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

Postscript Primary Care - August 2012

High dose dexamethasone added to repeat in error

Request for vigilance as we are now aware that short course high dose dexamethasone with reduction regimens have on occasion been added in error onto the repeat prescription systems in surgeries.  This has occurred when a request for low dose maintenance was made by the palliative care team.

HPV vaccine 2012-13

The national immunisation programme for human papilloma virus (HPV) to protect against cervical cancer continues to be very successful.  Provisional uptake figures for the schools-based element of the third year of the programme indicate that, by August 2011, uptake of the first dose in S2 reached 92% with 90% achieved for the second dose and 81% for the third dose.  It is routinely provided to girls aged 12-13 years in the second year of secondary school but any girls who are under 18 remain eligible regardless of school year. 

Recently the Scottish Government announced the change in contract from Cervarix® to Gardasil® from 1st September 2012 view HERE. Gardasil® protects against the two strains of HPV that cause over 70 per cent of cases of cervical cancer in the UK, and also provides protection against a further two strains of HPV that cause around 90 per cent of genital warts.

Girls who have previously received one or two doses of Cervarix® should complete their course of vaccination using Cervarix® where possible.  The aim is to complete any Cervarix® courses by April 2013 which is when current Cervarix® stock expires.  The PDC can supply Cervarix® on a named patient basis to complete immunisation if required (tel 0141 347 8981). It is important that girls receive the full 3-dose schedule to ensure maximum protection.

The primary purpose of the national immunisation programme is protection against cervical cancer. GPs are reminded that it is, therefore, not appropriate to offer Gardasil® as part of the NHS programme, to those who have had a full course of Cervarix®.

 Full details on the vaccine schedule and dosage will shortly be available in the Green Book chapter available HERE.

Dementia therapy in primary care

At present the first 3 months of cognitive enhancer therapy is supplied through Mental Health hospital pharmacies, before prescribing is transferred to GPs.

A decision was made on governance and patient safety grounds that prescribing would be initiated in primary care.  Initiation would be on the recommendation of a mental health consultant with appropriate monitoring of effectiveness by the initiating consultant.

Prescribing Management Group for Mental Health developed in consultation with GPs and LMC a protocol ‘Cognitive Enhancers and Memantine in Dementia’.  Budget will also follow prescribing from secondary to primary care.

Primary care responsibilities are;

  • Prescribe in collaboration with specialist according to the protocol
  • Prescribe and supply first 3 months trial of recommended cognitive enhancer
  • Provide ongoing supply following trial period if assessed effective and appropriate

From 1st September 2012 it is expected that psychiatrists will letter patients’ GP to recommend initiation of treatment and the review process to assess treatment effectiveness.

It is not expected that any other aspect of care including diagnosis and clinical monitoring by mental health services will be affected by this change.

Managed repeat/express repeat prescription schemes

GP practices and community pharmacies have recently received a letter from Scottish Government in relation to the above services offered by some community pharmacies.

The letter raises some concerns that the implementation of Chronic Medication Service prescriptions will likely solve.

Practice staff should be reassured that the implementation of serial prescriptions will create additional information flows into their clinical system which allows for closer monitoring of dispensing events by both GP practice and community pharmacies.

NHSGGC is currently undergoing a roll out of CMS serial prescriptions and practices will be contacted in due course.

Shingles vaccine

Public Health Protection Unit (PHPU) have received queries from GP practices regarding the prescription of Zostavax®, a live attenuated vaccine indicated for prevention of herpes zoster (“zoster” or shingles) and herpes zoster-related post-herpetic neuralgia (PHN) in individuals 50 years of age or older. Until recently supplies of the vaccine were limited and only available on private prescription. Key points

a. The Joint Committee on Vaccination and Immunisation (JCVI) has recommended the introduction of a shingles vaccination programme for those aged 70-79 years, conditional on a cost effective purchase price for the vaccine. Current cost is £99.96 per vaccine.

A nationally funded NHS programme is anticipated to commence in 2013.

b. The Green Book and BNF are not yet updated to include Zostavax®. The Summary of Product Characteristics states however,

  • The vaccine is not indicated for treatment of shingles or PHN.
  • Contraindications include primary and acquired immunodeficiency states and immunosuppressive therapy, active tuberculosis and pregnancy.
  • Post marketing experience with varicella vaccines suggests a theoretical risk of transmission of the attenuated virus from a vaccine to a susceptible contact. Although this has not been demonstrated in clinical trials with Zostavax®

Orlistat supply problem

There is no supply currently of orlistat. Neither 60mg (Alli®) nor 120mg orlistat (Xenical®) are presently available. Glasgow and Clyde Weight Management Service are replacing their pharmacotherapy programme with an alternative programme until a secure supply of orlistat is available. An update is expected from the main supplier of orlistat (Roche) at the end of August.

Warticon® supply problem

Sandyford Clinic has become aware that podophyllotoxin 0.15% cream (Warticon®) which is used to treat external genital and perianal warts is currently unavailable and supply problems may extend to March 2013.

Dr Andrew Winter has advised that GPs should prescribe as an alternative product, podophyllotoxin 0.5% (Condyline®) solution (£11.50).   Imiquimod (Aldara®) cream (£48.39) is restricted to specialist initiation only within the GGC Formulary.

Simvastatin interactions – MHRA safety update

NHS GGC is developing guidance for practices which will be available from Friday 31st August in Postscript 71.