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Blood pressure drug among 7 treatments scrapped from prescriptions

NHS England has recommended scrapping hypertension medication aliskiren and six other drugs and items from prescriptions following a public consultation.

The seven treatments are the latest to be added to NHS England’s growing list of medications and treatments which should not be prescribed in primary care, because it believes they have “low clinical effectiveness” or “more cost-effective products are available”.

Following the results of a public consultation – which ran from November 2018 to February 2019 – NHS England will restrict the prescribing of the following medicines and items:

  • aliskiren
  • amiodarone
  • dronedarone
  • minocycline for acne
  • needles for pre-filled and reusable insulin pens that cost more than £5 per 100 needles
  • emollient bath and shower preparations for dry and pruritic skin conditions
  • silk garments.

Blood glucose testing strips for type 2 diabetes that cost more than £10 for 50 strips were also included in the consultation. However, NHS England said it is “undertaking further work” to determine “which factors influence the choice of blood testing strips”, so has not added them to the list.

Commenting on the results of the consultation, NHS England said it had listened to a “range of views from patients, clinicians, local commissioners and members of the public”.

It “also considered additional clinical evidence reviewed by the [NHS] Specialist Pharmacy Service on the use of bath and shower preparations and silk garments for the treatment of dry and pruritic skin conditions”, the commissioning body added.

Discretion will lie with individual clinical commissioning groups (CCGs) to decide whether to implement the national commissioning guidance, it said.

Which additional items has NHS England recommended be scrapped from prescriptions and why?

Items considered to be of “low clinical effectiveness”:

Amiodarone: “Amiodarone has an important place in the treatment of severe cardiac rhythm disorders, where other treatments either cannot be used or have failed,” NHS England said.

However, “it has potential major toxicity and its use requires monitoring both clinically and via laboratory testing”. It therefore should only be prescribed in “exceptional circumstances” by a specialist, in cooperation with a multidisciplinary team.

The National Institute for health and Care Excellence (Nice) has issued a recommendation against offering amiodarone for long-term rate control.

Dronedarone: “Dronedarone was originally approved to prevent atrial fibrillation from coming back or to lower the heart rate in adults who have had or have non-permanent atrial fibrillation. In September 2011, this indication was restricted to the maintenance of normal heart rhythm in ‘persistent’ or ‘paroxysmal’ atrial fibrillation after normal heart rhythm has been restored,” NHS England explained.

The drug should only be prescribed for new patients in “exceptional circumstances” and “must be initiated by a specialist”, the commissioning body stressed.

Nice clinical guidance puts “greater emphasis on rate rather than rhythm control”, NHS England added.

Emollient bath and shower preparations for dry and pruritic skin conditions: A study from May 2018 found “no evidence of clinical benefit” for bath emollients in the standard management of childhood eczema, NHS England said, therefore they should not be prescribed for any new patient, and “deprescribing” should be encouraged for existing patients. “Leave-on” emollients can be prescribed as an alternative if needed, it added.

Minocycline for acne: “Minocycline is mainly used for acne; however, there are various safety risks associated with its use,” such as drug-induced lupus, skin pigmentation and hepatitis, NHS England said. It recommended it not be prescribed for new patients.

CCGs should support prescribers in “deprescribng minocycline” in all patients with acne, NHS England added.

Silk garments: Evidence relating to the use of silk garments for skin conditions “is weak and of low quality”, NHS England said. A 2017 trial by the University of Nottingham concluded “that using silk garments for the management of eczema is unlikely to be cost-effective for the NHS”, NHS England said.

Items where more cost-effective products are available:

Aliskiren: While it is considered clinically effective, there are cheaper alternatives, NHS England said.

Needles for pre-filled and reusable insulin pens that cost more than £5 per 100 needles: “There are many different types of insulin pen needles available at a varying cost from £3.95 to £30.08 for 100,” NHS England said. “The 4mm needle [is considered] to be the safest pen needle for adults and children regardless of age, gender and body mass index.”

It recommended insulin pen needles that cost more than £5 per 100 needles no longer be prescribed for any new diabetes patients.

Source: Items which should not routinely be prescribed in primary care: an update and a consultation on further guidance for CCGs, version two, June 2019.

The initial list of 18 items that should not be prescribed can be found here.

 

In 2017, C+D hosted a roundtable debate to discuss what plans to scrap certain treatments – including gluten-free items – from prescriptions would mean for pharmacists, patients, and the wider NHS. Listen to it below, and subscribe to all of C+D's podcasts here.

What do you make of the decision to add these items to the list?

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