Meeting Name: Pharmacy Forum Date: 14 th 2012 Venue: Halton Stadium, Lower House Lane, Widnes, Cheshire, WA8 7DZ In Attendance: Jo Bateman (Chair), Countess of Chester Hospital () Diane Hornsby, (Secretary) NHS Western Cheshire (DH) Anne Henshaw, Knowsley Shadow CCG (AH) Caroline Bagley, Southport and Ormskirk Hospital NHS Trust (CB) Dave Thornton, Aintree Hospital (DT) Nicola Baxter, NHS Central Lancashire PCT (NB) Mina McFaul, North Cheshire Hospitals NHS Trust (MM) Jenny Lunn, Warrington Health Consortium (JL) Anu Brough, Liverpool PCT (AB) Cassandra Edgar, St Helens and Knowsley NHS Trust (CE) Rebecca Curran, Wirral University Teaching Hospital (RC) Anne Porter, CMCN (AP) Erika Baker, NHS Merseyside (EB) Apologies Danny Forrest, Liverpool Heart and Chest Hospital (DF) Sarah Roden, NHS Western Cheshire (SR) Catherine Lee, Royal Liverpool Hospital (CL) Judith Green, NHS Wirral (JG) Michael Lloyd, St Helens and Knowsley NHS Trust (ML) Jane Eyres, Sefton PCT (JE) Page 1 of 6
Agenda Item Notes/Action points Lead Actions AP to finalise draft minutes from 15 th June 2012 and send out to Pharmacy Forum members and store on CMCN website to e-mail DF re the fact that several versions of PPCI protocol seemed to be available, and to ask him to send what is required for the final updated document to AP for incorporation into her document. pharmacists (who have not already done so) to forward TTR measurement information through to. RC to circulate palliative care heart failure guidelines to the Pharmacy Forum once approved. to forward information from the Company making Digifab, re using Digifab and Digibind together. to ask Dr Somauroo to draw up some guidance regarding use of bendroflumethiazide in place of metolozone, for use in the area. Pharmacists to send information regarding CCG structure/commissioners to, even if the information is temporary. EB to forward the Omacor recommendation to, who will To be completed by ASAP (latest 25 th Sept) As soon as available Mid October October take it to the Network Board meeting 1. Budget impact of eplerenone in Heart failure A presentation was given by Ivan Beard, Pfizer. Karen O Grady, Pfizer, was also present 2. Minutes from 15 th June 2012. The minutes from the previous meeting were approved AP to finalise and send out to Pharmacy Forum members and store on CMCN website AP /DF RC EB/ AP 3. Matters arising from 9 th March 2012 There were no matters arising 4. NSTEACS and PPCI guidance updates/ticagrelor AP stated that there had been a Cardiac Advisory Board (CAB) meeting on 13/9/12 where the NSTEACs guidelines had been discussed and amendments made. The updated guidelines were due to be published on 22 nd Page 2 of 6 AH asked who would be responsible for renal function testing at 30 days after starting ticagrelor, and how the requirement would be communicated to clinicians. DH stated that DF had advised her that at LHCH he was in the
process of making it a default on the electronic system and that the responsibility would lie with GPs. A baseline U&E would be provided. There was discussion around the need to ensure that all initiating centres provided this baseline U&E measurement to Primary Care, and for the need to ensure that the discharge letter was received in time for the 30 day test to be performed. It was agreed that this information needed to go on the electronic transfer, to avoid any delays in communication. MM stated that at Warrington Hospital, an automatic pop-up box came up on the system if ticagrelor was prescribed. This had a standard sentence regarding the need for a 30 day renal function test and a space to enter the baseline U&E values. The group agreed that this seemed like a good system. DT requested that it was minuted that the Pharmacy Team at the Secondary or Tertiary Care Centre where ticagrelor was initiated, should not be held responsible for communicating this information to Primary Care. It was noted that the PPCI transfer sheet still stated prasugrel rather than ticagrelor. The group felt that DF would be updating this. However, AP stated that she in fact held this document and she had not been asked to amend it. The fact that several versions of this form may be in circulation was also raised. RC queried if prasugrel had been taken off Formulary yet in other Secondary Care centres. There was a mixed picture within the group, with some Centres not using prasugrel and some Centres keeping it on Formulary until the Network Pathways were released. It was noted that education around ticagrelor was required for Secondary Care doctors. The group discussed the fact that if a patient can t have aspirin, then they should be given clopidogrel rather than ticagrelor, as ticagrelor not licensed as single therapy. It was also noted that there is currently no evidence to support triple therapy, e.g. warfarin, aspirin and ticagrelor. asked if the ticagrelor information sheet was also going to be published on 22 nd Sept. AP said that as far as she was aware it was. stated that some changes had been made to the patient information leaflet, and it was important to ensure that these had been included. to e-mail DF re the fact that several versions of PPCI protocol seemed to be available and to ask him to send what is required for the final updated document to AP for incorporation into her document. 5. TTR measurement update stated that she had only had 2 responses to her request at the last meeting for information regarding which areas have TTR routinely reported for each patient. She requested again that this information be sent through to her. MM stated that Warrington Hospital can t measure TTRs at all. pharmacists (who have not already done so) to forward TTR measurement information through to. Page 3 of 6
6. NOAC update DT updated the group, saying that rivaroxaban and dabigatran position statements had been released. An agreed bleeding protocol was still needed. DT stated that some Haematologists were not happy to have blood products on the bleeding protocol, as they were expensive, didn t work and possibly were pro-coagulant, so increasing the risk of stroke. DT said that he had drawn up a protocol for Aintree Hospital, based on the protocol from Barts, but without the blood products on it, and with a statement to contact Haematology in the case of a bleed. Discussions around the table highlighted the fact that bleeding protocols were being discussed in all areas, but there was little consensus. RC agreed to forward the Wirral s bleeding protocol to the Forum once it had been approved. stated that she would start working on the patient information leaflet again, as the one coming from NICE had been delayed further. DT stated that TTR and warfarin instability monitoring would be discussed at the next AF Task Group meeting, scheduled for 27 th. He said that education was needed around what TTR was and how it was calculated. DH queried the reference to TTR <67% with warfarin as the point at which rivaroxaban treatment might be considered, in the Network Rivaroxaban Position Statement. DT stated that this figure was different to the one in the rivaroxaban (ROCKET) study, but that it had been decided to stay with 67% as for dabigatran. It was agreed that the first choice NOAC should be dabigatran, rather than rivaroxaban. 7. Stable angina guidelines AP stated that the update to these had been agreed and that they would be published on 22 nd. 8. Palliative Care Heart Failure Guidelines RC stated that she had requested the whole document to be rewritten, as it had escalated to 65 pages. It is expected that it will be published towards the end of. RC will circulate it to the Forum when it has been approved. RC to circulate palliative care heart failure guidelines to the Pharmacy Forum once approved RC 9. Digifab This item followed discussion at the last meeting regarding the possibility of keeping a centrally located stock of Digifab. told the group that the College of Emergency Medicine s document stated that each hospital must hold 10 vials of antidote in stock and that this must be available within 1 hour of needing it. In theory, up to 20 vials might be needed. It was also noted that the central location would have to be a hospital with a Residency, and this only applied to Arrowe Park hospital. The Forum felt that it would be unfair to expect APH to always be the central stock holder and so it was concluded that each hospital would need to keep their own supply of Digifab. stated that the company making Digifab had issued guidance re how to use Digifab and Digibind together. Page 4 of 6
to forward info re using Digifab and Digibind together 10. Metolozone The discontinuation of this product had not been discussed at CAB. The consensus within the Pharmacy Forum was that bendroflumethiazide should be used instead, although it was noted that no specific guidelines regarding this existed. to ask Dr Somauroo to draw up some guidance regarding use of bendroflumethiazide in place of metolozone, for use in the area 11. Commissioners said that there had been little response to her request at the last meeting for information regarding who the Commissioners were now in each area. stated that specific names were needed, so that the Cardiac Network could communicate and work effectively. Pharmacists to send information regarding CCG structure/ Commissioners to, even if the information is temporary 12. Omacor post MI EB stated that she was working on a document whereby Omacor, as secondary prevention of MI, would not be prescribed in Secondary Care, but instead would be prescribed by the patient s GP, who could assess lifestyle issues. EB requested that the Cardiac Network agree with this position. There was a lot of discussion around this, and it was noted that at CAB, all of the Consultants had stated that it was important to prescribe Omacor and wanted to continue to do so. RC stated that if Omacor was to be stopped or not prescribed, then it was important to ensure that Omacor was not being recommended for patients with heart failure or arrhythmias. EB to forward the Omacor recommendation to, who will take it to the Network Board meeting for consideration 13. Presentation for November meeting It was agreed that the next presentation should be on rivaroxaban in acute coronary syndrome. EB AP 14. A.O.B. CMCN statin guidelines. This had been discussed at CAB and it had been agreed that new guidance from NICE (due 2013) should be published before a sub-group was set up to look at this. Page 5 of 6 New data regarding drug interactions for simvastatin. There was no definite consensus within the group regarding what to do w.r.t. the new data showing an increased risk of myopathy and/or rhabdomyolysis when simvastatin is given with various drugs (MHRA Drug safety Update Aug 2012). With respect to the specific interaction between simvastatin and
amlodipine. The two main options discussed involved either reducing the dose of simvastatin to 20mg, or switching simvastatin to atorvastatin (no agreement on dose). Representation at CAB. EB stated that there should be a representative from the Pharmacy Forum attending the CAB meetings. At the least, the Forum should receive a copy of the agenda for each CAB meeting. stated that due to the number of other meetings she already attends, she could not commit to attending the CAB meetings as well. However, if the Network Board felt that a Pharmacy Forum representative was appropriate, then this could be discussed within the Forum Date & Time of next meeting: 1.30-30 TH November 2012 Page 6 of 6