BEDFORDSHIRE AND LUTON JOINT PRESCRIBING COMMITTEE (JPC)

Transcription

1 BEDFORDSHIRE AND LUTON JOINT PRESCRIBING COMMITTEE (JPC) June 2017 Review: June 2020 Bulletin 251: The Management f Hyperhidrsis Bedfrdshire and Hertfrdshire INTERIM Pririties Frum Guidance JPC Recmmendatins: As BCCG and LCCG had previusly ratified the Bedfrdshire and Hertfrdshire INTERIM Pririties Frum Guidance plicy statement (N. 51, April 17) and recmmendatins, the JPC nted the attached dcument fr infrmatin and implementatin nly.

2 Bedfrdshire and Hertfrdshire INTERIM Pririties Frum Guidance Number: 51 Subject: The Management f Hyperhidrsis Date: April 2017 Date Review Due: April 2018 Interim Guidance Patients with lcalised hyperhidrsis (Hyperhidrsis Disease Severity Scale (HDSS) scre f 1-3) shuld be treated in primary care. Patients with generalised hyperhidrsis shuld be referred t secndary care. Apprpriate self-management including ver the cunter medicatins and tap water intphresis shuld be tried befre ther measures are cnsidered. Tap-water intphresis is nn-invasive and shuld be recmmended fr self-management in patients with fr palmar, plantar and axillary hyperhidrsis. Axillary intphresis may be effective in practice despite lack f published evidence (expert pinin). Intphresis with glycpyrrnium brmide is nt recmmended as the level f evidence fr adding glycpyrrnium brmide slutin is weak and wuld nt be cst-effective. Oxybutynin immediate release (IR, ff-label) shuld be prescribed in preference t glycpyrrnium brmide (unlicensed fr this indicatin) r prpantheline brmide (less effective). The level f evidence fr xybutynin IR and glycpyrrnium brmide are f similar strength (weak).* It is nt apprpriate fr nging prescriptins t riginate frm secndary care as patients culd be discharged frm the service after a successful trial f intphresis Endscpic Thracic Sympathectmy (ETS) shuld n lnger be ffered due t weak evidence and a significant risk f mrbidity Ablatin surgery f the axillae shuld be ffered as an alternative t btulinum txin A in specialised centres. *Bedfrdshire and Lutn Jint Prescribing Cmmittee has agreed that either xybutynin immediate release r prpantheline can be used as a first line ral antichlinergic. This recmmendatin has been supprted by LCCG and BCCG Executive Teams. Backgrund Multiple lcalised and systemic therapies are available fr the management f hyperhidrsis. The purpse f this dcument is t prvide an evidence based and cst-effective treatment pathway fr primary and secndary care. Hyperhidrsis is a disrder f excessive sweating beynd what is required fr thermregulatin. The cnditin may be lcalised (als referred t as primary r fcal hyperhidrsis) r secndary t medicatin r a medical cnditin (generalised hyperhidrsis).1 The mst imprtant issue in directing therapy fr hyperhidrsis is t differentiate between primary and secndary hyperhidrsis and between subtypes f primary hyperhidrsis (i.e. palmar, plantar, axillary, r cranifacial the areas with a high density f eccrine sweat glands). A cmplex dysfunctin f the innervatin f sweat glands via the sympathetic nervus system is likely t play a rle in the pathphysilgy f hyperhidrsis. Primary hyperhidrsis increases the risk f cutaneus infectin and has a significant psychscial burden and a negative impact n quality f life. As there is n standardised definitin f excessive sweating, clinicians base their diagnses in part n measures t estimate hw hyperhidrsis affects a patient s quality f life. The Hyperhidrsis Disease Severity Scale (HDSS) shuld be used as this is easy t use and validated against ther questinnaires. The recmmendatins in this plicy are bradly in line with a recent publicatin in the British Medical Jurnal and the Clinical Knwledge Summary n hyperhidrsis. Hwever, the pathway is simplified by recmmending GPs culd initiate treatment with an ral antichlinergic prir t referral int secndary care. Detailed recmmendatins are fund in the pathways in the Annexes at the end f this plicy.

3 Diagnstic criteria fr primary hyperhidrsis Fcal visible excess sweating Present fr at least 6 mnths N apparent secndary causes At least 2 f the fllwing: Bilateral and symmetric Impairs activities f daily life At least ne episde/week Age f nset <25 years Psitive family histry (in 60-80% f cases) N symptms during sleep Lifestyle advice Mdify behaviur t avid identified triggers (such as crwded rms, caffeine, r spicy fds), where pssible. Fr peple with primary axillary hyperhidrsis: Use a cmmercial antiperspirant (as ppsed t a dedrant) frequently. Avid tight clthing and manmade fabrics. Wear white (as ppsed t blue) shirts r black clthing t minimize the signs f sweating. Cnsider using dress shields (als knwn as armpit r sweat shields) t absrb excess sweat and prtect delicate r expensive clthing. These can be btained via the internet r the Hyperhidrsis Supprt Grup. Fr peple with primary plantar hyperhidrsis: Wear misture-wicking scks, changing them at least twice daily. Use absrbent sles, and use absrbent ft pwder twice daily. Avid cclusive ftwear (such as bts r sprts shes; wear leather shes. Alternate pairs f shes n a daily basis t allw them t dry ut fully befre wearing them again. Fr peple with primary cranifacial hyperhidrsis: Avid fd and drink triggers where pssible, if they exacerbate symptms (including caffeinated prducts, chclate, spicy r sur fds, ht fds, alchl, fds r drinks cntaining citric acid, r sweets). Hyperhidrsis Disease Severity Scale (HDSS) Subjective scre My sweating is never nticeable and never interferes with my daily activities My sweating is tlerable but smetimes interferes with my daily activities My sweating is barely tlerable and frequently interferes with my daily activities My sweating is intlerable and always interferes with my daily activities Clinical interpretatin 1 - mild 2 - mderate 3 - severe 4 - severe

4 References 1. British Assciatin f Dermatlgists website. Accessed 11/04/ Walling HW, Swick BL. Treatment Optins fr Hyperhidrsis. Am J Clin Dermatl 2011; 12 (5): Slish N et al. A cmprehensive apprach t the recgnitin, diagnsis, and severity-based treatment f fcal hyperhidrsis: recmmendatins f the Canadian Hyperhidrsis Advisry Cmmittee. Dermatl Surg 2007;33(8): Available nline: 4. Bensn RA, Palin R, Hlt PJE. Diagnsis and management f hyperhidrsis. BMJ 2013;347: f6800. Di: //bmj.f6800 [Epub]. Available nline: 5. NICE Clinical Knwledge Summary - Hyperhidrsis. Last updated July Available nline: 6. Shams K, Rzany BJ, Presctt LE, Musekiwa A. Interventins fr excessive sweating f unknwn cause (Prtcl). Cchrane Database f Systematic Reviews Available at: Human Rights and Equality Legislatin has been cnsidered in the frmatin f this guidance

5 Annex 1: Treatment fr Fcal Hyperhidrsis in Primary Care Patient presents with symptms f hyperhidrsis Histry and diagnsis (exclude secndary hyperhidrsis) Offer lifestyle advice - see previus page and: and Diagnstic criteria fr primary hyperhidrsis Fcal visible excess sweating Present fr at least 6 mnths N apparent secndary causes At least 2 f the fllwing: Bilateral and symmetric Impairs activities f daily life At least ne episde/week Age f nset <25 years Psitive family histry (in 60-80% f cases) N symptms during sleep Assess site and HDSS scre (see previus page) Primary/fcal hyperhidrsis: Tpical aluminium salt + 1% hydrcrtisne cream if necessary. Advise t purchase ver the cunter. Secndary hyperhidrsis: address cause if knwn (e.g. hyperthryidism, menpause, medicatin, amphetamines) Secndary hyperhidrsis f unknwn cause Refer t secndary care fr investigatin as apprpriate Treatment nt successful after 1 mnth Recmmend further self- management with intphresis if axillary, plantar r palmar hyperhidrsis (see next page). Patients are expected t purchase their wn machine fr hme treatment if successful. Self-management (including ral antichlinergic if tried) nt successful** after 3-6 mnths. Successful** after 1-3 mnths, cntinue and review regularly Cnsider ral antichlinergic* (ff label) =*First-line Oxybutynin 2.5mg IR: start with 2.5mg OD & gradually titrate accrding t respnse. Alternative ptins culd be ffered if effective but nt well tlerated See NICE CG171: Management f urinary incntinence (fflabel) fr alternative antichlinergics, thugh lack evidence. Prpantheline brmide is licensed fr hyperhidrsis but less effective. Oral glycpyrrnium brmide is unlicensed in the UK & csts are prhibitive: evidence base is similar as fr xybutynin. See als, Beds and Lutn mdificatin n page 1 HDSS scre: 1-3: stp treatment HDSS 4 despite all self management treatments as abve: refer t secndary care **Criteria fr successful treatment f hyperhidrsis: reductin in HDSS scre. Treatment failure can be defined as n change in HDSS scre after 1 mnth f therapy r lack f tlerability fr the treatment.

6 Annex 2: Treatment fr Fcal Hyperhidrsis in Secndary Care Investigate secndary hyperhidrsis f unknwn cause Management f hyperhidrsis if HDSS less than 4, refer back fr primary care and self management HDSS 4 AND all self management (including intphresis fr axillary and palmar/plantar hyperhidrsis) tried but nt successful. Axillary Palmar/ Cranifacial Plantar Btulinum txin A (Btx ) 50 units per axilla OR lcal surgery (laser sweat ablatin r retrdermal curettage where available and cmmissined). Patients shuld be fully infrmed re alternatives Cnsider antichlinergic (if nt already tried in primary care) r Btulinum txin A Cnsider antichlinergic (if nt already tried in primary care) (Btulinum txin A NOT recmmended) If successful Btulinum Txin A treatment, repeat can be given when sweat prductin is back t 50% f baseline, with a minimum treatment interval f 16 weeks. Prphylactic treatment befre reaching 50% f baseline is nt rutinely funded. If nt successful treatment r treatment limiting side effects, STOP treatment. At the time f publicatin, there was n Btulinum A prduct available in the UK That is licensed fr hyperhidrsis ther than axillary hyperhidrsis. Prducts are nt Interchangeable. Centres are advised t cnsult the latest infrmatin available Frm the UK marketing authrisatin hlders f the btulinum txin A preparatins. *Criteria fr successful treatment f hyperhidrsis: reductin in HDSS scre frm 4 t 1-2 after 4 weeks f therapy (3 mnths fr surgery).