Issue 40 - November 2020
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Welcome to November's edition of Tablets, a prescribing newsletter produced monthly by the Medicines Management team at Midlands and Lancashire CSU.


Formulary Update

New medicines

GREY SOLRIAMFETOL HYDROCHLORIDE tablets (Sunosi®▼) for excessive daytime sleepiness in narcolepsy 
Not recommended until NICE TA published.

GREY SOLRIAMFETOL HYDROCHLORIDE tablets (Sunosi®▼) for excessive daytime sleepiness in obstructive sleep apnoea 
Not recommended until NICE TA published.

GREEN NALDEMEDINE tablets (Rizmoic®▼) for the treatment of opioid-induced constipation
Naldemedine is recommended as an option for treating opioid-induced constipation in adults who have had laxative treatment. It can be used alone to treat opioid-induced constipation or with other laxatives for constipation of mixed aetiology. The annual treatment cost of naldemedine is £543.85. NICE do not expect implementing this guidance to have a significant impact on resources (less than £9,000 per 100,000 population) because naldemedine is a further treatment option at similar cost to other treatment options. 

Formulary and guidelines

BLACK SILK garments (Dermasilk®, Dreamskin®, Skinnies Silk®) for eczema or atopic dermatitis
Routine review of current statement, no significant changes

RED BOTULINUM TOXIN TYPE A for severe axillary hyperhidrosis
Routine review of current statement, no significant changes

RED BOTULINUM TOXIN TYPE A injection for chronic anal fissure
Routine review of current statement, no significant changes

Avoidance of Clostridium difficile infection
Routine review of current statement, no significant changes



The Midlands and Lancashire CSU has a dedicated COVID-19 webpage which is updated daily.

Please note that this information is up to date at the time of publication. 

The list of resources will be updated as new material becomes available so please check back regularly for updates.

This page groups the resources by subject matter. The same list of resources is also available grouped by the organisation that issued it.

COVID-19 Resources

Safety Update

Please click here for a full summary of safety updates and SPC updates in October.

Warfarin and other anticoagulants – monitoring of patients during the COVID-19 pandemic
14 October 2020

MHRA has published guidance following concerns over an apparent increase in the number of patients taking warfarin found to have elevated INR values during the pandemic; and reminds healthcare professionals and patients that continued close INR monitoring is crucial.

DTB Select: Steroid emergency cards - action needed
21 October 2020

Article summarises the actions for organisations to take to implement the new steroid emergency card following a safety alert. The new card features aims to help healthcare staff identify adult patients with adrenal insufficiency and give emergency treatment for adrenal crisis.

Prescribing News

NICE Guidelines October 2020

There have been three guidelines, one technology appraisal and one antimicrobial guideline published in October 2020 by the National Institute for Clinical Excellence which has impact upon primary care. 

The COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community guideline has been updated and published. The guideline provides recommendations for managing COVID-19 symptoms for patients in community, at the end of life. Recommendations regarding the management of medicines and protection for staff from infection has also been made. The guideline has also amended recommendations on considering a patient’s existing medicines with reference to the MHRA advice on warfarin and other anticoagulants. 

The Rheumatoid arthritis in adults: management guideline has been updated and published. The guideline covers diagnosing and managing rheumatoid arthritis. It aims to improve quality of life by ensuring people have the right treatment. The updated guideline has amended the ‘treat to target’ recommendations to clarify that multiple disease-modifying anti-rheumatic drugs can be offered one after the other to achieve treatment targets. 

The Behaviour change: digital and mobile health interventions guideline has been published. The guideline covers interventions that use a digital or mobile platform to help people live a healthier lifestyle. The interventions include those delivered by text message, apps, internet device or the internet. The guideline only covers those that are delivered by the technology and not the healthcare professions delivering the interventions.  

Clinicians should be aware of these guidelines and implement any necessary changes to their practice. 

CKS Updates October 2020

During the month of October 2020, the following Clinical Knowledge Summaries were published or updated:
All the above topics have been reviewed and updated in line with NICE guidance with minor layout changes. The Gastroenteritis topic has had several nodes merged to improved clarity and navigation.  

Clinicians can use the updated and new information when reviewing patients.

The information in the Prescribing News section has been adapted from the Prescribing Advice for GPs blog 

This section has been adapted from

Drug Availability

Products in Short Supply and Product Discontinuations

The following links provide prescribers with up to date information on commonly prescribed products which are currently in short supply from the manufacturers.

The information held on these lists is not exhaustive. Availability can vary geographically and also between wholesalers. Up-to-date information should be sought from manufacturers, local community pharmacies and suppliers.

Supply Issue Update for Primary and Secondary Care

Registered users can access the monthly drug availability update for primary and secondary care produced by the Department for Health and Social Care (DHSC), on the Specialist Pharmacy Service (SPS) website. 

Please note you must be registered with SPS, with the relevant permissions, and logged in to view this page. Click on ‘sign in’ in the top right hand.

Drug Tariff Changes

Drug tariff price changes are summarised as the top 10 price reductions and top 10 price increases since last month, the top 25 increases and decreases compared to three months ago, and the top 50 changes since last year.

Drug tariff price changes for November


Antimicrobial Update

Please see below for a full summary of antimicrobial related guidelines and SPC updates in October.

Guidance and Advice

Management of suspected bacterial lower urinary tract infection in adult women 
This updated guideline covers younger women aged 16–64 years, older women aged 65 years and over and women of any age using an indwelling, intermittent or suprapubic catheter. It also includes the diagnosis and management of recurrent UTI in these groups. 

National Seasonal Influenza Immunisation Programme 2020/21: primary care frequently asked questions 
These FAQs, to be updated regularly, provide information to support GP practices and community pharmacies in delivery of the 2020/21 annual flu programme. They should be read alongside the updated annual flu letter (published 5th August) and the relevant service specifications. 

Primary Research

Developing a behavioural intervention package to identify and amend incorrect penicillin allergy records in UK general practice and subsequently change antibiotic use 
The authors present a behavioural intervention package designed to address the multiple barriers to uptake of penicillin allergy testing in general practice, that will go on to be tested in a feasibility trial and randomised controlled trial in England. 

Systematic Review

Oral versus intra‐vaginal imidazole and triazole anti‐fungal treatment of uncomplicated vulvovaginal candidiasis (thrush) 
Review (26 trials; n=5007) found oral anti‐fungal treatment probably improves short‐ and long‐term mycological cure over intra‐vaginal treatment for uncomplicated vaginal candidiasis. Low certainty evidence suggest oral treatment was preferred. 

Topical antibiotics with steroids for chronic suppurative otitis media 
Review (17 studies, 11 treatment comparisons, n=1901) found uncertain evidence about effectiveness of this intervention in improving resolution of ear discharge, no evidence on benefit of adding steroid, and uncertainty about relative effectiveness of different antibiotics. 

Antibiotic therapy for pelvic inflammatory disease 
This review (39 RCTs; n=6894) concludes there is uncertainty over whether one treatment is safer or more effective than another. Based on one study (low risk of bias) a macrolide (azithromycin) probably improves cure rate vs. tetracycline (doxycycline) in mild-moderate disease. 

Media and commentaries

Coroner calls for MHRA to review side effects of doxycycline after student jumped from plane 
The inquest report notes it was ‘apparent from the evidence’ that the individual had a psychotic reaction as a result of taking doxycycline. The MHRA is reviewing the available evidence on the suspected association which is not currently a recognised side-effect of doxycycline. 

Summary of Product Characteristics updates

Exocin (ofloxacin) 3 mg/ml Eye Drops 
SPC warns that the preservative, benzalkonium chloride, may cause symptoms of dry eyes, and may affect the tear film and corneal surface. Caution is required in dry eyes and where the cornea may be compromised. Patients should be monitored in case of prolonged use. 

Please note that the information in this newsletter is correct at the time of publication.
Clinicians should always refer to the most up to date information.


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