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

Medicines Update Primary Care November 2015

New Side Effect of PPI's

The MHRA Drug Safety Update published in September 2015 highlighted a link between proton pump inhibitors (PPIs) and very infrequent cases of subacute cutaneous lupus erythematosus (SCLE), a non-scarring dermatosis that can develop in sun-exposed areas1.
Although the incidence of this side effect is very low considering the extensive use of PPIs, it is estimated to be almost 3 times higher in patients on PPIs than in the general population2.  Product information is being updated to include this side effect. 
Prescribers are advised to be alert to the possibility of this side effect if a patient on a PPI develops lesions, especially in sun-exposed areas of the skin and accompanied by arthralgia.  In such cases -

  • Consider SCLE as a possible diagnosis
  • Consider stopping the PPI unless it is imperative for a serious acid related condition.  Changing to another PPI may not resolve the issue as this side effect appears to be a class effect1.
  • Advise the patient to avoid sun exposure
  • In most cases symptoms resolve on withdrawal of the PPI1 but topical or systemic corticosteroids may be necessary if symptoms do not resolve.
  • Report any suspected side effect on a yellow card.

1 Drug Safety Update volume 9 issue 2 September 2015: 1
2 Grönhagen CM and others. Subacute cutaneous lupus erythematosus and its association with drugs: a population-based matched case-control study of 234 patients in Sweden. Br J Dermatol. 2012; 167: 296–305.

Prescribing for Yourself

The professional bodies linked to medicine, dentistry, pharmacy, and nursing and midwifery have all issued standards or guidance on prescribing. They all recommend that practitioners should not prescribe for themselves or anyone with whom they have a close personal relationship. This is because it can be difficult to remain objective and so prescribers risk overlooking serious problems, tolerating unsuitable behaviour, or interfering with care or treatment provided by other healthcare professionals. See link to full article on blog HERE

Outcome of the Review of the Gluten Free Foods Service

NHS Circular: PCA (P) (2015) 24 announced that the Gluten Free Food Service (GFFS) is to continue being provided by community pharmacies that have opted to deliver the service. The GFFS will be a permanent service within the NHS Scotland community pharmacy contract arrangements from 1 October 2015. Evaluation of the service has demonstrated a high level of satisfaction with the GFFS. A range of issues and suggested improvements highlighted in the report will be taken forward by the Scottish Government in conjunction with Health Boards over the coming period. A further evaluation of the annual pharmacy coeliac health check will be carried out within the next 12 months. The full review report has been published at http://www.gov.scot/Publications/2015/09/4234  and the Scottish Government response to the recommendations contained in the report can be accessed at http://www.gov.scot/Publications/2015/09/5884.
Information for GP Practices -The majority of patients in NHS GGC have transferred to the GFFS but some eligible patients continue to receive their gluten free foods on GP10 for unknown reasons. We are asking all prescribers to ensure that only patients with a confirmed diagnosis of coeliac disease or dermatitis herpetiformis are prescribed gluten free foods and to encourage their eligible patients to register with the GFFS. To register, the patient needs their GP to complete a registration form. The patient can then take this to a community pharmacy where they can then register and start to receive their monthly allowance of gluten free foods which they will select from the NHS GGC formulary GGC Medicines : Non-medicines formularies.

Sildenafil Prescribing

Despite changes to legislation in England which relaxed the prescribing requirements and clinical conditions associated with the prescribing of sildenafil, this has not been replicated in Scotland. GPs should note that the SLS requirement remains in place as does the clinical conditions in which this drug can be prescribed within Scotland for men with ED.

Shared Care Protocols

The Prescribing Interface Subcommittee of the Area Drug & Therapeutics Committee (ADTC) co-ordinates the formal management of prescribing issues between primary care and the acute setting including the review, approval and collation of Shared Care Protocols (SCPs). The committee also manages processes to ensure that interface agreements are standardised. The overall aim is to ensure there is clarity and consistency in NHSGGC on the utilisation of medicines and treatments and the associated responsibilities of different healthcare professionals.  The development of agreed shared care protocols for suitable medicines (licensed or in some cases unlicensed/ “off label” use) is one way of achieving this aim.

The committee meets quarterly, in March, June, September and December.

Shared care protocols clearly define the roles and responsibilities of clinical staff in each care setting, and require agreement from both acute and primary care before they can be signed off as approved for use. Since most protocols will involve GPs being asked to prescribe specific medicines, then it is sensible for GPs to be involved in the development of the protocol. All medicines included in a shared care protocol that meet the criteria for a “high cost expensive medicine” and are prescribed in accordance with the shared care protocol are automatically accounted for in the “high cost/ expensive medicines list” for budget-setting purposes. No additional action is therefore required by GPs to request funding. For those medicines which are the subject of a shared care protocol but which do not meet the high cost expensive medicines criteria, transfer of prescribing costs will be considered if this is appropriate.

Current approved shared care protocols include four medicines for the treatment of Hepatitis B, and melatonin for sleep disturbance in children.  Several new SCPs are also under development.  SCPs are reviewed every two years to ensure that they are still relevant and fit for purpose.
Further information including approved SCPs, the standard template, checklist and criteria for shared care, and the submission documentation can be found on the NHS GGC prescribing pages, within the Shared Care Protocols section at http://www.ggcmedicines.org.uk/shared-care-protocols/
NHS GGC clinical staff enquires about shared care protocols should be sent to the following email address: scp@ggc.scot.nhs.uk

Healthy Start Vitamin Scheme

The Healthy Start Vitamin Scheme is changing.
The Department of Health has published guidance on population “at risk” groups who might benefit from vitamin D supplementation, including pregnant women, babies and young children.  Provision for these groups is available through the Healthy Start Scheme.  For guidance on eligibility for NHS prescription of vitamin D supplements in other groups please refer to GGC guidance and frequently asked questions on staffnet.

From 1st. October 2015 the distribution of Healthy Start Vitamins within NHS Greater Glasgow and Clyde will become part of a Community Pharmacy Local Enhanced Service (LES) as opposed to being part of the Public Health Service element of the Community Pharmacy contract.  Approximately 80 pharmacies primarily located in areas of high deprivation have been invited to participate.  GPs will not be required to provide prescriptions for these products.

The scheme will operate as follows -
The registration process and eligibility for the scheme will not change.  All pregnant women will be given four packs of tablets (eight months supply), by maternity services.  All new breastfeeding mums will be given one pack of vitamins on the ante-natal wards. If eligible for Healthy Start the woman will be guided by their midwife to register.   If ineligible, they will be encouraged to continue to purchase Healthy Start for one year after the birth of their baby.

Following the birth Healthy Start recipients need to contact the Department of Health to initiate a supply of vouchers for Healthy Start Drops.  In babies receiving less than 500mls of formula milk a day, drops should be given from 4 weeks to 4 years.  In babies taking more than 500mls of formula daily, drops should be given from 6 months to 4 years.
Enrolment in the current scheme has been very poor to date.  Participating pharmacies have been asked to encourage the scheme and/or promote appropriate use of vitamins in pregnant women, babies and children.