DATE: TUESDAY 16 APRIL 2013, 1 - 4PM
VENUE: CHANDLERS FORD METHODIST CHURCH, WINCHESTER RD, CHANDLERS FORD, SO53 2GJ
NOTES
The Notes from this Meeting will be available to the public under the
Freedom of Information Act
Organisation Represented / Role / NameNorth Hampshire CCG / GP representative
CCG Lead Pharmacist / Dr Chris Hunter
Dr Philip Hiorns
Alma Kilgarriff / Apologies
Present
Present
Southampton City CCG / GP representative
Head of Medicines Management / Dr Tony Kelpie
Julia Bowey / Apologies
Present
West Hampshire CCG / GP representative
Head of Medicines Management
CCG Interface Pharmacist / Dr Madelyn Dakeyne
Dr Mike Zardis
Dr Emma Harris
Neil Hardy
Catherine Mclean / Present
Present
Present
Present
Present
Hampshire Hospitals NHS Foundation Trust / Medical representative
Chief Pharmacist / Dr Salah Matti
Malcolm Irons / Apologies
Present
Solent Healthcare NHS Trust / Medical representative
Chief pharmacist / Dr Tony Snell
Caroline Bowyer / Apologies
Apologies
Southern Health NHS Foundation Trust / Medical representative
Chief Pharmacist / Vacant
David Jones / Present
University Hospital Southampton NHS Foundation Trust / Medical representative
Chief Pharmacist / Dr Derek Waller
Sue Ladds / Apologies
Present
Medicines Evaluation Sub-Committee / MEC Chair
Medicines Evaluation Pharmacist / Dr Anastasios Lekkas
Sue Gough / Apologies
Present
Commissioning / Specialist Pharmacist for Commissioning (SHIP) / Sarah Kerr
Julia Wright / Apologies
Present
Public Health / Clinical Effectiveness / Associate Medical Director Clinical Effectiveness (UHS) / Martin Stephens (Chair) / Present
Finance / Deputy Chief Financial Officer – West Hampshire CCG / John Vaughan / Apologies
Nursing / Nurse member of UHS Drugs Committee / Jacquie Trim / Apologies
Local Medical Committee / Nominated representative / Dr Laura Edwards / Present
Local Pharmaceutical Committee / Nominated representative / Sarah Billington / Apologies
Lay Member / Patient representation / Angelina Whitmarsh / Apologies
1. / Apologies and Introductions / The apologies were noted.
MS welcomed Laura Edwards (LMC representative) and Philip Newland – Jones (specialist pharmacist for diabetes UHS and vice-chair diabetes sub-group) to their first meeting.
Mr Brian Birch (Consultant Urologist UHS) was welcomed to the meeting for item 6 (mirabegron).
2. / Declarations of Interests / MS informed the Committee that he was currently interim Managing Director for the Wessex Academic Health Sciences Network and as part of the work programme was working with GSK, Pfizer, Astra Zeneca, Novartis and the ABPI.
JW informed the Committee that she had undertaken advisory work on incontinence and mirabegron sponsored by Astellas.
PN-J informed the Committee that he had been sponsored by Sanofi, Novo and Lilly to attend meetings.
EH informed the Committee that her husband is a locum consultant urologist at UHS.
3. / Notes
3.1 / Notes of the Meeting held on 12 February 2013 / With the following amendments the notes of the previous meeting were agreed as an accurate record:
4.5 Carbetocin – include the indication that the Committee supported – i.e. for the prevention of uterine atony following delivery of the infant by caesarean section under epidural or spinal anaesthesia.
Section 6 - correct spelling – Lisdexamfetamine. / NH
NH
3.2 / Matters Arising
3.2.1 / Medicines Safety sub group / The minutes of the meeting held on 18 March 2013 were noted.
AK explained that the choice of NSAID in hospital was still being worked through. The Committee asked for an update at the next meeting. / AK
3.2.2 / Diabetes sub group / The minutes of the meeting held on 24 January 2013 were noted.
PN-J provided the following update:
Linagliptin –the sub group supported access to this gliptin as it does not require dose adjustment in patients with renal impairment. Following discussion the Committee supported the availability of linagliptin locally.
Dapagliflozin – PN-J noted the sub group recommendations (specialist recommendation) vs. the NICE draft guidance. Following discussion PN-J agreed to draft guidance on a possible niche role pending final NICE guidance. The Committee supported by exception – i.e. not routinely supported. If recommended by exception then the specialist to advise the GP on side effects and cautions.
Lixisenatide – PJ-N explained that this GLP-1 mimetic was a once daily dose regimen and less expensive than exenatide and liraglutide. The sub group has proposed it should be recommended as the first choice GLP-1 mimetic locally. It is licensed for use with insulin.
SG noted that the sub group had considered the NICE new medicines evaluation and it was therefore agreed that an evaluation was not required.
JB asked whether it should be considered as a replacement for the alternative GLP-1 mimetics including a managed switch.
Following discussion the Committee supported the availability of lixisenatide locally on the basis of its once daily administration and lower acquisition costs. Consideration should be given to using it as the first choice GLP-1 mimetic in new patients.
Insulin Degludec – PN-J explained that this is ultra long acting insulin that is significantly more expensive than the current long acting analogues. The sub group supported the availability locally as specialist recommendation only for patients with problematic type 1 diabetes. The Committee supported this recommendation and classified insulin Degludec as ‘Amber’ with initiation and stabilisation by the specialist clinician.
PN-J explained that at the meeting of the sub group held on 11 April the following actions were agreed:
Local guidance on access to glucagon would be developed.
Blood glucose test strips – guidance on the use of those with a low acquisition costs would be developed.
3.2.3 / Wound Formulary Group / NH informed the Committee that the final Wound Formulary had now been published and is being distributed.
3.2.4 / Epipen / JEXT Pen / The statement from the Wessex Allergy Network was discussed.
NH explained that there was on-going discussion between the specialists in UHS and HHFT as to their preferred option.
Following discussion the Committee agreed that NH would meet with Mich Lejeunesse, Keith Foote and Priya Llangovan to agree the approach.
LE noted the possible resources implications for general practice in regard to regular retraining of patients and parents. The Committee highlighted the role of the community pharmacist when dispensing these devices. / NH
3.2.5 / Choice of low molecular weight heparin / MI updated the Committee and explained that he needs to discuss with other provider chief pharmacists. MI noted that Regional price agreements might be disappearing.
HHFT – MI no plans for a switch as yet.
UHS - SL would want a locality wide price. Considering a switch in the Autumn. / MI
3.2.6 / Osteoporosis guidelines and denosumab shared care guidelines / The revised guidelines were noted. MS reminded the Committee that at the last meeting it had been requested to include the indication in the shared care guideline title and add hyperlinks to the SIGN calcium calculator. These had been actioned.
LE had a number of suggestions regarding the clarity of the shared care guideline and would forward to NH.
SG highlighted the recent warnings regarding strontium and would forward these to the guideline authors.
The Committee then discussed the UHS proposal that denosumab for osteoporosis be classified as ‘Green’.
NH explained that within West Hampshire a small number of practices had declined to take on prescribing responsibility for denosumab for workload reasons. Figures from UHS demonstrated that 12 out of 199 patients have had to return for their next injection. It was the workload implication for UHS that had lead to the request to reclassify it as green.
MZ highlighted the need for a decision from the specialists regarding stopping treatment after three years.
JB highlighted the recent UHS audit and agreed to share the results with the Committee.
Following discussion the Committee recommended that denosumab for the treatment of osteoporosis should remain as ‘Amber’. If a GP wished to initiate this therapy they are able to. / LE
SG
JB
3.2.7 / Coagucheck / MS updated the Committee. He has discussed with lead haematologist who believe that Coagucheck has a role in certain patients but needs to be part of a properly assured quality control system.
3.2.8 / Ranolazine / This was discussed under priorities (item 6).
3.2.9 / Terms of Reference / The revised terms of reference were agreed.
NH to add LE as LMC representative. / NH
3.2.10 / Eplerenone / The recommendation of the Committee at the last meeting was noted. A number of specialists had indicated that they would continue to use spironolactone before eplerenone, whilst others would use eplerenone, particularly in younger patients.
4. / Update from the Medicines Evaluation Committee / The minutes of the virtual MEC meeting held on 26 March 2013 were noted.
4.1 / SportVis (hyaluronic acid injection) / The evaluation (undertaken by Sue Gough), and the recommendations of the MEC were noted.
SG explained that it is now listed in the Drug Tariff and therefore prescribable on the NHS. SG highlighted the poor evidence base – no studies compared to active treatment and the study population was sports people rather than the general population.
Following discussion the Committee did not support the availability locally of SportVis.
4.2 / Treatments for actinic keratosis / The evaluation (undertaken by Sue Gough), and the recommendations of the MEC were noted.
SG explained that Ameluz is used in conjunction with photodynamic therapy.
Zyclara contains imiquimod 3.75%. SG noted that the only trial was against the vehicle not the higher strength product Aldara.
Ingenol is available in two strengths. The MEC noted that ingenol has benefits of a short course of only 2 or 3 days therefore the duration of side effects is less.
The recommendation of the MEC was that the use of ingenol is supported due to its short duration of treatment. Ameluz could be used in place of Metvix as efficacy and safety are similar but it costs slightly less.
The Committee supported the MEC’s recommendations but wished to take advice from specialists regarding the place of the various treatments Including Actikerall) in pathways. JB agreed to contact Sarah Macfarlane (UHS). / JB
5. / Shared care and Red, Amber, Green recommendations / NH provided an update:
· Apomorphine – Liz Bere will bring to the next meeting.
· Lanreotide and octreotide – Rhian Drewson (UHS) is updating.
· Dornase alfa, inhaled colistimethate and inhaled tobramycin – Amanda Bevan (UHS) is updating.
The draft naltrexone 50mg oral tablets for maintaining alcohol abstinence GP summary shared care guidelines were discussed.
MD explained that she and CB had discussed the key messages required for the GP summary. It was agreed that the short summary would be suitable to send to the patient’s GP and therefore a box for patient name and date initiated was required. It was agreed that MD and CB would finalise and then the short guideline could be piloted.
The Committee supported the proposal to have a GP summary / quick reference guide backed up by the full shared care guideline. This would be introduced as shared care guidelines were updated or introduced. / JB
SL
SL
CB/MD
6. / Priorities for Medicines Appraisals / The priorities for medicines appraisals were discussed and the following agreed:
· Fidaxomicin – priority for evaluation.
· Teriparatide for the treatment of atypical subtrochanteric fractures NH explained that UHS had submitted a business case for the use of denosumab for this indication – priority for evaluation.
· Pirfenidone for idiopathic pulmonary fibrosis. This treatment will be commissioned by the NHSE. PN-J agreed to discuss with NHSE –noted but no action.
· Ranolazine – note the Committee has reviewed previously in June 2010. SG informed the Committee that there was no new evidence - not a priority for evaluation.
· Fesoterodine – the Committee agreed to wait for the NICE clinical guidelines to be published.
· Lisdexamfetamine for ADHD – Being considered by Sussex Partnership Trust. NH to discuss with Ray Lyon.
· Omalizumab – note comes under NHSE Specialised commissioning. NH to discuss with Lynne Richley.
· Aflibercept for the treatment of macular degeneration – Professor Lotery (UHS) is keen to make this agent available before NICE guidance is issued (expected August 2013). The application noted the current capacity issues within the service. There was also a suggestion that aflibercept could be used in patients who have failed on ranibizumab. Following discussion it was agreed that SG would evaluate the evidence for the use of aflibercept as an alternative first line agent (i.e. in line with the NICE appraisal) but not the use for patients who have failed treatment on ranibizumab.
· Testosterone gel – NH explained that these had not been reviewed. If they were effective alternatives to injections there would be potential benefits to patients and reduced workload for GP surgeries – priority for evaluation.
Mirabegron for overactive bladder. MS welcomed Brian Birch to the meeting.
The Committee noted the NICE Appraisal Committee's preliminary recommendations:
1.1Mirabegron is recommended as an option for treating the symptoms of overactive bladder only for people in whom antimuscarinic drugs are contraindicated or clinically ineffective, or have unacceptable side effects.