Prescribing-Leads-Clinical-Update课件.ppt

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1、Prescribing Leads Clinical UpdateDecember2015Clinical UpdateNew&updatedguidelinesSignificanttrafficlightupdatesSignificantsafetyissuesOtherissuesFeedbackfrompracticesClinical GuidelinesManagement of dyspepsia and GORD-UPDATEDBasedonNICEDyspepsia&GORDguidelineandNICEsuspectedcancerguidelineAlarmsigna

2、lsandsignsarethemajordeterminantoftheneedforendoscopy,notageonitsown.Long-termuseofPPIsisassociatedwithhipfractures,hypomagnesaemiaandClostridiumdifficilePatientsonalong-termPPIforGORDshouldbeencouragedtolstep-downtothelowesteffectivedosetocontrolsymptoms,lcontinuetreatmentonawhenneededbasislstoptre

3、atmentPrescribing for oral thrush in babies&surface and ductal thrush in lactating women-UPDATEDGuidelinesupportstheuseofmiconazoleoralgelforinfants-itisthemosteffectiveproductfororalthrushbutisunlicensedinchildrenunder4monthsduetopotentialriskofchokingifnotcarefullyapplied.Ensurethegeldoesnotobstru

4、ctthethroatininfants(avoidapplicationtothebackofthethroatandsubdividedosesifnecessary).Useafterfeeds,carefullysmearingaroundthemouth.Nystatinislesseffectiveandoralfluconazolehasthepotentialforside-effects.Prescribing for oral thrush in babies&surface and ductal thrush in lactating women-UPDATEDTopre

5、ventre-infection,bothmotherandinfantneedtobetreatedsimultaneouslyevenifonlyoneshowsymptomsofthrush:Oral thrush in baby:treat baby for oral thrush+surface thrush in motherSurface thrush in mother:treat baby for oral thrush+surface thrush in motherDuctal thrush in mother+/-oral thrush in baby:treat ba

6、by for oral thrush+ductal and surface thrush in motherVarenicline prescribing advice-UPDATEDConcernshavebeenraisedaboutsuicidalthoughtsandbehaviourlinkedwiththeuseofvarenicline.Cliniciansshouldbeawareofthepossibleemergenceofanxiety,psychosis,moodswings,aggressivebehaviour,depression,suicidalideation

7、etc.Recentstudieshavenotshownthatsmokerswithpre-existingmentalhealthproblemsaremorevulnerabletoneuropsychiatricsideeffectsthanotherpatients.Varenicline prescribing advice-UPDATEDTherehavebeensomereportsofseriousCVeventsinpatientstakingvarenicline.ReviewslookingatriskhavebeenconflictingbuttheEMAhasco

8、ncludedthatthebenefitsasasmokingcessationmedicineoutweighanypotentialslightincreaseincardiovascularevents.PatientsshouldbeadvisedtoreportanyneworworseningCVsymptoms.Derbyshire medication and risk of falls guidance-UPDATEDReformattedtolistalldrugsalphabetically.Usefulfornon-medicalstafftohelpidentify

9、patientswhowarrantamedicationreviewduetoriskoffalls.Updatedversionwillbeonthewebsitesoon.Glaucoma guideline-UPDATEDTreatmentalgorithmsofcost-effectivechoiceswhichophthalmologistsshouldfollowfornewpatients.FirstlinepreparationsGREEN.OtherpreparationsBROWN.Notadvocatingchangingtherapyinstablepatientsu

10、nlessrecommendedbytheophthalmologist.Oral anticoagulation with warfarin guideline-UPDATEDOnlyminorchanges.On-goingdiscussionsonincludingguidanceforpatientswithsub-therapeuticINRswhomayrequireshort-term“bridging”therapywithLMWHShared-Care GuidelinesUpdated shared care guidelinesLiothyroninefortreatme

11、ntresistantdepressionnomajorchanges.LithiummonitoringalignedtoNICECG(every3monthsforthefirstyearandthenadjustedaccordingtolithiumlevelsandotherfactors),lithiumlevelsforbipolardisorderclarified.Significant traffic light updates:REDCyclosporin eye drops RED.Forseverekeratitisinadultswithdryeyes.NICETA

12、expectedDecember2015.Significant traffic light updates:GREENEdoxabanGREEN after specialist initiation as per NICE TA for DVT/PE and for stroke prevention in adults.IncludedintheAFresourcesbutnoadvantageovertheotherNOACs.Tizanidine-GREEN after specialist initiation following 4 month dose stabilisatio

13、n,assessment of response and monthly LFTs.UsedforspasticityassociatedwithMSorspinalcordinjurySignificant traffic light updates:GREENInsulin Abasaglar(insulin glargine biosimilar 100 units per ml)GREEN 1st line insulin glargine in new patients when indicated.BasedonLantusbuttherapeuticeffectisnotiden

14、tical.Around15%cheaperthanLantus.NotrecommendingroutineswitchesfromLantus.Insulinglargineshouldbeprescribedbybrandtoavoidconfusionandriskofunexpectedhypoglycaemiaifinadvertentlyswitched.Significant traffic light updates:BROWNDemeclocycline BROWN after specialist initiationUsedtotreatchronichyponatra

15、emiaassociatedwithSIADHsecondarytomalignantdiseasewherewaterrestrictionisineffective.NospecificdrugmonitoringrequirementsbutpatientswithSIADHshouldbeunderspecialistreview.Monitoringofserumsodiumlevelsshouldbespecifiedbythespecialist.N.B.rapidlydecreasinglevelscanbelifethreatening.Prescribingexpected

16、tobeverylow.Currentsupplyissuewithlicensedproduct.Significant traffic light updates:BROWNDulaglutideBROWNAnotheronceweeklyGLP1agonist,pricehasjustbeenreducedinpricetobeinlinewithexenatideMR.SamerecommendationasexenatideMRplianceissuesorpatientrequiresnursingteamtoadminister.Significant traffic light

17、 updates-BLACKInsulin glargine 300 units per ml(Toujeo)-BLACKNotbioequivalenttoLantusPotentialforconfusionduetodifferentstrengthEvolocumab BLACKHumanmonoclonalantibody,SCinjectionforhypercholesterolaemiaandFH.NICETAexpectedApril16Significant Safety UpdatesDrug safety Update Sep 15Proton Pump Inhibit

18、ors very low risk of subacute cutaneous lupus erythromatosus.SCLEisanon-scarringdermatosisthatcandevelopinsun-exposedareasaccompaniedbyarthralgia.DruginducedSCLEcanoccurweeks,monthsoryearsafterexposuretothedrug.Affectedpatientsshouldbeadvisedtoavoidexposuretosun-lightandstopPPIifpossible(andavoidfut

19、urePPItreatment).SymptomsusuallyresolvewithPPIwithdrawal.Topicalorsystemicsteroidsmayberequiredifsymptomsdontresolveafterafewweeksormonths.Drug safety Update Sep 15Yellow Card AppCanbeusedtoeasilyreportsuspectedadversedrugreactions.Canalsocreateawatchlistofmedicinesofinterestandreceiveregularupdates

20、andalerts.Drug safety Update Oct 15Mirabegron risk of severe hypertension and associated cerebrovascular and cardiac events.Mirabegronisabeta-3adrenoceptoragonistusedinover-activebladdersyndrome.Alreadyknownthatmirabegroncanincreasebloodpressure,butcasesofseverehypertensionhavebeenreportedincludingr

21、eportsofTIAorstroke.Mirabegronisnowcontra-indicatedinpatientswithuncontrolledhypertension(systolic180ordiastolic110orboth).Usewithcautioninpatientswithstage2hypertension(systolic160ordiastolic100)Drug safety Update Oct 15Bloodpressureshouldbemeasuredbeforestartingtreatmentandregularlyduringtreatment

22、,especiallyinpatientswithhypertension.ReminderthatinpatientstakingstronginhibitorsofcytochromeP450e.g.itraconazole,ketoconazole,ritonavirorclarithromycin,mirabegronisnotrecommendedifeGFRisbelow30ml/minanddoseshouldbereducedto25mgdailyofeGFR3089ml/minDrug safety Update Nov 15Crizotinib:riskofcardiacf

23、ailureVemurafenib:riskofpotentiationofradiationtoxicity.Other issuesJanssen OCP discontinuations in 2016Ovysmen,TrinovumandBinovumoralcontraceptivetabletswillbediscontinuedin2016.Thisplanneddiscontinuationisnotrelatedtoanysafety,qualityorefficacyissues.Ovysmenisonourformulary,butsameformulationasBre

24、vinor.MinimalprescribingofOvysmen.TriNovumandBinovum=ethinylestradiol35mcg+norethisteronephasicpreps.Nodirectalternatives,Synphaseinsamecategorybutnorethisteronedoseslightlydifferent.Verylittleprescribed.Advice on“quickstarting”hormonal contraception after use of ulipristal acetate 30mg(ellaOne)fore

25、mergency contraception(EC).In2010,theFSRHintroducedguidelinessupportingimmediatecommencement(“quickstart”)ofhormonalcontraceptionafteradministrationoforalemergencycontraception(levonorgestrolorulipristal).Concernshavebeenraisedthatquickstartingaprogesteronecontainingcontraceptiveafterulipristalemerg

26、encycontraceptivemayreduceeffectivenessofbothpreparations.Adviceisnowtowait5daysafterulipristalemergencycontraceptionbeforestartinglong-termhormonalcontraceptionandadvisebarriermethodsuntileffectivehormonalcontraceptivecoverhasbeenachieved(another2to9daysdependingonwhichlong-termhormonalcontraceptiv

27、eischosen).Haloperidol 5mg/ml injection supply issuesSupplyissuesexpectedforatleast12monthsPositionstatementcirculatedprovidesinfoonusinglevomepromazineasapossiblealternative.DCHSconsideringupdatingtheanticipatoryprescriptionsheet,atwhichpointMMTwillupdateJICautoconsultationsInthemeantime,ifhaloperi

28、dolnotavailable,levomepromazineinjectionmayneedtobeprescribedseparatelyandaddedtotheanticipatoryprescriptionsheetbyhand.LevomepromazineanddiamorphinearecompatibleinasyringedriverforothercombinationsadviceistocheckwithspecialistorPaulineLove.NOACsPositionstatementissued,summary:Increasing uptake of a

29、nticoagulation for AF patients is a national and local priority and current guidelines suggest that either warfarin or a NOAC can be considered based on clinical features and patient preferences.However,NOACs are expensive and it is vital that they are prescribed and taken correctly to make sure tha

30、t their potential benefits are realised.A clinician may choose to initiate dabigatran,rivaroxaban,apixaban or edoxaban for any patient within the NICE TA criteria if clinically appropriate.Warfarin remains a suitable first line oral anticoagulant in most patients.Annual drug costs of NOACsWarfarinap

31、prox42(plusmonitoring)Apixaban801.70Dabigatran801.78Edoxaban-766.50Rivaroxaban-657Annual spend on NOACs based on October data is 1.2mNoterivaroxabananddabigatranreducingpricetoapprox.600soon.Warfarin and NOAC item and spend trendNOAC resourcesTemplateAFpatientleafletNOACpatientleafletTreatmentalgori

32、thmMonitoringrequiredwithNOACsguideAF toolkit Keele UniversityNICEapprovedonlinetoolforhelpingtodecidewhichanticoagulanttochooseforstrokepreventioninAFThefirstpartallowsGPstoenterhealthinformationaboutaparticularpersonintotheonlinetool,whichthenprovidesindividualisedprescribingrecommendationsbasedon

33、theNICEguideline.ThesecondpartincorporatesNICEspatientdecisionaid,tohelphealthcareprofessionalssupportthepersonwithAFweighupthepossiblebenefits,harms,advantagesanddisadvantagesofdifferenttreatmentoptions.Medicines Waste Campaign-#dontjusttickthebox Newwastemedicinescampaigntohelptacklethe forecast 1

34、.6millionprescribingbudgetoverspend.Tailoredmessagestoaddressthedifferentissuesfacedbypatients,GPs,pharmacists,carehomesandcarers.ThefirstpartofthecampaignistargetingpatientsinGPpractices.Regularmediareleasesandnewsletterarticlesonthesubject,workingwithcolleaguesacrossthesystemandsocialmedia.Allprac

35、ticeswillbereceivedaletter,someinformationforprescribersandprescriptionclerkstohelpreducewastemedicinesandsomeposterstodisplayinyourpractice.JPEGswillbeavailableforpracticestouseontheircustomerinformationscreens.Pullupbannerswhichcanusedinpractices.Waste campaign posters please display them in your

36、practicePrescribing interval guidance&Compliance Aid position statementGuidanceonprescribingintervaldiscussedatPSG.28daysoftengivesthebestbalancebetweensafety,convenienceandminimisingwaste,butisanindividualprescriberdecisionandtimeswhenashorterorlongerprescriptionlengthisappropriatelPatientswhopaypr

37、escriptionchargesmaywarrantlongerprescriptionlengths(butrememberpre-paymentcertificates)lPatientsatriskofoverdosing,frequentlychangingdosesorstabilityissuesmaywarrantshorterprescriptionlengths.lSchedule2,3and4controlleddrugsshouldbelimitedto30dayssupply.Prescribing interval guidance&Compliance Aid p

38、osition statementRegardlessoftheprescriptionsupplylengthdeemedsuitable,considerthefollowingpracticalissues:lEnsureprescriptionsupplylengthsarethesameforanindividualpatient(usually7,28or56days)tominimiseinadvertentover-ordering.Inparticularavoidmixing28and56dayprescriptionlengths.lItemsrequiredonlyoc

39、casionallyshouldnotgenerallybeplacedonrepeatunlessthereisongoingneed.Ensurethequantityprescribedissufficienttocovertheprescriptionsupplylength,butnotexcessive.lEnsuretheissuedurationisenteredcorrectlyontherepeattemplateandisinlinewiththequantitytobeissuedtoensuresystemstoalerttooverandunderorderingw

40、orkproperly.Prescribing interval guidance&Compliance Aid position statementForpatientswhorequireaMCA,providing7dayscriptsisatthediscretionoftheprescriberandisnotamethodoffundingMCAs.7dayscriptswouldberequirediftherearepharmaceuticalorclinicalissueswithalongerprescriptionlengthe.g.stabilityissues,ris

41、kofoverdose,rapidlychangingdoses.7dayscriptsshouldbedeliveredtothepatientonaweeklybasis.PatientsassessedbytheCPasneedinganMCAwithnoclinicalorpharmaceuticalissuesshouldbeprovidedfreeofchargeona28dayprescription.SystmOne recording allergies best practice documentKeypointisalsotoaddspecificcommentsabou

42、tthenatureofthereaction.ThiswillshowonthepatienthomescreenandtheSCRandcanhelpotherprescribersassessthelevelofrisk.RaisingatSystmOneandEMISwebusergroupstoseparateallergiesandadversereactions.Reporting prescribing concerns to CRHFT GP portalDirectreportingfunctionontheirCRHFTwebsitethatpracticescanuse

43、toreportanynon-urgentCRHFTissuerelatedtomedicinesorprescribingdirecttoMartinShepherd,ChiefPharmacist.ThewebsiteaddressisThistakesyoutotheGPloginsectionofthewebsite.Tologintothewebsite:lusername=gpuserlpassword=mozartThenclickon“prescribingconcern”inthelefthandlistandthenclickonthe“emailformtemplate”

44、.ThiswillopenupanautomaticemailwhichtheGPorpracticemembercancompleteandsenddirecttoMartinShepherdatCRHFT.Iaccountcanincludepatientdata.BNF paper editions some errorsOnlineversionisupdatedregularlyPaperversion,nowsuppliedannually.SignificantchangesforthisversionListoferrorspublishedCanprintofflistfromwebsite(theywillnotbesendingprintedamendmentsheets)Wewillcirculatetheamendmentlistpracticestoconsiderhowtheyusethesee.g.printoffandstickinallpracticeBNFsoruseonlineversion