updateFife Prescribing

Welcome to the 33rd edition of the Fife Prescribing Update - a bi-monthly newsletter aimed at all medical and non-medical prescribersacross NHS Fife. I hope you enjoy reading the newsletter!If you have enquiries about the content or articles covered in this newsletter, please contact your Locality Pharmacist. Articles in thisnewsletter are for guidance only and appropriate medical information e.g. BNF, Summary of Product Characteristics etc. should beconsulted before use. Similarly, if you do not wish to receive this newsletter or your contact details are incorrect; please drop a line to gilliankerr1@nhs.net.

NHS FIFE WOUND FORMULARY and WOUNDMANAGEMENT GUIDELINES - ReminderAn updated version of the NHS Fife Wound Formulary and Wound Management Guidelines was launched in March / April.

Copies of the booklet and the summary sheets have been distributed to relevant practitioners and prescribers. Further copies of the

documents can be accessed and downloaded from the intranet or via the ADTC website www.fifeadtc.scot.nhs.uk//. Health

care professionals are reminded that they should familiarise themselves with the contents of the Woundcare Formulary and Wound

Management Guidelines and be aware of the NHS Fife Formulary choices. Formulary choices must be prescribed for the majority of

patients. The two summary sheets which have been produced (Quick reference guide to choice of dressings and Woundcare

products conversion chart) will help prescribers to ensure the most appropriate Formulary dressings are prescribed.

Woundcare products account for a significant proportion of the medicines budget. The annual spend on all wound management

products and dressings over the last financial year, was £1,202,011. Of this amount, £237,266 was for silver dressings.

NHS Fife have agreed a target of 50% reduction in use of silver dressings by March 2012 and an 80% reduction by March 2013.

As discussed in a previous article (Fife prescribing Update Issue 28 August 2010) there is no robust evidence that dressings

that contain silver are more effective than unmedicated dressings for the prevention or treatment of wound

infection. If silver dressings are deemed necessary, only Fife Formulary choices must be prescribed i.e. Silvercel NA®, Acticoat

Flex® or Acticoat Moisture Control® (see the Wound Formulary for further information).

KEY POINTS:

• SILVER DRESSINGS must only be used in accordance with the Wound Formulary

• Only FORMULARY CHOICES of silver dressings are to be prescribed

The formulary can be easily accessed on the Fife intranet by searching for “Wound Formulary” or by using

the link for Guidance documents and then Fife wide guidance on the ADTC website

www.fifeadtc.scot.nhs.uk/.

A BI-MONTHLY NEWSLETTER AIMED AT ALL MEDICAL AND NON-MEDICAL PRESCRIBERS ACROSS NHS FIFE

ISSUE 33 AUGUST 2011

If you require this newsletter in alternative formatsplease telephone 01383 565375

ISSUE 33 AUGUST 2011FIFE PRESCRIBING UPDATE

Update on Just in Case BoxesAs mentioned in a previous Newsletter (Fife Prescribing updateIssue 28 August 2010 ) NHS Fife has been piloting theeffectiveness of Just in Case (JIC) Boxes for Palliative Carepatients at home. The development reflects one of the actionsthat NHS Boards were asked to deliver through the NationalPalliative Care Action Plan Living and Dying Well. The Plansuggests that patients should be given the opportunity of dyingin their preferred place of care.

To tackle potential symptoms that may occur as diseaseprogresses, a short list of medicines can be prescribed and keptwithin a JIC box in the patient’s home for use by an attendinghealth professional. This is potentially of most benefit during theOut-of Hours period enabling patients to be managed in theirown environment and reducing the need for unwantedadmission to hospital and minimising delays in patientsreceiving treatment. JIC boxes are distributed through the 20

NHS Fife Palliative Care Network Community Pharmacies whenprescriptions are received for four of the medicines listed alongwith a completed Prescription Kardex. The Prescription Kardexallows Community Nursing staff to administer the medicinesprescribed and acts as a signal to the pharmacy that a box isneeded.

Up to the end of May 2011, 44 boxes have been issued acrossthe 3 three CHPs. 15 boxes had been used, 15 returned unusedand 14 were still in the community. Information from 11 of theused boxes showed that the most commonly used medicineswere analgesics and midazolam (4 each), cyclizine used in 2and Hyoscine in 1.

Of the first 12 boxes used, 9 were used in the Out of Hoursperiod. It was felt by the Healthcare Professional first using thebox that the use of the JIC boxes provided the followingoutcomes:

• OOH doctors visit avoided ( in 9 cases)

• Hospital admission avoided (7 cases)

• Patient was allowed to remain at home (all cases)

• Medicines included were felt to be appropriate (all cases)

Reminder to practices:

• Remember to let PCES know when a JIC box is in thepatient’s home and which analgesics and antiemetics havebeen included. This should be done either through the ePCSor Special Notes forms.

The first indications are that the boxes are being well receivedby patients and their carers , and enabling timely treatment andavoiding unnecessary visits and hospital admissions. Manythanks to all of the practice teams that have used the boxes sofar. A full evaluation of how the boxes have been used will takeplace in early 2012.

SYMPTOM MEDICINE INCLUDED

Pain Morphine Sulphate orOxyNorm Injection

Nausea & / Vomiting Cyclizine orlevomepromazine

Restlessness and Agitation Midazolam

Respiratory Secretions Hyoscine Butylbromide

Breathlessness Morphine Sulphate orOxyNorm Injection

SEASONAL INFLUENZA VACCINATIONPROGRAMME 2011-12The recent CMO letter “Seasonal influenza vaccination programme 2011-12” of 4 July 2011http://www.sehd.scot.nhs.uk/cmo/CMO(2011)08.pdf sets out the arrangements for the coming flu season. The keypoints to note, or where there are significant changes for the coming flu season, are noted below as follows:

• Uptake targets for the over 65 group will remain at 75%. Uptake targets for the under 65 at-risk population will this year beraised to 75%.

• In line with advice from the Joint Committee on Vaccination and Immunisation, poultry workers no longer require to bevaccinated as part of the seasonal flu programme (see Annex B of letter).

• As with last year, all pregnant women at any stage of pregnancy, remain eligible for vaccination (see Annex D).

• It is expected that an egg-free vaccine will be available this season (see Annex A).

• NHS Boards and staff are asked to ensure that staff are offered the seasonal flu vaccine. A 50% uptake of vaccine in keyclinical areas is being aimed for and sample surveys will be conducted next year to monitor this. Boards are asked to makethe vaccine as accessible as possible (see Annex E).

If you require this newsletter in alternative formatsplease telephone 01383 565375

Helping patients onbisphosphonates preventBONJ – new guidanceBONJ or bisphosphonate-related osteonecrosis of the jaw is anextremely rare but very serious condition in which the bone ofthe maxilla or mandible becomes irreversibly damaged.

Bisphosphonates have an important role in the prophylaxis andtreatment of osteoporosis and corticosteroid-inducedosteoporosis. They are also used in the treatment of Paget’sdisease, hypercalcaemia of malignancy and in bone metastasesin breast cancer.

However, due to their effect on bone turnover, a patient taking abisphosphonate is at increased risk of oral health complications,namely BONJ. Concern over the lack of clarity about providingdental care for patients taking bisphosphonates has prompted thedevelopment of new guidance by the Scottish Dental ClinicalEffectiveness Programme (SDCEP).

Maintaining good oral health helps to minimise the risk of BONJdeveloping. Being primarily directed towards primary caredentists, the new guidance provides clear and practical adviceon how to advise and care for patients prescribed these drugs,focussing on the prevention of BONJ.

However, part of the guidance is specifically aimed at doctorsand pharmacists who prescribe or dispense bisphosphonatesbecause it is particularly important that patients receiving thesedrugs are encouraged to attend for appropriate dental care.

The guidance for anyone who prescribes or dispensesbisphosphonates is straightforward:

Advise the patient:

• that the medication they have just been given is abisphosphonate and it is associated with a verysmall risk of BONJ

• to make an appointment with a dentist as soon aspossible to ensure they are dentally fit (thisincludes patients who have dentures)

• to tell their dentist that they are taking abisphosphonate

By following this guidance, patient awareness of the potentialoral health implications of taking bisphosphonates will be raisedand preventive dental care is more likely to be provided at anearly stage. That said, BONJ is an extremely rare condition andso it is very important that patients are not discouraged fromtaking their bisphosphonate drugs or from undergoing dentaltreatment.

The new guidance, entitled ‘Oral Health Management of PatientsPrescribed Bisphosphonates’, can be viewed at the SDCEPwebsite (www.sdcep.org.uk/index.aspx?o=3017).SDCEP is an initiative of the National Dental Advisory Committeeand operates within NHS Education for Scotland. For further information go to www.sdcep.org.uk, emailscottishdental.cep@nes.scot.nhs.uk or telephone 01382 425751.

New guidance onchemoprophylaxis formeningococcal diseaseissued by HPAPlease note the Health Protection Agency has recently updated

guidance on meningococcal disease (Feb 2011) which means

there will be a change in chemoprophylaxis:

Ciprofloxacin is now recommended for use in all age

groups and in pregnancy.

Rifampicin had been the drug of choice for meningococcal

chemoprophylaxis because it was licensed for

chemoprophylaxis. However, the advantages of ciprofloxacin

are that it is given as a single dose, does not interact with oral

contraceptives, and is more readily available in local

pharmacies. It is contraindicated in cases of known

ciprofloxacin hypersensitivity. Rifampicin can be an alternative in

this case.

The dosage recommended is:

Adults and children over 12 years 500 mg as a single dose

* Children aged 5‐12 years 250 mg as a single dose

(Suspension requires reconstitution)

* Children 1 month ‐4 years 125 mg as a single dose

(Suspension requires reconstitution)

* Note: chemoprophylaxis is an unlicensed indication in

children.

The guidance reassures prescribers that it is safe for use in

pregnancy, lactation and in young children but that anaphylactic

reaction can occur and information on side effects should be

provided. It has an unpredictable effect on epilepsy but is

preferred to rifampicin if the patient is prescribed phenytoin.

Read the full HPA guidance at:

www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947389261

ISSUE 33 AUGUST 2011FIFE PRESCRIBING UPDATE

MEDICINES WITHOUTSCOTTISH MEDICINESCONSORTIUM (SMC)APPROVAL- Information for prescribersPrescribers are reminded that medicines that have not beenapproved for use in Scotland by the SMC should not beprescribed unless approved by an Individual PatientTreatment Request to the Medical Director.

Non- SMC approved medicines are medicines which have:

• been submitted to SMC and have not been approved

• not been reviewed pending a submission or an evaluation ofa submission

How will I know if it is a non-SMC medicine?

Non-approved medicines will not be included in the NHS Fifeformulary/ e formulary.

The status of a medicine can be checked by logging on to theSMC website:

www.scottishmedicines.org.uk/SMC_Advice/Advice_Directory

Simply enter the medicine name (generic or brand) into thekeyword section and click search.

If a non-SMC medicine is being considered for apatient what actions must the prescriber take?

Prior to all new patients being commenced on a non-SMCapproved medicine, an individual patient treatment request form(IPTR) form must be completed.

If the medicine has been recommended by secondary care, theprescriber should confirm with the specialist whether themedicine has been approved for use by the local IPTR panel. Ifthere has been no prior approval, the prescriber should advisethe specialist that an IPTR request needs to be submitted andapproved, before a supply will be made in primary care.Copies of the IPTR submission form are on the ADTC website:www.fifeadtc.scot.nhs.uk.

If a non-SMC approved drug is to be initiated in primarycare, then the prescriber must complete the IPTR form anddiscuss the submission with the CHP Primary Care DevelopmentPharmacist, before submitting it.

All IPTR submissions should be sent to Dr Montgomery, MedicalDirector, Hayfield House for consideration by the IPTR panel.An IPTR should only be considered when a patient’s clinicalcircumstances and potential response to treatment with themedicine are significantly different to the generalpopulation of patients and he/she is likely to gainsignificantly more benefit from the intervention than mightnormally be expected from other patients.

If a patient is already being prescribed a non-SMCapproved medicine, what actions must the prescribertake?

No immediate action is required, however when the patient isnext reviewed, the prescriber should consider if an alternative

NHS Fife formulary medicine would be suitable for the patient.

Which non SMC approved medicines are currentlyprescribed in NHS Fife Primary Care?

KEY MESSAGES:

• Non- SMC approved medicines should notroutinely be prescribed for patients in Fife

• For a non SMC approved medicine, an IPTR mustbe completed on each occasion and thesubmission approved before prescribing to apatient.

• New medicines (or new indications for existingmedicines) are considered non-Formulary andshould not be prescribed routinely until they havebeen reviewed by the SMC and considered by theADTC for inclusion in the Formulary.

• Local ADTC decisions on new medicines can bechecked by referring to the ADTC bulletin orchecking on the ADTC website.

Reference

1. NHS Fife Policy - INTRODUCTION ANDAVAILABILITY OF NEWLY LICENSEDMEDICINES IN THE NHS INSCOTLAND

SMC NOT RECOMMENDED DRUGS

INDICATION

ANNUALSPEND IN FIFE-PRIMARY CARE2010/11

Aliskiren (Rasilez®) Hypertension £5894

Buprenorphine patch(BuTrans®)

Pain (non-malignant) £176,537

Buprenorphine patch(Transtec®) Pain £26,491

Glucosamine HCL (Alateris ®)

Osteoarthritis(knee) £22,513

GTN ointment(Rectogesic®) Anal fissure £17,783

Paracetamol withtramadol (Tramacet®) Pain £17,232

Cannabinoids (Sativex® ) Multiplesclerosis £14,123

Drospirenone/ethinyloestradiol (Yasmin ®)

Oralcontraceptive £48,340

Prucalopride(Resolor®)

Chronicconstipation inwomen whenother laxativesfail to providea response

£3456

Total spend for the above £332,371