Prescribing Update
Catherine Armstrong
Lead Pharmacist - Pharmicus
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
GMC – Unlicensed Medicines
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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)
Which are specials?
Drug
• Paracetamol 120mg/5ml
• Paracetamol 250mg/5ml
• Paracetamol 500mg/5ml
Average cost
• £1.12 per 200ml
• £1.30 per 200ml
• £73.76 per 200ml
• Morphine 10mg/5ml
• Morphine 20mg/5ml
• Morphine 20mg/1ml
• £1.78 per 100ml
• £689.57 per 420ml
• £4.98 per 30ml
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
Controlled Drug Prescribing
Not
needed
Form?
Needs
dose
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
Domperidone Interaction
• Small increased risk of serious ventricular
arrhythmia or sudden cardiac death
• Higher risk
– Patients aged 60+
– Daily doses >30mg
• MHRA advice
– Use lowest effective dose
– Consider QT prolongation interacting meds
Metoclopramide Interaction
• August MHRA Drug Safety Update
• Contraindicated in <1 year old
• Restricted use/doses <18 years old
• Maximum of 30mg per day for 5 days in adults
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
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 < 4mmol/l, LDL-C (fasting) <
2mmol, or non-HDL < 2.8mmol/l
• Titrate to Atorvastatin 40mg then 80mg
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 <
4mmol/l, LDL-C (fasting) < 2mmol, or non-HDL < 2.8mmol/l
• Titrate to Atorvastatin 40mg then 80mg
• If Type 2 diabetes and triglycerides > 1.7 & < 10 mmol/l
– lifestyle measures for 6 months then consider adding a fibrate
(Fenofibrate 200mg daily, reduced doses in CKD)
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)
FATS6 - Other points to note
• Consider familial hyperlipidaemia (FH) if TC >
7.5mmol/l, LDL cholesterol > 4.9
• Suspected FH if triglycerides > 4.5mmol/l
• If triglycerides > 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.
Dual Antiplatelet Therapy
Aspirin 75mg daily
STEMI
NSTEMI
UNSTABLE ANGINA
EITHER
INVASIVE THERAPY
INVASIVE THERAPY
TICAGRELOR 90MG BD FOR TICAGRELOR 90MG BD FOR TICAGRELOR 90MG BD FOR
12 MONTHS
12 MONTHS
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
Respiratory
• Beclometasone inhalers – BRAND
• Consider combinations
• 2 new COPD inhalers
• Consider quantities when reviewing
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
Paracetamol doses
120MG/5ML
250MG/5ML
AGE
DOSE
AGE
DOSE
3-6M
2.5ML
6-8Y
5ML
6-24M
5ML
8-10Y
7.5ML
2-4Y
7.5ML
10-12Y
10ML
4-6Y
10ML
ALL UP TO QDS
ALL UP TO QDS
Do NOT use in under 6yrs
Antibiotics
• “Preferred” antibiotics:
Amoxicillin
Clarithromycin
Doxycycline
Flucloxacillin
Metronidazole
Nitrofurantoin
Oxytetracycline
Penicillin V
Trimethoprim
(Erythromycin)
• Aim for 85% of prescribing to be these
• Linezolid = HOSPITAL PRESCRIBING ONLY
C Diff
• THINK
– Patient - aged 65+, frequent Abx, recent Abx
– Environment – contact, hospital admission,
institutionalised
– Action – avoid high risk: cephalosporins,
ciprofloxacin/quinolones, clindamycin, coamoxiclav
• TEST
• TREAT
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
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)
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
Bisphosphonates
• Alendronate or Risedronate 1st line
• Strontium has VTE warning
– Avoid if current/previous VTE
– Avoid if temporary/permanent immobilisation
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
Wound management
Strong opioid prescribing
(morphine)
Laxatives
Emollient s – Gateshead
1st line antidepressants - Gateshead
Erectile Dysfunction Drugs – Newcastle
Ezetimibe – Newcastle North & East
Effervescent analgesics – Newcastle West
Venlafaxine MR caps to MR tabs – Newcastle West
Specials – Newcastle North & East
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