Issue 3 - March, 2017
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Welcome to the March edition of Tablets, a prescribing newsletter produced monthly by the Medicines Management team of Midlands and Lancashire CSU.


Local news

Wirral Home Blood Glucose Testing Guidelines – updated 
The Wirral Home Blood Glucose Testing Guidelines have been updated to include a cost effective ketone testing meter called the Glucomen Areo 2K.  
The Glucomen Areo 2K meter is the most cost effective if a patient requires both blood glucose and ketone testing. The testing strips required for this meter are the Glucomen Areo sensors (for blood glucose) and the Glucomen Areo β Ketone sensors (for ketone testing).     
NICE BITES: Antimicrobial stewardship: changing risk-related behaviours in the general population. 
Recently a NICE Bites has been published providing a summary of prescribing recommendations from NICE NG63 – Antimicrobial Stewardship: changing risk-related behaviours in the general population. 
The guideline aims to change people’s behaviour to reduce antimicrobial resistance and the spread of resistant microbes. It includes making people aware of:
  • Measures to prevent and control infection that can stop people needing antimicrobials or spreading infection to others 
  • How to correctly use antimicrobial medicines 
  • Dangers associated with the overuse and misuse of antimicrobial medicines 
  • Self-care – where to obtain advice 
TheNICE BITES bulletin should be read in conjunction with NICE NG15 – Antimicrobial Stewardship: systems and processes for effective antimicrobial medicine use. 
DOAC Information 
The Wirral CCG Cardiovascular Clinical Group has recently discussed the need for GPs to have more information about DOACs, including cost. The document at the link below is taken from the Wirral Oral Anticoagulant Guidelines, but has been updated to include current costs. 
Warfarin 500 microgram tablets 
Warfarin 500 microgram tablets are not recommended for prescribing in Wirral. The Wirral Oral Anticoagulation Guidelines state that: 
The 500 microgram warfarin tablets should not be used to avoid confusion with other white tablets and 5mg doses of warfarin. The 1mg tablets can be easily broken in half or cut with a tablet cutter to achieve a 500 microgram dose. 
The Cardiovascular Clinical Group has confirmed that Wirral GPs should not prescribe warfarin 500 microgram tablets. ScriptSwitch messages already highlight this information. Community pharmacies have been asked to support this. 
Post-dated Prescriptions 
The use of post-dated prescriptions is generally not recommended unless being used for delayed antibiotic prescribing.  All prescribers should carefully consider the necessity and potential consequences of issuing a post-dated prescription, for situations other than delayed antibiotic prescribing.  Alternatives such as repeat dispensing may be a more suitable solution. 
An incident occurred recently in which a pharmacy inadvertently dispensed a post-dated prescription for a controlled drug before the date on which it became effective.  Whilst investigation into this case is ongoing, we believe it resulted in the patient commencing new treatment of a controlled drug at three times the intended starting dose. 
Post-dated EPS prescriptions have less potential to cause problems when compared to handwritten or printed prescriptions, as a post-dated EPS prescription will ‘held’ on the spine and won’t be ‘released’ before its due date.  This does not however cancel all risks. 
Three examples of potential harm are shown below, but these are not exhaustive.  
  1. The prescription may be issued in advance and harm may result.   
  2. It may result in additional prescriptions being issued if the patient (or carer, relative etc.) claims to have lost post-dated prescriptions.  An incident occurred in Cheshire in the recent past in which a GPs intention was to better manage controlled drug abuse by using post-dated prescriptions but doing so actually resulted in more prescriptions being provided. 
  3. Treatment needs to be discontinued (and/or changed) or the dose adjusted*. 
 * Whilst post-dated EPS prescriptions will be held until the date they become in to effect, it is still necessary to cancel these if treatment changes. For paper prescriptions, the patient would need to be informed of any changes in a timely fashion.
Please consider: 
Why – is a posted dated prescription necessary? 
What – are the potential risks? 
How – can/will I manage the risks? 
Do – I have any alternatives (e.g. repeat dispensing)? 
Please note: for delayed prescribing of antibiotics using post-dated prescriptions is still recommended where appropriate
Case Study: over-ordering of fentanyl patches via repeat prescriptions (MLCSU Medicines Safety Assurance Tool January 2017) 
Patient A had a problem with his fentanyl patches falling off and was replacing them after one to two days. This resulted in Patient A over-ordering fentanyl patches via repeat prescriptions. Patient A over a 12 month period was legitimately prescribed 520 days’ supply of fentanyl patches.  
A teenage friend of Patient A’s son was found dead after ingesting a fentanyl patch. Patient A’s son had been stealing his father’s patches and had given one to his friend. Patient A had suspected his son of stealing his fentanyl patches. A full investigation was undertaken and it was noted there were various points at which the excessive amount of prescribed fentanyl patches could have been picked up. These included the staff printing off the repeat scripts, the doctors signing the repeat scripts and the pharmacy staff dispensing the prescriptions.  
Nystatin Dose Update 
On the 15th March 2017, there was a dose change for nystatin in the BNF and BNFc. The BNF and BNFc now state that “The nystatin dose for oral candidiasis in the BNF has historically reflected the posology recommendations in the Nystan® Summary of Product Characteristics (SPC). Following discussions with the MHRA the dose has been updated  and now reflects current posology recommendations for generic nystatin products.” 
The dosage for nystatin for oral candidiasis in the BNF and BNFc is now:
  • Child - 100,000 units 4 times a day usually for 7 days, and continued for 48 hours after lesions have resolved. 
  • Adult - 100,000 units 4 times a day usually for 7 days, and continued for 48 hours after lesions have resolved. 
Please note: The Nystan SPC continues to recommend the increased dose. 
The Wirral Antimicrobial Guidelines for the Management of Common Infections in Primary Care has been updated to reflect this change: 
Miconazole oral gel remains the first choice for the treatment of oral candidiasis.

Safety Update

Access a copy of March's safety report for more information on all of the safety updates below:

SPC Updates:
  • Revised SPC: Exviera (dasabuvir) 250 mg film-coated tablets
  • Revised SPC: Olysio (simeprevir) 150mg hard capsules
  • Revised SPC: Viekirax (12.5 mg ombitasvir / 75mg paritaprevir /50 mg ritonavir) film-coated tablets

Newsletter articles:
  • Precautionary recall of Ergometrine Injections
  • Hyoscine butylbromide (Buscopan) injection: risk of serious adverse effects in patients with underlying cardiac disease
  • Precautionary recall of Viridal Duo Powder and Solvent for Injection

Medical Device Alerts
  • Oxylog 3000 And Oxylog 3000 Plus Ventilator - Risk Of Failure

Drug Availability

Short Supply / Out of Stock

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.

Product Discontinuations
Kwells (hyoscine hydrobromide)
Bayer is currently facing some technical issues relating to manufacturing of, hyoscine hydrobromide and is thus not able to supply further stock for at least 6 months.
The memo which can be accessed below advises on alternative treatment options in the interim, with a focus on the off-label use for hypersalivation.
Shortage of hyoscine hydrobromide (Kwells) 150 and 300 microgram tablets
Prempak C and Premique
Pfizer had discontinued the manufacture of both strengths of Prempak C and Premique 625mcg tablets. Existing patients should be identified and reviewed with a view to switching to an alternative form of hormone replacement therapy in line with local formulary recommendations.

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

The National Institute of Health and Care Excellence (NICE) have published new or updated guidance.  
The Drug misuse prevention guideline covers targeted interventions to prevent misuse of drugs, including illegal drugs, 'legal highs' and prescription-only medicines. It aims to prevent or delay harmful use of drugs in children, young people and adults who are most likely to start using drugs or who are already experimenting or using drugs occasionally
The Osteoporosis: assessing the risk of fragility fracture clinical guideline has been updated and covers assessing the risk of fragility fracture in people aged 18 and over with osteoporosis. It aims to provide guidance on the selection and use of risk assessment tools in the care of adults at risk of fragility fractures in all NHS settings. The update corrects the reference to the WHO in relation to the FRAX tool. 
Action: Clinicians should be aware of this month's new guidance and implement any necessary changes to practice.


Clinical Knowledge Summaries

During February 2017 Clinical Knowledge Summaries were updated for the following topics:

The following topics were all reviewed:

The topics have undergone minor restructures. More significant changes include recommendations for urgent referral for suspected cancer in the breathlessness topic and amending several recommendations about repeating swabs for staphylococcal carriage, reducing period of treatment for recurrent boils and antiseptic choice in line with advice from Public Health England.

Action: Clinicians who see patients with any of these conditions may find the new and updated information 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.

Victoria Vincent:  0151 541 5390

Copyright © 2017 Midlands & Lancashire Commissioning Support Unit, All rights reserved.

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