Re:As Required Tadalafil

Re:As Required Tadalafil

Dear Colleague,

For the November “Hints and Tips on Prescribing”, the Medicines Management Team would like to encourage practices to review patients who have been prescribed tadalafil 10mg or 20mg tablets on an as required basis.

Recommendations from PrescQIPP

(PrescQIPP is acommunity interest company which operates on a not for profit basis for the benefit of NHS patients, commissioners and organisations.)

• Sildenafil should be offered as first choice for patients presenting with erectile dysfunction (ED). This can be prescribed on the NHS for any appropriate patient with ED, regardless of the cause.
• If clinically appropriate, switch patients who are on an alternative PDE5 inhibitor (tadalafil, avanafil, vardenafil) for ED to generic sildenafil.
• A meta-analysis of 14 trials of the highest fixed doses of sildenafil, tadalafil and vardenafil found that sildenafil was significantly more effective than vardenafil and that other comparisons showed no difference in efficacy. The meta-analysis concluded that all PDE5 inhibitors are highly effective in the treatment of ED.
• The PDE5 inhibitors have similar side-effects, contra-indications, precautions and drug interactions.

Potential Savings

There is the potential to save £48k in HaRD CCG, if 50% of patients who are currently on PRN tadalafil are switched to PRN sildenafil. This switch has been discussed and approved at the Harrogate Area Prescribing Committee with HDFT colleagues. There may also be potential savings by reviewing the prescribing of once a day tadalafil (2.5mg and 5mg) and this is being discussed with the urologists at HDFT.

Prescribing of PRN Phosphodiesterase-5 Inhibitors licensed for ED in HaRD – 3months to July 16

Recommended Order of Prescribing PRN Phosphodiesterase-5 Inhibitors

1st choice: Sildenafil

2nd choice: Avanafil

3rd choice: Tadalafil or Vardenafil.

Comparative Costs (£) of Phosphodiesterase-5 Inhibitors (4 tablets)

Tadalafil tablets (10mg and 20mg) prescribed in HaRD (June – Aug 2016)

Action Points

• Ensure that sildenafil is used as the first choice PRN PDE5 inhibitor for new patients with ED.
• Please review all patients who are currently prescribed PRN tadalafil. Consider switching to sildenafil any patients who have not previously tried sildenafil.

Patients on tadalafil 10mg PRN, switch to sildenafil 50mg tablets PRN initially and increase to sildenafil 100mg tablets PRN if necessary.

Patients on tadalafil 20mg PRN, switch to sildenafil 100mg tablets PRN.

• If patients who are switched to sildenafil experience any problems, consider trying avanafil as a second option.

Patients who have been on tadalafil 10mg or sildenafil 50mg, prescribe avanafil 100mg PRN.

Patients who have been on tadalafil 20mg or sildenafil 100mg, prescribe avanafil 200mg PRN.

• Ensure that patients who continue to receive tadalafil, vardenafil and avanafil on the NHS meet the NHS criteria.
• Please prescribe all PDE5 inhibitors generically. Branded generics of sildenafil are not recommended as these are more costly than generic sildenafil tablets.
• Please share this information with all members of staff in the practice who are involved in the prescribing or issuing of prescriptions.

OurPrescribing Support Team is available to help practices with this work if required.HaRD versions of OptimiseRx and SystmOne and EMIS formularies will be amended to incorporate these recommendations.

Local community pharmacies have been e-mailed to inform them that practices will be undertaking this switch. As the timings of the switch will vary between practices it is advisable that each practice notifies its local pharmacies in advance of the switch to enable effective management of stock.

Should you have any queries, recommendations or ideas about this or future initiatives then we would be pleased to hear from you.

Yours sincerely,

The Medicines Management Team, HaRD CCG.

References

1. eBNF accessed 8.9.16
2. Department of Health Drug Tariff. Accessed on-line 6.10.16
3. Male sexual dysfunction: Management of erectile dysfunction and premature ejaculation. PrescQIPP Bulletin no 73
   January 2015.

Tadalafil PRN

Monthly briefing/letter – Nov 16Page 1 of 3HaRD Medicines Management Team