COVENTRY & WARWICKSHIRE AREA PRESCRIBING COMMITTEE MINUTES OF THE COVENTRY AND WARWICKSHIRE AREA PRESCRIBING COMMITTEE HELD ON FRIDAY 15 TH SEPTEMBER 2017 AT 12.30 PM IN THE CLINICAL SCIENCES BUILDING (CSB) AT UHC&W NHS TRUST PRESENT:- Richard Lambert South Warwickshire GP (RL) - Vice-chair Altaz Dhanani Coventry & Rugby CCG (AD) - Interim secretary Joe Booker Coventry LMC (JB) Jane Smith Coventry GP (JS) Claire Keane Coventry GP (CK) Rita Sanghera Arden & GEM CSU representing Warwickshire North and South Warwickshire CCG (RS) Nigel Johnson Warwickshire LMC (NJ) Kim Panting South Warwickshire GP (KP) Caroline Coupe South Warwickshire NHS Trust (CC) Portia Chikwanha South Warwickshire NHS Trust (PC) Satyan Kotecha Warwickshire LPC (SK) Cath Sansby - University Hospitals Coventry & Warwickshire NHS Trust (CS) Paul Mills George Eliot Hospital NHS Trust (PM) Loay David George Eliot Hospital NHS Trust (LD) David Tait Coventry & Warwickshire Partnership Trust (DT) Priti Ved Coventry & Warwickshire Partnership Trust (PV) Ian Bayman Lay Member (IB) Terry Spicer Lay Member (TS) IN ATTENDANCE: Anita Hunjan (AH), Susan Dhesi (SD) Sumara Parvez (SP) Chief Pharmacist SWFT observing 1. APOLOGIES Simon Fletcher, Franco Cappuccio, Suki Dhesi, Paula Harris, Ashwin Hindocha RL introduced Sumara Parvez, new Chief Pharmacist for South Warwickshire Foundation Trust (SWFT), who was attending today s meeting as an observer. 2. MINUTES OF THE LAST MEETING The minutes of the last meeting held Friday 21 st July 2017 were agreed with the exception of some minor grammatical changes to sections 7.2.5 and 7.8.1 which were to be amended prior to publication of the minutes. 1
2.2 - Action log RL went through some outstanding actions that still required the committee s response. 3. MATTERS ARISING There were no matters arising. 4. APC Development There were no papers for discussion. 5. Drug Positioning Statements 5.1 - Insulin Glargine U300 A decision review request was submitted by Dr Winston Crasto on behalf of the Arden Group of Diabetes & Endocrinology Consultants with the recommendation to change the Drug Positioning Statement (DPS) verdict from specialist initiation (SI) to primary care prescribing; 5.1.1 - AD gave a brief summary of the application request; he said that the drug was more cost effective than the normal glargine U100 5.1.2 - NJ thought there would not be an issue for primary care prescribing except that the CCGs would need to sort out the funding process 5.1.3 - SK enquired about comparison costs between this drug and basal glargine, AD replied that the unit cost details were on page 4 of the application 5.1.4 - IB noted that it was fundamental for primary references to be correct in all APC documents The committee agreed to change the verdict to primary care prescribing and state preferred choice on the netformulary. Section 5 Decisions 5A Amend insulin glargine DPS verdict and republish, update netformulary AD/SD 5B Write to GEH specialist regarding insulin glargine decision review outcome AD 6. Specialist Drugs List 6.1 - SDL Amendment - An amendment from Coventry and Rugby Clinical Commissioning Group (CRCCG) was brought to the committee for consideration to change somatropin (generic and brands) from shared care (SC) to specialist only (SO); 6.1.1 - AD briefly informed the committee that this drug has been repatriated to our hospital trusts The committee agreed for this proposal to be changed on the netformulary. 2
6.2 - SDL Amendments - Nine proposed amendments from ArdenGEM CSU for inclusion on the netformulary were brought to the committee for consideration; 6.2.1 - AD highlighted that these were all SO status 6.2.2 - AD mentioned the drugs on pages 2, 3 and 4 were either in tariff or non-tariff on the acute drug specialist list (ADSL) and these submissions were to ensure they were initiated as SO The committee agreed for these proposals to be included on the netformulary. 6.3 - SDL Amendments - Two proposed amendments from UHCW were brought to the committee for consideration to change tizanidine and apraclonidine to specialist advised (SA); 6.3.1 - CS highlighted that tizanidine is currently classified as shared care (SC), but there is no shared care agreement (SCA). Apraclonidine eye drops are currently SO, Ophthalmologist requested the change for those patients waiting for glaucoma surgery. She confirmed that the licence recommendation is for 28 days but the eye drops could be used for 3 months as long as the clinician thought it was beneficial 6.3.2 - IB queried the efficacy of the drug after 4 weeks 6.3.3 - The committee felt the classification for apraclonidine to remain as SO; this would ensure patients were reviewed every 4 weeks by the ophthalmologist The committee agreed to only change tizanidine proposal on the netformulary. Section 6 Decisions 6A Publish the agreed SDL amendments to the netformulary RS/CS/SD 7. Guidelines/Resource Documents 7.1 - Local Blacklist amendment One proposed amendment from CRCCG was brought to the committee to consider changing the current blacklist status; 7.1.1 - AD explained that omega-3-acid-ethyl esters (fish-oils) are currently blacklisted for all indications. The supporting evidence for the request to change the unlicensed indication for pancreatitis prevention to SI would only apply for a small cohort of patients with triglycerides between 5 and 10 mmol/l 7.1.2 - IB noted that further trials were still to be completed; he thought that this decision should be delayed until the end of the year 7.1.3 - Committee briefly debated on the specialist status 3
The committee agreed for this proposal to be amended on the netformulary. 7.2 - Local Blacklist amendments Three proposed amendments from ArdenGEM CSU were brought to the committee for consideration; 7.2.1 - AD highlighted for the inclusion of pelvic toners for stress incontinence, kerraped all purpose boot and dermasilk clothing The committee agreed for these proposals to be included on the netformulary. 7.3 - ONS Prescribing A revised guidance was presented with some changes to the oral nutritional supplements. AD read out the minor changes to the products and prices for the 3 tables on page 8. The committee agreed to republish this guidance. 7.4 - Vitamin D - A decision review request from GEH specialist was brought to the committee for consideration; 7.4.1 - AD summarised the application request, he read out a response from authors (CRCCG Medicines Management Team Pharmacists) of the guidance to the key issues raised in this application 7.4.2 - LD felt that more detailed evidence was required around specific patient conditions, he suggested that the CRCCG pharmacists liaise with Dr Vinod Patel in the first instance and he should resubmit application to the next meeting 7.4.3 - JS thought it was vital to have appropriate guidance for maintenance doses 7.4.4 - AD noted that the decision options would be whether to add all new maintenance doses as blacklisted or to add non-formulary status on the netformulary website 7.4.5 - NJ clarified that if drug/products are blacklisted, this does not mean they are not prescribable and GP s who refuse to prescribe could be deemed to have breached their GMC contract; which states doctors are obliged to prescribe and such prescribing must be cost-effective if patients refuse to buy The committee agreed that more clarification was required and for the application to be resubmitted to the next meeting. 7.5 - Formulary inclusion An application from SWFT and UHCW respiratory consultants to include a new triple therapy inhaler (Trimbow ) product was brought to the committee for consideration; 7.5.1 - AH summarised the details of this request, it has been compared with Fostair and Tiotropium. The benefits are that all three molecules are in one device to ease compliance 7.5.2 - IB wondered if the drug positioning statement had been done, he read out the evidence for exacerbations and pneumonia risk 4
7.5.3 - SK asked if there was a way of identifying which patients could be suitable for triple therapy, AD answered that if might be possible to retrieve data from the eclipse system 7.5.4 - AD asked the committee if they wanted to include trimbow in the COPD guidance The committee agreed to this inclusion, the draft DPS and revised COPD guidance to be disseminated to the committee for virtual ratification, then publish to the website. 7.6 Oral Anticoagulants - A UHCW guidance was brought to the committee to consider whether it was useful to publish all or part of the document on the APC website; 7.6.1 - RL thought that parts of the guidance would be useful information 7.6.2 - LD asked if the guidance was approved by the other 2 trusts 7.6.3 - PM and SP confirmed that they have similar documents for their trusts, it was suggested that they liaise with ME around combining these into a single document 7.6.4 - SK suggested that it would also be useful to have some clear anticoagulant guidance for primary care, AD replied that the APC office will look into this The committee agreed for the guidance to be harmonised between the three trusts and present an update at the next meeting. Section 7 Decisions 7A Publish the agreed blacklist additions to the netformulary RS/SD 7B Republish the ONS Prescribing guidance AD/SD 7C CRCCG Pharmacists to liaise with GEH specialist regarding Vitamin D decision review application AD 7D Specialist to revise application and resubmit for November meeting AD 7E Email draft trimbow DPS to committee members for virtual ratification, then publish AD/AH/SD 7F Amend COPD guidance, send out to committee members for virtual ratification, then republish AD/AH/SD 7G Write to SWFT specialist regarding trimbow formulary application outcome AD 7H Trust chief pharmacists to review the oral anticoagulant guidelines with haematologists, bring back final document to the meeting ME/PM/CC/SP 8. Shared Care Agreements 8.1 - Dexamfetamine - A CWPT proposed SCA for treatment of adult attention deficit hyperactivity disorder (ADHD) was brought to the committee for consideration; 5
8.1.1 DT explained that as part of the new transition for adult ADHD, it appeared that this drug did not have a shared care agreement, this document brings it into line with other ADHD drugs that were approved at the last meeting 8.1.2 - NJ commented that some GP's did have issues with prescribing ADHD drugs as shared care. DT replied that they were aware that some GP practices in Warwickshire North were reluctant to prescribe these drugs. He clarified that this treatment was in line with the national guidance The committee agreed for the document to be published and to update the netformulary. Section 8 Decisions 8A Format dexamfetamine adult ADHD SCA and publish, amend netformulary AD/SD 9. AOB 9.1 - New Medicines & Pathway Committee A draft document was presented to the committee for approval; 9.1.1 - PM briefed the committee on the draft paper on behalf of ME, he spoke about the purpose and terms of reference for this new committee which would be focussing on non-tariff high cost drugs across the three acute trusts. To look at creating some consolidated pathways for certain health conditions to achieve some consistency across the sustainability and transformation partnerships (STP) footprint and improve patient care across the whole health economy 9.1.2 - RL thought that in the first instance, the document needs to be shared with CCG commissioners 9.1.3 - AD confirmed that this new committee would not impact directly on primary care 9.1.4 - LD felt that discussions around these speciality drugs required input from the different speciality areas rather than have a DTC chair representative 9.1.5 - RL mentioned that the current high cost drugs and pathway remit was discussed separately in the 3 CCGs, he emphasised that the commissioners would need to be involved in this new group The committee agreed for the draft paper to be disseminated to all 3 CCGs for approval. 9.2 - NJ highlighted that Warwickshire LMC were aware that some GP practices had been advised by Care Quality Commission (CQC) that their procedures for methotrexate prescribing were inadequate. The CQC view was that the GP must see the blood test results before prescribing the drug as it is otherwise classed as unsafe; he stated that this goes against the current shared care protocol. 6
NJ asked the committee if this blood results statement should be included in the shared care agreement. Committee followed on with a brief discussion around the current prescribing. RL concluded that this question was more for CQC. AH clarified that the methotrexate SCA is currently being reviewed by the secondary care. To bring back a reviewed methotrexate SCA to the next meeting. 9.3 - SK highlighted that there appears to be a big issue with the shortage of generic medicines, the current price concessions list NCSO is advertised on the PSNC website but it does not include the whole host of other medicines that are short in supply. 9.4 - JS quoted that she had managed to download the netformulary mobile application and found this tool very useful. She queried the timescale for completing information in all of the BNF chapters. AD replied that at present only the APC drug status is included but in time, we will look at populating all of the BNF categories. 9.5 - AD informed the committee that there will be a new blood glucose monitoring system available soon on the market called FreeStyle Libre ; it is a sensor that is placed on the upper arm to monitor patients sugar levels. The cost is approximately 60 for the meter and 57 for the patch which would need to be changed every 2 weeks. He advised that an interim positioning statement will be presented at the next meeting for primary care advice. Section 9 Decisions Disseminate new medicines & pathway committee paper to all three ME/PM 9A CCGs for approval 10. Date of next meeting The date and time of the next meeting is Friday 17 th November 2017 at 12.30pm until 3pm. 7