Minutes of the meeting of the AREA PRESCRIBING COMMITTEE held on Wednesday 13 th February 2013 in the Boardroom at Hillder House. PRESENT: Dr M Ghani (Chair) Medical Director Barnsley CCG (Designate) Dr M Al-Bazzaz Consultant in Elderly Medicine (BHNFT) (items 13/13.6 onwards) Mr T Bisset Community Pharmacist (LPC) Mrs S Hudson Lead Pharmacist (SWYPFT) (items 13/12 to 13/15.2 and item 13/21.3) Dr P Jha Consultant Physician General & Geriatric Medicine (SWYPFT) (items 13/13.6 to 13/15.2 and item 13/21.3) Dr J Maters General Practitioner (items 13/13.5 onwards) Mr M Smith Chief Pharmacist (BHNFT) Ms D Cooke Lead Pharmacist (NHS Barnsley) IN ATTENDANCE: Ms C Applebee Ms G Smith APOLOGIES: Dr R Hirst Dr S Chari Ms L Haygarth Dr K Kapur Dr K Sands Mrs C Lawson Dr Munzar Prescribing Support Pharmacist (NHS Barnsley) Medicines Information Pharmacist (BHNFT) Palliative Care Consultant (Barnsley Hospice) Associate Medical Director (SWYPFT) Chief Pharmacist (SWYPFT) Consultant Gastroenterologist (BHNFT) Associate Medical Director (SWYPFT) Head of Medicines Management (NHS Barnsley) General Practitioner APC 13/12 MINUTES OF PREVIOUS MEETING The minutes of the meeting held on 9 th January 2013 were agreed as a correct record. ACTION APC 13/13 MATTERS ARISING 13.1 Omacor Post MI Caron Applebee presented the academic detail aid for the prescribing of omega-3 supplements which had been updated to incorporate the changes discussed at previous APC meetings (items 12/112.1 and 12/122.1). The updated document had been approved by the Cardiologists. The guidance was endorsed by the Committee and it was agreed that the guidance would be circulated with the APC memo. DC 13.2 D1s Mike Smith explained that BHNFT had been undertaking a significant amount of work around D1s. The acute trust had recently received authorisation to access primary care records through the Summary Care Records and would be working with the SHA to facilitate this. Pharmacy will be one of the first areas where
this initiative is rolled out. NHS BARNSLEY BHNFT is also in the process of producing an SOP and booklet for prescribers on how to complete electronic D1s. Mike Smith confirmed that medicines management was also back on the junior doctors induction programme. Dr Ghani explained that the CCG was looking at introducing a CQUIN into the acute trust contract from 2013-14 around the quality of information on D1s. The CCG has also approved funding for a new IT system for D1s. Dr Ghani explained that part of the CQUIN may involve freeing up ward pharmacists to allow them to spend more time with the patient and less time completing administrative tasks. Mike Smith confirmed that this fitted in with the Pharmacy Transformation Programme and that in 2013-14 automation will be introduced into the dispensing process for inpatients which will also free up pharmacist time. Tom Bisset explained that a number of pharmacies did not currently have nhs.net email accounts and were therefore unable to receive discharge information electronically. It was highlighted that pharmacies were unable to choose their own domain names which has caused issues for some of the larger pharmacy chains. Gillian Smith confirmed that she would follow up the suggestion raised in the last meeting relating to pharmacists ensuring that shared care arrangements were in place for shared care drugs started during hospital admission. The Committee discussed ways in which shared care drugs could be highlighted on the D1. Gillian Smith suggested adding this information to the drug selection drop down box on the system and agreed to take this to the next Pharmacy Operations Group. It was noted that there had been a slight delay in setting up the Interface Group and that Richard Sykes would be organising this in the near future. Richard Sykes 13.3 DMARD Shared Care Guideline Caron Applebee presented the guideline which had been updated to incorporate the changes discussed at the previous meeting. The updated shared care guideline was approved by the Committee subject to ratification by the LMC. It was agreed that the tick box to confirm whether the shared care request had been accepted or rejected by the GP would be included in all future shared care guidelines. 13.4 Retigabine Shared Care Guideline Gillian Smith presented the shared care guideline. It was noted that the guideline had not yet been agreed by secondary care consultants and could therefore not be approved as a shared care guideline at this current time. It was noted that the information
regarding the quantity to be supplied by the initiating prescriber should be consistent throughout the document. The Committee agreed that the guideline would serve as an information resource to support GPs who were asked to prescribe retigabine by hospitals outside of the local area in the interim until the shared care guideline could be approved in its entirety. 13.5 Vitamin D Prescribing Guidance Gillian Smith informed the Committee that regular calcium monitoring was recommended for pregnant women receiving treatment doses of vitamin D (4000 units daily). Gillian Smith agreed to update the guideline in consultation with the Obstetricians. It was also noted that the vitamin D guidance was due to be updated in March 2013 and Gillian Smith agreed to liaise with Dr Jha regarding the update. It was highlighted that different consultants used different dosing regimes and it was agreed that the updated guideline would contain information on the various drugs and doses used locally. A discussion followed regarding whether patients should be advised to purchase high dose vitamin D over the counter or if this should be prescribed. Although there was a difference in opinion amongst Committee members the majority view was that patients could be encouraged to purchase the lower doses but treatment doses should be prescribed. Dr Jha informed the Committee that NICE vitamin D guidance was due to be published in May 2013 and it was agreed that the local guideline would be reviewed in a few months time when the NICE guidance was available. 13.6 Esomeprazole and Gaviscon Advance prescribing by ENT Committee members confirmed that this was still an ongoing issue and that requests to prescribe were also coming from Speech and Language Therapy as well as from ENT. Sarah Hudson agreed to follow up with Deborah McCloud, Speech and Language Therapy Service Manager. Gillian Smith confirmed that there had been little prescribing of esomeprazole by ENT in the acute trust. It was noted that ENT appeared to be bypassing the hospital pharmacy and asking GPs to prescribe both esomeprazole and Gaviscon Advance. Gillian Smith confirmed that ENT had been informed that Gaviscon Advance wasn t on the formulary on a number of previous occasions. It was agreed that this should now be escalated to the acute trust Medical Director and Gillian Smith agreed to pursue SH
this. 13.7 Stroke prevention in AF Dr Jha fed back on a review he had been involved with in a local GP practice. Mike Smith explained that the anticoagulant clinic within BHNFT had experienced a significant increase in the number of referrals as a result of the GRASP-AF work being undertaken in primary care which was causing capacity issues. Dr Ghani informed the Committee that an AF review local enhanced service was in the process of being introduced in primary care. Training will be provided for practices signing up to this to enable them to prescribe in accordance with the NORCOM guidance and minimise the number of secondary care referrals. Mike Smith asked if the practices delivering the existing anticoagulant service would be authorised to initiate warfarin. Deborah Cooke agreed to find out how many practices were signed up to the existing anticoagulation local enhanced service and how many of these could initiate warfarin and feedback to Mike Smith. DC Dr Jha queried if patients with a CHADS2 score of 1 would be reviewed as part of this work. Dr Ghani confirmed that practices would be advised to review patients with a CHADS2 score of 1 and above who were not prescribed anticoagulants. Mike Smith confirmed that the anticoagulant clinic followed the NORCOM guidance in response to a query raised. Tom Bisset requested that a letter was sent to community pharmacists to inform them of the expected increase in patients commencing anticoagulants over the coming months. DC/CL 13.8 Management of depression in Primary Care The guidance which had been updated in light of comments received at the previous meeting was accepted by the Committee. Sarah Hudson confirmed that she had compared the SWYFT guidance against the drugs on the Barnsley antidepressant formulary and a few differences were noted. Dosulepin was still included on the Barnsley formulary but was no longer recommended. Imipramine which had been included as a second line option for severe depression in the SWYFT guidance was in the Barnsley formulary for enuresis but not depression and paroxetine was included in the Barnsley formulary but was not recommended for the treatment of depression in the SWYFT guideline. Following a query Sarah Hudson confirmed that whilst
paroxetine would no longer be initiated for depression in new patients, there was no need to switch treatment in patients currently stabilised on this. It was agreed that agomelatine, phenelzine and mianserin would remain non formulary and would be available on consultant request. Gillian Smith agreed to update the formulary with the above information. It was agreed that the dosulepin entry would be updated with the advice that it should no longer be initiated in new patients. 13/14 New Product Applications The updated new product application log was noted. Gillian Smith confirmed that she was awaiting feedback from the consultants on the dry eye guidelines and confirmed that this would be brought to the March meeting. 14.1 Consillient Health Oral Contraceptives Caron Applebee presented the new product application and supporting information. It was noted that the preparations were equivalent to existing contraceptive brands but cost approximately 30% less. Sarah Hudson confirmed that these brands were currently being used within the SH team. It was agreed that Rigevidon, Gedarel 30/150, Gedarel 20/150, Millinette 30/75, Millinette 20/75 and Cerelle would be added to the formulary with a green classification. / 14.2 Perampanel Gillian Smith presented the new product application and supporting evidence and confirmed that she would bring the signed application to the next meeting. Following a discussion of the evidence and place in therapy it was agreed that perampanel would be approved with a red classification. Gillian Smith agreed to feed this back to Dr Grunewald and informed the Committee that she was intending to produce an algorithm outlining the place in therapy of this and other anticonvulsants used for refractory epilepsy. 13/15 Shared Care Guidelines 15.1 Quetiapine shared care guideline Sarah Hudson presented the updated shared care guideline. It was agreed that a section to confirm whether the GP accepted or rejected the shared care agreement would be added to the proforma. The shared care guideline was approved by the Committee subject to ratification by the LMC.
Sarah Hudson confirmed that SWYFT were advising prescribers to use standard release quetiapine in new patients and reserving the XL preparation for patients currently stabilised on it. Dr Maters queried whether patients could be switched to the standard release preparation when doses were increased. Sarah Hudson agreed to clarify this with the consultants. SH 15.2 Risperidone shared care guideline The shared care guideline was approved by the Committee subject to ratification by the LMC. It was agreed that a section to confirm whether the GP accepted or rejected the shared care agreement would be added to the form. 13/16 Primary Care Antimicrobial prescribing guidelines Caron Applebee presented the updated guidance to the Committee which included guidance on urinary tract infections produced by Dr Pang. The Committee approved the updated guidance and it was agreed that this would be taken to the next LMC meeting. 13/17 Newer oral anticoagulant guidance (NORCOM) It was noted that the Clinical Advisory Group had confirmed that clinicians could exercise their clinical judgement when prescribing the newer oral anticoagulants and prescribe dabigatran if considered clinically appropriate. 13/18 Feedback on opioid prescribing audit at BHNFT Gillian Smith informed the Committee that the percentage of fentanyl and buprenorphine patches from all strong opioids prescribed in the acute trust was 25% and 35% respectively. Gillian Smith confirmed that work was ongoing in this area of prescribing within BHNFT as part of the Transformation Programme. This will include the production of guidance on the prescribing of strong opioids and the promotion of oral morphine (Zomorph ) as the first line strong opioid of choice. 13/19 Feedback on diclofenac audit at BHNFT Gillian Smith confirmed that diclofenac use within BHNFT had reduced by 15% since the NSAID guidance had been circulated. Orthopaedics were still prescribing significant quantities of diclofenac and Gynaecology was highlighted as another area where diclofenac was still used. Gillian Smith agreed to approach both of these clinical areas and escalate to the Medical Director if necessary.
13/20 NICE guidance summary December 2012 and January 2013 Deborah Cooke reminded the Committee that all organisations were required to include all drugs which had received a positive NICE Technology Appraisal in local formularies by the 1st April 2013, if the drug was clinically appropriate and relevant to the services provided by the organisation. The summary of NICE guidance produced in December and January was considered by the Committee. Mike Smith informed the Committee that the BHNFT Clinical and Guidelines and Policy Group currently considered all new NICE TAs and agreed to share this information with the APC in future meetings. It was agreed that Sarah Hudson would be asked about the process for considering new NICE TAs within SWYFT and if this information could also be brought to the Committee. It was noted that NICE advised that new NICE TAs were included as a standing agenda item on formulary decision making groups. The Committee agreed that NICE TAs and feedback from the relevant groups would be included as a standing agenda item in future meetings. MS DC/SH DC 13/21 FEEDBACK FROM THE MEDICINES MANAGEMENT GROUPS ACTIONS TO DATE IN ADDITION TO PLANNED FUTURE ACTIONS:- Quality & Cost Effective Prescribing Group NHS Barnsley The Group were due to meet later this month. Medicines Management Committee BHNFT No actions to report Drug and Therapeutics Committee SYWPFT (considered after item 13/16.2) The contents of the newsletter were noted. Tom Bisset fed back on an issue he had encountered when prescriptions had been left in patients homes by the Memory Team and the relative/carer had not been informed which had resulted in a delay in the prescription(s) reaching the pharmacy. In response to a query, Sarah Hudson confirmed that aripiprazole should not be used first line but should be reserved for patients who were unable to tolerate other antipsychotics.
13/22 BarnsleyAPCreport@nhs.net feedback A MHS consultant had informed the Committee that a small number of practices were not accepting shared care requests for ADHD drugs. Deborah Cooke confirmed that the Medicines Management Team were in the process of following up with the practices involved. 13/23 MHRA DRUG SAFETY UPDATE JANUARY 2013 The Drug Safety Update was noted for information. 13/24 NEW PRODUCT BULLETIN JANUARY AND FEBRUARY 2013 The bulletin for January and February 2013 was received and noted. Members considered the items and awarded a provisional traffic light status subject to a new product application as follows:- New Formulations Saxagliptin plus metformin 2.5/850mg and 2.5/1000mg (Komboglyze ) provisional grey Estradiol 1.5mg plus Nomegestrol 2.5mg (Zoely ) provisional grey The SPC change for Fostair was noted and it was suggested that its position on the formulary should be reviewed in the near future. 13/25 SOUTH YORKSHIRE APC MINUTES Doncaster and Bassetlaw APC - November 2012 The minutes from Doncaster and Bassetlaw APC for the September meeting were noted for information. 13/26 ANY OTHER BUSINESS 26.1 Neurologists prescribing Alzheimer s Drugs Dr Ghani referred to a request from the Neurologists to prescribe Alzheimer s Drugs without a shared care agreement being in place and before patients had been referred to the Memory Service. It was agreed that the prescribing should remain with the initiating specialist until the patient had been reviewed by the Memory Team. Gillian Smith agreed to feed this back. 26.2 Declarations of interest Dr Ghani explained that Committee members would need to start signing a declaration of interest form and it was agreed that this would be included as a standing agenda item from April. DC Date and Time of Next Meeting Wednesday 13 th Hillder House. March 2013 at 12.15 pm, Boardroom left,