Greater Glasgow and Clyde Medicines

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• NHS Public Health Scotland advise giving paracetamol suspension 120mg/5ml (sugar free) at the time of Meningitis B (MenB) vaccination, or as soon as possible afterwards, in order to reduce the risk of the baby developing a vaccine associated fever.
• Parents and carers are given an information leaflet prior to the first set of infant vaccinations, which provides advice on giving paracetamol for MenB vaccination. Paracetamol infant suspension (120mg/5ml sugar free) can be obtained from community pharmacies, if they meet the eligibility criteria of being born ≥32 weeks gestational age and being over 4kg at the time of immunisation.
• For babies born before 32 weeks gestation, and all babies currently weighing less than 4kg (regardless of gestational age) at the time of immunisations, paracetamol for post vaccination fever must be prescribed by a GP according to the baby’s weight at this time.
• The dosing instructions for giving paracetamol after MenB vaccination are based on expert recommendation within NHSGGC, produced by specialist neonatal pharmacists and agreed with public health teams, for this specific situation and may differ to those in the product literature for paracetamol suspension (for the relief of pain and other causes of fever). They ensure that doses given to babies less than 4kg do not exceed the recommended paracetamol daily dose of 60mg/kg/day.
• The key points to note in dosing instructions relate to how many doses of paracetamol to give the baby before seeking medical advice:
• The baby should be given 3 doses of paracetamol at specified intervals following MenB vaccination even if they do not have a fever (see tables, caution with frequency required).
• In the 48 hours after vaccination, if the baby has a fever but is otherwise well, further doses of paracetamol can be given according to the product literature (or prescription for babies born before 32 weeks gestation and/or currently weighing less than 4kg).
• If the baby still has a fever more than 48 hours after vaccination then medical advice should be sought.

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• Lithium is a gold standard treatment for maintenance treatment of bipolar affective disorder.
• Lithium has a high potential for toxicity and requires careful monitoring to ensure its safe and effective use.
• Staff and patients using lithium must be aware of the common signs and symptoms of toxicity. Symptoms of toxicity include: coarse tremor, muscle twitching or weakness, unsteady gait, GI upset, blurred vision, slurred speech.
• Lithium preparations vary in bioavailability and should be prescribed as a brand (Priadel® is the recommended lithium preparation in NHSGGC).
• A lithium level should be taken for all patients on lithium on admission to hospital and advice on interpreting levels can be obtained from NHSGGC mental health services (MHS).

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• Delirium affects 1 in 7 hospitalised patients and is a medical emergency. It is associated with poor outcomes, including subsequent development of dementia and doubling risk of falls and mortality.
• Addressing contributory factors (such as medicines) can reduce the risk of developing in-hospital delirium in high-risk patients by a third. Undertaking a medication review is a key part of delirium care and should be undertaken on admission for all high-risk patients and at any time for patients who develop delirium. This is described in the NHSGGC Delirium Diagnosis, Risk Reduction and Management in Acute Setting guideline.
• This blog provides advice on how to undertake a medication review using the TIME checklist (NHSGGC network access required).
• Where possible, medicines associated with a risk of precipitating delirium, e.g. tramadol, should be stopped (or doses reduced).
• Analgesics AND pain itself may contribute to delirium; therefore, uncontrolled pain must be managed. Prescribe regular analgesia and, in frail people, start low and go slow.
• No medication can treat delirium. Using medicines to treat agitation and distress associated with delirium has a place only in specific circumstances when non-pharmacological measures are ineffective.
• For more general information on delirium (including completion of the TIME checklist) see the GGC- Delirium page on Staffnet (NHSGGC network access required).

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This post summarises the latest NHS Greater Glasgow and Clyde decisions relating to new medicines assessed by SMC and considered by the Area Drug and Therapeutics Committee (ADTC) and uses a nationally developed format specifically aimed for patients and the public.

For full details of the medicines included in this post that are available for use, including any restrictions on prescribing, please see the relevant entry in the GGC Formulary.

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• Covert medication is the administration of any medical treatment in disguised form. Therefore, an injectable medication or patch cannot be ‘covert’. The most common way is via liquid or food stuff.

• Covert medication must never be given to someone who is capable of deciding about their medical treatment. It is an option for patients who lack capacity and are unwilling to take essential medication. Patients’ wishes should be considered, ideally consulting others who know them well.

• It must be of benefit and the least restrictive option. It’s an alternative to more distressing methods of giving medication, for example intramuscular injections.

• A pharmacist must be consulted to provide specialist advice on mixing medication with foodstuffs. Altering the form of a medication is unlicensed and could result in harm - see NHSGGC Safe and Cost-Effective Administration for Covert Medication and in Dysphagia.

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Adding “outside” medicines (those prescribed and supplied outside the practice) to patient prescriptions will result in:

• Safer prescribing: prescription record is complete, allowing GP practice clinical decision support to flag drug interactions.
• Increased patient safety: these medicines appear in the Emergency Care Summary (ECS).
• Improved medicines reconciliation: due to more complete record of prescribing in ECS.

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