Issue 25 - May 2019
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Welcome to the May edition of Tablets, a prescribing newsletter produced monthly by the Medicines Management team at Midlands and Lancashire CSU.


Formulary Update

New Medicines 

GREY BUDESONIDE orodispersible tablets (Jorveza®▼) for eosinophilic oesophagitis 
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of BUDESONIDE orodispersible tablets (Jorveza®▼) for eosinophilic oesophagitis.

GREY DAPAGLIFLOZIN tablets (Forxiga®) in combination with insulin for the treatment of Type 1 Diabetes Mellitus 
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of DAPAGLIFLOZIN tablets (Forxiga®) in combination with insulin for the treatment of Type 1 Diabetes Mellitus.

GREY FLUOCINOLONE intravitreal implant (Iluvien®) 
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of FLUOCINOLONE intravitreal implant (Iluvien®) for non-infectious uveitis.

GREY MELATONIN prolonged-release tablets (Slenyto®) for the treatment of insomnia in children 
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of MELATONIN prolonged-release tablets (Slenyto®) for the treatment of insomnia in children with neurodevelopmental conditions.

The Pan Mersey Area Prescribing Committee recommends the prescribing of DAPOXETINE tablets (Priligy®) for the treatment of premature ejaculation when recommended by a psychosexual service or a specialist clinician with experience of treating psychosexual disorders. Treatment is restricted to three doses per month.

GREEN Gliptin (DPP-4 inhibitor) statement 
The Pan Mersey Area Prescribing Committee recommends the prescribing of DPP-4 inhibitors in accordance with
NG28-Type 2 diabetes in adults: management.


OVERACTIVE BLADDER in children over 5 years old, prescribing algorithm


BLACK Vitamin B Compound Strong 
Change of designation from green to black except 10 days therapy for re-feeding syndrome. Cost saving.

BLACK DOSULEPIN capsules and tablets 
The Pan Mersey Area Prescribing Committee does not recommend the prescribing of DOSULEPIN capsules and tablets.

BLACK TRIMIPRAMINE capsules and tablets (Surmontil®) 
The Pan Mersey Area Prescribing Committee does not recommend the prescribing of TRIMIPRAMINE capsules and tablets.

AMBER INITIATED  Insulin glargine (Semglee®) 
Additional biosimilar brand.

Off-label use – formulary wording 
Off-label use Drugs are included in the formulary for their licensed indications – where inclusion of off-label use is considered to be included in the formulary this is specifically stated in the formulary entry for the drug.

Paediatrics: Drugs are included in the formulary for paediatric use for their BNF for Children recommended indications (indicated by   symbol) which may be off-label, unless otherwise stated.


Skin infections

Safety Updates

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

Methotrexate: updated recommendations for conception and contraception 
BNF eNewsletter | 01 Apr 
Manufacturer advises effective contraception during and for at least 6 months after treatment in men and women.

How to minimise the risks of medication errors with rivastigmine patches 
Specialist Pharmacy Service | 01 Apr 
This updated Q&A aims to raise awareness on the types of medication errors reported with rivastigmine patches, as well as highlighting strategies to improve medication safety on the prescribing and administration of these patches.

Pregabalin (Lyrica), gabapentin (Neurontin) and risk of abuse and dependence: new scheduling requirements from 1 April 
Medicines and Healthcare Regulatory Agency | 17 Apr 
Under the Misuse of Drugs Act 1971, pregabalin and gabapentin are classified as Schedule 3 drugs. Healthcare professionals are advised to evaluate patients for a history of drug abuse before prescribing and observe patients for development of signs of abuse and dependence.

Valproate medicines and serious harms in pregnancy: new Annual Risk Acknowledgement Form and clinical guidance from professional bodies to support compliance with the Pregnancy Prevention Programme 
Medicines and Healthcare Regulatory Agency | 17 Apr 
The Annual Risk Acknowledgement Form for the valproate Pregnancy Prevention Programme has been updated and should be used during annual specialist review of all women and girls of childbearing potential on valproate medicines.

Yellow fever vaccine (Stamaril) and fatal adverse reactions: extreme caution needed in people who may be immunosuppressed and those 60 years and older 
Medicines and Healthcare Regulatory Agency | 17 Apr 
Following two fatal adverse reactions, yellow fever vaccine must not be given to anyone with a history of thymus dysfunction or who is immunosuppressed. Due to a substantially increased risk in people aged >60 years, a careful risk assessment should be conducted.


Prescribing News

NICE Guidance April 2019

There have been three guidelines published in April 2019 by the National Institute for Clinical Excellence which have an impact upon primary care.

The Urinary incontinence and pelvic organ prolapse in women has been published. The guideline covers the assessment and management of urinary incontinence and pelvic organ prolapse in women aged 18 and over. The guideline also covers the complications associated with mesh surgery for these conditions. The guideline now replaces four previous guidance documents.

The Surgical site infections: prevention and treatment guideline has been published. The guideline covers the prevention and treatment of surgical site infections in adults, young people and children who are having a surgical procedure involving a cut through the skin. In order to minimise the risk of infection, the guideline focuses on methods used before, during and after surgery.

The Ectopic pregnancy and miscarriage: diagnosis and initial management guideline has been published. The guideline covers the diagnosis and management of ectopic pregnancy and miscarriage in women with complications, such as pain and bleeding, in early pregnancy (that is, up to 13 weeks completed pregnancy). The guideline aims to improve how early pregnancy loss is diagnosed, and the support women are given, to limit the psychological impact of their loss.

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

CKS Updates April 2019

During the month of April 2019, the following Clinical Knowledge Summaries were published or updated: All the above topics have undergone reviews and minor restructures. The use of the QRISK3 risk prediction tool has been recommended in the CVD risk assessment and management topic. A new assessment section has been added to the Chronic Kidney disease topic and more information on the management of people with diabetes mellitus and chronic kidney disease has been provided. In addition, the prescribing information section of the topic has also been updated.
Clinicians can use the updated and new information when reviewing patients.

Useful Resources

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.

DHSC report April 2019 

This report has been produced by the Department of Health and Social Care (DHSC) Medicine Supply team. This report is updated monthly to provide information on the current primary and secondary care medicine supply issues being worked on.  This information is confidential to the NHS as it may be commercially sensitive.

New Issues

Diamorphine 5mg Injection supply issue (Accord and Wockhardt)
NHS England and DHSC have been notified by Accord and Wockhardt that they are experiencing issues with the manufacture and availability of diamorphine 5mg injection. Please see link for full details.

Epanutin (phenytoin) 50mg Chewable Infatabs
Pfizer have informed DHSC of a temporary supply issue with Epanutin Infatabs from 15th May until November 2019 due to a delay in manufacturing.  To help mitigate the shortage Pfizer has obtained approval from the MHRA to import stock of Dilantin (phenytoin) Infatabs from Canada. Canadian packs of Dilantin are considered as an unlicensed product in the UK. A copy of the product information and the DHCP letter can be found attached to this update.
Epanutin 30 mg/5 ml Oral Suspension remains available, however, supplies are only available to meet normal market demand as such patients should not be switched to Epanutin Oral Suspension as this may precipitate a shortage of this presentation.

Questran Powder for Oral Suspension/Questran Light (colestyramine) 4g sachets
Bristol-Myers Squibb (BMS) will be out of stock of Questran Powder 4g sachets until August 2019. Emergency supply measures are already in place via Alliance Healthcare for Questran Light sachets and will be sufficient to support both products, if a switch is deemed clinically appropriate. This process will remain in place until May to avoid a total out of stock situation. Contact Alliance Healthcare for further information on the emergency supply process.

Sinemet (co-careldopa) tablets
Ongoing issues with the supply of Sinemet from MSD due to capacity constraints at their manufacturing facility - please see attached company letter. The latest update on the current supply position is:
Sinemet 10/100mg - currently out of stock; further stock expected in early May;
Sinemet 25/250mg - currently out of stock; further stock expected in early June; 
Sinemet 12.5/50mg - currently out of stock; further stock expected at the end of May;
Sinemet Controlled Release 50/200mg - currently out of stock; further stock is expected at the end of May.
DHSC has been working with generic suppliers and can confirm generic co-careldopa supplies in the above strengths will be available to support. All other Sinemet preparations are unaffected and remain available. 

DHSC are continuing to work with MSD and generic manufacturers to manage the overall supply position over the coming months and will provide updates as information becomes available.

Thorens (colecalciferol) 10,000i.u./ml oral drops
Galen are out of stock of Thorens 10,000i.u./ml oral drops until end of June 2019. Several other strength colecalciferol oral drops remain available from alternative suppliers. Please see the link below for UKMI advice on alternate preparations:

Zolmitriptan 2.5mg orodispersible tablets
Several suppliers are currently experiencing supply issues with zolmitriptan 2.5mg orodispersible tablets, however, further supplies are expected w/c 6th May.  Grunenthal, manufacturers of Zomig Rapimelt, are out of stock of this product from May until mid July 2019. Zomig Rapimelt 5mg and Zomig 2.5mg tablets remain available but are unable to support full uplift in demand.  

Loestrin 20 and Loestrin 30 tablets
Galen Limited are currently out of stock Loestrin 20 tablets and anticipate they will go out of stock of Loestrin 30 tablets at the beginning of June and are currently unable to provide a resupply date.  Galen Limited have produced the attached Dear Health Care Professional letter providing further details on the issue. 

Eye drops/treatments
Iopidine (apraclonidine hydrochloride) 0.5% eye drops
Novartis, the sole UK supplier of iopidine 0.5% eye drops, will be out of stock until 1st June 2019. Please see the link below for clinical advice from the Royal College of Ophthalmologists regarding suitable management

Ongoing Issues:
For advice on ongoing issues please click here

Drug Tariff 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.

Antimicrobial Updates

Please click here for a full summary of antimicrobial related guidelines and SPC updates in March.

Antimicrobial resistance CQUIN 2019/20
NHS Improvement | 09 Apr

Cellulitis and erysipelas: antimicrobial prescribing – DRAFT guidance consultation
National Institute for Health and Care Excellence | 10 Apr

DTB Select: Comparison of antibiotics for Clostridium difficile infection
Drug and Therapeutics Bulletin | 24 Apr

Case report Nitrofurantoin: friend or foe?
Drug and Therapeutics Bulletin | 24 Apr

Antimicrobial use in UK long-term care facilities: results of a point prevalence survey
Journal of Antimicrobial Chemotherapy | 25 Apr
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.


Kieron Donlon: - 0151 296 7076

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