1 Issue 15, May 2015 Wirral Clinical Guidelines Group ................................................................................................................................................. 1 Current Issues............................................................................................................................................................................. 1 Query Corner .............................................................................................................................................................................. 4 Topic of the month ..................................................................................................................................................................... 5 Drug Tariff .................................................................................................................................................................................. 8 Safety ....................................................................................................................................................................................... 11 Public Health England ............................................................................................................................................................... 14 Wirral Medicines Clinical Guidelines sub group of D&T (April 2015) The following guidelines were approved at the April committee: Checklist for the initial medical and surgical management of patients with Parkinson's disease. Guidelines for the treatment and care of children and young adults with ADHD. Antiplatelet and anticoagulant in stroke guidelines – quick reference guide. The following shared-care guidelines were approved: Lisdexamfetamine shared-care in children and adolescents. Methotrexate (oral and subcutaneous) for psoriasis and other dermatological conditions. Mycophenolate mofetil for pemphigus and other dermatological disease (adults). Hydroxycarbamide for psoriasis (adults). These will shortly be available on the Medicines Management Website at http://mm.wirral.nhs.uk/guidelines/. Current Issues GP Reporting of Hospital Prescribing Issues The most recent report for hospital prescribing issues can be found via the following link: http://mm.wirral.nhs.uk/document_uploads/hospital-concerns/InterfaceReportQ4201415.pdf There were only three issues reported in Q4 of 2014-15, which is very low compared to the usual numbers. Taking the time to report concerns will ensure the Medicines Management Team are aware of problems with hospital prescribing. They can then be addressed to prevent further occurrences and so improve patient care.
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Issue 15, May 2015
Wirral Clinical Guidelines Group ................................................................................................................................................. 1 Current Issues ............................................................................................................................................................................. 1 Query Corner .............................................................................................................................................................................. 4 Topic of the month ..................................................................................................................................................................... 5 Drug Tariff .................................................................................................................................................................................. 8 Safety ....................................................................................................................................................................................... 11 Public Health England ............................................................................................................................................................... 14
Wirral Medicines Clinical Guidelines sub group of D&T (April 2015)
The following guidelines were approved at the April committee:
Checklist for the initial medical and surgical management of patients with Parkinson's disease.
Guidelines for the treatment and care of children and young adults with ADHD.
Antiplatelet and anticoagulant in stroke guidelines – quick reference guide.
The following shared-care guidelines were approved:
Lisdexamfetamine shared-care in children and adolescents.
Methotrexate (oral and subcutaneous) for psoriasis and other dermatological conditions.
Mycophenolate mofetil for pemphigus and other dermatological disease (adults).
Hydroxycarbamide for psoriasis (adults).
These will shortly be available on the Medicines Management Website at http://mm.wirral.nhs.uk/guidelines/.
Current Issues GP Reporting of Hospital Prescribing Issues
The most recent report for hospital prescribing issues can be found via the following link:
Depression in children and young people: Identification and management in Primary, Community and Secondary Care CG28 March 2015 http://www.nice.org.uk/guidance/cg28
Prescribing data for Mental Health (BNF Sections 4.1-4.4)
Items / Astro PUs Cost / Astro PUs Total actual cost
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.
Description
Due date
Comment
Anusol® suppositories x12 and 24 Supplier unable to
confirm
A manufacturing issue is causing a delay
in supply
Bisacodyl suppositories 10mg Supplier unable to
confirm
A manufacturing issue is causing a delay
in supply
Caverject® Dual Chamber (Pfizer) January 2016 A manufacturing issue is causing a delay
in supply. Medical Information Enquiries
- 0845 608 8866
Colofac® tablets 135mg x 100
(Bgp Products)
June 2015 A manufacturing issue is causing a delay
in supply
Co-Phenotrope tablets
2.5/0.025mg x 100 (Amco Rwa /
Mercury Pharma)
June 2015 A supplier issue is causing a delay in
supply.
Diclofenac EC 50mg tablets
(different brands)
Limited supplies ongoing A supplier issue is causing a delay in
supply.
Ferrous Fumerate tablets 210mg
x 84 (Amco Rwa / Mercury
Pharma)
June 2015 A manufacturing issue is causing a delay
in supply.
Glucophage® SR tablets 750mg x
56 (Merck Serono)
Supplier unable to
confirm
A manufacturing issue is causing a delay
in supply
Hormonin® tablets x 84 (Amco
Rwa / Mercury Pharma)
Limited supplies ongoing A supplier issue is causing a delay in
supply
Modrasone® cream 50g (Teva) Supplier unable to
confirm
A manufacturing issue is causing a delay
in supply
Securon® SR tablets 240mg x 28
(Bgp Products)
Supplier unable to
confirm
A manufacturing issue is causing a delay
in supply
Sno Tears® 10ml (Bausch&Lomb) Supplier unable to
confirm
A manufacturing issue is causing a delay
in supply
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Tegretol® Chewtab 100mg x 56
(Novartis Pharma)
Supplier unable to
confirm
A manufacturing issue is causing a delay
in supply
Traxam® gel 3% 100g (Amco Rwa
/ Mercury Pharma)
Supplier unable to
confirm
A manufacturing issue is causing a delay
in supply
Unistik® 3 Comfort Lancet 28G x
1. 8mm x 100 (Owen Mumford)
Limited supplies ongoing A supplier issue is causing a delay in
supply
Unistik® 3 Comfort Lancet 28G x
1.8mm x 50 (Owen Mumford)
Limited supplies ongoing A supplier issue is causing a delay in
supply
Zacin® cream 0.025% 45g (Teva) Supplier unable to
confirm
A manufacturing issue is causing a delay
in supply
Zoton® Fastab® 15mg x 28
(Pfizer)
Supplier unable to
confirm
Product awaiting QC/QA approval
For any further information regarding supply problems please contact your Practice Pharmacist/Technician or the
Medicines Management Team.
Safety
Revised Summary of Product Characteristics (SPC) for Tildiem®
SPC for Tildiem® (diltiazem) products have been revised to include a new warning regarding the potential for
interaction between the combination of grapefruit juice and diltiazem. This is within the current SPC in the Electronic
Medicines Compendium under Interactions (section 4.5).
This section states that grapefruit juice exposure may increase diltiazem exposure (1.2 fold) and advises that patients
who consume grapefruit juice should be monitored for increased adverse effects.
European Medicines Agency (EMA) recommends avoiding the concomitant use of certain hepatitis C medicines
and amiodarone together
Hepatitis C medicines Harvoni® (sofosbuvir with ledipasvir) or a combination of Sovaldi® (sofosbuvir) and Daklinza®
(daclatasvir) have been confirmed by the EMA to cause severe bradycardia or heart block when used in patients
taking amiodarone. A total of eight cases have been reviewed up to April 2015, one of which resulted in a fatal
cardiac arrest and a further two needed pacemaker intervention.
The advice from the EMA is to only use amiodarone in patients taking these hepatitis C medicines if other
antiarrhythmics cannot be used or are contra-indicated. In these circumstances, close monitoring is recommended
and, as amiodarone has a long half-life, monitoring is also required if the hepatitis C drugs mentioned above are
given within a few months of stopping amiodarone. Patients who have no alternative but to take amiodarone with
these hepatitis C drugs should be monitored in a clinical setting for at least 48 hours, and should be told to inform
their doctor immediately if they experience symptoms such as dizziness, slow heart beat, faintness, unusual
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tiredness, shortness of breath or chest pain during treatment. The exact mechanism of action with this interaction is
unknown and further investigations with Sovaldi® and other hepatitis C medicines are taking place. Harvoni®,
Sovaldi® and Daklinza® product information will be updated to highlight avoiding their use with amiodarone. These
hepatitis C treatments are novel agents, which have allowed a more simplified management of the disease and also
have the prospect of curing the infection.
EMA’s Pharmacovigilance Risk Assessment Committee (PRAC) warn of increased cardiovascular risks with high doses of ibuprofen
The EMA’s PRAC carried out a review which confirmed that a small increase in cardiovascular risk such as stroke or
heart attacks can occur with high doses of ibuprofen (at or above the maximum 2400 mg daily dose). The review
highlights that the risk with high-dose ibuprofen is similar to the risks with other non-steroidal anti-inflammatory
drugs (NSAID) and COX-2 inhibitors.
The highest dose used over-the-counter (OTC) is 1200 mg per day and no increase in cardiovascular risk was seen at
this dose. The conclusion by PRAC was that the benefits of ibuprofen do outweigh the risks but advice should be
updated on the use of high-dose ibuprofen in order to minimise cardiovascular risk. High-doses of ibuprofen (2400
mg a day or higher) should not be used in patients who have heart failure, heart disease, previous heart attack or
stroke, or underlying circulatory conditions.
The advice for Prescribers is to assess the risk factors for a patient before initiating long-term treatment with
ibuprofen, particularly when higher doses may be needed. Risk factors such as smoking, diabetes, high blood
cholesterol and high blood pressure should be considered. Similar recommendations should also be applied to
dexibuprofen, a medicine similar to ibuprofen. A high dose of dexibuprofen is considered to be a dose at or above
1200 mg per day (equivalent to 2400mg of ibuprofen). This review only considers ibuprofen and dexibuprofen for
systemic use and so excludes other formulations such as gels and sprays. A warning for NSAIDs is already in place for
this group of medicines to be used at the lowest effective dose and for the shortest time possible needed to control