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

Medicines Update Primary Care May 2016

Trazodone: Significant Cost Increase


In recent months there have been a number of price increases affecting medicines prescribed for mental health indications.  It is projected that these price increases will cost NHSGGC an extra £600k in 2016/17 for trazodone alone. There is significant work being undertaken in primary care, especially in care homes, to review patients receiving trazodone to ensure this is the most appropriate drug and preparation.
Some of the affected agents and prices are listed in the table below.

Drug

Pack size

March 2015 SDT price

Feb 2016 SDT Price

Trazodone 50mg/5ml Liquid

120ml

£40.12

£160

Trazodone 50mg Capsules 

84

£24.37

£36.80

Trazodone 100mg Capsules 

56

£28.69

£41.99

Trazodone 150mg Tablets

28

£18.59

£35.25

Nitrazepam 2.5mg/5ml

70ml

£10.60

£114.00

 

For these medicines, searches should be run on GP systems to allow a case by case review of the patients’ situation and ongoing need for the medicine (and specifically the necessity for liquid formulations) with advice from specialist services or prescribing support pharmacists where appropriate.
Other agents affected by recent large price increases include:
• Disulfiram 200mg tablets
• Tranylcypromine 10mg tablets
• Doxepin 25mg and 50mg tablets
• Camcolit 250mg tablets
For some of the medicines, eg disulfiram, tranylcypromine and doxepin, there may be no viable alternative for individual patients.
Messages highlighting costs have also been added to ScriptSwitch to prompt review where possible.

Liothyronine


Levothyroxine is included in the NHSGGC Adult Formulary preferred list and is the NHSGGC thyroid hormone of choice. It is cost-effective, suitable for once daily dosing due to its long half-life and provides stable and physiological levels of thyroid hormones for patients requiring replacement.

Liothyronine is not routinely recommended for prescribing as it has a much shorter half-life and steady-state levels cannot be maintained with once daily dosing.

The combination of levothyroxine and liothyronine as replacement therapy has not consistently been shown to be more beneficial than levothyroxine alone with respect to cognitive function, social functioning and wellbeing. Inappropriate variation in serum T3 may cause thyrotoxic symptoms, such as palpitations and tremor.

Liothyronine is available as licensed (and unlicensed) 20microgram tablets and unlicensed 5microgram tablets. Many other liothyronine-containing preparations, eg Armour Thyroid, are also unlicensed. The safety and quality of these products cannot be assured.

An audit of 21 patients prescribed liothyronine in primary care in NHSGGC showed that on rare occasions, specialists within the Board will recommend a patient receives liothyronine.
Before prescribing liothyronine, prescribers should consider the following:
• Liothyronine is not a standard treatment. Liothyronine should only be used under the recommendation and care of an endocrinologist, where the patient has given informed consent and understands the risks of treatment
• In line with MHRA advice, licensed products with the appropriate Marketing Authorisation should be used (within the licensed indications) to treat patients in preference to unlicensed medicines, off-label use or use of unlicensed specials
• Liothyronine is an expensive medicine with a typical annual  cost of £365 , compared with £26 for levothyroxine
• Patients prescribed liothyronine post-thyroidectomy to avoid interference with  radioiodine uptake scan should be switched to levothyroxine after the scan has been completed (as per recommendations from endocrinology/oncology)
• Regular review of patients prescribed liothyronine is essential due to the risks and costs associated with treatment. Patients who do not show significant improvement should be switched to levothyroxine on the advice of an endocrinologist

Self Monitoring of Blood Glucose

Self monitoring of blood glucose is necessary for patients treated with insulin or other medication with a high risk of hypoglycaemia. The updated NHSGGC Guideline for Self Monitoring of Blood Glucose reflects updates in the recent NICE guidance for Type 1 and Type 2 diabetes and includes information relevant to the DVLA guidance on Fitness to Drive.

The NHS Greater Glasgow & Clyde Blood Glucose Meter and Test Strip Formulary was developed by the Diabetes MCN who undertook a review to compare available meters and testing strips. The Preferred List meters and test strips chosen exceed the international accuracy standard (ISO 15197 (2013)),  are simple to use and offer  substantial savings to the Health Board with packs of test strips costing less than £10 per pack. The Formulary is for use across primary and secondary care settings.

Preferred List Blood Glucose Meters and Strips
Preferred blood glucose meters for adult patients with type 1 and type 2 diabetes and not on an insulin pump are:
• GlucoRx Nexus® system meters and GlucoRx Nexus® strips
There are three device options:
o Nexus®, the standard device which is easy to read,
o Voice® provides an audible option for the visually impaired,
o Mini® a small discrete meter
• Glucomen Areo® meter and Glucomen Areo® strips
This is an easy to read and use device. It uses blue tooth technology which allows easy electronic transfer of results.
Initial sample meters will be sent to all practices. Supplies of the preferred meters and starter packs can be obtained by contacting the local representatives.

The lancet devices associated with the meters, Apollo Twist® or Omnican Soft Lance®, are compatible with the Formulary lancets.

Preferred List meters are suitable for use by the majority of patients with diabetes. It is recognised that variation in product choice may occur in specialist areas where there is a clear clinical need for a non-Formulary choice to be made.

 Implementation of Formulary preferred list in GP practices is a Prescribing Activity for 2016-17 supported by the Prescribing Teams.  The Team will agree an implementation plan with each practice with the aim of increasing Preferred List compliance. Practices should not accept non-Preferred List meters from drug companies and put existing unused non-Formulary meter packs away out of use.  Full details of meters and how to source them can be found within the Formulary guidance. This information has been shared with community pharmacists.

Galantamine: Severe Skin Reactions


Updated information regarding reports of skin reactions to Reminyl®.  Although extremely rare, there have been reports of Stevens Johnson Syndrome (SJS), acute generalised exanthematous pustulosis (AGEP) and erythema multiforme (EM).  Patients (or carers) should be advised to be vigilant for signs of serious skin reactions and to stop galantamine and seek medical help if a rash, particularly with blistering develops.  Please report using the yellow card system.