1. Specials November Update
Medicines Optimisation Forum

2. Specials Total Spend (£s)

4. Spend on Melatonin alone…
This equates to over £70,000 per annum

7. Other High Cost Specials
In some cases such as 6MP, NaCL high strength nebules, Mexilitene, Phenobarb and Nefazodone a special may be unavoidable. However, a licensed alternative exists for Midazolam, Mag Glycerophos, Levomeprom and Topiramate.

8. Colecalciferol Specials
There is now an extensive range of licensed Vit D products available, thus very little rationale exists for prescribing of this product in an unlicensed manner.

9. Fosfomycin 3g granules for oral solution are now a licensed product from August 1st
Launched for the treatment of acute uncomplicated lower urinary tract infections in adults and for periprocedural prophylaxis in transurethral procedures.
It is now classed as a green drug, but must only be prescribed following sensitivities
A single 3g dose is to be taken on an empty stomach. The capsule remains a special (unlicensed drug).
Please ensure that it is prescribed as the brand Monuril®, and not as Fosfomycin 3G Sachets. This is because the price varies between companies that produce it and could be anything between £4.86 for Monuril® and £75.45 for the Amco product.

10. Co-proxamol prescribing
Following safety concerns (CSM Jan 2005) relating to therapeutic use, abuse potential and a lack of evidence of efficacy, Co-proxamol was withdrawn from the UK market over a phased period between 2005 and However, prescribing is still occurring for a number of patients in the CCG.
Safety concerns:
Co-proxamol is an analgesic, containing a sub-therapeutic dose of paracetamol (325mg) and dextropropoxyphene 32.5mg.
It should not be used for acute pain indications.
Even at normal therapeutic doses, the dextropropoxyphene component has serious effects on the heart resulting in prolongation of the PR & QT intervals and widening QRS complexes.
Co- proxamol related deaths are usually due to the toxic effects of dextropropoxyphene on respiration or cardiac function.
Co-proxamol is contraindicated in alcohol-dependent patients, patients who are likely to consume alcohol whilst taking co-proxamol & in patients who are suicidal or have a history of addiction.
Death from overdose may occur rapidly, even at a relatively low dose.
Alcohol and other CNS depressants potentiate the effects of co-proxamol.
The risk of dying after co-proxamol overdose was
2.3x greater than from tricyclics and 28.1x greater than paracetamol.
Treatment of dextropropoxyphene overdose is complex and due to its long duration of action patients need to be monitored for a long period.
Apart from the safety concerns, there has been a significant increase in the cost of co-proxamol following its removal from the Drug Tariff and is now sourced as an unlicensed “special,” with no set price (prices in excess of £300/ 100 tablets are not unusual).

11. Prescribers are asked to:
Carry out a review of patients still being prescribed co-proxamol with a view to switch them to an alternative pain management regime, if an analgesic is still needed.
Remember co-proxamol should not be used for acute pain indications.
Document clinical reason(s) for continuing to prescribe co-proxamol and efforts made to switch to suitable alternatives.
Highlight co-proxamol’s potential for serious cardiac side-effects, even at therapeutic doses, and make patient aware of the symptoms and what to do if they experience any of them.