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Issue 23 - March 2019
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Welcome to the March edition of Tablets, a prescribing newsletter produced monthly by the Medicines Management team at Midlands and Lancashire CSU.
 

Contents

Formulary Update

Safety
 

VALPROATE: safe prescribing and dispensing to girls of any age and women of child bearing potential 
  • Licensed use of valproate medicines in girls and women of childbearing potential requires a Pregnancy Prevention Programme to be in place.
  • Valproate treatment must be started and supervised by an experienced specialist.
  • Fulfilment of the conditions of the Pregnancy Prevention Programme must be checked at each point of prescribing and dispensing.
https://www.panmerseyapc.nhs.uk/media/2162/valproate.pdf

Safety Updates

Please click here for a summary of  safety updates and SPC updates in February.

Carbimazole - increased risk of congenital malformations; strengthened advice on contraception 
Medicines and Healthcare products Regulatory Agency | 18 February 2019 
Carbimazole is associated with increased risk of congenital malformations when used during pregnancy, particularly in first trimester and at high doses (>15mg carbimazole daily). Women of childbearing potential should use effective contraception during treatment with carbimazole.
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/779462/DSU-PDF-Feb-2019.pdf
 
Carbimazole and risk of acute pancreatitis 
Medicines and Healthcare products Regulatory Agency | 18 February 2019 
This Safety Update alerts that cases of acute pancreatitis have been reported very infrequently during treatment with carbimazole; if acute pancreatitis occurs, treatment should be discontinued immediately. Re-exposure may result in life-threatening acute pancreatitis.
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/779462/DSU-PDF-Feb-2019.pdf
 
SGLT2 inhibitors and reports of Fournier’s gangrene (necrotising fasciitis of the genitalia or perineum) 
Medicines and Healthcare products Regulatory Agency | 18 February 2019 
The safety alert states if Fournier’s gangrene is suspected, stop the SGLT2 inhibitor and start treatment urgently. Patients should be advised to seek urgent medical attention if they experience severe pain, tenderness, erythema, or swelling in genital or perineal area, accompanied by fever or malaise.
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/779462/DSU-PDF-Feb-2019.pdf
 
Royal Pharmaceutical Society issues warning about DNP (2,4-dinitrophenol) in products used for weight loss 
Royal Pharmaceutical Society | 27 February 2019
The warning advises DNP is an industrial chemical used in pesticides and explosives and is unfit for human consumption but sold illegally via the internet for weight loss. It acts as a 'fat burner' by raising metabolism and has contributed to a significant number of deaths.
https://www.rpharms.com/about-us/news/details/Deadly-diet-drug-DNP-can-kill

Prescribing News

NICE Guidance February 2019

There have been two guidelines published in February 2019 by the National Institute for Clinical Excellence which has impact upon primary care.
The cough (acute): antimicrobial prescribing has been published. The guideline covers the antimicrobial prescribing strategy for acute cough associated with an upper respiratory tract infection or acute bronchitis in adults, young people and children. The aim of the guideline is to limit antibiotic use and reduce antibiotic resistance.

The antenatal care for uncomplicated pregnancies guideline has been updated and published. The recommendation on screening for German measles (rubella) has been removed as this is no longer offered by the NHS.

Clinicians should be aware of these guidelines and implement any necessary changes to their practice. 
 

CKS Updates February 2019

During the month of February 2019, the following Clinical Knowledge Summaries were published or updated: There have been minor restructures to the topics listed above. The most significant changes have been made to the Diarrhoea – adult’s assessment. New recommendations have been added to the referral section, in line with recommendations on the recognition and referral of suspected cancer. The urinary tract infection (lower) – women topic has been updated in line with antimicrobial prescribing guidance. The Blackouts topic is new.
 
Clinicians can use the updated and new information when reviewing patients.


Useful Resources Gabapentin and Pregabalin to become Schedule 3 Controlled Drugs 
From the 1st April 2019, gabapentin and pregabalin will be reclassified as schedule 3 controlled drugs. The prescriptions will be valid for 28 days from the date of issue. EMIS Health has undertaken a system update in order to update the prescription requirements for gabapentin and pregabalin. Vision and SystmOne practices are due to go live for electronic prescribing of Controlled Drugs, therefore the reclassification of gabapentin and gabapentin are expected to cause less disruption than anticipated. For further information on the roll out of updates for controlled drugs, please click here 

Over the Counter medicines guidance
The National Medical Director of NHS England has issued a letter to all general practitioners providing reassurance that the commissioner will not find practices in breach of their GP contract if they follow the guidance on Conditions for which over the counter items should not be routinely be prescribed in primary care.

National catheter resources 
The urinary catheter tools have been developed collaboratively with nationals experts to support providers in delivering consistent evidence based catheter care. It has been recommended that the use of the tools needs to be supported by strong leadership and education. 

Medicines Supply on EU Exit - Update
The Minister of State for Health has indicated that local stockpiling is not necessary and could cause shortages in other areas, putting patient care at risk. The advice reinstates the importance of patients ordering their repeat prescriptions and to take their medicines as normal. Please click here for the update.

Implementing the Falsified Medicines Directive (FMD)
NHS England has produced guidance on implementing the Falsified Medicines Directive (FMD) which came into force on the 9th February 2019. NHS Digital has uploaded a FMD guide for General Practice. 

Drug Availability

Products in short supply and product discontinuations

The following links provide prescribers with up to date information on commonly prescribed products which are currently in short supply from the manufacturers.  
The information held on these lists is not exhaustive. Availability can vary geographically and also between wholesalers. Up-to-date information should be sought from manufacturers, local community pharmacies and suppliers.



Supply issues update for March 2019

This report is based on information which has been produced by the Department of Health and Social Care (DHSC) Medicine Supply team. Please click here to view the full report.

Drug Tariff Changes

This summary document shows the top 10 price changes since last month, the top 25 changes compared to three months ago, and the top 50 since last year.
 
Tell me more about drug tariff price changes.

Antimicrobial Updates

Please click here for a full summary of antimicrobial related guidelines and SPC updates in February.

January 2019 BNF/ BNF C eNewsletter 
British National Formulary | 05 Feb 
BNF updated with dose changes for Gyno-Daktarin® 2% vaginal cream, colistimethate sodium and information on doxycycline license extension for children aged 8 to 11 years; updated routine immunisation schedule, recent MHRA safety advice and latest case study on Lyme disease.
https://pharmaceuticalpress.cmail19.com/t/ViewEmail/y/E121109A6224A510/7071F82C996F6C90FCACEB58A033025D


Pneumonia (community-acquired): antimicrobial prescribing- draft guideline for consultation 
National Institute for Health and Care Excellence | 12 Feb 
This DRAFT guideline sets out an antimicrobial prescribing strategy to optimise antibiotic use and reduce antibiotic resistance in adults, young people and children with community-acquired pneumonia.
https://www.nice.org.uk/guidance/GID-NG10130/documents/draft-guideline-2


Helicobacter pylori in dyspepsia: test and treat 
Public Health England | 22 Feb 
These quick reference guides for primary care advisers aim to provide a simple, effective, economical and empirical approach to the test and treat of Helicobacter pylori and minimise the emergence of antibiotic resistance in the community.
https://www.gov.uk/government/publications/helicobacter-pylori-diagnosis-and-treatment


Pertussis (whooping cough) 
British Medical Journal | 25 Feb 
This article reviews the management of pertussis and outlines recent evidence and guidance on prevention through vaccination.
https://www.bmj.com/content/364/bmj.l401


Antibiotics for treating urogenital Chlamydia trachomatis infection in men and non‐pregnant women 
Cochrane Database of Systematic Reviews | 26 Feb 
Review of 14 RCTs (n=2715) concludes in men, regimens with azithromycin are less effective than doxycycline for microbiological failure, but no difference for clinical failure; in women, it is uncertain whether azithromycin vs doxycycline increases risk of microbiological failure
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010871.pub2/full


Updated PHE PGD templates: Influenza post exposure prophylaxis and treatment 
Public Health England | 26 Feb 
PGDs for the zanamivir inhalation powder for treatment or post-exposure prophylaxis of influenza have now been issued.
https://www.gov.uk/government/publications/influenza-post-exposure-prophylaxis-and-treatment-pgd-templates


Antibiotic management of urinary tract infection in elderly patients in primary care and its association with bloodstream infections and all cause mortality: population based cohort study 
British Medical Journal | 28 Feb 
Study (312,896 UTI episodes) found in patients with diagnosis of UTI in primary care, no antibiotics [AB] (OR 8.08, 95% CI, 7.12-9.16) and deferred AB (OR 7.12; 6.22-8.14) were linked to significant increase in bloodstream infection and in all cause mortality vs. immediate AB.
https://www.bmj.com/content/364/bmj.l525


Duration of antibiotic treatment for common infections in English primary care: cross sectional analysis and comparison with guidelines 
British Medical Journal | 28 Feb 
Study found for most common infections treated in primary care, a substantial proportion of antibiotic prescriptions have durations exceeding those recommended in guidelines. For 931,015 consultations resulting in prescriptions, about 1.3m days were beyond recommended durations
https://www.bmj.com/content/364/bmj.l440
Please note that the information in this newsletter is correct at the time of publication.
Clinicians should always refer to the most up to date information.

Contacts
Kieron Donlon: kieron.donlon1@nhs.net - 0151 296 7076


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