Prescribing Update
CATHERINE ARMSTRONG – MAY 2014
Summary
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Hot topics
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New inhalers

NICE guidelines
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Drug shortages

Updated BNF distribution schedules
Hot Topic: Domperidone

MHRA Alert – 25th April

Small increased risk of potentially life-threatening effects on the heart

ONLY for nausea and vomiting
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MAX 7 days treatment
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ADULT dose – 10mg TDS

Check for QT prolongation meds and CYP3A4 inhibitors

Review patients at next routine appointment
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
New Inhalers


COPD

Aclidinium bromide

Glycopyrronium bromide

Indacaterol + Glycopyrronium
Asthma

Fluticasone furorate + vilanterol
Aclidinium bromide (Eklira Genuir®)

LAMA – 400micrograms/dose – TWICE daily for COPD

↑ effect on lung function vs placebo

No robust evidence of benefit vs other LAMA options
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Device: multi-dose dry powder inhaler
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On some local formularies:

North of Tyne 

Gateshead ?

South Tyneside 

Sunderland ?

Durham&Darlington 
Glycopyrronium bromide (Seebri
Breezhaler®)

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 
Indacaterol + Glycopyrronium (Ultibro
Breezhaler®

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
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
NICE Guidelines

CG171: Urinary Incontinence in Women


CG172: Myocardial Infarction – secondary prevention


Darifenacin, oxybutynin (IR) & tolteridone (IR) – 1st line
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
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Carbamazepine ONLY for trigeminal neuralgia
Drug Shortages - Valsartan
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Intermittent supply problems – all strengths & forms

May last several months
A2RA
Valsartan
Approximate dose conversions *
40mg daily#
80mg daily#
160mg daily#
320mg daily#
Candesartan
4mg OD
8mg OD
16mg OD
16-32mg OD
Losartan
25mg OD
50mg OD
100mg OD
* 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-SEEngland/Medicines-Information/Discontinuation-Supply-Shortage-Memos/Shortage-of-Valsartan-/
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)
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Ibuprofen 10% gel £5.79 (100g)
Drug shortages - various
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Clomipramine
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Branded product discontinued
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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

Use ONLY where clinically appropriate
625mg £6.93/21
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
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
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