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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 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 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. Patients at risk of having an exacerbation can be given a rescue pack as part of a self-management plan. 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 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