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

Medicines Update Primary Care September 2017

Oral Nutritional Supplements (ONS) Project

In NHSGG&C over the last 5 years there has been a continued growth in the volume and total spend of prescribed ONS.   At this time of high financial pressure, as ONS are within the top 10 products for prescribing budget spends and the age of the population continues to increase, it is imperative that resources are used efficiently.  There are known inefficiencies and variation in current prescribing, dispensing and monitoring of ONS used in GGC.  As a result various work streams are currently underway to encourage efficient and appropriate ONS prescribing including a Primary Care Prescribing Indicator for ONS.  Additionally earlier this year a prescribing project dietitian was recruited to lead a ‘Test of Change for New Ways of Working’.  This project aims to deliver:
• improved governance,
• more targeted, clinical and cost-effective prescribing for ONS,
• improved safety through patient centred nutritional care pathways,
• a reduction in variation and waste.
A Test of Change Sub Group is established which has representation from GPs, community pharmacy and dietetics to identify how to achieve these aims.   
The project takes a similar approach to the already successful model adopted for gluten free food dispensing via the Gluten Free Food Scheme (GFFS) which;
• reduces demand on GPs,
• supports timely and cost effective access to care for patients,
• promotes direct working relations between dietitians and community pharmacists.

An approved Dietetic ONS Prescribing Protocol will allow dietitians to initiate standard ONS products without the need for a GP or non medical prescriber to issue a prescription. Standard ONS products include; Ensure® Shake, Ensure® Plus Milkshake Style and Ensure® Compact. Current plans will see this model rolled out for testing towards the end of 2017 / beginning of 2018 to patients using a participating community pharmacy in West Dunbartonshire and Renfrewshire Health and Social Care Partnerships. 
GP / Prescriber Involvement. It should be noted that there will be circumstances in which GPs or non medical prescribers will still be required to complete prescriptions for ONS products.  Patients will also continue to present to GP, nursing and other healthcare colleagues with nutritional concerns and problems.  This project will work in conjunction with existing NHSGG&C nutritional pathways and policies, including the Community MUST Pathway, and will encourage appropriate use of ONS for such patients. 
Community Pharmacy. In addition to prescribing and dispensing ONS products as requested by the dietitian, this model will also allow dietitians the option of transferring long term monitoring of ONS to community pharmacy with clear instructions and targets for review.  Regular checks will give patients the opportunity to discuss any concerns, check progression toward set nutritional treatment goals and allow reduction and discontinuation of the ONS product as specified in the patients care plan.  Patients may also be signposted to other health professionals as appropriate. 
Training plans for Community Pharmacy and Dietetic staff are under development and engagement with GPs and nursing staff is underway.  Further, more formal communication regarding the finer details of the project will be disseminated to staff involved in the project over the coming months. 

Regaine® or Minoxidil

We have been made aware by PSD that a number of prescriptions have been issued recently for Regaine®.
Prescribers are reminded that Regaine® or Minoxidil is a blacklisted item and can only be prescribed on a private prescription form or alternatively the patient can purchase it over the counter in the community pharmacy.

MHRA Updated Advice: Adrenaline Auto-injectors

As a result of a European review the MHRA have issued updated advice for healthcare professionals;

• it is recommended that 2 adrenaline auto-injectors are prescribed, which patients should carry at all times

• ensure that people with allergies and their carers have been trained to use the particular auto-injector that they have been prescribed—technique varies between injectors

• encourage people with allergies and their carers to obtain and practise using a trainer device (available for free from the manufacturers’ websites)
Also MHRA have produced an advice sheet for patients and carers.

MHRA Warning: Brimonidine Gel (Mirvaso®)

Brimonidine (Mirvaso®) is a topical gel indicated for the symptomatic treatment of facial erythema of rosacea in adults. It is an α-2 adrenergic agonist. A recent MHRA warning highlighted the information below for prescribers;

• cases of bradycardia, hypotension (including orthostatic hypotension), and dizziness after application of brimonidine gel have been reported, some of which required hospitalisation.
• some cases were associated with application of brimonidine gel after laser procedures to the skin, which possibly caused increased absorption of the gel.
• warn patients not to apply brimonidine gel to irritated or damaged skin, including after laser therapy to the skin.

MHRA Reclassifies Maloff Protect®

The MHRA has announced the approval of an antimalarial tablet which will be available through pharmacies without prescription. Maloff Protect® tablets contain two anti-malarial agents, atovaquone and proguanil.
Following a discussion with the pharmacist they will be made available to adults aged over 18, weighing more than 40kg, travelling to areas affected by malaria and where the malaria parasite is not resistant to the Maloff Protect® ingredients.
Pharmacists will be able to advise if Maloff Protect® is suitable to protect from malaria depending on which countries are being visited, pre-existing medical conditions, and any other medicines being taken.
Travax website advises;
• The maximum duration of travel for which Maloff Protect® can be supplied without prescription is 12 weeks (93 tablets). For longer durations of travel, advice should be sought from a doctor or other qualified prescriber.
• For individuals who fall out with these criteria, for example children and long stay (>3 months) travellers, Atovaquone/Proguanil still requires to be prescribed by a qualified prescriber before it can be dispensed.


Drug Shortages

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