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Issue 19 - October 2018
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Welcome to the October edition of Tablets, a prescribing newsletter produced monthly by the Medicines Management team at Midlands and Lancashire CSU.
 

Contents

Formulary Update

New medicines 

RED Dupilumab solution for injection (Dupixent®▼) 
The Pan Mersey Area Prescribing Committee recommends the prescribing of Dupilumab solution for injection (Dupixent®▼), by specialists only, for the treatment of moderate to severe atopic dermatitis in adults in accordance with NICE TA534. 

RED Ixekizumab subcutaneous injection (Taltz®▼)
The Pan Mersey Area Prescribing Committee recommends the prescribing of IXEKIZUMAB subcutaneous injection (Taltz®▼), by specialists only, for active psoriatic arthritis in adults after inadequate response to DMARDs in accordance with NICE TA537. 

AMBER RETAINED  Degarelix subcutaneous injection (Firmagon®)
The Pan Mersey Area Prescribing Committee recommends the prescribing of DEGARELIX SC injection (Firmagon®) following specialist initiation for treating advanced hormone-dependent prostate cancer in people with spinal metastases in accordance with NICE TA404. 

AMBER INITIATED   Brivaracetam tablets and oral solution (Briviact®▼) 
The Pan Mersey Area Prescribing Committee recommends the prescribing of BRIVARACETAM tablets/oral solution (Briviact®▼) for adjunctive treatment of focal seizures following initiation by a consultant neurologist. 

GREY Tofacitinib film-coated tablets (Xeljanz®▼) tablets 
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of TOFACITINIB film-coated tablets (Xeljanz®▼) for the treatment of Ulcerative Colitis. 

GREY Certolizumab pegol solution for injection (Cimzia®) 
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of CERTOLIZUMAB PEGOL solution for injection (Cimzia®) for the treatment of Plaque Psoriasis. 

GREY Denosumab solution for injection (Prolia®)
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of DENOSUMAB solution for injection (Prolia®) for the treatment of bone loss associated with long-term systemic glucocorticoid therapy. 

GREY Cariprazine hard capsules (Reagila®▼) 
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of Cariprazine capsules (Reagila®▼), for the treatment of schizophrenia in adult patients. 

GREY Erenumab solution for injection (Aimovig®▼)
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of ERENUMAB pre-filled syringes (Aimovig®▼) for prophylaxis of migraine. 
 
Formulary and guidelines 

BLACK Lidocaine plaster (Ralvo®, Versatis®)
The Pan Mersey Area Prescribing Committee does not recommend the prescribing of lidocaine plaster 5% (Ralvo®, 
Versatis®), except in limited circumstances outlined below. 

RED Probenecid
Addition to formulary in line with BSR gout guideline – alternative to sulfinpyrazone or benzbromarone where allopurinol or febuxostat are unsuitable. No additional drug cost for primary care. 

RED Sequential use of biological agents in the management of psoriasis in adults
The Pan Mersey Area Prescribing Committee recommends the sequential use of biological agents, adalimumab (Humira®), brodalumab (Kyntheum®▼), etanercept (Benepali®▼, Enbrel®), guselkumab (Tremfya®▼), infliximab (Inflectra®▼, Remicade®, Remsima®▼), ixekizumab (Taltz®▼), secukinumab (Cosentyx®▼) and ustekinumab (Stelara®), in the management of psoriasis according to the attached flowchart. 

AMBER INITIATED  Quetiapine I/R tablets 
The Pan Mersey Area Prescribing Committee recommends that IMMEDIATE RELEASE QUETIAPINE is the preferred formulation of quetiapine for prescribing across the Pan Mersey Area. 

AMBER INITIATED Insulin lispro (Humalog Junior®) 
Additional formulation suitable for administering 0.5-unit increments. No cost implication. 

GREEN Nefopam
Change of designation to 2nd line therapy after simple analgesics, NSAIDs and mild opiates in view of greater cost. Possible small cost reduction. 

Chapter 13 
Routine review of chapter. Some costs savings anticipated from removal of bath emollient and shower preparations from formulary. 

Shared Care

AMBER RETAINED  Gonadorelin analogues Prescribing Support Information
Addition of supporting information for the prescribing of add-back tibolone (see below) plus the addition of precocious puberty in children to the list of indications. 

AMBER RECOMMENDED  Tibolone 2.5mg tablets
Addition to the formulary. To be prescribed for the duration of treatment with a gonadorelin analogue. The first month to be prescribed by the specialist. 

PURPLE Lithium Shared Care Framework 
Routine review of the existing shared care framework. 

Safety 

Safe Prescribing and Dispensing of Methotrexate
Exceptional specialist co-prescription of trimethoprim with methotrexate amended to accurately reflect APC discussion. Three- day treatment of UTI removed. 

Antimicrobials 

Genital tract infections 
Revision of antimicrobial formulary section. 

ENT update
Ciprofloxacin ear drops (Cetraxal®): licensed product replaces Otomize® as preferred second line option, and offlabel use of eye drops in tympanic perforation. Perichondritis: ciprofloxacin replaces flucloxacillin. 

Safety Update September

Please click here for a summary of  safety updates and SPC updates in September

Can small volume intramuscular injections be given to patients taking oral anticoagulants?
Specialist Pharmacy Service | 18 September 2018
This Q&A discussing potential risks linked to administration of small volume IM injections to patients on oral anticoagulants, has been partially updated to include latest advice from Public Health England’s “green book” on administration of influenza vaccine to this group.

Valproate Pregnancy Prevention Programme: actions required now from GPs, specialists, and dispensers
Medicines and Health Products Regulatory| 25 September 2018 
Valproate medicines must not be used in women of childbearing potential unless the Pregnancy Prevention Programme is in place.

Epipen And Epipen Junior - Supply Disruption
Central Alerting System | 28 September 2018 
EpiPen and EpiPen Junior will be subject to limited availability for the remainder of 2018. Mylan are now out of stock of EpiPen Junior and interruptions in the supply are anticipated to continue for the coming months. This alert provides details of actions to take around the prescribing, dispensing and administration of adrenaline auto-injectors. Whilst the deadline for completing the actions is the end of this year, it is expected for organisations to begin following the actions immediately upon receipt of this alert.

Prescribing News

NICE Guidance September 2018

There have been three guidelines published in September 2018 by the National Institute for Clinical Excellence which impact upon primary care. The Preventing suicide in community custodial settings guideline covers ways to reduce suicide and help people bereaved or affected by suicides. It aims to:
  • help local services work more effectively together to prevent suicide
  • identify and help people at risk
  • prevent suicide in places where it is currently more likely
The Pancreatitis guideline covers managing acute and chronic pancreatitis in children, young people and adults. The guideline aims to improve quality of life by ensuring that people have the right treatment and follow up and get timely information and support after diagnosis.

The Chronic heart failure in adults guideline covers the diagnosis and management of chronic heart failure in people aged 18 and over. The guideline aims to improve diagnosis and treatment to increase the length and quality of life for people with heart failure.
Clinicians should be aware of the new and updated information in their practice.


CKS Updates September 2018

During the month of September 2018, the following Clinical Knowledge Summaries were updated:  
The updated topics have had minor restructures. The most significant changes are to the Impetigo topic where the duration of topical treatment is now reduced to 5 days based on the recommendation issued by Public Health England.  The role of Mycoplasma genitalium and antibiotic treatment has now also been detailed in the Pelvic inflammatory disease topic. Clinicians should use the updated and new information when reviewing patients.

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 issues update for primary care September 2018

New issues

Epanutin® (phenytoin) 30mg/5ml oral suspension

There is an interruption in the supply of Epanutin® (phenytoin) 30mg/5ml oral suspension which may impact patients. It is anticipated to result in an out of stock period between the 29th October 2018 and early December. Please click here for further information.

 
Sinemet (co-careldopa) tablets:
 
MSD have advised that there is currently a supply issue affecting their Sinemet range.
 
The latest update we have on the current supply position is
  • Sinemet 12.5mg/50mg -  product is now back in stock and further deliveries are expected in November. No further issues are expected
  • Sinemet Plus 25mg/100mg – product currently in stock, but will be unavailable from approximately mid-October until end of November with intermittent supplies then expected from the end of Nov until Q1 2019
  • Sinemet 25mg/250mg - MSD are currently out of stock and further supplies will not be available until Q1 2019
  • All other Sinemet preparations are unaffected
Work has been undertaken with generic suppliers on this issue and they confirm that generic co-careldopa supplies in all the above strengths will be available to support the intermittent supply constraints. Work continues with MSD and generic manufacturers to manage the overall supply position over the coming months and an update will be provided  when more information is available.
 
MSD have provided information to Parkinson’s UK which can accessed on their website.

Ativan (lorazepam) injection:
 
Pfizer has advised of a supply issue and are currently out of stock. Pfizer are the sole supplier of this product in the UK. Further supplies are currently expected 26th October 2018.
 
To help manage the supply issues, UKMI have prepared the following advice on alternatives, which can be found here.

Supply information relating to the suggested alternatives can be found here.

There are a number of specialist importer companies who have been able to source supplies from abroad, although lead times will vary. If pharmacies are requiring unlicensed stock, they should place orders with the unlicensed companies as soon as possible due to the longer lead times for this stock
 
Tambocor (flecainide) 200mg modified release tablets:

Teva are experiencing a supply issue affecting Tambocor (flecainide) 200mg modified release tablets due to a recent change in ownership that has resulted in a disruption to supply. Generic presentations of Flecainide 50mg and 100mg immediate release tablets remain available and resupply for Tambocor (flecainide) 200mg modified release tablets is anticipated in 2019.

 
 Ongoing Issues:

Drug tariff price Changes


This summary document shows the top 10 price changes since last month, the top 25 changes compared to three months ago, and the top 50 since last year. 

Tell me more about drug tariff price changes. 
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.

Contacts
Kieron Donlon: kieron.donlon1@nhs.net - 0151 296 7076


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