When might a Special be prescribed?
There are a number of clinical situations where there may not be a suitable licensed product available, in terms of a formulation or dose. As previously mentioned, many medicines are unlicensed in children generally and in most cases lower doses would be needed. A Special may be used to achieve a low dose consistently and safely. Patients who have a feeding tube fitted or have swallowing difficulties, for instance the elderly or in palliative care, will also need alternatives to solid dosage forms. There are also a large number of Specials prescribed in dermatology where the specific needs of a patient are not met by an available licensed product.
The choice of medicinal product for a patient who is unable to take solid oral dosage forms should be made on a case by case basis for each patient. The decision should take into account the physical status of the patient and their ability to self-administer as well as the quality and cost of the product.
The Royal Pharmaceutical Society (RPS) guidance for prescribers of specials advocates five guiding principles when prescribing a special7:
- Establish the optimal treatment for the patient
A Special should only be prescribed where a clinical need cannot be met by a licensed medicine of established efficacy, quality and stability. - Understand the patient's experience and make a shared decision
Discuss the patient's needs, values and preferences to ensure that the implications and practicalities of treatment options are understood. - Identify medicines and preparations
Prescribers need to take into account the safety, efficacy, quality and cost of the Specials options available. - Monitor and review
The ongoing need for a special should be reviewed to ensure it remains the best option for the patient. - Ensure effective prescribing governance
Effective communication between primary and secondary care is essential to ensure continuity of supply and consistency of formulation
The pharmacy team is well placed to support these prescribing principles and ensure continuity and quality of patient care. You may be required to advise on available licensed products as well as off-licence use such as crushing tablets or the use of a Special. You may be able to identify and address practical difficulties for the patient and influence the treatment decision to optimise safety and efficacy. It is also important to communicate changes in supplier, formulation and storage requirements and to ensure that the continued suitability of the product is reviewed in terms of the patient's actual medicine use. Where a licensed formulation becomes available the prescriber should be informed and treatment with the Special discontinued.