The healthiest place to live and work, by 2025

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1 28/04/ /06/ /08/ /10/ /12/2017 Cannock Chase Clinical Commissioning Group The healthiest place to live and work, by 2025 Joint Clinical Commissioning Group (CCG) South Staffordshire Area Prescribing (APG) Meeting Friday 18 August pm Boardroom 1, Edric House, Rugeley WS15 1UW Members: Dr Mark Stone (MS) - Chair S&S CCG GP Representative Mohammed Azar (MA), Deputy Chief Pharmacist South Staffordshire & Shropshire Healthcare NHS FT (SSSFT) A Sue Baker (SBa) (SSSFT) A Susan Bamford (SB), Head of Medicines Management East Staffordshire (ES) CCG A Samantha Buckingham (), Interim Head of Medicines Optimisation Cannock Chase (CC), South East Staffordshire & Seisdon Peninsula (SES&SP), and Stafford & Surrounds (S&S) CCGs Tania Carruthers (TC), Clinical Director of Pharmacy Heart of England NHS Trust (HEFT) A A Dr Judith Crosse (JC) ES CCG GP Representative A A Sarah Duckworth (SD), Senior Pharmacist Burton Hospitals NHS Foundation Trust (BHFT) A A Gill Hall (GH), Service Development Manager for Community Pharmacy SS LPC A Tracy Hall (TH), Non-Medical Prescribing Lead Staffordshire & Stoke on Trent Partnership Trust (SSOTP) Daniel Hurley (DH), Pharmacist Virgin Healthcare Mary Johnson (), Senior Pharmacist SES&SP CCG A A Fiona McKean (FM), Assistant Director for Clinical Services and Medicines Management, Royal Wolverhampton Hospitals NHS Trust (RWT) Bina Mistry (BM), Clinical director Pharmacy Services, SSOTP A A Lisa Nock (LN), Principal Pharmacist in Surgery BHFT Dr Anna Onabolu (AO) CC CCG GP Representative Dr Clare Pilkington (CP) SES CCG GP Rep Sharuna Reddy (SR), Pharmaceutical Adviser CC CCG A Dr Mukesh Singh (MuS) CC CCG GP Representative Jonathan Snape (JS), Interim Principal Pharmacist Clinical Transformation County Hospital Elizabeth Street (ES), Chief Pharmacist Burton Hospitals NHS Foundation Trust (BHFT) A Susan Thomson (ST), Chief Pharmacist University Hospitals North Midlands (UHNM) Richard Thorpe (RT) ES CCG Page 1 of 8

2 28/04/ /06/ /08/ /10/ /12/2017 Cannock Chase Clinical Commissioning Group Members: In Attendance: Vanessa Ridout (VR), Executive Assistant Primary Care CC, SES&SP and S&S CCGs Kelly Carter (KC), Administrative Assistant Primary Care CC, SES&SP and S&S CCGs 1. Welcome and Apologies Apologies from Dr Clare Pilkington; Susan Bamford, Fiona McKean, Tania Carruthers, Dr Anna Onabolu, There were no declarations of interest made. 2. Minutes of the previous meeting held on Friday 23 June 2017 The minutes of the meeting held on 23 June were agreed as an accurate record subject to the following amendments Page 3, Item 4.2 Multiple Sclerosis therapies MS to send through revised wording. MS Page 4, Item 5.3 Diabetes Guideline To include Sarah Orme, Diabetic Nurse Specialist attended for this item. Page 6, Item 5.4 ESCA s from SSSFT MS to send through revised wording to 2 nd paragraph. MS 3. Matters arising not on the agenda or carried forward from the last meeting There were no additional items for discussion. The following actions were updated: Item 5.3, Diabetes Guidelines Still waiting for follow up date for meeting. Meeting to be arranged for diabetes specialist teams and medicines optimisation to finalise guideline. Item 5.4, ESCAs ADHD in adults Changes to be made and ESCAs approved post-meeting by the Chair to chase this up. Page 8, Item 8, Any Other Business It was confirmed that HalerAids is not prescribable on FP10 prescriptions. 4. Items for Information 4.1 NICE Technology Appraisals The following technology appraisals were noted as CCG responsibility. Ta455 Adalimumab, etanercept and ustekinumab for treating plaque psoriasis Page 2 of 8

3 in children and young people. NICE suggest that the number of people who will receive treatment is small and it is unlikely that current practice will change substantially as a result of this guidance. No significant financial impact within CCGs. TA 456 Ustekinumab for moderately to severely active Crohn s disease after previous treatment. No significant financial impact within CCGs because the technology is an option alongside current standard treatment options, the drugs are similarly priced and NICE do not think practice will change substantially as a result of this guidance. TA459 Collagenase Clostridium Hisolyticum (CCH) Not in the PbR-excluded drug list at present, commissioning teams are aware however a statement needs to be issued stating that there is currently no commissioning route. No significant impact on funding however there will be some commissioning impacts that need to be looked at to see how this fits in with the pathway. TA461 Roflumilast for treating COPD Can be used for severe COPD patients. Clarification sought on whether this needs to be clarified as a red or amber drug. Need to clarify how this fits in with the current COPD guidelines within the COPD guideline at GOLD group D. MuS informed members that whilst the NICE guidelines state GPs can prescribe there has been no request to use this locally by respiratory specialists and that the drug should therefore go on the formulary as RED at present. With regard to the pathway, this is an addition drug that would be used after treatment therapy in certain groups of patients and costs about 33 per month. Formulary status will be reviewed as required. TA464 Bisphosphonates for treating osteoporosis Looking to reduce the 10 year threshold for bisphosphonates. Treatment of men and use of zolendronic acid and ibandronic acid was not included in previous guidelines. NICE expect no significant financial impact within CCGs. Action: net.formulary to be updated with all NICE TA's 4.2 MHRA Drug safety updates June and July 2017 MS advised members on the highlights from the June 2017 safety updates. Denosumab LIS and LES are being reviewed in Cannock and Stafford. Limited prescribing of this in primary care at present within South Staffordshire poor uptake of LIS in East and South East Staffs. RICAD to be checked to ensure safety updates are covered to confirm. Safety update to be highlighted again in the APG newsletter. Action: to include in APG newsletter and check existing RICaD. Brimonidine Gel discussed previously at APG. Not currently within the formulary but to check existing prescribing within primary care. If there is some Page 3 of 8

4 prescribing to include update in APG newsletter. Action: to check current prescribing and include in APG newsletter if appropriate. Pseudoephedrine and ephedrine noted for information. E-cigarettes not much input from primary care. Wider issues for discussion with public health consultant when they attend the APG at future meeting regarding smoking cessation changes. MS advised members on the highlights from the July 2017 safety updates. No issues for primary care from the July safety updates. 4.3 CAS alert for antiviral medicines CAS alert letter issued. Prescribers working in primary care and community pharmacists should no longer prescribe or supply antiviral medicines for the prophylaxis and treatment of influenza. It was unsure who receives the CAS alerts but MS confirmed that Practice Managers do receive the alerts and then cascade to GPs. Community Pharmacists receive alerts via a different link. 5. Items for approval 5.1 NOAC dosing advice Sheet Members discuss the dosing advice sheet and the following points were noted: In the first column 1 st Choice in ESCCG to be removed. confirmed this has been taken off on the net.formulary to comply with NICE TA requirements. The document would be added to the formulary. MS asked about how this sits with the changes on anti-coagulation changes at UHNM as this moves towards the primary provider model and questions how it fits in with UHNM. Members were advised that Marianne Holmes (Stafford GP) has tried to raise concerns with haematology as they are saying that the BNF and product license is wrong. It was noted that Gary Free has raised similar issues with Wolverhampton Trust. This is being followed up with specific Trusts involved. It was agreed that an update would be included within the newsletter stating that GPs should query any unlicensed or off-license use of NOACs and have the support to push back to consultant. Any issues need to go through Datix so that it can be picked up and discussed at the CQRM and should then be reported back to the relevant CCGs. The line stopping preoperatively to be removed from the advice sheet. Action: updates to be made to NOAC summary and uploaded onto net.formulary Page 4 of 8

5 5.2 Degludec formulary application Members discussed the application for Insulin Degludec. Degludec comes in two strength, 100 ml and 200 ml and concern was raised around errors in dosage due to the packaging. It was agreed to add Degludec to net.formulary with a RICAD for the higher strength product. It was noted that Sarah Orme (DSN - SSOTP) is keen to put appropriate patients onto this insulin. TH asked whether this was in line with UHNM as there are quite a few differences between the South and North. MS advised members that he had raised this concern at the Stafford & Surrounds Membership Board and highlighted that from a consultant s point of view it is difficult to look at everyone s postcode. It was suggested that maybe a launch date be agreed to ensure the north and south are working collaboratively. Patients that are currently on this insulin will need to remain on it. It was noted that in Burton several practices are not happy with the finance of Amber 2 drugs and so are no accepting care shared agreements and that is not just for this drug but for all Amber 2 drugs. It was noted that any patient on a care shared agreement should actively be followed up by the Trust. The Group approved Degludec on to South Staffordshire Formulary as follows: Tresiba 100 Green Tresiba 200 Amber 1 with RICAD. To remain as RED until RICAD is produced. Action: net.formulary to be updated and RICAD produced for degludec 300units/ml. 5.3 Opioid pain management information Members discussed the Opioid Management Plan Bundle. It was felt that overall it was very useful to have a contract with patients to avoid them carrying on with high dosage opioids. Concern was that GPs may not have the capacity to do but recognised best practice should be having contracts in place. If taking forward then members asked for a change to be made that the form is signed by a practitioner/prescriber. It was agreed that would take the information to the medicines optimisation teams to discuss how this could be implemented prior to including on net.formulary. The opioids guidelines are due to be updated and the guidelines need review before coming back to APG. Page 5 of 8

6 5.4 Gluco-Juce (BFTH) SD presented the Gluco-Juce application to the group. The request had come from a paediatric diabetic nurse specialist as the usual treatments for hypoglycaemia (including Lucozade and Ribena) now contains less sugar than previously. The gluco-juce comes in small amounts with a set amount of glucose in it. The Diabetes UK web site recommends this also. As it is not a medicine patients can purchase it however some patients are unable to. The Gluco-Juce will form part of the starting pack issued to newly diagnosed patients from BFTH. Members agreed to include Gluco-Juce on the formulary but to restrict it to children with type 1 diabetes under the age of 18. Action: net.formulary to be updated with Gluco-Juce and restriction for type 1 diabetics <18years. 5.5 PGD template for salbutamol reversibility testing The PGD has been developed with NICE guidance, GP, pharmacy and chief nurse input. Need to include professional responsibilities i.e. physio, nurses although the overall responsibility falls with the GP. The Group Approved the application subject to those changes. Action: changes to be made then Chair s approval 5.6 FWG joint formulary recommendations The recommendation from the task and review group had been submitted to July FWG and most were accepted. The following items were noted: Fidoxamicin - will be non-formulary Predfoam to Colifoam Burton have agreed, UHNM, Birmingham and Wolverhampton are considering. Letter agreed for BFTH. Sulfasalazine - change status to amber 2 Chapter Take off unlicensed for chapter 10 since EN are licensed. State plain tablets more cost effective than EN on chapter Diclofenac Amber 1 for new initiation of renal colic ONLY. Add warning from B ham formulary. Indometacin remain as green Meloxicam to be listed as 3 rd line before diclofenac Celecoxib - currently green, not first line choice and highlight cardiovascular risks. Celecoxib more cost effective. Remain as green but need to be reviewed by rheumatologists and FWG to review safety aspects. Etoricoxib move to non-formulary as not cost-effective Alimemazine extremely expensive. Add as non-formulary. Carbocisteine liquid change on website to use sachets which are cheaper. Chapter 11.5 Mydriatics and cycloplegics Add all as Red Page 6 of 8

7 Sildenafil Sildenafil will have a note added to state usual monthly quantity should be 4-8 tablets. NHS prescriptions above 8 tablets per month should be based on individual clinical circumstances and be advised by a specialist in erectile dysfunction. Asasantin MR to Moalita Asasantin MR discontinued. Dipyridamole should be non-formulary and a note added patients should be reviewed to change to clopidogrel in-line with NICE guidance on anti-platelets. Fluoxetine liquid 20mg dispersible tablets to be added as a costeffective alternative to liquid Omeprazole reviewing guidance from Children s Hospital about using tables and making up MUPS to liquid form. Omeprazole MUPS tablets are licensed in patients >1year old and doses smaller than 10mg can be achieved by dispersing tablets in water and drawing up the correct dose. This method of administration is preferable than the prescribing of unlicensed omeprazole liquids for patients >1years. Liquid form only to be used in children under 1 year old. Salmeterol Sotel brand to be included as non-formulary (cost-effective option compared to generic salmeterol also non-formulary). To add note re: monotherapy in asthma in-line with BTS guidelines. Brivaracetam non-formulary Morphine sulphate most cost effective as Zomorph capsules and to avoid confusion with other branded preparations available. Thickeners review new choice for formulary. Nutulis Clear will be 1 st line choice. Menadiol needs to be amber 1 for patients with CF or over 7 years. Action: all changes to be updated on net.formulary 5.7 Biosimilar Low Molecular Weight Heparins (LMWH) / Pharmacy Procurement SBAR The group agreed the SBAR and agreed to include details in the next newsletter. There is a national shortage of the product so costs likely to be higher. This is a branded name so GPs need to prescribe by brand name. 5.8 Proposed pathway for the use of Esmya (Ulipristal Acetate) The pathway was submitted and approved by the group. This would be added to the formulary. Action: to be added to net.formulary 5.9 Preferred brand prescribing list Joint preferred brand prescribing list was shared with the group. The list is being pulled together where there are preferred brands or recommendations that have come through scriptswitch. Most have previously been through FWG but the following were noted: Lidocaine medicated plaster - new brand Ralvo which is significantly cheaper. Page 7 of 8

8 Metformin MR tables preferred brand Sukkarto which is cheaper although there are issues with avaiability GH asked for plenty of notice to pharmacists to ensure they are able to accommodate any switches to medications. 6. Items for Discussion 6.1 Rebate schemes SB confirmed that some had been approved by PrescQiPP and stated that a more in depth report will come back to the next APG for those other schemes. Action: to prepare paper on rebates within SAS, CC and SES&SP CCG s for next meeting. 6.2 Medicines Committee Minutes - FWG July BFTH D&T meeting Members noted the minutes of the above groups. 6.3 Future APG/FWG venue It was noted that the venue of future meetings would need to be reviewed and it was suggested alternating the venue. Admin to look at alternative venues. 7. Any Other Business TH dieticians had raised concern about the Jevity feeds being greyed out. Issue within GP clinical systems but the formulary section needs to be updated for all nutritional supplements. SR community pharmacy and the pharmacy first scheme. Practices are now starting with winter pressures and need to review scheme on how patients can be referred to the correct service. Web site does give details for patients but doesn t separate out UTI, common ailments. Gill Hall confirmed that the website does have links to each service and pharmacies commissioned to provide the service. 8. Date and Time of Next Meeting Date: Friday 13 October 2017 Papers to be received by Friday 29 th September Time: pm Venue: TBC ALL Page 8 of 8