Emollient prescribing formularies in England and Wales: a cross-sectional study

Selective serotonin reuptake inhibitors (SSRIs) in women of reproductive age: a systematic review of local formularies

BACKGROUND

Depression is the second most common chronic condition affecting women of reproductive age; 23.4% of women enter pregnancy with depression and use of selective serotonin reuptake inhibitors (SSRIs) in pregnancy is often necessary for maternal wellbeing. However, SSRI use during pregnancy can cause congenital malformations, postpartum haemorrhage (PPH), and persistent pulmonary hypertension of the newborn (PPHN). In UK primary care, prescribing formularies are one medium by which prescribers are provided with local medicines advice.

AIM

To review all local prescribing formularies with respect to prescribing SSRIs in women of reproductive age, during pregnancy, and during breastfeeding.

DESIGN & SETTING

A systematic review of prescribing formularies in England and Wales.

METHOD

A systematic keyword search of all clinical commissioning group and Integrated Care Board websites in England and Local Health Board websites in Wales was undertaken between December 2021-22 to identify prescribing formularies. Data were extracted on prescribing guidance for SSRIs.

RESULTS

Seventy-four prescribing formularies were reviewed. Of these, 14.9% (n = 11/74) provided links to the Medicines and Healthcare products Regulatory Agency guidance on congenital abnormalities associated with SSRIs, 28.4% (n = 21/74) provided links to guidance on PPH risk, and 1.4% (n = 1/74) provided links to guidance on PPHN. Specific local guidance was given on SSRI prescribing for women of reproductive age, during pregnancy, and during breastfeeding in 12.2% (n = 9/74), 23.0% (n = 17/74), and 21.6% (n = 16/74) of formularies, respectively.

CONCLUSION

Our results suggest that prescribers may be poorly informed by local formularies about the risks of SSRI use around pregnancy. This could place babies at increased risk of unintentional SSRI exposure.

Comparison of lotions, creams, gels and ointments for the treatment of childhood eczema: the BEE RCT

Background

Emollients are recommended for children with eczema (atopic eczema/dermatitis). A lack of head-to-head comparisons of the effectiveness and acceptability of the different types of emollients has resulted in a 'trial and error' approach to prescribing.

Objective

To compare the effectiveness and acceptability of four commonly used types of emollients for the treatment of childhood eczema.

Design

Four group, parallel, individually randomised, superiority randomised clinical trials with a nested qualitative study, completed in 2021. A purposeful sample of parents/children was interviewed at ≈ 4 and ≈ 16 weeks.

Setting

Primary care (78 general practitioner surgeries) in England.

Participants

Children aged between 6 months and 12 years with eczema, of at least mild severity, and with no known sensitivity to the study emollients or their constituents.

Interventions

Study emollients sharing the same characteristics in the four types of lotion, cream, gel or ointment, alongside usual care, and allocated using a web-based randomisation system. Participants were unmasked and the researcher assessing the Eczema Area Severity Index scores was masked.

Main outcome measures

The primary outcome was Patient-Oriented Eczema Measure scores over 16 weeks. The secondary outcomes were Patient-Oriented Eczema Measure scores over 52 weeks, Eczema Area Severity Index score at 16 weeks, quality of life (Atopic Dermatitis Quality of Life, Child Health Utility-9 Dimensions and EuroQol-5 Dimensions, five-level version, scores), Dermatitis Family Impact and satisfaction levels at 16 weeks.

Results

A total of 550 children were randomised to receive lotion (analysed for primary outcome 131/allocated 137), cream (137/140), gel (130/135) or ointment (126/138). At baseline, 86.0% of participants were white and 46.4% were female. The median (interquartile range) age was 4 (2-8) years and the median Patient-Oriented Eczema Measure score was 9.3 (SD 5.5). There was no evidence of a difference in mean Patient-Oriented Eczema Measure scores over the first 16 weeks between emollient types (global p = 0.765): adjusted Patient-Oriented Eczema Measure pairwise differences - cream-lotion 0.42 (95% confidence interval -0.48 to 1.32), gel-lotion 0.17 (95% confidence interval -0.75 to 1.09), ointment-lotion -0.01 (95% confidence interval -0.93 to 0.91), gel-cream -0.25 (95% confidence interval -1.15 to 0.65), ointment-cream -0.43 (95% confidence interval -1.34 to 0.48) and ointment-gel -0.18 (95% confidence interval -1.11 to 0.75). There was no effect modification by parent expectation, age, disease severity or the application of UK diagnostic criteria, and no differences between groups in any of the secondary outcomes. Median weekly use of allocated emollient, non-allocated emollient and topical corticosteroids was similar across groups. Overall satisfaction was highest for lotions and gels. There was no difference in the number of adverse reactions and there were no significant adverse events. In the nested qualitative study (n = 44 parents, n = 25 children), opinions about the acceptability of creams and ointments varied most, yet problems with all types were reported. Effectiveness may be favoured over acceptability. Parents preferred pumps and bottles over tubs and reported improved knowledge about, and use of, emollients as a result of taking part in the trial.

Limitations

Parents and clinicians were unmasked to allocation. The findings may not apply to non-study emollients of the same type or to children from more ethnically diverse backgrounds.

Conclusions

The four emollient types were equally effective. Satisfaction with the same emollient types varies, with different parents/children favouring different ones. Users need to be able to choose from a range of emollient types to find one that suits them.

Future work

Future work could focus on how best to support shared decision-making of different emollient types and evaluations of other paraffin-based, non-paraffin and 'novel' emollients.

Trial registration

This trial is registered as ISRCTN84540529 and EudraCT 2017-000688-34.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (HTA 15/130/07) and will be published in full in Health Technology Assessment; Vol. 27, No. 19. See the NIHR Journals Library website for further project information.

Emollient prescribing formularies and guidelines in England, 2021: cross sectional study

Background

Emollients are a mainstay of treatment for dry skin conditions. In the UK, prescribers are usually expected to follow local National Health Service (NHS) formularies. A previous study in 2018 showed that the recommended emollients across England and Wales varied widely. Evidence has since emerged that bath additives provide no additional clinical benefit in eczema.

Aim

To compare emollient formularies and guidelines in England.

Methods

Clinical Commissioning Group (CCG) formularies and guidelines were identified in April–May 2021, compiled and then analysed descriptively.

Results

In total, 105 CCGs, 72 emollient formularies and 47 emollient prescribing guidelines were identified. There were internal inconsistencies between formularies and their accompanying guidelines in 19% of cases. The majority (68%) of formularies/guidelines were organized using a ranking system. In total, 126 different leave‐on emollients were named. Creams and ointments were universally available and were the most recommended first‐line types. Cost was more likely than patient choice to be recommended as a criterion for selecting which emollient to prescribe. Aqueous cream was the leave‐on emollient most commonly not recommended. Nearly three‐quarters (74%) of formularies stated that bath additives should not be prescribed.

Conclusion

All CCGs in England have an emollient formulary/guideline, but there is still great variability between them in their recommendations. Although the number of formularies/guidelines has reduced since 2017, there has been an increase in the total number of unique recommended leave‐on emollients. Most CCGs are no longer recommending bath emollients for eczema.

Assessing the potential fire risk of laundered fabrics after contamination with emollients using ATR-FTIR spectroscopy and chemometrics

Since 2010, more than 50 UK fire deaths, have been reported as linked with emollients. This prompted the Medicines and Healthcare products Regulatory Agency (MHRA) to issue advice on their safer use in 2018. The advice was in response to concerns raised by the National Fire Chiefs Council, coroners' reports, and flammability tests. The test results show a significant reduction in ignition time of fabrics contaminated with paraffin-based and paraffin-free skin care product residues. The MHRA report also included advice on washing clothing and bedding at high temperatures but warned this may not remove all emollient residues. This paper reports on new research on the removal of skin care products from clothing investigated by laundering contaminated 100% cotton fabric at 30, 40 and 60 °C using both biological and non-biological based detergents. As part of the experiment, non-contaminated (blank) napkin samples were included in the wash experiments to assess the possible transfer from fabrics contaminated with emollients to uncontaminated clean fabrics during washing. Washed and dried fabrics were analysed using Attenuated Total Reflectance, Fourier Transform Infrared (ATR-FTIR) spectroscopy and further interpreted via principal component analysis (PCA) and network analysis. Results suggest that the majority of the 6% white soft paraffin-based lotion and paraffin-free cream were removed at all temperatures. Residues of 21% paraffin-based cream (6% light paraffin/15% white soft paraffin) remain, and more residues persist of the 100% paraffin-based ointment (5% light paraffin/95% white soft paraffin) after washing at 30, 40 and 60 °C. The wash experiments show unequivocal transfer of the 100% ointment from the contaminated napkins to clean control napkins placed within washes at 30 °C. Furthermore, residues of the ointment were observed within the machine drum, and washing machine door seal, though this did not cause secondary transfer to subsequent wash experiments. There were no differences observed when using biological versus non-biological detergents, nor when employing a pre-wash treatment in the removal of residues of the 21% cream and 100% ointment. These results suggest that a single application of an emollient when soaked and dried into a fabric is not removed by a single wash at 30, 40 or 60 °C. Instead, the residue remains a persistent potential fire risk and, its high paraffin content presents an additional fire risk via contamination of other fabrics.

Using emollients to promote safe and effective skin care for patients

The role of emollients in the treatment of dry skin conditions is often underestimated. Emollients promote optimal skin health and prevent skin breakdown, and their use can improve patients' quality of life. However, when advising patients on emollient use, nurses must consider the challenges involved such as the extensive choice of products and the necessity of regular applications. This article explores the development of dry skin conditions and outlines the role of emollients in maintaining the skin barrier function. The author also details optimal nursing practice in areas such as emollient prescribing and application.

Changes in prescribing rates of sodium-containing medications in the UK from 2009 to 2018: a cross-sectional study with interrupted time series analysis

OBJECTIVE

Effervescent, soluble, dispersible formulations contain considerable amounts of sodium. In 2013, we previously confirmed the association between sodium-containing medications and cardiovascular risks. This study aimed to determine the changes in the prescribing pattern in clinical practice following this publication.

DESIGN

A longitudinal cross-sectional study.

SETTING

Primary care in the UK from 2009 to 2018.

PARTICIPANTS

Prescribing information in The Health Improvement Network (THIN) and Prescription Cost Analysis (PCA) databases in the UK.

OUTCOME MEASUREMENTS

Prescription rates per 10 000 inhabitants were calculated using the number of prescriptions or the number of drug-using patients over the total number of inhabitants, and the prescription rates were measured at annual intervals. Prescribing trends from 2009 to 2018 were indexed with yearly data from THIN and PCA. Interrupted time series analysis (ITSA) was conducted with monthly data in THIN.

RESULTS

From the THIN database, a total of 3 651 419 prescription records from 446 233 patients were included. The prescribing rate of sodium-containing medications changed from 848.3/10 000 inhabitants in 2009 to 571.6/10 000 inhabitants in 2018. The corresponding figures from PCA data were of 631.0/10 000 inhabitants in 2009 and 423.8/10 000 inhabitants in 2018. ITSA showed the prescribing trend reduced significantly during the postpublication period (prescribing rate: slope change=-0.26; 95% CI -0.45 to -0.07; p=0.009; proportion of patients: slope change=-0.22; 95% CI -0.35 to -0.09; p<0.001), but no change in postpublication level from baseline. The prescribing rates for the non-sodium-containing standard formulations were relatively stable over the study period. The reduction in the proportion of patients using sodium-containing medications was only significant in patients over 45 years old.

CONCLUSIONS

The prescribing of sodium-containing medications in the UK primary care has declined significantly during the postpublication period. Changes in the prescribing trends for sodium-containing medications varied across regions of the UK and patient age groups.

Best emollients for eczema (BEE) - comparing four types of emollients in children with eczema: protocol for randomised trial and nested qualitative study

INTRODUCTION

Atopic dermatitis/eczema affects around 20% of children and is characterised by inflamed, dry, itchy skin. Guidelines recommend 'leave-on' emollients that are applied directly to the skin to add or trap moisture and used regularly, they can soothe, enhance the skin barrier and may prevent disease 'flares'. However, the suitability of the many different emollients varies between people and there is little evidence to help prescribers and parents and carers decide which type to try first.

METHODS AND ANALYSIS

Design: pragmatic, multicentre, individually randomised, parallel group superiority trial of four types of emollient (lotions, creams, gel or ointments).

SETTING

general practitioner surgeries in England.

PARTICIPANTS

children aged over 6 months and less than 12 years with mild-to-severe eczema and no known sensitivity to study emollients.

INTERVENTIONS

study-approved lotion, cream, gel or ointment as the only leave-on emollient for 16 weeks, with directions to apply twice daily and as required. Other treatments, such as topical corticosteroids, used as standard care.

FOLLOW-UP

52 weeks.

PRIMARY OUTCOME

validated patient-orientated eczema measure measured weekly for 16 weeks.

SECONDARY OUTCOMES

eczema signs (Eczema Area Severity Index) by masked researcher, treatment use, parent satisfaction, adverse events, child and family quality of life (Atopic Dermatitis Quality of Life, Child Health Utility 9D and Dermatitis Family Impact).

SAMPLE SIZE

520 participants (130 per group).

ANALYSIS

intention-to-treat using linear mixed models for repeated measures.Nested qualitative study: audio-recording of sample of baseline appointments and up to 60 interviews with participants at 4 and 16 weeks, interviews to be transcribed and analysed thematically.

ETHICS AND DISSEMINATION

Ethics approval granted by the NHS REC (South West - Central Bristol Research Ethics Committee 17/SW/0089). Findings will be presented at conferences, published in open-access peer-reviewed journals and the study website; and summaries shared with key stakeholders.

TRIAL REGISTRATION NUMBER

ISRCTN84540529.