East Berkshire
Clinical Commissioning Groups
BERKSHIRE EAST CCGs
Medicines Optimisation
Prescribing Update
Contact Details for the
Medicines Optimisation
Team
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
Volume 2, Issue 3
June 2013
Contents of this issue
Page
no
Cerelle (Desogestrel 75 Microgram) available
as a generic version of Cerazette
Naproxen once again shown to have safest
CV profile compared to other NSAIDS
Prescribing Guidelines for Adult ADHD
2
Co-Enzyme Q10 for side-effects ofstatins is
notrecommended locally
Ticagrelor – an antiplatelet
Omega - 3 Fatty acid supplement no longer
recommended
3
2
2
3
4
-----Practice Support
Pharmacist
Sundus Bilal
07909 505658
Email sundusbilal@nhs.net
-----Prescribing Support
Pharmacist
Caroline Pote
01753 636845
Email: caroline.pote@nhs.net
1
CERELLE(DESOGESTREL 75 MICROGRAM) AVAILABLE AS A
GENERIC VERSION OF CERAZETTE
The Effective Prescribing Group recommends the use of Cerelle in place of Cerazette.
Cerelle contains the same active ingredient, at the same strength as Cerazette and costs
half the price (3x28: £4.20 versus £8.68).
Action: Consider using Cerelle in place of Cerazette for new and existing patients.
NAPROXEN ONCE AGAIN SHOWN TO HAVE SAFEST CV PROFILE
COMPARED TO OTHER NSAIDS
A Lancet meta-analysis this month has once again highlighted the cardiovascular toxicity of
NSAIDs and that Naproxen has the safest cardiovascular profile1. This article was widely
reported in the media.
The review found that for every 1000 patients treated for one year with Diclofenac or a
COX2 (Etoricoxib or Celecoxib) there are three additional major vascular events over
placebo or Naproxen. All NSAIDs were shown to be associated with upper GI complications.
Action: Naproxen (plus Lansoprazole 15mg or Omeprazole 20mg) is recommended as
NSAID of choice locally.
Reference: 1. Bhala N et al. Vascular and upper gastrointestinal effects of non-steroidalantiinflammatory drugs: meta-analyses of individual participant data from randomised trials.
www.thelancet.com
Published online May 30, 2013 http://dx.doi.org/10.1016/S01406736(13)60900-9
PRESCRIBING GUIDELINES FOR ADULT ADHD
Prescribing Guidelines for Adult ADHD have recently been ratified since our last newsletter.
These guidelines have been the product of a joint working group including GP Mental Health
Lead and Medicines Optimisation Team input. The intention of these guidelines is to give
prescribing information and advice to enable any GP who wishes to prescribe for their
patients following an assessment and recommendation for treatment by medication by the
Adult ADHD team. The drugs detailed will be listed on the formulary as red for Children with
ADHD but acceptable for prescribing by a GP in line with Prescribing Guidelines for Adult
ADHD.
If you have any questions about these guidelines please contact Catriona Khetyar, Head of
Medicines Optimisation.
The guidelines will be made available via the CCG websites.
2
CO-ENZYME Q10 FOR SIDE-EFFECTS OF STATINS IS NOT
RECOMMENDED LOCALLY
Some practices have recently been asked to prescribe Co-enzyme Q10 for reduction of
muscle-related side-effects of statins.
Co-enzyme Q10 is not a licensed medicine and is not recommended for prescribing on the
NHS locally.
The evidence for use of Coenzyme Q10 to reduce the risk of myotoxicity was reviewed by
UKMI in 20121. It found only 2 RCTs, one with 32 patients and one with 4 patients enrolled.
One of these trials found benefit on muscle-related side-effects of statins and one found no
benefit. The review concluded that “the evidence does not support the use of coenzyme Q10
supplementation with statin treatment”.
A previous systematic review examining articles addressing the relationship between statin
treatment and coenzyme Q10 levels found that there was insufficient evidence to
recommend the routine use of coenzyme Q10 in statin-treated patients to relieve myopathic
symptoms2.
Action – Co-enzyme Q10 should not be co-prescribed with statins on the NHS for
muscle protection.
Note – Co-enzyme Q10 can be prescribed on the NHS for some rare metabolic disorders.
References:
1. Should patients on statins take Coenzyme Q10 supplementation to reduce the risk of
myotoxicity? UKMI Q&A September 2012, available via www.evidence.nhs.uk .
2. Marcoff L, Thompson PD. The role of coenzyme Q10 in statin-associated myopathy.
A systematic review. J Am CollCardiol 2007; 49(23):2231-2237.
TICAGRELOR – AN ANTIPLATELET
Ticagrelor is now included in the pathway for treating ACS, at Wexham Park Hospital. It is
an amber drug which on the initiation of a consultant cardiologist may be continued for up to
12 months. Please be aware that other centres may still be discharging patients on
prasugrel, which should also be continued for up to 12 months only.
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Ticagrelor is given in combination with aspirin for prevention of atherothrombotic
events in patients with acute coronary syndrome.
Co-administration with aspirin is for 12 months only, followed by aspirin
monotherapy.
Shortly after initiation a commonly reported side effect is dyspnoea, this resolves
after 7 days.
The SPC recommends that renal function is checked one month after initiating
treatment, as creatinine levels may increase during treatment.
Co-administration with strong CYP3A4 inhibitors (e.g. ketoconazole, clarithromycin,
nefazodone, ritonavir and atazanavir) is contraindicated, as these drugs increase the
levels of ticagrelor.
Co-administration with simvastatin 80mg is not recommended.
Common side effects include bruising, increased bleeding and shortness of breath.
3
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As with clopidogrel, it is recommended that a stop date is entered onto the
prescription label directions and as a note on the computer system.
RECOMMENDATIONS


Please search for patients on ticagrelor to ensure that a stop date has been
added to the computer records and entered in the prescription directions.
Treatment beyond 12 months has not been studied. 1
Patients on prasugrel, should also have a stop date added into the computer
records, prescription directions and treatment stopped at 12 months.
1. SPC Ticagrelor, available at
http://www.medicines.org.uk/emc/medicine/23935/spc#PRODUCTINFO
OMEGA- 3 FATTY ACID SUPPLEMENT NO LONGER RECOMMENDED
Use of omega-3 fatty acids post MI was based on one trial, the GISSI-P Trial. However,
GISSI-P was an open-label trial that was not controlled with placebo, and other secondary
prevention treatments, in particular statins, had not been optimised.
In 2012, two meta-analyses were published, which do not confirm the results seen in GISSIP and do not support the use of fatty acid supplementation in primary nor secondary
prevention.
The first meta-analysis, published in the Arch Intern Med, of 14 randomised, double-blind,
placebo-controlled trials of omega-3 fatty acid supplements in people with a history of CVD
found no reduction in the risk of CV events or all-cause mortality.1
The second meta-analysis of 20 randomised controlled trials, found similar results. Omega-3
supplements did not reduce the risk of all-cause mortality, cardiac death, sudden death, MI
or stroke. 2 This larger meta-analysis included the ORIGIN study, which looked at people
with early type 2 diabetes who also had cardiovascular risk factors (about 60% had previous
MI, stroke or revascularisation). ORIGIN found that daily supplementation with 1 g of omega3 fatty acids for 6 years did not reduce the rate of cardiovascular events or mortality
compared with placebo.
Based on the lack of evidence for reduction in CVD can this spend be justified? Omega-3
preparations are available OTC and a patient information leaflet is available, whereby
patients may be advised about incorporating oily fish into their diet.
RECOMMENDATION:
Review and stop prescribing of omega-3 products for primary and secondary prevention of
CVD .
References
1.
2.
Arch Intern Med. 2012;172(9):686-694
JAMA. 2012;308(10):1024-1033
4