NHS Blackburn with Darwen NHS East Lancashire East Lancashire Hospitals NHS Trust
A MONTHLY MEDICINES AND PRESCRIBING BULLETIN FOR HEALTHCARE PROFESSIONALS IN EAST LANCASHIRE FOCUSING ON NEW THERAPIES.
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– Generic vs. Brand Prescribing
As you will no doubt be aware, there are now multiple formulations of various post-transplant immunosuppressants available, including mycophenolate.
ESPRIT (Efficacy and Safety of Prescribing In ransplantation), an independent group of multidisciplinary healthcare professionals, has provided their recommendations on the prescribing of mycophenolate which has been developed following an in-depth review of the latest evidence available.
For more information on ESPRIT and details on their other prescribing recommendations for similar agents, under general news when visiting www.esprit.org.uk.
ESPRIT Group recommendations
There are likely to be a number of different mycophenolate formulations introduced in the UK in the forthcoming months. Indeed the first generics were introduced in the week in which the patent expired on mycophenolate mofetil (original
C e l l C e p t ® b r a n d ) . T h e E S P R I T
have assessed the evidence currently available on the potential differences between mycophenolate mofetil (MMF)
Please note that it is only the patent on MMF which expired in November 2010, and not that of ECMPS.
Mycophenolate Mofetil (MMF) vs. Enteric Coated Mycophenolate Sodium (ECMP , M y f o r t i c ® b r a n d )
There are definite differences apparent between MMF and ECMPS, most notably in terms of interactions with proton pump inhibitors (PPIs), which affect the pharmacokinetics of MMF, but not ECMPS. Given the almost universal use of PPIs post-transplant, this is an important difference.
As a result it is not recommended that ECMPS and MMF products are interchanged. ECMPS should be prescribed by brand and patients should be made aware that they are different.
Mycophenolate Mofetil (MMF) vs. Mycophenolate Mofetil (MMF) new generics
There is a high degree of variability apparent with all MMF formulations reviewed, be it the original CellCept® formulation itself or the new generics. This is both in terms of pharmacokinetics and reported side effects.
The evidence as to whether mycophenolate is a critical dose drug or not is equivocal.
Monitoring of blood levels is not routinely recommended, but there is some evidence that it may be desirable on certain occasions.
As there is no real evidence that different MMF formulations cannot be viewed as interchangeable, an immediate blanket ‘prescribe by brand’ recommendation was not thought to be warranted at this stage, unlike with ciclosporin and tacrolimus.
Having said that, there is no real evidence that the different MMF products can be safely interchanged either, SO the overall ESPRIT Group recommendation is that MMF formulations should only be changed in collaboration with the transplant unit. Patients should be fully informed of potential changes in MMF formulations and encouraged to report any changes experienced (especially adverse events) to their transplant unit. In this way collaboration between patients and their transplant units may enable real-life data to be collected and any potential issues highlighted as soon as possible.
Patients should also be made aware that they can self-report adverse events via the yellow card scheme at http://yellowcard.mhra.gov. uk/, although they should always discuss them with the transplant unit as well.
East Lancashire Health Economy Recommendations
In conjunction with the above recommendations from ESPRIT, we would urge prescribers to prescribe all formulations of mycophenolate (MMF and ECMPS) by brand. This way there can be no confusion as to what the patient should be receiving.
Acknowledgement: ESPRIT recommendation November 2010
Despite limited evidence of efficacy, in excess of £520,000 was spent on topical non-steroidal anti-inflammatory drugs (NSAIDs) across NHS Blackburn with Darwen and NHS East Lancashire over the last 12 months. Around £100,000 of this was spent on Movelat® which is one of the most expensive preparations. A more cost effective alternative is Algesal®, which if used first line could save around £320,000.
Most evidence for topical NSAID use is in people who experience acute flare-ups of osteoarthritis of the knees, fingers and toes. The evidence suggests that the benefit is obtained in the first couple of weeks and after that there is limited evidence of benefit to the patient.
Different NSAIDs appear to have different efficacies, with ketoprofen being significantly better than all others in direct comparison studies. However, topical ketoprofen has been associated with a risk of photosensitivity reactions and patients should be advised to keep the area being treated protected from sunlight during the treatment period, and for a further 2 weeks afterwards. They should also carefully was their hands after every application. In addition, ketoprofen is only licensed for 7-10 days use.
Cost comparisons of the most commonly prescribed topical NSAIDs:
Movelat® gel/cream (125g)
Ibuprofen 5% gel (100g)
Ketoprofen gel (100g)
Piroxicam gel (112g)
Due to the cost implications mentioned above, Movelat® has been removed from the East Lancashire Joint Medicines Formulary and Algesal® has been added as a first line agent.
n Mycophenolate – Generic vs. Brand Prescribing n Topical NSAIDs n INTERFACE Articles from 2010 n MMB Guidance n INTERFACE Xmas Quiz
FOR NHS USE ONLY – NOT TO BE USED OR REPRODUCED FOR COMMERCIAL PURPOSES