P05 A project to rationalise the prescribing of unlicensed specials for children in a UK clinical commissioning group
Authors: Cooper Helen , Abumehdi Sheatha 
Published: April 2022

Aim

Due to a lack of licensed formulations for children, the use of unlicensed and off-label medicines is, in many circumstances, the only appropriate alternative.1 Data obtained on prescribing of unlicensed specials to children <18 years of age in a UK Clinical Commissioning Group (CCG) demonstrated both a wide variability in concentrations being supplied, and a significant amount being spent. A project was therefore set up with the aim of standardising prescribing of these medicines, to improve patient safety (through reduction of inadvertent dose misadministration due to changes in concentrations) and reduce costs.

Method ePACT2 data on medicines prescribed within the CCG and identified as unlicensed specials (as designated by the Drug Tariff) was used to create a specials dashboard in Microsoft Excel. A target list of medicines, based on variability of strengths and preparations available, as well as cost, was identified. A team of two dedicated specialist paediatric pharmacists was funded to set out strategies to standardise prescribing of those target list medicines, as well as to improve awareness of prescribing and supply of unlicensed medicines to children.

The project team employed a variety of methods to achieve their aim including; email communications advertising their roles and the support offered; coordinating meetings with GP’s and primary care pharmacists to discuss practice and primary care network-specific specials prescribing; promoting use of the local paediatric formulary; delivery of a paediatric prescribing webinar; and guidance on switches to alternative formulations.

Results

Since July 2021, the project team have responded to 12 e-mail queries related to specials prescribing from GP practices. 21 meetings to discuss practice-level specials prescribing data were co-ordinated between July-August 2021, with 61 switches to a preferred formulation for safety and/or cost-effectiveness identified and discussed with GP’s and practice pharmacists for review. The webinar was well attended by multiple boroughs and healthcare sectors, and although it cannot be quantified, awareness of the local paediatric formulary has improved.

In one instance the dashboard highlighted a significant patient safety issue, whereby a child was prescribed three different concentrations of unlicensed phenobarbital oral liquid over three consecutive months. The project team worked with the GP practice pharmacist to ensure the patient was receiving the correct dose of phenobarbital, and to rationalise the concentration of oral liquid for future prescriptions.

The project is on-going and at this time the impact on spend cannot be shown but will be reported later this year.

Conclusion

Although work has been undertaken at national level to standardise concentrations of unlicensed liquid medicines,2 this work has highlighted that there is still much to be done to reduce the variability in concentrations of prescribed medicines and the potential harm associated with this. The number of queries received from colleagues within primary care has emphasised a need for greater understanding of prescribing and supply of unlicensed medicines to children, as well as clear lines of communication between healthcare sectors. The specific knowledge and skills of specialist paediatric pharmacists are highly valuable in driving specials medicines rationalisation for children in the community.

Reference

Rawlence E, Lowey A, Tomlin S, et al. Is the provision of paediatric oral liquid unlicensed medicines safe? Arch Dis Child Educ Pract Ed 2018;103:310-313.

Neonatal and Paediatric Pharmacists Group and Royal College of Paediatrics and Child Health, UK. Using Standardised Concentrations of Unlicensed Liquid Medicines in Children. April 2020. Available at: https://nppg.org.uk/wp-content/uploads/2020/04/NPPG-Position-Statement-18-01-V5-April-2020.pdf