Transcript Prescribing Update

Prescribing Update
CATHERINE ARMSTRONG – MAY 2014
Summary
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Hot topics
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New inhalers
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NICE guidelines
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Drug shortages
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Updated BNF distribution schedules
Hot Topic: Domperidone
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MHRA Alert – 25th April
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Small increased risk of potentially life-threatening effects on the heart
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ONLY for nausea and vomiting
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MAX 7 days treatment
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ADULT dose – 10mg TDS
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Check for QT prolongation meds and CYP3A4 inhibitors
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Review patients at next routine appointment
Hot Topic: Strontium
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Restricted to severe osteoporosis
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…who cannot use any other treatments
Do NOT start in patients who have or had
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Ischaemic heart disease
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Peripheral arterial disease
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Cerebrovascular disease
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Uncontrolled hypertension
STOP if develop any of the above
New Inhalers
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COPD
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Aclidinium bromide
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Glycopyrronium bromide
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Indacaterol + Glycopyrronium
Asthma
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Fluticasone furorate + vilanterol
Aclidinium bromide (Eklira Genuir®)
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LAMA – 400micrograms/dose – TWICE daily for COPD
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↑ effect on lung function vs placebo
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No robust evidence of benefit vs other LAMA options
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Device: multi-dose dry powder inhaler
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On some local formularies:
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North of Tyne 
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Gateshead ?
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South Tyneside 
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Sunderland ?
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Durham&Darlington 
Glycopyrronium bromide (Seebri
Breezhaler®)
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LAMA – 44micrograms/dose – ONCE daily for COPD
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↑ effect on lung function, exercise endurance & patient outcomes vs placebo
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May provide more rapid bronchdilation than tiotropium
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Needs long term safety data & direct comparator trials
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Device = capsule based dry powder inhaler
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On some local formularies:
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North of Tyne 
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Gateshead ?
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South Tyneside 
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Sunderland ?
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Durham&Darlington 
Indacaterol + Glycopyrronium (Ultibro
Breezhaler®
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LABA+LAMA 85micrograms indacaterol + 43micrograms glycopyronnium
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ONCE daily for COPD
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Device = capsule based dry powder inhaler
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↑ lung function vs placebo, separates + fluticasone/salmeterol
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↓ rate of exacerbations compared to glycopyronnium alone
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Not considered locally yet
Fluticasone furorate + vilanterol
(Relvar®)
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ICS+LABA – 2 strengths 92/22 & 184/22micrograms
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ONCE daily for asthma
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Superior to fluticasone furoate alone
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92/22 comparable efficacy to fluticasone/salmeterol 250/50 BD
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CONCERNS re product – MHRA review
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Not considered locally yet
NICE Guidelines
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CG171: Urinary Incontinence in Women
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CG172: Myocardial Infarction – secondary prevention
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Darifenacin, oxybutynin (IR) & tolteridone (IR) – 1st line
Omega 3 fatty acids – DO NOT RECOMMEND for 2ndry prevention of MI
CG173: Neuropathic Pain – pharmacological management
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Tramadol not for long-term neuropathic pain control
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Carbamazepine ONLY for trigeminal neuralgia
Drug Shortages - Valsartan
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Intermittent supply problems – all strengths & forms
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May last several months
A2RA
Valsartan
Approximate dose conversions *
40mg daily#
80mg daily#
160mg daily#
320mg daily#
Candesartan
4mg OD
8mg OD
16mg OD
16-32mg OD
Losartan
25mg OD
50mg OD
100mg OD
* Dose equivalences are approximate and individual responses may vary so BP should be monitored following the
switch and dosing adjusted accordingly, if needed
#Valsartan doses may be given as 2 divided doses depending on indication
Taken from NHS England Memo 10/3/2014: http://www.medicinesresources.nhs.uk/en/Communities/NHS/SPS-E-and-SEEngland/Medicines-Information/Discontinuation-Supply-Shortage-Memos/Shortage-of-Valsartan-/
Drug shortages – Piroxicam gel
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Some supplies available
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NHS prices currenly based on Feldene® gel
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60g = £6.00
(was £2.71)
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112g = £9.41
(was £5.06)
Compared with
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Ibuprofen 5% gel £2.11 (50g), £4.22 (100g)
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Ibuprofen 10% gel £5.79 (100g)
Drug shortages - various
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Clomipramine
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Branded product discontinued
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Cross-tapering with SSRIs, venlafaxine or duloxetine – specialist use only
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Example switch to imipramine:
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Gradually reduce to 75mg/day, stop and start imipramine 50-100mg/day the next day
Co-amoxiclav
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Can be obtained – prices higher than usual
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375mg £5.30/21
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Use ONLY where clinically appropriate
625mg £6.93/21
Drug shortages – various (2)
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Amiloride
£19.10 per 28
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Co-amilofruse
2.5/20 £4.32 per 28
5/40 £5.29 per 28
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Co-tenidone
50/12.5 £5.18 per 28
100/25 £5.18 per 28
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Is a potassium sparing diuretic needed?
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Avoid combination products where possible
Drug shortages – various (3)
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Mebeverine
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135mg tablets £17.50 per 100
Peppermint oil 0.2ml caps £7.04 per 84
Propranolol
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10mg £5.30 (28)
40mg £4.10 (28)
80mg £6.44 (56)
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Consider alternative beta-blocker
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HF – bisoprolol, carvedilol and nebivolol = licensed options
BNF Distribution
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From Sept 2013 edition – annually in PRINT
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Still updated every 6 months (print copy)
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Online/App versions updated monthly
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Register for NHS Athens account:
http://www.nice.org.uk/mpc/BritishNationalFormulary.jsp
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Info regarding print distribution:
http://www.nice.org.uk/mpc/BritishNationalFormulary.jsp
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ALL GPs should receive annual PRINT copy to place of work
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Email [email protected]