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

PostScript Primary Care - April 2014

Valsartan Shortage

There are currently supply problems with valsartan products.  Where a patient is unable to obtain their normal valsartan prescription, prescribers may need to consider switching patients to an alternative Angiotensin-2 receptor antagonist (A2RA).

Valsartan is licensed for:
 
Hypertension – all eight A2RAs on the UK market are licensed for hypertension. 
Heart Failure - candesartan and losartan are licensed for heart failure and are the preferred list options in the NHSGGC Formulary.
Post-MI with left ventricular failure or left ventricular systolic dysfunction (LVSD) – there are no other A2RAs licensed for use in the post-MI setting and specialist advice should be sought before switching to an alternative.

There is no information on direct dose-equivalences of A2RAs, the table below provides approximate conversions for the Formulary preferred list options. When changing from one drug to another, consideration should be given to where on the dosing range the current dose falls, ie bottom, middle or top of range.  If switching from a twice daily valsartan dose to a once daily dose of an alternative such as losartan or candesartan, the patient should be advised of this to reduce the risk of a dosing error.

A2RA

Approximate Dose conversions (monitor BP following switch and adjust as needed)

Valsartan

40mg DAILY*

80mg DAILY*

160mg DAILY*

320mg DAILY*

Candesartan

4mg DAILY

8mg DAILY

16mg DAILY

16-32mg DAILY

Losartan**

25mg DAILY

50mg DAILY

100mg DAILY

 

* Dose may be given as two divided doses.
** The target dose of losartan for heart failure is 150mg daily if tolerated.

Acknowledgement: Yuet Wan, London and South East Regional Medicines Information Service

Drug Safety Advice

The MHRA’s March Drug Safety Update provides information on the theoretical interaction between orlistat (Xenical® and alli®) and antiretroviral HIV medicines.  Orlistat may theoretically reduce the absorption of antiretroviral HIV medicines due to retention of lipophilic medicines in the gastrointestinal tract or reduced gastrointestinal transit time.  Orlistat should thus only be initiated after consideration of the possible impact on efficacy of antiretroviral therapy.

The update also provides information on suspected interactions between St John’s Wort and implanted contraceptives (Nexplanon® and Implanon®).  Prescribers and pharmacists are reminded of the interaction between St John’s Wort and all hormonal contraceptives (except intrauterine devices for which there is currently no data).  Patients should be advised not to take herbal St John’s Wort products if taking/using hormonal contraception.

Patient Medication and Problem Linkage

Following feedback from practices participating in the Polypharmacy LES, prescribers are encouraged to ensure that patient problems are properly coded and the problems linked to the relevant medication. The linkage function displays the patient’s problems alongside their current medication and can be accessed from either the Medical Record or Prescribing screens.
Linking medicines and problems is good practice that will support the medication review process by highlighting diagnoses and treatments together on the one screen, without the need to search consultations or Docman®.

If medication is not linked to any problems, or to an incorrect problem, it is easily amended in EMIS PCS using the Problem Medication Linker. The EMIS Medication and Problem Linkage training handout is available within EMIS (Go to Help then EMIS online client zone then in the search box type ‘Problem Linkage’.

Controlled Drugs Accountable Officer (CDAO)

Professor Norman Lannigan has taken up position as CDAO for NHS Greater Glasgow and Clyde following the retirement of Dr Kate McKean. Please continue to report any incidents or concerns relating to CD use to cdgovernance@ggc.scot.nhs.uk.  For any CD related queries, contact the Controlled Drugs Governance Team on 0141 201 5348.

Indicators for 2014/15

The following indicators have been agreed by the Prescribing Management Group for Primary Care for consideration by general practices for action for GMS indicators: MM001 and MM002.  They are largely based on the National Therapeutic Indicators developed by the Scottish Government and complimented by two local indicators – Lipid Regulating Drugs and Lidocaine plasters.

Prescribing Indicators for 2014-15

GASTROINTESTINAL

1 

Proton Pump Inhibitors 

DDDs per 1,000 weighted patients per day 

CARDIOVASCULAR

2

Lipid Regulating Drugs

Non-preferred list Lipid Regulating Drugs  as a percentage of all lipid-regulating drugs (BNF 2.12) (items)

RESPIRATORY

3

Corticosteroid Inhalers (High Strength)

High Strength Corticosteroid Inhalers (excluding Fostair®) as a percentage of all corticosteroid inhalers (items)

CNS (PSYCHOTROPICS)

4

Hypnotics and Anxiolytics

DDDs per 1,000 weighted patients per day

CNS (PAIN)

5a

Opioid analgesics (Strong)

Strong opioids DDDs per 1,000 weighted patients per day

5b

Opioid analgesics (Step 2)

Step 2 Opioids other than strong opioids DDDs per 1,000 weighted patients per day

6

Lidocaine

Lidocaine plasters cost per 1,000 weighted patients per day

ANTIBIOTICS

7a

Antibiotics (Total)

Total antibiotic script items per 1,000 patients per day

7b

Antibiotics (4C)

4C antibiotics script items per 1,000 patients per 100 days

8

Antimicrobial Wound Products

Antimicrobial wound products as percentage of total wound products (items)

DIABETES

9

Antidiabetic Drugs (Metformin)

Metformin as percentage of all anti-diabetic drugs (DDDs)

MUSCULOSKELETAL, ANTI-INFLAMMATORIES & OSTEOPOROSIS

10a

NSAIDs including Cox-2 inhibitors (Total)

DDDs per 1,000 weighted patients per day

10b

NSAIDs including Cox-2 inhibitors (Preferred)

Ibuprofen and naproxen as a percentage of all NSAIDs (DDDs)