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Walsall Medicines of Limited Clinical Value Interactive Guidelines 2017

References

Vitamin D

Omega 3 fatty acids

Summary

Liothyronine

Lidocaine plasters Cough and cold remedies

Flexitol

Gluten Free

Eflornithine (Vaniqa®)

Doxazosin modified-release

Self-Care resources

Background Information Policy Aims

Please click on individual lines for guidance information

v1.4 (Feb 17)

Walsall CCG Policy Guidance MEDICINES OF LIMITED CLINICAL VALUE

Liothyronine

Cough and cold remedies

Flexitol

Gluten Free

Vitamin D

Lidocaine plasters

Omega 3 fatty acids

Eflornithine (Vaniqa®)

Doxazosin modified-release

Run as a slide show only. Clicking on the coloured boxes in the slides e.g. will direct you to the part of the guidelines that you have selected. Click on the “Return to start” box to return to the Front Page Use your mouse in the presentation Do not use the slide controls or return and back buttons as these will operate the normal PowerPoint actions.

Introduction These guidelines are intended to assist healthcare professionals when prescribing Medicines of Limited Clinical Value. They have been ratified by the Walsall Joint Medicines Management Committee (JMMC in February 2017.

These guidelines are based on the best available evidence but their application can always be modified by professional judgement.

Acknowledgments Many thanks to Dudley CCG, Sandwell and West Birmingham CCG and Wolverhampton CCG, in addition to all health care professionals and patient representatives who have inputted to and commented on this guideline.

Self-Care resources Return to start

Please click on individual lines for guidance information

Aims

References

Background

Summary

Walsall CCG advises that only treatments which are clinically effective

and provide a clear health benefit to patients should be prescribed on

NHS prescriptions. Clinicians have a responsibility to only prescribe

medicines that are known to be clinically effective and provide a health

benefit to the patient.

Walsall CCG Policy Guidance MEDICINES OF LIMITED CLINICAL VALUE

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Background

Medicines optimisation is key to achieving the best outcomes for patients. The Royal

Pharmaceutical Society good practice guide on medicines optimisation outlines principles to

help patients get the most out of their medicines.

Walsall CCG has reviewed the prescribing of medicines and prescribable products available

on the NHS in line with these principles and has decided that medicines deemed to be of

limited or no clinical value and should not be routinely prescribed for adults and children within

Walsall are referred to as “Medicines of Limited Clinical Value” (MOLCV).

Walsall CCG is keen to ensure that only treatments that are clinically effective and provide a

clear health benefit to patients are prescribed on NHS prescriptions. This is to ensure that

CCG resources provide interventions with a proven health gain for the population. Therefore

Walsall CCG recommends that clinicians prioritise resources based on evidence of the clinical

effectiveness and safety of treatments, their cost effectiveness, and on which interventions

provide the best health outcomes.

In the case of treatments which can be prescribed on NHS prescriptions, the CCG is

reviewing treatments that provide limited health benefit. They should be considered a LOW

PRIORITY and not suitable for prescribing unless patients fall into an exception category.

Some medicines that are used to treat minor ailments do not require the patient to be seen by

a GP or Nurse employed within General Practice. Self-care products can be purchased from

pharmacies and supermarkets. Pharmacists and other trained staff members are experts on

providing advice around minor ailments; they are easy to access without an appointment and

most local pharmacies provide the Minor Ailments Scheme (MAS), known locally as the

Pharmacy First Scheme. Use of the MAS will free up GP time to see more complex patients.

Click HERE for list of providers.

Some other products are clinically ineffective or not cost effective. These treatments will not

have undergone rigorous clinical trials to demonstrate that they are effective. It is

inappropriate to direct NHS resources towards products that do not have proven efficacy or

safety, i.e. unlicensed medicines. Walsall CCG encourages clinicians to refer to the local

health economy formulary and guidelines:

http://walsallccg.nhs.uk/publications

Clinicians will be required to consider whether the benefit of prescribing a treatment for an

individual justifies the expense to the NHS. Such judgements should be based purely on

clinical factors and should not be influenced by socio-economic aspects such as the patient’s

ability to purchase. It is best practice to clearly document any decisions made on the clinical

systems.

Walsall CCG Policy Guidance MEDICINES OF LIMITED CLINICAL VALUE

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Walsall CCG Policy Guidance MEDICINES OF LIMITED CLINICAL VALUE

Aims The aim of this guidance is to ensure that: • The prescribing of Medicines of Limited Clinical Value is not made routine • To support the review of the prescribing of Medicines of Limited Clinical Value • The CCG prescribing budget is utilised on evidence based medicines and

interventions. • Patients will be supported to understand more about their medicines and to make

choices about prevention, self-care and healthy living, where possible being directed to Community Pharmacy who can provide advice on medicines and supply either over the counter or via the Minor Ailments Scheme (Pharmacy First Scheme).

• It becomes routine practice to signpost patients to further help with their medicines and to local patient support groups.

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Signposting resources

Self-care forum

http://www.selfcareforum.org/

NHS CHOICES:

http://www.nhs.uk/pages/home.aspx

PATIENT.CO.UK

http://patient.info/

Self-care section on Walsall CCG website

http://walsallccg.nhs.uk/stay-well-walsall

Patients may be directed to the following resources to help support self-care.

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Gluten-Free

Indicated for Not indicated for

Patients confirmed as Coeliac via serological testing (refer to NICE guidance) – to only be prescribed staple foods.

Non-coeliac patients

Potential alternative

Although some GF foods are more expensive than their gluten containing equivalents the price paid by the NHS for GF foods on prescription is much higher than supermarket prices and in some cases it may be twice as expensive. It is therefore recommended that patients are only prescribed staple foods, such as bread and flour on prescription and that prescribed quantities do not exceed 6-8 units of bread or flour (depending on the age of the patient).

Further guidance on gluten-free staple foods that are approved by the Advisory Committee on Borderline Substances (ACBS) can be found HERE or on the Coeliac UK website

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Rationale

• In England, the current annual spend on gluten-free (GF) products is £24.7 million (based on ePACT data April to June 2014), which is significant. Given the current challenges facing the NHS, prescribers need to ensure a fair use of resources for all their patients.

• Historically, availability of GF foods was low, therefore obtaining these products from community pharmacies via prescriptions improved access to them. However, with the increased awareness of coeliac disease and gluten sensitivity as well as a general trend towards eating less gluten, GF foods are now much more accessible and easier to purchase. A wide and expanding range of GF foods are now available from supermarkets and online.

• It is not equitable that some people are able to receive a significant amount of food on prescription whilst others, who may have special dietary needs, are not. It is reasonable that coeliac patients should purchase non-staple GF foods themselves, e.g. pasta, pizza bases, cakes, some breakfast cereals etc.

Supporting Resources

List of staple foods allowed on prescription

Listed below are the products that come in original packs when

ordered as a single item and the number of loaves etc. that come in

each pack.

Supporting resources

https://www.prescqipp.info/psck9-inhibitors-alirocumab-and-evolocumab/send/81-gluten-free/1586-bulletin-69-gluten-free-prescrbing (LOGIN REQUIRED)

https://www.coeliac.org.uk/gluten-free-diet-and-lifestyle/prescriptions/

http://patient.info/health/coeliac-disease-diet-sheet

NICE Guidance: Coeliac disease: recognition, assessment and management. https://www.nice.org.uk/guidance/ng20

Barkat home fresh bread Barkat home fresh country loaf

260g 260g

Genius brown bread\sliced Genius white bread\ sliced Genius sandwich bread Brown sliced \ white sliced

8 loaves 8 loaves 6 loaves

Glutafin Select fresh brown loaf sliced Glutafin Select fresh white sliced Glutafin select fresh seeded sliced

8 loaves 8 loaves 8 loaves

Just loaf white bread Just white rolls Just white sandwich bread

6 loaves 6 packs 6 loaves

Juvela fresh fibre rolls Juvela fresh white rolls Juvela fresh sliced white loaf Juvela fresh sliced fibre loaf

8 packs 8 packs 8 loaves 8 loaves

Warburtons brown bread Warburtons brown rolls Warburtons seeded loaf: Warburtons seeded thin rolls Warburtons white baguettes Warburtons white bread Warburtons white rolls Warburtons white thin rolls

4 loaves 4 packs 4 loaves 4 packs 4 packs 4 loaves 4 packs 4 packs

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Lidocaine Patches

Indicated for Not indicated for Symptomatic relief of neuropathic pain associated with previous herpes zoster infection.

Any other pain management

Potential alternative See Nice evidence for “Management of neuropathic pain “March 2010. Pregabalin or Amitriptyline for non-diabetic neuropathic pain Opioid based analgesia such as Tramadol can be used as third line or in combination with others.

Amitriptyline Gabapentin Pregabalin Duloxetine

Supporting resources

Patient Letter

PresQIPP Bulletin (Nov 13): Lidocaine Plasters

MTRAC Verdict and Summary Review: (May 10) Lidocaine 5% plaster

NICE CG173 (March 2010) Neuropathic pain in adults: pharmacological management in non-clinical settings

Rationale • Prescribing of the lidocaine 5% plaster in primary care should be RESTRICTED to patients diagnosed with

post-herpetic neuralgia (PHN), in whom alternative treatments have proved ineffective or where such treatments are contraindicated.

• Lidocaine patches are used to relieve the pain of post-herpetic neuralgia (PHN; the burning, stabbing pains, or aches that may last for months or years after a shingles infection).

• Lidocaine is in a class of medications called local anaesthetics. It works by stopping nerves from sending pain signals

Walsall Healthcare Guide to Prescribing Analgesics for Non-Malignant Chronic Pain

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IMPORTANT INFORMATION ABOUT YOUR MEDICATION

Dear (Insert patients name)

We are currently reviewing the usage of lidocaine Plasters, also known as Versatis® which has been prescribed for the treatment of pain. We have undertaken an audit of our prescribing of lidocaine plasters and have identified that you have not had your prescription reviewed recently. Please contact the surgery on the number below to arrange an appointment for a review of your medicines. Surgery telephone number 01922 xxxxxx Yours sincerely

Return to Lidocaine plasters guidance

Please not that all patient letters are available as a separate Word document. If you do not have

access to these, please contact your practice pharmacist.

Optimise PATHWAY before referring to Specialist Services

Regular paracetamol 1 g QDS (or appropriate lower dose)

+/- NSAID ibuprofen 400 mg TDS or naproxen 500 mg BD unless contraindicated

Comprehensive assessment: Somatic, visceral or neuropathic

NOCICEPTIVE NEUROPATHIC

Consider trial of opioid therapy

Stop and review diagnosis before switching to co-codamol

Start with co-codamol 8/500 1 or 2 tablets QDS, PRN titrate up

to co-codamol 30/500 2 tablets QDS. Dihydrocodeine may be

considered in patients who may be unable to metabolise

codeine (30 mg QDS max 240 mg). Prescribe drugs in Step 2

regularly to achieve effective analgesia

Stop and review before switching co-codamol to paracetamol

plus immediate release tramadol.

Start at 50 mg up to QDS (max.100 mg QDS).

Set maximum dose, treatment period (e.g. 1 month) and

acceptable response.

Zomorph® 10 mg BD as starting dose.

(morphine sulphate mr)

Swallowing difficulties: remember Zomorph® capsules

can be opened.

Stop and review diagnosis before switching to strong opioid

Where compliance is an issue consider buprenorphine patch

(BuTrans®)

Starting from 5 mcg/hr patch every 7 days, titrating up after 2

weeks if need be.

If there is cognitive impairment due to Zomorph® stop and

review diagnosis before switching to either.

Oxycodone modified release

Start with 10 mg BD.

Increase if necessary

according to severity.

Fentanyl Patch

For patients unable to

swallow or who are

renally impaired.

If ineffective switch to Tapentadol 50 mg bd and titrate

upwards as needed, up to 250 mg daily and review.

Neuropathic pain Diabetic Neuropathy

Amitriptyline (caution in the elderly>75yrs)

Start at 10 mg ON and titrate up to max. 50 mg/day

Pregabalin +/-

Amitriptyline

(dose above)

or when sleep deprivation is a

concern use Pregabalin.

Starting with 75 mg BD for 1

week and titrate up to 150 mg

BD while assessing response

max 300 mg BD.

If not tolerated then wean

down and discontinue.

Gabapentin +/- Amitriptyline (dose

above)

Titrate up to an effective dose (e.g..

2400 mg/day)

If not tolerated then titrate down

titrate up to 150 mg BD while

assessing response max 300 mg BD.

If not tolerated then wean down and

discontinue.

Duloxetine +/-

Gabapentin (dose

above)

Start with low dose of 30

mg/day.

Gradually titrate up to

an effective dose (max.

90 mg/day).

Pregabalin +/-

Duloxetine (dose above)

(Restricted for patients

who are intolerant of

gabapentin or where

gabapentin is ineffective)

Start at 75 mg bd and

titrate up to 150-300 mg

BD.

If not tolerated then

titrate down.

Add Tramadol 50 mg up to

QDS.

(Caution > 70 yrs of age)

Titrate up to max.100 mg QDS

if needed

Set treatment period (e.g. 1

month) and acceptable

response.

If Tramadol already titrated to

max dose then

See below for opioid

dose conversions

Reference:

West Midlands

Palliative Care

Physicians Guideline

Guide to Prescribing Analgesics for Non-Malignant Chronic Pain

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Flexitol

Indicated for Not indicated for Diabetics with severe dry (foot) skin Cosmetic Purposes

Non-diabetics

Potential alternative Readily available to purchase OTC

Flexitol is NOT on Walsall CCG Formulary List.

Supporting resources Diabetic Patient Letter

Non-Diabetic Patient Letter

Drug Alert: Fire hazard with paraffin-based skin products (November 2007)

RATIONALE There is limited evidence for the use of hydrating creams in the treatment and management of diabetics with severe xerosis (severe dry skin). Any patient with non-severe dry skin who requests Flexitol Heel™ balm or other hydrating creams (i.e. Dermatonics, Calmurid™ etc.) should be advised to purchase these themselves. It should not be prescribed on the NHS for cosmetic purposes. You may wish to treat diabetic patients, who present with severe dry (foot) skin only. Please also be aware that Flexitol™ contains lanolin so may cause allergic issues in some patients. In addition, any application of ointment/cream to feet can increase the risk of slips and falls. There has also been an MHRA drug alert to highlight the increased risk of injury, due to fire, with paraffin based emollients on clothing. Patients should be reminded of these safety issues every time a cream or ointment is prescribed.

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IMPORTANT INFORMATION ABOUT YOUR MEDICATION

Dear (Insert patients name)

As a practice are always striving to provide the best possible care for our patients, and

part of this process, involves the continual review of the medicines we prescribe.

We are currently reviewing the usage of Flexitol products in line with current Walsall

CCG guidelines. We have identified that you have been prescribed this treatment.

However there is limited evidence available for these products.

As you understand, foot care is a vital part of the management of your diabetes,

including your annual diabetic foot checks. We would therefore be grateful if you could

discuss this with your nurse/GP at your next appointment, so that the need for this

item can be reviewed.

Should you wish to continue using the Flexitol brand, it is available to purchase from

the pharmacy. Please speak to your pharmacist about this.

Should you have any queries or concerns, please do not hesitate to contact the

practice.

Yours sincerely

Return to flexitol guidance

Please not that all patient letters are available as a separate Word document. If you do not have

access to these, please contact your practice pharmacist.

Return to start

IMPORTANT INFORMATION ABOUT YOUR MEDICATION

Dear (Insert patients name)

As a practice, we are always striving to provide the best possible care for our patients,

and part of this process, involves the continual review of the medicines we prescribe.

We are currently reviewing the usage of Flexitol products in line with current Walsall

CCG guidelines. We have identified that you have been prescribed this treatment.

There is limited evidence available for these products, and it is not making the best

use of NHS resources when used for cosmetic purposes.

Should you wish to continue using this product, it is available to purchase from any

pharmacy.

Please speak to your pharmacist for further advice.

As a practice we will no longer be prescribing this treatment and will be

removing it from a repeat prescription.

Should you have any queries or concerns, please do not hesitate to contact the

practice.

Yours sincerely

Return to flexitol guidance

Please not that all patient letters are available as a separate Word document. If you do not have

access to these, please contact your practice pharmacist.

Return to start

Liothyronine

Indicated for Not indicated for

Patients who have unambiguously not benefited from L-T4, may benefit from a trial of L-T4/L-T3 combination therapy under the care of an endocrinologist.

Newly diagnosed hypothyroidism

Please click HERE for guidance on how to manage patients on liothyronine.

Supporting resources

Patient Letter

Liothyronine 20mg tablets SPC

https://www.prescqipp.info/droplist

Rationale • Levothyroxine (L-T4) is a prodrug and is converted to Liothyronine (L-T3) in the body • Levothyroxine is the NHS thyroid hormone of choice as it is cost-effective, suitable for once daily

dosing due to its long half-life and provides stable and physiological quantities of thyroid hormones for patients requiring replacement.

• Liothyronine is not routinely recommended for prescribing as it has a much shorter half-life and steady-state levels cannot be maintained with once daily dosing

• The combination of levothyroxine and liothyronine, in both non- psychological and physiological proportions, has not consistently been shown to be more beneficial than levothyroxine alone with respect to cognitive function, social functioning and wellbeing. The variation in hormonal content and large amounts of liothyronine may lead to increased serum concentrations of L-T3 and subsequent thyrotoxic symptoms, such as palpitations and tremor

• There is currently insufficient evidence of clinical and cost effectiveness to support the use of liothyronine (either alone or in combination) for the treatment of hypothyroidism

• Liothyronine (available as licensed 20 mcg tablets and unlicensed 5 mcg tablets) is considerably more expensive than levothyroxine. Many other liothyronine-containing preparations (i.e. Armour Thyroid) are also unlicensed, therefore the safety and quality of these products cannot be assured

• Liothyronine is subject to supply issues and the amount of active ingredient may not be standardised so can vary from batch-to-batch, providing variable control

N.B. The cost of Liothyronine has increased dramatically over time. The current cost is £258.20 for 28 tablets (December 2016 Drug Tariff).

The review process for patients on Liothyronine:

• Consider optimising dose of levothyroxine • Consider seeking specialist advice if considering stopping

liothyronine and increasing levothyroxine dose • Patients should have repeat TFTs 1-2 months after switching to

determine the appropriateness of their new dose. Patients under the care of a specialist endocrinologist should be referred back to consider suitability of switching in partnership.

The BNF states that 20–25 mcg of Liothyronine is equivalent to 100 mcg of levothyroxine.

Return to liothyronine guidance Return to start

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IMPORTANT INFORMATION ABOUT YOUR MEDICATION

Dear (Insert patients name)

This practice constantly reviews repeat prescriptions to make sure that our patients get

the most effective treatment, which provides good value for the NHS without affecting

their quality of care.

We are currently reviewing the medicines we use to treat an underactive thyroid,

particularly the medicine liothyronine (which is sometimes used with another thyroid

hormone called levothyroxine).

Please make an appointment to see your GP/practice nurse [delete where appropriate] to

discuss your medication further.

If you have any questions about this change please contact your GP/Nurse/Pharmacist.

Yours sincerely

Return to liothyronine guidance

Please not that all patient letters are available as a separate Word document. If you do not have

access to these, please contact your practice pharmacist.

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Cough and Cold remedies

Indicated for Not indicated for

N/A N/A

Potential alternative

Purchase as over-the-counter products. Promotion of self-care

Supporting resources

PATIENT LEAFLETS

Cough in Adults information leaflet http://www.selfcareforum.org/wp-content/uploads/2013/04/7-Cough.pdf

Sore Throat information leaflet http://www.selfcareforum.org/wp-content/uploads/2013/04/10-Sore-Throat.pdf

The common cold in adults information leaflet

http://www.selfcareforum.org/wp-content/uploads/2013/03/20131030-SCF-Fact-Sheet-No-12-Common-Cold-v1-final.pdf

Caring for children with coughs leaflet http://www.bristol.ac.uk/media-library/sites/primaryhealthcare/documents/target/caring-for-children-with-cough-leaflet-print-ready.pdf

TARGET leaflets by RCGP. http://www.rcgp.org.uk/clinical-and-research/toolkits/target-antibiotics-toolkit/patient-information-leaflets.aspx

EVIDENCE

NICE CKS: Common Cold http://cks.nice.org.uk/common-cold#!scenario

Rationale Limited clinical value for these treatments – cough mixtures, aromatic inhalations, decongestants, sore throat lozenges etc. E.g. pholcodine linctus; simple linctus; nasal decongestants- xylometazoline; ephedrine; systemic decongestants- pseudoephedrine; aromatic inhalations- Menthol & eucalyptus inhalation. Both the Royal College of General Practitioners and the GMC state that GPs must encourage patients to self-care. Over the counter products are suitable for most patients’ in-line with their product licenses. Many products are not prescribable on NHS prescriptions as set out in Part XVIIIA of the Drug Tariff.

RCGP – TARGET LEAFLET

The full PDF and word versions are available by clicking HERE. This also provides access to the leaflet in other languages.

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Doxazosin Modified Release (MR)

Indicated for Not indicated for Doxazosin is licensed for the treatment of hypertension and benign prostatic hypertrophy (BPH)

Any other indications.

Potential alternative

Doxazosin immediate release. Click HERE for guidance on converting from modified to immediate release formulations.

Supporting resources

1. UKMI Q&A 101.3 How should conversion between doxazosin formulations be carried out? May 2009. www.nelm.nhs.uk

2. Summary of Product Characteristics. Cardura. Pfizer Limited. Accessed 24/10/2016 available at www.medicines.org.uk

3. Summary of Product Characteristics. Cardura XL. Pfizer Limited. Accessed on 24/10/2016 https://www.medicines.org.uk/emc/medicine/4484

4. NICE Clinical Guideline 127, August 2011. Hypertension: Clinical management of primary hypertension in adults. Accessed on 9/2/12 and available at www.nice.org.uk

5. https://www.prescqipp.info/droplist

5. NICE Clinical Guideline 97, May 2010. The management of lower urinary tract symptoms in men. Accessed 14/2/12and available at www.nice.org.uk

Rationale

• Doxazosin has a long half-life of 22 hours making it suitable for once daily dosing Doxazosin immediate release and MR forms are available and they are both administered once daily and so a MR version of doxazosin offers no advantage in terms of patient compliance.

• There are no apparent differences in the type of adverse events reported in studies and the SPC. The MR version may have a slightly lower overall incidence of adverse effects, but most adverse effects are mild .

• Check and ensure that prescribing of doxazosin for hypertension is in line with NICE Clinical Guideline 127, Aug2011 or prescribing of doxazosin for BPH is in line with NICE Clinical Guideline 97 May 2010. Commence new patients requiring doxazosin on the immediate release tablet version of doxazosin.

• Review patients on doxazosin MR for suitability for switching to immediate release doxazosin tablets.

• Switch patients to immediate release doxazosin tablets where it is clinically suitable to switch them.

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Converting from modified to immediate release doxazosin

Switching from modified-release to standard preparation In the absence of any firm recommendations from the manufacturers of modified-release doxazosin, there are two possible strategies to convert patients from modified release to standard doxazosin and both scenarios require follow up monitoring of blood pressure and patient tolerability: 1. Give half the dose of modified-release doxazosin as standard doxazosin, i.e. 4mg XL switched to 2mg standard. There may be some patients who may require a higher dose and subsequent dose titration may be required. Or 2. Give the same dose as modified-release doxazosin but there may be some patients who suffer orthostatic hypotension and need a lower dose and subsequent dose titration may be required. The alternative is to comply with the licensed dosing recommendations and initiate therapy at 1mg daily, increasing at weekly/fortnightly intervals.

Whichever dose is chosen, it is important to monitor blood pressure (about 4 weeks after the switch) and patient symptoms closely and adjust the dose if necessary. More switching information on PrescQIPP.

Return to Doxazosin guidance Return to start

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IMPORTANT INFORMATION ABOUT YOUR MEDICATION

Dear (Insert patients name)

This practice constantly reviews repeat prescriptions to make sure that our patients get

the most effective treatment, which provides good value for the NHS without affecting

their quality of care.

We are currently reviewing the medicines we use to treat hypertension or BPH,

particularly the medicine doxazosin mr

Please make an appointment to see your GP/practice nurse [delete where appropriate] to

discuss your medication further.

If you have any questions about this change please contact your GP/Nurse/Pharmacist.

Yours sincerely

Return to doxazosin guidance

Please not that all patient letters are available as a separate Word document. If you do not have

access to these, please contact your practice pharmacist.

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Omega 3

NICE indications Not indicated for

No indications Schizophrenia

Myocardial Infarction (Primary prevention)

Multiple Sclerosis

Familial Hypercholesterolaemia

Potential alternative

Patients should be advised to increase their dietary intake of omega-3 fatty acids. • For hypertriglyceridemia, if used in conjunction with statins, consider a trial of statin in conjunction with

increased dietary intake. If used in conjunction with diet, consider a switch to a fibrate. • For post-MI use, omega-3 fatty acids should be stopped. Ensure patients are receiving optimal secondary

prevention medication. Patients who have had an MI should be advised to consume two to four portions of oily fish or other dietary sources per week.

• For schizophrenia (unlicensed), ensure response is monitored carefully. Consideration to stopping therapy, in conjunction with specialist opinion, should be undertaken if no improvement is seen after 3 months use.

• For all other indications, use is unlicensed and evidence of benefit is weak or non-existent. Patients should be advised that supplements are available to purchase if required or to increase their dietary intake if they wish.

Supporting resources https://www.prescqipp.info/-omega-3-fatty-acids/send/85-omega-3-fatty-acids/787-bulletin-47-omega-3-fatty-acids

http://www.nhs.uk/Livewell/superfoods/Pages/is-oily-fish-a-superfood.aspx

Omega 3 Food Fact sheet. BDA (2014). https://www.bda.uk.com/foodfacts/omega3.pdf

Patient Letter

Rationale • The NICE guideline on lipid modification recommends that people with or at high risk of CVD should be

advised to consume at least 2 portions of fish per week, including a portion of oily fish. However, it advises that omega-3 fatty acid compounds should not be offered for primary or secondary prevention of CVD, alone or in combination with a statin, including in people with CKD or type 1 or type 2 diabetes. Moreover, the guideline recommends that healthcare professionals should tell people that there is no evidence that omega-3 fatty acid compounds help to prevent CVD. In addition, the NICE guideline on secondary prevention of myocardial infarction (MI) recommends that healthcare professionals should not offer or advise people who have had an MI to use omega-3 fatty acid capsules or omega-3 fatty acid supplemented foods to prevent another MI.

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IMPORTANT INFORMATION ABOUT YOUR MEDICATION

Dear (Insert patients name)

We regularly review the medicines we prescribe to check that we are using the most

effective and good value medicines. You are currently taking omega-3 fatty acid

compounds and we have decided to stop prescribing of these products. There is

insufficient evidence to show that these products have beneficial effects for your

condition.

It is important, however, to maintain enough fish oils or other forms of omega-3 fatty

acids in your diet. The attached leaflet provides lots of information on dietary sources

of omega-3 fatty acid compounds. If you are taking this product because you have had

a heart attack (myocardial infarction), the National Institute for Health and Care

Excellence (NICE) recommend that you eat at least two to four portions of oily fish per

week.

We do not expect you to notice any difference when your prescription is stopped.

However, should you have any questions about this medicine change, please ask to

speak to your doctor, practice nurse or community pharmacist.

Please finish the remaining omega-3 fatty acid compounds tablets that you have at

home. We will add any additional medicines if we feel these are appropriate when we

review you in 2 months time

Yours sincerely

Return to Omega-3 guidance

Please not that all patient letters are available as a separate Word document. If you do not have

access to these, please contact your practice pharmacist.

Eflornithine 11.5% cream (Vaniqa)

Indicated for Not indicated for Co-cyprindiol- Treatment of moderate to severe hirsuitism, in women of reproductive age.

N/A

Potential alternative • Self-funded cosmetic treatments for reduction in hair growth or hair removal • Consider offering co-cyprindiol.

Supporting resources Patient Letter – cessation of prescribing

Patient Letter – Invite for review

SPC for co-cyprindiol

Clinical Knowledge Summaries- Hirsutism

https://www.prescqipp.info/droplist

Rationale The treatment of hirsuitism is a cosmetic procedure which is a low priority for funding by Walsall CCG. If hirsuitism is mild and does not significantly interfere with the woman’s quality of life, consider no additional treatment. Hirsutism is not usually associated with any significant medical abnormality. Eflornithine 11.5% cream offers very little benefit for the management of facial hirsuitism in women. There is limited evidence for efficacy and patient satisfaction with eflornithine. Self-funded cosmetic treatments for reduction in hair growth or hair removal (e.g. shaving, threading, plucking, laser treatment, electrolysis) should be the primary options for the majority of women with hirsuitism. If additional treatment is required, consider offering co-cyprindiol.

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IMPORTANT INFORMATION ABOUT YOUR MEDICATION

Dear (Insert patients name)

We are currently reviewing the usage of eflornithine 11.5% cream, also known as Vaniqa® which has been prescribed for excessive hair growth (hirsuitism). This treatment is considered a cosmetic treatment and experts recommend self-care for the majority of women instead of being prescribed treatment. As a practice we will no longer be prescribing this treatment and have removed it from your repeat prescription. This will help us to use our limited NHS resources to prioritise treatment where it is most needed. You can try one of the following methods of hair removal as self-funded treatment if you still wish to treat your hirsuitism: • Shaving, plucking, waxing or threading • Laser hair removal • Electrolysis. You can discuss the best form of treatment for you with a beauty therapist. If you have found the eflornithine to be effective and wish to continue to use it you will need to obtain a private prescription for its supply and self-fund this treatment. Yours sincerely

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Please not that all patient letters are available as a separate Word document. If you do not have

access to these, please contact your practice pharmacist.

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IMPORTANT INFORMATION ABOUT YOUR MEDICATION

Dear (Insert patients name)

We are currently reviewing the usage of eflornithine 11.5% cream, also known as Vaniqa® which has been prescribed for excessive hair growth (hirsuitism). We have undertaken an audit of our prescribing of eflornithine cream and have identified that you have not had your prescription reviewed recently. Please contact the surgery on the number below to arrange an appointment for a review of your medicines. Surgery telephone number 01922 xxxxxx Yours sincerely

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Please not that all patient letters are available as a separate Word document. If you do not have

access to these, please contact your practice pharmacist.

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Colecalciferol (Vitamin D3)

Indicated for – For further information refer to individual product SPC (HERE)

Potential alternatives (PRESCRIBE BY LICENSED BRAND)

Desunin Fultium D3

Aviticol Thorens

Invita D3 Strivit D3

Healthy Start Vitamins – Available for FREE Healthy Start children’s vitamin drops (For children from 6months old up until their 4th birthday). - Vitamin A (233 micrograms), vitamin C (20 mg) vitamin D (7.5 mcg) - Children who are having 500ml or more of formula a day do not need Healthy Start vitamins. - The vitamins are suitable for vegetarians and free from milk, egg, gluten, soya and peanut residues. - Healthy Start women’s vitamin tablets (For pregnant women, women with a child under 12 months). - The daily dose is one tablet, which contains: Folic acid (400mcg), vitamin C (70 mg) vitamin D (10 mcg). - They are suitable for vegetarians and free from wheat, fish, egg, salt. No colours, flavours or preservatives.

No gluten containing ingredients. For further information click HERE For the nearest stockists click HERE

Supporting resources

Patient letter

BDA Food Fact Sheet: Vitamin D

PrescQIPP bulletin 120 (April 2016)- Vitamin D prescribed as colecalciferol (D3) or ergocalciferol (D2) (SPOT-List)

Rationale – ALWAYS PRESCRIBE BY LICENSED BRAND

Many clinicians prescribe vitamin D3 generically as colecalciferol, in a wide range of strengths and formulations. Prescriptions written generically are often fulfilled with unlicensed preparations e.g. ProD3, Colevit D3, Solgar Vitamin D3 Osteocaps D3, Aciferol D3, Sunvit D3, Hux D3. Recently, there has been an increase of licensed low and high dose vitamin D3 products available on the UK market. Licensed products should always be considered first line over unlicensed alternatives. See GMC Guidance on prescribing unlicensed medicines.

Recommend self care wherever possible for prophylaxis of vitamin D deficiency for those who are at-risk.

Unlicensed preparations to avoid

Colecalciferol (written generically) Pro D3

Colevit D3 Solgar Vitamin D3 Sunvit D3

Osteocaps D3 Aciferol D3 Hux D3

Walsall CCG Vitamin D formulary products

Desunin tablets (V) 4000iu 800iu

Fultium-D3 capsules 800iu 3,200iu 20,000iu

Fultium drops 3 drops = 200iu

InVita D3 (V) 2,400iu drops 1 drop = 67iu 6drops = 400iu 25,000iu oral solution 50,000iu oral solution

Aviticol capsule 20,000iu

Alfacalcidol capsules

Calcitriol capsules

Thorens (V) 10,000iu oral drops 1drop = 200iu 25,000iu oral solution

Strivit D3 capsules (V) - avoid in peanut or soya allergy 800iu capsule

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IMPORTANT INFORMATION REGARDING CHANGES

TO YOUR REPEAT PRESCRIPTION Dear (Insert patients name)

We are currently reviewing our patients prescribed a Vitamin D only preparation (i.e.

name of unlicensed preparation) for previous Vitamin D deficiency or insufficiency (low

Vitamin D levels).

At the time we prescribed (name of unlicensed preparation) as this was widely available,

it is however classed as a food supplement and therefore not a licensed preparation.

We now have several licensed Vitamin D preparations available and it is best practice to

always prescribe licensed preparations where available.

Therefore your next prescription for:

Colecalciferol capsules- name of unlicensed preparation

HAS BEEN CHANGED TO

Name of licensed preparation

This change will be reflected on your next repeat prescription and will not have any

adverse effect on your treatment. You can finish off any medication you currently have.

Please do not hesitate to contact the GP, nurse or practice pharmacist at the surgery if

you have any queries or would like any further information.

Yours sincerely

Return to colecalciferol guidance

Please not that all patient letters are available as a separate Word document. If you do not have

access to these, please contact your practice pharmacist.

References

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• Coeliac UK https://www.coeliac.org.uk/home/ Accessed]14.11.2016 • Electronic Medicines Compendium. Summary of Product Characteristics. Liothyronine

https://www.medicines.org.uk/emc/medicine/24153 Accessed 14.11.16 • Electronic Medicines Compendium. Summary of Product Characteristics. Co-cyprindol.

https://www.medicines.org.uk/emc/medicine/32058 • GMC. Prescribing guidance: Prescribing unlicensed medicines • http://www.gmc-uk.org/guidance/ethical_guidance/14327.asp • GMC. Outcomes for provisionally registered doctors with a licence to practise (The Trainee

Doctor) July 2015 Available at http://www.gmc-uk.org/Outcomes_for_provisionally_registered_doctors_Jul_15.pdf_61407158.pdf Accessed 28.11.16

• NHSBSA Drug Tariff. December 2016. http://www.drugtariff.nhsbsa.nhs.uk/#/00414430-DD_2/DD00414138/Part VIIIA products L Accessed on 29.11.16

• NICE Clinical Knowledge Summaries. Hirsuitism. December 2014. https://cks.nice.org.uk/hirsutism • NICE NG20: Coeliac disease: recognition, assessment and management. Accessed 14.11.16

https://www.nice.org.uk/guidance/ng20 • NICE Clinical Guideline 127, August 2011. Hypertension: Clinical management of primary hypertension in

adults. Accessed on 9/2/12 and available at www.nice.org.uk • NICE Clinical Guideline 97, May 2010. The management of lower urinary tract symptoms in men.

Accessed 14/2/12and available at www.nice.org.uk • PresQIPP DROP-List guidance • Royal Pharmaceutical Society of Great Britain. Medicines Optimisation: Helping patients to get the most

of their medicines. May 2013. Available at http://www.rpharms.com/promoting-pharmacy-pdfs/helping-patients-make-the-most-of-their-medicines.pdf

• Summary of Product Characteristics. Cardura. Pfizer Limited. Accessed 24/10/2016 available at www.medicines.org.uk

• Summary of Product Characteristics. Cardura XL. Pfizer Limited. Accessed on 24/10/2016 https://www.medicines.org.uk/emc/medicine/4484

• The Association of UK Dieticians. BDS Food Fact Sheet. Omega 3. September 2014. Accessed 29.11.2016 • The Association of UK Dieticians. BDS Food Fact Sheet. Vitamin D. August 2016. Accessed

29.11.2016 • https://www.bda.uk.com/foodfacts/omega3.pdf • https://www.bda.uk.com/foodfacts/VitaminD.pdf • The Royal College of General Practitioners. The RCGP Curriculum: Core Curriculum Statement,

Being a General Practitioner. February 2016. Accessed 28.11.16 • The Self Care Forum • The University of Bristol • The Royal College of General Practitioners – TARGET antibiotics toolkit • UKMI Q&A 101.3 How should conversion between doxazosin formulations be carried out? May 2009.

www.nelm.nhs.uk