Download Pan Mersey Area Prescribing Committee

Issue 17, July 2015
Pan Mersey Area Prescribing Committee ................................................................................................................................... 1
Antimicrobial Stewardship and Resistance ................................................................................................................................. 2
Current Issues............................................................................................................................................................................. 3
Topic of the Month ..................................................................................................................................................................... 4
Drug Tariff .................................................................................................................................................................................. 5
Safety ......................................................................................................................................................................................... 8
Pan Mersey Area Prescribing Committee
RECOMMENDATIONS
ABATACEPT infusion and subcutaneous injection (Orencia®) in Rheumatoid Arthritis
The Pan Mersey Area Prescribing Committee recommends the prescribing of ABATACEPT infusion and
subcutaneous injection (Orencia®) for rheumatoid arthritis in accordance with NICE TA195 and TA280, and in
accordance with the Mersey Rheumatoid Arthritis Biologics Pathway. Treatment should be initiated and supervised
by a rheumatologist. http://www.panmerseyapc.nhs.uk/recommendations/documents/PS133.pdf
RITUXIMAB infusion (MabThera®) in rheuRheumatoid Arthritis (RA)
The Pan Mersey Area Prescribing Committee recommends the prescribing of rituximab infusion (MabThera®)
for rheumatoid arthritis in accordance with NICE TA195 and in accordance with the Mersey Rheumatoid
Arthritis Biologics Pathway. Treatment should be initiated and supervised by a rheumatologist.
http://www.panmerseyapc.nhs.uk/recommendations/documents/PS134.pdf
TOCILIZUMAB (RoActemra®) for Rheumatoid Arthritis (RA)
The Pan Mersey Area Prescribing Committee recommends the prescribing of TOCILIZUMAB intravenous infusion
and subcutaneous injection (RoActemra®) for the treatment of rheumatoid arthritis in accordance with NICE
TA247, and in accordance with the Mersey Rheumatoid Arthritis Biologics Pathway. Treatment should be initiated
and supervised by a rheumatologist. http://www.panmerseyapc.nhs.uk/recommendations/documents/PS135.pdf
USTEKINUMAB injection (Stelara®) for Psoriatic Arthritis
The Pan Mersey Area Prescribing Committee recommends the prescribing of USTEKINUMAB injection (Stelara®)
for active psoriatic arthritis in accordance with NICE TA340.
http://www.panmerseyapc.nhs.uk/recommendations/documents/PS68.pdf
VEDOLIZUMAB infusion (Entyvio®▼) for ulcerative colitis
The Pan Mersey Area Prescribing Committee recommends the prescribing of VEDOLIZUMAB infusion
(Entyvio®▼), by specialists only, for adult patients with moderately to severely active ulcerative colitis in
accordance with NICE TA342. http://www.panmerseyapc.nhs.uk/recommendations/documents/PS75.pdf
OXYCODONE with NALOXONE modified release tablets (Targinact®) for restless legs syndrome
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of OXYCODONE
with NALOXONE modified release tablets (Targinact®) for restless legs syndrome.
http://www.panmerseyapc.nhs.uk/recommendations/documents/PS132.pdf
TOLVAPTAN tablets (Jinarc®▼) for polycystic kidney disease
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of TOLVAPTAN
tablets (Jinarc®▼) for the treatment of autosomal dominant polycystic kidney disease.
http://www.panmerseyapc.nhs.uk/recommendations/documents/PS130.pdf
1
APIXABAN film-coated tablets (Eliquis®▼) for the treatment and secondary prevention of Deep Vein
Thrombosis and/or Pulmonary Embolism
The Pan Mersey Area Prescribing Committee recommends the prescribing of APIXABAN (Eliquis®▼) as an option
for treating and/or preventing recurrent deep vein thrombosis (DVT) and/or pulmonary embolism (PE) in
accordance with NICE TA341, following specialist initiation.
http://www.panmerseyapc.nhs.uk/recommendations/documents/PS93.pdf
EPLERENONE tablets for NYHA Class II Chronic Heart Failure
The Pan Mersey Area Prescribing Committee recommends the prescribing of EPLERENONE tablets, following
specialist initiation, in addition to standard optimal therapy to reduce the risk of cardiovascular morbidity
and mortality in adults with NYHA class II heart failure and left ventricular systolic dysfunction (LVEF 30% or
less). http://www.panmerseyapc.nhs.uk/recommendations/documents/PS131.pdf
EZETIMIBE (Ezetrol®) for hypercholesterolaemia
The Pan Mersey Area Prescribing Committee recommends EZETIMIBE (Ezetrol®) in the management
of hypercholesterolaemia only in line with the criteria in this policy statement.
http://www.panmerseyapc.nhs.uk/recommendations/documents/PS137.pdf
GUIDELINES
Depression
NICE BITES November 2009: No 11
The Pan Mersey Area Prescribing Committee endorses UKMI North West 'NICE Bites' summary of prescribing
recommendations from NICE Clinical Guideline 90 and 91 covering depression.
http://www.elmmb.nhs.uk/EasySiteWeb/getresource.axd?AssetID=37127&type=...&UNLID=888730423201561612
3558
Biological agents in the management of Rheumatoid Arthritis - pathway
Issued: June 2015 | Review: June 2017 http://www.panmerseyapc.nhs.uk/guidelines/documents/G9.pdf
Biological agents in the management of Psoriatic Arthritis - pathway
Issued: June 2015 | Review: June 2017 http://www.panmerseyapc.nhs.uk/guidelines/documents/G14.pdf
Oral Combination Products
Issued: June 2015 | Review: June 2017
http://www.panmerseyapc.nhs.uk/recommendations/documents/PS136.pdf
Antimicrobial Stewardship and Resistance
Pan Mersey Antimicrobial Guide and Management of Common Infections in Primary Care
The full Antimicrobial Guide and Management of Common Infections in Primary Care can be accessed via the Pan
Mersey website but prescribers may not be aware that there is also a quick reference guide for common infections
which they can use as a handy tool to help guide appropriate antibiotic prescribing.
The Quick Reference Guide is also available on the Pan Mersey website. The medicines management team have
laminated a number of copies for prescribers to keep in front of them as a handy reference source. These will be
distributed during August.
Antimicrobial Stewardship: Managing Antibiotic Resistance - On-line antibiotic stewardship course
Below is a link to a free online antibiotic stewardship course. This free online course starts on the 28th September
2015 and lasts for 6 weeks. Further information can be found here.
‘Treating your Infection' leaflet
We mentioned the 'Treating your infection' patient leaflet in last month’s newsletter – this is just a reminder to
prescribers that this is a tool they may wish to start using with appropriate patients. It is available via the following
link: http://www.rcgp.org.uk/targetantibiotics/~/~/media/2E1292605D174B318A5302223B04C175.ashx
Current Issues
Definitions and Criteria for Categorisation of Medicines in the Pan Mersey Formulary and RAG List
In January 2015 revised definitions and criteria were agreed by the Pan Mersey APC for classification of medicines to
be included in the formulary – these were then agreed by the CCG in February 2015.
In a rolling programme of work the formulary chapters are now being reviewed to ensure all amber drugs are
classified in line with the revised criteria. The new definitions are:
 Amber Recommended requires specialist assessment and recommendation to GP to prescribe in Primary
Care
 Amber Initiated requires specialist initiation of prescribing. Prescribing to be continued by the specialist until
stabilisation of the dose and the patient’s condition is achieved and the patient has been reviewed.
 Amber Patient Retained requires specialist initiation of prescribing. Prescribing to be continued by specialist
until stabilisation of the dose and the patient’s condition is achieved and the patient had been reviewed.
Patient remains under the care of specialist (i.e. not discharged) as occasional specialist input may be
required.
 Purple Shared Care – Traditionally shared care drugs were classified as amber along with all other amber
drugs. This category has now been changed to purple and the criteria for defining whether a drug should be
managed via shared care have been redefined to ensure a consistent approach across the health economy.
A Shared Care Agreement will always be available for Shared Care medicines and this document will include
a Shared Care Agreement pro-forma which will be completed by all involved clinicians. This pro-forma will
record agreement to take on defined aspects of care e.g. monitoring and/or on-going prescribing for the
individual patients.
Implicit in any shared care agreement is the understanding that participation is at the discretion of the
Primary Care prescriber subject to their clinical confidence.
As the chapters are reviewed all amber drugs will be assigned one of the categories above and this will then be
updated in the Pan Mersey formulary. As drugs are reviewed ScriptSwitch will also be updated with the new
classifications.
The following classifications remain the same within the formulary:
 Red - Drugs which should be prescribed only by a specialist clinician. Primary Care prescribing of these
medicines is NOT recommended unless there is a specific reason and a specific protocol and service set up to
support this. Primary Care prescribers may prescribe RED medicines in exceptional circumstances to ensure
continuity of supply while arrangements are made to obtain usual supplies from Secondary Care, but should
be mindful of the responsibilities they accept in doing this. Primary Care prescribers must ensure that details
of any RED drugs prescribed by the specialist clinician are recorded in individual patient records on computer
systems. Please speak to your medicines management pharmacist or technician for advice on the best
approach to do this.
 Grey - These medicines are still being evaluated according to local processes and a decision on whether to
commission their use has not yet been made. They should not be prescribed in any setting.
 Black - Medicines not recommended for use because of lack of evidence of clinical effectiveness, cost
prioritisation or concerns over safety.
 Green - Medicines for which GPs would normally take full responsibility for prescribing and monitoring.
Green status does not imply that a medicine is superior to existing first-line drugs or is a recommended
formulary choice. http://www.panmerseyapc.nhs.uk/index.html
Historic Mid Mersey Medicines Management Board RAG List
Information on the RAG classification of medicines held within the old 4MB RAG list has now been superseded by the
changes above and the development of the Pan Mersey formulary, this list should no longer be used – prescribers
can find the most up to date information on the Pan Mersey Website and Pan Mersey formulary
Paediatric Doses – Risk of Errors
We would like to remind all prescribers and pharmacists of the importance of checking paediatric doses of liquid
medication. Most children’s doses are determined by weight. Please double check the dose is appropriate as child’s
weight can change frequently. Also, be aware if there are different strengths of the same drug.
One example that we have recently been made aware of involved the commonly prescribed drug, ranitidine. This is
commonly prescribed for reflux in primary care but there are two different preparations that could be selected:
- a licensed solution of 75mg/5ml
- an un-licensed solution/suspension of 5mg/5ml
The dosage in the cBNF varies widely depending on the age and weight of the child and the two different
preparations contains very different amounts of ranitidine. For full dosage details please refer to cBNF. It is
recommended that the dosage is prescribed in milligrams (mg) and NOT millilitres (mls) as this is where errors have
occurred. There is a risk that children may be significantly over dosed or even under dosed due to confusion over the
different preparations and errors in the calculation of the dose.
If you have any queries, please contact your medicines management pharmacist or technician for advice.
Reminder: Prescription requirement changes for temazepam
As of 1st June 2015, prescriptions for temazepam must fully comply with the prescription writing requirements for
Schedule 3 controlled drugs. Prescriptions for temazepam must now contain the following information:
 dose
 form
 strength (where appropriate)
 total quantity of the preparation in both words and figures
Topic of the Month
STRONG OPIOIDS AND TRANSDERMAL PATCHES
Strong opioids
Pain can be mild, moderate or severe. It can be treated using different strengths of painkiller, depending on the level
of pain experienced by the patient. The World Health Organisation (WHO) Pain Ladder(1) shows each level of pain and
the type of painkillers that are best to control it:
1.
Mild pain - Step one includes non-opioid drugs e.g. paracetamol and anti-inflammatory drugs (ibuprofen,
naproxen).
2.
Moderate pain - Step two includes weak opioid drugs e.g. dihydrocodeine, codeine phosphate or tramadol.
3.
Moderate to severe pain - Step three includes strong opioid drugs e.g. morphine, fentanyl and oxycodone.
Adjuvant drugs such as anti-depressants or anti-consultants may also be used to control pain.
Pain management
When starting a pain killer remember:



Mouth - use the oral route where possible, even for opioids.
By the clock - for persistent pain, provide medication at regular set intervals (around the clock) rather than
when required.
Use the WHO Pain Ladder (see diagram).
WHO Pain Ladder
Key Messages

Oral analgesics are generally preferred as first line therapy in chronic non-cancer pain. Buprenorphine patches
at lower doses (BuTrans®) are broadly as effective as codeine or tramadol but are much more expensive

NICE guidance recommends oral morphine as the first-line strong opioid for palliative care(2). Buprenorphine
patches cost several times more than oral morphine in equivalent doses.

The patches are unsuitable for acute or unstable pain due to the need for slow titration of doses; it may take up
to 72 hours to achieve a stable blood level after a change in dose.

Patches containing buprenorphine (Transtec®, BuTrans®) are an alternative to oral opioid analgesics.
Buprenorphine patches are generally not recommended as a first-line analgesic and should not be used for
unstable pain. Analgesic patches are considerably more expensive than oral therapy.
Circumstances when patches may be considered preferable to oral products include if the patient:
•
•
•
•
•
has difficulty/inability to swallow, or the oral route is inappropriate
is intolerant of oral analgesics or is experiencing unacceptable side-effects with oral analgesics
has poor absorption from the gastrointestinal tract
has renal impairment
has compliance problems – supervised patch changes will assist this.
Cost of patches (28 days)
Buprenorphine 5mcg/hr (BuTrans®)
Buprenorphine 10mcg/hr (BuTrans®)
Buprenorphine 20mcg/hr (BuTrans®)
Buprenorphine 35mcg/hr (Trantec®)
Buprenorphine 52.5mcg/hr (Transtec®)
Buprenorphine 70mcg/hr (Transtec®)
- £17.60
- £31.55
- £57.46
- £27.65
- £41.49
- £55.30
Prescribing data for buprenorphine patches in the last year (April 14- March 15):
 Halton spent a total of £134,700 on buprenorphine patches; 14% of this cost was as a result of prescribing the
weaker strength patch BuTrans®, which has a similar analgesic effect to co-codamol or tramadol
References:
1. World Health Organization (2009). WHO’s Pain Relief Ladder www.who.int/cancer/palliative/painladder/en/
2. NICE CG140 Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults.
http://publications.nice.org.uk/opioids-in-palliative-care-safe-and-effective-prescribing-of-strong-opioids-for-pain-in-palliativecg140/recommendations
Drug Tariff
PRICE CHANGES
Top 10 monthly price reductions
Methyldopa 125mg tablets [1 x 56] £116.27 (-£4.99)
Dexamethasone 500microgram tablets [1 x 28] £58.83 (-£4.59)
Aripiprazole 30mg tablets [1 x 28] £177.85 (-£3.56)
Aripiprazole 10mg tablets [1 x 28] £88.93 (-£1.78)
Aripiprazole 15mg tablets [1 x 28] £88.93 (-£1.78)
Aripiprazole 5mg tablets [1 x 28] £88.93 (-£1.78)
Isradipine 2.5mg tablets [1 x 56] £185.64 (-£1.63)
Dexamethasone 10mg/5ml oral solution sugar free [1 x 150] £96.05 (-£1.61)
Famciclovir 500mg tablets [1 x 14] £154.04 (-£1.08)
Ibuprofen 10% gel [1 x 100] £4.92 (-£0.87)
Top 10 monthly price increases
Nitrofurantoin 25mg/5ml oral suspension sugar free [1 x 300] £260.46 (+£64.63)
Trifluoperazine 1mg/5ml oral solution sugar free [1 x 200] £65.73 (+£32.87)
Ampicillin 250mg/5ml oral suspension [1 x 100] £38.86 (+£31.47)
Triamterene 50mg capsules [1 x 30] £41.90 (+£13.98)
Amantadine 50mg/5ml oral solution sugar free [1 x 150] £103.25 (+£13.95)
Chloral hydrate 143.3mg/5ml oral solution BP [1 x 150] £194.06 (+£13.45)
Disopyramide 150mg capsules [1 x 84] £27.58 (+£8.82)
Cloral betaine 707mg tablets [1 x 30] £110.06 (+£7.53)
Prochlorperazine 3mg buccal tablets [1 x 50] £23.98 (+£5.76)
Gentamicin 0.3% / Hydrocortisone acetate 1% ear drops [1 x 10] £11.98 (+£5.32)
Top 100 annual price reductions
http://www.panmerseyapc.nhs.uk/home/tariff_watch/partviiia_reductions_201506.pdf
Top 100 annual price increases
http://www.panmerseyapc.nhs.uk/home//tariff_watch/partviiia_increases_201506.pdf
DRUG AVAILABILITY
Drugs with long-term supply issues
The following drugs have long-term supply issues. The table below shows the reason for the supply issue, where
known, and possible return to stock dates.
Description
Anusol Hc® suppositories x12 and x24
(Johnson & Johnson)
Aptamil® lactose free milk powder
x400g
(Danone Nutricia)
Caverject® Dual Chamber
20micrograms x2 (Pfizer)
Colofac® tablets 135mg x100
(Bgp Products)
Co-phenotrope tablets
2.5/0.025mg x100
(Amco Rwa / Mercury Pharma)
Creon® 40 000 capsules x100
(Abbott Healthcare)
Diclofenac sodium ec tablets 50mg
(various makes)
Freestyle® blood glucose test strips
x50 (Abbott)
Genticin® eye/ear drop 0.3% x10ml
(Amco / Amdipharm)
Hormonin® tablets x84
(Amco Rwa / Mercury Pharma)
Methotrexate tablets 2.5mg x24
(Various brands)
Modrasone® cream x50g (Teva)
Due date
Comment
Supplier unable to confirm
Manufacturing issue is causing a delay in
supply
Supplier unable to confirm
Stock on allocation from supplier.
January 2016
Supplier unable to confirm
July 2015
January 2016
Supplier unable to confirm
Limited supplies ongoing
Supplier unable to confirm
Limited supplies ongoing
October 2015
July 2015
Sno Tears®eye drops 10ml (Bausch &
Lomb)
Supplier unable to confirm
Synalar® cream x30g (Derma UK)
Supplier unable to confirm
Synalar® cream 1:4 x50g (Derma UK)
Supplier unable to confirm
Traxam® gel 3% x100g
(Amco Rwa / Mercury Pharma)
Traxam® pain relief gel x30g
(Amco Rwa / Mercury Pharma)
Unistik® 3 comfort lancet 28G X 1. 8mm
x100 (Owen Mumford)
Unilet® C touch lancets 28Gx0.38mm
100
VitA-POS® eye ointment x5g
(Scope Opthalmics)
Zidoval® vaginal gel 0.75% x40g
(Meda Pharma)
Zacin® cream 0.025% x45g
(Teva)
Manufacturing issue is causing a delay in
supply. Medical Information Enquiries 0845 608 8866
Manufacturing issue is causing a delay in
supply
Supplier issue is causing a delay in
supply.
Manufacturing issue is causing a delay in
supply.
Market shortage is causing a delay in
supply.
Ongoing supply issue.
Manufacturing issue is causing a delay in
supply
Supplier issue is causing a delay in
supply
Market shortage is causing a delay in
supply
Manufacturing issue is causing a delay in
supply
Manufacturing issue is causing a delay in
supply
Manufacturing issue is causing a delay in
supply
Manufacturing issue is causing a delay in
supply
February 2016
Supplier issue is causing a delay in supply
February 2016
Supplier issue is causing a delay in supply
July 2015
Supplier issue is causing a delay in supply
Supplier unable to confirm
Supplier issue is causing a delay in supply
Supplier unable to confirm
Supplier issue is causing a delay in supply
August 2015
Supplier issue is causing a delay in supply
Supplier unable to confirm
Manufacturing issue is causing a delay in
supply
Zovirax® 3% eye ointment supply problems
There is a supply problem with Zovirax® 3% eye ointment (aciclovir 3% eye ointment) following a recall of
contaminated batches in November 2014. Although supplies were due to resume in April 2015, there are still very
limited stocks available.
UK licensed treatment options for managing herpes simplex keratitis are:
• Ganciclovir 0.15% eye gel (Virgan®) – licensed for the treatment of acute herpetic keratitis (dendritic and
geographic ulcers), given as ‘one drop five times daily’ until epithelial healing occurs. Treatment should not
exceed 21 days.
• A treatment course of oral aciclovir 400mg 5 times a day for 10 to 14 days.
UK Medicines Information (UKMi) have issued the following guidance:
http://www.medicinesresources.nhs.uk/en/Communities/NHS/SPS-E-and-SE-England/MedicinesInformation/Discontinuation-Supply-Shortage-Memos/Shortage-of-Zovirax-eye-ointment-3/
Creon® 40 000 capsules supply problems
The manufacturer has stated that due to a lower than expected yield for this biological enzyme, there are supply
constraints with the 40 000 strength of Creon® and they don’t have a stock availability date. However this should not
impact on patient care as there is ample stock of the 10 000 and 25 000 strengths of Creon®.
Patients who are prescribed Creon® 40 000 supplements should be switched to alternative strengths to ensure
continuity of supply.
Discontinued products- Co-danthramer (dantron/poloxamer 188 25mg/200 mg) and strong co-danthramer
(dantron/ poloxamer 188 37.5mg/500 mg) capsules
These have been discontinued by Napp. Stock of co-danthramer capsules is expected to last until the end of June
2015 and stock of strong co-danthramer capsules until the end of December 2015. Alternative suspension
formulations of co-danthramer are available.
For further information regarding supply problems, please contact your Medicines Management Team.
Safety
Can breastfeeding mothers take paracetamol?
Paracetamol has been widely used on prescription and over-the-counter since it launched in the UK in 1956.
Paracetamol can be given therapeutically to infants (including premature infants from 28 weeks corrected
gestational age) at a dose of 10-15mg/kg body weight every 8-12 hours for pain and pyrexia. It is also given to infants
for post-immunisation pyrexia. Although paracetamol is widely used, the evidence for its safety in breastfed infants
is based on mainly small, uncontrolled studies of single doses of paracetamol. However, it is considered to be
compatible with breastfeeding and there appears to be no significant risk to the infant. There is a risk to the infant of
hypersensitivity from low levels of exposure to paracetamol or its metabolites but it remains the choice of analgesia
for breastfeeding mothers. Paracetamol has a relatively short half-life in adults of approximately two hours and the
quantity of drug which passes in to the breast milk is very small.
If the infant is pre-term, has a low birth weight or has an underlying medical condition, then further advice should be
sought as it may affect the disposition and excretion of the drug.
Full details are available from this link;
http://www.evidence.nhs.uk/Search?q=%22Can+breastfeeding+mothers+take+paracetamol%22
MHRA DRUG SAFETY UPDATE
SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin): risk of diabetic ketoacidosis
Sodium glucose co-transporter 2 (SGLT2) inhibitors are licensed for use in adults with type 2 diabetes to improve
glycaemic control. Serious and life-threatening cases of diabetic ketoacidosis (DKA) have been reported in patients
taking SGLT2 inhibitors (canagliflozin, dapagliflozin or empagliflozin).
When treating patients who are taking an SGLT2 inhibitor:






test for raised ketones in patients with symptoms of diabetic ketoacidosis (DKA); omitting this test could delay
diagnosis of DKA
if you suspect DKA, stop SGLT2 inhibitor treatment
if DKA is confirmed, take appropriate measures to correct the DKA and to monitor glucose levels
inform patients of the symptoms and signs of DKA e.g. nausea, vomiting, anorexia, abdominal pain, excessive
thirst, difficulty breathing, confusion, unusual fatigue or sleepiness. Advise them to get immediate medical help
if these occur
be aware that SGLT2 inhibitors are not approved for treatment of type 1 diabetes
please continue to report suspected side effects to SGLT2 inhibitors or any other medicines on a Yellow Card
Full details are available from this link https://www.gov.uk/drug-safety-update/sglt2-inhibitors-canagliflozindapagliflozin-empagliflozin-risk-of-diabetic-ketoacidosis
Medicines Management Team contacts:
Lucy Reid (Halton)
[email protected]
01928 593 452