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P33 Standardising concentrations for licensed liquids- can we achieve consensus?
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  1. Andrew Wignell1,
  2. Andrea Gill2,
  3. Stephen Tomlin3,
  4. Emma Kirk4,
  5. Nanna Christiansen5
  1. 1Nottingham University Hospitals NHS Trust
  2. 2Alder Hey Children’s NHS Foundation Trust, Liverpool
  3. 3Great Ormond Street Hospital, London
  4. 4NHS Specialist Pharmacy Service
  5. 5Evelina Children’s Hospital, London

Abstract

Aim Multiple concentrations exist for several licensed oral liquids. For example, two concentrations exist for clobazam (1 mg/mL, 2 mg/mL) and omeprazole (2 mg/mL, 4 mg/mL); and four for propranolol (1 mg/mL, 2 mg/mL, 8 mg/mL, 10 mg/mL).1 Existence of multiple concentrations can lead to dosing errors, including ten-fold overdoses leading to hospital admission.2 3

The Neonatal and Paediatric Pharmacists Group and the Royal College of Paediatrics and Child Health recommend standard concentrations for some unlicensed liquids,4 but no recommendation exists for licensed products.

Although much use of oral liquid medicine is in children, there is also use in adults. Most hospital and community pharmacies dispense for both children and adults, and so for the safety benefits of standardisation to be fully realised, consensus is needed across all specialties and patient groups. This project aimed to capture views of staff working in a range of sectors, both on the general concept of standardisation and on specific proposed standard concentrations.

Method An on-line survey, built using SmartSurvey®, was distributed to the NHS England (NHSE) Medicines Safety Officer (MSO) Network. MSOs were asked to engage with relevant specialists in their organisations prior to responding, gauging views on standardisation generally and seeking consensus on proposed standard concentrations for six drugs available as licensed liquid products.

Results 51 responses were received, a response rate of 13% from the 400-member MSO network. 94% of respondents supported the concept of standardisation. The need to consider excipients; balance needs of premature neonates and adults; work across boundaries; and use of electronic prescribing systems to influence choices were identified as requirements for achieving standardisation. Potential barriers to standardisation include increased risk of medicines shortages if fewer concentrations are available; increased risk when transitioning patients between concentrations; decreased ability to make formulary choices to limit expenditure; patient reluctance to change; and a considerable amount of staff time required to safely support switching.

Relatively strong consensus was achieved for four drugs: Clobazam 10 mg/5 mL (85%), Hydrocortisone 5 mg/5 mL (85%), Omeprazole 20 mg/5 mL (87%) and Oxybutynin 5 mg/5 mL (91%). For clobazam, two respondents suggested that 5 mg/5 mL may be preferable to reduce confusion between ‘mL’ and ‘mg’. Ease of measuring a 10 mg dose with a 5 mL spoon and lower acquisition cost were given as reasons for preferring Omeprazole 10 mg/5 mL; conversely lower sodium benzoate (excipient) exposure when treating neonates was cited as a reason for favouring 20 mg/5 mL.

Lower consensus was achieved for Propranolol 40 mg/5 mL (67%) and Furosemide 40 mg/5 mL (65%). Most concern was expressed by centres with established use of 50 mg/5 mL for both drugs. Reasons for preferring 50 mg/5 mL include smaller dose volumes, ‘easier calculations’, making dose volumes the same as with spironolactone, and lower excipient exposure. However, whilst 50 mg/5 mL may be more widely used in hospitals, it was noted that 40 mg/5 mL is probably more commonly available in community pharmacies.

Conclusions Although not without challenges, the principle of standardisation is widely supported. Some drugs will be easier to standardise than others; furosemide and propranolol are likely to be more challenging. For standardisation to become a reality, a centrally led approach involving stakeholders from all healthcare sectors is needed.

References

  1. Joint Formulary Committee. British National Formulary for Children (Online). London: BMJ Group and Pharmaceutical Press. Available from: http://www.medicinescomplete.com (Accessed 16 December 2022).

  2. General Pharmaceutical Council (2021). Patient safety spotlight: the risks of prescribing and supplying medicines to children. https://www.pharmacyregulation.org/regulate/article/patient-safety-spotlight-risks-prescribing-and-supplying-medicines-children (Accessed 16 December 2022).

  3. Renwick CE, Makhecha S, Till J, et al. Case series: propranolol liquid in the treatment of tachyarrhythmias in neonates and infants: potential for errors. Cardiology in the Young 2022;33:482–484.

  4. Using Standardised Concentrations of Liquid Medicines in Children. Neonatal and Paediatric Pharmacists Group and Royal College of Paediatrics and Child Health. Available from http://nppg.org.uk/standardised-strengths-of-liquid-medicines-for-children/ (Accessed 16/12/2022).

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