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


North of Tyne APC Formulary Update

Below is a summary of the main changes affecting primary care prescribing following the November 2013 and January 2014 meetings.

For full details, including formulary requests that were refused or deferred, see LINK

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 however the current MHRA safety alert at: http://www.mhra.gov.uk/Publications/Safetywarnings/DrugAlerts/CON380456

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. For patients requiring high doses which would result in need for a significant number of ampoules or multiple syringe drivers to be used. 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).

Quetiapine XL

The following information has been reproduced with the permission of NTW with whom we are working with to ensure patients have the appropriate medication for them whilst controlling expenditure.

Quetiapine is an oral second generation antipsychotic available as an immediate release (IR) and an extended release (XL) formulation. Since March 2012, Quetiapine IR has been available as a generic preparation, at a considerably cheaper cost than the XL formulation (patent protected until 2017)

Formulary use of XL is currently restricted to:

  1. Patients who need an outside carer to administer medicines.
  2. Short-term use when rapid titration is considered important.

What is quetiapine licensed for?

  • IR is licensed in the UK for treatment of
    • schizophrenia
    • treatment of moderate to severe manic episodes in bipolar disorder,
    • treatment of major depressive episodes in bipolar disorder
    • prevention of recurrence in patients with bipolar disorder, in patients whose manic or depressive episode has responded to Quetiapine treatment.
  • XL is licensed in the UK for the same conditions as IR plus
    • as maintenance therapy in schizophrenia
    • as add-on treatment of major depressive episode in MDD (major depressive disorder)

Are there any differences in effectiveness?

  • To date, no randomised clinical trials exist that directly compare the effectiveness of IR with XL.
  • In randomised clinical trials, XL was more effective than placebo in treating and preventing relapse in schizophrenia. For manic or mixed episodes and acute depressive episodes in bipolar disorder, XL and IR were equally effective.
  • The XL demonstrated effectiveness in a randomised placebo controlled study as add-on treatment in major depressive disorder (MDD). Long term safety and effectivness as add-on treatment has not been evaluated; the IR preparation is not licensed for add-on treatment of MDD.

Are there any differences in safety?

  • To date, no randomised clinical trials exist that directly compare the safety of IR with XL
  • Types and frequencies of adverse drug reactions for XL and IR quetiapine are identical  in their summary of product characteristics
  • Similar tolerability and rates of discontinuation have been seen for IR and XL formulations
  • Drug interactions listed in their summary of product characteristics are identical for both products.

What is the difference in cost?

Cost of 30 days treatment (Drug Tariff February 2014)

Daily Dose

XL

IR

300mg

£85.00

£5.07

400mg

£113.10

£7.44

600mg

£170.00

£10.14

800mg

£226.20

£14.88

Wound Formulary

A revised wound formulary is to be launched on 1st April. Whilst the majority of wound products remain unchanged there are some additions and removals that practice staff involved in wound management or prescriptions should be aware of.  New order forms and formulary cards will be made available and there will also be launch events that Medicine Managers, Pharmacists, Practice Nurses and GPs will be invited to attend.

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

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

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.

A range of lower- cost blood glucose testing strips are now available -£10 per pack of 50 test strips compared to the average cost of £15 per pack of 50. Of these, GlucoLab and Element test strips and meters are included as the first line option in the majority of patients in the updated guideline. 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.

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.

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.

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.

Neon Diagnostics, the company that market the GlucoLab and Element meters and strips can provide support in implementation, dependent of the needs and requirements of the practice, including; letters and communications (with prepaid postage), training and nursing staff to facilitate the change face to face with patients. Please contact Oliver Cook on 07983 309 964 or 01376 500 720 or via email: oliver@neondiagnostics.co.uk for further information on the support provided.

For further details please refer to the information sent to practices from medicines optimisation via practice medicines managers and GP Prescribing Leads in February and is available on GP Team Net, practice managers have been sent a copy of the link.

Change to NICE recommendations for Omega-3

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.

Oral Nutrition Service

When the community dietitians receive a referral they will:

  • Aim to see urgent patients within 10 working days.  If the GP feels it is necessary to provide a supplement (in addition to food fortification advice*), until the patient can be seen by a dietitian, it should be given in the form of two 1.5kcal/ml milkshake or juice style supplements (dependent on patient preference) per day for 2 weeks , this should be noted in the referral. Please note exceptions: if the patient has any religious or personal dietary restrictions (including vegans) do not offer standard 1.5kcal/ml supplements – seek advice from the dietetics department and make this information clear on the referral form.
  • Aim to see routine referrals within 6 weeks. However, as from the start of this year and due to high DNA/CNA rates, routine patients that are able to attend clinic will be sent a letter (as soon as we receive a referral) inviting them to contact the department if they wish to be seen; if and when they do contact us we start the 6 week clock from then. GPs will be copied into this letter so that they see we have made contact, if a patient declines input or does not contact us within 4 weeks from the date on the letter, we write to the GP to discharge the patient with recommendations regarding future supplement provision, should the patient already be receiving them.
  • Aim to arrange routine Nursing Home and Home Visit appointments within 6 weeks from the date the referral is received.

Please note this is the aim and the dietetic service cannot always guarantee these time deadlines will be met. 

*food fortification advice sheets are available from the dietetics department and can be given out by the GP practice before dietetic assessment 

Cost Savings

The cost saving initiatives launched in November 2013 continue to be a very high priority for the CCG and practices should ensure that work is underway in achieving these savings.

Please note the new service specification states that the payment linked to these will be paid if 90% savings, from those identified at baseline, are achieved. Information has been sent to practices regarding the savings achieved to the end of December 2013. 

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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