East Berkshire Collaborative Newsletter. February 2018 Volume 7 Issue 10

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1 East Berkshire Collaborative Newsletter February 2018 Volume 7 Issue 10 GUIDANCE UPDATE/EVIDENCE 2 Barrier creams 2 UTI Guidelines 2 SAFETY UPDATE 3 MHRA drug safety update - February Esmya (ulipristal acetate) for uterine fibroids 3 Drug Interactions with senna or salbutamol increasing the risk of torsade de pointes 3 Following death by misadventure use clear dosing instructions - an NHS England 4 reminder For information only: recall of Ventolin Accuhaler 200mcg (60 dose) and Seretide 5 Accuhaler 50/250mcg (60 dose) FORMULARY UPDATE 5 Traffic light classification reminder 5 Crockcroft Gault creatinine clearance calculator in EMIS web 6 SAVINGS 6 Accrete D3 one a day chewable tablet 6 Ensure Plus Beware change in bottle size 6 SUPPLY ISSUES 6 Lacri-Lube out of stock 6 LOCAL CASE STUDIES SIGNIFICANT EVENT 7 Event - Different strengths and licensing of topical NSAID 7 CONTACT DETAILS FOR THE MEDICINES OPTIMISATION TEAM 8 If you have a GP leaving or Non-Medical Prescriber (NMP) leaving or joining your practice please remember to fill in the relevant forms promptly to ensure prescribing costs are attributed correctly to your practice. Please complete and to Catriona Khetyar (catriona.khetyar@nhs.net) who is now the authorised signatory. She will sign off the changes and inform NHS Business Prescription Services. Here are the links.

2 GUIDANCE UPDATE/EVIDENCE BARRIER CREAMS Proshield Plus barrier cream and Conotrane cream are now both available on the nursing home woundcare formulary and prescribing on FP10 should be avoided for nursing home patients. Faecal and/or urinary incontinence are experienced by a high proportion of residents living in nursing homes and care homes. Incontinence-associated dermatitis (IAD) is a painful skin condition characterised by irritation and inflammation and occurs when skin comes into prolonged contact with urine and/or faeces resulting in tissue breakdown, increased risk of infection and pressure ulcers. The table below provides guidance on what and when to prescribe in Nursing and Residential Care settings. Cream Indication Instructions Nursing Home Conotrane cream IAD with no exudate or tissue breakdown Residential Home (Prescribe on FP10) Proshield Plus barrier cream Exudate or tissue breakdown due to IAD To be applied thinly to the area needing prophylactic protection from IAD when required. To be applied thinly to the area needing prophylactic protection from IAD when required Conotrane cream Use 1st line for IAD Apply thinly when required or after each napkin change. Please note: Barrier creams prescribed for stoma patients should not be switched. If excessive quantities/products are ordered, you may request a review by a stoma nurse. Stoma patients are often sent samples which are requested on prescription, but please only add barrier creams (or any stoma accessory) to a stoma patients repeat medication on the request of a stoma nurse. UTI GUIDELINES Updated comprehensive guidelines for UTIs can be found on the prescribing pages of the CCG website. 2

3 SAFETY UPDATE MHRA DRUG SAFETY UPDATE - FEBRUARY 2018 Mycophenolate mofetil or mycophenolic acid have teratogenic and genotoxic effects and while the current evidence does not indicate an increased risk of malformations or miscarriage in pregnancies while fathers were taking these medicines it is insufficient to rule out a risk. ESMYA (ULIPRISTAL ACETATE) FOR UTERINE FIBROIDS For this indication, ulipristal acetate has formulary traffic light status RED, and therefore should not be prescribe in primary care. An epact search revealed some prescribing; for practices who have prescribed within the previous 6m the following information will apply. For this indication, ulipristal acetate has formulary traffic light status RED, and therefore should not be prescribe in primary care. An epact search revealed some prescribing; for practices who have prescribed within the previous 6m the following information will apply. Five reports of serious liver injury, including four cases of hepatic failure needing liver transplantation, have been reported worldwide in women using Esmya for uterine fibroids. The following temporary safety measures have been introduced while an EU-wide review of the evidence is ongoing: Do not initiate new treatment courses of Esmya, including in women who have completed one or more treatment courses previously Perform liver function tests at least once a month in all women currently taking Esmya. Stop Esmya treatment in any woman who develops transaminase levels more than 2 times the upper limit of normal, closely monitor and refer for specialist hepatology evaluation as clinically indicated. Liver function tests should be repeated in all women 2 to 4 weeks after stopping treatment. Check transaminase levels immediately in current or recent users of Esmya who present with signs or symptoms suggestive of liver injury (such as nausea, vomiting, malaise, right hypochondrial pain, anorexia, asthenia, jaundice). If transaminase levels are more than 2 times the upper limit of normal, stop treatment, closely monitor and refer for specialist hepatology evaluation as clinically indicated. Advise women using Esmya on the signs and symptoms of liver injury. The emergency contraceptive ellaone also contains ulipristal acetate (single-dose, 30mg). No cases of serious liver injury have been reported with ellaone and there are no concerns with this medicine at this time. DRUG INTERACTIONS WITH SENNA OR SALBUTAMOL INCREASING THE RISK OF TORSADE DE POINTES Medicine Information have had a flurry of questions from primary care prescribers and pharmacists concerned about seemingly innocuous drug combinations flagged up on prescribing systems. Particular examples are: Salbutamol inhaler + clarithromycin 3

4 Senna tablets + citalopram These combinations have been prescribed uneventfully for many years but computer systems are now flagging them as high risk alert risk of torsade de pointes. What is the nature of the interaction? Hypokalaemia is a risk factor for torsade de pointes. Salbutamol and senna are listed in the BNF as causing hypokalaemia; clarithromycin and citalopram are listed in the BNF as causing QT prolongation. Why are these interactions being flagged up now? The potential interactions are not new but the BNF has changed the way it presents information on interactions. Are these interactions relevant? The BNF table of drugs that reduce serum potassium includes some examples where hypokalaemia is unlikely. For example: Senna is associated with hypokalaemia if there is long term abuse of laxatives or overdose leading to diarrhoea. Inhaled beta2 agonists are unlikely to cause hypokalaemia; it is an adverse effect more commonly associated with oral or parenteral administration. Similarly, hypokalaemia is a rare adverse effect of inhaled corticosteroids; it is more commonly associated with oral or parenteral administration. Most cases of hypokalaemia are due to diuretics or loss of gastrointestinal fluids through persistent vomiting, chronic diarrhoea or laxative abuse. Combinations such as salbutamol inhaler + clarithromycin or senna + citalopram need not be avoided. FOLLOWING DEATH BY MISADVENTURE USE CLEAR DOSING INSTRUCTIONS- AN NHS ENGLAND REMINDER NHS England has received a coroner s report in relation to a patient who was prescribed liquid morphine (Schedule 5 CD) by their GP, and who later died through misadventure. The medication label printed was take as directed by your doctor every four hours. The prescription was sent using the Electronic Prescription Service (EPS) but the concerns apply equally to all prescriptions. The dose to be taken was discussed with the patient by their GP and this understanding was checked further at the point of dispensing. The coroner s concern was that neither the individual unit dose nor the maximum total daily dose was printed on the label of the medication. To reduce the risk of confusion or misunderstanding at a later date, terms such as as directed, when required or similar phrases should not be used. Guidance contained in the BNF and NICE guideline 46, Controlled Drugs Safe Use and Management, states that it is considered best practice to include the following: clear dosing instructions on the prescription clear dosing instruction on the corresponding medicine label, such as the individual unit dose and maximum total daily dose. 4

5 FOR INFORMATION ONLY: RECALL OF VENTOLIN ACCUHALER 200MCG (60 DOSE) AND SERETIDE ACCUHALER 50/250MCG (60 DOSE) GSK has sent a letter to pharmacies recalling two lots of Ventolin Accuhaler 200mcg and a pharmacy level recall for a single lot of Seretide Accuhaler 50/250mcg. This is as a result of a manufacturing issue that may result in a small number of devices not delivering the full number of doses in the device. Prescribers do not need to take any action, however should be aware of the recall, in case concerned patients call the practice. FORMULARY UPDATE TRAFFIC LIGHT CLASSIFICATION REMINDER The Frimley Health Area Prescribing Committee Formulary uses the following traffic light classification: Red = Prescribing remains with a specialist Amber with shared care = After initial recommendation by a specialist, prescribing can move to primary care after shared care responsibilities are agreed Amber = After initial recommendation by a specialist, prescribing can move to primary care Green = Prescribing can be started in primary or secondary care Non-formulary =The medication is not on the local formulary and is not recommended for prescribing in primary or secondary care (denoted as light grey font in the EMIS formulary). COCKCROFT- GAULT CREATININE CLEARANCE CALCULATOR IN EMIS WEB When calculating renal function when dosing many medications it is recommended that creatinine clearance is calculated using Cockcroft-Gault rather than using estimated GFR. ` A key example where this can improve the safety of prescribing is when DOACs/NOACs are being prescribed. This is recommended by licences and BNF. Additionally, egfr is more likely to be inaccurate for people who are underweight or obese and so a more accurate estimate of renal function may be calculated using Cockcroft-Gault. EMISWeb has a template that calculates creatinine clearance using Cockcroft-Gault for you. The template is called Estimate Creatinine Clearance (Cockcroft-Gault formula). 5

6 SAVINGS ACCRETE D CHEWABLE & ACCRETE D3 STANDARD TABLETS RECOMMENDED AS 1ST LINE OPTIONS Accrete D3 one a day chewable tablet has been added to the formulary. This is in addition to Accrete D3 tablet (non-chewable) that was already 1st line on the formulary. Therefore, Accrete D3 is now the preferred calcium and vitamin D supplement when either a chewable or swallowable product is required. Adcal D3 caplets (but not chewable tablets) remain available when a certified Halal or Kosher product is required. Product Dose Price p.a. Accrete D3 tablets 1.5g/400iu Two tablets per day Accrete D3 one a day chewable One tablet per day tablets 1g/880iu Adcal D3 chewable tablets Two tablets per day g/400iu Adcal D3 caplets 750mg/200iu Four tablets per day SUPPLY ISSUES ENSURE PLUS: BEWARE CHANGE IN BOTTLE SIZE The size of bottles which Ensure Plus is supplied in is being reduced from 220ml to 200ml. This does not change the recommended dose of two bottles per day. However, the change is causing clinical systems to incorrectly calculate the number of bottles required for repeat prescriptions. This is because it is trying to give the same total quantity in millilitres rather than the same number of bottles of the new product size. When re-issuing prescriptions for Ensure Plus please correct the prescribed quantities to 56 bottles per 28 days if the dose is two bottles per day. LACRI-LUBE OUT OF STOCK It has come to our attention that Lacri-Lube is out of stock. VitA-POS, a preservative-free eye ointment containing liquid paraffin may be prescribed instead for dry eyes. Another product for dry eyes that may be considered is Vismed Multi, which contains sodium hyaluronate, 6

7 LOCAL CASE STUDIES - SIGNIFICANT EVENT EVENT DIFFERENT STRENGTHS AND LICENSING OF TOPICAL NSAID GP prescribed Diclofenac Gel for knee pain post fall, however in error prescribed 3% gel (Solaraze) instead of Diclofenac Gel 1.16% or 2.32% which are licensed for pain. The 3% preparation is licensed only for use in Actinic keratosis. The patient suffered no ill effects from this gel which was picked up by another GP when the patient requested a repeat prescription for Diclofenac 3% gel. LEARNING POINTS Different formulations and strengths of a drug can have different licensed indications; the correct formulation and strength must be selected for the indication. Always double check the BNF when prescribing to match a formulation and strength of a drug to the licensed therapeutic indication being treated. This incident took place before the changeover to OptimiseRx. In this situation OptimiseRx would flag Review the prescription for Diclofenac gel 3% - as there was no record of actinic keratosis in the patient record within the last 2 years. Such an error is potentially easily continued and regular review of medications can prevent this. 7

8 CONTACT DETAILS FOR THE MEDICINES OPTIMISATION TEAM King Edward VII Hospital, St Leonards Rd, Windsor SL4 3DP Main office phone number Fax: Generic in box Catriona Khetyar Head of Medicines Optimisation Tim Langran Slough CCG Lead Support Prescribing Pharmacist Melody Chapman Bracknell & Ascot CCG Lead Support Prescribing Pharmacist Dawn Best Windsor/Ascot & Maidenhead CCG Lead Support Prescribing Pharmacist Caroline Pote CCG Prescribing Support Pharmacist Sundus Jawad CCG Care Home & Prescribing Support Pharmacist Sally Clarke CCG Care Home & Prescribing Support Pharmacist Caroline Hailstone CCG Project Pharmacist Cathy Macqueen Prescribing Dietitian (Part time) Maureen Maul PA to Catriona Khetyar Mobile E: mail