MEETING OF THE BORDERS FORMULARY COMMITTEE HELD ON WEDNESDAY 8 th FEBRUARY P.M. IN THE ESTATES MEETING ROOM MINUTE

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1 MEETING OF THE BORDERS FORMULARY COMMITTEE HELD ON WEDNESDAY 8 th FEBRUARY P.M. IN THE ESTATES MEETING ROOM MINUTE In attendance: Alison Wilson (Director of Pharmacy & Chair of BFC); Liz Leitch (Formulary Pharmacist); Catherine Scott (Senior Pharmacist); Dr Paul Neary (Consultant); Keith Maclure (Lead Pharmacist Medicines Utilisation & Planning); Dr Paul Marynicz; Kate Warner (BFC Minute Secretary) 1. Apologies: Dr Lindsay Burton (Medical Registrar); Item Situation ; Background Assessment Recommendation Person Timescale No. Responsible 2. Declaration of Interest: - None 3. BFC meeting Draft Minute from meeting 14 th December 2016 was approved as an accurate Remove draft; upload record of the meeting with no changes. to internet/intranet 4. Matters Arising From Previous Minute: Borders Formulary App is now available on both the Android and Apple stores and can be found by searching NHS Borders or Joint Formulary. This will be updated in future by us but for now Nugensis update. Updates are taking too long to process updates sent December 2016 are only just coming for checking at beginning of February. Search facility is same as formulary Ask DR to the next meeting to demonstrate. Review of lessons DR app which goes to chapter not item. learned and what can be improved. 5. Dr Paul Neary gave an update from a recently attended NOAC/DOAC national meeting (Novel Oral Anti-Coagulants / Direct Oral Anti-Coagulants). He reported that some attendees hoped to discuss best evidence and recommend products; others are looking to form a national strategy and negotiate a better price for products already in use. In product discussions, Rivaroxaban, Apixaban and Edoxaban were compared for evidence, cost effectiveness and the differences in data available. PN reported that NHS GG&C have no new starts for Warfarin as PN Page 1 of 5

2 no slots are available for anti-coagulation. In other places, Warfarin is still the first choice. PN felt that there should not be different policies throughout Scotland. BFC discussed Rivaroxaban and Apixaban and agreed that there would be no changes until it is understood what is happening nationally and that NHS Borders would continue to use the current products. Second choice may change after this is known. Cost effectiveness of Warfarin vs Apixaban was discussed; also district nurse staff time. It was agreed that choice should be Warfarin unless good reason not to; if difficult to comply or nursing time difficult then patient choice should be taken into consideration. Rivaroxaban is high in Top 50 within NHS Borders, for some other Boards use is Apixaban, Forth Valley and Fife - Rivaroxaban. It was agreed that new patients would not be started on Rivaroxaban. BFC commented that it was important to NHS Borders to be involved in these discussions, organised by ADTC Collaborative, as although a small Board we have a lot to offer in experience and knowledge. PN is unable to attend the next NOAC/DOAC meeting in March; Dr Paul Syme may attend; future meetings will be attended. 6. New Medicine Applications: a) Lurasidone (Latuda) - Applicant: Dr Joanna Bredski Indication: Treatment of schizophrenia in adults aged 18 years and over; Generic Name: Lurasidone; Brand Name: Latuda; Dosage: The recommended starting dose of Lurasidone is 37mg once daily. No initial dose titration is required. Lurasidone is effective in a dose range of 37 to 148mg once daily. Dose increase should be based on physician judgement and observed clinical response. The maximum daily dosage should not exceed 148mg; Cost per Month: refer to application; Number of patients in first year: 1 5. The advantages over Olanzapine were discussed; Lurasidone has potential to be beneficial for patients who have had issues with weight gain. Clinical evidence presented shows benefits over placebo and SMC advice was included in the application. Current alternatives are cheaper but the application is only for up to five patients. Olanzapine is associated with long Q-T and ECG is recommended annually; sudden death and cardiovascular, weight gain can be side effects. Also additive effects of additional drugs being taken must be considered. It was thought that although this was a more expensive option that the clinical benefits outweigh the cost and that patient numbers are low. BFC agreed that patient numbers are to be monitored and patient feedback would be of interest. b) Elbasvir 50mg, Grazoprevir 100mg film-coated tablet (Zepatier) - Applicant: Dr Chris Evans Indication: Treatment of chronic hepatitis C (CHC) in adults. (The efficacy of elbasvirgrazoprevir has not been demonstrated in genotypes 2, 3, 5 and 6. Elbasvir-grazoprevir is not recommended in patients infected with these genotypes); Generic Name: Elbasvir 50mg, Grazoprevir 100mg film-coated tablet; Brand Name: Zepatier; Dosage: 1 tablet once daily. In patients with genotype 1a, 1b or 4 who have no cirrhosis or who have Child-Pugh A BFC approved for Consultant Initiation and subsequent general use hospital and general practice. Letter to applicant Monitor patient numbers BFC approved for Specialist Use Only Letter to applicant Page 2 of 5

3 compensated cirrhosis, treatment should be continued for 12 weeks; Cost per Month: Refer to SMC advice ; Number of patients in first year: 5. National guidelines were included as part of this application as evidence and information. BFC felt it was useful to look at the national strategy. This is a first line treatment for Hep C. Guidelines have been used to drive down the cost and this is one of the cheaper options. CE follows the guidelines as do others successfully, this has just been updated. BFC agreed that in this specialist and complicated area that the follow up would be done by specialist nurse and that with around 16 patients completed and one part way through at the end of 2016 the results so far were positive. c) Evolocumab 140mg (Repatha) - Applicant: John O Donnell Indication: Primary hypercholesterolaemia (heterozygous familial hypercholesterolaemia and non-familial) or mixed dyslipidaemia, as an adjunct to diet: in combination with a statin or statin with other lipid lowering therapies in patients unable to reach low density lipoproteincholesterol (LDL-C) goals with the maximum tolerated dose of a statin or, alone or in combination with other lipid-lowering therapies in patients who are statin-intolerant, or for whom a statin is contraindicated. See SMC Advice for restrictions; Generic Name: Evolocumab 140mg; Brand Name: Repatha; Dosage: See NMA; Cost per Month: refer to application; Number of patients in first year: 0 1. This monoclonal antibody is the second made available; a powerful agent seriously reducing cholesterol. This product is an injection (unlike alternatives). BFC agreed that there are clinical benefits but that the data is lagging behind the evidence. More outcome data would be beneficial but that for the right patients (familial/intolerant statins) it would be appropriate to use. BFC asked if patients were attending Lipid Clinic at the Royal and if there were any Unpacs patients that could be repatriated. It was agreed to approve 1 patient. d) Non Formulary Request 5-Fluorouracil for injection - Applicant: Dr Simone Laube Indication: Extensive Keloid Scarring; Generic Name: 5-Fluorouacil; Brand Name:; Dosage: 50mg/ml; 3 cycles; Cost: refer to application; Number of patient: 1. Single patient for off label use discussed. Previous therapy has had failure to respond to treatment and no other treatments. Clinical evidence provided and BFC heard this evidence summarised. Trial data is not huge Page 3 of 5 Approved for the numbers requested on Specialist Use only Letter to applicant. LL meet with PN and JO D to discuss. Check we haven t missed anything in the gap of no s from SMC. Check Unpacs with Shona Aprile LL AW BFC approved for one patient Specialist Use only Letter to applicant numbers. Product is more cost effective. 7. SMC Recommendations December 2016 and January 2017 decisions. Commented on Burpenorphine transdernal Butec now approved by SMC. DME not applying to use but pain team may respond. Mainly prescribed in primary care; 4 and 7 day patches; there is a concern of using wrong patch and it was agreed that there needs to be clear instruction and that patients have the correct duration patch for that duration time. Currently classified as non formulary and wait for any response that may come from pain team. 8. Borders Joint Formulary Updates:

4 a) Bisacodyl 5mg; Tablets; Oral; Indication: Constipation; Formulary Section: Gastrointestinal; 1 st Reason: Drug cost efficiency saving 60/patient/year. Currently Senna is NHS Borders first choice; Bisacodyl is cheaper drug. There is no detail on efficacy. Bisacodyl would have larger annual savings if using larger tubs; although cheaper they would need patient safety info leaflets and are not as convenient. Patients who need liquid would still have to have Senna. b) Alogliptin 6.25mg, 12.5mg, 25mg; Tablets; Oral; Indication: Type 2 diabetes mellitus; Formulary Section: Endocrine; 1 st ; Reason: Replacing Sitagliptin 25mg, 50mg, 100mg cost efficiency saving 80/patient/year. Dr Herlihy and Dr Williamson are supportive of this change. No immediate patent expiry on alternative. Active switching to be encouraged. c) Borders Joint Formulary Updates document (updates to December 2016 BFC meeting) sent through GP Bulletin in January Also available on Intranet. BFC discussed how to bring this to the attention of GPs; possibly send twice a month. Feedback from other GPs of interest. Other Items for Approval 9. Buprenorphine Patches; Dr Reddy s manufacture both the 4 Day (Bupeaze Brand equivalent to Transtec) and 7 Day (Panitaz Brand equivalent to BuTrans) Buprenorphine patches are currently offering savings and this led to a discussion as to whether we should be prescribing branded generics. This would need a patient by patient review but we should consider moving to cheaper alternative and consider this product. For Information and Noting 10. Montgomery Review was undertaken to assess the impact of the new report introduced in 2014 by SMC. The new approach aimed to increase access to end-of-life, orphan and ultra-orphan medicines. The Review has made 28 recommendations on how to improve increased access to new medicines in Scotland. BFC felt that whilst the report raised a query about money, it describes the problem without a solution. It raises where we are with ultra orphan drugs and the discrepancy between Boards. It also raises the issue of a national formulary and BFC agreed that they should be part of that discussion. It was felt that because the NHS Borders formulary was not available publically for sometime whilst the app was being created, that we have been overlooked. It is important that we are involved in discussions through DoPs and ADTC Collaborative and any equivalent for Medical Directors. 11. Minute of Tissue Viability Group - Meeting in January cancelled. 12. Action Plan - Wound Formulary Group - No update available. 13. Minute of Lothian Formulary Committee - Approved Minute from LFC meetings held on 14 th December Page 4 of 5 Introduce as an equal first choice in formulary and ask for response from wards compared to Senna LL Approved LL Increase distribution Feedback from GPs Ask Fiona Kilgour to take a lead in pain and look at numbers and get onto equivalent cheaper. BFC noted BFC noted PM AMack A.O.C.B. Acapella device for loosening mucus. Requested additional information to be brought to future meeting of BFC. Next Meeting: Wednesday 12 th April 2017 at 12:30 in the Estates Meeting Room

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