POWYS TEACHING HEALTH BOARD Meeting 04/12/12 Present: PRIMARY CARE PRESCRIBING AND THERAPEUTICS COMMITTEE Minutes of the meeting held on Thursday, 06 September 2012 at 09.30am in Training Room 1, Bronllys Hospital In Attendance: Item Note Action 1 Welcome and Apologies welcomed all those present and members introduced themselves. Apologies were received from Dr Brendan Lloyd, Medical Director, Powys thb; Page 1 of 8
2 (a) Minutes of the PDC&TC Committee meeting held on 03 May 2012 The minutes of the meeting held on 03 May 2012 were AGREED as a correct record. (b) Minutes of the P&T Strategic Committee meeting held on 03 May 2012 The minutes of the meeting held on 03 May 2012 were AGREED as a correct record. 3 (a) Matters arising from the minutes of the meeting of PCD&TC Committee held on 03 May 2012 ARBs would be discussed at the next meeting. informed those present that would eventually be taking charge of all prescribing of products available on the continence formulary. There were no other matters arising. (b) Matters arising from the minutes of the meeting of P&T Strategic Committed held on 03 May 2012 reported that the Methotrexate documentation would be presented to the next Clinical Effectiveness Committee meeting, for approval. There were no other matters arising. 4 Shared Care: (a) Methylphenidate had been in discussion with, Clinical Director, Women & Children s Services, for more shared care arrangements with Primary Care, beginning with methylphenidate. In discussions with some consultants from the adult CMHTs it was agreed that a children, adolescents and adults shared care protocol be developed for methylphenidate. This had highlighted issues around the current provision of ADHD Adult Services within Powys, which were discussed and considered to be in need of addressing. suggested that the protocols could be split into children and adults. However, GPs expressed concerns that this could raise issues around the transition of care from children to adult services and there was the potential for Primary Care to carry the responsibility for patient care they were not competent in. informed the group that the adult CMHT consultant had expressed the same concerns. Of particular concern were patients first diagnosed in adulthood, newly accessing services. Page 2 of 8
There was a need to stress in any shared care protocol for parents to agree to attend clinics with their child so that doctors do not have to prescribe for a child that does not attend fixed appointments. In principle the contents of the shared care protocol were AGREED. However, members did not feel comfortable using the protocol whilst there was still no official adult ADHD service(s) in place. It was proposed that the protocol should not be adopted until these were matters were resolved and the issues had been brought to the attention of Brendan Lloyd and Powys Manager for Mental Health. (b) Melatonin Guidelines indicated that there were the same issues highlighted as with the Methylphenidate. was going to meet with Ingrid Prosser to discuss matters and would inform members of the outcome of that discussion at the next meeting in December. 5 Regular Updates a) AOF/AQF gave a powerpoint presentation. highlighted that Powys use of statins, which included atorvastatin, was still slightly below target as a Health Board, but was moving in the right direction. Powys was on target with use of dosulepin, however there was some increase in the south. With regard to hypnotics & anxiolytics, numbers were slightly above target, but again, were moving in the right direction. NSAIDs are a challenge for Powys, partly due to the age of the population. Ibuprofen and naproxen usage was moving towards targets. indicated that it was unfortunate that A&E departments were sending patients out with supplies of these medicines. indicated that it was noted that this situation was difficult to change but positive action was already being taken with a view to improvements. Antibacterial usage was rising. This was happening over Wales as a whole. Cephalosporins there were variations in usage across Powys and slightly above targets. The biggest changes were happening in the south locality. Quinoline usage was above target. Co-Amoxiclav all practices were above target, but a downward trend was indicated. b) ScriptSwitch reported that the system was working well on the whole. He thanked those present for their feedback on the messages and asked for continued input. c) Community Pharmacy Update indicated that training on flu vaccinations would be taking place Page 3 of 8
in September and that training should be finished by October. emphasised that this was not designed to replace the service that practices provide, but was designed to act as a safety net. also highlighted the Stroke and Diabetes Campaign. informed members that over the last couple of years, the Waste Reduction Scheme had saved the sum of 9,000. d) Q&E Scheme indicated that there was little to report at present. emphasised that constructive feedback from practices, good or bad, was most welcome. e) Adverse Reactions/Significant Events reported a warfarin related incident that was under investigation. It had brought up many issues. indicated that a patient had been to many nursing homes and each time, there had not been a full case history available and this had resulted in the incident. Social Services were also involved. There were no other adverse incidents reported. f) Horizon Scanning and Drug Safety highlighted interactions with regard to simvastatin usage, which members discussed. will update members at the next meeting. also advised on the use of dabigatran, domperidone and strontium. g) NICE Updates enquired whether anyone knew of any instances where carers refused to administer medication to patients. There were none reported. reported that Marie Curie employees were calling ambulances in instances where the DNAR forms were not physically in patient s homes, even though matters had been discussed with the patient and family. There were no other regular updates. 6 Formulary a) Dabigatran & Rivaroxaban had attended a meeting and concern had been expressed that little was known about these agents, given that there is no antidote. The situation had been debated at the meeting, the outcomes of which were: Warfarin would remain the first line agent for anticoagulation in AF. Proposal that initiation of new oral anticoagulants is undertaken by level 3 or 4 anticoagulant NES practices for patients switching from warfarin and by secondary care for new AF patients. This was felt to be unworkable for Powys and there was an overall feel that this restriction was Page 4 of 8
another barrier to change. The term secondary care clinician specialising in stroke prevention in AF was felt to be too rigid and could even preclude from initiating. CHADS 2 is no longer evidence based and so should be taken out and the document should refer to CHA 2 DS 2 VASc only. Many practices do not measure TTR so this would be difficult to use when deciding to switch from warfarin. There was concern that using recurrent INR variation as an indicator for a reason to switch could actually indicate a compliance problem. b) Denosumab enquired whether those present had encountered any problems with Denosumab there were none. c) Prasugrel, Ticagrelor and Clopidogrel had contacted, Consultant Cardiologist. had indicated that the guidance was to change soon. d) Prescribing of Vitamin D presented a letter from the CMO regarding Vitamin D advice on supplements for at risk groups, which members NOTED. raised the issue of poor compliance associated with commonly prescribed calcium and vitamin D preparations. It was explained that a nonchewable tablet formulation was now available which may be an option for a significant proportion of patients. It was AGREED that a non-chewable formulation would be a useful consideration and agreed to liaise with the manufacturer and attempt to gain an assurance of ongoing cost effectiveness. Healthy Start Vitamins - had prepared a paper for the meeting regarding Healthy Start Vitamins in particular. went though her paper. Healthy Start Vitamins are difficult to acquire as they have to be ordered from WHS. Discussions took place with regard to who were best to receive the supplements. indicated that Cardiff was doing a pilot with regard to Healthy Start Vitamins. suggested that this was an important subject and ought to be well publicised. would contact PAVO to ascertain what they knew. It was felt that this was a public health issue, not a primary care one; it needs to be led by public health as it is a prevention scheme and would put undue pressure on GP surgeries. indicated that public health were already involved and stressed that it was a Welsh Government Page 5 of 8
initiative. e) Herpes Zoster Vaccine indicated that the pharmaceutical companies were actively pushing the use of this product. However, Public Health Wales were not recommending routine vaccination at the moment and are awaiting guidance from JCVI regarding a national programme. asked if it could be prescribed for older patients. indicated that advice does allow for that, but suggests that it has limited availability. f) Strontium new licence update has asked to inform the meeting that this was now available for men. g) Fluenz Supplies are likely to be limited. It will possibly be included in 2014/15 campaign for children up to the age of 17. This is a live vaccine and is an intra-nasal preparation. h) Diabetes Formulary indicated that the document is in draft at present. He asked for comments on how the document reflects what is being done in practice, to make sure that the contents are current and relevant. It was AGREED that members would email with any comments. i) Resperate indicated that this could be bought in various places (including a book to go with it), which included Amazon. j) New formulary website gave a presentation showing members how the new website would look. indicated that the website set-up would be the same for the whole of Wales. indicated that it was part of the new NWIS development and will also provide the basis for the electronic discharge system. It will also be part of an electronic prescribing system. indicated that the new formulary website followed the BNF tree and will be available on the intranet. It will show the traffic light colours for 1 st, 2 nd line drugs, etc. There will be hyperlinks to NICE guidance and also have external links, which will include the BNF. suggested that leaflets and guidelines could be added to the pages. However, this will take some time to develop. It was AGREED that will send the link to the site to members, bearing in mind it is still very much a work in progress. 7 Long Acting Insulin Analogues had worked with the Diabetic Specialist Nurses (DSNs) and also Consultants on this and had drafted an example of a pathway. This will develop into a threestep pathway. The system is intended for use in practices and DSNs will be facilitating training at the Page 6 of 8
end of this year, into the beginning of next year. It was AGREED that members will email with any comments. 8 Orlistat Powys Wide Audit had prepared a power-point presentation showing the results of the audit and thanked for all the help had given in devising the audit. 10 practices (132 patients) had taken part in the audit. From this audit an Action Plan had been devised for practices: Initiation of Orlistat as an acute prescription for the first 3 months to ensure patient attends for weight monitoring Patients who have not been weighed at appropriate time intervals to be called in for weight measurement Patients with no/minimal weight loss to be recalled for a medication review with GP Patients taking Orlistat for longer than 12 months to be called in for a review of treatment with GP Patients taking both levothyroxine and Orlistat to have instructions amended on both medicines reminding patients to leave a 4 hour gap between each medicine informed those present that we need to be aware that a new weight loss drug from America will soon be on the market. The next audit will be looking at long-term prescribing of corticosteroids. 9 Sip Feeds audit and proposed way forward gave a power-point presentation indicating the audit results she had received back from five practices. had also sent out surveys the community pharmacies and GPs. The survey had shown that GPs and pharmacies felt ineffective with regard to the use of sip feeds. informed those present that the HB was looking at several options, including employing a medicines management dietitian and formulating a formulary, having a devolved approach, devising a top up scheme for care homes, availability of information and educational resources. GPs felt that this should be dealt with by experienced, specialised people, that patients could be referred to, i.e. specialised community nurses or other appropriate health professionals. This would all need careful management and needs the appropriate financial input. The locality teams need to be aware of the problems, also. Full audit results will be presented to the next meeting. Page 7 of 8
10 Traffic Light Guidelines Update indicated that the guidelines were constantly updated and was now on version 5. This system would be on the new formulary and also on ScriptSwitch. was now able to input more detail into the system. There was a need to close the gap regarding communication between secondary/tertiary care. would welcome comments on this. 11 European Antibiotic Awareness Day This takes place every year on November 18 th, which is a Sunday this year. asked for ideas on communicating the purpose of this day to patients. 12 Gluten Free Prescribing This was deferred to the next meeting. 13 Medicines Incidents had prepared a report for the meeting, the contents of which she addressed to the meeting. highlighted issues regarding the Administration Chart, which would report to the All Wales Chief Pharmacists meeting. 14 Policies and Procedures to Note The HPV (Gardasil) PGD and the MIU Paracetamol PGD were NOTED. 15 Any Other Business Members discussed the issue of headlice. Members felt that by going into surgeries to get a prescription for headlice medication, it was perpetuating the spread. It was felt that medication could, and should, be bought from the community pharmacies. Members also agreed that they should not be prescribing headlice medication just in case. felt that meeting papers should be sent out earlier. indicated that it was a one-off situation that papers had been sent out late for this particular meeting, but would be sent out in a timely manner in future. There was no other business to transact. 16 Date and time of next meeting Members discussed the day and date for the next meeting. It was felt that Thursday was not a good day. Members preferred either a Wednesday or a Tuesday. It was AGREED that the next meeting date should be moved from Thursday 6 th December to Tuesday 4 th December. will arrange a venue and let members know when this has been done. Post Meeting Note: The next joint meeting will be held at 9:30am on Tuesday 4 th December 2012 in Caer Beris Manor Hotel, Builth Wells. Page 8 of 8