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CEMO News April 2015
This is the April 2015 edition of NEW Devon CCG Medicines Optimisation News. Please
note that the primary audience for this newsletter are GP practices and community
pharmacies within NEW Devon and that the information may be specific to them and also to
the North & East Formulary and South & West Formulary. This is produced by the Clinical
Effectiveness and Medicines Optimisation team at NEW Devon CCG. Content of this
newsletter is available on NEW Devon CCG intranet here
Contents of this newsletter: (click on hyperlink to go straight to that article)
Medicines Optimisation news
 Bimatoprost (Lumigan) 300mcg/ml 3ml eye drop discontinuation
 Modified release and standard release preparations - care when selecting formulations
 Recent guidance on Statins
 Temporary unavailability of supply of Creon® (pancreatin) 40,000 gastro-resistant
capsules
 Medicines Optimisation: the safe and effective use of medicines to enable the best
possible outcomes
 Supply of medicines from Pharmacies
 Top Tips for Wound Healing and Cost Effective Prescribing of Wound Care Productsupdated format
Formulary news
 South and West, North and East Formularies: Revised Antibacterial Guidance
 Recent updates for the North and East Devon Formulary
Medicines Optimisation Governance news
 Dose optimisation – Don’t forget to let the patient know
 Tacrolimus and ciclosporin – prescribe by Brand only
 Childhood vaccine errors involving Infanrix-IPV+Hib and Infanrix-IPV
 Correct use of Humalog 200 units/ml Kwikpen (insulin lispro) to minimise medication
errors
 How to report medication safety incidents from a GP practice on the National Reporting
and Learning System (NRLS)
Medicines Optimisation news
Bimatoprost (Lumigan) 300mcg/ml 3ml eye drop discontinuation
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Bimatoprost (Lumigan) 300mcg/ml (0.03%) 3ml will be discontinued by 15th July 2015 by
manufacturer Allergan
Bimatoprost (Lumigan) 100mcg/ml (0.01%) has been shown in trials to show noninferiority to the higher strength with benefit of reduced side-effects from dose reduction.
Change of prescribing from Bimatoprost (Lumigan) 300mcg/ml (0.03%) 3ml to
Bimatoprost (Lumigan) 100mcg/ml (0.01%) 3ml is supported by West of England Eye
unit, R, D & E, North Devon District Hospital consultants and Royal Eye Infirmary
Derriford and requires no referral.
Please note there is a small increased cost associated from Bimatoprost (Lumigan) 0.03%
3ml £10.30 to Bimatoprost (Lumigan) 0.01% 3ml £11.71.
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Modified release and standard release preparations - care when selecting
formulations
There are several products that are available as both standard release and modified release
formulations. The timing, rate and location of drug release in modified release product can
be altered in order to achieve a particular therapeutic advantage or improve patient
compliance.
The Medicines Optimisation team is currently working with practices across NEW Devon to
ensure the preferred formulary brand of modified release quetiapine (Zaluron XL®) is used
when a modified release preparation of quetiapine is required.
A small number of patients have been identified receiving modified release products either
twice or in some cases three times daily. It appears in some cases that the MR products
may have been selected inadvertently when doses have been increased or
decreased. Prescribers are asked to take care to ensure the correct product is
selected. Practices should have systems in place to ensure appropriate governance for all
practice staff that may use clinical systems. If a patient is receiving quetiapine twice or three
times daily it’s unlikely that a modified release product is required.
Quetiapine modified release products are licensed for once daily administration and should
only be used when individuals cannot tolerate the immediate release presentation or if
concordance with a twice daily regimen is difficult.
See the North and East and South and West formularies here
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Recent guidance on Statins
Statin therapy is one of the greatest therapeutic advances in modern medicine.
The first article is about Statin Intolerance and has some guidance on how to manage statin
intolerance.
This guidance includes:
 Make sure there is no reversible cause such as: Medication interaction and
Hypothyroidism
 With mild symptoms, try reducing the dose of statin
 With intolerable symptoms, stop the statin
 When symptoms resolve, attempt rechallenge: Low dose of same or different statin or
Dose statin intermittently, for instance, 2–3 times a week
 Use an alternative statin
 Encourage a healthy lifestyle in any event in all patients such as smoking cessation,
weight loss, diet low in saturated fat, increased physical activity
For the full article click here
The second article from the BMJ is in relation to Rosuvastatin which looks at the evidence
available behind Rosuvastatin. For the full article click here
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Temporary unavailability of supply of Creon® (pancreatin) 40,000 gastro-resistant
capsules
Abbott is experiencing supply constraints of Creon 40,000, one of the strengths of its
Pancreatic Enzyme Replacement Therapy (PERT). As a result, there will be temporary
unavailability of Creon 40,000 supply.
Abbott are unable to predict when it will resume normal supply of Creon 40,000 and
therefore request that prescribing of Creon 40,000 is stopped and patients are switched to
an alternative Creon capsule to achieve their required dose.
Abbott proposes patients' prescriptions are amended to the corresponding amount of lipase
delivered as Creon 25,000, which may be preferable to patients due to the lower pill burden
when compared to Creon 10,000. The attached conversion table can be used as a guide to
transition patients currently taking Creon 40,000 to Creon 25,000 or Creon 10,000.
Abbott Pharmacist letter.pdf (334.19 kb)
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Medicines Optimisation: the safe and effective use of medicines to enable the best
possible outcomes
This guideline offers best practice advice on the care of all people who are using medicines
and also those who are receiving suboptimal benefit from medicines. It updates and replaces
recommendation 1.4.2 in the NICE guideline on medicines adherence. It also replaces
PSG001 Technical patient safety solutions for medicines reconciliation on admission of
adults to hospital. http://www.nice.org.uk/guidance/ng5/chapter/introduction
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Supply of medicines from Pharmacies
Under the terms of the NHS Community Pharmacy Contractual Framework pharmacies are
contractually required to supply a medication to a patient with 'reasonable promptness'.
When choosing preferred products the Medicines Optimisation team ensures these are
available via the main national wholesalers. This is a key part of the development and
selection of products therefore when a product is apparently out of stock it is important that
the pharmacy have tried to obtain stock from alternative suppliers before contacting the
prescriber for an alternative prescription. For example products manufactured by Fontus
Health Ltd (Zaluron and Luventa) are only available from Alliance Healthcare and Phoenix
not AAH Pharmaceuticals.
Communication is regularly sent out to pharmacies to ensure they are up to date with current
and future work which is being rolled out to practices and patients.
For further information please see the Quick Guide to medicines supply problems here
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Top Tips for Wound Healing and Cost Effective Prescribing of Wound Care Productsupdated format
Top tips for wound healing and cost effective prescribing of wound care products are to
support the efficient use of wound care products to maximise healing and minimise waste.
Topics covered are:
 Assessment of the patient and product selection
 Use of the Wound Management and Dressings Formulary
 Prescribing or requesting the products, quantities, size, repeat prescribing, frequency of
dressing change etc.
 Compression bandaging
 Anti-microbial products
 Legal issues
 Staff competency
Please click here for further information (only available on N3 connection)
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Formulary News
South and West, North and East Formularies Revised Antibacterial Guidance
Public Health England has revised their antibacterial guidance (previously known as the
HPA Guidance) and NICE issued some Clinical Guidelines on pneumonia. Therefore, in both
of the Devon Formularies the whole of the antibacterial guidance has been reviewed and
updated. This has been done together with Microbiologists from the four Acute Trusts,
Derriford and South Devon, RD&E and NDDH.
Remember: If you have not deleted the old app from you mobile device and re-loaded
the new one none of these changes to the formularies will be available to you 'on the
move'. The new App was available from the 1st March. To download the new App, go to the
home page of your local formulary and click on either the Apple or Google Play buttons at
the bottom of the page.
Please check with your local formulary, but some of the changes in the formularies are:
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As well as for acute self-limiting upper respiratory tract infections, a back-up or delayed
antibiotic prescription may be considered for mild UTI symptoms (from PH England
guidance)
Community acquired pneumonia (CAP) (NICE CG191):
For low severity CAP choices remain amoxicillin first-line, or doxycycline for penicillin
allergy. Dual therapy should not be routinely offered for low severity infection
For moderate severity CAP, if managed in the community, doxycycline alone for 7-10
days may be given or dual therapy by adding in amoxicillin
Catheter associated UTI; this section has been added new to the South and West
Formulary. Gives advice for when antibiotic prophylaxis may be considered
Recurrent C. difficile disease, guidance has been added to the South and West
Formulary in regard to consider a tapering course of vancomycin to try and prevent
relapse
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Lyme disease, this section has been added new to the North and East Formulary. There
is information on serology testing and the antibacterial choices if appropriate
Oral and dental sections, these have been added to the North and East Formulary.
Ordinarily GPs should not be prescribing for dental problems, but it was thought better to
have information to guide for the times when patients do present at the surgery. The
contact numbers for emergency dental services have also been added for information.
A quick reference guide has been produced for each of the Devon Formularies, the link can
be found at the bottom of the index page of Chapter 5 Infection or here:
North and East Formulary – antibacterial quick reference guide
South and West Formulary – antibacterial quick reference guide
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Recent updates for the North and East Devon Formulary
New Chapter:
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Chapter 16 Palliative Care has been added to the formulary. Consultation and support
for this has come from both North Devon and Exeter palliative care services. We are
hoping this will be a useful resource of information and where to obtain extra guidance
when needed.
Revised section:
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The section on infant feeds has been revised and can be found here
Anticoagulants, warfarin: this section has been expanded to add into the formulary the
advice from the BNF on haemorrhage. See section 2.8
Drug changes and additions:
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Lixisenatide: The Clinical Policy Committee has approved the addition of lixisenatide to
the Devon formularies; click here for the revised Diabetes Guidance which includes
lixisenatide in step 3 of the type 2 diabetes treatment pathway.
Xenidate® XL: This has been added as an alternative, lower cost, brand for Conerta®
XL 18mg and 36mg. The 27mg Concerta® XL will remain on the formulary.
See section 4.4
Metformin MR: Sukkarto® MR has been added as the preferred brand of metformin MR,
lower costs than prescribing alternative brands or as a generic drug. See section 6.1.2.2
Venlafaxine MR: Vensir® XL has been added as the preferred brand of venlafaxine MR,
lower costs than prescribing alternative brand or as a generic drug. See section 4.3.4
Galantamine MR: Luventa® XL has been added as the preferred brand of galantamine
MR, lower costs than prescribing alternative brand or as a generic drug.
See section 4.11
Bimatoprost 300 microgram/mL multi dose eye drops are going to be discontinued;
therefore the 100 microgram/mL eye drop has been added to the formulary. We have
confirmation from the ophthalmologists at both the RD&E and NDDH that patients can be
safely switched from the 300 microgram/mL to the 100 microgram/mL preparation. See
chapter 11
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Medicines Optimisation Governance news
Dose Optimisation – Don’t forget to let the patient know
We were recently informed about a patient whose medicine had been dose-optimised from
2x50mg twice daily to 1x100mg twice daily. Unfortunately the prescription continued to be
written as ‘as directed’ and the patient was not informed of the change. The patient therefore
continued to take two capsules twice daily resulting in a dose of 400mg daily rather than the
200mg dose intended. Whilst the patient came to no significant harm from this, they did
experience troublesome side effects and it was only when they ran out of their medicine
early, that the problem was identified. Unfortunately the dispensing pharmacy did not query
the prescription, but this may have been because no specific dose was stated.
Two useful learning points from this include:
1. If any prescribed medicine is dose-optimised, it is important to inform the patient of
the change
2. Review the use of ‘as directed’ prescribing where possible.
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Tacrolimus and ciclosporin – prescribe by Brand only
Tacrolimus
We would like to thank all Practices who have previously reviewed patients prescribed
tacrolimus to ensure the prescribing is by brand. We are pleased to report that in the latest
set of data only 3% of prescriptions for this product across NEW Devon CCG and SD&T
CCG were still being written generically.
Growing numbers of oral tacrolimus products increases the potential for inadvertent
switching between products. Inadvertent substitution may result in toxicity and/or graft
rejection. To ensure maintenance of therapeutic response oral tacrolimus products should
be prescribed and dispensed by brand name only.
Updated recommendations from MHRA in 2012 do not preclude patients changing to a
different tacrolimus brand if the prescriber considers this to be of benefit to the patient.
However, changes between different brands (which may or may not involve changes in
dosing regimen), should always be accompanied by careful therapeutic monitoring under the
supervision of an appropriate specialist.
The 2012 MHRA recommendations are available here: Drug Safety Update 2012
Ciclosporin
From latest data collected we know that across NEW Devon CCG and South Devon and
Torbay CCG only 9% of the prescriptions for ciclosporin were written generically.
Please continue to prescribe by brand name to avoid inadvertent switching and review any
prescriptions that are not currently branded. If it is necessary to switch a patient to a different
brand of ciclosporin, the patient should be monitored closely for changes in blood-ciclosporin
concentration, serum creatinine, blood pressure, and transplant function. Please refer to
BNF for further information.
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Childhood vaccine errors involving Infanrix-IPV+Hib and Infanrix-IPV
Vaccine errors have been identified involving the use of Infanrix®-IPV+Hib and Infanrix®IPV. Further errors have been identified when Infanrix®-IPV+Hib has not been reconstituted
as intended.
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Since July 2014 Infanrix®-IPV+Hib has been available for primary immunisation against
diphtheria, tetanus, pertussis, polio and Haemophilus influenza (Hib) (DTaP/IPV/Hib) in
children aged 2, 3 and 4 months.
Additionally, a pre-school booster against diphtheria, tetanus, pertussis and polio (but not
Hib) is offered to children at 3 years 4months. One choice of vaccine for this booster
dose is Infanrix®-IPV (DTaP/IPV)
Infanrix®-IPV+Hib contains the Hib component supplied as a freeze dried preparation in
a separate glass vial that must be reconstituted with the pre-filled syringe containing the
diphtheria, tetanus, acellular pertussis and inactivated poliomyelitis antigens, prior to
administration.
During primary immunisation programmes for 2, 3 and 4 month old babies errors have
occurred:
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Infanrix®-IPV (the pre-school booster dose) has been administered when Infanrix®IPV+Hib should have been used
Where the correct product Infranrix®-IPV+Hib has been used for immunisation of 2, 3
and 4 month old babies there have been occasions when the freeze dried Hib
component has not been reconstituted with the pre-filled syringe.
Both types of error have resulted in children missing out on a Hib dose.
Suggested actions to avoid further errors:
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Ensure that primary immunisations are given using Infanrix®-IPV+Hib
When administering Infanrix®-IPV+Hib ensure the separate freeze dried Hib component
is reconstituted and administered with the other vaccine antigens
Ensure Infanrix®-IPV is used only for booster immunisations
All vaccine errors should be reported to the local NHS England Screening and
Immunisation Team. As an error could also be deemed to be a medication error we
request that the error is also reported through NRLS.
Advice for the management of children who have missed out on one or more Hib primary
doses can be found: Use of Infanrix-IPV+Hib in the infant immunisation schedule Publications - GOV.UK – this attachment also has a useful power point presentation with
training slides in connection with the administration of Infanrix®-IPV+Hib
Public Health England is working with the MHRA and the vaccine manufacturer (GSK) to
improve the labelling of both Infanrix®-IPV+Hib and Infanrix®-IPV
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Correct use of Humalog 200 units/ml Kwikpen (insulin lispro) to minimise medication
errors
Insulin lispro (IL) is now available in strength of 200units/ml and it should only be
administered using Humalog 200 units/ml prefilled pen (Kwikpen). Patients must not transfer
IL in a Kwikpen to different delivery system because overdose and serious hypoglycaemia
could result.
For full details please refer to the SPC available here
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How to report medication safety incidents from a GP practice on the National
Reporting and Learning System (NRLS)
Reporting patient safety incidents on the National Reporting and Learning System (NRLS)
is important so risks can be identified across NHS England. The learning from these
incidents enables action to be taken to improve patient safety e.g. the cascading of patient
safety alerts. Increasing the number of patient safety incidents reported on NRLS, especially
from primary care, is a key priority for NHS England.
To make the reporting process quicker and easier in General Practice a new GP e-form has
recently been launched by NHS England and is available here. Practice staff should use the
new GP e-form to report all patient safety incidents and near misses whether they result in
harm or not.
A guide to downloading the GP patient safety incident reporting icon directly to a desktop for
easy access is available here
A web page titled "Patient Safety in general practice" summarises these details at: NHS
England » Patient safety in general practice
Guides to help staff in GP practices report medication safety incidents have been developed.
The guides are aimed at anyone in the GP practice environment who might be reporting
medication safety incidents and the details are available below:
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How to Report Medication Safety Incidents from a GP Practice on the National Reporting
and Learning System (NRLS)
Guide for general practice staff on reporting patient safety incidents to the National
Reporting and Learning System
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Useful links
Medicines Optimisation: Information for Healthcare professionals
Joint Formularies
Medicines Optimisation Post Live
Please send us your comments, queries and any other feedback to the
Medicines Optimisation Team email: d-ccg.medicinesoptimisation@nhs.net
Information within this Newsletter is published on the Medicines Optimisation Post Live
Every effort is made to ensure the accuracy of information contained within this newsletter;
for full prescribing information on any of the drugs mentioned please consult the reference
source cited, individual Data Sheets, Summary of Product Characteristics and the current
edition of the British National Formulary (BNF).