Clinical Update

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Clinical Update

• New updated guidelines
• Significant traffic light updates
• Significant safety issues
• Other issues
• Feedback from practices

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Clinical Guidelines
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Chronic rhinosinusitis with or without nasal
polyps - NEW

• 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.

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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

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Chronic rhinosinusitis with or without nasal
polyps - NEW

• Antibiotic prescribing
• A short course of antibiotics might be
  appropriate as per local antimicrobial
  guidelines.
• Seek specialist advice before prescribing
  long-term antibiotics, as evidence for this
  approach is limited

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Chronic rhinosinusitis with or without nasal
polyps - NEW

• Treatment
• Most idiopathic inflammatory polyps are steroid
  responsive.
• A ladder or stepped approach, but ideally
  patients shouldnt 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.

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Chronic rhinosinusitis with or without nasal
polyps - NEW
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Childrens asthma guideline 5 to 12 years - UPDATE

• Main change is at step 3a (adding a LABA)

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Childrens asthma guideline 5 to 12 years - UPDATE

• Included more options to assess control

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Gastro-oesophageal reflux disease in children and
young people

• 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

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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.

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Breast fed infants with frequent regurgitation
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Formula-fed infants with frequent regurgitation
with marked distress
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Thickened formula information

• Carobel first line option (more cost-effective
  and allows easy review).
• Needs a wide or vari-flow teat.
• Endorse ACBS.
• Powdered antiregurgitation formula is an
  alternative.
• Enfamil AR and SMA Staydown are ACBS approved for
  significant GOR
• Not to be used for a period gt6 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.

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Pharmacological treatment of GORD
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Alginate, H2RA and PPI dosing information
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AF guideline - UPDATE

• 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.

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Other guideline updates

• 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.

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Shared-Care Guidelines
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Colomycin for pseudomonal lung infection in
adults with bronchiectasis

• Updated to clarify consultant responsibilities
  regarding sputum monitoring
• 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

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ADHD in children and adults

• Matoride XL included as a cost-effective
  alternative to Concerta XL for new patients.
• Bioequivalent and GPs could consider changing
  existing patients, after a face to face review.

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Denosumab for the prevention of osteoporotic
fractures

• Updated to include men with osteoporosis
  including the specific sub-set of men with
  prostate cancer treated with androgen deprivation
  therapy.

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Significant Traffic Light Changes
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Significant traffic light updates RED

• Rivaroxaban 2.5mg new strength, licensed for the
  prevention of atherothrombotic events in patients
  with ACS in combination with aspirin,
  aspirinclopidogrel 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.

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Significant traffic light updates GREEN

• 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.

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Significant traffic light updates GREEN

• Lamotrigine after specialist initiation for
  indications in addition to epilepsy e.g. bipolar
  disorder.

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Significant traffic light updates BROWN

• 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.

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Significant traffic light updates BROWN

• 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.

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Significant traffic light updates BROWN

• 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 cost-effective.

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Significant traffic light updates BLACK

• Olodaterol. Once daily LABA for COPD but less
  cost-effective formulary choice, formoterol
  Easyhaler.

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Significant Safety Updates
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Drug safety Update March 15

• 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
• Commonly used corticosteroids.
• Adverse effects.
• Reducing risks.
• Specific treatment of adverse effects.

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Drug safety Update April 15

• Hydroxyzine risk of QT interval prolongation and
  Torsade de Pointes.
• 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.

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Drug safety Update April 15

• 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.

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Drug safety Update April 15

• Ketoprofen gel letter sent to HCPs to remind
  about risk of photosensitivity reactions
• 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

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Drug safety Update May 15

• 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)

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Other issues
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Bimatoprost eye drops

• 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)