Issue 43- March 2021
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Welcome to March's edition of Tablets, a prescribing newsletter produced monthly by the Medicines Management team at Midlands and Lancashire CSU.

This newsletter replaces the previous edition with correction to article regarding chloramphenicol eye drops. 


Formulary Update

New Medicines
Brolucizumab is an additional anti-VEGF agent for treating wAMD, to sit alongside ranibizumab and aflibercept in the treatment pathway. PBR excluded high cost drug, for specialist use only.  
Not recommended until NICE TA published.  
Not recommended until NICE TA published.  
Not recommended until NICE TA published.  
Formulary and Guidelines 
Addition of oral formulation to formulary. Cost neutral in comparison with injectable formulation. 
Update of current statement at review-by date – minor changes regarding specialist to specify garment size. 

This document brings together a number of resources clinicians can use to support the appropriate use and review of opioids used for chronic pain. 

The final part now complete. All chapters are available on the APC websiteCCG medicines management teams are requested to circulate this information to prescribers.


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 February. 

Opioid safety: striking the right balance
08 February 2021
Editorial discusses difficulties in balancing benefits of treatment in limited life expectancy against risks of opioid addiction with long term use and adds that healthcare professionals will need to be aware of the patient’s circumstances to avoid giving conflicting advice.

Pregabalin (Lyrica): reports of severe respiratory depression
18 February 2021
Pregabalin has been associated with infrequent reports of severe respiratory depression, including some cases without the presence of concomitant opioid medicines.

Alkindi (hydrocortisone granules): risk of acute adrenal insufficiency in children when switching from hydrocortisone tablet formulations to granules  
18 February 2021
When children receiving replacement therapy for adrenal insufficiency are being switched from hydrocortisone tablets to Alkindi granules, parents or carers should be informed of the need to be extra vigilant for symptoms of adrenal insufficiency.

Discontinuation Of Morphine Sulphate (Mst Continus) 20mg, 30mg, 60mg, 100mg And 200mg Prolonged Release Granules For Oral Suspension
26 February 2021
All strengths of MST Continus® prolonged release granules for oral suspension are being permanently discontinued during 2021 due to difficulty sourcing a key excipient. Alternative morphine presentations, both prolonged release and immediate release, remain available and will be able to support increased demand. This alert contains further information and action for providers.

Chloramphenicol eye drops 0.5% w/v
December 2020
SPC section 4.3 updated to include the contraindication that it must not be given to a child less than 2 years old as it contains boron and may impair fertility in the future. In line with the European Commission guideline on `Excipients in the labelling and package leaflet of medicinal products for human use' (Reference: EMA/CHMP/302620/2017). Off-label use of chloramphenicol eye ointment for children aged under 2 years should follow
General Medical Council guidance on prescribing unlicensed medicines

Prescribing News

NICE Guidelines February 2021

There is one technology appraisal published in February 2021 by the National Institute for Clinical Excellence which has impact upon primary care.

The Dapagliflozin for treating chronic heart failure with reduced ejection fraction technology appraisal has been published. It is noted that this treatment should only be started on the advice of a heart failure specialist. This treatment is recommended as an option for treating symptomatic chronic heart failure with reduced ejection fraction in adults, only if it is used as an add-on to optimised standard care with:
  • angiotensin-converting enzyme (ACE) inhibitors or angiotensin‑2 receptor blockers (ARBs), with beta blockers and, if tolerated, mineralocorticoid receptor antagonists (MRAs), or
  • sacubitril valsartan, with beta blockers and, if tolerated, MRAs
Clinicians should be aware of this guideline and implement any necessary changes to their practice. 

CKS Updates February 2021

During the month of February 2021, the following Clinical Knowledge Summaries were published or updated: All of the above topics have been reviewed and updated in line with NICE guidance with minor layout changes. The two Contraception topics have had references to retired QOF indicators removed and have been updated in line with the Faculty of Sexual and Reproductive Healthcare (FSRH) guidance.

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 
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 February


Antimicrobial Update

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

Association between use of macrolides in pregnancy and risk of major birth defects: nationwide, register based cohort study
Study (n=1,192,539; 13,019 exposed) reports use of macrolide antibiotics in pregnancy was not associated with an increased risk of major birth defects compared with women who did not use any antibiotics (relative risk ratio 1.05; 95% CI 0.95 to 1.17 per 1000 pregnancies).

Comparative effectiveness and harms of antibiotics for outpatient diverticulitis
This American cohort study (n=106361) found treating diverticulitis in the outpatient setting with amoxicillin–clavulanate vs metronidazole with fluoroquinolone may reduce the risk for fluoroquinolone-related harms without adversely affecting diverticulitis-specific outcomes.

Systemic antibiotics for chronic suppurative otitis media
Review (18 studies; n=2135) concludes it is very uncertain if systemic antibiotics are more effective than placebo/no treatment, with seemingly little or no difference in resolution of ear discharge when added to an effective intervention, e.g. topical antibiotics (low certainty)

Best Practice Reminder: Avoid Nitrofurantoin in the Treatment of Pyelonephritis
This reminder highlights that nitrofurantoin should not be used if there are symptoms of pyelonephritis (such as fever), because it will not achieve adequate levels in renal tissue.

Enteric fever
Enteric fever (typhoid fever) is the commonest bacterial cause of fever in returning travellers and migrants from low and middle-income countries. This article discusses its presentation, diagnosis, investigations, complications, treatment and prevention.

Summary of Product Characteristics updates

Vibramycin-D (doxycycline) Dispersible Tablets 100mg
SPC updated with an addition of a warning regarding risk of exacerbating systemic lupus erythematous and undesirable effects of visual disturbances and link to cranial hypertension.
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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