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

Medicines Update Primary Care - January 2015

Gabapentin and Pregabalin - Potential for Misuse

Misuse potential of pregabalin and gabapentin has been reported in previous bulletins. Recent advice from NHS England suggests prescribers should be aware of the following key messages regarding the potential for misuse of pregabalin and gabapentin:
• Pregabalin and gabapentin have a well-defined role in the management of disabling long-term conditions, including epilepsy, neuropathic pain and generalised anxiety disorder (pregabalin).
• When used for pain the drugs do not work for everyone but a proportion of patients benefit sufficiently to notice an improvement in quality of life.
• Practitioners should prescribe pregabalin and gabapentin appropriately to minimise the risks of misuse and dependence (as listed in the Summary of Product Characteristics for both drugs), and should be able to identify and manage problems of misuse if they arise. Most patients who are prescribed these drugs will use their medicines appropriately without misuse.
• Prescribers must make a careful assessment to balance the potential benefits against the risks particularly in prescribing for patients with a known or suspected tendency to misuse, divert or become dependent on these drugs. Patients may also however, have a higher prevalence of the indicated conditions with a proportion deriving benefit from their use.
• Patients should be made aware of the likely efficacy of the drugs for management of their symptoms and also about the risk of harms, including dependence to establish their consent to the intended treatment plan.
• While no patient should normally be excluded from access to medication that may help them simply because of a current or past problem with misuse or dependence (or because of concern about propensity to such risk), that concern is a proper and relevant consideration in how and even whether to prescribe these drugs. Prescribing decisions should be discussed in full with patients and they should be made aware of the importance of their co-morbidities and context in making a safe prescribing decision.
• Less harmful, alternative drugs can often be first-line treatments for the indicated conditions for which pregabalin and gabapentin are now used, and may be tried preferentially in higher risk settings or in patients who may be more likely to be harmed by the drugs.

Full NHS England advice contains additional information including advice on dose tapering.

Gabapentin and Pregabalin - Prescribing Trends

The total numbers of gabapentin and pregabalin prescribed items has increased by 8.5% in a twelve month period in 2012-2013 compared with the same time period in 2013-2014. This equates to a 6.5% increase in gabapentin and a 12% increase in pregabalin.

Please continue to prescribe and review pregabalin and gabapentin appropriately. NHSGGC Neuropathic guidelines are currently under review and details of the updated guidelines will be communicated when available. Additional information on the management of chronic pain can be found at http://www.paindata.org./

Trend in number of patients treated with pregabalin/gabapentin in NHSGGC:


 Prescribing costs for NHSGGC:


 Medicines related to Valproate - risks of abnormal pregnancy outcome

The MHRA have recently provided information to healthcare professionals about strengthened warnings on the risks of medicines related to valproate (sodium valproate, valproic acid and valproate semisodium).  Data from a Europe-wide review shows that children exposed to valproate in utero are at higher risk of congenital malformations, serious developmental disorders, lower IQ, autistic spectrum disorder and Attention deficit/ hyperactivity disorder.
• Valproate should not be prescribed to female children, female adolescents, women of childbearing potential or pregnant women unless other treatments are ineffective or not tolerated.
• Valproate treatment must be started and supervised by a doctor experienced in managing epilepsy or bipolar disorder.
• Carefully balance the benefits of valproate treatment against the risks when prescribing valproate for the first time, at routine treatment reviews, when a female child reaches puberty and when a woman plans a pregnancy or becomes pregnant.
• Prescribers must inform female patients and ensure they understand:
- risks associated with valproate during   pregnancy;
- need to use effective contraception;
- need for regular review of treatment;
- the need to rapidly consult if she is planning a pregnancy or becomes pregnant

Synonyms Update

The prescribing synonyms for use within the EMIS prescribing system will be updated by the end of January 2015.  The key changes are the paediatric antibiotic doses in line with the BNF and amendments to the wound formulary.

We will write to practices with details of how to download the updated synonyms file.

Lithium (Priadel® 200mg Tablets): Stock shortage

Sanofi, the manufacturers of Priadel® tablets, have issued notice that there is a supply problem with Priadel® 200mg tablets. There is no indication of when this will be resolved. Priadel® 400mg Tablets and Priadel® Liquid preparations are unaffected. However as Priadel® liquid is a different salt from the tablets, direct switching is not possible and not recommended.

The NHSGGC Prescribing Management Group - Mental Health has issued this advice on how to manage patients who are currently using Priadel® 200mg tablets.