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Please note that these are national generic supply
There are a number of generic medications which are shortages identified by the Department of Health, and
not
influenced
by
local
ScriptSwitch
currently reported to be in short supply as recognised are
by the Department of Health, and hence are incurring recommendations.
increased costs (although many of these do appear
Other drug shortages:
to be available locally):
Generic stock shortages - August 2014
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Amiloride 5mg tablets
Cefalexin 500mg/5ml oral suspension
Co-amilofruse 2.5/20 tablets
Co-amilofruse 5/40 tablets
Co-tenidone 50/12.5mg tablets (new)
Co-tenidone 100/25mg tablets (new)
Exemestane 25mg tablets (new)
Fenofibrate micronised 200mg capsules
Hydrocortisone 10mg tablets
Naftidrofuryl 100mg capsules
Naproxen 500mg gastro-resistant tablets
Pizotifen 500mcg tablets
Pizotifen 1.5mg tablets
Tamoxifen 20mg tablets
Valsartan 40mg, 80mg and 160mg capsules
Prescribing
Update
September 2014 Newsletter
On behalf of Thurrock CCG and BBCCG
 Diamox (acetazolamide) SR 250mg MR capsulesexpected to be back in stock by November 2014.
Please note that standard acetazolamide 250mg
tablets are available
 Co-Phenotrope 2.5/0.25 mg (diphenoxylate
hydrochloride/atropine
sulphate)
tablets-not
expected to be back in stock until June 2015, but
does appear to be available locally
 Demeclocycline 150mg capsules-not expected to
be back in stock until June 2015. We recommend
that you seek specialist advice for alternative
treatment on an individual patient basis.
Please contact the Medicines Management Team to
enquire about any other reported local drug
shortages and/or advice regarding suggested
alternatives.
Mirvaso (brimonidine) gel
Mirvaso is a new topical gel containing brimonidine 3mg/g, and is licensed for the symptomatic treatment of
facial erythema of rosacea in adult patients. This preparation has not yet been reviewed by the Medicines
Management Committee for clinical and cost effectiveness, and therefore it is currently not recommended
locally. Please do not prescribe Mirvaso gel until it has been locally reviewed.
Magnesium oxide and magnesium glycerophosphate-unlicensed specials products
Magnesium supplements represent one of the highest cost specials products locally, with no licensed
equivalents available. Please consider the use of the requisition route for the supply of some of the
magnesium oxide preparations (details available from the Medicines Management Team). Alternatively,
please ensure that prescriptions for magnesium oxide and magnesium glycerophosphate are written as the
following brand names to ensure that the most cost effective product is supplied:
-Magnesium glycerophosphate capsules/tablets 97.2mg (4mmol) as Magnaphate tablets 97.2mg (4mmol)
-Magnesium glycerophosphate chewable tablets 97.2mg (4mmol) as Magnaphate tablets (which are
chewable) 97.2mg (4mmol)
-Magnesium oxide capsules 160mg (4mmol) as OroMag capsules 160mg (4mmol)
These recommendations are on the ScriptSwitch profile and the products are readily available for community
pharmacies to order through the main pharmacy wholesalers. Prescribing as these branded products could
significantly reduce prescribing costs of magnesium products in primary care.
Sildenafil schedule change
On 1st August 2014, changes to the SLS regulations removed generic sildenafil from the list of medicines
that may be prescribed only where patients meet the SLS requirements. This means that patients can be
prescribed generic sildenafil without needing to meet the previous Department of Health criteria (ie having
one of the defined health conditions when suffering from erectile dysfunction), and that generically written
prescriptions for sildenafil no longer require the prescriber to annotate them with the letters “SLS”.
In June 2013, the UK patent protection for Viagra expired. Following this, the price of generic preparations of
sildenafil dropped by around 95% of the price of branded Viagra, from £21.27 to £1.12 currently for a 4 tablet
pack (50mg tablets). Therefore, due to a reduction in the cost of generic sildenafil, the prescribing restrictions
have been removed and prescriptions for generic sildenafil no longer need to be annotated with “SLS”.
However, the remainder of the Department of Health information regarding frequency of prescribing still
applies. Viagra, however, has been added to the SLS list and so must be annotated “SLS” in order to be
valid. Prescribing restrictions are still in place for all other in-patent and branded erectile dysfunction
treatments.
The generic drugs apomorphine hydrochloride, moxisylyte hydrochloride and thymoxamine hydrochloride are
also all removed from the list and can be prescribed in their generic form without annotating with the letters
“SLS”.
Avanafil (new agent, currently non-formulary) has been added to the list of drugs used for the treatment of
erectile dysfunction, which must be annotated “SLS”.
As a result of this change, patients who have been prescribed sildenafil privately because they did not
previously meet the SLS eligibility criteria will now be able to have generic sildenafil prescribed on the NHS.
Please note that the once daily tadalafil (Cialis) regimen (2.5mg and 5mg daily) is non-formulary locally and
not recommended for prescribing in primary care.
Fluoxetine dispersible tablets
Olena 20mg dispersible tablet is a new formulation of fluoxetine 20mg. This provides a more cost effective
option than the fluoxetine oral solution for patients that have a genuine swallowing difficulty with the standard
fluoxetine capsules (cost of £3.44 for 28 dispersible tablets).
Olena may also be an option for patients who are on a reducing dose regimen or require a 10mg dose of
fluoxetine. There is currently no licensed fluoxetine 10mg tablet/capsule formulation, and if prescribed this
would therefore be supplied as an unlicensed and potentially costly special product (recent prescribing data
shows that one prescription for unlicensed 30 fluoxetine tablets costs £174). The Olena 20mg dispersible
tablets have a score line and can therefore be broken in half to provide a 10mg dose. The tablet or half tablet
can be swallowed with a sufficient amount of fluid or can be dispersed in water.
COPD/Asthma Guidance
Guidance updates on the management of COPD and the management of asthma are available and
have been approved by the local Respiratory Clinical Network. Both documents aim to support
prescribers and nurses implement COPD/asthma medicines optimisation, the QIPP respiratory
agenda and cost effective prescribing. The guidance also details first choice inhaler products and
devices for each step of management. Please find some key points from the guidance summarised
below.
Long acting
β2-agonist (LABA) plus
corticosteroid (ICS) in a combination inhaler
inhaled
 First line LABA/ICS combination inhaler:
 Fostair (MDI) (beclometasone/formoterol) 100/6 2
puffs BD
 Licensed and first line in COPD and asthma
 Second line: Symbicort Turbohaler in COPD and asthma
 Third line: Seretide Accuhaler
 Third line in COPD if patient can’t use/tolerate 1st/2nd
line: Seretide 500 Accuhaler 1 puff BD
 Step 4 only in asthma if patient can’t use/tolerate
Symbicort Turbohaler: Seretide 500 Accuhaler 1 puff
BD
 Seretide 250 Evohaler is not licensed in the
management of COPD
 A switch from unlicensed Seretide 250 Evohaler (2
puffs BD) to licensed Seretide 500 Accuhaler (1 puff
BD) is encouraged and is a more cost effective option
Mucolytics-carbocisteine (Mucodyne)
 Mucolytics may reduce exacerbations in
 Initially use a higher starting dose,
decrease dose as condition improves
 Discontinue treatment if no symptomatic
improvement after a 4 week trial (patient
should show a decreased frequency of
cough and sputum production)
 Mucolytics should not be used for acute
exacerbations of COPD
muscarinic
agents
 Tiotropium (Spiriva) HandiHaler is currently
first line
 Tiotropium (Spiriva) Respimat device is
not recommended (MHRA safety advice)
 Housekeeping-please ensure HandiHaler
device is not supplied on regular repeat
prescription
 Newer LAMAs on the market: aclidinium
(Eklira Genuair) and glycopyrronium (Seebri
Breezhaler)
 Formulary application shortly
 May be an option if patient unable to use
HandiHaler device
 More cost effective options
COPD Rescue Packs
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Providing self-management advice on responding
promptly to symptoms and starting appropriate treatment
with oral steroids and/or antibiotics can help to reduce
the severity of COPD exacerbations and may reduce the
need for hospital admission.
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Patients at risk of having an exacerbation can be given a
rescue pack as part of a self-management plan.
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What to include in the rescue packs:
 Antibiotics: doxycycline 200mg as a single dose,
followed by 100mg once daily for 5 days.
 Prednisolone 30mg once daily in the morning (plain
tablets-not enteric coated) for 7 days
patients with a chronic productive cough
with COPD. However, the overall benefit
seems to be small and evidence is
controversial
 Review mucolytic treatment after 4 weeks
Regular long acting
(LAMAs) in COPD
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Patients should be advised to contact a healthcare
professional if they do not improve.
Non-formulary/not recommended therapy:
 Roflumilast (Daxas) is only recommended by NICE when used as part of a clinical trial.
 Indacaterol (Onbrez Breezhaler) a long acting β2-agonist, is non-formulary and not recommended.
 Relvar Ellipta (vilanterol/fluticasone furoate) inhaler is non-formulary and should not be used for COPD or
asthma. This is due to a lack of evidence of clinical superiority and potential safety risks and concerns
regarding the product and inhaler design.
 Anti-tussive therapy should not be used in the management of stable COPD.
MHRA Drug Safety Update August 2014
E-learning module on oral anticoagulants
The MHRA has launched an online oral anticoagulants learning module for health professionals. The
module outlines the key risks of these valuable and widely prescribed medicines. Designed for use by
all clinical practitioners, the module covers:
 a description of important adverse effects
 factors that increase the risk of adverse effects
 how the clinician and the patient can reduce the risk
 specific treatment of the adverse effect
The learning module on oral anticoagulants has been approved for up to 1.5 continuing professional
development (CPD) credits by the Faculty of Pharmaceutical Medicine of the Royal Colleges of
Physicians of the United Kingdom.
There are other CPD-approved MHRA learning modules on antipsychotics, benzodiazepines, opioids,
and selective serotonin reuptake inhibitors.
MHRA oral anticoagulants learning module:
http://www.mhra.gov.uk/ConferencesLearningCentre/LearningCentre/Medicineslearningmodules/
Oralanticoagulants/index.htm
Update on shingles (Zostavax) immunisation programme from 1st September 2014NHS England
Public Health NHS England recently provided information on the second year of the shingles
immunisation programme.
Shingles immunisation was introduced on 1st September 2013 for patients aged 70 and 79 on that
date. In time the programme will work towards offering immunisation to all 70 to 79 year-olds, subject
to the availability of the vaccine and the capacity of the system to deliver the full range of
immunisations which make up the national immunisation programme.
Any individual who reaches their 80th birthday is no longer eligible for the vaccination due to the
reducing efficacy of the vaccine as age increases. This follows the recommendation made by the Joint
Committee on Vaccination and Immunisation for the shingles vaccination programme.
Changes from September 2014 are as follows:
 From 1st September 2014, immunisation should be offered to patients aged 70 for the routine

programme, and aged 78 and 79 for the catch-up programme. Eligibility is determined by the
patient’s age on 1st September 2014.
From 1st September 2014 GPs may continue to offer immunisation to all those who became
eligible as 70 year-olds from 1 September 2013 but have not yet been immunised. NOTE-No Item
of Service fee will be applicable.
Supplies of Zostavax for use in the national programme should continue to be ordered online via the
ImmForm website:
https://www.immform.dh.gov.uk/SignIn.aspx?ReturnUrl=%2f