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

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1 BHR CCGs AREA PRESCRIBING SUB-COMMITTEES Thursday 17 th September 2015 BOARDROOM A, BECKETTS HOUSE, ILFORD, IG1 2QX PRESENT Dr G Kalkat (GK) Oge Chesa (OC) Belinda Krishek (BK) Mohamed Kanji (MK) Julia Quant (JQ) Sanjay Patel (SP) Imran Khan (IK) Olufunlola Apakama (OA) Saiqa Mughal (SM) Heather Walker (HW) Dr C Okorie (CO) Dr A Tran (AT) Tutu Ogunsanwo (TO) Dr K Kugathas (KK) Dr U Haque (UH) Imran Jan (IJ) Diane Meid (DM) Denise Baker (DB) APOLOGIES Yemi Osho IN ATTENDANCE Dr Khalid Saja 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 Prescribing Advisor for BHR CCGs, representing Havering CCG Prescribing Advisor for BHR CCGs, representing Redbridge CCG QIPP Pharmacist, BHR CCGs QIPP Pharmacist & Prescribing Advisor for BHR CCGs Prescribing Advisor for BHR CCGs, representing Barking & Dagenham (B&D) CCG Prescribing Advisor for BHR CCGs, representing Redbridge CCG Chief Pharmacist, NELFT GP, Clinical Director Prescribing Lead, Redbridge CCG GP, Clinical Director Prescribing Lead, Havering CCG Formulary Pharmacist, Barking Havering and Redbridge University Hospital Trust (BHRUT) GP, Redbridge Local Medical Committee (LMC) Representative GP, Barking and Havering Local Medical Committee (LMC) Representative Pharmacist, North East London (NEL) Local Pharmaceutical Committee (LPC) Lay member Business Manager, BHR CCG s Interim Head of Nursing, Partnership of East London Cooperative (PELC) Consultant Haematologist, BHRUT 1 P a g e

2 25.1 Welcome / Introduction / Apologies A list of apologies was received as shown on page 1. The Chair thanked the Barking and Havering Local Medical Committee (LMC) for their contribution and support to the committee and was welcomed the new representative who would be attending future meetings. Action and by whom The committee was advised that the lunch provided at the meeting had not been sponsored by a pharmaceutical company and that all future meetings where lunch was required would be accounted to BHR CCGs; pharmaceutical sponsorship would not be requested for any future APC meetings Declarations of potential conflicts of interest None were received Minutes of the previous meeting The minutes of the previous meeting were agreed with an amendment to item 24.5 on page 3. The redacted minutes for the May 2015 were agreed for addition to the BHR CCG websites. - Amend the following action: Page 3, Prescribing guidelines of infant formula for infants with Cow s Milk Protein Allergy (CMPA) Liaise with paediatricians, neonatologists and outreach nurses to review the guideline - Add the agreed redacted minutes to the BHR CCG websites 25.4a Prescribing in alcohol detoxification regimes (item 24.4a in July minutes) We were advised that a service with prescribing responsibility had been commissioned from the Westminster Drug Project (WDP) for the borough of Havering and would commence from the 1 st October A response regarding a service in Barking and Dagenham was still awaited and the chair advised that a Prescribing Lead, LBBD would be contacting the medicines management team to consider the prescribing element as an enhanced service. 25.4b Shared Care Guideline Checklist (item 24.4b in July minutes) There was no update as to the progress in the provision of an e-platform for shared care guidelines at BHRUT. It was therefore agreed that a letter from the Chair on behalf of the committee would be forwarded to BHRUT requesting an update for this item. 25.4c New drug evaluation for DuoResp Spiromax (item 24.4c in July minutes) BHRUT advised that a respiratory lead together with the Respiratory Lead Pharmacist had produced a draft formulary of preferred devices for the management of asthma and a meeting was to be arranged with the Medicines Management team. Once this meeting had taken place and the formulary agreed it would be submitted to the BHRUT Drugs and Therapeutics Committee (DTC) for approval. The urgency for this meeting was noted. - Update to be provided at a future meeting Chair - To forward a letter to BHRUT requesting an update on the progress of the e-platform for shared care guidelines - To liaise with BHRUT and arrange a meeting to agree the draft formulary before submission to the BHRUT DTC for consideration at its next meeting 2 P a g e

3 25.4d Evidence behind the proposed amendments to the Dementia Share Care Guideline (SCG) (NELFT) (item 24.4d in July minutes) A revised draft shared care guideline incorporating the agreed amendments including combination therapy as an option, was not yet available for consideration. An update would be requested from the Associate Medical Director, NELFT, regarding availability of the draft document for the next meeting. 25.4e Formation of an outer NEL Antimicrobial Resistance Strategy Group (AMRSG) (item 24.4e in July minutes) We were provided background to the formation of the outer NEL AMRSG and details of the stakeholders that had attended the inaugural meeting on 27 th July At this meeting discussions had focused on preparing for the forthcoming European Antibiotic Awareness Day on 18 th November together with identifying various works areas which were collated in a draft work-plan for consideration at the next meeting, 1 st October f Prescribing guidelines of infant formula for infants with Cow s Milk Protein Allergy (CMPA)(item 24.5 in July minutes) We were advised that the NELFT dietitians were in the process of updating the guidelines with the comments received from the previous APC meeting, together with additional comments received from the paediatricians and the neo-natal nurses in BHRUT. Assurance was provided that the revised document would address the prescribing queries and issues being experienced by GP practices. 25.4g Labelling of Insulin pens by community pharmacies (BHRUT)(item 24.6 in July minutes) We were advised by the LPC representative that there had not been an opportunity to review the paper previously circulated regarding this item and was therefore the LPC representative unable to provide any comments on behalf of the North East London Local Pharmaceutical Committee (LPC). It was agreed that this item would be deferred to the APC meeting in November. NELFT - Produce the revised draft SCG for consideration at the November APC meeting - To provide an update at the next APC meeting NELFT - To produce the revised CMPA guidance for consideration and approval at the November APC meeting LPC - To ensure comments of LPC members are available to support discussion at the November APC meeting Agenda item for the November APC meeting GP access to carbon-13 urea breath test in re-testing for helicobacter pylori infection (BHR CCGs) We were informed that currently a urea breath test service was not available for GP practices to access at either BHRUT or Barts Health Trust. Subsequently, the medicines management team had prepared a report to outline two possible options to ensure that an agreed method was in place to access carbon-13 urea breath tests in re-testing for H.pylori eradication across the three boroughs; currently insufficient evidence was available to recommend the stool antigen test for eradication. NELCSU - To provide cost analysis of the following: Cost of stool antigen testing vs urea breath test Explore the option of an enhanced service proposal Explore the use of a specialist department to access the service - To establish the number of stool antigen positives identified for the year from Health Analytics 3 P a g e

4 Both the following options were discussed and the conclusions reached: Option 1: Pursue a commissioned service with local acute providers; the cost of provision will require negotiation - this service was not commissioned in the current contract but could be negotiated with the respective Acute Trust for the future Option2: Advise practices that carbon-13 urea breath test kits are prescribable on FP10, will bypass the costs incurred from laboratory interpretation of the findings - concerns were raised regarding the time and resources that would be necessary to conduct the tests within GP practices, once the patients had obtained the breath test kit and returned for a further appointment. One member described his experience of using the breath test kit in practice. It was agreed that costings should be established relating to both the stool antigen and the urea breath tests and the possibility of an enhanced service proposal, or access to specialist service should also be considered. The NEL Commissioning Support Unit would be requested to provide full details of the above for the November APC meeting. It was also agreed that would request from the Health Analytics team data identifying the number of positive stool antigen tests across BHR for the year, which would give an idea of potential numbers requiring re-testing. Further discussion required, agenda item for the November APC meeting Safe and legal driving for people on medicines with health problems handy fact sheet (BHR CCGs) A revised version of the original document considered at a previous APC meeting had been circulated as consent had since been received from the original authors for amendments to be made. It was noted that the revised version had also been circulated to the patient engagement forum and it was confirmed that LMC members had also considered the suggested amendments and required the final copy for the LMC newsletter. - The following amendments were requested to the fact sheet: Remove the question mark from the statement Do I need to drive Remove from the last paragraph of the section What are the new laws that came into force on 2 nd March 2015? or our website for more information Remove the from the first sentence in the section Medical rules for all drivers This document was agreed subject to amendments Novel Oral Anticoagulants (NOACs) in Primary Care (BHRUT) a) Follow up and Transfer of Care Letter anticoagulant therapy for AF b) Notification Letter Initiation of Warfarin therapy for AF c) Notification Letter Initiation of anticoagulant therapy for AF A Consultant Haematologist from BHRUT was welcomed to the meeting having prepared the above three letters in response to the request from the previous APC meeting. Haematologist - Add copy to patient on each letter to ensure that they are received - Add all three letters once finalised to CCGs websites The circulated letters were considered and with the added requirement of patients also receiving a copy of the letter addressed to the GP, all three letters received approval. 4 P a g e

5 All three letters approved subject to amendment. Rivaroxaban Shared Care Guideline & Apixaban Shared Care Guideline (SCG) - both documents had been circulated prior to the meeting but not in time for inclusion on the agenda. Both documents were discussed and it became apparent that they did not truly reflect a shared care treatment guideline but were in fact providing information for transfer of care to the GP. Several amendments were requested including a change to the layout so that the look of the document differed from the SCG template thus avoiding any possible confusion amongst clinicians. It was suggested that the relevant areas to be included in the transfer of care documents be identified so that he was able to produce documents that would be suitable for approval at the next APC meeting. Discussions also included responsibility and the legalities of the documents and the necessary training and recall mechanisms required to support transfer to primary care. The consultant haematologist advised that he would consider all these elements within the new documents. BHRUT - To prepare Transfer of Care documents in respect for Dabigatran, Rivaroxaban and Apixaban in the management of Atrial Fibrillation (AF). They should include the following: Normal dose and administration Monitoring standards Key adverse effects and actions Pregnancy and breast feeding Important considerations including dental procedures Contact numbers It was highlighted that several anti-coagulation studies were currently taking place to monitor the impact of NOAC use to date. We were advised of the Orange Registry a national three year study underway collecting major haemorrhage data identifying for example, those associated with aspirin, falls, patients with dementia and warfarin. Data so far had shown that for both GI and cerebral bleeds findings reflected those of the trials. However, mortality was equivalent between both NOACs and warfarin although the majority of bleeds had been in patients receiving warfarin than rivaroxaban. It was felt that the higher mortality for both may be because most sites were neurological centres so skewing the data. Once more District General Hospital (DGH) data was obtained it may taper down. A PHD fellow working at the London Hospital was due to start an adherence study; the study protocol was still unknown but BHRUT had agreed to participate. Transfer of care documents to be submitted for consideration at the next APC meeting Vaccine Fridge Temperature Out of Range Guidance (BHR CCGs) We were advised that due to a number of recent enquiries regarding fridge temperature incidents, guidance has been produced to support practices with decision making following a deviation in temperature range from the recommended +2 to 8 C range. The draft guidance provided contact details for the various vaccine manufacturers together with algorithms for managing cold chain breaches where vaccines had and had not been administered to patients. It was to be noted that the algorithms were taken from a document produced by the Health Protection Agency (HPA) in 2012 and did not therefore display organisational changes that had since taken place. A note to this effect was to be added to the front page of the guidance. - Add the following information to page 1 of the guidance: Bullet point 1, the following statement to be added Please note Some of the acronyms may be out of date however the flowchart is current. Add bullet point 6 Practice staff should consider keeping an internal record of such incidents, actions taken and any significant lessons learnt if applicable which would be useful for CQC inspections. Reference CQC requirements if found - Provide details of the guidance at future GP and Practice Nurse prescribing forums 5 P a g e

6 A discussion commenced regarding the use of data loggers and whether this was now a requirement for GP practices to implement as part of CQC inspections. However, it was established that whilst a data logger would assist practices with fridge temperature incidents, the CQC website would be searched for evidence of this requirement as to cite in the guidance where necessary. This document was approved subject to amendments Guidelines for the diagnosis and management of Vitamin D deficiency in adult patients (BHRUT/BHR CCGs) The above guidance had been reviewed and we were informed about minor amendments which had been made to the document following NICE s public health update on vitamin D and increasing supplement use. The management strategy for treatments had remained the same as previously agreed. - The following amendments were requested to page 3: Vitamin D in pregnancy and breast feeding women, paragraph 4 to be reworded Amend NELC to NELFT in the box referring to Vitamin D and Children There was discussion regarding the advice for women during the period of pregnancy and lactation and a further amendment was requested regarding the wording of paragraph four of this section. It was confirmed that the guidance referred only to formulary treatments, however when next reviewed would incorporate supplementation options. The document was agreed subject to amendments for two years /15 Medicines Management End of Year Report (BHR CCGs) We were presented the end of year report for the Medicines Management team 2014/15 and identified certain areas for attention. It was acknowledged that the comprehensive report related to the medicines management work streams for 2014/15 across all three BHR CCGs. The document once amended would be submitted for noting at each CCG s next board meeting. - Amend the report with the following: Page 6, Redbridge CCG, point 2 amend underspend to overspend - Submit the full report to each CCG s board meeting for noting Approved subject to amendment North East London(NEL)/North Central London(NCL) Ophthalmology Pathways We were advised that the following two ophthalmology pathways had been produced through joint working between Moorfields Eye Hospital, eye units across NEL & NCL and respective commissioners, and were now required to be agreed for use locally. Branch Retinal Vein Occlusion (BRVO) Pathway Central Retinal Vein Occlusion (CRVO) Pathway 6 P a g e

7 Both documents were approved for local use Modified Release Quetiapine and Galantamine Preparations (BHR CCGs) We were informed that due to financial pressures, the committee should consider switching prescribing of quetiapine XL and galatamine XL to cost effective brand options. Details of possible savings had been explored and provided in the paper circulated. It was to be noted that the change for both quetiapine and galantamine preparations would only be for patients receiving XL formulations. The paper identified the following brands as the most cost effective for primary care: Galentex XL (Creo Pharma Ltd) and Luventa XL (Fontus Health Ltd) for galatatmine XL Zaluron XL (Fontus Health Ltd) for quetiapine XL NELFT - to forward their paperwork (PIL and letter) regarding XL to immediate release (IR) switch - Produce letter to support the switch, including rationale and reference areas to minimise patient concerns - Set clear criteria for switching of patients - Add details to the CCGs websites - to explore the quetiapine XL to IR switch We were advised that since this document had been prepared prices had changed and Zaluron ZL tablets and Sondate XL tablets (TEVA Ltd) were now priced the same for quietiapine XL and should therefore also be considered. Fontus Health Ltd and TEVA Ltd had provided sufficient price guarantees and as at least two companies had been chosen there was some reassurance if any one product was temporarily unavailable. Concerns were raised regarding bio equivalence and interchangeability of the drugs. It was acknowledged that whilst this information was not available to support this work initiative discussions had been had with NELFT who had not identified any concerns regarding this switch. It was confirmed that NELFT currently prescribed generically for these drugs and therefore this work area would not affect any prescribing within the community services. A letter would be produced for general practice which would include rationale and address the concerns raised. We were provided with details of other areas where switches to branded generic XL formulations had occurred -Birmingham, States of Guernsey, NHS Anglia & Norfolk. It was noted that for quetiapine, the most savings were in a XL to IR switch and it was agreed to explore further this switch. It was stated that quetiapine XL was non formulary at NELFT and that a paper had been presented previously for this switch. Approved to address the XL prescribing for both quetiapine and galantamine preparations using the most cost effective brands End of Year Report: Cost avoidance from use of Outpatient Parenteral Antibiotic Therapy (OPAT) in conjunction with the Royal National Orthopaedic Hospital (RNOH) - To discuss a possible change to the process in consenting of patients for the service 7 P a g e

8 (BHR CCGs) We were provided background to this report explaining the work that had been undertaken during the past two years which had enabled RNOH patients to receive the continuation of IV antibiotics post discharge in the community in their homes; thus avoiding the cost of an inpatient stay. whilst maintaining the monitoring of appropriateness of treatments It was reported that patient discharge was subject to the approval of the Chief Pharmacist which implied that if she were to be on annual leave patients would remain in hospital. All were in agreement that the current commissioning arrangement for utilisation of the post discharge arrangement with RNOH was to continue. However, it was agreed that the medicines management team should liaise with the Deputy Director Chief Pharmacist, North East London Commissioning Support Unit (NELCSU) regarding the current need to refer each individual patient for the service which was extremely time consuming for the medicines management team; however verification and monitoring arrangements would still be required. Report was noted Adrenaline Auto-injectors a review of clinical and quality considerations We were informed that Barts Health NHS Trust were considering a switch from Epipen to Emerade auto injectors for the following: i. New diagnosis:initiate Emerade ii. Patients on Epipen presenting with anaphylaxis: Switch to Emerade (as supply of Epipen with likely have been used) iii. Patients on Epipen being reviewed in clinic / not presenting with anayphylaxis: remain on Epipen until their supply is expired. Then advise GP to prescribe Emerade for future supplies BHRUT - To ensure Emerade is considered at a future DTC meeting NELFT - To consider Emerade for use by community services - to feedback APC response to Barts Health NHS Trust It was also stated that a concern was raised as to whether patients would know how to use the new device, however it was explained that the auto-injector had a similar mechanism. It was also acknowledged that the Emerade device had a longer needle to ensure IM administration as outlined as a potential benefit within the document, MHRA Adrenaline Auto-injectors: A Review of Clinical and Quality Considerations (June 2014). We were advised that BHRUT were unaware of the Emerade device and would therefore refer the product details to the BHRUT Drugs & Therapeutics Committee (DTC) for consideration and would also liaise with the Resuscitation Committee for feedback. It was confirmed that NELFT would also consider the new device for use within community services. Strategy for a switch from Epipen to Emerade was approved for Barts Health NHS Trust. 8 P a g e

9 25.15 Rivaroxaban proposal for the preventions of stroke and embolism in adults with non valvular atrial fibrillation in the NELFT (BHR CCGs Health Economy) The above proposal had been presented which outlined three possible options with regard to the prescribing of rivaroxaban within NELFT; due to a delay in patients being offered rivaroxaban once warfarin had been established as not appropriate, NELFT clinicians were seeking approval to initiate rivaroxaban for appropriate patients. It was highlighted that NELFT clinicians were not commissioned or had the funding available to prescribe rivaroxaban however this proposal could be considered as part of the commissioning intentions for 2016/17. After discussion, Option 3 was agreed as the preferred option maintaining the current practice of referral to the anti-coagulation service within BHRUT for initiation of NOACs. Option 3 agreed Herpes Zoster Vaccine GP Patient Specific Direction (NELFT) The above document had been reviewed and the amendments had been highlighted in red on the circulated version. It was confirmed that the Patient Specific Direction (PSD) would be used for housebound patients and patients who were already part of the district nurses caseload. It was to be noted that multiple names were not to be added to the PSD as each patient record would require a copy of the document filed. Approved for use Pneumococcal Polysaccharide Vaccine GP Patient Specific Direction (NELFT) The above document had been reviewed and the amendment had been highlighted in red on the circulated version. It was confirmed that the Patient Specific Direction (PSD) would be used for housebound patients and those who were already part of the district nurses caseload. It was to be noted that multiple names were not to be added to the PSD as each patient record would require a copy of the document filed. Approved for use Summaries of BHR CCGs Prescribing Incentive Scheme 2014/15 & 2015/16 The above summaries had been circulated for information purposes and were noted Any other business None For information a. Barts Health NHS Trust & Local GPs Joint Prescribing Group minutes for February & March P a g e

10 b. BHRuT DTC minutes for February & March 2015 c. BHR CCGs APC final minutes for May 2015 d. Important new evidence relating to prescribing and medicines optimisation June Documents approved subject to amendments since last BHR CCGs APC meeting: Shared Care for Vitamin D prescribing in children Letter regarding Repeat Dispensing PELC PGDs (six) Date of next meeting: Thursday, 5 th November at 12.30, Boardroom A, Becketts House, Ilford 10 P a g e