Issue 24 - April 2019
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Welcome to the April edition of Tablets, a prescribing newsletter produced monthly by the Medicines Management team at Midlands and Lancashire CSU.


Formulary Update

New Medicines 

RED PITOLISANT Tablets (Wakix®▼) 
The Pan Mersey Area Prescribing Committee recommends the prescribing of PITOLISANT tablets (Wakix®▼), by specialists working in a regional and national tertiary commissioned sleep service only, for the treatment of Narcolepsy with or without cataplexy in those who are contraindicated or have not tolerated other standard treatments.

RED SODIUM OXYBATE Oral Solution (Xyrem®) 
The Pan Mersey Area Prescribing Committee recommends SODIUM OXYBATE oral solution (Xyrem®) as a treatment option for Narcolepsy with cataplexy in adult patients only when recommended by a consultant in a specialist commissioned sleep service.

GREY ERTUGLIFLOZIN film-coated tablets (Steglatro®▼) 
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of ERTUGLIFLOZIN film-coated tablets (Steglatro®▼) for use as part of a triple therapy regimen for the treatment of type 2 diabetes.

GREY DEOXYCHOLIC ACID injection (Belkyra®▼) 
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of DEOXYCHOLIC ACID injection (Belkyra®▼) for submental (under chin) fat.

GREY TILDRAKIZUMAB solution for injection (Ilumetri®▼) 
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of TILDRAKIZUMAB solution for injection (Ilumetri®▼) for the treatment of plaque psoriasis.

GREEN ERTUGLIFLOZIN film-coated tablets (Steglatro®▼) as monotherapy or with metformin for treating type 2 diabetes 
The Pan Mersey Area Prescribing Committee recommends the prescribing of ERTUGLIFLOZIN film-coated tablets (Steglatro®▼) as monotherapy or with metformin for treating type 2 diabetes in accordance with NICE TA572.


BLACK Ascorbic acid tablets 
The Pan Mersey Area Prescribing Committee does not recommend the prescribing of ASCORBIC ACID for any indication, other than scurvy.

Lactase enzyme drops 50,000 units/g (Colief®) 
The Pan-Mersey Area Prescribing Committee recommends that Lactase Enzyme Drops 50,000 units/g (Colief®) are not prescribed on the NHS. Patients are advised to purchase Colief® if they wish.

RED Drugs used in medically assisted reproduction 
Clarification that use of any drug in medically assisted reproduction is designated red, even where the drug has an alternative designation for other indications.

AMBER INITIATED Aviptadil 25micrograms + phentolamine 2mg intracavernosal injection (Invicorp®) 
Additional option to alprostadil in treatment of erectile dysfunction where oral therapy unsuitable.

AMBER INITIATED Hydrocortisone granules 0.5mg, 1mg, 2mg and 5mg (Alkindi®) 
Licensed formulation for use instead of unlicensed “special”. The unlicensed “special” to be retained for children requiring dose increments of less than 0.5mg.

GREEN Calcium carbonate 750 mg + colecalciferol 200 units caplets 
Additional formulation for patients who cannot swallow/ chew higher dose formulations.

GREEN Ibuprofen and naproxen oral formulations 
The Pan Mersey Area Prescribing Committee recommends the prescribing of IBUPROFEN (low dose) and NAPROXEN (low dose) as the non-steroidal anti-inflammatory drugs (NSAIDs) of choice, if an NSAID is appropriate.

GREEN Preferred choice direct – acting oral anti-coagulant (DOAC) 
The Pan Mersey APC recommends, in the absence of a specific clinical reason to select a particular DOAC, that the least costly DOAC is the first line DOAC for patients with non-valvular AF. Currently this is edoxaban.

Chapter 3 Respiratory system 
Routine update of chapter.

Chapter 12 Ear, nose and oropharynx 
Routine update of chapter.

Definitions and Criteria for the Categorisation of Medicines in Pan Mersey 
Updated to reflect that specialists may be located in specifically commissioned services in community settings, as well as hospitals.


AMBER INITIATED Insulin – criteria for transfer of prescribing to primary care 
Before requesting that Primary Care take over prescribing of newly initiated insulin the specialist team must be assured that the patient is willing, competent and trained to: administer the insulin (or District Nurse arranged); if and when required amend the dose of the insulin, either with the support of their diabetes HCP or independently.

During this time prior to requesting Primary Care take over prescribing, the specialist team must maintain clinical responsibility, review the patient (either face to face or by telephone) and prescribe the insulin and administration devices for: a minimum of 4 weeks supply; OR a supply length that allows enough time for the patient to be reviewed by the specialist team, whichever of the above is the longer.
A copy of the final review must be sent to the primary care prescriber with the request for transfer of prescribing.

Asthma guideline in primary care – adults 
Updated guideline based on current BTS/SIGN British Asthma guideline in preference to NICE guideline.

Paediatric chronic pain guideline 
Incorporation of previously agreed restrictions on use of lidocaine plaster into the paediatric chronic pain guideline.

Prescribing support

Minor amendments to documentation to decrease in recommended maximum daily dose and emphasise that specialist is responsible for arranging and managing eye monitoring.


The Pan Mersey Area Prescribing Committee recommends that the risk of fire should be considered when issuing paraffin-based emollient preparations.

Safety Updates

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

NIHR Signal: Medication to reduce stomach acid may increase risk of hip fractures
National Institute for Health Research Signal | 06 Mar
Expert commentary is provided for a meta-analysis of 24 observational studies (total n=2,103,800) which found that PPIs increased the risk of hip fracture by 20%. The findings don’t suggest stopping use of PPIs, but they should be used with caution, and no drug is totally safe.

What is the sodium content of medicines?
Specialist Pharmacy Service | 06 Mar
This Q&A provides lists of preparations that could contain high levels of sodium, and so might be unsuitable for people with conditions associated with sodium retention (e.g hypertension, heart failure or renal impairment) or who are on a salt-restricted diet.

Chloramphenicol: is it safe in breastfeeding?
Central Specialist Pharmacy Service | 15 Mar
This updated Medicines Q&A discusses the safety of the antibiotic, chloramphenicol (systemic and ophthalmic), in breastfeeding women.

Fluoroquinolone Antibiotics: New Restrictions and Precautions Due To Very Rare Reports Of Disabling And Potentially Long-Lasting Or Irreversible Side Effects
Central Alerting System | 21 Mar
See alert for new restrictions and precautions for fluoroquinolone antibiotics (ciprofloxacin, levofloxacin, moxifloxacin, ofloxacin) following a review of disabling, long-lasting or potentially irreversible adverse reactions affecting musculoskeletal (including tendonitis and tendon rupture) and nervous systems with fluoroquinolone antibiotics.

Medicines with teratogenic potential: what is effective contraception and how often is pregnancy testing needed?
Medicines and Healthcare products Regulatory Agency | 21 Mar
MHRA has issued new guidance on contraceptive methods and frequency of pregnancy testing to reduce inadvertent exposures during pregnancy in a woman taking a medicine of teratogenic potential.

Triptans and SSRI or SNRI antidepressants - is there an interaction?
Specialist Pharmacy Service | 27 Mar
This Q&A advises that using these antidepressants together may have additive effects on the serotonin system with potential for adverse effects. Clinical experience however indicates that combined use is normally uneventful and they can be co-prescribed if clinically required.

Direct Oral Anticoagulant (DOAC) Dosing in renal impairment
Drug and Therapeutics Bulletin | 28 Mar
In light of > 4,000 yellow card reports of DOAC-associated haemorrhagic events since their launch, the author of this editorial highlights the urgent need for national guidance to help clinicians prescribe DOACs safely, particularly for patients with declining renal function.

Valproate and the Pregnancy Prevention Programme: exceptional circumstances
British Journal of General Practice | 29 Mar
This editorial argues that there are exceptional circumstances, and personal and practical implications, that have not been adequately considered in the MHRA’s regulations on valproate prescribing.

NICE publishes a summary of its guidance and other safety advice on valproate
National Institute for Health and Care Excellence | 29 Mar
Summary sheet brings together existing information and advice on safe prescribing from other sources (e.g. MHRA safety alerts, BNF, SPCs and information from DVLA) with NICE’s existing guideline recommendations, to produce easy to access, practical recommendations.

Prescribing News

NICE Guidance March 2019

There has been one guideline published in March 2019 by the National Institute for Clinical Excellence which has impact upon primary care.

The delirium: prevention, diagnosis and management guideline has been updated and published. The guideline covers diagnosing and treating delirium in people aged 18 and over in hospital and in long term residential care or a nursing home. The guideline also covers identifying people at risk of developing delirium in these settings and preventing onset. The aim is to improve the diagnosis of delirium and reduce hospital stays and complications. The update removed the recommendation of the use of olanzapine for the treatment of delirium in people who are distressed or considered a risk to themselves or others.

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

CKS Updates March 2019

During the month of March 2019, the following Clinical Knowledge Summaries were published or updated:  
All the above topics have undergone reviews and minor restructures. No major changes have been made.  
Clinicians can use the updated and new information when reviewing patients.

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.

DHSC report April 2019 

This report has been produced by the Department of Health and Social Care (DHSC) Medicine Supply team. This report is updated monthly to provide information on the current primary and secondary care medicine supply issues being worked on.  This information is confidential to the NHS as it may be commercially sensitive.

New Issues

Please click here for the full article of new issues in March.

Furosemide injection
Suppliers have confirmed they all currently have stock. Information on how to order is provided in the full article.

Neurobloc (Botulinum Toxin Type B)
Not available until July 2019. Unlicensed stock is available from abroad, but lead times may vary.

Levomepromazine 25mg/ml injection

Currently out of stock. New stock expected to be available from the end of April. Full details of article included in above link.

Epanutin (phenytoin) 50mg Chewable Infatabs
Temporary supply issue until September 2019. Pfizer has import stock of Dilantin (phenytoin) Infatabs from Canada. Dilantin are unlicensed in the UK. A copy of the product information can be found attached. Epanutin 30 mg/5 ml Oral Suspension is available to meet normal market demand. Patients should not be switched to the suspension as this may precipitate a shortage of supply.
Epilim preparations
Short-term supply issues. Quotas of all preparations are currently available. Pharmacies having difficulty obtaining stock should contact Sanofi Customer Care on: 01483 505 515
FemSeven Products
Conti and Sequi patches are unavailble until late 2019. Mono patches are not affected. Other HRT patches and products remain available.

Elleste Range
Elleste Solo 1mg, 2mg; Elleste Duet Conti; Elleste Duet 1mg are currently unavailable. Resupply is expected to be the end of April 2019.

UKMI advice for equivalent alternatives currently available on the market is provided.
Hydroxyzine 25mg tablets
Creo Pharma are out of stock until July 2019. Alliance Pharmaceuticals can support the full market of the 25mg tablets during this time.
Levitra (vardenafil) tablets
5mg and 10mg tablets, and 10mg orodispersible tablets are out of stock until November 2019. Generic vardenafil tablets remain available.
Olena (fluoxetine) 20mg dispersible tablets
Out of stock; further supplies are expected in May 2019. Fluoxetine 20mg/5ml oral solution is available. Drug Tariff April 2019: 20mg/5ml oral solution, 70ml £2.93; 20mg/5ml oral solution sugar free, 70ml £12.95.
Questran Light (colestyramine) 4g sachets
limited resupply expected by week ending 19th April 2019.

Ranitidine effervescent 150mg tablets
Out of stock until September 2019. Other generic preparations remain available.
Vibramycin-D (doxycycline) dispersible tablets
Out of stock until at least the end of April 2019. Refer to local guidance for alternatives or consult microbiologists in more complex cases.

Labetalol tablets – all strengths
Pfizer have reported a supply issue with Vibramycin-D dispersible tablets and expect to be out of stock for at least 5 weeks from 25th March to the end of April 2019. Full details included in the full article link.

Canestan (clotrimazole) 500mg pessaries
Pfizer are out of stock until June 2019 for the [P] medicines and until early May 2019 for the [POM]. Alternative suppliers are available.
Betnesol (betamethasone 0.1%) eye/ear/nose drops
RPH Pharmaceuticals out of stock with a resupply date of late 2019. Martindale Pharma stock remains available

Ongoing Issues:
For advice on ongoing issues please click here

Drug Tariff Changes

This summary document shows the top 10 price changes since last month, the top 25 changes compared to three months ago, and the top 50 since last year.
Tell me more about drug tariff price changes.

Antimicrobial Updates

Please click here for a full summary of antimicrobial related guidelines and SPC updates in March.

Parents encouraged to be aware of scarlet fever symptoms 
Public Health England | 01 Mar

Association between urinary community-acquired fluoroquinolone-resistant Escherichia coli and neighbourhood antibiotic consumption: a population-based case-control study 
The Lancet Infectious Diseases | 05 Mar

Patients’ understanding of cellulitis and their information needs: a mixed-methods study in primary and secondary care 
British Journal of General Practice | 12 Mar

NIHR Signal: Antimicrobial stewardship programmes reduce antibiotic use in long-term care homes 
National Institute for Health Research Signal | 13 Mar

Asymptomatic bacteriuria in pregnancy: systematic reviews of screening and treatment effectiveness and patient preferences 
BMJ Open | 14 Mar

Chloramphenicol: is it safe in breastfeeding? 
Specialist Pharmacy Service | 15 Mar

Oseltamivir and zanamivir for prophylaxis and treatment of seasonal influenza in care facilities: updated patient group direction (PGD) template 
Public Health England | 19 Mar

Clinical implications of the association between fluoroquinolones and tendon rupture: The magnitude of the effect with and without corticosteroids 
British Journal of Clinical Pharmacology | 20 Mar

Fluoroquinolone antibiotics: new restrictions and precautions for use due to very rare reports of disabling and potentially long-lasting or irreversible side effects 
Medicines and Healthcare products Regulatory Agency | 21 Mar

Helicobacter pylori Infection 
New England Journal of Medicine | 21 Mar

Electronically delivered interventions to reduce antibiotic prescribing for respiratory infections in primary care: cluster RCT using electronic health records and cohort study 
National Institute for Health Research | 22 Mar

Antimicrobial stewardship - prescribing antibiotics: Key therapeutic topic (KTT9) 
National Institute for Health and Care Excellence | 26 Mar

Summary of Product Characteristics  
electronic Medicines Compendium | March 2019

Bexsero Meningococcal Group B vaccine for injection in pre-filled syringe

Rifater Tablets (isoniazid/rifampicin/pyrazinamide)

Rifinah (isoniazid/rifampicin) tablets – all strengths

Tarivid (ofloxacin) 400mg film-coated tablets

Trivalent Influenza Vaccine (Split Virion, Inactivated) High Dose 
electronic Medicines Compendium | March 2019
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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