been added for this treatment option.

The Urinary tract infection (catheter-associated): antimicrobial prescribing guideline has also been published. It sets out an antimicrobial prescribing strategy for catheter-associated urinary tract infection in children, young people and adults. It aims to optimise antibiotic use and reduce antibiotic resistance.

Last month several similar guidelines were issued that were not included in last month's post, they are as follows:

As above, each aims to provide an antimicrobial prescribing strategy that aims to optimise antibiotic use and reduce antibiotic resistance.

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

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Cilest to be discontinued

The manufacturer of Cilest® (norgestimate and ethinyl estradiol) has written to healthcare professionals advising that this product will be discontinued with effect from July 2019.

The letter states that this was a commercial decision to exit the oral hormonal contraceptive market and it is stressed that the are no safety, efficacy or quality issues with the product. Current supplies are expected to last until mid-July 2019.

There are two alternative products that are currently available in the UK with the same active ingredients - Cilique® and Lizinna®.

Action: Clinicians should be aware of this product being discontinued. It would be prudent to run clinical system searches to identify any patients who are currently prescribed this product to allow a review and arrangements made to identify a suitable alternative.

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Drug Safety Update - November 2018

The Medicines and Healthcare products Regulatory Agency (MHRA) has published Drug Safety Update for November 2018 (PDF).

This issue advises of a small increased risk non-melanoma skin cancer seen in association with hydrochlorothiazine. The risk is cumulative and dose-dependent and as such is seen more after long-term use. Patients taking such medicines should be advised to regularly check for and report any new or changed skin lesions or moles. Sensible exposure to sunlight and UV rays, including using adequate protection should also be advised. Use in patients with a history of skin cancers should be reconsidered.

This issue also reports a small increased risk of aortic aneurysm and dissection, particularly on older patients, using fluoroquinolones. These antibiotics should only be used after careful consideration in patients at risk of aortic aneurysm and dissection, for example those with a family history, pre-existing aortic aneurysm or dissection and diseases that increase the risk such as Marfan syndrome, Ehlers-Danlos syndrome and hypertension.

It is also reported that a clinical study of sildenafil (Revatio® and Viagra®) in early-onset intrauterine growth restriction has been terminated early after reports of persistent pulmonary hypertension of the newborn (PPHN). It is noted that sildenafil is not licensed for this condition and that Revatio is not recommended in pregnancy unless strictly necessary while Viagra is not authorised for use in women.

A Europe wide campaign is running from 19–23 November 2018 to support the safe use of medicines in babies, children, and pregnant and breastfeeding women. Social media will be used to discuss the importance of reporting suspected side effects via the Yellow Card Scheme.

Also this month, the summary of letters to healthcare professionals includes information about expiry date extension of Jext® adrenaline autoinjectors, a reminder of the advice about phenytoin (Epanutin®) 30mg/5ml oral suspension supply disruption and shortage of sodium valproate modified release (Epilim Chronosphere®▼). CoaguChek Test Strips have also been found to give false high readings and it is recommended that readings above 4.5 are confirmed using a laboratory method or unaffected batches of test strips before adjusting treatment.

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

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Guidance on cannabis-based products

NHS England has issued guidance on the use of cannabis-based products for medicinal use.

Following high-profile news stories over the summer, the Home Office reviewed the legal status of cannabis-based products for medicinal use. In light of evidence of therapeutic benefit in certain medical conditions these products will be rescheduled.

The guidance document notes that cannabis-based products for medicinal use should only be prescribed:

  • for indications where there is clear published evidence of benefit or UK
    Guidelines
  • where there is a clinical need which cannot be met by a licensed medicine
  • where established treatment options have been exhausted
  • under the prescription or direction of a specialist doctor (listed on the Specialist Register of the General Medical Council)

Action: Clinicians should be aware of this guidance. It essentially rules out prescribing in primary care and places restrictions on specialist prescribing.

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