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Medicines Management Matters

Medicines Management Team

Number: 8 | December 2020

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TRANSDERMAL FENTANYL PATCHES FOR NON-CANCER PAIN: DO NOT USE IN OPIOID-NAIVE PATIENTS

The MHRA (Medicines and healthcare Regulatory Agency) released this DSU (Drug safety update) on the 23rd of September 2020.

Considerable concern has been raised regarding the prescribing of opioids in the UK (see Drug Safety Update on risk of dependence and addiction with opioids). In 2019, the Commission on Human Medicines (CHM) convened an Expert Working Group to examine the benefits and risks of opioids in the relief of non-cancer pain. During this review it was noted that there have been reports of serious harm, including fatalities, associated with fentanyl patches in both opioid-naive patients and opioid-experienced patients.

Good practice guidance includes:

  • do not use fentanyl patches in opioid-naive patients
  • use other analgesics and other opioid medicines (opioids) for non-cancer pain before prescribing fentanyl patches
  • if prescribing fentanyl patches, remind patients of the importance of:
    • not exceeding the prescribed dose
    • following the correct frequency of patch application, avoiding touching the adhesive side of patches, and washing hands after application
    • not cutting patches and avoiding exposure of patches to heat including via hot water (bath, shower)
    • ensuring that old patches are removed before applying a new one
    • following instructions for safe storage and properly disposing of used patches or patches that are not needed; it is particularly important to keep patches out of sight and reach of children at all times
  • make patients and caregivers aware of the signs and symptoms of fentanyl overdose and advise them to seek medical attention immediately (by dialling 999 and requesting an ambulance) if overdose is suspected
  • remind patients that long-term use of opioids in non-cancer pain (longer than 3 months) carries an increased risk of dependence and addiction, even at therapeutic doses (see Drug Safety Update on risk of dependence and addiction with opioids); before starting treatment with opioids, agree with the patient a treatment strategy and plan for end of treatment

Don’t forget that a fentanyl 25 microgram patch is equivalent to 60mg morphine daily

A general note on opioid initiation: agree with the patient a treatment strategy and plan for end of treatment.

PRESCRIBING OF HIGH RISK MEDICATION

High risk medication is identified on SystmOne in bold red lettering.

An example is insulin glargine (Toujeo). This is to alert prescribers that they need to take extra care in prescribing due to risks around the frequency of dosing, strength of the formulation or differences between devices.

This shows on SystmOne as:

The warning then flags up as:

If in doubt as to whether to prescribe then please refer to the Bedfordshire and Luton Joint Formulary Click here This will give you all the guidance needed to prescribe safely.

Another example of a High Risk Medication would be methotrexate.  We suggest reading the recent MHRA alert which can be found Here

When prescribing on SystmOne the Risk Warning pop-up box appears

Followed by the dosing instructions

We strongly recommend that you add the day of the week the patient is to take the medication on the dose instructions e.g.

Please do not add it as a Script Note as this is not automatically printed on the dispensing label.

Denosumab – Information for GPs

This information has been updated in response to :-

This updated version includes specific information regarding the duration of treatment and emphasises the following key points:-

  1. DO NOT STOP or DELAY ongoing treatment with denosumab without a specialist review (due to increased risk of multiple vertebral fractures reported)
  2. GPs should request a DXA after 3-5 years of treatment, specifying duration of treatment so far and any changes in risk factors since treatment started.
  3. Specialist advice regarding duration of treatment will be provided in the DXA report or alternatively advice is available via ‘Advice and Guidance’.

Click here to access the updated guidance

The Primary Care Osteoporosis Treatment Guidelines will also be updated to include the warnings outlined above.

PresQIPP PMC training (Practice Medicines Co-ordinators)

PresQIPP have just relaunched their Practice Medicines Co-ordinators e-learning course designed for non-clinical staff in GP practices who manage the repeat prescribing process.

The course is funded by HEE and is available to GP practice staff.  Further information can be found Here

Useful Links

Bedfordshire and Luton Joint Formulary
Care Home Medicines Management information can be found here
Joint Prescribing Committee newsletters can be accessed here
Care Home newsletters can be accessed here

Monthly prescribing practice reports are now available on TeamNet. Log in to see the most up to date data.

For further advice on any of the drugs/issues highlighted in this newsletter, please contact your Medicines Management Team: Tel 01525 624375. E-mail BEDCCG.bedsmeds@nhs.net

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