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

PostScript Primary Care - June 2013 Summer & Travel

This edition contains articles on

  • Jext® adrenaline auto-injector
  • Travel vaccines
  • Hay fever and allergies
  • Sunscreens and ACBS
  • Malaria prophylaxis
  • Extended travel abroad
  • Useful resources

Jext® adrenaline auto-injector 

Jext® is the preferred brand of adrenaline injection for self-administration in the NHSGGC Formulary (SMC advice can be accessed click here). Jext® has an expiry date of 24 months compared to Epipen® with 18 months, is as easy to use and has no restrictions on storage.

It should be noted that different devices differ in the practicalities of administration, and if a patient's device is changed for any reason then training needs to be provided to ensure that the dispensed device is used correctly by all who are likely to be required to administer it.

Travel vaccines

Travel vaccines which may be prescribed on the NHS under the General Medical Service Contract are:

  • Hepatitis A - first and second dose
  • Combined hepatitis A and B - all doses
  • Typhoid - first and any subsequent doses
  • Combined hepatitis A and typhoid - first dose (second dose monovalent hepatitis A)
  • Tetanus, diphtheria and polio - given as combined vaccine
  • Cholera

All other travel vaccines and malaria prophylaxis should be prescribed via a private prescription. NHS travel vaccines are supplied and administered on an individual basis and therefore should be prescribed on a GP10. Stock orders should not be used in place of a GP10 to supply medication to named patients. MMR vaccine is not classed as a travel vaccine but patients should have all their routine vaccinations up to date before travel.

Travel vaccines should not be obtained by stock order. The purpose of a stock order is:

• To order drugs and appliances for the immediate treatment of patients and drugs which are to be administered by the doctor himself, eg adrenaline injection for anaphylaxis or benzylpenicillin for suspected meningitis

• For supply to a patient when their need cannot be met by giving a prescription in normal way, eg in emergencies

Unlike prescriptions, stock orders are subject to the addition of 17.5% oncost plus VAT which increases the cost of such supplies to the NHS.

Hay fever and allergies

Patients with symptoms such as runny nose, sneezing, watery eyes, itching of the soft palate and sometimes wheezing or shortness of breath may have allergic rhinitis (hayfever). Symptoms normally occur between March and September. For information on the diagnosis and treatment of hay fever see Allergic rhinitis - NICE CKS. Medicines Q&A documents, providing information on the management of patients who are pregnant or breast feeding, can be accessed via NELM.

The community pharmacy Minor Ailments Scheme allows repeated prescribing for conditions such as hay fever with no need for GP referral.

Intranasal corticosteroids

Intranasal corticosteroids are the preferred treatment option for moderate/severe or persistent hay fever symptoms. The first line choice is beclometasone nasal spray (50mcg/spray, 200 dose pack size) with budesonide as an alternative in patients in whom beclometasone is ineffective or not tolerated.

Rhinocort Aqua® nasal spray (budesonide 64mcg/spray) replaced mometasone as the Formulary preferred list second choice steroid nasal spray in February 2012.

Fluticasone propionate and fluticasone furoate (Avamys®) are included in the total formulary but restricted to specialist initiation and should be reserved for patients that cannot tolerate or do not respond to the preferred list drugs.

Dymista® nasal spray

Dymista® is a new combination antihistamine and corticosteroid nasal spray (azelastine and fluticasone propionate) which has not been through SMC and is therefore non-Formulary.

Antihistamines

Oral antihistamines are appropriate for patients with mild or intermittent symptoms. Non-sedating antihistamines are recommended first line. The preferred Formulary choices are cetirizine or loratadine. Fexofenadine is a suitable alternative. Chlorphenamine is the only sedating antihistamine on the preferred list with promethazine as a suitable alternative.

Desloratadine and levocetirizine remain non-Formulary. They offer no real advantage over Formulary options and are less cost-effective. Rupatadine (Rupafin®) is not recommended for use in NHS Scotland by the Scottish Medicines Consortium (SMC) and is non-Formulary.

Azelastine is the only intranasal antihistamine licensed in the UK for the treatment of allergic rhinitis and is available on the total formulary.

Eye drops

Sodium cromoglicate is the first line choice for seasonal allergic conjunctivitis, with olopatadine also included in the preferred list but restricted to second line treatment. Emedastine is included in the total formulary as the third line choice. Eye drops containing benzalkonium chloride should not be used while wearing soft contact lenses.

Sunscreens and ACBS

Sunscreen preparations marked ‘ACBS’ (Advisory Committee on Borderline Substances) should not be prescribed unless for skin protection against ultraviolet radiation in abnormal cutaneous photosensitivity resulting from genetic disorders or photodermatoses, including vitiligo and those resulting from radiotherapy; chronic or recurrent herpes simplex labialis. Preparations with SPF less than 30 should not normally be prescribed.

NHSGGC Formulary options-

  • Preferred List - Sunsense® Ultra lotion SPF 50
  • Total Formulary - Uvistat® cream SPF 30

Malaria prophylaxis

Anti-malarials should not be prescribed on the NHS. If chloroquine and/or proguanil are recommended, these can be bought over-the-counter or obtained via private prescription. If any of the other medications such as doxycycline, Malarone® or mefloquine are recommended, they should be prescribed on a private prescription.

Patients should be advised to purchase or obtain sufficient quantities to cover the period of their travel. Depending on the medication, the treatment commences up to three weeks before travel and continues for at least 4 weeks on return (much less for Malarone®). No malaria prophylaxis can guarantee complete protection. If the returning traveller gets a fever between one week after first exposure and up to one year after their return, they should seek medical attention and tell the doctor of being in a malaria area.

For guidance see Travax, Health Protection Scotland or Public Health England.

Extended travel abroad

The NHS accepts responsibility for supplying ongoing medication for temporary periods abroad of up to 3 months. If a person is going to be abroad for more than 3 months then they are entitled to receive sufficient supply of their regular medication to get to the destination and find an alternative supply of that medication. (General Practitioners Committee - Prescribing in General Practice, May 2013)

The Department of Health recommends that the period for which prescriptions should be issued is best decided by the patient’s GP, taking into account their detailed knowledge of the patient’s medical history, current condition and specific monitoring requirements

The prescriber of a drug is clinically and legally responsible for any results of that decision. In view of this it would not be considered good clinical practice for to prescribe large quantities of medicines to a patient going abroad for an extended period of time, whose progress the GP is not able to assess. For example, many prescribers would be happy to take clinical responsibility for prescribing 6-12 months of the oral contraceptive pill whereas most would not be prepared to prescribe psychotropic medication for this length of time.

Useful resources

Up-to-date information may be obtained from:

  • National Travel Health Network and Centre (for healthcare professionals only) 0845 602 6712 (09.00-12.00 and 14.00-16.30 weekdays)
  • Travel Medicine Team, Health Protection Scotland 0141 – 300 1130 (14.00-16.00 weekdays)
  • NHS Travax - for registered users of the NHS website Travax only
  • NHS Fit For Travel - for public access to country-by-country guidance on travel risks by destination. Advice on reducing travel-associated health risks, information on vaccinations and anti-malarial prophylaxis.  Recommended to be used with other travel health advice obtainable through GP or Travel Medicine Clinic services.
  • Dept of Health Green Book – vaccination info