Prescribing Advisor for BHR CCGs, representing Barking & Dagenham (B&D) CCG Prescribing Advisor for BHR CCGs, representing Redbridge CCG

Transcription

1 BHR CCGs AREA PRESCRIBING SUB-COMMITTEES Thursday 7 th January 2016 BOARDROOM A, BECKETTS HOUSE, ILFORD, IG1 2QX PRESENT Dr G Kalkat (GK) Oge Chesa (OC) Belinda Krishek (BK) Dr C Okorie (CO) Dr K Kugathas (KK) Dr A Tran (AT) Dr Uzma Haque (UH) Diane Meid (DM) Sue Perry (SUP) Sanjay Patel (SP) Olufunlola Apakama (OA) Mohamed Kanji (MK) Saiqa Mughal (SM) Julia Quant (JQ) Sarla Drayan (SD) Heather Walker (HW) Richard Duffett (RD) Kam Takhar (KT) Philippa Imes-Taylor (PI) Rubina Ahmed (RA) APOLOGIES Denise Baker (DB) IN ATTENDANCE Cathy Lobendhan (CL) Louise Botham Dr Christopher Watson Enrico Pagani Professor Arthur Tucker Dr Ajith James (AJ) (by phone) Chair, GP, Clinical Director Prescribing Lead, Barking & Dagenham (B&D) Clinical Commissioning Group (CCG) Deputy Chief Pharmacist, Barking & Dagenham, Havering and Redbridge CCGs (BHR CCGs) Chief Pharmacist, BHR CCGs GP, Clinical Director Prescribing Lead, Redbridge CCG GP, Redbridge Local Medical Committee (LMC) Representative GP, Clinical Director Prescribing Lead, Havering CCG GP, Local Medical Committee (LMC) Representative, BHR CCGs Lay member Prescribing Support Dietitian, North East London Foundation Trust (NELFT) QIPP Pharmacist, BHR CCGs Prescribing Advisor for BHR CCGs, representing Barking & Dagenham (B&D) CCG Prescribing Advisor for BHR CCGs, representing Havering CCG Prescribing Advisor for BHR CCGs, representing Redbridge CCG Prescribing Advisor for BHR CCGs, representing Redbridge CCG Chief Pharmacist, Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT) Chief Pharmacist, North East London Foundation Trust (NELFT) Chair North East London Foundation Trust (NELFT) DTG Deputy Chief Pharmacist, (Community Health Services) North East London Foundation Trust (NELFT) Work experience student, Forest School (observing) Information Analyst, BHR CCGs Business Manager, BHR CCGs Locality Lead, Havering CCG Director of Technical Operations, Torbet Laboratories Limited Laboratory Manager, INFAI UK Executive Director, Seahorse Laboratories Ltd. Managing Director, Seahorse Laboratories Ltd. Consultant Renal Physician, BHRUT 1

2 27.1 Welcome / Introduction / Apologies A list of apologies was received as shown on page 1. Introductions were provided. Action and by whom 27.2 Declarations of potential conflicts of interest Potential conflicts of interest were declared. It was noted that the entire medicines management team had attended Aspire to Inspire Facilitation Skills and Inhaler Technique training delivered by Education for Health, funded by TEVA Pharmaceuticals in December Minutes of previous meeting The minutes of the previous meeting were agreed. The redacted minutes for the September meeting were agreed subject to amendment for addition to the BHR CCG websites. 27.4a Electronic platform for Shared Care Guideline (Item 26.4b in November minutes) The BHRUT representative reported that the current Trust system is not good enough to accommodate the stated eplatform. The trust has longer term plans for Electronic Discharge (ED) at which point this agenda will be revisited. When requested as to when ED would exist in the Trust, she stated that chemotherapy currently utilises ED and other areas are subject to a business case with a 2-3 year timeline. A six month timeline was requested. BHRUT - to provide an update in six months time (June 2016) 27.4b New drug evaluation for DuoResp Spiromax (Item 26.4c in November minutes) A Medicines Management representative reported that a meeting was held with the respiratory leads in on 9/12/15. A draft COPD guideline and the subsequent new drug additions to formulary, which included DuoResp Spiromax were discussed and agreed. Asthma will be the focus of subsequent discussions once the British Thoracic Society guidelines update, which is imminent. 27.4c Labelling of Insulin pens by community pharmacies (Item 26.4g in November minutes) A Medicines Management representative reported that there will be a joint meeting between the CCGs, LPC and BHRuT on 22/1/16 where this matter will be discussed. 27.4d Novel Oral Anticoagulants (NOACs) in Primary Care (BHRUT) / Transfer of Care documents for NOACs (Item 26.4h in November minutes) A BHRUT representative reported that this was not yet completed and that BHRuT will be requesting copies of the Barts Health process as they have already delivered on moving from shared care guidelines for NOACs to Transfer of Care documentation instead. - to feedback on the LPCs implementation of this agenda BHRUT - to submit adapted Barts Health documents to a subsequent meeting 2

3 27.4e Lidocaine Patient Group Direction (PGD)(PELC) (Item 26.5 in November minutes) A Medicines Management representative reported that though this item was approved subsequent to amendments she is making the committee aware of a requested amendment that was not upheld and the reasons why. PELC advised that the PGD would not just apply to adults as the Emergency and Urgent Care Centres where the teams are based have access to resuscitation trolleys and can cater for children too. This update was noted. 27.4f Smoking Cessation (NELFT) - Guidance on Medication and Smoking / Dosing Schedule Smoking Cessation (Item 26.7 in November minutes) - to feedback post NELFT DTG A NELFT representative reported that she was unsure as to whether this had been actioned by the lead for this document and requested that clarification be received at the NELFT DTC taking place on 19/1/ g Rivaroxaban proposal for the prevention of stroke and embolism in adults with non valvular atrial fibrillation (AF) in the NELFT (BHR CCGs Health Economy) (Item in November minutes) A NELFT representative stated that NELFT were waiting for the revised process involving Transfer of Care documentation to be in place before aligning their practice to that of BHRuT. NELFT clinicians would be requested to liaise with the consultant haematologist of BHRuT on the current process in the interim Revised Dementia Shared Care Guideline (SCG) (NELFT) A NELFT representative presented the shared care on behalf of the author. Reference to NICE was not accurately presented and a number of amendments were suggested. LMC comments were noted. The shared care was not approved. NELFT - to provide an update as to assurances of the NELFT service level provision NELFT - Page 1: under NICE GUIDANCE 2011 No. 3 bullet point 1 to remove specialist direction bullet point 3 patients who continue on treatment should be reviewed at least annually under Combination treatment last sentence All patients prescribed combination treatment will be reviewed within three months by consultant and this should also be included under consultant responsibilities on page 4 - Page 2, under Patient Pathway delete (may be initiated by a GP on the advice of specialist) delete branded drug names - Page 3, under Monitoring NELFT to clarify or recommend a tool for global functional abilities 3

4 - Page 4, under Shared Care Consultant, item no 5 to remove patient held booklet GP, item no 2 monitor patient s overall health and well- being qualify what exactly is required. Item no 6, maintain a patient held monitoring booklet to be removed - Page 5, Item no 4, to delete eg. plans for pregnancy Resources available, no mobile number for locum 27.6 Shared Care Guideline for Mercaptopurine & Azathioprine in Inflammatory Bowel Disease (BHRUT) A BHRUT representative reported that there has been an update of the document in light of comments raised at the last APC meeting. Unfortunately additional comments were presented. Discussion arose as to how the patient would return to the Trust when for any reason they became unstable and required re-stabilisation. A need for an IBD pathway was expressed. GPs did not want to have to discuss with the IBD nurses as it was felt that they had a lower threshold for risk than other clinicians in the team. The shared care was not approved. BHRUT - To amend the Mercaptopurine and Azathioprine SCG with the following: Page 2, under Monitoring any increment of doses needs to be clarified that this would be done by the hospital and not the GP so heading to include dose changes after initiating Page 3, under Action First box delete IBD nurse and leave specialist hospital clinician Third box delete all and replace with Discuss with IBD specialist clinician Page 4: under Shared Care responsibilities Under Consultants item no 2 initiate treatment (after 3 months or after dose changes) Add item 1, If dose change required recall patient to monitor until stable Under GP, item no 6 -BHRUT to develop a pathway that enables the GP to facilitate this function e.g. What to do and when Appendix 1: Bullet point 4, to add if you do please inform your GP/consultant no later than 10 days from exposure 27.7 End of Life and Palliative Care Guidance (NELFT) for use in support of the End of Life care pathway A BHRUT representative presented the guide as a useful reference tool in support of End of Life care. All agreed very good and useful guide. Discussion around Haloperidol being long term out of stock, but agreed to stick with 1 st line status as an unlicensed version is obtainable and clinically appropriate. Discussion about midazolam strengths commonly NELFT - The following amendments were requested to the guidance: Page 7 in the Pain row 4 th column all reference to For patients already on oral opioids use conversion below to state For patients already on oral opioids refer to conversion table in Appendix 1 4

5 seen in practice 5mg/5ml and 10mg/2ml, asked to ensure that any reference to midazolam states that the 10mg/2ml strength is used to reduce potential for errors. Approved subject to amendments. Appendix 1 table is referenced Clarify strength of midazolamto be used as to reduce potential for error - Upload final version to website 27.8 Primary care medication switch letter post discharge Deferred until next meeting Prescribing guidelines on prescribing infant formula for infants with cow s milk protein allergy (CMPA) A Medicines Management representative advised that these guidelines had been updated since last presented in September. Amendments were made following comments received previously at the APC and from BHRuT s neonatal team and NELFT s community paediatric team. The major changes included the sign and symptoms section (p4) which had been expanded and the flowchart on page 14 had also changed significantly. The committee asked why lactose intolerance was stated in the guidance. Redbridge s prescribing support dietitian, clarified that lactose intolerance is an intolerance to lactose sugar in milk whereas CMPA is an intolerance to milk protein. Lactose intolerance would be typified by predominantly gastrointestinal symptoms and that it was important to differentiate this from CMPA as the management would differ. The guidelines were approved Nutritional supplements patient information leaflet A Medicines Management representative and a dietician presented an information leaflet aimed at supporting patients being prescribed a nutritional supplement. The leaflet would be given to patients newly initiated on a nutritional supplement by either the community dietetic team or by general practice. It was suggested that the same leaflet be used at the hospital as well. The committee found the leaflet useful but suggested several amendments. The leaflet was approved subject to the amendments. SUP - To amend the following: Insert an area to capture the date Amend the line Powdered drinks: When mixed, these must be drunk within 2hours. They can be kept in the fridge to Powdered drinks: When mixed, these must be drunk within 2hours unless they are kept in the fridge Include a section advising patients that the product they receive in primary care may differ from the product they received in the hospital - To take the leaflet to the BHRuT dietetic teams to implement Shared Care Guidelines on Lithium (NELFT) Deferred until the next meeting Dispensing Health in Later Life (NELLPC) Deferred until the next meeting. 5

6 27.13 Good Practice Guidance 7 versus 28 day dispensing for Monitored Dosage System (MDS) (BHR CCGs) Deferred until the next meeting GP access to carbon-13 urea breath test in re-testing for Helicobacter pylori infection (BHR CCGs) A Medicines Management representative introduced a table of questions for comparing urea breath tests. This was followed by short presentations from the following three companies: INFAI UK (INFAI), Torbet Laboratories Ltd (Pylobactell ) and Seahorse Laboratories Ltd (Diabact). Following discussion, it was agreed for Medicines Management to summarise all information received into a table for discussion and recommendation of product(s) at the next APC meeting Acute Kidney Injury (AKI) Sick Day Guidance (BHR CCGs) patient information Sick Day Guidance in patients at risk of Acute Kidney Injury (BHR CCGs) A Consultant Nephrologist dialled in remotely and a Havering CCG representative attended the meeting to discuss this section. The consultant nephrologist introduced the reason the Sick Day rules project is underway. It was an initiative started in Scotland (who developed the initial leaflet which was adapted by NHS Salford and provided for review by the APC). This project is now being rolled out nationally. A member raised a query regarding if there was adequate evidence to support this initiative. According to an article in the Drugs and Therapeutics Bulletin (DTB), the evidence of benefit was weak and in fact there is a risk that patients are not restarted on their medicines after an episode where they are stopped. Some members raised concerns about risks to patients on certain medications and the impact of stopping on their disease e.g. a diabetic patient stopping metformin or heart failure patients stopping diuretics for example. A member stated that GP s in Redbridge are suggesting contacting Consultant Cardiologists and Endocrinologists for their views on the application of Sick Day rules to complex patients with heart failure and diabetes respectively. The consultant nephrologist stated that he will be attending the PTI for all 3 CCG s to introduce the subject to all GP s and this would give the opportunity for further discussion and development of the guidance. Medicines Management representative stated that with regards to the leaflet, it would be better to list all the relevant drugs rather than just give examples so that it is easier for patients to identify their own particular medicines (e.g. they may not know what a nonsteroidal anti-inflammatory is). The consultant nephrologist suggested that pharmacists should label the medicines with this sick day rule information. The BHRUT representative suggested that this message could be added to the repeat prescription and put on EPS so the community pharmacists could prompt the patient at each dispensing. It was suggested that patients need reassurance that it is alright to stop their medicines briefly otherwise - to produce summary of presentations, outcomes and the questions for discussion and decision at the next meeting - To forward the community related suggestion to the LPC Consultant Nephrologist - To discuss the guidance with GPs at the PTIs for further feedback - To liaise with cardiologists and endocrinologists on the impact of stopping in patients with heart failure and diabetes respectively 6

7 they would worry and may not comply with the guidance. The Havering CCG representative stated that she would collate all the feedback and work through with the consultant nephrologist. Also there are plans to roll this out in care homes as they are a controlled environment to see the effect of this guidance. Not approved Any other business Long term shortage of Haloperidol injection The BHRUT representative informed the committee that due to the prolonged shortage NELFT were sourcing an unlicensed version of haloperidol from IDIS for the management of appropriate palliative care patients. She enquired if GPs would be able to prescribe this if required. A Medicines Management representative stated that where it is required it will have to be provided as a special item in spite of the potential cost pressure For information a. Barts Health NHS Trust & Local GPs Joint Prescribing Group minutes for August 2015 b. BHRuT DTC minutes for July 2015 c. BHR CCGs APC final minutes for September 2015 d. Outer NEL Antimicrobial Resistance Strategy Group (AMRSG) minutes for July Documents approved subject to amendments since last BHR CCGs APC meeting: Lidocaine Patient Group Direction (PELC) - To advise GPs to endorse prescriptions for haloperidol injection as unlicensed specials. - Inform LPC to communicate this to community pharmacists Date of next meeting: Thursday 3 rd March at 12.30, Boardroom A, Becketts House, Ilford 7