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

PostScript Primary Care (Nov 2012)

Specials

Below is a table of commonly prescribed specials that have an available alternative for the prescriber to consider. It is suggested that these five preparations listed are initially targeted for review. A further list of alternative preparations is provided HERE 

Special Liquid

Average Cost / Item 

Alternative

Average Cost / Item

Amlodipine

£123

Amlodipine Tabs(crushed and dispersed in water)

£1.59

Atorvastatin

£137

Atorvastatin Chewable Tablets

£30.91

Lansoprazole

£179

Lansoprazole Orodispersible Tablets

£6.60

Omeprazole

£193

Omeprazole Dispersible Tablets

£17.68

Ranitidine 1mg/1ml

£203

Ranitidine Oral Soln 75mg/5ml

£18.43

Ranitidine 5mg/5ml

Prescribers across NHS GGC last year made 94 requests for ranitidine 5mg/5ml at a total cost of £19,078. This is an average cost of £203 per item, some with only a 7 day expiry date.

It is recommended that prescribers use the licensed 75mg/5ml with a 1ml oral syringe instead of the unlicensed ranitidine 5mg/5ml. In practice a 1ml oral syringe can measure down to 0.1ml which is equivalent to 1.5mg ranitidine therefore dilution should not be necessary considering the relative safety of ranitidine.
Prescribers must always specify on the prescription if they wish a 1ml oral syringe to be supplied

Diclofenac and cardiovascular risk  

MHRA recently reported that a new review on the cardiovascular safety of NSAIDs highlighted further evidence that diclofenac is associated with cardiovascular risks that are higher than the other non-selective NSAIDs, and similar to the selective COX-2 inhibitors. Naproxen and low-dose ibuprofen, NHS GGC preferred list NSAIDs, are still considered to have the most favourable cardiovascular safety profiles of all non-selective NSAIDs. The need for any update to the existing treatment advice for diclofenac will now be assessed by the European Medicines Agency’s Pharmacovigilance and Risk Assessment Committee (PRAC).
Healthcare professionals are reminded that, when prescribing NSAIDs, patients should use the lowest effective dose for the shortest time necessary to control symptoms. The patient’s individual risk factors, including any history of cardiovascular and gastrointestinal illness, should also be taken into account. For further information click HERE

Simvastatin 40mg and amlodipine MHRA advice

The MHRA recently published further advice for prescribers;

  • The treatment of patients currently receiving concomitant simvastatin 40mg or diltiazem should be reviewed at their next routine appointment. The maximum recommended dose of simvastatin co-administered with amlodipine or diltiazem is now 20mg daily.
  • A patient article on the new information for simvastatin is available to complement the consultation

Benzodiazepine use and risk of dementia 

A recent BMJ article HERE reported on a prospective population based study that new use of benzodiazepines was associated with increased risk of dementia. The result was robust in pooled analyses across cohorts of new users of benzodiazepines throughout the study and in a complementary case-control study. Considering the extent to which benzodiazepines are prescribed and the number of potential adverse effects of this drug class in the general population, the authors cautioned against indiscriminate widespread use.

Prescribing Points
Benzodiazepines are indicated for

  • anxiety short term relief (2-4 weeks) if severe, disabling or causing the patient unacceptable distress.
  • insomnia if severe, disabling or causing the patient extreme distress
  • Follow BNF guidance when considering withdrawal of a benzodiazepine prescribed long term.
  • Temazepam - due to a number of generic manufacturers withdrawing from the market there are problems with the supply of temazepam causing a five fold cost increase.

 For further information on shortages see Community Pharmacy Scotland

Scriptswitch Software Pilot

This pilot using GP clinical systems in Inverclyde and East Dunbartonshire CH(C)Ps started on 1st September. ScriptSwitch is a prescribing support tool that provides automatic messages on the GP’s clinical systems at the point of prescribing.
Recommendations are health board specific. The NHS GGC recommendations contain information on drug safety and complement current NHS GGC approved cost efficiency initiatives. If the prescriber accepts the recommendation, the prescription is automatically changed to the recommended alternative. Recommendation messages only appear to clinicians when they issue an acute, new repeat or serial script or when they re-authorise a patients current repeats. In the eight weeks to date £10k of cost savings have come from 3 switches alone in the 33 pilot practices (below)

  1. SERETIDE® evohaler  to SERETIDE® accuhaler
  2. NITROFURANTOIN 50mg tablets to capsules
  3. VENLAFAXINE modified release capsules to VENLAFAXINE tablets

Non availability of INADINE® PVP-I

Recommended antibacterial alternatives are as follows:

  • Bactigras ® chlorhexidene
  • If chlorhexidene allergy please use Actilite® manuka
  • If no antimicrobial is needed then Atrauman® polyester non adherent dressing with triglycerides. Further information contact, jane.camp@ggc.scot.nhs.uk

Contraindications on the use of silver containing wound management products when breastfeeding.

Wound management products containing silver are currently available on the NHS GGC wound formulary for use on infected wounds.  Contraindications for using silver tend to be limited to a known sensitivity to silver. However, there is very limited data on the long term effects of prolonged or repeated use of silver products, particularly on children and neonates. 
For this reason silver containing products should only be used under strict medical guidance on wounds of pregnant or breastfeeding mothers, neonates or children.

Sorbion Sachet S® now rebranded Sorbion Sachet Extra®

Changes include an increase in product size, but no change to specification- The stated sizes now refer to the inner pad dimensions of Sorbion Sachet Extra®. Please refer to GGC Wound Formulary HERE. Sorbion Sachet Extra® will be constructed in exactly the same material and to identical specifications as Sorbion Sachet S®                                                   
Please only order the number of dressings required for 14 days. There are also new PIP codes when ordering.

Prescribing Interface Subcommittee

The Prescribing Interface Subcommittee (PI) is a subcommittee of the Area Drugs & Therapeutics Committee (ADTC), tasked with reviewing and approving new and existing shared care protocols. This newly formed group seeks representation from three GPs from Greater Glasgow and Clyde. Meetings will be held quarterly and attendance will be remunerated on a sessional basis. If you are interested in supporting the work of the subcommittee and would like the opportunity to shape the shared care process please email SCP@ggc.scot.nhs.uk by the 7th December.