June 2013 meeting minutes - Leicestershire Medicines Strategy Group

LeicestershireMedicines StrategyGroupMinutes of the Leicestershire Medicines Strategy Group meetingHeld on Tuesday 6 TH June 2.30pm - 4.30pmBoard Room (George Hine House)Present:Dr Liz Hepplewhite (LH) (Chair)Phyllis Navti (PN)Helen Hardman (HH)Lesley Gant (LG)Dr Graham Johnson (GJ)Dr Hanna Blackledge (HB)Zeibun Patel (ZP)Kath Carter (KC)Bhavisha Pattani (BP)Jasmeen Islam (JI)Dr Phil Rathbone (PR)Dr Paul Danaher (PD)Rachel Simmons (RS)Dr Beverley Collett (BC)In Attendance: Rosemary Plum (RP) - LPC SecretaryHitesh Parmar (note-taker)Dr Hafiz Qureshi (HQ) – Consultant Haematologist at UHLNo.1. Apologies: Gill Stead, Dr Adrian Stanley, Anthony Oxley2. Conflict of interestAll present signed and declared. Once finalised to be put on LMSG website forthe public domain3. Minutes of meeting held on 7 th May 2013JI asked about the outcome of the Paediatric traffic light list discussed at thelast meeting. HH advised each Paediatric medicine would be considered on itsown merit. In addition, HH had received replies from Secondary careconsultants so far. The list of Paediatric medications with suggested trafficlights will come to LMSG to be approved. The minutes of the meeting held on7 th May 2013 were agreed as an accurate record and will be added to LMSGwebsite.4. Matters Arising Not Covered ElsewhereSimple Amber Policy Review:A discussion took place on the meaning of “Simple” amber drugs. The groupagreed patients should be assessed by a specialist in secondary care before anamber drug is initiated and prescribing transferred to Primary care. Hence, itwas decided the wording to be included in the policy should read:A Simple Amber medicine is defined as “a medicine which is suitable to beinitiated and prescribed in primary care only after specialist assessment andrecommendation. A shared care agreement is not required.”HH to update simple amber policy and put on web.MHRA drug safety updates:Dabigatran in patients with a prosthetic heart valve – UHL have updated thenew patient request form to state this contraindication.Post meeting note – agreed in May’s meeting that it is more practical for GPs tosearch their clinical systems to identify existing patient’s that may be affected.ActionHHHHHHHHJI/PN/LGLMSG Minutes Page 1 of 5 4 th June 2013

Gluten Free Foods:HH informed the group she had liaised with Cathy Steel, dietetic manager UHL,and feedback was received from Secondary care. Secondary care would like“exceptions” for patients that require additional units e.g. patients receivingchemotherapy that are also losing weight, this addition was agreed. CathySteel would ensure that newly diagnosed patients have access to LMSG orderforms. RS commented she had also received feedback from having a limitedlist of GF products to choose from and the group accepted advice to alert thelocal Coeliac society to enable them to handle queries. It was suggested avoucher system for obtaining GF foods could be explored by the 3 Heads ofPrescribing for City, East and West CCG. JI commented this could be exploredfurther at the next Medicines Optimisation Steering Group meeting.5. Hydroxycarbamide Shared Care Agreement (Dr Hafiz Qureshi inattendance, Consultant Haematologist UHL)HQ advised the group there is a shared care booklet for patients takinghydroxycarbamide and this process has worked well so far. The booklet is to berevised soon. HQ acknowledged there was a delay in sending patient letters toPrimary care but this has now been addressed and the time taken to receivepatient letters is now 7-10 days. HQ advised the group that the reason fordifferences in monitoring between the use of hydroxycarbamide inmyeloproliferative disorders and sickle cell disease is that patients with sicklecell disease are less prone to cytotoxic side effects. HQ mentioned he wouldprefer a SCA for patients taking hydroxycarbamide in sickle cell disease.However, in myeloproliferative disease, the bone marrow of patients isabnormal and frequent testing is required. Continual dose adjustments are tobe overseen by Secondary care because steady state dosages are unlikely tooccur. It was mentioned that robust communication is required particularly if apatient does not attend Secondary care appointments. HQ advised they sendletters to GPs regarding any patients who do not attend their appointments atthe clinic. In these circumstances, the patient will be offered anotherappointment in 2-3 weeks’ time and if the patient were to continue at the samedose prescribed at the previous clinic appointment, it is unlikely to cause aproblem. HQ advised his concern would be if the patient never attended afollow up appointment. HQ also advised the patient hand held record forhydroxycarbamide is completed at the clinic in Secondary care which will helpassure GPs that patients are taking the correct dose as instructed bySecondary care. LH suggested when blood tests results are received by theSecondary care clinic, a copy could be sent to the appropriate Primary careclinician. HQ raised his concerns about patient waiting times in pharmacy atLRI. BP agreed to audit current patient waiting times in the pharmacydepartment at LRI.LH advised HH to table the SCA for hydroxycarbamide in myeloproliferativedisorders at the next LMSG meeting for review6. Formulary Working Party minutes, Formulary Working Party AnnualReport, TAS Annual ReportJI advised of a discrepancy in the minutes to item 3, paragraph 1. She advisedthere is no widespread audit of discharge letters and hence an amendmentwould be required. KC advised under item 3, paragraph 2; she has compiled alist of all TAS decisions made since 1996 to include as specialist drugs in theLeicestershire formulary under the restricted category. HH advised Chris Clarkewas not keen on cancer drugs being listed individually on LMSG. KC advisedthis would be discussed with HH outside of this meeting.HHPN/JI/LGBPHHHH/KCLMSG Minutes Page 2 of 5 4 th June 2013

7. LMSG Website ReviewPeter Golightly was unable to attend. It was envisaged this item could be onnext month’s agenda8. Traffic Light DecisionsTapentadol SR: KC advised that there is a cost impact of around £50k perannum to primary care however the group were advised this had been includedin the horizon scanning document. This drug would be only be initiated in thepain clinic by Secondary care, it was suggested the proposed traffic light statusshould be simple amber.BC declared a conflict of interest – attended an advisory board for the manufacturerLurasidone – black status agreedAclidinium inhaler – green status agreedGlycopyrronium inhaler – black status agreedMoviprep – red status agreedBudenofalk – simple amber status agreedRifaximin - KC advised it has a high cost although not excluded to tariff. Therequestor advised that this would apply to around 25 patients per annum,although national predictions based on LLR population are lower. Cost impact£42-80k per annum. BP advised the NICE TA was due for publication inNovember 2013. The group were happy for this drug to have a LMSG status ofsimple amber but this is subject to confirmation of funding.Lixisenatide - KC mentioned feedback from Secondary care was to keepLiraglutide on the formulary since it has a NICE TA. Secondary care clinicianswere concerned that patients in Primary care may be switched fromExenatide/Liraglutide to Lixisenatide on cost grounds. The group suggested toremove twice daily Exenatide from the formulary and to retain Liraglutide. Thegroup also agreed with the proposed TAS decision to have a dual traffic lightstatus for Lixisenatide; which is “full amber” for GPs who have not receivedappropriate training and “green” for GPs who have. TAS to be informed of thegroup’s feedback at the July meeting and the shared care agreement needs tobe written.9. Shared Care Agreements:Methylphenidate, Dexamfetamine and Atomoxetine for Adult ADHDZP mentioned there had been concerns regarding the transfer of care frompaediatric services to adult services for patients suffering with ADHD. Pathwayshave now been attached to the proposed SCA with particular reference to hownew patients are diagnosed. NICE guidelines state to monitor patients at leastonce a year, but the SCA on page 6 states to review patients at least 6monthly. ZP mentioned she would investigate this further to clarify.ZP advised CAMHS are responsible for referring patients from paediatrics toadult psychiatric services. LH commented contact details are needed to ensurepatients are followed up. The need for GPs to see patients 3 monthly washighlighted to LH. The group felt it was necessary for the SCA to state whenpatients are to be reviewed in Primary care for BP and pulse. JI queried theformulary for ADHD products. ZP advised this was to be reviewed soon.However, it is important for patients to continue with the same brand asdifferent brands have different release profiles.The group decided CAMHS and paediatric services are to be made aware ofthe new ADHD pathways and HH was instructed to contact Dr M Arif(Consultant Psychiatrist) to ensure he is happy to be the lead contact forsupport and advice.HHKCKCZPZPZPHHVenlafaxine doses of 300mg daily or aboveLMSG Minutes Page 3 of 5 4 th June 2013

HH advised she had made changes to the SCA to clarify what is meant by‘cardiac status’ i.e. recent MI or change in the risk of serious arrhythmia and alink was added to the MHRA alert in the document.HH to add reviewed document to website10. MHRA Drug Safety UpdatesThe group stated they were happy with UHL’s actions on MHRA updates11. Primary Care Cellulitis PathwayHH advised the group Primary care were taking the lead on reviewing Primarycare antibiotic pathways. The group agreed they were happy to have the LMSGlogo on the “Adult Primary Care Cellulitis Pathway” document once finalised.HH opened discussions on the review of this draft document. The followingamendments to the document were suggested:Page 3 – “treated diabetes or blood glucose > 11mmol/L should be stated onthis page and throughout the whole document for consistencyPage 4 – to remove the statement “For all Lymphoedema patients please referto LOROS guidelines”Page 5 – wording to change to “Refer to SPA”. Other amendment on this pageaccepted for “Symptoms persist”Page 6 – to keep IV/IM requirement for Teicoplanin. GJ advised the term“recent” must be defined under the “notes” section. GJ suggested 4 weeks foran eGFR was appropriate. The requirement for a blood test is to be highlightedin boldPage 7 – on the 1 st sentence; remove the wording “and/or treatment of fever”.PD advised the need to avoid an NSAID because of the risk of maskingnecrotizing fasciitis to be highlighted in bold throughout the whole document.The comment on IV use was accepted. It was suggested to remove thesentence “Patient has history of severe reaction to penicillin”. HH to feedback toAWP (Antibiotic Working Party) for confirmation. Also, requirement to confirmwhen necessary to refer patient to hospital if “Cellulitis affects face or orbit”Page 8 – Statement to “swab for causal organism”. Is this statementnecessary? AWP to define “appropriate resuscitation facilities” and the term“severe pyrexia” to ensure patients are entered into the correct pathway. Thegroup felt a “scoring mechanism” may be appropriate e.g. a warning score forreferral.Page 9 – highlight in bold that NSAIDs may increase the risk of necrotizingfasciitis developing as mentioned earlierPage 10 – explain the acronym IVDU. GJ advised to define “severe pyrexia”with figuresPage 12 – the bullet point on the “fosse house pharmacist” to be removed. PDsuggested intermediate care (SPA) should stock a few vials of Teicoplanin. HHagreed to ring SPA to confirm if this was possible. KC advised to put thealgorithm on the front of the documentPage 15 – GJ advised figures are required if “blood glucose levels becomeunstable”. BP mentioned the patient information leaflet should go to patientadvisors to make the leaflet more patient friendlyLH advised the rest of the document to be revisited next month12. QIPP Detail Aid – Sip Feeds Use Food FirstGJ asked whether care homes use full fat milk or semi-skimmed? HH advised“food first” is to be promoted first line and LH suggested to give ONS on acuteprescriptions only. RP mentioned she would like community pharmacists toalert GPs if they find inappropriate requests for large quantities of ONS and tobe able to contact local dieticians with their concerns. HH advised a link tocurrent ONS guidance should be in the detail aid.13. Any Other BusinessHHHHAWPHHHHRPHHLMSG Minutes Page 4 of 5 4 th June 2013

HH commented she was on annual leave between 10th-23rd June 2013inclusiveLay member recruitmentHH advised a lay member has been recruited and will attend the next meeting.The group suggested the lay member be paid by submitting invoices toAnthony Oxley. HH to confirm with AO.MMR vaccine & egg allergyThe paediatric allergy team at UHL are receiving a number of queries about thesafety of the MMR vaccine in children with egg allergy. The information fromthe DoH green book was presented, the group had no further queries and HHwill publicise this in the next LMSG newsletter.14. Date, time and venue of next meeting:Tuesday 2nd July 2013, 2:30 - 4:30pm, Board Room, George Hine HouseHHHHALLLMSG Minutes Page 5 of 5 4 th June 2013