Issue 41 - January 2021
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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 DAPAGLIFLOZIN tablets (Forxiga®) for heart failure with reduced ejection fractionNot recommended until NICE TA published.

AMBER INITIATED SACUBITRIL/VALSARTAN film-coated tablets (Entresto®▼) for chronic heart failure
Routine review of existing amber initiated statement, for inclusion on the static list. Key changes are the removal of the requirement for patients to be on stable optimised ACE inhibitor/Angiotensin-II receptor inhibitor for 3 months before sacubitril/valsartan is commenced and to clarify the definition of ‘specialist’. Cost impact unclear as uptake locally has been significantly less than estimated by NICE at the time the TA was published.

Supporting NWCSCN documents have also been updated and are hyperlinked within the policy statement.

Formulary and Guidelines

Vitamin B12 deficiency in adults
New guideline to address need for oral dosing instead of hydroxocobalamin injection during pandemic, and to promote self-care for prevention of dietary insufficiency. Includes use of newly licensed cyanocobalamin 1mg tablets.

GREEN Addition of cyanocobalamin 1mg tablets to formulary

TEMPORARY WITHDRAWAL Direct Oral Anticoagulants (DOAC) in venous thromboembolism - RAG designation, for suspected venous thromboembolism (VTE) within agreed local treatment pathway
The current Pan Mersey statement is no longer up to date with respect to NICE guidance and it is preferable to temporarily withdraw it pending review in line with NICE NG158

GREEN Vitamin D Deficiency in Adults guideline
Minor amendment to current guideline with information regarding vitamin D supplementation during COVID‑19 pandemic.

AMBER RECOMMENDED Thick & Easy® for dysphagia in paediatrics
Established choice of thickener for dysphagia in paediatrics – added to formulary to bring it in line with current practice.

Shared Care

PURPLE Routine review of the existing shared care frameworks for adults and children which follow NICE NG87 PURPLE New shared care frameworks for children attending Alder Hey Hospital and Wirral University Hospital


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 December.

Systemic and inhaled fluoroquinolones: small risk of heart valve regurgitation; consider other therapeutic options first in patients at risk
18 December 2020
Fluoroquinolones should only be used after careful benefit-risk assessment and after consideration of other therapeutic options in patients at risk for heart valve regurgitation (incompetence).

Erythromycin: caution required due to cardiac risks (QT interval prolongation); drug interaction with rivaroxaban
18 December 2020
Erythromycin has been associated with events secondary to QT interval prolongation such as cardiac arrest and ventricular fibrillation. Erythromycin should not be given to patients with a history of QT interval prolongation or ventricular cardiac arrhythmia, including torsades de pointes, or patients with electrolyte disturbances. 

Erythromycin: update on known risk of infantile hypertrophic pyloric stenosis
18 December 2020
Updates have been made to the magnitude of the known risk of infantile hypertrophic pyloric stenosis following exposure to erythromycin in infancy as a result of new epidemiological data.

Letter sent to Healthcare Professionals: Midazolam maleate (Epistatus 10mg in 1ml oromucosal soln, multidose bottle
21 December 2020
Letter advises of reports of unsecured bottle tops which can be removed without unscrewing. Consequences include evaporation of ethanol and subsequent crystallisation which may reduce concentration of midazolam. Bottles should be checked for secure caps and presence of crystals.

Prescribing News

NICE Guidelines December 2020

There have been eight guidelines, two COVID-19 rapid guidelines and one technology appraisal published in December 2020 by the National Institute for Clinical Excellence which has impact upon primary care.

The COVID-19 rapid guideline: managing the long -term effects of COVID-19 guideline has been published. The guideline covers identifying, assessing and managing the long-term effects of COVID-19, often referred to as ‘long COVID’.

The COVID-19 rapid guideline: vitamin D guideline has been published. The guideline covers vitamin D use in the context of COVID-19. It is for adults, young people and children in hospitals and community settings.

The Liraglutide for managing overweight and obesity technology appraisal has been published. The prescribing is restricted to secondary care by a specialist multidisciplinary tier 3 weight management service with a commercial agreement in place.

The Osteoarthritis: care and management guideline, Low back pain and sciatica in over 16s: assessment and management guideline and the Peripheral arterial disease: diagnosis and management guideline have both been updated in line with guidance on the use of opioids for non-cancer pain in response to a Public Health England evidence review on dependence on, and withdrawal from, prescribed medicines.

The Pancreatitis guideline and the Eating disorders: recognition and treatment guideline have both been updated in line with MHRA advice highlighting the importance of rotating insulin injection sites within the same body region.

The Type 1 diabetes in adults: diagnosis and management guideline and the Type 2 diabetes in adults: management guideline have both seen minor changes to the recommendations on diabetic retinopathy to align them with the NHS diabetic eye screening programme.

The Diabetes in pregnancy: management from preconception to the postnatal period guideline has seen changed recommendations on intermittently scanned CGM (isCGM, also commonly referred to as flash) and continuous glucose monitoring during pregnancy for women with type 1 diabetes.

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

NICE Guidelines November 2020

There has been one guideline published in November 2020 by the National Institute for Clinical Excellence which has impact upon primary care.

The Human and animal bites: antimicrobial prescribing guideline has been updated and published. The guideline sets out an antimicrobial prescribing strategy for human and animal bites (excluding insect bites) in adults, young people and children aged 72 hours and over.

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

CKS Updates November 2020
During the month of November 2020, 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 Menopause topic includes a lower age range of 35 to include the diagnosis and management of suspected premature ovarian insufficiency. Further information on non-hormonal therapy for the management of vasomotor symptoms and women with hypothyroidism, has been added to the section on managing co-morbidities. 

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 December

Drug tariff price changes for January


Antimicrobial Update

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

Human and animal bites: antimicrobial prescribing – guidance [NG184]
This guideline sets out an antimicrobial prescribing strategy for human and animal bites (excluding insect bites) in adults, young people and children aged 1 month and over. It aims to optimise antibiotic use and reduce antibiotic resistance.

DTB select: Safety of topical and oral terbinafine in pregnancy
Summary and context is provided for a large retrospective cohort study that reported oral or topical terbinafine use in pregnancy does not appear to be associated with an increased risk of major malformations or spontaneous abortion.

GP perspectives on acne management in primary care: qualitative interview study
Qualitative study (interviews with 20 GPs) revealed uncertainties regarding topical treatments, particularly around available products. Topical treatments were perceived as less effective, and there may be an element of patient pressure for prescribing oral antibiotics.

Antibiotic use and resistance: what the public know
This report presents the findings of a national household survey of public knowledge about anti-microbial resistance (AMR). It will help design campaigns to improve public understanding, reduce inappropriate antibiotic use and raise general awareness of the threat posed by AMR.

Using antibiotics wisely for respiratory tract infection in the era of covid-19
This practice pointer article outlines an approach to assessment and the role of antibiotics in patients presenting with respiratory tract infections based on their clinical presentations and whether their symptoms and testing results are compatible with covid-19.

English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) Report 2019 to 2020
Annual report shows there were an estimated 65,162 antimicrobial resistance infections diagnosed in 2019, up from 61,946 in 2018. E. coli remains the most common bloodstream infection, rising 14% in 2015 to 77.5 in 2019, which is a significant concern.

DTB select: Safety of oral fluconazole in early pregnancy
Expert review of large US population-based study (n=1,969,954 pregnancies) highlights that compared with topical azoles, oral fluconazole was associated with increased risk of musculoskeletal malformations equivalent to 12 additional incidents per 10,000 exposed pregnancies.

Natural history of non-bullous impetigo: A systematic review of time to resolution or improvement without antibiotic treatment
Review of 7 RCTs notes although uncertainty around natural history of non-bullous impetigo remains, symptoms resolve in some patients by ~7 days without using antibiotics, with ~about one-quarter of patients not improving, suggesting immediate antibiotic use may not be mandatory.

Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis, and Treatment of Lyme Disease
These guidelines, from the US perspective, make recommendations on reducing the risk of exposure to the disease, criteria for testing, antibiotic strategies, and how to manage specific manifestations e.g. Lyme disease–associated meningitis.

Summary of Product Characteristics updates

Ciproxin (ciprofloxacin) preparations
SPC has been updated following PRAC recommendation to include detail on the increased risk of aortic aneurysm and dissection, and of aortic and mitral valve regurgitation with fluoroquinolones. They should only be used after careful benefit-risk assessment.

Dalacin (clindamycin) T Topical Solution
SPC updated with information on congenital abnormalities associated with use of clindamycin in the first, second and third trimester of pregnancy; and warn about risk of use during breast-feeding. Also now advises that clindamycin has no effects on fertility/mating ability.

Flucelvax Tetra (influenza vaccine, surface antigen, inactivated) - suspension for injection in pre-filled syringe
SPC updated to reflect licence extension to cover use from age 2 years (previously 9 years).
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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