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Formulary Working Group 21

st March 2013

14.00 – 16.00 Seminar Room 7, The Academy GWH

Attendees: Lisa King (LK) (Chair) Formulary Pharmacist, GWHNHSFT Dr Rachel Hobson (RH) Formulary Pharmacist, NHS Wiltshire Katherine Roe (KR) (mins) Formulary Pharmacy Technician, GWHNHSFT Dr Andrew Thornton (AT) GP, NHS Wiltshire Paul Clarke (PC) Pharmaceutical Lead, NHS Swindon Guy Rooney (GR) 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 – LK 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 LK 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. LK to circulate second draft to FWG and Rheumatology consultants. Actinic keratosis Awaiting draft pathway from Dermatology consultant. LK to follow-up. Rivaroxaban for DVT LK 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.

LK/SG

LK/SM

KR/LK

LK

LK/SG

LK

01.04.13

18.04.13

18.04.13

18.04.13

18.04.13

18.04.13

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)




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. LK will ask ML to contact AT directly to discuss the issue further. Generic desogestrel KR/ LK 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

LK

KR/LK

RC

18.04.13

18.04.13

18.04.13

18.04.13

18.04.13

18.04.13

3 3i 3ii

CHAPTER/SECTION UPDATES Chapter 6 – update Awaiting feedback from consultants. LK to chase and confirm completion date. Chapter 12 – first draft Initial review of evidence completed. LK to circulate first draft to FWG and ENT consultants.

LK

LK

18.04.13

18.04.13

4

NEW DRUG UPDATE – March 2013 A report detailing New Drug Updates for March 2013 was discussed and KR will update New Drug database.

KR

15.04.13

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




5ii

in depth price comparison of like for like products, it is also more expensive. Additional feedback needed from BM and paediatric team. LK to follow-up with RC / BM. 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. LK 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 LK will feedback the decision to TH. KR will update database with details of discussions

BM/LK/

RC

LK

KR/LK

LK

KR

18.04.13 18.04.13 15.04.13 18.04.13 15.04.13

6 6 i

NICE 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. KR/LK to circulate final documents to stroke and

RH

KR/LK

18.04.13 18.04.13




6 ii

haematology consultants for comment. Once prescribing guidance documents agreed, Apixaban may be added to formulary as Green for this indication. NICE GPG1 LK and KR 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.KR will circulate the document to FWG showing the current 3Ts position, all are asked to comment on this. The patient internet site will need to be live by 1st April. As an interim measure, all formulary documents have been uploaded as PDFs onto the GWH website. LK/KR will work with the GWH communication team to make these pages ‘live’. LK/KR will send these links to PC/RH/BS so that appropriate links can be added to their websites.

KR All

LK/KR

25.03.13 ASAP 31.03.13

7

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 non-pharmacological 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. LK will feedback to the pain and hospice teams.

RH LK

18.04.13 22.03.13




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.

KR/LK KR/LK

15.04.13 15.04.13

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. LK will this back and encourage the urologists to apply if they feel this could be a useful 4th line option. All agreed that the GWH formulary adherence is encouraging and helped by the use of e-prescribing.

LK

18.04.13

10 10.1

AOB Drug tariff and contract changes – None to discuss

Next Meeting: Thursday 18th April 2013 2pm, Seminar Room 4, GWH

Future Meetings:

16th May 2013 Liden Room, Brunel Treatment Centre, GWH 2 – 5pm

20th June 2013 Seminar Room 7, The Academy, GWH 2 – 5pm

18th July 2013 Cherwell Education Room, GWH 2 – 5pm

15th August 2013 Seminar Room 7, The Academy, GWH 2 – 5pm

19th September 2013 Liden Room, Brunel Treatment Centre, GWH 2 – 5pm

17th October 2013 Liden Room, Brunel Treatment Centre, GWH 2 – 5pm

21st November 2013 Seminar Room 7, The Academy, GWH 2 – 5pm

19th December 2013 Seminar Room 4, The Academy, GWH 2 – 5pm

Agreed as an Accurate Record:

Chair: Dated:




NEW/OUTSTANDING ACTIONS

Meeting Date Subject Action Required Action By

Comments Date for completion

Status

17.01.2013 Romiplostim Follow up with GWH Haematologist LK SG has said she will look at this in mid March

18.04.2013 Pending

17.01.2013 Hydroxycarbamide SCA

Follow up with Sarah McGlue LK SM is looking at this and will feedback to LK

18.04.2013 Pending

17.01.2013 Optive Plus Meet with Mr Smith KR/LK Awaiting confirmation of meeting date

18.04.2013 Pending

21.02.2013 Actinic Keratosis SG to send draft pathway out for comment SG LK to follow-up with SG

18.04.2013 Pending

17.01.2013 Chapter 6 Follow up with Diabetes team RC/LK PP now back from leave.LK to follow-up with PP

18.04.2013 Pending

17.01.2013 Chapter 12 Circulate for comment LK 18.04.2013 Pending

17.01.2013 Chapter 10 Methotrexate SCA LK Delayed due to GPG1

18.04.2013 Pending

21.03.2013 New Drug update Update database KR 18.04.2013 Pending

21.03.2013 COPD Inhalers AU to arrange meeting with respiratory consultants

AU 18.04.2013 Pending

21.02.2013 Liposomal Lidocaine

RC to discuss with colleagues within paediatrics

RC Initial feedback negative await formal feedback

18.04.2013 Pending

21.03.2013 Apixaban Approval of new documents. Aim to add Apixaban to formulary as green

RH KR/LK

18.04.2013 Pending

21.03.2013 New drug requests

Update database with details of discussions

KR 28.02.2013 Pending

21.02.2013 NICE GPG1 Go through document in detail & establish current position

LK/KR

21.03.2013

Complete




Provide feedback on positive and negative aspects of 3Ts adherence

All 18.04.2013 Pending

21.03.2013 Wiltshire Pain Guidance

Make final amendments prior to sign off and circulation Feedback outcome of Longtec discussions to pain and hospice teams

RH LK

18.04.2013 22.03.2013

Pending Pending

21.02.2013 Dosette prescribing

JC to provide response to FWG JC ML discussing current position with commissioners

21.03.2013 Pending

21.03.2013 DVT Pathway LK has discussed with anticoagulant pharmacist. Pathway is being discussed at local meetings. Rivaroxaban to remain as Amber until final pathway.

LK Await final pathway 18.04.2013 Pending

21.02.2013 Botox in migraine Confirm progress of discussions with commissioners

KB PC to discuss with KB

21.03.2013 Pending

21.02.2013 Mannitol Feedback Cathy Dewdney’s comments & confirm with TPC if inclusion on formulary required.

KR Delayed due to TPC cancellation

18.04.2013 Pending

21.02.2013 NICE TA Process Update FWG on NICE TA process following TPC

KR Postponed until CCGs in place

21.03.2013 POSTPONED

21.02.2013 Lithium SCA Rewrite an abridged version in 3Ts format with additional details re. monitoring & discontinuation.

BS/TT

No AWP rep at meeting on 21.03.13

18.04.2013 Pending

21.02.2013 Epistatus Obtain agreement for FWG recommendation from TPC.

KR Delayed due to TPC cancellation

18.04.2013 Pending

21.03.2013 Venofer/Ferrinject Update formulary KR/LK 15.04.2013 Pending

21.02.2013 ADHD SCA Identify geographical location of patients RC Awaiting feedback from RC

21.03.2013 Pending

Recently completed actions




Meeting Date Subject Action Required Action By

Comments Date for completion

Status

17.01.2013 Alteplase Approve and update e-formulary PC/KR 25.01.2013 COMPLETE

17.01.2013 Actikerall Send out guidance for comment. Update e-formulary

RH KR

21.02.2013 COMPLETE

17.01.2013 Bevacizumab Follow up with NF RH Added to TPC at request of NF

21.02.2013 COMPLETE

17.01.2013 TA267 Update e-formulary KR 31.01.2013 COMPLETE

17.01.2013 Denosumab Add to TPC and FWG agendas KR 14.02.2013 COMPLETE

17.01.2013 Horizon Scanning Send report to FWG KR 25.01.2013 COMPLETE

21.02.2013 Ticagrelor RH to share cardiac network information RH Added following discussion

28.02.2013 COMPLETE

17.01.2013 NICE patient website

Prepare site for go live by April 1st deadline KR 1st draft completed Plan updated to include addition of PDF versions of formulary

31.03.2013 COMPLETE

21.02.2013 Oxycodone SR Complete oxycontin vs. generic price comparison

KR 28.02.2013 COMPLETE

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