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 153
In this issue:
Jext back in stock?
Letters for referring prescribing back to
consultant, and list of high cost / specialist
drugs
Medications liable to abuse / diversion
April 2014
NICE evidence commentary: Pneumonia
in COPD pts using ICS
ScriptSwitch ‘feedback’ button
DTB topics: metformin in CKD;
lubiprostone in constipation
Jext back in stock at Alliance?
Jext is back in stock according to the manufacturer, ALK. Therefore, there should be no further need
to switch patients from Jext to Epipen.
Those who have already been switched from Jext to Epipen can be left on Epipen, or switched back
to Jext when they next request a Rx, depending on patient preference.
It would probably be unwise to leave patients with a mixture of Jext pens and Epipens as they do
have slightly different administration techniques and so there could be an administration error.
High cost / specialist drugs list and letters for returning / not accepting prescribing from
consultants
On HARMLESS / GRACE (in ‘General practice/ prescribing/miscellaneous’) you can now find:
- A list of high cost / specialist drugs detailing whether they should or should not be prescribed
by GPs. This list is not exhaustive and may even be out of date when you access it as NHS
England are continually reviewing specialist commissioning. If in doubt – ask the MM team!
o http://nww.esdwgpinfo.nhs.uk/prescribing/docsapr14/GP%20HCD%20list%200314%20v2.pdf
- Hints and tips for managing high cost prescribing
- 2 letter templates to assist GPs in either declining requests from consultants to prescribe items
(letter B), or to return prescribing back to consultants (letter A).
Medications which have the potential for abuse / diversion
This list has been requested at a locality meeting and has been compiled with the local police CD
liaison officer.
The most common groups of drugs likely to be abused are:
 opiates
 benzos
 barbiturates
 drugs for ADHD.
Drugs or categories of drugs which are known have been abused or diverted:
 Anabolic steroids
Eastbourne, Hailsham and Seaford CCG
Hastings and Rother CCG
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Z drugs
Pregabalin
Gabapentin
Duloxetine
Codeine based products (co-codamol, Solpadeine, Nurofen Plus)
Dihydrocodeine
Drugs used for erectile dysfunction
Antidepressants
Antihistamines
Laxatives
Cyclizine
Dextromethorphan (found in OTC cough medicines)
Pseudoephedrine
Growth hormone
NICE Medicines Evidence Commentary - COPD: risk of pneumonia with inhaled
corticosteroids
The risk of pneumonia in COPD patients using ICS is known and is reflected in current NICE
guidance on COPD, and the MHRA has also issued advice about the risk.
ICS should therefore only be used in COPD where indicated by NICE guidance i.e. where FEV1 <50%
and patient is having exacerbations and/or persistent breathlessness. In these patients the benefits
usually exceed the risks.
In the TORCH trial the probability of pneumonia was 19.6% in the fluticasone propionate/salmeterol
group and 18.3% with fluticasone propionate alone compared with 12.3% in the placebo group.
The relative risk of pneumonia with different ICS is unclear.
A recent observational study (http://thorax.bmj.com/content/68/11/1029.full) has shown that the risk of
pneumonia appears to be sustained with long-term use, but declines after stopping ICS, and
disappears after 6 months of no use. Fluticasone was associated with a greater risk of serious
pneumonia than budesonide, but this might be due to differences between the groups.
- current use of ICS was associated with a 69% relative increase in the rate of serious
pneumonia (rate ratio [RR] 1.69, 95% CI 1.63 to 1.75)
- the risk appeared to increase with the dose of ICS, ranging from a RR 1.24, 95% CI 1.13 to
1.36 with low doses (equivalent to less than 500 micrograms/day of fluticasone propionate) to
RR 1.86; 95% CI 1.77 to 1.94 with high doses (equivalent to at least 1000 micrograms/day of
fluticasone propionate).
- current use of fluticasone was associated with double the rate of pneumonia (RR 2.01, 95% CI
1.93 to 2.10), but budesonide was only associated with a 17% relative increase in the rate (RR
1.17, 95% CI 1.09 to 1.26)
- in another group who were mostly receiving beclometasone, there was a 41% relative increase
in the rate of serious pneumonia (RR 1.41, 95% CI 1.33 to 1.51).
- For fluticasone, the rate of serious pneumonia increased with the dose, but this was not the
case for budesonide.
ScriptSwitch ‘feedback’ button – NOT for justifications for prescribing decisions
There is now a ‘feedback’ button on ScriptSwitch for users to send comments on switches /
messages to the CCG. This is intended to be used for any messages / switches which may need
amending / removing as they are no longer relevant or contain an error.
Eastbourne, Hailsham and Seaford CCG
Hastings and Rother CCG
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It is not for recording justification for your prescribing decisions for individual patients e.g. ‘ intolerant
of drug x’.
DTB - topics (April 14)
Metformin OK in CKD?
Phenformin was withdrawn in the ‘70s due to a high rate of lactic acidosis. Since then metformin has
been implicated in case reports of lactic acidosis, particularly in people with kidney disease, but
causality has been debated as most of these patients have already been at high risk of lactic
acidosis.
A Cochrane systematic review in 2010 found no evidence of excess lactic acidosis.
A UK case-control study in 2008 actually found higher rates of lactic acidosis in those on
sulphonylureas (4.8/100,000 person-years) compared with metformin (3.3/100,000 person-years).
Metformin needs dose reduction in renal impairment, but dosage advice from the SPC, BNF, and
NICE varies in terminology and dosage thresholds, which is unhelpful to prescribers.
Specialists are increasingly of the opinion that the current restrictions are overly cautious, and there is
a need to standardise dosing advice in renal impairment.
However, it would be unwise for prescribers to deviate from the licensed contraindications.
Lubiprostone for chronic constipation in adults - not on formulary and should not be used by
GPs or recommended by secondary care
Lubiprostone (Amitiza) is an intestinal prostaglandin chloride-channel activator licensed for the
treatment of chronic idiopathic constipation in adults when response to diet and other non-drug
measures are inappropriate. It increases the chloride concentration of intestinal fluid, with sodium and
water following, which in turn promotes small bowel and colonic transit. The dose is one 24μg capsule
twice daily for 2 weeks; how frequently treatment courses can be repeated is not stated.
Evidence shows it improves the number of spontaneous bowel movements and symptoms associated
with chronic constipation (including abdominal bloating, abdominal discomfort, stool consistency and
straining).
The rationale for the limitation of treatment to 2 weeks is unclear, but there do not seem to be any
safety concerns with longer treatment.
NICE is developing a technology appraisal.
The cost is £59 for 56 i.e. 28 days. As it must be dispensed in the original container and used within 4
weeks of opening, this means that for a licensed two week course every Rx will result in 2 weeks of
wastage.
Eastbourne, Hailsham and Seaford CCG
Hastings and Rother CCG
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