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

PostScript Primary Care - March 2014

Clomipramine Shortage

There are supply problems currently with clomipramine 25mg and 50mg capsules, we have been made aware that there is no stock of either of these strengths by suppliers across the UK.  There is stock of clomipramine (Anafranil®) 75mg modified release tablets available.

Clomipramine is a tricyclic antidepressant but is most often used in the treatment of severe obsessional compulsive disorder (OCD) and generally as a second line option after selective serotonin reuptake inhibitors prove ineffective or are not tolerated. Consequently there is a small but important group of patients who rely on this drug.

The Prescribing Management Group – Mental Health recommends that clinicians take the following actions for affected patients:
1. Review ongoing need for treatment
2. Where clomipramine is to continue, switch to the nearest equivalent dose using clomipramine 75mg MR tablets.
3. If an exact equivalent dose is not possible, consider switching to the nearest dose that can be given using clomipramine 75mg MR tablets eg

50mg or 100mg total daily dose to 75mg MR daily

125mg or 175mg total daily dose to 150mg MR daily

200mg total daily dose to 225mg MR daily

Once the stock situation resolves, where clinically appropriate, patients may return to their original dose and preparation.

4. Licensed alternatives to clomipramine in OCD and panic disorder are available and GPs may with to refer to Psychiatrists if a change to antidepressant is required.

Contraceptives

The Medicines and Healthcare Regulatory Agency (MHRA) have recently provided information on combined hormonal contraceptives (CHCs).  A European review of the latest evidence on the risk of thromboembolism with CHCs has concluded that:
• The risk of blood clots with all low dose CHCs is low
• The risk of venous thromboembolism (VTE) may vary between products depending on the progestogen
• Levonorgestrel, norethisterone or norgestimate have the lowest risk of VTE
• The benefits of any CHC outweigh the risk of serious side effects
• Prescribers and patients should be aware of the risk factors for thromboembolism and the key signs and symptoms

The preferred list choices in the NHSGGC Formulary contain the progestogens with lowest risk and are:
- Low strength: Loestrin 20® (norethisterone)
- Standard strength: Rigevidon® (Levonorgestrel)
For further information please see: http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON377645

Addison's Disease

General Practitioners (GPs) have recently been made aware by separate communication from NHS24 of a couple of incidents where patients with Addison’s Disease presented to NHS24 unwell but their medical history of Addison’s Disease was not provided to NHS24.  GPs should ensure that patients’ diagnosis is clearly flagged in their medical history on a key information summary or special note.  Prescribers and community pharmacists should ensure they are familiar with the standard drug combinations used to manage Addison’s Disease so that referrals to NHS24 include this information.  Steroid cards should also be issued to all patients receiving long-term corticosteroid therapy.

Polypharmacy LES 2013/14 Final Submission

On the final submission of quarter 4 data (due 7th April 2014), the Practice should press the Q1, Q2, Q3 and Q4 submission buttons in turn before attaching the Export data spreadsheet to the submissions e-mail. This will ensure lists are accurate and up-to-date.

Vitamin D FAQ and Patient Information Leaflet

In response to a number of enquiries about the application of the NHSGGC Vitamin D guidelines, the Prescribing Management Group for Primary Care have approved a Question and Answer document and Patient Information Leaflet which can be found here.

Strontium (Protelos®) Restriction

The European Medicines Agency has completed its review of Protelos® (Strontium Ranelate) and has recommended further restricting its use.  Strontium should now only be used to treat severe osteoporosis in postmenopausal women and men at high risk of fracture, for whom treatment with other medicines for osteoporosis is not possible, eg due to contraindication or intolerance.
• Strontium is contra-indicated in patients with ischaemic heart disease (IHD), peripheral vascular disease, cerebrovacular disease or uncontrolled hypertension.
• Decision to prescribe strontium should be based on an assessment of the individual patient’s risks.  The risk of developing cardiovascular disease should be evaluated before starting treatment and every 6-12 months thereafter.
• Treatment with strontium should be stopped if the patient develops IHD, peripheral arterial disease or cerebrovascular disease or if hypertension is uncontrolled.

Patients currently taking strontium should be reviewed as necessary at the next available opportunity.
The use of strontium is restricted in the NHSGGC Formulary to females over 75 years with a T-score under 2.4 who cannot take oral bisphosphonates.  Treatment of males with osteoporosis is not approved by the Scottish Medicines Consortium and is non-Formulary.

Searching for drug allergies or adverse reactions on EMIS

EMISDRGA alerts – If a drug adverse reaction or allergy is coded on EMIS using the allergy tab in the consultation mode, or the ‘add allergy in summary’ mode, the EMIS code associated with this is EMISDRGA or EMISALLERGY.

If a drug adverse reaction or allergy is coded on EMIS using ‘Add Clinical Term (Read Code)’ eg ‘Adverse reaction to penicillin NOS’ read code is
TJ00z.

In the searches and reports function of EMIS, it is not possible to search for adverse reaction or allergies to a specific drug if the EMISDRGA or EMISALLERGY code has been applied.
eg Search for patients on enalapril  with a view to changing them to a Formulary listed angiotensin converting enzyme inhibitor, if you wish to exclude patients who previously have had an adverse reaction to ramipril it is possible to do so if the adverse reaction was coded as U60C4-3 ([x] adverse reaction to ramipril) or TJC79 (adverse reaction to ramipril). If the adverse reaction was coded as an EMISDRGA, then it will not be picked up.

It is therefore essential when searching on EMIS to screen patients individually after Population searches are run to ensure that all adverse events have been identified.

If a prescriber tries to prescribe the drug or associated drugs a red warning will be displayed irrespective as to how it was coded.

Changes to PostScript Alerts

From April 2014, PostScript email alerts will be synchronised and sent out once a month.  The monthly alert will include links to all relevant PostScript bulletins.  PostScript Primary Care will continue to be included in the weekly GP and Community Pharmacy mailings in addition to the individual monthly mailing list.