Issue 32 - February 2020
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Welcome to the February's edition of Tablets, a prescribing newsletter produced monthly by the Medicines Management team at Midlands and Lancashire CSU.


Formulary Update

New medicines

BLACK FLUOCINOLONE intravitreal implant (Iluvien®) for chronic diabetic macular oedema in phakic eyes
The Pan Mersey Area Prescribing Committee does not recommend the prescribing of FLUOCINOLONE intravitreal implant (Iluvien®) for treating chronic diabetic macular oedema in phakic eyes after an inadequate response to previous therapy, in accordance with NICE TA613.

RED LUSUTROMBOPAG tablets (Mulpleo®▼) for treating severe thrombocytopenia in adults with chronic liver disease having planned invasive procedures
The Pan Mersey Area Prescribing Committee recommends the prescribing of LUSUTROMBOPAG tablets (Mulpleo®▼), by specialists only, for treating severe thrombocytopenia in adults with chronic liver disease having planned invasive procedures in accordance with NICE TA617.

GREY NICOTINE inhaler (Voke®) for nicotine dependence
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of NICOTINE inhaler (Voke®) for nicotine dependence.

GREY RANIBIZUMAB solution for injection (Lucentis®) for the treatment of proliferative diabetic retinopathy
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of RANIBIZUMAB solution for injection (Lucentis®) for the treatment of proliferative diabetic retinopathy.

GREEN BRIMONIDINE TARTRATE Gel (Mirvaso®) for facial erythema of rosacea
Routine review of existing green statement; no significant changes. For inclusion on static list.The Pan Mersey Area Prescribing Committee recommends the prescribing of BRIMONIDINE TARTRATE Gel (Mirvaso®) for the treatment of moderate to severe, persistent facial erythema associated with rosacea in adults.


BLACK Aliskiren for hypertension
The Pan Mersey Area Prescribing Committee does not recommend the prescribing of ALISKIREN tablets (Rasilez®).

BLACK Co-trimoxazole
Designated red for long-term use, and for short-term use where the hospital clinician has requested sensitivities on a sample.

Designated amber recommended for short-term use where the GP has initially requested sensitivities on a sample, and they would then receive or request advice from a specialist with the recommendation for prescribing co-trimoxazole.

BLACK Eflornithine cream for hirsutism
The Pan Mersey Area Prescribing Committee does not recommend the prescribing of EFLORNITHINE 11.5% Cream (Vaniqa®) for hirsutism.

BLACK Minocycline for acne
The Pan Mersey Area Prescribing Committee does not recommend the prescribing of MINOCYCLINE for acne.

AMBER RECOMMENDED Freestyle Optium® blood glucose and ketone testing strips
The Pan Mersey Area Prescribing Committee recommends the prescribing of FreeStyle Optium® blood glucose and FreeStyle Optium® ß-ketone test strips only for use with FreeStyle Libre® specifically in patients who are using carbohydrate counting/ bolus advice.

AMBER RECOMMENDED Hydrocortisone injection
for adrenocortical insufficiency
For patients with adrenocortical insufficiency who may occasionally require intramuscular injection in an emergency when unable to take their oral medication. Secondary care will supply the needles and syringes as necessary to patients (as unable to be prescribed on FP10). Hydrocortisone injection and sharps disposal containers can be prescribed in primary care.

Ibuprofen and naproxen
Archiving of statement and replacement with link to NICE Clinical Knowledge Summary. Diclofenac now represents only 5% by volume of NSAID prescribing.


GREEN Guideline for non-specialist management of dry eye
Update to include Thealoz Duo®.

Shared care

AMBER RETAINED Ursodeoxycholic acid prescribing support information
New document that covers all the licensed indications (various hepatobiliary disorders).

PURPLE ADHD shared care frameworks
Extension of expiry to May 2020 while additional information is developed.


BLACK Ingenol mebutate gel (Picato) – risk of skin cancer
Previously green now black. Follows EMA and MHRA advice to stop prescribing. This advice was informed by the results of a three-year safety study that showed a 3.3% incidence of patients developing skin cancer versus 0.4% in the comparator group (imiquimod).

Safety Update

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

Sodium valproate Pregnancy Prevention Programme – updated Guide for Healthcare Professionals
17 Jan 2020
Changes include new sections titled “definition of specialist prescriber”, “contraception” and “does this apply to my patient”. The updated guide now also clarifies that provisions of prevent apply when a patient is switched from valproate to another treatment.

European Medicines Agency (EMA) suspends Picato (ingenol mebutate) gel as a precaution while review of skin cancer risk continues
23 Jan 2020
Final results from a study comparing Picato with imiquimod indicate a higher occurrence of skin cancer in the treatment area with Picato than with imiquimod. EMA’s safety committee (PRAC) is currently reviewing data on skin cancer in patients using Picato.

PRAC confirms four-week limit for use of high-strength estradiol creams (100 micrograms/gram [0.01%])
23 Jan 2020
Following a re-examination procedure, PRAC has confirmed its recommendation to minimise risk of side effects from absorption of high-strength estradiol creams into the bloodstream, following intravaginal administration to treat symptoms of vaginal atrophy in post-menopausal women

E-cigarette use or vaping: reporting suspected adverse reactions, including lung injury
28 Jan 2020
Be vigilant for any suspected adverse reactions associated with use of e-cigarettes or vaping (including lung injury) and report them to the MHRA via the Yellow Card Scheme. In this article we provide UK case definitions of e-cigarette or vaping associated lung injury (EVALI) to facilitate identification.

Ondansetron: small increased risk of oral clefts following use in the first 12 weeks of pregnancy
28 Jan 2020 
Recent epidemiological studies suggest exposure to ondansetron during the first trimester of pregnancy is associated with a small increased risk of the baby having a cleft lip and/or cleft palate.

Prescribing News

NICE Guidance January 2020 

There have been two guidelines and one technology appraisal published in January 2020 by the National Institute for Clinical Excellence which has impact upon primary care.

The Supporting adult carers guideline has been published. The topic covers support for adults (aged 18 and over) who provide unpaid care for anyone aged 16 or over with health or social care needs. The guideline aims to improve the lives of carers by helping health and social care practitioners identify people who are caring for someone and give them the right information and support. This guideline aims to cover carer’s assessment, practical, emotional and social support and training, and support for carer providing end of life care

The Colorectal cancer guideline has been published. The guideline covers managing colorectal cancer in people aged 18 and over and aims to improve the quality of life and survival for adults with colorectal cancer through management of local disease and management of secondary tumours (metastatic disease).   

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

CKS Updates January 2020 

During the month of January 2020, the following Clinical Knowledge Summaries were published or updated: The Cow’s milk protein allergy in children topic has been renamed in the topic area and the recommendations have been amended in line with current evidence regarding the assessment and management of suspected cow’s milk allergy. The topic also has a new prescribing information section which has been added to provide information on prescribing oral antihistamines, in line with the CKS topic on food allergy. The Tamoxifen – managing adverse effects topic now includes primary breast cancer in women at moderate or high risk as a licensed indication for tamoxifen in keeping with the product license.
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

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.

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 corner at 

To register on SPS click here.

Drug Tariff Changes

Drug tariff price changes for February 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. 

Antimicrobial Update

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

Oseltamivir plus usual care versus usual care for influenza-like illness in primary care: an open-label, pragmatic, randomised controlled trial
RCT (n=3266) found patients treated with oseltamivir recovered 1 day sooner on average than those managed by usual care alone (HR 1.29, 95% CI,1.20–1.39), whilst older, sicker patients with comorbidities and longer previous symptom duration recovered 2–3 days sooner.

DTB Select: Trends in antimicrobial prescribing in England 2014–2018
Summary and context is provided for this NHS England report. It discusses initiatives for next 5 years including diagnostic stewardship programs, support from clinical pharmacists & public awareness campaigns to encourage self-care & reduce expectations of antibiotics.

Vaccination in pregnancy
PHE has issued an updated request to healthcare practitioners to share details of any incidents where MMR, varicella or HPV vaccine was inadvertently given to women during their pregnancy or shortly before conception.

Efficacy, immunogenicity, and safety of an oral influenza vaccine: a placebo-controlled and active-controlled phase 2 human challenge study
RCT (n=179) found that influenza positive illness was detected in 29% of patients given an oral influenza vaccine vs 35% given intramuscular inactivated influenza vaccine and 48% given placebo after challenge. The oral vaccine was reported to be well tolerated.

Risk of herpes zoster after exposure to varicella to explore the exogenous boosting hypothesis: self controlled case series study using UK electronic healthcare data
Study of 9604 adults with both household exposure to varicella and an episode of zoster found that exposure to varicella is linked to reduction in risk of zoster by ~30% over 20 years, though findings cannot be used to justify for or against specific vaccination schedules.

Preventing healthcare associated Gram-negative bloodstream infections
This report makes suggestions about how to reduce infections with a collection of tools for local teams; emphasizing effective prevention of infection is multifaceted and requires strong leadership, effective training programmes and evidence-based guidelines and interventions.

Zinc acetate lozenges for the treatment of the common cold: a randomised controlled trial
Small RCT (n=87) reports no difference in the recovery rate between those randomised to zinc vs placebo during a 10-day follow-up (rate ratio for zinc vs placebo=0.68, 95% CI 0.42 to 1.08; p=0.10).

Increased fluid intake to prevent urinary tract infections: systematic review and meta-analysis
Review of 7 RCTs concludes increased fluid intake reduced the overall rate of all recurrent UTIs (rate ratio [RR] 0.46, 95% CI 0.40 to 0.54, P<0.001); however, further research is warranted to establish the optimal volume and type of fluid.

Recurrent Urinary Tract Infections in Adult Women
This JAMA Insights summarizes prevention and management recommendations and proposes individualizing approaches by age and menopausal status, underlying conditions (e.g. diabetes), risk of pyelonephritis/sepsis, and patient preferences. 
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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