Transcript Treatment - North Derbyshire CCG

Clinical Update
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New & updated guidelines
Significant traffic light updates
Significant safety issues
Other issues
Feedback from practices
Clinical Guidelines
Chronic rhinosinusitis with or
without nasal polyps - NEW
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Categorised as chronic if symptoms
persist for more than 12 weeks.
Affects around 10% of the population.
May occur with or without nasal
polyps.
Treatment consists of step wise steroid
use, aiming for the lowest dose that is
most effective for an individual patient.
Surgery reserved for resistant cases.
Chronic rhinosinusitis with or
without nasal polyps - NEW
Self-management advice for acute
exacerbations:
 Simple analgesics such as paracetamol or
ibuprofen to reduce pain and fever
 Intranasal decongestants used occasionally in
adults only (for a maximum of 1 week) – can
help if nasal congestion is problematic. Oral
decongestants are not recommended.
 Many patients find nasal douching with saline
prior to administration of topical steroids
helpful, e.g. SinuRinse and Sterimar which are
OTC preparations
 Applying warm (not hot) face packs
 Steam inhalation is not recommended
Chronic rhinosinusitis with or
without nasal polyps - NEW
Antibiotic prescribing:
o A short course of antibiotics might be appropriate –
as per local antimicrobial guidelines.
o Seek specialist advice before prescribing long-term
antibiotics, as evidence for this approach is limited
Chronic rhinosinusitis with or
without nasal polyps - NEW
Treatment:
 Most idiopathic inflammatory polyps are
steroid responsive.
 A “ladder” or stepped approach, but ideally
patients shouldn’t be left long term on
anything other than the 1st “rung”.
 Management is long term, generally not
curative.
 Consider nasal irrigation with saline
solution to relieve congestion and nasal
discharge.
Chronic rhinosinusitis with or
without nasal polyps - NEW
Children’s asthma guideline 5 to
12 years - UPDATE
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Main change is at step 3a (adding a LABA):
Children’s asthma guideline 5 to
12 years - UPDATE
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Included more options to assess
control:
Gastro-oesophageal reflux disease
in children and young people
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Based on the NICE guideline published in
January.
GOR (asymptomatic regurgitation of feeds
in young babies) is very common and most
cases resolve by age 1.
Only a small proportion will need to be
managed as GORD (GOR causing
symptoms e.g. discomfort or pain or
complications e.g. oesophagitis).
Table of “red flags” included for infants,
children and young people with vomiting or
regurgitation
Gastro-oesophageal reflux disease
in children and young people
When reassuring parents and carers about regurgitation,
advise them that they should return for review if any of
the following occur:
• The regurgitation becomes persistently projectile
• There is bile-stained (green or yellow-green) vomiting
or haematemesis (blood in vomit)
• There are new concerns, such as signs of marked
distress, feeding difficulties or faltering growth
• There is persistent, frequent regurgitation beyond the
first year of life.
Advise patients not to use positional management
to treat GOR in sleeping infants. Infants should be
placed on their back when sleeping.
Breast fed infants with frequent
regurgitation
Formula-fed infants with frequent
regurgitation with marked distress
Thickened formula information
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Carobel first line option (more cost-effective
and allows easy review).
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Needs a wide or vari-flow teat.
Endorse ACBS.
Powdered “antiregurgitation” formula is an
alternative.
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Enfamil AR and SMA Staydown are ACBS
approved for significant GOR
Not to be used for a period >6 months,
Not to be used in conjunction with any other feed
thickener or antacid products.
Available over the counter for parents to buy special instructions for preparation.
Pharmacological treatment of
GORD
Alginate, H2RA and PPI dosing
information
AF guideline - UPDATE
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Now includes a useful algorithm to
help guide anticoagulant choice and
choice of NOAC if a NOAC is
required.
Considers clinical issues (e.g. renal
impairment, higher bleeding risk)
and practical issues (e.g. need for
once daily dose, swallowing
difficulties, need for compliance aid)
N.B.no head to head trials of the
NOACs.
Other guideline updates:
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Adult asthma: no major changes
but table added with assessment
options.
Familial hypercholesterolaemia:
updated with atorvastatin as
preferred statin for new patients (10
to 20mg initially, increasing to 40 to
80mg if LDL-C not reduced by 50%)
ACS, NSTEMI and unstable
angina antiplatelet flow chart
used by CRHFT: no changes.
Shared-Care Guidelines
Colomycin for pseudomonal lung
infection in adults with bronchiectasis
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Updated to clarify consultant
responsibilities regarding sputum
monitoring:
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once a month for 6 months and include
copy to GP for information in the event
of an exacerbation that may need
treating due to other isolates
Longer term monitoring of sputum will
be decided by clinician in the
bronchiectasis OPD clinic
ADHD in children and adults
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Matoride XL included as a costeffective alternative to Concerta XL
for new patients.
Bioequivalent and GPs could
consider changing existing patients,
after a face to face review.
Denosumab for the prevention of
osteoporotic fractures
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Updated to include men with
osteoporosis including the specific
sub-set of men with prostate cancer
treated with androgen deprivation
therapy.
Significant Traffic Light
Changes
Significant traffic light updates: RED
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Rivaroxaban 2.5mg: new strength, licensed
for the prevention of atherothrombotic
events in patients with ACS in combination
with aspirin, aspirin+clopidogrel or
ticlodipine.
Cardiologists at Chesterfield and Derby still
considering its place in the pathway and
length of treatment.
No immediate plans for use at Chesterfield
and will continue with dual antiplatelet
therapy as per guidelines.
Significant traffic light updates: GREEN
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Fluticasone nasules: as per chronic
rhinosinusitis guideline.
Acetazolamide: for idiopathic intracranial
hypertension, after consultant initiation and
stabilisation (requested by RDH
consultants).
Exenatide weekly: reclassified from
brown. Now available as a pre-filled pen.
Same cost as previous weekly powder and
solvent formulation but easier to administer.
An option for patients with compliance
problems or when nursing staff are required
to administer the injection.
Significant traffic light updates: GREEN
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Lamotrigine: after specialist
initiation for indications in addition
to epilepsy e.g. bipolar disorder.
Significant traffic light updates: BROWN
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Levocetirizine, desloratidine and
esomeprazole reclassified from black
due to significant reduction in cost.
Silica gel/sheets reclassified from black
for patients under specialist burns units.
Dapagliflozin + metformin. Cheaper to
use combination product if patient on
both, but does not allow metformin dose
to be increased to UKPDS target dose
(around 2.5g/day). Dapagliflozin
specialist initiation.
Significant traffic light updates: BROWN
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Escitalopram: reclassified from
black due to reduction in cost. For
continued use in those responding
to treatment or who have had a
good response previously, after
trying formulary choices.
Empagliflozin: following specialist
initiation when a gliptin considered
inappropriate.
Significant traffic light updates: BROWN
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Aclidinium + formoterol (Duaklir
Genuair): reclassified from black in
line with other LABA/LAMA
combination inhalers.
Limited place of LABA/LAMA in
COPD and weak evidence but if
patient deriving benefit from
separate consituents, the
combination inhaler is more costeffective.
Significant traffic light updates: BLACK
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Olodaterol. Once daily LABA for COPD but
less cost-effective formulary choice,
formoterol Easyhaler.
Significant Safety Updates
Drug safety Update – March 15
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Dimethyl fumarate: fatal progressive
multifocal leukoencephalopathy in an MS
patient.
Ferumoxytol (IV iron): no longer available.
Cortocosteroid e-learning module launched:
interactive module for clinical practitioners
covering:
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Commonly used corticosteroids.
Adverse effects.
Reducing risks.
Specific treatment of adverse effects.
Drug safety Update – April 15
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Hydroxyzine: risk of QT interval
prolongation and Torsade de Pointes.
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Do not prescribe with known prolonged QT
interval or risk factors (other medicines, CV
disease, family history sudden cardiac death,
significant electrolyte imbalance - low K or Mg,
significant bradycardia).
Avoid in the elderly.
Consider risks if patient taking medicines that
lower heart rate or potassium levels.
Maximum adult daily dose 100mg (50mg for
elderly if use cannot be avoided); 2mg/kg for
children up to 40kg.
Lowest effective dose for shortest period of time.
Drug safety Update – April 15
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Codeine for cough and cold: do not use in
children under 12 due to respiratory side
effects related opiate toxicity.
Not recommended in adolescents who have
problems with breathing.
Brings advice in line with 2013 warning to
avoid codeine for analgesia in under 12s
and only use in over 12s if ibuprofen or
paracetamol not effective; avoid completely
after tonsillectomy or adenoidectomy.
Drug safety Update – April 15
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Ketoprofen gel: letter sent to HCPs
to remind about risk of
photosensitivity reactions:
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protect from sunlight during the whole
period of topical ketoprofen treatment
and for 2 weeks after stopping
treatment;
wash hands after every application;
stop treatment immediately if they
develop any skin reaction
Drug safety Update – May 15
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Sofosbuvir with daclatasvir; sofasbuvir
with ledipasvir (for hepatitis C): risk of
severe bradycardia and heart block if
taken with amiodarone.
Pomalidomide (for multiple myeloma):
risk of cardiac failure, interstitial lung
disease and hepatotoxity.
Epoetin beta (NeoRecormin): increased
risk of retinopathy in pre-term infants)
Other issues
Bimatoprost eye drops
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300mcg 3ml bottles discontinued
April 15.
CRHFT ophthalmologists generally
use the 100mcg strength and have
advised that patients on the
300mcg strength can be changed to
the 100mcg strength in primary
care.
Intra-ocular pressure to be checked
at next routine appointment (unless
other issues)