National Prescribing Indicators

Managing Infections in Primary Care

PTHB Microguide

^{The MicroGuide provides advice on the effective and safe treatment of infections commonly presenting in primary care and are based on NICE and Public Health Wales advice with input from local experts.}

AWTTC - Primary Care Antimicrobial Guidelines

RCGP - Summary of Antimicrobial Prescribing Guidance - Managing Common Infections

AWTTC - Management of C.Diff Infection in Wales

AWTTC - Management of Recurrent Symptomatic Urinary Tract Infection in Adult Women

Safety Updates

AWTTC - Best Practice Reminder: Avoid Nitrofurantoin in the Treatment of Pyelonephritis

Prescribing Tools and Audits

Antimicrobial Prescribing and Stewardship (APS) Competency Framework

^{The APS competency framework can be used by both medical and non-medical prescribers in any care setting to support the development of their prescribing practice at any point in their professional development in relation to prescribing antimicrobials and embodying stewardship practices.}

AWMSG - CEPP National Audit - focus on antibiotic prescribing

^{Using the correct antibiotics only when needed, with the correct dose and for the correct duration, is vital to help tackle growing antibiotic resistance. These audits aim to:}

• ^{Promote antibiotic prescribing in accordance with existing guidelines; including the Primary care antimicrobial guidelines endorsed by AWMSG.}
• ^{Support clinicians with quality improvement by promoting review of antimicrobial prescribing in their practice}

RCGP - Target Antibiotics Toolkit

^{This toolkit has been designed to support primary care clinicians to champion and implement antimicrobial stewardship activities. The resources can also be used to support CPD and revalidation requirements. This website has many patient resources when prescribing antimicrobials such as information on how long common infections usually last and self- care information.}

Relevant MHRA Alerts

September 2023 - Fluoroquinolone Antibiotics: Suicidal Thoughts and Behaviour

August 2023 - Fluoroquinolone Antibiotics: Reminder of the Risk of Disabling and Potentially Long-lasting or Irreversible Side Effects

April 2023 - Nitrofurantoin: Reminder of the Risks of Pulmonary and Hepatic Adverse Drug Reactions

Pain Management in Palliative Care

AWMSG - Opioids in Palliative Care: A Patient Guide (English) (Welsh)

Chronic Pain Management

AWTTC - Resources for pharmacological management of pain

Morphine Equivalence Tool

MDCalc - Morphine Equivalence Calculator

Pain Management Services

Living Well with Pain and Fatigue Service - Powys Teaching Health Board

Relevant MHRA Alerts

October 2018 - Transdermal Fentanyl Patches: Life-Threatening and Fatal Opioid Toxicity from Accidental Exposure, Particularly in Children

^{Prescribers should provide clear information to patients and caregivers about how to minimise the risk of accidental exposure and the importance of appropriate disposal of patches.}

March 2020 - Benzodiazepines and Opioids: Reminder of Risk of Potentially Fatal Respiratory Depression

^{Benzodiazepines and opioids can both cause respiratory depression, which can be fatal if not recognised in time. Only prescribe together if there is no alternative and closely monitor patients for signs of respiratory depression.}

September 2020 - Opioids: risk of dependence and addiction

^{Before prescribing opioids, prescribers should discuss with the patient the risks and features of tolerance, dependence, and addiction, and agree together a treatment strategy and plan for end of treatment.}

September 2020 - Transdermal Fentanyl Patches for Non-Cancer Pain: Do Not Use in Opioid-Naive Patients

^{Following a review of the risks associated with use of opioid medicines for non-cancer pain, the Commission on Human Medicines (CHM) has recommended that fentanyl transdermal patches are contraindicated in opioid-naive patients in the UK.}

AWTTC - All Wales Advice on Oral Anticoagulation for Non-valvular Atrial Fibrillation

Relevant MHRA Alerts

February 2021 - Pregabalin (Lyrica): Reports of Severe Respiratory Depression

^{Patients with compromised respiratory function, respiratory or neurological disease, renal impairment; those using concomitant central nervous system (CNS) depressants; and people older than 65 years might be at higher risk of experiencing these events and adjustments in dose or dosing regimen may be necessary.}

September 2020 - Gabapentin (Neurontin): Risk of Severe Respiratory Depression

^{Patients with compromised respiratory function, respiratory or neurological disease, renal impairment, concomitant use of central nervous system (CNS) depressants, and elderly people might be at higher risk of experiencing severe respiratory depression. Dose adjustments might be necessary in these patients.}

April 2019 - Pregabalin (Lyrica), gabapentin (Neurontin) and Risk of Abuse and Dependence: New Scheduling Requirements from 1 April

^{As of 1 April 2019, pregabalin and gabapentin are controlled under the Misuse of Drugs Act 1971 as Class C substances and scheduled under the Misuse of Drugs Regulations 2001 as Schedule 3.}

April 2022 - Pregabalin (Lyrica): Findings of Safety Study on Risks During Pregnancy

^{A new study has suggested pregabalin may slightly increase the risk of major congenital malformations if used in pregnancy. Patients should continue to use effective contraception during treatment and avoid use in pregnancy unless clearly necessary.}

AWTTC - Safe Use of Proton Pump Inhibitors

Relevant MHRA Alerts

December 2014 - Proton Pump Inhibitors in Long-Term Use: Reports of Hypomagnesaemia

^{Healthcare professionals should consider measuring magnesium levels before starting PPI treatment and repeat measurements periodically during prolonged treatment.}

December 2014 - Proton Pump Inhibitors in Long-Term Use: Increased Risk of Fracture

^{Recent epidemiological evidence of an increased risk of fracture with long-term use of proton pump inhibitors (PPIs).}

AWTTC - Material to Support Appropriate Prescribing of Hypnotics and Anxiolytics

^{This educational pack aims to support the appropriate prescribing of hypnotics and anxiolytics across Wales by providing key health professionals with a practical approach for the initiation and review of hypnotic and anxiolytic prescribing. It includes examples of support material which can be used or adapted for this purpose. Appendices, although included in the main document, are linked below for quick reference:}

• Appendix 1: Patient information leaflets
• Appendix 2: Assessment tools
• Appendix 3: Information for patients
• Appendix 4: Guides for healthcare professionals
• Appendix 5: Hypnotic and anxiolytic reduction/withdrawal resources

Relevant MHRA Alerts

December 2014 - Lorazepam: Reduction of Recommended Maximum Daily Dose

^{Maximum dose of lorazepam for short term, symptomatic treatment is 4 mg per day for severe, disabling anxiety, and 2 mg per day for severe, disabling insomnia.}

March 2020 - Benzodiazepines and Opioids: Reminder of Risk of Potentially Fatal Respiratory Depression

^{Benzodiazepines and opioids can both cause respiratory depression, which can be fatal if not recognised in time. Only prescribe together if there is no alternative and closely monitor patients for signs of respiratory depression.}

All Wales Guidance

AWTTC - All Wales COPD Management and Prescribing Guideline

AWTTC - All Wales Adult Asthma Management and Prescribing Guideline

AWTTC - All Wales Paediatric Asthma Management and Prescribing Guideline

Prescribing Data

SPIRA - Decarbonisation Dashboard

^{This AWTTC dashboard allows practices to see their respiratory prescribing data benchmarked against other practices. Indicators such as carbon footprint and DPIs/SMIs as a % of all inhalers prescribed are used.}

All Wales Guidance

AWMSG - Low Value for Prescribing (Paper 1)

^{Co-proxamol, lidocaine plasters, tadalafil once daily preparations, liothyronine and doxazosin modified release tablets.}

AWMSG - Low Value for Prescribing (Paper 2)

^{Omega-3 fatty acid compounds, oxycodone and naloxone combination product, paracetamol and tramadol combination product and perindopril arginine.}

AWMSG - Low Value for Prescribing (Paper 3)

^{Items of low clinical effectiveness: chloral hydrate (cloral betaine), minocycline, probiotics, rubefacients, silk garments and vitamins and minerals}

^{Items where more cost-effective alternatives are available: alimemazine, aliskiren and blood glucose testing strips.}

Prescribing Data

SPIRA - Low Value for Prescribing Dashboard

^{This AWTTC dashboard allows practices to view prescribing data relating to the clinical areas described in the three AWMSG Low Value papers above.}

AWTTC - Tramadol educational resources - 2021 review