Prescribing Update

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Prescribing Update

• Catherine Armstrong
• Lead Pharmacist - Pharmicus

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GMC Good Practice in Prescribing Managing
Medicines and Devices

• Effective from 25.2.13
• Must explain and justify decisions / actions
• YOU are responsible for any script you sign
• Several MUSTs and SHOULDs
• Full guidance available
• http//www.gmc-uk.org/Prescribing_Guidance__2013__
  50955425.pdf

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GMC Unlicensed Medicines

• GMC recommends that GPs can prescribe unlicensed
  or off license medicines but, if you decide to
  do so, you must
• Be satisfied that an alternative, licensed
  medicine would not meet the patient's needs
• Be satisfied that there is a sufficient evidence
  base and/or experience of using the medicine to
  demonstrate its safety and efficacy
• Take responsibility for prescribing the medicine
  and for overseeing the patient's care, including
  monitoring and any follow up treatment
• Record the medicine prescribed and, where you are
  not following common practice, the reasons for
  choosing this medicine in the patient's notes.
  (Code 8B2V)

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Which are specials?

• Drug

• Average cost

• Paracetamol 120mg/5ml
• Paracetamol 250mg/5ml
• Paracetamol 500mg/5ml
• Morphine 10mg/5ml
• Morphine 20mg/5ml
• Morphine 20mg/1ml

• 1.12 per 200ml
• 1.30 per 200ml
• 73.76 per 200ml
• 1.78 per 100ml
• 689.57 per 420ml
• 4.98 per 30ml

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Specials

• Is a liquid formulation needed?
• Is the drug readily available in a liquid form?
• Can another drug be substituted?
• e.g. fluoxetine liquid for sertraline tablets
• COST of licensed option is not a reason to avoid
  using

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Controlled Drug Prescribing
Form?
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Gastro-Intestinal

• Mucogel not Maalox
• Peptac not Gaviscon Advance
• Can use Gaviscon Advance tablets for portability
• PPI Omeprazole / Lansoprazole / Pantoprazole
• Avoid Omeprazole 40mg use 2x20mg
• Consider C Diff risk

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Domperidone Interaction

• Small increased risk of serious ventricular
  arrhythmia or sudden cardiac death
• Higher risk
• Patients aged 60
• Daily doses gt30mg
• MHRA advice
• Use lowest effective dose
• Consider QT prolongation interacting meds

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Metoclopramide Interaction

• August MHRA Drug Safety Update
• Contraindicated in lt1 year old
• Restricted use/doses lt18 years old
• Maximum of 30mg per day for 5 days in adults

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MHRA Simvastatin Alert

• List of drugs contra-indicated with simvastatin
• List of drugs - maximum dose of simvastatin
• Main action amlodipine diltiazem
• Primary Prevention ? simvastatin 20mg
• Secondary prevention depends on latest lipid
  profile
• Action at next review of patient

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FATS6 - Secondary Prevention of CVD (symptomatic
or prior occlusive vascular disease)

• Acute Coronary syndrome / Acute MI
• Initiate Atorvastatin 80mg
• All other conditions
• Simvastatin 40mg 1st-line (unless interactions)
• Repeat lipid profile 8 weekly and consider
  titration unless TC lt 4mmol/l, LDL-C (fasting) lt
  2mmol, or non-HDL lt 2.8mmol/l
• Titrate to Atorvastatin 40mg then 80mg

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FATS6 - Type 1 and Type 2 diabetes

• Consider drug treatment in all Type 1 and 2
  diabetics
• with microalbuminuria/proteinuria (any age)
• over 40 years
• under 40 years if other CV risk factors present.
• Simvastatin 40mg 1st-line (unless interactions)
• Repeat lipid profile 8 weekly and consider
  titration unless TC lt 4mmol/l, LDL-C (fasting) lt
  2mmol, or non-HDL lt 2.8mmol/l
• Titrate to Atorvastatin 40mg then 80mg
• If Type 2 diabetes and triglycerides gt 1.7 lt 10
  mmol/l
• lifestyle measures for 6 months then consider
  adding a fibrate (Fenofibrate 200mg daily,
  reduced doses in CKD)

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FATS6 - Primary Prevention (no symptomatic or
prior occlusive vascular disease)

• Treatment is based on risk and not cholesterol
  levels
• If 10 year CVD risk 20, consider Simvastatin
  40mg (reduce dose for drug interaction more
  detail in full guidance)

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FATS6 - Other points to note

• Consider familial hyperlipidaemia (FH) if TC gt
  7.5mmol/l, LDL cholesterol gt 4.9
• Suspected FH if triglycerides gt 4.5mmol/l
• If triglycerides gt 10mmol/l, seek specialist
  advice
• Simvastatin 80mg
• Prescribing of Simvastatin 80mg is no longer
  recommended due to risk of myopathy.
• Review patients taking Simvastatin 80mg their
  next routine appointment.

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Dual Antiplatelet Therapy
Aspirin 75mg daily Aspirin 75mg daily Aspirin 75mg daily
STEMI NSTEMI UNSTABLE ANGINA
EITHER INVASIVE THERAPY INVASIVE THERAPY
TICAGRELOR 90MG BD FOR 12 MONTHS TICAGRELOR 90MG BD FOR 12 MONTHS TICAGRELOR 90MG BD FOR 12 MONTHS
OR INVASIVE NOT SUITABLE INVASIVE NOT SUITABLE
PRASUGREL 5MG OR 10MG OD FOR 12 MONTHS CLOPIDOGREL 75MG OD FOR 12 MONTHS CLOPIDOGREL 75MG OD FOR 12 MONTHS
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Respiratory

• Beclometasone inhalers BRAND
• Consider combinations
• 2 new COPD inhalers
• Consider quantities when reviewing

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Pregabalin

• Avoid more than 1 capsule per dose
• QDS is not licensed, use maximum of TDS
• Each capsule/strength priced the same - 1.15
• Most popular street drug abused

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Paracetamol doses
120MG/5ML 120MG/5ML
AGE DOSE
3-6M 2.5ML
6-24M 5ML
2-4Y 7.5ML
4-6Y 10ML
ALL UP TO QDS ALL UP TO QDS
250MG/5ML 250MG/5ML
AGE DOSE
6-8Y 5ML
8-10Y 7.5ML
10-12Y 10ML
ALL UP TO QDS ALL UP TO QDS
Do NOT use in under 6yrs Do NOT use in under 6yrs
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Antibiotics

• Preferred antibiotics
• Amoxicillin Nitrofurantoin
• Clarithromycin Oxytetracycline
• Doxycycline Penicillin V
• Flucloxacillin Trimethoprim
• Metronidazole (Erythromycin)
• Aim for 85 of prescribing to be these
• Linezolid HOSPITAL PRESCRIBING ONLY

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C Diff

• THINK
• Patient - aged 65, frequent Abx, recent Abx
• Environment contact, hospital admission,
  institutionalised
• Action avoid high risk cephalosporins,
  ciprofloxacin/quinolones, clindamycin,
  co-amoxiclav
• TEST
• TREAT

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Role of 4C antibiotics on local guidelines

• Sinusitis
• 1st amoxicillin, 2nd doxycycline
• Co-amoxiclav 625mg tds x21 for persistant
  symptoms only
• COPD exacerbation
• 1st amoxicilllin, 2nd doxycycline
• Co-amoxiclav 625mg tds x15 if resistant risk
  factors
• Prostatitis
• ?Ciprofloxacin 500mg BD x56

• Cellulitis/Wounds
• 1st flucloxacillin, 2nd clarithromycin
• Co-amoxiclav 625mg tds x21 only if facial
  involvement
• Human/Animal Bites
• ? Co-amoxiclav 625mg tds x21
• Pyelonephritis
• Co-amoxiclav 625mg tds x42
• Ciprofloxacin 500mg bd x14

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Minocycline

• No clear evidence better than alternatives
• Safety concerns monitoring
• Higher cost

Minocycline 100mg M/R caps OD 10.04 Doxycycline 100mg caps OD 3.92
Minocycline 100mg caps OD 13.09 Lymecycline 408mg caps OD 6.22
Minocycline 100mg tabs OD 13.72 Erythromycin 250mg tabs 2BD 7.96
Minocycline 50mg caps BD 15.27 Oxytetracycline 250mg tabs 2BD 5.32
Minocycline 50mg tabs BD 11.42 28 day courses (Drug Tariff August 2013) 28 day courses (Drug Tariff August 2013)
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Diabetic Drugs

• Prescribe all insulin by brand name
• Blood Glucose Testing advice
• Type 1 - appropriate amounts
• Type 2 - see local guidance
• Consider latest DVLA advice also local guidance
  under review as a result
• Insulin Passports NPSA safety alert, all
  patients aged 18 using insulin should have or
  have opted out

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Bisphosphonates

• Alendronate or Risedronate 1st line
• Strontium has VTE warning
• Avoid if current/previous VTE
• Avoid if temporary/permanent immobilisation

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Prescribing Engagement Scheme

• MANDATORY - Review of repeat prescribing and
  dispensing systems AND engagement with Pharmicus
  / Medicines Optimisation support
• FINANCIAL Collectively deliver financial
  balance for CCG

ALL 3 AREAS Emollient s Gateshead
Wound management 1st line antidepressants - Gateshead
Strong opioid prescribing (morphine) Erectile Dysfunction Drugs Newcastle
Strong opioid prescribing (morphine) Ezetimibe Newcastle North East
Laxatives Effervescent analgesics Newcastle West
Venlafaxine MR caps to MR tabs Newcastle West
Specials Newcastle North East
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Useful websites

• Gateshead Information Network
• www.ginportal.info
• North of Tyne Area Prescribing Committe
  www.northoftyneapc.nhs.uk
• Electronic Medicines Compendium
• www.medicines.org.uk
• Athens registration
• https//register.athensams.net/nhs/nhseng/
• Medicines and Prescribing support from NICE
• http//www.nice.org.uk/mpc/index.jsp