Download Minutes September 2015 - Peterborough and Stamford

Peterborough Hospitals Formulary and Medicines Management Committee
Minutes of the meeting held on Thursday 17th September 2015
Room 4 Learning Centre, 4th floor, PCH
There were no declarations of interest with regard to items discussed.
In Attendance:
Dr C Gardner
Mrs C McIntyre
Mrs A Ritchie
Mrs S Mavani
Deputy Medical Director – Chair
Chief Pharmacist – Deputy Chair
Pharmacist Team Manager Procurement and Formulary - Joint Secretary
Pharmacist Team Manager Medicines Governance – Joint Secretary
Ms K Broad
Specialist Pharmacist – C&PJPG/HCD, Cambridgeshire and Peterborough
CCG
Consultant Paediatrician
Consultant Oncologist (from 12.55 onwards)
Pharmacy Technician-Higher Level
Consultant Microbiologist
Interface Lead Pharmacist, Greater East Midlands Commissioning Support
Unit.
Lead Pharmacist, Peterborough and Borderline LCG
Dr D Woolf
Dr C Jephcott
Mrs S Milne
Dr D Mlangeni
Ms C Johnson
Mr K Claire
Minute Taker: ML Denton, PA to Chief Pharmacist
15/39 Apologies for Absence:
Dr R Mittra
Mr A Massraf
15/40
Consultant in General Medicine
Consultant Orthopaedic Surgeon
Minutes of the Formulary and Medicines Management Meeting held on
Thursday 16th July 2015.
The following changes were requested:
15/17 2nd sentence - “Medicines” to be changed to “Medicine”
15/31 1st sentence – “urticarial” should be “urticaria”
15/37.5 “Dexamehasone” should be spelt “Dexamethasone”.
Once these amendments are made, the minutes are agreed as a true record of the
meeting.
15/41
Matters arising from the minutes:
15.16.13 Guidance for Post-operative Analgesia after Day-case Arthroscopic
Shoulder procedure. Still awaiting confirmation that the leaflet has been approved. If
Lesley Crosby confirms approval the policy is approved.
15/27.4: Protocol for the Prescribing and Administration of Tecfidera (Dimethyl
Minutes of Formulary and Medicines Management Committee
September 2015
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Fumarate) This is still being looked at by C Semple and the specialist pharmacist.
ACTION: To be deferred to the next agenda.
15/27.8 Peripheral Venous Cannulation in Babies, Children and Young People
Guideline: this needs to be chased as it has not been sent back to SMavani. There
were only minor changes to be made.
15/31: Discussion took place about concerns over NICE Technology Appraisals that
cannot be fully implemented in the Trust. It is likely that it will be agreed that
rifaximin can be prescribed by GPs in Cambridgeshire and Peterborough CCG
following specialist initiation.
15/36 Reports from Groups and Subcommittees: information will need to be pulled
together from these groups to inform the Committee. Some may be removed if no
longer active; to be discussed later in the agenda.
15/37.3 Antibiotic Prescribing: if this is new prescribing it must be shared. No
feedback has been received from N. Phillimore (pharmacist).
15/37.5 Dexamethasone: a poster is being worked on to explain the confusion in
different strengths and to be taken to the Medication Safety Committee for approval
15/42
15/26 Chair’s Approval given from cancelled meeting from March 2015. There
is a need for the outstanding decisions to be agreed and documented.
New Drug Requests:
Colesevalm and Linaclotide; the quality of the submissions and evidence provided
was poor. Dr Das had not responded to Mrs Ritchie’s email explaining concerns
over the submissions in the format presented or asking who would be coming to the
original meeting to present the case. Mrs Ritchie to email again.
.
Outcome: Not approved.
Glaucoma eye drops and glaucoma protocol: only to be used if problems with
compliance or true allergy. Will be added to formulary where appropriate.
Outcome: Approved
Clinical Guideline given Chair’s Approval
Clinical Guidelines Pre-conceptual care for women with Diabetes.
Outcome: Approved
Guidelines and Policies
Disease Modifying Therapy Care Pathway Multiple Sclerosis Service. Policy not
approved, issues addressed with the author and the Policy is with her now.
Outcome: Referred back to author. Not approved.
Guidance for Post-operative Analgesia after Day-case Arthroscopic Shoulder
Procedures: this is still on-going and will need to be chased.
Outcome: not approved
Guideline for the Management of Sedation, Analgesia and Delirium in the intubated
Adult Patient within the Critical Care Unit: On agenda
Guidelines for the Management of patients on Warfarin or Clopidogrel undergoing all
endoscopic procedures: this had been withdrawn and the author has now left. To
be taken to Sunny Nair.
Minutes of Formulary and Medicines Management Committee
September 2015
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Guidelines for the use of Variable Rate Intravenous Insulin Infusion (VR 111) in
Adult Inpatients: Chair’s Action was given.
Outcome: Approved
Guidelines for the Management of Carotid Artery Rupture in Patients with Advanced
Head and Neck Cancer: Chair’s Action was given.
Outcome: Approved
Policy for the Management Deep Vein Thrombosis (DVT) Nurse Led DVT Clinic:
Outcome: not approved - on the agenda.
Guidelines for the Therapy of Fungal Infections in Adults: Guideline approved at July
2015 meeting, sent to the Chair for QA to be signed and forwarded to Caroline
Sykes.
Outcome: Approved
Guideline for the Use of Granulocyte Colony Stimulating Factors (G-CSF: Guideline
approved at July 2015 meeting.
Outcome: Approved
NICE Technology Appraisals: confirmed addition to Formulary for appropriate
products.
NICE technology appraisal guidance TA 329 - Infliximab, adalimumab and
golimumab for treating moderately to severely active ulcerative colitis after the
failure of conventional therapy.
NICE technology appraisal guidance TA 330 - Sofosbuvir for treating chronic
hepatitis C.
NICE technology appraisal guidance TA 331 - Simprevir in combination with
peginterferon alfa and ribavirin for treating genotypes 1 and 4 chronic hepatitis C.
NICE technology appraisal guidance TA 332 - Sipuleucel-T for treating
asymptomatic or minimally symptomatic metastatic hormone-relapsed prostate
cancer. Not recommended.
NICE technology appraisal guidance TA 333 - Axitinib for treating advanced renal
cell carcinoma after failure of prior systemic treatment.
NICE technology appraisal guidance TA 334 - TA 334 - Regorafenib for metastatic
colorectal cancer after treatment for metastatic disease (terminated appraisal).
15/43
Moviprep v Citramag/Senna: Discussion took place regarding why Citramag and
Senna was stopped as it is more effective than the Moviprep and there is less risk.
Naveen Kumar presented the data around the effectiveness of Moviprep vs
Citramag and Senna. Other hospitals have not had an issue with Moviprep as they
were previously using Picolax which is not very good anyway. Citramag and Senna
PGDs will need to be unarchived. Any Moviprep stock is to be used up. Checks will
be made as one hospital is supplying without an overlabel.
Outcome: Citramag and Senna to replace Moviprep.
Peppermint water – the Chair decided that this could be added to the formulary to
prevent spasms during colonoscopy. The product is an unlicensed medicine and
therefore the processes in the Policy for Unlicensed Medicines will need to be
followed.
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September 2015
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Special solution for lifting polyps: Naveen Kumar also discussed the issue
around preparing methylene blue and adrenaline in a special solution for lifting
polyps. C.McIntyre raised concerns that this is not a stable product and will look into
this.
Action: CMc
15/44
Formulary Items given Chair’s Approval, New Drug Requests and Updates
15/44.1 Levofloxacin eye drops: Miss Ramirez Florez explained the reasons for
wanting this product to be available. There were concerns regarding infections and
it was agreed that a little ciprofloxacin should be kept in stock as a 3rd line treatment.
Outcome: Levofloxacin eye drops were approved.
Ciclosporin eye ointment/drops: this product has been in use for 12 years for severe
dry eyes, allergic conjunctivitis and similar problems. The product used has not
been licensed for human use. There is now a licensed eye drop on the market and
NICE is producing a TA, the consultation papers suggest that it will not be
recommended.
Outcome: Ciclosporin eye drops have been approved.
15/44.2 Proposal to remove Tripotassium dicitratobismuthate (De-noltab) from the
formulary with immediate effect: this will be discontinued at the end of year, none
has been used for two years.
Outcome: Tripotassium dicitratobismuthate (De-noltab) can be removed from
the formulary.
15/45
Horizon Scanning: New Drugs Online newsletter July 015 and NICE Technology
Appraisals in Development expected publication September 2015 to February 2016.
Each year the Trust is expected to predict the amount of spend on tariff excluded
drugs for the following year. This will tie up with the data from Guy Sabbagh.
Specialists and directorate pharmacists plus more information which can be
obtained from coding. The Senior Clinical Leadership Team in Pharmacy will liaise
with consultants.
It was agreed that it would be useful to receive these documents on a regular basis.
15/46
Trust policies and guidelines for approval
15/46.1 Policies given Chair’s Approval
15/46.1.1 Hepatitis Policy: this policy has been amended but unfortunately the
changes are tracked. This policy to be given Chair’s approval when the final version
is available. Final version has been made available via S Mavani and has been
approved by Callum Gardner
Outcome:Policy approved
15/46.2 Guidelines for the safe withdrawal of Corticosteroids after long-term use:
this item was discussed. Prolonged use is 3 months or more. Make sure main
specialisms know about the guidelines. It was suggested it should contain a one
liner to explain what a Synacthen test is.
Outcome: approved
15/46.3 Guidelines for Glycaemic Control during Contrast Angiography: these are
old guidelines which now require reviewing. A number of changes were requested
such as referring to combination preparations with metformin also. Approval
committee should be changed to FMMC.
Outcome: approved with changes
.
Minutes of Formulary and Medicines Management Committee
September 2015
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15/46.4 Nutritional Guidelines for adults in Critical Care: this document is again for
reviewing. There are no major changes or changes in drugs but this must be
recorded as being for over 18s only. The amended document must come back to
the Committee.
Outcome: approved with changes
15/46.5 Guideline for the Use and Administration of Intravenous Iloprost for
Raynaud’s, Severe Peripheral Arterial Occlusive Disease and Buerger’s Disease:
this document is approved with changes.
Outcome: approved with changes – not seen yet. Needs to be chased
15/46.6 Guideline for the management of Sedation, Analgesia and Delirium in the
intubated adult patient within the CCU: a number of amendments are needed.
Outcome: approved subject to changes – need to be chased.
15/46.7 Guideline for the Management of Children and Young People with Diabetic
Ketoacidosis: Dr McDevitt explained that NICE has changed the fluid rates and
these would need changing. The committee raised concerns that that the guideline
suggested making products titled 0.45% sodium chloride/ 10% glucose and 0.9%
sodium chloride / 10% glucose with solutions containing potassium. This needs to
be changed. Mrs Ritchie explained that 0.45% sodium chloride with 10% glucose is
already bought in for paediatric use and that it could be possible to buy in the 0.9%
sodium chloride with 10% glucose; she will confirm this is still available and inform
Dr McDevitt.
Outcome: approved
15/46.8 Seizures in Neonates-Guideline for Management:
Outcome: approved
15/46.9 Percutaneous Endoscopic Gastroscopy (PEG) Feeding Tube Placement
Pre and Post Insertion Care and Management Procedure: this is a procedural
document regarding administration of medication through tube. There are 2 other
policies on SharePoint, could these all be combined? A section needs to be added
regarding seeking the opinion of a member of the microbiology team.
Outcome: Not approved.
15/46.10 Pain relief advice document: there was discussion regarding this document
and concerns regarding nursing staff translating the doses into mls rather than this
being done by the doctors. Discussion took place as to whether this would be
classed as transcribing It was finally agreed that the doctors would write the dose in
mgs in the drug chart and fill in the information sheet in mls; the calculation of which
will be checked by the nurses and countersigned. The prescribers name must be
added for the audit trial.
Outcome: the document was approved as long the procedure was carried out
as described.
15/46.11 Citrate Haemofiltration Prescription & Monitoring Chart: discussion took
place and it was agreed that all the drugs need to be on one chart. Saline should be
changed to sodium chloride. The chart is to be sent back for amendment.
Outcome: not approved
15/46.12 Guidelines for the Management of Anticoagulant reversal in Adults: a
number of changes were requested and the advice given is currently different to that
on the anticoagulation drug chart. Not to be used until pink chart is revised and
updated. Callum Gardner to email Sateesh Nagumantry regarding this action
Action: CG
Outcome: To be put on hold
Minutes of Formulary and Medicines Management Committee
September 2015
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15/46.13 Policy for the Management of Deep Vein Thrombosis (DVT) Nurse Led
Clinic: a number of minor changes were requested.
Outcome: approved with changes
15/46.14 Misoprostol-General Risk Assessment:
15/47
Outcome: approved
NICE Technology Appraisals published July and August 2015:
TA345 Naloxegol for treating opioid‑induced constipation: not yet is use; added to
formulary for this indication.
TA346 Aflibercept for treating diabetic macular oedema: a different drug used for
this condition, added to formulary for this indication.
TA347 Nintedanib for previously treated locally advanced, metastatic, or locally
recurrent non‑small‑cell lung cancer: added to formulary for this indication.
TA348 Everolimus for preventing organ rejection in liver transplantation: Not needed
in this Trust as transplants not done here.
TA349 Dexamethasone intravitreal implant for treating diabetic macular oedema: a
different drug used for this condition. Added to formulary for this indication.
TA350 Secukinumab for treating moderate to severe plaque psoriasis added to
formulary for this indication.
TA351 Cangrelor for reducing atherothrombotic events in people undergoing
percutaneous coronary intervention or awaiting surgery requiring interruption of
anti‑platelet therapy (terminated appraisal).
TA352 Vedolizumab for treating moderately to severely active Crohn's disease after
prior therapy: added to formulary for this indication.
TA353 Bevacizumab for treating relapsed, platinum‑resistant epithelial ovarian,
fallopian tube or primary peritoneal cancer (terminated appraisal).
TA354 Edoxaban for treating and for preventing deep vein thrombosis and
pulmonary embolism: added to formulary for this indication.
Information is needed from Clinical Audit team who ask the directorates about their
adherence to NICE. Without information from clinicians it is not possible to predict
the amount used; the commissioners require this information. There needs to be a
robust system/process in place. The Chair suggested that Dr Sabbagh attends
future meetings. (C Jephcott left at 3.05)
15/48
NICE-Medicines Management Guidance
There are problems with getting guidance as baseline assessments are not being
returned to Guy Sabbagh and his team. There are 3 recent medicines management
NICE guidelines:



Medicines Optimisation
Medicines Adherence
Drug Allergies
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September 2015
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There needs to be a medicines adherence discussion between clinicians and
patient. Discussion took place as to whether this should be a pharmacy issue or
use pharmacy as a safety net?
It was agreed that there should be further discussion on how to take this forward;
possibly with individual team governance meetings. However it is the responsibility
of clinicians to ask patients if they are taking their medications. C.McIntyre will put
something together to go out to Governance Meetings.
Action: CMc
15/49
QIPP / CIP initiatives
This will be picked by the new Pharmacy Clinical Leadership Group.
15/50
Unlicensed Medicines Update
N.Phillimore asked that Chlorapep be discussed as we currently use an unlicensed
product. However, Dr Gardner requested this not be discussed because of a Datix
he had received.
15/51
Reports from Groups and Subcommittees:
15/51.1 Antibiotic Prescribing Group: This group continues to meet and is planning
an Awareness Day in November with activities, teaching and education sessions for
junior doctors. The minutes of meetings to be sent for information (S Oyibo left at
3.15).
15/51.2 Medication Safety Committee (Safer Prescribing Group): Prescribing errors
need to feed back to actual prescriber. With regard to having a “duty of candor”, if
patients are given wrong the drug then we should be telling them even if it does
them no harm. Datix need to be actioned in regard to patients.
15/51.3 IVIG demand management panel: Although needed a meeting has not been
held for some time. A.Ritchie to check if there is a requirement for this group to
report to the Committee.
Action: AR
15/51.4 Thrombosis Committee: there have been a lot of discussions on VTE
assessments. Paper risk assessment done by the doctors would be best. The Trust
is currently failing on VTE assessments because they are not being done on-line
and this results in fines. An electronic tick box to inform then national return would
be helpful. Also the new Maternity system that does not talk to current system.
15/51.5 Oxygen Committee: no meeting to report on, next due in October.
15/51.6 C&PJPG : takes place next week.
15/51.7 NMAG: S.Mavani is working on Cquin for omitted medicines.
The Chair suggested that the highlights of each meeting should be presented as a
summary to this meeting. It needs to be agreed who should do this and also resolve
the difficulty of obtaining the minutes from each meeting.
15/52
Future format of the Formulary and Medicines Management Committee
Meetings: CMcIntyre went through the proposed future agenda.

NPSAs should be on the agenda. Also MHRA safety alerts and pharmacy audits.

Any policies to go through a named pharmacist first to ensure policies are ready
Minutes of Formulary and Medicines Management Committee
September 2015
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to go to the Committee. It is not the Committee’s role to make these changes.
Pharmacists will liaise with policy writers etc and sign off policies as appropriate.
It was proposed that a new front page with signatures, similar to that on PGDs
should be put on the front page of the policies. A checklist to go in the policy for
policies. Pharmacists will then present any new policies etc; not the consultants.

Formulary applications: there should be joint responsibility with the pharmacist
and clinicians to produce applications and the pharmacist will present the
applications at the meetings. However this process must be clinician led with
support by pharmacists.

Senior Pharmacy Clinical Team will have training to enable them to assist.

Medicine optimisation (cost of drugs, review of formulary is important; cost
effective use of drug budget) should be looked at.

Speak to Guy Sabbagh regarding representation.
Any other ideas regarding the formula of the future meetings please pass on to
CMcIntyre.
15/53
Drugs added to infusion labels.
It was agreed that the colour of the infusion labels could be changed.
15/54
Any Other Business
Internal auditors: will be looking at Medicines Management and Controlled Drugs.
The committee was asked to approve a minor change to the policy. This states that
TTO CDs if not going to be taken home straight away by patients should be locked
away and this information recorded in the “appropriate register”.
Outcome: Above minor change to the Controlled Drugs policy agreed.
15/55
Date of Next Meeting: Thursday,12th November 2015, 12.45pm Pharmacy Seminar
Room, First Floor, PCH
Minutes of Formulary and Medicines Management Committee
September 2015
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