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


Formulary Update

New Medicines
Erenumab is the third CGRP antagonist to be recommended by NICE for preventing migraine. PBR excluded high cost drug, for specialist use only and at the 140mg dose only. NICE does not expect implementing this guidance to have a significant impact on resources because this is a further treatment option, alongside fremanezumab and galcanezumab, and the overall cost of treatment will be similar once the PAS discounts are applied. 
There is no significant new evidence and no significant changes have been made. Although this would meet criteria for Amber Initiated, the patient numbers are not enough to alleviate concerns raised at the previous APC meeting and this will be kept as Amber Retained, with a view to changing to Amber Initiated in a further 12 months following another review 

Formulary and Guidelines
NHS England has advised romiplostim and eltrombopag are to be considered first-line treatments for idiopathic thrombocytopenia purpura (ITP) rather than conventional treatments (steroids, immunoglobulin) for the duration of the Covid-19 pandemic. 
Update of existing guideline. Revisions to guideline and drug recommendations amended in response to changes in cost. 
Update of existing guideline with updated list of preferred first line choices of oral nutritional supplements 
Update of current pathway. Includes CGRP antagonists (erenumabfremanezumabgalcanezumab), migraine prevention drugs (hospital only) for information, and clarification on topiramate contraceptive advice. 
Minor amendment to existing guideline, clarifying soft mist inhaler is not a metered-dose inhaler.

Safety Update

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

Polyethylene glycol (PEG) laxatives and starch-based thickeners: potential interactive effect when mixed, leading to an increased risk of aspiration
27 April 2021
Addition of a polyethylene glycol (PEG)-based laxative to a liquid that has been thickened with a starch-based thickener may counteract the thickening action, placing patients with dysphagia at a greater risk of aspiration.

Using chloramphenicol eye drops in children under 2 years
29 April 2021
The SPS website now features a webpage signposting information on this issue, which currently includes regulatory advice from the European Medicines Agency and clinical advice from the Royal College of Ophthalmologists.


Prescribing News

NICE Guidelines April 2021

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

The Chronic pain (primary and secondary) in over 16s guideline has been published. The guideline covers assessing all chronic pain and the management in people aged 16 years and over.

The Neonatal infection: antibiotics for prevention and treatment guideline has been published. The guideline covers preventing bacterial infection in healthy babies of up to and including 28 days corrected gestational age, treating pregnant women whose unborn baby is at risk of infection, and caring for babies of up to and including 28 days corrected gestational age with a suspected or confirmed bacterial infection.  

The Postnatal care guideline has been published. The guideline covers the routine postnatal care that women and their babies should receive in the first 8 weeks after the birth.

The Atrial fibrillation: diagnosis and management guideline has been published. The guideline covers diagnosing and managing atrial fibrillation in adults, including assessing and managing risks of stroke and bleeding.
The Bempedoic acid with ezetimibe for treating primary hypercholesterolaemia or mixed dyslipidaemia technology appraisal has been published. The treatment is recommended as an option for treating primary hypercholesterolaemia (heterozygous familial and non-familial or mixed dyslipidaemia as an adjunct to diet in adults. It is recommended only if:  
  • statins are contraindicated or not tolerated,
  • ezetimibe alone does not control low-density lipoprotein cholesterol well enough, and
  • the company provides bempedoic acid and bempedoic acid with ezetimibe according to the commercial arrangement
It is noted that bempedoic acid with ezetimibe can be used as separate tablets or a fixed-dose combination.

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

CKS Updates April 2021

During the month of April 2021, the following Clinical Knowledge Summaries were published or updated: The Chronic Pain topic is new, and covers the assessment and management of people with chronic pain. All of the other above topics have been reviewed and updated in line with NICE guidance with minor layout changes.

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

The information in the Prescribing News section has been adapted from the Prescribing Advice for GPs blog at

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 May 

Antimicrobial Update

Please see below for the antimicrobial related guidelines and SPC updates in April.
At the present time, the Royal College of Ophthalmologists believes that the benefits of chloramphenicol eyedrops in paediatric ophthalmic practice for appropriate indications and with courses of appropriate duration outweigh the possible risks posed by boron ingestion.  
The SPS website now features a webpage signposting information on this issue, which currently includes regulatory advice from the European Medicines Agency and clinical advice from the Royal College of Ophthalmologists.  
Cross-sectional survey of US nursing homes, found prevalence of antimicrobial use was 8.2 per 100 residents (95% CI, 7.8-8.8). Antimicrobials were most often used to treat active infections, primarily UTIs, and fluoroquinolones were the most common antimicrobial class.  
Study (58 patients <16yrs discharged on oral anti-infectives) found only 51.7% were adherent to therapy. Non-adherence was mostly due to not following the administration schedule. Adherence rate for those taking 1-2 doses per day was double that of those taking >2 doses per day.  
Review notes that in 98% of cases the cause is bacterial, with Pseudomonas aeruginosa and Staphylococcus aureus the most common pathogens. Acute uncomplicated otitis externa can be managed effectively with topical treatments, for up to 14 days if required.  
This best practice advice, which is based on best available evidence (although not a formal systematic review), describes appropriate use of shorter durations of antibiotic therapy for common bacterial infections seen in both inpatient and outpatient health care settings.  
This JAMA Patient Page summarizes risk factors, symptoms, diagnosis, and treatment of giardiasis, an intestinal parasite infection that can cause gastrointestinal symptoms including nausea, stomach cramps, and prolonged diarrhoea.  
The randomised, double-blind 12-week study compared IDP-126 to vehicle gel, applied once daily for 12 weeks, in patients aged ≥9 years with acne vulgaris. All three co-primary endpoints were achieved, with treatment success in 50.5% versus 20.5% with the vehicle gel. 
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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