All the latest prescribing news from your
Medicines Management Team at the CCG.
View this email in your browser


September - October 2016

Prescribing Newsletter
Brighton and Hove CCG & High Weald Lewes Havens CCG 

This newsletter is produced by the Medicines Management Team at the CCG, and is sent to all local GPs, Practice Nurses and Community Pharmacists.  We would welcome any feedback on the content and usefulness of the newsletter and suggestions for future topics.
With many thanks to neighbouring CCGs 
who have contributed material to this newsletter.
This edition comes to you jointly from the Medicines Management Teams at Brighton and Hove CCG and High Weald Lewes Havens CCG.  
Many of the articles will be of interest to both CCG localities however, please be aware that a few may be CCG specific. In this instance the articles will be clearly highlighted.


The following articles are relevant to both BHCCG and HWLHCCG:

The following articles are relevant to BHCCG only:

The following articles are relevant to HWLHCCG only:

Antibiotics: Handle with care

This year, World Antibiotic Awareness Week (WAAW) will be marked 14-20 November.

Led by WHO, but bringing together many organizations, WAAW is a global campaign to increase awareness of antibiotic resistance and the actions individuals, policymakers, health workers, veterinarians, and the agriculture sector can take to address it.

The campaign theme, ‘Antibiotics: Handle with Care’, reflects the overarching message that antibiotics are a precious, life-saving resource that must only be used when necessary, so they remain effective for as long as possible.

WHO encourages all governments, human and animal health professionals, students, and the public to join this campaign to help raise awareness of antibiotic resistance and what we can all do to address it.

For more information, visit the campaign website or email
***FREE antibiotic webinars***
TARGET RCGP antibiotic webinar series
Public Health England and the British Society for Antimicrobial Chemotherapy (BASC) have worked with primary care colleagues to develop a series of 7 free TARGET antibiotic webinars, highlighting key actions GPs can take to help improve their antibiotic prescribing, and at the same time improve the patient experience and self-care, therefore freeing up time.
The webinars start on Wednesday 2nd November, and will also be available after the event. To find out more and to sign up please go to:

We would like to remind prescribers that T3 (liothyronine) is locally blacklisted and should not to be prescribed for routine thyroid replacement.

This decision is joint with BSUH as they are no longer accepting referrals for patients enquiring about T3 therapy or prescribing T3 via their outpatient department/pharmacy.

An information leaflet for patients currently treated with T3 has been produced by the endocrinology department and can be found here: 

GPs may also find the leaflet useful when discussing T3 discontinuation with patients.

Please contact your Medicines Management Team for specialist advice on converting existing patients to levothyroxine. 
Centrally supplied vaccines
This is a reminder to practices that where vaccines have been centrally procured through Public Health England, they should not make a claim under personal administration arrangements to NHS Prescription Services on form FP34D/PD Appendix or FP10.
An FP34D/PD Appendix or FP10 form should only be submitted for payment to cover the dispensing of a vaccine by personal administration where the vaccine has been purchased by the practice.
Recently NHS Prescription Services has conducted an exercise to recover payments for Meningococcal vaccines claimed by GP practices where they had been centrally supplied and payment had been claimed under personal administration arrangements. 
For the period October 2015 – July 2016 a total of £333,500 has been recovered.
Allergies and Anaphylaxis
A number of patients can potentially have either food or non -drug related allergies that can result in anaphylaxis. As healthcare professionals it is prudent to be aware of this with regards to medicines.

If a patient has known anaphylaxis hypersensitivity always check if the medication prescribed contains the related allergen.

Patients with such allergies should always be encouraged by healthcare professionals to take owner ship and to always check before medicines are prescribed, dispensed or purchased over the counter that it is suitable with regards to their allergy status.

As the allergens in question may not always be the active component of a medicine and could be listed as excipients, the GP clinical prescribing system may not always trigger an alert therefore it would be wise to refer to the summary of product characteristics (SPC)  or patient information leaflet( PIL) to check the list of excipients of medicines, when a patient is known to have an anaphylactic hypersensitivity

The SPC and PIL can be accessed on the emc website
Out of pocket expenses
We ask that all dispensing contractors within Brighton & Hove engage, where possible, in reducing Out Of Pocket (OOP) expenses. The key requirements for claiming OOP expenses are ‘exceptional circumstances’, and ‘reasonable steps to avoid claiming’ as stated in clause 12 of the Drug Tariff:

“Where, in exceptional circumstances, out-of-pocket expenses have been incurred in obtaining a drug…and not required to be frequently supplied by the contractor…The endorsement shall be ‘XP’ or ‘OOP’ to indicate the contractor has taken all reasonable steps to avoid claiming.”

Should an item be available without incurring OOP expenses, please ensure that it is being ordered via this route. One example that has come to the attention of Brighton and Hove CCG as an item with a handling charge being levied by some wholesales is Mimpara (Cinacalcet). This item is available directly from the manufacturer Movianto, with no handling charge, arriving within 24 hours.

Contractors should ensure that invoices and a record of what has been claimed is retained  for future verification and reconciliation. In 2015, during Post Payment Verification completed by NHS England South, recoveries were made from contractors who; had misclaimed, were unable to provide evidence of an invoice, or had claimed the wrong amount for the drug/product dispensed.

Movianto UK Limited +44(0)1234 248500 (Setting up an account takes 48 hours to verify but will incur no cost).
Diazepam message
We have noticed that one of the top rejected messages on our OptimiseRx profile is for a switch from 5mg or 10mg tablets to diazepam 2mg tablets.  This message has been rejected 1262 times in the past 3 months.  
It is local protocol to prescribe as multiples of 2mg tablets except in exceptional circumstances.  
We would like prescribers to consider accepting the switch message for the following reasons:
  • Prescribing diazepam 2mg tablets allows for easier step-down of dosage during withdrawal
  • Diazepam 2mg tablets have a lower potential for diversion.  Valies are common on the black market and currently cost approx. £1 per tablet.
Specials (unlicensed) items containing coal tar
There is evidence that prescribing and dispensing errors for specials products (unlicensed products) containing coal tar can result in some patients receiving an inappropriate product.
This leads to a risk of significant harm. The British Association of Dermatologists’ List of Preferred Specials lists products containing coal in terms of the % of one of the official coal tar preparations. 
There are three of these:
• Coal Tar BP
• Coal Tar Solution BP
• Coal Tar Solution Strong, BP.
An important factor contributing to the errors appears to be confusion as to which of these preparations is needed. Prescribers and dispensers should therefore ensure that prescribed orders for specials items containing coal tar clearly specify the coal tar preparation. 
The Royal Pharmaceutical Society has published updated guidance for the procurement and supply of specials and guidance for the prescribers of specials:
RCGP sepsis toolkit
to support GPs with sepsis identification and treatment
The RCGP, in partnership with Health Education England and NHS England, has launched a new toolkit to support GPs and healthcare professionals assessing people in the community with acute infection, to identify and manage sepsis.
RCGP’s Clinical Lead for sepsis Dr Simon Stockley, who developed the toolkit, comments “Sepsis is responsible for 37,000 deaths a year in England alone. Recognising sepsis at an early stage among the huge number of ordinary infections can be a challenge even to experienced clinicians. The RCGP’s Sepsis toolkit is designed to help GPs better identify possible sepsis, and provide education resources for healthcare professionals and patients alike.”
Sepsis affected 123,000 people in England in 2014, resulting in approximately 37,000 deaths. 70% of cases derived from an infection developed in the community. It is estimated that there is potential to reduce deaths by up to 10,000 per annum by the optimisation of care.
The toolkit contains a series of educational materials, up-to-date guidance and training resources, as well as information for patients, carers and parents, including an adult and child sepsis ‘symptom checker’, to illustrate the signs and symptoms to look for when concerned about a sudden deterioration in a person’s health in the presence of infection.
Message from Grant Foster, 
Local Training Manager Sussex, National Engagement Team

For those who I haven’t met at your local practice manager meetings recently, I am your Local Training Manager for Sussex, and part of the PCSE National Engagement Team for the South East. I previously worked for Lancing Primary Care Support, and take my knowledge and experience going forward to help support you.  In my new role I am here to answer questions you may have, and to provide hands-on support with the new services. I will also be carrying out the face to face identification meetings with any new Performer List applicant in the area, now that Lancing/KPCA has closed. Below is a list of issues I’m able to advise and escalate for practices.
  • If practices have not had a collection of records.
  • Practices have received the incorrect records and require them to be returned
  • Urgent Records, if a practice have still not received an urgent record. Please forward to me ASAP and I will escalate this to the records team.
  • Record security breach i.e ripped bag etc
  • The practice have raised their payment query but have still had not had a response from PCSE.
Performer List
  • Practices that have new GP’s starting in there practice and have still not been issued Prescribing number (Please note I do not issue new prescribing numbers for GP’s and have no access to do this). Please email me when you first sent of your docs and the names of the doctor effected
  • New GP Registrars awaiting a F2F interview check of documents. Please contact me and I can arrange this.
  • For registration issues practices need to call the 0333 014 2884 number and ask to speak to the Clacton registration team.
GlucaGen HypoKit® recall

Novo Nordisk Ltd. is recalling seven batches of GlucaGen HypoKit® due to a small number of needles being detached from the syringe. It would not be possible to use a syringe with a detached needle, which could cause a delay in emergency treatment of severe hypoglycaemia. Patients are requested to return their Kit to their community pharmacy for a replacement. 
Useful SMS resources and factsheets from RCGP
We would like to promote the useful resources and factsheets from the RCGP on substance misuse and associated health.

The link to the webpage is here:

In particular we would like to highlight Factsheet 2 on Prescription and over-the-counter medicines misuse and dependence which is available here:
The Medicines and Healthcare products Regulatory Agency (MHRA)
has published
Drug Safety Update for:

September 2016 advises:

Levonorgestrel-containing emergency hormonal contraception: advice on interactions with hepatic enzyme inducers and contraceptive efficacy.  Updated advice for healthcare professionals:
  • Women seeking emergency contraception who have used cytochrome P450 3A4 (CYP3A4) enzyme inducers (see below) within the last 4 weeks, should:
    • preferably use a non-hormonal emergency contraceptive—ie, a copper intrauterine device
    • if this is not an option, double the usual dose of levonorgestrel from 1.5 milligrams to 3 milligrams (ie, 2 packs)
  • For these women:
    • provide advice on highly effective ongoing contraception that is not affected by hepatic enzyme-inducing drugs (see guidance from the Faculty of Sexual and Reproductive Health)
    • advise them to have a pregnancy test to exclude pregnancy after use of levonorgestrel-containing emergency contraception
    • advise them to seek prompt medical advice if they do become pregnant
This updated advice is in line with existing guidance from UK experts in sexual and reproductive health, and applies to both prescription and nonprescription supply which will help ensure that women receive consistent advice. Product information for healthcare professionals and women and the outer packaging for levonorgestrel emergency contraception are being updated with this advice.

Posaconazole (Noxafil): tablets and oral suspension are not directly interchangeable
Switching from posaconazole oral solution to tablets has resulted in cases of dose-related toxicity, whereas switching from tablets to oral solution has resulted in underdosing and lack of efficacy.
Advice for healthcare professionals:
  • posaconazole tablets and oral suspension are not directly interchangeable
  • switching from oral suspension to tablets can lead to overdosing and serious adverse drug reactions, whereas switching from tablets to oral suspension can lead to underdosing and lack of efficacy
  • prescribers should specify the dosage form for posaconazole on every prescription
  • pharmacists should ensure that the correct oral form is dispensed to patients
Idelalisib (Zydelig▼): updated indications and advice on minimising the risk of infection.
Summary Updated advice for healthcare professionals is available, after conclusion of a review of the safety of idelalisib, including the risk of infection. Advice for healthcare professionals:

Indications for idelalisib (Zydelig▼)
Chronic lymphocytic leukaemia (CLL):
  • combined with rituximab for adults with CLL as first-line treatment in the presence of 17p deletion or P53 mutation in patients who are ineligible for any other therapies (note that this is the updated indication).
  • idelalisib continues to be indicated in combination with rituximab for adults with CLL who have received at least one prior therapy
Follicular lymphoma:
  • idelalisib continues to be indicated as monotherapy for adults with follicular lymphoma that is refractory to two previous lines of treatment
Measures to minimise risk of infection in all patients 
Pneumocystis jirovecii pneumonia (updated):
  • all patients should receive prophylaxis for P jirovecii pneumonia during treatment with idelalisib and for up to 2–6 months after stopping
  • duration of post-treatment prophylaxis should be based on clinical judgment, taking into account the patient’s risk factors such as concomitant corticosteroid treatment and prolonged neutropenia
Cytomegalovirus infection (updated):
  • regular clinical and laboratory monitoring for cytomegalovirus infection is recommended in patients who are seropositive at the start of treatment with idelalisib or who have other evidence of a history of infection with this virus
  • patients with cytomegalovirus viraemia but without signs of infection should be carefully monitored
  • for patients with evidence of viraemia and clinical signs of infection, consideration should be given to interrupting idelalisib. Treatment may be restarted if the infection has resolved and if the benefits of resuming are judged to outweigh the risks. If idelalisib treatment is restarted, preemptive cytomegalovirus therapy should be considered
General advice about risk of infection (reminder):
  • patients should be informed about the risk of serious or fatal infections during treatment
  • idelalisib should not be started in patients with any evidence of ongoing systemic bacterial, fungal, or viral infection
  • patients should be monitored for respiratory signs and symptoms throughout treatment, and should be advised to promptly report new respiratory symptoms
  • absolute neutrophil counts should be monitored in all patients at least every 2 weeks for the first 6 months of treatment, and then at least weekly while count is less than 1000 per mm3. Treatment should be discontinued if absolute neutrophil count falls below 500 per mm3.  Treatment can be restarted at a lower dose (100 mg twice daily) when the count rises above 500 per mm3.
October 2016 advises:

Etoricoxib (Arcoxia): revised dose recommendation for rheumatoid arthritis and ankylosing spondylitis
Prescribing information has been updated to introduce a lower recommended dose of 60 mg daily for patients with rheumatoid arthritis or ankylosing spondylitis.
Advice for healthcare professionals:
  • the cardiovascular and other important risks of etoricoxib (Arcoxia) may increase with dose and duration of exposure. Therefore, the lowest effective daily dose should be used, and the need for treatment should be regularly reassessed
  • the recommended dose is 60 mg once daily
  • in patients with insufficient relief from symptoms, an increased dose of 90 mg once daily may improve efficacy
  • once the patient is clinically stabilised, down-titration to 60 mg once daily may be appropriate
  • in the absence of therapeutic benefit, other treatment options should be considered
See Letter sent to healthcare professionals in September 2016
Brighton Area Prescribing Committee and Joint Formulary Update

The Brighton APC makes decisions concerning additions to the Joint Formulary. The following summarises decisions made by the APC in September 2016:

Utrogestan: GREEN suitable for non-specialist prescribing
Testosterone gel: NOT APPROVED for use in menopausal women with low libido
RED specialist only
RED specialist only
Laxido Paediatric: 
GREEN suitable for non-specialist prescribing 
Carbocisteine sachets: 
BLUE specialist initiation or recommendation only
Paliperidone 3 monthly long acting IM injection: Brighton = 
BLUE specialist initiation or recommendation only (under the SMI LES) HWLH = RED specialist only
Ikervis: BLUE specialist initiation or recommendation only (see information sheet)
Esomeprazole sachets: 
BLUE specialist initiation or recommendation only.  Approved for use in children with enteral feeding tubes, gastrostomies and Jejunostomies, at risk of gastric ulceration due to initiation on high dose / long term steroid use or NSAID use. (see information sheet)
BLUE specialist initiation or recommendation only for use in children with ADHD. (see information sheet)
BLUE specialist initiation or recommendation only (see information sheet) (was previously red)
Lumacaftor-ivacaftor: BLACK not approved in any healthcare setting as per NICE TA393
BLACK not approved in any healthcare setting as per NICE TA399
RED specialist only as per NICE TA400
RED specialist only as per NICE TA401
RED specialist only as per NICE TA402
BLACK not approved in any healthcare setting as per NICE TA403
RED specialist only as per NICE TA404
Trifluridine - tipiracil:
RED specialist only as per NICE TA405
That's NICE...  
Reference number Title Published Last updated
NG48 Oral health for adults in care homes July 2016 July 2016
NG49 Non-alcoholic fatty liver disease (NAFLD): assessment and management July 2016 July 2016
NG50 Cirrhosis in over 16s: assessment and management July 2016 July 2016
CG64 Prophylaxis against infective endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures March 2008 July 2016
QS125 Diabetes in children and young people July 2016 July 2016
NG17 Type 1 diabetes in adults: diagnosis and management August 2015 July 2016
NG28 Type 2 diabetes in adults: management December 2015 July 2016
NG52 Non-Hodgkin’s lymphoma: diagnosis and management July 2016 July 2016
NG51 Sepsis: recognition, diagnosis and early management July 2016 July 2016
CG71 Familial hypercholesterolaemia: identification and management August 2008 July 2016
QS126 Motor neurone disease July 2016 July 2016
TA259 Abiraterone for castration-resistant metastatic prostate cancer previously treated with a docetaxel-containing regimen June 2012 July 2016
TA387 Abiraterone for treating metastatic hormone-relapsed prostate cancer before chemotherapy is indicated April 2016 July 2016
TA398 Lumacaftor–ivacaftor for treating cystic fibrosis homozygous for the F508del mutation July 2016 July 2016
TA399 Azacitidine for treating acute myeloid leukaemia with more than 30% bone marrow blasts July 2016 July 2016
TA400 Nivolumab in combination with ipilimumab for treating advanced melanoma July 2016 July 2016
CG140 Palliative care for adults: strong opioids for pain relief May 2012 August 2016
QS127 Obesity: clinical assessment and management August 2016 August 2016
QS128 Early years: promoting health and wellbeing in under 5s August 2016 August 2016
CG156 Fertility problems: assessment and treatment February 2013 August 2016
CG142 Autism spectrum disorder in adults: diagnosis and management June 2012 August 2016
QS6 Diabetes in adults March 2011 August 2016
CG44 Heavy menstrual bleeding: assessment and management January 2007 August 2016
TA391 Cabazitaxel for hormone-relapsed metastatic prostate cancer treated with docetaxel May 2016 August 2016
TA401 Bosutinib for previously treated chronic myeloid leukaemia August 2016 August 2016
TA402 Pemetrexed maintenance treatment for non-squamous non-small-cell lung cancer after pemetrexed and cisplatin August 2016 August 2016
TA403 Ramucirumab for previously treated locally advanced or metastatic non-small-cell lung cancer August 2016 August 2016
TA404 Degarelix for treating advanced hormone-dependent prostate cancer August 2016 August 2016
TA405 Trifluridine–tipiracil for previously treated metastatic colorectal cancer August 2016 August 2016
CG126 Stable angina: management July 2011 August 2016
CG141 Acute upper gastrointestinal bleeding in over 16s: management June 2012 August 2016
NG53 Transition between inpatient mental health settings and community or care home settings August 2016 August 2016
QS129 Contraception September 2016 September 2016
CG42 Dementia: supporting people with dementia and their carers in health and social care November 2006 September 2016
NG54 Mental health problems in people with learning disabilities: prevention, assessment and management September 2016 September 2016
NG55 Harmful sexual behaviour among children and young people September 2016 September 2016
NG56 Multimorbidity: clinical assessment and management September 2016 September 2016
QS130 Skin cancer September 2016 September 2016
QS131 Intravenous fluid therapy in children and young people in hospital September 2016 September 2016
QS132 Social care for older people with multiple long-term conditions September 2016 September 2016
CG181 Cardiovascular disease: risk assessment and reduction, including lipid modification July 2014 September 2016
TA406 Crizotinib for untreated anaplastic lymphoma kinase-positive advanced non-small-cell lung cancer September 2016 September 2016
TA407 Secukinumab for active ankylosing spondylitis after treatment with non-steroidal anti-inflammatory drugs or TNF-alpha inhibitors September 2016 September 2016
TA408 Pegaspargase for treating acute lymphoblastic leukaemia September 2016 September 2016
TA409 Aflibercept for treating visual impairment caused by macular oedema after branch retinal vein occlusion September 2016 September 2016
TA410 Talimogene laherparepvec for treating unresectable metastatic melanoma September 2016 September 2016
TA411 Necitumumab for untreated advanced or metastatic squamous non-small-cell lung cancer September 2016 September 2016
TA412 Radium-223 dichloride for treating hormone-relapsed prostate cancer with bone metastases September 2016 September 2016
  NICE Bites September 2016 (221 KB) 05/10/2016
  Multimorbidity: clinical assessment and management This guideline covers optimising care for adults with multimorbidity, by reducing treatment burden (polypharmacy and multiple appointments) and unplanned care.
  NICE Bites August 2016 (282 KB) 05/09/2016
  This guideline covers recognition, diagnosis and early management of sepsis for all populations. It should be used together with: algorithms organised by age group and treatment location and risk stratification tools. There is significant overlap between this guideline and other NICE guidance: acutely ill patients in hospital, fever in under 5s, meningitis (bacterial) and meningococcal septicaemia in under 16s, neutropenic sepsis, neonatal infection, and pneumonia in adults.
  NICE Bites June /July 2016 (235 KB) 27/07/2016
  This guideline covers identifying, assessing and managing Non-Alcoholic Fatty Liver Disease in children (1 to 15 years), young people (16 to 17 years) and adults (≥ 18 years).
  NICE Bites May 2016 (289 KB) 08/06/2016
  This guideline covers systems and processes for using and managing CDs safely in all NHS settings except care homes.
The following is intended for healthcare professionals in the Brighton and Hove CCG locality.
Medicines Management Team Update:

New Starters
Welcome to Scott Sweeney who has joined the team as Lead Pharmacy Technician for Medicines Optimisation.  He will be leading the co-ordination of projects to support the delivery of the medicines management team strategy and objectives.   
Brighton and Hove Clinical Commissioning Group have moved office.  We now reside at:
Hove Town Hall, Norton Road, Hove, BN3 4AH

All of the team member's telephone numbers have changed, so please check a recent email signature to confirm the correct number before ringing.  (All telephone numbers should begin with 238.)  
Alternatively, the team can be contacted via the switchboard: 01273 238700.
Prescribing support Dietitian- SIP feed project update

David Broadbent is in month 4 of his 12 month project and currently working in his second surgery.
Projected annual savings are £27,232.92 based on the prescription changes/ interventions he has made so far.
There have been some common themes and based on David's findings, the following recommendations should be followed to promote cost effective prescribing of sip feeds:
  • All patients on long term ONS (more than 3/6 months) should be referred to the community dietitians for assessment/review.
  • Powder based sip feeds should be used as first line instead of ready made sip feeds as they are at least 50% more cost effective. I.e. Complan shake instead of Fortisip bottle unless they have been assessed by a dietitian.
  • Prescribable puddings such as Forticreme are not cost effective. There are lots of home-made or shop bought items of similar consistency and calories which can be recommended to patients as alternatives.
  • Patients who have had prescriptions instigated for ONS as an inpatient (either in hospital or intermediate care) should not automatically be started on a repeat prescription once discharged. Refer to community Dietitian if MUST score 2 or more. If MUST 0-1 then ‘Food as Treatment’ should be followed. If patients with MUST 0-1 wish to continue with nutritional supplements then OTC can be advised i.e Meritine, Complan
If you have any questions or comments please e-mail David on
Contact the BH medicines management team
The following has been written by the medicines management team at High Weald Lewes Havens CCG and is intended for healthcare professionals in this CCG locality.
Medicines Management Team Update:

David Chapman – we wish David all the best for the future in his new role working with SCfT.
Contact the HWLH medicines management team
Feedback to the author of this newsletter
Although every effort is made to ensure this newsletter is accurate, the producers can accept no responsibility for errors or omissions in information provided by external organisations. Any opinions expressed are those of the editor/s and do not necessarily represent the opinions of Brighton and Hove Clinical Commissioning Group or High Weald Lewes Havens Clinical Commissioning Group
BHCCG Website
BHCCG MedsMan Email
BHCCG Twitter
HWLHCCG MedsMan Email
Copyright © 2016 Medicines Management Team, Brighton & Hove Clinical Commissioning Group, All rights reserved.

Want to change how you receive these emails?
You can update your preferences or unsubscribe from this list

Email Marketing Powered by Mailchimp