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Issue 14 April 2015

Pan Mersey Area Prescribing Committee ................................................................................................................................... 1 Current Issues ............................................................................................................................................................................. 4 Topic of the month………………………………………………………………………………………………………………………………………………………………….5 Query Corner…………………………………………………………………………………………………………………………………………………………………………..8 Drug Tariff ................................................................................................................................................................................ 10 Safety…………………………………………………………………………………………………………………………………………………………………………………….12

Pan Mersey Area Prescribing Committee

RECOMMENDATIONS

INFLIXIMAB, ADALIMUMAB and GOLIMUMAB in ulcerative colitis

The Pan Mersey Area Prescribing Committee recommends the prescribing of infliximab, adalimumab and golimumab for treating moderately to severely active ulcerative colitis after the failure of conventional therapy in accordance with NICE TA329. http://www.panmerseyapc.nhs.uk/recommendations/documents/PS22.pdf

ACLIDINIUM with FORMOTEROL inhaler (Duaklir Genuair®▼)

The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of ACLIDINIUM with FORMOTEROL inhaler (Duaklir Genuair®▼) for COPD. http://www.panmerseyapc.nhs.uk/recommendations/documents/PS106.pdf

AFLIBERCEPT (Eylea®▼) for macular oedema secondary to branch retinal vein occlusion

The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of AFLIBERCEPT (Eylea®▼) for macular oedema secondary to branch retinal vein occlusion. http://www.panmerseyapc.nhs.uk/recommendations/documents/PS121.pdf

BRIMONIDINE Gel (Mirvaso®▼)

The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of BRIMONIDINE Gel (Mirvaso®▼) for facial erythema of rosacea. http://www.panmerseyapc.nhs.uk/recommendations/documents/PS48.pdf

UMECLIDINIUM with VILANTEROL inhaler (Anoro Ellipta®▼)

The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of UMECLIDINIUM with VILANTEROL Inhaler (Anoro Ellipta®▼) for the treatment of Chronic Obstructive Airways Disease (COPD). http://www.panmerseyapc.nhs.uk/recommendations/documents/PS71.pdf

APREMILAST tablets (Otezla®▼)

The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of APREMILAST tablets (Otezla®▼) for psoriatic arthritis or psoriasis. http://www.panmerseyapc.nhs.uk/recommendations/documents/PS112.pdf

COLLAGENASE CLOSTRIDIUM HISTOLYTICUM injection (Xiapex®▼) for Peyronie's disease

The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of COLLAGENASE CLOSTRIDIUM HISTOLYTICUM injection (Xiapex®▼) for Peyronie's disease. http://www.panmerseyapc.nhs.uk/recommendations/documents/PS113.pdf

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DULAGLUTIDE subcutaneous injection (Trulicity®▼)

The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of DULAGLUTIDE subcutaneous injection (Trulicity®▼) for type 2 diabetes. http://www.panmerseyapc.nhs.uk/recommendations/documents/PS115.pdf

SECUKINUMAB subcutaneous injection (Cosentyx®▼)

The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of SECUKINUMB subcutaneous injection (Cosentyx®▼) for psoriasis. http://www.panmerseyapc.nhs.uk/recommendations/documents/PS114.pdf

OXYCODONE with NALOXONE modified release tablets (Targinact®)

Pan Mersey Area Prescribing Committee recommends the restricted prescribing of oxycodone/naloxone (2:1 fixed ratio) modified release tablets (Targinact®) for adults with chronic pain as specified in the link below. http://www.panmerseyapc.nhs.uk/recommendations/documents/PS117.pdf

AVANAFIL tablets (Spedra®▼)

The Pan Mersey Area Prescribing Committee recommends, where sildenafil is not suitable, second choice of PDE-5 inhibitor should preferably be one with the least acquisition cost. http://www.panmerseyapc.nhs.uk/recommendations/documents/PS116.pdf

LEVONORGESTREL (Jaydess®▼) for contraception

The Pan Mersey Area Prescribing Committee recommends the prescribing of LEVONORGESTREL (Jaydess®▼) for contraception for up to 3 years in patients over 18 years. http://www.panmerseyapc.nhs.uk/recommendations/documents/PS69.pdf

UMECLIDINIUM Bromide Inhaler (Incruse Ellipta®▼) for COPD

The Pan Mersey Area Prescribing Committee recommends the prescribing of UMECLIDINIUM inhaler (Incruse Ellipta®▼) as a second line maintenance bronchodilator treatment, to relieve symptoms of chronic obstructive pulmonary disease (COPD). http://www.panmerseyapc.nhs.uk/recommendations/documents/PS92.pdf

FLUTICASONE FUROATE with VILANTEROL inhaler (Relvar Ellipta®▼) for asthma

The Pan Mersey Area Prescribing Committee recommends the prescribing of FLUTICASONE FUROATE with VILANTEROL inhaler (Relvar Ellipta®▼) for the treatment of asthma, when alternative treatment options are unsuitable. http://www.panmerseyapc.nhs.uk/recommendations/documents/PS89.pdf

NAFTIDROFURYL OXALATE capsules 100mg

The Pan Mersey Area Prescribing Committee recommends the prescribing of NAFTIDROFURYL OXALATE for the treatment of intermittent claudication in people with peripheral arterial disease. http://www.panmerseyapc.nhs.uk/recommendations/documents/PS119.pdf

PHOSPHODIESTERASE TYPE-5 INHIBITORS for the treatment of erectile dysfunction

The Pan Mersey Area Prescribing Committee recommends generic sildenafil as the first choice phosphodiesterase type-5 inhibitor for the treatment of erectile dysfunction. http://www.panmerseyapc.nhs.uk/recommendations/documents/PS116.pdf

CILOSTAZOL tablets (Pletal®), PENTOXIFYLLINE tablets (Trental 400®) and INOSITOL NICOTINATE tablets (Hexopal® and Hexopal Forte®)

The Pan Mersey Area Prescribing Committee does NOT recommend cilostazol tablets (Pletal®), pentoxifylline tablets (Trental®) or inositol nicotinate tablets (Hexopal® and Hexopal Forte®) for the treatment of intermittent claudication in people with peripheral arterial disease. http://www.panmerseyapc.nhs.uk/recommendations/documents/PS118.pdf

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GUIDELINES

Avoidance of Clostridium difficile infection

Clostridium difficile infection (CDI) is a leading cause of iatrogenic diarrhoea. Patients most at risk from CDI are the elderly, immunosuppressed and those with co-morbidities.

Previous antimicrobial use is a major risk factor for CDI. Antimicrobials disrupt the normal microflora of the colon and allow overgrowth of CD.

Broad spectrum antimicrobials particulary cephalopsorins, clindamycin, quinolones and co-amoxiclav carry a greater risk of causing CDI. However use of any antibiotic can cause CDI.

Risk of CDI is increased by long or repeated courses and use of multiple antimicrobials.

There is evidence of a dose-dependent relationship between long term proton pump inhibitor (PPI) therapy and increased risk of CD-associated diarrhoea

http://www.panmerseyapc.nhs.uk/guidelines/documents/G19.pdf

Malnutrition, managing adults in the community

Assessment Of Malnutrition Risk

Formulary for Prescribable FIRST LINE Oral Nutritional Supplements

Managing malnutrition using the ‘Malnutrition Universal Screening Tool’ (‘MUST’) and guidance for initiation of sip feeds in adults

GP Guidance For Patients Discharged From Hospital On Sip Feeds With No Planned Dietetic Follow Up

A Guide to Fortifying Meals and Store Cupboard Ideas

http://www.panmerseyapc.nhs.uk/guidelines/documents/G20.pdf

NEWS

What’s that? New app? netFormulary app Pan Mersey APC

The netFormulary app is available from the Apple store and Google Play. Search for ‘netformulary’ and then download and install in the usual way.

First time users should read through the help file and watch the getting started video.

Select ‘Help’ at the top-left of the home screen.

Select ‘Getting Started’ at the top-right of the help screen to watch the video.

Synchronising the app

From any screen, select ‘Region’ and choose ‘Cheshire and Merseyside’ from the list.

From the home page select ‘Update’.

You can navigate to the home page by selecting ‘Home’ (bottom-left). You’ll find ‘Update’ at the top-right of the home screen.

Updates

Update the app at least once a month by selecting ‘Update’ from the home screen.

When connected to a wireless network the traffic light system at the bottom of the home page will alert you to the presence of further updates.

Searching the formulary

Select ‘Formulary’ from the main menu at the bottom of any screen.

Enter your search term into the dialog box at the top-right of the formulary page.

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Browsing the formulary

Select ‘Formulary’ from the main menu at the bottom of any screen.

Select ‘Menu’ at the top-left of the formulary page to activate a slide-in menu. Tap the chapter and sub-chapter headings in the menu to navigate through the formulary.

Current Issues

Oxycodone 10mg/ml concentrated oral solution – picking error

NHS England have had reports highlighting incidents of Prescribers inadvertently selecting oxycodone 10mg/ml (concentrated oral solution) oral solution instead of oxycodone 5mg/5ml oral solution from the clinical system drug picking list. This appears to be because for some prescribers oxycodone 10mg/ml oral solution is appearing as first choice on the EMIS Web picking list.

There are reports of at least two people being hospitalised as a result of selection errors. Please can all Prescribers be vigilant when selecting oxycodone oral solution.

Community Pharmacists have been asked to query with the Prescriber all new prescriptions for the 10mg/ml strength to ensure that this is the intended strength.

If you have any concerns over Controlled Drugs you can contact the Controlled Drugs Accountable Officer at england.cmcd@nhs.net

Diltiazem modified-release preparations - reminder to prescribe by brand name Different versions of diltiazem modified-release preparations containing more than 60mg diltiazem hydrochloride may not have the same clinical effect. To avoid confusion between these different formulations prescribers should specify the brand to be dispensed (BNF 68). Depending on the modified release preparation chosen the diltiazem can be in a once-daily (24-hourly release) profile or a twice-daily (12-hourly release) profile.

Osteoarthritis: chondroitin evidence remains of poor quality A Cochrane Review of 43 randomised, controlled trials found that chondroitin (with or without glucosamine) improved pain scores and a composite of pain, function and disability, compared with placebo or active control in adults with osteoarthritis. However, for many of the other outcomes assessed there were no statistically significant differences between chondroitin and placebo. The findings of the review were limited by the poor quality of the included studies, and sensitivity analyses that took several limitations into account often did not show statistically significant benefits with chondroitin. This is consistent with the NICE Guideline, Osteoarthritis: Care and management in adults, http://www.nice.org.uk/guidance/cg177, that advises healthcare professionals not to offer glucosamine or chondroitin products for the management of osteoarthritis on the basis that the evidence base is poor.

The NICE Pathway, Osteoarthritis, http://pathways.nice.org.uk/pathways/osteoarthritis, brings together all related NICE guidance and associated products on the condition, in a set of interactive, topic-based diagrams. NICE has also produced a Key Therapeutic Topic on NSAIDs, https://www.nice.org.uk/advice/ktt13.

New product: exenatide 2mg M/R (Bydureon®) dual chamber pen

A new presentation of exenatide 2mg M/R (once weekly GLP-1 injection) was launched in January 2015. This is a pre-filled, single-use pen injector, which is the same formulation and dose as the exenatide once-weekly vial. The new pen eliminates the need for the patient to transfer the medication between a vial and a syringe, simplifying administration of the injection. The vial presentation remains available and Clinicians can continue to prescribe this.

MHRA online learning module on reducing the side effects of steroid medicines

The Medicines and Healthcare products Regulatory Agency (MHRA) has launched an online learning module on reducing the side effects of steroid medicines. The module will help Clinicians to optimise the use of corticosteroids.

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Corticosteroids are vital medicines for treating and preventing diverse disorders such as asthma, transplant rejection and arthritis. But they can cause troublesome and occasionally serious side effects. Health professionals and patients need to be clear about precautions that minimise corticosteroid side effects.

Designed for Doctors, Nurses and Pharmacists, the interactive programme runs through the important side effects of corticosteroids and shows the learner how the risks can be managed. The learning module draws on proven techniques for enhancing online learning.

The course has been approved for continuing professional development (CPD) by the Faculty of Pharmaceutical Medicine of the Royal Colleges of Physicians of the United Kingdom.

Access: www.gov.uk/government/publications/e-learning-modules-medicines-and-medical-devices/e-learning-modules-medicines-and-medical-devices#corticosteroids

Topic of the month

HAYFEVER (SEASONAL ALLERGIC RHINITIS) UPDATE 2015 Allergic rhinitis is an inflammatory disorder of the nose which occurs when the membranes lining the nose become sensitised to allergens. People may be sensitive to more than one allergen and the most common allergens include1:

house dust mites

grass, tree and weed pollens

allergens carried on animal hair

allergens encountered at work such as latex gloves and wood dust.

Prescribers will soon find themselves being asked for an array of items to relieve symptoms of seasonal allergic rhinitis. Now may be the time to review what is being prescribed to avoid inadvertently prescribing high cost, non – formulary, or OTC products.

For 'as-required' treatment of occasional rhinitis symptoms, an antihistamine should be prescribed. For people who want preventive treatment to control more frequent or persistent symptoms, the importance of regular treatment should be explained. If the predominant symptoms are nasal discharge or sneezing, either an antihistamine or an intranasal corticosteroid should be given.

Oral antihistamines

Drug Adult dose Cost/28 days

Comments

Cetirizine 10mg 1 OD 99p 1st LINE Formulary choice Loratadine 10mg 1 OD £1.03 1st LINE Formulary choice Fexofenadine 120mg 1 OD £3.34 2nd LINE Formulary choice Chlorpheniramine 4mg 1 QDS £3.92 1st LINE Formulary choice

(Sedating) Acrivastine 8mg 1 TDS £20.37 Non Formulary Bilastine 20mg (Ilaxten®▼) 1 OD £14.08 Non Formulary Desloratadine 5mg 1 OD £1.65 Non Formulary Levocetirizine 5mg 1 OD £3.69 Non Formulary Mizolastine 10mg m/r (Mizollen®) 1 OD £6.46 Non Formulary Rupatidine 10mg (Rupafin®▼) 1 OD £4.67 Non Formulary

Liquid formulations

Drug Dose range for children according to age/weight

Cost/200ml Comments

Cetirizine 5mg/5ml 2.5-5mg BD £1.79 Prescribe generically Loratadine 5mg/5ml 5-10mg OD £4.68 Prescribe generically

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Nasal preparations The most cost effective nasal steroid choice continues to be beclometasone 50mcg nasal spray. If the 100 or 180 dose pack is prescribed, the more costly OTC version will be dispensed. This is more than twice the cost of the 200 dose pack. Fluticasone furoate (Avamys®) is currently the most cost effective 2nd line option after beclometasone.

Anti-inflammatory eye drops

Drug Adult Dose

Cost/ bottle Comments

Sodium cromoglicate 2%

QDS £1.86 (13.5ml)

1st LINE FORMULARY CHOICE

Available OTC at less than the charge for a prescription

The 13.5ml bottle is most economical to prescribe

Antazoline 0.5% & xylometazoline 0.05%

BD-TDS £2.35 (10ml) 2nd line FORMULARY CHOICE

Azelastine 0.05% BD £6.40 (8ml) 2nd line FORMULARY CHOICE Lodoxamide 0.1% ophthalmic solution

QDS £5.21 (10ml) 2nd line FORMULARY CHOICE

Nedocromil 2% BD £2.86 (5ml) 2nd line FORMULARY CHOICE

Drug Adult dose to each nostril

Cost/ 28 days (Approx)

Comments

Beclometasone 50mcg nasal spray (generic)

2 puffs BD reducing to 1puff BD

£1.29-£2.58 1st LINE Formulary choice £2.30/ 200 dose OP £4.52/100 dose OP £6.46/180 dose OP

Fluticasone furoate nasal spray (Avamys®)

2 puffs OD reducing to 1 puff OD

£3.01-£6.01 2nd LINE Formulary choice £6.44/120 dose OP

Fluticasone propionate nasal spray (Flixonase®)

2 puffs OD-BD reducing to 1 puff OD

£4.11-£8.22 2nd LINE Formulary choice £11.01/150 dose OP

Fluticasone propionate nasal spray (Nasofan®)

2 puffs OD-BD reducing to 1 puff OD

£3.00-£6.00 2nd LINE Formulary choice £8.04/150 dose OP

Mometasone furoate nasal spray (Nasonex®)

2-4 puffs OD reducing to 1 puff OD

£3.07-£6.14 2nd LINE Formulary choice £7.68/140 dose OP

Fluticasone propionate 50mcg /Azelastine HCl 137mcg (Dymista ®)

1 puff BD £7.40 2nd LINE Formulary choice (steroid plus antihistamine nasal spray) £14.80/120 dose OP

Azelastine HCl 140mcg/spray

1 puff BD £7.49 Formulary choice (antihistamine nasal spray) £10.50/157 dose OP

Sodium cromoglicate 4% aqueous nasal spray

1 puff BD-QDS £6.37-£12.75 Formulary choice (cromoglicate nasal spray) £17.07/150 dose OP

Ipratropium bromide 0.03% nasal spray

2puffs BD-TDS £4.07-£6.10 Formulary choice (antimuscarinic nasal spray) £6.54 /180 dose OP

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Over The Counter (OTC) medicines

Many of the commonly used treatments for hay fever are available as OTC medicines. Oral antihistamines including

loratadine, cetirizine, and chlorpheniramine; sodium cromoglicate eye drops and corticosteroid nasal sprays are

generally inexpensive.

Branded OTC formulations such as Benadryl allergy relief®, Benadryl Once Daily®, Zirtek Allergy®, NasalGuard®

Allergy Block gel and Prevalin® allergy nasal spray should not be prescribed. Patients should be advised to purchase

them directly from their local pharmacy or supermarket if they expressly wish to have such products.

Treatment in Pregnancy

The preferred treatment for allergic rhinitis in pregnancy is the application of topical preparations as these have

lower systemic absorption. Intranasal corticosteroids are the treatment of choice during pregnancy, however if this

does not completely relieve symptoms, or it is not tolerated, an oral antihistamine, e.g. loratadine or cetirizine, can

be considered. Any medication prescribed during pregnancy should be at the lowest effective dose for the shortest

time necessary.2 For further information UKMI have produced a Q&A document available via the following link:

http://www.medicinesresources.nhs.uk/upload/documents/Evidence/Medicines Q & A/2014-2015/QA29_6_Hayfever_and_Pregnancy_final.doc Advice for patients about reducing exposure to allergens could include the following:

If possible, try to stay indoors when the pollen count is high (over 50). Keep windows and doors shut in the house. If it gets too warm, draw the curtains to keep out the sun and keep the temperature down.

Don't keep fresh flowers in the house.

Vacuum regularly, ideally using a machine with a HEPA (high-efficiency particle arresting) filter.

Damp-dust regularly. Dusting with a wet cloth, rather than a dry one, will collect the dust and stop any pollen from being spread around.

Keep pets out of the house during the hay fever season. If your pet does come indoors, wash them regularly to remove any pollen from their fur.

Don't smoke or let other people smoke in your house. Smoking and breathing in other people's smoke will irritate the lining of your nose, eyes, throat and airways, and can make your symptoms worse.

If possible, avoid drying clothes outside. This will help prevent bringing pollen into your house.

Avoiding pollen outside:

Avoid cutting grass, playing or walking in grassy areas and camping – particularly in the early morning, evening and at night when pollen counts are highest.

Wear wraparound sunglasses to stop pollen getting in your eyes.

Change your clothes and take a shower after being outdoors to remove the pollen on your body.

Keep car windows closed. You can buy a pollen filter for the air vents in your car. This will need to be changed every time the car is serviced.3

Further patient information is available at Patient.co.uk http://www.patient.co.uk/health/hay-fever-leaflet

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References:

1. NICE Clinical Knowledge Summaries (accessed 20/03/2015) http://cks.nice.org.uk/allergic-rhinitis#!topicsummary

2. UKMI Medicines Q&A 29.6: Which medicines can be used to treat intermittent allergic rhinitis during pregnancy? (May 2014) http://www.medicinesresources.nhs.uk/upload/documents/Evidence/Medicines Q & A/2014-2015/QA29_6_Hayfever_and_Pregnancy_final.doc

3. NHS choices – Hayfever http://www.nhs.uk/conditions/Hay-fever/Pages/Introduction.aspx

Query corner VACUUM PUMPS FOR ERECTILE DYSFUNCTION The Medicines Management Team (MMT) has received several queries about the prescribing of vacuum pumps for erectile dysfunction (ED). The information below has been developed in conjunction with the Pharmacy Department at Warrington and Halton Hospitals NHS Foundation Trust (WHHFT) in order to provide a better understanding of the management of ED using vacuum pumps.

When is a vacuum pump indicated for use? A vacuum pump is indicated at patient request or where treatment with phosphodiesterase-5 (PDE-5) inhibitors or alprostadil given by intracavernosal injection or intraurethral application is unsuitable or has failed. Which patients are eligible for prescribing on the NHS? There are prescribing restrictions applied to vacuum pumps and constrictor rings for erectile dysfunction. To be eligible for an NHS prescription, patients must meet the ‘SLS’ (selected list scheme)1 criteria below and prescriptions must be endorsed ‘SLS’ by the Prescriber. SLS criteria:

Men with ED secondary to one of the following conditions are eligible for NHS prescription:

diabetes

multiple sclerosis

Parkinson’s disease

poliomyelitis

prostate cancer

severe pelvic injury

single gene neurological disease

spina bifida

spinal cord injury

radical pelvic surgery

renal failure treated by dialysis or transplant

prostatectomy

The Urology Team at WHHFT will inform patients if they have met the criteria for an NHS prescription and communicate this information via a letter to the GP. Patients who do not meet the ‘SLS’ criteria will be advised to purchase their vacuum pump privately.

Which brand of vacuum pumps does the WHHFT recommend? iMEDicare is the preferred brand of vacuum pumps recommended by the Urology Team. There is a range of vacuum pumps available for this brand, see below. Selection is mainly based on size and breadth of the penis.

Name Price per pump1 Comments

SomaCorrect® £159 Manually operated device with large, medium and standard cylinder sizing options. Ideal for men with the penile curvature associated with Peyronie’s

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disease. Device is not suitable for men with extra-wide penile diameter.

There is a battery-operated version of this pump for men with poor manual dexterity.

SomaCorrect® Xtra £179 As above plus a supply of all the various iMEDicare penile rings.

SomaErect® Response II £160.81 Manually operated. This is a standard pump which is suitable for most patients excluding those with extra-wide penile diameter

SomaErect® Response II - XL £160.81 Manually operated. For patients with extra-wide penile diameter only

SomaErect® Touch II £169 Battery operated for patients with dexterity problems only

How is a vacuum pump selected for an individual patient? Patients are normally given a choice of treatment options for their ED. If a vacuum pump is preferred, then training and information is provided by the Urology Team to ensure that the patient is happy with the mechanism and effect of the vacuum pump. Are vacuum pumps interchangeable? No, vacuum pumps are not interchangeable so it’s important to always stick with the same brand. How often should a vacuum pump be replaced? Vacuum pumps are durable and therefore only a one-off issue of one pump on prescription is usually needed. To help the lifespan of a vacuum pump, patients are advised to only use a water based lubricant with the pump. Vacuum pumps and cylinders generally have a 5-year warranty when prescribed on the NHS, and lifetime warranty if purchased privately. Are there any parts on different vacuum pumps that need to be replaced, and if so, how often? Only the penile rings need to be replaced annually or biannually depending on use. Below is a list of iMEDicare tension rings available in different sizes.

Ultra Maintenance Ring Set

£34.00

Ultimate (Surefit) Maintenance Ring Set £34.00

SureEase Maintenance Ring Set £32.00

Select Maintenance Ring Set £29.00

High

Tension

Low

Tension

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Does the WHHFT make the first supply of a vacuum pump to patients? No, patients who meet the ‘SLS’ criteria should obtain a prescription for a vacuum pump from their GP. Patients who do not meet the ‘SLS’ criteria are advised to purchase their vacuum pump directly from a company. How often are patients reviewed by the Urology Team at WHHFT? Patients are reviewed at 3 months after a vacuum pump has been recommended. If there no problems and the patient is managing well with their vacuum pump then, the patient is discharged from the Urology Team but with the option of seeking further advice from the Team if necessary. Further information If you require any further information or have any questions, please contact the Urology Nurse Practitioners at WHHFT on 01925 275547. Reference:

1. NHSBSA, Drug Tariff, February 2015.

Drug Tariff

PRICE CHANGES Top ten monthly price reductions March 2015 Peppermint oil liquid [1 x 100] £17.56 (-£9.86) Disopyramide 150mg capsules [1 x 84] £18.76 (-£8.82) Squill oxymel [1 x 2000] £32.78 (-£7.85) Morphine sulfate 15mg/1ml solution for injection ampoules [1 x 10] £2.12 (-£6.83) Chloral hydrate crystals [1 x 100] £11.14 (-£4.97) Benzoin tincture [1 x 500] £12.62 (-£2.90) Famciclovir 500mg tablets [1 x 14] £158.40 (-£2.60) Morphine sulfate 30mg/1ml solution for injection ampoules [1 x 5] £1.95 (-£2.57) Thiamine 100mg tablets [1 x 100] £9.18 (-£2.37) Dutasteride 500microgram capsules [1 x 30] £14.60 (-£2.20) Top 10 monthly price increases March 2015 Cyclophosphamide 50mg tablets [1 x 100] £139.00 (+£57.00) Dipipanone 10mg / Cyclizine 30mg tablets [1 x 50] £181.67 (+£51.93) Cilazapril 5mg tablets [1 x 28] £51.80 (+£39.29) Doxepin 50mg capsules [1 x 28] £84.00 (+£36.00) Acetazolamide 250mg tablets [1 x 112] £86.50 (+£24.38) Doxepin 25mg capsules [1 x 28] £48.00 (+£24.00) Chloral hydrate 143.3mg/5ml oral solution BP [1 x 150] £156.90 (+£8.70) Triamterene 50mg capsules [1 x 30] £27.92 (+£7.97) Dicycloverine 20mg tablets [1 x 84] £106.35 (+£7.04) Dicycloverine 10mg/5ml oral solution [1 x 120] £99.77 (+£6.59) Top 100 annual price reductions March 2015 http://www.panmerseyapc.nhs.uk/home/tariff_watch/partviiia_reductions_201503.pdf Top 100 annual price increases March 2015 http://www.panmerseyapc.nhs.uk/home//tariff_watch/partviiia_increases_201503.pdf

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DRUG AVAILABILITY

Medication supply issues The following generic drugs have supply issues and hence are incurring increased costs; they have been given a NCSO (NO CHEAPER STOCK OBTAINABLE) status for March 2015. Please consider the costs of the following drugs before prescribing.

Product Quantity Price concession

Clonidine 250microgram tablets 112 £6.99

Digoxin 125microgram tablets 28 £4.99

Digoxin 250microgram tablets 28 £4.99

Digoxin 62.5microgram tablets 28 £4.99

Exemestane 25mg tablets 30 £45.74

Lisinopril 20mg/Hydrochlorothiazide 12.5mg tablets (new)

28 £8.00

Lofepramine 70mg tablets 56 £24.18

Mebeverine 135mg tablets 100 £18.00

Olsalazine 250mg capsules 112 £75.00

Olsalazine 500mg tablets 60 £85.00

Pizotifen 500microgram tablets (new) 28 £7.00

Pizotifen 1.5mg tablets 28 £7.81

Tamoxifen 20mg tablets 30 £3.93

Trimethoprim 100mg tablets 28 £7.55

Trimethoprim 200mg tablets 6 £2.98

Trimethoprim 200mg tablets 14 £6.95

Other drugs with long-term supply issues

The following drugs have long-term supply issues. The table below shows the reason for the supply issue, where known, and possible return to stock dates.

Description

Due date

Comment

Abbott Thin® lancets (200) Supplier unable to confirm Manufacturing issue is causing a delay in supply

Bisacodyl suppositories (10mg) Supplier unable to confirm Manufacturing issue is causing a delay in supply

Caverject® Dual Chamber 20micrograms

January 2016 Manufacturing issue is causing a delay in supply. Medical Information Enquiries - 0845 608 8866

Colofac® tablets 135mg Supplier unable to confirm Manufacturing issue is causing a delay in supply

Co-phenotrope tablets 2.5/0.025mg (100)

June 2015 Supplier issue is causing a delay in supply

Eurax® cream 10% (100g) Limited supplies ongoing Supplier issue is causing a delay in supply

Ferrous fumarate tablets 210mg June 2015 Manufacturing issue is causing a delay in supply

Glucophage® SR tablets 750mg Supplier unable to confirm Manufacturing issue is causing a delay in supply

Hormonin® tablets (84) Limited supplies ongoing Supplier issue is causing a delay in supply

Methotrexate tablets 2.5mg June 2015 Market shortage is causing a delay in supply

Modrasone® cream (50g) Supplier unable to confirm Manufacturing issue is causing a delay in supply

Mefenamic acid tablets 500mg Supplier unable to confirm Ongoing supply issue

Sno Tears® (10ml) Supplier unable to confirm Manufacturing issue is causing a delay in supply

Unistik 3® Comfort lancet 28Gx1, 8mm (50 and 100)

Limited supplies ongoing Supplier issue is causing a delay in supply

Zacin® cream 0.025% (45g) Supplier unable to confirm Manufacturing issue is causing a delay in supply

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For any further information regarding supply problems please contact your Practice Pharmacist/Technician or the Medicines Management Team.

Safety

FDA warning: bradycardia associated with hepatitis C treatments and amiodarone The hepatitis C treatments ledipasvir/sofosbuvir (Harvoni®▼) or sofosbuvir (Sovaldi®▼) when combined with another direct-acting antiviral daclatasvir (Daklinza®▼) or simeprevir (Olysio®▼) and co-administered with amiodarone, have been associated with serious and life-threatening symptomatic bradycardia. The FDA has reviewed post-marketing adverse events and has identified nine cases of bradycardia which also included one fatality. The exact cause of these events has not been established and so the recommendation to health professionals is not to co-prescribe Harvoni®▼ or Sovaldi®▼ with another direct-acting antiviral along with amiodarone. If there is no alternative, then patients should be monitored in an inpatient setting for the first 48 hours and monitoring in a community setting should be carried out daily for the first two weeks of treatment. Even if amiodarone is discontinued prior to the combination treatment of Harvoni®▼ or Sovaldi®▼ with another direct-acting antiviral, cardiac monitoring should be undertaken due to the long half-life of amiodarone.

http://www.medicinesresources.nhs.uk/en/Medicines-Awareness/Safety-Alerts/Safety-alerts/Hepatitis-C-Treatments-Containing-Sofosbuvir-in-Combination-With-Another-Direct-Acting-Antiviral-Drug-Drug-Safety-Communication---Serious--6356289366/

Pharmacovigilance Risk Assessment Committee (PRAC) recommends use of a patient reminder card to minimise risk of osteonecrosis with zoledronic acid (Aclasta®) Further measures have been announced by PRAC to reduce the risk of osteonecrosis of the jaw with zoledronic acid (Aclasta®▼). These measures may also be extended to denosumab (Prolia®, XGEVA®▼) and other intravenous bisphosphonates. PRAC has recommended that patients should be given a reminder card with the following information:

• the benefit of treatment of osteoporosis

• the risk of osteonecrosis of the jaw during treatment with zolendronic acid (Aclasta®▼)

• the need to highlight any dental problems to their Doctors/Nurses before starting treatment

• the need to ensure good dental hygiene during treatment

• the need to inform their Dentist of treatment with zolendronic acid (Aclasta®▼) and to contact the Doctor and Dentist if problems with the mouth or teeth occur during treatment.

Zoledronic acid (Aclasta®▼) is a bisphosphonate used to treat osteoporosis in women who have been through the menopause, and for use in men. It is also used for Paget’s disease in adults. PRAC has stated that although the risk of osteonecrosis remains low, measures have been recommended to minimise the risk even further. The Patient Information Leaflet and Summary of Product Characteristics will also be updated.

http://www.ema.europa.eu/docs/en_GB/document_library/Press_release/2015/03/WC500184259.pdf

EMA recommends restrictions for the use of codeine in children PRAC has recommended that the use of codeine-containing medicines in children should be restricted due to safety concerns of the risk of side effects caused by codeine, such as breathing problems. PRAC has recommended the following:

codeine should be contraindicated in children below 12 years of age. This means it must not be used in this patient group

use of codeine for coughs and colds is not recommended in children and adolescents between 12 and 18 years of age who have problems with breathing

all liquid codeine medicines should be available in child-resistant containers to avoid accidental ingestion. The risk of codeine arises from its conversion to morphine in the body, and as children under 12 years of age have unpredictable and varied metabolism, the risk is higher in this age group. Children who already suffer from breathing difficulties may be more prone to the risk of breathing problems with codeine. PRAC also recommends that codeine

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should be avoided in all adults who are considered to be ‘ultra-rapid metabolisers’. This group of people convert codeine to morphine at a faster rate than normal, resulting in higher levels of morphine in the body. Coughs and colds are considered to be self-limiting, so the evidence for the use of codeine in children is not enough to recommend its use. It also should be noted that breast-feeding mothers should avoid the use of codeine as it passes into the breast milk. http://www.ema.europa.eu/docs/en_GB/document_library/Referrals_document/Codeine_cough_or_cold_in_children/Recommendation_provided_by_Pharmacovigilance_Risk_Assessment_Committee/WC500184257.pdf MHRA Alert: Dimethyl fumarate (Tecfidera®): fatal PML in an MS patient with severe, prolonged lymphopenia Dimethyl fumarate is licensed for use in treating relapsing remitting multiple sclerosis in adults. Dimethyl fumarate has been found to reduce lymphocyte counts in clinical trials by approximately 30% from baseline values causing severe lymphopenia. The fatal case of progressive multifocal leukoencephalopathy (PML) was reported in a patient participating in an open-label ENDORSE study in Germany and occurred in October 2014. The patient received dimethy fumarate for 4.5 years and experienced severe lymphopenia for more than 3.5 years. To date this is the only known cause of PML in a multiple sclerosis patient.

The MHRA has issued the following advice when prescribing dimethyl fumarate:

ensure that the full blood count (including lymphocytes) has been checked - note that dimethyl fumarate has not been studied in patients with pre-existing lymphopenia or in combination with other immunosuppressive medicines

explain the risk of lymphopenia and potential risk of progressive multifocal leukoencephalopathy (PML) to patients and carers – see Information to give to patients and carers: https://assets.digital.cabinet-office.gov.uk/media/55159c5ee5274a142b000067/Dimethyl_fumarate_patient_info_March_2015.pdf

During dimethyl fumarate treatment:

monitor patients - check full blood counts, including lymphocytes, every 6 to 12 months or more frequently if clinically indicated

monitor patients with lymphopenia closely for features of PML (e.g. signs and symptoms of neurological dysfunction) and other opportunistic infections

stop dimethyl fumarate treatment immediately and investigate appropriately if you suspect PML

consider that PML can present with similar features to multiple sclerosis because PML is also a demyelinating disease

continue to report suspected adverse drug reactions to dimethyl fumarate or any other medicine on a Yellow Card:

https://www.gov.uk/report-problem-medicine-medical-device

https://www.gov.uk/drug-safety-update/dimethyl-fumarate-tecfidera-fatal-pml-in-a-ms-patient-with-severe-prolonged-lymphopenia

Medicines Management Team contacts:

Lucy Reid (Halton) lucy.reid2@nhs.net 01928 593 452