1. Reason Avamys contains the corticosteroid fluticasone furoate (27.

5mcg/spray) and Flixonase nasal spray contains fluticasone propionate (50mcg/spray). They are licensed for the prophylaxis and treatment of allergic and perennial rhinitis. With the imminent arrival of the hay fever season, there is opportunity to make savings in switching patients from Flixonase to Avamys nasal spray, in line with the Dumfries and Galloway Joint Formulary 2010; see Table below. PRISMS data for the 12 month period of February 2009 to January 2010 suggests that these savings would be around 7,500 per annum across NHS Dumfries & Galloway. NB First line treatment continues to be beclometasone nasal spray (50mcg/spray). Costs Product Flixonase (50mcg/spray) 150 dose pack Avamys (27.5mcg/spray) 120 dose pack Cost per Pack 11.23 6.44

Protocol for Flixonase to Avamys Nasal Spray Switch May 2010

Cost per 28 days (assuming 2 sprays od) 8.39 6.02

Dosing schedule is as follows Age group Flixonase (50mcg/spray) Adults and children over 100mcg in both nostrils 12 od (increasing to max bd prn), reducing to 50mcg od when symptoms controlled Children 4-11 years 50mcg in both nostrils od (increasing to max bd prn) Not recommended under 4 yrs

Avamys (27.5mcg/spray) 55mcg in both nostrils od reducing to 27.5mcg od when symptoms controlled 6-11 years 27.5mcg in both nostrils od (increasing to 55mcg od prn) Not recommended under 6 yrs

The strength and mist formulation of Avamys allows for a once daily dosing regimen (as with Flixonase) providing 24 hour relief from symptoms. Avamys has the added benefit of having a quicker onset of action; typically taking as little as 8-24 hrs (although occasionally this may take longer) compared to 3-4 days for Flixonase. 2. Inclusion Criteria Search for all patients prescribed fluticasone/Flixonase nasal spray in the last 1-2 years

3. Exclusion Criteria Previous switch that caused distress Any individual patient exclusion deemed necessary by the GPs e.g. patients not open to change as judged by GP Patients with terminal cancer Patients with severe liver disease Children under 6 years

4. Preparation and Planning Implementation of audit in selected GP practices Prescribing Support Team is as follows: Protocol to be discussed with all GPs in the practice to ensure that agreement to proceed is reached Computer search of all patients according to the inclusion criteria Review of patients medical notes and repeat prescribing records List of patients who are on regular or seasonal fluticasone. List of eligible patients to be checked by GP/GPs Letters to be sent to eligible patients and switch to be undertaken on the computer system (Appendix 1)

5. Action

Letters written to all patients outlining the reasons for the switch to ensure they are fully informed and given an opportunity to discuss the switch with either their GP or practice pharmacist. (Appendix 1 and 2) Admin staff in practices to be made aware of changes of repeat medication. Local pharmacies to be informed of need to amend stock of Flixonase and Avamys and of counselling for patients (copy of patient letters supplied) Report for practices will include number of switches made by the pharmacist/technician and projected cost savings as a result of the recommendations.

Review to be undertaken by: GP Authorisation: Date:

Prescribing Support Team

Appendix 1: Patient letter if switching from Flixonase to Avamys.

Patient name Address

Dear Mr/Mrs __________

As part of a review, NHS Dumfries and Galloway are currently reviewing all patients prescribed fluticasone (Flixonase) nasal spray for seasonal allergic rhinitis (hayfever). We are currently switching patients from Flixonase to Avamys Nasal Spray. The active ingredient is the same (fluticasone) as is the dose* so there should be no noticeable difference in the new treatment. Avamys also has the benefit of generally working quicker than Flixonase. This change has been made to ensure that patients are using the most appropriate product and it also helps GPs make the most effective use of available resources. Should you have any queries, please contact your GP Surgery on the number above or, alternatively, you can contact a member of the Prescribing Support Team on xxxxxx
Yours sincerely

Name Prescribing Support Technician On behalf of the Doctors

* Dose for adults and adolescents from 12 years: Starting Dose 2 sprays per nostril once daily. Maintenance Dose 1 spray per nostril once daily.

Data collection sheet for Flixonase to Avamys nasal spray switch.

SURGERY Patients name and CHI number. DATE History of Excluded Compliance sensitivity/adverse from change (allow for seasonal usage). effects/unsuccessful (see protocol treatment with for details). Avamys.

Prescribed medication and dosage.

Proposed change.

GP approved.

Actioned.