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Lofepramine Shortage – 21/12/2018

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Lofepramine Shortage – 21/12/2018 Lofepramine Shortage – 21/12/2018 There is a shortage of lofepramine tablets. The shortage is due to the fact that two out of the four generic manufacturers making the product in the UK have stopped making it. These two manufacturers had a large share of the lofepramine market. Secondary Care has access to some supplies of lofepramine but this won’t be enough to meet the demand for all the patients needing it in Leeds. Creo Pharma, who are one of the manufacturers of generic lofepramine, have confirmed they have put 50,000 packs into wholesalers at the end of last week with no restrictions. However, we are unsure if these supplies will be available in primary care. The following can be done while lofepramine is unavailable: 1. Most patients will need to be switched to an alternative antidepressant by cross-tapering to an alternative. Lofepramine is a non-sedating tricyclic antidepressant, which is fairly safe in overdose unlike most tricyclic antidepressants and it mainly affects noradrenaline reuptake rather than serotonin. Nortriptyline or imipramine could be used as alternative tricyclic antidepressants as the cause a low level of sedation and the parent drug or active metabolites favour noradrenaline reuptake inhibition over serotonin reuptake inhibition. The Psychotropic Drug Directory gives the following approximate antidepressant equivalent dosesi: - Lofepramine 125mg/day - Imipramine 70mg/day - Nortriptyline 50mg/day - Escitalopram 9mg/day - Sertraline 50mg/day - Mirtazapine 25mg/day - Trazodone 200mg/day - Venlafaxine 75mg/day This table compares antidepressants and their side effectsi,ii: Antidepressant Anticholinergic Drowsiness Cardiac side Overdose Nausea side effects effects toxicity Lofepramine xx X X 0 x Imipramine xx xx xx xxx xx Nortriptyline xx x xx xx xx Sertraline 0 0 0 0 xx Escitalopram 0 0 QT 0 xx prolongation Mirtazapine 0 xxx 0 0 0 Trazodone x xxx x x xxx Venlafaxine 0 0 0 x xx 0 – minimal effect, x- mild effect, xx – moderate effect, xxx – marked effect Cost of 28 days from Drug Tariff January 2019 (approximate equivalent doses): - Lofepramine 140mg/day - £8.30 (70mg tabs) - Nortriptyline 50mg/day - £2.05 (25mg tabs) or £23.20 using 50mg tabs - Imipramine 75mg/day - £2.28 (25mg tabs) - Escitalopram 10mg/day - £1.10 - Sertraline 50mg/day - £0.72 - Mirtazapine 30mg/day - £1.03 - Trazodone 200mg/day - £5.70 - Venlafaxine 75mg/day - £2.05 as 37.5mg bd or £2.60 as xl 75mg od Switching Table Switch Nortriptyline/imipramine Trazodone Mirtazapine Venlafaxine Sertraline/ to/from escitalopram Cross taper Cross taper Cross taper Cross taper Cross taper e.g reduce lofepramine by e.g Halve e.g reduce e.g. reduce e.g. halve 70mg every 3-7 days and lofepramine lofepramine lofepramine lofepramine start dose and by 70mg by 70mg dose then imipramine/nortriptyline add every 3-7 every 3-7 reduce by Lofepramine at 25mg/day and increase trazodone, days and days and 70mg every in steps of 25mg every 3- slowly cross start start 3-7 days and 7days titatre mirtazapine venlafaxine start at 15mg ON at 37.5mg sertraline at and od and 50mg/day or increase in increase in escitalopram up to 30mg steps of at 5mg/day ON after 3-7 37.5mg days every 3 -7 days The above information is the ideal but if the patient hasn’t got enough medicines to do this, then try to do a small crossover to reduce any antidepressant withdrawal symptoms and chances of a relapse in their mental health condition. Withdrawal symptoms from tricyclic antidepressants include flu-like symptoms (chills, muscle aches, sweating, headache, nausea), insomnia and dreaming. 2. For a small number of patients who have tried all the above options in the past and nothing has worked, the patients could be referred to Leeds and York Partnership Foundation Trust for a psychiatrist to prescribe the drug and the Trust pharmacy to supply the drug for a short period until lofepramine comes available again in primary care. Unfortunately the Trust pharmacy cannot dispense FP10 prescriptions done by GPs. The patient would need to be referred through the usual process i.e. via the LYPFT single point of access tel. 0300 3001485 or [email protected] Michael Dixon, Lead Pharmacist for Medicines Information. Leeds and York Partnership NHS Foundation Trust i Bazire S. Psychotropic Drug Directory 2018. ii Taylor D et al. The Maudsley Prescribing Guidelines in Psychiatry. 13th ed .
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