COVENTRY & WARWICKSHIRE AREA PRESCRIBING COMMITTEE MINUTES OF THE COVENTRY AND WARWICKSHIRE AREA PRESCRIBING COMMITTEE HELD ON FRIDAY 16 TH MARCH 2018 AT 12.30 PM IN THE CLINICAL SCIENCES BUILDING (CSB) AT UHC&W NHS TRUST PRESENT: - Richard Lambert South Warwickshire GP (RL) Vice-chair Altaz Dhanani Coventry & Rugby CCG (AD) - APC Secretary Joe Booker Coventry LMC (JB) Jane Smith Coventry GP (JS) Helen Edwards Arden & GEM CSU representing South Warwickshire CCG (HE) Amin Mitha Arden & GEM CSU representing Warwickshire North CCG (AM) Kim Panting South Warwickshire GP (KP) Caroline Coupe South Warwickshire NHS Trust (CC) Sumara Parvez South Warwickshire NHS Trust (SP) Jennie Knight - Coventry & Warwickshire Partnership Trust (JK) Ashwin Hindocha Coventry LPC (Ahi) Cath Sansby - University Hospitals Coventry & Warwickshire NHS Trust (CS) Debra Armstrong George Eliot Hospital NHS Trust (DA) Paul Mills George Eliot Hospital NHS Trust (PM) Winston Crasto (deputy) George Eliot Hospital NHS Trust (WC) David Tait Coventry & Warwickshire Partnership Trust (DT) Priti Ved Coventry & Warwickshire Partnership Trust (PV) Ian Bayman Lay Member (IB) IN ATTENDANCE: Anita Hunjan (AH), Susan Dhesi (SD) Zoulikha Zair - UHCW FY1 doctor observing 1. APOLOGIES Simon Fletcher (Chair), Bernhard Usselmann, Loay David, Sukhi Dhesi, Jo Brader, Claire Keane, Satyan Kotecha, Mark Easter RL chaired today s meeting. AD introduced 5 new committee representatives; Jennie Knight (JK) from CWPT Community Nursing Amin Mitha (AM) and Helen Edwards (HE) both from Arden GEM CSU Debra Armstrong (DE) from George Eliot Hospital (GEH) in attendance with PM at his last meeting. 1
Also, Zoulika Zair foundation junior doctor from University Hospital Coventry and Warwickshire NHS Trust (UHCW) - who is observing today s meeting but will be attending as a non-voting member. A round table introduction followed on. 2. MINUTES OF THE LAST MEETING The minutes of the last meeting held 19 th January 2018 were agreed as accurate and to be published onto the website accordingly. 2.2 Action log RL went through some of the outstanding and in progress actions. Section 2 Decisions 2A Chase Harpal Randeva regarding draft PCSK9i Pathway AD 3. MATTERS ARISING DT updated the committee that the Substance Misuse in Acute Settings guidance was circulated last week by Public Health England to all Coventry and Warwickshire Hospital Trusts Medical Directors and Chief Executives requesting feedback. 4. APC Development There were no items to discuss. 5. Drug Positioning Statements 5.1 - Trelegy Ellipta A DPS for maintenance treatment in adult patients with moderate to severe chronic obstructive pulmonary disease (COPD) and a formulary inclusion application from a Respiratory Consultant at GEH were brought to the committee for consideration; 5.1.1 - AH summarised the contents of the draft DPS, a second triple combination therapy Ellipta device. The price is similar to the Trimbow device, the license is based on the FULFIL 24 weeks trial which showed improvement in lung function and quality of life. There are limitations in relation to different devices and inhalers 5.1.2 - IB pointed out several grammatical errors in the drug profile, clinical effectiveness and interactions paragraphs 5.1.3 - WC asked about the position of Trelegy, he thought that it should be classified as Specialist Initiation (SI) or Specialist Advised (SA). AH stated that it would be placed as triple therapy under ICS + LABA+LAMA and will follow on from the LABA + LAMA Ellipta device 5.1.4 - A brief discussion took place on the therapeutic options for combination and triple devices 2
The committee agreed that the DPS verdict status should read for use in primary care, similar statement to the Trimbow DPS. 5.2 - Trelegy Ellipta application - This item was discussed as above, to advise the specialist of the application outcome. 5.3 - Glycopyrronium A DPS and a revised Shared Care Agreement (SCA) for treatment of severe sialorrhoea (chronic pathological drooling) in children and adolescents were brought to the committee for reconsideration; 5.3.1 - PV briefly summarised the changes to both documents that were in line with the licensed indication 5.3.2 - IB noted some inconsistency in distinguishing between glycopyrronium and glycopyrronium bromide in both documents 5.3.3 - RL asked for the clarification of the age range for adolescents, PV confirmed The committee agreed to amend the DPS and SCA with the committee s comments and republish both documents. The two DPSs would be reformatted into the correct template before publication. Section 5 Decisions 5A Write Trelegy DPS verdict & send out for virtual ratification, amend/ format document & publish AD/AH/Members/SD 5B Write to GEH specialist regarding Trelegy formulary application outcome AD 5C Amend Glycopyrroninum DPS & send final revised document to APC office, then republish on both websites PV/SD 6. Specialist Drugs/netFormulary 6.1 - NetFormulary Amendments Seven proposed amendments from UHCW were brought to the committee for consideration; 6.1.1 - CS highlighted the following to the committee: TB medications - prophylaxic use for renal transplant patients from Black, Asian ethnicity or previous TB exposure. JB thought that it should be classified as SI rather than SA, the committee agreed to this change Enstilar & Dovobet - licensed for 4 weeks treatment and currently not on the netformulary website. JB commented that Dovobet is already prescribed in primary care, the committee felt it was more appropriate to be classified as preferred option rather than SA Lamivudine for Hepatitis B infection - at present this drug is infrequently used and 3
classified as Shared Care (SC) but has no SCA. RL thought lamivudine had special monitoring, the committee agreed for the classification to remain as SC Interferon alpha for Hepatitis B infection - at present is classified as SC but has no SCA, recommendation to change to Specialist Only (SO) Omeprazole Dispersible tablets MUPS is not on netformulary; suggest it be classified as Non Formulary (NF) with added notes about use in neonates The committee agreed for these proposals to be included or changed on the netformulary. 6.2 - NetFormulary Amendments - Ten proposed unlicensed End of Life drugs from UHCW were brought to the committee for consideration; 6.2.1 - This item was discussed along with item 7.1 The committee agreed for these proposals to be included on the netformulary. 6.3 - NetFormulary Amendments Two proposed drugs from ArdenGEM CSU were brought to the committee for consideration; 6.3.1 - AD highlighted that Ezetimibe and Varenicline have NICE TAs but are not classified on the netformulary The committee agreed for these proposals to be included on the netformulary and to amend and republish the Lipid Modification guidance. 6.4 - NetFormulary Amendments A number of proposed high cost drugs from ArdenGEM CSU were brought to the committee for consideration; 6.4.1 - AD highlighted that most of these drugs were recommended as SO except for Irinotecan for pancreatic and metastatic colorectal cancers, Vismodegib, Lesinurad that are not recommended by NICE The committee agreed for these proposals to be included on the netformulary. 6.5 - NetFormulary Amendment - One proposed amendment from Coventry and Rugby CCG (CRCCG) to review the current classification was brought to the committee for consideration; 6.5.1 - AD highlighted that a MHRA alert for Ulipristal acetate (Esmya ) was recently published stating that there have been 5 cases of severe liver failure; they recommend that no new treatment in women should be initiated and for those patients that are already on the treatment should have liver function tests once a month AD advised that he had received some enquiries from GPs suggesting this drug be reclassified, he asked the committee what their thoughts were 6.5.2 - JS raised concerns about occurrences that had recently happened in primary care, she felt that more controlled monitoring was required The committee agreed to change Ulipristal acetate (Esmya ) to not recommended and amend the 4
DPS verdict accordingly. Section 6 Decisions 6A Publish the agreed specialist drug amendments to the netformulary AD/SD 6B Add Ezetimibe to the Lipid Modification guideline HE/SD 6C Publish Ulipristal acetate (Esmya ) amendment to the netformulary AD/SD 6D Amend Ulipristal acetate (Esmya ) DPS & republish AH/AD/SD 7. Guidelines/Resource Documents 7.1 - End of Life booklet - A booklet devised by the Palliative Care Physicians under the Castle Group (Care and Support Towards Life s End) was brought to the committee for consideration; 7.1.1 - CS gave a brief summary of the draft contents; the guidance was designed for nonspecialist use and should be used in conjunction with the individual patient s end of life care plan. The vast majority of drugs are unlicensed though supported by world-wide published data. The booklet has already been approved by the three DTCs and accepted in hospices around the country 7.1.2 - SP requested that the booklet say for contact details refer to own trust guidance 7.1.3 - RL queried the inclusion of fentanyl patches and benefit of having a conversion chart 7.1.4 - The committee discussed at length the safety impact of fentanyl use and the CD drugs supply and stock issue The committee agreed to amend the booklet to include the fentanyl patches and a full conversion chart for all of the drugs, send out for virtual ratification then publish. 7.2 - Wound Management & Continence - A revised preferred prescribing booklet from Coventry and Warwickshire Partnership NHS Trust (CWPT) was brought to the committee for approval; 7.2.1 PV briefed that the 2 separate booklets were now combined into one format, she summarised the minor changes 7.2.2 - RL urged that it would be useful to have a singular guidance across Coventry and Warwickshire patch AD mentioned that from a commissioning point of view, the Rugby area follows the South Warwickshire Foundation NHS Trust (SWFT) resource document which has more products than the Coventry document. He felt that this was a commissioning challenge 7.2.3 - JS thought the new booklet format was much easier for finding products The committee agreed to republish the resource document. 5
Section 7 Decisions 7A Amend End of Life booklet with committee comments & send out for virtual ratification, then publish CS/AD/SD 7B Republish the revised Wound Management & Continence PPL AD/SD 8. Shared Care Agreements 8.1 - Glycopyrronium This item was discussed with item 5.3. Section 8 Decisions 8A Amend Glycopyrronium SCA & send final document to APC office, then republish on both websites PV/SD 9. AOB 9.1 - JS enquired about progress on two actions that were discussed at November s meeting. NOACS - She reported that in Coventry they were implementing a local Atrial Fibrillation (AF) initiative and that she had been asked by GPs of the current status of NOAC prescribing in primary care. AD stated that the revised DPSs have been delayed due to some concerns arising from hospital pharmacists that patients were being missed in terms of their monitoring JS felt that it was crucial for those GPs who feel confident to prescribe to have an appropriate pathway in place. She said that it appears that there are different work streams applied across the Coventry and Warwickshire patch. A brief discussion took place around having a NOAC package for prescribers and education session for GPs. AD concluded that he will liaise with JS around rewording the DPSs verdict statements before publication. 9.2 - Freestyle Libre - AD updated the committee that they have agreed to follow the Regional Medicines Optimisation Committee (RMOC) positioning statement. The three Coventry and Warwickshire CCGs have got together within their own policy group to form a commissioning policy for Freestyle Libre. This policy is now awaiting approval from the governing bodies and after this process the commissioners and secondary care will discuss the funding arrangements. JS felt that this long process impacts on patient care. 10. Date of next meeting The date and time of the next meeting is Friday 18 th May 2018 at 12.30pm until 3pm. 6