Issue 47 - July 2021
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Welcome to July's edition of Tablets, a prescribing newsletter produced monthly by the Medicines Management team at Midlands and Lancashire CSU.


Formulary Update

Updated document. Red RAG status now only applies to use of sodium zirconium cyclosilicate for the emergency treatment of hyperkalaemia (previously also included use in persistent hyperkalaemia). In-tariff use so no cost impact anticipated for CCGs. 
Prescribing and monitoring of sodium zirconium cyclosilicate must be retained by the specialist for at least one month after the patient is stabilised on the optimum RAAS inhibitor therapy / sodium zirconium cyclosilicate combination, with stable urea and electrolytes. 
Routine review at expiry, to be added to the static list due to no new evidence or significant changes within the document.  

Formulary and Guidelines
New Red statement developed to support existing secondary care use for achalasia, gastric motility disorder and gastroparesis. It is estimated that there will be 50-60 patients per year across the Cheshire & Mersey Network. This is the number being treated currently and no change in patient numbers is expected, therefore no significant cost impact. 
Prescribed by the Substance Misuse Service. 
Pathway updated to include upadacitinib and filgotinib use in line with recent NICE technology appraisals previously presented to APC (upadacitinib TA665, filgotinib TA676). 
AMBER INITIATED Freestyle Libre® 2 flash glucose monitor – updated  statement,  background information, and template GP letter.  
Background information document to provide sufficient information for primary care prescribers to switch existing Freestyle Libre® users to Freestyle Libre® 2. Flash glucose monitoring statement updated to state switching may take place in primary care. Template GP letter for use by specialist if they suggest switching to Freestyle Libre® 2. 
Change in designation from Black to Amber initiated for paediatrics only (remains designated Black for adults). Minimal cost impact. 
GREEN Sumatriptan pen injection 3mg – migrainecluster headache 
Additional strength, less expensive than 6mg strength already included in formulary. 

Safety Update

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

Letter to women and girls taking sodium valproate
15 June 2021
This letter has been sent to women and girls aged 12-55 who are currently prescribed sodium valproate and contains important reminders of safety considerations, including around contraception, pregnancy and regular prescribing reviews.

Public Assessment Report: safety of macrolide antibiotics in pregnancy: a review of the epidemiological evidence
28 June 2021
The overarching findings of this review are that the available evidence is insufficient to confirm with certainty the presence or absence of a small increased risk of malformations or miscarriage when macrolides are taken in early pregnancy.

Prescribing News

NICE Guidelines June 2021

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

The COVID-19 rapid guideline: managing COVID-19 has been updated and published. The update references publication via a global evidence platform.  

The Atrial fibrillation: diagnosis and management guideline has been updated and published. The update recommends using the ORBIT score to assess bleeding risk.

The Autism spectrum disorder in under 19s: support and management guideline has been updated and published. The update adds new recommendations on interventions for feeding problems, including restricted diets.

The Autism spectrum disorder in adults: diagnosis and management guideline has been updated and published. The updates clarifies that a person who scores 6 or above on the AQ-10 should be offered a comprehensive assessment.

The Patient experience in adult NHS services guideline has been updated and published. The update replaces several recommendations on shared decision making.

The Acne vulgaris: management guideline has been published. The guideline covers the management of acne vulgaris in primary and specialist care including advice on topical and oral treatments, treatment using physical modalities, and the impact of acne vulgaris on mental health and wellbeing.

The Shared decision making guideline has been published. The guideline includes recommendations on training, communicating risks, benefits and consequences, using decision aids, and how to embed decision making in organisational culture and practices.

The Budesonide orodispersible tablet for inducing remission of eosinophilic oesophagitis technology appraisal has been published. The treatment is recommended as an option for inducing remission of eosinophilic oesophagitis in adults. Since the appraisal process began, the product license has been extended to include maintenance treatment but as no evidence was submitted for the newly licensed indication, no recommendation is made at this time for maintenance.

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

CKS Updates June 2021

During the month of June 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 Vitamin D deficiency in adults topic has updated the recommendation on who should take year-round vitamin D supplementation for the prevention of vitamin D deficiency, in line with PHE guidance. The Vitamin D deficiency in children topic has changed the recommended dose for vitamin D supplementation for prevention of vitamin D deficiency in line with ROS guidance.  
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 price tariff changes in July

Antimicrobial Update

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

Revised SPC: Efracea (doxycycline) 40mg Modified Release Hard Capsules
Data from the ANSWER study, evaluating doxycycline modified-release capsules (versus placebo) added to ivermectin for the treatment of adults with severe rosacea have been added to the SPC.

New products: Cefazolin 1g and 2g powder for solution for injection/infusion
This is licensed for treatment of skin/soft tissue infections and bone/joint infections caused by susceptible micro-organisms, and perioperative prophylaxis (combination with drug with anaerobic activity recommended for operations with increased risk of infections with anaerobes)

A Case of Acute Pancreatitis Induced by Voriconazole during Treatment of Cryptococcal Meningitis
This care report describes the use of voriconazole in a 16-year-old adolescent female who developed acute severe pancreatitis for 35 days, which resolved when treatment was discontinued. The phenomenon of voriconazole-induced pancreatitis is considered extremely rare.

Tuberculosis (TB) action plan for England, 2021-26

The TB action plan will build on the improvements in prevention, detection and control of TB in England over the past 10 years, and enable the UK to meet its commitment to the World Health Organisation and eliminate TB in England by 2035.
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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