Shared care policies are developed when sophisticated or complex treatments that were initiated in secondary care are then prescribed by a GP. They set out the process that needs to be followed for the GP to take on prescribing responsibility. The term 'Effective Shared Care Agreement' (ESCA) is now being used. ESCAs should be patient specific and encompass all aspects relevant to that particular patient.
Clinical responsibility should be considered for transfer to primary care only where it is agreed that the patient's clinical condition is stable or predictable.
Applies to: NHS Grampian Version 3
Prepared by
Author(s) as job title(s)
Brian Porteous
Authorised for issue by
Medicines Guidelines and Policies Group
Caroline Hind
Document no:
NHSG/RenalSCP/Cyclo/MGPG715
Effective date: January 2015
Review Date: January 2017 or sooner if recommendations change
Supersedes: Version 2, 2006

PATIENT NAME

CHI NUMBER
ADDRESS
DATE OF BIRTH

Insert patient sticker here

HOSPITAL
TELEPHONE NO
CONSULTANT
(print name)
SIGNATURE
WARD
DATE
THERAPEUTIC INDICATION FOR THIS PATIENT:
(To be completed by consultant)
DOSAGE/FREQUENCY OF ADMINISTRATION:
SAFE PRACTICE IS THAT THE CLINICIAN WHO ORDERS THE TEST MUST ACT ON THE RESULT
CARE WHICH IS THE RESPONSIBILITY OF THE
HOSPITAL CONSULTANT
1. Baseline:
Full Blood Count (FBC); liver function tests (LFTs);
U&E and urinalysis.
2. Copy of results to be sent to GP.
3. Exclude pregnancy before starting therapy. Advise effective contraception essential during treatment and for at least 3 months after discontinuation in women and men.
4. Initiation of therapy and recommendations for dose increments. This will be controlled by the Renal
Unit.
5. Monitoring clinical response to treatment.

FBC and LFTs (inc. ALT and Alk Phos) U&E and urinalysis weekly for the first 3 months.

FBC, LFTs, U&E and urinalysis 4 weekly thereafter.
6. Advise patients to immediately report any signs or symptoms of bone marrow suppression eg sore throat, fever, infection, inexplicable bruising or bleeding, mouth ulcers or rash.
CARE WHICH IS THE RESPONSIBILITY OF THE
GENERAL PRACTITIONER (GP)
1. Prescribing of medication under guidance of consultant.
2. To preserve vital venous access, monitoring will be done by the renal service at ARI unless otherwise notified.
3. The GP should be aware that the drug can cause

Bone marrow depression such as infection, unexpected bruising or bleeding.

Leucopenia.

Amenorrhoea and azoospermia which is reversible.

Haematuria and acute haemorrhagic cystitis may occur during or after therapy.
When the patient has an intercurrent illness a FBC, U&E and LFTs should be done and any abnormal results including those noted above should be reported to the consultant or on call Registrar.
NOTE: In addition to absolute value for haematological indices a rapid fall or a consistent downward trend in any value should prompt caution and extra vigilance.
When writing laboratory request forms always include details of the patient’s medication
NOTE: If something unexpected occurs contact Renal Unit/On
Call Registrar or Consultant.
UNCONTROLLED WHEN PRINTED Review Date: January 2017 (sooner if recommendations change) NHSG/RenalSCP/Cyclo/MGPG715
Shared Care Policy and Prescribing Information for Cyclophosphamide [Renal Patients] (Adults only) - Version 3, January 2015
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Shared Care Policy and Prescribing information for General Practitioners
CYCLOPHOSAMIDE (Renal patients, adults only continued )
Abnormal Monitoring Results

WBC < 4.0 x 10 9 /L
Action To Be Taken
Withhold until discussed with consultant

Neutrophils < 2.0 x 10 9 /L

Platelets < 150x10 9 /L

> 2-fold rise in ALT or Alk Phos (from upper limit of reference range)

MCV>105fl

Rash, oral ulceration, unexplained fever
Withhold until discussed with consultant
Withhold until discussed with consultant
Withhold until discussed with consultant
Investigate and if B12 or folate low start appropriate supplementation
Withhold until discussed with consultant

Abnormal bruising or sore throat

Dipstick haematuria
Withhold until FBC results available. Discuss with consultant.
Advise increased fluid intake and discuss with consultant. Monitor closely

Macroscopic haematuria or haematuria with dysuria
Withhold until discussed with consultant
For specific product information please consult the current summary of product characteristics
( http://www.medicines.org.uk/emc/) and the BNF ( https://www.medicinescomplete.com/mc/ )
Other information

Live vaccines should be avoided in patients taking cyclophosphamide.

A single dose of pneumococcal polysaccharide vaccine and annual influenza vaccine should be given.

A high fluid intake should be encouraged to reduce the risk of haemorrhagic cystitis.

There are a number of drug interactions that must be considered when a new drug is prescribed. Please refer to Summary of Product Characteristics, BNF, or contact Medicines Information.
Some important interactions to consider include the following o Interactions have been reported with allopurinol (increased bone marrow depression), Sulphonylureas
(enhanced hypoglycaemia) and suxamethonium (prolonged apnoea).

Oral tablets are only available in strengths of 50mg. These are sugar coated and cannot be divided.
Pregnancy
Discuss with consultant. Pregnancy should be avoided during and for 3 months after stopping therapy. Advise the patient to contact their physician immediately should pregnancy occur.
Breast-feeding
Not recommended during and for 36 hours after stopping treatment. Discuss with Aberdeen Maternity Hospital.
Responsibilities of GPs
A GP should:

Contact a consultant or registrar in the Renal Unit in the event of a drug reaction or monitoring abnormality or anything you are unhappy about.

Only continue to prescribe cyclophosphamide if it is being satisfactorily monitored.

Be alert for any of the known adverse reactions.
** The patient should be encouraged to ensure blood tests are taken at the correct intervals. **
Reference
DH Shared Care Guidelines - http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/Browsable/DH_4898588
Grampian Medicines Management Website, Shared Care Policies webpage - http://www.nhsgrampian.org/nhsgrampian/GJF_general_new.jsp?pContentID=4382&pMenuID=464&pElementID=470&p_service=Content.s
how
UNCONTROLLED WHEN PRINTED Review Date: January 2017 (sooner if recommendations change) NHSG/RenalSCP/Cyclo/MGPG715
- 2 -
Shared Care Policy and Prescribing Information for Cyclophosphamide [Renal Patients] (Adults only) - Version 3, January 2015