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Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

NICE Guidance - July 2019

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

The Suspected neurological conditions guideline has been updated. It covers the initial assessment of symptoms and signs that might indicate a neurological condition. It helps non-specialist healthcare professionals to identify people who should be offered referral for specialist investigation. The update changed the timing of referral from urgent to immediate for adults with sudden-onset speech or language disturbance and children under 4 years with a change in head circumference and signs or symptoms of raised intracranial pressure following user feedback.

The Long-acting reversible contraception guideline has been updated. It covers long-acting reversible contraception. It aims to increase the use of long-action reversible contraception by improving the information given to women about their contraceptive choices. The update notes the wider range of LARC products now available and recognises the different ways contraceptive services are commissioned and provided in England.

The Neuropathic pain in adults: pharmacological management in non-specialist settings guideline has been updated. It covers managing neuropathic pain with pharmacological treatments in adults in non-specialist settings. It aims to improve quality of life for people with conditions such as neuralgia, shingles and diabetic neuropathy by reducing pain and promoting increased participation in all aspects of daily living. The guideline sets out how drug treatments for neuropathic pain differ from traditional pain management. The update has amended footnotes reflecting the legal status of gabapentin and pregabalin.

The Motor neurone disease: assessment and management guideline has been updated. It covers assessing and managing motor neurone disease (MND). It aims to improve care from the time of diagnosis, and covers information and support, organisation of care, managing symptoms and preparing for end of life care. The update has amended footnotes reflecting the legal status of gabapentin and pregabalin.

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 - July 2019

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

This issue advises that febuxostat should be avoided, unless no other therapy options are appropriate, in patients with pre-existing major cardiovascular disease due to an increased risks observed in a clinical trial. The study (CARES) found a higher risk for cardiovascular-related death and for all-cause mortality in patients assigned to febuxostat than in those assigned to allopurinol.

This issue also advises that tocilizumab (RoActemra®) has been linked with rare risk of serious liver injury including cases requiring transplantation. It is recommended that alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels should be measured before starting treatment with tocilizumab and monitored every 4–8 weeks for the first 6 months of treatment followed by every 12 weeks thereafter. Some areas may arrange monitoring under shared care.

There is also a reminder that rivaroxaban (Xarelto®) 15 mg and 20 mg tablets should be taken with food. There have been reports of reduced efficacy when taken on an empty stomach. The lower strengths can be taken with or without food.

Finally this month, the summary of letters to healthcare professionals includes a letter regarding the risk of teratogenicity and neuropsychiatric disorders with retinoids and the pregnancy prevention programme launched last month. There is also a link to a letter regarding the febuxostat advice mentioned above.

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

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CKS Updates - June 2019

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

The majority of topics have undergone reviews and minor restructures. The Bowel screening topic has been updated regarding the adoption of the faecal immunochemical test (FIT). The Cellulitis - acute topic now recommends doxycycline as the antibiotic of choice in patients taking a stain who cannot take penicillin antibiotics. The Developmental rheumatology in children is a new topic and the Premenstrual syndrome topic has been updated to clarify the definition of and information on the severity of premenstrual syndrome.

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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