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

Medicines Update Primary Care December 2016

Propranolol for Anxiety

Propranolol has been used in treatment of anxiety for many years. Recent significant critical incidents have identified it amongst other drugs used when a person suicides. Propranolol may be considered by some as an innocuous drug; however all drugs have adverse effects and it is important that it is prescribed appropriately. This article summarises the licensed indications, cautions and side effects with regards to the use of propranolol to treat anxiety.
Indications and dosage:
Situational and generalised anxiety:
It is most useful for patients exhibiting somatic symptoms particularly tachycardia, sweating and tremor.
• Acute situational anxiety a dose of 40mg daily may provide short term relief.
• Generalised anxiety, requiring longer term therapy, usually responds adequately to 40mg twice daily which, in individual cases, may be increased to 40mg three times daily.
• Anxiety tachycardia a dose of 10mg to 40mg three to four times a day.
Treatment should be continued according to response. Patients should be reviewed after six to twelve months' treatment.
Side effects, cautions and contra-indications:
Common side effects from propranolol include fatigue, cold extremities, stomach upset, sleep disturbances (including nightmares), dizziness, wheeziness and bradycardia.
Propranolol should be used cautiously in people with severe hepatic or renal impairment, AV block, diabetes, thyroid disorders, Raynaud’s disease or intermittent claudication.
The use of propranolol is contra-indicated in people with asthma, COPD, hypersensitivity to propranolol hydrochloride or to any of the excipients, cardiac decompensation which is not adequately treated, sick sinus syndrome/SA-block,  metabolic acidosis, second and third-degree heart block, prolonged fasting (eg hypoglycaemia), cardiogenic shock, untreated phaeochromocytoma, severe bradycardia, severe hypotension, severe peripheral arterial disturbances and Prinzmetal's angina.
Propranolol is not a benign drug. If used to treat anxiety the lowest effective dose for the shortest period possible should be prescribed. Treatment should be reviewed at least 6 monthly.

Controlled Drug Instalments

Prescribers are reminded to follow instalment advice for prescribing controlled drugs over the holiday period. 
Prescriptions for controlled drugs in;
Schedule 2 (e.g. diamorphine, morphine, pethidine) or
Schedule 3 (e.g. buprenorphine, temazepam, midazolam, tramadol or
Schedule 4 (Part 1) (eg, diazepam, nitrazepam, zaleplon, zolpidem and zopiclone;

• should not exceed more than 30 days of supply, unless otherwise justified.
• are valid for 28 days after the appropriate date. The appropriate date is the date on the prescription or some other indicated start date.
• The issuing of prescriptions should be adjusted for bank holidays using the Home Office Approved Wording  by clearly stating “Please dispense instalments due on pharmacy closed days on a prior suitable day”. 

Buprenorphine Patches

The prescribing of transdermal buprenorphine patches is increasing as are the number of manufacturers and range of doses and duration of action. There are a number of potential errors that can occur at various points in the prescribing, dispensing and administration of transdermal buprenorphine patches. Further information can be found here
Medication errors with buprenorphine patches can be minimised by -
• Being aware of the wide range of buprenorphine patches, as well as other opiates that are presented in this formulation, and the range of strengths and frequency of replacement.
• Ensuring that the doses are individualised and suitable for patients who are either
o Opiate naïve or
o Being transferred from another opiate.
• Specifying the dose rate and the frequency of patch replacement on the prescription and dispensing labelling.
• Properly advising the patient about the need to remove existing patches before replacing them at the appropriate frequency.  Patients may find it useful to keep a record of when old patches are removed and new patches applied.
• Applying any additional dispensing labelling so as not to obscure useful patient information on the packaging


Etoricoxib: MHRA update

Prescribing information has been updated to introduce a lower recommended dose of etoricoxib 60 mg daily for patients with rheumatoid arthritis or ankylosing spondylitis. Advice for healthcare professionals can be found here

Brimonidine Gel: MHRA update

Brimonidine gel is indicated for the treatment of facial erythema of rosacea in adults.  The MHRA bulletin in November this year advised that 16% of patients who were receiving brimonidine gel had symptom exacerbation.  To reduce the risk, prescribing advice has been updated as follows:–
• Start treatment with a small amount of gel (less than the maximum dose) for at least 1 week and increase the dose gradually, based on tolerability and response to treatment.
• Advice should be given on how to apply the gel and build up the dose gradually.
• Do not exceed the maximum daily dose (1 g of gel in total weight, approximately 5 pea-sized amounts).
•  Stop treatment and see GP if worsening of rosacea symptoms occurs.

Fluoxetine 10mg Licensed Product

A new licensed Fluoxetine 10mg capsule is now available from wholesalers. If a 10mg dose is required health board advice would be to use the 20mg capsule on alternate days. This is possible because fluoxetine has a long half life.
There is a significant cost difference between the two strengths. Fluoxetine 20mg capsules cost 50 pence per month whereas 10mg capsules cost £55 to £66 per month. Consequently, NHS Greater Glasgow & Clyde does not recommend the use of this product.


Vaccination Programme- Residential Care Services - 2016 to 2017

An NHSGGC resource supporting local implementation of this updated care inspectorate document can be viewed here.