Prescribing Newsletter PCT Prescribing Committee No.26 June 200

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Prescribing Newsletter PCT Prescribing Committee No.26 June 200 Powered By Docstoc
					      Prescribing Newsletter
      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
         x day
                                                                                           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
                                                                                           Practical information
                                                                                            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
        tabs TDS
                                                                                              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
                                                                                                    Formulary Decisions
  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
                                                                                               evidence
  NPSA anticoagulant alert – see haematology                                                Solifenacin     for  incontinence    offers no
  section of the intranet for e-learning materials:
  http://nww.herefordshire.nhs.uk/ClinicalInfo/Haematolog
                                                                                               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
                                                                                               hospital)
  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
                                 700

                                 600                                                                                                        All oral NSAIDS                                                                           diclofenac                                                                                                                 WM Prescribing Metrics
  Items per 1000 pts YE Dec 07




                                                                                                                                                                                                                                                                                                                                                                 2008 - 2009
                                 500
                                                                                                                                                                                                                                                                                                                                                                 Two West Midland targets for
                                 400                                                                                                                                                                                                                                                                                                                             2008-9 concern NSAID
                                                                                                                                                                                                                                                                                                                                                                 prescribing:
                                 300
                                                                                                                                                                                                                                                                                                                                                                 1. NSAIDs –volume of NSAID
                                 200                                                                                                                                                                                                                                                                                                                             use (ADQ/STAR PU) low is
                                                                                                                                                                                                                                                                                                                                                                 good!
                                 100                                                                                                                                                                                                                                                                                                                             2. % NSAIDs prescribed as
                                   0
                                                                                                                                                                                                                                                                                                                                                                 ibuprofen and naproxen.
                                                                                                                                                                                                                                                                                                                                                                 Target 60%, high is good!
                                                                                                                                                                                                                                                                                                                                     Golden Valley
                                                                                                                                                                                                                                                     Fownhope




                                                                                                                                                                                                                                                                                                                           Weobley
                                                                                                                                                                                                                                                                                           Kington
                                                                                                                                                                                                                                                                Westfield Walk
                                       St.Katherines




                                                                                                                                                                                                                                                                                                                                                     Kingstone
                                                                                                                                                                                                                                 Nunwell
                                                                                                                                            King Street
                                                                                                             Greyfriars
                                                                                  Quay House




                                                                                                                                                                                                                                                                                 Colwall
                                                                                                                                                                                     Much Birch



                                                                                                                                                                                                                   The Marches
                                                                      Cantilupe



                                                                                               Sarum House




                                                                                                                                                                                                  Wargrave House
                                                                                                                          Moorfield House




                                                                                                                                                                                                                                                                                                                 Belmont
                                                       Alton Street




                                                                                                                                                          Ledbury Market

                                                                                                                                                                           Cradley




                                                                                                                                                                                                                                           Pendeen




                                                                                                                                                                                                                                                                                                      Mortimer




                                                                                                                                                                                                                                                                                                                                                                 All comparative graphs for the
                                                                                                                                                                                                                                                                                                                                                                 08-9 metrics on intranet here:
                                                                                                                                                                                                                                                                                                                                                                 http://nww.herefordshire.nhs.uk/Med
                                                                                                                                                                                                                                                                                                                                                                 icinesManagement/PCTPrescribingT
                                                                                                                                                                                                                                                                                                                                                                 eam/QualityPrescribingSchemeQPS
                                                                                                                                                                                                                                                                                                                                                                 /tabid/843/Default.aspx
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.

				
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posted:9/27/2011
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