April 2015  Produced by The Central Prescribing Team Neuropathic Pain Creon® (pancreatin) 40,000 Neuropathic pain is defined as “Pain initiated or This strength will be unavailable from mid April caused by a primary lesion or dysfunction of the 2015. There is no indication when it will next be nervous system”. Symptoms include:- available. This issue does not affect the lower dose Creon 25, 000 and 10, 000 products which • Burning remain available. It is recommended that an • Electric shocks equivalent dose of a lower strength be • Numbness prescribed. Using Creon 25, 000 will reduce the • Tingling number of capsules required compared to use of • Shooting/stabbing the 10, 000 product.

The nature of neuropathic pain and its Creon 25, 000 is just over half the strength of management should be explained to the patient Creon 40, 000 so the number of capsules should and the value of compliance with treatment. be approximately doubled as a starting point. As Healthcare professionals should encourage self- with all changes to pancreatin usage, dosage management and provide education to the should be adjusted according to size, number patient, including coping strategies for flare up. and consistency of stools so that the patient Patients should understand that effective thrives. treatment is considered as 30% reduction in pain score and / or improved function. The Current Creon Approximate Equivalent benefits and possible adverse effects of 40 000 dose Creon 25 000 Creon 10 000 pharmacological treatment should be discussed, dose dose including the importance of titration and review. (number of capsules) (number of (number of Regular assessment of effectiveness of capsules) capsules) treatment is needed, particularly during the 1 2 4 titration period. Assessment of pain control 2 3 8 includes the impact on daily activities and 3 5 12 lifestyle. Prescribers should also consider the 4 7 16 patient’s physical and psychological well being including adverse effects of therapy and the 5 8 20 continued need for treatment. 6 10 24

The updated NHSGGC Chronic Non-Malignant Ranitidine 5mg/5ml Pain Neuropathic Pain Guidelines are now Since July 2011 until November 2014, the available in the Clinical Guideline Repository on prescribing of unlicensed “special” ranitidine StaffNet. 5mg/5ml has almost trebled and at the same The guideline contains information on: time the average cost per item increasing from • Causes of neuropathic pain £208 to £280. This strength is not • Assessing neuropathic pain with link to recommended by Yorkhill who use the licensed sLANSS tool 75mg/5ml product (£20.76 per 300ml). This • Need for regular assessment and review requires the use of a 1ml oral syringe which • More detailed information on stepwise needs to be specified on the prescription. treatment of neuropathic pain and titration schedules In practice, a 1ml oral syringe can measure • Links to Patient Information Leaflets down to 0.1ml which is equivalent to 1.5mg • When to consider referral to pain clinic. ranitidine therefore dilution should not be

Produced by: The Prescribing Team, Queens Park House, Victoria Infirmary, Langside Road, G42 9TT Tel. 0141 201 5157 [email protected] necessary considering the relative safety of ranitidine.

Prescribers should be aware that the licensed Drug OCD dose Panic Disorder product contains a small amount of ethanol dose equivalent to 5ml of wine per 5ml dose. Fluoxetine 20mg initially n/a However, advice from Yorkhill is that the doses increased used of the licensed preparations are so small gradually to that this is not a problem for most patients and 60mg daily parents should be assured of this. Currently Paroxetine 20mg 10mg there is a Script Switch warning in place to alert increased increased prescribers that ranitidine 5mg/5ml is unlicensed gradually in gradually in and will be updated to reflect that this is not 10mg steps to 10mg steps to recommended by Yorkhill. 40mg daily 40mg daily Sertraline 50mg 25mg Omeprazole Oral Solution increased if increased to It should be noted that omeprazole oral solution necessary in 50mg after 1 5mg,10mg and 20mg/5ml strengths are also weekly steps week then if unlicensed products and are not used by of 50mg to necessary in Yorkhill, who recommend omeprazole MUPS. 200mg daily weekly steps There is no evidence to support the use of of 50mg to unlicensed omeprazole solutions due to the 200mg daily action of gastric juices negating the pharmacological effect of the drug. 4. Switching from clomipramine – stop the clomipramine then, 24 hours later add fluoxetine, paroxetine or sertraline, taking Clomipramine MR discontinuation care to increase dose gradually. Be aware Clomipramine is a tricyclic antidepressant but is of the risk of serotonin syndrome, most often used in the treatment of severe cholinergic rebound & tricyclic withdrawal. obsessional compulsive disorder (OCD) and (Sources – Maudsley Prescribing Guidelines generally as a second line option after selective 11th Edition & Psychotropic Drug Directory serotonin reuptake inhibitors prove ineffective or 2012) are not tolerated. Consequently there is a small but important group of patients who rely on this drug. New MHRA E- Learning Corticosteroids Module Launched Having considered this issue, the Prescribing Interactive and designed for clinical Management Group – Mental Health, practitioners, the module covers: recommend clinicians take the following actions • recognition of commonly used for patients affected by the discontinuation of corticosteroids clompiramine MR. • important corticosteroid adverse effects • factors that increase the risk of adverse 1. Review the on-going need for treatment effects • how clinicians and patients can reduce 2. Where on-going treatment is required the risk consider changing to an equivalent dose • specific treatment of the adverse effects using clomipramine standard-release capsules (10mg, 25mg and 50mg capsules A link to this module can be found HERE are available), given using the same dosing frequency i.e. once daily, twice daily etc. Other e-learning modules on antipsychotics, benzodiazepines, opioids, oral anticoagulants, 3. The following table highlights licensed selective serotonin reuptake inhibitors (SSRIs) alternatives to clomipramine in OCD & panic are available on the same site. disorder

Produced by: The Prescribing Team, Queens Park House, Victoria Infirmary, Langside Road, G42 9TT Tel. 0141 201 5157 [email protected]