June 2021
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Welcome to June's edition of Tablets, a prescribing newsletter produced monthly by the Medicines Management team at Midlands and Lancashire CSU.


Formulary Update

New medicines

RED ANDEXANET ALFA infusion (Ondexxya®▼) for reversing anticoagulation from apixaban or rivaroxaban
Andexanet alfa is recommended for anticoagulant reversal in adults taking apixaban or rivaroxaban and only for those experiencing life threatening or uncontrolled bleeding where the bleed is in the gastrointestinal tract.  

GREEN BEMPEDOIC ACID tablets (Nilemdo®▼) and BEMPEDOIC ACID-EZETIMIBE tablets (Nustendi®▼) for primary hypercholesterolaemia or mixed dyslipidaemia: a multiple prescribing statement 
Bempedoic acid is only recommended when given in combination with ezetimibe, either as separate tablets or a fixed-dose combination.  

Formulary and guidelines

RED Inflammatory Bowel Disease High Cost Drugs Treatment Pathway for Adults
Minor update to include the use of infliximab for acute exacerbations of ulcerative colitis. This is in the additional information box on page 3. Methotrexate and polymeric diets have been added to the top box in the Crohn’s disease pathway. 

AMBER INITIATED Direct Oral Anticoagulants(DOACs) for the treatment and prevention of Deep Vein thrombosis and/or pulmonary embolism
Full review of the existing statement which follows NICE NG158 (Venous thromboembolic diseases: diagnosis, management and thrombophilia testing), published in March 2020. NICE say these new recommendations are expected to lead to increased use of DOACs, particularly apixaban and rivaroxaban, but this guidance will result in savings for the NHS. 

AMBER RECOMMENDED AZITHROMYCIN tablets for prevention of exacerbations of COPD and bronchiectasis in selected high-risk patients
Routine review of the existing statement which is now based on the British Thoracic Society Guideline for Long Term Macrolide Use, published in April 2020. Some dosing and supporting evidence have been updated and a new GP letter was developed.

Shared care

AMBER RETAINED Amiodarone prescribing support information
Routine review of the existing prescribing support information and a new GP letter. 6monthly U&E monitoring as recommended in the NICE CKS on atrial fibrillation was added. 

AMBER RETAINED Hydroxychloroquine prescribing support information
Routine review of the existing prescribing support information incorporating additional guidance from the Royal College of Ophthalmology guidelines published in 2020. The GP letter has also been adapted to reflect the updated guidance. 


CLOZAPINE: reducing the risk of harm
New document, originally in response to an MHRA update on the risk of constipation, broadened to accommodate prescribing advice issued to GPs from specialist mental health trusts. Advice is intended to support best practice to reduce the risk of or mitigate the harms from clozapine use.

Safety Update

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

Management of chronic asthma in children aged 16 years and under - Report  
05 May 2021 
Report was produced following a case of a near fatal attack of asthma in a 5 year old. It makes seven recommendations that provide system solutions to the management of asthma. They focus broadly on developing resources to encourage behaviour change and information sharing.  
19 May 2021 
If a patient reports persistent symptoms when switching between different levothyroxine tablet formulations, consider consistently prescribing a specific product known to be well tolerated by the patient. If symptoms or poor control of thyroid function persist (despite adhering to a specific product), consider prescribing levothyroxine in an oral solution formulation.

Prescribing News

NICE Guidelines May 2021

There have been three guidelines and one technology appraisal published in May 2021 by the National Institute for Clinical Excellence which has impact upon primary care.

The Heavy menstrual bleeding: assessment and management guideline has been updated and published. The update reinstates recommendations on the use of ulipristal acetate (Esmya®) for uterine fibroids in line with updated MHRA safety advice on risk of serious liver injury.

The Epilepsies: diagnosis and management guideline has been updated and published. The update has reviewed and amended recommendations on carbamazepine, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, phenobarbital, phenytoin, pregabalin, topiramate and zonisamide in line with the MHRA updated safety advice on antiepileptic drugs in pregnancy.

The Headaches in over 12s: diagnosis and management guideline has been updated and published. The update has amended it’s recommendation on topiramate for migraine prophylaxis to include discussion of the potential benefits and risks, and the importance of effective contraception for women and girls of childbearing potential when taking topiramate.

The Crisaborole for treating mild to moderate atopic dermatitis in people 2 years and older technology appraisal has been terminated. The manufacturer withdrew its evidence submission and therefore no recommendation can be made at this time.  

Clinicians should be aware of this guideline and implement any necessary changes to their practice. 

CKS Updates May 2021

During the month of May 2021, the following Clinical Knowledge Summaries were published or updated: All the above topics have been reviewed and updated in line with NICE guidance with minor layout changes. No major changes have been made within these topics.

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.

Drug Tariff Price 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 in June 

Antimicrobial Update

Please see below for the antimicrobial related guidelines and SPC updates in May.

Malaria prevention guidelines for travellers from the UK: 2021 update 
Due to the COVID-19 Pandemic, it was not possible to finalise a 2020 edition. Key changes in this update of the guidelines include changes to the section on insect bite avoidance, and addition of several new maps.

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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