PCT Prescribing Committee No.26 June 2008
In Brief: HPV vaccine (Gardasil®, Cervarix®)
Antivirals The introduction of human papillomavirus (HPV)
There is currently no good evidence to vaccine into the national immunisation
suggest superiority of either valaciclovir or programme starts September 2008 in schools.
famciclovir over aciclovir within their licensed Following advice received from the Joint
indications; due to the cost considerations, Committee on Vaccination and Immunisation
aciclovir should be considered as first-line for (JCVI), HPV immunisation will be offered
treatment & suppression of genital herpes routinely to all 12- to 13-year-old girls (school
and treatment of herpes zoster unless year 8) to protect them against their future risk
compliance or other issues favour the use of of cervical cancer. A two-year catch-up
an alternative. campaign starts in schools September 2009 and
http://www.nelm.nhs.uk/Record%20Viewing/vR.aspx?id=589892 will cover all girls aged up to 18 years born
Antiviral Cost Comparison (April 08) between 1 Sept 1991 and 31 Aug 1995. The DH
Aciclovir Disp 200mg 5
is considering further advice for girls that will
Aciclovir 200mg 5 x day miss out on grounds of age. For more
Herpes Simplex doses (5 days)
information see DH CMO letter (Gateway no:
Valaciclovir 500mg BD 9780) and the NHS immunisation website:
Famciclovir 250mg TDS http://www.immunisation.nhs.uk/Vaccines/HPV
GPs should not prescribe as part of NHS
Aciclovir 800mg 5 x day services.
Aciclovir Disp 800mg 5
Shingles doses (7 days) A 3 dose course costs approx £250 cost price
x day on FP10; DH distributes free vaccine to PCTs
Valaciclovir 500mg 2
for the school programme.
The 2 licensed vaccines are neither
Famciclovir 750mg OD
equivalent nor interchangeable and DH will
£0 £20 £40 £60 £80 £100 £120 £140
decide soon which vaccine(s) will be used for
the NHS immunisation programme.
EpiPen®/Anapen® disposal: out of date Vaccines don’t protect against all strains of
adrenaline held by patients cannot be returned to HPV so cervical screening must continue
pharmacies (they can’t accept sharps under waste Injection site reactions are very common
regs) and should be disposed of in a sharps bin
e.g. by returning to GP practice, even if unused.
HHT Drug & Therapeutics Committee
CD changes – midazolam has been upgraded to
a schedule 3 CD meaning full CD prescription
writing requirements are necessary e.g. words & Drugs refused for addition to the formulary
figures. Midazolam is exempt from safe custody include:
(CD cupboard) storage. Grazax for hay fever on grounds of lack of
NPSA anticoagulant alert – see haematology Solifenacin for incontinence offers no
section of the intranet for e-learning materials:
improvement over existing therapy.
y/Education/tabid/1722/Default.aspx Drugs approved for addition to formulary:
Rivastigmine for dementia in Parkinson’s
MHRA Drug Safety Updates have replaced Disease (no shared care – all prescribing by
Problems in Pharmacovigilance. See website for
publications & to sign up for email alerts:
http://www.mhra.gov.uk/Publications/Safetyguidance/Dr Mycophenolate various unlicensed indications
ugSafetyUpdate/index.htm (shared care under development)
Rotigotine patches (2nd line use only).
Safer NSAID Prescribing
Piroxicam – are you still prescribing it?
The European Medicines Agency (EMEA) issued advice in 2007 on the use of the NSAID piroxicam. The
prescribing advice only relates to the oral, injectable, and suppository forms of the drug, not the topical skin
formulations & can be found on the EMEA website: http://www.emea.europa.eu/pdfs/human/press/pr/26514407en.pdf
In summary piroxicam:
should be limited only to the symptomatic relief of osteoarthritis, rheumatoid arthritis and ankylosing
spondylitis, initiated by specialists, with gastro-protection co-prescribed . Alternative treatment should be
considered at the patient’s next routine appointment.
should not be used as a first-line treatment and the dose limited to a maximum of 20mg a day
In Herefordshire 3 practices are not prescribing any piroxicam – practices can check their NSAID prescribing on
the intranet: http://nww.herefordshire.nhs.uk/MedicinesManagement/PCTPrescribingTeam/QualityPrescribingSchemeQPS/tabid/843/Default.aspx
NSAID risk summary (MeReC Extra no.30 http://www.npc.co.uk/MeReC_Extra/2008/no30_2007.html)
CV risk GI risk
All “Coxibs” e.g. celecoxib are associated with a small “Coxibs” are associated with a lower GI risk than
excess risk of thrombotic events compared with no traditional NSAIDs. However, their GI-safety
treatment (about three events per 1000 users treated for advantage is diminished when they are co-
one year), and they are contraindicated in patients with administered with aspirin.
established CV disease. Of the traditional NSAIDs, low-dose ibuprofen is
Diclofenac 150mg/day appears to be associated with a associated with a lower GI risk than diclofenac or
similar excess risk of thrombotic events to “coxibs” naproxen.
Low-dose ibuprofen (1200mg/day) and naproxen Use of a proton pump inhibitor (PPI) with any NSAID
1000mg/day appear to be associated with a lower risk. significantly reduces the risk of GI side effects.
Herefordshire primary care NSAID prescribing & % as diclofenac
600 All oral NSAIDS diclofenac WM Prescribing Metrics
Items per 1000 pts YE Dec 07
2008 - 2009
Two West Midland targets for
400 2008-9 concern NSAID
1. NSAIDs –volume of NSAID
200 use (ADQ/STAR PU) low is
100 2. % NSAIDs prescribed as
ibuprofen and naproxen.
Target 60%, high is good!
All comparative graphs for the
08-9 metrics on intranet here:
Practice Review Points for patients taking Diclofenac 150mg/day
It may be appropriate for some patients to continue treatment with diclofenac; however, in some cases,
especially patients with significant risk factors for CV disease, consider alternatives:
1. Change to paracetamol 4g/day – may be less efficacious for some patients but certainly safer.
2. Change to 1200mg ibuprofen/day - reduces both their GI and CV thrombotic risk, especially if the
opportunity is taken to introduce a PPI for highest risk patients. High doses of ibuprofen (e.g. 2400mg/day) are
not prescribed frequently in clinical practice but may be required for full anti-inflammatory effect.
3. Change to naproxen 1000mg/day - reduces CV thrombotic risk, but may slightly increase their risk of GI
complications. However, if the opportunity is taken to introduce a PPI, the GI risks may also be reduced.
Priority Patients for Review:
People at high CV risk including: Patients with established CVD (e.g. check those prescribed aspirin, ACEI –
remember ACEI + NSAID increases risk of renal toxicity), diabetic patients, older men, smokers.
People at high GI risk including: older than 65 years; history of GI bleeding, ulcer etc; other meds that increase
risk e.g. prednisolone, aspirin, SSRIs; co-morbidity such as diabetes, hypertension, CVD, renal or hepatic
impairment; excessive alcohol; heavy smokers; max dose NSAID or long duration of treatment.