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.