Newcastle North & East and Newcastle West Update October 2014

North of Tyne APC update

Guidelines approved:

  • Guideline for management of erectile dysfunction in adults ≥ 18 years
  • Guidelines for the use of feminising hormone therapy in gender dysphoria
  • Newcastle, North Tyneside and Northumberland Guidelines for the Management of Adults with Asyptomatic Liver Function Abnormalities
  • Seven Day prescriptions
  • Guidelines for the management of Patients with Swallowing Difficulties

Information leaflets for primary care  approved :

  • Buccal Midazolam (Midazolam Hydrochloride 5mg/ml) – Buccolam®
  • Buccal Midazolam (Midazolam maleate 10mg/ml) – Epistatus®

Shared Care Guidelines  approved:

  • Vigabatran

Requests for Riamixin

Recently, there have been a number of reports of GPs being asked by secondary care to prescribe Rifaximin. This is a RED drug in the North of Tyne formulary for use in the treatment of persistent hepatic encephalopathy where lactulose and neomycin have failed or are unsuitable.

Red drugs are for hospital use only and GPs should not be asked to prescribe them. You can check the formulary status of drugs in the North of Tyne Formulary at http://www.northoftyneapc.nhs.uk/formulary/. If you are asked to prescribe a RED drug you should inform the requesting doctor that you are not willing to do so as it is RED and then report this as an interface issue via SIRMs.

 

Prescribing Engagement Scheme 2014/15 GP Peer Review Sessions

The Newcastle CCGs’ Prescribing Engagement Scheme for 2014/15 includes a mandatory indicator that a GP from each practice will attend a peer review session and produce a practice action plan detailing how the practice will achieve the targets included in the scheme. Each practice must fulfil this to qualify for the scheme.

The aims of this peer review session were to support the formation of a peer support network of practice prescribing leads – including sharing of contact details, practice resources and examples of good practice. We reviewed baseline prescribing data for each practice and compared with others in the CCG, discussed the prescribing engagement scheme indicators and ways to improve prescribing, and learned from each other’s experiences. The learning from this event can be used to inform the action plan outlining how the practice will achieve the targets included in the scheme.

We produced a resource pack with prescribing data, information and resources for each of the prescribing engagement scheme indicators which informed the discussions and is intended to be kept as a working document. These were circulated to the prescribing leads and practice managers prior to the meeting and further copies can be obtained from your practice pharmacist or the medicines optimisation team.

The peer review sessions for both Newcastle North and East CCG and Newcastle West CCG have now taken place, on September 2nd 2014 and October 9th 2014 respectively, at the end of each CCG’s Educational time out events.

The sessions were very well received and we had almost 100% attendance. During the sessions we split into 4 groups and within these discussed the Prescribing Engagement Scheme indicators and fed back the main action points to the whole group. Everyone was extremely engaged and the discussions were very constructive, interactive and supportive. A summary of all the action points from each session is being sent to the prescribing leads (or GP representative) and practice managers.

The feedback was overwhelmingly positive and indicated that it was actually GPs getting together to share one another’s ideas and experiences that was most useful. Based on this positive experience and feedback we are planning to another similar session in the new year.

North of Tyne Area Prescribing Committee

Summary of decisions relevant to Primary Care made at the September APC meeting

Product Decision Comments/notes
Approved Refused Deferred
 

Tocilizumab 162mg subcutaneous injection

(RoActemra®)

 

 

 

R

 

 

Tocilizumab subcutaneous injection (SC) has recently been licensed for rheumatoid arthritis. The SC preparation has the advantage of being able to be self-administered, and therefore potentially delivered via Homecare arrangements. The application was previously clinically approvedbut an impact assessment for CCGs was requested prior to commencement of service.

Decision: Approved

The request for Tocilizumab s/c was approved for use in rheumatoid arthritis in line with the IV approval NICE TA 247.

 

Tocofersolan 50mg/ml oral solution (Vedrop ®) Tocofersolan oral solution has been requested to treat vitamin E deficiency in children due to fat malabsorption syndromes.

Decision: Approved

The request for tocofersolan was approved for the treatment of vitamin E deficiency in children due to fat malabsorption syndromes. Treatment is to be initiated by specialists .

Brimonidine 0.33% gel (Mirvaso®) Brimonidine gel has been requested for the treatment of moderate to severe persistent erythema of rosacea, which is catergorised as causing psychological or social distress.

Decision: Approved

The request for Brimonidine was approved for specialist initiation for the treatment of severe rosacea. Following specialist review of effectiveness, primary care can continue supply.

Movicol liquid Movicol liquid was requested for care home patients on multiple oral laxatives who have poor compliance and require enemas to alleviate constipation. It was previously felt there was not sufficient advantage over Laxido sachets to justify a 30% cost increase however additional data was presented on appeal.

Decision: Approved

The request for Movicol liquid was approved as a second line macrogol laxative for care home residents only where the sachet formulation is not tolerated.

Community Matrons are requested to provide audit data regarding admissions avoidance due to constipation to a future MGUG meeting.

TA 317 Acute coronary syndrome – prasugrel with PCI (review of TA182)    noted The formulary will reflect the NICE position
TA 318 Lubiprostone for treating chronic idiopathic constipation noted The formulary will reflect the NICE position
Melatonin review See notes The review recommended the use of three products

–           Melatonin 2mg MR tablets – first line

–           Melatonin 2mg MR tablets (crushed) – second line

–           Melatonin 5mg/5ml oral solution – third line.

Decision: Approved

The formulary will be amended to include the above three formulations of melatonin as the only formulations approved North of Tyne.

The Blue leaflet will be revised.

Ropinirole for the treatment of restless legs syndrome Rotigotine is on the formulary as a second line agent for restless legs syndrome, however there is no specified first line agent. Ropinirole is recommended for the treatment of restless legs syndrome by CKS, therefore the committee agreed to add ropinirole to the formulary as the first line agent for this indication, and update the blue information leaflet accordingly.

 

Management of acute otitis externa

It is important to exclude an underlying chronic otitis media before treatment is commenced. Many cases recover after thorough cleansing of the external ear canal by suction or dry mopping.

Cure rates are similar at 7 days for topical acetic acid or antibiotic +/- steroid.

If cellulitis or disease extending outside ear canal start oral antibiotics +/- steroid.

Treatment

First line: Acetic acid 2% spray (Ear-calm®) 1 spray TDS for 7 days and analgesia

*For patients who pay for prescriptions Ear-calm® spray is available to purchase from pharmacies for less than a prescription charge.

Alternative: Neomycin sulfate with corticosteroid drops (Betnesol N® or Predsol N®) 3 drops TDS for a minimum of 7 days; maximum 14 days. Note: This is contraindicated if the tympanic membrane is perforated. Topical aminoglycoside ear drops are ototoxic in people with a perforated tympanic membrane, and that the changes are permanent (CMS 1997).

Or Otomize® spray (neomycin sulfate with dexamethasone) 1 spray TDS

Availability of some specific products for Oititis externa:

– Otosporin was discontinued. However, it is currently on the North of Tyne formulary guidelines.

– Locorten Vioform ear drops have been discontinued as a brand, but are available as a generic product. Therefore, must be prescribed generically to obtain this product.

– Gentisone has had supply problems previously, and in light of the changes to the above products, this may have affected current availability.

Management of acute otitis externa includes:

  • Assessing the severity of symptoms (e.g. pain, itch, hearing loss, and ear discharge).
  • Removing or treating any aggravating or precipitating factors (such as diabetes, dermatitis, and trauma to the ear).
  • Offering paracetamol or ibuprofen for symptomatic relief (with codeine for severe pain).
  • Treating infection, if necessary, usually with a topical preparation.
  • Considering the need for investigations. Investigations are rarely useful but may be necessary if symptoms are persistent or recurrent.
  • Providing appropriate self-care advice to aid recovery and reduce risk of recurrence (e.g. keeping the ears dry and clean, avoiding the use of cotton buds, treating generalized skin conditions such as eczema).

For further information refer to NICE Clinical Knowledge Summaries: Otitis externa

 

Brief Decision Aid – Atrial fibrillation (non-valvular) and reducing the risk of a stroke

This Brief Decision Aid (BDA) was developed from work started as part of The Health Foundation supported MAGIC shared decision making (SDM) programme. BDAs are now produced by Newcastle with Patient.co.uk.

This has been developed by Dave Tomson (GP, NHS North Tyneside CCG)and Shirley Simpson (Medicines Optimisation Pharmacist, NECS), reviewed by Jane Skinner (Consultant Cardiologist NuTH) and John Bourke (Consultant Cardiologist NuTH), and in collaboration with Newcastle University.

It is shorter than the recently published NICE guideline PDA and more comprehensive than then current Option Grid. Both of these are useful, this BDA may be more helpful for clinicians and patients trying to make a decision together that is right for the patient.

This BDA includes the benefits, risks and consequences of the main evidence-based options. It encourages the patient and doctor (or nurse) to make a decision together whether to take any form of anticoagulant after a diagnosis of non valvular atrial fibrillation, taking account of what is important to the patient. In particular the BDA allows the clinician to give the patient a personalised risk score, and lays out the information in a way that ‘makes sense’ for patients and clinicians. Using the CHA2DS2-Vasc score (to estimate the risk of having a stroke) and the HAS-BLED score (to calculate the risk of bleeding), the baseline risks can be explained to the patient and an informed decision reached.

The atrial fibrillation BDA will be available on patient.co.uk shortly. Until then, you can access it via the medicines optimisation website, along with instructions for using the BDA, a Stroke Risk chart – for non valvular atrial fibrillation, and a NOACs checklist.

 

CKD Guideline and Guideline for the Acute Treatment of Hyperkalaemia

The North of Tyne Chronic Kidney Disease Guideline and Hyperkalaemia Guideline were due for review and updating. Following advice from Dr Alison Brown, Consultant Nephrologist at Newcastle upon Tyne Hospitals, we will no longer have North of Tyne guidelines. Instead there will be a link to relevant national guidance placed on appropriate websites (North of Tyne APC, Medicines Optimisation website and CCG).

The recent NICE clinical guideline 182 Chronic kidney disease: early identification and management of chronic kidney disease in adults in primary and secondary care (July 2014) are comprehensive and include all relevant aspects of primary care management of CKD. Specifically, the new and updated areas include:

  • identification and investigation of people who have or are at risk of developing CKD
  • classification of CKD and identification of people at risk of CKD complications and progression
  • the definition of CKD progression
  • the relationship between acute kidney injury and CKD
  • self-management of CKD
  • pharmacotherapy for CKD

As the disease carries no symptoms it can often be hard to recognise, leading to late presentation. In addition, the way CKD has been previously classified has raised concerns that it may have been over diagnosed in the past. NICE now recommends that CKD should be classified using a combination of glomerular filtration rate (GFR) and albumin:creatinine ratios (ACR) categories.

NICE recommends that testing for CKD using eGFR, creatinine and ACR should be offered to people with certain risk factors, which include acute kidney injury, diabetes, hypertension, heart disease; patients who have had acute kidney injury should be warned that they are at increased risk of developing CKD and should be monitored for at least 2-3 years after the AKI, even if serum creatinine has returned to normal levels.

NICE now recommends starting a statin (atorvastatin 20 mg) for the primary or secondary prevention of CVD to people with CKD, in line with the NICE guidance Lipid modification (2014).

The NICE Clinical Knowledge Summaries (CKS) topic Chronic Kidney Disease which was updated in October 2014 is based on the updated NICE guidance covers the identification and management of chronic kidney disease in adults in primary care.

For the acute treatment of hyperkalaemia, clinicians should refer to the Renal Association hyperkalaemia guidelines.