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

Medicines Update Primary Care December 2015

Lidocaine 5% plasters (Versatis®)

Lidocaine 5% plasters (Versatis®) are licensed for the symptomatic relief of neuropathic pain associated with previous herpes zoster infection (post-herpetic neuralgia, PHN) in adults.  Included in the GGC Formulary for this indication they are restricted to patients who are intolerant of first line therapies for PHN, or where these therapies have been ineffective. Use for other indications remains non-Formulary. The quantity of lidocaine plasters being prescribed and dispensed in GGC is growing steadily each year.

Collated GP audit work within GGC has highlighted that lidocaine plasters are often prescribed for off-label indications other than PHN. Here full clinical responsibility lies with the prescriber and the GGC Unlicensed Medicines Policy also applies.

Audit activity showed that the majority (65%) of prescribing originated within acute care: at outpatient clinics or during admission.  Following discharge, Summary of Product Characteristics recommendation is that treatment outcomes should be reviewed after 2-4 weeks, and treatment discontinued if no response.
‘Benefit’ is normally considered as at least a 30% or 3 point reduction in pain score, and/or significant improvement in functional ability.  It was found that only 27% of audited patients received a review of benefit at 4 weeks, highlighting the need for robust practice systems and procedures to ensure that patients are routinely reviewed. Consequently practices have made changes to their procedures, including the addition of an alert to patients’ records; not adding lidocaine plasters to repeat; flagging up patients at discharge for review and ensuring locums are made aware of the practice’s policy on prescribing lidocaine plasters.

Treatment should be reassessed at regular intervals to decide whether the number of plasters needed to cover the painful area can be reduced, or if the plaster-free period can be extended. A trial without can also be considered to assess ongoing need and benefit. Audit identified that 42% of patients had their lidocaine plaster discontinued after GP review.
Other points to consider:
• Have first line therapies for neuropathic pain have been trialled?
• Alter other analgesia?
• Check patients’ understanding of  local effect not systemic,
•  Review patients’ expectations and support self-management of pain.

An outcome from the audit is the development of a 'Guide to Reviewing patients using Lidocaine 5% plasters' available from your prescribing support pharmacist through their teamsite.

Minor Ailment Service Formulary Update

The Minor Ailment Service (MAS) Formulary that supports the community pharmacy service has recently been updated and is available for use. A copy can be downloaded from the GGC Prescribing website to help GPs, practice nurses, DNs and health visitors triage patients into the local community pharmacy by listing the types of conditions that can be treated and the products available.
The main changes are:
• Removal of unused products based on prescribing data.
• Updating first and second line products to align with NHS GGC preferred list for GPs.
• Inclusion of Colief® with associated prescribing cautions.
• Inclusion of budesonide nasal spray.
• Guidance added to paracetamol prescribing including use in post-vaccination pyrexia. (Please read in conjunction with the recent NHS circular regarding supply of prophylactic paracetamol for Men B vaccination)
• Thrush and UTI advice updated in line with Sandyford and SAPG guidance.
• Skin section products updated, including nappy rash.
MAS is available to patients who are eligible to register for the service. Further information is available from local Prescribing teams and Community Pharmacy Development Team.

Mirabegron and Severe Hypertension

Following reports of severe hypertension including hypertensive crisis associated with cerebrovascular and cardiac events, the MHRA have announced that mirabegron is now contraindicated in patients with severe uncontrolled hypertension (systolic blood pressure ≥180 mmHg or diastolic blood pressure ≥110 mmHg, or both). It should be used with caution in patients with systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥100 mmHg.
 Regular monitoring of blood pressure is important, especially in patients with pre-existing hypertension. Please report suspected side effects of mirabegron on a Yellow Card.
 The recently published Medicines Update Extra bulletin has more information on management of urinary incontinence and overactive bladder.

Drugs for Doctors' Medical Bags

The Drug and Therapeutics Bulletin has published advice on which drugs might be suitable for GPs to carry on home visits. One article looks at adults; one at children.
Although GPs now attend fewer emergency or out of hours calls for their patients, there is still a need for some GPs to carry a range of medicines for use in acute situations when on home visits. The drugs chosen will be determined by the medical conditions likely to be met; GP familiarity with medicines; storage requirements, shelf-lives of drugs etc. A range of medicines is discussed which are suitable for GPs for emergency or acute treatment of patients.

As a practical means of ensuring that all doctors in the practice, including Locum GPs, have access to suitable emergency medication when seeing patients both within the surgery and during home visits, GP practices could maintain one or two medical bags within the practice for use by any doctor.

Some of the therapeutic areas and recommended products are listed HERE. The intention is not to imply that every doctor should carry every drug but to highlight key treatments in some common clinical scenarios. As usage is likely to be low, consider the appropriate minimum level of stock. There should be systems in place for date checking and stock replacement.

Controlled Drug Instalments

The Home Office has recently published updated sets of wording which can be used on instalment prescriptions for Controlled Drugs to allow supply in advance of closures. It is important to note that the previous agreed wording can still be used as long as the prescriber’s intentions are clear. Prescriptions with the previous wording should be dispensed as usual where legally compliant and there are no other concerns about supply.
More information on CD Instalments

Medication Compliance Aids

The Royal Pharmaceutical Society (RPS) states that “For many medicines, removing doses from original packaging and placing them in a multi-compartment compliance aid (MCA) will be outside the terms of the marketing authorisation (i.e. unlicensed use)”.
Removal from packaging, therefore, transfers responsibility for stability from the manufacturer to the prescriber and pharmacist’
Some examples of the effects of medication being placed in MCA include -
• Carbamazepine tablets have been reported to lose a third of their efficacy.
• Drug release from modified-release tablets can be affected by humidity.
• Putting alendronate in an MCA may result in it being swallowed like any other tablet, instead of at least 30 minutes before breakfast / any other medicine.
• Putting capsules and tablets in the same compartment can result in hydrolysis of susceptible drugs due to the high water content of gelatin capsule shells (soft or hard).

Black Ink on Prescriptions

There has been a request from National Services Scotland (NSS) Practitioner Services Division that all prescriptions are written / signed in black ink to ensure the scanners pick up the detail properly. It has been highlighted that red or green ink does not get picked up and blue ink can also be difficult.