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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
Care Home & Practice Support
Pharmacist
Sundus Bilal
07909 505658
Email sundusbilal@nhs.net
Prescribing Support Pharmacist
Caroline Pote
01753 636845
Email: caroline.pote@nhs.net
Prescribing Support Pharmacist
Sally Clarke
07747007934
Email: sally.clarke6@nhs.net
Introduction
Topics covered in recent newsletters
Renavit®: UK Version of Dialyvit® now available
Blood glucose test strips – Guidance on recommended quantities on prescription
Outpatient Prescription requests from HWPH
Co-Amoxiclav (Augmentin®) for back pain
Importance of generic prescribing – eye drops
Prescribing changes affecting practices for some PbR excluded high drugs
– this month
Somatostatin analogues
Vacuum erection devices for erectile dysfunction – Low Priority
Dapagliflozin (Forxgia®) Nice Ta288
Dapagliflozin Combination Therapy
Mirabegron (Betmiga®) Nice Ta290
Mirabegron for treating symptoms of overactive bladder
Shingles
Soluble Prednisolone tablets
Managed Repeat Prescription Service
Through Community Pharmacies
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Welcome to the first Community Pharmacy edition of the Berkshire East GP Practice newsletter. This newsletter is developed by the Berkshire East Medicines Optimisation Team and sent to all Berkshire East GP practices monthly. It contains information and advice to prescribers based on local and national guidance and recent queries.
Where possible this newsletter will help keep you informed of local activities, if you have anything you would like to see included please do not hesitate to contact us. Suggestions and comments welcome.
The newsletter will be distributed by email in future so please ensure you email Maureen
Maul on Maureen.maul@nhs.net
with your details so she can update the community pharmacy distribution list.
Medicines Optimisation is about helping health professionals and patients make the right treatment choices. This is an evidence based approach to product choices which balances the safety, tolerability, effectiveness, price and simplicity of treatments.
Doctors, pharmacists, nurses and other health professionals all do some medicines optimisation as part of their day-to-day work. The list below gives you some examples of the types of things which come under "medicines optimisation" - there are many more!
1. Giving health professionals unbiased information on new and existing drugs
2. Supporting practitioners and patients to make best use of medicines
3. Helping to avoid harm caused by medicines such as side effects
4. Developing local guidelines for managing conditions
5. Communicating with hospitals and community pharmacies
6. Giving advice on how to store and dispose of medicines safely
The Berkshire East Medicines Optimisation Team consists of 7 pharmacists who cover the
Berkshire East CCGs as follows:
Catriona Khetyar: Head of Medicines Optimisation
Melody Chapman: Bracknell and Ascot
Dawn Best: Maidenhead, Ascot and Windsor
Tim Langran: Slough
Sally Clarke: CCG Prescribing Support Pharmacist
Caroline Pote: CCG Prescribing Support Pharmacist
The team have just finished their Annual Practice Meetings where they agreed priorities for the year ahead with each individual practice. These priorities are based on the following nation document produced by NICE - Key therapeutic topics: Medicines management options for local implementation at http://www.nice.org.uk/media/8AA/C0/Key_therapeutic_topics_full_document.pdf
Our aim is to improve the health of the population in Berkshire by promoting the safe, effective and efficient use of medicines.
To contact the NHS Berkshire Medicines Management Team with any queries please email: WAMCCG.medicines-optimisation-team@nhs.net
or call 01753 636845.
Individual pharmacist contact details are on the front page of this newsletter.
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May 2013
OneTouch Verio glucose meters recalled
Statins in low risk population
Femulen discontinued
How to get medicines added to the formulary
Dementia Challenge East Berkshire Funding Bid Successful - Use of Anti-Psychotics in Dementia
June 2013
Cerelle (Desogestrel 75 Microgram) available as a generic version of Cerazette
EMIS WEB now allows scriptswitch to be activated for non-prescibers
Practice prescribing changes for some PbR excluded high costs drugs
Naproxen once again shown to have safest CV profile compared to other NSAIDS
Co-Enzyme Q10 for side-effects of statins is not recommended locally
Ticagrelor
– a new antiplatelet
Omega - 3 Fatty acid supplement no longer recommended
Prescribing Arrangements for the use of methylphenidate, dexamfetamine and atomoxetine in adult ADHD
(attention deficit hyperactivity disorder) in Berkshire
Safety with Warfarin
July 2013
New East Berkshire Diabetes Guidelines
Blood Glucose Meter upgrades
Summary Of East Berkshire Recommendations Regarding Choice Of Blood Glucose Test Strip - June 2013
Notes regarding the process to develop the guidance
COPD
–The Value Pyramid
Smoking Cessation service from pharmacies
Prescribing Tips
– June 2013
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
Please do not hesitate to contact us if you would like any more information on these past articles.
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This month a new product has been released called Renavit®. It is a multivitamin for dialysis patients containing water soluble vitamins. It is an alternative product to Dialyvit®, which has to be imported from the USA at significant cost. The vitamin cont ent of Renavit® is very similar to Dialyvit®. In fact Renavit® is more in line with Renal Association and European
Best Practice Guidelines on vitamins in patients on dialysis and so represents a preferable option. RBH Renal Unit have advised that patients are changed to Renavit.
Action: Please change prescriptions for Dialyvit® to Renavit®.
Last year the East Berkshire Diabetes Steering Group produced guidance on usual blood glucose testing frequency. It provided recommendations specific to the therapeutic class of diabetic medication that the patient was taking.
The guidance is available here (a copy may also be attached to the email accompanying this newsletter): http://www.sloughccg.nhs.uk/images/Prescribing/Blood%20Glucose%20testing%20flow%20 chart%20CCG.pdf
Action: Please familiarise yourself with the guidance.
Practices often flag to us prescription requests for non-formulary medications from HWPH following outpatient appointments. The team welcome these examples and take them up with the recommending clinician or hospital department.
However, please note the wording on the document:
“Could you please prescribe the following Rx or suitable alternative?”
This allows Primary Care to prescribe the locally recommended alternatives if the request does not fit with these.
The most common current example is Solifenacin (Vesicare). Practices are reporting that they are still getting requests for this product from HWPH despite it no longer being in their own guidance. We take these up with the hospital every time they are flagged to us.
However, it is appropriate for a practice to prescribe Trospium MR or Fesoterodine instead given that these are the preferred products based upon efficiency, safety and cost.
Action: The outpatient medication recommendations form allows for locally recommended alternatives to be started in place of the requested product.
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It has been reported to the team that recommendations to use Co-amoxiclav for some patients with lower back pain have been made by certain specialists. We wanted to highlight the trial which may be used to justify these recommendations and its limitations.
The researchers recruited 162 adult patients who had lower back pain for more than six months following a spinal disc herniation, commonly known as a slipped disc. To take part in the study they also had to have disease-related changes in the vertebrae next to the previous slipped disc site, so-called Modic type 1 changes, or bone oedema. These were confirmed through multiple MRI scans.
This select group of patients was randomised to receive either 100 days of antibiotic treatment with amoxicillin clavulanate tablets three times a day, or 100 days of an identical placebo.
The group given antibiotics improved their disease-specific disability and back pain scores after treatment (100 days) and showed even larger improvements at the one-year time point.
Back pain assessed by the RMDQ improved from 15 in the antibiotic group to 11.5 at 100 days and seven at one year, compared with a fall from 15 in the placebo group to 14 at 100 days remaining unchanged at 14 after one year.
Further research, most likely with larger numbers of people in the study, will be needed to confirm these findings. There will also need to be extensive safety investigations. Crucially, the study recruited a very select group of lower back pain sufferers (i.e. those with Modic type 1 changes, or bone oedema next to a previous slipped disc site, confirmed through multiple MRI scans). This select group is not representative of all lower back pain sufferers.
Co-amoxiclav is a broad spectrum antibiotic associated with growing resistance and healthcare acquired infections such as C.diff.
Action: Use of Co-amoxiclav (or any antibiotic) has risks and the evidence for treatment of lower back pain is limited at present. If a patient has the same specific pathophysiology included in this study then Co-amoxiclav could be trialled but prescribing should remain with the specialist.
References: Albert HB, Sorensen JS, Christensen BS, Manniche C. Antibiotic treatment in patients with chronic low back pain and vertebral bone edema (Modic type 1 changes): a double-blind randomized clinical controlled trial of efficacy . European Spine Journal.
Published online April 2013
The NHS expenditure on branded medication is considerable so where a cheaper generic is available, large potential savings can be achieved.
Drug therapy initiated with formulary choices and as recommended by guidelines, limits the need to switch or alter a patient’s medicine at a later date.
Eye drops are recommended by brand name or generic followed by brand name on discharge summaries, which when copied onto the patient’s repeat medication are repeated unless actively switched to generic. Now many of the most commonly used eye drops have lost their patent, substantial savings are available, especially in light of the large number of patients treated.
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We recommend that all eye drops are added to repeat medication by the generic name irrespective of whether a generic is currently available. 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.
In order to clear up any confusion regarding what is being recommended, we are working with our ophthalmology colleagues in secondary care to get a statement supporting generic eye drop use included on all letters to practices. Branded eye drops would continue to be available if necessary in extenuating circumstances – e.g. a patient is only able to manage a certain bottle design.
N.B. 1 bottle (2.5-5ml) is usually sufficient quantity to last for 28 days, even if used twice daily.
Eye drop BRAND name Eye drop GENERIC name
Alphagan 0.2% Brimonidine 0.2%
Azarga 10mg/5mg
Azopt 10mg
Brinzolamide 10mg/timolol 5mg
Brinzolamide 10mg
Combigan 0.2%/0.5%
Cosopt 2%/0.5%
DuoTrav 40mcg/5mg
Ganfort
Brimonidine 0.2%/timolol 0.5%
Dorzolamide 2%/timolol 0.5%
Travoprost 40mcg/timolol 5mg
Bimatoprost 300mcg/timolol 5mg
Lumigan 100mcg
Lumigan 300mcg
Timoptol 0.25%
Timoptol 0.5%
Travatan 40mcg
Trusopt 2%
Xalacom 50mcg/5mg
Xalatan 50mcg
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
Action: Add eye drops to repeat medication by the generic name, and one bottle is almost always sufficient to last 28 days.
As described in the previous prescribing newsletters, from 2013/14 there are changes in the way in which certain PbR excluded drugs are commissioned and funded by NHS England and hence how they 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 .
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Please refer to Prescribing News June & July 2013 for Cystic Fibrosis/other respiratory, pulmonary hypertension, renal & transplant drugs.
Drug name
Lanreotide
Octreotide
AIM: The aim is to halt the acceptance by practices of any new prescribing of these drugs.
Category Restriction Criteria
Somatostatin Analogues Cancer treatment only
Somatostatin Analogues Cancer treatment only
Centre name
Specialised cancer
Specialised cancer
Some hospital clinics may not yet be aware of these changes. We have provided a template letter (at the end of this article) which you may find useful to explain the changes in commissioning arrangements to specialist centres. Alternatively please feel free to contact your practice pharmacist.
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.
ACTION: Please do not agree to take over the prescribing of these listed drugs.
Scriptswitch will flag these medicines as “Red”.
“Dear Colleague,
From 1 April 2013, there have been changes in the commissioning arrangements for certain high cost PbR-excluded drugs. To help remove wide variations in pricing, specialised services commissioning is now operationally delivered via ten nominated Local Area Teams
(LATs), funded directly by NHS England as the statutory body. CCGs are no longer able to access funding for these drugs.
You have written to me to ask if we will take over the prescribing of
………………………………………………………………………………………
Since this/these drug(s) is/are included in the new arrangements we are unable to take over the prescribing in Primary Care. Specialist centres will need keep on-going prescribing and claim payment via NHS England.
Yours sincerely, ”
Please note, that requests to prescribe a vacuum pump for ED, should be declined. The
MOBB Priorities Committee state that vacuum pumps are LOW priority in view of limited evidence for effectiveness and cost effectiveness.
A copy of the statement may be found here: http://www.sph.nhs.uk/ebc/sph-files/mobb-policies/mobbb-policy-47a-erectile-dysfunction
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Dapagliflozin is recommended in combination therapy with metformin as an option for treating type 2 diabetes, if it is used as described for DPP4-inhibitors in Type 2 diabetes: the management of type 2 diabetes (NICE clinical guideline 87). The guidance also recommends dapagliflozin in combination with insulin as an option for treating type 2 diabetes.
Dapagliflozin, in combination with metformin and sulfonylurea is not recommended for treating type 2 diabetes, except in the context of research as part of a clinical trial.
Efficiency of dapagliflozin is dependent on renal function, and is reduced in patients who have moderate renal impairment and likely absent in patients with severe renal impairment.
Dapagliflozin is not recommended for use in patients with moderate to severe renal impairment (patients with creatinine clearance [CrCl] < 60 ml/min or estimated glomerular filtration rate [eGFR] < 60 ml/min/1.73 m 2 ). No dosage adjustment is indicated in patients with mild renal impairment.
Most commonly reported side effects leading to discontinuation included; raised blood creatinine, urine infection, nausea, dizziness and rash.
Dapagliflozin will be added into the recently updated diabetes guidelines and onto Berkshire
East Formulary following the next Berkshire East Drugs and Therapeutics Committee meeting in September.
Mirabegron is recommended by NICE as an option for treating the symptoms of overactive bladder only for people in whom antimuscarinic drugs are contraindicated or clinically ineffective, or have unacceptable side effects.
Mirabegron has not been studied in patients with end stage renal disease (GFR < 15 mL/min/1.73 m 2 or patients requiring haemodialysis) or severe hepatic impairment (Child-
Pugh Class C) and it is therefore not recommended for use in these patient populations.
Mirabegron metabolism is affected by strong CYP3A inhibitors, such as itraconazole, ketoconazole, ritonavir and clarithromycin, and the dosage needs adjusting in patients with mild to moderate renal impairment (GFR 30 to 89 mL/min/1.73 m 2 ) or mild hepatic impairment (Child-Pugh Class A) concomitantly receiving strong CYP3A inhibitors
Mirabegron will be incorporated into the update of the overactive bladder guidance and will be added onto the Berkshire East Formulary following the next Berkshire East Drugs and
Therapeutics Committee in September.
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Zostavax® (marketed by Sanofi Pasteur MSD) is the only licensed vaccine for the prevention of shingles in Europe and a dose of 0.65ml of Zostavax® is to be administered to each qualifying patient for this programme. It contains a live strain of the virus and is supplied in a pre-filled syringe.
It is likely that the vaccine confers protection against shingles for at least seven years for many people.
The vaccine has been centrally procured and GP practices will be able to order vaccines online via the ImmForm service.
Patients eligible for the NHS vaccination programme;
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Anyone already aged 70 on September 1 2013 will be eligible for the new shingles vaccine on the NHS which will be offered as part of the NHS vaccination programme.
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As part of a catch up programme, those aged 79 on September 1 2013 are also
•
• eligible and the programme may be extended in-year, to patients aged 78 years, subject to vaccine supply and advice from Public Health England.
Patients should not have the shingles vaccine if they: have a weakened immune system (eg cancer treatment, steroid tablets, splenectomy, organ transplant)
• have had serious allergic reaction (including an anaphylactic reaction) to a previous dose of any of the substances in the vaccine, such as neomycin and gelatin)
• have had a serious allergic reaction (including an anaphylactic reaction) to a previous dose of the chickenpox vaccine have an untreated TB infection
There is no requirement for practices to operate active call and recall, but instead offer vaccination opportunistically to eligible patients when they access GP services
The shingles vaccine may be given at the same time as the flu vaccine in the autumn.
PGD for administration of shingles vaccine will be provided by NHSE via the local Area
Team.
Important:

Vaccine supply from the manufacturer is at present limited. The Department of
Health have secured sufficient supplies to fully vaccinate two birth cohorts - the routine cohort, and one catch-up cohort (those aged 79 on 1 September 2013).
Because of the limited supply of vaccine, vaccinating patients earlier or later than indicated could result in those aged 79 being unable to receive vaccine while eligible.
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Whilst the vaccine is authorised for use from age 50 years, a study has shown that the most cost effective age to offer the vaccine is to individuals aged 70 to 79 years where the burden of shingles disease is generally most severe.

Anyone aged 80 and over will not be able to have the shingles vaccination on the
NHS because it seems to be less effective as you get older.
Supplies are extremely limited; individuals wishing to procure the vaccine privately may experience difficulties in doing so.
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Prescribing prednisolone plain tablets is significantly more cost effective than either the
EC or soluble tablets. The chart below compares the price of the 3 preparations.
Prednisolone soluble 5mg tablets
Prednisolone EC 5mg tablets
Prednisolone plain 5mg tablets £1,05
£3,14
£19,07
28 x 5mg dose prices taken from July 2013 Drug Tariff .
The Medicines Optimisation team recommends that prescribing of the soluble tablets is reserved for the following groups of patients:
1. children,
2. those with swallowing difficulties or
3. on enteral tube feeds.
Action: Ensure current and future prescribing of prednisolone soluble tablets is reserved for: children, those with swallowing difficulties and those on enteral tube foods.
It has come to our attention that some community pharmacies are operating a managed repeat prescription service – this is when the pharmacy retains the patient’s prescription repeat request form and submits it to the surgery on their behalf. The next prescription can then be processed and dispensed ready for the patient to collect it at a convenient time before they have run out of medication.
This can result in patients receiving all of the items on their repeat request forms irrespective of need and in medication changes being missed. It can lead to excess wastage of medicines.
Pharmacies are obliged to have a robust Standard Operating Procedure for the service which ideally would be developed with input from the local surgeries but this does not always happen.
Wastage of medicines has been identified as a problem nationwide and it is estimated that up to 50% of medicines waste is avoidable. Unused prescription medicines cost the NHS in the UK an estimated £300million every year, with approximately £4 million in Berkshire alone.
You may find some of the resources on the following website useful: http://www.manageyourmedicines.co.uk/
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