Issue 7, July/ August 2014
News 1
Current Issues 2
QIPP Key Messages: Minocycline 4
Topic of the month: Diabetes 5
Drug Tariff 6
Safety 8
News
Medicines Management Education Event
Details have been sent out of the Medicines Management Education Event for prescribers which is being held on Thursday 25th September 2014 1pm – 4.30pm
The afternoon will consist of a brief medicines management update followed by four breakout clinical education sessions – prescribers are able to attend two out of the four sessions. Details of the sessions are:
• Novel Oral Anticoagulants
• Strong Opioid prescribing including use of transdermal opioids
• New diabetes drugs and their place in therapy
• Antidepressant prescribing including switching between drugs and current issues
In order to facilitate planning of the event, it is important that Prescribers let us know the 2 sessions they would like to attend during the afternoon. Could you please confirm your attendance and session choices by Wednesday 10th September 2014 to and also notify us of any special dietary requirements.
We are aware that this is on the same date as a pre-existing In House PLT date, and as such this may pose a problem for some practices who already have pre-booked training in place. However, we are intending to hold another event later in the year to ensure all prescribers have the opportunity to attend a session if they wish.
NPSA Rapid Response Report NPSA/2008/RRR05 - Reducing dosing errors with opioid medicines
Due to further incidents with regards to prescribing of opioids we would like to remind everyone about the recommendations in the 2008 rapid response alert around prescribing of opioids.
http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=59888&p=3
When opioid medicines are prescribed, dispensed or administered, in anything other than acute emergencies, the healthcare practitioner concerned, or their clinical supervisor, should:
• Confirm any recent opioid dose, formulation, frequency of administration and any other analgesic medicines prescribed for the patient. This may be done for example through discussion with the patient or their representative (although not in the case of treatment for addiction), the prescriber or through medication records.
• Ensure where a dose increase is intended, that the calculated dose is safe for the patient (e.g. for oral morphine or oxycodone in adult patients, not normally more than 50% higher than the previous dose).
• Ensure they are familiar with the following characteristics of that medicine and formulation: usual starting dose, frequency of administration, standard dosing increments, symptoms of overdose, common side effects.
Healthcare organisations should ensure local medicines and prescribing policies, including Standard Operating Procedures, are reviewed to reflect this guidance.
Prescribers are also advised to be cautious when picking the appropriate drug from clinical system picking lists as they can be confusing and this has recently contributed to an error – where a particular risk has been identified we will be working with the system supplier to rectify the problem. It is recommended that prescribers’ double check the prescription generated to ensure the intended item, strength and dose has been chosen.
Pharmacists should always dispense off the prescription rather than off a pharmacy generated label in case an incorrect product has been selected.
If you have any queries please contact your medicines management team for advice.
Current Issues
Levonorgestrel and ulipristal remain suitable emergency contraceptives for all women, regardless of bodyweight
The MHRA have sent a letter to healthcare professionals to advise that Levonelle® (levonorgestrel) and ellaOne® (ulipristal acetate) can be used for emergency hormonal contraception in all women regardless of weight or BMI. This follows a Europe-wide review, triggered because the product information for one levonorgestrel containing emergency contraceptive approved in the rest of the EU (but not approved in the UK) was amended to suggest that it is less effective with increasing body weight. However, the review of all the available studies conducted with levonorgestrel and ulipristal acetate concluded that the data is not robust enough to establish that there is a reduction in efficacy of emergency contraceptives with increase in weight or BMI. The letter from the MHRA can be accessed through the link below:
https://www.cas.dh.gov.uk/ViewAndAcknowledgment/viewAttachment.aspx?Attachment_id=101945
When should medication be prescribed on the NHS following a private referral?
Patients who request to be referred privately are expected to pay the full cost of any treatment they receive in relation to the episode of care provided privately: consultation fees, drugs prescribed or treatment provided by a clinician in the course of the private consultation. Patients should be informed of this expectation prior to referral.
If a private consultation identifies a long term condition or a need for medication which is available as routine NHS treatment, this should be provided as such by the patients usual GP. However the NHS doctor would only be obliged to prescribe in line with NHS and the local Pan Mersey guidance and formulary. There is no obligation on behalf of the GP to prescribe the recommended treatment if it is contrary to his/her normal clinical practice.
Covert Administration of medicines in Care Homes
Following a number of recent queries about covert administration of medication we have put together some guidance for prescribers:
• Covert administration of medicines is a complex issue and involves the administration of a medicine disguised in food or drink to a patient without their knowledge or consent.
• A clear distinction should be made between those patients who have mental capacity to refuse a medicine and whose refusal should be respected, and those who lack this capacity.
• Prescribers should always assume that care home residents have the mental capacity to make decisions about their treatment. Care home residents should have the same opportunities to make decisions about their medicines as people who do not live in care homes.
• Covert administration should only be used in exceptional circumstances after exploring alternative ways of administering medication e.g. a change of formulation or timing of administration, if clinically appropriate. Administration of medicine covertly carries risks that the patient may not receive the full dose, the medicine may degrade in food or drink and crushing a tablet is an unlicensed activity all of which have to be balanced against the risks of not giving the medicine at all.
• If covert administration of medicines is being considered, health and social care practitioners should ensure that the process for covert administration of medicines to adults resident in care homes includes:
1. Assessing mental capacity of the resident in line with appropriate legislation (e.g. the Mental Capacity Act 2005)
2. Holding a best interests meeting involving care home staff, the health professional prescribing the medicine, pharmacist and family member or advocate to agree whether administering medicines to the resident covertly is in their best interests.
3. Recording the reasons for presuming mental incapacity and the proposed management plan along with details of how each medicine will be administered without the resident knowing. The suitability of each medicine for covert administration must be assessed separately.
4. Regularly reviewing whether covert administration is still needed.
If you have any further queries please contact our care home pharmacist via email
or on 01928 593452
Fluticasone furoate with vilanterol Inhaler (Relvar Ellipta®▼)
We are aware drug reps are currently promoting fluticasone furoate with vilanterol inhaler (Relvar Ellipta®▼ ). Prescribers are reminded Pan Mersey APC does not currently recommend the prescribing of fluticasone furoate with vilanterol inhaler (Relvar Ellipta®▼) for the treatment of asthma or Chronic Pulmonary Airways Disease (COPD): http://www.panmerseyapc.nhs.uk/recommendations/documents/PS31.pdf
The New Medicines Subgroup is currently reviewing the evidence and any change to the status of the drug will be communicated to prescribers.
Medicines Management work plan
A summary of the work the Medicines Management Team are currently working on or plan to start in the next few weeks is detailed below:
Asthma patients on combination inhalers (ICS/LABA) reviewed for stepping downErectile dysfunction review –NHS patients on vardanafil/ tadalafil for switch to sildenafil.
Special unlicensed meds review
Vitamin B Co review
Clopidogrel, Prasugrel & Ticagrelor review
Insulin/needles/lancet/ strips- review of quantities
Stoma prescribing audit
Nexium review – switch to generic
query corner
Sunscreens – who can I prescribe for?
Formulary products Sunsense® Ultra lotion factor 50 and Uvistat® cream factor 30 and 50 are prescribable as drugs as advised by the Advisory Committee on Borderline Substances (ACBS) for the following conditions:
· Abnormal cutaneous photosensitivity resulting from genetic disorders
· Photodermatoses, including vitiligo and those resulting from radiotherapy
· Chronic or recurrent herpes simplex labialis
Patients requesting prescriptions for sun cream for other conditions such as eczema, following surgery for skin cancers or who experience allergies to regular sun cream should be advised to purchase these products, which are readily available over the counter.
For optimum protection, sunscreen preparations should be applied thickly and frequently (approximately every 2 hours). In photodermatoses, they should be used from spring to autumn. As maximum protection from sunlight is desirable, preparations with the highest sun protection factor should be prescribed.
QIPP Key Messages: Minocycline
Minocycline Prescribing-
· There is no clear evidence to support the preference of minocycline over other oral antibiotics in the treatment of inflammatory acne or rosacea.
· Minocycline appears to be associated with a broader spectrum and higher incidence of adverse drug reactions than other tetracyclines.
· Minocycline is not included in the local formulary as a treatment option for inflammatory acne or rosacea.
· Minocycline is more expensive than other antibiotic treatment options.
· In an individual any possible benefits of minocycline must be carefully weighed against the risks.
Topic of the month: Diabetes
SELF-MONITORING OF BLOOD GLUCOSE IN PATIENTS WITH DIABETES MELLITUS
Self-monitoring of blood glucose (SMBG) is essential for people with diabetes on insulin therapy and can be required for some people on other hypoglycaemic agents. Where SMBG is not serving a specific purpose in the management of the condition, it is a waste of NHS resources and may even worsen quality of life. 1,2 NICE recommend that SMBG should only be used in type 2 diabetes if it is going to be an integral part of the patient’s self-management education, and the continued benefit of SMBG should be assessed in a structured way each year. 3
In recent years the cost of prescribing blood glucose test strips (BGTS) has grown rapidly. In NHS Halton CCG in 2013/14, 18% of the spend on diabetes prescribing was for BGTS at a cost of £400,000. There has been a 0.5% increase in the number of items prescribed and a 6% increase in spend compared with this period last year.4
Background
SMBG is an essential component in managing patients treated with insulin to help them to achieve tight blood glucose control and to prevent severe hypoglycaemia. The purpose of this is to allow a patient to make necessary adjustments to their insulin dose (applicable in type 1 diabetes) and also to make informed lifestyle changes. In non-insulin treated type 2 diabetes the benefits of regular SMBG are unclear.
A Cochrane review found the overall effect of SMBG on glycaemic control in people with type 2 diabetes who were not using insulin was small up to 6 months after initiation, and subsided after 12 months. There was no evidence that SMBG affects patient satisfaction, general wellbeing or general health-related quality of life.5
It is recognised that patients treated with sulfonylureas are at risk of hypoglycaemia and SMBG may benefit people who are less able to identify early signs of hypoglycaemia.
The usual method for monitoring blood glucose control is by measuring glycated haemoglobin (HbA1c) which gives an indication of the overall blood glucose control over the preceding three months.
Guidance for reviewing the need to test for blood glucose
Current prescribing of BGTS should be evaluated on an individual patient basis in discussion with the patient; if there is felt to be no need for SMBG, prescribing should be reduced or discontinued.
- SMBG should only be provided routinely to people with type 2 diabetes not treated with insulin or sulfonylureas where there is an agreed purpose or goal to testing
- Patients being treated with insulin or other diabetes agents that carry a risk of hypoglycaemia (sulfonylureas, glinides) must be prescribed BGTS to allow them to satisfy the level of testing stipulated by the Driver and Vehicle Licensing Agency (DVLA)
Table 1: Summary of DVLA requirements with regards to self-monitoring of blood glucose
Group 1 Entitlement – Car, motorcycle / Group 2 Entitlement – LGV/PCV(updated Dec 2011 & Apr 2012)
Insulin treated patients / There must be appropriate blood glucose monitoring. This is defined as 2 hours before the start of the first journey and every 2 hours while driving. / Regularly monitors glucose at least twice daily and at times relevant to driving using a glucose meter with a memory function to measure and record blood glucose levels.
Patients managed by tablets which carry a risk of inducing hypoglycaemia (includes sulfonylureas and glinides) / It may be appropriate to monitor blood glucose regularly and at times relevant to driving to enable the detection of hypoglycaemia. / Regularly monitors blood glucose at least twice daily and at times relevant to driving.
Further guidance from the DVLA is available from the link below:
https://www.gov.uk/government/collections/current-medical-guidelines-dvla-guidance-for-professionals
3. SMBG should be used to assist the optimisation of blood glucose control prior to conception and during pregnancy in Type 1 and 2 diabetes, including gestational diabetes7
4. SMBG should be used only within a care package, accompanied by structured education with regular review. The education should include clear instructions as to the place of monitoring and how results can be used to reinforce lifestyle change, adjust therapy or alert healthcare professionals
5. The quantity of test strips on prescription should reflect the frequency of testing required by the individual patient. Where testing is only required intermittently, prescriptions should be generated only when needed and not as a repeat prescription
The Pan Mersey Diabetes Guidelines are available via the following link;