Issue 18 - September 2018
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Welcome to the September edition of Tablets, a prescribing newsletter produced monthly by the Medicines Management team at Midlands and Lancashire CSU.


Formulary Update


BLACK E-Cigarettes
The Pan Mersey Area Prescribing Committee does not recommend the prescribing of E - Cigarettes, except as part of Local Authority commissioned Stop Smoking Service arrangements.

GREEN PHOSPHODIESTERASE TYPE-5 INHIBITORS  for the treatment of erectile dysfunction 
The Pan Mersey Area Prescribing Committee recommends generic sildenafil as the first choice phosphodiesterase type-5 inhibitor for the treatment of erectile dysfunction.

GREY BRIVARACETAM tablets and oral solution (Briviact®▼) for the treatment of epilepsy in children and adolescents 
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of BRIVARACETAM tablets or oral solution (Briviact®▼) for the treatment of epilepsy in children and adolescents.

The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of electromagnetic pulse therapy (Actipatch®) for pain relief.

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


Pharmacological management of gastro-oesophageal reflux disease (GORD) in children and young people in primary and secondary care 
Issued: July 2018 | Review: July 2021

Opioids and Gabapentinoids for Chronic Pain in Adults
Issued: July 2018 | Review: July 2021

Prescribing for patients living or travelling abroad or otherwise absent from the UK
Pan Mersey Area Prescribing Committee recommends that prescribers should NOT supply treatment durations in excess of THREE MONTHS for patients who are going to live or travelling abroad or otherwise absent from the UK. Patients should make local arrangements in their country of residence for on-going medical care.

Vitamin D Deficiency, Treatment in Adults
Issued: March 2018 | Updated: July 2018 | Review: February 2021

Vitamin D Deficiency: Primary and Secondary Care Prevention and Treatment in Paediatrics
Issued: July 2018 | Review: July 2021

Prescribing support information 

DENOSUMAB 60mg in 1ml prefilled syringe
Issued: January 2017 | Updated: July 2018 | Review: January 2020

Safety Update July and August

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

Combur10 Test UX and Chemstrip 10 A test strips – risk of falsely low results when measuring test strips on the Urisys 1100 urine analyser
Central Alerting System | 05 July 2018 
Manufactured by Roche Diagnostics GmbH – Due to incorrect limit of detection (LoD) for protein, nitrite, ketone bodies, leukocytes, blood: intact erythrocytes, patient treatment may be adversely impacted.

Pressurised metered dose inhalers (pMDI): risk of airway obstruction from aspiration of loose objects
Medicines and Health Products Regulatory Agency | 18 July 2018  
Due to reports of patients inhaling objects to the back of the throat, healthcare professionals are reminded to counsel patients on the correct use of their inhaler as well as emphasising the need to clean the device regularly.

NOACs and Antidepressants – What are the risks of using these together and how should these risks be managed?
Specialist Pharmacy Services | 23 July 2018
This article considers the risk of interactions between non-vitamin K antagonist oral anticoagulants (NOACs; also known as direct oral anticoagulants [DOACs]) and antidepressants.

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

Esmya (Ulipristal Acetate) For Symptoms of Uterine Fibroids: Restrictions To Use And Requirement To Check Liver Function Before, During And After Treatment 
Medicines and Health Products Regulatory | 07 August 2018
This alert has been established to advise that with immediate effect, Esmya should not be used unless the new restricted indication is met, and the patient does not have an underlying liver disorder; more than one treatment course is now authorised only in women who are not eligible for surgery following the completion of an EU review to investigate the link between Esmya and cases of serious liver injury.

Resources to support safe and timely management of hyperkalaemia
NHS Improvement | 08 Aug 2018
Several resources are included for organisations to ensure staff have access to information to guide prompt and appropriate investigation and treatment. Resources include the UK Renal Association guidelines for acute hyperkalaemia in adults and Resuscitation Council guidelines

Updated restrictions on use of Varicella Zoster Immunoglobulin (VZIG) during supply shortage: advice to health professionals
Public Health England | 09 August 2018 
This updated guidance includes the extension of the restriction of VZIG to include all immunosuppressed individuals except for those where oral aciclovir/valganciclovir may be contraindicated; and strengthening guidance on the use of aciclovir in susceptible women with exposure from week 20 of pregnancy.

Prescribing News

A statement has been released by the Department of Health & Social Care in preparation for a March 2019 'no deal brexit' scenario. This statement provides an update on the Government's  ongoing preparations for a March 2019 'no deal brexit' scenario and what health and care systems need to consider leading up to March 2019. 

We would like to emphasise the following paragraph from the letter:

'Hospitals, GPs and community pharmacies throughout the UK do not need to take any steps to stockpile additional medicines, beyond their business as usual stock levels. There is also no need for clinicians to write longer NHS prescriptions. Local stockpiling is not necessary and any incidences involving the over ordering of medicines will be investigated and followed up with the relevant Chief or Responsible directly.'

NICE Guidance August 2018

There have been two guidelines published in August 2018 by the National Institute for Clinical Excellence which impact upon primary care.

Flu vaccination: an increasing uptake guideline has been published to ensure more eligible patients are able to receive the free flu vaccination. The guideline details how to increase awareness and use existing opportunities in primary and secondary care to identify people who should be encouraged to have the vaccination.

The community pharmacies: promoting health and wellbeing guideline has also been published. It details how community pharmacies can help maintain and improve peoples' physical and mental health and wellbeing; including people with a long-term conditions. The guideline aims to encourage more people to use community pharmacies by integrating them within existing health and care pathways. The guideline may be relevant to those who work in related services e.g. GP practice and out-of-hours services.

CKS Updates August 2018

During the month of August 2018, the following Clinical Knowledge Summaries were updated:  New topics were published for: The updated topics have had minor reforms. The most significant changes have been to the nappy rash topic where the complications and prognosis sections have been added and the differential diagnosis section has been expanded. Prevalence, complications and antibiotic choice sections have been added to the sinusitis topic for acute sinusitis. Clinicians should be aware of the updated and new information.

NICE Guidance July 2018

There has been one guideline published in July 2018 by the National Institute for Clinical Excellence which has an impact upon primary care.

The new Rheumatoid arthritis in adults guideline covers diagnosis and management of rheumatoid arthritis and replaces existing guidance. The guideline aims to improve quality of life for patients with rheumatoid arthritis by ensuring they have access to the right treatment to slow the progression of their condition and to control their symptoms. The guideline also states that patients should have immediate access to specialist care if their condition worsens.

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

CKS Updates July 2018

During the month of July 2018, the following Clinical Knowledge Summaries were updated:  New topics were published for: There have been substantial changes to some of the topics listed above.  Notably, the fungal skin infection – foot, has had notes on complications, definition, prevalence, prognosis, risk factors and complications added to the background information section. The prescribing information section has been updated and expanded for this topic and the osteoarthritis topic. Clinicians should be aware of the updated and new information.

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 August 2018
New issues


There is currently limited availability of enoxaparin sodium 120mg and 150mg in the UK. AROVI (20 / 40 / 60 / 80 / 100 / 120 and 150mg) is an alternative product which is currently available with those 2 strengths which can be ordered via Alloga UK (Trusts/Hospitals) or Alliance Healthcare (Community Pharmacies).  
The company has educational materials to support HCP and patients on the use of the product.


Teva, who are the sole supplier of promazine, have advised that this line is currently out of stock and they are expecting stock to return as follows;
  • 25mg due back end of September
  • 50mg due back mid-October 2018
As the 50mg is not due back until October, this will increase demand for the 25mg so supplies for the 25mg may become restricted when they do return back into stock. Work has been undertaken with Teva to try and make supplies available as soon as possible. Rosemont have advised that the oral liquid preparation remains available in both 25mg/5ml and 50mg/5ml.
Adalat (Nifedipine) all products 

Bayer, the supplier of Adalat which is a range of Nifedipine oral preparations is due to be out of stock of several of the Adalat (Nifedipine) range. They have provided official communications about the shortage and listed the other preparations of Adalat (Nifedipine) that remain available to order as well as contact details for healthcare professionals to obtain further advice and support.

The supplies of other Nifedipine capsules and tablets remain available currently, including;
  • Adipine (Chiesi)
  • Coracten (UCB)
  • Nifedipress (Dexcel)
  • Tensipine (Genus)
UKMI have issued a shortages memo, which will provide advice on alternatives, this is available on the SPS website:
Alvesco (Ciclesonide)  

AstraZeneca have alerted us to a supply issue with Alvesco (Ciclesonide) inhalers which is affecting all strengths. Resupply is anticipated mid-September 2018 for the Alvesco 160 and mid-October for the Alvesco 80. AstraZeneca have issued a communication letter to customers. Please see attached.


There have been recent supply issues with Phenergan (Promethazine) 25mg tablets from Sanofi and there is currently no stock available and no dates have been advised as to when they will be back in stock. Phenergan (Promethazine) 10mg tablets and Phenergan (Promethazine) oral liquid remain available to order. Avomine (Promethazine) 25mg tablets remain available from Manx Healthcare via wholesalers.

 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.

Kieron Donlon: - 0151 296 7076

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