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

PostScript Primary Care - May 2013

This edition contains articles on

  • Trazodone short supply
  • Cilostazol (Pletal®)
  • Strontium ranelate (Protelos®)
  • Rotigitine (Neupro®) patches
  • Dermatology Formulary update
  • Enteral feeding algorithm
  • Liothyronine short supply

Trazodone short supply

Where supply is problematic, PMG(MH) advises that prescribers review the need for ongoing trazodone treatment. Advice may be sought from Mental Health Services. For specific advice on discontinuing antidepressants, see the relevant NICE Clinical Knowledge Summaries.

Where an alternative treatment is indicated, the following may be of value:

  • Trazodone is a serotonin reuptake inhibitor and 5HT2 antagonist with alpha1 antagonist and antihistamine properties. It can be considered a low-potency antidepressant with marked sedative properties1.
  • If an alternative antidepressant is indicated the NHSGGC Formulary should guide choice. While each case should be assessed on its own merits, specialists from Older People's Mental Health and Learning Disability have suggested that mirtazapine may be considered. It should be noted that the sedative properties of mirtazapine may be more pronounced at the lower dose1.
  • Advice on switching from trazodone is also available from the relevant NICE CKS.

Ideally, antidepressant treatment should be discontinued or switched by tapering over four weeks. Where this is not possible due to shortage of supply of trazodone then stopping/switching should occur as slowly as the remaining supply of trazodone allows.

References

1. Stahl, S.M Psychopharmacology of Antidepressants. Martin Dunitz 1997.

Cilostazol (Pletal®) - risks of cardiovascular & bleeding events

A review of the benefits and risks of cilostazol (Pletal®) was triggered by reports of adverse reactions (mainly cardiac and haemorrhagic), and by the potential for drug interactions.

The MHRA issued a Drug Safety Update in April 2012 with the following advice:

  • Cilostazol is restricted to second-line treatment where lifestyle modifications and other appropriate interventions have failed to provide sufficient improvement.
  • Cilostazol is contraindicated in patients with
    • unstable angina, recent myocardial infarction or coronary intervention (within 6 months)
    • history of severe tachyarrhythmia
    • those receiving two or more other antiplatelet or anticoagulant treatments
  • Advise patients to take cilostazol 30 minutes before breakfast and evening meal
  • Reassess patients after 3 months of starting cilostazol and consider stopping treatment if there is no clinically relevant improvement in walking distance
  • A dose reduction to 50 mg twice a day is recommended when cilostazol is taken in combination with any of the following: erythromycin; clarithromycin; ketoconazole; itraconazole; omeprazole; or any strong inhibitors of CYP3A4 or CYP2C19
  • Reassess patients currently receiving long-term treatment with cilostazol at a routine appointment, in order to advise on treatment continuation, dose change, or cessation

Strontium ranelate (Protelos®) - risk of serious cardiac disorders

In April 2013, MHRA issued a drug safety alert around the use of strontium ranelate (Protelos®).  A review of available safety data for strontium ranelate has raised concern about its cardiovascular safety beyond the already recognised risk of venous thromboembolism. An analysis of RCT data has identified an increased risk of serious cardiac disorders, including myocardial infarction.

The European Medicines Agency will fully evaluate the benefits and risks of strontium ranelate, but updated advice is available here.

This alert will necessitate a review of patients currently receiving strontium ranelate. When reviewing patients, please consider the decision making around the initial treatment - was the decision based upon patient being at high risk of fracture? If necessary please assess fracture risk using

NHSGGC Formulary guidance on drugs affecting bone metabolism is available.

Change in rotigotine (Neupro®) patches storage conditions

A new room-temperature formulation of Neupro® (rotigotine transdermal patch) became available from April 2013. The product to be stored at room temperature (up to 25oC) and has a shelf-life of 24 months.

Until the previous refrigerated product is fully replaced, both formulations may be dispensed. Therefore, caution to patients is advised to ensure they are stored under the conditions detailed on the packaging.

The room-temperature formulation has distinctive new packaging and UCB has produced a patient leaflet to highlight the different packaging and storage requirements. The once-daily application remains unchanged.

Dermatology Formulary update

Following Formulary Appeals, the following changes were agreed by ADTC in April 2013:

  • Liquid paraffin 11% cream (Zerobase®) is included in the Preferred List and is more cost effective than Diprobase® cream.
  • Light liquid paraffin 12.6% cream (Zerocream®) is included in the Total Formulary and is more cost effective than E45® cream.
  • Light liquid paraffin 40% ointment (Zeroderm®) is included in the Preferred List and is more cost effective than Hydromol® ointment (It is also equivalent to Epaderm® ointment).

Other Formulary decisions:

  • Coal tar 6% and lecithin 0.4% cream (Psoriderm®) is included in the Preferred List for the treatment of psoriasis of the scalp. It replaces Alphosyl HC® which has been discontinued.

ScriptSwitch®, Synonyms and the electronic Formularies will be used to highlight these new additions to the Formulary to prescribers.

Enteral feeding algorithm

ADTC have recently approved the NHSGGC Prescribing Guideline for patients on enteral feeding in community. The guideline can be accessed on StaffNet. This details the pathway of a patient commencing on enteral feeding, registering with Nutricia Homeward home delivery service and appropriate routing for enteral tube/bolus feed. GPs are encouraged to scan any requests for enteral tube feeds into the patient’s Docman®. If you have any queries, contact the prescribing support dietitians on 0141 201 5214 or presupdiet@ggc.scot.nhs.uk.

Liothyronine short supply

The only UK licensed liothyronine 20mcg tablets are experiencing a short term supply problem and unlicensed alternatives may be required over the next few weeks. Prescribers should be alert that switching between products may produce a change in a patient’s symptoms and TSH status.

Most patients are unlikely to be affected, but patients with a significant change in symptoms should have their TSH status reviewed and the dose adjusted accordingly. Pregnant women, patients with heart disease and those following treatment for thyroid cancer may be most susceptible to changes. More information is available on the MHRA website. Prescribing of unlicensed products should be in accordance with the NHSGGC Unlicensed medicines policy.