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

PostScript Primary Care - Jan 2014

Gluten-free food scheme

From the start of 2014, prescribing of gluten free (GF) foods will move from prescribing by GPs to a new community pharmacy service. This is a pilot until March 2015. This new service is optional and only available to patients with a confirmed diagnosis of Coeliac Disease/Dermatitis Herpetiformis (CD/DH). These patients can choose for their prescribing of GF foods to remain with GP prescribing, continuing unchanged. The service is available to all patients except care home residents. If patients do not have a confirmed diagnosis of CD/DH the prescribing of their GF Foods must remain with their GP.

Each patient will have a registration form partially completed by their GP. This form will stipulate the maximum number of units of GF foods the patient can order per month. The patient will take the form to their chosen pharmacy where they will register for the duration of the pilot (unless they move home). The community pharmacist will explain the service and provide a NHSGGC Formulary list of the foods they are able to order. The patient will complete an order form each month for GF foods required. The patient can change products requested each month but must stay within their allocated maximum units. Patients can only order more than the maximum units if they have been assessed by a dietitian and the dietitian has requested extra units for them.

As per the Coeliac UK Prescribing Guidelines, sweet biscuits will only be provided through this scheme in exceptional situations. Patients who have been ordering sweet biscuits will be allowed two units of sweet biscuits per month for the duration of the pilot.

Community pharmacists will carry out an annual health check on adult patients (≥16 years) registered to them for the GF Food Service to assess the patient’s understanding and adherence to a GF diet. The community pharmacist will signpost the patient to sources of advice eg Coeliac UK and if required will refer the patient back to the GP for onward referral to dietetics, DEXA scanning etc.

Community pharmacist training is being organised nationally by NES and started in December via Webinar presentation. A further local training event is planned for 29th January.


A National patient Information Leaflet and other online information sources will be available from the end of January.

'Just in Case' Synonyms

The main aim of the synonyms on EMIS is to promote safe and cost-effective prescribing with guidance available to prescribers at the point of prescribing. The entries are based on the NHSGGC Formulary and clinical guidelines. The synonyms are accessed by entering the synonym name (which always starts with a dot/full stop, eg .JUST) in the Name field of the Add Drugs window and pressing enter. 

Primary Care teams will now be considering which patients may benefit from having subcutaneous medications prescribed, dispensed, written up and available in the home before they are actually needed eg subcutaneous morphine/diamorphine, midazolam, hyoscine butylbromide and levomepromazine. There are 9 Palliative Care ‘Just in case’ synonyms available which begin with:

.JUST IN CASE
Click here for more information on the ‘Just in case’ initiative. Useful websites:

www.palliativecareggc.org.uk
www.palliativecareguidelines.scot.nhs.uk

Accrete D3®

Accrete D3® film coated tablets are a calcium and vitamin D supplement licensed for the prevention and treatment of vitamin D and calcium deficiency in the elderly and a supplement as an adjunct to specific osteoporosis treatments of patients at risk of vitamin D and calcium deficiency. Each tablet contains 600mg of calcium and 10micrograms of colecalciferol. It has recently been added to the NHSGGC Formulary preferred list.
 
Accrete® contains the same dose of calcium and vitamin D as Adcal D3® chewable tablets but offers the advantage of being able to be swallowed without chewing or being halved and swallowed.  Accrete® is currently the most cost-effective calcium and vitamin D product available on the Formulary preferred list.

Hypertension Guideline Revision

The NHSGGC Hypertension guideline has been updated and is available here.
The key changes to this version are:
• Recommendation to use calcium channel blocker therapy first line for patients aged ≥ 55 years and of African or Caribbean origin patients of any age.  Diuretic therapy with a thiazide has been moved to step 3.
• Recommendation to use ambulatory or home blood pressure readings
• Addition of target for over 80 years of 150/90mmHg (clinic)


Treatment of Dental abcess

The National Prescribing Guidelines for dentistry ‘Drug Prescribing for Dentistry’ has been updated.  Where antibiotic treatment of a dental abscess is required, the recommended dose of amoxicillin has increased to 500mg, three times daily for five days.

Nalmefene

The ADTC has added nalmefene film coated tablets (Selincro®) to the NHSGGC Adult Formulary following SMC acceptance for use in Scotland. Nalmefene is an opioid receptor modulator with antagonistic activity at the mu and delta receptors and partial agonist activity at the kappa receptor. It is licensed for the reduction of alcohol consumption in adult patients with alcohol dependence who have a high drinking risk level (DRL), without physical withdrawal symptoms and who do not require immediate detoxification. The licence dictates that nalmefene should only be prescribed in conjunction with continuous psychosocial support focused on treatment adherence and reducing alcohol consumption; and should only be initiated in patients who continue to have a high DRL two weeks after initial assessment.


As this medicine is a new concept in alcohol care and treatment, ie a harm reduction rather than an abstinence approach it does not clearly fit within current specialist services.  It has been added to the NHSGGC Formulary and is available for prescribers to consider in suitable patients where the full package of care including continuous psychosocial support can be provided by appropriate NHS personnel.  Prescribers should consider whether a strategy of detoxification and abstinence may be more appropriate than the reduction approach offered by this medicine alongside a programme of psychosocial support. http://publications.nice.org.uk/esnm29-alcohol-dependence-nalmefene-esnm29

Nuelin® Supply Issue

It has been reported that there are currently supply problems with Nuelin SA® tablets which may continue for some time. Patients should be changed to the nearest equivalent dose of Slo-Phyllin® or Uniphyllin Continus® if necessary. The rate of absorption of theophylline can vary between formulations and therefore patients being switched should be monitored closely for symptoms. If the patient’s theophylline concentration is at the upper end of the target range to begin with, close monitoring of levels may be required.

Ensure® Plus Milkshake name change

Abbott® has changed the name on its 220ml bottles of supplements from 'Ensure® Plus Milkshake Style' to 'Ensure® Plus'. The name 'Ensure® Plus Milkshake Style' is still included in the drug dictionaries for both EMIS and Vision so any prescription issued will be for 'Ensure® Plus Milkshake Style' but dispensed as 'Ensure® Plus'. They are the same product. Abbott have not confirmed whether they will be updating ‘Ensure® Plus Milkshake Style’ to ‘Ensure® Plus’ in the Dictionary of Medicines and Devices (DM&D).