Prescribing newsletter for NHS Trafford CCG XXXX2016

The money bit

The latest budget figures indicate that we will are likely to overspend by £1.4m. This figure does however depend on us delivering all agreed savings including the recent recovery plan work shared by Nigel.

Your help and support with achieving savings are much appreciated and the team will be in touch if they haven’t already to come and action the recovery work.

Prescribing ‘top-tips’

  1. Treatment of tonsillitis
  • If antibiotics are considered necessary, first-line treatment is with phenoxymethylpenicillin 500mg four times daily for 10 days.
  • For patients with penicillin allergy, clarithromycin 250-500mg twice daily can be used; however please note the treatment duration is FIVE days.
  1. Pregabalin dose optimisation
  • Pregabalin capsules have a flat pricing structure which means that all strengths of capsules are the same price.
  • Giving the daily dose in two doses rather than three is more cost effective and more convenient for the patient as fewer tablets to take.
  • For example, if a patient taking 150mg capsules three times daily is switched to 225mg capsules twice daily, this would be a cost saving of £418.60 per year.
  1. Azithromycin capsules vs. tablets
  • Azithromycin capsules cost £15.13 for 6 vs. azithromycin tablets which cost £2.60 for 6.
  • Switching a patient from 250mg capsules three times weekly, to tablets could save £325.00 per year.
  1. Levothyroxine liquid to tablets
  • Levothyroxine 100micrograms/5ml oral solution costs £162.92 for 100ml. For a patient taking 100micrograms daily, one month’s supply costs £228.
  • The Eltroxin brand of levothyroxine tablets cost £1.71 for 28 tablets. Eltroxin tablets can be disintegrated in water and are a cost-effective alternative.
  • TheSummary of Product Characteristics for Eltroxinstates: Tablets can be disintegrated in 10 to 15 ml of water and the resultant suspension can be administered with more liquid (5 to 10 ml).
  • When making a change from liquid preparations to tablets ensure the patient and/or carer are able to take/administer the tablets disintegrated in water.
  1. Trazodone liquid vs. capsules
  • Trazodone 50mg/5ml liquid costs £153.06 for 120ml.
  • Trazodone 50mg capsulescost £30.16 for 84.
  • Cost per dose is £6.40 (liquid) vs. 35p (capsules).
  • The monthly cost for a patient taking 150mgliquid daily is £540 vs. £30 for capsules.
  • Patients should be reviewed to assess whether there is a need for trazodone liquid.
  • For patients who have been prescribed trazodone liquid due to the use of a low dose of 25mg, it may be appropriate to increase the dose to 50mg capsules which would still be unlikely to increase the likelihood of anticholinergic side effects and dependence, and would potentially deliver a better therapeutic effect.
  1. Brand prescribing of strong opioids
  • Brand prescribing of strong opioids is recommended so patients always receive the same product.
  • The medicines management team have been working in practices to switch patients prescribed generic oxycodone MR tablets, buprenorphine patches or fentanyl patches to the following brands:
  • Oxycodone MR tablets to Abtard MR – costsaving£25.04per month for 56 x 20mg tablets.
  • Buprenorphine patches to BuTec - costsaving £11.49 per month for 4 x 20microgram patches.
  • Fentanyl patches to Fencino– cost saving £11.78 for per month for 10 x 25microgram patches.
  • Prescribing opioids by brand name is safer for patients and will also provide cost-savings for your practice.

GMMMG panel/guidance

Do Not Prescribe updates

  1. Alimemazine tablets and oral solution are now included in the GMMMG ‘Do Not Prescribe’ list as they are not considered a cost effective use of NHS resources:
  2. Alimemazine 28 x 10mg tablets cost £96.10.
  3. Alimemazine 100ml x 30mg/5ml oral solution costs £207.58.
  4. Alimemazine 100ml x 7.5mg/5ml oral solution costs £152.88.

Suggested alternatives included in the GMMMG formulary are chlorphenamine and hydroxyzine.

  1. Dosulepin capsules are now included in the DNP list for all licensed and unlicensed indications due to concerns over risk of toxicity in overdose. Dosulepin is included in the NICE “do not do” list and is no longer recommended in the current NICE depression guidelines. Dosulepin should no longer be initiated in primary care and prescribers may wish to review those patients currently taking dosulepin to see if an alternative may be suitable – further advice is available from the medicines management team.

Safety

Brand prescribing of inhalers

  • Although generic prescribing is encouraged in primary care to reduce drug expenditure, this is not appropriate for inhaled drugs.
  • Generic prescribing leaves the brand and inhaler device that may be dispensed open to interpretation by the pharmacist and may result in variability in the type of inhaler device the patient receives which can affect complianceand disease control.
  • To ensure every patient with asthma or COPD always receives the same inhaler, we recommend prescribing inhalers by brand name. For example, for fluticasone furoate 92 micrograms/Vilanterol 22micrograms/ dry powder inhaler prescribe: Relvar Ellipta; for umeclidinium bromide 65micrograms dry powder inhaler prescribe: Incruse Ellipta 55micrograms dry powder inhaler.

Vaccines post-transplant

Following an incident in a GP practice where a patient who had recently had a renal transplant was offered a shingles vaccine; we would like to remind practices that patients post-transplant should not be given any live vaccines such as:

  • Varicella-Zoster (to prevent shingles),
  • MMR,
  • BCG,
  • Yellow fever,
  • Live attenuated influenza vaccine including nasal spray,
  • Small pox,
  • Oral polio.

Due to transplant patients being at risk of infection, they should receive inactivated influenza and pneumococcal vaccines.

Clinical

PHE advice on vitamin D

In the last newsletter when we advised that Public Health England now recommend that to protect bone and muscle health, everyone needs an average daily intake of 10 micrograms vitamin D. Details are available here:

Vitamin D 10microgram supplements should not be prescribed. They can be purchased from supermarkets and pharmacies. Alternatively, they are available free-of-charge for eligible patients on a low income via the Healthy Start scheme.Further information for patients about the Healthy Start scheme is available here:

Current issues

Amoxil shortage

  • Some prescribers may have noticed that ScriptSwitch recommended a switch from generic amoxicillin to Amoxil, due to Amoxil being cheaper. However, we have been informed by the manufacturer of Amoxil that it is now out of stock until early next year.
  • A message has now been put on ScriptSwitch to advise prescribers that Amoxil is unavailable and to prescribe generically in the interim.

Product withdrawals

Asasantin Retard (aspirin 25mg/dipyridamole 200mg) capsules will be discontinued at the end of December. Alternative combination products are available and patients currently prescribed Asasantin Retard may have their prescription amended to “aspirin 25mg/ dipyridamole 200mg modified-release capsules.”

  • However, please note that clopidogrel is now recommended as first-line treatment for patients following a stroke or TIA. The Royal College of Physicians National Clinical Guideline for Stroke (5th Edition 2016) recommends for long-term vascular prevention in people with ischaemic stroke or TIA, clopidogrel 75mg daily should be standard treatment.
  • For those unable to tolerate clopidogrel, aspirin 75mg daily with dipyridamole MR 200mg twice daily can be used.
  • It should be noted that for TIAs this is outside of licence, and NICE guidance, which currently recommends dipyridamole and aspirin. If clinicians wish to change patients to clopidogrel monotherapy post TIA they should make the patient aware that this is an unlicensed indication.

New product

  • Levothyroxine (12.5, 25, 50, 75 and 100 micrograms) tablets have been launched by Teva.
  • Two of the strengths (12.5 and 75mcg) are new to the UK market, allowing optimal dose adjustment and removing the need to split tablets.
  • All tablet strengths are lactose-free, providing an alternative to levothyroxine oral solution for patients requiring a lactose-free formulation.
  • Cost for 28 tablets: 12.5mcg, £15.00; 75mcg, £4.00.

Congratulations

Congratulations to Alison Haigh and

Elizabeth Pearce, medical students at Manchester University, and Dr Marik Sangha, GP at St Johns Medical Centre, who won runner up prize at the RCGP North West Faculty dinner for their poster presentation on their audit “Recognising antibiotic resistance inUrinary Tract Infections”. Their study found:

  • Diagnostic tools, especially MSUs, are not used appropriately potentially resulting in over-treatment.
  • High levels of resistance to trimethoprim, the recommended first line treatment, indicating that guidelines need to be readdressed.
  • Ongoing inappropriate prescribing of cefalexin potentially contributing to further drug resistance.

In addition to improved diagnostic processes,they recommend:

  • A change in prescribing practice; adopting nitrofurantoin as first line treatment in place of trimethoprim for uncomplicated UTIs in Trafford.
  • Provision of modified release Nitrofurantoin, prescribed BD rather than QDS, may confer further benefits by promoting adherence and causing fewer side effects.

On the basis of their findings the medicines management team has produced aPrescribing Alert adopting the recommendations.Please contact us for a copy if you have not received it already.

Wishing you a Merry Christmas and a Happy New Year from all the Medicines

Management Team

Medicines Management Team 0161 873 9506/7 and 9585