Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

NICE Guidance - June 2019

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

The Urinary incontinence and pelvic organ prolapse in women guideline has been updated. It covers assessing and managing urinary incontinence and pelvic organ prolapse in women aged 18 and over. It also covers complications associated with mesh surgery for these conditions. Two recommendations on the use of synthetic polypropylene or biological mesh insertion for women with recurrent anterior vaginal wall prolapse have been withdrawn.

The Hypertension in pregnancy guideline has been published; it replaces previous guidance. It covers diagnosing and managing hypertension (high blood pressure), including pre-eclampsia, during pregnancy, labour and birth. It also includes advice for women with hypertension who wish to conceive and women who have had a pregnancy complicated by hypertension. It aims to improve care during pregnancy, labour and birth for women and their babies.

The Depression in children and young people guideline has been published; it replaces previous guidance. It covers identifying and managing depression in children and young people aged 5 to 18 years. Based on the stepped-care model, it aims to improve recognition and assessment and promote effective treatments for mild and moderate to severe depression.

The Ertugliflozin with metformin and a dipeptidyl peptidase-4 inhibitor for treating type 2 diabetes technology appraisal has been published. Ertugliflozin is recommended as an option for treating type 2 diabetes in adults when diet and exercise alone do not provide adequate glycaemic control, only if:

  • the disease is uncontrolled with metformin and a DPP‑4 inhibitor, and
  • a sulfonylurea or pioglitazone is not appropriate.

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

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HPV vaccination extended to include boys

Public Health England has announced that the human papillomavirus (HPV) vaccination programme is to be extended to include boys from 1 September 2019.

The vaccine has been offered to girls as part of the NHS immunisation programme since 2008. Based on the advice of the Joint Committee of Vaccination and Immunisation (JCVI) the programme is being expanded and will now have universal coverage.

Action: This information is aimed at health professionals who will be responsible for implementing the new programme but may be useful for anyone who may see patients presenting following vaccination.

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Drug Safety Update - June 2019

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

This issue advises that direct-acting oral anticoagulants (DOACs) are not recommended in patients with antiphospholipid syndrome due to an increased risk of recurrent thrombotic events. A clinical trial has shown an increased risk of recurrent thrombotic events associated with rivaroxaban compared with warfarin in patients with antiphospholipid syndrome and a history of thrombosis. This particularly affects high-risk patients who test positive for all 3 antiphospholipid tests. It is also recommended to review any patients with antiphospholipid syndrome who are currently prescribed a DOAC and consider switching to a vitamin K antagonist such as warfarin.

This issue also advises of reports of diabetic ketoacidosis seen in patients on GLP-1 receptor agonists when concomitant insulin was rapidly reduced or discontinued. It is recommended that insulin reductions should be done in a step-wise manner with careful glucose self-monitoring if GLP-1 receptor agonist therapy is initiated and the insulin is dose is reduced.

New materials have been launched to support the pregnancy prevention programme including a new prescribed checklist for oral retinoid medicines. In conjunction with this, advice about the risk of neuropsychiatric reactions has been made consistent for all oral retinoid medicines.

Finally this month, the summary of letters to healthcare professionals includes a letter regarding the shortage of Epanutin (phenytoin) oral solution which contains prescribing and dispensing advice. There is also a link to a letter regarding DOAC use in patients with antiphospholipid syndrome.

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

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SMC Update - June 2019

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

Fluticasone/formoterol (Flutiform®) has been accepted for use in the regular treatment of asthma in children aged 5 to 12 years where the use of a combination product (an inhaled corticosteroid and a long-acting β2 agonist) is appropriate:

  • for patients not adequately controlled with inhaled corticosteroids and 'as required' inhaled short-acting β2 agonist
  • or for patients already adequately controlled on both an inhaled corticosteroid and a long-acting β2 agonist

This product has already been accepted for use in adults and adolescents aged 12 years and above on the same basis.

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 - May 2019

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

The majority of topics have undergone reviews and minor restructures. The Hypercholesterolaemia - familial topic has been updated in line with current NICE guidance. The Ulcerative colitis topic has been significantly restructured with recommendations on the diagnosis and management amended in line with current evidence and the sections on specialist investigations and management have been updated and expanded.

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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