Prescribing Newsletter

Produced by Herefordshire CCG Medicines Optimisation Team March 2017

Alimemazine STOP PRESS!

The sedating antihistamine alimemazine (formerly ‘trimeprazine tartate’) has significantly increased in Flu Vaccination 2017 price over the last 12 months. Licensed for the The quadrivalent influenza vaccine is treatment of urticaria and pruritus, as of March NOT recommended for at risk adults – 2017 the cost listed in the Drug Tariff increased to: this position is shared by Herefordshire and Worcestershire. The vaccine is  £113 for 28 10mg tablets 50% more expensive, and evidence  £180-244 for 100mL oral solution remains mixed. Eligible patients should be offered trivalent influenza vaccines Prescribers are advised to review the continued in line with national guidance. indication for alimemazine, and if appropriate consider switching to another sedating *NEW Specials Guidance* antihistamine (e.g. chlorphenamine tablets cost of Updated guidance on prescribing £0.92 for 28 4mg tablets and £2.62 for 150mL oral unlicensed special order medicines is solution). now available on the internet. MHRA Recommendations: guidance plus alternatives to commonly 1. Identify patients who may be receiving prescribed high cost “specials”. alimemazine on a regular basis and review as Disulfiram Stock appropriate. The sole supplier of disulfiram, Teva, 2. Consider initiating treatment with an alternative has advised that the medication may be sedating antihistamine. out-of-stock until July 2017. Given the Every switch from alimemazine to shortage, prescribers should consider chlorphenamine represents a saving of £1,459 initiation with an alternative therapy. For per year. existing patients, if alternatives are not appropriate, specialist advice should be sought.

Antihistamine Cost/28 Breach reports (non-sedating, Report to the CCG requests to prescribe drugs in primary care Days (£) sedating) which may not be considered suitable for primary care prescribing

Cetirizine for example: 0.71 10mg OD • Drugs that are not on the Herefordshire Joint Formulary • Unlicensed “specials” or drugs for use outside their licensed Loratadine 0.78 indications, unless there is established practice to support it 10mg OD • Drugs that are not in line with Herefordshire CCG NHS Fexofenadine Prescribing Guidance, Low Priority Treatments list, or “RED Drugs” 1.58 120mg OD Form is available Here

Acrivastine 20.37 New CD Accountable Officer 8mg TDS Until further notice and with immediate effect, Dr Kiran Patel is the

Promethazine newly appointed CD Accountable Officer (CDAO) for NHS England 2.33 25mg nocte Midlands & East (West Midlands). Email [email protected] . Any urgent matters requiring the CDAO’s attention can be sent Chlorphenamine 2.28 using this email. Please remember all other CD enquiries and 4mg TDS incidents should be sent to NHS Arden & GEM Medicines Alimemazine Optimisation Team, please find below the contact details. 225.70 10mg BD Controlled Drugs queries Tel: 01926 353830 Secure Email: [email protected]

The information contained in this newsletter is issued on the understanding that it is the best available from the resources at our disposal at the time of issue. Comments, suggestions, contributions welcome! Medicines Optimisation Team [email protected]

LAMAs Licensed for COPD Key issues for LAMA prescribing £/28days March 2017 1. Prescribe by BRAND to ensure correct device dispensed and continuity now there is a new branded generic Spiriva Respimat 2.5mcg £21.47 (tiotropium) SMI 2 puffs OD tiotropium DPI ie specify brand ie Spiriva or Braltus. For new patients that Braltus ®Zonda 10mcg £24.08 need a DPI consider Braltus Zonda due to (tiotropium) DPI 1 OD cost saving, however Spiriva Respimat is Seebri Breezhaler® 50mcg the most cost effective tiotropium option £25.67 (glycopyrronium) DPI 1 puff OD (see cost chart). Incruse Ellipta® 55mcg £25.67 (umeclidinium) DPI 1 OD 2. Consider patient factors, device & patient technique; DPIs require deep and Eklira Genuair® 322mcg £26.69 fast inhalation whilst respimat mist spray (aclidinium) DPI 1 puff BD requires slow co-ordinated inhalation Spiriva Handihaler 18mcg £31.27 (tiotropium) DPI OD 3. Stop SAMA ie ipratropium (Atrovent) £0 £5 £10 £15 £20 £25 £30 £35 when LAMA (eg tiotropium) is prescribed

4. Review and document patient inhaler device technique & training regularly and at least annually 5. For persistent symptoms; review non pharmacological measures i.e. pulmonary rehabilitation, smoking cessation advice, review diagnosis and/or consider specialist advice 6. Patients reviewed and under care of respiratory team -please reinforce device training at follow up and do not change unless technique poor or problematic or brand unclear. Any potential cost savings are likely to be greatest by patient face to face review, stopping unnecessary treatment, improving technique and compliance rather than simple switches.

Diazepam should not routinely be added to Low Priority Treatments NSAIDs for the treatment of acute lower back Low Priority Treatments (LPTs) are not a pain. cost-effective use of NHS resources. Despite There is very high variation in GP Practice diazepam prescribing guidance and the circulation of prescribing - see graph sent out to practices separately. support information, prescribing of LPTs A study published in Annals of Emergency Medicine (online, continues to increase. 7 February 2017) found that diazepam did not improve pain or functional outcomes over placebo, when added to In November 2016, spending on LPTs in naproxen for lower back pain. Herefordshire was over £30,100. The top 10 products accounted for 63% of Oral non-steroidal anti-inflammatory drugs (NSAIDs) are LPT expenditure as below. All require patient recommended for patients with acute back pain. review in 2017, ask your practice pharmacist. Benzodiazepines, such as diazepam, are often concomitantly prescribed but there is no clear evidence to November 2016 Items Cost support this practice. LPT Items 1 Researchers randomly assigned 112 patients presenting at Liothyronine 23 £8,724 an emergency department for acute lower back pain to 2 Co-Proxamol 14 £1,934 receive the NSAID naproxen and placebo, or naproxen and 3 Orlistat 92 £1,733 diazepam, for one week. 4 Lidocaine plaster 5% 29 £1,442 5 Nexium 20mg 44 £1,088 One week following discharge, mean scores on the Roland- 6 Gliclazide 30mg M/R 187 £904 Morris Disability Questionnaire were 11 for both groups (CI 7 Tadalafil 5mg 16 £887 9-13 and 8-13). Interestingly, patients assigned to the diazepam group had a higher percentage of moderate or 8 Nexium 40mg 27 £886 severe pain – 32% (CI 21-45%) – compared to placebo at 9 Omacor 23 £722 22% (CI 13-35%). 10 Fexofenadine180mg 177 £648 Citation: Clinical Pharmacist, Vol 9, No 3, online | DOI: 10.1211/CP.2017.20202403 £18,968

Medicines Optimisation Newsletter produced by Herefordshire CCG March 2017