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Medicines Management Team at the CCG.
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CITY SCRIPTS

June - Oct 2015

Brighton & Hove CCG Prescribing Newsletter

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.
It's been a busy summer and a while since we last published City Scripts, so we do apologise for this XL issue.  
We've really tried to streamline this edition but feel we have so much to tell you! We do hope you find the content useful and informative.

IN THIS EDITION:

Medicines Management Team Update
"Hello... Goodbye!"


Niamh Kelly has joined the medicines management team at Brighton and Hove CCG for three days per week working Monday-Wednesdays. She is covering Barbara Pawulska’s sabbatical leave.
Niamh is an experienced clinical pharmacist and continues to work 2 days a week as a renal specialist pharmacist at BSUH.
In the CCG Niamh will be responsible for 14 practices within cluster 2 and 3. She will also be leading on medicines management input into mental health, palliative care, pain management and substance misuse. Niamh can be contacted on niamh.kelly6@nhs.net
 
It is with sadness that we will be saying goodbye to Helen Wells at the end of November.  Helen has been a part of the team since 2008 and has recently been seconded to the clinical informatics team supporting the roll out EPS2 in the city. We wish her a very happy retirement!

Minimising drug interactions

Drug selection should aim to minimise drug interactions. If it is necessary to prescribe a potentially serious combination of drugs, patients should be monitored appropriately. Details of drug interactions can be found in Appendix 1 of the BNF.

In the online version of the BNF, you can review drug interactions between several drugs at the same time by typing in each non-proprietary drug name separated by a space in the Search box. You will be provided with results for a free text search. Refine the search by clicking on 'Interactions'. The search result for interactions displays an explanation of: 
  • what has been searched;
  • the number of matching documents;
  • the list of known interactants between pairs of drugs;
  • whether an interaction is potentially serious.
You can obtain further information about a specific interaction by clicking on the link to the pair of interacting drugs. In the digital versions, interactions shown in bold and against a pink background are potentially serious; concomitant administration of the drugs involved should be avoided (or only undertaken with caution and appropriate monitoring). Interactions that are not in bold type do not usually have serious consequences.

In the print edition of the BNF, drugs and their interactions are listed in alphabetical order of the non-proprietary drug name and cross-references to drug classes are provided where appropriate. Each drug or drug class is listed twice: in the alphabetical list and also against the drug or class with which it interacts. The symbol • is placed against interactions that are potentially serious and where combined administration of drugs should be avoided (or only undertaken with caution and appropriate monitoring). Interactions that have no symbol do not usually have serious consequences. If a drug or drug class has interactions, a cross reference to where these can be found in Appendix 1 is provided under the Cautions of the drug monograph or prescribing notes.
Medication side-effects; how likely are they to occur?

Sussex Partership Foundation Trust  (SPfT) have produced a medication side-effect leaflet to assist patients’ understanding of the different levels of risks in relation to how likely side-effects could occur.
 
This is important because of the differences in terminology used in product information leaflets inside packs and that perceived understanding by lay people. For instance, a lay person might assume common means most people might suffer from a side-effect, whilst a product information leaflet terminology uses the term:
  • ‘common’ to mean between 1 in 10 and 1 in 100 people will suffer from the side-effect,
  • ‘very common’ is used for side-effects suffered usually by all to 1 in 10 people taking the medicine. 
Action: Clinicians should be aware that this leaflet as a resource to convey side-effect risks

New Yellow Card app for reporting suspected side effects

The free app enables healthcare professionals, patients, or carers to report any suspected side effects directly to us—a convenient and secure alternative to using paper Yellow Card forms or the Yellow Card website.

On reporting, you will receive an immediate response to show that your Yellow Card report has been accepted, and it is simple to view information for any Yellow Cards already submitted (even if you don’t have a side effect to report at the time).

Moreover, you can create a watchlist that enables you to receive news and alerts about particular medicines of interest, and to look up numbers of Yellow Cards received about them. Download the app via iTunes Yellow Card for iOS devices or via PlayStore Yellow Card for Android devices. 
 
PDE5 Inhibitors for Treatment of Erectile Dysfunction 

The policy for treating ED has been updated to reflect the recent changes regarding sildenafil. 
Generic sildenafil can now be prescribed on the NHS for all patients presenting with erectile dysfunction where clinically appropriate for its licensed indication. These patients no longer have to conform to SLS criteria. The updated policy also includes a treatment pathway and highlights when a referral to the ED clinic is appropriate.  The policy can be found HERE.
Prescribing of Gluten Free Products
 
The guideline for the prescribing of GF products has been updated.  The formulary approved product list has been extended to include a variety of brands of fresh bread.  The have been selected as the products can be ordered through Alliance Wholesalers with no extra delivery / handling charges.  It is worth noting that packs of fresh bread cannot be split and can only be ordered in multiples of 6 or 8 depending on pack size.  This may account for a full month's quota as a maximum of 8 items may be provided per month on NHS prescription.  The full guideline can be found HERE.    

Omnican® Fine Pen needles


We have had reports that there may be supply issues with Omnican Fine pen needles.  We have followed this up with the manufacturers B.Braun who have advised us that there are no supply issues at their end.     
  • Omnican Fine can be ordered through the 3 main pharmacy wholesalers (AAH, Alliance and Phoenix) and currently there are ample stocks of all needle lengths in the warehouse with no back orders.
  • Each of the wholesalers stock Omnican fine in all their local distribution centres however, B.Braun will request an increase in local stock levels given the probable rise in demand due to Omnican Fine being included on the Brighton & Hove formulary.
If you are experiencing any problems in obtaining Omnican Fine please contact:
Emily Slater email: emily.slater@bbraun.com Tel: 07528968208
or the generic email: diabetes.bbmuk@bbraun.com and freephone 0800 840 0498
Click HERE for more information on the local blood glucose monitoring formulary.
 
On-line training materials on
antipsychotics, benzodiazepines and SSRIs

 
The Medicines and Healthcare Products Regulatory Authority (MHRA) has developed several learning modules for clinical practitioners. These are self-directed learning packages, which are approved for continuing professional education (CPD).  They outline the key risks of prescribing these widely prescribed classes of medicines. For the different adverse effects, the module outlines the main features of the adverse effect:
  • Factors that increase the risk
  • How the risk can be reduced
  • Specific treatment for the adverse effect
 The credits and estimated time to undertake each of these modules are:
  • Antipsychotics learning module (up to 3.5 CPD credits – estimated time 3.5 hours)
  • Benzodiazepine module (up to 2.5 CPD credits – estimated time 2.5 hours)
  • SSRI learning module (up to 2.5 CPD credits – estimated time 2.5 hours)

The UK Drugs in Lactation Advisory Service (UKDILAS)

UKDILAS have launched its official drugs in lactation database.  This free NHS resource for healthcare professionals risk assesses the safety of medicines during breastfeeding and gives suitable alternatives where necessary. UKDILAS is a specialist service provided jointly by the Trent and West Midlands Regional Medicines Information Centres.

Fosfomycin

Following on from the availability of a licensed version of fosfomycin 3g sachets (Monuril), the previous arrangements involving faxing a request to the commissioned pharmacy will no longer be in place. Fosfomycin is blue on the Brighton Joint Formulary, and may be prescribed on FP10 on the recommendation of microbiology. Community UTI pathway can be found here.
Top Ten Tips

The Medicines Management Team has developed a list of top ten tips for prescribers, covering information on using the Joint formulary, antimicrobial guidelines, ONPOS and other important areas. This is especially useful for locums or new starters and is a useful resource to refresh established prescribers with the CCGs prescribing systems. The document can be found here.

Lithium

Following a serious incident (SI) review of lithium toxicity at SPFT, please could all prescribers treating patients with lithium ensure they are aware of the following documents from SPFT:
 Please be vigilant for signs of toxicity such as
•             Severe hand shake (tremor)
•             Blurred vision
•             Stomach ache along with feeling sick and having diarrhoea
•             Being unsteady on your feet

New Prednisolone Product

The price of 5mg soluble tablets has significantly increased recently (£53.48/30).

There is a newly licensed oral solution preparation, prednisolone Dompé® 1mg/ml Oral Solution available in 5mg/5ml single dose units (£11.41/10 single-dose units; honey and vanilla/cream flavour).

The oral solution is licensed for use in children and adults (on 30mg per day or less) and allows for partial dosing at increments of 1.25ml, 2.5ml, 3.75ml and 5ml. It must be prescribed as “oral solution unit dose” to prevent an unlicensed special being dispensed.

Prednisolone 25mg tablets (£75/56) are also significantly more expensive than using multiples of 5mg tabs (£1.21/28).

Toujeo®

Insulin glargine 300 units/ml pre-filled disposable pen injection has been launched for treatment of diabetes mellitus in adults. It is a high-strength insulin glargine formulation. Each 1.5ml pen contains 450 units of insulin. These units are specific to Toujeo® and the product is not interchangeable with other forms of insulin glargine or other insulin analogues.

Toujeo® is given once daily, preferably at the same time each day, but its prolonged duration of action (>24 hours) allows dosing up to 3 hours before or after the usual time of administration. Cost: 3 x 1.5ml SoloStar pre-filled pen, £33.13. See SPC.

The MHRA has issued guidance on Toujeo for healthcare professionals.

ACTION: GPs are advised NOT to prescribe Toujeo® until it has been considered by the Brighton APC.

Overseas Travel Prescribing Guidance and Patient Resource

The Brighton Area Prescribing Committee have approved guidance on prescribing for overseas travel. The guidance has been produced to help clarify which vaccines and medicines may be prescribed on the NHS and those that should be prescribed privately for the purpose of travel. Further advice on issues that may arise when prescribing for travellers is also included.  The guidance covers:
  • Travel advice
  • Malaria prophylaxis
  • Medication that may be needed when travelling
  • Vaccines for the purpose of travel
  • Prescribing of medication for existing long term conditions
  • Taking syringes and needles on flights
  • Taking controlled drugs abroad
  • Prevention of Deep Vein Thrombosis (DVT) during long distance travel
  • Sources of information
A Q&A style patient information leaflet on overseas travel guidance has also been produced to support the prescribing guidance.  
 

Preferred Brand of Quetiapine XL

Mintreleq XL® has been accepted onto the Joint Formulary as the most cost effective brand for modified release quetiapine. This has been supported by the APC and SPFT.
The Medicines Management Team will be supporting GP practices to switch all suitable patients to Mintreleq XL®. For all new prescriptions of quetiapine modified release please review if modified release is intended, the immediate release product can be given as a once a day dose and is the preferred option from Sussex Partnership Foundation Trust.  See information on switching XL to plain tablets

MenB Vaccination and Paracetamol

Public Health England has produced a number of new resources to support the childhood vaccination schedule. MenB vaccine and paracetamol leaflets inform parents of the increased risk of fever when the MenB vaccine is given alongside other immunisations at 2 and 4 months of age. They provide advice on how to prevent and treat fever in babies by giving them paracetamol after their MenB vaccinations and recommend having paracetamol at home in advance of immunisation appointments.

Practices should also have received an email containing information from the Surrey and Sussex Area Team answering FAQs about the prophylactic use of paracetamol, which in this situation means giving paracetamol in the absence of a temperature. Paracetamol may be given around the time of immunisation or shortly after. Nurses may advise parents to administer the paracetamol straight after the baby has received all the primary immunisations including MenB whilst the nurse is still doing her documentation or can advise the parents to administer the paracetamol when they are in the waiting area post vaccination.
For further information please consult the Medicines Management Team.

Repeat Prescribing Co-ordinators (RCP)

We have recently run our 2nd training session for non-clinical admin staff who are involved with the repeat prescribing process.  

The session covered controlled and high risk drugs, drugs not suitable for repeat prescribing, medication synchronisation and repeat dispensing, as well as some interesting case studies and group discussions to share learning and promote best practice.  

We have received fantastic feedback and would value your thoughts on what you would like covered in future training session. Email us.

Equipped with their new knowledge, we have encouraged attendees to get involved with this year's Prescribing Incentive Scheme domain 6, where practices have been asked to review their repeat prescribing policy.  

ACTION:
We recommend you support this by allocating some protected time between the Practice Prescribing Lead and RPC.     

RESOURCES

All the slides and handouts from both sessions are available to download here: http://www.gp.brightonandhoveccg.nhs.uk/prescribing/non-clinical-prescribing-documents-and-resources
In addition, the Medicines Management Team has developed an information resource pack to support all non-clinical staff involved in repeat prescribing in practices. It is full of useful information and advice to help practice staff deliver an efficient and effective repeat prescribing service.

ACTION: 
Download from the B&H CCG website www.gp.brightonandhoveccg.nhs.uk/file/757 and ensure that this is accessible to non-clinical staff to refer to.

The new 'Breathe Better Waste Less' project has been launched by Brighton and Hove CCG and aims to improve patient care for people with asthma and COPD, while reducing pharmaceutical waste across the city. 

The project hopes to encourage respiratory patients to get their inhaler technique checked by their local pharmacist through a respiratory Medicine User Review (MUR). Pharmacists participating in the project are also receiving a refresher course on inhaler technique from an experienced trainer. Pharmacists are using an enhanced MUR feedback form which they are encouraged to send to GPs. This feedback form contains valuable questions that will assist with QOF. If an action is required by the GP, this will be marked and should be forwarded to the appropriate person. Otherwise it will be marked ‘ for Information’ and practice staff can use these forms to input useful data about the patient to their file.  
 
At the same time, GlaxoSmithKline (GSK) are working with us as part of the project to encourage respiratory patients to return their used inhalers to their local pharmacies to be recycled. Before being recycled, the inhalers will be analysed to measure the amount of remaining medicine left in each inhaler. This information will be used to enable an understanding of the pattern of wastage and will highlight where extra focus is needed.  

Pharmacies all over the city are signing up to the project, so look out for 'Breathe Better, Waste Less' posters and ‘Complete the cycle’ recycling bins in your local pharmacy. 

Ascorbic Acid

In the past 12 months the CCG has spent nearly £300,000 on ascorbic acid.
Cost of ascorbic acid on FP10 (Drug Tariff October 2015)

 
50mg (28) = £12.42 
100mg (28) = £14.30
200mg (28) = £18.60
500mg (28) = £26.86

Patients should be encouraged to eat a balanced diet which provides adequate Vitamin C. Or Vitamin C preparations are readily available to buy over the counter.
If prescribed, the licensed indication for Ascorbic acid 500mg is for the treatment of scurvy.
ACTION: Review patients' need to obtain ascorbic acid on prescription. 

Gliptins Warning

The 
FDA has issued a safety announcement warning the DPP-4 inhibitors or gliptins may cause joint pain that can be "severe and disabling".

A review of adverse events reported to the FDA and also medical literature identified cases of severe joint pain associated with the use of DPP-4 inhibitors. The pain may begin soon after starting treatment or after several years.

Arthralgia is listed as a known side effect in the current 
SPCs for sitagliptin, saxagliptin and vildagliptin. However, alogliptin and linagliptin are also mentioned in the FDA announcement.

2015-16 Switching Action Plan

The Medicines management team has now finalised and approved the Switching Action Plan for this year. Details have been emailed to all practice managers and are available to download from the CCG website. Our Prescribing Support Technicians will be getting in touch over the coming months following your annual prescribing meetings to arrange to come in and carry out the agreed work on behalf of practices.
 
The 2014-15 Action Plan achieved projected annual savings of over £315,555 for Brighton & Hove practices and we hope to achieve a similar figure this year. Cost savings achieved from this work will mean that more money can be invested in other areas of healthcare provision and prescribing.
 
We hope that you find this targeted switching work valuable and hope you will continue to be receptive to our team providing practice-based support work to help improve prescribing efficiency across the city.  

Please note there has been a slight amendment to the 1st version you may have received via email.  The preferred branded generic of levodopa/ carbidopa/ entacapone (Stalevo) is 'Sastravi' NOT Stanek.  This is due to BSUH now using Sastravi and therefore we have decided to keep the brand consistent throughout the local health economy.
  • Several treatments for hepatitis C infection, namely ledipasvir-sofosbuvir (Harvoni®), sofosbuvir (Sovaldi®) and daclatasvir (Daklinza®), have been found to interact with amiodarone and increase the risk of severe bradycardia and heart block. It is recommended that amiodarone only be used in conjunction with these treatments when other antiarrhythmics cannot be given and patients being started on amiodarone should be closely monitored for 48 hours.
  • Pomalidomide (Imnovid®), used in relapsed and refractory multiple myeloma, has been found to cause interstitial lung disease (ILD), cardiac failure and hepatotoxicity.
  • Also included is a reminder that ketoprofen gel is associated with photosensitivity reactions and of risk minimisation measures should be undertaken when skin is exposed to sunlight during treatment.
June 2015 notes
  • SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin) have been linked with an increased risk of diabetic ketoacidosis (DKA) even when plasma glucose levels are near-normal. It is recommended that patients presenting with symptoms of acidosis are tested for raised ketones and that SGLT2 inhibitors are stopped if DKA is suspected.
  • High dose ibuprofen (>2400mg per day) has identified cardiovascular risks similar to COX 2 inhibitors and diclofenac, and therefore such doses should be  avoided in people with cardiovascular diseases (including ischaemic heart disease, peripheral arterial disease, cerebrovascular disease, congestive heart failure and uncontrolled hypertension). Individuals with these conditions who are already taking high dose ibuprofen should be reviewed at their next routine appointment.
  • Clinicians are also advised to inform women of the risks of uterine perforation before inserting an intrauterine system (IUS) or intrauterine device (IUD). It is noted that perforation occurs in less than 1 in 1,000 women and that the symptoms include:
    • severe pelvic pain after insertion (worse than period cramps)
    • pain or heavy bleeding after insertion which continues for more than a few weeks
    • sudden changes in periods
    • pain during sex
    • not being able to feel the threads
It is advised that women are told to report any of the above symptoms and also advised how to check their threads and are told to return for a check-up if they cannot feel them.

July 2015 notes
  • Introduction of patient reminder cards about the risk of osteonecrosis of the jaw  for Denosumab (Prolia®, Xgeva®) and intravenous bisphosphonates. Additionally, denosumab 120mg (Xgeva®) is now contraindicated in patients with unhealed lesions from dental or oral surgery.
  • The Xalatan® formulation of latanoprost has recently been changed such that the pH is now 6.0 compared to 6.7 previously. This change allows for longer term storage at room temperature however it has also been associated with an increase in reporting of eye irritation. Patients as advised to tell their health professional promptly (within a week) if they have eye irritation (e.g. excessive watering) severe enough to make them consider stopping treatment.
August 2015 notes
  • Amiodarone use associated with severe bradycardia and heart block when used with simeprevir (Olysio®) and sofosbuvir (Sovaldi®) combination therapy for chronic hepatitis C, similar to the May 15 DSU. Amiodarone is only recommended in this combination when all other antiarrhythmics cannot be given. When there is no alternative, very careful monitoring is recommended. Patients should be advised to report symptoms of bradycardia including shortness of breath, light-headedness, palpitations and fainting.
September 2015 notes
  • Proton pump inhibitors (PPIs) associated with very infrequent cases of subacute cutaneous lupus erythematosus (SCLE), particularly after sun exposure, with concurrent arthralgia. If this is suspected, PPI treatment should be stopped if possible. If continued treatment is imperative, sun exposure should therefore be avoided. The condition may resolve after withdrawal of the PPI but topical steroids may be necessary.

Electronic Prescription Service Release 2- October 2015 Update 

Brighton and Hove CCG are continuing the successful roll out of the Electronic Prescription Service locally and are committed to supporting our remaining GP practices to complete deployment before the end of March 2016.
Where are we at the moment:-
Period
 
Live with EPSR2
 
End of September 2015     16 practices (36%)
End of October 2015 18 practices (41%)
End of November 2015 23 practices (52%)
End of December 2015 27 practices (61%)
   
For those practices that are currently live with EPS and are confident with the process, it is worth considering increasing the volume of electronic repeat dispensing that you are currently generating. For further information on the benefits of repeat dispensing to the practice and patient, please refer to the NHSE Repeat Dispensing Guidance. 
For assistance with identifying suitable patients for repeat dispensing who on stable medication regimes, please speak to your key pharmacies and/or our Medicine Management Team.
For those practices yet to Go-live with EPSR2, we will be contacting you again shortly to agree a timetable for enablement.
For further information on EPSR2 please contact helen.wells1@nhs.net or tina.hayes@nhs.net
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 May, June, July and September 2015:

Nebulised tobramycin: BLUE specialist initiation only (with an information sheet)
Golimumab: 
RED specialist only
Rivaroxaban 2.5mg: BLUE specialist initiation only for ACS
Mintreleq XL: 
BLUE specialist initiation only
Demeclocycline: 
BLUE specialist initiation only
Azithromycin: 
GREEN suitable for non-specialist initiation
Clindamycin: 
GREEN suitable for non-specialist initiation
Daptomycin: 
BLUE specialist initiation only
Teicoplanin: 
GREEN suitable for non-specialist initiation for celulitis
                 
BLUE for other indications
Streptomycin: 
REMOVED
Ciprofloxacin: 
GREEN suitable for non-specialist initiation
Ofloxacin: GREEN suitable for non-specialist initiation
Norfloxacin: 
REMOVED
Itraconazole: GREEN suitable for non-specialist initiation
Nitrofurantoin 100mg tablets and capsules: REMOVED
Itraconazole infusion: RED specialist only
Riamet: RED specialist only
Artesunate injection: RED specialist only
Albendazole tablets: REMOVED under section 5.4.4
Sirdupla: GREEN suitable for non-specialist initiation
Organ gluten free products: REMOVED
Prednisolone Dompé oral solution 5mg/5ml: GREEN suitable for non-specialist initiation
Sukkarto MR tablets: 
GREEN suitable for non-specialist initiation
Epimax Cream:  
GREEN suitable for non-specialist initiation
Glycopyrronium: BLUE specialist initiation only for hypersalivation
Triamcinolone (Kenalog) 40mg/1ml: GREEN suitable for non-specialist initiation
Triamcinolone 20mg/1ml: RED specialist paediatric use only
Auranofin 3mg tablets: REMOVED
Sodium aurothiomalate injection: REMOVED
Etoricoxib 120mg tablets: GREEN suitable for non-specialist initiation (Gout)
Intrathecal baclofen: RED specialist only
Capsaicin 0.075% cream: BLUE specialist initiation only
Omalizumab:
RED specialist only
Ustekinumab: RED specialist only
Secukinumab: RED specialist only
Xenidate XL: BLUE specialist initiation only
Matoride XL: BLUE specialist initiation only
Apixaban: GREEN suitable for non-specialist initiation
Vedolizumab: RED specialist only
Galfer capsules: GREEN suitable for non-specialist initiation
Cinacalcet*: RED specialist only
Sevelamer*: RED specialist only
Lanthanum*: RED specialist only
Calceos: REMOVED
Calcichew D3 forte: REMOVED
Calcichew D3 500/400 capsules: REMOVED
Neokay capsules: BLUE specialist initiation only
Dalivit drops: GREEN suitable for non-specialist initiation
Nintedanib: RED specialist only
Octreotide: RED specialist only
Dornase alpha*: RED specialist only
Carbocisteine 125mg/5ml liquid: REMOVED

*Prescribing pre 1st April 2013 may continue in primary care under previous arrangements
That's NICE... https://www.nice.org.uk/guidance  

May 2015


NG9: Bronchiolitis in children 
This guideline offers evidence-based advice on the diagnosis and management of bronchiolitis in children.
NG10: Violence and aggression: short-term management in mental health, health and community settings
This guideline updates and replaces NICE guideline CG25 (published February 2005). It offers evidence-based advice on the short-term management of violence and aggression in mental health, health and community settings.
NG11: Challenging behaviour and learning disabilities: prevention and interventions for people with learning disabilities whose behaviour challenges
This guideline offers evidence-based advice on prevention and interventions for children, young people and adults with a learning disability and behaviour that challenges. 


NICE BITES May 2015 includes:
  • Irritable bowel syndrome in adults NICE CG61; 2015
  • Drug allergy: diagnosis and management NICE CG183; 2014
June 2015

TA339: Omalizumab for previously treated chronic spontaneous urticaria
Omalizumab (Xolair) is recommended as a possible treatment for people aged 12 years and over with severe chronic spontaneous urticaria if:
  • a doctor has objectively diagnosed the condition as severe
  • the condition has not improved with standard treatment with H1‑antihistamines or leukotriene receptor antagonists
  • the drug is stopped at or before the fourth dose if the condition has not responded
  • the drug is stopped at the end of a course of treatment (6 doses) if the condition has responded, and is only restarted if the condition comes back
  • the drug is given by a secondary care specialist in dermatology, immunology or allergy.
TA342: Vedolizumab for treating moderately to severe ulcerative colitis
Vedolizumab (Entyvio) is recommended as a possible treatment for adults with moderate to severe ulcerative colitis.
People should be able to have the treatment until it stops working or surgery is needed. Their condition should be assessed 12 months after they started taking vedolizumab. If they still have symptoms but it is clear that the treatment is helping, they can continue to have it. If they no longer have symptoms, treatment could be stopped, and later restarted if symptoms return.
People who continue to take vedolizumab should be assessed at least every 12 months to see whether the treatment is working well enough for them to carry on taking it.
TA341: Apixaban for the treatment of  Pulmonary Embolism
Apixaban (Eliquis) is recommended as an option for treating and preventing recurrent deep vein thrombosis or pulmonary embolism.
TA340: Ustekinumab for treating active psoriatic arthritis (rapid review of technology appraisal guidance 313)
Ustekinumab (Stelara) is recommended as a possible treatment, alone or with a drug called methotrexate, for adults with active psoriatic arthritis when treatment with non-biological disease-modifying antirheumatic drugs (or DMARDS) has not worked well enough if:
  • treatment with tumour necrosis factor (TNF) alpha inhibitors is not suitable for them, or
  • the person has had a TNF alpha inhibitor before.
Treatment with ustekinumab should be stopped after 24 weeks if it is not working well enough.
NG8: Anaemia management in people with chronic kidney disease
This guideline updates and replaces NICE guideline CG114 (published February 2011). It offers evidence-based advice on diagnosing and managing anaemia of chronic kidney disease. It discusses when and when not to initiate erythropoietic stimulating agent (ESA). 
TA343: Obinutuzumab in combination with chlorambucil for untreated chronic lymphocytic leukaemia
Obinutuzumab (Gazyvaro), given with a drug called chlorambucil, is recommended as a possible treatment for adults with untreated chronic lymphocytic leukaemia only if:
  • they have other conditions that make full-dose fludarabine unsuitable for them and
  • bendamustine is not suitable for them.
TA344: Ofatumumab in combination with chlorambucil or bendamustine for untreated chronic lymphocytic leukaemia
Ofatumumab (Arzerra) given with a drug called chlorambucil is recommended as a possible treatment for people with untreated chronic lymphocytic leukaemia if treatments containing fludarabine or bendamustine are not suitable.
QS90: Urinary tract infections in adults 
This quality standard covers the management of suspected community-acquired bacterial urinary tract infection in adults aged 16 years and over. This includes women who are pregnant, people with indwelling catheters and people with other diseases or medical conditions such as diabetes.
CG97: Lower urinary tract symptoms in men: assessment & management (Updated June 2015)
1.4.10    Do not offer phosphodiesterase 5 inhibitors solely for the purpose of treating lower urinary tract symptoms in men, except as part of a randomised controlled trial. [new 2015]


NICE BITES June 2015 includes:
  • Depression in children and young people
    NICE CG28; 2005 (updated 2015)
July 2015

HTTA329: Introducing biosimilar versions of infliximab: Inflectra and Remsima
This resource has been developed to provide practical information and advice on the use of biosimilar versions of infliximab (Inflectra and Remsima).
TA347: Nintedanib for previously treated locally advanced, metastatic, or locally recurrent non small cell lung cancer
Nintedanib in combination with docetaxel is recommended, within its marketing authorisation, as an option for treating locally advanced, metastatic or locally recurrent non‑small‑cell lung cancer of adenocarcinoma histology that has progressed after first‑line chemotherapy, only if the company provides nintedanib with the discount agreed in the patient access scheme.
TA346: Aflibercept for treating diabetic macular oedema
Aflibercept solution for injection is recommended as an option for treating visual impairment caused by diabetic macular oedema only if:
  • the eye has a central retinal thickness of 400 micrometres or more at the start of treatment and 
  • the company provides aflibercept with the discount agreed in the patient access scheme.
TA348: Everolimus for preventing organ rejection in liver transplantation
Everolimus is not recommended within its marketing authorisation for preventing organ rejection in people having a liver transplant.
TA350: Secukinumab for treating moderate to severe plaque psoriasis
Secukinumab (Cosentyx) is recommended as a possible treatment for people with plaque psoriasis if:
  • standard assessments show that their psoriasis is severe and is affecting their quality of life, and
  • their psoriasis has not improved with other treatments including ciclosporin, methotrexate and PUVA (psoralen and long-wave ultraviolet radiation), or they have had side effects with these treatments in the past or there is a reason why they cannot have them.
Treatment with secukinumab should be stopped after 12 weeks if the psoriasis does not improve enough according to standard measures.
TA349: Dexamethasone intravitreal implant for treating diabetic macular oedema
Dexamethasone intravitreal implant (Ozurdex) is recommended as a possible treatment for people with sight problems caused by diabetic macular oedema if:
  • there is an artificial lens in the eye to be treated, and
  • their diabetic macular oedema has not improved with non‑corticosteroid treatment, or such treatment is not suitable for them.
TA351: Cangrelor for reducing atherothrombotic events in people undergoing percutaneous coronary intervention or awaiting surgery requiring interruption of anti platelet therapy
Terminated appraisal
TA345:Naloxegol for treating opioid‑induced constipation
Naloxegol is recommended, within its marketing authorisation, as an option for treating opioid induced constipation in adults whose constipation has not adequately responded to laxatives.  An inadequate response is defined as opioid‑induced constipation symptoms of at least moderate severity in at least 1 of the 4 stool symptom domains (that is, incomplete bowel movement, hard stools, straining or false alarms) while taking at least 1 laxative class for at least 4 days during the prior 2 weeks.
NG14: Melanoma: assessment and management
This guideline covers the assessment and management of melanoma (a type of skin cancer) in children, young people and adults. It aims to reduce variation in practice and improve survival. 
QS92: Smoking: harm reduction
This quality standard covers ways of reducing harm from smoking. In particular, this includes people who are highly dependent on nicotine and who may not be able (or want) to stop smoking in one step, who may want to stop smoking without giving up nicotine, who may want to reduce the amount they smoke without stopping, or who want to abstain temporarily from smoking.
QS93: Atrial fibrillation: treatment and management
This quality standard covers identification, treatment and management of atrial fibrillation (including paroxysmal, persistent and permanent atrial fibrillation, and atrial flutter) in adults (18 years and older).
QS96: Dyspepsia and gastro oesophageal reflux disease in adults: investigation and management
This quality standard covers the investigation and management of dyspepsia and gastro-oesophageal reflux disease (GORD) symptoms in adults 18 and older. It includes the investigation of dyspepsia and GORD symptoms as a risk factor for oesophagogastric cancer but it does not include the diagnosis and management of oesophagogastric cancer because this will be covered by a separate quality standard.
QS95: Bipolar disorder in adults
This quality standard covers recognition, assessment and management of bipolar disorder (including bipolar I, bipolar II, mixed affective and rapid cycling disorder) in adults (18 years and older) in primary and secondary care.
QS97: Drug allergy: diagnosis and management
This quality standard covers the diagnosis and management of drug allergy in adults, young people and children. It does not cover treatment of the acute phase, including anaphylaxis, because this will be covered by a separate quality standard.


NICE BITES July 2015 includes:
  • Diabetes in pregnancy NICE NG3; 2015
August 2015

TA352: Vedolizumab for treating moderately to severely active Crohn's disease after prior therapy
Vedolizumab (Entyvio) is recommended. It is a possible option for adults with moderate to severe Crohn’s disease if a type of treatment called a tumour necrosis factor (TNF)‑alpha inhibitor isn’t suitable or hasn’t worked well enough.
People should be able to have vedolizumab until it stops working, or surgery is needed, or for 12 months after starting it, whichever is shorter. Their condition should be assessed 12 months after they started taking vedolizumab. If they still have symptoms but it is clear that the treatment is helping, they can continue to have it. If they no longer have symptoms, treatment can be stopped, and later restarted if symptoms return.
People who continue to take vedolizumab should be assessed at least every 12 months to see whether the treatment is working well enough for them to carry on taking it.
TA353: Bevacizumab for treating relapsed, platinum resistant epithelial ovarian, fallopian tube or primary peritoneal cancer  
Terminated appraisal
TA354: Edoxaban for treating and for preventing deep vein thrombosis and pulmonary embolism 
Edoxaban (Lixiana) is recommended as an option for treating and preventing recurrent deep vein thrombosis or pulmonary embolism.
NG17: Type 1 diabetes in adults: diagnosis and management 
This guideline covers the care and treatment of adults (aged 18 and over) with type 1 diabetes. This guideline updates and replaces the sections for adults in NICE guideline CG15.
NG18: Diabetes (type 1 and type 2) in children and young people: diagnosis and management 
This guideline covers the diagnosis and management of type 1 and type 2 diabetes in children and young people aged under 18. The guideline recommends strict targets for blood glucose control to reduce the long-term risks associated with diabetes.
NG19: Diabetic foot problems: prevention and management 
This guideline covers preventing and managing foot problems in children, young people and adults with diabetes. The guideline aims to reduce variation in practice.
NG15: Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use 
This guideline covers the effective use of antimicrobials (including antibiotics) in children, young people and adults. It aims to change prescribing practice to help slow the emergence of antimicrobial resistance and ensure that antimicrobials remain an effective treatment for infection.


NICE BITES August 2015 includes:
  • Anaemia management in people with CKD NICE NG8; 2015
Feedback to the BH CCG Medicines Management Team
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 and do not necessarily represent the opinions of Brighton and Hove CCG
Copyright © 2015 Medicines Management Team, Brighton & Hove Clinical Commissioning Group, All rights reserved.


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