South East London Area Prescribing Committee (APC) 9 October at Lower Marsh. Final minutes

Transcription

1 South East London Area Prescribing Committee (APC) 9 October at Lower Marsh Final minutes 1. Welcome, Introductions and Apologies received. 2. Conflicts of Interest declarations The Chair requested any interests relating to the meeting agenda be declared. The following interests were declared in relation to the NOACS guidance: Helen Williams attendance at NOACS advisory board Dr Arun Gupta sponsorship to attend meetings from Boehringer-Ingelheim 3. Minutes and attendance list of Last Meeting and Matters Arising. The minutes were accepted as accurate subject to following amendments: The Oxleas representative noted that rather than not having considered the mental health dashboard, clarification on the content has been requested. The SLAM representative noted that although the dashboard as a whole has not been discussed by SLAMs, specific items included have been discussed. She requested that the minutes be amended to reflect this. Item 10 for the action noted, the communication should be with LGT not LGH The attendance list was noted. ACTION: Minutes to be amended as agreed and circulated to group. Matters Arising i. IBD Pathway The IBD Pathway Development Group is due to meet on 16 October to approve the final draft of the pathway. Action The final pathway is to be presented to NDP in November 2014 and ratified by APC in January ii. Eltrombopag pathway The pathway has been delayed by some problems with engagement of clinicians. KCH anticipate resolving these soon. iii. Intra-vitreal ophthalmology drug pathways The draft pathway is progressing and is almost ready for circulation. A one-off meeting is to be arranged to review. There was some discussion of the need to review the pathway in light of the Lucentis licensing change. ACTION: Greenwich CCG to arrange one-off group to review pathway iv. LPP Mental Health Dashboard There are ongoing discussions around mental health trusts engagement with APC and a joint meeting with CCGs is planned for 25 November. The dashboard has not been discussed as a whole by SLAM and Oxleas. However as every item has been discussed separately the 1

2 trusts could provide a report on their respective positions for each item, if required. This item was closed. ACTION: Update on the outcome of the discussions around mental health engagement to be presented to January APC. v. SEL Red List GSTT are working on updating the formulary in line with the red list but there is a design issue which is delaying completion. The amber list is progressing and will be presented at a future NDP. ACTION: GSTT to complete formulary update ACTION: Amber list to be presented at NDP when ready 4. Cardiovascular Guidance It was noted that the APC cover sheet template should be updated to reflect the Lewisham and Greenwich Trust. ACTION: Cover sheet to be updated The guidelines have been updated in line with current NICE guidance and supersede the existing Cardiac Network guidelines, which have expired and will be removed from the website. The committee is asked to approve the following: i. Summary of antiplatelet options in CV Disease The summary is for use across the board and has been combined into a 1-page summary, rather than the separate guidelines that were previously in use. Add even in diabetics to the sentence Aspirin is no longer recommended for routine use for the primary prevention of cardiovascular disease to clarify. The committee was informed there may be an extra cost impact this financial year but growth is not anticipated beyond this. Data will be monitored for the cost impact however. It was suggested that a roll-out by all six CCGs would be helpful. The guidance will be available to all CCGs at the same time but timing of the roll-out is a local decision. The guidance was approved by consensus subject to the above amendment. ACTION: Imran Hafiz (Hypertension Team) to be added to consultation list ACTION: HW to amend and arrange for circulation of final guideline ACTION: Individual CCG Medicines Optimisation teams to develop a short implementation plans for the guidance ii. Hypertension guidelines a. Managing uncomplicated hypertension The guideline has been updated in line with NICE guidance. Approved by consensus. b. Traffic light guide to BP measurement The guide has been developed for use in community settings to clarify referral process and has been well received in South West London. The sentence Refer to GP for review on the same day (if out of hours, to urgent care or A&E*), to be amended to Refer to GP for review on the same day (if out of hours, to on-call medical services or urgent care). Approved by consensus, subject to amendment. c. BP monitoring/management for non-diabetic patients 2

3 The guidance summarises the key issues of monitoring BP from a practical standpoint. The committee requested that the following be added to encourage the concept of home monitoring: consider/discuss with your patient the option of home monitoring of BP. Approved by consensus. ACTION: Agreed amendments to be completed and revised guidelines to be recirculated by 16 October. iii. South London Algorithm for lipid management for the primary and secondary prevention of CVD The algorithm has been updated in line with the new NICE Clinical Guideline on lipid modification (July 2014).The algorithm applies to new patients we would not expect well managed patients to be switched to atorvastatin. The guidance now recommends the use of the QRISK tool, including in people with type2 diabetes. In primary prevention where QRISK score is >10%, lifestyle measures should be implemented first and then a statin considered if these fail. People with type 1 diabetes are highlighted for treatment as are people with chronic kidney disease stage 3 or more. Public Health England commission Health Checks but these are not currently aligned with the updated NICE recommendations. CCGs will therefore need to liaise with their Public Health teams to ensure that this occurs. The committee was informed that CCG engagement with public health is essential for implementation of the guidance.. This is already under way in Lambeth and Southwark. The following statement: *People 85years are at high CV risk due to age alone, but also consider other CV risk factors to be clarified to read consider other risk factors/patient preference. Costings for the guideline were tabled at the meeting. The costings assume an 80% uptake, locally in SEL, the uptake is currently around 20%. The figures presented for each CCG however, are unlikely in reality as many patient don t wish to go on statins and the use of lifestyle first will also remove some of the drug cost pressure. A patient decision aid is available and should be used to discuss the benefits and risks with patients. Approved by consensus subject to amendments ACTION: Revised guidance to be circulated. iv. Oral anticoagulation guidelines a. Stroke prevention in atrial fibrillation The changes, which are in line with the updated NICE clinical guideline for atrial fibrillation, were summarised. The following amendment to paragraph 4 was agreed: A NOAC should also be considered as an alternative to warfarin for stroke prevention in AF patients, to be amended to All patients with AF at risk of stroke should be reviewed to ensure optimal anticoagulant therapy. In addition the wording will be clarified to differentiate regarding new patients/existing patients who cannot tolerate warfarin. Approved by consensus subject to amendments. It was also noted that NICE signposts to US College of Cardiology which is not 3

4 relevant to the UK, which the consultant cardiovascular pharmacist will flag to NICE. More local guidance will be needed. UKMi is working on an FAQ document. b. Summary of treatment options for stroke prevention in AF The guidance covers both secondary care and primary care initiation. A transfer of care document and notification of initiation will be presented to a future NDP. Dabigatran box to be bullet pointed and pricing information/reference to cost-effective to be removed. The guidance was approved by consensus subject to amendments. The committee also agreed that the addition of the Cockcroft-Gault calculator to EMIS would be useful. c. Cost model for South East London The costings model was noted for information. ACTION: Revised documents to be circulated for Chair s action ACTION: Practices to request that the Cockcroft-Gault calculator be added to EMIS Web 5. Update Southwark and Lambeth Integrated Care Pilot (SLIC) SLIC received charity funding via GSTT and is the focus is to enable integration of services and locality development. Programmes under SLIC include an older peoples project and long term conditions programme (now renamed Resilient Communities and Individuals programme). Three medicines adherence pilots were initiated in the Chest Clinic KCH, a Clapham community pharmacy and a North Brixton practice, with the aim of increasing adherence rates. The pilots found that 44% of patients do not take their medicines correctly, which matches national rates. An adherence questionnaire for patients has been developed along with online training for clinicians with a focus on negotiating with patients. The outcomes of the programme will be available in June 2015nd will be shared with the Committee. 6. Items for ratification i. New Drugs Panel Recommendations and Decisions Summary Dymista The Dymista appeal has helped to clarify the appeals process and confirmed that any appeal must be process-driven. The Committee can make recommendations but the individual prescriber makes the clinical decision on whether or not to prescribe Lixisenatide in combination with insulin Ingenol Mebutate for Actinic Keratosis Relvar Ellipta for asthma- COPD Diltiazem cream for anal fissures Hydrocortisone modified release (Plenadren ) tablets for adrenal insufficiency in adults Levonorgestrel (Jaydess ) Intrauterine device for use in contraception ii. Minutes, attendance and action logs of New Drugs Panel iii. Minutes and action log of Inflammatory Bowel Disease working group iv. Minutes and action log of RA Pathway Development Group The committee confirmed the ratification of the above items. 7. For information 4

5 i. NICE TAs forward planning and implementation The dapagliflozin information sheet has been updated to include canagliflozin. Lubiprostone and prucalopride are included in the Irritable Bowel Syndrome pathway which is going to NDP for discussion later in October. Nalmefene for reducing alcohol consumption in people with alcohol dependence will be submitted to NDP in November. There will be service delivery and public health costs if recommended. The Committee noted that a SEL Public Health representative should be invited to the APC. NICE guidance on empagliflozin has been delayed until March. ACTION: SLAM to provide current usage figures for nalmefene ACTION: APC to invite SEL PH representative to be part of the Committee ii. Shared care guidance for ADHD amended Noted Communications iii. NHS E Sharing of path lab results The sharing of path lab results with CCGs is subject to negotiation by individual CCGs with path lab chiefs and is not an APC matter. Action closed. iv. CCG Chief Officers- ADHD Commissioning It was noted that Lewisham has an adult service provided by SLAM and that all CCGs would welcome guidance around all drugs for treatment of adults with ADHD. CCG leads are to meet with mental health trusts to discuss adult services in January v. SLAM/Oxleas - Mental health topics Discussions are ongoing and a meeting has been arranged in November to progress. vi. GSTT/KCH - dapoxetine prescribing KCH is completing a submission to NDP. 8. AOB There were no AOB items meetings: Tuesday 20 January pm-4.00pm Room 407, 1 Lower Marsh Tuesday 3 March pm-4.00pm Room 407, 1 Lower Marsh Tuesday 30 June pm-4.00pm Room 407, 1 Lower Marsh Tuesday 6 October pm-4.00pm Room 407, 1 Lower Marsh 5