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ROTHERHAM
AREA PRESCRIBING COMMITTEE
NEWSLETTER
BULLETIN NO 16
September 2006
Following meeting 20 September 2006
HOT TOPIC 1: Ivabradine
Ivabradine (Procoralan) is a new drug for the symptomatic treatment of chronic
stable angina. It is licensed only for people with normal sinus rhythm who have a
contraindication or intolerance to beta-blockers. It is a selective sinus node If
inhibitor (It blocks a specific ion channel, the funny channel). Ivabradine has been
shown to be more effective than placebo and non-inferior to atenolol 100mg daily
and amlodipine 10mg daily.
It has a number of contraindications, cautions, and potential drug interactions.
Visual symptoms were the most common adverse effect reported in clinical trials.
Ivabradine is much more expensive than the standard treatment options for angina.
If a beta-blocker is not appropriate for first-line therapy, then verapamil or diltiazem
are the recommended alternatives. The APC has decided this drug should be amber
light.
HOT TOPIC 2: Agomelatine.
This drug is to be licensed for the treatment of severe depression. It is a melatonin
receptor agonist and a partial antagonist of serotonin receptors. Its efficacy has not
been directly compared in trials with existing treatments. Having considered current
NICE guidance, Rotherham PCT has red lighted this drug until its place in therapy
has been established.
HOT TOPIC 3: Bevacizumab
Already a first line treatment for the treatment of metastatic bowel cancer. An
application is expected for the treatment of advanced small cell and advanced none
squamous lung cancer. This drug has been red lighted.
HOT TOPIC 4: Natalizumab
This is another monoclonal antibody drug. This time for the treatment of relapsing
remitting multiple sclerosis which has failed to respond to beta interferon. The APC
has red lighted this drug.
HOT TOPIC 5: Triptorelin
This drug is used for the treatment of central precocious puberty in children. The
APC discussed this at some length and decided to red light this drug.
HOT TOPIC 6: Choice of Inhaled Steroid
The PCT first choice inhaled steroid is CFC- containing beclometasone, delivered by
pressurised metered dose inhaler, wherever possible. There are no plans for CFCcontaining beclometasone inhalers to be discontinued. Two CFC- free beclometasone
inhaled products, Qvar® and Clenil Modulite®, are now available, but these are very
different in potency and licensed indications. There is great potential for confusion
and for patients to receive the incorrect dose. Qvar®, CFC- free beclometasone, is
twice as potent as the CFC- containing beclometasone inhalers and the new CFCfree beclometasone inhaler, Clenil Modulite®. Qvar® is not licensed for use in
children.
Action: CFC-containing Beclometasone is the PCT first choice inhaled steroid. Care
should be taken when prescribing and dispensing prescriptions for beclometasone
inhalers to ensure the intended product is provided. The Medicines & Healthcare
Regulatory Authority http://www.mhra.gov.uk/ recommend that, to avoid
confusion for the patient and during dispensing, prescriptions for CFC-free
beclometasone products are written for branded products.
HOT TOPIC 7: Atrial Fibrillation
NICE Clinical Guideline 36 is on the clinical management of Atrial Fibrillation.
Management of new patients involves two clinical decisions each of which has a
separate flow chart in the guidance:
 What should the management for rate or rhythm control be?
 What should the management be regarding stroke thromboprophylaxis
Many newly diagnosed patients are likely to need referral, but GPs will need to use
the stroke risk stratification decision chart from the point of diagnosis. This divides
patients into those who should be treated with aspirin and those that should have
warfarin. The recommended INR target range for warfarin is 2-3. Given the fact that
atrial fibrillation also features in the new QOF and the new CHD NSF chapter the
PCT is planning a TARGET session.
HOT TOPIC 8: Parkinson’s disease
NICE Clinical Guideline 35 is on Parkinson’s disease. An important recommendation
is that all new patients with Parkinson’s disease are referred to a specialist before
treatment is started. The Foundation Trust is revising their referral guidelines in light
of the guidance. These will include tips on accurate diagnosis and whether all
patients, including those in younger age groups, should be referred to a single
specialist Parkinson’s Team. As soon as the guidelines are agreed with the PCT they
will be sent out to GPs. Practice Based Commissioning Groups may find that this is
an area where there is scope for improving the accuracy of referrals, which could
help waiting times and prevent people receiving unnecessary treatment.
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