Download Tablets issue 17 - Wirral Medicines Management

Issue 17, July 2015
Current Issues............................................................................................................................................................................. 1
Topic of the Month ..................................................................................................................................................................... 1
Drug Tariff .................................................................................................................................................................................. 3
Safety ......................................................................................................................................................................................... 5
Current Issues
Prescription requirement changes for temazepam
As of 1st June 2015, prescriptions for temazepam must fully comply with the prescription writing requirements for
Schedule 3 controlled drugs. Prescriptions for temazepam must now contain the following information:
 dose
 form
 strength (where appropriate)
 total quantity of the preparation in both words and figures
Topic of the Month
STRONG OPIOIDS AND TRANSDERMAL PATCHES
Strong opioids
Pain can be mild, moderate or severe. It can be treated using different strengths of painkiller, depending on the level
of pain experienced by the patient. The World Health Organisation (WHO) Pain Ladder(1) shows each level of pain and
the type of painkillers that are best to control it:
1.
Mild pain - Step one includes non-opioid drugs e.g. paracetamol and anti-inflammatory drugs (ibuprofen,
naproxen).
2.
Moderate pain - Step two includes weak opioid drugs e.g. dihydrocodeine, codeine phosphate or tramadol.
3.
Moderate to severe pain - Step three includes strong opioid drugs e.g. morphine, fentanyl and oxycodone.
Adjuvant drugs such as anti-depressants or anti-consultants may also be used to control pain.
Pain management
When starting a painkiller remember:



Mouth - use the oral route where possible, even for opioids.
By the clock - for persistent pain, provide medication at regular set intervals (around the clock) rather than
when required.
Use the WHO Pain Ladder (see diagram).
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WHO Pain Ladder
Key Messages

Oral analgesics are generally preferred as first line therapy in chronic non-cancer pain. Buprenorphine patches
at lower doses (BuTrans®) are broadly as effective as codeine or tramadol but are much more expensive.

NICE guidance recommends oral morphine as the first-line strong opioid for palliative care(2). Buprenorphine
patches cost several times more than oral morphine in equivalent doses.

The patches are unsuitable for acute or unstable pain due to the need for slow titration of doses; it may take up
to 72 hours to achieve a stable blood level after a change in dose.

Patches containing buprenorphine (Transtec®, BuTrans®) are an alternative to oral opioid analgesics.
Buprenorphine patches are generally not recommended as a first-line analgesic and should not be used for
unstable pain. Analgesic patches are considerably more expensive than oral therapy.
Circumstances when patches may be considered preferable to oral products include if the patient:
•
•
•
•
•
has difficulty/inability to swallow, or the oral route is inappropriate
is intolerant of oral analgesics or is experiencing unacceptable side-effects with oral analgesics
has poor absorption from the gastrointestinal tract
has renal impairment
has compliance problems – supervised patch changes will assist this.
Cost of patches (28 days)3
Buprenorphine 5mcg/hr (BuTrans®)
Buprenorphine 10mcg/hr (BuTrans®)
Buprenorphine 20mcg/hr (BuTrans®)
Buprenorphine 35mcg/hr (Trantec®)
Buprenorphine 52.5mcg/hr (Transtec®)
Buprenorphine 70mcg/hr (Transtec®)
- £17.60
- £31.55
- £57.46
- £27.65
- £41.49
- £55.30
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Prescribing data
Prescribing data for buprenorphine patches in the last year (April 14- March 15):
Wirral spent a total of £113,346 on buprenorphine patches; 10% of this cost was as a result of prescribing the
weaker strength patch BuTrans®, which has a similar analgesic effect to co-codamol or tramadol.
References:
1. World Health Organization (2009). WHO’s Pain Relief Ladder www.who.int/cancer/palliative/painladder/en/
2. NICE CG140 Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults.
http://publications.nice.org.uk/opioids-in-palliative-care-safe-and-effective-prescribing-of-strong-opioids-for-pain-in-palliativecg140/recommendations
3. Drug Tariff online July 2015
Drug Tariff
PRICE CHANGES
Top 10 monthly price reductions
Methyldopa 125mg tablets [1 x 56] £116.27 (-£4.99)
Dexamethasone 500microgram tablets [1 x 28] £58.83 (-£4.59)
Aripiprazole 30mg tablets [1 x 28] £177.85 (-£3.56)
Aripiprazole 10mg tablets [1 x 28] £88.93 (-£1.78)
Aripiprazole 15mg tablets [1 x 28] £88.93 (-£1.78)
Aripiprazole 5mg tablets [1 x 28] £88.93 (-£1.78)
Isradipine 2.5mg tablets [1 x 56] £185.64 (-£1.63)
Dexamethasone 10mg/5ml oral solution sugar free [1 x 150] £96.05 (-£1.61)
Famciclovir 500mg tablets [1 x 14] £154.04 (-£1.08)
Ibuprofen 10% gel [1 x 100] £4.92 (-£0.87)
Top 10 monthly price increases
Nitrofurantoin 25mg/5ml oral suspension sugar free [1 x 300] £260.46 (+£64.63)
Trifluoperazine 1mg/5ml oral solution sugar free [1 x 200] £65.73 (+£32.87)
Ampicillin 250mg/5ml oral suspension [1 x 100] £38.86 (+£31.47)
Triamterene 50mg capsules [1 x 30] £41.90 (+£13.98)
Amantadine 50mg/5ml oral solution sugar free [1 x 150] £103.25 (+£13.95)
Chloral hydrate 143.3mg/5ml oral solution BP [1 x 150] £194.06 (+£13.45)
Disopyramide 150mg capsules [1 x 84] £27.58 (+£8.82)
Cloral betaine 707mg tablets [1 x 30] £110.06 (+£7.53)
Prochlorperazine 3mg buccal tablets [1 x 50] £23.98 (+£5.76)
Gentamicin 0.3% / Hydrocortisone acetate 1% ear drops [1 x 10] £11.98 (+£5.32)
Top 100 annual price reductions
http://www.panmerseyapc.nhs.uk/home/tariff_watch/partviiia_reductions_201506.pdf
Top 100 annual price increases
http://www.panmerseyapc.nhs.uk/home//tariff_watch/partviiia_increases_201506.pdf
DRUG AVAILABILITY
Drugs with long-term supply issues
The following drugs have long-term supply issues. The table below shows the reason for the supply issue, where
known, and possible return to stock dates.
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Description
Anusol Hc® suppositories x12 and x24
(Johnson & Johnson)
Aptamil® lactose free milk powder
x400g
(Danone Nutricia)
Caverject® Dual Chamber
20micrograms x2 (Pfizer)
Colofac® tablets 135mg x100
(Bgp Products)
Co-phenotrope tablets
2.5/0.025mg x100
(Amco Rwa / Mercury Pharma)
Creon® 40 000 capsules x100
(Abbott Healthcare)
Diclofenac sodium ec tablets 50mg
(various makes)
Freestyle® blood glucose test strips
x50 (Abbott)
Genticin® eye/ear drop 0.3% x10ml
(Amco / Amdipharm)
Hormonin® tablets x84
(Amco Rwa / Mercury Pharma)
Methotrexate tablets 2.5mg x24
(Various brands)
Modrasone® cream x50g (Teva)
Due date
Comment
Supplier unable to confirm
Manufacturing issue is causing a delay in
supply
Supplier unable to confirm
Stock on allocation from supplier.
January 2016
Supplier unable to confirm
July 2015
January 2016
Supplier unable to confirm
Limited supplies ongoing
Supplier unable to confirm
Limited supplies ongoing
October 2015
July 2015
Sno Tears®eye drops 10ml (Bausch &
Lomb)
Supplier unable to confirm
Synalar® cream x30g (Derma UK)
Supplier unable to confirm
Synalar® cream 1:4 x50g (Derma UK)
Supplier unable to confirm
Traxam® gel 3% x100g
(Amco Rwa / Mercury Pharma)
Traxam® pain relief gel x30g
(Amco Rwa / Mercury Pharma)
Unistik® 3 comfort lancet 28G X 1. 8mm
x100 (Owen Mumford)
Unilet® C touch lancets 28Gx0.38mm
100
VitA-POS® eye ointment x5g
(Scope Opthalmics)
Zidoval® vaginal gel 0.75% x40g
(Meda Pharma)
Zacin® cream 0.025% x45g
(Teva)
Manufacturing issue is causing a delay in
supply. Medical Information Enquiries 0845 608 8866
Manufacturing issue is causing a delay in
supply
Supplier issue is causing a delay in
supply.
Manufacturing issue is causing a delay in
supply.
Market shortage is causing a delay in
supply.
Ongoing supply issue.
Manufacturing issue is causing a delay in
supply
Supplier issue is causing a delay in
supply
Market shortage is causing a delay in
supply
Manufacturing issue is causing a delay in
supply
Manufacturing issue is causing a delay in
supply
Manufacturing issue is causing a delay in
supply
Manufacturing issue is causing a delay in
supply
February 2016
Supplier issue is causing a delay in supply
February 2016
Supplier issue is causing a delay in supply
July 2015
Supplier issue is causing a delay in supply
Supplier unable to confirm
Supplier issue is causing a delay in supply
Supplier unable to confirm
Supplier issue is causing a delay in supply
August 2015
Supplier issue is causing a delay in supply
Supplier unable to confirm
Manufacturing issue is causing a delay in
supply
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Zovirax® 3% eye ointment supply problems
There is a supply problem with Zovirax® 3% eye ointment (aciclovir 3% eye ointment) following a recall of
contaminated batches in November 2014. Although supplies were due to resume in April 2015, there are still very
limited stocks available.
UK licensed treatment options for managing herpes simplex keratitis are:
• Ganciclovir 0.15% eye gel (Virgan®) – licensed for the treatment of acute herpetic keratitis (dendritic and
geographic ulcers), given as ‘one drop five times daily’ until epithelial healing occurs. Treatment should not
exceed 21 days.
• A treatment course of oral aciclovir 400mg 5 times a day for 10 to 14 days.
UK Medicines Information (UKMi) have issued the following guidance:
http://www.medicinesresources.nhs.uk/en/Communities/NHS/SPS-E-and-SE-England/MedicinesInformation/Discontinuation-Supply-Shortage-Memos/Shortage-of-Zovirax-eye-ointment-3/
Creon® 40 000 capsules supply problems
The manufacturer has stated that due to a lower than expected yield for this biological enzyme, there are supply
constraints with the 40 000 strength of Creon® and they don’t have a stock availability date. However this should not
impact on patient care as there is ample stock of the 10 000 and 25 000 strengths of Creon®.
Patients who are prescribed Creon® 40 000 supplements should be switched to alternative strengths to ensure
continuity of supply.
Discontinued products- Co-danthramer (dantron/poloxamer 188 25mg/200 mg) and strong co-danthramer
(dantron/ poloxamer 188 37.5mg/500 mg) capsules
These have been discontinued by Napp. Stock of co-danthramer capsules is expected to last until the end of June
2015 and stock of strong co-danthramer capsules until the end of December 2015. Alternative suspension
formulations of co-danthramer are available.
For further information regarding supply problems, please contact Medicines Information.
Safety
Can breastfeeding mothers take paracetamol?
Paracetamol has been widely used on prescription and over-the-counter since it launched in the UK in 1956.
Paracetamol can be given therapeutically to infants (including premature infants from 28 weeks corrected
gestational age) at a dose of 10-15mg/kg body weight every 8-12 hours for pain and pyrexia. It is also given to infants
for post-immunisation pyrexia. Although paracetamol is widely used, the evidence for its safety in breastfed infants
is based on mainly small, uncontrolled studies of single doses of paracetamol. However, it is considered to be
compatible with breastfeeding and there appears to be no significant risk to the infant. There is a risk to the infant of
hypersensitivity from low levels of exposure to paracetamol or its metabolites but it remains the choice of analgesia
for breastfeeding mothers. Paracetamol has a relatively short half-life in adults of approximately two hours and the
quantity of drug which passes in to the breast milk is very small.
If the infant is pre-term, has a low birth weight or has an underlying medical condition, then further advice should be
sought as it may affect the disposition and excretion of the drug.
Full details are available from this link;
http://www.evidence.nhs.uk/Search?q=%22Can+breastfeeding+mothers+take+paracetamol%22
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MHRA DRUG SAFETY UPDATE
SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin): risk of diabetic ketoacidosis
Sodium glucose co-transporter 2 (SGLT2) inhibitors are licensed for use in adults with type 2 diabetes to improve
glycaemic control. Serious and life-threatening cases of diabetic ketoacidosis (DKA) have been reported in patients
taking SGLT2 inhibitors (canagliflozin, dapagliflozin or empagliflozin).
When treating patients who are taking an SGLT2 inhibitor:

test for raised ketones in patients with symptoms of diabetic ketoacidosis (DKA); omitting this test could delay
diagnosis of DKA

if you suspect DKA, stop SGLT2 inhibitor treatment

if DKA is confirmed, take appropriate measures to correct the DKA and to monitor glucose levels

inform patients of the symptoms and signs of DKA e.g. nausea, vomiting, anorexia, abdominal pain, excessive
thirst, difficulty breathing, confusion, unusual fatigue or sleepiness. Advise them to get immediate medical help
if these occur

be aware that SGLT2 inhibitors are not approved for treatment of type 1 diabetes

please continue to report suspected side effects to SGLT2 inhibitors or any other medicines on a Yellow Card
Full details are available from this link
https://www.gov.uk/drug-safety-update/sglt2-inhibitors-canagliflozin-dapagliflozin-empagliflozin-risk-of-diabeticketoacidosis
Medicines Management Team contacts:
Victoria Vincent (Wirral)
[email protected]
0151 643 5319
For any feedback or suggestions on content, please email [email protected]
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