Prescribing Update

Catherine ArmstrongLead Pharmacist - Pharmicus

GMC – Good Practice in Prescribing & Managing Medicines and Devices

• Effective from 25.2.13• Must explain and justify decisions / actions• YOU are responsible for any script you sign

• Several MUSTs and SHOULDs• Full guidance available:http://www.gmc-uk.org/Prescribing_Guidance__2013__50955425.pdf

GMC – Unlicensed MedicinesGMC recommends that GPs can prescribe unlicensed or “off license” medicines but, if you decide to do so, you must:

• Be satisfied that an alternative, licensed medicine would not meet the patient's needs

• Be satisfied that there is a sufficient evidence base and/or experience of using the medicine to demonstrate its safety and efficacy

• Take responsibility for prescribing the medicine and for overseeing the patient's care, including monitoring and any follow up treatment

• Record the medicine prescribed and, where you are not following common practice, the reasons for choosing this medicine in the patient's notes. (Code 8B2V)

Which are specials?

Drug• Paracetamol 120mg/5ml• Paracetamol 250mg/5ml• Paracetamol 500mg/5ml

• Morphine 10mg/5ml• Morphine 20mg/5ml• Morphine 20mg/1ml

Average cost• £1.12 per 200ml• £1.30 per 200ml• £73.76 per 200ml

• £1.78 per 100ml• £689.57 per 420ml• £4.98 per 30ml

Specials

• Is a liquid formulation needed?• Is the drug readily available in a liquid form?• Can another drug be substituted?• e.g. fluoxetine liquid for sertraline tablets

• COST of licensed option is not a reason to avoid using

Controlled Drug Prescribing

Form? Needs dose

Not needed

Gastro-Intestinal

• Mucogel not Maalox• Peptac not Gaviscon Advance– Can use Gaviscon Advance tablets for portability

• PPI – Omeprazole / Lansoprazole / Pantoprazole– Avoid Omeprazole 40mg – use 2x20mg– Consider C Diff risk

Domperidone Interaction

• Small increased risk of serious ventricular arrhythmia or sudden cardiac death

• Higher risk – Patients aged 60+ – Daily doses >30mg

• MHRA advice – Use lowest effective dose– Consider QT prolongation interacting meds

Metoclopramide Interaction

• August MHRA Drug Safety Update

• Contraindicated in <1 year old• Restricted use/doses <18 years old• Maximum of 30mg per day for 5 days in adults

MHRA Simvastatin Alert

• List of drugs contra-indicated with simvastatin• List of drugs - maximum dose of simvastatin– Main action: amlodipine & diltiazem

• Primary Prevention – ↓ simvastatin 20mg• Secondary prevention – depends on latest

lipid profile• Action at next review of patient

FATS6 - Secondary Prevention of CVD (symptomatic or prior occlusive vascular disease)

Acute Coronary syndrome / Acute MI • Initiate Atorvastatin 80mgAll other conditions• Simvastatin 40mg 1st-line (unless interactions)• Repeat lipid profile 8 weekly and consider

titration unless TC < 4mmol/l, LDL-C (fasting) < 2mmol, or non-HDL < 2.8mmol/l

• Titrate to Atorvastatin 40mg then 80mg

FATS6 - Type 1 and Type 2 diabetes

Consider drug treatment in all Type 1 and 2 diabetics:• with microalbuminuria/proteinuria (any age)• over 40 years• under 40 years if other CV risk factors present.• Simvastatin 40mg 1st-line (unless interactions)• Repeat lipid profile 8 weekly and consider titration unless TC <

4mmol/l, LDL-C (fasting) < 2mmol, or non-HDL < 2.8mmol/l• Titrate to Atorvastatin 40mg then 80mg

• If Type 2 diabetes and triglycerides > 1.7 & < 10 mmol/l– lifestyle measures for 6 months then consider adding a fibrate

(Fenofibrate 200mg daily, reduced doses in CKD)

FATS6 - Primary Prevention (no symptomatic or prior occlusive vascular disease)

• Treatment is based on risk and not cholesterol levels

• If 10 year CVD risk ≥ 20%, consider Simvastatin 40mg (reduce dose for drug interaction – more detail in full guidance)

FATS6 - Other points to note

• Consider familial hyperlipidaemia (FH) if TC > 7.5mmol/l, LDL cholesterol > 4.9

• Suspected FH if triglycerides > 4.5mmol/l• If triglycerides > 10mmol/l, seek specialist advice

Simvastatin 80mg• Prescribing of Simvastatin 80mg is no longer

recommended due to risk of myopathy. • Review patients taking Simvastatin 80mg their next

routine appointment.

Dual Antiplatelet Therapy

Aspirin 75mg daily

STEMI NSTEMI UNSTABLE ANGINA

EITHER INVASIVE THERAPY INVASIVE THERAPY

TICAGRELOR 90MG BD FOR 12 MONTHS

TICAGRELOR 90MG BD FOR 12 MONTHS

TICAGRELOR 90MG BD FOR 12 MONTHS

OR INVASIVE NOT SUITABLE INVASIVE NOT SUITABLE

PRASUGREL 5MG OR 10MG OD FOR 12 MONTHS

CLOPIDOGREL 75MG OD FOR 12 MONTHS

CLOPIDOGREL 75MG OD FOR 12 MONTHS

Respiratory

• Beclometasone inhalers – BRAND

• Consider combinations

• 2 new COPD inhalers

• Consider quantities when reviewing

Pregabalin

• Avoid more than 1 capsule per dose

• QDS is not licensed, use maximum of TDS

• Each capsule/strength priced the same - £1.15

• Most popular “street” drug abused

Paracetamol doses

120MG/5ML

AGE DOSE

3-6M 2.5ML

6-24M 5ML

2-4Y 7.5ML

4-6Y 10ML

ALL UP TO QDS

250MG/5ML

AGE DOSE

6-8Y 5ML

8-10Y 7.5ML

10-12Y 10ML

ALL UP TO QDS

Do NOT use in under 6yrs

Antibiotics

• “Preferred” antibiotics:Amoxicillin NitrofurantoinClarithromycin OxytetracyclineDoxycycline Penicillin VFlucloxacillin TrimethoprimMetronidazole (Erythromycin)

• Aim for 85% of prescribing to be these

• Linezolid = HOSPITAL PRESCRIBING ONLY

C Diff

• THINK– Patient - aged 65+, frequent Abx, recent Abx– Environment – contact, hospital admission,

institutionalised– Action – avoid high risk: cephalosporins,

ciprofloxacin/quinolones, clindamycin, co-amoxiclav

• TEST• TREAT

Role of 4C antibiotics on local guidelines

• Sinusitis– 1st = amoxicillin, 2nd =

doxycycline– Co-amoxiclav 625mg tds x21

for persistant symptoms only

• COPD exacerbation– 1st – amoxicilllin, 2nd =

doxycycline– Co-amoxiclav 625mg tds x15

if resistant risk factors

• ProstatitisCiprofloxacin 500mg BD x56

• Cellulitis/Wounds– 1st = flucloxacillin, 2nd =

clarithromycin– Co-amoxiclav 625mg tds x21

only if facial involvement

• Human/Animal Bites Co-amoxiclav 625mg tds x21

• Pyelonephritis Co-amoxiclav 625mg tds x42 Ciprofloxacin 500mg bd x14

Minocycline

• No clear evidence better than alternatives• Safety concerns + monitoring• Higher cost:

Minocycline 100mg M/R caps OD £10.04 Doxycycline 100mg caps OD £3.92

Minocycline 100mg caps OD £13.09 Lymecycline 408mg caps OD £6.22

Minocycline 100mg tabs OD £13.72 Erythromycin 250mg tabs 2BD £7.96

Minocycline 50mg caps BD £15.27 Oxytetracycline 250mg tabs 2BD £5.32

Minocycline 50mg tabs BD £11.42 28 day courses (Drug Tariff August 2013)

Diabetic Drugs

• Prescribe all insulin by brand name• Blood Glucose Testing advice– Type 1 - appropriate amounts– Type 2 - see local guidance– Consider latest DVLA advice also – local guidance under

review as a result

• Insulin Passports – NPSA safety alert, all patients aged 18+ using insulin should have or have opted out

Bisphosphonates

• Alendronate or Risedronate 1st line

• Strontium has VTE warning– Avoid if current/previous VTE– Avoid if temporary/permanent immobilisation

Prescribing Engagement Scheme• MANDATORY - Review of repeat prescribing and dispensing systems AND

engagement with Pharmicus / Medicines Optimisation support

• FINANCIAL – Collectively deliver financial balance for CCG

ALL 3 AREAS Emollient s – Gateshead

Wound management 1st line antidepressants - Gateshead

Strong opioid prescribing (morphine)

Erectile Dysfunction Drugs – Newcastle

Ezetimibe – Newcastle North & East

Laxatives Effervescent analgesics – Newcastle West

Venlafaxine MR caps to MR tabs – Newcastle West

Specials – Newcastle North & East

Useful websites

• Gateshead Information Network

www.ginportal.info• North of Tyne Area Prescribing Committe

www.northoftyneapc.nhs.uk• Electronic Medicines Compendium

www.medicines.org.uk• Athens registration

https://register.athensams.net/nhs/nhseng/• Medicines and Prescribing support from NICE

http://www.nice.org.uk/mpc/index.jsp