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

PostScript Primary Care Oct 2012

Vaccination Against Pertussis

The following resources are now available on the NHS Education for Scotland website:

  • Vaccination against pertussis (whooping cough)- the use of Repevax- An update for midwifery (slides and notes). Healthcare professionals generally will find this useful. 
  • Vaccination of pregnant women against pertussis- questions and answers- link to resource  

Ordering of pertussis vaccine is directly through health visitors (HV) from the pharmacy distribution centre (PDC). GPs who wish to order the pertussis vaccine for pregnant women can obtain a copy of the form from the person who normally undertakes the ordering in their health centre or practice. These forms are practice specific and need GP number and name etc. The GP needs to clearly identify across the form for pregnant women and delivery address name, GP practice otherwise it will go into HV stock. Alternatively the GP should request the HV to order x number of doses on their behalf clearly marked on their order for pregnant women and obtain the stock from the HV when it arrives. It is important that the PDC are aware that the order is for pregnant women as opposed to childhood vaccine.

Vitamin D

Fultium-D3® contains 800 units of colecalciferol. It should be noted that this preparation is double the daily recommended dose of Vitamin D for adults who are considered to be at risk of vitamin D deficiency as outlined in guidance issued from the Chief Medical Officer for Scotland in February 2012. Healthy Start vitamins contain 400units of vitamin D and are available for eligible patient groups in NHSGGC. Vitamin supplement preparations containing 400units of vitamin D are readily available for purchase by patients over the counter from pharmacies and health food shops.

Guidance on when to measure vitamin D levels and the subsequent management are currently in development by the NHSGGC Osteoporosis Group and Biochemistry Department.

Dipeptidylpeptidase-4 (DPP-4) inhibitor antidiabetic agents (‘gliptins’)

The MHRA recently reported cases of acute pancreatitis associated with DPP-4 inhibitor class of antidiabetic agents (‘gliptins’).  Pancreatitis is listed as a potential side effect in the product information of all DPP-4 inhibitors with a reporting rate of between 1/1000 and 1/100. Patients should be informed of the characteristic symptoms of acute pancreatitis – persistent, severe abdominal pain (sometimes radiating to the back) – and encouraged to tell their healthcare provider if they have such symptoms. If pancreatitis is suspected, the DPP-4 inhibitor and any other potentially suspect medicinal products should be discontinued and reported using the MHRA `yellow card` scheme.

Thromboprophylaxis Guidelines for Orthopaedic Patients.

A general NHSGGC guideline is now available for orthopaedic patients. The guideline contains recommendations for thromboprophylaxis which is dependant on procedure and risk stratification during admission and on discharge.

Please note rivaroxaban prescribing if recommended within this guideline will have the complete course supplied by the hospital.

Antiplatelet therapy in secondary prevention of stroke and TIA.

New NHSGGC guidelines for above are available HERE. See key recommendations below. 

  • For patients in sinus rhythm who have had an ischaemic stroke or transient ischaemic attack (TIA), the standard long-term antithrombotic treatment should be clopidogrel 75mg once daily
  • Patients who cannot tolerate clopidogrel should receive aspirin dispersible 75mg once daily and dipyridamole modified-release (MR) 200mg twice daily
  • Aspirin dispersible 75mg once daily should be used if both clopidogrel and dipyridamole MR are contraindicated or not tolerated
  • If both clopidogrel and aspirin are contraindicated or not tolerated, then use
    dipyridamole MR 200mg twice daily
  • All patients with a diagnosis of stroke or TIA should receive life-long antiplatelet therapy as outlined above 
  • The combination of aspirin and clopidogrel is not recommended for long-term prevention following a stroke or TIA stroke unless there is another indication to consider, such as acute coronary syndrome or recent coronary stent procedure.

European Antibiotic Awareness Day

NHSGGC will be supporting European Antibiotic Awareness Day on Friday 16 November with promotion of the message "Get well soon without antibiotics". This message will be displayed on posters in Health centres, general practice surgeries and community pharmacies. Supporting leaflets will be available in practices for self-selection or for patients presenting with symptoms of a cold who may be anticipating an antibiotic prescription. 

This specific event provides a focus for this topic but antibiotic use is an ongoing priority with guideline development and use of prescribing indicators to benchmark and monitor practice. The Antimicrobial Management Team is also  using this focus on antibiotics to highlight the successful reduction in prescribing of some of the antibiotics most associated with C difficile infection. The exception are quinolones where prescribing remains higher than desirable.

Changes to prescribing and availability of Epanutin®.

  • Epanutin® (phenytoin sodium) capsules have been discontinued.
  • Phenytoin Sodium Flynn Hard Capsules are available and are identical to Epanutin® capsules in all but brand name.
  • Prescriptions should be written as Phenytoin Sodium Flynn Hard Capsules.
  • Epanutin® Infatabs, suspension and solution continue to be available under the Epanutin® brand name.

EMIS software; Future drug update 360 will contain an entry to allow prescribing of the Flynn generic. In the interim, EMIS practices can safely prescribe generic phenytoin capsules as currently only Flynn generic is available.
VISION software; Immediately prior to selecting phenytoin capsules in the drug selection window tick the box marked ‘all generics’ and select the Flynn generic hard capsule.

Success of voluntary ban on methotrexate 10mg tablets

On 1st April 2012 NHSGGC primary care implemented a "voluntary ban" on the use of methotrexate 10mg tablets for patient safety reasons. All GP practices were requested to identify initially all adults then latterly paediatric patients prescribed methotrexate 10mg with a view to switching patients to the equivalent weekly dose using only the 2.5 mg methotrexate tablets.

Despite the NPSA issuing alerts in 2004 and 2006 regarding the risks of prescribing different strengths of methotrexate tablets and a NHS GGC policy recommending a 2.5mg strength only policy, this was not reflected in practice. NHS GGC was one of the poorest performing health boards in Scotland. From the first communication regarding the "voluntary ban" in PostScript Primary Care in Nov 2011 through to July 2012, prescribing analysis through PRISMS shows NHS GGC has moved from 85% to 98.1% of oral methotrexate as the 2.5mg tablet strength and is now one of the highest performing health boards.
A huge congratulations and thanks to all who have helped to achieve this shift.