Ascorbic acid is included on the NHSGGC formulary for prevention and treatment of scurvy. Most patients should be able to get adequate vitamin C via a balanced diet and advice on fruit and vegetable intake should be offered. Prescribed ascorbic acid may be necessary in a few limited situations such as treatment of scurvy, homocystinuria or autistic spectrum disorder when the diet is restricted to a limited number of foods. All other patients should be reviewed and stopped as appropriate.
Ascorbic acid is not recommended in the new Obstetric Management Guideline to increase absorption of oral iron for anaemia during pregnancy for patients with Haemoglobin < 105g/l.
Licensed ascorbic acid preparations have been subject to significant price increases recently and may cost up to 50p per tablet. Currently around £200,000 is spent annually on this across GGC.
SGLT2 (sodium-glucose co-transporter 2) inhibitors are licensed for use in type 2 diabetes to improve diabetic control.
Preliminary advice on the risk of diabetic ketoacidosis (DKA) with SGLT2 inhibitors was published in the Drug Safety Update and the GGC Medicines Update in 2015. The EU medicines regulators have since completed a review of DKA with SGLT2 inhibitors and further guidance has been published in the Drug Safety Update in April 2016.
Suggested actions to reduce the risk of patients on SGLT2 inhibitors developing DKA are:
Points to note from the new guidance are as follows:
The mechanism by which SGLT2 inhibitors might lead to DKA has not been established, however some potentially predisposing risk factors have been identified as follows:
The Drug Safety Update published in April 2016 reminds healthcare professionals of the risks of administering live attenuated vaccines to patients who are clinically immunosuppressed, either due to drug therapy or underlying illness.
Reminder for healthcare professionals:
Quetiapine is on the NHSGGC formulary for the treatment of schizophrenia and bipolar disorder. It is available in licensed tablet and modified release tablet formulations in various strengths. All quetiapine liquid formulations are unlicensed.
Prescribing in Dementia
The licensed indications for quetiapine are wider than the formulary indications, but it should be noted that quetiapine is not licensed for the treatment of behavioural and psychological symptoms of dementia i.e. the often distressing non-cognitive symptoms including agitation and aggressive behaviour. However on occasion old age specialists may recommend its use for such symptoms as part of a considered care plan. Prescribers are reminded of the general advice to choose a licensed medication whenever possible when initiating a prescription. Risks associated with prescribing of antipsychotics in dementia are well documented and should be considered before prescribing. An excellent Presqipp toolkit is available to aid decision making. Advice should be sought from secondary care as appropriate.
If a patient with dementia established on quetiapine develops swallowing difficulties or poor oral intake, all medication should be re-assessed for appropriateness in light of the deterioration in their clinical condition. In particular, a review of continued need for an antipsychotic should take place.
ScriptSwitch messages have been added to the following preparations;
Prescribers are advised to review the need for the higher cost formulations and particularly the use of quetiapine liquid due to the unlicensed status of this product and discuss with secondary care as appropriate.The costs per dose of various strengths of quetiapine are listed below for comparison (Scottish Drug Tariff March 2016).
|Product||Standard release tablets||Modified release tablets||Liquid / 5mL (unlicensed)|
Published July 11th 2016