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

Medicines Update Primary Care September 2016

 Melatonin Shared Care Protocol

The Shared Care Protocol for melatonin for use in children with sleep disturbance has been reviewed, with new products added and a change to how it will be prescribed in the community. The products listed are Bio-melatonin 3mg tablets, Circadin 2mg SR tablets and melatonin 1mg/ml liquid (available as a ‘special’).  The solid dose formulations are the preferred option and are suitable for the majority of patients. More details of the licensing status of these medicines can be found in the shared care protocol.

These products allow a variety of doses to be prescribed and can be used in combination to achieve the total daily dose. It is not uncommon to find immediate and sustained release formulations co-prescribed as the combination addresses issues with sleep onset and sleep latency. The Bio-melatonin tablets can also be crushed and sprinkled on foodstuff where required.

Secondary care specialists, e.g. consultant psychiatrists and community paediatricians will initiate melatonin therapy using HBP prescription pads (“blue pads”) until the patient is stabilised on a maintenance dose (usual range 3-9mg daily). After this, with agreement, the GP will prescribe. Each Child and Adolescent Mental Health Services (CAMHS) or child health community base will have access to HBPs for melatonin prescribing. These should not be used for regular out-patient prescribing.  Usage of the pads will be monitored and reviewed on a regular basis.
Supply of BioMelatonin and the 1mg/ml liquid in the hospital setting requires an unlicensed medicine (ULM) form to be completed including a consultant signature.
This new arrangement for melatonin prescribing in the community is expected to start in October 2016, however existing prescribing arrangements will continue until the new arrangements for HBP pads are fully in place. Use of melatonin in adults remains non-Formulary.

Please note that after discussion with the Local Medical Committee, shared care protocols are now to be called shared care agreements and the terminology will be updated as each reaches its review date. All information on the shared care agreements can be found on our website.

Flu Vaccines: Supply

The new supply arrangements for influenza vaccine for the forthcoming 2016/17 season commencing in October 2016 are outlined in the recent CMO letters for Adults and Children.

Practices should have already placed their initial order for vaccines and will receive a confirmation email from Movianto in early September. Any subsequent orders should be ordered as required according to the schedule provided by Movianto. 
Key Points:
• Saturday deliveries cannot be accommodated. 
• Adhere to the order ‘cut off’ times provided to practices.
• Practices should place their order at least a day before their ‘cut off’ order window in order to review the accuracy of the confirmation e- mail.
• Track and trace ordering is available via the on line ordering platform. 
• Request the minimum number of orders bearing in mind fridge capacity to accommodate any single order as each order incurs a delivery cost of £25.
• If required a second delivery in any given week can be arranged in advance.
• GP practices should not arrange mass clinics unless their flu vaccine is already in stock or they are assured of delivery.
• Any queries regarding delivery of influenza vaccine should be directed to Movianto Customer Services Tel. 01234 248 623 between 8am and 6pm.
• In exceptional circumstances Movianto can provide delivery within 24hours but due to the additional cost incurred (£100) prior Board authorisation is required from Public Health Tel  0141 201 4917.

Public Health Protection Unit (PHPU) plan to issue a ‘Special edition’ newsletter covering all key points. Further information and FAQs are available from the Practitioner Services Division PSD website 
Arrangements for childhood flu vaccines remain the same as last year and these should be ordered from the pharmacy distribution centre (PDC). Practices initially requesting more than 50% of their expected cohort should discuss their requirements with the PDC. 

Dietary Intolerances or Allergies

People with dietary intolerances or allergies may request a medicine that is free of particular excipients. However, this may not always be necessary. DRUG and Therapeutics Bulletin BMJ Pub
Key Points:
• Patients with lactose intolerance should be reassured that it is highly unlikely that severe gastrointestinal symptoms can be attributed to lactose in a conventional oral solid-dosage form.
• For patients with coeliac disease, it should be noted that the majority of prescribed medicines in the UK are gluten free.
• Although refined pharmaceutical grade peanut (arachis) oil should not contain allergenic peanut proteins, pharmaceutical products containing arachis oil are still contraindicated in people with peanut allergy due to concerns that very small amounts of peanut protein may remain.
• As there is a possible relationship between peanut allergy and soya allergy, patients allergic to soya should also avoid medicinal products containing peanut (arachis) oil.
• Of the three vaccines that are cultured on derivatives of chicken's eggs,

o The MMR vaccine is safe to use in children with egg allergy.
o Individuals with a confirmed anaphylactic reaction to egg should not receive yellow fever vaccine.
o Inactivated influenza vaccines that are egg-free are no longer manufactured but those that have very low ovalbumin content are available and studies show they may be used safely in individuals with egg allergy, except for those with severe anaphylaxis to egg that has previously required intensive care.

As excipients in medicines that contain the same active drug may vary depending on the manufacturer, formulation and strength, a suitable alternative can usually be sourced.

National Therapeutic Indicators 2017-18

The National Therapeutic Indicators and Additional Prescribing Measures for 2017-18 are currently under development. A national reference group of health board representatives will meet three times (virtually via Webex) between now and December.  If you have an interest in the development of prescribing indicators/measures for GP practices and want to be involved by joining the reference group please contact sean.macbride-stewart@ggc.scot.nhs.uk