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Medicines Management Team at the CCG.
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CITY SCRIPTS

November - December 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.
MPORTANT - PLEASE READ
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.

IN THIS EDITION:


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:
Insulin Abasaglar® – Joint formulary approved biosimilar to Insulin Lantus®
 
In type 2 diabetes, long acting insulin analogues (LAIA) should be initiated / recommended by a specialist and only when NPH (isophane) insulin is not suitable, as per NICE NG28.
Abasaglar® is a branded version of insulin glargine and biosimilar to the originator product Lantus®. In June 2016, it was approved on to the Joint Formulary as the preferred LAIA, since it is 15% cheaper than Lantus®.
Whilst savings achieved through initiation of the biosimilar will ultimately be significant, more substantial savings could be achieved through a coordinated switching programme from Lantus® to Abasaglar®. However this will require patient consent as well as possible training for those unfamiliar with the Eli Lilly pen devices.
  Pre-filled pen Cartridge Pen Device Other
Abasaglar® KwikPen Savvio Humapen
 
 
Lantus® SoloStar Autopen 24,  ClikSTAR, JuniorSTAR Vial
 
Prescribe insulin glargine by brand name to ensure the intended product is dispensed.

Action: The 23 BHCCG practices and 14 HWLHCCG practices currently prescribing insulin glargine generically, should review current practice and prescribe by brand name

https://www.prescqipp.info/biosimilars-insulin-analogues/send/247-biosimilars-insulin-analogues/2433-bulletin-130-biosimilars-insulin-analogues-briefing
New Inhaler Resources

After feedback from Non-Medical Prescribers, a handy inhaler guide has been developed by the Brighton and Hove CCG Medicines Management Team.  The guide contains information on the generic and brand names of inhalers, cost, licensing information and includes pictures of the devices.  

Also, at the back of the document are links to short inhaler training videos which can be used during patient consultations or as a refresher to healthcare professionals who may undertake asthma or COPD reviews and are required to check and teach inhaler technique.      

LINKS
Joint Formulary Inhaler Guide: http://www.gp.brightonandhoveccg.nhs.uk/file/7001/

Accuhaler: https://player.vimeo.com/video/178617772
Metered Dose Inhaler: https://player.vimeo.com/video/179464068
Metered Dose Inhaler & Volumatic spacer device: https://player.vimeo.com/video/179464174
Metered Dose Inhaler & AeroChamber Plus spacer device: https://player.vimeo.com/video/179464864
Autohaler: https://player.vimeo.com/video/178617776
Breezhaler Inhaler: https://player.vimeo.com/video/178617778
Easi-Breathe Inhaler: https://player.vimeo.com/video/178617774
Easyhaler Inhaler: https://player.vimeo.com/video/178887205
Fospiro Inhaler: https://player.vimeo.com/video/180739286
Genuair Inhaler: https://player.vimeo.com/video/178617775
Spiriva Handihaler Inhaler: https://player.vimeo.com/video/178617777
NEXThaler Inhaler: https://player.vimeo.com/video/180738083
Respimat Inhaler: https://player.vimeo.com/video/178874074
Spiromax Inhaler: https://player.vimeo.com/video/179442880
Turbohaler Inhaler: https://player.vimeo.com/video/178887846

If you require any placebo inhalers, please get in contact with your Medicines Management Team.
NEW CONTINENCE FORMULARY

Following approval at the Brighton Area Prescribing Committee in November 2016 the continence formulary may now be accessed here:http://www.gp.brightonandhoveccg.nhs.uk/file/7136 
It has been developed in conjunction with the Bladder and Bowel Team at Sussex Community NHS Foundation Trust. 
All continence items to be added to patient repeats will be communicated from the community bladder and bowel service via the following forms:sheath equipment, catheter equipment and anal irrigation.

Please contact your Medicines Management Team if you have any queries regarding the continence formulary.

Manage the Christmas prescription workload with eRD


The Electronic Repeat Dispensing (eRD) function within the Electronic Prescription Service (EPS) allows prescribers to authorise and issue a batch of repeatable prescriptions for up to 12 months with just one digital signature. GP practices using EPS are on average sending over half of their prescriptions electronically, but eRD makes up less than 12% of these. Read the NHS England guidance about eRD. If you’d like to find out more about eRD, download the Maximising eRD toolkit or register for a webinar to understand patient consent, cancellation and prescription synching, as well how to identify suitable patients.
The Medicines and Healthcare products Regulatory Agency (MHRA)
has published
Drug Safety Update for:


November 2016 advises:
Brimonidine gel (Mirvaso): risk of exacerbation of rosacea Some patients may have exacerbation or rebound symptoms of rosacea. It is important to initiate treatment with a small amount of gel and increase the dose gradually, based on tolerability and treatment response.

PLEASE NOTE:

Mirvaso has been considered by the Brighton Area Prescribing Committee and was coded as BLACK - not approved for use in any healthcare setting for the following reasons: 
  • Limited study data available, absence of economic data for the local health economy and unclear place in treatment pathway (as 1st drug in its class).
  • Difficulty in obtaining a clear diagnosis in primary care and measuring effectiveness due to the subjective evaluation of the treatment.
  • When brimonidine gel was compared to vehicle 25% - 30% saw improvement with the active ingredient gel compared to 10% with the vehicle. 40% were satisfied with outcome, 26% were not satisfied.
  • Other areas in the country have rejected brimonidine gel due to lack of/weak evidence, considering the drug to be of cosmetic nature and lack of long term trial data.
December 2016 advises:
Spironolactone and renin-angiotensin system drugs in heart failure: risk of potentially fatal hyperkalaemia—clarification In light of feedback, the MHRA clarified an article on concomitant use of these medicines in heart failure.  They now clarify that concomitant use of spironolactone with ACEi or ARB increases the risk of severe hyperkalaemia, particularly in patients with marked renal impairment, and should be used with caution. The article now also clarifies that the same advice applies for concomitant use of the aldosterone antagonist eplerenone with ACEi or ARB in heart failure. The full article can be accessed here.
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 October and November 2016:

Enstilar Foam (calcipotriene and betamethasone dipropionate): Not approved
Cetraben Ointment: Not approved
Nifedipine: GREEN (suitable for non-specialist prescribing) for use in Raynaud's phenomenon
Dymista: (2nd application reconsidered) BLACK (not suitable for prescribing in any healthcare setting) for allergic rhinitis (no change to current status)
Qvar beclometasone 250 microgram/dose EasiBreathe: Removed as discontinued.
Crizotinib: RED (specialist prescribing only) for untreated anaplastic lymphoma kinase-positive advanced non-small-cell lung cancer as per NICE TA406
Secukinumab: RED (specialist prescribing only) for active ankylosing spondylitis after treatment with non-steroidal anti-inflammatory drugs or TNF-alpha inhibitors as per NICE TA407
Pegaspargase: RED (specialist prescribing only) for treating acute lymphoblastic leukaemia as per NICE TA408
Aflibercept: RED (specialist prescribing only) for treating visual impairment caused by macular oedema after branch retinal vein occlusion as per NICE TA409
Talimogene laherparepvec: RED (specialist prescribing only) for treating unresectable metastatic melanoma as per NICE TA410 
Necitumumab: BLACK (not suitable for prescribing in any healthcare setting) for untreated advanced or metastatic squamous non-small-cell lung cancer as per NICE TA411
Radium-223 dichloride: RED (specialist prescribing only) for treating hormone-relapsed prostate cancer with bone metastases as per NICE TA412
Retigabine: Removed as discontinued.
Brivaracetam: BLUE (specialist initiation) for use as adjunctive therapy in the treatment of partial-onset seizures with or without secondary generalization in adult and adolescent patients from 16 years of age with epilepsy.
Elbasvir–grazoprevir: RED (specialist prescribing only) for treating chronic hepatitis C as per NICE TA413
Cobimetinib (in combination with vemurafenib): BLACK (not suitable for prescribing in any healthcare setting) for treating unresectable or metastatic BRAF V600 mutation-positive melanoma as per NICE TA414
Certolizumab pegol: RED (specialist prescribing only) for treating rheumatoid arthritis after inadequate response to a TNF-alpha inhibitor as per NICE TA415
Osimertinib: RED (specialist prescribing only) for treating locally advanced or metastatic EGFR T790M mutation-positive non-small-cell lung cancer as per NICE TA416
Paliperidone (Trevicta): Changed to RED (specialist prescribing only)
That's NICE... https://www.nice.org.uk/guidance  

NICE Bites October/November: This guideline covers preventing, assessing and managing mental health problems in people with learning disabilities in all settings and should be used in conjunction with NICE guidelines on specific mental health problems.
The following is intended for healthcare professionals in the Brighton and Hove CCG locality.
Antibiotic Prescribing Update Brighton and Hove CCG
 
Antibiotic resistance is now a major threat to public health. With 80% of the UK’s antibiotics currently prescribed in primary care, primary care prescribers are in a position to be able to significantly influence the future viability of antibiotics.
Healthcare workers have a vital role in preserving the power of antimicrobials. Antibiotic prescribing and antibiotic resistance are inextricably linked. Overuse and incorrect use of antibiotics are major drivers of resistance. Inadequate hygiene and infection prevention and control measures help to spread infections.
The more we can do to prevent infections and control their spread, the more we will reduce the need for antibiotics and limit opportunities for antimicrobial resistant strains to develop. Where infections do occur we need to diagnose them quickly and use the antibiotics we have appropriately.
Review of antibiotic prescribing is a key tool used in antimicrobial stewardship. Please see below Antibiotic prescribing data for the First 2 financial quarters 16/17

Overview of Antibiotic Prescribing Data in Brighton and Hove CCG
  • Brighton and Hove CCG as a whole continue to be low prescribers of antibiotics however at a practice level break down there do appear to be some outliers
  • Brighton and Hove historically have been below the national average for the prescribing of high risk antibiotics (Co-amoxiclav, cephalosporins and quinolones). Current data for the first 2 financial quarters 16/17 indicates that we are currently prescribing slightly above the national average
  • At a practice level breakdown there are variations in the city concerning the prescribing of high risk antibiotics (co-amoxiclav, cephalosporins and quinolones).
 
The data provided is for information to prompt review and discussion between colleagues and GP practices to encourage the sharing of good practice.
  1. Antibacterial items/STAR-PU Q1 Apr-Jun 16 and Q2 Jul-Sep 16
  2. Percentage of co-amoxiclav, cephalosporins and quinolones prescribed of all antibiotics Q1 Apr-Jun 16 and Q2 Jul-Sep 16
For information on STAR PUs (Prescribing Units) see here: http://content.digital.nhs.uk/prescribing/measures
Prescribing Incentive Scheme - important update

Domain 6 of this year’s PIS asks you to look at your BZD/Z-drug prescribing and either reduce it or audit your patients.
If you chose to do option 2 – the patient audit, you will need to fill in the ‘Patient Audit & Summary Sheet’.
It has been decided to add a further column to this form for ‘who initiated the prescribing and when’.
 
If your practice is going to do option 2 please could you use this updated form.
If you have already conducted the review using the original form then you will still be awarded the points as appropriate (you will not be penalised). But if you are only part way through the review please could the rest of the data be entered on this new form with the additional column.

If you have any queries please email kathryn.steele2@nhs.net
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.
Antibiotic prescribing - performance  indicators to end of September 2016

I thought it would be useful to share the latest performance data regarding antibiotic prescribing, rather timely as we now have data up to end of Sep 16. You’ll recall that there are 2 measures:
  1. Antibacterial items per STAR PU, i.e. a measure of total volume of antibiotics prescribed
  2. % cephalosporins, co-amoxiclav and quinolones of total , i.e. a measure of ‘risky’antibiotics 
As a CCG, HWLH trend for volume of antibiotics prescribed is mirroring others and we are below the national average. However, we are one of the highest CCGs nationally (red lines) for % ‘risky’ antibiotics, and the trend is much higher and rising more steeply than both the local area team (deep blue line in graph) and England total (bright blue line in graph).  (See links above for graphs.)
 
Overall, the CCG is meeting its target for volume, but not for % cephalosporins, quinolones & co-amoxiclav. There is huge variation amongst practices and outliers are being contacted to offer further support.
 
Over the summer months the Medicines Management Team conducted a ran a small audit in 6 HWLH practices over the summer, to determine whether cephalosporins, quinolones and co-amoxiclav had been prescribed during November 2015 in accordance with the Primary Care antimicrobial guidelines.  We are very grateful to practices for participating, and these are the key learns
  1. Guidelines are not being followed all of the time -  there are improvements that can be made, particularly with regard to cephalosporins and co-amoxiclav where around 50% of prescriptions issued were not formulary choices, and could not be rationalised from information within the patients’ notes. Quinolones were more often being used according to guidelines, with 31% lying outside of recommendations.
  2. UTI management is the most challenging. Choice should be nitrofurantoin where possible, or trimethoprim - uncomplicated lower UTI in men can also be treated with 7-day course of nitrofurantoin or trimethoprim. If a liquid preparation is needed, trimethoprim rather than nitrofurantoin should be used if possible, followed by nitrofurantoin. Please be guided by the UTI algorithm for UTI management. For recurrent UTI, the Primary Care Antimicrobial Guidelines stipulate to use nitrofurantoin or trimethoprim nightly and review after 6 months, though often other regimes employed by specialists.
  3. Documentation could be improved – in 3% of cases it was not clear what the indication for treatment was, and it is not always recorded where prescriber has consciously used an agent that is not preferred, e.g. where symptoms are more severe than usual or where the patient is complex. Also, a number of different read-codes are used for the same condition which means that searches have to be based on the drug prescribed. Non-urgent (delayed) scripts are being used, though this could be more clearly recorded.
Please do get in touch with alisonm.evans@nhs.net if more information or support is required.
Electronic Repeat Dispensing (eRD)
 
The rollout of eRD (previously known as batch prescribing) across the CCG is underway and data from our pilot site shows a clear reduction in prescription traffic through the surgery. Currently six practices across the CCG are sending over 10% of their electronic prescriptions through eRD each month, which is a great starting point to build from.
 
NHS Digital has recently released an online eRD training tool which will help train staff to utilise eRD and is tailored to whichever clinical system your surgery uses. A variety of toolkits for surgeries are also available (please see links below), these will be helpful for practices that are already using repeat dispensing as well as those who wish to start utilising the system. There are also toolkits available for community pharmacies to help maximise the benefits of the service to the patient as well their business.
 
If you would like to start using eRD in your practice or are already using it and would like to increase utilisation please get in touch with Michael Watson (michael.watson7@nhs.net).
 
eRD eLearning:
https://learning.necsu.nhs.uk/nhs-digital-electronic-repeat-dispensing-elearning/
Online eRD toolkits for surgeries:
https://www.digital.nhs.uk/article/913/Electronic-repeat-dispensing-for-prescribers
Online eRD toolkits for pharmacies:
https://digital.nhs.uk/article/914/Electronic-repeat-dispensing-for-dispensers
Contact the HWLH medicines management team
Both Medicines Management Teams would like to wish their colleagues 
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
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