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

Medicines Update Primary Care November 2017

Zomorph® Preferred Brand Oral Morphine in Adults

MST® was the most frequently prescribed brand of morphine sulphate modified release (M/R) across NHSGGC. From 01/09/2017 the preferred choice of solid morphine sulphate M/R across primary and secondary care changed to Zomorph® capsules. GGC Formulary click here

As Zomorph® is not licensed for use in children this change applies to adults only. It is not proposed to change patients prescribed MST® sachets to Zomorph® capsules at present.
Patients on MST Continus® tablets and Morphgesic® tablets can be safely switched to Zomorph® capsules at the same dose and frequency as the brands are considered therapeutically equivalent. No loss in pain control is expected.

Zomorph® capsules are available in the same range of strengths as MST Continus® and Morphgesic® tablets with the exception of 5mg and 15mg strengths. If these strengths are required MST® tablets can continue to be prescribed.

NHSGGC recommends that, unless there are clinical or patient reasons suggesting otherwise, Zomorph® capsules should be prescribed by all clinicians in all care settings including hospices.

Palliative care and chronic pain teams are aware of this change.

Those involved in prescribing, dispensing, and recording stocks of controlled drugs are asked to remember the following points:
• Modified-release preparations of controlled drugs should be prescribed by brand name.
• It is a legal requirement to specify the formulation of the product on any prescription for a controlled drug i.e. the word “capsule” must be clearly stated on Zomorph® prescriptions.

Primary Care Implementation
• Community pharmacists have been notified of a likely reduction in prescribing of MST® and to monitor demand and adjust stock levels of products accordingly.
• Prescribers in primary care have been made aware of this recommendation via a ScriptSwitch message.

Mefenamic Acid: Non Formulary

Mefenamic acid is now non-formulary.
Prescribers should review ongoing use and consider whether other NSAIDs may be more appropriate.  Ibuprofen and naproxen are the Preferred List first line options.

Following consultation with specialists and review of the available evidence for mefenamic acid in gynaecological conditions, no evidence was found for any preferred NSAID so prescribers should follow the normal GGC Oral NSAID Guideline for pain.

Given the substantial cost difference between mefenamic acid and preferred list choices, an appeal to remove it from the formulary has been successful.
A previous blog Oral NSAIDs - What's new? discussed the place in therapy of NSAIDs and also provided an update to new evidence.


Freestyle Libre: What is it?

The Freestyle Libre is a flash glucose monitoring system which measures interstitial fluid glucose levels. A sensor, with a microfilament sited in the skin is placed on the back of the arm and the reader when passed over the sensor displays interstitial glucose levels. It is offered by the manufacturer as an alternative to regular finger pricking blood glucose testing. The sensor needs to be scanned every 8 hours to give a continuous record of glucose levels over time. A sensor must be replaced every 14 days.  Current retail price for a sensor is £57.95.

Is it available on the NHS?
Specific advice has been received from the Scottish Diabetes Group which details those individuals who may be suitable for this technology. The advice emphasises that this product should only be initiated by secondary care diabetes specialist teams. The position of Freestyle Libre has yet to be established on the NHSGGC Formulary. Until that is agreed, it is strongly recommended that GPs do not prescribe.

Does this mean patients don’t need to monitor blood glucose?
No. Finger pricking blood glucose tests will still be required as interstitial fluid glucose readings are not as accurate as blood glucose.
Blood glucose monitoring is still required to confirm hypoglycaemia and at times of rapidly changing blood glucose or unexpected sensor results. Importantly; the DVLA has defined blood glucose self-monitoring requirements for patients treated with insulin who drive.

Patient Requests
Freestyle Libre is not clinically appropriate for all patients. Patient advocacy groups are promoting the expectation of availability on the Drug Tariff however Diabetes teams and GPs should not prescribe this product until its position on NHS GGC formulary is established.
A number of patients purchase sensors with the readers supplied free from the manufacturer as part of trials with this technology. These patients may not be clinically suitable for use of this product and should not automatically have the sensors provided by the NHS.

Homeopathic Prescribing Reminder

We have had an increase in the number of queries to the central team about prescribing homeopathic medicines. Advice given to GP's from the Glasgow Local Medical Committee (LMC) /GP Subcommittee when the homeopathic pharmacy at the Glasgow Homeopathic Hospital closed was:
We believe that GPs have no obligation to prescribe such remedies especially where either the GP does not believe they are therapeutic or where the GP has not been trained in their use.
Therefore, prescribers should consider carefully any prescribing of these medicines.

Healthy Start Vitamin Reminder

Recently a number of GP 10 prescriptions have been issued for Healthy Start Vitamins. Prescribers are reminded that these are not available in GGC on prescription but are funded separately by the Government via a voucher scheme to exchange at pharmacies for those who meet specific criteria (recipients must be receiving certain benefits).

Gabapentin (Neurontin®) MHRA Warning: Rare Risk Respiratory Depression

Risk of CNS depression has been identified with gabapentin, including severe respiratory depression, even without concomitant opioid use.
Prescribers should consider whether dose adjustments might be necessary in patients at risk of respiratory depression, including older adults and patients with compromised respiratory function, neurological disease, renal impairment, or taking other CNS depressants.

Drug Shortages (Staffnet)

For information on known drug shortages click here. Please contact your local prescribing support team if further information is required.