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

Medicines Update Primary Care September 2015

New Epilepsy Guideline

May 2015 saw the launch of SIGN 143, the updated version of SIGN 70: Diagnosis and management of epilepsy in adults (2003), to reflect the most recent evidence.
In Scotland there are 54,000 people with active epilepsy, with 2,000 to 3,500 new diagnoses each year. Evidence suggests that 70% of people with epilepsy could be seizure free but only 52% are. For most, epilepsy carries a small risk of mortality however this increases in significance where seizure control is incomplete. Better provision of information and advice for people with epilepsy has been highlighted.
Key recommendations relating to treatment:
• Routine switching between different manufacturers of antiepileptic drugs (AED's) should be avoided. Previous advice at http://www.ggcprescribing.org.uk/blog/anti-epileptic-drug-prescribing/
• Failure to respond to appropriate AEDs should prompt a review of the diagnosis and adherence to medication.
•  Referral for assessment for neurosurgical treatment should be considered if the epilepsy is drug resistant.
• Management of Prolonged Seizures
Patients with prolonged tonic-clonic seizures that have lasted five minutes or more should be given midazolam 10 mg buccally or nasally.
• Epilepsy and Women’s Health
To minimise the risk of contraceptive failure, a woman using any combined hormonal contraception, or a combined oral contraceptive pill, or a progesterone–only pill should be prescribed an AED that does not induce hepatic enzymes.
Women with epilepsy should:
o Receive pregnancy counselling at the time of diagnosis and at regular intervals during their management, especially if they are taking AED treatment
o Have their diagnosis and treatment, if appropriate, reviewed by specialist services before conception; a concerted effort should be made to optimise seizure control and rationalise AED therapy prior to conception.
• Mortality
o The aim should be for complete seizure freedom to reduce the risk of sudden unexpected death in epilepsy (SUDEP) and counselling about the risks given by an appropriate healthcare professional.
o Adherence to the prescribed AED regime should be strongly encouraged and the patient asked to report any adverse effects that might compromise adherence in order to reduce the risk of increased mortality and morbidity.
o Patients who have sustained seizures, and in particular generalised tonic-clinic seizures, in the past year, should be assessed by a specialist physician and epilepsy nurse specialist.
o A structured management system for patients with epilepsy should be established in primary care. As with other chronic diseases, an annual review is desirable.
The full clinical guideline SIGN 143 and a Quick Reference Guide are available at www.sign.ac.uk.
Grant Wright
Epilepsy Specialist Nurse
Epilepsy Scotland

Depression in Children and Young People: NICE guidance update

As per previous depression guidance NICE recommend a stepped care model with watchful waiting, psychological therapies or guided self-help for mild depression, and specific psychological therapy with or without an antidepressant for moderate to severe depression. 

The preferred antidepressant is fluoxetine, however specialists may advise alternative SSRIs, such as sertraline or citalopram, in certain circumstances i.e. where drug treatment is indicated but the patient is intolerant of fluoxetine.  NICE also advise, ‘following multidisciplinary review, offer fluoxetine if moderate to severe depression in a young person (12–18 years) is unresponsive to a specific psychological therapy after 4 to 6 sessions.’  Whereas for a child (5-11 years) with similar circumstances NICE advises, ‘cautiously consider fluoxetine’, although ‘the evidence for fluoxetine's effectiveness in this age group is not established.’

Where antidepressants are indicated, the child/young person and their parent(s)/carer(s) should be fully involved in discussion about the: rationale, time to effect, duration of treatment, possible side effects and need to take the medicine as prescribed, and provided with written information appropriate to their needs.  It is also important to inform and obtain consent if the prescribed antidepressant is not licensed for that age group. Specific arrangements must be made for careful monitoring for efficacy and adverse drug effects, e.g. weekly contacts with the child/young person and their parent(s)/carer(s), but the precise frequency needs to be decided on an individual basis. 

Links and useful information
• NICE CG28: Depression in children and young people 2005 (Updated 2015)
• UKMI NICE Bites Number 76: Depression in children and young people.  June 2015

Bydureon ® Device Change

The BYDUREON® 2mg (Exenatide prolonged release) vial & syringe delivery device is being withdrawn and will change to a pre-filled pen device. Bydureon® is a glucagon-like peptide-1 (GLP-1) receptor agonist prepared as a once weekly subcutaneous injection indicated for treatment of type 2 diabetes mellitus.

Currently the Bydureon® 2mg (vial) powder and solvent for prolonged –release suspension is still available and Astra Zeneca the manufacturer have advised that supplies of the old device will still be available in the UK until November - December 2015.

The new BYDUREON® (Exenatide prolonged release) 2mg powder and solvent in PREFILLED PENS has been introduced gradually since earlier this year. This new pen permits reconstitution of the powder more easily and is easier for patients with manual dexterity problems to use safely. 

A User Manual providing step by step guidance on how to use the new pre-filled pen is available.

Information on the different devices along with a patient information leaflet (PIL) can be found HERE
All new patients being initiated on BYDUREON® (Exenatide 2 mg prolonged release) will now be commenced on the new PREFILLED PEN DEVICE.

Existing patients using the vial and syringe will need additional training in advance of switching to the prefilled pen before supplies of the vial are discontinued at the end of 2015. This should be provided wherever possible by the team currently managing that patient's diabetes care, which will usually be the GP and the community Diabetic Specialist Nurse (DSN).
The DSN network across primary and secondary care will make arrangements to facilitate patient education and the switch of Bydureon® to the new prefilled pen device.  Patients affected by this change should be encouraged to contact their usual DSN for advice in the first instance, and GP surgeries looking for advice should contact their link cDSN. Secondary care teams who are managing patients affected by this change will also make arrangements to facilitate smooth transition.

A few patients have received the wrong preparation.

Community Pharmacists
To reduce the risk that patients receive the wrong preparation:
Community pharmacists are advised to be vigilant:
• To ensure the correct device is dispensed.
• To confirm what is on the prescription is what the patient is expecting i.e. the vial or the new prefilled pen device.
• To confirm with all patients expecting the new prefilled pen device they know or HAVE ARRANGED TO BE SHOWN by a healthcare professional how to use the new prefilled pen device.
GP practices
To reduce the risk that patients receive the wrong preparation:
GP practices are asked to be vigilant when selecting the BYDUREON® prefilled pen device on EMIS or VISION to ensure the correct descriptor is selected.
Descriptions are very similar and the wrong one may be chosen in error. The descriptors for the prefilled pen device are in bold below.
Bydureon® powder and solvent for suspension for injection 2mg vial
Bydureon® powder and solvent for suspension for injection 2mg device
 Exenatide powder and solvent for suspension for injection 2mg vial
Exenatide powder and solvent for suspension for injection 2mg pen

Bydureon® 2mg powder and solvent for suspension for injection vials (AstraZeneca UK Ltd)
Bydureon® 2mg powder and solvent for suspension for injection pre-filled pen (AstraZeneca UK Ltd)
Exenatide 2mg powder and solvent for suspension for injection vials
Exenatide 2mg powder and solvent for suspension for injection pre-filled disposable devices

Gluten Free Foods Formulary Update

The NHS Greater Glasgow & Clyde formulary for gluten free foods has been updated and can be accessed at http://www.ggcprescribing.org.uk – in the other formularies section in the non medicine formularies sub section.
The new formulary reflects the products most commonly requested by patients in the last year and also includes some new products which have been launched in recent months. Sweet biscuits have been removed to bring GGC in line with other Health Boards in Scotland.  The new formulary should be used for all patients receiving gluten free foods whether this is on prescription from their GP or through the Community Pharmacy Service. For patients using the community pharmacy gluten free foods service a new shortened version of the formulary has been developed which  used as an order form will simplify ordering for patients. For any queries on the new formulary please contact the prescribing support dietetic team on 0141 201 5214.

Synonyms Update (EMIS)

The latest synonyms update covers a number of therapeutic areas and contains some additions to the file. The main changes are outlined below:
.DAPT - Dual Antiplatelet Therapy
•        New synonyms added under .DAPT to cover aspirin, clopidogrel and ticagrelor. The dosage instructions field for clopidogrel and ticagrelor require the prescriber to enter a stop date when this synonym is used. By doing so, it is expected that DAPT is less likely to be continued beyond the intended course. As the stop date is annotated in the dosage instructions, patients are able to read it on the medicines label and community pharmacists are alerted at the point of dispensing, so can discuss this with the patient. Any subsequent changes to the stop date (e.g. due to the patient undergoing further percutaneous coronary intervention) should be updated in the dosage field to maintain accuracy and avoid confusion.

Other changes include:
•       Synonyms covering BNF Chapter 2 (Cardiovascular):   .AF, .ANGINA, .BP, .IHD,  .LIPID and .HEART FAILURE have been updated.
•        NOACs (apixaban and dabigatran) are now included in the .ANTICOAGULANT synonym
•        .EYE has been updated in line with the dry eye guideline update
All changes to synonyms are highlighted on the synonyms update summary which is available on StaffNet. For suggestions or comments on these or any other synonyms, please email Prescribing@ggc.scot.nhs.uk

TheiCal-D3 ®

TheiCal-D3® chewable tablets (contain 1,000 mg of calcium and 22 micrograms of colecalciferol per tablet) have recently been added to the NHSGGC Formulary preferred list. The higher content of calcium and vitamin D per tablet compared to other brands confers the advantage of once-daily dosing. The tablets can also be halved if needed.

TheiCal-D3® are licensed for the prevention and treatment of Vitamin D and calcium deficiency in the elderly and as an adjunct to specific osteoporosis treatments of patients at risk of vitamin D and calcium deficiency.

ScriptSwitch® messages will be active from the end of October to alert prescribers of the formulary choices, giving the opportunity to switch patients’ calcium and vitamin D supplements when initiating a new acute or repeat prescription, or re-authorising a repeat.