Prescribing Newsletter

Produced by Herefordshire CCG Medicines Optimisation Team December 2013 Newer Oral Anticoagulants (NOACs) STOP PRESS! Key Points: 1. Adherence: not suitable for patients with poor adherence. Urgent Calls Community pharmacists will target patients prescribed anti- The festive season coagulants for the New Medicines Service (NMS) and workload is upon us which makes annual Medicines Use Review (MUR). it even more important to ensure 2. Patient information & alert cards: vital for all patients, effective communication between including advice on bleeding risk and action to take in the health professionals to avoid patient safety incidents. event of bleeding. Obtain from pharmaceutical companies. 3. Check renal function: dose reduction may be required. Practices are asked to review 4. Monitoring: baseline and annual (minimum) U&Es. systems to ensure front line staff are aware of the need for prompt Annual review by GP and pharmacist to reinforce connection to prescribers to solve importance of adherence to treatment and check for ADRs. medicines queries to reduce Rivaroxaban in DVT Treatment delays for patients and carers save Patients experiencing DVT now have a new treatment option in time for both clinical and admin line with NICE TA261: staff. Rivaroxaban 15mg BD x 21 days, followed by 20mg OD Examples include alternatives to Guidelines for the safe use of rivaroxaban in DVT are available out of stock medicines, palliative on the intranet. care queries, medicine overuse GPs suspecting a DVT diagnosis will be likely to offer oral concerns and medicine queries rivaroxaban instead of LMWH injections (enoxaparin) for most from hospital staff relating to patients. Treatment will be limited to a maximum of 7 days until admission and discharge. diagnosis is confirmed. Pharmacies are asked to consider Contractors are requested to stocking small quantities of 15mg tablets (new 14 tablet pack document any occurrences as now available) to ensure there is no delay in starting treatment. incident reports. NOACs for Stroke Prevention in AF Prescribing guidelines for anticoagulants in AF have been updated to include apixaban in line with NICE TA275. The patient FAQs have also been updated accordingly. Both documents may be found on the intranet. Dose regimens for Oral Anticoagulants:

Standard Dosing Regimen

AF (non- Other eg TKR THR DVT / PE valve valvular) replacement Warfarin OD as per INR

110mg stat 110mg stat then 220mg* 150mg* Dabigatran then 220mg* not licensed not licensed OD for 27-34 BD OD x 9 days days 15mg BD x 21 10mg OD 10mg OD Rivaroxaban 20mg* OD days then not licensed for 2 weeks for 5 weeks 20mg* OD

2.5mg BD x 2.5mg BD for Apixaban 5mg* BD not licensed not licensed 10-14 days 32-38 days *NB dose reductions for age and / or risk factors eg renal function check BNF/SmPC

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]

DOSULEPIN PRESCRIBING Reducing dosulepin prescribing has been included as a national prescribing indicator in Wales since April 2011 and as a Regional West Midlands indicator for the first time in 2013/4. There is significant variation in the level of prescribing and Herefordshire GPs prescribe significantly more dosulepin than other areas in the West Midlands. See graph below for local prescribing data. In 2011 200 deaths related to tricyclic antidepressants were reported, 49 with dosulepin. 20% of fatal dosulepin overdose cases are unintentional (MHRA). Alternatives to Dosulepin Review Points

Depression and anxiety: SSRIs are first line choice  Don’t switch to or initiate dosulepin for new

and are anxiolytic in long term use. Consider trial of patients beta-blockers for somatic symptoms of anxiety  Only re-start dosulepin where previous use Other Sedative Anti-depressants include has been under the care of a consultant mirtazapine and alternative sedative TCAs eg  Review existing patients to assess their clomipramine, trazodone: both sedative but less ongoing need and suitability for dosulepin – cardiotoxic than dosulepin Consider reduction in dose, change or stop. Hypnotics: use short term eg zopiclone or sedating Max fax use is recommended to be reviewed antihistamine eg promethazine after 6-12 months. Neuropathic Pain: see Herefordshire guidelines and consider amitriptyline or nortriptyline (also unlicensed  Review quantities prescribed for those but quoted in BNF & NICE CG173), gabapentin etc requiring ongoing prescription and assess Discontinuation risk of self harm and falls etc Discontinue dosulepin slowly where possible, over one  SSRIs remain first line choice in moderate month if long term continuous use. Discontinuation depression and anxiety. Warn patients re symptoms can include insomnia, anxiety, GI symptoms transient side effects eg GI, anxiety. Consider short term hypnotic or benzodiazepine if Licensed Indication: “…treatment of symptoms of agitated depressive illness especially where an anti-anxiety  Do not co-prescribe SSRIs and other effect is required”. antidepressants with tricyclics (TCA) eg NICE CG90: “Do not switch to, or start, dosulepin amitriptyline, dosulepin, nortriptyline [risk of because evidence supporting its tolerability relative to serotonin syndrome] other antidepressants is outweighed by the increased cardiac risk and toxicity in overdose” TCA contra-indications / cautions MHRA Advice restricts initiation of treatment for C/I: Immediate post MI, arrhythmias & heart patients who have not previously received dosulepin to block; manic phase BAD specialists and provides advice on safe quantities, Cautions: cardiovascular disease, storage and potential drug interactions. hyperthyroidism (risk of arrhythmia), epilepsy, diabetes, dementia, BPH, chronic constipation, Dosulepin Audit glaucoma, urinary retention A Cardiff audit reviewed 845 patients. 255 (30%) 700 Dosulepin Prescribing stopped treatment with no 600 (by volume, ADQ per 1000 patients) alternative prescribed and   412 (49%) switched to an 500 QE Mar 13 QE Sep 13 alternative. Local audits in 400 Aspiration 2013 showed some patients initiated in the last 300 2 years for indications 200 such as insomnia, depression, bereavement, 100

anxiety plus bruxism & patients 1000 per ADQ 0 related maxillofacial

conditions. Kington

A local audit template is Colwall

Cradley

Nunwell

Weobley

Belmont

Mortimer

Pendeen

Greyfriars

Kingstone

Cantilupe Fownhope

available as is prescribing Street King

Much Birch Much

Alton Street Alton

Quay House Quay

St.Katherines

The Marches The Golden Valley Golden

support to help with House Sarum

Ledbury Market Ledbury Moorfield House Moorfield

reviews in practices. Wargrave House Westfield Surgery Westfield Medicines Optimisation Newsletter produced by Herefordshire CCG December 2013