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Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

NICE Guidance - November 2021

The National Institute for Health and Care Excellence (NICE) have published new or updated guidance for the month of November 2021. This month there are four guidelines and one COVID-19 rapid guideline that impact upon primary care.

The Heart valve disease presenting in adults: investigation and management guideline has been published. It covers investigation and management of heart valve disease presenting in adults. It aims to improve quality of life and survival for people with heart valve disease through timely diagnosis and appropriate intervention.

The Acute heart failure: diagnosis and management guideline has been updated. Recommendations on valvular surgery and percutaneous intervention have been withdrawn and replaced by the new guideline above.

The Type 2 diabetes in adults: management guideline has been updated. The update reviewed the evidence and made new recommendations for SGLT2 inhibitors for adults with type 2 diabetes and chronic kidney disease.

The Chronic kidney disease: assessment and management guideline has been updated. The guidance on SGLT2 inhibitors for adults with type 2 diabetes and chronic kidney disease has been updated and links to the Type 2 diabetes in adults guideline.

The COVID-19 rapid guideline: managing the long-term effects of COVID-19 guideline has been updated. The update makes new recommendations and updates existing recommendations in several areas including identification, planning care, multidisciplinary rehabilitation and follow up. The list of common symptoms was also updated, emphasising that these may be different for children.

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 - November 2021

The Medicines and Healthcare products Regulatory Agency (MHRA) has published Drug Safety Update for November 2021 (PDF).

This issue advises clinicians of a new pre-vaccination checklist for the yellow fever vaccine (Stamaril®). The standardised pre-vaccination checklist has been introduced to ensure the yellow fever vaccine is indicated for the intended travel destination and to enable vaccinators to identify existing contraindications or precautions in individuals before vaccination.

Readers are also advised that Emerade® adrenaline auto-injectors have been re-supplied to the market after resolution of an issue that caused some devices to fail to activate and deliver adrenaline. Prescribers are reminded to support safe and effective use with training and advice specific to their prescribed adrenaline auto-injector.

This issue also advises readers of the latest COVID-19 vaccine safety information including regulatory approval for molnupiravir (Lagevrio®) and summaries of Yellow Card reporting noting that Guillain-Barré syndrome (GBS) is now a recognised and very rare side effect for Vaxzevria (previously COVID-19 Vaccine AstraZeneca).

Lastly in this issue is a summary of letters to healthcare professionals in October. These generally related to supply issues and recalls.

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

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Dapagliflozin no longer indicated in T1DM

The manufacturer of dapagliflozin (Forxiga®) has written to healthcare professionals advising that dapagliflozin 5mg is no longer recommended in patients with Type 1 Diabetes Mellitus. The other licensed indications are unaffected.

The communication states that this decision has not been made due to any safety concerns for the withdrawn or any continued indications. The letter goes on state that DKA was reported in studies at a rate of at least 1 per 100 patients. Additional risk minimisation measures have always been recommended with patient alert cards and guides for healthcare professionals made available. With the removal of this indication, the risk minimisation materials will no longer be available.

It is recommended that the treatment is reviewed and discontinued by or in consultation with a specialist and that this is done as soon as clinically practical.

Action: Clinicians should be aware of this license change. It would be prudent to run clinical system searches to identify any patients who are currently prescribed this product to allow a review.

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CKS Updates - October 2021

During October 2021 Clinical Knowledge Summaries were updated in the following areas.

All topics have been reviewed and updated in keeping with current guidance with minor layout changes. The Candida - female genital topic has updated to remove the terms 'uncomplicated' and 'complicated' as they are no longer recommended in the BASHH national guideline. The Immunizations - seasonal influenza topic has been update to include the recommendation that children aged over 2 years with a history of severe anaphylaxis to egg who have previously required intensive care management in hospital can be offered the egg-free cell-based quadrivalent influenza vaccine (QIVc) as an alternative to referral to a specialist for immunisation in hospital. And the Tiredness/fatigue in adults topic has seen an update to the recommended blood tests, referral timescales, the range of supportive measures which should be considered and the follow up recommended in primary care.

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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NHS England to review HRT charges

As reported in the general media (BBC), NHS England are to review how prescriptions charges are applied to prescription for Hormone Replacement Therapy treatments.

The current NHS prescription levy is £9.35 with 3 and 12 month Prepayment Certificates available to assist people on regular medication. HRT however has always been an area that causes some confusion, some treatments that contain 2 different treatment regimens is charged at two fees, so £18.70.

It is being proposed that fees are charged on an annual basis irrespective of the treatment used or how it is prescribed. It is noted in the linked article that prescription duration also plays a part with some areas issuing monthly prescriptions. NHS England are being asked to investigate what changes can be made to implement the charging changes. Prescriptions are already free in Scotland and Wales.

Action: Clinicians should be aware of this imminent change. In the short term, clinicians may wish to consider issuing extended durations of supply, perhaps 6 or 12 months of treatment to women established and stable on their preferred treatment.

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