Minutes of the Lambeth and Southwark Joint Prescribing Committee (JPC) meeting 2. 00 pm, Wednesday 9 September 2013 Room 407, 1 Lower Marsh Present: Dr Di Aitken Catherine Otty Sian Howell Sadru Kheraj Iris Javaid Rimal Patel Liz Williams Tase Oputu Vanessa Burgess Anna Jenkins Anna Hodgkinson Devika Sennik Helen Magnusen Baker Helen Williams Jenny Sivaganam Georgina Fihosy Shena Chauhan Kath McPherson In Attendance: Mike Salter Apologies: Gaurang Purohit Dilip Patel GP, Chair (Lambeth CCG) GP, Southwark CCG and LMC Representative, Lambeth GP, CCG Board Medicines Management Lead, Southwark CCG GP, CCG Board Medicines Management Lead (Lambeth CCG) Practice Nurse (Lambeth CCG) Community Pharmacist GP (Lambeth CCG) Formulary Pharmacist, KCH Chief Pharmacist/AD Medicines Management, Lambeth CCG Chief Pharmacist, Southwark CCG Senior Prescribing Advisor, Lambeth CCG Senior Pharmaceutical Advisor, Southwark CCG Senior Pharmaceutical Advisor, Southwark CCG Consultant Pharmacist CVD, Lambeth & Southwark CCGs Prescribing Advisor, Lambeth CCG Senior Primary Care Pharmacist, Southwark CCG Prescribing Advisor, Southwark CCG Medicines Management Intelligence, Lambeth CCG (Minutes) Chief Pharmacist, NHS Lewisham CCG Formulary Pharmacist, GSTT Community Pharmacist, LPC 1. Introduction and welcome DA welcomed members to the meeting. 2. Minutes July 2013 and Declaration of Interests/Conflicts The minutes were accepted as an accurate record subject to deleting LPC rep from RP s role. DA asked for any declarations of interest for the meeting agenda. Page 1 of 5
3. Matters Arising i. Guideline on managing ED in severe distress HB presented the checklist which could not be emailed in advance due to copyright restrictions. Feedback on the guideline has been received from Dr Popelyuk as follows: Patients may be identified as having organic causes for ED but can also have psychological distress therefore should not be excluded from assessment. It was agreed that the table on page 2 would be deleted. Depression to be replaced by Distress on page 3 scoring table. ** It is important to remember that severity of sexual problems does not always correlate well with CORE 10, so the decision about whether to prescribe PDE-5 should be based on the overall clinical presentation and not on CORE -10 alone. - to be moved to above the scoring table. A score of 15-19 is highlighted as being outside of NHS prescribing. Dr Hopkirk does not agree and states that prescribing of PD-5s should be considered based on clinical appearance e.g. if the patient appears distressed then PD-5s on FP10 should be considered. The committee agreed this should be worded to suggest rather than recommend. Dr Popelyuk recommended that patients with severe distress should receive an immediate referral to SLAM. JPC felt this would generate multiple referrals and the guideline should be amended to assess mental health status and to refer as appropriate. This also applied to increased despair/suicide risk. The committee questioned why point 5 of the prescribing notes referred to trying 2 PD-5s rather than 3 before referring as failing to respond. HB advised that clinical experts had advised that trying 3 PD-5s increases psychological morbidity. NICE guidance agrees with this. JPC also queried how long a patient should remain on PD-5s and HB responded that it is difficult to have a blanket rule as it depends on individual response. Caution should be taken not to stop treatment before the patient is ready. Counselling should be available to manage expectations. The guideline states there will be no prescribing of tadalafil in primary care. AH felt this was unwise as there may be occasions when it is unavoidable. To be amended to there should not normally be prescribing of tadalafil in primary care. LW suggested the checklist could be added to EMIS web. ACTION: HB to amend as agreed then circulate for review/chair s action and to investigate adding the checklist to EMIS. (Post meeting note: HB has followed up adding to EMIS web with Ryszard Stepaniuk. In his opinion this cannot be done as any form of recreating the check list will be seen as copyright infringement). i. Lambeth & Southwark SOP for Rescue Pack assessment Guideline to facilitate assessment of patients for issue of rescue packs. Patients who are issued with 2 or more in a 12-month period will need to be referred to the specialist. Approved. ii. Southwark COPD Self-Management plan It was noted that currently Lambeth and Southwark are using different versions of the COPD Action plan. Approved ACTION: AH to forward action plan to HB iii. Lambeth and Southwark management of COPD Turbohalers which are the only licensed inhaler are not suitable for COPD patients with a low respiratory rate so local expert opinion recommends prescribing mdi/spacer. VB noted that pharma companies claim to have data that supports use of turbohalers in these patients. JPC discussed the Page 2 of 5
use of incheck devices to assess respiratory rate but it was felt this was too much of a leap for primary care. VB cautioned against the principle of including an unlicensed preparation while not including a licensed one. This could be open to challenge. There was some discussion around prescribing dry powder preps but HB added that there is good evidence that maintaining patients on the same type of device has better outcomes. Do not initiate ICS should be in bold caps and stop smoking advice and pulmonary rehabilitation should be listed as steps before referral to secondary care. ACTION: HB to amend and recirculate. 4. GSTT Switch to Dalteparin JPC discussed the unilateral switch from enoxaparin to dalteparin proposed by GSTT. The discussion highlighted the following key areas of concern: The decision to use only one LMWH across all local institutions was taken many years ago to minimise risk, and primary care prescribing for some indications was agreed on the basis of standardisation on one LMWH. A switch to dalteparin at GSTT will undermine this principle and will inevitably increase risk in the system, particularly for primary care where two agents would be in use. The committee also discussed that primary care prescribing of LMWH is not undertaken in most areas across England as this therapy is seen as specialist. The CCGs recognised the potential cost savings from a switch are significant and GSTT. Although, the modelling process used by GSTT has not been made available for scrutiny and the cost modelling undertaken at KCH does not support the same potential for savings. Safe prescribing of Dalteparin in the community. The nomenclature of dalteparin on GP systems significantly increases the risk of prescribing errors. EMIS buys its drug dictionary externally, and the supplier will need to be contacted to see if the drug dictionary can be amended, we do not know if this can be done in a timely manner. There is a cost associated with stocking multiple LMWHS for community pharmacies, particularly in view of the numerous strengths available. If community pharmacies are unwilling to stock both enoxaparin and dalteparin, there may be delays in supply for individual patients There is a lack of clarity over the indications for LMWH prescribing which are currently being transferred to the GP for community prescribing of LMWHs discussion and agreement regarding this is needed. It is understood that a revised pricing structure for Enoxaparin may be proposed by Sanofi Aventis. The committee would recommend: Awaiting an outcome of the change in enoxaparin price - currently with the CMU. Ideally, maintaining the status quo with only one LMWH in the locality; but if GSTFT wish to go ahead with a unilateral switch, that prescribing of all LMWH remain with GSTFT including continuation of medium to long term therapy from the date of the switch. This supply process must be designed to minimise the risks and costs to primary care ie through a repeat dispensing process, rather than incurring additional tariff costs. This process needs to be agreed with the CCGs before implementation ACTION: HW to draft response to GSTT, follow up with JFC and to update on pricing outcome for enoxaparin 5. Bisphosphonate Pathway The pathway has been developed by the MSK group for the use of IV Denosumab. HB informed JPC that she has fed back the following comments which are not yet reflected: P6 of pathway- Clarity required on use in men with a creatinine level under 35mls More cost effective to use denosumab rather than zolendronic acid in the community NICE guidance is that prescribing to be kept in secondary care for 1-year in patients under 35mls - the algorithm states this but shared care does not. P6 of shared care NICE does not recommend denosumab in prostate cancer Remove primary prevention reference and add statement re local agreement around use in men. Approved subject to changes outlined. Page 3 of 5
6. Denosumab Shared Care See Item 5 7. Malnutrition and Oral Nutritional Supplements the case for change VB reported that a Task Force has been set up to look at the use of ONS on FP10, in particular procurement of ONS and hospital feeds. Currently hospitals get ONS very cheaply with add-ons such as nurse support and advice lines funded through volumes in primary care prescribing. Options given are: Retain as is model hospitals and HEN/CHANT team to procure, GPs prescribe on FP10 and no additional dietician support to manage malnutrition Dedicated dietician support for primary care dieticians to be integrated into GP practice teams either by FP10 prescribing or non-fp10 managed by dieticians who would have budgetary responsibility. Could be single or multiple supplier based Primary care voucher scheme dieticians would review and recommend food fortification and/or ONS Patients would be issued with vouchers which could be redeemed at supermarkets or pharmacy. JPC recommended Option 1 subject to the following modifications: JPC are keen to commit to better management of malnutrition but would like to approach this as a multidisciplinary, integrated team. JPC would encourage integration into the work of the LAMP project, as part of the Southwark and Lambeth Integrated Care programme and development of a malnutrition pathway as a part of this work. JPC acknowledge that malnutrition could be a more integral part of care pathway commissioning and will raise this internally within our CCGs. JPC would like to work closely with dietician expertise in maximising benefits from ONS, reducing waste and better nutrition, however feel that a procurement solution is not the best way of delivering this at this moment in time ACTION: VB to draft a response to Task Force for Chair s approval. 8. PGD for administration of vaccines by Practice Nurses The revised PGD, which has been developed by Public Health England on behalf of NHS England, was presented to JPC. Rotavirus and shingles have been removed along with some other minor amendments. NICE have recommended a review date of 3 years for PGDs. IJ raised the issue of the new recommendation of nasal spray vaccination for children over 6 years old. The PGD update still refers to vaccination by injection. PSDs will need to be used until PGD is ready. JPC suggested that practices could print a list of the relevant patients which could then be signed by GP. The shingles, rotavirus and nasal spray PGDs are due to be issued very soon by NHS England and a covering letter can be added to this PGD to explain this. The dosage frequency is to be inserted on p36. VB added thanks to Josie Mansell for her work on the update. ACTION: JM to make amendments and circulate for Chair s action 9. Standing Item i. Community Pharmacy Update RP reported some issues with electronic prescribing system and will ask DJ to raise these at LPC. He added that tokens could be printed in the practice when prescriptions fail to arrive at pharmacies. Page 4 of 5
10. Items for information i. Minutes of GKLT Joint Formulary Committee (JFC) - noted ii. Minutes of GSTfT Drugs and Therapeutics Committee (DTC) - noted iii. Secondary Care monitoring frameworks (GSTfT) practices should feedback any issues with secondary care prescribing of tadalafil to MMT. iv. NICE Update - noted v. Emollients Guidelines JS summarised the minor amendments and JPC approved the guidelines. To be circulated to practices, community pharmacists, community teams, practice nurses and walk-in centres. 11. AOB None Page 5 of 5