CCG Updates Prescribing Edition Issue 41 - October 2014 Welcome to the October issue of CCG Updates - Prescribing Edition Patient Safety! Alerts this month are for e-cigarettes & domperidone, We are also aware of a number of dual anti-platelet significant events – good quality medication reviews are essential…. NICE bites is a comprehensive review of the recent CKD guidance (July 2014). This includes a table showing the new classification including ACR measurements, and recommended frequency of monitoring. The progression of CKD is clarified, and a reminder that NSAID use is associated with progression. Please note that the recent Lipid Modification guidance is under review by Greater Manchester & Stockport CCG, so do not change prescribing practice yet. Dr Heather Procter Domperidone Electronic Cigarettes The UK Commission on Human Medicines has reviewed the safety of this medicine for supply over the counter in pharmacies and advised that medical supervision is required. Recent guidance from oxygen homecare providers state that electronic cigarettes should not be used whilst a patient is undergoing oxygen therapy. Additionally, batteries of electronic cigarettes should not be charged in the vicinity of a patient undergoing oxygen therapy or the oxygen source itself. As of 4th September 2014, medicines containing domperidone will only be available on prescription. Please reiterate to patients that the dangers of using an electronic cigarette or similar device whilst using oxygen therapy are exactly the same as they would be with smoking ordinary cigarettes. Electronic devices also carry a risk of explosion or ignition and can cause a fire whilst recharging. For more information click here. Useful information: • Use of e-cigarettes with homecare oxygen • Guidance for long-stay environments Inside this issue: • Grey and black list changes • Testosterone guidance • Dual anti-platelet therapy • Denosumab prescribing • Nitrofurantoin Nice Bites – Sept 2014 Chronic kidney disease in adults in primary and secondary care. Click here to view. CCG Updates - Issue 41 - Prescribing edition New Product! Grey and Black List changes Molludab® Potassium hydroxide soln 5% There is poor evidence of efficacy for the licensed indication. Condition is self-limiting and prescribing would not be an appropriate use of NHS resources. Insulin Degludec & Liraglutide (IDegLira®) This has a negative recommendation from GMMMG, see here. Pollinex Use is restricted to within the specialist allergy service. COPD Rescue Prescriptions As the winter months approach, please could practices consider identifying their COPD patients who self-manage exacerbations at home with rescue medicines i.e. steroids and antibiotics, to check and ensure they have an adequate supply of in date medication. Testosterone Guidance The testosterone guidance has been updated and added to the CCG website here. This is a good tool to help you review your testosterone patients, who should be small in number, but can yield impressive savings to your prescribing budget. DuoResp Spiromax (Budesonide/formoterol fumarate dihydrate) inhalation powder has been launched for treatment of asthma or chronic obstructive pulmonary disease in adults, where use of an inhaled corticosteroid and a long-acting beta2 agonist is appropriate. The breath-actuated dry powder inhaler is available in two strengths: • 160/4.5 (equivalent to a metered dose of budesonide 200 microgram/formoterol fumarate dihydrate 6 microgram per dose) • 320/9 (equivalent to a metered dose of budesonide 400 microgram/formoterol fumarate dihydrate 12 microgram per dose) This dry powder device offers a cost effective alternative for patients who may have difficulty using Symbicort Turbohalers. PBMC Corner Latest black, grey, red and specials epact reports were shared, these included the newly updated GMMMG red list drugs , some of which remain amber in Stockport if supported by Shared Care Protocols. A further reminder was given that the dual antiplatelet SOP should be run every month to support the prevention of further significant events. The newly published compound haemorrhoidal SOP was shared, this supports changes from various products to either Uniroid-HC or Scheriproct preparations. The prescribing lead in the practice must decide which of the two products they would like to change the patients over to. Scheriproct is slightly less expensive but has had supply issues in the past, although they are currently resolved. Uniroid is a bit more expensive but hasn’t historically had any supply issues. Ahead of the forthcoming waste campaign, PBMC’s were asked to check prescription requests to identify potential quantity and alignment changes to repeat medication items. CCG Updates - Issue 41 - Prescribing edition Dual Anti-platelet Therapy Please ensure that patients taking dual anti-platelets are regularly audited and have stop dates added to their prescriptions. There have been quite a few serious incidents recently where patients have been continued after their stipulated stop date. Your PBMC’s should be completing a monthly audit and presenting clinicians with a monthly sheet comprising of new patients initiated on dual antiplatelets and also patients who are due to stop in that month. Please look out for these sheets and ask your PBMC or prescribing advisor if this is not happening in your practice. Further support for these reviews has come this week from NICE: ‘A randomised controlled trial reported that continuing dual antiplatelet therapy beyond a year after stent implantation did not statistically significantly reduce the risk of the combined outcome of death or cardiovascular events compared with continuing aspirin monotherapy. However, continuing dual antiplatelet therapy was associated with a statistically significant increase in the combined risk of major or minor bleeding. This is consistent with NICE guidance that recommends dual antiplatelet therapy as a treatment option for up to 12 months after stenting.’ Nitrofurantoin – can now be prescribed for short courses in patients not previously recommended. Nitrofurantoin is now contraindicated in patients with an estimated glomerular filtration rate (eGFR) of less than 45 ml/min. However, a short course (3 to 7 days) may be used with caution in certain patients with an eGFR of 30 to 44 ml/min. Only prescribe to such patients to treat lower urinary tract infection with suspected or proven multidrug resistant pathogens when the benefits of nitrofurantoin are considered to outweigh the risks of side effects. Click here for more information. New MHRA guidance on reporting suspected adverse drug reactions in children The MHRA are publishing new guidelines for reporting suspected adverse drug reactions (ADRs) in children and adolescents aged under 18 years via the Yellow Card Scheme. The advice on which suspected ADRs to report in children is now the same as for adults (ie, they are no longer requesting all suspected ADRs to be reported for children). Click here to view. Denosumab prescribing A MHRA Drug Safety Update (click here to view) advises healthcare professionals of updated recommendations to minimise the risk of osteonecrosis of the jaw and hypocalcaemia during treatment with denosumab. Before starting denosumab treatment, a dental examination and appropriate preventive dentistry are now recommended. Patients should be advised to maintain good oral hygiene and report any oral symptoms. The risk of hypocalcaemia increases with degree of renal impairment. Calcium levels should be monitored depending on the indication and patients should report symptoms of hypocalcaemia. We are currently working with Secondary care to update the Shared Care Protocol.