Issue 10 - November 2017
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Welcome to the November edition of Tablets, a prescribing newsletter produced monthly by the Medicines Management team at Midlands and Lancashire Commissioning Support Unit.


Formulary Update


The Pan Mersey Area Prescribing Committee does not recommend the prescribing of EFLORNITHINE 11.5% cream for facial hirsutism.
Tell me more about eflornithine

GREY PATIROMER powder for oral suspension (Veltassa®▼)
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of PATIROMER powder for oral suspension (Veltassa®▼) for the treatment of hyperkalaemia in adults.
Tell me more about patiromer

RED TOFACITINIB film-coated tablets (Xeljanz®▼) 
The Pan Mersey Area Prescribing Committee recommends the prescribing of TOFACITINIB film-coated tablets (Xeljanz®▼), by specialists only, for the treatment of moderate to severe Rheumatoid Arthritis in accordance with NICE TA480.
Tell me more about tofacitinib

The Pan Mersey Area Prescribing Committee recommends the prescribing of CANAGLIFLOZIN, DAPAGLIFLOZIN and EMPAGLIFLOZIN as MONOTHERAPIES as options for treating type 2 diabetes in adults in accordance with NICE TA390.
Tell me more about SGLT2 monotherapy

The Pan Mersey Area Prescribing Committee recommends the prescribing of CANAGLIFLOZIN, DAPAGLIFLOZIN and EMPAGLIFLOZIN as combination therapies for the treatment of type 2 diabetes in accordance with NICE guidance.
Tell me more about SGLT2 combination therapy


Dental Prescribing in Primary Care
Issued: November 2017 | Review: November 2020
Tell me more about dental prescribing

Gastro-oesophageal reflux disease (GORD) in children and young people, pharmacological management in primary and secondary care
Issued: June 2016 | Revised: November 2017 | Review: June 2018
Tell me more about GORD

Hypersalivation in Children and Adults
Issued: November 2017 | Review: November 2020
Tell me more about hypersalivation


VALPROATE - safe prescribing and dispensing to women and girls of child bearing potential
Babies born to mothers who take sodium valproate and valproic acid medicines during pregnancy have a 30–40% risk of developmental disability and a 10% risk of birth defects.
Tell me more about valproate safety and the checklist for initiating therapy.

Safety Update

For more information on the updates listed below, please click here:
Safety Articles

Professional use HIV test: Alere HIV Combo – risk of false positive results
Central Alerting System | 05 Oct 2017
Specific lots are affected, listed in the manufacturer’s Field Safety Notice.

HIV Pharmacy Association of the UK advises no interaction between the influenza vaccine and antiretrovirals
HIV Pharmacists Association | 12 Oct 2017
The HIV Pharmacy Association is advising that it is safe to give patients on antiretroviral therapy the influenza vaccine without compromising either the vaccine or the patient’s HIV treatment.

Methylprednisolone injectable medicine containing lactose (Solu-Medrone 40 mg)
Medicines and Healthcare Regulatory Agency | 26 Oct 2017
Do not use in patients with a known or suspected allergy to cows’ milk.

Gabapentin (Neurontin) Risk of severe respiratory depression.
Medicines and Healthcare Regulatory Agency | 26 Oct 2017
Patients with compromised respiratory function, respiratory or neurological disease, renal impairment, concomitant use of central nervous system (CNS) depressants, and elderly people might be at higher risk of experiencing severe respiratory depression.

Isotretinoin (Roaccutane)
Medicines and Healthcare Regulatory Agency | 26 Oct 2017
Rare reports of erectile dysfunction and decreased libido.

Clozapine: reminder of potentially fatal risk of intestinal obstruction, faecal impaction, and paralytic ileus
Medicines and Healthcare Regulatory Agency | 26 Oct 2017
If constipation occurs during treatment with clozapine (Clozaril, Denzapine, Zaponex), it is vital that it is recognised and actively treated.

Eperzan▼(albiglutide): global discontinuation of medicine
Medicines and Healthcare Regulatory Agency | 26 Oct 2017
Do not initiate new patients; transition all current patients to an alternative therapy by July 2018.

All Accu-Chek® Insight insulin pumps – risk of alarm failure
Medicines and Healthcare Regulatory Agency | 26 Oct 2017
The audible and/or vibration alarms might not function, which may lead to hyperglycaemia if the user doesn’t see the notification message on the pump.

For more information about SPC Updates click here

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

Stanek (levodopa/carbidopa/entacapone) supplies

Teva regret to advise that there will be a severe supply disruption to Stanek due to an unforeseen and unavoidable shortage of the active pharmaceutical ingredient levodopa. There are likely to be supply issues affecting Stanek (multiple strengths and pack sizes) between now and December 2017. Product specific information can be found in the attached DHCP letter from Teva. In the interim period, we have alerted the suppliers of the alternative levodopa/ carbidopa/ entacapone supplies about this disruption, who have confirmed the following:
  • Orion- good supplies of Stalevo remain available for all strengths.
  • Accord- supplies of Sastravi remain available for all strengths, but they do have some short term issues on some lines but further stock expected in next two weeks.

Shortage of Pneumococcal polysaccharide vaccine
There is a current shortage of the PPV23 vaccine which is likely to continue for the foreseeable future. There is only one licensed vaccine available and although the company are expecting more stock deliveries during October, the volume anticipated is unlikely to be sufficient to vaccinate the whole 65 year old cohort this winter.

After discussion with the BMA's General Practitioners Committee, the attached document has been produced to provide advice for general practices during this time. The main recommendation is that practices plan to deliver the bulk vaccine programme across the year. For those at high risk, it is important to ensure that other preventive measures, including influenza vaccination, are implemented. It is also recommended that the records of such patients are flagged so that they can be called for vaccine once the stock situation improves.
There is no shortage of the PCV13 vaccine used in infants and toddlers but this vaccine is not suitable for protection of older people.

Trifluoperazine tablets
There have been ongoing supply issues affecting trifluoperazine 1mg and 2mg tablets but we have had a recent update to say supplies will not improve until some point in 2018 due to manufacturing issues with the active ingredient.
Concordia and Rosemont have trifluoperazine available in liquid formulations and they have good supplies available. We are also aware that unlicensed supplies of both the 1mg and 5mg tablet are available from both Ennogen and a number of specialist importer companies. Under the medicines legislation, doctors can prescribe unlicensed products for their patients if they think it appropriate, but do so entirely on their own responsibility. Pharmacies can obtain unlicensed supplies via these specialist companies or Ennogen.


We are aware that there is a national shortage of glipizide and this is not due to resolve until January 2018. The Medicines Management team have received numerous queries from practices for advice.In light of this the following information has been prepared in consultation with the Diabetes team at the Countess of Chester.

Patients should be reviewed on an individual case basis taking into account the following:
• hepatic function
• renal function
• HBA1c/diabetic control
• Age
• hypoglycaemic risk
• other prescribed medication/doses (especially other antidiabetic medication)

This would be a good opportunity to review the appropriateness of a sulphonylurea for each patient. If the decision is made to switch to another sulphonylurea, below are doses that equate approximately to Glipizide 2.5-5mg daily:

  • Gliclazide 40mg daily
  • Glimepiride 1mg daily
  • Tolbutamilde 500mg daily
The latest BNF or product SPC should be consulted for details on the dosage regime and the maximum prescribable dose of individual sulphonylureas. Patients would need to monitor blood glucose more frequently (especially at night) and be counselled to recognise signs of hypo and hyperglycaemia.

Discontinued items

Clickstar pen

The Clickstar pen is being discontinued but is being replaced by the All-star cartridge pen, so once Clickstar stocks run out then the replacement would be the All-star. 

Accolate 20mg Tablets
AstraZeneca will be discontinuing Accolate 20mg (zafirlukast) on 31st March 2018. A company communication has been attached. Clinical advice from UKMI has advised montelukast as a likely alternative.

Drug tariff price Changes

This summary document shows the top 10 price changes this month, the top 25 changes this quarter, and the top 100 this year. 
Tell me more about drug tariff price changes.

Prescribing News

NICE Guidance - October 2017.

The National Institute of Health and Care Excellence (NICE) have published new or updated guidance that impact upon primary care.
The Cystic fibrosis guideline covers diagnosing and managing cystic fibrosis. It specifies how to monitor the condition and manage the symptoms to improve quality of life. There are also detailed recommendations on treating the most common infections in people with cystic fibrosis.
The Child maltreatment clinical guideline covers the signs of possible child maltreatment in children and young people aged under 18 years. It aims to raise awareness and help health professionals who are not child protection specialists to identify the features of physical, sexual and emotional abuse, neglect and fabricated or induced illness.
The Sinusitis (acute) antimicrobial prescribing guideline covers the use of antibiotics in sinusitis. It aims to limit antibiotic use and reduce antimicrobial resistance.The guideline gives recommendations on managing symptoms, choice of antibiotics and self-care. The visual summary pdf can be accessed here.
Action: Clinicians should be aware of this month's new guidance and implement any necessary changes to practice.

CKS Updates – October 2017

Clinical Knowledge Summaries were reviewed and updated in the following areas;

The most significant changes are in the Crohn's disease topic where recommendations on the diagnosis and management of confirmed Crohn's disease have been amended in line with current evidence. The Prostate cancer topic has been updated with recommendations on prostate-specific antigen (PSA) testing and treatments for prostate cancer.
Action: Clinicians may find the updates useful when reviewing current clinical practice.
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.