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

Postscript Primary Care - May 2012

Good Practice in Safe Management of CDs in Primary Care

The Accountable Officer’s Network (Scotland) has just published the first edition of this guidance available here.

Key points

  • The guide focuses on the roles and responsibilities of healthcare professionals working within primary care and who are commonly involved in the management of controlled drugs (CDs). It also covers issues raised at the interface between primary, secondary and social care. The Scottish Government issued specific guidance on the management of CDs in secondary care (CEL 7 (2008)) in February 2008.
  • This guide aims to identify robust systems for obtaining, storing, supplying, recording, monitoring and disposing CDs safely, while helping to ensure appropriate and convenient access for patients who require CDs. It does not advise on the clinical choice and use of CDs.
  • The guide aims to help healthcare professionals to adopt a systematic approach to improvement in the management and control of CDs. This will strengthen patient and public safety while ensuring that there is minimum additional bureaucracy resulting in reluctance to prescribe CDs.

Organisations holding stocks of CDs are legally required to develop and use standard operating procedures (SOPs) as a means of ensuring good practice becomes part of everyday health care activities. Advice on the development of SOPs can be found in Scottish Government CEL 14 (2007).

This guide should be of value in a wide range of settings where CDs are used including:
 
• GP and out of hours services
• Dental practices
• Pharmacies
• Midwifery services
• Care services / care homes
• Community nursing services
• Community palliative care services
• Substance misuse services

Prescribing of trimethoprim in pregnancy

Infection Management Guidelines in NHSGGC recommend trimethoprim or nitrofurantoin as first-line drug choices for lower urinary tract infection (UTI) in pregnancy.  Prescribers should be aware that use of trimethoprim in pregnancy is off-label due to the theoretical risk in the first trimester as it is a folate antagonist.  This risk is greatest in patients with a poor diet and prescribers should ensure pregnant patients prescribed trimethoprim are taking folic acid supplementation.  The use of trimethoprim for this indication is recommended by the Health Protection Agency and also supported by the Scottish Antimicrobial Prescribing Group.

Pregnancy and chicken pox exposure

An incident recently occurred in general practice where an antibody-negative pregnant woman was administered varicella vaccine instead of varicella zoster immunoglobulin (VZIG).

If a pregnant woman thinks she has been exposed to chicken pox and is not immune, she should contact her midwife who will either –

• reassure her that if she has had chickenpox in the past there is nothing to worry about, or

• if she has not, or is unsure, then the midwife can arrange for antibody levels to be checked on the booking bloods at the virus lab with the understanding being that any follow up, eg a repeat test or assessment for immunoglobulin, is the decision of the obstetrician as the woman, by contacting the midwife, is under their care

It would also be appropriate for GPs to reassure pregnant women who have had contact with chickenpox but had it in the past that there is nothing to worry about. If a patient has not had it, or is uncertain, GPs should advise them to contact their midwife who will arrange for bloods to be checked and organise follow-up as necessary, eg VZIG administration.

GGC Chickenpox in Pregnancy Guideline - available here.

Vitamin D guidance

Although all UK Health Departments issued advice on vitamin D supplements for at risk groups in February 2012, there is currently no vitamin D supplement included in the NHSGGC Formulary.

Fultium-D3® is a new product (containing 20mcg vitamin D3 per capsule) which has yet to be evaluated by the SMC and is therefore non-Formulary and should not be routinely prescribed.

Fultium-D3® is only licensed for adults and children over 12 years and contains arachis (peanut) oil so should be avoided in patients with peanut or soya allergy.

Combination calcium and vitamin D products are available for osteoporosis prevention and treatment. Pregnant or breastfeeding women and children up to 4 years may qualify for free Healthy Start vitamins which contain the recommended daily vitamin D.
(www.healthystart.nhs.uk )

Asylum seekers and refugees who have darker skin (such people of African or African-Caribbean origin) and who are pregnant, breastfeeding or children up to 4 years qualify for NHSGGC Sunshine Vitamin Club Cards for a free supply of Healthy Start vitamins.

Metolazone (Metenix®) discontinuation

Metolazone, a diuretic licensed for hypertension and oedema, is no longer available from the sole manufacturer Sanofi. Only limited quantities remain in the supply chain.

The Heart Failure (HF) service uses metolazone for resistant oedema and will review their patients with a view to switching from metolazone to bendroflumethiazide at a ratio of 1:1 (ie 2.5mg=2.5mg) , as recommended by the Heart Disease MCN.
 
It is likely that, in the absence of a generic, GPs will need to review those patients not under the care of the HF service. Both the HF specialist pharmacist (201 5654) and community HF nurses (see local guidelines) can be contacted for patient specific advice if needed.

New Urinary Catheter Formulary

The first NHSGGC Urinary Catheter Formulary is now available and lists those products that should be used along with their relevant ordering codes. These products will be included in the next electronic formulary and synonyms updates for GP prescribing systems. The Formulary can be viewed here

Glasgow Addictions Service – New contact details

NHSGGC Addiction Service
Templeton Business Centre
Ground Floor/ Building 3
62 Templeton Street
Glasgow
G40 1DA

Tel: 0141 277 7660 
Fax: 0141 277 7655

Action Required - Withdrawal of ProvideXtra® Juice

Fresenius Kabi has ceased production of their milk free juice supplement ProvideXtra® with expected stock availability until July 2012. As there is no alternative for patients who are vegan/allergic to milk any prescribing enquiries should be referred to the prescribing support dietetic team (0141 201 5197 / 5928) or dietitian managing the patient. Patients should not be switched without dietitian involvement.