Prescribing POM-Vs: joint guidance from the RCVS and VMD

(NB: for controlled drugs, see FAQ 6).

The clinical notes should show that you have carried out a clinical assessment and prescribed a POM-V for ongoing treatment.

Your clinical notes should then include the following:

• the product name
• the pack size/volume/quantity of the product
• the dosage instructions
• any necessary warnings or instructions
• either a frequency and time period, eg ‘1 bottle a month for the next 3 months’, or a number of repeats, eg ‘can be repeated twice’.
• an end time for the repeats, eg the decision on when you next want to see the animal)
• any other information you consider relevant

When you prescribe a POM-V for treatment across several months, you should consider whether the weight of the animal is likely to change during the period covered by the prescription.

If that is likely to be the case, you should record in the clinical notes what action should be taken if the animal’s weight does change.

You should make it clear that the animal’s weight needs to be checked prior to the medicine being supplied, and a record of that weight check should be made in the clinical notes.

If a change in the animal’s weight would mean that a different presentation of the same product would be required, for example, 2-10kg to 10-20kg, you should note either:

• the presentation and pack size to be supplied in the case of weight change, or
• the need to carry out a further clinical assessment, which may include a physical examination depending on the nature of the POM-V, before a different product can be supplied.

The recent guidance changes have prompted the RCVS and VMD to review certain areas with a renewed focus. Following this review, our advice is that noting prescriptions as mg/kg is not recommended due to possible errors being made when the dose is calculated. However, where the generic active ingredient is prescribed in mg/kg, you will need to authorise this prior to the product being dispensed.

This scenario covers a manufacturer-level production issue with a product that has been prescribed to cover several months’ treatment, ie not one-off supply issues with your usual wholesaler.

Although including a list of alternatives in the clinical records is not generally acceptable, the VMD advise it is acceptable to note an alternative authorised prescription product to be supplied in the event of a manufacturer-level production issue. Please note that where there is a clinical reason to list an alternative product, e.g. possible adverse reaction, one alternative may be listed to account for this (more on this below).

If no alternative has been noted at the time of the initial prescription, you must carry out a further clinical assessment and prescribe an alternative. A manufacturer-level production issue of this kind would be considered an exceptional circumstance, meaning that if the drug being prescribed is an antiparasitic, antibiotic, antifungal or antiviral, a further physical examination would not be required.

Where there is a manufacturer-level production issue of this kind, you may wish to:

• introduce a standard operating procedure (SOP) on the change and what information must be given to the clients on the change of product;
• place a record in the dispensary of which products are affected and what the alternative is for each pack size/version;
• ensure that records are kept of when the alternative version(s) were used (date start – end);
• record that each vet in the practice has agreed to the SOP, eg by signatures on the document; and,
• train dispensing staff on SOP and ensure a record or note is kept of this training.

Where a POM-V cannot be supplied due to stock issues at practice level, you should:

• ask the client to return when the product is in stock; or
• provide the client with a written prescription to be dispensed elsewhere; or
• carry out a clinical assessment before prescribing a different product and note this on the clinical records.

Depending on the nature of the POM-V supplied, a physical examination may be required as part of the clinical assessment.

In the case of an adverse reaction (of the kind to be reported to the marketing authorisation holder or VMD) to the originally prescribed product, you must carry out a clinical assessment before prescribing a different product and note this in the clinical records.

Depending on factors such as the nature of the product being prescribed, the condition of the animal and the severity of the reaction, you may need to carry out a physical examination as part of your clinical assessment.

As always, whether a physical examination is required is a matter of your professional judgement.

Listing one alternative POM-V to be supplied in case of recognised side effects is acceptable. However, where an alternative prescription exists, it must be dispensed against in the usual way, ie the person dispensing would have to get the vet’s authorisation before handing over the alternative medicine.

Controlled drugs (CDs) are subject to additional legal requirements as they have been identified as at risk of abuse or misuse. For acute conditions, the maximum quantity of CDs prescribed should not exceed 30 days’ worth; exceptionally, to cover a justifiable clinical need and after consideration of any risk, a prescription can be issued for a longer period, but the reasons for the decision should be recorded in the animal’s clinical notes.

When prescribing CDs, a physical examination must form part of the clinical assessment unless there are exceptional circumstances. One further prescription for the same product may be supplied without the need for a physical examination, but that there must still be a clinical assessment. For example, you may initially decide to prescribe 4 days’ worth of CDs but towards the end of that period, you may decide that the animal needs another few days’ supply. This can be prescribed without another physical examination. However, if a further prescription is required, you should make a fresh prescription after following a clinical assessment, which includes a physical examination unless there are exceptional circumstances.

Controlled drugs are subject to additional legal requirements as they have been identified as at risk of abuse or misuse. Usually, the maximum quantity of CDs prescribed should not exceed 30 days; exceptionally, to cover a justifiable clinical need and after consideration of any risk, a prescription can be issued for a longer period, but the reasons for the decision should be recorded in the animal’s notes.

Where you consider that prescribing more than 30 days’ worth is appropriate but do not feel comfortable supplying more than that in one go, you may supply the medicine at intervals (where the client is buying from your practice) or give the client an instalment prescription to be fulfilled elsewhere (see below).

Please note that, generally, CDs should not be sent through the post. In exceptional circumstances, eg for a client unable to travel to the practice and unable to send a representative, recorded delivery or ‘signed for’ courier delivery are most appropriate. Prescription medicines may be sent via Royal Mail, but it is advisable to check the Royal Mail's current guidelines on prohibited goods and packaging first.

Where you decide it is justifiable to prescribe more than 30 days’ worth of CDs and, exceptionally, decide to supply the whole quantity in one go, you should note your reasons for doing so (as per the above guidance) and ensure that the following details are recorded:

• the product name
• the pack size/volume/quantity of the product
• the dosage instructions
• any necessary warnings or instructions

Where you decide it is justifiable to prescribe more than 30 days’ worth of CDs but wish to supply the medicine at intervals, in addition to the above, you should record how much to be supplied at each interval and the frequency/dates of the intervals.

Where more than 30 days’ worth of CDs are prescribed and the client requests a prescription to be fulfilled elsewhere, unless there are exceptional circumstances that mean this is not appropriate, you should issue the client with an instalment prescription to be dispensed by a supplier of their choice in order to reduce the risk of misuse.

You should bear in mind that instalment prescriptions are not commonly used in this way in human medicine and, as such, pharmacists used to dealing with prescriptions from doctors may approach these with caution.

Please remember that instalment prescriptions are instructions to supply and must be followed to the letter. You should therefore ensure the client is fully aware of what you have stated. If you have said that a specific amount must be supplied on a specific date, then that’s what the dispenser must follow. When an instalment prescription is used, the client isn’t able to get it filled a day earlier or later for convenience, so you should consider this lack of flexibility before issuing one.

In line with RCVS guidance, veterinary surgeons may make reasonable charges for written prescriptions, but must not discriminate between those who are supplied with a prescription and those who are not, in relation to fees charged for other goods or services.