Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

Drug Safety Update - April 2020

The Medicines and Healthcare products Regulatory Agency (MHRA) has published Drug Safety Update for April 2020 (PDF).

This month clinicians are provided with a summary of the key advice and guidance issued so far on medicines safety and pharmacovigilance during the Coronavirus (COVID-19) pandemic. This includes a reminder to make use of the Yellow Card system to notify all suspected side effects. Advice on medicines use issued during COVID-19 includes:

Ibuprofen and NSAIDs
There is currently insufficient evidence to establish a link between use of ibuprofen, or other non-steroidal anti-inflammatory drugs (NSAIDs), and susceptibility to contracting COVID-19 or the worsening of its symptoms.

Antihypertensives
The is no evidence from clinical or epidemiological studies to support the concern that treatment with angiotensin-converting-enzyme inhibitors (ACE inhibitors or ACE-i) or angiotensin-receptor blockers (ARBs) might worsen COVID-19 infection

Chloroquine and hydroxychloroquine.
It is advised that trials are underway, and until there is clear, definitive evidence that these treatments are safe and effective these agents should only be used for this purpose within a clinical trial.

Interestingly, the Journal of the American Medical Association has recently published research advising against using high-dose chloroquine due to "safety concerns regarding QTc interval prolongation and increased lethality".

The summary of letters to healthcare professionals includes information about a recall of Emerade auto-injectors as some pens to fail to activate and deliver adrenaline and a recall of Esmya 5mg tablets following a new case of liver failure requiring liver transplant in a patient taking the medicine.

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

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NICE Guidance - April 2020

The National Institute for Health and Care Excellence (NICE) have published new or updated guidance for the month of April 2020. This month there are seven rapid guideline and evidence reviews and one evidence summary related to COVID-19 that impact upon primary care.

The Acute use of non-steroidal anti-inflammatory drugs (NSAIDs) for people with or at risk of COVID-19 evidence summary has been published. This review found no evidence from published scientific studies to determine whether acute use of NSAIDs is related to increased risk of developing COVID-19 or increased risk of a more severe illness. It is noted that NSAIDs may either have no effect on, or worsen, long-term outcomes, possibly by masking symptoms of worsening acute respiratory tract infection. For now, paracetamol use to control fever symptoms would seem prudent in keeping with previous recommendations.

The COVID-19 rapid guideline: community-based care of patients with chronic obstructive pulmonary disease (COPD) guideline has been published. It aims to maximise the safety of patients with chronic obstructive pulmonary disease (COPD) during the COVID-19 pandemic, while protecting staff from infection. It will also enable services to make the best use of NHS resources.

The COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community guideline has been published. It aims to provide recommendations for managing COVID‑19 symptoms for patients in the community, including at the end of life. It also includes recommendations about managing medicines for these patients, and protecting staff from infection.

The COVID-19 rapid guideline: managing suspected or confirmed pneumonia in adults in the community guideline has been published. It aims to ensure the best treatment for adults with suspected or confirmed pneumonia in the community during the COVID-19 pandemic. It will also enable services to make the best use of NHS resources.

There are also COVID-19 rapid guidelines in the following areas that broadly apply to secondary care, but the recommendations to minimise face-to-face contact to reduce the risk of infection by using electronic means of communication, consultation and prescribing are pertinent to primary care as well.

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

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SMC Update - April 2020

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

Fampridine (Fampyra®) has been accepted, following a resubmission, for use to aid the improvement of walking in adult patients with multiple sclerosis with walking disability (EDSS 4-7). It should be noted that this advice applies only in the context of an approved NHSScotland Patient Access Scheme (PAS) arrangement and is therefore expected to be supplied via hospitals. It is also noted that the current NICE Guidance recommends against using this medication in England "because it is not a cost effective treatment".

Insulin glargine / Lixisenatide (Suliqua®) has been accepted for restricted use, in combination with metformin, for the treatment of adults with type 2 diabetes mellitus, to improve glycaemic control when this has not been provided by metformin alone or metformin combined with another oral glucose-lowering medicinal product or with basal insulin. The restriction limits use to patients who are uncontrolled on basal insulin (glycosylated haemoglobin [HbA1c] > 7.5% [59mmol/mol]) and for whom a GLP-1 receptor agonist is appropriate as an add-on intensification therapy to basal insulin analogues.

Naldemedine (Rizmoic®) has been accepted for use in the treatment of opioid-induced constipation (OIC) in adult patients who have previously been treated with a laxative. It is noted that compared to placebo this medication significantly improved the spontaneous bowel movement response rate in patients with opioid-induced constipation and either non-cancer or cancer pain.

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 - March 2020

During March 2020 a further eleven Clinical Knowledge Summaries were published or updated in the following areas. [Updated April 2, 2020 to correctly note that these topics are new and updated for March]

The Coronavirus - COVID 19 topic is new.

All of the remaining topics have been reviewed and undergone minor restructuring. The most significant changes are to the Giant cell arteritis topic which has been updated in line with British Society for Rheumatology guidelines. The Scarlet fever topic has a new risk factors section and advice on admission is now held in the management section. The Tiredness/fatigue in adults topic has been updated in line with current evidence and the red flags are now detailed in the assessment section. The Undescended testes topic has been updated in line with current evidence and possible differential diagnoses are now contained in the diagnosis section.

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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