Greater Glasgow and Clyde Medicines

Key Messages

• The increased risk of bleeding observed with the combination of selective serotonin reuptake inhibitors (SSRIs) and non-steroidal anti-inflammatory drugs (NSAIDs) and SSRIs and oral anticoagulants (OACs) is higher than with use of each medicine class alone.
• The evidence for serotonin-noradrenaline reuptake inhibitors (SNRIs) (e.g. venlafaxine and duloxetine) is limited, however due to the similar effects on serotonin, the same advice given for SSRIs should be followed.
• The combination of SSRIs and NSAIDs is not recommended; if this is unavoidable, a formulary choice Proton Pump Inhibitor (PPI) should be used (Refer to the GGC PPI Guidelines and NSAID Guidelines).
• Due to the increased risk of major bleeding with concomitant SSRIs and OACs, consider individual patient factors before co-prescribing; if clinically appropriate, prescribe a formulary choice PPI.
• The evidence for increased risk of bleeding in the combination of an SSRI and low molecular weight heparin (LMWH) is limited. When deciding if a PPI is necessary, an individual patient’s additional risk factors should be considered.
• For patients on any of the above combinations, risk factors should be monitored and managed to improve safety outcomes.

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Key messages: 

• Antidepressant prescribing continues to rise, while benzodiazepine and z-hypnotic (B-Z) prescribing is reducing slowly, and long-term use remains an issue.
• Proactively reviewing antidepressant and B-Z prescribing aligns with a range of NHSGGC prescribing initiatives and National Therapeutic Indicators (NTIs).
• Proactive medication reviews, when patients are stable and not experiencing crises, may be lacking and leads to medicines being continued inappropriately.
• Toolkits to support reviews are now available on Right Decision Service (antidepressants and B-Zs).

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Key messages: 

• NHSGGC has various online clinical resources designed to aid safe prescribing and administration of medicines. The resources detailed in this blog should be your first port of call when looking for information.
• Search engines may find clinical information that is out-of-date or not relevant for use in NHSGGC. Using a search engine is not advised for finding NHSGGC clinical information, however, if using one, make sure any results you find are relevant to NHSGGC. Including “GGC” in your search term may help narrow down relevant results, but still always check the information is applicable to GGC and that it is the most current guidance.
• Only use the NHSGGC validated calculators for gentamicin, vancomycin and creatinine clearance (CrCl). These are available within NHSGGC resources (via Clinical Info on Staffnet and the GGC Medicines App). Do not use calculators found elsewhere on the internet, as other health boards’ guidance and dosing may differ.

To access the full blog via Microsoft Sway, click here

To access the full blog via Microsoft Sway, click here

To access the full blog via Microsoft Sway, click here

Key messages:

• The NHSGGC Adult Blood Glucose and Combined Ketone Meter and Test Strip Formulary has been updated.
• The following products for continuous/flash glucose monitoring have been added to the formulary:
  • Freestyle Libre 2 Plus® in line with NHSGGC CGM MDI insulin users guidance
  • Dexcom One+® in line with NHSGGC CGM MDI insulin users guidance
• Continuous/flash glucose monitoring systems are intended to be used as an alternative to routine finger-prick blood glucose monitoring for people who meet the eligibility criteria described in the guidance.
• The Freestyle Libre 2® and Dexcom One® monitoring systems are being discontinued, patients currently using these systems will be transitioned to Freestyle Libre 2 Plus® or Dexcom One+®.
• Specialist diabetes teams and Primary Care teams will facilitate changes to repeat prescriptions and offer support to patients if needed when they change product.

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Key messages:

• Tirzepatide can be used as a 3rd line agent in insufficiently controlled type 2 diabetes in addition to oral anti-diabetic medicines such as metformin, sulfonylureas, sodium-glucose cotransporter 2 inhibitors (SGLT2i), gliptins or pioglitazone. Refer to updated Management of Type 2 diabetes mellitus guidelines.
• Currently, tirzepatide for weight management is non-formulary in NHSGGC and should not be initiated for this indication. Refer to Weight Management Prescribing of GLP1-RAs and GLP1-RAs/GIPs in Primary and Secondary Care – Non-Formulary Position Statement. 
• The NHSGGC guideline on initiation and management of GLP-1RA and other incretin mimetics in primary care has been updated to include tirzepatide for the management of type 2 diabetes. 

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GGC Medicines Update is a series of blogs with important medicines related messages relevant to all healthcare professionals across NHSGGC.

If you are a healthcare professional in NHSGGC and you would like to contribute to Medicines Update, we would love to hear from you.

To access the full blog via Microsoft Sway, click here

To access the full blog via Microsoft Sway, click here

• Glucocorticoid-induced adrenal insufficiency can occur upon cessation of prednisolone and cause adverse effects such as fatigue, weakness, and weight loss.

• A new NHSGGC guideline has been developed to minimise the risk of adrenal insufficiency when withdrawing prednisolone therapy in non-endocrine disease.

• The guideline is relevant to primary care and outpatient settings and is intended for use in:

• • Adult, non-pregnant patients who have received ≥5mg prednisolone daily for ≥4 weeks for a non-endocrine condition

  • Patients who have been on higher doses of prednisolone and have now titrated down to <5mg daily and no longer require prednisolone therapy

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