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									        Doncaster Apothecary
                                                  DONCASTER PCT PRESCRIBING NEWSLETTER                        JANUARY 2008



         Short-acting  agonists: myocardial ischaemia
         Myocardial ischaemia may occur with use of short-acting  agonists: patients with pre-existing ischaemic heart
         disease or risk factors for cardiovascular disease should be alert to symptoms of worsening heart disease if
         receiving treatment for respiratory disease.
         Patients with a history of heart disease, including angina and rhythm disturbance, should be advised to
         continue treatment with short-acting  agonists, but to seek medical advice if symptoms such as shortness of
         breath or chest pain occur during treatment because they may suggest worsening heart disease.
         Source: Drug Safety Update 2007; 1(5): 10

         Secure requisition forms for controlled drugs (CDS)
         Regulatory changes came into force 1 January
         2008 which apply to requisitions used for the
         supply of schedule 1, 2 and 3 CDs by authorised
         practitioners working in any health care setting in
         the community, for the purpose of treating
         patients. Dispensing Doctors should not supply
         CDs ordered on a requisition as they are not
         permitted to carry out a wholesale function unless
         they have a wholesalers licence.
         A dedicated requisition form has been introduced
         for the supply of schedule 1, 2 and 3 CDs
         (otherwise than on prescription or by way of
         administration) for human use in the community.
         In exceptional circumstances, where for example
         an individual may have difficulty in obtaining the
         standard form, a CD can be supplied in response
         to an order written on a non standard form,
         providing all the legal requirements are met.
         The PCT hold stocks of CD requisitions and will
         (endevour to) issue an appropriate number to the
         practitioner by the end of the month.
         Sources:
         www.epact.ppa.nhs.uk/
         Personal correspondence – Fiona Williamson

         Inhaled steroids for asthma in children
         For children under 12 with chronic asthma in whom treatment with an
         inhaled corticosteroid (ICS) is considered appropriate, the least costly product
         that is suitable for an individual child (taking into consideration TAG 38 and 10),
         within its marketing authorization (MA), is recommended.
         For children under 12 with chronic asthma in whom treatment with an ICS
         and long-acting beta-2 agonist is considered appropriate, the following apply:
         • The use of a combination device within its MA is recommended as an option.
         • The decision to use a combination device or the two agents in separate devices
         should be made on an individual basis, taking into consideration therapeutic need
         and the likelihood of treatment adherence.
         • If a combination device is chosen then the least costly                       In This Issue:
         device that is suitable for the individual child is               Short-acting  agonists: myocardial ischaemia
         recommended.                                                              Secure requisition forms for CDs
         Source: www.nice.org.uk                                               NICE TA 131 – inhaled corticosteroids
                                                                              for the treatment of asthma in under 12s
                                                                           NICE CG 57 – treatment of atopic eczema in
                                                                           children (from birth up to the age of 12 years)


Prescribing Support Team • Park Lodge• St Catherine’s Hospital, DN4 8QN
                                                                                       Doncaster Apothecary


         NICE CG 57–Treatment of Atopic CV and GI risk
         NSAIDs and coxibs: balancing Eczema in Children
         Gastrointestinal (GI) toxicity and cardiovascular
          Stepped approach to management                      • For ibuprofen at high doses (eg, 2400 mg daily)
                toxicity are the should important to the      there may be a small Emollients should form
         (CV) treatment steptwo mostbe tailoredsafety severity of the eczema.thrombotic risk, but at lower
          The
          the basis of management and should always be doses (eg, 1200 mg the eczema is clear.
         concerns for non-steroidal anti-inflammatory         used, even when daily or less) epidemiological
         drugs (NSAIDs) and COX-2 inhibitors (coxibs).
          Emollients                                          data do not suggest an increased risk of MI
          Offer a choice epidemiological data have given
         Clinical trial andof unperfumed emollients to use for everyday moisturising, washing and
                                                              Gastrointestinal risks
                     information on the level of risk with    The and preferences, and may include a
         important These should be suited to the child’s needs Commission on Human Medicines recently,
          bathing.
                                                              highlighted the high GI risk with piroxicam
         individual medicines. However, these data are all purposes. Leave-on emollients should be and
          combination of products or one product for
                        there are no robust (250–500 g weekly) and easily available at nursery/school.
         complex and in large quantities comparisons for
          prescribed                                          ketoprofen. Of the traditional NSAIDs, low-dose
         many NSAIDs. Most evidence relates to the
          Topical steroids                                    ibuprofen offers the lowest risk. Coxibs are
                              ibuprofen, and diclofenac.      tailored to the severity of the child’s to most
         coxibs, naproxen, topical corticosteroids should be associated with reduced GI risk relative atopic
          The potency of
         Thrombotic risks                                     NSAIDs at equivalent doses. However, coxibs
          eczema, which may vary according to body site. They should be used as follows:
         •Diclofenac 150 mg daily has a thrombotic risk
               Use mild potency for mild atopic eczema        (like NSAIDs) may vary in their effects,
                                 of etoricoxib and possibly   and evidence for a reduction in the most
         profile similar to that potency for moderate atopic eczema
           Use moderate
                coxibs                                        clinically important GI risks for etoricoxib is
         otherUse potent for severe atopic eczema for as short a time as possible and no longer than
          
                                 daily has a lower thrombotic weak. Proton pump inhibitors reduce the GI
         • Naproxen 1000 mgwith specialist dermatological supervision in children under 12 months risks
               14 days: only
                           and, overall, epidemiological      associated alternative to stepping up where
         risk than coxibsa different steroid of the same potency as anwith NSAIDs, and may reduce the
           Consider
         data do not suggest an increased risk of
               tachyphylaxis is suspected                     risks to a similar level as use of a coxib alone.
                                                              Source: Drug Safety Update 2007; 1(5):
         myocardial infarction (MI) the face and neck, except for short-term (3–5 days) use of 10
           use mild potency for
               moderate potency for severe flares: do not use potent preparations on the face or neck
              Use moderate or potent preparations for short periods only (7–14 days) for flares in
                      Missed an issue? Want more copies to send to friends and family?
               vulnerable sites such as axillae and groin
                         Send potent preparations in children without specialist dermatological advice
           Do not use verySASE to Agency Update, POB 345, Anytown, MD 01010
           Prescribe for application only once or twice daily: start as soon as sign and symptoms
               appear. Continue for approximately 48 hours after symptoms subside.
           Where more than one topical corticosteroid is appropriate within a potency class,
               prescribe the drug with the lowest acquisition cost, taking into account pack size and
               frequency of application
          Treatment for infections
          Children with atopic eczema and their parents or carers should be offered information on:
           How to recognise the symptoms and signs of bacterial infection with staphylococcus
               and/or streptococcus (weeping, pustules, crusts, eczema failing to respond to therapy,
               rapidly worsening eczema, fever and malaise). Provide clear information on how to
               access appropriate treatment when a child’s atopic eczema becomes infected:
                Localised clinical infection – topical antibiotics including those combined with
                   steroids: maximum 2 weeks. Obtain new supply at end of treatment.
                Widespread bacterial infection – systemic antibiotics active against S. aureus and
                   streptococcus: 1-2 weeks
           How to recognise eczema herpeticum. Signs of eczema herpeticum are:
                Areas of rapidly worsening, painful eczema
                Clustered blisters consistent with early-stage cold sores
                Punched-out erosions (usually 1–3 mm) uniform in appearance which may coalesce
                Possible fever, lethargy or distress.
                Treat suspected eczema herpeticum immediately with systemic aciclovir and refer
                   for same-day specialist dermatological advice (and ophthalmological advice, if skin
                   around the eyes involved)
          Education and adherence to therapy
          Provide information in verbal and written forms, with practical demonstrations, and cover:
           How much of the treatments to use
           How often to apply treatments
           When and how to step treatment up or down
           How to treat infected atopic eczema.
          Explain that the effectiveness and safety of complementary therapies and food supplements
          for atopic eczema have not been adequately assessed.
          Source: www.nice.org.uk




Prescribing Support Team • Park Lodge• St Catherine’s Hospital, DN4 8QN

								
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