Minocycline Audit
background
A recent GP update course highlighted the issue of minocycline. It is a drug used primarily to treat acne and to its benefit can be prescribed once daily. It also does not need to be taken on an empty stomach. However, evidence suggests that it is no superior to other tetracyclines either in efficacy or tolerance and unlike other tetracyclines has greater side effects. As such the advise from the course was not to prescribe it and in fact to take it off formularies.
The above was discussed with our pharmacist who directed me to NICE information on key therapeutic topics. They too have highlighted minocycline due to the above. In addition it has a relatively high acquisition cost and there are alternative once daily treatments such as doxycycline and lymecycline. According to a Cochrane review in 2012 minocycline has been associated with :
1) early-onset dose related toxicity reactions resulting in single organ dysfunction (including potentially fatal liver failure)
2) autoimmune disorders (SLE like syndrome – this is related to duration of exposure, and autoimmune hepatitis)
3) hypersensitivity reactions (eosinophilia, pneumonitis and nephritis)
4) slate-grey hyperpigmentation of the skin which may be irreversible (drugs and therapeutics bulletin 2006)
They found it was not possible to estimate the likelihood of an adverse effect and there was no evidence to suggest the slow release preparation was any safer. They felt there was no evidence to justify the use of minocycline for first line treatment of acne.
NICE also highlight the cost implications in addition to the quality issues. They estimate that using an alternative tetracycline could save the NHS 2.2 million pounds. Rates of prescribing currently vary hugely from region to region and overall prescribing is reducing. The NICE information is to support the QIPP medicines use and is not formal NICE guidance.
Method and Results
I performed a search on system 1 on our patient population searching under all preparations of minocycline (50mg, 100mg and the S/R preparation). This showed 78 patients who have been prescribed minocycline. After looking through all of these patients notes the vast majority are historical prescriptions and only 5 are current.
1. One of these patients was commenced in secondary care for pemphigoid and they are currently in the process of reducing the dose. I suggest we continue with this as per advise from dermatology.
2,3 Two are on repeat but were last issued in July and September respectively and have not been requested since. I suggest these are taken off repeat so if it is requested again will need to go through a doctor as an acute. I will make an entry in their notes to this effect and should they request more this will need discussing and I suggest an alternative is used.
4. One was issued in November for 4 months so half the script should already have been used. This is not on repeat. I suggest writing in her notes re minocycline and again discussing and issuing an alternative if requested.
5. The fifth patient has been on it long term for rosacea and has it on repeat. This has been since 2009. The NICE information would suggest she is at greater risk of autoimmune problems due to duration of use so I suggest asking her to come in to discuss it and trying an alternative. She had attempted to stop it at some point in the past and her symptoms had worsened but an alternative wasn’t offered at that time.
Actions
1) re. patients currently prescribed minocycline actions are as above.
2) TO discuss at Drs meeting to highlight the issue and hopefully agree to no longer prescribe so no new scripts will be issued.
3) TO check our formulary with the pharmacist and if minocycline is on to remove it.
4) TO re-audit at a later date to ensure no new prescriptions have occurred.
Re-audit
Update at 3 months post audit (bullet points correspond to numbering above)
1) Notes were made in the records of patients who had recently been prescribed minocycline to ensure no further scripts were issued. For patients where it was on repeat this was cancelled and the patient contacted and ultimately minocycline stopped. Of the patients highlighted only the patient where it is prescribed from secondary care continue to be on it.
2) The audit was discussed at a practice meeting and a notification sent out for any missing doctors to update on minocycline and for it not to be used for acne treatment in the future.
3) The audit was discussed with our pharmacist and minocycline has been removed from our formulary (it was up until the audit on the formulary as an acne treatment).
4) A reaudit was done to check that no new prescriptions had been issued. On searching against the same criteria one additional patient was noted (80 to the previous 79). All notes were reviewed and there were no new issues, the additional patient was new to the practice but it was a historical prescription.
In conclusion no new minocycline scripts have been issued since the audit other than to the patient who is prescribed it by secondary care for bullous pemphigoid. The patients who were previously on it have been addressed. The audit has altered the clinical practice at Ashcroft surgery.