Items which should not be routinely prescribed in primary care

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

Bath and shower preparations for dry and pruritic skin conditions

The use of bath and shower emollients is controversial and, until recently, evidence to inform practice was lacking. It is generally accepted that soap is drying and potentially irritating to skin and is best avoided by those with dry skin conditions. There is therefore clinical consensus that soap substitutes are necessary for people with dry skin conditions to wash with, and a guide on how to use these emollients as soap substitutes is available here: Bathing, showering and washing clothes | ECO (eczemacareonline.org.uk)

The recently published BATHE study aimed to address some of the uncertainty regarding emollient bath additives (i.e. those that are poured into bath water). This pragmatic randomised controlled trial (n=483) in children with eczema (aged one to eleven years) found no evidence of a clinically meaningful benefit from emollient bath additives, when used in addition to standard eczema management. This study indicated that efforts and resources should be targeted at effective use of leave-on emollients and soap substitutes in children with eczema, rather than the use of bath emollients. A full summary of the clinical evidence is available here.

Proprietary wash products (such as soap substitute shower gels) can be expensive, and evidence to justify their use over lower-cost alternatives is lacking. People with eczema should therefore be advised to wash with a regular leave-on emollient that is suitable for use as a soap substitute. Bath and Shower emollients are available to purchase over the counter if the patient wishes to use them.

Bath and shower emollients are therefore included in the NHS England » Items which should not be routinely prescribed in primary care. 

The Lincolnshire emollient guidance details formulary products that can be used as soap substitutes; PACE_Bulletin_Vol_17_No_1_Emollient_Guidance.pdf (lincolnshire-pacef.nhs.uk)

NHSE recommendation: Do not initiate bath and shower preparations for any new patient. Deprescribe bath and shower preparations and substitute with "leave-on" emollients. If the patient would like to continue to use bath and shower products, advise them to purchase over the counter (OTC).

Clinical evidence for bath and shower preparations (england.nhs.uk)

Overview | Atopic eczema in under 12s: diagnosis and management | Guidance | NICE

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.

European Medicines Agency (EMEA) recommends withdrawal of dextropropoxyphene-containing medicines (including co-proxamol)

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

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.

Minocycline for acne

Minocycline has various safety risks associated with its use, such as drug induced lupus erythematosus, pigmentation and hepatitis. There are alternative tetracyclines (lymecycline or doxycycline) which can be taken once daily to aid compliance, with a lower risk of side effects.

NHSE recommendation: Do not initiate minocycline for any new patients with acne. There is no evidence to support the use of one tetracycline over another in terms of efficacy for the treatment of acne vulgaris and alternative once daily products are available. Review existing patients and deprescribe accordingly e.g. change to an alternative drug for acne e.g. lymecycline.

Recommendations | Acne vulgaris: management | Guidance | NICE

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.

Oxycodone and Naloxone Combination Product (e.g. Targinact®)

Naloxone is included within this preparation with the aim of counteracting opioid-induced constipation by blocking the action of oxycodone at opioid receptors locally in the gut. The benefit of using an oxycodone/ naloxone combination product in patients receiving regular laxatives is uncertain. Furthermore, there is no evidence that it reduces the need for additional laxatives.

NHSE recommendation: Do not initiate oxycodone and naloxone combination product for any new patient. Review existing patients and deprescribe, or switch to an appropriate formulary analgesic, with laxative if required.

Perindopril Arginine

Rubefacients (excluding topical NSAIDs and capsaicin)

Silk Garments

Silk garments have primarily been used in the past for patients with atopic eczema although they have also been used for a variety of other conditions including vulvar conditions, epidermolysis bullosa and burns. A range of garments are available including eye masks, socks, gloves, vests, pyjamas, and body suits.

Silk garments are classified as medical devices. Currently, manufacturers need to ensure that their devices are safe and fit for their intended purpose to gain the CE mark; there is no requirement for clinical trials of efficacy. NHS England has designated silk garments as having low clinical effectiveness, and a lack of robust evidence of clinical efficacy. A summary of the available evidence is available here, but the small sample sizes in the available trials limit any conclusions which can be drawn.

Due in part to the limited evidence available, the NIHR HTA programme commissioned the CLOTHES trial to look at whether silk garments had a role in reducing eczema severity. This concluded that silk garments are unlikely to be cost effective to the NHS.

It is important when reviewing silk garment prescribing not to confuse all Skinnies brand prescribing with silk garments. Very, very rarely a tertiary referral centre may recommend a silk garment for one of the rarer dermatological diseases and potentially burn injuries. These recommendations should come from very specialist clinics, and the GP should expect to see evidence of MDT consultation and seek advice on duration of treatment, so that they are aware of how best to approach prescribing.

NHSE recommendation: Do not initiate silk garments for any new patient. Review existing patients and deprescribe accordingly - cease prescribing or advise patient to purchase.

Clinical evidence for silk garments (england.nhs.uk)

Tramacet® (Paracetamol with Tramadol)

The amount of paracetamol and tramadol in each Tramacet® tablet is less than the amount in standard paracetamol tablets and standard tramadol tablets and these are lower than the doses which are known to work.

Tramacet® does not work any better than other similar painkillers in the treatment of short- or long-term pain and it is more expensive, so it is not good value for money.

Combination analgesics should not be a first-line treatment choice, as the use of single ingredient analgesics is preferred to allow for independent titration of each drug. Practices are advised to discuss the options available with the patient and make a joint decision about what is best to relieve their pain.

NHSE recommendation: Do not initiate paracetamol and tramadol combination product for any new patient. Review existing patients and deprescribe e.g. prescribe paracetamol and tramadol generically as separate components or an alternative analgesic.

Travel vaccines (vaccines administered exclusively for the purposes of travel)

NHSE recommendation: The following vaccinations should not be prescribed on the NHS exclusively for the purposes of travel:

• Hepatitis B
• Japanese Encephalitis
• Meningitis ACWY
• Yellow Fever
• Tick-borne encephalitis
• Rabies
• BCG

These vaccines should continue to be recommended for travel, but the individual traveller will need to pay for the vaccination (by private prescription):PrescQIPP b316 Travel Vaccines bulletin

Only the following vaccines may be administered on the NHS exclusively for the purposes of travel, if clinically appropriate:

• Cholera
• Diphtheria/tetanus/polio
• Hepatitis A
• Typhoid

For all other indications, as outlined in Immunisation Against Infectious Disease, the Green Book, the vaccines remain free on the NHS.

The Green Book

Travel Health Pro (NaTHNaC)