Aneurin Bevan University Health Board Medicines & Therapeutics Committee PRESCRIBING enewsletter archive at: http://www.wales.nhs.uk/sites3/page.cfm?orgid=814&pid=48407 Dear Gwent Prescriber At its last two meetings (5 th December 2013 and 23 rd January 2014) ABUHB s Medicines & Therapeutics Committee made the following decisions in relation to the ABUHB Formulary: FORMULARY UPDATES ABUHB s Drug Formulary is at: http://aneurinbevanhb.inform.wales.nhs.uk/ March 2014 BNF section 4.4 LISDEXAMFETAMINE mesylate ( Elvanse ) capsules ADDED for the treatment of ADHD (as part of a comprehensive treatment programme) in children 6 years when response to previous methylphenidate treatment is considered clinically inadequate. The MTC has designated lisdexamfetamine an Amber with Shared Care drug (i.e. specialist initiation only with Shared Care arrangements recommended for GP repeat prescribing) this is consistent with arrangements for prescribing methylphenidate and atomoxetine for ADHD and in accordance with AWMSG s recommendation. A Gwent Shared Care Protocol is in development. Full prescribing information on lisdexamfetamine at: http://www.medicines.org.uk/emc/medicine/27442/spc/ BNF section 6.1.2.3 LIXISENATIDE ( Lyxumia ) injection ADDED for the treatment of type 2 diabetes mellitus (in combination with oral glucose lowering medicines and/or basal insulin). The MTC has designated lixisenatide an Amber without Shared Care drug (appropriate only for initiation within a consultant led team or by accredited GPs with a special interest in diabetes including GPs based in practices that have a relevant accreditation to provide an advanced diabetic service). This recommendation is consistent with other GLP 1 agonists (exenatide and liraglutide) in the ABUHB Formulary. Comparative acquisition costs (from BNF March 2014) of GLP 1 agonists: Drug Dose Regimen Cost per year Lixisenatide 20microgram once daily 706 Liraglutide 1.2 once daily 955 Note NICE do not recommend 1.8mg once daily Exenatide m/r 2mg once weekly 954 Exenatide 5 to 10microgram twice daily 830 Doses are for general comparison and do not imply therapeutic equivalence. All GLP 1s are administered via subcutaneous injection. Full prescribing information on lixisenatide at: http://www.medicines.org.uk/emc/medicine/27405/spc/ Page 1 of 5
BNF 13.5.2 EXOREX lotion (coal tar solution 5% in an emollient basis) for psoriasis ADDED as a Formulary replacement for Alphosyl HC cream (a fixed combination of a tar with hydrocortisone and discontinued in September 2012). Although Exorex is not an exact equivalent to Alphosyl HC (as it contains no steroid) ABUHB Dermatology felt that a tar lotion was useful for patients with extensive psoriasis as it was easier to apply over a wider area than a cream. Exorex lotion is considered suitable for initiation by non specialist prescribers i.e. designated a Green drug. Full prescribing information on Exorex lotion is at: http://www.medicines.org.uk/emc/medicine/7628/spc/ BNF 4.7.2 TAPENTADOL modified release (Palexia SR ) The Traffic light recommendation has been changed from Red (Specialist only initiation and repeat prescribing) to Amber without Shared Care i.e. now considered appropriate for GP repeat prescribing but with the recommendation that only specialists in treating severe chronic pain should initiate it. Tapentadol film coated immediate release tablets and the oral solution remain non Formulary in Gwent as, in the absence of submissions to AWMSG for appraisal, they cannot be endorsed for use: http://www.awmsg.org/awmsgonline/app/appraisalinfo/771 Full prescribing information on tapentadol m/r tablets is at: http://www.medicines.org.uk/emc/medicine/28373/spc/ OTHER PRESCRIBING NEWS SHARED CARE PROTOCOLS Prescribers should note the following changes to Gwent Protocols: ATOMOXETINE UPDATED to cover the initiation of treatment in adults with ADHD, in line with this license extension. METHYLPHENIDATE UPDATED to clarify the differential licensing of Concerta XL (now licensed for continuing ADHD treatment into adulthood) and to highlight that NICE CG72 recommends that (following a decision to start drug treatment in adults with ADHD) methylphenidate should normally be tried first (UNLICENSED use). Prescribers should also note that this Protocol does NOT cover the use of: methylphenidate in narcolepsy. methylphenidate at doses above the maximum recommended in ADHD. Medikinet XL in ADHD (non Formulary preparation). MELATONIN NEW Protocol covering the treatment of sleep onset insomnia and delayed sleep phase syndrome in children (UNLICENSED USE). DENOSUMAB 60mg (Prolia ) NEW Protocol (plus existing Local Enhanced Service funding) covering the prescribing, monitoring and administration of this monoclonal antibody in the treatment of osteoporosis in postmenopausal women. Prescribers should note that specialist requests to take on these responsibilities should only take place once the first dose of denosumab has been prescribed and administered within Secondary Care. All the Gwent Shared Care Protocols can be found at: http://www.wales.nhs.uk/sites3/page.cfm?orgid=814&pid=38180 OMEGA 3 FATTY ACID USE POST MI Prescribers should note that NICE CG172 (MI secondary prevention of November 2013 http:// guidance.nice.org.uk/cg172) now states do not offer or advise people to use omega 3 fatty acid capsules (Omacor, Prestylon or Maxepa ) to prevent another MI. The previous position in NICE CG48 was to stop omega 3 fatty acids 4 years post MI. A letter communicating this change to practices is at: http://www.wales.nhs.uk/sites3/documents/814/omega3%26nicec172letterdec2013.pdf Page 2 of 5
PRESCRIBING ANALGESICS All local prescribing guidelines and resources (plus links to national pain resources) relating to pain management (palliative care excepted) are now available at: http://www.wales.nhs.uk/sites3/page.cfm?orgid=814&pid=72052 UPDATED NEUROPATHIC PAIN PATHWAY Following the publication of NICE CG173 Neuropathic pain pharmacological management in adults in non specialist settings in November 2013, the MTC reviewed the two local pathways for the treatment of neuropathic pain and diabetic peripheral neuropathic pain (DPNP). The two pathways have now been combined into a single one on one page. The pathway (one page) is at: http://www.wales.nhs.uk/sites3/documents/814/np%26dpnp TreatmentALGORITHM%5B31Jan2014%5D.pdf KEY POINTS TO NOTE ABOUT THE UPDATED NP/DPNP PATHWAY: The pathway now includes a recommendation NOT TO EXCEED 50mg OF AMITRIPTYLINE DAILY IF CO ADMINISTERED WITH AN SSRI The pathway supports use of the Brief Pain Inventory (Short Form) [at: http://www.npcrc.org/ files/news/briefpain_short.pdf] to assess pain with a note that improvement in function (question 9) may be more marked than improvement in the pain questions. The Pain Team in Secondary Care have agreed to provide GPs with the initial Brief Pain Inventory score so that improvements can be determined. The pathway no longer includes the advice that Versatis can play a role as a rescue analgesic (while waiting for a referral to a specialist pain service) in a very small subgroup of people with localised pain unable to take oral medication, as this is no longer a recommendation in CG173. CHRONIC PERSISTENT PAIN and TRAMADOL New advice in the form of 10 KEY MESSAGES covering each of the following topics is now available: the use of strong opiates in chronic persistent pain, the general management of chronic persistent pain tramadol These messages are all in one 3 page document at: http://www.wales.nhs.uk/sites3/documents/814/10keymessages TramadolStrongOpiates%26CPPfinalFeb2014.pdf TRAMADOL Tramadol educational resource materials produced by the All Wales Therapeutic and Toxicology Centre (AWTTC) and All Wales Prescribing Advisory Group (AWPAG) are now available. The purpose of these resources is to raise awareness amongst prescribers and patients of the potential harms associated with the misuse and diversion of tramadol, and to provide healthcare professionals with information and training to aid in the appropriate prescribing of tramadol as part of an overall pain management strategy. The resources can be found at: http://www.awmsg.org/medman_library.html?jqprselect=button1 They include: Initial prescribing analysis Audit Materials Educational Slide Set WeMeReC Maps and WeMeReC Things to Know Patient Information Leaflet Shared Decision Making Toolkit If you require a Word or PowerPoint version of any of the materials please contact awttc@wales.nhs.uk Page 3 of 5
COPD A Stepped approach to management in Primary Care The MTC has endorsed a new one page guide setting out the stepped management of COPD in Primary Care. It includes referral criteria and inhaler options. The plan is to update this as new inhalers become available through 2014 and beyond. A copy of the guide (1 page) is at: http://www.wales.nhs.uk/sites3/documents/814/copdmanagement PrimaryCare10Jan2014.pdf CAPTOPRIL 5mg/5ml and 25mg/5ml sugar free oral solutions (Noyada ) There is now a licensed captopril liquid for children covering the same indications as captopril tablets: http://www.martindalepharma.co.uk/news/martindale pharma launches noyada first licensed oral liquid solution captopril/ Those practices with patients on the oral suspension should consider changing them over to the licensed oral solution formulation. NHS costs for the solution are 108.94 for 100ml of 25mg/5ml and 98.21 for 100ml of 5mg/5ml Full prescribing information on Noyada is at: http://www.medicines.org.uk/emc/medicine/28547/spc/ SWITCHING Antiepileptic Drugs advice on LEVETIRACETAM (Keppra ) Further to the news item in the MTC s autumn enewsletter (November 2013) highlighting the MHRA s guidance on prescribing antiepileptic drugs (AEDs), local specialist advice on levetiracetam has been issued. The key prescribing point from this is: Levetiracetam is in category 3, which means that it is usually unnecessary to ensure that patients are maintained on a specific manufacturer s product, unless there are specific concerns such as patient anxiety, and risk of confusion or dosing errors. The full advice on levetiracetam is available at: http://www.wales.nhs.uk/sites3/documents/814/levetiracetam GenericPrescribingLetterMarch2014.pdf NICE BNF and BNFC Apps for Apple and Android devices To get these Apps you need an NHS Wales Athens account. To set one of these accounts up go to: https://register.athensams.net/cym/ The BNF Apps provide downloadable content and can operate even if there is no network access. The Apps (like the online version of the BNF http://www.bnf.org/bnf/) are updated each month in contrast to the now annually distributed print versions of the BNF and BNFC. BNF: Android smartphone and tablet users BNF: iphone and ipad users BNFC: Android smartphone and tablet users BNFC: iphone and ipad users NICE are currently conducting a public consultation on its vision for an enhanced BNF service, and if you want to submit your views there is still time as the consultation will run to 9am on 31 March 2014. See for more information: http://www.nice.org.uk/mpc/britishnationalformulary.jsp Page 4 of 5
DRONEDARONE (Multaq ) All Wales advice that dronedarone should be prescribed and monitored by specialist teams only (a Red drug) was reviewed by AWMSG and it was agreed that this prescribing status recommendation should remain unchanged. Dronedarone is only licensed for the maintenance of sinus rhythm after successful cardioversion in adult clinically stable patients with paroxysmal or persistent AF (after other treatment options have been considered). See: http://www.awmsg.org/docs/awmsg/medman/prescribing%20of%20dronedarone%20(multaq).pdf REVIEW of High Intensity STATINS for Acute Coronary Syndrome (ACS) REMINDER OF 2012 GUIDANCE The MTC s Summer enewsletter of 2012 (circulated in August 2012) contained the following advice for patients with ACS: Patients with ACS should be assessed according to their co morbidities and if deemed appropriate by the cardiology team then they should be offered atorvastatin 80mg daily as a high intensity statin treatment for THREE MONTHS duration post ACS. THREE MONTHS after ACS, the statin dose should be reviewed. If initial cholesterol was <7.5mmol/L then switch to simvastatin 40mg daily or a drug of similar acquisition cost. If there are potential drug interactions or simvastatin 40mg is contraindicated, offer a lower dose of simvastatin or pravastatin. If initial cholesterol was 7.5mmol/L then switch to atorvastatin 40mg daily and consider referral to the lipid clinic for screening if any suggestion of familial hyperlipidaemia. Patients with a recorded total cholesterol (TC) >5mmol/L at three months post ACS event (despite treatment with atorvastatin 80mg daily) should be EXCLUDED FROM SWITCH ING, continued on high intensity atorvastatin and referred to the lipid clinic for assessment and possible family screening. The full ABUHB guidance (1 page) is available at: http://www.wales.nhs.uk/sites3/documents/814/highintensitystatinforacs ABHBprotocol%5BFeb12%5D.pdf Feedback on any item in this enewsletter is welcome. Suggested agenda items for the MTC are also welcome. Follow us @ABHB_Rx Trevor Batt Pharmacist & Professional Secretary to: Aneurin Bevan HB Medicines & Therapeutics Committee Aneurin Bevan Health Board Based at Victoria House, Corporation Rd, Newport NP19 0BH Email: trevor.batt@wales.nhs.uk Tel: 01633 261394 (DIRECT LINE) Page 5 of 5