Medicines Clinical Guidelines Team – December 2017
 

Wirral Drug & Therapeutics Panel – January 2018

Recommendations

AMBER Ticagrelor (NICE TA420)

Ticagrelor, in combination with aspirin, is recommended as an option for preventing atherothrombotic events in adults who had a myocardial infarction and who are at high risk of a further event.
Treatment should be stopped when clinically indicated or at a maximum of 3 years. Please see RAG list for further information. A statement with the recommendations will also be available on the Wirral Medicines Management website shortly.

RED Ferric carboxymaltose (Ferinject) injection.
Approved for the treatment of adults with iron deficiency anaemia associated with heart failure to alleviate heart failure symptoms and improve exercise capacity and quality of life.

RED Zerbaxa® (ceftolozane and tazobactam) infusion
Approved for the treatment of pseudomonas and multi-drug resistant Gram-negative infections (excluding CPE) on the recommendation of a Consultant Medical Microbiologist where other options are not appropriate or have failed.

RED Zavicefta® (ceftazidime/avibactam)
Approved for the treatment of CPE infections caused by the OXA-48 and KPC strain and to treat infections caused by multi-drug resistant Gram-negative organisms. Only on the recommendation of a Consultant Medical Microbiologist where other options are not appropriate or have failed.

RED Monofer® (Iron Isomaltoside 1000) 
Approved for use in gastroenterology in place of Cosmofer®.


Guidelines

Wirral Guidelines for the Management of Osteoporosis

The guidelines have been updated and will be available on the Medicines Management website.

Extension of review dates 

The following joint Wirral Guidance, due for review in the next 6 months, have been extended to September 2018 to enable a review of Wirral guidance with the Pan Mersey Guidance and Formulary:

· Asthma-Chronic asthma in adults
· Erectile Dysfunction
· Dyspepsia
· Laxatives for Adults
· Laxatives for Children
· Antiplatelets in stroke
· Attention Deficit Hyperactivity Disorder (ADHD)
· Chronic idiopathic constipation in adults (Pan Mersey guideline went out for consultation November 2017)

They are all available on the Medicines Management website.

Warfarin 500 micrograms

Warfarin 500 microgram tablets are not recommended for prescribing in Wirral.

The Wirral Oral Anticoagulation Guidelines state that:

The 500 microgram warfarin tablets should not be used to avoid confusion with other white tablets and 5mg doses of warfarin. The 1mg tablets can be easily broken in half or cut with a tablet cutter to achieve a 500 microgram dose.
The Cardiovascular Clinical Group has confirmed that Wirral GPs should not prescribe warfarin 500 microgram tablets. ScriptSwitch messages already highlight this information. Community pharmacies have been asked to support this.

Wirral Health Economy have now joined the Pan Mersey Area Prescribing Committee.

Following a review of the current formulary processes it was agreed that Wirral will join Pan Mersey Area Prescribing Committee (APC) from January 2018.

This encompasses NHS Wirral CCG, Wirral University Teaching Hospital NHS Foundation Trust (WUTH), Wirral Community NHS Foundation Trust and Cheshire and Wirral Partnership NHS Foundation Trust.

Joining Pan Mersey APC will ensure the processes on Wirral are efficient and robust and duplication of work will be reduced. It will also minimise unnecessary variation in medicines use and policy across the area (Merseyside, Warrington, West Lancashire and Wirral) thus improving outcomes and value.

Wirral will NOT automatically adopt all current Pan Mersey recommendations from 1st January and there will be a process for merging guidelines, medicines recommendations, formularies etc. New recommendations / guidelines submitted to Pan Mersey APC will be consulted on and adopted as appropriate.

Please continue to use the current Wirral Medicines Management website for guidelines / formulary recommendations until further notice.

The first APC committee meeting is 31st Jan and the relevant Pan Mersey guidance will be linked from the Wirral Medicines Management site. The last joint Wirral Drug and Therapeutics Panel meeting in its current format took place on 10th January. Going forward this will be a hospital only D&T for new medicines with a subsection remaining for joint shared care guidelines which will be attended by CCG representatives.

Reporting Lost/Stolen NHS Prescriptions

There is a new proforma from NHS England for reporting missing/lost/stolen prescription forms. It is available on the Wirral Medicines Management Website. Once completed the form should be sent to england.cwwalerts@nhs.net. Police should be informed where there is evidence of criminal activity and medication prescribed is liable for abuse. Information should be disseminated to local pharmacies and GP surgeries as deemed appropriate.

Supply issues with Bactroban (mupirocin) Nasal Ointment (taken from UKMI bulletin)

Bactroban Nasal Ointment contains mupirocin 2% in white soft paraffin. It is licensed for the elimination of nasal carriage of staphylococci, including methicillin resistant Staphylococcus aureus (MRSA). It is applied to the anterior nares two to three times a day.1
GSK are currently out of stock due to issues with transfer of this product to another manufacturing site. They are unable to confirm the exact resupply date but have advised that new stock should be available by the end of first quarter of 2018. Advice should be sought from the Wirral IPC Team (0151 604 7750 or email ipc.wirralct@nhs.net) on use of alternative products. Please also refer to table for details of available options.


C difficile Post Infection Review feedback from the Infection Prevention & Control Team, Wirral Community Trust

There were six reported cases of community attributed Clostridium difficile infection in November 2017. The key points from these reviews were:
All six patients had multiple co-morbidities
Out of the six cases:

The key learning points from these reviews were:
 

For more information on the updates listed below, please click here:
 

Products in short supply and product discontinuations
 

• GSK
• Scriptswitch 

• Naseptin Nasal Cream (Alliance Pharmaceuticals) - available via the wholesalers: AAH, Alliance Healthcare and Well Pharmacy
• Prontoderm (Braun) - available via NHS supply Chain and wholesalers: AAH and Alliance
• Octenisan Nasal gel (Schülke & Mayr UK Ltd ) - available via NHS supply Chain and wholesalers: AAH, Alliance and Phoenix

Antiviral Medicines Authorised for Influenza Season 2017/18
 

The Department of Health has written a letter to healthcare professionals via the Central Alerting System to advise that antiviral medicines may now be prescribed at NHS expense due to rising levels in reporting of influenza-like illness.
Surveillance data indicates an increase in influenza cases in the community; GPs and other prescribers working in primary care may now prescribe antiviral medicines for the prophylaxis and treatment of influenza. Doses and treatment schedules are contained in existing Public Health England guidance. Clinicians are reminded to endorse the prescription with 'SLS' to ensure that it can be dispensed in community pharmacies without undue delay.

NICE BNF apps replaced by BNF & BNFC app

Following the recent launch by the publishers of the British National Formulary (BNF) and British National Formulary for Children (BNFC) of a new, faster, easier to access and use BNF and BNFC app, the NICE BNF apps have been withdrawn.
The new BNF and BNFC app can be downloaded using the following link: BNF and BNFC app
Aimed at prescribers, pharmacists, and other health and social care professionals, the new app has been purpose built for iOS and Android platforms. This has enabled an intuitive design and enhanced features around search and interactions checking and updating mechanisms. These features provide enhanced access to high quality, authoritative information and guidance on the move.
For the first time, adult and child BNF content is available through a single app providing ease of use and saving space on a user’s device. Those working in health and social care can download and use the app for free.

NICE Guidance

The National Institute of Health and Care Excellence (NICE) have published new or updated guidance that impact upon primary care.       
  
New NICE guidance on asthma has been published, covering the diagnosis, monitoring and management of chronic asthma in adults and children. NICE has recognised that in implementing the guidance will require a change in practice. Healthcare professionals will need to become familiar with new recommendations on pharmacological treatment that differ from the established BTS/SIGN stepwise treatment pathways. A notable change is the use of leukotriene receptor antagonists, ahead of the introduction of long-acting beta agonists.

Action: Clinicians should be aware of this new guidance and implement any necessary changes to practice. NICE recommends that in people whose asthma is well-controlled on their current treatment, they should not have their treatment changed purely to follow the guideline.

The Autism spectrum disorder in under 19s clinical guideline has been updated to include ADHD as a factor associated with an increased prevalence of autism and changed references from DSM-4 to DSM-5. The guideline covers recognising and diagnosing autism spectrum disorder in children and young people from birth up to 19 years and it also covers referral.

The Atrial fibrillation and heart valve disease: self-monitoring diagnostic guideline has been updated removing the recommendations for the InRatio2 PT/INR monitor as this device is no longer available.

The Naltrexone–bupropion for managing overweight and obesity technology appraisal has been published. Naltrexone–bupropion (Mysimba®) is not recommended within its marketing authorisation for managing overweight and obesity in adults alongside a reduced-calorie diet and increased physical activity.

Action: Clinicians should be aware of this month's new guidance and implement any necessary changes to practice.

CKS Updates

Clinical Knowledge Summaries were reviewed and updated in the following areas;

• Benign paroxysmal positional vertigo
• DMARDs
• Generalized anxiety disorder
• Irritable bowel syndrome
• Psoriasis
• Urinary tract infection - children

The most significant changes are in the Irritable bowel syndrome and Psoriasis topics. The Irritable bowel syndrome topic has been updated where the recommendations on the diagnosis and management of irritable bowel syndrome have been amended in line with current evidence, including the addition of linaclotide as a drug treatment option. The Psoriasis topic has been updated where recommendations on the diagnosis and management of psoriasis have been amended in line with current evidence.

Action: Clinicians may find the updates useful when reviewing current clinical practice.

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.

Contacts
Victoria Vincent: victoriavincent@nhs.net  0151 541 5390

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