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

Medicines Update Primary Care February 2015

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Drugs and driving - impaired ability to drive


The Department for Transport has introduced a new offence of driving with certain controlled drugs above specified limits in the blood; this is likely to come into force in England and Wales on 2 March 2015, however information from Police Scotland is that this legislation will not apply to Scotland. It remains an offence to drive while impaired by drugs.

The list of drugs includes some licensed medicines (table 1). In England and Wales, anyone found to have any of these drugs in their blood above the specified limits will be guilty of an offence, whether their driving was impaired or not. However, there is a medical defence for people taking the drugs for medical reasons in accordance with the prescriber’s or manufacturer’s directions, as long as their ability to drive was not impaired.

Table 1: Drugs included in new legislation

Routinely Prescribed Medicines

Others

Morphine

Cannabis

Diamorphine

Cocaine

Clonazepam

Ketamine

Diazepam

Amphetamine

Lorazepam

Flunitrazepam

Oxazepam

 

Temazepam

 


Consider the effect on ability to drive when reviewing prescribed medicines for patients who drive.  Patients’ ability to drive can be affected by drowsiness and/or cognitive impairment caused by medicines listed above and other medicines such as antidepressants, antipsychotics, antiepileptics, antihistamines, etc.  Other side effects such as blurred vision, dizziness or nausea may also impair ability to drive and patients should be suitably counselled.  Where appropriate, consider reducing such medicines to minimum effective doses or reduce and stop if appropriate. Warnings on the risks of driving impairment are already in the patient information leaflet. Advise patients to continue taking their medicines as prescribed but not to drive if they feel their ability has been impaired by prescribed, OTC or other drugs or by any illness / medical condition.   The DVLA medical standards on fitness to drive are at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/390134/aagv1.pdf.

Vaccination Programmes for patients in care homes

After 31st March 2015, patients in nursing homes will access influenza, pneumococcal and shingles vaccines through their registered GP following closure of the Nursing Home Medical Practice. For the influenza vaccine season 2015-2016, GP practices should order now from community pharmacy to ensure continuity of supply.

Yellow Card Scheme extended

The MHRA have simplified their medicine and device incident report schemes by bringing them all under the Yellow Card Scheme. Any of the following can now be reported under the Yellow Card Scheme:
• suspected adverse drug reactions
• medical device incidents
• defective medicines
• suspected fake medicines

ACWY Vax®

ACWY Vax® meningococcal vaccine has been discontinued by the manufacturer. Alternatives are Menveo® and Nimenrix® injections, which are interchangeable.

New Diabetes Guidelines


New guidance on the diagnosis and management of diabetes mellitus has been produced by NHS GGC’s Managed Clinical Network for Diabetes.


Nitrofurantoin Dosing and Preparation


Nitrofurantoin is available in a number of preparations.  If you require to prescribe this, the most cost-effective preparation for acute treatment in primary care is currently nitrofurantoin 100mg modified release capsules.  This should be prescribed in line with the NHSGGC Primary Care Infection Management Guidance.  Note that other less expensive options are still available where appropriate (e.g. trimethoprim), but nitrofurantoin indications and durations are as follows:

Lower UTI non-pregnant females - nitrofurantoin 100mg MR BD 3 days (6 capsules)
Lower UTI in adult men - nitrofurantoin 100mg MR BD 7 days (14 capsules)
Catheter associated UTI - nitrofurantoin 100mg MR BD 7 days (14 capsules)
Lower UTI in pregnancy - nitrofurantoin 100mg MR BD 7 days (14 capsules)

Messages are deployed on ScriptSwitch to promote this choice for acute treatment, and it is included within the Synonym functionality on EMIS under '.UTI'.  The negative saving displayed on ScriptSwitch should be disregarded as current savings are in the region of £7 per 7 day course.  For treatment it is important to ensure that the modified release preparation is not confused with the 100mg standard release tablets which are not usually recommended. 

Where UTI antibiotic prophylaxis is required nitrofurantoin 50mg capsules once at night, is the preparation of choice. Nitrofurantoin liquid 25mg/5ml should be reserved for cases where there is no suitable alternative as current costs are £195.83 for 300ml.

Ivabradine Safety Update


Ivabradine (Procoralan®) is licensed to treat both chronic stable angina and chronic heart failure. In Dec 2014 the MHRA issued new safety advice in relation to its use for chronic stable angina, after further analysis of the SIGNIFY clinical trial. When using ivabradine to treat the symptoms of chronic angina:
• only start ivabradine if resting heart rate ≥70 bpm;
• do not prescribe ivabradine with other medicines that cause bradycardia, such as verapamil, diltiazem, or strong CYP3A4 inhibitors;
• monitor patients regularly for atrial fibrillation. If atrial fibrillation occurs, carefully reconsider whether the benefits of continuing ivabradine treatment outweigh the risks;
• consider stopping if there is no or only limited improvement or angina after 3 months.
 
In June 2014, the MHRA issued advice regarding the dosing of ivabradine in relation to the management of chronic stable angina, based on results from the SIGNIFY clinical trial.

The Scottish Medicines Consortium does not recommend the use of ivabradine for chronic stable angina in combination with beta-blockers in patients for whom an optimal beta-blocker dose is not enough [link] [link]

This guidance may not necessarily apply when ivabradine is used in the treatment of chronic heart failure. For further information on the use of ivabradine in heart failure, please refer to local heart failure guidelines.

Patient changing GP practice: deducting patients on a CMS prescription


All GP practices are reminded that if a patient leaves their practice register and has any outstanding serial prescriptions running for the Chronic Medication Service (CMS), then there is a process to follow to inactivate these scripts to prevent further dispensing by the patient’s registered pharmacy.

Details can be found for each GP clinical system within the CMS General Practice Guide. It is the responsibility of the practice to inactivate these scripts as part of their deduction process when a patient leaves the practice.

Once the patient registers with another practice, then a decision can be made as to whether to supply a serial prescription if appropriate by the new practice.

Community pharmacists are not informed if a patient moves practice and will not be aware that the scripts have to be stopped if the correct process is not followed.