Medicines management tips for skin prescribing

Prescribing tips

• Betnovate cream and ointment (30g and 100g) is currently about half the cost if prescribed as a brand rather than generically.

Betnovate cream/ointment 30 g = £1.43Generic betamethasone valerate 0.1% cream 30g = £2.73 ointment 30g = £3.16

Betnovate cream/ointment 100g = £4.05Generic betamethasone valerate 0.1% cream 100g = £9.10 ointment 100g =

£10.53

• NDCCG could save approximately £21,600…… per year if switched to Betnovate.

Prescribing by brand – sometimes it is cheaper!

Jan 14 Generic or brand Betnovate prescribing by practice

Potential annual saving by practice

Prescribing tips

• Aqueous cream 500g = £4.95 switch to ZeroAQS 500g = £3.29 (SLS free, can be used as cream, soap substitute and bath additive)

• Diprobase 500g = £6.32 consider switch to Oilatum Junior Cream 500ml = £4.99

Prices – March Mims / Drug Tariff

Consider switches or cheaper products for new patients

Trend of bath additive prescribing

LPL 63.4 500mls = £3.10

Prescribing sunscreen Endorse ACBS Not eligible if on

medicines that sensitise skin

Abnormal cutaneous photosensitivity resulting from genetic disorders or photodermatoses

AK prescribing

BNF Name Total Items

Quantity Total Quant x items

Total Act Cost

Diclofenac Sod_Gel 3% 22 50 1,100 £778.33

Diclofenac Sod_Gel 3% 2 100 200 £141.49

Picato_Gel 150mcg/g 1 0 0 £20.12

Picato_Gel 500mcg/g 1 1 1 £60.04

Solaraze_Gel 3% 20 50 1,000 £707.57

46 2,301 £1,707.54

• Review diclofenac 3% / solaraze prescribing – has it been picked in error?

Prescribing tips

• When a product is not listed in the drug tariff e.g. specials and some generic names for branded products, pharmacies and dispensing practices can endorse the invoice price of products they have obtained for prescriptions, and can potentially claim out of pocket expenses as well

• Movelat cream / gel £7.19 for 125g• Mucopolysaccharide polysulphate/salicylic cream and gel – claims have been submitted

for £65.00/125gm

• We can’t easily identify these on epact – as they are likely to have been listed as unspec. on epact

Don’t generic prescribe if there isn’t a listed generic in the drug tariff

Prescribing tips

Specials drug tariff products are still expensive, but cost will be the same whichever pharmacy or dispensing practice dispenses the product:•Coal tar solution 5% in betamethasone valerate 0.025% ointment 100g (and less) = £173.67 (£0.13 per g above 100g)

•Diltiazem 2% cream 30g (and less) = £81.49 (£2.16 per g above 30g)•Diltiazem 2% ointment 30g (and less) = £125.89 (£0.06 per g above 30g)Scripts <52g cheaper diltiazem cream, >=52g cheaper diltiazem ointment

•Glyceryl trinitrate 0.2% ointment 30g (and less) = £36.44 (£1.21 per g above 30g)

Look at specials A-Z on www.derbyshiremedicinesmanagement.nhs.uk

Specials – costs vary substantially unless they are in the specials drug tariff

www.derbyshiremedicinesmanagement.nhs.uk

Specials A-Z on websiteTechnicians can set up quick keys to the specials A-Z or medicines management website

Drug

Step 1: Use a licensed medicine in a suitable formulation (incl change to

different drug in same therapeutic class)

Step 2: Use a licensed medicine in an unlicensed manner *

Step 3: LAST RESORT: Use an unlicensed special

Diltiazem Hcl Cream/Gel/Ointment 2%

For anal fissures consider switching to licensed Glyceryl trinitrate ointment 0.4%

(Rectogesic)

2% CREAM & OINTMENT included in Part VIIIB of Drug Tariff from 2012

Drug

Step 1: Use a licensed medicine in a suitable formulation (incl change to

different drug in same therapeutic class)

Step 2: Use a licensed medicine in an unlicensed manner *

Step 3: LAST RESORT: Use an unlicensed special

Glyceryl Trinitrate Ointment For anal fissures consider LICENSED glyceryl trinitrate ointment 0.4%

(Rectogesic)

Unlikely to need: licensed products available

Drug

Step 1: Use a licensed medicine in a suitable formulation (incl change to different drug in same therapeutic

class)

Step 2: Use a licensed medicine in an unlicensed manner *

Step 3: LAST RESORT: Use an unlicensed special

Coal Tar Paste Consider switching to LICENSED, commercially available coal tar

preperation if appropriate e.g Carbo-Dome (coal tar 10%). Cocois scalp

ointment (Coal Tar 12%, Salicylic acid 2%, precipitated sulphur 4%), Psoriderm

cream (coal tar 6%, Lecithin 0.4%)

Coal tar soln 5% Betameth Val. 0.25% Oint

Consider Alphsol HC (coal tar 5%, hydrocortisone 0.5%, allantoin 2%)

Included in Part VIIIB of Drug tariff from November 2012

Urea and salicylic acid preparations

10% salicylic acid in aqueous cream, 100g = £266.95Unspec drug code – can’t tell what was prescribed for many itemsUnlicensed, shorter expiry – BNF recommends 2 weeks expTime to order

Consider trial of urea containing product instead e.g. 1.Instead of 10% salicylic acid cream trial 10% urea cream (Aquadrate or Hydromol intensive)2.Instead of 25% salicylic acid cream consider 25% urea cream (Flexitol Heel balm)Prescribe as brand to prevent a “special” urea cream being dispensed

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Specials December 13

Period Name BNF Name

Total Items Quantity

Total Act Cost Medication Ordered

Dec-13Unspec Drug Code_(Discount Not Deducted) 1 100 £205.14

Unguentum M Cream -Cholestyramine 5% W/W in Unguentum M

Dec-13 Unspec Drug Code_ 1 100 £223.80Hydrocortisone 1% cream 50% with 3% Sulpha, 3% salicyclic acid to 100% with AqCr

Dec-13Unspec Drug Code_(Discount Not Deducted) 1 100 £208.77

Betamethasone valerate 0.1% ointment - 25% in coal tar paste

Dec-13Unspec Drug Code_(Discount Not Deducted) 1 100 £208.78

Betamethasone valerate 0.1% ointment - 25% in coal tar paste

Acne National Spend Trend

Cost of acne products (Sept 13)

Acne pathway

Mild comedonal acne - start with topical retinoid e.g. adapalene (Differin) cream or gel is the formulary choice. Mild inflammatory acne (papular/pustular) - use both a topical anti-inflammatory agent (benzoyl peroxide) e.g. Quinoderm cream / Acnecide 5% gel and an antibacterial one e.g. clindamycin (Dalacin T topical solution or lotion). If there are comedones add a topical retinoid as well. Consider using combination products e.g. Duac Once Daily gel (clindamycin & benzoyl peroxide) or Epiduo gel (adapalene & benzoyl peroxide 2.5%) although these tend to be more expensive. Moderate acne - combine systemic & topical treatmentQuinoderm / Acnecide cream in the morning Topical adapalene at night e.g. Differin cream or gelOral antibioticsModerately severe acne in women- consider adding co-cyprindiol 2000/35 (if no contra-indications). Once sustained improvement (3 months) consider changing to an oestrogenic COC e.g. Gedarel 30/150 to prevent rebound. Acne in pregnancy – Benzoyl peroxide, topical and oral erythromycin are all considered safe if treatment considered appropriate. Severe acne- as for moderate acne but consider early referral for oral isotretinoin if large nodulocystic lesions, scarring or no rapid response to treatment.

CRHFT how to send in prescribing issues

•CRHFT direct reporting function on their website that practices can use to report any CRHFT issue related to medicines e.g. discharge concerns, inappropriate prescribing requests, any other prescribing related issue.

•Martin Shepherd will then find an answer to the issue and report this back to whoever submits the issue (please note urgent clinical queries will still need to made via phone calls to the relevant person at the hospital).

•Martin will also collate information on issues raised and take those to the bimonthly drug and therapeutics committee at CRHFT, and also to the prescribing sub group.

CRHFT how to send in prescribing issueshttp://www.chesterfieldroyal.nhs.uk/gp/?_ts=1

username = gpuser password = mozartThen click on “prescribing concern” in the left hand list and then click on the blue words, in the text on the right hand side – email form template – this will open up an automatic email which the GP or practice member can complete and send direct to Martin Shepherd at CRHFT.