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Nov 11 • Issue 31

Sodium chloride 5% eye drops previously only available as an

Antiplatelets updated: at a ‘stroke’! :

often very costly ‘special’, are now a CE registered medical device (listed in part IXA of the Drug Tariff as an appliance) at £25.25 for a 10ml bottle from Alissa Healthcare. Prescriptions claims for other manufacturer’s products will NOT now be allowed.

‘Zero’ cost options: Cost effective emollient recommendations: Zerobase (instead of Diprobase Cream) and Zerocream (instead of E45).

Yasmin: consider V (venous thrombotic risk) T (tolerability) E (expense) ► Yasmin costs 2 - 10 x more than most other oral contraceptives (COC) and accounts for nearly HALF the annual spend on standard strength COCs. ► Which raises the question … WHY? As Yasmin was: ● rejected by SMC (economic case not sufficiently robust), ● has no efficacy advantage over other COCs and ● at best only a slight tolerability advantage (in ADR-related discontinuations), ● Recent data suggests Yasmin VTE risk (drospirenone-containing pills): o is higher than that of levonorgestrelcontaining ‘second generation’ pills (e.g. Logynon, Microgynon 30 & Rigevidon) and o may be similar to that of ‘thirdgeneration’ pills that contain desogestrel or gestodene (e.g. Femodene, Femodette, Marvelon, Mercilon & Gedarel 20/150 & 30/150). VTE risk of all COCs remains very small and less than for pregnancy. Bottom line: MHRA (Drug Safety Update Jun 11) advise levonorgestrelcontaining COCs have the lowest thrombotic risk and are the safest option for COC initiation/switching. Yasmin is an expensive option which should NOT be routinely prescribed.

Notes: ● Prescribe clopidogrel generically; ● Patients on combination aspirin + dipyridamole prior to guideline publication have the option to continue therapy until they/their clinician consider it appropriate to stop; ●Treatment for ischaemic stroke & TIA is no longer limited to 2 years’ duration from the most recent event. Stroke due to underlying AF: This guidance does not relate to a stroke associated with atrial fibrillation. For these patients a CHADS2 score should be done and warfarin initiated if appropriate.

Aspirin is no longer recommended for primary CV prevention. Action: Consider switching patients on dipyridamole + aspirin for stroke to clopidogrel.

More Webbed Wonders: 1) European Antibiotic Awareness Day (18.11.11) – lots of very useful resources to promote prudent antibiotic use: nsandstatistics/Publications/Public ationsPolicyAndGuidance/DH_130 267 2) Map of Medicine now available on NHS Choices: with the tagline: ‘See what your doctor can see with Map of Medicine Healthguides’: http://healthguides.mapofmedicine .com/choices/map/index.html 3) one stop online resource for Royal Pharmaceutical Society pharmacy - based health campaigns e.g. New Medicines Service, Chlamydia, counterfeit medicines & lung cancer awareness (also includes useful information on medicines, pharmacy and pharmacists in GB): HP_ipharmacist_logo_large 4) is a selfhelp website for patients with functional & dissociative neurological symptoms (which are surprisingly common, but as they are not caused by neurological disease can be difficult for both patients and health professionals to understand). The site includes web links, downloads & patient stories: 5) Puff-o-meter: is a simple free iPhone app designed to allow patients to keep a track of how many puffs are left in their corticosteroid inhaler (pMDI): puff-o-meter/. 6) Tools for Practice: Alberta College of Family Physicians provide brief focused reviews of the evidence base for common clinical questions, put into context and summarized as a bottom-line:

NICE’s finger on the pulse…updated hypertension guidelines (CG127 Aug 11) Significant changes: ● Ambulatory blood pressure monitoring preferred for diagnosis confirmation (clinic blood pressure ≥ 140/90). ● Role of thiazide diuretics reduced and chlortalidone (12.5–25 mg once daily)* or indapamide** (1.5mg modified-release or 2.5 mg once daily) preferred to bendroflumethiazide or hydrochlorothiazide (on evidence base). NB If BP stable & well controlled with current thiazide therapy it may be continued. ● Combined ACEi + ARB should NOT be used for hypertension. [*Chlorthalidone is only available in UK as 50mg strength tablet, requiring halving or quartering of tablets to give the recommended dose - may be difficult and would not guarantee a consistent daily dose. ** 1.5mg MR tabs are more costly than 2.5mg plain tabs.]

Aged under 55 years

Aged over 55 years or black person of African or Caribbean family origin of any age C2


Summary of antihypertensive drug treatment Step 1

A + C2

Step 2

A+C +D

Step 3

Resistant hypertension

Step 4

Key A – ACE inhibitor or low-cost angiotensin II receptor blocker (ARB)1 C – Calcium-channel blocker (CCB) D – Thiazide-like diuretic

A + C + D + consider further diuretic3, 4 or alpha- or beta-blocker5 Consider seeking expert advice

See slide notes for details of footnotes 1-5

1. E.g. generic losartan. 2. A CCB is preferred but consider a thiazide-like diuretic if a CCB is not tolerated or the person has oedema, evidence of heart failure or a 4 high risk of heart failure. 3. Consider a low dose of spironolactone or higher doses of a thiazide-like diuretic. 4. Spironolactone is not licensed for this indication. Obtain & document patient consent. 5. Consider an alpha- or betablocker if further diuretic therapy is not tolerated, contraindicated or ineffective.

Local shared care guidelines updated: ►The latest batch of SWY APC shared care guidelines (SCGs) have now been added to the website ( delines/APC/Red_Amber_Green/Re d_Amber_Green_List.htm). ►The new SCGs are: ●Azathioprine ●Ciclosporin ●Hydroxychloroquine ●Leflunomide ●Methotrexate ●Modafinil ●Mycophenolate ●Penicillamine Sodium Aurothiomalate IM ●Sulfasalazine EC ►Reminder: all requests for transfer to shared care arrangements should be in writing by the consultant concerned and include a copy of the SCG. There is no obligation on the GP to accept such requests.

Lipotrim: ●Very low calorie diets (VLCD) such as Lipotrim are offered by a range of private organisations. ●GPs/community pharmacists can be involved in terms of patient selection & monitoring but: ●Lipotrim (& similar products) should NOT be prescribed at NHS expense.

Neuropathic pain …NICE to have a change of heart! NICE is consulting on proposed changes to some of the recommendations made in its neuropathic pain clinical guideline (CG 96 Mar 10) including a switch of first line treatment from pregabalin to gabapentin (due to concern about excess costs pregabalin may bring to the NHS).

Produced by NHS Kirklees Medicines Management & Prescribing Team. This newsletter is available to download from the intranet: