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Kirklees.nhs.uk

www.kirklees-pct.nhs.uk
Prescribing & Medicines Management
Newsletter
New:
Cervarix, a 2nd HPV vaccine - PCT advice remains that
Cervarix (& Gardasil) should NOT be prescribed in primary
care outside of the agreed DOH vaccination programme
• A number of medications are available in liquid form (as well as the more traditional (which is proposed to begin September 2008) • Escitalopram (Cipralex) – new indication of OCD, but generic
• Unlicensed liquid medications from Specials manufacturers (e.g. Rosemont) can be fluoxetine is a considerably less expensive option, also SMC has already rejected this use for escitalopram in Scotland • Even where a licensed version is available, these still tend to attract a significant price • Alateris - the first UK licensed glucosamine product (two
625mg tabs daily for symptom relief in mild/moderate OA of Drug Tariff Oct 07 (28 days supply)
Liquid (licensed)
Adcal-D3 – new flavour (lemon)
Frusemide 40mg daily
Levothyroxine 25mcg-100mcg daily
SPC changes – warnings added (see individual SPCs on
Metformin 500mg tds
www.medicines.org.uk for more detail):
Lumiracoxib (Prexige) – liver toxicity (monthly LFTs required)
• There are no national guidelines on the use of liquid medications (local guidelines are • Pregabalin (Lyrica) – reports of loss of consciousness/
limited to those patients being enterally fed) confusion/mental impairment, also of renal failure • Not all liquid products are licensed (increased prescriber liability) • Alpha1-blockers - doxazosin, alfuzosin, prazosin –
Action: Prescribers are reminded that liquid formulations should be reserved for
Intraoperative Floppy Iris Syndrome (IFIS) - class effect? patients with genuine swallowing difficulties in order to conserve NHS finances.
Dopamine agonists e.g. ropinirole (Adartrel & Requip) and/or
levodopa (e.g. Madopar) – impulse control disorders e.g.
The ADVANCE trial
• Statin use was lower than might have pathological gambling/hypersexuality/increased libido • Lactose content warning - a number of SPCs e.g. Climaval
the effects of the routine administration of an ACE inhibitor (ACEI)/diuretic
Pioglitazone (Actos & Competact) – fracture risk
combination (perindopril/indapamide) on
reduction in those treated with statins, • Citalopram (Cipramil) & Duloxetine (Cymbalta & Yentreve) –
serious vascular events in people with
discontinuation (particularly abrupt) commonly leads to type 2-diabetes (irrespective of initial
withdrawal symptoms (+ reports of akathisia with citalopram) blood pressure levels / use of other blood Bottom-line:
Propafenone (Arythmol) & mycophenolate (Cellcept) –
• The results of ADVANCE are not
sufficiently robust to change practice.
Prochlorperazine (Stemetil), Sulpiride (Dolmatil), Pericyazine micro-vascular outcomes was reported,
• The trial does NOT prove that any effect (Neulactil), flupentixol (Depixol) – updated re QT prolongation
seen was specific to the combination • Maalox/Maalox Plus (aluminium & magnesium hydroxide) -
only just statistically significant, with a warning re use in renal impairment & porphyria confidence interval including 1 (a hazard • Generic perindopril is now available - • Promethazine (Phenergan) - contraindicated for < 2yrs old
difference between the two interventions). • Hydroxychloroquine (Plaquenil) – blood disorder reports
• Whatever treatment effect was present • Olanzapine (Zyprexa) – undesirable lipid changes
most likely resulted from the lower blood • Exemestane (Aromasin) – osteoporosis & fracture risk
pressure achieved (5.6/2.2 mmHg lower) in • Several NSAIDs have multiple SPC changes e.g. diclofenac/
misoprostol (Arthrotec), Tiaprofenic acid (Surgam) &
thiazide use in the placebo arm (only 5%). Ketoprofen (Oruvail)
• The primary endpoint was only reduced to difficulty of dose titration/excess cost. Discontinued:
Use only where a significant positive effect • Deteclo (chlortetracycline/tetracycline/demeclocycline) tabs
hypertension & ≥ 65yrs old (not in those • Tertroxin (liothyronine) 20mcg tablets but generic available
Sustac (GTN m/r) 2.6mg & 6.4mg tabs
Calcort (deflazacort) 1mg & 30mg (6mg remain available);
Costs for one year’s supply (Drug Tariff Oct 07):
Moditen (fluphenazine) 1mg tabs (end June 08)
• Coversyl plus (4mg/1.25mg), one daily • Zoton (lansoprazole) suspension
• Coversyl plus (4mg/1.25mg), two daily • Lasonil (heparinoid/hyaluronidase) ointment
Minulet & Tri-Minulet (with immediate effect)
• Ramipril 5mg cap + indapamide 2.5mg daily Shortages:
• Ramipril 5mg cap + Bendroflumethiazide 2.5mg daily • Trinordiol (early 2008?) • Medrone 100mg
(methylprednisolone) tabs (end Nov 07) • Colofac tabs (generic
mebeverine available) • Trasidrex tabs • Retin-A 0.025%
The National Prescribing Centre (NPC) has just launched a new
(tretinoin) cream (gel available) • Chloramphenicol 0.5% eye interactive educational website designed specifically for “busy healthcare professionals
drops/ointment (patchy availability). Possible alternative = fusidic and managers” - NPCi (www.npci.org.uk) containing:
acid 1% eye drops (Fucithalmic) • Atropine 1% eye drops
• High quality evidence-based materials in ‘bite sized chunks’ relating to prescribing, (Nov 07) - no direct alternative but Minims 0.5ml (x 20) available • Betnesol-N eye ointment (long term) • Neo-Cortef
• Existing NPC materials e.g. MeReC & On The Horizon (hydrocortisone 1.5% & neomycin 0.5%) eye/ear ointment (long
term) • Risperdal (risperidone 1mg/ml) liquid (no date)
Oestrogel (estradiol 0.06% gel)
• A blog (rapid commentary on recent newsworthy health topics).
Drug safety update (issues 2 & 3)
A new monthly publication by The Medicines The Drug & Therapeutics Bulletin recently assessed the role of SBOT & concluded: and Healthcare products Regulatory Agency (MHRA) which contains a wealth of drug safety • No compelling evidence to support the use of
• Lack of transparency in the pricing of home advice that all clinicians will find invaluable SBOT for COPD, chronic cardiac failure, cluster oxygen created with the awarding of contracts headache & dyspnoea in advanced cancer to four national contractors makes it difficult to obtain information on current costs. • ‘Stop Press’ section including recent MHRA • No benefit in COPD
No better than air in relieving dyspnoea in
• Close scrutiny of home oxygen services could provide opportunities for significant cost savings in primary care.
• ‘‘Hot topics’ section (2nd edition: Duloxetine, • Where oxygen therapy is needed, it should always be started and monitored under the Reminder: It is the responsibility of the
serious risk & Rosiglitazone and pioglitazone: supervision of an appropriate specialist, initiating consultant to complete the HOOF
cardiovascular safety and fracture risk). treatment should be reviewed regularly and and not the GP practice.
supplies of oxygen withdrawn where there is no evidence of benefit 2nd edition:
• Hormone-replacement therapy (HRT)/tibolone:
updated advice (including a useful table comparing benefit to risks) When a patient who has been receiving oxygen dies: • Desmopressin nasal spray: nocturnal enuresis • Responsibility to inform Air Products (AP) lies with the patient’s GP and/or family. In practical terms this would indicate that it should be the GP as the family will obviously be going through a grieving • Corticosteroids: early psychiatric side-effects process and shouldn’t be given the responsibility of having to contact AP 3rd edition:
• The number to ring is the usual free phone number for AP – 0800 373580 • Piroxicam: new restrictions, including specialist • No cancellation HOOF needs to be written, the process for removal of equipment will be implemented on the direction of the notification of death via the original notification by phone. • Ketoprofen and ketorolac: gastrointestinal risk • Inhaled corticosteroids: pneumonia Aliskiren (Rasilez)
• Pneumovax II: tolerability of re-vaccination Novartis may recently have approached you with regards to prescribing aliskiren, the PCT does not • Bisphosphonates: osteonecrosis of the jaw support the use of this medicine in preference to currently available antihypertensive agents, particularly • Lorazepam: reduction of recommended those that are NICE recommended, generically available & cost-effective (thiazides, ACE inhibitors & • Lumiracoxib and hepatotoxicity: prescribing Can be accessed at: http://www.mhra.gov.uk/ The Prescribing Team has been made aware that on occasions GP practices might have written named patient prescriptions for items to replenish stocks of medication which they have already administered Action: Use of aliskiren is NOT
to the patient at the practice. This method of product replacement is illegal and should only be done via a “signed order” where the medication will be paid for by the practice and recorded appropriately by the pharmacy. Under no circumstances should a prescriber replace medication in this way. It is perfectly legal to issue a prescription to a patient, who then takes it to the Drug Tariff Oct 07 prices £/28
pharmacy of their choice to be dispensed, they can then return to the practice to have the medication Reminder!!
Ezetimibe is NOT recommended by
Ordering childhood vaccinations
the PCT for routine use
viral-infections-that-cannot-be-treated-with-
Practices are reminded that when ordering • Tolerance to individual statins varies, so if a antibiotics-time-of-year-again……luckily the
childhood vaccines via an electronic order form patient is intolerant of one statin, PCT advice on Health Care Logistics website care is taken to Delayed Antibiotic Prescriptions*
ensure the correct number of vaccines are • If the patient is intolerant of the second statin, Prescribing Memos (issued since the
ordered. There was a paragraph in the Vaccine update April 2007 about over ordering which highlighted the fact that quite often orders are • NB Statins (as a group) have positive outcome placed for 10 packs when only 10 doses are data to back their use, ezetimibe does not,
• Atorvastatin to Simvastatin Conversion required. Most of the vaccines are in single and a different mechanism of action/lower
doses but Prevenar and BCG are in packs of 10.
efficacy when used alone, preclude
* Copies available from the Prescribing Team
assumptions of outcome
(01484 344352)
The information contained in this newsletter is issued on the understanding it is the best • benefit in use still outweighs risks available from the resources at our disposal at the • in patients with IHD, rosiglitazone should only time of going to print. For further information or 1. Inhaled insulin (Exubera) removed from
to share any suggestions of your own please contact the Prescribing Team on 01484 344352.
2. European Medicines Agency review of
• rosiglitazone/insulin combination SHOULD glitazone safety has concluded:
ONLY be used in EXCEPTIONAL circumstances This newsletter is available to download from the intranet: nww.kirklees-pct.nhs.uk
Produced by Kirklees PCT Prescribing Team: Shohaib Ali, Michael Duckworth, Linda Fox, Patrick Heaton, Suzanne Hill, Tasawer Hussain, Helen Knapp,
Nikki Lawton, Lisa Meeks, Majid Mehboob, Neill McDonald, Helen Pickering, Anna Place, Lucianne Ricketts, Judith Stones, Maghira Younis.

Source: http://www.kirklees.nhs.uk/fileadmin/documents/New/Public_Information/med_mgt/Newsletters/Archived_MM_newsletter/Prescribing_Meds_October_2007.pdf

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Neural Integration II: The Autonomic Nervous System and Higher-Order Functions  Operates under conscious control  Seldom affects long-term survival  SNS controls skeletal muscles  Operates without conscious instruction  ANS controls visceral effectors  Coordinates system functions: cardiovascular, respiratory, digestive, urinary, reproductive  Integrative center

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