COVENTRY & WARWICKSHIRE AREA PRESCRIBING COMMITTEE MINUTES OF THE COVENTRY AND WARWICKSHIRE AREA PRESCRIBING COMMITTEE HELD ON 19 TH JANUARY 2018 AT 12.30 PM IN THE CLINICAL SCIENCES BUILDING (CSB) AT UHC&W NHS TRUST PRESENT:- Simon Fletcher University Hospitals Coventry & Warwickshire NHS Trust (SF) Chair Altaz Dhanani Coventry & Rugby CCG (AD) - APC Secretary Joe Booker Coventry LMC (JB) Jane Smith Coventry GP (JS) Claire Keane Coventry GP (CK) Nigel Johnson Warwickshire LMC (NJ) Kim Panting South Warwickshire GP (KP) Bernhard Usselmann South Warwickshire NHS Trust (BU) Caroline Coupe South Warwickshire NHS Trust (CC) Sumara Parvez South Warwickshire NHS Trust (SP) Joanne Brader South Warwickshire NHS Trust (JBr) Satyan Kotecha Warwickshire LPC (SK) Cath Sansby - University Hospitals Coventry & Warwickshire NHS Trust (CS) Hardeep Bagga (deputy) University Hospitals Coventry & Warwickshire NHS Trust (HB) 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) Vishal Mashru (deputy) Coventry LPC (VM) IN ATTENDANCE: Anita Hunjan (AH), Susan Dhesi (SD) 1. APOLOGIES Franco Cappuccio, Mark Easter, Sukhi Dhesi, Ashwin Hindocha, Richard Lambert 2. MINUTES OF THE LAST MEETING The minutes of the last meeting held Friday 17 th November 2017 were agreed as accurate and to be published onto the website accordingly. 2.2 - Action Log - SF went through some of the outstanding actions. 1
1. Sept 16 Pain Clinic data due to the lack of response, the committee agreed this action was no longer required 2. Mar 17 Hypertension guidance AD informed that FC will be resigning from his membership role, however, he was still committed to producing a revised guidance 3. AD reminded the committee that he had sent them the last meeting s DPS verdict ratification email action, committee to respond accordingly 4. Sept 17 Oral Anticoagulant guidance SP notified that each trust has approved their local guidance therefore this action was complete 3. MATTERS ARISING DOACs - JS enquired about the educational literature on the checklist for GPs and anticoagulant drugs education training for patients. AD replied that CCGs are considering an education session in conjunction with Professor Fitzmaurice from the University of Warwick. He stated that there will be an official training package for GPs to follow and the AF group are looking at developing a new pathway for patients. AD expressed that a single anticoagulant reference document will eventually be published on the APC website. SK added that regarding patient education; GPs can refer patients to the community pharmacy new medicines service whereby a community pharmacist will support patient education through interventions. SP and PM both updated the committee that each trust has their local guidance in place and these will be amended when they are reviewed in the future. AD asked SP and PM to forward him their local guidelines; he felt that it would be useful to develop a simplified guidance for publication on the website. Section 3 Decisions 3A Email the community pharmacy new medicines service information to APC members SK 3B Send trust oral anticoagulants guidance to APC office SP/PM 4. APC Development AD introduced this item by firstly notifying the committee that he has been officially appointed to the role of Head of Medicines Optimisation for Coventry and Rugby CCG and Warwickshire North CCG. He thought that it was an appropriate time to start to review the APC functions and relevant key documents: membership list, terms of reference (TOR) and mission statement. 4.1 - Membership List - The committee went through the list of current members. SF urged that it was vital that member s attendance requirement was at least 50% for the year. The following key comments raised were: 1. Continuity of representation of the Drug and Therapeutic Committee chair (DTC chair) from Coventry and Warwickshire Partnership Trust (CWPT). DT answered that the lack of commitment was due to a capacity issue and that he had fed this back to the organisation 2
2. LD pointed out that there has been no representative from Warwickshire North (WN) GP leads. JBr said that she was the trainee community matron for Warwickshire North area and could canvass some support and feedback at the next meeting. AD emphasised that he will also try to recruit a GP lead from the WN GP practices 3. KP pointed out that it was herself and RL in regular attendance not SDh, committee felt there was no need for a third alternative member 4. PM mentioned that this was his last meeting as he was retiring from George Eliot Hospital (GEH). He informed the committee that his successor was Debra Armstrong who is commencing her post in February 5. PM informed the committee that the nurse member for secondary care has unfortunately passed away and requested the removal of the name from the list immediately. SF suggested to liaise with trust chief nursing officers for a replacement representative, he quoted that it was important to have a nurse prescriber on the committee 6. DT said that they could look within CWPT services for another community nurse representative 7. AD added that FC will be retiring from his membership position. SF acknowledged that there was no longer a department of clinical pharmacology; he wondered whether representation from the universities who lead on the teaching and training for nurses and medical students would be more feasible. LD added that the member position could be called research and development 8. AD questioned CC role, it was decided to add her representation as interface pharmacist 9. A brief discussion took place on whether it is beneficial to have 2 lay representatives 10. SF read out an email from a junior medical student expressing an interest in becoming a member of this committee, he thought that a medical student would be valuable member. The committee agreed to the inclusion of this post and to seek volunteers The committee agreed that to update the list, the appropriate route would be to send out a notification letter to those members that have not been in regular attendance informing them that their membership will be ceased. 4.2 - Terms of Reference - The committee went through the sections of the document to see if it was still fit for purpose. Key comments raised were: 1. AD confirmed that the terms of reference (TOR) will be reviewed on an annual basis 2. Discussion took place as to whether a paragraph on RMOC should be included 3. Item 6 to remove this paragraph as not applicable 4. Objectives to change the wording of medicines management to medicines optimisation and bullet point 9 to change the wording for the audit paragraph 5. Election period of the chairman and vice-chairman positions to be every 2 years 6. Quoracy add statement to say that this excludes the chairman and APC secretary 7. Voting AD read an email on behalf of ME suggesting which members should have voting rights. The committee noted that historically the voting system has never been required, however, they disagreed with ME suggestions and felt that it was crucial for all members to vote, otherwise it would delay the decision processes. 8. Discussion took place around junior doctor voting rights, the committee agreed that the person(s) should be a non-voting member because their attendance might be intermittent 3
4.3 - Mission Statement The committee agreed that there was no amendment required on this document. All of the three documents to be amended accordingly and republished. Section 4 Decisions 4A Seek Warwickshire North CCG clinical commissioner representative, send expression of interest to APC office AD/JBr 4B Write a final letter to RH, SDh, PH to remove membership status AD/SF 4C Seek community nurse representative, send information to APC office DT 4D Write to trust chief nursing officers to seek suitable secondary care nurse representative AD 4E Replace academic sector role with research & development role AD/SD 4F Write to Warwick Medical School to seek suitable academic clinician representative AD 4G Write to Coventry University Faculty of Health and Life Sciences to seek suitable academic nurse representative AD 4H Write a response email to junior doctor interested in being an APC representative SF 4I Amend membership list and republish AD/SD 4J For TOR document email a form of words for objectives paragraph to DT APC office 4K Amend TOR document and republish AD/SD 4L Republish mission statement AD/SD 5. Drug Positioning Statements There were no items to discuss. 6. Specialist Drugs/netFormulary 6.1 - NetFormulary Amendments Four proposed amendments from UHCW were brought to the committee for consideration; 6.1.1 - CS highlighted that these drugs were classified as shared care but no shared care agreement (SCA) document was in place. Vigabatrin was rarely used; the specialist recommends changing to specialist initiation (SI) Chloroquine was rarely used for discoid and systemic lupus erythematosus, and rheumatoid arthritis indications. The rheumatologist recommends changing to specialist only (SO) Octreotide not used at UHCW; the palliative care team would advise use as per their palliative care guidelines, they recommend changing to specialist advised (SA) Ciclosporin unlicensed indication for ulcerative colitis, this is no longer used at UHCW 4
CS asked the committee for thoughts on an appropriate classification change. BU confirmed that this unlicensed indication was not used at SWFT. The committee decided the classification be changed to non-formulary The committee agreed to these proposals and for all four drugs to be amended on the netformulary. 6.2 - Modecate discontinuation A briefing paper from Coventry and Warwickshire Partnership Trust (CWPT) was brought to the committee for consideration; 6.2.1 - DT briefly mentioned that from May 2018 there would be a permanent discontinuation of Modecate (fluphenazine decanoate) injection, advising primary care to contact the GP advice line for support on switching to alternatives. The committee agreed for a statement to be added to the netformulary. Section 6 Decisions 6A Publish the agreed specialist drug amendments to the AD/SD netformulary 6B Add Modecate discontinuation statement to netformulary and APC newsfeeds AD/SD 7. Guidelines/Resource Documents 7.1 - Local Blacklist Amendment One proposed deletion from CRCCG was brought to the committee for consideration; 7.1.1 - AD highlighted that folic acid 400 microgram tablets for pregnant women was not appropriate to be classified as a blacklisted medicine. He stated that it should be available to be prescribed in primary care The committee agreed to remove and amend folic acid on the netformulary. 7.2 - Local Blacklist Amendment One proposed amendment from CRCCG was brought to the committee for consideration; 7.2.1 - AD highlighted the inclusion of cannabidiol preparation (e.g. CBD oils) 7.2.2 - DT mentioned that this is designated as a food supplement and that there is MHRA guidance that has been sent to manufacturers stating that they need to apply for a license. He explained that CWPT healthcare professionals have been informed that they should not be recommending this food supplement as currently there is no designated evidence-base. DT added that he will forward the statement to AD 7.2.3 - PV pointed out that the preparation should also not be used in children with epilepsy The committee agreed to include this addition to the netformulary along with the MHRA statement. 5
7.3 - Local Blacklist Amendments - Five proposed amendments from the NHS England national list were brought to the committee for consideration; 7.3.1 - AH briefed on the background to the national commissioning guidance. NHS England has formulated a list of drugs that should not be routinely prescribed in primary care. AH stated that out of the initial list of eighteen drugs, fifteen of them have already been assigned to our local blacklist. 7.3.2 - The committee went through the 5 proposed amendments: Dosulepin - currently classified as non-formulary DT and NJ confirmed that they did have some limited prescribing; mainly historic patients. Committee agreed a statement should be added to review the historic patients Fentanyl - immediate release lozenges are currently classified as SA, indication for use is prior to painful dressings when short acting oral morphine ineffective Omega fatty acids (all indications) currently classified SI for the management of hypertriglyceridaemia, reducing the risk of pancreatitis. DT noted that there was some limited prescribing in CWPT; he felt the classification change would impact on those patients. DT suggested bringing back a positioning statement with an exception for mental health patients. The committee felt that clarity was required from the lipid specialist for the SI indications Diethylamine salicylate cream currently classified as preferred choice for all licensed indications Trimipramine currently classified as non-formulary 7.3.3 - AD read out further information from the consultation paper, seven proposed medicines will be forwarded to the Secretary of State to place on the national blacklist The committee agreed for these additions to be amended on the netformulary and to write to the lipid specialist regarding omega fatty acids indications. 7.4 - Asthma Prescribing A revised guidance in a redesigned format in line with the latest BTS guidance was brought to the committee for approval; 7.4.1 - AH mentioned that it did not incorporate the recent NICE guidance and that further discussions would be initially needed 7.4.2 - SK felt that reformatted version was much easier to follow The committee agreed to republish. 6
Section 7 Decisions 7A Remove the agreed blacklist deletion and change the classification on netformulary AD/SD 7B Email CWPT CBD oils prescriber statement to APC office DT 7C Publish the agreed blacklist amendment to the netformulary AD/SD 7D Write to lipid specialist regarding the national NHS England blacklist guidance relating to omega-3 fatty acids AD 7E Publish the agreed blacklist amendments to the netformulary AD/SD 7F Republish the asthma guidance to both websites AD/SD 8. Shared Care Agreements A number of revised shared care agreements (SCA) for rheumatology indications were brought to the committee for approval; item deferred from the last meeting 8.1 - AH explained the amendments that applied to methotrexate, azathioprine, sulphasalazine, leflunomide, hydroxychloroquine, ciclosporin, gold and penicillamine. The changes were all in line with the BSR guidance 8.2 - A brief discussion took place around the patient safety aspect, CRRS system issues, 3 months supply, monitoring process, communication of dose changes. Committee asked for clarification on blood pressure monitoring, patients being stabilised before transfer for SC in primary care, 3 monthly prescription wording The committee agreed for the SCAs to be amended with the comments raised and sent out for a final virtual ratification before republication. Section 8 Decisions 8A Amend the rheumatology SCAs with committee comments and send out for virtual ratification AH/SD/Members 9. AOB 9.1 - AD reminded the committee to hand their completed annual declaration of interest forms to SD before departing the meeting. 9.2 - DT updated that a simplified version of the substance misuse guidance has now been completed and submitted to Public Health England, who will send the guidance for consultation to all CCGs, and hospital trusts. The final document will then be presented at this meeting. 9.3 - AD thanked PM for his contribution to the committee meetings. 7
Section 9 Decisions 9A Email asap completed declaration of interest form to Susan ME/RL 10. Date of next meeting The date and time of the next meeting is Friday 16 th March 2018 at 12.30pm until 3pm. 8