In August 2019 NHS England updated guidance for CCGs* to support them with prescribing. This highlighted drugs which fall into the following categories;
- Products of low clinical effectiveness, where there is a lack of robust evidence of clinical effectiveness or there are significant safety concerns;
- Products which are clinically effective but where more cost-effective products are available, including some products that have been subject to excessive price inflation; and
- Products which are clinically effective but due to the nature of the product are deemed a low priority for NHS funding.
In the majority of cases there are other more effective, safer and/or cheaper alternatives available to the treatments that NHS England is recommending should not be routinely prescribed in primary care.
The guidance is available at: NHS England » Items which should not be routinely prescribed in primary care
The information in the below resource packs should be used in conjunction with the references provided, and the guidance does not remove the clinical discretion of the prescriber in accordance with their professional duties.
*The original guidance was produced when there were CCG's, we have now formed ICB's however the guidance still applies
Co-proxamol
Co-proxamol is markedly more toxic in overdose than paracetamol alone. It was fully withdrawn in 2007 due to safety concerns. This has saved the lives of around 300–400 people per annum in the UK from self-poisoning, of which around a fifth would have been accidental. Any prescriptions are now unlicensed ‘special-order’ products (“specials”).
Lincolnshire ICB DOES NOT support the prescribing of co-proxamol for any indication, in line with NHS England’s national guidance on medicines which should no longer be prescribed in primary care and due to the safety concerns.
Lincolnshire ICB Position statement on the prescribing of co-proxamol tablets
NHSE recommendation: Do not initiate co-proxamol for any new patient. Review existing patients and deprescribe accordingly e.g. change to an alternative analgesic (e.g. paracetamol or co-codamol) or consider referral to pain management service for assessment.
| Title |
|---|
| Patient Information Leaflet Change to Co-proxamol Prescribing |
| PrescQIPP b194-co-proxamol bulletin |
Doxazosin Modified Release
Glucosamine and chondroitin
NICE states that glucosamine (with or without Chondroitin) should not be offered to manage osteoarthritis as there is no strong evidence of benefit. See PrescQIPP bulletin listed below for more information.
NHSE recommendation: Do not initiate glucosamine and chondroitin for any new patient. Review existing patients and deprescribe. If the patient would still like to take the supplement after understanding that there is a lack of efficacy, advise them to purchase OTC.
Overview | Osteoarthritis in over 16s: diagnosis and management | Guidance | NICE
| Title |
|---|
| Patient Information Leaflet Changes to Glucosamine Prescribing |
| PrescQIPP b205 Glucosamine bulletin |
Herbal Treatments
These treatments will often hold what is called a “traditional herbal registration” (THR). The THR is based on a minimum of 30 years use of the product as a traditional medicine for a stated condition, with no requirement for clinical trials or scientific evidence of the products efficacy. THR products are intended for conditions that can be self-medicated and don't require medical supervision, such as coughs, colds or general aches and pains.
In addition to herbal treatments with a THR, there are other available natural products without a THR (e.g., eucalyptus and almond oils), coenzyme Q10 (ubiquinone and ubidecarenone) and evening primrose (gamolenic acid). These also do not have robust evidence of clinical effectiveness and should not be prescribed at NHS expense.
NHSE recommendation: Do not initiate herbal items for any new patient. Review existing patients and deprescribe. If the patient would like to continue, advise them to purchase OTC, with guidance from their pharmacist as to whether it is safe to take e.g. in case of potential interaction with other medicines.
Traditional herbal medicines: registration form and guidance - GOV.UK (www.gov.uk)
Herbal medicines granted a traditional herbal registration (THR) - GOV.UK (www.gov.uk)
Homeopathic remedies
Homeopathy seeks to treat patients with highly diluted substances that are administered orally. A Specialist Pharmacy Service (SPS) review found no clear or robust evidence to support the use of homeopathy on the NHS.
NHSE recommendation: Do not initiate homeopathic items for any new patient. Review existing patients and deprescribe. If the patient would like to continue, advise them to purchase.
| Title |
|---|
| Patient Information Leaflet Changes to Homeopathy Prescribing |
| SPS Clinical Evidence for Homeopathy |
Omega-3 Fatty Acid Compounds
This workstream was discussed with the department of Diabetes & Endocrinology at United Lincolnshire Hospitals NHS Trust, specifically with a consultant who has been involved in the new lipid management pathway. The Medicines Optimisation team clarified the position of omega-3 treatment in patients with raised lipids.
Icosapent Ethyl (an ethyl ester of the omega-3 fatty acid, eicosapentaenoic acid) is the only omega-3 related product which is now recommended, as this has a NICE TA for use in specific secondary prevention situations. This is Amber 2 on our formulary and can be started and then prescribed in primary care on specialist recommendation. In other situations, the recommendation to the patient would be to buy high strength Omega 3 from the supermarket.
Any patients who have historically been started on Omega-3 preparations (such as Omacor) by lipid clinics can now be deprescribed without re-referral. Obviously if the patient’s lipids remain high, then they can be considered for Icosapent Ethyl if needed. If patients do not qualify for that and wish to continue treatment, then they will need to buy their own Omega 3.