GREAT WESTERN HOSPITALS NHS FOUNDATION TRUST

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1 The 3T s Formulary NHS Swindon NHS Wiltshire Great Western Hospitals NHS Foundation Trust (In collaboration with Avon and Wiltshire Mental Health Partnership and Oxford Health NHS Foundation Trust) Attendees: Lisa King () (Chair) Dr Rachel Hobson (RH) Katherine Roe () (mins) Dr Andrew Thornton (AT) Paul Clarke (PC) Guy Rooney (GR) Formulary Working Group 21 st March Seminar Room 7, The Academy GWH Formulary Pharmacist, GWHNHSFT Formulary Pharmacist, NHS Wiltshire Formulary Pharmacy Technician, GWHNHSFT GP, NHS Wiltshire Pharmaceutical Lead, NHS Swindon Associate Medical Director, Diagnostics & Outpatients, GWHNHSFT Apologies: Dr Peter Mack (PM) GP & Deputy Chair Swindon CCG (From 15.00) Jane Coleborn (JC) Chief Pharmacist, GWHNHSFT Agenda Item Description Action by whom Action by when 1 2 APOLOGIES MINUTES & MATTERS ARISING Romiplostim will follow up with haematologists at the end of the month Hydroxycarbamide SCA Haematology / oncology pharmacist is looking at this document and will feedback to Eye lubricant review Awaiting confirmation of meeting date from ophthalmology consultant. Chapter 10 Methotrexate SCA This item has been delayed due to work focusing on NICE GPG1. to circulate second draft to FWG and Rheumatology consultants. Actinic keratosis Awaiting draft pathway from Dermatology consultant. to followup. Rivaroxaban for DVT has discussed this with the anticoagulant pharmacist and the pathway is being discussed at a local haematology meeting. Rivaroxaban to remain as Amber until further feedback received. /SG /SM / /SG Page 1 of 8

2 Bevacizumab for non-amd indications Delayed due to cancellation of TPC meeting. RH to follow-up with Nadine Fox (NF). Currently exceptions forms are being completed by consultants at GWH, despite Swindon Commissioning statement. COPD Inhalers Adegbayi Ukoha (AU) has asked the respiratory consultants for their thoughts on the new COPD inhalers. FWG agreed that, if they would like either added to formulary, a formal application would be required and consultants would also be encouraged to attend FWG to discuss options. NICE TA Botox in migraine Await feedback from KB. PC to follow-up. Dossette Prescribing Mike Lewis (ML) is discussing current provision with commissioners. will ask ML to contact AT directly to discuss the issue further. Generic desogestrel / to feedback details of discussions of last FWG to sexual health /family planning consultants and liaise with GWH pharmacy to implement change. ADHD SCA Awaiting feedback from RC on which CCG s GPs are reluctant to share care of ADHD drugs. RH/NF AU PC/KB / RC 3 CHAPTER/SECTION UPDATES 3i Chapter 6 update Awaiting feedback from consultants. to chase and confirm completion date. 3ii Chapter 12 first draft Initial review of evidence completed. to circulate first draft to FWG and ENT consultants. 4 NEW DRUG UPDATE March 2013 A report detailing New Drug Updates for March 2013 was discussed and will update New Drug database. 5 5i NEW DRUG REQUESTS 4% Liposomal Lidocaine Cream Dr Ben Maxwell (BM) Preliminary feedback from paediatric team was negative; one consultant did not feel the product was effective. Following a more Page 2 of 8

3 in depth price comparison of like for like products, it is also more expensive. Additional feedback needed from BM and paediatric team. to follow-up with RC / BM. BM// RC 5ii Ticagrelor Dr Tom Hyde (TH) Dr Hyde attended for this item Application for use in patients with STEMI and PCI. Treatment is twice a day for 12 months with aspirin. Ticagrelor has mortality benefit over clopidogrel. There is no head to head data with prasugrel available, but prasugrel does not have mortality data. More patients are able to receive treatment with ticagrelor as there are less contra indications and no age or weight restrictions compared with prasugrel. About 25% of patients currently end up on clopidogrel because they have contraindications to prasugrel. The projected additional cost of ticagrelor compared to prasugrel is 5000 p.a., based on 100 patients p.a. (Post-meeting note: This figure rises to 20,000 p.a. if the 25% of patients with contraindications to prasugrel have ticagrelor instead of clopidogrel). The local cardiac network meeting on 15 th March agreed to stay with their current recommendation to use prasugrel for STEMI patients. Ticagrelor is recommended by NICE as a treatment option in ACS. FWG agreed to roll out ticagrelor for STEMI patients to gain experience prior to possible future use in all ACS patients. to discuss current OAP guidance with TH as this will need to be updated. Ticagrelor to be added to formulary as Amber for indication as described. / TH also discussed the application last year for Ranolazine. Ranolazine was added to formulary as a red drug with agreement this would be reviewed once there was more experience of its use. Following a positive trial period, TH requested that a switch to Amber be considered. This will be discussed outside of the meeting and will feedback the decision to TH. will update database with details of discussions 6 NICE 6 i NICE TA Apixaban in stroke prevention in AF patients RH has updated the current anticoagulation guidance documents to include apixaban following the NICE TA for use in stroke. These documents will need approval by haematologists and stroke consultants. The updated versions also include information on the new contraindications for dabigatran and rivaroxaban. RH will also produce a new table showing all the available anticoagulants, their indications, contraindications and preferred treatment options. Apixaban is likely to be first choice of the newer agents. RH is awaiting additional data from the manufacturers prior to making final amendments. / to circulate final documents to stroke and RH / Page 3 of 8

4 haematology consultants for comment. Once prescribing guidance documents agreed, Apixaban may be added to formulary as Green for this indication. 6 ii NICE GPG1 and have been through the guidance and assessed the current 3Ts position based on the current FWG/TPC structure. It was noted that TPC s structure / terms of reference will be reviewed once CCG structures have bedded in. It was also noted that Wiltshire CCG are producing a paper proposing one formulary to cover the whole of the Wiltshire area and that Swindon CCG are in support of this. It was agreed to proceed with review of 3Ts performance against GPG1 recommendations based on current position. will circulate the document to FWG showing the current 3Ts position, all are asked to comment on this. All ASAP The patient internet site will need to be live by 1 st April. As an interim measure, all formulary documents have been uploaded as PDFs onto the GWH website. / will work with the GWH communication team to make these pages live. / will send these links to PC/RH/BS so that appropriate links can be added to their websites. / Wiltshire Pain Guidance RH has revised Wiltshire CCGs Pain Guidance. A review of current services is needed to reduce usage of medication and optimise use of other therapies. The British Pain Society recommends that any prescribing of morphine in doses over 120mg should be discussed with a pain specialist. Wiltshire commissioners are looking at increasing the provision of pain clinics in primary care, including those which are pharmacist led, as well as provision of nonpharmacological therapies. The new guidance includes guidance on the use of low strength buprenorphine patches, currently there is very high usage and the aim is to improve the appropriateness of this usage. RH needs to make some final amendments to the document prior to final approval. The potential switch to Longtec was discussed. Wiltshire are not interested in switching at this time. The GWH pain team are cautious about switching due to limited experience with the preparation, but would be happy to consider an appropriately managed switch. They feel awareness of the product needs to be raised as there is already some usage. The hospice is happy to consider a managed switch including a wider education programme. Swindon has very high usage of Oxycontin and are planning a programme to encourage use of morphine first-line. It was agreed to await the release of Shortec (anticipated within the next 6-8months) prior to any switch. will feedback to the pain and hospice teams. RH Page 4 of 8

5 8 Ferrinject/Venofer Both Ferrinject and Venofer are currently non-formulary. Venofer is used in the renal unit on the advice of the team from oxford. Cosmofer is the current formulary option. Ferrinject is used as an alternative to Cosmofer in patients who are asthmatic or have allergic conditions. It was agreed to add Ferinject as red for patients who are contraindicated from receiving Cosmofer. It was agreed to add Venofer as red for use by the renal unit only. / / 9 GWH Formulary adherence A report detailing GWH formulary adherence was discussed. All areas are over the 90% target; only one chapter fell below 95%. The main issue in this chapter is non-formulary prescribing of solifenacin; this has been added to the formularies at Bath and Salisbury as a fourth line option. will this back and encourage the urologists to apply if they feel this could be a useful 4 th line option. All agreed that the GWH formulary adherence is encouraging and helped by the use of e-prescribing AOB Drug tariff and contract changes None to discuss Next Meeting: Thursday 18 th April pm, Seminar Room 4, GWH Future Meetings: 16 th May 2013 Liden Room, Brunel Treatment Centre, GWH 2 5pm 20 th June 2013 Seminar Room 7, The Academy, GWH 2 5pm 18 th July 2013 Cherwell Education Room, GWH 2 5pm 15 th August 2013 Seminar Room 7, The Academy, GWH 2 5pm 19 th September 2013 Liden Room, Brunel Treatment Centre, GWH 2 5pm 17 th October 2013 Liden Room, Brunel Treatment Centre, GWH 2 5pm 21 st November 2013 Seminar Room 7, The Academy, GWH 2 5pm 19 th December 2013 Seminar Room 4, The Academy, GWH 2 5pm Agreed as an Accurate Record: Chair: Dated: Page 5 of 8

6 Trust as part of compliance with the Freedom of Information Act. NEW/OUTSTANDING ACTIONS Meeting Date Subject Action Required Action By Comments Romiplostim Follow up with GWH Haematologist SG has said she will look at this in mid March Hydroxycarbamide Follow up with Sarah McGlue SM is looking at this SCA and will feedback to Optive Plus Meet with Mr Smith / Awaiting confirmation of meeting date Actinic Keratosis SG to send draft pathway out for comment SG to follow-up with SG Chapter 6 Follow up with Diabetes team RC/ PP now back from leave. to followup with PP Date for Status completion Chapter 12 Circulate for comment Chapter 10 Methotrexate SCA Delayed due to GPG New Drug update Update database COPD Inhalers AU to arrange meeting with respiratory AU consultants Liposomal Lidocaine RC to discuss with colleagues within paediatrics RC Apixaban Approval of new documents. Aim to add Apixaban to formulary as green New drug Update database with details of requests discussions NICE GPG1 Go through document in detail & establish current position Initial feedback negative await formal feedback RH / Pending / Complete Page 6 of 8

7 Trust as part of compliance with the Freedom of Information Act Wiltshire Pain Guidance Dosette prescribing Provide feedback on positive and negative aspects of 3Ts adherence All Make final amendments prior to sign off RH and circulation Feedback outcome of Longtec discussions Pending to pain and hospice teams JC to provide response to FWG JC ML discussing Pending current position with commissioners Await final pathway DVT Pathway has discussed with anticoagulant pharmacist. Pathway is being discussed at local meetings. Rivaroxaban to remain as Amber until final pathway Botox in migraine Confirm progress of discussions with commissioners Mannitol Feedback Cathy Dewdney s comments & confirm with TPC if inclusion on formulary required NICE TA Process Update FWG on NICE TA process following TPC Lithium SCA Rewrite an abridged version in 3Ts format with additional details re. monitoring & discontinuation. KB BS/TT PC to discuss with KB Delayed due to TPC cancellation Postponed until CCGs in place No AWP rep at meeting on Pending POSTPONED Epistatus Obtain agreement for FWG Delayed due to TPC recommendation from TPC. cancellation Venofer/Ferrinject Update formulary / Pending ADHD SCA Identify geographical location of patients RC Awaiting feedback from RC Pending Recently completed actions Page 7 of 8

8 Trust as part of compliance with the Freedom of Information Act. Meeting Date Subject Action Required Action Comments Date for Status By completion Alteplase Approve and update e-formulary PC/ COMPLETE Actikerall Send out guidance for comment. Update RH COMPLETE e-formulary Bevacizumab Follow up with NF RH Added to TPC at COMPLETE request of NF TA267 Update e-formulary COMPLETE Denosumab Add to TPC and FWG agendas COMPLETE Horizon Scanning Send report to FWG COMPLETE Ticagrelor RH to share cardiac network information RH Added following COMPLETE discussion NICE patient website Prepare site for go live by April 1 st deadline 1 st draft completed Plan updated to include addition of PDF versions of COMPLETE Oxycodone SR Complete oxycontin vs. generic price comparison formulary COMPLETE Page 8 of 8