BERKSHIRE EAST CCGs
Medicines Optimisation
Prescribing Update
Contact Details for the
Medicines Optimisation
Team
Volume 1, Issue 7
March 2013
Contents of this issue
Page
no:
CCG Support Pharmacists:
Head of MOT/Pharmaceutical
Interface Manager
Catriona Khetyar
07500 606169
Email: catriona.khetyar@nhs.net
-----Bracknell & Ascot
Melody Chapman
07826 533736
melody.chapman@nhs.net
Shortage of Isosorbide Mononitrate
Southampton MI service
Medication Error risk with Insulin Degludec
(Tresiba®)
Eye drops – Importance of generic prescribing
Fresubin Extra Powder Available as alternative to
Complan
Eltroxin® tablets withdrawn
Mesren® name change to Octasa
Easyhaler Formoterol recommended as long
acting B2 Agonist of choice
Cephalosporin And Quinolone Prescribing
Improving Safety With Warfarin Administration In
Care Homes
GSK Benzoyl peroxide – PanOxyl ® range and
Brevoxyl® Cream
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5
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6/7
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-----Maidenhead/Windsor/Ascot
Dawn Best
07793 007976
dawnbest@nhs.net
-------Slough
Tim Langran
07775 010727
tim.langran@nhs.net
-------Practice Support
Pharmacist
Sundus Bilal
07909
07909 505658
sundusbilal@nhs.net
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SHORTAGE OF ISOSORBIDE MONONITRATE
There is currently a shortage of all normal release isosorbide mononitrate presentations:
• Isosorbide mononitrate 10mg tablets
• Isosorbide mononitrate 20mg tablets
• Isosorbide mononitrate 40mg tablets
The shortage of this medicine may last for several months and current information
indicates that normal supply is unlikely to resume before the end of April 2013. Slow
release mononitrate preparations are not affected by this supply problem.
Because of the large price difference between standard Isosorbide mononitrate tablets and
the higher cost slow release preparations, please only consider switching for those with
insufficient supply to last until late April. We advise that the one off supply of slow release
formulation is added to acute/current and it is explained to the patient that the change is
only temporary due to supply problems.
Limited data exists regarding switching from normal release to modified release tablets but
initially a mg per mg substitution would be appropriate (i.e. same daily dose overall) in
most patients, and where available formulations allow. Because information on the dose
equivalence of these products is uncertain, clinical oversight to consider further dose
adjustment is advised. If any clinician has concern about prescribing for a particular
patient, consultant cardiological advice should be sought.
BNF name (Drug Tariff February 13)
Quantity
Cost
Category
Brand
Isosorbide mononitrate 10mg tablets
Isosorbide mononitrate 20mg tablets
Isosorbide mononitrate 40mg tablets
Isosorbide mononitrate 25mg modifiedrelease capsules
Isosorbide mononitrate 25mg modifiedrelease tablets
Isosorbide mononitrate 50mg modifiedrelease capsules
Isosorbide mononitrate 50mg modifiedrelease tablets
Isosorbide mononitrate 60mg modifiedrelease capsules
Isosorbide mononitrate 60mg modifiedrelease tablets
56
56
56
174
183
214
M
M
M
28
513
A
28
595
C
28
1108
A
28
675
C
Isotard 50 XL
28
886
C
Monomax SR 60
28
1050
C
Isotard 25XL
SOUTHAMPTON MI CENTRE
The regional MI centre for Berkshire East CCGs is Southampton. The centre is staffed by
pharmacists with clinical expertise and skills in locating, analysing and interpreting
information about medicines. If you have a clinical query please direct it to the centre.
The service has been commissioned by Department of Health for 2013/14 and we would
strongly encourage clinicians to make use of this service.
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The types of questions answered recently include:
 Can opioids be used for pain relief during pregnancy?
 What is the most appropriate antidepressant to use in epileptics?
 Can NSAIDs be used in adult patients with asthma?
 What malaria prophylaxis can be given to breast feeding mothers?
Medicines Information (MI) Services Southampton
6908/9
Contact Tel: 023 8079
MEDICATION ERROR RISK WITH INSULIN DEGLUDEC (TRESIBA®)
The manufacturer of insulin degludec (Tresiba®) has written to healthcare professionals to
pre-emptively warn about the potential risk of medication errors with this new product.
The new insulin will be available in two strengths, 100 units/ml and 200 units/ml, and as such
there is a risk of incorrect dose administration should the wrong strength product be
supplied. The manufacturer has visually differentiated the two strengths with the lower
strength pen being bright green and in boxes of five whereas the higher strength is dark
green and in boxes or three. The higher strength also contains a prominent indication of the
strength in a red box on both the packaging and the pen. Finally, there are tactile differences
on the injector button for visually impaired patients. The manufacturer advises that:
 The dose counter indicates the exact dose to be injected in units. As such there
is no need to dose adjust when changing pen strength for an individual patient.
 Strength must be specified on prescriptions.
 Pharmacists must contact the prescriber where the strength is unclear.
 Pharmacists must ask patients to visually identify the strength at the time of
dispensing.
 Patients should be provided with a patient brochure and trained in use of the pen.
 Patients who self-administer their insulin must be able to read the dose counter.
 Patients should check they have the correct product at the time of dispensing.
 Patients must seek medical advice is the wrong dose is administered.
Action: Clinicians who initiate or prescribe insulin should be aware of the differences
in these products. Great care should be taken when prescribing, dispensing and
using this product.
EYE DROPS – IMPORTANCE OF GENERIC PRESCRIBING
The medicine optimisation team work to ensure that drug therapy is initiated in line with
current local and national formularies and guidance, therefore limiting the need to switch or
alter a patient’s medicine at a later date.
This particularly applies to eye drops which are used long term. These are often prescribed
by brand name on discharge summaries, which are copied onto the patient’s repeat
medication by prescription clerks.
Up until fairly recently, this has not had a cost implication because few patents had ended.
This has now changed, and substantial savings are available, especially in light of the large
number of patients treated.
We recommend that all eye drops are added to repeat medication by the generic name
irrespective of whether a generic is currently available.
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Whilst the patent is still protected the patient will receive the brand anyway, but will
automatically receive the cheaper generic once the patent has ended, avoiding the need to
alter the repeat medication at a later date.
Because not all prescription clerks are able to work at a computer with Scriptswitch, we have
produced an “aide memoire” which can be printed and placed in areas where they work for
those who have permission to make the changes themselves.
Eye drops should be added to patient’s medication by the GENERIC name
Eye drop BRAND name
Alphagan 0.2%
Azarga 10mg/5mg
Azopt 10mg
Combigan 0.2%/0.5%
Cosopt 2%/0.5%
DuoTrav 40mcg/5mg
Ganfort
Lumigan 100mcg
Lumigan 300mcg
Timoptol 0.25%
Timoptol 0.5%
Travatan 40mcg
Trusopt 2%
Xalacom 50mcg/5mg
Xalatan 50mcg
Eye drop GENERIC name
Brimonidine 0.2%
Brinzolamide 10mg/timolol 5mg
Brinzolamide 10mg
Brimonidine 0.2%/timolol 0.5%
Dorzolamide 2%/timolol 0.5%
Travoprost 40mcg/timolol 5mg
Bimatoprost 300mcg/timolol 5mg
Bimatoprost 100mcg
Bimatoprost 300mcg
Timolol 0.25%
Timolol 0.5%
Travoprost 40mcg
Dorzolamide 2%
Latanoprost 50mcg/timolol 5mg
Latanoprost 50mcg
Current annual saving
£54.86
Expiry 2.4.2016
Expiry 2.4.2016
No current generic
£85.93
Expiry 2.8.2014
Expiry 7.3.2017
Expiry 7.3.2017
Expiry 7.3.2017
£23.79
£20.02
Expiry 2.8.2014
£46.02
£71.63
£120.38
Expiry dates liable to alteration.
FRESUBIN EXTRA POWDER AVAILABLE AS AN ALTERNATIVE TO
COMPLAN
A new product has become available that is comparable in nutritional content to Ensure and
Complan Shake but is 15% lower cost than Complan Shake. It also may be more acceptable
to patients as it is not readily available to buy and so may be perceived by them as a more
exclusive product.
There is no need to change patients from Complan Shake but Fresubin Extra Powder
represents an effective and excellent value sip feed for new patients or for patients who did
not like Complan Shake. It is a powder in sachets. The recommended dose is 2 sachets per
day and it comes in boxes of 7 sachets of 62g each. Available flavours are: Chocolate,
Strawberry, Vanilla and Neutral.
Summary: For new patients or patients who did not like Complan Shake please use
Fresubin Extra Powder as sip feed of choice.
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ELTROXIN® TABLETS WITHDRAWN
Summary - Eltroxin® tablets have been withdrawn from the market and so patients will need
to be changed to generic Levothyroxine.
MESREN® NAME CHANGED TO OCTASA®
The name of the Mesren® brand of Mesalazine has changed to Octasa®. Prescriptions will
need to be changed to Octasa®. Octasa® will now be the MR mesalazine brand of choice
locally as it is best value brand available (Octasa 400mg = £26.00 per 120 x MR tablets vs
Asacol 400mg = £39.21).
Potential annual savings to the CCG if Octasa® were used as 1st line brand are: B&A
£22,000 / Slough £22,000 / WAM £28,000
Summary – Prescriptions for Mesren® will need to be changed to the new name
Octasa®. Consider using Octasa® as 1st choice brand of Mesalazine MR.
EASYHALER FORMOTEROL RECOMMENDED AS LONG-ACTING
B2-AGONIST OF CHOICE
East Berkshire Respiratory Guidelines recommend Easyhaler Formoterol breath-actuated
dry power inhaler as 1st choice long acting B2-agonist. Formoterol has a quicker onset of
action than Salmeterol and the Easyhaler costs £11.08 per 28 days in comparison to £27.31
for Salmeterol Evohaler or Accuhaler.
Potential annual savings to the CCG if Easyhaler Formoterol was used 1st choice are: B&A
£8,000 / Sough £13,000 / WAM £11,000
Summary – Ensure that Easyhaler Formoterol is used as 1st choice long-acting B2agonist.
CEPHALOSPORIN AND QUINOLONE PRESCRIBING
The CCG average % of cephalosporin and quinolone prescribing of all antibiotics remains
comparable in Q3 to Q2. A great deal of progress was made in reducing the amount of
cephalosporins and quinolones prescribing over the past year and it is good that levels are
not increasing. It is important that this trend is not reversed, so please continue to follow the
prescribing advice below:
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Only prescribe an antibiotic where truly necessary. Only by resisting inappropriate
requests will public behaviour change.
Follow local guidelines on antibiotic choice as these will recommend the most
effective and safe option based upon local resistance patterns.
Give high doses for short courses. Low doses and prolonged courses increase the
development of resistance.
Avoid empirical use of broad-spectrum antibiotics as these have a higher risk of
HCAIs and also increase development of resistance. In particular avoid use of
Cephalopsporins (e.g. Cefalexin), Quinolones (e.g. Ciprofloxacin), Co-amoxiclav and
Clindamycin.
Particular care should be taken in patients at particular risk of C.difficile e.g. elderly,
care home residents, repeat antibiotic courses, immunosupression, recent hospital
admission.
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IMPROVING SAFETY WITH WARFARIN ADMINISTRATION IN CARE
HOMES
Warfarin is the most frequently prescribed oral anticoagulant medicine in the UK. It is
responsible for a significant number of hospital admissions because of poor monitoring of
INR.
The National Patient Safety Agency (NPSA) has published a Patient Safety Alert
recommending that care homes have written safe procedures for the administration of
warfarin and other anticoagulants.
The majority of GP practices in Berkshire East use the Heatherwood & Wexham Park
Hospitals NHS Trust Anticoagulation Service. The anticoagulation service will contact the
GP with details of a care home resident’s INR test result, new dose and the date of the next
blood test.
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Practices are responsible for ensuring that the appropriate care home member of
staff receives the results in a timely and accurate manner. NPSA guidance clarifies
that GPs should ensure that all dose changes, originated by the surgery, for patients
in care homes are confirmed in writing, for example by fax.
GPs and pharmacists should check that the resident’s INR is at a safe level before
issuing or dispensing a prescription for warfarin.
There should also be a process in place to follow up results if they have not been
received within 3 days. If you have not received the record within 3 days, the
anticoagulation service should be contacted on 01753 633964.
How should a prescription for warfarin be written?
Residents are often given supplies of one or more strengths of warfarin tablets to enable
doses to be adjusted. It is good practice to indicate the colour of the tablet strength on the
prescription so this can be transcribed onto the MAR sheet correctly.
Doses should be expressed in mg and not in number of tablets. ‘Half tablet’ doses are not
recommended because of the risk of error through cutting and also to avoid medicines
wastage. If a 0.5mg dose is needed, then 0.5mg tablets should be prescribed.
What are the problems with the use of warfarin?
The most common side effect of warfarin is bleeding. You should advise care staff to contact
the GP surgery immediately if residents taking warfarin experience any of the following:
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nose bleeds that last more than 10 minutes
blood in vomit or sputum
passing blood in urine or faeces
passing black coloured faeces
severe or spontaneous bruising
unusual headaches
What factors can affect the control of anticoagulation?
 If a resident is starting or stopping other medication whilst taking warfarin, the
prescriber may advise that they have a blood test within 5 to 7 days to ensure that
the INR remains within the desired range.
 Oral anticoagulants interact with a wide variety of other medicines (for example,
commonly prescribed antibiotics and painkillers), in most cases leading to an
increased anticoagulant (blood thinning) effect.
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Before using over-the-counter medicines or homely remedies (including herbal or
alternative remedies) care home staff should be advised to seek advice from their
community pharmacist or contact the resident’s GP practice.
Advise care staff to report any requests by a resident or their family to administer any
health shop herbal remedies such as St John's Wort, Cod Liver Oil and Vitamin
capsules which are not advised to be consumed when taking warfarin.
It is important that Care homes are advised that residents eat a well balanced diet.
Any major changes in diet may affect how a resident’s body responds to any
anticoagulant medication.
Foods rich in vitamin K may affect an INR result. Such foods include green leafy
vegetables, broccoli, chick peas, liver, egg yolks, cereals containing wheat bran and
oats, mature cheese, the seaweed found in sushi, blue cheese, avocado and olive
oil. It is advised that care home staff are made aware of this with new patients
prescribed warfarin because eating them in large amounts may affect the INR result.
Care staff should be advised that it is important to provide the same amount of these
foods on a regular basis as it is the change in vitamin K intake that affects an INR
result.
Drinking cranberry juice can also affect INR and so advice should be that It is
avoided in large quantities.
A moderate intake of alcohol will not affect anticoagulation.
The Anticoagulation Service can be contacted on 01753-633964 if you require more
information about diet and anti-coagulation.
References:
Actions that can make anticoagulant therapy safer: Alert and other information, 2007.
http://www.nrls.npsa.nhs.uk/resources/?entryid45=59814&q=0%C2%ACanticoagulant%C2%AC
GSK BENZOYL PEROXIDE PRODUCTS – PANOXYL® RANGE AND
BREVOXYL® CREAM.
GSK have notified prescribers that there will be an ongoing supply problem with the PanOxyl
range and their Brevoxyl cream.
These products are not being discontinued but will be out of stock for some time. Our advice
therefore is to prescribe either Quinoderm® which also contains a mild antimicrobial
(Benzoyl peroxide/potassium hydroxyquinoline sulfate cream 5%/0.5%, 50g and 10%/0.5%,
25g, 50g) and may be more beneficial to those patients with acneform eruptions and
folliculitis. Quinoderm is available over the counter and patients may wish to purchase rather
than pay for a NHS prescription.
Another alternative or mild to moderate acne is Skinoren® (Azelaic acid cream 20%, 30g).
This product is only available on prescription. Please refer to the BNF for further information
on both these products.
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