Greater Glasgow and Clyde Medicines

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• Alfentanil is an injectable strong opioid, which is 30 times more potent than oral morphine.
• It should only be used following specialist advice and is considered 3rd line for pain unresponsive to other opioids (see below for further guidance).
• A NHSGGC 8-minute video (NHSGGC network access required), on how to safely prescribe alfentanil in the Acute Sector, is available.
• There are many potential risks associated with prescribing and administering alfentanil, e.g. wide dose range and availability of more than one strength of injection.
• It is important to follow the good practice points outlined below.

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• ALL NHSGGC mental health policies will move to the MyPsych toolkit which is hosted within the Right Decisions Service (RDS) app and website

• Effective from Wednesday 21st May 2025

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• The NHSGGC primary care asthma guidelines have been updated to align with BTS/NICE/SIGN 2024. 

• Asthma is an inflammatory condition therefore the preferred pathway uses one inhaler combining inhaled corticosteroid (ICS) with formoterol, a quick acting reliever. There is therefore no need for a salbutamol inhaler. 

• It represents a step away from as required (prn) salbutamol and other short-acting beta-2 agonist (SABA) devices for the relief of asthma symptoms. 

• This preferred approach is referred to as the AIR/MART pathway (anti-inflammatory reliever / maintenance and reliever therapy). 

• Patients can be moved to an ICS-containing device in the AIR/MART pathway, as they also contain the long-acting beta-2 agonist (LABA) formoterol, which has an onset of action comparable to SABAs. Current ICS devices licensed contain either budesonide (AIR or MART) or beclometasone (MART only). 

• If patients are stable, there is no need to switch them to the AIR/MART pathway – consider switching opportunistically at a routine review. 

• Reduces the risk of SABA reliever overuse and preventer underuse as per MHRA drug safety update. 

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• Metalyse® (tenecteplase) 25mg (5,000 units) has replaced alteplase as the agent of choice for thrombolysis in acute ischaemic stroke patients in NHSGGC (see GGC guideline). Clinical trials have shown Metalyse® to be non-inferior to alteplase for this indication.
• Metalyse® is RESTRICTED to specialist use and should ONLY be used by local stroke teams who have undergone training. 
• It is anticipated that Metalyse® will reduce door-to-needle times and facilitate transfer of patients to the hyper-acute stroke ward for ongoing management and monitoring.
• Metalyse® 25mg (5,000 units) is licensed only for acute ischaemic strokes. Be aware that Metalyse® 50mg (10,000 units) is available and is licensed only for acute myocardial infarction. The formulations should not be used interchangeably.
• If you work in an area that uses Metalyse®, please ensure that you are aware of the differences between the two products, i.e. different indications and licensing.

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In March 2020 the MHRA issued a reminder notice highlighting the dangers associated with co-prescribing of benzodiazepines (B-Zs) and opioids. This was prompted by a coroner’s report following the death of a man prescribed clonazepam and, among other drugs, the opioid methadone. His death was attributed to the combination causing respiratory depression.

The GGC clinical guideline Opioid prescribing for chronic non-malignant pain advises “do not prescribe opioids to patients currently taking B-Zs”. Co-prescribing has additive effects in the central nervous system (CNS) leading to increased sedation, impaired alertness, reduced motor response and respiratory depression.

Despite the risks, Torrance et al 2018 found opioid prescribing in Scotland was increasing and co- prescribing of B-Zs was common.

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The GGC Formulary primarily recommends the prescription of generic medicines and the NHS Greater Glasgow and Clyde Area Drug and Therapeutics Committee (ADTC) have previously issued guidance for prescribers to support generic prescribing.

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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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Key messages:

• Lidocaine plasters are now non-formulary in NHSGGC.
• Prescribing data shows a sustained downward trend in the number of patients prescribed lidocaine plasters, with the associated reduction in spend within NHSGGC.
• April 2024 – January 2025  - there has been a 48.78 % reduction in the number of patients prescribed lidocaine plasters in Primary Care and a 47.41% reduction in spend.
• Reducing inappropriate prescribing of lidocaine plasters has been a focus of the NHSGGC Cost Efficiency Workplan since April 2024 and will continue to be a focus for 2025/26.
• Continue to review regularly with trials of reduction/cessation.
• Patients who have been using lidocaine plasters for more than 6 months, should trial stopping.
• De-prescribe in all patients where possible.