East Berkshire CCG Prescribing Newsletter. August 2018 Volume 9 Issue 4

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1 East Berkshire CCG Prescribing Newsletter Volume 9 Issue 4 GUIDANCE UPDATE/EVIDENCE 2 Infant feed guidelines update - GOR 2 Major changes to the childrens antibiotic prescribing recommendations in the scan 3 antibiotic guidelines FORMULARY UPDATE 3 Pivmecillinam- prescribing advice in urinary tract infections 3 Fosfomycin- prescribing advice in urinary tract infections 4 SAFETY UPDATES 4 Reminder Prescribe dry powder inhalers by brand 4 Metformin adjustment for renal disease - audit findings 4 JOURNAL WATCH 5 Opioid analgesics and Z-Drugs linked to harmful effects in dementia patients 5 SAVINGS 6 Adding emollients to the bath unlikely to help children with eczema 6 Blood glucose test strips 7 Review prescribing of alimemazine 8 CONTACT DETAILS FOR THE MEDICINES OPTIMISATION TEAM 10 If you have a GP 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 maureen.maul@nhs.net who will pass the form onto one of the authorised signatories. An authorised signatory is required to sign off the changes and inform NHS Business Prescription Services. Here are the links to the forms.

2 GUIDANCE UPDATE/EVIDENCE INFANT FEEDING GUIDELINES UPDATE GASTRO-OESOPHAGEAL REFLUX If you have a child presenting to you with suspected Gastro-Oesophageal Reflux (GOR), please check for Red Flag symptoms and follow the flow chart, below. Please note that Instant Carobel and the thickening formulae SMA PRO Anti-reflux & Enfamil A.R. should be purchased OTC. Thickening formulae should not be used with separate thickeners or in conjunction with medication such as Infant Gaviscon, antacids or proton pump inhibitors. ACTION: For further information about the appropriate prescribing of specialist paediatric formulas in Berkshire East Primary Care, please go to: Prescribing-Guidelines-September-2017-APPROVED-final.pdf 2

3 MAJOR CHANGES TO THE CHILDRENS ANTIBIOTIC PRESCRIBING RECOMMENDATIONS IN THE SCAN ANTIBIOTIC GUIDELINE In order to optimise patient adherence the authors of the updated antibiotic guidelines have recommended antibiotics that are palatable and minimise dosing frequency. Penicillin V and flucloxacillin suspensions are not well tolerated by children due to their taste, hence changing from penicillin V suspension in young children to amoxicillin twice a day dosing in the guidelines. Although there has been great anxiety about prescribing amoxicillin in patients with tonsillitis due to the risk of adverse events associated with EBV, there is emerging data to suggest that the use of amoxicillin does not significantly increase the risk of rash in acute EBV see In addition, data suggests that EBV accounts for as little as 1% of tonsillitis presenting to doctors ( see ) and more importantly, EBV is extremely rare in children below 12 years of age. For this reason, the current recommendation is to use penicillin V bd tablets for children able to swallow tablets. It should also be noted that the guidelines recommends higher doses of oral antibiotics for children (you may find that the dosing for children above 12 years of age exceeds that routinely used in adults!) This is because there is emerging data demonstrating underdoing of antibiotics in children using the current BNFc age-bands (See ). The consensus of the guideline development group was to base antibiotic doses on the upper limit of BNFc recommendations. The rationale for this is to avoid treatment failures due to underdosing in the small number of children that require antibiotic treatment for respiratory tract infections. ACTION: The SCAN guidelines website has a comprehensive document detailing the above and other changes that should be noted in the prescribing recommendations for respiratory tract infections in children. Please read the document in full, at FORMULARY UPDATE PIVMECILLINAM TABLETS PRESCRIBING INFORMATION IN URINARY TRACT INFECTIONS Pivmecillinam has significant activity against many Gram-negative bacteria including Escherichia coli, klebsiella, enterobacter, and salmonellae. It is not active against Pseudomonas aeruginosa or enterococci. Contraindicated in patients allergic to penicillins and/or cephalosporins. Place in treatment: The SCAN antibiotic guidelines recommend the antibiotic 2 nd line, if nitrofurantoin or trimethoprim is unsuitable and in those with egfr<45 ml/min. Recommended Dose: In uncomplicated UTI in women of all ages, 400mg stat THEN 200mg tds for 3 days. If high resistance risk or known previous resistance, 400mg tds for 3 days. In Lower UTI in men, 400mg stat THEN 200mg tds for 7 days. If high resistance risk, or known previous resistance, 400mg tds for 7 days. 3

4 It is recommended that tablets are taken with a full glass of water and with or after food (due to the risk of oesophagitis). FOSFOMYCIN GRANULES - PRESCRIBING INFORMATION IN URINARY TRACT INFECTIONS Fosfomycin, a phosphonic acid antibacterial, is active against a range of Gram-positive and Gramnegative bacteria including Staphylococcus aureus and Enterobacteriaceae. Caution in patients with cardiac insufficiency, elderly (high doses), hyperaldosteronism, hypernatraemia, hypertension and pulmonary oedema. Place in treatment: The SCAN antibiotic guidelines recommend the antibiotic if high resistance risk e.g. care-home resident, recurrent UTI, hospitalisation for >7 days in the last 6 months, unresolving urinary symptoms, recent travel to a country with increased resistance, previous UTI resistant to trimethoprim, cephalosporins, or quinolones. Recommended Dose: In uncomplicated UTI in women of all ages, Fosfomycin 3g single dose. In Lower UTI in men, Fosfomycin 3g single dose, then repeat on day 3 (unlicensed). ACTION: Follow the SCAN guidelines for treatment of UTIs SAFETY UPDATE REMINDER - PRESCRIBE DRY POWDER INHALERS BY BRAND There has been an incident locally where a combination LABA/ICS inhaler was prescribed generically and the pharmacy dispensed a different dry powder inhaler from the one the individual was used to using. Communication of the different inhaler technique required was not good enough and after a few days the individual developed shortness of breath and attended A&E with an asthma attack. Please note that it is recommended by NHS UKMI Specialist Pharmacy Service that dry powder inhalers are prescribed by brand name to ensure that a consistent device is dispensed. ACTION: Please prescribe dry powder inhalers by their brand name. METFORMIN ADJUSTMENT FOR RENAL DISEASE- AUDIT FINDINGS An audit of patients with type 2 diabetes with an egfr < 60mls/ min to ascertain if prescribing of diabetes medication is in line with the BNF and licenses will be undertaken in every practice in East Berkshire CCG, as part of the prescribing indicators for Preliminary findings suggest that, understandably, the most common drug highlighted in these audits is metformin, and dose adjustments are generally being missed in patients with a reduced egfr reading 4

5 outside of a diabetes review. Our recommendations to all clinicians reviewing renal function test results in type 2 diabetes patients are: 1. egfr 30 and <45ml/min halve dose of metformin e.g. 1g daily or 500mg twice a day maximum. 2. egfr < 30ml/min, stop metformin. 3. Withdraw or interrupt treatment in those at risk of AKI, as per Sick Day Rule recommendations. Patients with a sudden deterioration of renal function e.g. dehydration, severe infection, shock, sepsis, acute heart failure, respiratory failure should be told to stop metformin temporarily until they can drink properly/ no further dehydration risk. Other diabetes medication requiring dose adjustment, please see the table below. ACTION: Adjust metformin doses with reduced renal function as above. JOURNAL WATCH OPIOID ANALGESICS AND Z-DRUGS LINKED TO HARMFUL EFFECTS IN DEMENTIA PATIENTS Medicines commonly prescribed to dementia patients have been linked to an increase in harmful sideeffects, according to new research involving the University of Exeter and King s College London. The research looked at the impact of opioid-based painkillers and Z drugs prescribed to an estimated 200,000 people with dementia living in care homes across the UK. 5

6 This research suggests that people with dementia may be particularly susceptible to harmful side-effects of common opioid-based painkillers. Researchers found a tripling in harmful side effects such as personality changes, confusion and sedation related to buprenorphine use in people with dementia compared to those on a placebo, and those given buprenorphine were significantly less active during the day. Data for 2,952 dementia patients prescribed zolpidem, zopiclone or zaleplon, were compared to data for 1,651 patients who were not. Z drugs increased risk of fractures by 40%, 59% of patients were more likely to break a hip, 34% were more likely to die in the following 2 years. ACTION: Underlying pain can be a significant contributor to distress in people with dementia, who are not always able to communicate their needs to those around them. In order to protect frail elderly people with dementia from fractures, serious side effects and increased risk of death, consider non-drug approaches to treating pain and insomnia before prescribing. Tailoring the dose of painkillers for people with dementia could limit their side-effects while retaining their important benefits. SAVINGS ADDING EMOLLIENTS TO THE BATH UNLIKELY TO HELP CHILDREN WITH ECZEMA Published on 7 doi: /signal A National Institute for Health Research Signal (NIHR) funded year-long trial included 482 children, mostly with mild eczema. It found there was little change in skin-related outcomes or quality of life between those that did or did not have emollients poured into their bath NICE 2007 guidance states that eczema should be managed according to the severity of the condition and use of emollients should be the mainstay of treatment for the condition and need to be used even when the skin is clear. The signal concludes that it is important that children's caregivers are aware of the need for regular application, regardless of the type of emollient used, but that adding that these products to the bath is in most cases unnecessary and adds costs for the NHS. Therefore they concluded that adding emollients to children s bath water does not significantly improve their eczema. Prescriptions should focus on emollients applied directly to the skin or used as a soap substitute. Over the last 12m, East Berkshire Practices have prescribed > 85,000 on bath emollients See the list on the next page. 6

7 BNF 12m (June 17 - May 18) Items Cost ( ) Soya Oil_Bath Oil 84.75% SoyaOil/Lauromacrogols_BathOil 82.95/15% E45_Emollient Bath Oil 270 1, Aveeno_Bath Oil Balneum_Bath Oil 84.75% 294 1, Balneum Plus_Bath Oil 372 2, Dermol 600_Bath Emollient 713 5, Dermol 200_Shower Emollient 2,422 15, Liq Paraf Light_Bath Add 82.8% 219 1, Liq Paraf Light_Bath Add 63.4% 873 4, Oilatum Plus_Bath Additive 844 6, Cetraben_Emollient Bath Add 82.8% 1,068 6, Oilatum_Shower Gel Fragrance Free 477 4, Oilatum_Bath 1,647 9, Oilatum_Emollient 1,215 5, Oilatum Jnr_Bath Additive 2,412 13, Zerolatum Plus_Bath Additive Liq Paraf/Acetyl Wool Alc_Bath Oil 65/5% Liq Paraf_Bath Add 65% Dermalo_Bath Emollient Doublebase_Emollient Bath Add Doublebase_Emollient Shower Gel 414 3, Doublebase_Emollient Wash Gel ,729 85, ACTION: For the majority of children, there appears to be little benefit adding the emollients used in this trial (Oilatum, Balneum and Aveeno ) to the bath in addition to creams or emollients for direct application. Please take into account this evidence and consider deprescribing. BLOOD GLUCOSE TEST STRIPS The range of available blood glucose meters has recently been reviewed and we now recommend an amended range of best value meters. These meters have been chosen together with the King Edward diabetes service and choices are based on accuracy, price and features. Table 1 lists the meters/strips that are best value. These meters are suitable for all patients. Table 2 lists the meters/strips in those patients who carbohydrate count or have regular hypos, have gestational diabetes or require ketone test. 7

8 Table 1- cost effective options Volume 9 Issue 4 Meter Strip Cost Helpline tel nos for meters GlucoMen Areo 2k GlucoMen Areo 9.95/ Sensor GlucoRx Nexus GlucoRx Nexus 9.95/ Accuchek Performa Nano Performa 9.95/ Wavesense Jazz Wavesense Jazz 8.74/ Accu-Chek Mobile Mobile 9.99/ Table 2-specified situations Meter Strip Cost Helpline tel Specified situation nos for meters Accu-Chek Aviva / Aviva Expert Aviva 16.09/ Carb counting/ regular hypos Freestyle Insulinx Freestyle Lite 16.10/ Carb counting/ regular hypos Contour Next Contour Next 15.05/ Gestational diabetes/ carb counting Freestyle Optium Neo Freestyle Optium 16.00/ Ketone testing GlucoRx HCT GlucoRx HCT 9.95/ Ketone testing ACTION: When stocking blood glucose meters, please arrange for supplies of one of the formulary machines. In the main, the meters in table 2 will be recommended and supplied by the diabetes centre. REVIEW PRESCRIBING OF ALIMEMAZINE The cost of Alimemazine (both tablets and oral solution) has increased significantly over the last year (see cost table). It now costs for 28 tablets of alimemazine 10mg (DT Aug 18). NICE guidance recommends chlorphenamine as a 1st line choice if a sedating antihistamine is required for urticaria. Product Cost for 28 tablets Chlorphenamine 4mg tablets 76p Hydroxyzine 25mg tablets 79p Promethazine 25mg tablets 2.32 Alimemazine 10mg tablets There is no published literature available to state that alimemazine is superior in efficacy to other antihistamines. Sedating antihistamines should not be used long term unless clinically indicated. East Berkshire practices currently spend around 26,000 each year for only 140 items of antihistamine, with prices up to nearly 500/item. 8

9 Practice BNF 12m June 17 - May 18) Items Cost ( ) Q X Items Cost/Item ( ) BOUNDARY HOUSE SURGERY (K81032) ( D 02-JUL-18 ) Alimemazine Tart_Tab 10mg COOKHAM MEDICAL CENTRE (K81042) Alimemazine Tart_Tab 10mg CROSBY HOUSE SURGERY (K81034) Alimemazine Tart_Oral Soln 7.5mg/5ml EASTHAMPSTEAD SURGERY (K81087) Alimemazine Tart_Tab 10mg 13 2, FARNHAM ROAD PRACTICE (K81075) Alimemazine Tart_Oral Soln 7.5mg/5ml 4 1, HEATH HILL SURGERY (K81023) Alimemazine Tart_Tab 10mg 25 1, HERSCHEL MEDICAL CENTRE (K81043) Alimemazine Tart_Oral Soln 30mg/5ml KUMAR MEDICAL CENTRE (K81616) Alimemazine Tart_Oral Soln 7.5mg/5ml 6 1, KUMAR MEDICAL CENTRE (K81616) Alimemazine Tart_Oral Soln 30mg/5ml 10 2, , LANGLEY HEALTH CENTRE (K81024) Alimemazine Tart_Oral Soln 7.5mg/5ml MANOR PARK MEDICAL CENTRE (K81086) Alimemazine Tart_Tab 10mg RINGMEAD MEDICAL PRACTICE (K81030) Alimemazine Tart_Oral Soln 7.5mg/5ml 8 1, RUNNYMEDE MEDICAL PRACTICE (H81047) Alimemazine Tart_Oral Soln 7.5mg/5ml 9 4, , SLOUGH WALK-IN HEALTH CENTRE (Y00265) Alimemazine Tart_Oral Soln 7.5mg/5ml 3 1, THE CEDARS SURGERY (K81036) Alimemazine Tart_Tab 10mg THE GAINSBOROUGH PRACTICE (K81059) Alimemazine Tart_Oral Soln 7.5mg/5ml THE GAINSBOROUGH PRACTICE (K81059) Alimemazine Tart_Tab 10mg 12 1, THE SANDHURST GROUP PRACTICE (K81006) Alimemazine Tart_Oral Soln 7.5mg/5ml 14 2, , THE SYMONS MEDICAL CENTRE (K81066) Alimemazine Tart_Tab 10mg 24 3, , , , ACTION: Review patients prescribed alimemazine for urticaria. If suitable, switch to either chlorphenamine or another appropriate sedating antihistamine. Patients should also be reviewed if alimemazine is being used for an off label indication. All new patients requiring a sedating antihistamine should be commenced on chlorphenamine as per NICE guidance if appropriate. N.B. Please remember to check the indication and anticholinergic burden (ACB) of concurrent medicines and calculate the total ACB when starting chlorphenamine, particularly for frail patients who are especially susceptible to anticholinergic side effects. (Alimemazine has a anticholinergic score of 1 vs 3 for chlorphenamine). References 1. NICE CKS Urticaria Last revised March MHRA Drug Safety Update (2015) Hydroxyzine: risk of QT interval prolongation and Torsade de Pointes. SUPPLY ISSUES HEPATITIS B VACCINE STOCKS AVAILABLE Since mid 2017 there has been a shortage of hepatitis B vaccine due to global manufacturing issues. GSK are now confident that supplies are now sufficient for the entire UK market. NHS England published a list of travel vaccines that should not be prescribed exclusively for travel on the NHS, the list includes Hepatitis B (others: Japanese Encephalitis, Meningitis ACWY, Yellow Fever, Tickborne encephalitis, Rabies, BCG). We are also aware that Public Health Emgland have written in a Briefing Note dated 6 th, that the combined hepatitis A/B vaccine is the preferred 1 st line choice for travellers. Further clarification has therefore been sought and will be shared with practices as soon as possible. 9

10 ACTION: Please continue to follow the NHS England guidance that hepatitis B vaccines should not be prescribed on the NHS when given exclusively for the purposes of travel. CONTACT DETAILS FOR THE MEDICINES OPTIMISATION TEAM King Edward VII Hospital, St Leonards Rd, Windsor SL4 3DP Main office phone number Fax: NEW GENERIC IN BOX ADDRESS: eastberksccg.medicines-optimisation-team@nhs.net Mobile E: mail Catriona Khetyar catriona.khetyar@nhs.net Head of Medicines Optimisation Tim Langran tim.langran@nhs.net Slough CCG Lead Support Prescribing Pharmacist Melody Chapman melody.chapman@nhs.net Bracknell & Ascot CCG Lead Support Prescribing Pharmacist Dawn Best dawnbest@nhs.net Windsor/Ascot & Maidenhead CCG Lead Support Prescribing Pharmacist Caroline Pote caroline.pote@nhs.net CCG Prescribing Support Pharmacist Sundus Jawad CCG Care Home & Prescribing Support Pharmacist sundus.jawad@nhs.net Sally Clarke CCG Care Home & Prescribing Support Pharmacist Caroline Hailstone CCG Project Pharmacist Cathy Macqueen Prescribing Dietitian (Part time) Dhara Thacker Care Homes Medicine Technician Maureen Maul PA to Catriona Khetyar sally.clarke6@nhs.net caroline.hailstone@nhs.net catherine.macqueen@nhs.net dhara.thacker2@nhs.net maureen.maul@nhs.net 10