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Category: Clinical Issues



Gabapentin and Pregabalin to be reclassified as Controlled Drugs

From 00:01 on 1 April 2019, gabapentin and pregabalin will be reclassified as Schedule 3 controlled drugs.  Full details were emailed to practice managers on 13 February.  This is an alert to those who have not yet been informed of the change.  When prescribing for Schedule 3 controlled drugs note particularly that:

  • The dose must be clearly defined ('as directed' is not acceptable.)
  • DHSC recommends that the maximum quantity should not exceed 30 days' supply.
  • Emergency supply is not permitted.
  • There must be a valid controlled drug prescription to obtain supplies from a pharmacy. 
  • From 1 April 2019, it will be not be possible to supply pregabalin and gabapentin through repeat dispensing, e.g. paper FP10 RD form or electronic repeat dispensing (eRD). This means prescribers must not issue repeatable prescriptions. (This is distinct from issuing a repeat prescription, to be requested and issued by the practice, with a wet signature attached.) Suppliers of EPS systems will update their systems by 31 March 2019 to support the change to the classification of gabapentin and pregabalin. Although system suppliers will make these changes prior to 1 April 2019, gabapentin and pregabalin prescriptions should not be treated as Schedule 3 controlled drugs until 1 April 2019.

You should now:

  • Ensure your practice team is aware of the change.
  • Stop repeat dispensing for gabapentin and pregabalin as early as possible before 1 April 2019 and put transition arrangements in place for patients.  
  • Inform all patients currently taking pregabalin and gabapentin about the impact this change will have on their prescriptions. Ask them to ensure they request any prescriptions in plenty of time, to help the NHS to manage the transition process.

It is not helpful or appropriate for anyone to stockpile these medicines. 

Flu vaccine ordering for 2019/20 season

Practices should place their orders as soon as possible (given the issues we had this season), to avoid any delay in delivery of vaccines and to ensure you have supplies of the recommended vaccines in September, ready for the start of the season for all your eligible population.  We have been assured that there will be no phased delivery for next season and a practice can choose to have their order delivered in one batch at the start of the season or split into two deliveries, depending on available fridge space.  Most pharmaceutical companies offer a sale or return service on a percentage of their order, so there is scope to return unused vaccine to the supplier.

Vaccines recommended are as follows:

  • The standard egg cultured quadrivalent inactivated vaccine (QIVe) will continue to be recommended for 18 to 64-year olds in clinical at-risk groups and other eligible groups, including frontline health and social care workers.
  • The adjuvanted trivalent inactivated vaccine (aTIV) will continue to be recommended for individuals aged 65 years and over.
  • In addition, the cell grown quadrivalent vaccine (QIVc), Flucelvax® Tetra, is now licensed for use in the UK for patients aged nine years and upwards and is suitable for those aged 9 to 64 years in clinical at-risk groups, frontline health and social care workers and for individuals aged 65 years and over.

Note that all children's vaccines will be centrally procured, as in previous seasons, and can be ordered from ImmForm.

Flu vaccination for pregnant women

Proportionately the risk of dying from flu is far greater for pregnant women than for other cohorts.  The LMC and LPC are equally concerned that the uptake of vaccination is still too low in this group.  From our side, please do everything you can to liaise with your local midwives to ensure that this group are all protected.  It should not matter who gives the vaccination, but whoever is best placed to do it should do it while they have the woman in front of them.

Flu vaccines for 2019/2020

As already circulated by email, the definitive list of flu vaccines for this coming season can be seen here.  Please note that Public Health England will continue to procure and supply all LAIV and injected flu vaccines for those aged under 18 years. These vaccines are to be ordered through Immform:

Seqirus plan to have a 'soft close' on ordering of adjuvanted trivalent influenza vaccines (aTIV/Fluad recommended for patients aged over 65 years) at the end of February. They are allocating delivery slots and the current 'week available' (as of 22.01.19) is the 23.09.2019.  Seqirus have confirmed that the aTIV vaccines will be delivered with staked needles.

EU's Falsified Medicines Directive (FMD)

Counterfeit, high-priced medicines are a threat to public health worldwide.  You may have heard that the FMD (Directive 2011/62/EU) was published on 1 July 2011 in the Official Journal of the European Union and will be rolled out from 8th February 2019. The European Commission itself estimates that only 0.005% of prescribed drugs are counterfeit.  The FMD is therefore something of a sledgehammer to crack a minute nut, albeit potentially serious for any patient affected. FMD will introduce tougher rules to ensure that medicines are safe and that the trade in medicines is rigorously controlled.  

Under the FMD all prescription medicines for sale will have to carry a unique and randomised serial number encoded in a 2D-barcode, and a visible anti-tampering device.  At each stage of the supply chain, the product will be inspected to ensure it has not been tampered with, has not previously been dispensed and that the packaging remains intact.  On supplying the medicine to the patient, the unique identifier must be 'decommissioned' via a scan from the FMD system, to prevent any duplication of a legitimate identifier for use on a falsified medicine.  The trouble is that if the patient does not collect the medicine within 10 days the FMD will require it to be destroyed.  This could be hugely wasteful.  This is being looked at nationally.

All practices (dispensing and non-dispensing) will need to have the infrastructure and processes in place to decommission medicines, including for prescription and administration of vaccines.  Clearly it will be up to the designers of the clinical systems to ensure that the functionality is provided but it will be for the CCG, via the CSU, to ensure that practice IT hardware is up to the task. Practices are advised not to take any precipitate purchasing action which they may regret later. Inevitably there will be workload implications, particularly for dispensing practices. 

You can read more about it in the BMA's focus document

Vaccines for the 2019/20 seasonal flu vaccination programme

The formal letter (NHS England gateway reference 08529 dated 20 Nov 18) announcing which vaccines you can order is coming out to practices; you may already have received it.  Note that there is a move from vaccines cultured on eggs (suffixed 'e') to those cultured on mammalian cells (suffixed 'c').  These new vaccines are expected to be licensed by NHS England in time for them to be ordered, but it has not yet happened.  In outline:

  • 18-64 year olds.
    • Quadrivalent inactivated vaccine (QIVe) - already licensed.
    • QIVc - when licensed,

both being better than TIVe for this group.

  • 65s and over
    • Adjuvanted trivalent inactivated vaccine (aTIV) - already licensed.
    • Cell-grown quadrivalent vaccine (QIVc) - once licensed, probably before Christmas.
    • High-dose trivalent vaccine (TIV-HD) - once licensed, again expected in December.
  • Children. Public Health England will continue to procure and supply vaccines for all children aged 6 months to 17 years.

Practices should begin ordering currently licensed vaccines; ordering of these licensed vaccines should not be unnecessarily delayed. For the new, currently unlicensed vaccines, please wait for confirmation from NHS England that they are eligible for reimbursement before ordering.  

Keep Fit and Enjoy Your Retirement

Your golden years can be precisely that: golden.  Time is yours to do what you want instead of sweating it out from nine to five, and there are plenty of activities to keep you busy. Taking long walks on the beach, playing with the grandkids and enjoying epic meals at your favourite restaurant are all on life's menu, so you should be making the most of these years.

Poor health, however, could keep all of that fun out of reach. The truth is, you're at higher risk of weight gain, cardiovascular disease and dementia than ever before, though there are measures you can take to stay fit and get the most out of your retirement.

Hang out with friends.  This is one of the most important things you can do to stay fit physically and mentally, according to an article in the Boston Globe that states how relationships are particularly important in your golden years. That's more than enough reason to invite someone over for a cup of tea or a game of cards, though it'll also be fun just to keep up on current events.

Get your brain buzzing.  This is absolutely vital if you want to keep that wit razor sharp, and it is as easy to do as picking up a book and reading. If that's not your cup of tea, how about adding some crossword puzzles or Sudoku into your weekly routine? Both will help you build neural connections as well as retain a quick short-term memory and keen concentration.

Improve your diet.  First off, reduce the amount of calories you consume, as your metabolism has slowed down over the years. However, you do need to broaden the amount of nutrients you get, which means adding more fruits, vegetables, legumes, nuts and seeds to your diet while cooking with less fat, salt and sugar. Lucky for you, healthy meals aren't hard to find.

Move your body.  Without exercise, you risk weight gain, heart disease and diabetes, but there's no reason to be too negative, as staying in top form is just a matter of finding exercise you enjoy and can do regularly. Jogging, swimming and cycling are excellent forms of cardio, and you should aim for about five 30-minute sessions a week with strength, balance and flexibility training thrown in as well.

Take up a hobby.  Hobbies help relieve stress, partly by putting you into a state of 'flow', which is a deep connection between your mind and body generated while playing the piano, knitting or working the pottery wheel. It's also a wonderful way to challenge yourself and capture some of the energy and excitement you had when you were younger.

Be mindful.  This means doing things in the present with your full concentration devoted to the task at hand. Hobbies are one way to do that, as is meditation. It serves as yet another way to find relief from stress while also reducing the intensity of chronic pain by more than 50 percent, and you don't have to be an expert to gain those benefits.

Go outside.  Nature keeps you healthy, in a variety of ways. First off, it encourages physical activity that counts toward your weekly cardio routine. Secondly, you'll get a boost of energy from the fresh air and sunshine. Thirdly, being among the grass and trees wards off depression. There's a fourth, fifth and sixth reason, too, if you're interested.

Hit the road. You've wanted to do this for a long time, and now you have an excuse: travel is healthy. One of the main reasons is quite simple, as exploring the world keeps you happy and active. You'll also gain benefits in the forms of improved cognitive power and mental health from broadening your perspectives and learning more about cultures near and far.

You've got a roadmap for enjoying the years ahead. Keep yourself mentally and physically well, and you'll make the most of this exciting new chapter of your life.




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