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

PostScript Primary Care - October 2013

Hyoscine hydrobromide shortage

The manufacturers of hyoscine hydrobromide tablets (Kwells® & Kwells Kids®) have advised of a supply issue that will result in these preparations being unavailable until early 2014. In addition to their licensed indication, motion sickness, these preparations are often used off label to treat hypersalivation.  Hypersalivation is a common and potentially distressing side effect of clozapine and many clozapine patients are currently prescribed hyoscine hydrobromide for this indication. It is also occasionally seen with other antipsychotic drugs. Failure to manage it effectively has sometimes resulted in patients stopping clozapine treatment. The majority of patients receive prescriptions for hyoscine hydrobromide tablets from their GP.

The Mental Health Prescribing Management Group has prepared guidance to support mental health and primary care services manage patients affected by this problem and this is summarised below:
1. Identify and review all patients prescribed hyoscine hydrobromide tablets for hypersalivation associated with Clozapine
2. If the patient has known aspiration risk associated with a diagnosed swallowing difficulty, prescribe hyoscine patches 1mg/72 hours.
3. If not and treatment is still required, prescribe either trihexiphenidyl tablets 2-5mg at night or up to 15mg per day in three divided doses or procyclidine tablets 5mg at night or up to 15mg per day in three divided doses.
4. If this proves ineffective refer the patient to Mental Health Services for review.
It is worth noting that the evidence base for any drug used for hypersalivation associated with Clozapine therapy is weak. Treatment relies upon the antimuscarinic properties of the drugs recommended. It should be remembered that any drug with antimuscarinic properties may worsen clozapine associated constipation and therefore patients should be regularly asked about their bowel habits and if constipation is found it must be treated.

Shingles vaccine

A new shingles vaccination programme was introduced in Scotland in September. The vaccine (Zostavax®) is in limited supply from the manufacturer at present, and between 1st September 2013 and 31st August 2014, there will only be enough vaccine to vaccinate the routine cohort (those aged 70 on 1st Sep 2013) and one catch-up cohort (those aged 79 years on 1 Sep 2013). 

The vaccine for the national programme is being provided centrally and GPs will order supplies along with their routine childhood immunizations from the pharmacy distribution centre. Under exceptional circumstances prescribers have the discretion to provide immunization via a NHS prescription to patients out with the national programme.  Due to the expense of this vaccine GPs have been made aware of the importance of maintaining the cold chain and have been advised about securing adequate storage, twice daily temperature monitoring and annual audit of storage arrangements.

Spiriva Respimat

July’s bulletin provided advice on prescribing of tiotropium. This advice has been revised by the Respiratory MCN, following results from the Tiotropium Safety and Performance in Respimat study (TIOSPIR):
• Spiriva (Tiotropium) Respimat® at doses of 2.5 micrograms or 5 micrograms daily had a safety profile and exacerbation efficacy similar to those of Spiriva (Tiotropium) HandiHaler® at a dose of 18 micrograms daily in patients with COPD.
• Spiriva (Tiotropium) Respimat® remains non-Formulary in NHSGGC
• Spiriva (Tiotropium) Respimat® SPC continues to state "Spiriva Respimat should be used with caution in patients with known cardiac rhythm disorders"
• As part of the annual COPD review, patients prescribed Spiriva Respimat® should have their overall condition taken into account, eg cardiovascular risk factors as well as response to treatment
• Where alternative treatment is required, other Formulary preferred list options include long-acting beta2 agonists, Spiriva HandiHaler® or, where appropriate, ICS/LABA combination inhaler
• Report all suspected tiotropium (Spiriva HandiHaler® and Respimat®), aclidinium bromide (Eklira Genuair®) and glycopyrronium bromide (Seebri Breezhaler®) adverse reactions as usual via the Yellow Card scheme

New Oral Anticoagulants

The three new oral anticoagulants (dabigatran, rivaroxaban, apixaban) are all licensed for prevention of stroke/systemic embolism in patients with non-valvular atrial fibrillation. They are included in the Formulary for specific groups of patients as described in local guidance:
• patients currently receiving warfarin who have poor INR control despite evidence that they are complying (this will be highlighted by GCAS)
• patients with allergy or intolerable side effects from coumarin anticoagulants
• patients for whom warfarin has been clinically excluded as a therapeutic option but anticoagulation is deemed safe and appropriate
Potential for use in a wider population is under consideration but is currently non-formulary. Advice on any change to this guidance will be published in a future PostScript.

No preference in agent is identified at present but this may emerge after clinical experience is gained.


Metoclopramide

The MHRA have recently issued advice on the use of metoclopramide.  This was following a review by the European Medicines Agency which found the risks of neurological side-effects outweighed the benefits of high dose or long-term use.
• In children (1-18years) it should only be used as second-line option for preventing delayed chemotherapy induced nausea and vomiting and for treatment of established post operative nausea and vomiting.
• It is contraindicated in babies under 1 year
• It should only be prescribed for short-term use (up to five days)
• Maximum dose in adults is 30mg in 24 hours (or 0.5mg/kg bodyweight)
• For children, 0.1-0.15mg/kg bodyweight up to three times daily. Max daily dose is 0.5mg/kg

Lecicarbon A suppositories

A new suppository containing sodium hydrogen carbonate and sodium dihydrogen phosphate (Lecicarbon A®) has recently been licensed for use in the UK as a Pharmacy-only medicine for frequent constipation.  As this is a Pharmacy-only medicine this medicine is not subject to SMC assessment and is currently non-Formulary.

Request for access to NHSGGC Urinary Catheter Formulary

It was suggested at the recent Area Drugs and Therapeutics Committee meeting that GPs and Community Pharmacists may wish to access the NHSGGC Catheter Formulary. This is available at: www.ggcprescribing.org.uk under ‘Other Formularies’ on the left hand side.

Cold Chain LearnPro Module

All staff with responsibility for handling and managing vaccines are asked to complete the Cold Chain management module on LearnPro at http://nhs.learnprouk.com 

However LearnPro has recently amended its registration protocol and staff registering to use the site are required to submit a payroll number in a recognised NHS format. The LearnPro team are aware that this will cause problems for staff not working in the NHS managed service and are working on a fix. Until then any staff having difficulty should email Learning.E-Support@ggc.scot.nhs.uk for a temporary ID that will get them in to the LearnPro site.