Download East Berkshire Clinical Commissioning Groups Volume 4 Issue 3

BERKSHIRE EAST CCGs
Medicines Optimisation
East Berkshire
Clinical Commissioning Groups
Prescribing Update
General Newsletter
Volume 4 Issue 3
June 2014
INTRODUCTION
FORMULARY UPDATE DECISIONS THIS MONTH
2
2
DTC DECISIONS
WOUND CARE UPDATE
2
3
GUIDANCE UPDATE
4
GLUTEN FREE PRESCRIBING POLICY
GROWTH HORMONE IN CHILDREN
NICE AF GUIDELINES
HAYFEVER
RESPIRATORY GUIDELINES LAUNCH AND KEY CHANGES
4
4
5
5
8
SAFETY UPDATE
8
RECOMMENDATIONS OF REVIEW OF ASTHMA DEATHS
GLUCOSE METERS – ACCU-CHEK®
ABUSE POTENTIAL OF GABAPENTIN AND PREGABALIN
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9
10
SUPPLY NEWS
10
METHOTREXATE – NEW METOJECT DEVICE
FUCITHALMIC EYE DROPS
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10
CONTACT DETAILS FOR THE MEDICINES OPTIMISATION TEAM
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INTRODUCTION
Welcome to the June newsletter.
FORMULARY UPDATE DECISIONS THIS MONTH
DTC DECISIONS
ENSURE SHAKE POWDERED SIP FEED
This powdered shake was added to the formulary and Complan Shake was removed as it is
more expensive. All patients should be risk scored using the MUST tool prior to starting a sip
feed and during treatment to see if continuation is appropriate.
Recommended 1st line sip feeds are now:
Fresubin Powder Extra – 7 sachets = £5.60
Ensure Shake Powder – 7 sachets = £6.16
(Non-formulary – Complan Shake Powder – 7 sachets = £6.62)
N.B. Ensure Plus Liquid is 1st choice liquid feed if a powder cannot be used – 7 bottles =
£14.14
NUVARING VAGINAL DELIVERY SYSTEM
This contraceptive vaginal ring was not added to the formulary. It is more expensive than
other forms of contraception without proof of significant benefit.
ALOGLIPTIN TABLETS
This DPP-4 inhibitor is added to the formulary for use in Type 2 Diabetes in line with NICE
CG87 and its license (dual therapy or with metformin and pioglitazone/insulin as triple
therapy). It represents a cost-effective option:
Alogliptin 25mg once daily = £347p.a.
Saxagliptin 5mg once daily = £412p.a.
Sitagliptin 100mg once daily = £434p.a.
(Non-formulary – Linagliptin 5mg once daily = £434p.a.)
See BNF or SPC for dosing in renal impairment. All three formulary options above can be
used in renal impairment at reduced doses.
Sitagliptin will remain on formulary for a further 6 months but will be considered for removal
in November.
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ACAPELLA AND FLUTTER DEVICES
These devices are for mucus clearance in bronchiectasis and COPD. The first device will be
supplied by Respiratory Physiotherapist and should last 1 year. At this point it should be
reviewed and if effective then a replacement device can be prescribed in Primary Care.
WOUND CARE UPDATE
BARRIER PRODUCTS
Sensi-care & Proshield products are available to order online, but are only intended to be
used as a barrier for those prone to tissue damage caused by the wound itself.
Items for incontinence & stoma skin damage should still be provided on prescription. Orders
for a regular supply or a large number of these products should instigate a review and may
need to involve the incontinence/stoma service as regular use should not be required with
correctly fitted products (stoma) or regular pad changing (nursing homes).
WOUND CARE FORMULARY
A joint collaboration between East & West Berkshire has produced a Berkshire wide online
formulary, which has been approved at the East Berkshire wound care meeting.
There are some minor changes and some additions for the East, but the major change is the
agreed switch from Profore to K-four compression bandaging. K-four represents a saving of
£50-60,000 for East Berkshire with no reduction in quality.
Because the 2 systems are different, the Tissue Viability service has arranged a series of
training road shows where practice nurses can drop in to receive the training update. It is
hoped that each practice will send a representative who can share the information with their
practice team. The nurse will also receive a practice pack with the new formulary, a
classification chart and samples of formulary products.
The 2 compression systems are different and cannot be combined. To avoid unnecessary
waste with the upcoming launch of the formulary (planned 1 July 2014), please be mindful of
reducing Profore holding stock and only order the absolute minimum required.
TISSUE VIABILITY WEBSITE
A website for the Tissue Viability Service is currently being built and should be shortly
available. There will be:




Link to TVN team email address
Form for specialist requests (email to TVN team – link on website)
Berkshire Wound Care formulary - practice, nursing home & specialist formularies
Wound Classification chart
A link to the website will be provided on the online ordering site.
IODOFLEX
Due to changes in the licensing of this product, it is now available to order online and will no
longer be required to be supplied on prescription.
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GUIDANCE UPDATE
GLUTEN FREE PRESCRIBING POLICY
The Medicines Optimisation Team are reviewing the Gluten-Free prescribing policy in
conjunction with other CCGs in South Central (Oxfordshire, Buckinghamshire and Berkshire
West) and we would like to forewarn you of a gluten-free prescribing survey which will be
sent out via the communications team, CSCSU. The aim of the survey will be to gather
opinions from clinicians. It's expected that the survey will be sent out in July. It will contain 4
questions and has been designed to take under 5 minutes.
GROWTH HORMONE (GH) IN CHILDREN
The Medicines Optimisation Team has received a number of queries relating to growth
hormone, here are the key points that clinicians need to be aware of.

Growth hormone is a high cost PBR excluded drug, unlike some of the other PBR
excluded drugs, the funding of growth hormone has remained with the CCGs.

Children have to meet NICE TA188 criteria to be eligible to receive it. The link to the
policy may be found on the Central Southern Priorities website.
http://www.fundingrequestscentralsouthern.co.uk/berkshire-east/medicines-andvaccines-berkshire-east/

Assessment and establishment of need must be carried out by a specialist. Where a
patient does not meet the routine NICE criteria, however there are believed to be
exceptional circumstances, an individual funding application may be made via the
IFR route.

Once the treatment has been initiated and stabilised by the specialist, GPs may be
asked to take over prescribing in primary care. GH is AMBER, however currently
there is no formal local shared care document for GPs to follow.

In absence of a shared care document it is recommended that before accepting
prescribing that the GP confirms that the consultant agrees to:
o Monitor the response to treatment.
o Write to the GP advising of results of assessments/tests, response to
treatment and any dose adjustment required.
o Check for concordance with treatment.
o Check for side effects and report suspected serious adverse drug reactions,
and all suspected adverse drug reactions for black triangle drugs, to the CSM
using the yellow card scheme.
o Stop growth hormone treatment when indicated and to write to the GP to
confirm this.
o Arrange transition to adult service when appropriate.

Private patients: If an NHS prescription is requested post private referral, then a
referral into the NHS should be made to ensure the patient falls under the NICE
criteria, please do not prescribe GH on the request of a private consultant.
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NICE atrial fibrillation clinical guideline
http://guidance.nice.org.uk/CG180
The Atrial fibrillation clinical guideline is an update to guidance issued in June 2006 and it
offers evidence-based advice on the care and treatment of people with atrial fibrillation. New
recommendations have been added for a personalised package of care and information,
referral for specialised management, stroke prevention, rate and rhythm control and the
management of acute atrial fibrillation.
Additionally, this guideline recommends using CHA2DS2-VASc score to assess stroke risk
and the HAS-BLED score to assess bleeding risk. Stroke prevention therapy is not
recommended at low levels of stroke risk (CHA2DS2-VASc 0 for men and 1 for women).
Anticoagulation should be considered in men with a CHA2DS2-VASc risk score of 1 and
offered to everyone with a risk score of 2 and above. Anticoagulation may be with a
vitamin K antagonist or apixaban, dabigatran and rivaroxaban. Recommendations for the
newer agents are adopted from existing technology appraisals.
If a vitamin K antagonist is used, time in therapeutic range (TTR) should be calculated
regularly and used with INR results to assess anticoagulation control. If control is poor
and remains poor despite addressing factors that may contribute to poor control (cognitive
function, adherence, illness, drug interactions, and lifestyle) the risks and benefits of
alternative stroke prevention strategies should be evaluated and discussed with the
patient.
HAYFEVER UPDATE
Choice of treatment for hayfever is influenced not only by the efficacy of the treatment
options but also by the patient preferences as to route and frequency of administration,
availability over the counter and whether preventative or episodic treatment is required.
Allergen and trigger avoidance where possible will minimise symptoms but is not always
practical.
Advise people to reconsult after 2-4weeks if symptoms remain inadequately controlled.
Check concordance as well as technique, especially with the use of nasal sprays or drops,
before adding additional treatment.
For more information please see the attached update from the UKMI below.
Please prescribe generically and use formulary choice with lowest acquisition cost.
Formulary choices: see table below.
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Prices based on Drug Tariff June 2014 or Mimms June-Aug 2014
Steroid nasal
sprays
1st line
Beclometasone diproprionate
50microgram/metered spray
– 200spray unit = £2.12
2nd line
Budesonide
100microgram/metered
spray – 100spray unit =
£5.90
3rd line
Mometasone Furoate
(Nasonex)
50microgram/metered
spray – 140spray unit
= £7.57
Fluticasone Furoate
(Avamys)
27.5microgram/dose –
120spray unit = £6.44
Tabs
Cetirizine 10mg tabs - 30tabs
= £1.06
Loratadine 10mg tabs –
30tabs = £1.00
E/drops
Sodium cromoglycate 2% 13.5ml = £1.67
*Please note items in italics are available to buy over the counter and may be a cheaper
option for the patient.
RED (RESTRICTED):
Flixonase (fluticasone proprionate 50microgram/dose) nasal spray 150dose unit = £11.01 restricted for use by ENT specialists for short-term treatment of nasal polyps
NON FORMULARY (DO NOT PRESCRIBE) –list not exclusive but more commonly
used :
Dymista (fluticasone 50microgram and azelastine 137microgram per dose) nasal spray
120dose unit = £18.91
Rhinocort Aqua (budesonide 64microgram / metered spray) nasal spray 120 dose unit =
£3.49 (generic 120 dose unit = £3.85)
Rhinolast (Azelastine 140 microgram metered dose nasal spray 22ml (157metered doses) =
£10.46
Benadryl (Acrivastine 8mg) caps x12 = £2.75
Neoclarityn (Desloratadine 5mg) tabs x30 = £1.35
Xyzal (Levocetirizine 5mg) tabs x30 = £3.94
Optilast (Azelastine 0.05%) eye drops 8ml = £6.40
Otrivine-Antistin (Antazoline 0.5% with Xylometazoline 0.05%) eye drops 10ml = £2.35
Rapitil (Nedocromil 2%) eye drops 5ml = £2.86
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Hay Fever Season –
Thinking Ahead
May to August 2014
Guidelines
Newer Treatments
NICE Clinical Knowledge Summaries (CKS)
 Allergic rhinitis (Nov 2012) includes seasonal rhinitis (hay fever).
Information on the management of mild, moderate and severe
symptoms, treatment failure and treatment in pregnancy. Also
includes patient information leaflets.
DTB (Athens password or subscription may be required)
DTB: Grazax for hay fever – what’s new? 2010 – Update of 2008 review and DTB
Select: 1 February 2011
 Licensed as a ‘disease-modifying’ treatment in adults and children (5 yrs and
over).
 DTB still remains unconvinced of any worthwhile benefit and does not
recommend its use.

Conjunctivitis - allergic (Aug 2012) Includes information on
management of seasonal or perennial allergic conjunctivitis.
Patient Information
NHS Choices:



Hay Fever - Patient information on various aspects of hay fever
including symptoms, causes, diagnosis, treatment and prevention.
Live well – Hay Fever - Includes specific information on hay fever in
children and hay fever and the weather.
Antihistamines - General information about uses, how they work and
side effects.
Patient UK:

Hay Fever - Includes information on symptoms, avoidance methods
and overview of treatment options.
General Reviews


An update on the management of Hay Fever in adults. DTB
2013;51:30-33 (password or subscription required for full text).
DTB: Azelastine and fluticasone nasal spray: any advantage? Feb 2014
 New combination product Dymista.
 Statistically significant improvements in nasal symptoms seen in short term
studies, but clinical significance of results unclear.
 Has not been compared with concomitant use of an oral antihistamine with an
intranasal corticosteroid.
Other Useful Information

Q&A 29.6: Which medicines can be used to treat intermittent allergic rhinitis
during pregnancy? (May 2014).

BSACI guidelines for the management of allergic and non-allergic rhinitis. Clin
Exp Allergy 2008;38:19-42.
BSACI guidelines: Immunotherapy for allergic rhinitis. Clin Exp Allergy 2011;
41:1177-2000.


Subcutaneous immunotherapy and pharmacotherapy in seasonal allergic rhinitis:
A comparison based on meta-analyses Allergy Clin Immunol. 2011;128:791-9.
Cochrane Reviews
 Sublingual immunotherapy for treating allergic conjunctivitis (2011)
Lancet Seminar: Allergic rhinitis. Lancet 2011;378:2112-22. (Athens
 Helminth therapy (worms) for allergic rhinitis (2011). Insufficient evidence to
password or subscription may be required).
support to support its use.
 Sublingual immunotherapy for allergic rhinitis (2009)
 Topical nasal steroids for intermittent and persistent allergic rhinitis in children
(2006). Available evidence to support use is weak and unreliable.
Produced by Nicola Watts, Medicines Information Pharmacist, Wessex Drug & Medicines Information Centre, Southampton.May 2014
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RESPIRATORY GUIDELINES
The Berkshire East Respiratory Guidelines have been reviewed and updated; they have
been circulated together with a poster summary for both Asthma and COPD
Key changes include:
ASTHMA
Inhaler should be prescribed after patient has received training and demonstrated
satisfactory technique.
Inhaler technique to be checked at every appointment and assessed at least annually by a
HCP who has competency.
If excessive β2 agonist use asthma management should be reviewed by a Respiratory Nurse
Practitioner or Doctor.
Easyhalers have been added as an option, but should only be trialled after patient has had
an asthma management plan/ inhaler technique check and unable to use an MDI (with
spacer).
Ciclesonide added if patient is unable to tolerate inhaled corticosteroids due to severe mouth
soreness or thrush.
Stepping down guidance – decrease dose by 25-30% each time where clinically appropriate;
review patient every 3 months as they step down.
COPD
LABAs should be used in patients who have two or more exacerbations per year
Easyhalers have been added as an option.
All LAMAs should be reviewed at 3 months to check effectiveness.
Aclidinium added third line as an option to Tiotropium.
RESCUE PACKS
Contents of Rescue packs detailed in Appendix II of guidelines; Rescue pack patients should
be reviewed during the Rescue course, informed how to increase inhaled bronchodilator
therapy and when more urgent care is required.
SAFETY UPDATE
WHY ASTHMA STILL KILLS – THE NATIONAL REVIEW OF ASTHMA
DEATHS
The Royal college of Physicians has published a report into asthma deaths in the UK.
Please consider reading the full report. However, there were 4 key prescribing
recommendations:
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1. All asthma patients who have been prescribed more than 12 short-acting reliever
inhalers in the previous 12 months should be invited for urgent review of their asthma
control, with the aim of improving their asthma through education and change of
treatment if required.
2. An assessment of inhaler technique to ensure effectiveness should be routinely
undertaken and formally documented at annual review, and also checked by the
pharmacist when a new device is dispensed.
3. Non-adherence to preventer inhaled corticosteroids is associated with increased risk
of poor asthma control and should be continually monitored.
4. The use of combination inhalers should be encouraged. Where long-acting beta
agonist (LABA) bronchodilators are prescribed for people with asthma, they should
be prescribed with an inhaled corticosteroid in a single combination inhaler.
MHRA ASKS PEOPLE TO CHECK THEIR DIABETES METERS
The Medicines and Healthcare products Regulatory Agency (MHRA) is asking people with
diabetes who use Accu-Chek® Mobile blood glucose meters to ensure they follow the
important testing instructions. This is because the meter may give false high blood glucose
readings if testing instructions are not followed accordingly.
An incorrect blood glucose reading can lead to people using the incorrect dose of insulin
which, in some circumstances, could lead to hypoglycaemia.
The manufacturer, Roche Diabetes Care, has identified a small number of people using the
strip-free Accu-Chek® Mobile blood glucose monitoring system who have experienced
falsely high blood glucose readings. This meter requires users to follow different testing
instructions compared to other diabetes meters. If this procedure is not followed correctly an
incorrect reading may be given even though the meter is working properly.
The manufacturer has issued enhanced training and handling instructions which are
available online. People using this particular blood glucose monitoring device are
encouraged
to
access
the
updated
testing
instructions
at:
www.accuchek.co.uk/mobilepropertesting. If people have any questions about their blood glucose
readings they should speak with their practice nurse or they can contact the Accu-Chek®
customer care line on 0800 701 000.
N.B. People who purchase a meter that is not recommended in East Berkshire should not
receive test strips for that meter on prescription. They should be offered a meter that is
compatible with a recommended test strip at no cost to the patient.
1st line (for patients who don’t fit exceptions
below)
Wavesense Jazz®
Alternative option
Supercheck 2®
For visually impaired patients
Supercheck 2®
Gestational diabetes
Contour Next® can be initiated by specialist
Highly unstable insulin treated patients (predominantly
patients prone to repeated hypoglycaemic events)
Contour Next® can be initiated by specialist
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Carbohydrate counting
Either: Accucheck Aviva Expert or Freestyle
Insulinx. Follow advice of initiating specialist
Insulin pumps
Follow advice of initiating specialist
Paediatrics
To undergo a separate review
PREGABALIN AND GABAPENTIN
The Medicines Optimisation Team has received a request to highlight to other clinicians in
the CCG that both pregabalin and gabapentin have the potential for misuse as recreational
drugs and have a “street value”.
Pregabalin and gabapentin may be sold as a street drug under a number of pretexts
including, as a mood enhancer, to augment the effects of other drugs, to manage opiate
withdrawals and cravings, or as a substitute for other drugs such as cocaine. If a patient
demonstrates suspicious behaviour related to pregabalin or gabapentin (e.g. appearing to
seek larger than needed doses, losing prescriptions, frequent over-ordering), the possibility
of abuse or diversion of medication should be considered. Use of these drugs in prisons is
also known to be a problem.
SUPPLY NEWS
METOJECT PEN: NEW DEVICE FOR METHOTREXATE INJECTIONS
Metoject syringe is being discontinued and replaced by Metoject Single Dose Pen. The
doses, strength and colour coding is the same as for the syringe.
The new device has an automatic needle shield and administration is different: it uses a one
click button rather than syringe plunger to administer. Homecare providers, pharmacies and
specialists have been provided with guides to help them explain the change to patients.
FUCITHALMIC EYE DROPS- SUPPLY PROBLEM
There is a current supply problem with Fucithalmic eye drops due to Leo Pharma divesting
the product to another manufacturing company. Following a telephone conversation with the
new manufacturers supplies are expected to resume by the end of June.
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CONTACT DETAILS FOR THE MEDICINES OPTIMISATION TEAM
King Edward VII Hospital, St Leonards Rd, Windsor SL4 3DP
Main office number 01753 636845
Fax: 01753 636055
Email: [email protected]
Tim Langran
Melody Chapman
Dawn Best
Caroline Pote
Sundus Bilal
Sally Clarke
Acting Head of Optimisation
Slough CCG
CCG Lead Support Pharmacist
Bracknell & Ascot CCG
CCG Lead Support Pharmacist
Maidenhead/Windsor/Ascot
CCG Lead Support Pharmacist
CCG Prescribing Support
Pharmacist
Care Home & Practice Support
Pharmacist
CCG Prescribing Support
Pharmacist
Mobile:
07775 010727
Email: [email protected]
Mobile:
07826 533736
Mobile:
07825 691163
Mobile
07824 476439
Mobile:
07909 505658
Mobile:
07747007934
Email [email protected]
Email: [email protected]
Email: [email protected]
Email:[email protected]
Email:[email protected]
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