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Nostrum October 2014
A newsletter from the Prescribing Support Team, NHS Dumfries and Galloway
In this edition of Nostrum:
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Endocrine matters
Emergency Inhalers in
Schools
Formulary Review
HBGM Aide Memoire
Latest SMC Advice
Specific Drug Issues
Scriptswitch Update
ScriptSwitch Update
ScriptSwitch has now been running in 29 out of the 34 practices in NHS Dumfries and Galloway since November
2013. The graph below shows the variation in its use amongst practices. The dark dots within the bars represent
actual savings made against the potential savings. There are obviously practices who are more inclined to accept
the recommendations offered by ScriptSwitch than others. We recognise that some recommendations are never
accepted and never likely to be, and are therefore working with ScriptSwitch to remove these. However, it is also
evident where more savings could be made, including simple switches to formulary choices and avoiding
branded prescribing where appropriate. Practice-based PST pharmacists and technicians can help facilitate
these changes- just ask ☺!
Emergency Inhalers
in Schools
From the 1st October, schools
will be allowed to hold spare
emergency inhalers. ‘Asthma
UK’ report that 86% of
children have been without
their own inhaler because it
was lost, forgotten, broken or
had run out, so the change in
legislation which has been
made, will help to keep
children with asthma safe.
The Scottish Government is
reviewing guidance for
schools on managing
medicines and this will
contain advice for schools on
emergency inhaler use for
children with asthma. Schools
will have the option to
purchase their own inhaler
and spacer devices for
inclusion in their first aid kit, so
that children with asthma are
not at risk of being without
emergency reliever
treatment.
Formulary Review
Meetings
Formulary review meetings
will be taking place Please
contact a member of the
team if you have any
comments or suggestions you
would like to make regarding
formulary drug choices
and/or associated text.
Quick Guide to Blood Glucose Monitoring Equipment
Patient
Type I
Meter
GlucoMen LX Plus
(Menarini)
Test Strip
GlucoMen LX Sensor
GlucoMen LX Ketone
Type I Carb Counting
Freestyle InsuLinx
(Abbott)
GlucoRx Nexus
Freestyle Lite
Type II
GlucoRx Nexus
Lancet
Unilet ComforTouch
OR Glucoject Lancet
Plus
Unilet ComforTouch
GlucoRx
Unilet ComforTouch
GlucoRx
Visually Impaired
Nexus Voice
GlucoRx Nexus
NOTES
o
The needle of choice is Omnican (4mm, 6mm 8mm)
o
Type 2 patients not on insulin - only those on oral sulphonylureas should definitely be testing due to the
recognised risk of hypoglycaemia
o
If patient is using a insulin pump please check with Diabetes Centre re BGM/strips
o
If patient is visually impaired or has dexterity problems a Unistix 3 lancet may be considered
Healthcare Professionals should be using a CareSensN meter – strips have the same name and are available
through PECOS 3457546, £6.91.
Those not on Pecos should send their requisition to Procurement quoting the above product number. The needle is
BD-Autoshield Duo and the lancet is Unistix 3.
Hydrocortisone for Addison’s Disease
A recent article in the BMJ in July of this year (BMJ 2014; 349:g48433 Amin et al) discussed the use of prednisolone as a potential glucocorticoid
replacement therapy in the treatment of Addison’s disease. Coupled with the fact that the cost of hydrocortisone has escalated in the last year,
would it be reasonable to use prednisolone as an alternative to hydrocortisone? Dr Fiona Green, Consultant Endocrinologist DGRI has advised that;
hydrocortisone is preferable to prednisolone as it’s easily recognisable as replacement therapy and therefore less likely to be stopped/omitted
(prednisolone potentially being used for several other indications). Also by using hydrocortisone, there is the potential to monitor replacement doses in
blood and urine collections which is not possible with prednisolone; this is helpful in the context of monitoring under and over-replacement therapy. In
addition, the use of hydrocortisone acts as a flag to double doses in times of stress/ill health.[Prednisolone may be used for those who struggle to take
hydrocortisone two to three times daily.]
Liothyronine
As mentioned in last month’s edition, the price of liothyronine in comparison to levothyroxine has prompted the Health Board to look into the
prescribing of this. There are no formal guidelines on the use of liothyronone vs levothyroxine; Dr Green states that there are a very small number of
patients who request a trial of liothyronine (T3) based on the theory that in the context of another chronic illness, there is a lack of peripheral
conversion of T4 (levothyroxine) to T3 and anecdotally patients feel better on it. However, the number of patients involved would be expected to be
low and closely supervised by the Consultant specialist.
Specific Drug Issues
Domperidone for Enhancing
Breast Milk Production
This is an unlicensed use of
domperidone although
occasionally
recommended by
midwives. Prescribers are
advised to exercise caution
when this is requested in
light of the recent MHRA
safety advice relating to
the cardiac side effects of
domperidone and the fact
that it can no longer be
purchased over the
counter. Full details at:
http://www.mhra.gov.uk/N
ewsCentre/Whatsnew/CON
452545
Antibiotic Awareness
Day
Latest SMC Decisions For full advice see www.scottishmedicnes.org.uk
Accepted for Use in NHS Scotland
Nostrum extra – wound
Azelastine hydrochloride + fluticasone propionate (Dymista ). Indication under review: for the relief of symptoms of
management.
March
2006 or
moderate to severe seasonal and perennial allergic rhinitis if monotherapy
with either intranasal
antihistamine
®
glucocorticoid is not considered sufficient. For patients in whom the combination of azelastine hydrochloride and
fluticasone propionate nasal spray is an appropriate choice of therapy, Dymista® provides the two ingredients in a
single nasal spray. This SMC advice takes account of the benefits of a Patient Access Scheme (PAS) that improves
the cost-effectiveness of Dymista®. This SMC advice is contingent upon the continuing availability of the Patient
Access Scheme in NHS Scotland or a list price that is equivalent or lower. Accepted with PAS but NOT added to the
D&G formulary
Dabigatran etexilate (Pradaxa®). Indication under review: Treatment of deep vein thrombosis (DVT) and pulmonary
embolism (PE), and prevention of recurrent DVT and PE in adults. Accepted but NOT added to the D&G formulary for
this indication, pending a protocol
Picato Gel (Ingenol mebutate 150mcg/g and 500mcg/g). Indication under review: Cutaneous treatment of nonhyperkeratotic, non-hypertrophic actinic keratosis in adults. Accepted and added to the D&G formulary
Accepted for Restricted use in NHS Scotland
Alogliptin plus metformin (Vipdomet®). Indication under review:Treatment of adult patients aged 18 years and older
with type 2 diabetes mellitus. Accepted Restricted but NOT added to the D&G formulary
Antibiotic awareness day is
now held on the 18th
November every year; this is
well-timed to discourage
the inappropriate use of
antibiotics. Some GPs have
already undertaken the
Scottish Reduction in
Antimicrobial Prescribing
(ScRAP) programme which
focuses on appropriate
prescribing in RTIs and
recommends the use of
delayed prescriptions. With
the current focus on this
coupled with the fact that
NHS Dumfries and Galloway
are performing poorly in this
area compared to all other
HBs in Scotland, next month
there will be a ‘Nostrum
Xtra’ dedicated entirely to
antibiotic prescribing.
Ocriplasmin (Jetrea®). Indication under review: In adults for the treatment of vitreomacular traction, including when
associated with macular hole of diameter less than or equal to 400 microns. Accepted Restricted and approved for
use in D&G pending a business case
Prednisolone 25mg
tablets
Posaconazole (Noxafil®). Indication under review: for the treatment of fungal infections in adults. Accepted
Restricted but NOT added to the D&G formulary pending a protocol
Some GPs have noted the
cost difference between
prednisolone 25mg and
5mg strengths when issuing
scripts for treatments that
are initiated in hospital.
DGRI are aware of this
difference and try to limit
the use of 25mg strength
tablets where possible.
Please ensure multiples of
5mg tablets are prescribed
where appropriate.
New Oral
Anticoagulants (NOACs)
NOAC therapy should only
be initiated if an individual
is intolerant/allergic to
warfarin therapy or where
there is poor INR control on
warfarin (target INR <60% of
the time). Warfarin is the first
line anticoagulant in NHS
D&G; the inconvenience of
INR testing is not a valid
reason to commence
NOAC therapy.
Capsaicin (Qutenza®). Indication under review: For the treatment of peripheral neuropathic pain in non-diabetic
adults either alone or in combination with other medicinal products for pain. SMC restriction: For use in patients who
have not achieved adequate pain relief from, or have not tolerated, conventional first and second line treatments
Accepted Restricted but NOT added to the D&G formulary pending a protocol
Dapagliflozin + metformin (Xigduo®). Indication under review: in adults aged 18 years and older with type 2 diabetes
mellitus as an adjunct to diet and exercise to improve glycaemic control. Accepted Restricted but NOT added to
the D&G formulary
Empagliflozin (Jardiance®). Indication under review: Treatment of type 2 diabetes to improve glycaemic control in
adults as add-on combination therapy: in combination with other glucose–lowering medicinal products including
insulin, when these, together with diet and exercise, do not provide adequate glycaemic control. SMC restriction: to
use in the following situations: dual therapy in combination with metformin, when a sulphonylurea is inappropriate;
triple therapy in combination with metformin plus standard care; add-on to insulin therapy in combination with
insulin plus standard care. Accepted Restricted but NOT added to the D&G formulary
Lurasidone (Latuda®). Indication under review: For the treatment of schizophrenia in adults aged 18 years and over.
SMC Restriction: as an alternative treatment option in patients in whom it is important to avoid weight gain and
metabolic adverse effects. Accepted Restricted but NOT added to the D&G formulary pending a protocol
Tocilizumab (RoActemra®). Indication under review: In combination with methotrexate for the treatment of
moderate to severe active rheumatoid arthritis (RA) in adult patients who have either responded inadequately to, or
who were intolerant to previous therapy with one or more disease-modifying anti-rheumatic drugs or tumour
necrosis factor (TNF) antagonists. Accepted Restricted with PAS and approved for use in D&G
Not accepted for use in NHS Scotland
Colestilan (BindRen®). Indication under review: treatment of hyperphosphataemia in adult patients with chronic
kidney disease (CKD) stage 5 receiving haemodialysis or peritoneal dialysis. Not Recommended and NOT added to
the D&G formulary
Racecadotril (Hidrasec®). Indication under review: Complementary symptomatic treatment of acute diarrhoea in
infants older than three months and in children, together with oral rehydration and the usual support measures,
when these measures alone are insufficient to control the clinical condition and when causal treatment is not
possible. If causal treatment is possible racecadotril can be administered as a complementary treatment. Not
Recommended and NOT added to the D&G formulary
Trastuzumab emtansine (Kadcyla). Indication under review: as a single agent, for the treatment of adult patients
with human epidermal growth factor type 2 (HER2)-positive, unresectable locally advanced or metastatic breast
cancer who previously received trastuzumab and a taxane, separately or in combination. Patients should have
either: Received prior therapy for locally advanced or metastatic disease, or
Developed disease recurrence during or within six months of completing adjuvant therapy. Not Recommended and
NOT added to the D&G formulary
Contact the Prescribing Support Team @
Dr Paul Beardon [email protected]; Dr Jennifer Dillett [email protected]
Dr Emily Kennedy [email protected]; Dorothy Kirkpatrick [email protected]
Gordon Loughran [email protected]; Mandy Mackintosh [email protected]
Susan Roberts [email protected]