NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Medicines
Medicines Update Primary Care

Medicines Update Primary Care April 2015

Neuropathic Pain

Neuropathic pain is defined as “Pain initiated or caused by a primary lesion or dysfunction of the nervous system”. Symptoms include:-

• Burning
• Electric shocks
• Numbness
• Tingling
• Shooting/stabbing

The nature of neuropathic pain and its management should be explained to the patient and the value of compliance with treatment. Healthcare professionals should encourage self-management and provide education to the patient, including coping strategies for flare up. Patients should understand that effective treatment is considered as 30% reduction in pain score and / or improved function. The benefits and possible adverse effects of pharmacological treatment should be discussed, including the importance of titration and review.

Regular assessment of effectiveness of treatment is needed, particularly during the titration period. Assessment of pain control includes the impact on daily activities and lifestyle. Prescribers should also consider the patient’s physical and psychological well being including adverse effects of therapy and the continued need for treatment.

The updated NHSGGC Chronic Non-Malignant Pain Neuropathic Pain Guidelines are now available in the Clinical Guideline Repository on StaffNet.
The guideline contains information on:
• Causes of neuropathic pain
• Assessing neuropathic pain with link to sLANSS tool
• Need for regular assessment and review
• More detailed information on stepwise treatment of neuropathic pain and titration schedules
• Links to Patient Information Leaflets
• When to consider referral to pain clinic.

Creon®(pancreatin) 40,000

This strength will be unavailable from mid April 2015. There is no indication when it will next be available. This issue does not affect the lower dose Creon 25, 000 and 10, 000 products which remain available. It is recommended that an equivalent dose of a lower strength be prescribed. Using Creon 25, 000 will reduce the number of capsules required compared to use of the 10, 000 product.

Creon 25, 000 is just over half the strength of Creon 40, 000 so the number of capsules should be approximately doubled as a starting point. As with all changes to pancreatin usage, dosage should be adjusted according to size, number and consistency of stools so that the patient thrives.

Current Creon 40 000 dose

(number of capsules)

Approximate Creon 25 000 dose

(number of capsules)

Equivalent Creon 10 000 dose

(number of capsules)

1

2

4

2

3

8

3

5

12

4

7

16

5

8

20

6

10

24


Ranitidine 5mg/5ml


Since July 2011 until November 2014, the prescribing of unlicensed “special” ranitidine 5mg/5ml has almost trebled and at the same time the average cost per item increasing from £208 to £280. This strength is not recommended by Yorkhill who use the licensed 75mg/5ml product (£20.76 per 300ml). This requires the use of a 1ml oral syringe which needs to be specified on the prescription.

In practice, a 1ml oral syringe can measure down to 0.1ml which is equivalent to 1.5mg ranitidine therefore dilution should not be necessary considering the relative safety of ranitidine.

Prescribers should be aware that the licensed product contains a small amount of ethanol equivalent to 5ml of wine per 5ml dose. However, advice from Yorkhill is that the doses used of the licensed preparations are so small that this is not a problem for most patients and parents should be assured of this. Currently there is a Script Switch warning in place to alert prescribers that ranitidine 5mg/5ml is unlicensed and will be updated to reflect that this is not recommended by Yorkhill.

Omeprazole Oral Solution

 
It should be noted that omeprazole oral solution 5mg,10mg and 20mg/5ml strengths are also unlicensed products and are not used by Yorkhill, who recommend omeprazole MUPS. There is no evidence to support the use of unlicensed omeprazole solutions due to the action of gastric juices negating the pharmacological effect of the drug.

Clomipramine MR discontinuation

Clomipramine is a tricyclic antidepressant but is most often used in the treatment of severe obsessional compulsive disorder (OCD) and generally as a second line option after selective serotonin reuptake inhibitors prove ineffective or are not tolerated. Consequently there is a small but important group of patients who rely on this drug.

Having considered this issue, the Prescribing Management Group – Mental Health, recommend clinicians take the following actions for patients affected by the discontinuation of clompiramine MR.

1. Review the on-going need for treatment

2. Where on-going treatment is required consider changing to an equivalent dose using clomipramine standard-release capsules (10mg, 25mg and 50mg capsules are available), given using the same dosing frequency i.e. once daily, twice daily etc.

3. The following table highlights licensed alternatives to clomipramine in OCD & panic disorder

 

Drug

OCD dose

Panic Disorder dose

Fluoxetine

20mg initially increased gradually to 60mg daily

n/a

Paroxetine

20mg increased gradually in 10mg steps to 40mg daily

10mg increased gradually in 10mg steps to 40mg daily

Sertraline

50mg increased if necessary in weekly steps of 50mg to 200mg daily

25mg increased to 50mg after 1 week then if necessary in weekly steps of 50mg to 200mg daily


4. Switching from clomipramine – stop the clomipramine then, 24 hours later add fluoxetine, paroxetine or sertraline, taking care to increase dose gradually.  Be aware of the risk of serotonin syndrome, cholinergic rebound & tricyclic withdrawal. (Sources – Maudsley Prescribing Guidelines 11th Edition & Psychotropic Drug Directory 2012)

New MHRA E- Learning Corticosteroids Module Launched

Interactive and designed for clinical practitioners, the module covers:
• recognition of commonly used corticosteroids
• important corticosteroid adverse effects
• factors that increase the risk of adverse effects
• how clinicians and patients can reduce the risk
• specific treatment of the adverse effects

A link to this module can be found HERE

Other e-learning modules on antipsychotics, benzodiazepines, opioids, oral anticoagulants, selective serotonin reuptake inhibitors (SSRIs) are available on the same site.