Prescribing Matters
Please circulate to all prescribers, including nurses, registrars and locums.
Newsletter archive can be found at: http://nww.hastingsandrothergpinfo.nhs.uk/gp/prescribing/index.asp
http://nww.esdwgpinfo.nhs.uk/prescribing/index.asp
Issue 159
In this issue:
Nitrofurantoin can be used in more severe
renal impairment
Men B vacs for asplenic patients
Citalopram / escitalopram dosing reminders
Oct 2014
Scriptswitch – pros and cons of activating for
non-prescribers
Prescribing Scheme – your thoughts?
Flu – a few reminders
Nitrofurantoin can now be used in patients with more severe renal impairment
http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON452539
The efficacy of nitrofurantoin depends on its renal secretion into the urinary tract. In patients with
renal impairment, renal secretion of nitrofurantoin is reduced, so reducing the efficacy, and increasing
the risk of side effects (eg, nausea, vomiting, loss of appetite).
Nitrofurantoin was previously contraindicated in patients with a creatinine clearance of less than 60
ml/min, but this has been revised to being contraindicated with an eGFR of less than 45 ml/min.
Some reminders for prescribers:

antibiotic treatment of asymptomatic bacteriuria is not advised except during pregnancy and
other special circumstances

Nitrofurantoin should not be used to treat sepsis syndrome secondary to urinary tract infection
or suspected upper urinary tract infections

A short course (3 to 7 days) may be used with caution in some patients with an eGFR of 30 to
44 ml/min. Only prescribe to such patients to treat lower urinary tract infection with suspected or
proven multidrug resistant pathogens when the benefits of nitrofurantoin are considered to outweigh
the risks of side effects.

Consider checking renal function when nitrofurantoin may be used, especially in the elderly.

Closely monitor for signs of pulmonary, hepatic, neurological, haematological, and
gastrointestinal side effects during treatment.
NB if not using the mr prep, plain capsules are cheaper than plain tablets, and the liquid is very
expensive.
Men B vaccination (Bexsero) for asplenic patients
From May 2014 this vaccine has been recommended for patients with asplenia, splenic dysfunction
or complement disorders (including those receiving complement inhibitor therapy).
This is in the Green Book but is not yet included in BNF section 14.4 for some reason.
Therefore, GPs may receive requests from secondary care to provide this vaccination to patients.
The schedule varies depending on the age at diagnosis, but is either 2 or 3 doses (see green book
chapter 7 Box 7.1).
Eastbourne, Hailsham and Seaford CCG
Hastings and Rother CCG
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We do not plan to develop a PGD for this indication as patient numbers are small.
However, there are plans to introduce this vaccine to the childhood immunisation programme, and a
PGD will be developed when this is finalised.
Citalopram and escitalopram dosing reminders
A reminder about maximum doses of these 2 drugs in the elderly, as we are finding many patients still
prescribed dose above the recommended maximum.
Maximum daily doses are as follows:
Citalopram
Escitalopram
Adults
Adults >65 years
40 mg
20 mg
20 mg
10 mg
Adults with hepatic
impairment
20 mg
10 mg
They are also both contraindicated in patients with known QT interval prolongation or congenital long
QT syndrome, or taking other medicines known to prolong QT interval.
Caution should also be exercised in patients at higher risk of developing Torsade de Pointes,
including those with congestive heart failure, recent MI, bradyarrhythmias, or a predisposition to
hypokalaemia or hypomagnesaemia due to illness or drug therapy.
Also please take care if transferring a patient to or from the drops, as it is easy to make an error in the
dose conversion, which is different for each drug:
- Citalopram 40mg/ml oral drops – 4 drops = 8mg = equivalent to 10mg tablet
- Escitalopram 20mg/ml oral drops – 10 drops = 10mg = equivalent to 10mg tablet
Scriptswitch – pros and cons of activating non-prescribers
Most practices do not have Scriptswitch activated for non-prescribers, such as staff processing Rx,
because the risk of errors potentially outweighs the benefits of the Scriptswitch advice.
Therefore, if practices decide to activate non-prescribers for Scriptswitch then the practice needs a
robust procedure for staff to follow. Issues to consider include:
- Do staff flag all messages/switches to GPs or a defined selection? If not all messages, then
how do you ensure they are competent to make such triage decisions?
- What effect will this have on Rx flow and workload within the practice?
- What will your process be for alerting prescribers to the message, and for the message to be
clearly conveyed to them? (a screen print of every message would seem the only way to avoid
transcribing risks)
- Should the default for non-prescribers be to accept or reject switches?
- Switches may be accepted where not clinically appropriate (there have been incidents of this
nature reported).
Each practice needs to consider the pros and cons of each option, and discuss with the Medicines
Management team if you need further advice.
Prescribing Support Scheme 2014-15 feedback
We are seeking feedback on the Prescribing Support Scheme this year, and ideas / suggestions for
the 2015-16 scheme.
Please email the Meds Management team.
Eastbourne, Hailsham and Seaford CCG
Hastings and Rother CCG
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Flu – a few reminders
Antivirals
Should not be prescribed until the DoH notifies prescribers flu is circulating and they can be used.
Nursing homes
If a patient in a nursing home requires a flu vaccine, the options are:
A member of the practice goes to the home to administer it using practice stock and
carrying their own anaphylaxis kit; practice can then claim under the flu LES and using
FP34
you issue a Rx for the vaccine which the home can have dispensed by a pharmacy (or
dispensing practice if on dispensing list); a member of the practice goes to the home to
administer it, carrying their own anaphylaxis kit; practice can then claim under flu LES only
you issue a Rx for the vaccine which the home can have dispensed by a pharmacy (or
dispensing practice if on dispensing list); NH staff administer it; no fees can be claimed by
the practice.
(Dispensing practices can obviously also claim usual dispensing reimbursement).
You cannot supply flu vaccine to the home directly for the nursing home staff to administer.
Adrenaline:
NHs are required to have anaphylaxis treatment available when administering vaccines;
therefore their staff should be suitably trained to manage anaphylaxis, and ensure they
have the required equipment and drugs available
You cannot supply adrenaline to the home as stock for the nursing staff to administer; you
can only supply as a Rx for individual patients, which is wasteful and unnecessary
There is no legal reason why NHs cannot purchase adrenaline for stock, but some homes
say it is company policy not to stock POMs, or misquote / misunderstand CQC guidance;
this is an issue for the home to resolve
DO NOT prescribe an adrenaline pen (Jext / Epipen / Emerade) other than for someone
with a known severe allergy who is routinely prescribed such a device
Supply of needles and syringes has also been an issue - as these are not medicines the
NH should be able to obtain these readily.
Housebound patients
You should not supply vaccines from practice stock to community nurses to take to patients homes to
administer. These patients will require a Rx to be dispensed at a pharmacy (or dispensing practice)
and collected / delivered before the community nurse arrives.
(For any community nurses reading this – practices ask that you complete the relevant paperwork
and email it to the surgery so they can code correctly and retain in the records asap - thanks).
Care homes without nursing
These patients will either be mobile and can attend the surgery, or if housebound will come under
community nurse criteria.
HCAs
HCAs can only administer flu vaccine if there is a Patient Specific Direction (PSD) in place i.e. signed
Rx, record made in notes by a prescriber, or a signed list of patients assessed by a prescriber to be
given flu vaccine. HCAs should not be giving flu vaccines outside the practice.
(Contact Janet Tyler if you require more clarification of HCA roles in vaccination)
Eastbourne, Hailsham and Seaford CCG
Hastings and Rother CCG
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