Minutes of meeting Thursday 11 March 2010 13:00 – 15.30

Board Room, The Old School Surgery, Manor Road, Fishponds. Bristol BS16 2D

1. Present:

Head of Medicines Management NHS N SomersetPCT

BNSSG NICE & Joint Formulary Pharmacist NHS Bristol

HoMM NHS Bristol

Prescribing Lead – Bristol

Director of Pharmacy – North Bristol Trust

Formulary Pharmacist - North Bristol Trust

Deputy HoMM

Chief Pharmacist – UHB

Apologies:

Clinical Lead - North Bristol Trust (NBT)

HoMM NHS South Gloucestershire

Chief Pharmacist - Avon & Wiltshire Mental Health Partnership

Chief Pharmacist – Western Area Health Trust

MAG Chair University HospitalsBristol

HoMM Bristol Community Health

GP Prescribing Lead – Bristol

GP – Seymour Medical Practice, Bristol

Topic / Action
Minutes of Last Meeting:
No minutes available. GK to circulate by e-mail. / GK
3 Matters Arising
3.1 Clopidogrel guidelines final version (including prasugrel)
12 months for TIA as per NBT stroke protocol to be added.
Details on prasugrel to be added; awaiting cardiac network decision.
3.2 Fentanyl treatment pathway
SM has circulated to palliative care who have made following comments:
  • Do not feel comfortable with previous committee decision that all fentanyl preparations made green. Advise that fentanyl preparations should be recommended by specialists.
  • Would like intranasal fentanyl for small niche of patients. Will apply to formulary.
Potential solution to make fentanyl preparations green for palliative care indications and red for all other or amber. SM attending BNSSG Paiiliative Care Group to finalise.
TW reported that chapter 16, palliative care of interim Joint Formulary has been circulated to Dr K. The chapter is being considered by palliative care.
Discussion resulted in agreement that although hospice is independent contractor engagement with the Joint Formulary is expected.
3.3 TLS & SCP from January meeting
SBe updated committee on list of drugs discussed by e-mail from last meetingand summarised:
Drug / Trust / Committee decision
Traffic Light Status
a / Azacitidine / UHB / red
b / Histrelin / UHB / to CAF
c / Quinagolide / NBT / red
d / Pivmecillinam / NBT / red
e / Acetazolamide injection / NBT / not discussed
f / exemestane / NBT / amber to green
g / anastrazole / NBT / amber to green
h / letrazole / NBT / amber to green
i / cilostazol / NHSB / amber to green
Shared Care Protocols
j / sodium clodronate - myeloma / UHB / amber
k / liraglutide / UHB / amber
l / captopril - children / UHB / amber
m / apomorphine / NBT / red
n / lacosamide / UHB / amber
o / lanthanum / NBT / amber
p / penicillamine - cystinuria / NBT / amber
q / ivadrabine / UHB / amber
r / lithium / AWP / amber
s / aripiprazole / AWP / amber
t / galantamine / AWP / amber
u / lamotrigine / AWP / amber
The Committee rejected the SCP for apomorphine for the following reasons:
  1. Clinically inappropriate for GPs to assume prescribing responsibility for a low number (circa 10 in BNSSG) of complicated Parkinson’s patients on apomorphine pumps.
  2. In addition NICE clinical guideline recommends monitoring by an expert unit.
“The initiation of apomorphine should be restricted to expert units with the availability of a
home monitoring system by a suitably trained health professional such as a PDNS.”
Therefore for new patients initiated on an apomorphine pump is TLS RED.
For existing patients, governance and access arrangements will be addressed.
TW to feedback to directorate and liaise with SM/SBe.
SM will also follow up funding arrangements, repatriation occurring where appropriate.
SBe to update TLS. / GK/DC
SM/TW
SM/SBe/TW
4 BNSSG Website
TLS version 11 on Avon web. Lacosamide, liraglutide and captopril (paeds) SCP published. / SBe
5 BNSSG Joint Formulary
SBe reported progress of Interim Joint Formulary chapter review:
  1. Chapters 1 & 2 sent out for specialist review due back 26th March for comment at Joint Formulary Group 8th April.
  2. Chapters 4,6,16 sent out for specialist review due back 9th April for comment at Joint Formulary Group 22nd April.
Comments are being collated. Reminder to all to circulate. / All
6 Traffic Light System
6.1 Prasugrel
Committee decision TLS AMBER with secondary care prescribing for at least 1 month.
Following UHB MAG decision that prasugrel will be used for 1 month only and GPs then asked to continue treatment with clopidogrel.
SBr reported that UHB clinicians have requested to extend to 12 months prasugrel to be discussed at next MAG meeting.
6.2 Colistin nebules
TW reported problems where primary care have refused to prescribe colistin nebules. Essentially NBT use injection to nebulise. TLS is confusing and licensed colistin preparation for nebulisation is RED.
TW will check preparation recommended to GPs. GPs should be asked to prescribe colisitn nebules; TW will follow-up a SCP. Committee agreed SCP to be circulated by e-mail to expedite approval.
6.3 Saxagliptin
Request from DrSC for TLS GREEN. SBr will follow-up a MAG application. In addition UHB can consider in chapter 3 review of interim Joint Formulary.
6.4 Febuxostat
Now marketed in UK following NICE approval in December 2008. Trust D&TC/MAG have approved. Committee decision for TLS GREEN. / SBe
SBe/TW
SBr
SBe
7Shared Care Protocols
ADHD – WHAT
Comments made by Committee include:
  1. Prescribing for at least 3 months
  2. If patient defaults follow-up and is discharged from secondary care, GP to consider if prescribing is still justified.
  3. Review of drug interactions and contraindications as per BNF.
  4. Clarity of age group and that GPs not expected to prescribe for adults.
DC will circulate the amendments.
7.2 Stalevo- NBT
Approved by Committee pending:
  1. Clarification of “locally agreed guideline” as under section 9.
TW to investigate and feedback.
7.3 Hydroxycarbamide – stable myeloproliferative disorders (MPD)
Approved by Committee pending:
  1. To prevent prescription of high-cost tablets, SCP must state in section 2 under dose that should be ‘prescribed as 500mg capsules’.
SBe to feedback. / DC
TW
SBe
8 Items for discussion
8.1 NPSA Safety in Doses published Sept 09
8.2 CQC ‘Managing patients medications after discharge from hospital’
SBr brought above two items to Committee. Discussed at length. Action as follows:
  1. SM to circulate Connecting for Care and investigate arrangements with lead, AK .
8.3 Amber status of medications and shared care arrangements
After much discussion, given that AMBER drugs should be initiated by specialists there are some in which transfer to primary care is appropriate before the currently stipulated 3 month period. Committee agreed way forward is to list those in which secondary care should prescribe for at least 1 month and those for at least 3 months. SBe will circulate draft of new AMBER classification for comment and propose a list of AMBER drugs into shared care 1 month and 3 month respectively. For consideration at next Committee meeting.
8.4 Perindopril
TW sought confirmation on status of perindopril in stroke and cardiology given that now catergory M. Committee would still like current Formulary arrangements to remain, perindopril for stroke.
8.5 Terms of Reference
SBe tabled at meeting. First draft, needs plenty of comment. To circulate by e-mail for action by all. / SM
SBe
SBe
9 Protocols and Guidelines
nil
10 CAF update
SM to circulate by e-mail. / SM
11 AOB
SM – QIPP update
SM sought input into work programmes, agreed following:
  • MG supports dressing and care homes
  • DC supports NICE and respiratory
  • JHi – antibiotics
SBr
  • Highlighted Department of Health strategy to promote engagement between Public Health and Pharmacy. Regional partnerships on campaigns to improve quality.
  • Melatonin – will bring paediatric pharmacist to Committee to discuss.
DC
  • To circulate process for AMBER drugs by e-mail for comment.
TW
  • Sought clarification of UHB medicines discharge policy discussed at last meeting.
/ DC