NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Medicines
Medicines Update Primary Care

Postscript Primary Care - March 2012

Homely Remedies

While many care home organisations have very clearly defined policies and procedures around homely remedies, the prescribing teams across NHSGGC have been contacted on a number of occasions for advice on how to establish a Policy. The availability of a Homely Remedy Policy reduces the need for some ‘when required’ medicines to remain on a patient’s repeat medication list for very occasional use for the management of minor ailments. In addition it is recognised that there are benefits if homes are encouraged to stock a supply of simple dressings for first aid purposes.
In response to these queries, NHSGGC guidance has now been developed to help any care home organisation develop or review their Homely Remedy Policy. The information in the guidance pack is as follows:
• Overarching guidance notes
• A template training pack for staff
• A flowchart to describe the key steps in the process
• A template for Homely Remedy medicines
• A template for Homely Remedy dressings
• A sample GP cover letter
• A sample stock book
It is important to clarify that the information provided in the guidance notes suggests best practice, however, each care home organisation assumes sole responsibility for content and implementation of a Homely Remedy Policy within their own care setting in line with their existing company policies.
The information is available on staffnet or by contacting Noreen Downes, Lead Clinical Pharmacist for Prescribing Development – Care Homes: noreen.downes@nhs.net

Buccal Midazolam

The newly licensed buccal midazolam solution (Buccolam®) was accepted by the Scottish Medicines Consortium and is being considered in NHSGGC. Any potential change will require careful implementation with training for all involved in the prescribing, dispensing and administration of buccal midazolam since Epistatus® (the unlicensed product currently in use in paediatrics) is twice the strength of Buccolam®. Until the local assessment is complete please continue to prescribe and dispense midazolam 10mg/ml. More detail will follow shortly.

Gliptins and Renal Disease

A review of the gliptins (dipeptidylpeptidase-4 (DPP-4) inhibitors) will be undertaken shortly to identify the preferred gliptin of choice for use in NHSGGC.  The glipins are licensed for use in type 2 diabetes in combination with metformin or sulfonylurea. There are currently four gliptins with a UK product licence and a fifth agent likely to receive a product licence in 2012/13.  In mild renal impairment the gliptins can be used without a dose reduction. Sitagliptin and vildagliptin can be used in severe renal failure and end stage renal disease (ESRD) following a dose reduction while saxagliptin is subject to caution in severe renal impairment and contraindicated in ESRD. Linagliptin can be used without a dose reduction. Vildagliptin should be avoided in hepatic impairment.
• Sitagliptin 25mg and 50mg will be available from April 2012.
• Gliptins would be considered as second line therapy if metformin, sulfonylurea or pioglitazone are contraindicated or not tolerated
• Gliptins should only be continued if a reduction of 0.5% HbA1c (5.5mmol/mol) is achieved at 6 months according to NICE
• Gliptins are all still black triangle drugs (▼) under close scrutiny by the MHRA for the development of adverse drug reactions. New safety information regarding saxagliptin use and the associated risk of hypersensitivity reactions and acute pancreatitis was released in March.

Adult Infection Management Guideline Revision

The NHSGGC Infection Management Guidance for Primary Care has been revised and is available now on StaffNet.

There will be a poster summary developed which will be sent to primary care prescribers as with previous infection guidelines. The Synonyms on EMIS have been updated to reflect these changes and the updated files will be available to practices this month.

The key changes from the 2009 version are summarised below:
• New sections added on epididymitis and otitis externa
• Lower UTI in men, change of first-line drug to trimethoprim rather than ciprofloxacin
• Removal of co-trimoxazole from UTI treatments
• Acne – change to preferred topical treatment formulations
• Change from ceftriaxone to cefotaxime for immediate treatment of suspected meningococcal disease
A number of other minor changes have been made to ensure consistency with Formulary changes and national guideline recommendations.  Please refer to the guideline.

Prescribers are reminded that quinolone antibiotics such as ciprofloxacin are associated with an increased risk of C.difficile infection and thus their use should be restricted. Quinolones should not be prescribed for the empiric treatment of respiratory tract infections or for uncomplicated lower urinary tract infection.  The only indications where quinolones should be used in first-line treatment are upper urinary tract infections (except in pregnancy) and epididymitis (ofloxacin).

Methotrexate Voluntary Ban - 10mg Tablets

GP practices were sent information at the end of January about the voluntary ban on methotrexate 10mg tablet prescribing for adults which is supported by the GP Sub Committee, Clinical Governance forum, Area Drugs and Therapeutics Committee and Area Pharmaceutical Committee. 

The letter asks that prescribers change adult patients on 10mg tablets to 2.5mg tablets by April 2012.  Prescribing support teams can assist practices in running patient searches.

Oral Nutrition Contract

As you will be aware, the awards for the contract are as follows:
Sip feeds - Abbott range, both adult and paediatric

Enteral Feeds and home delivery service – Nutricia. Again the feed range is for both adult and paediatric feeds.

We have had challenges implementing the contract for those patients who use sip feeds as bolus enteral feeds. These patients need to use the Nutricia home delivery service ('Homeward') as they require ancillaries such as syringes and tubes delivered to their homes.

The agreed contractual outcome is that patients who require sip feeds for bolus enteral feeding will be set up on Nutricia's Home delivery service ('Homeward') and prescriptions will be requested for Nutricia sip feeds - the Fortisip® range.  This will also allow these patients to access the Nutricia enteral feeding nurses that cover GGC.  There are only a relatively small number of these patients across GGC and new patients will be initiated within secondary care.

GP practices that have these patients on Nutricia sip feeds for bolus enteral feeding will not be disadvantaged with regard to the sip feed prescribing indicator.
Nutricia sip feeds will be considered non-formulary for any indication other than bolus feeding.

Please contact Vicki Welch (Lead Prescribing Dietitian) if you have any further questions. Tel. 0141 201 5157.

Ensure® Plus Starter Packs

Prescribers are reminded that when prescribing Ensure® Plus Commence starter packs that the quantity entered on the prescription should be 1.  This will ensure that only one pack of 10 bottles is dispensed and reimbursed.  We have been made aware of a number of prescriptions for multiple starter packs which when investigated was in excess of what was intended.