1. Prescribing Update Catherine Armstrong Lead Pharmacist - Pharmicus

2. GMC – Good Practice in Prescribing & Managing Medicines and Devices Effective from 25.2.13 Must explain and justify decisions / actions YOU are responsible for any script you sign Several MUSTs and SHOULDs Full guidance available: http://www.gmc-uk.org/Prescribing_Guidance__2013__50955425.pdf

3. GMC – Unlicensed Medicines GMC recommends that GPs can prescribe unlicensed or “off license” medicines but, if you decide to do so, you must: Be satisfied that an alternative, licensed medicine would not meet the patient's needs Be satisfied that there is a sufficient evidence base and/or experience of using the medicine to demonstrate its safety and efficacy Take responsibility for prescribing the medicine and for overseeing the patient's care, including monitoring and any follow up treatment Record the medicine prescribed and, where you are not following common practice, the reasons for choosing this medicine in the patient's notes. (Code 8B2V)

4. Which are specials? Drug Paracetamol 120mg/5ml Paracetamol 250mg/5ml Paracetamol 500mg/5ml Morphine 10mg/5ml Morphine 20mg/5ml Morphine 20mg/1ml Average cost £1.12 per 200ml £1.30 per 200ml £73.76 per 200ml £1.78 per 100ml £689.57 per 420ml £4.98 per 30ml

5. Specials Is a liquid formulation needed? Is the drug readily available in a liquid form? Can another drug be substituted? e.g. fluoxetine liquid for sertraline tablets COST of licensed option is not a reason to avoid using

6. Controlled Drug Prescribing Form? Needs dose Not needed

7. Gastro-Intestinal Mucogel not Maalox Peptac not Gaviscon Advance – Can use Gaviscon Advance tablets for portability PPI – Omeprazole / Lansoprazole / Pantoprazole – Avoid Omeprazole 40mg – use 2x20mg – Consider C Diff risk

10. Domperidone Interaction Small increased risk of serious ventricular arrhythmia or sudden cardiac death Higher risk – Patients aged 60+ – Daily doses >30mg MHRA advice – Use lowest effective dose – Consider QT prolongation interacting meds

11. Metoclopramide Interaction August MHRA Drug Safety Update Contraindicated in <1 year old Restricted use/doses <18 years old Maximum of 30mg per day for 5 days in adults

12. MHRA Simvastatin Alert List of drugs contra-indicated with simvastatin List of drugs - maximum dose of simvastatin – Main action: amlodipine & diltiazem Primary Prevention – ↓ simvastatin 20mg Secondary prevention – depends on latest lipid profile Action at next review of patient

13. FATS6 - Secondary Prevention of CVD (symptomatic or prior occlusive vascular disease) Acute Coronary syndrome / Acute MI Initiate Atorvastatin 80mg All other conditions Simvastatin 40mg 1st-line (unless interactions) Repeat lipid profile 8 weekly and consider titration unless TC < 4mmol/l, LDL-C (fasting) < 2mmol, or non-HDL < 2.8mmol/l Titrate to Atorvastatin 40mg then 80mg

14. FATS6 - Type 1 and Type 2 diabetes Consider drug treatment in all Type 1 and 2 diabetics: with microalbuminuria/proteinuria (any age) over 40 years under 40 years if other CV risk factors present. Simvastatin 40mg 1st-line (unless interactions) Repeat lipid profile 8 weekly and consider titration unless TC < 4mmol/l, LDL-C (fasting) < 2mmol, or non-HDL < 2.8mmol/l Titrate to Atorvastatin 40mg then 80mg If Type 2 diabetes and triglycerides > 1.7 & < 10 mmol/l – lifestyle measures for 6 months then consider adding a fibrate (Fenofibrate 200mg daily, reduced doses in CKD)

15. FATS6 - Primary Prevention (no symptomatic or prior occlusive vascular disease) Treatment is based on risk and not cholesterol levels If 10 year CVD risk ≥ 20%, consider Simvastatin 40mg (reduce dose for drug interaction – more detail in full guidance)

16. FATS6 - Other points to note Consider familial hyperlipidaemia (FH) if TC > 7.5mmol/l, LDL cholesterol > 4.9 Suspected FH if triglycerides > 4.5mmol/l If triglycerides > 10mmol/l, seek specialist advice Simvastatin 80mg Prescribing of Simvastatin 80mg is no longer recommended due to risk of myopathy. Review patients taking Simvastatin 80mg their next routine appointment.

17. Dual Antiplatelet Therapy Aspirin 75mg daily STEMINSTEMIUNSTABLE ANGINA EITHERINVASIVE THERAPY TICAGRELOR 90MG BD FOR 12 MONTHS ORINVASIVE NOT SUITABLE PRASUGREL 5MG OR 10MG OD FOR 12 MONTHS CLOPIDOGREL 75MG OD FOR 12 MONTHS

18. Respiratory Beclometasone inhalers – BRAND Consider combinations 2 new COPD inhalers Consider quantities when reviewing

19. Pregabalin Avoid more than 1 capsule per dose QDS is not licensed, use maximum of TDS Each capsule/strength priced the same - £1.15 Most popular “street” drug abused

20. Paracetamol doses 120MG/5ML AGEDOSE 3-6M2.5ML 6-24M5ML 2-4Y7.5ML 4-6Y10ML ALL UP TO QDS 250MG/5ML AGEDOSE 6-8Y5ML 8-10Y7.5ML 10-12Y10ML ALL UP TO QDS Do NOT use in under 6yrs

21. Antibiotics “Preferred” antibiotics: AmoxicillinNitrofurantoin ClarithromycinOxytetracycline DoxycyclinePenicillin V Flucloxacillin Trimethoprim Metronidazole(Erythromycin) Aim for 85% of prescribing to be these Linezolid = HOSPITAL PRESCRIBING ONLY

22. C Diff THINK – Patient - aged 65+, frequent Abx, recent Abx – Environment – contact, hospital admission, institutionalised – Action – avoid high risk: cephalosporins, ciprofloxacin/quinolones, clindamycin, co- amoxiclav TEST TREAT

23. Role of 4C antibiotics on local guidelines Sinusitis – 1 st = amoxicillin, 2 nd = doxycycline – Co-amoxiclav 625mg tds x21 for persistant symptoms only COPD exacerbation – 1 st – amoxicilllin, 2 nd = doxycycline – Co-amoxiclav 625mg tds x15 if resistant risk factors Prostatitis  Ciprofloxacin 500mg BD x56 Cellulitis/Wounds – 1 st = flucloxacillin, 2 nd = clarithromycin – Co-amoxiclav 625mg tds x21 only if facial involvement Human/Animal Bites  Co-amoxiclav 625mg tds x21 Pyelonephritis  Co-amoxiclav 625mg tds x42  Ciprofloxacin 500mg bd x14

24. Minocycline No clear evidence better than alternatives Safety concerns + monitoring Higher cost: Minocycline 100mg M/R caps OD£10.04Doxycycline 100mg caps OD£3.92 Minocycline 100mg caps OD£13.09Lymecycline 408mg caps OD£6.22 Minocycline 100mg tabs OD£13.72Erythromycin 250mg tabs 2BD£7.96 Minocycline 50mg caps BD£15.27Oxytetracycline 250mg tabs 2BD£5.32 Minocycline 50mg tabs BD£11.4228 day courses (Drug Tariff August 2013)

25. Diabetic Drugs Prescribe all insulin by brand name Blood Glucose Testing advice – Type 1 - appropriate amounts – Type 2 - see local guidance – Consider latest DVLA advice also – local guidance under review as a result Insulin Passports – NPSA safety alert, all patients aged 18+ using insulin should have or have opted out

26. Bisphosphonates Alendronate or Risedronate 1 st line Strontium has VTE warning – Avoid if current/previous VTE – Avoid if temporary/permanent immobilisation

27. Prescribing Engagement Scheme MANDATORY - Review of repeat prescribing and dispensing systems AND engagement with Pharmicus / Medicines Optimisation support FINANCIAL – Collectively deliver financial balance for CCG ALL 3 AREASEmollient s – Gateshead Wound management1 st line antidepressants - Gateshead Strong opioid prescribing (morphine) Erectile Dysfunction Drugs – Newcastle Ezetimibe – Newcastle North & East LaxativesEffervescent analgesics – Newcastle West Venlafaxine MR caps to MR tabs – Newcastle West Specials – Newcastle North & East

28. Useful websites Gateshead Information Network www.ginportal.info North of Tyne Area Prescribing Committe www.northoftyneapc.nhs.uk Electronic Medicines Compendium www.medicines.org.uk Athens registration https://register.athensams.net/nhs/nhseng/ Medicines and Prescribing support from NICE http://www.nice.org.uk/mpc/index.jsp