Summary of Lothian Joint Formulary Amendments The purpose of this summary is to detail the main changes to the LJF sections and provide additional information on the reasons for some of the changes. The website chapters should be referred to for full details. The month indicates when Formulary Committee approved the changes. March 2016 Chapter 3 Respiratory Adults The general aim of this review of the respiratory chapter has been to simplify the extensive range of inhalers (devices) that are now available. Choice is more closely based on the ability to use the device either a metered dose inhaler (MDI) or a dry powder inhaler (DPI.) General notes The prescribing notes have been amended to provide more information regarding assessing inhaler technique and counseling patients on correct device use. A link is provided to leaflets that can be printed out for use with patients. A new note is included about in use expiries of inhalers and ensuring that patients understand how/when to use their inhalers to minimise waste. 3.1 Bronchodilators 3.1.1 Adrenoceptor agonists (a) short acting beta 2 agonist bronchodilators Salbutamol Accuhaler has been deleted the Easyhaler is now the only dry powder device included. (b) long acting beta 2 agonist bronchodilators (LABA) Formoterol turbohaler (Oxis) has been deleted, the Easyhaler is now the only dry powder device included. Indacaterol has been removed from the choices box. It had been included as an option in COPD instead of a LAMA.
3.1.2 Antimuscarinic bronchodilators The choices box has been amended extensively. Tiotropium and glycopyrronium are no longer included as options for moderate-severe COPD. First choice LAMA is umeclidinium and second choice is aclidinium. Tiotropium (Spiriva Respimat) is included for use in asthma. Combination LAMA/LABA inhalers have now been included: Anoro Ellipta (umeclidinum with vilanterol) is first choice and Duaklir Genuair (aclidinium with formoterol) is second choice. These new inhalers have the potential for confusion over their strengths, depending on whether the drug or the salt or the dose delivered is described. Information has been included detailing the strength as described on the box and in the prescribing systems in primary care these are different. 3.1.3 Theophylline preparations A new note has been added to state that low dose theophylline is sometimes used in COPD patients. Routine drug level monitoring is not required with this low dose use, unless there are concerns regarding toxic effects. 3.1.4 Compound bronchodilator preparations A reminder is included that patients should not be prescribed nebules when they have purchased a nebuliser themselves. Nebulisers are supplied following assessment by a respiratory specialist, if the patient requires one. 3.2 Corticosteroids (a) inhaled corticosteroids Fluticasone has been deleted as a second choice inhaled steroid. First choice is Clenil Modulite (MDI) or beclometasone Easyhaler (DPI) Budesonide Easyhaler remains as second choice. (b) other corticosteroids A table of equivalent doses for intravenous hydrocortisone and oral prednisolone is now included. The dose and course length for an exacerbation of COPD has been clarified, it is 40mg prednisolone for 5 days. (c) combination corticosteroid products The choices have been amended for asthma. Seretide and Symbicort have been deleted. First choices for asthma and COPD are now the same although the strengths of the inhalers are different. Information has been added to the choices box detailing the doses to be prescribed at step 3 or 4 of asthma management and in COPD.
Chapter 4 Central Nervous System Adults 4.10 (f) benzodiazepine prescribing Diazepam 5mg strength tablets have been added back in to the section. Due to the current prescribing patterns in NHS Lothian, the cost implication of removing 10mg and 5mg strength at the same time has been revisited. The addition of the 5mg tablets is an interim measure to allow work to take place in reviewing current prescribing. Chapter 6 Endocrine Adults 6.1 Drugs used in diabetes 6.1.1 Insulins Insulin Glargine is available as different branded products, some are biosimilars. It is important that they are prescribed by brand name to ensure the patient receives the intended product. Currently Abasaglar 100units/ml is first choice in Lothian. Toujeo 300units/ml is not on the formulary and should not be prescribed. 6.1.2 antidiabetes drugs (iv) sodium-glucose co-transporter 2 (SGLT2) inhibitor Empagliflozin is now first choice SGLT2 inhibitor, replacing dapagliflozin. There is new evidence that shows that empagliflozin has benefits on cardiovascular disease. As with all SLGT2 inhibitors there is specific advice about dosing in renal impairment.
Chapter 7 Obstetrics, gynaecology and urinary tract disorders - Adults 7.4.1 Drugs for symptoms caused by benign prostatic obstruction (a) alpha blockers Alfuzosin has been changed from joint first choice to joint second choice alpha-blocker. A prescribing note has been added to note that tamsulosin and doxazosin are once daily preparations. There is no need to prescribe doxazosin modified release. (b) 5α-reductase inhibitors A prescribing note has been updated to note that treatment with finasteride or dutasteride should be reviewed after 3-6months, then every 6-12months. A new prescribing note has been added stating that a combination tablet of dutasteride and tamsulosin is no more expensive than the two component drugs and may be useful in patients prescribed both drugs. 7.4.2 Drugs for urinary frequency, enuresis and incontinence (a) urinary frequency due to bladder instability Oxybutynin is no longer a formulary choice. Joint first choice is tolterodine or solifenacin. Second choice is fesoterodine. A prescribing note has been added providing further information about anticholinergics and impaired cognition, falls, morbidity and mortality. A link is provided to the Scottish Government Polypharmacy guidance and reducing anticholinergic loads. Chapter 8 Malignant disease and Immunosuppression - Adults 8.3.4.3 somatostatin analogues The choices for a long acting drug in neuroendocrine tumours have been reversed. Lanreotide (Somatuline Autogel) is now first choice and octroetide depot (Sandostatin LAR) is now second choice.
Chapter 9 Nutrition and Blood - Adults Hyperphosphataemia in Chronic Renal Impairment Completely new section. A hyperlink is also included to a document proving guidance on the stepwise approach to managing hyperphosphataemia and phosphate binders in renal patients. Chapter 9 Nutrition and Blood - Paediatrics 9.2.1.2 oral sodium and water There is now a licensed version of sodium chloride oral solution. The section has been updated to remove reference to the unlicensed product. Chapter 10 Musculoskeletal - Paediatrics 10.1.3 slow-acting antirheumatic drugs There is now a licensed version of methotrexate oral solution. The section has been updated to remove reference to the unlicensed product.