Neridronic Acid (Nerixia) for Complex Regional Pain Syndrome

The cause of CRPS is unknown, but it is generally thought to be the result of the body reacting abnormally to an injury. It is difficult to estimate exactly how common CRPS is, as many cases may go undiagnosed or misdiagnosed. Currently there are no approved treatments for CRPS. Neridronic acid administered by injection is currently being developed to treat CRPS and early results indicate that it has the possibility to control the condition. If approved neridronic acid will be a potential new treatment for CRPS.

From NIHR Innovation Observatory

Upadacitinib for Adults with Moderate to Severe Active Rheumatoid Arthritis After Conventional Synthetic Disease-Modifying Anti-Rheumatic Drugs (DMARDs) or Biologic DMARDs Failure

There is currently no cure for rheumatoid arthritis and treatment aims to improve quality of life and to prevent or reduce joint damage. The most common treatment options are steroids to reduce inflammation, medications to reduce pain and swelling, and medications that slow the progression of joint damage from RA. Upadacitinib is currently being developed to be taken orally as a treatment option for those who have active moderate to severe RA who do not respond to certain treatment options. This drug works by stopping the inflammation caused by a specific type of protein and if licensed, it may be an option that can be used earlier in the treatment pathway.

From NIHR Innovation Observatory

RCOphth Safety Announcement: BSS and Open Systems for Injectable Medicines

Following reported errors of drug misidentification in other specialties causing serious harm, when an injectable medication was decanted into an ‘open system’, e.g. a gallipot, before administration, NHS Improvement has expressed concerns to RCOphth about the widespread practice during cataract surgery of decanting BSS (balanced salt solution) from the infusion bag into a gallipot at the start of the procedure which may then be drawn up and used to re-inflate the eye later in the operation. In addition, concern was raised that BSS kept in a gallipot might pose a risk of potential bacterial contamination.

In response, the College has replied that given the short duration that BSS typically remains in a sterile gallipot during cataract surgery, it does not consider that this practice poses a sterility issue. However there is a potential risk for drug misidentification although no other drug would commonly be placed into a gallipot during cataract surgery. RCOphth has pointed out that BSS is not currently available as a pre-filled syringe and that preparing and labelling of several syringes of BSS at the beginning of each case would be both impractical and potentially wasteful.

Significant improvement in response to the GLP1-agonist 'Liraglutide' following change in injection site

Endocrine Abstracts (2017) 50 EP054 DOI:10.1530/endoabs.50.EP054

Variability in treatment response with respect to GLP1 agents is well-accepted but incompletely understood. In a specialist GLP-1 clinic at UHCW, we describe a case of improved therapeutic response following change in injection site. Currently, advice is injection in the abdomen or thigh.

A 61 year old man was commenced on Liraglutide 1.2 mg subcutaneous OD injection, in 2013. Previously managed with glimepiride 4 mg and metformin 1 g BD, with suboptimal HbA1c of 93 mmol/mol, weight 111.4 kg.

This case highlights, therefore, anecdotal evidence suggesting site-specific efficacy with relation to liraglutide, and further work should focus on this and its potential mechanisms, including site-specific differences in absorption.

UHCW Research: Daniel Border, Wendy Clayton, Tom Barber & Harpal Randeva

Confirming removal or flushing of lines and cannulae after procedures

A patient safety alert from NHS Improvement on the need to confirm intravenous (IV) lines and cannulae have been effectively flushed or removed at the end of the procedure.

Study suggests epidural does not slow second stage of labour

A study published in the journal Obstetrics & Gynaecology, showed that the use of epidural analgesia in the second stage of labour made no difference to duration of labour, and suggests that the practise of minimising pain management in labour may be outdated.

The results show epidural also had no effect on normal vaginal delivery rate, incidence of episiotomy, the position of the fetus at birth or any other measures of fetal well-being. The study compared the effects of catheter-infused, low-concentration epidural anesthetic to a catheter-infused saline placebo in this double-blinded, randomized trial of 400 women.

Lidocaine with propofol to reduce pain on injection

New from BestBETs:

Lidnocaine pre-treatment or mixed with propofol reduced pain at the injection site. Further research is however required to see how much of this effect is that of lidocaine alone or the change in propofol formulation.

Antipsychotic combinations for schizophrenia

Many people with schizophrenia do not achieve a satisfactory treatment response with their initial antipsychotic drug treatment. Sometimes a second antipsychotic, in combination with the first, is used in these situations.

This Cochrane Review examines whether:
1. treatment with antipsychotic combinations is effective for schizophrenia; and
2. treatment with antipsychotic combinations is safe for the same illness.

'Painless' flu vaccine skin patch shows promise

"A 'painless' sticking plaster flu jab that delivers vaccine into the skin has passed important safety tests in the first trial in people," BBC News reports. Results of a small phase 1 trial were encouraging, with no serious side effects reported.

The patch, around the size of a standard plaster, contains 100 "microneedles" – tiny needles containing the vaccine, which then dissolve after delivering a dose.

The trial including 100 people in the US and aimed to see whether the patch was safe and tolerable and may be able to deliver flu vaccine as effectively as an injection.

People who had the patch found it less painful, but were more likely to get redness and itching where the patch had been applied.

There were signs that the patch was just as effective as standard injection in terms of antibody response, but larger studies will be needed to confirm this.

Community pharmacists gave 37% more flu jabs 2016/17

Community pharmacy teams administered at least 221,000 more flu vaccinations in 2016/17 than in the previous year, an increase of more than 37%.

The total number of vaccines provided under the national flu vaccination service rose from 595,467 in 2015/16 to over 817k vaccinations last year, according to the Pharmaceutical Services Negotiating Committee.

Non-cystic fibrosis bronchiectasis: inhaled tobramycin

This evidence summary includes 3 randomised controlled trials that investigated the efficacy of nebulised tobramycin, 300 mg twice daily compared with placebo for treating infective exacerbations caused by P aeruginosa in people with non-cystic fibrosis bronchiectasis. The treatment duration varied across the studies from 4 weeks to 6 months.

Immunoglobulin: when to use

PHE's immunoglobulin handbook, providing guidance on administering immunoglobulin to prevent serious disease.

Inhaler Standards and Competency Document

Using an inhaler is the most common and effective way to take respiratory medications and remains the cornerstone for treating airways diseases such as asthma and COPD.

Concerned that people are still unable to use their devices and that many health care professionals are unable to assist people effectively in optimising their technique, The UK Inhaler Group (UKIG) has developed standards and competencies for those prescribing inhaled medications. The standards set out how healthcare professionals can work with patients to optimise their technique and maximise the benefit of their medication.

Infusion therapy standards: rapid evidence review

This report summarises the rapid review of evidence undertaken to support development of updated RCN Standards for Infusion Therapy, last published in 2010.

Intermittent inhaled steroids reduce asthma attacks in wheezing preschool children

Regular daily steroid inhalers reduce the number of severe asthma exacerbations requiring soluble tablets or injections in wheezing preschool children by about a third.

From the NIHR Dissemination Centre

Risk of severe harm and death due to withdrawing insulin from pen devices

A patient safety alert has been issued by NHS England to warn NHS providers of the risk of severe harm and death if an insulin needle and syringe is used to administer insulin withdrawn directly from a pen device or replacement cartridge.

Syringe Labelling in Critical Care Areas Review 2014 (updated November 2016)

Since the new standard for syringe labelling was introduced in May 2003, a number of changes needed to be made. These changes are to bring the standard in line with the change from British Approved Names (BANs) to recommended International Non-Propriety Names (rINNs) , and also to bring the standard in line with the Australian/New Zealand Standard3 and ISO Standard which have superseded it.

Guidance on competencies for Intrathecal Drug Delivery

This document describes two levels of involvement in the practice of IDD:

• The first level outlines the core knowledge, skills and attitudes for all anaesthetists specialising in Pain Medicine who may need to be involved with this therapy.
• The second level outlines the advanced knowledge, skills and attitudes required of Pain Medicine specialists who work in teams providing an IDD service.

What are the equivalent doses of oral morphine to other oral opioids when used as analgesics in adult palliative care?

This NHS Specialist Pharmacy Service Q&A gives advice on converting between oral morphine and other oral opioids when they are used as analgesics in adult palliative care. In addition it gives details on the issues that need to be considered when switching a patient from morphine to an alternative opioid or vice versa.

A cadaveric study on subjective feel of injection pressure-are we getting it right?.

Regional Anesthesia and Pain Medicine. Conference: 35th Annual European Society of Regional Anaesthesia and Pain Therapy Congress, ESRA 2016. Netherlands. Conference Start: 20160907. Conference End: 20160910. 41 (5 Supplement 1) (pp e72), 2016. Date of Publication: September - October 2016.

Nerve injury remains a serious risk of peripheral nerve blockade. High opening injection pressures (OIP) may indicate direct needle nerve contact and/or intrafascicular needle placement. Subjective syringe hand-feel technique may not reflect the actual pressures in the system. This study demonstrates that subjective hand-feel of injection pressure is not an accurate confirmation of the actual pressure within the system. Subjective hand-feel and ultrasound visualisation methods on its own are unreliable indicators for intraneural needle placement. (Figure Presented).

UHCW Research: Sadasivan R.