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

Medicines Update Primary Care - October 2014

Antiepileptic Drugs

The MHRA issued advice in November 2013 which advised on the appropriateness of generic prescribing of AEDs and when it is advisable to maintain a patient on a particular brand or manufacturer in order to reduce adverse side effects or loss of seizure control. Advice has recently been provided to GPs and community pharmacists within NHSGGC on how to implement this advice safely and effectively.

GPs are asked to identify epilepsy patients on category 1 antiepileptic drugs (AEDs) and add to the dosage instructions the words ‘Maintain on same manufacturer’s product’. 

Epilepsy patients on category 2 drugs should be considered individually and based on clinical judgement and patient preference the same process may be applied as for category 1 drugs.

A patient information leaflet will be available soon on the website under ‘Patient Information’ and the GP guidance contains a link to an electronic search tool for EMIS.

Epistatus®

In the July bulletin, we provided prescribing advice on buccal midazolam which included the recommendation to avoid changing formulation. Epistatus® 10mg/ml is available both as the 5ml vial and a range of pre-filled syringes in four different doses of midazolam (2.5mg, 5mg, 7.5mg and 10mg).  Prescribers should ensure that patients and their carers understand how to use the particular medicine they are prescribed and pharmacists should ensure that the patient receives the correct product for which they are trained to use.  Epistatus® products are currently unlicensed in the UK.

Zerodouble® Gel

Zerodouble® Gel was added to the NHSGGC Formulary in August 2014. Zerodouble® Gel is a lower acquisition cost alternative to Doublebase®. This has been added to ScriptSwitch® as a prompt to switch.

MHRA Nitrofurantoin Advice

The MHRA have recently changed the contraindication relating to the use of nitrofurantoin in renal impairment.  Nitrofurantoin is now contraindicated in patients with eGFR less than 45ml/min (previously 60ml/min). And a short course of 3-7 days may be used with caution to treat patients with an eGFR of 30-44 ml/min for treatment of lower UTI with multidrug resistant pathogens when benefits outweigh risk of side effects.

Eye Lid Products

We have received a few queries about the prescribing of products for eye lid hygiene on the NHS.  Blephasol®, Blephaclean® and Blephagel® which are classed as devices rather than medicines, have recently been added to Part 7U of the drug tariff.  These products are not licensed and thus would be subject to ‘Pay and Report’.  Prescribing of these products within NHSGGC is not supported. Patients may purchase these products over the counter.  Optometrists within NHSGGC are being advised of this also to discourage referral to GP for prescription.

For a NHSGGC patient information leaflet on blepharitis and lid hygiene click here.

Adrenaline Pen Advice

The MHRA produced advice in May this year regarding the use of adrenaline in the management of anaphylaxis risk.  Key points:
• People with allergies and their carers should be trained to use the particular auto-injector they have been prescribed as technique varies between products
• Encourage patients and carers to obtain and practice using a trainer device (available from manufacturers’ websites)
• Patients should carry two auto-injectors at all times
• Patients should be advised to check the expiry dates and order replacements before this date occurs.
In June 2013, we provided advice on the preferred brand of auto-injector (Jext®).

Change to yellow card reporting

The MHRA have recently advised that their guidelines for reporting suspected adverse drug reactions (ADRs) in children and adolescents under 18 years has changed.  Rather than reporting all ADRs for these patients, they should be reported the same as for adult patients:
• Report all suspected ADRs that are serious or result in harm.  Serious reactions are those that are fatal, life-threatening, disabling or incapacitating, those that cause a congenital abnormality or result in hospitalisation, and those that are considered medically significant for any other reason.
• Report all suspected ADRs associated with new drugs and vaccines and those under additional monitoring (identified by the black triangle symbol ▼ beside the medicine name in the BNF, Summary of Product Characteristics (SPC) and patient information leaflets)

Praziquantel

Praziquantel is an expensive unlicensed medicine used to treat schistosoma worm infections.  Patients requiring such treatment should be referred to the Brownlee travel clinic for assessment, treatment and follow up.

Antibiotic Awareness Day 2014

November the 18th is European Antibiotic Awareness Day.  This highlights the global increasing problem of antimicrobial resistance both to patients and health professionals.  The Department of Health published the 5-year Antimicrobial Resistance Strategy last year which aims to slow down the development and spread of antimicrobial resistance by improving knowledge and understanding of resistance, conserving effectiveness of existing antibiotics and stimulating the development of new drugs and diagnostics.  The Scottish Government published the Scottish Management of Antimicrobial Resistance Action Plan 2014-18 (ScotMARAP2) in July and this informs the work plan of the Scottish Antimicrobial Prescribing Group (SAPG) for the next four years. The Antibiotic Guardian campaign has been developed by Public Health England for the UK.  The Scottish Government has funded the printing and distribution of campaign materials such as posters for general practices, dentists, hospitals and community pharmacies.  These documents will be available from the SAPG website soon.  The GP posters incorporate elements of the Antibiotic Guardian Pledge:

Prescribe according to guidelines.
Leave self limiting infections to resolve.
Educate others.
Don’t respond to inappropriate requests.
Get a culture if appropriate.
Effective prescribing reduces risk - for patients - for your community.

Prescribers are reminded of the RCGP patient information leaflet which includes usual self-limiting infection durations.  A similar self-care leaflet has also been developed for community pharmacists.

In May 2013 a quality indicator on total antibiotic use in primary care was introduced by the Scottish Government. This indicator aimed to provide an additional stimulus to reduce unnecessary prescribing which will consequently reduce the selection of antimicrobial resistance and other forms of ecological damage associated with antibiotic use. The indicator is that antibiotic use, expressed in items/1000patients/day in at least 50% of practices in each NHS board will be at or below the 25th percentile of Scottish practices or will have made the minimum acceptable reduction toward that level (using January-March 2013 as the baseline).

In January to March 2014, 29% of NHSGGC practices met the target and 30% met the target by achieving an acceptable reduction.