Issue 11 - January 2018
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Welcome to the January edition of Tablets, a prescribing newsletter produced monthly by the Medicines Management team at Midlands and Lancashire Commissioning Support Unit.


Formulary Update


RED AFLIBERCEPT intravitreal injection (Eylea®) for mCNV 
The Pan Mersey Area Prescribing Committee recommends the prescribing of AFLIBERCEPT intravitreal injection (Eylea®), by ophthalmologists only, for treating myopic choroidal neovascularisation (mCNV) in accordance with NICE TA486.

RED SARILUMAB solution for injection (Kevzara®▼) 
The Pan Mersey Area Prescribing Committee recommends the prescribing of SARILUMAB subcutaneous injection (Kevzara®▼), by specialists only, for severe, active Rheumatoid Arthritis in accordance with NICE TA485.

GREY ACETYLCYSTEINE for Mucolytic Respiratory Disorders 
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of ACETYLCYSTEINE for the treatment of mucolytic respiratory disorders, including COPD.

GREY DUPILUMAB injection (Dupixent®▼)
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of DUPILUMAB injection (Dupixent®▼) for the treatment of atopic dermatitis.

The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of FLUTICASONE FUROATE/ VILANTEROL/ UMECLIDINIUM inhaler (Trelegy®) for the maintenance treatment of Chronic Obstructive Pulmonary Disease (COPD).

GREY GUSELKUMAB solution for injection (Tremfya®▼) 
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of GUSELKUMAB solution for injection (Tremfya®▼) for the treatment of psoriasis.

GREY PITOLISANT HYDROCHLORIDE film-coated tablets (Wakix®▼) 
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of Pitolisant hydrochloride film coated tablets (Wakix®▼) for the treatment of narcolepsy.

GREY TELOTRISTAT film-coated tablets (Xermelo®▼) 
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of TELOTRISTAT film-coated tablets (Xermelo®▼) for the treatment of carcinoid syndrome diarrhoea.

The Pan Mersey Area Prescribing Committee recommends the restricted prescribing of BRIMONIDINE TARTRATE Gel (Mirvaso®) for the treatment of moderate to severe persistent facial erythema associated with rosacea in adults.


Codeine is contraindicated in all children aged 0-18 years who undergo tonsillectomy or adenoidectomy (or both) for obstructive sleep apnoea. Codeine is restricted to children over 12 years of age and only if the benefit outweighs the risks.

DOMPERIDONE: updated indications, dose and contraindications 
Domperidone is restricted to short term use in the relief of nausea and vomiting. The maximum recommended dose is 30 milligrams daily for one week. Contraindications include cardiac disorders, hepatic impairment, and concomitant QT prolonging or CYP3A4 inhibiting drugs.

Safety Update

For more information on the updates listed below, please click here:

Buccolam (midazolam) oromuscosal solution pre-filled syringes
Medicines and Healthcare products Regulatory Agency | 07 Dec 2017
The translucent tip-cap sometimes remains on the syringe tip when pulling the red cap off, as shown in the DHCP diagrams.

Eluxadoline (Truberzi▼): risk of pancreatitis; do not use in patients who have undergone cholecystectomy or in those with biliary disorders
Medicines and Healthcare Products Regulatory Agency | 15 Dec 2017
Cases of pancreatitis, with or without sphincter of Oddi spasm, have been reported in patients taking eluxadoline. Some cases have resulted in hospitalisation and death, primarily in patients who have undergone cholecystectomy.

Fingolimod (Gilenya▼): new contraindications in relation to cardiac risk
Medicines and Healthcare Products Regulatory Agency | 15 Dec 2017
Fingolimod can cause persistent bradycardia, which can increase the risk of serious cardiac arrhythmias. New contraindications have been introduced for patients with pre-existing cardiac disorders.

Fingolimod (Gilenya▼): updated advice about risk of cancers and serious infections
Medicines and Healthcare Products Regulatory Agency | 15 Dec 2017
Monitor patients closely for skin cancers. Advise patients to seek urgent attention if they develop signs or symptoms of serious infections.

Mycophenolate: updated recommendations for contraception for men and women
European Medicines Agency | 15 Dec 2017
The European Medicines Agency has concluded that current evidence does not indicate a risk of malformations or miscarriages when the father has taken mycophenolate, although risk of genotoxicity cannot be completely ruled out.

Which medicines should be considered for brand-name prescribing in primary care?
Specialist Pharmacy Services | 22 Dec 2017
There are some circumstances in which continuity of same product is important for patient safety and prescribing a specific manufacturer’s product (brand or generic) is preferred. Q&A describes such situations and lists medicines that may be considered for brand-name prescribing.

SPC Updates here

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


The manufacturer GSK have recently informed us they are approaching an imminent out of stock position affecting Bactroban nasal ointment. This issue is due to manufacturing issues, which GSK are working hard to resolve. They are unable to provide a specific resupply date, but have advised the product should be back in stock towards the end of Q1 2018.

UKMI have published a memo, which provides advice on clinical alternatives. This is available at the following link
The memo recommends that advice should be sought from the local infection control team on use of alternative products.

The suppliers of the alternative products have advised that supplies of the following products are all available and they are working with their supply chains to bring in additional stock:
  • Naseptin Nasal Cream (Alliance Pharmaceuticals) - available via the wholesalers: AAH, Alliance Healthcare and Well Pharmacy
  • Prontoderm (Braun) - available via NHS supply Chain and wholesalers: AAH and Alliance
  • Octenisan Nasal gel (Schülke & Mayr UK Ltd ) - available via NHS supply Chain and wholesalers: AAH, Alliance and Phoenix
Trimovate cream:

The manufacture of Trimovate cream has recently moved from GSK to Ennogen. However Ennogen will not have any stock available until some point in 2018, so there are likely to be long term supply issues with Trimovate cream.

Mianserin 10mg tablets:

Mylan the sole supplier of Mianserin 10mg tablets have advised they are out of stock until March 2018. Patients unable to obtain supplies may need to be referred to their prescriber. Mylan continue to have good supplies of Mianserin 30mg tablets.

Serenace (haloperidol) 500mcg capsules:

Teva are currently out of stock of haloperidol capsules due to manufacturing issues. Further stock is expected early in 2018.
Supplies of the 0.5mg tablets are available from Crescent, who has good supplies available. Supplies of liquid haloperidol 5mg/5ml oral solution are available from Pinewood. There is also a 10mg/5ml strength is also available from Pinewood and Rosemont.

Colifoam enemas:

There are long standing supply issues with Colifoam® enemas. Mylan, the manufacturers of Colifoam® have advised that they do not expect stocks to be available until around June 2018. The only suitable alternatives are prednisolone foam enemas however as these are significantly more expensive than Colifoam and are intended for short term use (max 4 weeks for prednisolone) practices should take care to ensure that these are not on repeat prescriptions, and only issued as an acute script.

Nystaform HC ointment:

Typharm manufacture brand Nystaform HC ointment which has now been discontinued and is not available (although there may be very little residual stock at wholesalers).
Typharm also manufacture a generic version of Nystaform HC (prescribe as nystatin, chlorhexidine acetate and hydrocortisone ointment) which is readily available in wholesalers so pharmacies should be able to get the stock. If patients are experiencing problems with obtaining supplies from their usual pharmacy they should be advised to try an alternative pharmacy. If prescriptions have been sent electronically to the patient’s nominated pharmacy and they have issues with obtaining stock then the pharmacy need to send the prescription back to the ‘spine’ and the GP practice would be better printing off a green prescription for the patient to take to another pharmacy.

Discontinued items

Izinova (sodium sulfate, anhydrous, magnesium sulfate heptahydrate & potassium sulfate) concentrate for oral solution (Ipsen):

Izinova is being discontinued at the end December 2017 due to problems with a third-party manufacturer. Therapeutic alternatives remain available.

Fosamax (alendronic acid) 10mg tablets (MSD):

MSD plans to discontinue Fosamax (alendronic acid) 10mg tablets with immediate effect from the UK market as part of a portfolio rationalisation process. Fosamax Once Weekly and generic alendronic acid 10mg tablets remain available.

Nizatidine 150mg capsules (Flynn):

Flynn plans to discontinue Nizatidine 150mg capsules with immediate effect from the UK market. Generic Nizatidine 150mg capsules remain available from other suppliers.

Drug tariff price Changes

This summary document shows the top 10 price changes this month, the top 25 changes this quarter, and the top 100 this year. 
Tell me more about drug tariff price changes.

Prescribing News

Antiviral Medicines Authorised for Influenza Season 2017/18
The Department of Health has written a letter to healthcare professionals via the Central Alerting System to advise that antiviral medicines may now be prescribed at NHS expense due to rising levels in reporting of influenza-like illness.
Surveillance data indicates an increase in influenza cases in the community; GPs and other prescribers working in primary care may now prescribe antiviral medicines for the prophylaxis and treatment of influenza. Doses and treatment schedules are contained in existing Public Health England guidance. Clinicians are reminded to endorse the prescription with 'SLS' to ensure that it can be dispensed in community pharmacies without undue delay.

NICE BNF apps replaced by BNF & BNFC app

Following the recent launch by the publishers of the British National Formulary (BNF) and British National Formulary for Children (BNFC) of a new, faster, easier to access and use BNF and BNFC app, the NICE BNF apps have been withdrawn.
The new BNF and BNFC app can be downloaded using the following link: BNF and BNFC app
Aimed at prescribers, pharmacists, and other health and social care professionals, the new app has been purpose built for iOS and Android platforms. This has enabled an intuitive design and enhanced features around search and interactions checking and updating mechanisms. These features provide enhanced access to high quality, authoritative information and guidance on the move.
For the first time, adult and child BNF content is available through a single app providing ease of use and saving space on a user’s device. Those working in health and social care can download and use the app for free.

NICE Guidance

The National Institute of Health and Care Excellence (NICE) have published new or updated guidance that impact upon primary care.       
New NICE guidance on asthma has been published, covering the diagnosis, monitoring and management of chronic asthma in adults and children. NICE has recognised that in implementing the guidance will require a change in practice. Healthcare professionals will need to become familiar with new recommendations on pharmacological treatment that differ from the established BTS/SIGN stepwise treatment pathways. A notable change is the use of leukotriene receptor antagonists, ahead of the introduction of long-acting beta agonists.

Action: Clinicians should be aware of this new guidance and implement any necessary changes to practice. NICE recommends that in people whose asthma is well-controlled on their current treatment, they should not have their treatment changed purely to follow the guideline.

The Autism spectrum disorder in under 19s clinical guideline has been updated to include ADHD as a factor associated with an increased prevalence of autism and changed references from DSM-4 to DSM-5. The guideline covers recognising and diagnosing autism spectrum disorder in children and young people from birth up to 19 years and it also covers referral.

The Atrial fibrillation and heart valve disease: self-monitoring diagnostic guideline has been updated removing the recommendations for the InRatio2 PT/INR monitor as this device is no longer available.

The Naltrexone–bupropion for managing overweight and obesity technology appraisal has been published. Naltrexone–bupropion (Mysimba®) is not recommended within its marketing authorisation for managing overweight and obesity in adults alongside a reduced-calorie diet and increased physical activity.

Action: Clinicians should be aware of this month's new guidance and implement any necessary changes to practice.

CKS Updates

Clinical Knowledge Summaries were reviewed and updated in the following areas;
The most significant changes are in the Irritable bowel syndrome and Psoriasis topics. The Irritable bowel syndrome topic has been updated where the recommendations on the diagnosis and management of irritable bowel syndrome have been amended in line with current evidence, including the addition of linaclotide as a drug treatment option. The Psoriasis topic has been updated where recommendations on the diagnosis and management of psoriasis have been amended in line with current evidence.

Action: Clinicians may find the updates useful when reviewing current clinical practice.
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.