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Changes to nicotine replacement therapy prescriptions

The maximum dispensing rules for nicotine replacement therapy (NRT) were removed from 1 January 2011. While there is no longer any restriction on how much NRT may be supplied to a patient, instructions for the dose, frequency of use and total quantity or period of supply are required on prescriptions.

For example, prescription instructions would be: 21 mg nicotine patch, one per day for eight weeks.

NB: NRT will be dispensed monthly and will also no longer be subsidised as an original pack (OP).

See BPJ 33 (Dec, 2010) “Update on smoking cessation” for further advice about prescribing NRT, including patches, gum and lozenges.

Topical acne treatment adapalene now fully funded

Until recently there has been a lack of fully funded topical acne preparations available. Adapalene is a naphthoic acid derivative, with pharmacological activity similar to retinoids, which is used in the treatment of acne vulgaris. Differin, a brand of topical adapalene, became fully funded on the Pharmaceutical Schedule on 1 October 2010.

Topical retinoids (and retinoid-like medicines such as adapalene) have a strong anti-comedogenic effect as well as being effective against inflammatory acne lesions. Adapalene is indicated for the topical treatment of mild comedo, papular and pustular acne vulgaris of the face, chest or back. It is a once-daily preparation available in a 0.1% cream and gel formulation, with a maximum subsidised quantity of 30 g per prescription. The choice of formulation can be guided by the patients skin type – a cream is used for dry skin and a gel for skin that is oilier.

Useful tips for adapalene:

  • Apply in a thin layer, to clean, dry skin, on the affected areas, once daily at bedtime
  • Adverse effects can include skin irritation such as drying or peeling of the skin – most adverse effects will lessen with continued use, however if bothersome, decreasing the frequency of application may help. Avoid contact with the eyes, lips and mucous membranes.
  • Adapalene is not recommended for use in patients with eczema or seborrhoeic dermatitis because of the risk of skin irritation
  • Adapalene use can increase the sensitivity of the skin to the sun, so excessive sun exposure should be avoided where possible and sunscreen used over the treated areas during sun exposure
  • Beneficial effects should be seen within four to eight weeks, with further improvement likely with ongoing use. Benefit should be re-assessed after three months.
  • Adapalene use should be avoided in women who are pregnant or planning to become pregnant during treatment

For further information on the management of acne see “How to treat acne” BPJ 20 (Apr, 2009)

Escitalopram and sertraline available and fully funded from 1 December 2010

Two newly available selective serotonin re-uptake inhibitor (SSRI) antidepressants have been fully funded without restriction from 1 December 2010 – escitalopram (Loxalate) 10 mg and 20 mg tablets and sertraline (Arrow-Sertraline) 50 mg and 100 mg tablets.

Escitalopram is a highly selective SSRI. It is the active enantiomer (mirror image) of citalopram and is indicated in New Zealand for the treatment of major depression.1 Although there is some conflicting evidence, a recent meta-analysis suggests that escitalopram is more effective than citalopram in the treatment of major depressive disorder.2

Escitalopram appears to be well tolerated. Adverse effects such as nausea, dry mouth, constipation, dizziness and headache may occur during the first few weeks of treatment but these effects are usually mild and transient.1 An increased risk of suicidality is associated with escitalopram, as with the majority of antidepressants.

Escitalopram may be associated with increased risk of QT interval prolongation. See "Correspondence: Dabigatran; Escitalopram and QT interval", BPJ 52 (April, 2013).

Dosing recommendations for escitalopram:1

  • The usual adult dose is 10 mg, once daily. If required, this may be increased to a maximum dose of 20 mg daily.
  • The recommended maximum maintenance dose in older people is 10 mg daily
  • The recommended starting dose for patients with impaired hepatic function is 5 mg, because decreased clearance may result in increased plasma concentrations. The dose may be increased to 10 mg if tolerated. A dose adjustment is not required for patients with impaired renal function.
  • It is recommended that 5 mg Loxalate tablets are not halved
  • Escitalopram should not be used in combination with a monoamine oxidase inhibitor (MAOI) or pimozide (for information about other potential drug interactions refer to the data sheet).

Sertraline is indicated for the treatment of depressive illness, including depression with symptoms of anxiety, obsessive-compulsive disorder (OCD) (including children with OCD), panic disorder, post-traumatic stress disorder, premenstrual dysphoric disorder and social anxiety.3 In comparison to fluoxetine and paroxetine, sertraline is less likely to interact with drugs metabolised by cytochrome P450, so may be a useful choice for elderly people who are taking a variety of other medicines.4

A recent systematic review suggests that sertraline may be more favourable than other antidepressants both in terms of efficacy and acceptability.5 As with other antidepressants, sertraline is associated with an increased risk of suicidality.3

Dosing recommendations for sertraline:3

  • The usual adult starting dose is 25-50 mg, depending on the indication. The dose may then be titrated slowly to a maximum of 200 mg daily if required.
  • A dose reduction may be required in patients with impaired hepatic function. The dose does not need to be reduced in elderly patients or patients with impaired renal function.
  • Sertraline should not be used in combination with a MAOI or pimozide. Sertraline may interact with other drugs such as lithium, phenytoin and sumatriptan, so should be used with caution in patients taking these medicines (see datasheet for a full list of drug interactions)
  • Halving the 100 mg tablet is not recommended as dose equivalence has not been established

References

  1. Mylan New Zealand Ltd. Loxalate. Medicine Safety Data Sheet. 2010. Available from: www.medsafe.govt.nz (Accessed Jan, 2010).
  2. Montgomery S, Hansen T, Kasper S. Efficacy of escitalopram compared to citalopram: a meta-analysis. Int J Neuropsychpharmacol.2010;29:1-8.
  3. Arrow Pharmaceuticals (NZ) Limited. Arrow – Sertraline. Medicine Safety Datasheet. 2010. Available from www.medsafe.govt.nz (Accessed Jan, 2010).
  4. Muijsers R, Plosker G, Noble S. Sertraline; a review of its use in the management of major depressive disorder in elderly patients. Drugs Aging 2002;19(5):377-92.
  5. Cipriani A, La Ferla T, Furukawa T, et al. Sertraline versus other antidepressive agents for depression. Cochrane Database Syst Rev.2010;(4):CD006117.

An alternative to combivent: Duolin HFA funded from 1 February 2011

Combivent (salbutamol with ipratropium bromide) has been discontinued in New Zealand because a CFC-free form was not available. It is estimated that stocks will be depleted within the next few months.

Many GPs will have already moved their patients onto an alternative regimen such as salbutamol alone, salbutamol and ipratropium (separate preparations) or tiotropium. If an alternative has not already been found, or if patients are dissatisfied with their new regimen, a CFC-free salbutamol/ipratropium combination has now been fully funded (from 1 February 2011) – Duolin HFA (salbutamol 100 mcg + ipratropium bromide 20 mcg).

Stocks of Duolin may not become available until mid-February. Combivent will continue to be listed at the current price and subsidy until stock is depleted.

Removal of month restriction for anxiolytics, sedatives and hypnotics

The “Month Restriction” that previously applied to most anxiolytics, sedatives and hypnotics was removed from 1 September 2010. These medicines will still be dispensed monthly, but they can be prescribed (and funded) for three months at a time. Prescribers still need to be mindful of the potential for dependence and addiction with use of anxiolytics, sedatives and hypnotics. The monthly restriction has been removed for the following medicines:

  • Alprazolam
  • Buspirone
  • Diazepam
  • Lorazepam
  • Lormetazepam
  • Midazolam
  • Nitrazepam
  • Oxazepam
  • Temazepam
  • Triazolam
  • Zopiclone