DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC) Minutes of the meeting held on Tuesday 8 th February 2011

Transcription

1 DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC) Minutes of the meeting held on Tuesday 8 th February 2011 Summary Points Shared care agreements Shared Care Agreements for the management of the care of drug users: buprenorphine sublingual lofexidine methadone naltrexone Traffic lights Drug Topical pimecrolimus Vimovo (naproxen + esomeprazole) Decision GREEN after consultant initiation BLACK Oral nutritional support The Nutricia range of products for liquid ONS and Complan Shake for powdered ONS were agreed as the preferred choices 1

2 Present: Derbyshire County PCT Dr J Bell Mr P Barrett Mr S Hulme Mr P Burrill Dr A Mott Dr I Tooley Mr M Steward Mrs S Qureshi Dr C Emslie Assistant Director of Public Health Clinical Effectiveness (Chair) Assistant Director of Finance Assistant Director of Medicines Management Specialist Pharmaceutical Adviser for Public Health GP Amber Valley GP Amber Valley Head of Pharmacy - DCHS NICE Liaison and Audit Pharmacist GP NE Derbyshire Derby City PCT Mr S Dhadli Dr N Qureshi Assistant Director of Medicines Management GP Derby Derby Hospitals NHS Foundation Trust Mr T Gray Dr J Leung Chief Pharmacist Chair D & T C Derbyshire Healthcare NHS Foundation Trust Mrs B Thompson Deputy Chief Pharmacist Chesterfield Royal Hospital NHS Foundation Trust Mr M Shepherd In Attendance: Mrs D Litchfield Mrs C Jones Chief Pharmacist PA Public Health / Minute Taker Specialist Pharmacist DMHST 1. APOLOGIES Mr I Gibbard, Mrs S Sims, Dr D Fitzsimons 2. DECLARATIONS OF INTEREST No declarations of interest were made. 3. MINUTES OF JAPC MEETING 11 th JANUARY 2011 The minutes of the meeting held on 11 th January 2011 were agreed as a true and accurate record. 4. MATTERS ARISING a. Sip feed project Mr Hulme advised that approximately 2 million is spent on sip feeds across Derbyshire and they regularly appear in GPs top 10 drug spend. Hospitals pay a lower price and primary care subsidises this. Mr Hulme explained that an East Midlands group had approved a scheme to reduce primary care costs involving a rebate on FP10 use. It had proved too difficult to co-ordinate across several PCTs 2

3 and hospitals. However, a Derbyshire-wide approach was planned. He described the process and how each bid was scored. Nutricia was chosen as the preferred provider. Currently the majority of sip feed use in primary care happens to be for Nutricia products so immediate savings can be realised. Savings will be returned to individual practice prescribing budgets. The period of rebate agreement will be for 18 months in order to align with secondary care contract re-tendering options for CRH and RDH. It is proposed that all three contracts will be tendered together in order to maximise the benefits obtained. Agreed: the Nutricia range of products for liquid ONS and Complan Shake for powdered ONS were agreed as the preferred choices. b. Topical pimecrolimus protocol Treatment plan topical tacrolimus to be amended to read topical pimecrolimus Agreed: protocol ratified. RED status to be changed to GREEN - after consultant initiation. c. Oral mycophenolate and oral tacrolimus Mr Hulme asked whether oral mycophenolate can be prescribed generically. It was confirmed that both RDH and CRH recommend oral tacrolimus as a brand. RDH are considering generic mycophenolate but currently recommend a brand for transplant patients. Agreed: generic prescribing of oral mycophenolate, unless a brand had been specified by the specialist, was recommended. d. CPD DVD session held after last meeting Dr Bell requested feedback as to the usefulness of this session and asked for future learning needs to be identified. : All All "Making decisions better" video can be found at: Dr Qureshi asked about the evidence base for local and national recommendations and how it can be shown that JAPC has considered all relevant material. Dr Bell will consider this as it is important to demonstrate how JAPC business in conducted. : Dr Bell Mr Shepherd reported that he attends JAPC as his Trust s representative and not to undertake CPD. This is managed and identified as a separate issue and he cannot justify attending to undertake CPD. Mr Hulme advised that members should be able to provide assurances on their competencies to be a member of JAPC, in line with the NHS constitution. Skill sets and core knowledge sets need to be developed in order to ascertain if there is a need for collective or individual training. Agreed: Dr Bell to develop a proposal. : Dr Bell 5. s from Derbyshire Healthcare NHS Foundation Trust a. Buprenorphine SCA Caroline Jones presented the Shared Care Agreement for buprenorphine sublingual in the management of the care of drug users. This is already in use and supports GPSIs and those GPs within the LES. It had been updated in the new SCA format but apart from that no other changes have been made. This document had been out to 3

4 Agreed: JAPC ratified the buprenorphine SCA b. Lofexidine SCA Caroline Jones presented the Shared Care Agreement for lofexidine in the management of the care of drug users. This is already in use and supports GPSIs and those GPs within the LES. It had been updated in the new SCA format but apart from that no other changes have been made. This document had been out to Agreed: JAPC ratified the lofexidine SCA c. Methadone SCA Caroline Jones presented the Shared Care Agreement for methadone in the management of the care of drug users. This is already in use and supports GPSIs and those GPs within the LES. It had been updated in the new SCA format and additional information had been provided with regard to responsibility for obtaining ECGs, inline with national best practice guidance. This document had been out to It was requested that a link be provided to a list of drugs that may cause QT interval prolongation so that GPs can screen patients. Agreed: JAPC ratified the methadone SCA with the above amendment : Mrs Jones CJ d. Naltrexone SCA Caroline Jones presented the Shared Care Agreement for naltrexone in the management of the care of drug users. This is already in use and supports GPSIs and those GPs within the LES. It had been updated in the new SCA format but apart from that no other changes have been made. This document had been out to Agreed: JAPC ratified the naltrexone SCA 6. BUPRENORPHINE AND FENTANYL PATCHES Deferred until next meeting. 7. TRAFFIC LIGHT CLASSIFICATION OF STRONG OPIOIDS Mr Hulme advised that discussions at the north County prescribing sub-group raised the issue of how oxycodone and fentanyl should be classified. Currently fentanyl patches are GREEN for third-line use only and oxycodone is BROWN, resulting in a lack of clarity on the appropriate treatment pathway. Prescribing data was presented that showed that in the north patch of County PCT prescribing of fentanyl and oxycodone was much higher than in the south patch of County PCT and in City PCT. Mr Burrill explained that he had drafted an algorithm on the use of strong opioids in primary care for the north prescribing sub-group. This had oral morphine as the firstline drug and reserved oxycodone and fentanyl as second-line drugs if there were problems with morphine. This had been welcomed by the GPs on the north County prescribing sub-group but had met strong resistance from Dr David Brooks, Palliative care consultant. Agreed: no change as yet to the traffic light classification. Mr Burrill to distribute the algorithm to JAPC members for discussion at the next meeting. PB 4

5 Agreed: Mr Gray to consult with relevant clinicians at RDH and feed back at the next meeting. TG 8. BIOLOGICALS IN RA Mrs Qureshi presented an algorithm based on the published NICE algorithm that brought together all the TAGs on the use of biological agents in RA. Dr Bell reported that a meeting had been held with the rheumatologists to discuss this algorithm. The clinicians stated that these drugs are roughly the same cost and they wanted to be free to choose the first-line option and that different ones suited different people. However, NICE states that the least expensive one should be used first-line and costs did in fact differ. Dr Bell was of the opinion that the NICE statement should be adhered to and had communicated this to the rheumatologists. Dr Leung read out comments received from Dr Chris Deighton, Consultant Rheumatologist at RDH who is unhappy with the way the decision had been made: 1. Certolizumab is the newest of the accessible anti-tnfs. We have no data on its long term safety and efficacy, whereas we have over a decade of observational and open trial data on some of the established anti-tnfs. 2. Certolizumab is an antibody, and although it may have less occurrence of patients developing neutralising antibodies that lead to a progressive diminution of effect than the other antibodies (adalimumab and infliximab show this in some patients). Etanercept does not have the same problem. 3. Most patients will only get one shot at an anti-tnf, and if they fail then would usually go onto rituximab. There are no head to head studies of anti-tnfs against each other. However, a meta-analysis of meta-analyses of indirect comparisons by Singh at al in the Cochrane Library shows that patients tend to stay on etanercept longer than the others, presumably due to sustained efficacy and toxicity that is at least equal if not better than the others. 4. Etanercept is undoubtedly safer in patients where there is a concern over TB and other chronic granulomatous and intracellular infections. I would insist on using this drug in such patients. Dr Leung noted that certolizumab had not been approved for use by the RDH DTC. Mr Shepherd reported that the rheumatologists at CRH were disappointed that the algorithm circulated was not in agreement with the discussions previously held and they wished to raise concerns around the safety of certolizumab and its evidence base. Although certolizumab would be suitable for some patients it would not be suitable for all and clinicians require the opportunity to use alternatives in specific circumstances. Mr Gray advised that patient access schemes require lots of time and effort to manage and they did not have the resources to do this. They would prefer a drug without a PAS unless the PCTs were prepared to invest to save. Mr Burrill noted that at a previous JAPC meeting it had agreed that this debate on the use of biologicals in RA would be resolved in a different forum. This was primarily about the implementation of NICE TAGs. It was commented that all the appropriate people were not present at JAPC to discuss this matter in the detail required and that the discussions held previously needed to be revisited. Dr Bell advised that JAPC sets medicine policy and anti-tnfs are one of the most expensive elements of that policy. In order to make savings all parties need to work together. Mr Gray stated that therapeutic tendering could give the opportunity to allow 5

6 clinicians to advise what their preferred first-line option would be and to procure that drug East Midlands-wide at a competitive price. This would result in significant savings if it were to be done through home care. He suggested inviting EMSCG to take a lead on this. : Dr Bell to contact Malcolm Qualie at EMSCG. Mr Shepherd suggested coming to an agreement with the clinicians on a cohort of patients that certolizumab would be most suitable for. This would enable experience to be gained and clinicians would feel more comfortable using it. Mr Barrett stated that more discussion was needed with the clinicians to come to a compromise. The use of certolizumab was dependant on the PAS working. If it did not work then it would cost the PCTs money. Agreed: a meeting to be convened to discuss this further in an attempt to reach an agreement on the staged introduction of certolizumab. : Dr Bell Dr Mott volunteered to participate in this meeting. 9. JAPC BULLETIN JANUARY 2011 Agreed: January 2011 bulletin ratified with the following amendment: Generic SSRIs to be amended to read citalopram and sertraline : Mr Dhadli to produce the next bulletin 10. TRAFFIC LIGHTS ANY CHANGES? Vimovo - combination of naproxen and esomeprazole Agreed: ratified as BLACK 11. COMMISSIONING POLICY FOR FIRDAPSE FOR INFORMATION Dr Bell presented this policy to JAPC for information. This was developed as a collaborative commissioning policy across the West Midlands and was taken to the East Midlands policy advisory group where it was adopted. Mr Gray reported that the MHRA were aware of this policy and did not like it. 12. RESEARCH GOVERNANCE UPDATE FOR INFORMATION Mr Burrill presented this update on behalf of Mick Bond and highlighted the SCOT trial, which had been given research governance approval by the PCT but Medicines Management were concerned that it recommends a BROWN drug. Mr Bond would like to attend a future meeting to give an update on research governance. Mr Burrill asked for any questions for Mr Bond to be forwarded to him before the next meeting. Dr Qureshi requested that a copy of the governance checklist to be circulated to all members prior to the next meeting. 13. THE SORT CLASSIFICATION Mr Burrill reported that this system was used to classify the evidence presented to support cases brought to the IFR panel for consideration. He proposed that this classification also be adopted by JAPC for consistency Agreed: JAPC agreed to this proposal. The SORT classification to be added to the JAPC front sheet and the new drug evaluation template. : Mr Burrill PB 14. ACTION SUMMARY The action summary was discussed and updated accordingly. 6

7 The group were informed at a previous JAPC meeting that the proposed Vitamin D policy was unclear on patient numbers and costs and therefore affordability remained a concern, as many products are only available as specials. Mr Dhadli reported that he had spoken to Dr Rida Elkheir and that a holding position would be for GPs to use health promotion type interventions. to be removed from the action summary. 15. MINUTES OF OTHER PRESCRIBING GROUPS FOR INFORMATION Stamp ANY OTHER BUSINESS None raised. 17. DATE AND TIME OF NEXT MEETING Tuesday 8 th March 2011, at 1.30pm in the Parkhouse Room, Coney Green, Clay Cross NB. Papers to Peter Burrill by 21 st February 2011 please 7