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

Medicines Update Primary Care - December 2014

Holiday Addictions Services

There are more “take-home” doses for methadone, buprenorphine and other Controlled drugs (CDs) around Christmas and New Year. Prescriptions for instalment dispensing of CDs must state the dose plus the amount to be supplied per instalment and the interval between instalments. Directions for take home instalments must be unambiguous. The wording approved by the Home Office to cover supplies when pharmacies are closed is included on the stamps supplied to practices. Use of the Home Office wording allows pharmacies to make supplies to patients in advance of any pharmacy closure.

Please remind patients of the importance of safe storage of methadone, buprenorphine and other CDs and the risks of overdose when taken with alcohol and other illicit or prescribed drugs. Medicines should be kept out of reach and out of sight of children, locked away if possible. Overdose prevention training and PGD supply of naloxone for those at risk of an opiate overdose is available from participating pharmacies, Community Addiction Teams/Drug Services and Glasgow Drug Crisis Centre at 123 West Street, Glasgow.

Please ensure that your Addiction Services local contact lists are updated and procedures in place for emergency closures. The pharmacy team at the Addictions Services can be contacted on 0141 800 0660 for further help or advice.

Unscheduled Care

For information on pharmacy opening hours over the festive period please see: http://www.nhsggc.org.uk/content/default.asp?page=s1187

All pharmacies are able to provide the Unscheduled Care service if patients run out of their medication or are unable to access their repeat prescription whilst GP surgeries are closed. Pharmacists can provide up to a normal prescription cycle for most repeat medications, excluding controlled drugs and injections, via a Patient Group Direction. Practices are asked to inform patients of this service to help ease burden of patients being unable to access their medication.

If the patient is unsure what medication they are on when they access the service, pharmacists can contact NHS 24 to seek clarification from the Emergency Care Summary, providing the patient is able to give consent. Please note that this is a verification of the patient’s medication and is not a means of seeking permission to supply. Pharmacists must use their own professional judgement as to whether a supply is required.

Details of all supplies made using the unscheduled Care PGD will be communicated to the patients’ GP within 3 days (usually by fax) for practices to update their records.

Scottish Patient Safety Programme in Primary Care (SPSC-PPC) Collaborative

The Scottish Patient Safety Programme (Primary Care) has expanded its work in improving patient safety into community pharmacy (CP) and was formally launched last month. This follows from the successful work that is currently being undertaken in General Practices. NHSGGC were successful in applying for funding from the Health Foundation along with three other Boards to test the Collaborative in the CP setting and will be focusing efforts in ten pharmacies in Paisley as part of the Renfrewshire Development Programme.

Year 1 will focus on reducing high risk drug co-prescribing, particularly NSAIDs. This area has been selected as these drugs are known to be associated with increased risk of GI bleeding and kidney injury. The CP is ideally placed to identify these patients and work in close relationship with the prescriber to review clinical need and support patient education.
Year 2 will involve greater CP involvement in the medicines reconciliation process and development of joint working practices with GPs and acute pharmacy staff from the RAH.

Initial testing has begun in two of the pharmacies to check the data collection and care bundle measures for feasibility with activity beginning in all 10 sites in January 2015 and will run until June 2016.

Agomelatine

The latest MHRA Drug Safety bulletin contains information on the risk of liver toxicity in patients taking Agomelatine (Valdoxan®). 

Agomelatine is a melatonin receptor agonist and selective serotonin-receptor antagonist indicated for major depression.

Advice for clinicians:
• Test liver function before and during treatment with agomelatine (after 3, 6, 12 and 24 weeks from starting it then regularly thereafter when clinically indicated)
• If serum transaminases are over 3 times the upper limit of normal do not start or continue treatment
• Avoid in patients over 75 years as efficacy in this group has not been established
• Patients should be advised to seek immediate medical attention if they experience symptoms of liver injury (eg dark urine, jaundice, abdominal pain, bruising or pruritis)
• Report any adverse effects including liver toxicity using the yellow card scheme

The Summary of Product Characteristics (SPC) for Valdoxan® advises monitoring of LFTs at the same frequency as when initiating treatment for any dose increase.  The SPC also advises repeating LFTs within 48 hours if serum transaminases increase.

Colobreathe®

The latest MHRA Drug Safety bulletin also has information on new instructions for use for Colobreathe® capsules. 

Colobreathe® capsules contain a dry powder formulation of colistimethate for use with the Turbospin® inhaler. This is a polymyxin antibiotic active against gram-negative organisms such as Pseudomonas aeruginosa and Klebsiella pneumoniae.  It is licensed for the management of chronic pulmonary infections due to Pseudomonas aeruginosa in patients with cystic fibrosis (CF) aged 6 years and older. 
Following reports of the capsules shattering when being pierced within the inhaler device, the instructions for use have been changed.
Healthcare professionals should demonstrate the new inhaler instructions to patients:
• Insert the capsule widest end first into the inhaler chamber
• Pierce the capsule gradually using a two-step process
• Only pierce each capsule once
Supervise patients taking their first dose and advise patients and carers to refer to the patient information leaflet in the pack.

Haloperidol Supply Problem

There are currently supply problems with haloperidol 500microgram capsules.  They are expected to be available again from February although this is not guaranteed. Prescribers should consider prescribing tablets (1.5mg, 5mg, 10mg, 20mg) or oral liquid which is available as a licensed product in a 5mg/5ml strength (Dozic®). A 0.5ml dose would provide 500mcg.  The higher strength liquid available (10mg/5ml) should be reserved for when higher doses are required.

New Oral and Enteral Nutrition Formularies

There are three new oral and enteral formularies available. These are in addition to the Gluten Free Foods List and the Adult and Older Children Oral and Enteral Nutrition Formulary that were developed earlier this year.

The Infant and Paediatric Oral and Enteral Nutrition formulary covers oral nutritional supplements, enteral feeds, specialist modular products and also specialised infant formulas.

The Low Protein Foods Formulary has been developed to support the prescribing of low protein foods for patients with inherited metabolic conditions. It gives advice as to recommended unit allocations and the low protein foods are coded red, amber and green to reflect whether more or less healthy.

The Metabolic Product Formulary is to be used alongside the Low Protein Formulary and details the metabolic products for diseases such as Phenylketonuria and Maple Syrup Urine Disease.