GREAT WESTERN HOSPITALS NHS FOUNDATION TRUST

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1 Attendees: Dr Ravi Chinthapalli (RC) (chair) Katherine Watkinson () (mins) Dr Rachel Hobson (RH) Paul Clarke (PC) Lisa King (LK) Formulary Working Group 17 th October Liden Meeting Room, GWH Consultant Paediatrician & Chair, GWHNHSFT Formulary Pharmacy Technician, GWHNHSFT Formulary Pharmacist, Wiltshire CCG Pharmaceutical Advisor, Swindon CCG Formulary Pharmacist, GWHNHSFT The 3T s Formulary Swindon CCG Wiltshire CCG Great Western Hospitals NHS Foundation Trust (In collaboration with Avon and Wiltshire Mental Health Partnership and Oxford Health NHS Foundation Trust Apologies: Dr Peter Mack (PM) Bethan Shepherd (BS) GP & Deputy Chair Swindon CCG Formulary Pharmacist, Avon & Wiltshire Mental Health Partnership Agenda Item Description Action by whom Action by when 1 2 & 3 APOLOGIES MINUTES & MATTERS ARISING The minutes of the September meeting were agreed by those present and signed by the chair. Wiltshire CCG GP representative A new GP representative for Wiltshire has been identified and RH is hopeful they will be able to attend the November FWG meeting. TA292 - Aripiprazole No response has been received from Oxford Health. A link to the TA has been added to formulary and no further action will be taken. OAB Guidance Mr Beck and Mr Griffiths have agreed that darifenacin can be removed from formulary. to remove darifenacin, update guidance document and add clarity to formulary entries. Vitamin D Guidance This guidance was approved at the last meeting and has been published but has not been seen by the orthogeriatricians. The orthogeriatricians are keen for secondary prevention to be included in any guidance. RH to send additional information to LK. LK/ to establish any potential cost impact for GWH. NH/LK to meet with GWH orthogeriatricians to discuss guidance. Current guidance to remain published until outcome of any discussions known. RH LK/ NH/LK Page 1 of 9

2 4 CHAPTER/SECTION UPDATES 4i Eye Chapter Review The referral criteria in the ocular lubricant guidance has been updated and this final version is with GS for final comments and then FWG approval outside of the meeting prior to publication. to update formulary as soon as approved An initial review of the rest of the eye chapter has been sent to the ophthalmologists for comment with a target date for completion of December The following items were raised for consideration during this chapter review: Add a note to the antibacterial section that antibiotics should only be used if the infection is severe and that treatment should only be initiated if there has been no improvement in symptoms within 3 days The fusidic acid 1% eye drop entry should be updated to state that it is 2 nd line for use in staphylococcal infections and 1 st line for use in pregnancy The antibiotic section needs to link to the primary care antibiotic guidelines The doxycycline entry in this chapter needs to be clarified to state for use in ocular Chlamydia. to confirm with ST if this would require referral to secondary care. The erythromycin entry is to be clarified to state for use in ocular Chlamydia and will be an amber drug. The chloramphenicol preservative free entry will need to be clarified to state when the preservative free preparation should be used. It is proposed that aciclovir eye ointment is changed to a green drug; this will require agreement of the ophthalmologists. Following agreement of the ophthalmologists the prednisolone entry will need re-writing with only licensed 0.5% and 1% eye drops being formulary choices due to the prohibitive cost of other unlicensed strengths. Dexamethasone implants need to be added to formulary Links to the new NICE TAs need to be added to formulary; a plan for formal implementation of these TAs is ongoing between TPC and the ophthalmologists. The latanoprost and latanoprost/timolol entries need to be updated to emphasise that they are to be used first line in their respective sections based on cost-effectiveness of the generic products Following agreement of the ophthalmologists saflutan will be removed from formulary and bimatoprost preservative free added based on cost-effectiveness Confirmation is needed from the antibiotic/microbiology team that oral moxifloxacin is approved for use in endophthalmitis PC shared various papers on the use of compliance devices to aid use of eye drops. to review these and draft a new section for this chapter /ST /ST ASAP 01/11/13 01/11/13 01/11/13 Page 2 of 9

3 will make these amendments to the draft chapter and these can then be reviewed by the ophthalmologists. 25/10/13 4ii ENT Chapter Review The ENT consultants have confirmed that a review of the initial draft is ongoing. The following items were raised for consideration during this chapter review: Earcalm spray is currently included in the summary notes at the beginning of the chapter. This will be moved to the otitis externa section as a green drug for first line use in primary care as per primary care antibiotic guidance The current entry for Otomize spray will be updated to show this is a second line option in primary care to be used after Earcalm Following approval from the ENT consultants the Rhinolast spray entry will be updated to state for use in children between 5 and 12 years of age. The licensed age range for Avamys needs to be clarified and the formulary entry updated Following approval from the ENT consultants Rynacrom spray (4%) will be replaced with Vividrin spray (2%) based on cost-effectiveness A prescribing note will be added to the nystatin suspension entry emphasising that Nystan is the most cost-effective brand in primary care FWG agreed for the pilocarpine tablets entry to be updated as per the draft will make these amendments to the draft chapter and these can then be reviewed by the ENT consultants. 25/10/13 4iii Endocrine Chapter Review The initial meeting with the diabetes team led to some minor amendments to the wording of some entries but since then due to the release of several new drugs and NICE TAs additional changes will be required. The following items were raised for consideration during this chapter review At the initial meeting it was proposed that some insulin preparations were changed to Amber on the formulary, FWG stated a preference for these to be Blue as prescribing is initiated in primary care It was agreed to add Humalog Mix50 to formulary /LK will liaise with the diabetic nurses to review the type of needles, there are several new brands available and there is potential for significant savings. There are numerous types of blood glucose testing strips and meters available which vary greatly in cost. Clinicians at GWH are currently reviewing the types of strips and meters being used and this will be brought to FWG for discussion and inclusion in formulary. Joint working and a clear formulary position is needed to ensure use of the most costeffective products. Page 3 of 9

4 Repaglinide is currently on 3Ts formulary but not on other local formularies. Swindon CCG usage is low, RH will review Wiltshire usage. Diabetes team to confirmation if this needs to remain on formulary. Current entries for saxagliptin and sitagliptin refer to licensed indications which differ from those recommended by NICE. The entries will be updated to remove licensed indications from the wording and detail areas of use as per the NICE guidance. For use in monotherapy will be removed from the sitagliptin entry. Recently published data for saxagliptin showed no improvement in CVS outcome and though slightly cheaper it cannot be used in end stage renal impairment or haemodialysis therefore FWG propose to remove from formulary, but this requires discussion with the diabetes team. Linagliptin has been added to other local formularies. /LK to confirm views of diabetes team on linagliptin but it was provisionally agreed that linagliptin and sitagliptin could be the formulary options. Dapagluflozin will be added to formulary as per the NICE TA. The diabetes team will be asked to confirm if they wish to use a similar entry to other local formularies where it is Green when used in combination with metformin alone where glycaemic control is inadequate and the patient has a significant risk of hypoglycaemia or a sulfonylurea is contraindicated or not tolerated, and Amber when used in combination with insulin (alone or with other antidiabetic drugs) Subject to discussions with the diabetes team Lixisenatide will be added to formulary as the first-line GLPG1, liraglutide will be the second line choice, according to the TA and for patients who require a once-daily dosing regimen. Exenatide will remain on formulary for use in existing patients only. PC agreed that these could be green for use in monotherapy. Use in combination with insulin will require discussion with the endocrinologists. The cyclogest entry needs to state that it is not to be used for fertility treatment Commissioning arrangements for growth hormone in adults need to be confirmed. Currently 3Ts have a SCA for use in children, BCAP have a SCA which 3Ts could adapt if needed. The chapter introduction needs to be updated to reflect the current practice of insulin initiation in primary care by specially trained GPs and practice nurses. The metformin renal failure guidance needs confirming against the guidance in the SPC Use of testosterone, growth hormone and sodium clodronate is higher in Swindon than the national average. This may be partially due to primary care prescribing of sodium clodronate which is not routine practice in other areas. Page 4 of 9

5 LK will collate comments and arrange meeting with endocrine team. LK 21/11/13 5 5i NEW DRUG UPDATE A report detailing New Drug Updates for October 2013 was discussed and actions suggested. will update the New Drug database. 25/10/ NEW DRUG REQUESTS COPD Inhalers Respiratory Team These were not received in time for discussion at the October meeting. If the applications are not received for discussion at the November meeting this item will be removed from the agenda i NEW EVIDENCE SUMMARY A report detailing new national guidelines issued in late September and early October 2013 was discussed and actions suggested. will update the database. NICE NICE TAs TA293 Eltrombopag/ ITP Pathway has produced a first draft of the guidance following the initial meeting with the haematologist. LK will add additional clinical detail and send to FWG for comment. The use of rituximab has previously been discussions with the PCTs, RH/PC to confirm if the agreed arrangements have transferred to the CCGs. 9 MHRA Drug Safety Updates/Letters to professionals NOACs A link has been added to formulary and RH will include this information in the next update of the guidance. Pomalidomide This drug safety update will be sent to the cancer services pharmacist for information/action. LK RH/PC RH Page 5 of 9

6 10. AOB 10.1 Drug Tariff and contract changes There were several changes to category M in October. FWG await a response from the urologists regarding use of sildenafil in postprostatectomy, RC to chase response. RC 10.2 Horizon Scanning RH will complete a detailed review of the horizon scanning document, highlighting any areas with potential for impact on FWG workload. RH FWG 2013/14 Work Plan Progress against the work plan has been delayed due to difficulties with clinician engagement and delays in response from all stakeholders. /LK to produce interim report on progress for FWG and TPC. /LK 10.4 Acne Guidance RH has shared Wiltshire CCG acne guidance with FWG. This has also been to Bath Formulary Group who have suggested some amendments and additional information on self-care. RH will send the latest version to FWG for comment. RH Epiduo HH will submit a New Drug Request for Epiduo to be discussed at the November FWG meeting. RH has initial concerns over the cost effectiveness of this combination product when compared with the individual ingredients. HH 10.6 Colistin The revised formulary entry was approved. to update formulary AK Guidance Following minor amendments to the wording and amendments to the presentation of the flow chart this was approved. to publish final documents and update formulary. Next Meeting: 2pm 21 st November 2013 Seminar Room 7, The Academy GWH. Page 6 of 9

7 Future Meetings: 19 th December 2013 Seminar Room 4, The Academy, GWH 2 5pm 16 th January 2014 Seminar Room 5, The Academy, GWH 2 5pm 20 th February 2014 Seminar Room 5, The Academy, GWH 2 5pm 20 th March 2014 Seminar Room 5, The Academy, GWH 2 5pm 17 th April 2014 Seminar Room 7, The Academy, GWH 2 5pm 15 th May 2014 Seminar Room 5, The Academy, GWH 2 5pm 19 th June 2014 Seminar Room 7, The Academy, GWH 2 5pm 17 th July 2014 Seminar Room 5, The Academy, GWH 2 5pm 21 st August 2014 Seminar Room 5, The Academy, GWH 2 5pm 18 th September 2014 Seminar Room 5, The Academy, GWH 2 5pm 16 th October 2014 Seminar Room 5, The Academy, GWH 2 5pm 20 th November 2014 Seminar Room 7, The Academy, GWH 2 5pm 18 th December 2014 Seminar Room 5, The Academy, GWH 2 5pm Agreed as an Accurate Record: Chair: Dated: Page 7 of 9

8 Trust as part of compliance with the Freedom of Information Act. NEW/OUTSTANDING ACTIONS Meeting Date Subject Action Required Action Comments Date for Status By completion Hydroxycarbamide Follow up with Sarah McGlue LK SCA Botox in migraine Confirm progress of discussions with KB commissioners NICE TA Process Update FWG on NICE TA process KR Postponed until - POSTPONED following TPC CCGs in place NHS Wiltshire GP Recruit a replacement GP representative RH/NF Aug 2013 representative Zoledronic Acid Produce costing paper Assess impact on local care pathways and confirm GWH capacity issues RH/NF All Page 8 of Temazepam Produce switching document SM/TT Sildenafil Confirm place in therapy with urology LK team Eye chapter review Collate initial FWG comments and discuss antibacterial issues with ST Produce compliance device section Chapter 6 Collate initial FWG comments Meet with endocrine team. /LK to arrange meeting ITP Pathway Add additional detail and send to FWG for comment. Confirm commissioning arrangements for Rituximab LK All /LK PC/RH ASAP OAB Guidance Remove darifenacin, update guidance & entries and publish Rivaroxaban Confirm pathway PC ASAP Vitamin D Meet with orthogeriatricians to discuss LK/NH ASAP Guidance Pain Guidance Update and circulate for approval Awaiting publication of NICE guidance

9 Trust as part of compliance with the Freedom of Information Act ENT Chapter Review Collate initial FWG comments. Discuss with ENT team LK/ Dec NOAC Guidance Update guidance with links to MHRA RH safety updates Horizon Scanning Detailed review of horizon scanning RH document FWG Work plan Complete 6 month review of progress /LK COMPLETE ACTIONS Meeting Date Subject Action Required Action Comments Date for Status By completion Cyanocobalamin Review guidance and feedback to FWG RH COMPLETE Eye Lubricant Meet with Mr Smith KR/LK COMPLETE Review Fosfomycin Confirmation of out of hours service Publicity of process/documentation ST All ASAP COMPLETE COMPLETE Actinic Keratosis Update draft pathway with comments SG/KR/LK COMPLETE received at June FWG Cyanocobalamin Review position of other local formularies KR COMPLETE GP Newsletter Send Fosfomycin & NOAC (Stroke LK COMPLETE Prevention) documents in GP Newsletter Chapter 12 Send 1 st draft to ENT consultant for LK COMPLETE comment Dalteparin Update Dalteparin use in community PC/KB Not required COMPLETE document SCAs Update Rheumatology SCAs review dates KR COMPLETE Hydroxychloroquine Finalise document and circulate for final KR/LK COMPLETE SCA- dermatology approval outside of meeting Eye Lubricant Final section and dry eye syndrome RH/KR/LK COMPLETE review guidance and circulate for comment Cerelle Update formulary entry to generic COMPLETE AK Pathway Confirm SG happy and publish ASAP COMPLETE Page 9 of 9