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

PostScript Primary Care - July 2014

Varenicline (Champix®) PGD

The community pharmacy Smokefree smoking cessation support service is part of the Public Health Service element of the community pharmacy contract. It aims to provide extended access to smoking cessation support, including the provision of patient centred behavioural support and evidence-based pharmacotherapy. In addition to NRT, accredited pharmacists can now supply varenicline under a national Patient Group Direction (PGD) as part of this service to suitable patients who have previously tried to stop smoking using NRT.

When a patient starts a quit attempt using varenicline as part of this service, the pharmacy will inform the patient’s GP by a standard letter following the first consultation.  GPs should add this to their prescribing system as a drug prescribed/supplied outwith the practice, see PostScript 78 for more details. Instructions for EMIS and Vision can be found in the Prescribing Resources section of the NHSGGC Prescribing website. For further details about the service and inclusion/exclusion criteria within the PGD please see the NHS circular.

Subcutaneous methotrexate

Metoject® is the preferred brand of parenteral methotrexate in GGC. For use in rheumatology, patients are started on parenteral methotrexate in secondary care and trained in self administration by Rheumatology Nurses at hospital clinics, but ongoing prescribing and blood monitoring is undertaken in primary care. The manufacturer has advised that from 1st July, the pre-filled syringe product will be replaced by Metoject® PEN, a single use pre-filled auto-injector device for self administration. Affected patients have been informed of the upcoming change by the Prescribing Support Team, and have been issued with a copy of the manufacturer’s patient leaflet and a letter from the Rheumatology MCN Clinical Lead with contact details of Rheumatology Nurses if they require more training or support. Community pharmacists should receive a printed instruction booklet for the patient with every order for Metoject® PEN device and have been asked to counsel the patient on its use and record it on the patient’s Chronic Medication Service, High Risk Medicine, Pharmacy Care Record.

Unfortunately the new PEN device description has not been included in the EMIS dictionary at the time of the change over. The new device will be prescribable on EMIS in NHSGGC on Release E which will be downloaded to Phase 1 sites on 8th August, and rolled out to all practices in NHSGGC over six weeks in four phases. For Vision, the description is included in July’s Gemscript. Prescriptions for the new device may require to be handwritten until the description is available on IT prescribing systems.
Further information is available from the manufacturer’s website.

Clostridium difficile and PPIs

Proton pump inhibitors (PPIs) have been identified as a risk factor for C. difficile infection(CDI) but evidence has been historically conflicting.  Four meta-analyses recently published provide further evidence that use of PPIs can increase the risk of C. difficile infection and its recurrence.  The Scottish Antimicrobial Prescribing Group has consulted with Scottish experts in gastroenterology and confirmed that there is a willingness to work together with primary care colleagues to reduce inappropriate PPI use which may reduce C. difficile infection and provide other clinical benefits.

A number of studies from the UK and the US suggest that 60-86% of PPIs may be used inappropriately. The recently published C. difficile infection guidelines from Health Protection Scotland, suggest that consideration should be given to stopping/reviewing the need for PPIs in patients with or at high risk of CDI (includes current or recent antibiotic treatment, increasing age, immunosuppression, prolonged hospital stay, serious underlying diseases, surgical procedures).  Prescribers are reminded of the NHSGGC guidance on PPI durations following discharge from hospital.

Rates of C. difficile infection have reduced significantly in the hospital setting but there have been recent reports of increasing community associated disease in patients without common risk factors such as age or recent antibiotics. This suggests there are other risk factors which are not well understood, and PPIs have been suggested.

PPIs have also been associated with an increased risk of spine, lower arm and total fractures and pneumonia, both community and hospital acquired.  Thus improved use of PPIs could have a number of benefits.

One of the Scottish Government National Therapeutic indicators relates to the volume of PPIs prescribed and encourages a reduction in their use.  Clinicians should regularly review patients prescribed these medicines to ensure that continued prescribing only occurs when clinically necessary and at the lowest possible dose.

Gabapentin - abuse potential

Gabapentin is believed to be one of the drugs most widely abused in the prison population but little is known about the potential for abuse among patients with drug and alcohol problems and in the wider chronic pain population as a whole. Abuse has been described in concurrent users of methadone and dependence also seems to have been reported in patients without any previous history of substance abuse.

There is currently limited knowledge of the extent of the problem and the population likely to abuse the drug is not well characterised. However, prescribers should be aware of the potential for abuse and ensure that gabapentin is only prescribed where it is clearly indicated. They should also be alert to signs of gabapentin misuse such as early requests for repeat prescriptions.  As with other drugs with potential for misuse, prescribers should closely monitor individual usage and may wish to consult the relevant clinical guidelines for alternative prescribing options if misuse is identified.

Buccal midazolam

Buccal midazolam is used as a rescue medication for status epilepticus and is often supported by a product specific administration protocol for care staff who must ensure that the protocol matches the prescribed midazolam.

Recent reports have highlighted issues around buccal midazolam prescribing and administration where patients have received incorrect formulations or doses. Different buccal midazolam preparations and strengths are available but are not interchangeable.

Epistatus® (10mg/ml) was the first (unlicensed) preparation available but Buccolam® (5mg/ml) is currently the only licensed product available (for patients up to 18 years of age). Normal guidance would be to prescribe a licensed product in preference to an unlicensed one. In this instance, it is not recommended changing a patient once they are established on one preparation due to the risk of patient harm.

Sucralfate (Antepsin®) shortage

There is currently a long-term supply problem with both sucralfate suspension and tablets.  It is anticipated that there will be no supplies available until the end of this year.  Clinicians should review the need for this preparation on a case by case basis and switch to a licensed formulary alternative where appropriate. Where the recommendation to prescribe this has come from a specialist, GPs may wish to seek their advice for ongoing treatment.

Visitors from overseas - Guidance for General Practice

The XX Commonwealth Games will take place in Glasgow from 23rd July - 3rd August and will be the largest multi-sport event ever held in Scotland.  Visitors to Glasgow may seek medical care from general practice and guidance has been produced to assist practices with queries that may arise such as entitlement to NHS treatment.

Community pharmacies can provide emergency supplies of medication to patients from within the EEA and Switzerland at the patient or prescriber’s request.  Patients from outwith this area may be referred to a local surgery or out of hours service.

Gameplan is a useful document by NES for community pharmacy preparedness for the Games, however there are useful sources of information such as foreign tablet identification references which may be useful within general practice also.

RIP PostScript - Rebranding

From next month, the PostScript family of bulletins will be re-branded as ‘Medicines Update’ with the website and new smartphone app being titled GGC Medicines.