The Top 10
What has been happening in the world of pharmacy? Here’s our pick of must-read news from the past month.
1. Target six high-risk drugs during reviews
Researchers have identified six high-risk medicines or combinations of medicines that should be targeted in medicines reviews to reduce iatrogenic disease in older people.
The research also shows that when GPs choose not to act on pharmacists’ recommendations to stop high-risk medicines, patients are more likely to suffer an adverse outcome.
The researchers, led by Clare Morrison, lead pharmacist north at NHS Highland, say the list will be invaluable to pharmacists who are under pressure and want to get the most out of medicines reviews.
The list includes the well-documented “triple whammy” combination — a non-steroid anti-inflammatory drug (NSAID), a diuretic and an angiotensin converting enzyme inhibitor — and the use of an NSAID taken by a patient who has reduced renal function. It also includes hypnotics or benzodiazepines, tricyclic antidepressants and antipsychotic drugs prescribed for patients aged over 60 years. Also considered particularly high risk are NSAIDs taken by patients aged over 75 years who are not prescribed a proton pump inhibitor.
Source: Sprout Pharmaceuticals
2. First drug to improve sexual desire in women approved
Addyi Premenopausal women in the United States now have a treatment option for hypoactive sexual desire disorder after the Food and Drug Administration approved Addyi (flibanserin).
The drug, a serotonin 1A receptor agonist and a serotonin 2A receptor antagonist, is the first to be approved for the treatment of the disorder, although the mechanism by which it improves sexual desire and related distress is unclear.
Flibanserin can cause severe low blood pressure and loss of consciousness. Women taking the drug must refrain from drinking alcohol and stop taking several common drugs, including certain antidepressants, antibiotics, antifungals, reflux treatments and protease inhibitors. Patients should not drive for at least six hours after taking flibanserin.
As a condition of its approval, the drug must be prescribed and dispensed by certified doctors and pharmacists, who will have undergone specific training.
The drug has previously been rejected twice by the FDA, which led to accusations of gender bias.
3. New edition of BNF brings ‘fundamental change’
Major changes have been made to the structure and appearance of the British National Formulary (BNF), the medicines and prescribing reference book used by NHS healthcare professionals.
The new print editions offer greater consolidation of medicines information that used to be found in introductory prescribing notes. There are now appendices of individual drug monographs, as well as the introduction of new visual cues to guide navigation. The section numbering system has also been replaced.
The updates will apply to print and online versions of the BNF and sister titles BNF for Children (BNFC) and Nurse Prescribers’ Formulary (NPF) from late September 2015.
4. Specification for national flu vaccination service published
Further details about how community pharmacists are expected to deliver a national influenza vaccination service in England have been published by the Department of Health and the Pharmaceutical Services Negotiating Committee (PSNC).
The service specifications spell out how pharmacists can ensure they have everything in place to provide the service, including systems for data collection and vaccine storage, and can confirm they are appropriately trained and know how to gain patient consent.
The new advanced service — announced in July 2015 as part of the national funding settlement for England — represents a “big step forward”, says PSNC’s director of NHS services Alastair Buxton.
5. UK launch for cholesterol-lowering PCSK9 inhibitor
An injectable treatment has been launched for people who struggle to control their cholesterol levels through established diet and drug regimes, including patients with the genetic lipid disorder familial hypercholesterolaemia.
Amgen’s Repatha (evolocumab) is a monoclonal antibody and the first treatment to inhibit proprotein convertase subtilisin/kexin type 9 (PCSK9), an enzyme that reduces the liver’s ability to clear LDL cholesterol (‘bad’ cholesterol) from the blood. In clinical trials, evolocumab reduced LDL levels to 75% lower than atorvastatin alone.
Evolocumab was approved in Europe in May 2015 and in the United States in August 2015 for patients with primary hypercholesterolaemia who are unable to control their cholesterol with current therapies, or with familial hypercholesterolaemia. It is a fortnightly injection and can be used in tandem with statins, or without for patients who are intolerant of statins.
A National Institute for Health and Care Excellence review is under way for treatment of primary hypercholesterolaemia and mixed dyslipidaemia, with recommendations expected in April 2016.
6. E-cigarettes at least 95% safer than tobacco cigarettes
Pharmacists offering stop smoking services can now support smokers trying to quit using e-cigarettes and even recommend would-be quitters try them, according to Public Health England (PHE).
However, the Royal Pharmaceutical Society (RPS) is advising pharmacies not to advertise or sell the products because they are unregulated.
PHE commissioned a review of e-cigarettes, published on 19 August 2015, which concluded that vaping was at least 95% safer than smoking tobacco cigarettes and did not act as a gateway to smoking for children and non-smokers.
“It is not known whether current e-cigarette products are more or less effective than licensed stop smoking medications, but they are much more popular, thereby providing an opportunity to expand the number of smokers stopping successfully,” the report says.
As a result, PHE has informed pharmacists and other health professionals offering stop smoking services that they can support smokers attempting to quit using the devices and can even suggest that they try using them.
7. Hospitals failing to pass on information about patients’ new drugs
A third of hospital trusts admit that they fail to pass on information about new medicines to GPs or carers when patients are discharged, according to an inquiry by Healthwatch England.
The organisation, which describes itself as the national consumer champion in health and care, also found that a third of the 102 hospital trusts it questioned in England failed to make a proper record of new drugs prescribed to patients during their hospital stay.
The findings follow its year-long inquiry into what happens when vulnerable patients leave hospital or care settings and are discharged back into the community.
8. NICE recommends tighter glucose control in updated diabetes guidelines
Tighter blood sugar control is among the recommendations in updated national guidelines for diabetes, published by the National Institute for Health and Care Excellence on 26 August 2015.
The guidance is for adults with type 1 diabetes, for children and young people with types 1 and 2 diabetes, and for patients with diabetic foot problems.
The revised guideline for children and young people recommends, for the first time, that they should aim for an HbA1c level that is near the normal range (i.e. 48mmol/mol) as well as near normal blood glucose readings.
9. MHRA review concludes alteplase is safe for treating acute ischaemic stroke
The Medicines and Healthcare products Regulatory Agency (MHRA) has backed the continued use of the thrombolytic alteplase for up to 4.5 hours after the onset of symptoms of acute ischaemic stroke, but says the chances of a more favourable outcome for patients are enhanced the earlier the treatment is given.
The review was set up after Roger Shinton, a former consultant physician at Birmingham Heartlands Hospital, questioned the evidence base supporting the drug in a letter to The Lancet in 2014. He raised concerns about the trial used to obtain marketing approval and a subsequent trial that was key to extending alteplase’s window of use.
An MHRA-appointed expert group concluded that the benefit/risk ratio of alteplase for treatment of acute ischaemic stroke is positive when used within the terms of its licence up to 4.0 hours after onset of symptoms. There was around a 2% risk of a fatal intracranial haemorrhage in the first two days post-treatment, but this risk was outweighed by the reduced risk of disability.
10. UK doctors could be reported for inappropriate antibiotic prescribing
Healthcare professionals should question their colleagues’ prescribing of antimicrobials when they don’t comply with local or national guidelines, according to Mark Baker, director of the clinical centre for practice at the National Institute for Health and Care Excellence (NICE).
Baker also suggested that doctors should be reported to the General Medical Council if their performance was consistently substandard.
NICE has launched a new guideline on antimicrobial stewardship that aims to reduce the number of prescriptions for antibiotics. In 2013–2014, there were 41.6 million prescriptions for antibiotics. If NICE guidance launched in 2007 had been followed, there would have been 10 million fewer prescriptions for antibiotics in 2014, a NICE spokesperson said.
NICE has recommended a process of ‘peer-review’ within GP practices, so that colleagues can examine who is prescribing what and why. In addition, antimicrobial stewardship teams should be established in all NHS organisations. The guideline places antimicrobial pharmacists at the core of these teams, which are tasked with monitoring antibiotic prescribing.
Citation: Clinical Pharmacist DOI: 10.1211/CP.2015.20069375
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