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Prescribing Update

Prescribing Update. Catherine Armstrong – May 2014. Summary. Hot topics New inhalers NICE guidelines Drug shortages Updated BNF distribution schedules. Hot Topic: Domperidone. MHRA Alert – 25 th April Small increased risk of potentially life-threatening effects on the heart

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Prescribing Update

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  1. Prescribing Update Catherine Armstrong – May 2014

  2. Summary • Hot topics • New inhalers • NICE guidelines • Drug shortages • Updated BNF distribution schedules

  3. Hot Topic: Domperidone • MHRA Alert – 25th April • Small increased risk of potentially life-threatening effects on the heart • ONLY for nausea and vomiting • MAX 7 days treatment • ADULT dose – 10mg TDS • Check for QT prolongation meds and CYP3A4 inhibitors • Review patients at next routine appointment

  4. Hot Topic: Strontium • Restricted to severe osteoporosis • …who cannot use any other treatments • Do NOT start in patients who have or had • Ischaemic heart disease • Peripheral arterial disease • Cerebrovascular disease • Uncontrolled hypertension • STOP if develop any of the above

  5. New Inhalers • COPD • Aclidinium bromide • Glycopyrronium bromide • Indacaterol + Glycopyrronium • Asthma • Fluticasone furorate + vilanterol

  6. Aclidinium bromide (EkliraGenuir®) • LAMA – 400micrograms/dose – TWICE daily for COPD • ↑ effect on lung function vs placebo • No robust evidence of benefit vs other LAMA options • Device: multi-dose dry powder inhaler • On some local formularies: • North of Tyne  • Gateshead ? • South Tyneside • Sunderland ? • Durham&Darlington

  7. Glycopyrronium bromide (SeebriBreezhaler®) • LAMA – 44micrograms/dose – ONCE daily for COPD • ↑ effect on lung function, exercise endurance & patient outcomes vs placebo • May provide more rapid bronchdilation than tiotropium • Needs long term safety data & direct comparator trials • Device = capsule based dry powder inhaler • On some local formularies: • North of Tyne  • Gateshead ? • South Tyneside • Sunderland ? • Durham&Darlington

  8. Indacaterol + Glycopyrronium (UltibroBreezhaler® • LABA+LAMA 85micrograms indacaterol + 43micrograms glycopyronnium • ONCE daily for COPD • Device = capsule based dry powder inhaler • ↑ lung function vs placebo, separates + fluticasone/salmeterol • ↓ rate of exacerbations compared to glycopyronnium alone • Not considered locally yet

  9. Fluticasone furorate + vilanterol (Relvar®) • ICS+LABA – 2 strengths 92/22 & 184/22micrograms • ONCE daily for asthma • Superior to fluticasone furoate alone • 92/22 comparable efficacy to fluticasone/salmeterol 250/50 BD • CONCERNS re product – MHRA review • Not considered locally yet

  10. NICE Guidelines • CG171: Urinary Incontinence in Women • Darifenacin, oxybutynin (IR) & tolteridone (IR) – 1st line • CG172: Myocardial Infarction – secondary prevention • Omega 3 fatty acids – DO NOT RECOMMEND for 2ndry prevention of MI • CG173: Neuropathic Pain – pharmacological management • Tramadol not for long-term neuropathic pain control • Carbamazepine ONLY for trigeminal neuralgia

  11. Drug Shortages - Valsartan • Intermittent supply problems – all strengths & forms • May last several months * Dose equivalences are approximate and individual responses may vary so BP should be monitored following the switch and dosing adjusted accordingly, if needed #Valsartan doses may be given as 2 divided doses depending on indication Taken from NHS England Memo 10/3/2014: http://www.medicinesresources.nhs.uk/en/Communities/NHS/SPS-E-and-SE-England/Medicines-Information/Discontinuation-Supply-Shortage-Memos/Shortage-of-Valsartan-/

  12. Drug shortages – Piroxicam gel • Some supplies available • NHS prices currenly based on Feldene® gel • 60g = £6.00 (was £2.71) • 112g = £9.41 (was £5.06) • Compared with • Ibuprofen 5% gel £2.11 (50g), £4.22 (100g) • Ibuprofen 10% gel £5.79 (100g)

  13. Drug shortages - various • Clomipramine • Branded product discontinued • Cross-tapering with SSRIs, venlafaxine or duloxetine – specialist use only • Example switch to imipramine: • Gradually reduce to 75mg/day, stop and start imipramine 50-100mg/day the next day • Co-amoxiclav • Can be obtained – prices higher than usual • 375mg £5.30/21 625mg £6.93/21 • Use ONLY where clinically appropriate

  14. Drug shortages – various (2) • Amiloride £19.10 per 28 • Co-amilofruse 2.5/20 £4.32 per 28 5/40 £5.29 per 28 • Co-tenidone 50/12.5 £5.18 per 28 100/25 £5.18 per 28 • Is a potassium sparing diuretic needed? • Avoid combination products where possible

  15. Drug shortages – various (3) • Mebeverine 135mg tablets £17.50 per 100 • Peppermint oil 0.2ml caps £7.04 per 84 • Propranolol • 10mg £5.30 (28) 40mg £4.10 (28) 80mg £6.44 (56) • Consider alternative beta-blocker • HF – bisoprolol, carvedilol and nebivolol = licensed options

  16. BNF Distribution • From Sept 2013 edition – annually in PRINT • Still updated every 6 months (print copy) • Online/App versions updated monthly • Register for NHS Athens account: http://www.nice.org.uk/mpc/BritishNationalFormulary.jsp • Info regarding print distribution: http://www.nice.org.uk/mpc/BritishNationalFormulary.jsp • ALL GPs should receive annual PRINT copy to place of work • Email BNF@binleys.com

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