MTRAC review perampanel and zonisamide

The latest MTRAC committee meeting discussed the prescribing of perampanel adjunctive therapy and zonisamide monotherapy for the treatment of partial (or focal) seizures in epilepsy.

It was the committee’s opinion that perampanel should only be used in a tertiary care setting, and that patients receiving treatment with perampanel were likely to receive continued specialist supervision and treatment.

With zonisamide the committee agreed that zonisamide monotherapy should only be considered when other NICE-recommended first- and second-line treatment options have proved ineffective or are not tolerated.

Each of the commissioning support sheets can be accessed from http://centreformedicinesoptimisation.co.uk/mtrac/committee-recommendations

The next committee meeting is on the 24^th October and will be discussing nalmefene for the treatment of alcohol dependency and melatonin for the treatment of primary insomnia.

If you’d like to know more about MTRAC or join the mailing list, more information is available from our website at http://centreformedicinesoptimisation.co.uk/mtrac

September's outputs from Keele's 'Medicines Optimisation' team

Another busy month for the team at Keele University's Centre for Medicines Optimisation, trying to get our antibiotics-themed educational outreach pack (we call them our Actions for Commissioning Teams [ACT] packs) out in time for the winter peak in antibiotic prescribing. This latest ACT pack actually addressed three 'antibiotics-related' QIPP topics from the medicines and prescribing team NICE:

1. Antibiotic prescribing, in particular the use of broad-spectrum antibiotics 
2. Three-day trimethoprim for uncomplicated UTIs in women
3. Minocycline for acne

In relation to the prescribing data provided to our CCGs and practices on the above topics, the variation in use of co-amoxiclav across CCGs was notable, as was use of minocycline (although the prescribing data indicate a marked decline in use of the latter in recent months). 
 

Our latest Monthly Script newsletter has also just been published (an 'open-access' version of the Monthly Script is available on our website).  In this latest newsletter, we highlight the recent update to the NICE guideline on Urinary Incontinence in women.  The updated guideline contains several changes concerning treatment-choice, including a new recommendation that immediate-release (I/R) tolterodine and once-daily darifenacin are now also both recommended as first-line antimuscarinics, in addition to I/R oxybutynin, for women with overactive bladder or mixed urinary incontinence).(We note that I/R tolterodine is now available as a lower cost generic and that there is evidence to suggest that it is associated with a lower risk of dry mouth than I/R oxybutynin).
In light of these new recommendations, we took the opportunity to look at current levels of use of these first-line treatments in our subscriber CCGs (calculated as number of items of I/R oxybutynin, I/R tolterodine and darifenacin as a % of antimuscarinic items). Use ranges from 10 to 36% currently across our subscriber CCGs. We also reported current average spend on antimuscarinincs (reported as Net Ingredient Cost [NIC]/antimuscarininc item) and estimated annual savings for CCGs based on a move to the 25th percentile value for NIC/item (amounting to >£200K for some subscriber CCGs). 

The Monthly Script also reported findings of the TIOSPIR trial, which appear to offer some reassurance over the safety of tiotropium delivered via the Respimat device for the treatment of COPD.  The trial, which  was a randomised, double-blind, head-to-head comparison of tiotropium Respimat and triotropium Handihaler, was undertaken following reports of a numerical increase in all-cause mortality with tiotropium Respimat compared with placebo (e.g. link to exisiting MHRA safety advice on tiotropium Respimat).  TIOSPIR randomised patients with COPD (n = 17,135) to either tiotropium Respimat (2.5 mcg or 5 mcg once daily) or tiotropium HandiHaler (18 mcg once daily).  The primary safety outcome for this study was risk of mortality (non-inferiority analysis). During a mean follow-up of 2.3 years, tiotropium Respimat 2.5 mcg/day and 5 mcg/day were both found tobe non-inferior to tiotropium HandiHaler for risk of mortality (Respimat at a dose of 5 mcg vs. HandiHaler:hazard ratio, 0.96; 95% confidence interval [CI], 0.84 to 1.09; Respimat at a dose of 2.5 mcg vs. HandiHaler: hazard ratio, 1.00; 95% CI, 0.87 to 1.14).

We also highlight a recent analysis of use of lipid lowering drugs for primary prevention of CVD amongst UK General Practices, which suggests that that over half of patients prescribed such treatments do not meet current guideline criteria for treatment. The study also found considerable underuse of the drugs in eligible patients.

Another month....another Monthly Script....!

Hello readers!

The August-13 open-access version of our Monthly Script Newsletter has just gone live. 

Included in this month's newsletter are updates from NICE, notably the new guidance on varicose veins (offer less invasive treatments before surgery) and new public health guidance on BMI measurements (extend the application of the lower BMI thresholds of 23 kg/m² to indicate ‘increased risk’ and 27.5 kg/m² to indicate ‘high risk’ of type 2 diabetes used in Asian populations also to black African and African-Caribbean populations). 

We were also interested to learn that the European Medical Agency (EMA) is now starting its review of zolpidem - the FDA recently mandated the lowering of recommended doses of zolpidem for some patients, in particular women, due to concerns over next-day effects. 

Some of you may recall the Dispatches Programme broadcast earlier this year on the safety of GLP-1 based therapies for diabetes.  The EMA has now completed its review of GLP-1 therapies, concluding that “presently available data do not confirm recent concerns over an increased risk of pancreatic adverse events with these medicines”. 

In  relation to prescribing data, this month we provide updated estimates of the additional (and substantial!) costs to our subscriber CCGs following divestment of Epanutin, and, prompted by the Advertising Standards Authority recent censure of the Society of Homeopaths, we report on comparative spend of homoeopathy products (interesting variation seen locally).

Hope you find the newsletter of interest!

New Website Launched

Hi readers,

We are pleased to announce the launch of a brand new website for the Centre for Medicines Optimisation at Keele University.

The address for our new website address is: http://www.centreformedicinesoptimisation.co.uk/

The site offers improved functionality as it is now fully searchable, and includes our subscriber-only prescribing support materials, MTRAC verdicts, and open-access resources.

For our subscribers, the existing PCT-wide log-on details used on the previous site will not work on the new site and you will need to sign-up for a new individual account using your NHS e-mail address.  A simple form needs to be completed on the home page of the website in order to set up your account.  If you need to access the reports for more than one CCG, this can all be managed via your single account - just specify all the organisations you require access to when you sign-up.  Our old site will now no longer be updated but will be retained as a legacy site in the immediate future.  

You may also be interested in connecting with the Centre for Medicines Optimisation via social media and we have the following accounts:

• Blog: http://centreformedicinesoptimisation.blogspot.co.uk/ 
• Twitter: https://twitter.com/MedManKeele
• Linked In: http://www.linkedin.com/groups/Centre-Medicines-Optimisation-5117603/about
• Facebook: https://www.facebook.com/MedManKeele

Please do get in touch if you have any questions regarding either the new website or any of our reports.

Keele Medicines Optimisation Team

July's Monthly Script

Hello readers!
We have just published the open access version of our latest Monthly Script Newsletter (July 13), which provides a round-up of developments relating to primary care; e.g. new NICE guidance, safety updates, recently-launched and 'on the horizon' products, and a commentary on new evidence.

We produce this newsletter for the CCGs in the West Midlands that subscribe to our prescribing support service.  You will see that the 'open access version' posted on our website has the data pertaining to our subscriber CCGs redacted, but we hope that other CCGs will still find this newsletter of interest.

Our latest Monthly Script reported on the draft update to the NICE neuropathic pain (NP) guideline, which has been out for consultation. Medicines management teams may recall that this update was initiated following concerns about the financial impact of pregabalin, which was recommended as a first-line treatment in the 2010 NP guideline ahead of the much lower-cost, longer-established gabapentin (the DTB’s article is suggested for further reading). Although final guidance isn't expected until later this year, it gave us a good reason to dip into the prescribing data and look at current use of gabapentin locally (calculated as "gabapentin items as a percentage of the total number of gabapentin and pregabalin items prescribed" for those of you familiar with the data), finding substantial variation across our subscriber CCGs.  We also calculated savings for our CCGs were they to move to the 75th percentile value, which were in excess of £100K per quarter for several CCGs. We await with interest publication of the final guideline, which is due out in October!

Welcome to our new blog

Hello and welcome to the new blog for the Centre for Medicines Optimisation at Keele University.

We work with medicines management teams, commissioners and GPs to offer services including prescribing data analysis, medicines management education and critical appraisal/commissioing support services.

We'll be posting lots of interesting and useful things on the blog over the coming months, ranging from extracts from our Monthly Script reports to news about the prescribing support solutions we can offer to the NHS.

We'll also publish links to our open access materials on our main site and publicise some of our up and coming Good Practice Day events.