Issue 51 - January 2022
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Welcome to January's edition of Tablets, a prescribing newsletter produced monthly by the Medicines Management team at Midlands and Lancashire CSU.


Formulary Update

New Medicines 

GREY ABROCITINIB tablets (Cibinqo®▼) for atopic dermatitis 
Not recommended until NICE TA published. 

GREY MOMETASONE / OLOPATADINE nasal spray (Ryaltris®) for allergic rhinitis 
Not recommended. This will be reviewed if a formal application for use is received and prioritised for in-year review. 

RED  UPADACITINIB prolonged-release tablets (RINVOQ®▼) for treating moderate rheumatoid arthritis  
Red statement in line with NICE TA744 that recommends  upadacitinib as an option for treating active rheumatoid arthritis in adults whose disease has responded inadequately to intensive therapy with 2 or more conventional disease modifying antirheumatic drugs, only if disease is moderate (a disease activity score [DAS28] of 3.2 to 5.1) and the company provides upadacitinib according to the commercial arrangement.  

RED  ANDEXANET ALFA infusion (OndexKxya®▼) for reversing anticoagulation from apixaban, edoxaban or rivaroxaban 
Update to the existing red statement for use of andexanet alfa for anticoagulant reversal for apixaban and rivaroxaban in accordance with NICE TA697 to include off-label use as anticoagulant reversal for edoxaban (using the same criteria as NICE TA697).  

AMBER DAPAGLIFLOZIN tablets(Forxiga ®) for symptomatic chronic heart failure with reduced ejection fraction 
Updated document, change in RAG rating to amber recommended. 

Formulary and Guidelines

RED  Risankizumab 150 mg pen and 150 mg pre-filled syringe - psoriasis, psoriatic arthritis 
Replaces 75 mg x 2 pre-filled syringe, being discontinued. Confidential NHS Patient Access Scheme (PAS) price per dose remains unchanged. 

RED  Tofacitinib 11mg m/r tablets (once daily formulation) - rheumatoid arthritis, psoriatic arthritis 
Additional to tofacitinib 5mg twice daily formulation. Confidential NHS Patient Access Scheme (PAS) daily cost same as for the 5mg tablets. 

GREEN  Exenatide 2mg BCise pen prolonged-release injectable suspension – type 2 diabetes 
Replaces exenatide 2 mg powder and solvent prolonged-release suspension for injection in pre-filled pen, which is discontinued. Price is unchanged. 

Guidelines for Managing Malnutrition in Adults in the Community 
Addition of clarification to Appendix 4 of guideline that contact with free online “direct to patient sample service” from manufacturers can only be made by health care professionals. 


Safety Update

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

Adrenaline auto-injectors: reminder for prescribers to support safe and effective use

16 November 2021

Emerade 300 and 500 microgram adrenaline auto-injectors have been re-supplied to the market following the implementation of corrective actions – patients and their caregivers should be provided with training and advice specific to their prescribed adrenaline auto-injector. Follow the advice in the Summary of Product Characteristics for dosing considerations and continue to reiterate to patients the importance of carrying 2 in-date adrenaline auto-injectors with them at all times.

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

Haloperidol (Haldol): reminder of risks when used in elderly patients for the acute treatment of delirium

10 December 2021

We remind healthcare professionals that elderly patients are at an increased risk of adverse neurological and cardiac effects when being treated with haloperidol for delirium. The lowest possible dose of haloperidol should be used for the shortest possible time, and cardiac and extrapyramidal adverse effects should be closely monitored.


Prescribing News

NICE Guidance November & December 2021

There are four guidelines and one COVID-19 rapid guideline published in November 2021 by the National Institute for Clinical Excellence which has an impact upon primary care.

The Heart valve disease presenting in adults: investigation and management guideline has been published. It covers the investigation and management of heart valve disease presenting in adults.

The Acute heart failure: diagnosis and management guideline has been updated. Recommendations on valvular surgery and percutaneous intervention have been withdrawn and replaced by the new guideline above.

Type 2 diabetes in adults: management guideline has been updated. The update reviewed the evidence and made new recommendations for SGLT2 inhibitors for adults with type 2 diabetes and chronic kidney disease.

The Chronic kidney disease: assessment and management guideline has been updated. The guidance on SGLT2 inhibitors for adults with type 2 diabetes and chronic kidney disease has been updated and links to the Type 2 diabetes in adults guideline.

The COVID-19 rapid guideline: managing the long-term effects of COVID-19 guideline has been updated. The update makes new recommendations and updates existing recommendations in several areas including identification, planning care, multidisciplinary rehabilitation, and follow-up. The list of common symptoms was also updated, emphasising that these may be different for children.

There are three guidelines and two technology appraisals published in December 2021 by the National Institute for Clinical Excellence which has an impact upon primary care.

The Headaches in Over 12s: diagnosis and management guideline has been updated. The update changed the strength of the recommendations on metoclopramide or prochlorperazine for acute migraine from ‘offer to ‘consider’, to reflect the balance of benefits and risks of these treatments.  

The Suspected cancer: recognition and referral guideline has been updated. This update reviewed the evidence on fixed and age-adjusted thresholds for prostate-specific antigen testing and updated the recommendations on referral for suspected prostate cancer.  

The Pelvic floor dysfunction: prevention and non-surgical management guideline has been published. The guideline covers the prevention, assessment and non-surgical management of pelvic floor dysfunction in women aged 12 and over.

The Mexiletine for treating the symptoms of myotonia in non-dystrophic myotonic disorders technology appraisal has been published. This treatment is recommended, within its marketing authorisation, as an option for treating the symptoms of myotonia in adults with non-dystrophic myotonic disorders.

The Liraglutide for managing obesity in people aged 12 to 17 years technology appraisal has been terminated due to the manufacturer not providing an evidence submission.
Clinicians should be aware of this guideline and implement any necessary changes to their practice. 

CKS November 2021

During the month of November 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. The Otitis externa topic has removed information on oral flucloxacillin, and clarithromycin as oral antibiotics are not routinely needed in primary care for the management of uncomplicated acute otitis externa. The Stroke and TIA topic has removed a recommendation that suspected Transient Ischaemic Attack (TIA) taking anticoagulants should not be given an immediate dose of aspirin 300mg. This intervention is likely to carry a low risk of causing or aggravating bleeding and aspirin can now be given.  

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 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. 

Antimicrobial Update

Please see below for the antimicrobial related guidelines and click here to find SPC updates in November.

Fever in under 5s: assessment and initial management – updated guidance (NG143) 

Updated guidance includes a definition of sepsis (a condition of life-threatening organ dysfunction due to a dysregulated host response to infection), and cross reference to the risk stratification tool in the NICE guidance on sepsis (NG51).

Identifying women’s preferences for treatment of urinary tract infection: a discrete choice experiment 
Dutch qualitative study (n=833) found a considerable proportion of women valued alternatives to antimicrobial treatment and were prepared to tolerate management that was less optimal in certain respects to avoid antimicrobial treatment.

Please see below for the antimicrobial related guidelines and click here to find SPC updates in December.

Recognition of the acutely ill infant

Investigation follows case of a 3-month-old infant admitted and discharged 4 hours later, then re-admitted less than four hours later, who died of Meningococcus (serogroup B). It makes five safety recommendations.

Using miconazole oral gel to treat oral thrush in adults taking a statin

Treatment of oral thrush with miconazole is complicated by concurrent statin use because of the potential for drug interactions. This article covers what to consider when prescribing, the interaction mechanism and advice for individual statin, and counselling points.
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:

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