GREAT WESTERN HOSPITALS NHS FOUNDATION TRUST

The 3T s Formulary Swindon CCG Wiltshire CCG Great Western Hospitals NHS Foundation Trust (In collaboration with Avon and Wiltshire Mental Health Partnership and Oxford Health NHS Foundation Trust Formulary Working Group 20 th February 2014 1400 1555 Seminar Room 5, The Academy, GWH Attendees: Paul Clarke (PC) (Chair) Pharmaceutical Advisor, Swindon CCG Lisa King () Formulary Pharmacist, GWHNHSFT Katherine Watkinson () (mins) Formulary Pharmacy Technician, GWHNHSFT Dr Peter Mack (PM) GP representative, Swindon CCG (from 1415) Dr Tony Wright (TW) GP representative, Wiltshire CCG Commissioning Support Unit Gill Wicks (GW) Tissue Viability Nurse, GWHNHSFT Nadine Fox (NF) Pharmacist, Wiltshire CCG Dr Simon Manchip (SM) Consultant Psychiatrist, Avon & Wiltshire Mental Health Partnership (from 1400 1515) Dr Nirmalan Arulanantham (NA) Locum Consultant, GWHNHSFT (from 1415) Apologies: Dr Ravi Chinthapalli (RC) Dr Rachel Hobson (RH) Bethan Shepherd (BS) Consultant Paediatrician & Chair, GWHNHSFT Formulary Pharmacist, Wiltshire CCG Formulary Pharmacist, Avon & Wiltshire Mental Health Partnership Agend a Item Description Action by whom Action by when 1 2 3 APOLOGIES MINUTES OF LAST MEETING The minutes of the January meeting were agreed. MATTERS ARISING Formulary Extranet The extranet is now live and no problems have been reported. Information on how to use the new site has been sent out to prescribers. The old site is running concurrently whilst Script Switch messages are updated. Infection Chapter The first draft of the infections chapter is being developed and will be presented to FWG as soon as complete. Dabigatran and Apixaban in cardioversion FWG awaiting formal New Drug Request. RH is in the process of developing a pathway. NICE TAs Ranibizumab, Fluocinolone, Aflibercept All of these NICE TA drugs have been added to formulary. Discussions between CCGs, commissioners and TPC are ongoing as complete service redesign is required. to liaise with CD to confirm any action required by FWG. RH 17.04.14 Page 1 of 8

Sodium Fluoride 1.1% Toothpaste FWG await a formal application. Generic Fentanyl and Oxycodone RH has updated Wilts Pain Guidance to include information on Longtec and Shortec. PC to open discussions with Prospect Hospice. Red Drug prescribing in primary care Comments have been made by and RH and sent to KB. KB to feedback at future FWG meeting. PC KB 4 CHAPTER/SECTION UPDATES 4i Endocrine Chapter The final draft of the chapter was approved. The following points were clarified and will be reflected in the final version: Insulin Degludec will not be added to formulary until further discussion with diabetes team have taken place; RC to meet with diabetes team and feedback decision made at December FWG meeting; RC to communicate outcome of meeting with diabetes team at next FWG meeting. GlucoRx needles it will not be possible for GWH to routinely hold these for Ward Stock. FWG have not been able to contact any other unit which has successfully switched to GlucoRx needles. It was agreed to add GlucoRx needles to formulary as a 1 st line option, with BD microfine needles to remain on formulary as a 2 nd line option. TLS of repaglinide agreed as Amber. Metformin rewording of entry agreed Linagliptin will not be added to formulary as part of the chapter review Alogliptin will be discussed separately from the chapter review The entries for dapagliflozin were agreed subject to additional information regarding use in patients with thrush and UTI being added as per NICE Lixisenatide will be added to formulary as Amber with additional information regarding use in patients with renal impairment Progesterone pessaries will be added as a red drug for prevention of recurrent miscarriage, a formal New Drug Request will be required for use in post natal depression Ocreotide and lanreotide entries will be updated to reflect commissioning arrangements and NICE guidance for acromegaly, use in carcinoid tumours is through specialist commissioning and other indications are through CCGs. Amended entries for growth hormone were agreed Desmopression Nasal Spray will be added to formulary as an Amber drug as per NICE The entry for Blood Glucose Meters will be published as per the draft. Wiltshire CCG are currently reviewing Blood Glucose Meters and the Home Blood Glucose Monitor guidance is being updated by the GWH diabetes team; once these reviews are RC ASAP Page 2 of 8

complete the entry may require further reworking Oral liothyronine will remain listed on formulary as an Red drug, in view of the high cost of unlicensed tablets. Wiltshire CCG are developing HRT guidance which will be presented at a future FWG meeting once finalised. to update e-formulary, GWH e-prescribing and produce summary of changes for prescribers. 5 5i 6 6i NEW DRUG UPDATE The New Drug Update report for February 2014 was discussed and actions suggested. will update the New Drug database. 28.02.14 NEW DRUG REQUESTS Adcal D3 Caplets Dr David Collins The application for use of Adcal D3 Caplets in patients who cannot tolerate chewable tablets was tabled. It was noted that there are currently a group of patients who are non-compliant due to the chewable formulation. It was agreed to add Adcal D3 Caplets for the group of patients detailed in the request. to update e-formulary. 7 8 8i 8ii 9 9.1 NEW EVIDENCE SUMMARY A report detailing new national guidelines and evidence published since the January meeting was discussed and actions suggested. will update the database accordingly. NICE NICE TAs There were no TAs for discussion this month. NICE CGs Secondary Prevention of MI circulated the updated guidance ahead of the meeting. The GWH cardiologists are happy with the revised guidance. The main changes are for use in STEMI without PCI, with treatment duration increasing from 28 days to up to 1 year; it was noted that this was a small patient group. Clarification from UBT is required on treatment for secondary prevention after coronary artery bypass graft. FWG to approve the guidance outside of the meeting following clarification from UBT. MHRA Drug Safety Updates/Letters to professionals Antiepileptic Drugs FWG await an update from the FWG neurologists. The CCGs are keen to begin generic switches where appropriate and will commence this in accordance with the MHRA guidance. Formal guidance will be added to the formulary once agreed by the neurologists. 28.01.14 FWG Page 3 of 8

9.2 Prasugrel to add link to formulary. to ensure cardiologist are aware of safety alert. 9.3 Temozolomide to forward to cancer services pharmacist. 9.4 Capecitabine to forward to cancer services pharmacist. 9.5 Ofatumumab to forward to cancer services pharmacist. 9.6 Mecaserim to forward to cancer services pharmacist. 9.7 Combined Hormonal Contraceptives to add links to formulary. All prescribers to be reminded to prescribe combined oral contraceptives by brand. 9.8 Cosopt Preservative Free Eye Drops No action required; drug recall has been implemented. 9.9 Abraxane to forward to cancer services pharmacist. 9.10 Cetuximab to forward to cancer services pharmacist. 10 Methylphenidate SCA A final version of the SCA which includes Medikinet MR has been approved at BNSSG. Final version to be brought to FWG for final approval. BS 11 Wound Care Formulary (Gill Wicks attended for this item) GW summarised the key changes to the Wound Care Formulary and explained the rationale behind the changes. NF highlighted that there is a high volume of repeat prescribing of silver dressings and will share this data with GW. GW to provide targeted training for nursing staff in primary care. Currently the Wound Care Formulary only covers Wiltshire however it was agreed that it could be used in Swindon in the interim until the tissue viability service is established. The Wound Care Formulary was approved, to update e- formulary. NF ASAP 25.02.14 12 Acamprosate SCA The draft SCA has been developed by Turning Point, an organisation which provides substance misuse services in Wiltshire. Some of the wording in the SCA needs amendment as the current standard wording is not applicable. NF raised concerns that as the service develops GPs may be expected to prescribe nalmefene but do not have capacity for this. to comment on SCA and feedback to Turning Point. Swindon CCG have commissioned a new substance Page 4 of 8

misuse service and will share the completed SCA. 13. AOB 13.1 Drug Tariff and contract changes None to discuss 13.2 Fidaxomicin TLS It was agreed to switch to Amber on the advice of microbiology/c.difficile team only. The sector which iniitates treatment will need to prescribe the complete course. to update formulary 13.3 Generic Sildenafil post radical prostatectomy The urologists have provisionally agreed to use generic sildenafil instead of tadalafil twice weekly for post radical prostatectomy. Tadalafil was added to formulary for use twice weekly post radical prostatectomy subject to completion of an audit; no audit data has been presented to FWG. National consultation is ongoing and it was agreed that as no audit data has been submitted tadalafil for post radical prostatectomy will be removed from formulary and sildenafil will not be added for this indication as this time. to update e- formulary. /RC to feedback to urologists. /RC 13.4 Sodium cromoglicate nasal spray Vividrin 2% nasal spray had been added to formulary as part of the ENT chapter review but this has now been discontinued. It was agreed to add Rynacrom 4% nasal spray back to formulary as an alternative. 13.5 Polytar There is an ongoing supply problem with Polytar. The psoriasis association have issued guidance on alternative treatments during this shortage and the majority of suggested treatments are available on formulary. Dr Whittam has requested addition of psoriderm to formulary as option when other choices have failed. NF to share Salisbury guidance for discussion outside of the meeting. NF 13.6 Strontium National discussions on the withdrawal of strontium are ongoing. SFT are developing guidance in consultation with the rheumatologists. FWG to review guidance once finalised. FWG 13.7 Valsartan There are ongoing supply problems with valsartan. to discuss with cardiologists and feedback to FWG. 13.8 Formulary Pharmacy Technician will step down from her current post in mid-march. will require additional support in producing FWG minutes until a new technician is in post. All 13.9 Generic Yasmin Page 5 of 8

A generic formulation of Yasmin is now available. to discuss with Family Planning and update formulary if no objections to switch. Meeting closed 1555 Future Meetings: Next FWG Meeting: 2pm 20 th March 2014 Seminar Room 5, The Academy, GWH 17 th April 2014 Cherwell Education Room 2 5pm 15 th May 2014 Seminar Room 5, The Academy, GWH 2 5pm 19 th June 2014 Seminar Room 7, The Academy, GWH 2 5pm 17 th July 2014 Seminar Room 5, The Academy, GWH 2 5pm 21 st August 2014 Seminar Room 5, The Academy, GWH 2 5pm 18 th September 2014 Seminar Room 5, The Academy, GWH 2 5pm 16 th October 2014 Seminar Room 5, The Academy, GWH 2 5pm 20 th November 2014 Seminar Room 7, The Academy, GWH 2 5pm 18 th December 2014 Seminar Room 5, The Academy, GWH 2 5pm Agreed as an Accurate Record: Chair: Dated: Page 6 of 8

Trust as part of compliance with the Freedom of Information Act. NEW/OUTSTANDING ACTIONS Meeting Date Subject Action Required Action By 18.07.2013 Zoledronic Acid Produce costing paper Assess impact on local care pathways and confirm GWH capacity issues 16.01.14 RH/NF All Comments 16.01.14 Guidance to be updated following withdrawal of strontium licence Page 7 of 8 Date for Status completion 19.09.13 18.07.2013 Temazepam Produce switching document SM/TT 19.09.13 21.11.13 MHRA AED / 19.12.13 guidance Work with Neurologists to update formulary entry in light of MHRA update. Perampenel New Drug request RC Neurologists developing draft formulary section following initial meeting 20.01.14 21.11.13 Acne Guidance Finalise document and circulate for RH 19.12.13 approval outside of the meeting ALL 19.12.13 Infection Chapter Produce 1 st draft of new style chapter / 16.01.14 19.12.13 ITP Pathway Send comments to RH 16.01.14 19.12.13 Secondary Prevention of MI 16.01.14 COMPLETE 16.01.14 NOACs in patients awaiting electrical cardioversion 16.01.14 Sodium Fluoride 1.1% Toothpaste 16.01.14 Generic fentanyl and oxycodone 20.02.14 Endocrine Chapter 20.02.14 Methylphenidate SCA NICE CG and amendment 3Ts guidance where necessary Produce draft statement on use of Omacor Request New Drug Request Source and Basingstoke Guidance. RH RC/PF 16.01.14 20.02.14 RH/ 20.02.14 Request New Drug Request 20.02.14 Check contract lines and cost implications for primary care Meet Prospect hospice team Produce oxycodone guidance Feedback to diabetes team Update formulary Bring final version to FWG for approval / 20.02.14 COMPLETE FWG RH/KB Feb 14 20.02.14 RC BS

Trust as part of compliance with the Freedom of Information Act. 20.02.14 Acamprosate SCA Feedback comments to Turning Point 20.02.14 Generic Sildenafil Feedback to consultants /RC 20.02.14 Polytar Circulate documents for discussion NF 20.02.14 Valsartan Discuss with cardiologists 20.02.14 Generic Yasmin Discuss with Family Planning COMPLETE ACTIONS Meeting Date Subject Action Required Action Comments Date for Status By completion 19.12.13 Eye Chapter Make final amendments and publish 10.01.14 COMPLETE updated chapter 19.12.13 ENT Chapter Publish updated chapter 10.01.14 COMPLETE 19.12.13 Neuropathic Pain Make amendments and circulate for 16.01.14 COMPLETE guidance approval 19.12.13 Extranet Send out links once live / ASAP COMPLETE 19.12.13 Endocrine Chapter Produce final draft and circulate to FWG 16.01.14 COMPLETE and endocrine team 19.12.13 Methylphenidate and comment on SCA All 16.01.14 COMPLETE SCA 16.01.14 Red Drug Prescribing in primary care list and identify actions KB/RH/ 20.02.14 COMPLETE 19.12.13 TA298, TA301, TA294 Add to formulary with links Produce pathways PC/NF 16.01.14 ASAP COMPLETE AWAIT TPC Page 8 of 8