/ Gateshead Medicines Management Committee
11th December2013 0900-1200
Room 4, Education Centre
QEH
Attendees: / Prescribing Lead, Gateshead Clinical Commissioning Group (Vice-Chair)
Consultant Microbiologist, Gateshead Health NHS Foundation Trust
GP (Primary care prescriber)
Chief Pharmacist, Gateshead Health NHS Foundation Trust
Medicines Governance Pharmacist, Gateshead Health NHS Foundation Trust (Secretary)
Regional Drug & Therapeutics Centre (Newcastle) Advisor
G Armstrong, Primary Care Medicines Management Provider
Community Pharmacist
Apologies: (item 1) / Consultant Anaesthetist, Gateshead Health NHS Foundation Trust (Chair)
Senior Pharmacist NECS
Pharmacist NECS
Item 2 / Declaration of Conflict of Interest With Any Agenda Items
Discussion:
No-one present had any interest to declare with today’s agenda items.
Item3 / Notes of meeting on 9th October 2013 & Decision Summary / Enc 1+2
Discussion:
Minutes & Decision Summary agreed as a true record.
Item4 / Ongoing Action Points / Enc 3
Discussion:
Circulated for information.
Item 5 / Matters Arising
Discussion:
a)Apomorphine in Parkinson’s disease Shared Care Guideline– guideline was approved at last GMMC meeting but problems remain with implementation and who is responsible for what for identified patient requiring treatment. Parkinson’s disease Team to arrange meeting with GP practice concerned and drug company to resolve outstanding issues.
b)Leuproprelin for Gynaecology Indications Shared Care Guideline –guideline was approved at last GMMC meeting. QEH consultants have also now approved the guideline for use within their department.
Item 6 / New Drug Requestsfor December 2013Meeting / Enc 3-5
Discussion:
Artiss Fibrin Sealant
Application not yet received,
Granisetron Patch
Requested by Dr Turnbull
Requested for use as an alternative to IV palonosetron in patients undergoing chemo unable to take oral antiemetics.
Evidence as per application form.
Reviews:
  • NICE – not considered
  • SMC – approved 7.10.13
  • AWMSG – not considered
  • RDTC – not considered
  • NoT APC – not yet considered
Application to be discussed by NECN Chemotherapy Group to ensure consistency in formulary status across the region.
Resource Pre-thickened Drugs
Requested by Alison Eden, SALT Team (in attendance)
Requested as alternative to Resource Clear in patients who have been recommended to take modified fluid consistencies but may have problems mixing drinks to the appropriate consistency in their home environment Evidence as per application form.
Resource Thicken Up Clear and Nutilis Clear
Requested by Alison Eden, SALT Team (in attendance)
Requested as replacement to Nutilis and Thick & Easy, the current formulary choices.
Evidence as per application form.
Have advantages over the current formulary choices in terms of efficacy and patient acceptance.
Conclusion:
  • Artiss Fibrin Sealant – application process on hold pending receipt of completed New Drug Request Form from surgeons.
  • Granisetron Patch – decision deferred pending view of Cancer Network
  • Resource Pre-thickened Drinks – approved as green + drug for use on advice of SALT team only.
  • Resource Thicken Up Clear – approved a green drug to replace Thick and Easy plus Nutilis on the formulary.
  • Nutulis Clear – decision deferred until issues with packaging and dosing scoop resolved by manufacturer.

Item 7 / New Drug Requests for January 2014
Discussion:
  • Fidaxomicin

Item 8 / Antimicrobial Update
Discussion:
To submit formulary request for fidaxomicin for use treatment of Clostridium difficle to January meeting.
Item 9 / Formulary Chapter Updates / Enc 6-10
Discussion:
The following chapters of the GHFNT formulary have been updated on the internet/intranet sites since the last meeting:
  • 2 - Cardiovascular
  • 6 – Endocrine
  • 9 – Nutrition & Blood
  • 14 – Immunologicals and vaccines
  • 15 - Anaesthetics

Conclusion:
Chapter updates approved.
Item 10 / Revised GMMC Terms of Reference / Enc 11
Discussion:
These have been updated to reflect governance structure in CCG around decision making.
Conclusion:
Approved with change that GHNFT responsible for maintaining formulary on hospital internet/intranet site, and Medicines Optimisation Team responsible for maintaining formulary in primary care.
Item 11 / Erectile Dysfunction Drugs, Vacuum Pumps, and Tadalafil Prescribing / Enc
Discussion:
Draft Gateshead & North of Tyne guidelines for the investigation and management of men with ED was discussed. Noted that vardenafil is not included and is no longer on North of Tyne formulary, and so should be removed from Gateshead formulary as GHFNT urology service provided by Newcastle consultants.
Vacuum pumps devices have never been to GMMC for approval and now with the cost of sildenafil dropping like a stone, they are no longer cost effective. GMMC has been asked to provide clarity regarding the situations when they would be used over and above oral preparations,
Compliant has been received from GP about use of tadalafil 5mg by urologists (attached). This is not on Gateshead or Newcastle formulary.
Conclusion:
  • Erectile Dysfunction Guideline – please send any comments to AMB. Members had several concerns about the guideline in its current draft.
  • GMMC confirmed tadalafil is not on the formulary and should not be prescribed.
  • Vacuum pumps – suggest information on their use and place in therapy to be included in Erectile Dysfunction Guideline currently under development.

Item 12 / CHM Advice 11.11.13 – Antiepileptic Drugs: new advice on switching between different manufacturers for a particular drug / Enc 12+13
Discussion:
CHM have issued new advice on switching between different manufacturers of particular antiepileptic drugs.
We already have the following guidance locally in our “Medicines not suitable for generic prescribing document” which largely covers this advice
Antiepileptics have been divided into 3 categories:
  1. For these drugs doctors are advised to ensure that their patient is maintained on a specific manufacturer’s product.
  2. For these drugs the need for continued supply of a particular manufacturer’s product should be based on clinical judgement and consultation with patient and/or carer taking into account factors such as seizure frequency and treatment history.
  3. For these drugs 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 key drugs are:
Carbemazepine - Brand names should be used for all preparations especially modified releasecarbamazepine. Different preparations may vary inbioavailability.
Phenytoin Loss of seizure control has been reported in patientsafter switching brands of antiepileptic medicines.
Continuity of the same brand or same genericpreparation is recommended.
Do not change between tablets and capsules.
Modified release sodiumvalproate, Valproic acid - Brand names should be used for all preparations especially modified release carbamazepine. Different preparations may vary in bioavailability.
In discussion it was felt the biggest issue with this advice is secondary care continuing the correct brand in patients who are admitted to hospital, so primary care need ensure the EMIS is correct, and also need use patients own drugs wherever possible.
Secondary care will ensure GP handover form specifies brand supplied only of the antiepileptic has been started during the current admission.
Conclusion:
  • Primary care to ensure EMIS is kept up-to-date with brand name
  • Secondary care will ensure GP handover form specifies brand supplied only of the antiepileptic has been started during the current admission.
  • To use Patients Own Drugs wherever possible
  • Secondary care to ensure their dispensing labels also specify the brand supplied

Item 13 / Guideline for VTE Prophylaxis
Discussion:
Issues arising with different guidelines from different surgical specialities and different surgeons within those specialities. Concerns also about impact of extended prophylaxis on District Nurses in those patients unable to self administer.
Conclusion:
Agreed this is not an issue for GMMC but one that should be on the agenda of the GHFNT Medicines Governance Committee.
Item 14 / Vitamin D Guidelines / Enc
Discussion:
National Osteoporosis Society have published new guidance on the use of vitamin D supplements. The attached paper compares the national guideline against the Gateshead guideline and identifies gaps and action required.
Conclusion:
Paper to be discussed with QEH Consultants before suggested actions and changes to Gateshead Vitamin D Guidelines are made.
Item 15 / Guidelines for Approval / Enc 14
Discussion:
Following guidelines have been revised & updated:
  • Parkinson’s disease guideline
Following new guidelines have been developed:
  • Vitamins in alcoholics
  • Erectile Dysfunction
  • Stoma Guideline
  • Diabetes
  • Infant milks

Conclusion:
  • Parkinson’s disease guideline – approved for secondary care use only with suggest changes e.g. highlight pramipexole is non-formulary.
  • Vitamins in alcoholics – deferred until next meeting as final version not available
  • Erectile Dysfunction – see earlier agenda item
  • Stoma Guideline – deferred until next meeting as final version not available
  • Diabetes – deferred until next meeting as final version not available
  • Infant milks – approved at last meeting

Item 16 / Shared Care Guidelines for Approval
Discussion:
None received this month.
Item 17 / Primary Care PGDs For Approval
Conclusion:
None received this month.
Item 18 / Exceptional Case Requests
Discussion:
None received this month.
Item 19 / NICE Guidance OctoberNovember 2013 / Enc
Discussion:
  • TA297 – Vitreomacular traction – ocriplasmin – n/a to QEH
  • TA298 – Choroidal neovascularisation – ranibizuamb - n/a to QEH
  • TA299 – CML – bosutinib - not recommended by NICE & not on local formulary
  • TA300 – Hep C Children & Young People – peginterferon alfa + ribavirin - n/a to QEH
  • TA301 – Diabetic macular odema – flucinolone implant - n/a to QEH
  • TA302 – Juvenile Idiopathic Arthritis – canakinumab - not recommended by NICE & not on local formulary
  • CG172 – Myocardical infarction – secondary prevention – local guidelines for use of beta-blockers and ACE inhibitors will need to be updated. Agreed to stop use of omega-3 in Gateshead.
  • CG173 – Neuropathic pain – pharmacological management – local pain guidelines will need to be updated as NICE now recommends Duloxetine as an option for all patients.
NICE guidance published in October and November 2013 can be found on the NICE website. The committee is asked to note any implications for prescribing guidance across Gateshead and any additional prescribing costs resulting from implementation of the guidance.
Item 20 / Drug Safety Updates OctoberNovember 2013 / Enc
Following MHRA Drug Safety Updates issued since last meeting:
  • October 2013 Drug Safety Update
  • November 2013 Drug Safety Update
Following other Safety Updates of note:
  • None
The committee is asked to note any implications for prescribing across Gateshead and recommend any actions required.
Item 21 / Items for Information Only / Enc
Discussion:
Items circulated were:-
  • GHFNT Drug Expenditure Report Q2 2013/14

Item 22 / AOB / Enc
Discussion:
Torasemide for Heart Failure
Increasing non-formulary use of Torasemide by cardiologist in heart failure patients resistant to furosemide. New drug request application has been request for next meeting of GMMC.
Letter from Newcastle Dermatology re Dermol Lotion
Letter has been received from Newcastle Dermatologists re our decision to remove dermol from the formulary. Vice-chair to respond stating the all GMMC have done is adopt Newcastle Emollient formulary which states that dermol should only be used on advice of specialist for short term use only. Vice-chair to ask dermatologists to be clear on duration of therapy and why dermol has been prescribed in their communications to GPs.
Lidocaine Patches
There is increasing off-label use of lidocaine patches by pain team. Pharmacius to collect specific examples so a review of use can be undertaken to see if appropriate or does further action need to be taken by GMMC.
Osigraft®
To be discussed at January 2014 GMMC meeting.
Dossette boxes
Ongoing concerns raised about communications around dossette boxes to community pharmacies by secondary care. Agreed onus is now on GPs to communicate with community pharmacies around dossette boxes not secondary care following recent changes to Medway. Any communication issues between secondary care and GPs around discharge prescriptions should go via Dr Helen Groom.

Date of Next Meeting: Wednesday15thJanuary 2014 9am-12noonRoom 4, QEH Education Centre