Prescribing UpdateCATHERINE ARMSTRONG – MAY 2014

Summary

Hot topics New inhalers NICE guidelines Drug shortages Updated BNF distribution schedules

Hot Topic: Domperidone

MHRA Alert – 25th April Small increased risk of potentially life-threatening effects on the heart ONLY for nausea and vomiting MAX 7 days treatment ADULT dose – 10mg TDS Check for QT prolongation meds and CYP3A4 inhibitors Review patients at next routine appointment

Hot Topic: Strontium

Restricted to severe osteoporosis …who cannot use any other treatments

Do NOT start in patients who have or had Ischaemic heart disease Peripheral arterial disease Cerebrovascular disease Uncontrolled hypertension

STOP if develop any of the above

New Inhalers

COPD Aclidinium bromide Glycopyrronium bromide Indacaterol + Glycopyrronium

Asthma Fluticasone furorate + vilanterol

Aclidinium bromide (Eklira Genuir®)

LAMA – 400micrograms/dose – TWICE daily for COPD ↑ effect on lung function vs placebo No robust evidence of benefit vs other LAMA options Device: multi-dose dry powder inhaler On some local formularies:

North of Tyne Gateshead ? South Tyneside Sunderland ? Durham&Darlington

Glycopyrronium bromide (Seebri Breezhaler®)

LAMA – 44micrograms/dose – ONCE daily for COPD ↑ effect on lung function, exercise endurance & patient outcomes vs placebo May provide more rapid bronchdilation than tiotropium Needs long term safety data & direct comparator trials Device = capsule based dry powder inhaler On some local formularies:

North of Tyne Gateshead ? South Tyneside Sunderland ? Durham&Darlington

Indacaterol + Glycopyrronium (Ultibro Breezhaler®

LABA+LAMA 85micrograms indacaterol + 43micrograms glycopyronnium

ONCE daily for COPD Device = capsule based dry powder inhaler ↑ lung function vs placebo, separates + fluticasone/salmeterol ↓ rate of exacerbations compared to glycopyronnium alone Not considered locally yet

Fluticasone furorate + vilanterol (Relvar®)

ICS+LABA – 2 strengths 92/22 & 184/22micrograms ONCE daily for asthma Superior to fluticasone furoate alone 92/22 comparable efficacy to fluticasone/salmeterol 250/50 BD CONCERNS re product – MHRA review Not considered locally yet

NICE Guidelines

CG171: Urinary Incontinence in Women Darifenacin, oxybutynin (IR) & tolteridone (IR) – 1st line

CG172: Myocardial Infarction – secondary prevention Omega 3 fatty acids – DO NOT RECOMMEND for 2ndry prevention of MI

CG173: Neuropathic Pain – pharmacological management Tramadol not for long-term neuropathic pain control Carbamazepine ONLY for trigeminal neuralgia

Drug Shortages - Valsartan

Intermittent supply problems – all strengths & forms May last several months

* Dose equivalences are approximate and individual responses may vary so BP should be monitored following the switch and dosing adjusted accordingly, if needed#Valsartan doses may be given as 2 divided doses depending on indication

Taken from NHS England Memo 10/3/2014: http://www.medicinesresources.nhs.uk/en/Communities/NHS/SPS-E-and-SE-England/Medicines-Information/Discontinuation-Supply-Shortage-Memos/Shortage-of-Valsartan-/

A2RA Approximate dose conversions *Valsartan 40mg daily# 80mg daily# 160mg daily# 320mg daily#Candesartan 4mg OD 8mg OD 16mg OD 16-32mg ODLosartan 25mg OD 50mg OD 100mg OD

Drug shortages – Piroxicam gel

Some supplies available NHS prices currenly based on Feldene® gel

60g = £6.00 (was £2.71) 112g = £9.41 (was £5.06)

Compared with Ibuprofen 5% gel £2.11 (50g), £4.22 (100g) Ibuprofen 10% gel £5.79 (100g)

Drug shortages - various

Clomipramine Branded product discontinued Cross-tapering with SSRIs, venlafaxine or duloxetine – specialist use only Example switch to imipramine:

Gradually reduce to 75mg/day, stop and start imipramine 50-100mg/day the next day

Co-amoxiclav Can be obtained – prices higher than usual 375mg £5.30/21 625mg £6.93/21 Use ONLY where clinically appropriate

Drug shortages – various (2)

Amiloride £19.10 per 28 Co-amilofruse 2.5/20 £4.32 per 28 5/40 £5.29 per 28 Co-tenidone 50/12.5 £5.18 per 28 100/25 £5.18

per 28

Is a potassium sparing diuretic needed? Avoid combination products where possible

Drug shortages – various (3)

Mebeverine 135mg tablets £17.50 per 100 Peppermint oil 0.2ml caps £7.04 per 84

Propranolol 10mg £5.30 (28) 40mg £4.10 (28) 80mg £6.44 (56) Consider alternative beta-blocker HF – bisoprolol, carvedilol and nebivolol = licensed options

BNF Distribution

From Sept 2013 edition – annually in PRINT Still updated every 6 months (print copy) Online/App versions updated monthly

Register for NHS Athens account: http://www.nice.org.uk/mpc/BritishNationalFormulary.jsp

Info regarding print distribution: http://www.nice.org.uk/mpc/BritishNationalFormulary.jsp

ALL GPs should receive annual PRINT copy to place of work Email BNF@binleys.com