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Medicines Management Team at the CCG.
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January - March 2017

Prescribing Newsletter - Brighton and Hove CCG 

This newsletter is produced by the Medicines Management Team at the CCG, and is sent to all local GPs, Practice Nurses and Community Pharmacists. We would welcome any feedback on the content and usefulness of the newsletter and suggestions for future topics.
With many thanks to neighbouring CCGs and organisations who may have contributed material.
In this edition:
Oral Nutrition Support Guidelines GO LIVE
The Oral Nutrition Support Guidelines are now approved and can be found in chapter 9 of the formulary (nutrition and blood). 
The guidelines include a leaflet you can print out to give to your patients as first line dietary advice called  ‘Food as Treatment’.
They also now include a care pathway, detailing which nutritional supplements can be prescribed as 1st line treatment and which are only to be prescribed on dietitian recommendation.
If you have any questions about how to use these guidelines or would like to arrange a training session please e-mail David Broadbent-Advanced Dietitian, prescribing support

Stoma Care Pilot Project

High stoma care product usage can be a sign that patients are experiencing problems such as sore skin or leakage.  This can significantly impact upon a patient’s quality of life and has cost implications for the NHS.  As part of the BHCCG Stoma Care Pilot Project, the Stoma Care Clinical Nurse Specialist was asked to review a lady who had been identified by a CCG Pharmaceutical Advisor as using higher than expected amounts of closed pouches. 

For six years this lady had experienced daily to weekly leakage problems from her stoma pouch.  She thought this was normal; it is not.   On examination the lady was cutting the pouch too small.  A simple intervention to ensure pouches were cut to the correct template has reduced the risk of leakage significantly and saved up to £529 per year.  

This demonstrates that pharmaceutical advisors/GP surgeries identifying patients with higher than expected usage can help identify problems which a Stoma Care Clinical Nurse Specialist may be able to resolve.  Advice on appropriate product usage can be obtained from or   

Feedback wanted
It is asked that when rejecting an OptimiseRx message, all prescribers use the "Reject/Overrule With Reason" button and provide meaningful justification why they did not accept the message or suggestion.  
The OptimiseRx profile of messages are constantly being reviewed and user feedback is crucial in ensuring that the messages add value to your prescribing whilst reducing alert fatigue.  
If you'd prefer, you could drop us an email (including a screenshot of the message) to give your feedback and we welcome any suggestions for improvement.    
Message from BSUH
Did you know...You can contact some specialties via email for non-urgent advice about patients already known to them. You should expect a response within three working days.
Please include clear patient details, including hospital number, and enough clinical information to avoid subsequent delay. Emails must be sent from an address if containing patient identifiable information.
Specialties offering non-urgent email advice:
Iron Preparations

The choice of iron preparations is based on cost and incidence of side effect. There is little difference in efficiency of absorption of iron between the different salts. Modified release preparations have no therapeutic advantage and the low incidence of side effects are related to the lower absorption of iron.

Ferrous fumarate 305mg capsules is the preferred oral iron product. Iron salts should be given orally until haemoglobin has reached reference range and then maintained for 3 months, to replenish iron stores before stopping.  
Iron preparation Content of ferrous iron Cost Therapeutic dose Monthly cost of therapeutic dose
Ferrous fumarate 305mg capsules 100mg £2.33 x 100 ONE capsule BD  £1.30
Ferrous fumarate 322mg tablets 105mg 95p x 28 ONE tablet BD  £1.90
Ferrous fumarate 210mg tablets 68mg £3.50 x 84 ONE tablet BD or TDS  £2.33 - £3.50
Ferrous sulphate 200mg tablets 65mg £2.23 x 28 ONE tablet TDS  £6.69
Ferrous gluconate 300mg 35mg £1.95 x 28 ONE tablet QDS  £7.80
Patients presenting with dental problems
The BMA have recently issued updated guidance for GPs on patients who present with dental problems or who are noted to have dental illness during treatment by the GP. In addition it includes guidance about patients who may present with a private dental prescription and who are requesting an NHS prescription or the recommendation of a drug by a dentist.
"Lost Prescriptions"
The use of EPS prevents prescriptions getting ‘lost’. When pharmacies or patients report missing prescriptions, please confirm they have checked the prescription tracker to identify where the EPS prescription is currently located. EPS prescriptions should not be re-issued until the tracker has been checked. 
Reduce the use of Trimethoprim
Mandatory surveillance of Escherichia coli blood stream infections has shown a rise nationally from 60.4 cases to 66.2 cases per 100,000 population from 2012-2015.
Due to this rise there will be a national focus on Escherichia coli bacteraemia over the next 2 years
The age group with the highest rates of E.coli bacteraemia in England were observed amongst the elderly (75 years and over).

The PHE enhanced data set reported to ARHAI 24-14 (01) for E coli BSI (including 3 months of data from 38 acute trusts Nov 2012-Jan 2013, reporting on 891 cases) stated;
50% of cases related to the urogenital tract, and in these 72% occurred in patients >65 years, and 64% of patients had reported at least one UTI in the previous 12 months.
It is clear a significant proportion of the rise may be due to patients being prescribed inappropriate antibiotics, resulting in relapsing infections. It is important that antimicrobial prescribing is appropriate and effective. However, there remains a difficult balance between the clinical management of UTIs and the empiric prescribing of broad-spectrum antimicrobials due to increasing resistance to narrow spectrum antibiotics which limits available treatment options. On-going mandatory surveillance continues to identify previous UTIs as a key risk factor.

The appropriate management and treatment of UTIs in primary care will be a key step in to help reduce the prevalence of E coli BSI.
There will now be a national drive to reduce the use of trimethoprim. Locally nitrofurantoin is the first line choice for empirical treatment of uncomplicated UTI in primary care, this is due to higher resistant rates associated with the use of trimethoprim.
Baseline practice level prescribing data comparing the use of trimethoprim to nitrofurantoin can be viewed on the link below. This information should be used to prompt review of current practice.
Was the use of trimethoprim appropriate?
Conjunctivitis in Children
An estimated 160,000 GP appointments could be freed up if schools stopped sending home children with infective conjunctivitis, according to the Royal College of General Practitioners. The RCGP says that cases of conjunctivitis are unintentionally ‘clogging up’ the GP appointments system because some schools are refusing to admit children with the condition unless they have a prescription for antibiotics - leaving many other patients struggling to see their family doctor or practice nurse. This goes against clinical guidance from Public Health England advising that treatment for conjunctivitis is only appropriate, and indeed necessary, in severe cases. The RCGP has written to OFSTED and also produced a poster that you may wish to display.
Unidentified non-medical prescriber prescription forms
NHS Prescription Services receives a substantial number of prescriptions from non-medical
prescribers. Non-medical prescribers are independent or supplementary prescribers and include
optometrists, pharmacists, physiotherapists, podiatrists, radiographers and dieticians.
Where these prescribers have not been registered with NHS Prescription Services at the practice they are issuing prescriptions from, a high volume of unidentified NMP prescribing results.  This then impacts on prescribing budgets and any clinical governance arrangements you have that rely on prescribing information.
To register NMPs at your practice you need to notify your authorised signatory (Primary Care
Support England (PCSE) and the NMP lead at Brighton and Hove CCG. They will submit a NMP
registration form to the NHS Prescription Services and all registration requests will be added to the their database within five working days of receipt. A link to the form is available at
From 1 April 2017, if the NHS Prescription Services are unable to identify the NMP from the prescriber details provided because the NMP isn’t registered, they will attribute the prescribing to the lead prescriber based on the practice code and address provided.
The Medicines and Healthcare products Regulatory Agency (MHRA) has published Drug Safety Update for:

January 2017 includes: 
Direct-acting antivirals to treat chronic hepatitis C: risk of interaction with vitamin K antagonists and changes in INR. INR should be monitored closely during treatment of chronic hepatitis C with direct-acting antivirals in patients also receiving vitamin K antagonists (eg, warfarin), because of possible changes in liver function during treatment.
Advice for healthcare professionals:
  • changes in liver function due to treatment with direct-acting antivirals for chronic hepatitis C infection may result in fluctuations of INR values in patients taking vitamin K antagonists
  • in these patients, INR should be monitored closely and, if necessary, anticoagulant therapy adjusted
Apremilast (Otezla ▼): risk of suicidal thoughts and behaviour There is an increased risk that some patients may experience psychiatric symptoms with apremilast, including depression and suicidal thoughts. Stop treatment if patients have new psychiatric symptoms or if existing symptoms worsen.
Advice for healthcare professionals:
  • apremilast is associated with an increased risk of psychiatric symptoms, including depression, suicidal thoughts, and suicidal behaviours
  • suicidal thoughts and behaviour, including completed suicide, have been reported in patients with or without a history of depression
  • carefully assess the benefits and risks of starting or continuing treatment in patients with a history of psychiatric symptoms, or in those who are taking other medicines likely to cause psychiatric symptoms
  • stop treatment if patients experience new psychiatric symptoms or if existing symptoms get worse
  • advise patients to inform a healthcare professional if they notice changes in their mood
In December 2016, the following letters were sent to relevant healthcare professionals: February 2017 includes:
Hyoscine butylbromide (Buscopan) injection: risk of serious adverse effects in patients with underlying cardiac disease Prescribing information has been updated to help to minimise the risk of serious adverse reactions in patients with cardiac disease.
Advice for healthcare professionals:
  • hyoscine butylbromide injection can cause serious adverse effects including tachycardia, hypotension, and anaphylaxis
  • these adverse effects can result in a fatal outcome in patients with underlying cardiac disease, such as those with heart failure, coronary heart disease, cardiac arrhythmia, or hypertension
  • hyoscine butylbromide injection should be used with caution in patients with cardiac disease
  • monitor these patients, and ensure that resuscitation equipment, and personnel who are trained how to use this equipment, are readily available
  • hyoscine butylbromide injection remains contraindicated in patients with tachycardia
In January 2017, letters were sent regarding:

Updates to the Joint Formulary and decisions made by the Brighton Area Prescribing Committee

The Brighton APC makes decisions concerning additions to the Joint Formulary. The following summarises decisions made by the APC in January 2017:  (The APC did not meet in December 2016.)

Denosumab: changed from BLUE to GREEN for the prevention of osteoporotic fractures in postmenopausal women.  Patients must satisfy NICE criteria TA204
 (Unable to comply with, intolerant to or where contraindication to alendronate and risedronate.)  The supporting information sheet has been updated to reflect the change in traffic light status.
Fortisip Bottle, Ensure Plus, Fortisip Compact, Fortijuice, Ensure Juice and Complan Shake: changed from BLUE to GREEN as part of the Oral Nutritional Supplements Care Pathway.  See article above.
Aymes Shake, Ensure Shake and Ensure Compact: added as GREEN as part of the Oral Nutritional Supplements Care Pathway (1st line choice for patients who require an oral nutritional supplement). See article above.
Toujeo: added as BLUE specialist initiation/recommendation only.  Suitable for patients with significant insulin resistance.
Tapentadol: REMOVED as local pain specialists agree very little usage. 
AAIs: removal of the 1st line preference against Jext 
Nivolumab: added as RED (specialist only) as per NICE TA417 

Dapagliflozin: added as GREEN for triple therapy for treating type 2 diabetes as per NICE TA418 
Apremilast: added as RED (specialist only) as per NICE TA419 
Ticagrelor: added as RED (specialist only) as per NICE TA420 
Everolimus: added as RED (specialist only) as per NICE TA421 
Crizotinib: added as RED (specialist only) as per NICE TA422 
Eribulin: added as RED (specialist only) as per NICE TA423 
Pertuzumab: added as RED (specialist only) as per NICE TA424 
Dasatinib, nilotinib and high-dose imatinib: added as RED (specialist only) as per NICE TA425 
Dasatinib, nilotinib and imatinib: added as RED (specialist only) as per NICE TA426 

Chapter 7 of the Brighton Joint Formulary was reviewed at the January 2017 meeting. (Obstetrics, gynaecology and urinary-tract disorders).  The main changes were to the contraceptives section.  All oral contraceptives are now listed generically with the locally preferred brand noted on the right hand side. Some of the preferred brands have changed and we expect these brands to be prescribed for all new patients.  Prescribing in this way will save money for the local NHS.   

7.3.1  Combined oral contraceptives (COCs)
The preferred brands have been chosen as they are available
from main wholesalers and are cost effective to the NHS (at the time of review).
ethinylestradiol and desogestrel
ethinylestradiol 20 micrograms and desogestrel 150 micrograms Tablets The preferred brand is Gedarel 20/150®
ethinylestradiol 30 micrograms and desogestrel 150 micrograms Tablets The preferred brand is Gedarel 30/150®
ethinylestradiol and drospirenone
ethinylestradiol 30 micrograms and drospirenone 3 mg Tablets The preferred brands are Yiznell® and Yacella® (available from May 2017)
ethinylestradiol and gestodene
ethinylestradiol 20 micrograms and gestodene 75 micrograms Tablets The preferred brand is Millinette 20®
ethinylestradiol and levonorgestrel
ethinylestradiol 30 micrograms and levonorgestrel 150 micrograms Tablets The preferred brand is Rigevidon®
ethinylestradiol and norethisterone
ethinylestradiol 35 micrograms and norethisterone 500 micrograms Tablets The preferred brand is Brevinor®
ethinylestradiol 20 micrograms and norethisterone 1 mg Tablets The preferred brand is Loestrin 20®
ethinylestradiol 30 micrograms and norethisterone 1.5 mg Tablets The preferred brand is Loestrin 30®
ethinylestradiol and norgestimate
ethinylestradiol 35 micrograms and norgestimate 250 micrograms Tablets The preferred brand is Lizinna®
Emergency hormonal contraception (EHC)
levonorgestrel 1.5mg Tablet  
ulipristal 30mg Tablet  
7.3.2  Progestogen-only contraceptives  Oral progestogen-only contraceptives
desogestrel 75 micrograms Tablets It is currently more cost effective for desogestrel to be prescribed generically.
levonorgestrel 30 micrograms Tablets The preferred brand is Norgeston®
norethisterone 350 micrograms Tablets The preferred brand is Noriday®
That's NICE...  

NICE Bites December 2016: Survey results 
NICE Bites January 2017: Low back pain and sciatica in over 16’s NICE NG59; 2016
NICE Bites February 2017: Antimicrobial stewardship: changing risk-related behaviours in the general population NICE NG63; 2017
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Although every effort is made to ensure this newsletter is accurate, the producers can accept no responsibility for errors or omissions in information provided by external organisations. Any opinions expressed are those of the editor/s and do not necessarily represent the opinions of Brighton and Hove Clinical Commissioning Group.
Copyright © 2017 Medicines Management Team, Brighton & Hove Clinical Commissioning Group, All rights reserved.

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