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

PostScript Primary Care - June 2014

Tramadol: Change in Legal Status to Schedule 3 Controlled Drug

• Tramadol is now classed as a controlled drug
• Prescribing: Tramadol must now be prescribed as a controlled drug (CD). Note the requirements for interval of supply, amount per supply plus daily dose to be included if prescribing by instalments. Prescriptions are only valid for 28 days. The GP software providers are making changes to the systems.
• Good practice recommendation is no more than 30 days supply per prescription
• Storage: There is no need to store in the CD cupboard. 
• Recording: No requirement to be recorded in the CD register.
• Stock orders: Orders must conform to CD requisition requirements.
• PGDs: tramadol will not be able to be included on any PGDs. The national PGD for community pharmacy urgent supply will be amended.
• Destruction: Tramadol, like all Schedule 2-4 CDs, should be denatured by use of a CD destruction kit before disposal in pharmaceutical waste.

A memo has been sent to all NHSGGC practices.

Gluten-Free Food Service from Community Pharmacies

Practice staff and prescribing support teams are asked to note that all non-care home patients with a confirmed diagnosis of coeliac disease (CD) and dermatitis herpetiformis (DH) who are registered with the practice are eligible to access the service from their local pharmacy. This is regardless whether the patient currently obtains their GF foods on GP10 or not.

Please note that all registration forms should be signed by the GP. This is the instruction to the pharmacy for the transfer of care for the patient and therefore, the form cannot be signed another member of the practice staff.
When a patient is registered with a particular pharmacy they will receive an annual health check which will include assessment of the patients understanding of and concordance with gluten-free diet; vitamin/mineral supplementation; symptoms and Body Mass Index. A summary of this will be sent to the GP.

Patients who receive sweet biscuits on GP10 must also be provided with the “Patient Form for Additional Gluten-Free Units and Sweet Biscuits” to allow the pharmacy to supply a maximum of two units of these products within the patient’s normal food unit allowance. This Patient Form must also be signed by the GP.

Domperidone

Further to the information in a previous bulletin, the MHRA have recently provided new information on the prescribing of domperidone. Due to the increased risk of serious cardiac side effects, domperidone use is now restricted:
• to the relief of nausea and vomiting symptoms
• contra-indicated in people with conditions where cardiac conduction is or may be impaired, cardiac diseases such as congestive heart failure, taking other drugs known to prolong QT or potent CYP3A4 inhibitors, and those with severe hepatic impairment.  These patients should have treatment reviewed at next routine appointment and switched to an alternative if required
• Maximum oral dose for patients over 12 years and weight 35kg or more: 30mg in 24 hours (10mg up to three times a day)
• Maximum oral dose for children under 12 years and weighing less than 35kg: 0.75mg/kg body weight (0.25mg/kg body weight up to three times a day)
• Maximum suppository dose (adults and adolescents over 35kg weight): 60mg in 24 hours (30mg twice a day)
• Maximum treatment duration is 7 days

UKMI have produced advice on alternative management options for patients with Dyspepsia/Reflux and gastroparesis.

Medicines for Children have a patient information leaflet on use of domperidone for reflux.

Dual Antiplatelet Therapy

Clopidogrel or ticagrelor are indicated as part of a dual anti-platelet therapy (DAPT) regimen along with indefinite aspirin for management of patients with acute coronary syndrome (ACS) and/or undergoing percutaneous coronary intervention (PCI). The NHSGGC Guideline for Antiplatelet Therapy in Secondary Prevention of Coronary Heart Disease makes recommendations for DAPT duration in accordance with clinical circumstances.

Systems are in place to prevent inappropriate continuation of DAPT. These include the immediate discharge letter stating recommended length of therapy, the patient and their General Practitioner (GP) being provided with an information leaflet and in the case of patients undergoing PCI at Golden Jubilee National Hospital (GJNH), a letter from the Prescribing Team advising the GP when DAPT should be stopped. Despite this, DAPT is often continued inappropriately.

Prescribing was audited in 43 Practices in Glasgow North East during April and May 2014.  More detailed results of this audit will be included in the next PostScript bulletin in July 2014.

The key findings:
Following publication of the antiplatelet guideline in May 2013, patients receiving a drug-eluting stent should have been prescribed DAPT for 26 weeks.
• 26% of patients had therapy recommended for 26 weeks
• Reasons for non-guideline durations were not routinely recorded.

70% of patients had emergency or elective PCI with the rest managed medically. Patients treated medically should receive 12 weeks of therapy, and this correlates with the number of patients prescribed 12 weeks therapy suggesting appropriate duration.
• 37.6% of patients exceeded the intended duration
• 76.8% of these were prescribed clopidogrel and 19% ticagrelor.
• A total of 7,537 weeks excess therapy was prescribed (average 11.9 weeks per patient)
• The cost of excess treatment was £8,386.  Had this been entirely for ticagrelor, the associated cost would have been £102,880.

202 (46.2%) of the 437 patients undergoing PCI at GJNH had Prescribing Team correspondence recommending DAPT cessation filed in the patient notes. A notable difference existed in the average excess duration between the groups who did receive a letter (20 weeks) and did not receive a letter (41 weeks).   Just over half the patients received the correct duration of treatment and that was regardless of whether the practice received a letter or not.

157 interventions were undertaken; 90 were to discontinue inappropriate DAPT. Had this intervention not been undertaken, there would have been an ongoing drug cost of £7700 per annum. As ticagrelor supersedes clopidogrel for ACS, it is anticipated that this would be greater in future. 26 patients had the intended stop date annotated on their prescription in accordance with best practice, as outlined in PostScript Primary Care (September 2013).

Patient Group Directions

A Patient Group Direction (PGD) is a legal document which requires approval by the health board before healthcare practitioners may work under it. In NHSGGC these documents are approved by a subgroup of the Area Drug and Therapeutics Committee (ADTC). The administration of the sub group distributes new and reviewed PGDs to appropriate practitioners by cascading the documents either through line managers or clinical leaders as appropriate. As the ADTC PGD sub group administration will know the best person to contact to answer any questions, any queries about the content of a PGD should ideally be referred directly to them rather than a line manager or clinical leader.


For any queries about an NHSGGC PGD please email Jacqueline.richardson@ggc.scot.nhs.uk