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

Medicines Update Primary Care March 2016

Zika Virus

There is an ongoing outbreak of Zika virus infections in South and Central America and the Caribbean, and increasing evidence that infection in pregnancy may be associated with fetal microcephaly and other central nervous system abnormalities.

Zika virus infection has also been linked with Guillain-Barre syndrome.

Symptomatic Zika virus infection is typically mild and short-lived in most individuals, but particular attention is required for travel-associated risks in women who are pregnant or who are planning a pregnancy.

Key messages;

• Mosquito bite avoidance.
• Pregnant women should consider avoiding travel to affected areas and any pregnant woman recently returned from such areas should consult medical advice.
• Insect repellant containing 50% DEET (N,N-diethyl-m-toluamide) will repel mosquitoes for approximately 12 hours.
• Repellents containing 50% DEET can be used by pregnant women, but higher concentrations should not be used.
• When both sunscreen and DEET are required, DEET should be applied after the sunscreen. Sunscreen with a 30 to 50 SPF rating should be applied to compensate for DEET-induced reduction in SPF.
• The use of DEET is not recommended for infants less than two months of age.
• Further information is available from the UK government HERE

For healthcare professionals detailed information on all travel related issues is available from TRAVAX  

Public access to guidance is available from Fit for Travel
 

Dual Antiplatelet Therapy

Clopidogrel or ticagrelor are indicated as part of a dual antiplatelet therapy (DAPT) regimen along with indefinite aspirin for management of patients presenting with acute coronary syndromes (ACS) and/or undergoing elective or emergency percutaneous coronary intervention (PCI).
The NHSGGC Guideline for Antiplatelet Therapy in Secondary Prevention of Coronary Heart Disease makes recommendations for the duration of clopidogrel or ticagrelor in accordance with clinical circumstances.
Audit of DAPT prescribing in 47 general practices in Glasgow North West (GNW) demonstrated that challenges remain to ensure appropriate prescribing and discontinuation of DAPT.
Key results:
• Golden Jubilee National Hospital initiates more of DAPT regimens than cardiology wards/ clinics. Increasingly DAPT prescribing originates from general medicine, vascular and neuro surgery
• More patients are  correctly recommended 26 weeks of DAPT following PCI with Drug Eluting Stents
• Around one half of DAPT recommendations are inconsistent with the NHSGGC Guidelines; there are various reasons for this.
• DAPT regimens continue to be added to Primary Care prescribing systems without  documentation of a discontinuation date
• Projected annual excess expenditure in the NW Locality due to DAPT therapy continued beyond the intended duration is approximately £13k
• Pharmacist intervention was required in 36% (n=331) patients to advise cessation, annotation of stop date or initiate discussion with the patient’s cardiologist and/or GP as a direct result of the audit.
As a result of this and a previous audit practices are advised to review processes for managing advice on duration of DAPT therapy and encouraged to use the  EMIS® .DAPT Synonym

The synonym allows:
• a stop date to be entered in the dosage instructions field for clopidogrel and ticagrelor.
• the stop date to be annotated in the dosage instructions where patients can read it on the medicines label and community pharmacists are alerted at the point of dispensing, so can discuss this with the patient.

• subsequent changes to the stop date to be updated in the dosage field to maintain accuracy and avoid confusion.


Omeprazole Oral Liquids


In 2015, prescribers in Greater Glasgow and Clyde prescribed omeprazole oral liquids at a cost of £157,541. This equates to approximately £5.58 per 20mg dose of oral liquid. If this had been prescribed as omeprazole MUPS at a price of 41pence per 20mg the cost to the health board would have been £10,126.
Please note that omeprazole oral liquids are unlicensed products and are not used by the Royal Hospital for Children, who recommend omeprazole MUPS.

Co-Proxamol-Cardiotoxicity


Dextropropoxyphene and paracetamol (co-proxamol) was withdrawn from the UK market and became an unlicensed product  in 2007.  However, from January to December 2015 prescribers in Greater Glasgow and Clyde prescribed 495 items for, the now unlicensed, co-proxamol at a cost of £31,848.
MHRA advises that it is estimated that the withdrawal of co-proxamol from the UK has saved around 300–400 lives each year from self-poisoning, around a fifth of which were accidental.
Further safety advice was issued by the MHRA in 2014 that (Dextro)propoxyphene can have serious effects on the electrical activity of the heart (resulting in prolongation of the P-R and Q-T intervals, and widened QRS complexes), even at normal therapeutic doses.
It is recommended by the MHRA that:
• prescribers reassess the balance of risks and benefits in each patient of continuing treatment with co-proxamol, taking into account the individual’s other medications and any comorbidities, in the light of the new evidence of cardiotoxicity.
• No new patients should start treatment with co-proxamol.

Bisphosphonates MHRA Warning


There is a well established link between osteonecrosis of the jaw and bisphosphonates.  The MHRA bulletin in December informed prescribers of a link between bisphosphonates and very rare reports of osteonecrosis of the external auditory canal.  Possible risk factors include steroid use and chemotherapy, with or without local risk factors such as infection or trauma.  Patients should be advised to report any ear pain, discharge from the ear or ear infection during bisphosphonate treatment.  Prescribers should be alert to the possibility of this side effect in patients who present with ear symptoms, including chronic ear infections, or in patients with suspected cholesteatoma.

The data do not currently support a causal relation between osteonecrosis of the external auditory canal and denosumab but this is being kept under review.  Suspected adverse drug reactions with bisphosphonates, including denosumab or any other medicines should be reported on a Yellow Card.


Levonorgestrel- Releasing IUDs

A recent MHRA warning advised that levonorgestrel-releasing intrauterine systems should always be prescribed by brand name because products have different indications, durations of use, and introducers.


Thickeners for Dysphagia

 
Nutilis Clear 3g Sachets are now available on prescription.
• Each box will contain 24 x 3g sachets.
• 1 sachet contains 3g of Nutilis Clear Powder which is equivalent to 1 x 3g scoop of  Nutilis Clear Powder. 
• Nutilis Clear 3g Sachets and Nutilis Clear 175g powder in tins, from the Nutricia Ltd product range, is the only thickener of choice for adults and older children on the GG&C Formulary.
• Children under 1 year should use Carobel, children 1 to 3 years should use Thick and Easy. Thick and Easy should only be used for older children and adults where Nutilis Clear is not tolerated.