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NHS North of England Commissioning Support (NECS) prescribing newsletter - March 2014
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North Tyneside CCG


North of Tyne Wound Care Formulary

The North of Tyne Wound Care formulary was reviewed in November by a multidisciplinary group comprising CCG GP prescribing leads and practice nurse representatives, Tissue Viability Nurses from both local foundation trusts and representatives from district nursing, podiatry, paediatric and adult dermatology, lymphoedema nursing, burns and plastics nursing specialists and medicines optimisation pharmacists.

The updated formulary was finalised at the end of January 2014 and is published in Chapter 18 of the current North of Tyne APC formulary available at www.northoftyneapc.nhs.uk

KEY POINTS FOR GP PRESCRIBERS

Although GPs may not often be directly involved with wound management, they are commonly asked to prescribe wound care items.

A guide to the most commonly prescribed, non-specialist products and the formulary choice is given below:

Product Type

First Line

 

Notes

Do NOT prescribe

Stockinette/ Tubular Bandages

Comfifast/Clinifast

Full range of products on formulary

Tubifast – much more expensive

Surgical Adhesive Tape

Scanpor

Alternative - Hypafix

Micropore – more expensive

Simple absorbent dressing with adhesive border

Mepore

Opsite Post-Op small size recommended following minor surgical procedures.

-

Simple low adherent absorbent dressing – no border

Solvaline N

Both sides of dressing are non-stick, low absorption capacity

-

Gauze Swab - Sterile

Non-woven fabric folded 4 ply swab – Sterile 7.5cm x7.5cm

 

 

-

Gauze Swab – Non-sterile

Non-woven fabric folded 4 ply – non-sterile 10cm x 10cm

 

-

Prescribing Budget Cost Pressures

Using RAIDR reports, the MO team have identified high cost areas common to most practices. These are listed below along with recommended actions which may be relevant to your practice.

Unlicensed ‘Specials’

See a ‘special’ – think Practice Pharmacist!

These –usually oral liquid –unlicensed medicines are a huge cost pressure in both CCGs, so much so there is a report on RAIDR dedicated solely to them!

For January – December 2013 the cost to North Tyneside CCGs for specials was £531,421 

Practice pharmacists review specials each month and suggest licensed and also lower-cost alternatives and make changes where possible.

The changes are mostly successful and patients can manage and are happy with the alternative, however, sometimes patients are restarted on specials and the reason is not always clear. While there are clearly times when this may be wholly appropriate, it would be helpful if prescribers could notify their practice pharmacist about requests to switch back to the special, because they may be able to provide further support to the patient to help them manage, or may know of another other safer or more cost-effective alternative that could be tried instead.

How to identify a special on the clinical system?

On EMIS – look at the price. There is generally no fixed price for specials therefore EMIS assign a price of ZERO. Treat this as a prompt to investigate further or ask your practice pharmacist for advice.

SystmOne has, of course, assigned symbols for unlicensed and special order products – these are shown below.

 - unlicensed

 special order, unlicensed

Enteral feeds

These feeds (including sip feeds, PEG feeds, and specialist infant feeds) accounted for £954,845 of prescribing costs across North Tyneside CCG. Significant savings could be achieved by taking steps to tackle waste and over ordering and supply. Prescribers and practice staff should check that patients are actually taking the feeds, they are ordering the correct quantities, and patients ordering large quantities are called in for review.  

Quetiapine XL – Modified Release Preparations

The North of Tyne APC Formulary states that Quetiapine XL is only approved for use:

  1. In patients who require an outside carer to administer their medicines
  2. For short term use when rapid dose titration is considered important e.g. where use might avoid the need to admit the patient to hospital

A protocol for identifying patients who do not meet these criteria and could potentially be switched to immediate release preparations is being developed with NTW and the medicines optimisation team.  Within this, any inappropriate secondary care initiations of Quetiapine XL will be raised as an interface issue with the trust by the Medicines Optimisation Team.

The Medicines Optimisation Team regularly review the RAIDR reports, however, you are encouraged to use RAIDR as it will help keep you up to date with your practice’s prescribing patterns and areas of high cost; and keep track of your financial data and achievement of prescribing engagement scheme targets.

For a guide to the prescribing section of RAIDR for analysing high cost prescribing areas please click this link. Alternatively, your practice pharmacist can show you how to access the reports.

Costs of commonly prescribed repeat medicines…and the potential costs of over ordering

The MO team have recently been asked by one CCG for list showing the cost of routinely ordered repeat prescription items to draw attention to the cost implications of over ordering and waste and to prompt practice staff to check with patients that they actually need everything they have ordered.

Click here for a list of the most commonly prescribed items which have significant cost implications if over ordered.

So if five patients in each practice in North Tyneside ordered only 1 extra prescription they didn’t need, of each of the following, the cost to the CCG would be £86,108.

For each drug, a commonly prescribed form has been selected with the cost of a treatment for one month based on standard daily doses and current drug tariff prices.

Physical Health Monitoring for patients on Antipsychotic medication

The APC formulary blue drug information sheet for antipsychotics has recently been updated and is now available here.

This details the routine physical monitoring for patients in primary care, and supports the QOF annual physical health check for patients with schizophrenia, bipolar disorder and other psychoses. It lists the tests/measurements, the frequency of monitoring and the rationale behind them, to support discussions with patients about why they are needed.

North of Tyne APC Formulary Update

Main changes to medicines affecting primary care prescribing following the November 2013 and January 2014 meetings. These have been reported in the local medicines optimisation bulletins and are included for reference. For full details see November meeting minutes and http://www.northoftyneapc.nhs.uk/latest-descisions/

 

Drug

Status

Key Points

Desogestrel 75mcg (Cerelle®)  oral contraceptive

Green -  GP prescribing allowed

A branded generic version of desogestrel which will achieve cost savings across North of Tyne if used instead of Cerazette.

 

Calcium Acetate 667mg capsules (PhosLo®)

Green -  GP prescribing allowed

Treatment of hyperphosphatemia in dialysis patients. PhosLo is smaller and more palatable than Phosex (Calcuim Acetate 1g) and  is the same price.

Ibuprofen gel 5%  

Green -  GP prescribing allowed

Will replace piroxicam gel on the formulary as there is little difference in efficacy and it is cheaper.

Please use first line if initiating a topical NSAID in new patients.

Ciclosporin eye drops 0.06%

Red -

Hospital

Only 

All ciclosporin eye preparations on the formulary are RED drugs. Practice pharmacists have found GP prescribing during their monthly review of red drugs.

Cosopt® preservative-free eye drops

Green Specialist advice/ initiation 

Approved for use in patients who demonstrate a clear allergy to the preservative as demonstrated by skin or conjunctival changes. Its use should be restricted to this cohort of patients and not for general use in patients who experience stinging as an adverse event. Note the MHRA safety alert issued warning of reports about the design of the dropper causing scratches to the cornea, and difficulty in administration of the drops onto the eye. MSD introduced a modified pipette in February 2014

Aclidinium bromide (Eklira Genuair®)

400 microgram inhalation powder

Green -  GP prescribing allowed 

Approved as an alternative for patients who are unable to tolerate or use the tiotropium bromide or glycopyrronium bromide inhaler devices. Tiotropium should still be regarded as first choice LAMA on the formulary.

Domperidone in breast feeding

Green -  GP prescribing allowed 

Use of domperidone as a galactagogue - an unlicensed indication but is standard practice throughout the UK.

Infant feeding coordinator support should always be available to women in whom this is started

Oxycodone 50mg/1ml Injection

Green -  GP prescribing allowed 

Approved for use in controlled circumstances in palliative care patients requiring high doses where the 10mg/ml strength is not suitable. It is the responsibility of each individual organisation to ensure appropriate risk management processes are in place.

Mini TT380 Slimline IUD

Green -  GP prescribing allowed 

Approved for use in women who have a uterine length between 5cm and 6.5cm

Loperamide 2mg oro-dispersible tablets

Green Specialist advice/ initiation 

Approved for use in primary care following specialist initiation for patients with high output stoma only.

Memantine 10mg/ml oral solution & Galantamine 4mg/ml oral solution

Green Specialist advice/ initiation 

Changed from RED status. Memantine oral solution is now approved for use in primary care on the condition that it remains cost neutral with its solid dose formulations. Galantamine oral solution was also re-classified due to its inclusion in NICE TA217. However it should only be used if no other preparation is appropriate, due to the additional cost.

Fosfomycin 3g oral sachets

Green Specialist advice/ initiation 

Fosfomycin oral sachets re-classified from  RED to allow for initiation in primary care, but only on the advice of a microbiologist (UTIs caused by multi-resistant organisms).

 

The following were refused or the decision deferred

Nalmefene (Selincro®) 18mg tablets - rejected but the APC would reconsider the application if an agreed pathway was in place that was supported and funded by local authority public health. Due to be reviewed by NTAG in February.

Combodart® capsules (tamsulosin hydrochloride 400microgram/ dutasteride 500micrograms)- rejected as there are more cost effective options are available on North of Tyne formulary for use in this cohort of patients.

Fluticasone 50 microgram / Azelastine 137 microgram (Dymista®) nasal spray – appeal - September’s decision (rejected) upheld as more cost effective options are available for this cohort of patients.

Granisetron transdermal patches — Decision deferred pending discussion at February’s Cancer Network meeting.

Rifaximin 550mg tablets — change from RED to BLUE— deferred pending NICE guidance

Azarga (brinzolamide 1%, timolol 0.5%) eyedrops —request to replace Cosopt—REFUSED

Vitamin B Co Strong— There was a request from commissioners to remove this from the formulary as it no longer represents good use of NHS resources, however it has a potential role in re-feeding syndrome. Decision deferred while further clarity is sought about this.

North of Tyne APC Formulary—Other Updates

NICE CG172: Myocardial infarction: secondary prevention LINK - Omega-3 preparations are no longer recommended for use in patients post myocardial infarction. The formulary will be amended in line with this.

Updated North of Tyne Clinical Guidelines approved by APC and available at www.northoftyneapc.nhs.uk 

  • Guideline on Medicines that are Not Suitable for Generic Prescribing - update of previous guideline, including information on antiepileptic drugs, following the recent MHRA alert.
  • Blood Glucose Monitoring Guideline

What’s New?

1. Lower Cost Test Strips (and meters provided free of change)

A range of lower- cost blood glucose testing strips are now available (£10 per pack of 50 compared to the average cost of £15 per pack of 50). Of these, GlucoLab and Element test strips and meters are included in the updated guideline. The diabetes lead nurses at our hospital trusts agree that these two meters and strips will meet the needs of the majority of patients and patients can be offered a choice between the two.

A number of other meters and test strips are also included in the guideline for patients with specific requirements e.g. ketone testing facility, hypo alert, USB download function etc.

This latest guideline update has arisen from a cost –saving perspective— the savings across a population of 100,000 patients could amount to approx. £100,000 per annum if this guideline is followed fully— but with a belief that there will be no detrimental impact on patient care.

It is absolutely acknowledged that not all patients will be suitable for a change in their meter therefore the focus is on what would be appropriate for the majority of patients whilst retaining flexibility for you to work with specific patients who need a more tailored approach.

Neon, the company that market the GlucoLab and Element meters and strips can provide letters and communications (with prepaid postage), training and nursing staff to facilitate the change face to face with patients, depending on practice requirements.

There are several options available for implementing this ranging from a gradual introduction of the meters for new patients, to an active changing programme assisted by the suppliers, Neon Diagnostics. To ensure that patient’s current supplies of strips are not wasted, a phased programme of switching is recommended. Please contact your practice pharmacist for further information and to discuss these options.

2. Update to ISO standard for blood glucose monitoring systems.

The ISO standard for blood glucose monitoring systems, has been updated, outlining stricter accuracy criteria. The standards are currently in a transition period until October 2016 by which time all machines must comply. The guideline details each company`s position in terms of current compliance with these new standards.

Development of this guideline has included representation from both Northumbria and Newcastle hospital diabetes lead nurses, as well as members of the Guidelines subgroup of the Area Prescribing committee, in order to ensure we have a consistent agreed message.

North of Tyne—New and updated Shared Care Guidelines / Information Sheets  approved by APC and available at www.northoftyneapc.nhs.uk 

  • Atomoxetine in the Treatment of ADHD in Children and Young People Shared Care Guideline
  • Immunosuppressive treatment following Heart and/or Lung Transplantation in Adults Shared Care Guideline
  • Immunosuppressive treatment following Liver Transplantation in Adults  Shared Care Guideline
  • Immunosuppressive treatment following Renal Transplantation in Adults Shared Care Guideline
  • Lithium Shared Care Guideline
  • Information Sheet—Humulin R Insulin 500 units per ml—RED drug, - not for GP prescribing.
  • Chorionic gonadotrophin information sheet
  • Dexamfetamine for primary sleep disorders information sheet
  • Lidocaine Patches- information sheet
  • Mexiletine  information sheet
  • Antipsychotics in psychosis, bipolar disorder and augmentation therapy in treatment resistant depression information sheet
  • Pramipexole information sheet
  • Rasagiline information sheet
  • Ropinirole information sheet
  • Rotigotine information sheet

Guidelines in development or under review/being updated

  • Shared Care Guideline for paediatric nephrotic syndrome
  • Lisdexamfetamine Shared Care Guideline
  • Ketamine in Palliative Care Shared Care Guideline
  • Dexamfetamine for the treatment of ADHD in children and young people Shared Care Guideline
  • Methylphenidate in the Treatment of ADHD in children and young people and for giggle incontinence in children aged 8-16 years Shared Care Guideline
  • Guidelines on monitoring Immune Modifying Drugs in Stable Adult Patients
  • Peripheral Arterial Disease Guideline
  • Immunosuppressive treatment following paediatric renal transplantation Shared Care Guideline
  • CKD and hyperkalaemia guidelines
  • Chronic non-malignant pain guidelines
  • Clostridium difficile risk assessment tool
  • Diagnosis and management of epilepsy guideline
  • Management of Angina due to Coronary Artery Disease
  • North of Tyne and Gateshead guidelines for management of common urological conditions in adults ≥ 18 years
  • COPD guidelines
  • Epistasis/Buccolam information sheet
  • Linaclotide information sheet
  • Lanreotide and Octreotide information sheets
  • Modafinil information sheet
  • Rosuvastatin information sheet
  • Retigabine information sheet
  • Triptorelin (Gonapeptyl Depot) – information sheet

What are sodium chloride 5% eyedrops and eye ointment – and when should they be used?

Sodium chloride 5% eye drops and ointment are used to reduce corneal oedema, typically for:

  • Short term use following eye surgery, such as cataract surgery, or
  • long term use in conditions causing recurrent corneal erosions

The hypertonic solution, i.e. 5% instead of physiological sodium chloride 0.9% creates a hypertonic tear film.  This creates a concentration gradient and water is pulled out of the oedematous cornea into the hypertonic tear film by the osmotic pressure exerted across the epithelium.  

Because evaporation from the tear film is minimal at night with the eyes closed (therefore, the tears are less hypertonic), corneal oedema tends to be worse in the morning. Use of hypertonic sodium chloride 5% ointment at night applied to the conjunctival cul-de-sac limits this build-up of oedema. Use of hypertonic drops in the morning also helps eliminate some of this nightly fluid accumulation.

Whilst reviewing specials prescribing three separate instances of sodium chloride 5% eye drops being prescribed in error rather than the 0.9% drops.  One patient received the wrong eyedrops for 3-4 weeks before being identified; the other two were identified within a week of prescribing.

Please be aware of the risk of confusing sodium chloride 0.9% eyedrops with sodium chloride 5% eyedrops and eye ointment.  A message has been added to Scriptswitch to alert prescribers to the risk of a picking error.

NoESCU
NHS North of England Commissioning Support (NECS)
www.necsu.nhs.uk
necsu.medicinesnewsletter@nhs.net
Tel: 0191 374 4121
2012 All Rights Reserved

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