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

Medicines Update Primary Care - August 2014

Blood Glucose Meter Choices

Blood glucose strips is an increasing area of prescribing (£3.5M spend/annum in primary care in NHSGGC). In addition the many meters and strips that are available presents a number of challenges which the Diabetes MCN are assessing.
1. MHRA Warnings - In the last year, seven warnings relating to Blood Glucose (BG) strips and meters have been issued. All are listed at www.mhra.gov.uk/index.htm but the most recent are noted below:
 a. Accu-Chek® Compact, Accu-Chek® Mobile and Accu-Chek® Active devices may give falsely low blood glucose readings for patients receiving ceftriaxone therapy.
 b. People with diabetes who use Accu-Chek®; Mobile blood glucose meters are advised to ensure they follow the important testing instructions as the meter may give false high blood glucose readings if testing instructions are not followed
2. Patient self monitoring skills - NICE recommend assessing patients’ self monitoring skills at least annually in a structured way along with the quality and appropriate frequency of testing by the patient. Eg If fingers are not clean when monitoring false readings will occur
3. Range of meters in use across NHSGGC. Over 50 BG meters are listed in MIMS but only the BG strips are available on the NHS. The Drug Tariff has BG strips ranging in price for packs of 50 from £6.99 to £16.30.  In the first 3 months of this year, 35 different strips /discs were prescribed in NHSGGC.
4. Quality - The international manufacturing standard for BG meters and test strips is ISO 15197, (updated 2013) which will be mandatory in June 2016. This includes:
 a. increased accuracy for BG readings from the strips and meters when compared to laboratory results. In addition the bias of haematocrit is evaluated and the impact of interfering substance eg triglycerides which can interfere with BG measurement.
 b. a comparison of user performance with a healthcare professional to demonstrate that the intended users are able to use the BG meter and obtain accurate glucose values following only the instructions and training materials routinely provided with the system.
It is against this background that the Diabetes MCN is about to carry out a review of available blood glucose meters for patients to identify a list of preferred options for inclusion in the NHSGGC formulary. The intention is to define a shortlist of meters that would be suitable for the majority of patients and so facilitate a more streamlined and efficient way of providing appropriate self monitoring to patients.

High Flow Oxygen

The NHSGGC Respiratory Managed Clinical Network (MCN) have recently produced a statement regarding the use of emergency oxygen and nebulisers in general practices. 

Oxygen is required for treating hypoxaemia during medical emergencies which may present in primary care settings.  Practices and health centres should have a supply of oxygen for emergency use as current best practice is to provide optimal oxygen therapy at the earliest opportunity while an acutely breathless and hypoxic patient is assessed and treated in the community.  The BTS guideline for emergency oxygen use states that early intervention can reduce hypoxaemia which can lead to cardiac arrhythmias, renal damage and ultimately cerebral damage.

The respiratory MCN state that: “health centres and practices should have a supply of oxygen for emergency use.  Generally, cylinders with high-flow regulators should be ordered, capable of delivering a flow of at least 6 litre/minute in order to deliver medium and high-dose oxygen therapy”

Under new arrangements, community pharmacies are no longer providing the domiciliary oxygen service.  Most pharmacies will not stock oxygen but some may continue to provide oxygen under private arrangement to general practices.  Oxygen cylinders which have previously been obtained from community pharmacies may not deliver adequate flow rates for emergency oxygen use and oxygen driven nebulisers and should be replaced.  Emergency high flow oxygen can be obtained from BOC (www.boclifeline.co.uk or telephone 0161 930 6010).  There is an annual charge which includes masks and servicing.

Fentanyl

The MHRA have recently highlighted the risk of harm which can occur from exposure to fentanyl by accidental contact or transfer of patches.  Children in particular may touch, chew or swallow a patch if not disposed of carefully.  Prescribers and pharmacists should ensure patients are aware of the risk to others if exposed to the patches.  Should unintended exposure occur, medical help should be sought immediately.  Following use, patches should be folded over and the sticky sides stuck together immediately after removing and then discarded in a safe place out of the reach of children and animals and not down the toilet.  If patients have concerns about safe disposal of medication, they should seek advice from their community pharmacist.

Prescribing for Sports Clubs

Prescribers who are providing medical services to sports clubs, or other patients not registered to their NHS practice, should not be issued with NHS prescriptions from that practice. NHS prescribing should be done through the NHS service the patient is registered to (or attending in the case of allied health professionals).  Prescribing for patients out with this should be done by private prescription.

Wound Formulary

The NHSGGC Wound Formulary 2014-15 has been approved by the ADTC Therapeutics Sub Committee.

Medicines Management LES

In 2013/14, 96% of practices within NHSGGC opted into the Medicines Management local enhanced service (LES).  We report some of the outcomes of this service below:
• Of those opted in, all but one practice installed the electronic version of the preferred list formulary and synonyms
• 80% of practices achieved the 78% target for formulary preferred list prescribing or an increase of 1% from baseline
• 28,301 patients using a compliance aid and 4498 care home patients had a level 1 medication review
• 84% of patients with repeat medication had a level 1 medication review
• 1,746 epilepsy patients and 973 heart failure patients were identified and reviewed to address potential under-ordering

Drugs for Urinary Retention

A new combination product containing tamsulosin and solifenacin (Vesomni®) has recently been added to the NHSGGC total formulary for the treatment of urinary frequency, urgency and obstructive symptoms associated with benign prostatic hyperplasia in men when monotherapy is ineffective.

Tamsulosin and Finasteride are the preferred list choices in the Formulary. Vesomni® would currently provide a cost-effective option for patients who require concomitant use of tamsulosin and solifenacin.

Paediatric Amoxicillin Doses

The latest edition of the Children’s BNF includes new higher doses for oral amoxicillin for children.  The NHSGGC e-formulary for EMIS and Vision have been amended accordingly.