Issue 39 - October 2020
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Welcome to October's edition of Tablets, a prescribing newsletter produced monthly by the Medicines Management team at Midlands and Lancashire CSU.


Formulary Update

New Medicines

BLACK ELTROMBOPAG film-coated tablets (Revolade®) for Acquired Severe Aplastic Anaemia
Routine review of existing black statement. No significant changes as no additional evidence was found to address any of the initial concerns around clinical- and cost-effectiveness. For inclusion on the static list.

GREY FOSTAMATINIB tablets (Tavlesse®▼) for the treatment of chronic immune thrombocytopenia (ITP) 
Not recommended until NICE TA published.

GREY OMALIZUMAB solution for injection (Xolair®) for chronic rhinosinusitis with nasal polyps 
Not recommended until NICE TA published.

Free of Charge Medicines Schemes
RMOC Free of Charge (FOC) Medicines Scheme Advice
Pan Mersey Free of Charge (FOC) Medicines Scheme - request for approval

The Pan Mersey APC has approved the RMOC FOC Medicines Scheme advice (2020) as local policy. 
Requests for approval should be submitted to the commissioner using this separate template. 

Formulary and Guidelines

Chronic obstructive pulmonary disease
COPD guideline updated version now based on latest NICE guidelines. Previous version was based on GOLD guideline as previous NICE guidelines were significantly out of date. Emphasis as before on suggested first line options, but actual choice of device can be any on formulary.

Out-of-area Prescribing Requests
Out of area requests (from secondary/tertiary care specialists outside Mersey) - position statement providing guidance to GPs on how to deal with non-formulary requests and requests that treat a drug as a different RAG designation to Mersey position.

Sequential use of biologics
Ankylosing spondylitis pathway
Psoriasis biologics guideline
Psoriatic arthritis pathway
Rheumatoid arthritis pathway

Minor wording changes to guidelines on sequential use of biologics and high cost drugs, intended to remove any ambiguity that the guidelines contradict the RMOC statement on sequential use of these agents. There is no actual change to the substance of each of the guidelines or costs, it is purely to avoid any perceived contradiction to RMOC. 


Managing common infections in adults
First of two parts covering upper and lower respiratory tract infection, urinary tract infection, meningitis, gastrointestinal and suspected dental infection.


The Midlands and Lancashire CSU has a dedicated COVID-19 webpage which is updated daily.

Please note that this information is up to date at the time of publication. 

The list of resources will be updated as new material becomes available so please check back regularly for updates.

This page groups the resources by subject matter. The same list of resources is also available grouped by the organisation that issued it.

COVID-19 Resources

Safety Update

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

Update From The CAS Helpdesk: Changes To MHRA Alerts And Amendments To The Website
17 September 2020

The Medicines and Healthcare products Regulatory Agency (MHRA) is now an accredited issuer of National Patient Safety Alerts. This means there will be some changes to what you receive from CAS as set out in the attached document. There are also some changes to the website and a reminder to organisations to register out of hours email addresses with us if you have them.

Opioids: risk of dependence and addiction 
23 September 2020

New recommendations following a review of the risks of dependence and addiction associated with prolonged use of opioid medicines (opioids) for non-cancer pain. Before prescribing opioids, discuss with the patient the risks and features of tolerance, dependence, and addiction, and agree together a treatment strategy and plan for end of treatment.

Transdermal fentanyl patches for non-cancer pain: do not use in opioid-naive patients
23 September 2020

Following a review of the risks associated with use of opioid medicines for non-cancer pain, the Commission on Human Medicines (CHM) has recommended that fentanyl transdermal patches are contraindicated in opioid-naive patients in the UK.

Methotrexate once-weekly for autoimmune diseases: new measures to reduce risk of fatal overdose due to inadvertent daily instead of weekly dosing
23 September 2020

In autoimmune conditions and some cancer therapies, methotrexate should be taken once a week; however, we continue to receive reports of inadvertent overdose due to more frequent dosing (including daily administration). New measures have been implemented to prompt healthcare professionals to record the day of the week for intake and to remind patients of the dosing schedule and the risks of overdose.

Insulins (all types): risk of cutaneous amyloidosis at injection site
23 September 2020

Cutaneous amyloidosis at the injection site has been reported in patients using insulin and this may affect glycaemic control. Remind patients to rotate injection sites within the same body region.

Prescribing News

NICE Guidelines September 2020

There have been three guidelines, one technology appraisal and one antimicrobial guideline published in September 2020 by the National Institute for Clinical Excellence which has impact upon primary care.

The Low back pain and sciatica in over 16s: assessment and management guideline has been updated and published. The guideline covers the assessment and management of low back pain and has been updated to include several recommendations on the pharmacological management of sciatica. The guideline makes reference to a guideline which is in development, medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management, which is due for publication next year.  

The Neuropathic pain in adults: pharmacological management in non-specialist settings guideline has been updated and published. The guideline covers the management of neuropathic pain with pharmacological treatments in adults in non-specialist settings. Evidence on treating sciatica has been reviewed and new recommendations on pharmacological treatments have been added.  

The Suspected cancer: recognition and referral guideline has been updated and published. The guideline covers identifying children, young people and adults with symptoms that could be caused by cancer.   

The Insect bites and stings: antimicrobial prescribing guideline has been published. An antimicrobial prescribing strategy for insect and spider bites and stings in adults, young people and children has been set out.    

The Naldemedine for treating opioid-induced constipation technology appraisal has been published. The appraisal recommends naldemedine within its marketing authorisation, as an option for treating opioid induced constipation in adults who have had laxative treatment.

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

CKS Updates September 2020

During the month of September 2020, the following Clinical Knowledge Summaries were published or updated: All the above topics have been reviewed and updated in line with NICE guidance.
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

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.

Drug Tariff Changes

Drug tariff price changes 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.

Drug tariff price changes for October


Antimicrobial Update

Please see below for a full summary of antimicrobial related guidelines and SPC updates in September.

Guidance and Advice

Inactivated influenza vaccine: information for healthcare practitioners
This document includes detailed information on: the background of the programme; the different types of inactivated influenza vaccine; influenza vaccine recommendations and eligibility; contraindications and precautions and vaccine administration issues. 

Insect bites and stings: antimicrobial prescribing - NG182 
Guidance sets out an antimicrobial prescribing strategy for insect bites and stings in adults, young people & children aged 72 hours and over, including those that occurred while travelling outside the UK. It aims to limit antibiotic use & reduce antibiotic resistance. 

Primary Research

Association of Fluoroquinolones With the Risk of Aortic Aneurysm or Aortic Dissection 
Cohort study found an increased rate of aortic aneurysm or aortic dissection for fluoroquinolones vs azithromycin for treatment of pneumonia (HR 2.57, 95%CI 1.36-4.86), but no increased rate vs combined trimethoprim and sulfamethoxazole for UTI. 

Association of Infections and Use of Fluoroquinolones With the Risk of Aortic Aneurysm or Aortic Dissection 
Study (28,948 cases and 289,480 matched controls) found that fluoroquinolones were not associated with increased risk of aortic aneurysm/aortic dissection risk vs amoxicillin-clavulanate, ampicillin-sulbactam or extended-spectrum cephalosporins. 

Imiquimod versus podophyllotoxin, with and without human papillomavirus vaccine, for anogenital warts: the HIPvac factorial RCT 
RCT (n=503) did not find a benefit of the vaccine; odds of clearance at week 16 and remaining clear at week 48 were 46% higher with vaccine, but difference was not statistically significant. Imiquimod and podophyllotoxin creams had similar efficacy for wart clearance. 

Systematic Review

Natural history of uncomplicated urinary tract infection without antibiotics: a systematic review 
Review (3 RCTs, n=346) states duration of symptoms without use of antibiotics remains unclear, but some women appear to improve or become symptom free spontaneously (with most improvement in the first 9 days) and others failed to improve or became worse over a variable timespan. 


Corticosteroids as standalone or add‐on treatment for sore throat 
In this updated review (9 RCTs, n=1,319) results showed participants who received corticosteroids were 2.4 times more likely to experience complete resolution of sore throat symptoms by 24 hours than those who received placebo. 

Efficacy and safety of rapid tests to guide antibiotic prescriptions for sore throat  
Review (5 trials; n=2545 children and adults) found that rapid testing to guide antibiotic treatment for sore throat in primary care probably reduces antibiotic prescription rates by 25% (absolute risk difference), but may have little or no impact on antibiotic dispensing. 

Summary of Product Characteristics Updates

Tamiflu (oseltamivir) 6 mg/ml Powder for Oral Suspension 
SPC now warns that excipient sorbitol may cause gastrointestinal discomfort and can have a mild laxative effect, and sodium benzoate (E211) may increase jaundice in newborn babies (up to 4 weeks old). 


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.

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