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CITY SCRIPTS

July - August 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.
IMPORTANT - 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:
Placebo Inhalers

If any practices need to obtain placebo Fostair or AirFlusal inhalers, please see contact details below
 
Contact details of pharmaceutical representatives to obtain placebo’s
Fostair: Christina Baddoo      Tel: Chiesi Limited HQ: 01614885555      Email: Medinfo.uk@chiesi.com
AirflusalGraham Cammish         Mobile: 07867193295         E-mail: Graham.Cammish@sandoz.com
Green bag supplies
Any pharmacy wanting to take part or needing more bags should email: greenbag.sps@nhs.net

Any queries or problems contact:
Carina Livingstone at (07909 000283)

carina.livingstone@nhs.net or
Sue Overton (01903 708042)

Following great support from East Sussex LPC we found that, each day, at least 3 patients newly admitted to Brighton and Sussex University Hospitals brought their medicines with them in a green bag provided by this scheme.
Changes to the meningococcal C (Men C)
vaccination schedule as of 1st July 2016

Please see link to Public Health England letter explaining the changes to Men C vaccination schedule and Immunisation schedule from spring 2016.

https://www.gov.uk/government/publications/menc-vaccination-schedule-planned-changes-from-july-2016

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/523050/PHE_Complete_Immunisation_Schedule_SPRING16.pdf
Morphine MR error

A local CCG has noted that there may be some confusing advice in the BNF with regard to morphine modified release preparations.

The error involved changing from morphine modified release 12-hourly capsules (Zomorph®) to MXL® capsules, a 24-hourly preparation which was still prescribed twice daily.

ACTION: Please ensure when prescribing or switching MR morphine capsules that you choose the correct formulation for the dosing schedule required. Brand prescribing is recommended, to help avoid any prescribing and/or dispensing errors.
UPDATE FROM THE MEDICINES MANAGEMENT TEAM

Optimise Rx, the new prescribing decision support software produced by First Databank has been rolled out in all our practices and has been running alongside the clinical systems since April/May 16.

The medicine management teams initially spent a lot of time reviewing and preparing the suite of messages ready for go live day. The suite of messages consists of national best practice and safety alerts, as well as formulary messages tailored to our CCGs.
 
The plan now is to review these messages on an on-going basis to ensure they are relevant and not overloading prescribers.

We have already started making some improvements to the profile by:
  • removing all BLUE (specialist recommended/initiated) formulary messages from the profile, unless it has a specific information sheet attached to it, as we found this message was popping up far too often.
  • refining other messages where we found them to be duplicates or contradicting each other.
  • reviewing the top 10 rejected messages and 7 messages have been disabled that otherwise popped up 2500 times and were only accepted 160 times.
Please continue to send us feedback on individual messages via the system. We are then able to run reports and collect your comments to help us refine the profile further.

Alternatively, get in touch with your usual practice technician/pharmacist directly or via the generic CCG medicines management email addresses at the bottom of the newsletter.

We really appreciate your input as you are the ones out there using it day to day.
OptimiseRx development requests
 
Did you know SystmOne users can vote on OptimiseRx development requests?

OptimiseRx is fully integrated into TPP SystmOne and as such, collaboration with TPP is required to enhance and amend certain aspects of the integration.

TPP have asked that users vote on development requests. 
The voting system aids TPP in prioritising the items which will be taken forward to development.
Please see the Development Request Guide for instructions on how to log your vote.  
This is your chance to have your say, so we would encourage all users to vote!  


If EMIS web users have any specific development requests, then please let your medicines management team know.
 
Hydroxyzine dihydrochloride discontinued
 
Hydroxyzine dihydrochloride (Ucerax®) tablets and liquid has been discontinued. Prescribers are encouraged to actively review patients prescribed hydroxyzine dihydrochloride to consider if a replacement therapy is required.  See chapter 4 of the joint formulary for alternatives.    
The Medicines and Healthcare products Regulatory Agency (MHRA) has published Drug Safety Update for:

July 2016 advises:

Warfarin: reports of calciphylaxis.
Calciphylaxis is a very rare but serious condition causing vascular calcification and skin necrosis. Advice for healthcare professionals: 
  • calciphylaxis is a very rare but serious condition that is most commonly observed in patients with known risk factors such as end-stage renal disease
  • cases have been reported in patients taking warfarin, including those with normal renal function, and evidence suggests that on rare occasions warfarin use might lead to calciphylaxis
  • if calciphylaxis is diagnosed, appropriate treatment should be started and consideration should be given to stopping treatment with warfarin
Citalopram: suspected drug interaction with cocaine; prescribers should consider enquiring about illicit drug use. 
Possible illicit drug use should be considered when prescribing medicines that have the potential to interact adversely.
Suspected drug interaction between citalopram and cocaine
MHRA have received a Coroner’s report that raised concerns about a suspected drug interaction between citalopram and cocaine after the death of a man due to subarachnoid haemorrhage. The case was discussed by the UK Commission on Human Medicine’s Pharmacovigilance Expert Advisory Group. There are plausible mechanisms for an interaction between cocaine and citalopram that could lead to subarachnoid haemorrhage, including hypertension related to cocaine and an additive increased bleeding risk in combination with citalopram.

N-acetylcysteine: risk of false-low biochemistry test results due to interference with Siemens assays.
N-acetylcysteine may interfere with assays from Siemens ADVIA Chemistry and Dimension/Dimension Vista instruments, leading to false-low biochemistry test results. Advice for healthcare professionals: Professionals who are treating patients with N-acetylcysteine for paracetamol overdose should establish whether Siemens ADVIA Chemistry and Dimension/Dimension Vista instruments are used for laboratory testing of biochemistry and, if so, should:
  • do venipuncture and blood sampling before N-acetylcysteine administration; there is a risk of false low biochemistry test results and potential misinterpretation of physiological status if done during or immediately after administration
  • state if a patient is receiving N-acetylcysteine when requests for biochemistry tests (eg, cholesterol, uric acid, lactate) include any affected assays from these instruments 
Letters sent to healthcare professionals in June 2016
On 20 June 2016, a letter was sent to healthcare professionals about risks of viral reactivation and pulmonary hypertension associated with Thalidomide Celgene.

August 2016 advises:

Riociguat (Adempas): not for use in patients with pulmonary hypertension associated with idiopathic interstitial pneumonias
Patients with pulmonary hypertension associated with idiopathic interstitial pneumonias should not be treated with riociguat in light of interim results from a recently terminated study. Advice for healthcare professionals:
  • patients with pulmonary hypertension associated with idiopathic interstitial pneumonias (PH-IIP) should not be treated with riociguat. PH-IIP is not authorised indication for riociguat
  • riociguat treatment should be discontinued in any patient with PH-IIP. The patient’s clinical status should be carefully monitored after stopping riociguat
  • the benefits of riociguat in its approved indications (see below) continue to outweigh the risks
Letters sent to healthcare professionals in July 2016
In July 2016, the following letters were sent to relevant healthcare professionals:
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 June and July 2016:

Doxapram: removed from the joint formulary
Insulin Degludec: BLUE specialist recommended/initiated for use on adult type 1s only, who meet the agreed criteria:
  • Documented severe hypoglycaemia;or
  • Risk of hypoglycycaemia because of reduced awareness; or
  • Frequent hypoglycaemia which prevents achieving predefined glycaemic targets
     AND individuals should have:
  • Received an appropriate level of education with respect to flexible insulin dosing and carbohydrate counting; and
  • Tried other basal insulin regimens including split dose detemir as recommended in NG17
  • Be prepared to complete hospital issued assessment questionnaire
Abasaglar (insulin glargine): BLUE specialist recommended/initiated.  1st line for all new patients.  The APC supports pro-active switching for established patients at the next review, which includes an informed discussion with the patient.  
Benepali (etanercept): RED specialist only.  1st line for new patients. 
Forceval: Changed to RED specialist only.  The green status for post bariatric patients has been removed as NHS England should be funding supplementation for 2 years post surgery.  Patients should then be encouraged to purchase further supplementation over the counter.  See policy HERE.
Evolocumab: RED specialist only 
Alirocumab: RED specialist only
Cabazitaxel: RED specialist only
Zemtard XL: GREEN suitable for non-specialist prescribing. This is preferred brand of diltiazem MR for new patients.
Tildiem MR: GREEN suitable for non-specialist prescribing. Prescribing diltiazem 60mg MR tablets by brand (Tildiem MR) is more cost effective to the NHS.
Nebbaro: BLUE Lipid clinic recommendation or use in HIV only. Cost effective brand of Omega-3-acid Ethyl Esters for new and existing patients. 
Butec:  GREEN suitable for non-specialist prescribing. Prescribing buprenorphine 7 days patches as Butec brand will be more cost effective to the NHS.
Monomil XL: GREEN suitable for non-specialist prescribing. Prescribing isosorbide mononitrate 60mg modified release preparations as Monomil XL brand will be more cost effective to the NHS.
Alzain: BLUE specialist recommended/initiated for GAD or epilepsy only.  Prescribing pregabalin as Alzain brand (for GAD or epilepsy) will be more cost effective to the NHS.
Growth Hormones: BLUE specialist recommended/initiated. (Was previously amber.) 

Following a review of Chapter 6 - Endocrine the below changes were made:
Humulin S: Added as BLUE specialist recommended/initiated.
Novorapid PumpCart: Added as BLUE specialist recommended/initiated.
Glucose Powder: changed to RED specialist only. (Was previously green.)
Methyl-prednisolone injection: changed to GREEN suitable for non-specialist prescribing. (Was previously red.) 
Testosterone (all products apart from enantate injection): changed to BLUE specialist recommended/initiated. (Was previously red.)
Estradiol implant: removed from the JF as previously discontinued.
Ethinylestradiol tablets: changed to BLUE specialist recommended/initiated. (was previously red.)
Pegvisomant: removed from the JF.
Desmopressin: removed all references to brands.  Only generic listed.
Gonadorelin analogues: changed to BLUE specialist recommended/initiated. (was previously green.)

The APC did not meet in August.
That's NICE... https://www.nice.org.uk/guidance  
 
Reference number Title Published Last updated
CG42 Dementia: supporting people with dementia and their carers in health and social care November 2006 May 2016
CG98 Jaundice in newborn babies under 28 days May 2010 May 2016
TA217 Donepezil, galantamine, rivastigmine and memantine for the treatment of Alzheimer's disease March 2011 May 2016
CG152 Crohn's disease: management October 2012 May 2016
CG155 Psychosis and schizophrenia in children and young people: recognition and management January 2013 May 2016
NG47 Haematological cancers: improving outcomes May 2016 May 2016
TA390 Canagliflozin, dapagliflozin and empagliflozin as monotherapies for treating type 2 diabetes May 2016 May 2016
NG33 Tuberculosis January 2016 May 2016
QS12 Breast cancer September 2011 June 2016
QS122 Bronchiolitis in children June 2016 June 2016
QS123 Home care for older people June 2016 June 2016
TA392 Adalimumab for treating moderate to severe hidradenitis suppurativa June 2016 June 2016
TA393 Alirocumab for treating primary hypercholesterolaemia and mixed dyslipidaemia June 2016 June 2016
TA394 Evolocumab for treating primary hypercholesterolaemia and mixed dyslipidaemia June 2016 June 2016
TA395 Ceritinib for previously treated anaplastic lymphoma kinase positive non-small-cell lung cancer June 2016 June 2016
TA396 Trametinib in combination with dabrafenib for treating unresectable or metastatic melanoma June 2016 June 2016
TA397 Belimumab for treating active autoantibody-positive systemic lupus erythematosus June 2016 June 2016
QS124 Suspected cancer June 2016 June 2016
The following is intended for healthcare professionals in the Brighton and Hove CCG locality.
REMINDER TO PARTICIPATING COMMUNITY PHARMACIES 
 
When community pharmacies sign up to supply wound care products through ONPOS the following conditions are required of the pharmacy:
  • Access to the internet
  • Next working day delivery service
  • Sufficient staff trained up to use ONPOS
The above elements are required to ensure a smooth and efficient service in the city and ensure that the patient receives their dressings in a timely manner to promote wound healing.

Before the inception of ONPOS, patients were waiting up to a week to receive their dressings since a prescriber had to issue a prescription.  WithIn this timeframe the wound may have changed, the ordered dressings no longer required and further dressings ordered, leading to wastage.  For this reason, ONPOS was chosen as the way to procure wound care products without a need for a signed prescription.

We have had reports of some community pharmacies not delivering a reliable or efficient service to the city which has lead to prescriptions being issued for items available to order on ONPOS. 

Please ensure that someone in the pharmacy is checking ONPOS notifications regularly  throughout the day to be aware of any pending orders to process. 

If support is required with training, please email admin@onpos.co.uk or the local Business Development Manager, Mark Beccarelli on 07766 245980 or your local Territory Manager, Brendan Clegg on 07703 477310.

If you feel you are unable to deliver the service expected and required of community pharmacies please contact the medicines management team to discuss further.  bhccg.medicinesmanagement@nhs.net    

Introduction to: 
Jenny Williams - Stoma Care Clinical Nurse Specialist, BHCCG


Brighton and Hove CCG have invested in a 12 month pilot project to review stoma care prescription management and I am delighted to be working on this project for 3 days a week. 
 
The project has been commissioned as it is widely recognised that inappropriate stoma care product usage is either a sign of problems or that the patient is at increased risk of developing problems such as sore skin and leakage.  These issues can significantly impact upon a patient's quality of life and has cost implications for the NHS.  
 
As part of this pilot project, I will be inviting GP practices with the highest spend on stoma care to take part.   Patients at participating practices will be offered a stoma care clinical review to problem solve issues experienced and clarify stoma care prescription requirements.   
 
The aim of this pilot project is to enable the development of a sustainable approach to promote appropriate stoma care product usage which meets patients' needs. 
 
If you would like further information on the project please email: 
jenny.williams26@nhs.net

Introduction to: 
Katie Clark - Paediatric Dietitian, BHCCG

 

I have been seconded 1 day a week to the Medicines Management Team in the CCG for the next 12 months.

My role is to support GPs in the appropriate prescribing of infant formulas.  I will be reviewing current prescribing patterns in highest spend GP Practices.  I will review infants / children prescribed formulas and assess whether the formula prescribed is best meeting nutritional needs for their clinical condition and whether any prescriptions can be changed or discontinued.

I hope to offer training sessions / education about common clinical paediatric conditions requiring specialist formulas such as cow’s milk protein allergy, faltering growth or nutrition in pre-term infants.

Working in secondary care, I am in a prime position to look at prescribing requests from the acute trust.  I also hope to link into dietetic initiatives to ensure parents of infants requiring a dietetic advice receive this in a timely manner.  We have just started our Cow’s Milk Protein Allergy patient group sessions.

If you would like further information on the project please email: 
Katie.Clarke11@NHS.net

Introduction to: 
David Broadbent - Community Dietitian, BHCCG


I have been seconded for 12 months to the CCG to review the prescribing of oral nutritional supplements (ONS).

National data shows that on average 50% of prescriptions for nutritional supplements are not appropriate, suggesting that malnutrition is not been effectively treated and resources are being wasted.

The population of Brighton and Hove CCG is around 300,000. There are 110 care homes across Brighton and Hove with a total bed establishment of 2000.

It is estimated that there are 3 million people in the UK with malnutrition and many more at risk of malnutrition. 30 - 42% of patients admitted to care homes are at risk of malnutrition according to BAPEN screening week surveys.

With high levels of malnutrition and limited resources, it is important that ONS is used appropriately as an addition to dietary advice with an ongoing monitoring plan.
 
Initially, I will be working with the highest spending GP surgeries to review patients on long-term ONS. I will also be reviewing the formulary and writing guidance for the use of ONS.

In this role, I will provide training to nursing homes to ensure that 'food first' is followed as first line to reduce the need for prescribable nutritional supplements.

If you would like any further information please contact me: 
davidbroadbent@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.
High Weald Lewes Havens CCG Medicines Management team update
 
New Starters
 
Paul McKenna – has joined us as our new Senior Strategic Pharmacist (a joint post shared with Brighton and Hove CCG).  He will be leading on local decision making for both teams as well as supporting our governance of High Cost Drugs within our acute trusts. 
 
Ingrid Philpot – will be re-joining the team as one of our Integrated Clinical Pharmacists.  Working with our practices she will be supporting the roll out of the integrated pharmacy workforce pilot within the emerging communities of practices.
 
Lucy Dowell - has re-joined the team as one of our Integrated Clinical Pharmacists.  Working with our practices she will be supporting the roll out of the integrated pharmacy workforce pilot within the emerging communities of practices.
 
Susan Finall – will be joining us as a Pharmacy Technician working directly with practices on our medicines optimisation work programme and strategy for integrated working in General Practice.
 
Leavers
 
Stephanie Butler – we wish Stephanie all the best and look forward to working with her in her new role working with SCfT as their new lead pharmacist for MSK.
Antibiotic audit update

A total of 6 practices have now been audited.  We looked at instances of cephalosporin, quinolone and co-amoxiclav prescribing for the month of November 2015 to see if choice complied with current Primary Care Guidelines. Thank you to all the practices involved.
Data is now being validated, and feedback sessions to individual prescribers arranged.
Further information will be provided in the coming weeks....watch this space.
Integrated Pharmacy pilot - first quarter report
 
The pilot to integrate a pharmacy workforce into GP practices in HWLH CCG began in January this year at Meridian and Rowe Avenue in Peacehaven.  Staffed by two pharmacists and a pharmacy technician.
 
The principal aims of the pilot are to:
  • Reduce avoidable harm associated with medicines (to include a reduction in medicines related hospital admissions)
  • Reduce medicines cost (prescribing savings)
  • Reduce GP workload
Some of the key outcomes from the first quarter include:
  1. A total of 998 pharmacy workforce interventions were made across both practices, 43 of which were deemed to have possibly avoided a hospital admission and 3 which were likely to have avoided an admission.  This equates to a cost saving of £14,600.
  2.  A total of £36,600 was achieved through prescribing savings
  3.  A total of just under 83 hours of GP time was estimated to have been saved on tasks completed by the pharmacy team which would have previously been carried out by GPs.
Outcomes generated from the initial pilot have been used to expand the workforce across all GP surgeries within a community of practice.  Further details on this will be circulated to practices in due course.  Please feel free to contact the Medicines Management team if you have any further questions relating to the integrated pharmacy pilot. 
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
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