East Berkshire
Clinical Commissioning Groups
BERKSHIRE EAST CCGs
Medicines Optimisation
Prescribing Update
Contact Details for the
Medicines Optimisation
Team
Volume 2, Issue 4
July 2013
CCG Support Pharmacists:
Head of Medicines
Optimisation Team
Catriona Khetyar
07500 606169
Email: catriona.khetyar@nhs.net
-----Bracknell & Ascot
Melody Chapman
07826 533736
Email melody.chapman@nhs.net
-----Maidenhead/Windsor/Ascot
Dawn Best
07793 007976
dawnbest@nhs.net
------Slough
Tim Langran
07775 010727
Email tim.langran@nhs.net
Contents of this issue
New East Berkshire Diabetes Guidelines
Blood Glucose Meter upgrades
Summary Of East Berkshire
Recommendations Regarding Choice Of
Blood Glucose Test Strip - June 2013
COPD –The Value Pyramid
Smoking Cessation
Is there any evidence to support the use of
Enteric Coated (Ec) over uncoated
Prednisolone Tables?
Prescribing changes affecting practices for
some PbR-excluded high costs drugs
Diclofenac: New Contraindications Due To
Increase In CV Events
Zuclopenthixol Decanoate Vs Acetate –
Recent Dispensing And Prescribing Errors
Medicines Optimisation in care homes –
Antipsychotics in dementia: Training the carers
Page
no
2
2
2
4/5
5/6
6/7
7
8
8
9
-----Practice Support
Pharmacist
Sundus Bilal
07909 505658
Email sundusbilal@nhs.net
-----Prescribing Support
Pharmacist
Caroline Pote
01753 636845
Email: caroline.pote@nhs.net
1
BERKSHIRE DIABETES GUIDELINES
East Berkshire Drugs & Therapeutics Committee has approved an update to our guidelines
for the management of Type 2 Diabetes. The guideline can be found here:
http://www.heatherwoodandwexham.nhs.uk/sites/default/files/services/BE_diabetes_201306
.pdf
Or alternatively it is on the Slough CCG website ( www.sloughccg.nhs.uk ) and linked to the
East Berkshire Formulary ( eastberks.formulary.co.uk ).
Key updates include: Notes on using HbA1C for the diagnosis of T2DM; the addition of
Lixisenatide (a new GLP-1) to the recommended treatments.
Action: Please familiarise yourself with the new guidelines.
BLOOD GLUCOSE METER UPGRADES
It has been brought to the attention of the Medicines Optimisation Team that patients, who
are currently using Accu-chek meters, are being sent Accu-chek. Mobile blood glucose
machines. These appear to be unrequested by patients and are being automatically sent out
as a free upgrade by the company who markets the machine.
The machines use cassettes, rather than strips. The cassettes are only available in packs of
100 tests and their cost per test is greater than the CCG’s formulary 1st line choice at £31.54
per 100.
ACTION: We request that practices explain to patients that the formulary meter available
free on the NHS is Wavesense JAZZ in the CCG. Please do not prescribe the cassettes
and if necessary offer the patient a Wavesense JAZZ meter.
SUMMARY OF EAST BERKSHIRE RECOMMENDATIONS
REGARDING CHOICE OF BLOOD GLUCOSE TEST STRIP - JUNE
2013
1st line (for patients who don’t fit exceptions below)
Wavesense Jazz®
Alternative option
Supercheck 2®
For visually impaired patients
Supercheck 2®
Highly unstable insulin treated patients (predominantly
patients prone to repeated hypoglycaemic events)
Contour Next® can be initiated by
specialist
Contour Next® can be initiated by
specialist
Carbohydrate counting
Follow advice of initiating specialist
Insulin pumps
Follow advice of initiating specialist
Paediatrics
To undergo a separate review
Gestational diabetes
2
Other recommendations:



The minimum expected accuracy of test strip to be prescribed in East Berkshire
is: 95% of results are within 15% of laboratory YSI meter result and;
90% of results are within 10% of laboratory YSI meter result and;
60% of results are within 5% of laboratory YSI meter result.
People prescribed a blood glucose test strip that does not meet the accuracy
criteria set above can be changed to a recommended alternative. Strips not
meeting criteria include:
Accucheck Aviva, Advantage Plus®, BGStar®, CareSens N®, Contour®,
CozyLab S7®, Element®, Freestyle®, Freestyle Optium, GlucoDock ®,
GlucoLab®, GLucomen®, Glucomen GM®, Glucomen LX®, Glucomen Visio®,
GlucoRx Original®, iCare Advanced®, IME-DC®, Medisense®, Meditouch®,
Medidot®, Myglucohealth®, Omnitest 3®, Oncall Advanced®, OneTouch Ultra®,
OneTouch Vita®, SDCodeFree®, Sensocard®, TrueOne®, TrueTrack®, TrueYou
Mini®
People who purchase a meter that is not recommended in East Berkshire should
not receive test strips for that meter on prescription. They should be offered a
meter that is compatible with a recommended test strip at no cost to the patient.
Recommendations approved by East Berkshire Drugs & Therapeutics Committee June 2013
Notes regarding the process to develop the guidance
The recommendations were made following a review of available blood glucose test
strips by a CCG Lead Pharmacist and Diabetes Specialist Nurse.
The review considered test strip accuracy, test strip expiry date, haematocrit range in
which strip functions, required blood sample size, if it is suitable for patients having
peritoneal dialysis, whether meter memory complied with DVLA requirements, availability of
trend analysis software, compatibility with Diasend® software.
Additionally, a patient group reviewed meters and their views on ease of use,
functions and appearance were also included in the review.
Finally, once all the above had been used to identify the most accurate, functional
and patient friendly options, the relative cost to the NHS was taken into account.
The resulting recommended choices represent the highest quality as well as best
value options available. By using these products it will ensure that we are providing the best
blood glucose test strips in our CCG.
Notes on implementation of the guidance
The recommended products will often be superior to previously prescribed blood
glucose test strips. Therefore, prescriptions can be changed with the assurance that the
patient is getting improved treatment as a result.
Suppliers of the recommended products provide free meters to practices or patients
on request. Ask your CCG Pharmacist for contact details if required. Additionally, drop-in
clinics to explain the new meter to patients can be arranged.
Switching of prescriptions using an automatic “batch” switch. Is not recommended in
case patients falling into the exception categories are changed in error.
It is important to explain to patients that results from different meters cannot be
compared side-by-side. This is due to allowable margins of error that exist for all test strips
as well as differences in the calibration used by different manufacturers. Patients should be
encouraged to use up any remaining test strips they have at home for their previous meter
and then start using their new one, rather than use both at the same time.
3
COPD – THE VALUE PYRAMID
The COPD value pyramid, shown below, was produced by the NHS London Respiratory
Team and was published in 2010. Are you aware that for COPD the 2 interventions which
provide most value in terms of improved patient out-comes are flu vaccination and smoking
cessation? The IMPRESS document, published in July 2012, suggests that smoking
cessation should be considered as “treatment” for COPD 1. Drawing your attention to the
top of the pyramid, triple inhaler therapy provides least value. Inhaled corticosteroids only
benefit some COPD patients through reduction of exacerbations. However, they also have
been shown to increase the cases of non-fatal pneumonia and should be given to patients
with a FEV1 less than 50%.
See diagram below.
Action:
Practices should review there re-call systems to ensure COPD patients receive their annual
flu vaccine.
4
Please ensure your patients are aware of stop smoking services available locally. Details of
clinics can be found here www.smokefreelifeberkshire.com and leaflets and posters for the
practice can also be ordered through this website.
In addition for those practices that are drawing up care plans and prescribing rescue packs
for their COPD patients, in preparation for the winter months, we would ask you to prescribe
prednisolone plain tablets and suggest the antibiotic prescribed is chosen from what’s
recommended for acute exacerbations of COPD in the local antibiotic guidelines i.e. either
amoxicillin 500mg tds
5 days, doxycycline 200mg stat, 100mg od 5 days or
clarithromycin 500mg bd 5 days.
References:
1. IMPRESS Guide to the relative Value of COPD Interventions.
http://www.impressresp.com/index.php?option=com_docman&task=doc_view&gid=5
1&Itemid=82
SMOKING CESSATION SERVICES
There are now clinics being run across the CCG in shops, offices, GP practices and
pharmacies.
Full
details
of
where
and
when
are
available
at
www.smokefreelifeberkshire.com . This site has sections for both public and professional.
Leaflets and posters for your practice can also be ordered through the website.
Previously, there was some difficulty in patients being able to get Varenicline (Champix) and
so it was agreed temporarily that prescriptions could be used by GP practices. Now that a
significant number of Community Pharmacies have signed up to provide the Smoking
Cessation service this is no longer a problem. Varenicline can be supplied on PGD from the
Pharmacies. Requests for prescriptions should now be rare, with patients seeing advisors
outside Berkshire being the usual reason (other areas do not have the same PGD available).
Community Pharmacies providing the service locally:
Slough
Alchem Pharmacy, Farnham Road Surgery, 301 Farnham Road, Slough, SL2 1HD
Boots Slough, 184 High Street, Slough, SL1 1JR
Boots Slough, 30 High Street, Burnham, SL1 7JP
B&P Pharmacy, 6 Stoneymead, Slough, SL1 2YL
H A McParland Pharmacy, 226 Farnham Road, Slough, SL1 4XE
H A McParland Pharmacy, 8 The Harrow Market, Langley, SL3 8HJ
H A McParland Pharmacy, 306 Trelawney Avenue, Langley, SL3 7UB
Windsor, Ascot & Maidenhead
Boots Maidenhead, 54 High Street, Maidenhead, SL6 1PY
Boots Windsor, 17-18 Peascod Street, Windsor, SL4 1DG
5
Boots Windsor, 83 Dedworth Road, Windsor, SL4 5BB
Cookham Pharmacy, Lower Road, Cookham Rise, SL6 9HF
H A McParland, 9 Shifford Crescent, Maidenhead, SL6 7UA
Hetpole Pharmacy, 398 Dedworth Road, Windsor, SL4 4JR
Park Pharmacy, 4 Cookham Road, Maidenhead, SL6 8AJ
Superdrug, 36-40 Nicholsons Centre, Maidenhead, SL6 1LL
Woodlands Park Pharmacy, Waltham Road, Maidenhead, SL6 3NH
Bracknell
Boots Ascot, 23 High Street, Ascot, SL5 7HG
Boots Bracknell, 13 Princess Square, Bracknell, RG12 1LS
Boots Bracknell, 5 The Square, Bracknell, RG12 9LP
Bullbrook Pharmacy, 3 Bullbrook Row, Bracknell, RG12 2NL
Tesco Bracknell, Jigs Lane, Bracknell, RG40 3JP
Action: Ensure your patients know how to find local clinics. Be aware that Varenicline
is now available via the Pharmacy clinics above and the need for prescriptions should
be li
mited.
IS THERE ANY EVIDENCE TO SUPPORT THE USE OF ENTERIC
COATED (EC) OVER UNCOATED PREDNISOLONE TABLETS?
UK Medicines Information (UKMi) asked again “Is there any evidence to support the use
of enteric coated (EC) over uncoated prednisolone tablets?”
Background: Data on this subject are sparse and the last overview published in the Drug
and Therapeutics Bulletin (DTB) 1987, concluded that uncertainty remains as to whether
enteric coating decreases the tendency of steroids to cause ulcers (1). It also noted that at
the time of writing some commentators believed dyspepsia was less common with EC
tablets, but its overall conclusion was that the use of EC prednisolone to decrease risk
remains speculative and probably leads to a false sense of security (1). This was also the
conclusion of the previous DTB on this subject in 1977, i.e. “there is no evidence that EC
prednisolone is less likely than the plain tablets to cause peptic ulceration (PU) and the
evidence that it is less likely to cause dyspepsia is not satisfactory (2).

Since these publications, the literature has remained sparse on this topic.
6

Most of the published pharmacokinetic studies have noted lower- and slower time topeak plasma concentration with EC than uncoated prednisolone tablets, though
bioavailability was generally found to be similar.

A small number of case reports have indicated problems with disease control with use of
EC or with switch to EC from the uncoated formulation.

From the limited available data, it would seem that EC tablets may be associated with
less predictable absorption; and in certain clinical conditions where plasma levels of
prednisolone need to be stable and predictable, some authors recommend the use of the
uncoated tablets, particularly in the absence of robust evidence to suggest that enteric
coating confers GI protection.

As with any therapeutic switching, additional monitoring of the patient may be required.

The BNF states there is no conclusive evidence that the use of EC preparations of
prednisolone reduces the risk of PU.
1. EMBASE; exp PREDNISOLONE/; 57883 results.
2. EMBASE; exp ENTERIC COATED TABLET/; 1321 results.
DT Price June 2013
Prednisolone EC 5mg tablets £3.43 (28)
Prednisolone 5mg tablets
£1.04 (28)
Prescribing changes affecting practices for some PbR-excluded
high costs drugs
As previously described in the April Prescribing Newsletter, from 2013/14 there are changes
in the way in which certain PbR-excluded drugs are prescribed across primary, secondary
and tertiary care which will affect GP practices.
From 1 April 2013, this will affect practices who currently take on the prescribing of
certain specialist high cost PbR excluded drugs. Each month we shall discuss one or
two disease areas highlighting the drugs affected by this change and describe the action that
will need to be taken.
AIM: The aim is to halt the acceptance by practices of any new prescribing of these
specialist drugs.
Once hospital contacts have been identified and informed, we will aim to repatriate existing
patients prescribed these drugs to the relevant specialist centres. Because this will involve
coordination between the patient, GP and centre, as more details become available, we will
contact you when we are able to start this process. A member of the team will shortly be in
contact to collect details of existing patient/drugs.
ACTION: Please do not agree to take over the prescribing of these listed drugs. The
formulary will list these medicines as “Red”.
7
DICLOFENAC: NEW CONTRAINDICATIONS DUE TO INCREASE IN
CV EVENTS
The MHRA and EMA (across Europe) has issued new advice for diclofenac1:
-
Diclofenac is now contraindicated in patients with established: ischaemic heart
disease; peripheral arterial disease; cerebrovascular disease; congestive heart
failure (New York Heart Association [NYHA] classification II–IV),
It is also recommended that patients with these conditions should be switched to an
alternative treatment at their next routine appointment,
Diclofenac treatment should only be initiated after careful consideration for patients
with significant risk factors for cardiovascular events (e.g. hypertension,
hyperlipidaemia, diabetes mellitus, smoking).
The MHRA has also re-issued the following reminder of existing advice for all NSAIDs1:
-
The decision to prescribe an NSAID should be based on an assessment of a
patient’s individual risk factors, including any history of cardiovascular and
gastrointestinal illness,
Naproxen and low-dose ibuprofen are considered to have the most favourable
thrombotic cardiovascular safety profiles of all non-selective NSAIDs,
The lowest effective dose should be used for the shortest duration necessary to
control symptoms. A patient’s need for symptomatic relief and response to treatment
should be re-evaluated periodically.
These recommendations follow a comprehensive review of the safety data available for
Diclofenac. They are supported by a meta-analysis published in the Lancet in the last month
that confirmed previous reviews that Diclofenac increases CV events to a similar extend to
COX2s i.e. 3-4 additional thrombotic events per 1000 patients treated for one year2.
Action: Diclofenac and COX2s should not be prescribed in patients with pre-existing
CVD. Additionally, use should be avoided in patients at risk of CVD. Naproxen plus a
separate maintenance dose PPI is the recommended NSAID locally.
References: 1. MHRA Drug Safety Update June 2013, 2. CNT Collaborators, Lancet
(published online) May 30, 2013 http://dx.doi.org/10.1016/S0140-6736(13)60900-9
ZUCLOPENTHIXOL DECANOATE VS ACETATE
DISPENSING AND PRESCRIBING ERRORS
–
RECENT
There have been two recent dispensing errors where Zuclopenthixol Acetate (Clopixol
Acuphase) was given instead of Zuclopenthixol Decanoate (Clopixol). These products are
very different in their duration of action and use of the incorrect product has caused serious
issues for the patients involved.
Zuclopenthixol Decanoate is more likely to be used in Primary Care following initiation by a
specialist, it is a depot lasting for up to 4 weeks. Zuclopenthixol Acetate is used for acute
management and is usually for inpatient use. In one of the cases the prescription only stated
Zuclopenthixol and did not specify the salt. Prescriptions for Zuclopenthixol should always
specify which salt is required.
Action: When prescribing Zuclopenthixol always check which form is required and
specify either Decanoate (more likely) or Acetate (rare in Primary Care).
8
MEDICINES OPTIMISATION IN CARE HOMES –
ANTIPSYCHOTICS IN DEMENTIA: TRAINING THE CARERS!
There are approximately 800,000 people currently living with dementia in the UK and
approximately a third of this number reside in care homes (Alzheimer’s society, 2011). The
majority of people living with dementia are likely to experience behavioural and
psychological symptoms of dementia (BPSD) at some point during their illness.
A local project, part of the Prime minister’s Dementia challenge, focuses on Medicines
Optimisation in care homes and a review of the use of ANTIPSYCHOTICS IN DEMENTIA in
the management of behavioural and psychological symptoms of dementia (BPSD).
Current guidance recommends the use of treatments using a non-pharmacological approach
in the initial stages of managing these behaviours (NICE/SCIE, 2006; Banerjee, 2009;
National dementia strategy, 2009). Consequently, psychological and behavioural
interventions are recommended as first line treatment of BPSD.
As part of this project, an exciting and new training event titled Alternatives to
antipsychotic medication: Psychological approaches in managing psychological and
behavioural distress in people with dementia was held for care staff from all care homes
in the Berkshire East on the 14th June. The free training was supported by multiple
organisations including the Alzheimer’s society, local charities and the Local authorities. The
training was delivered by two local consultants clinical psychologist Dr Chris Allen and
clinical psychiatrist, Dr Umar Bedi and the mostly excellent evaluation feedback showed that
this training was much needed and welcomed by all. As a result, the local authorities are
considering offering similar training in the future to care providers in the Berkshire East
region.
The training focussed on empowering care staff with the necessary steps to follow when
managing patients with BPSD and empowering them with the necessary skills to implement
non-pharmacological strategies as a first step rather than asking GPs to prescribe
antipsychotics. The training also covered the risks of antipsychotics and why all efforts must
be made to use psychological strategies first once other possible causes have been
eliminated (eg depression, pain, infections, environmental causes etc).
When behaviour is harmful or severely distressing to the individual or puts patients or others
at risk, medications such as anti-psychotics may be prescribed for a short period of time
whilst continuing a person-centred approach. The known risks associated with the use of
anti-psychotics in dementia include further worsening of cognitive function, increased risk of
stroke (x3) and death (x2), and can significantly reduce quality of life. They should only be
used after discussion with the patient (if s/he has capacity to understand) or family and carer
about possible benefits and risks. Risperidone is first line as it is the only antipsychotic
licensed for persistent aggression in Alzheimer’s patients and should not be used for more
than 6 weeks. During treatment, patients must be evaluated frequently and regularly, and the
need for continuing treatment reassessed.
9