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

Medicines Update Primary Care August 2017

Steroid Foam Enemas

Steroid foam enemas have a very limited place in therapy for acute flare ups of ulcerative colitis (UC) and Crohn’s disease (CD) in primary care.  They should not be added to repeat prescriptions as repeated use without monitoring is not recommended. If a steroid enema is required, cost should be one of the factors taken into account when selecting a product for an individual patient.

• In ulcerative colitis (UC), rectal administration of corticosteroids is only advocated in patients with proctosigmoiditis who have failed therapy with aminosalicylate (5-ASA) enemas as first line treatment.
• There is no robust evidence for using topical 5-ASAs or steroid enemas for Crohn’s disease (CD). Opinion is divided on the value of topical 5-ASAs as adjunctive therapy in left sided colonic CD, particularly proctitis, but generally best practice would be to treat systemically with disease modifying drugs in CD.
• Foams are generally better tolerated by patients than enemas.
• There are no head to head studies between prednisolone and hydrocortisone rectal foams.  One study suggests comparable safety and efficacy of hydrocortisone and budesonide rectal foam.

Product Cost Comments
Colifoam® - Hydrocortisone 10% foam aerosol enema £9.33 - 14 dose container  with 1 applicator The applicator has to be loaded before inserting into the rectum by pumping the foam into it in 3-4 steps, waiting for the foam to expand within the applicator between steps.  The single applicator requires washing after use.
Lowest acquisition cost foam enema.  May be less acceptable to some patients due to issues of hygiene and convenience than others.
Budenofalk® - Budesonide foam enema £57.00 - 14 dose container with 14 applicators Poorly absorbed corticosteroid with limited bioavailability and extensive first pass metabolism - therapeutic benefit with reduced systemic toxicity.
Significantly higher acquisition cost than hydrocortisone foam.
Prednisolone rectal foam 20mg/application (previously known as Predfoam®) £187.00 - 14 dose container with 14 applicators Very high acquisition cost and no clinical advantage over other products.

 Hydrocortisone acetate 10% rectal foam Colifoam®has the lowest acquisition cost and is the steroid foam enema of choice in NHSGGC.  Budenofalk® is an alternative for patients who are unable to tolerate hydrocortisone or find it difficult to use.  Prednisolone foam enemas should not be used in NHSGGC.


Online Medical / Pharmacy Services and the Direct Supply of Medicines

We have been made aware of some patients who have received medicines for pain such as dihydrocodeine or codeine from the internet after online consultations. In one case, the company had asked the GP practice to supply a prescription although the website stated that the cost of online consultation was £99 and included 200 codeine phosphate tablets.  As the patient had not attended the practice since joining and was not prescribed any medicines for pain the practice declined to supply the prescription. Another practice became aware that a patient had received at least three prescriptions for dihydrocodeine from this service and was also being prescribed dihydrocodeine by the GP. In this case the practice asked the provider not to supply any further medication to the patient.
Practices are advised not to issue prescriptions in response to such requests. If there are concerns around the professional practice of the dispensing pharmacy or the prescribing doctor, these should be referred to the appropriate regulator. The doctors and pharmacists involved must be appropriately registered, although the online service itself may be a gateway service not directly providing healthcare and as such would not need to be registered with any health regulator. Advice on controlled drugs related concerns can be obtained from the CD Governance Team (0141 232 1774 or cdgovernance@ggc.scot.nhs.uk).

Unallocated Prescriptions

Information Services Division (ISD) has reported a significant number of prescriptions that have been unallocated because of incorrect or missing cipher codes. This may happen when a GP leaves the practice and the code becomes invalid. Practices should ensure that they change the user in the EMIS User Manager to a type which does not require a cipher code e.g. 'Other'. This will prevent repeat prescriptions being issued with the retiring GP’s name on them. If there are still patients registered with the doctor, log a call to the IT Mentoring team to carry out a bulk transfer.


Wound Product Formulary

The updated Wound Product Formulary (April 2017) is now available which provides lists of wound products approved for use in acute and primary care and incorporates products that were formerly included in a separate Basic Wound Dressing and Accessories Formulary.
The main changes to the Primary Care Wound Formulary are:
• removal of Tegaderm and Tegaderm with pad
• removal of borderless soft polymer and foam dressings (ActivHeal Foam Non-adhesive, Allevyn Gentle, Kliniderm Foam Silicone, Tegaderm Foam Adhesive)
• new products – Allevyn Life and ActivHeal Silicone Foam Borderless

Other updates to the wound formulary include:
• prescribing guidance (including reminders that basic wound dressings should be considered for non complex wounds or for use as secondary dressings and that wound dressings containing an antimicrobial should only be used on the small number of patients who need them)
• Drug Tariff prices to aid selection of cost-effective dressings in primary care
• PECOS codes for dressings available in acute care
• a table to aid selection of dressings in primary care for patients who are discharged from hospital with a wound product that is included only on the Acute Wound Formulary
A guide to using foam and silicone dressings is included on the GGC Prescribing website here.
For further information please contact the non medical prescribing team via Mandy.Logan@ggc.scot.nhs.uk or Tissue Viability via Joanna.Horner@ggc.scot.nhs.uk.