1. Prescribing Update CATHERINE ARMSTRONG – MAY 2014

2. Summary  Hot topics  New inhalers  NICE guidelines  Drug shortages  Updated BNF distribution schedules

3. Hot Topic: Domperidone  MHRA Alert – 25 th 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

4. 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

5. New Inhalers  COPD  Aclidinium bromide  Glycopyrronium bromide  Indacaterol + Glycopyrronium  Asthma  Fluticasone furorate + vilanterol

6. 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

7. 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

8. 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

9. 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

10. NICE Guidelines  CG171: Urinary Incontinence in Women  Darifenacin, oxybutynin (IR) & tolteridone (IR) – 1 st 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

11. 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 * Valsartan40mg daily#80mg daily#160mg daily#320mg daily# Candesartan4mg OD8mg OD16mg OD16-32mg OD Losartan25mg OD50mg OD100mg OD

12. 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)

13. 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

14. Drug shortages – various (2)  Amiloride£19.10 per 28  Co-amilofruse2.5/20 £4.32 per 285/40 £5.29 per 28  Co-tenidone50/12.5 £5.18 per 28100/25 £5.18 per 28  Is a potassium sparing diuretic needed?  Avoid combination products where possible

15. Drug shortages – various (3)  Mebeverine135mg 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

16. 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