AGENDA FOR APPM FORMULARY MEETING 30/9/2011
Alder Hey Children’s Hospital, Liverpool
Present
Sat Jassal
Lynda Brook
Anita Aindow
AK Anderson
Emily Harrop
Apologies
Prof Ian Wong
Finella Craig
Susie Lapwood
Richard Hain (Sabbatical –
corresponding member only)
Julie Mycroft (nurse and non
medical prescriber)
Renee McCulloch
Sat.Jassal@gmail.com
Lynda.Brook@alderhey.nhs.uk
Anita.Aindow@alderhey.nhs.uk
Annakarenia.anderson@nhs.net
emilyharrop@yahoo.com
Agenda item
Key discussion points
Welcome and apologies
Minutes of last meeting
Matters arising
As above
Agreed as a true record
Terms of reference
 These were amended following the last meeting and agreed at the meeting
today
Ian.wong@pharmacy.ac.uk
CraigF@gosh.nhs.uk
SLapwood@helenanddouglas.org.uk
hainrd@cardif.ac.uk
Julie.Mycroft@rmh.nhs.uk
renee.mcculloch@googlemail.com
Actions
Steering group membership including links with BNFC and Children's
Medicines Research Group
 There is a need to get formal confirmation of Children’s Medicine’s
Research Group, identify formal representation for Master Formulary
Group and forward details to Sat
 We still haven’t established formal links with RCPCH/RCN Formulary
Group
 A Quality Control Group is needed as an adjunct to th Steering Group;
membership would include front line staff without specific expertise
including nurses, junior doctors, GPs
 No recent correspondence from BNFC
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Resend final terms of
reference with minutes
Owner/
timescale
LB Oct 2011
Master Formulary
LB
steering group terms of reference.doc
Contact Tony Nunn/
Matthew Peake
Contact David Vickers
and if necessary Imti
Choonara
Set up quality control
group
Contact Warren Lenney
Oct 2011
SJ Oct 2011
SJ Oct/Nov
2011
LB Oct 2011
Agenda item
Key discussion points
Actions
Owner/
timescale

Feedback from the First
Edition of the Formulary
Prescribing questionnaire
Article and abstract
Master formulary links will be on Palliativedrugs.com website from
November and in PCF 4. Hard copy is due out any time now (Order
quickly to get the 10% early bird discount). We can also have the
formulary PDF in the ‘document library’ on pall drugs.com site but suggest
wait until we’ve done the most immediate revisions.
ACT website
 Master formulary is now on the ACT Website but need to get APPM icon
and link on to the front page of the APPM website.
 Also need to find out whether we can have a record of the number of
downloads of the Master Formulary
 Generally feedback has been positive, constructive and welcome
 Sat has replied to all the E-mails in person.
 Claude Regnaud highlighted some of the discrepancies in terms of dose
conversions. The ensuing correspondence between Claude and Richard
was interesting but did not resolve the issues.
 The dosage chart outlines key areas in the current formulary where no
maximum doses are given and/or calculated doses may exceed adult
maximum e.g. midazolam infusion.
 The UK web-based survey results have been compiled. Five most
important prescribing issues identified were
o Equivalent starting doses of strong opioids administered PO, SC or IV in
babies and young children
o Ketamine
o Buccal or intranasal fentanyl
o Methadone
o Dexamethasone doses for different indications
 Prescribing practices varied considerably with some drugs being used
regularly by some prescribers but not at all by others
 Issues around ambiguity of wording, differences in practice with regard to
rounding doses and the need for clarity when dose ranges were used
 Suggested wording of “maximum dose … :doses of … have been used”
 The abstract below was discussed and approved for submission to
Palliative Care Congress and RCPCH. The questionnaire has now been
extended internationally. A full paper is anticipated in due course. It was
suggested that further analysis is undertaken to identify who is prescribing
ketamine and methadone – is it oncology specialists/ non hospice
2
LB Oct 2011
Contact ACT
Review current formulary
and develop
standardised wording
Agenda item
Key discussion points



Doses without upper
limits/ cross reference to
adult maximum





o
o
o
o
o
o
o
o
Actions
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Prescribing in
paediatric palliative care Congress 2012.doc
Publishing Anita’s work so far as a systematic review as also discussed.
However there are other priorities including getting WHO Essential
Medicines List published (this also includes systematic review evidence)
and it maybe better to wait until more detailed work has been undertaken
(see below).
Agreed to release summaries of work so far as a series of E-mail Master
Formulary briefings to APPM Members and on the website. This is in
addition to an article for the APPM newsletter
Discuss possible
publication of systematic
review with Imti
Choonara
EH Oct/Nov
2011
Release work so far as a
series of E-mail briefings
Draft article for APPM
newsletter
AA and SJ Nov
2011 onwards
LB & AA Nov
2011
Prepare updated table
and forward to Sat who
will circulate to APPM
AA Oct 2011
The dosage chart (28th September) was discussed. Version below
includes comments from Renee and also from Susie (25th August version
of dosage chart)
DOSAGE CHART
amended 28th Sept 2011 comments SL and RM.docx
This document was prepared to pull together available information to guide
prescribing for Formulary entries where no upper limit is given or where the
upper limits given apply only to adults. The emphasis here is on safety and
trouble-shooting the current formulary as it will not be possible to resolve
all of these issues immediately.
The list of drugs was reviewed and it was agreed that a modified version of
the table should be circulated to the whole of the APPM for feedback.
The following drugs will be included in this revised table:
Clonazepam
Cyclizine
Diamorphine
Diazepam
Fentanyl
Glycopyrronium
Hyoscine butylbromide
Hyoscine hydrobromide
3
Collate replies and
amend Master formulary
accordingly
SJ with EH and
AA
Nov/Dec 2011
Agenda item
Key discussion points
Actions
Owner/
timescale
o
Levomepromazine
o
Lorazepam
o
Midazolam
 Drugs that were removed from the list were as follows:
o Alfentanyl was removed as use in palliative medicine is unusual and almost
always rotation from another opioid thereby avoiding the issue of starting
doses
o Metoclopramide was removed because use is unusual in palliative care
and issues over maximum doses rarely arise
o Dexamethasone, ketamine and methadone will be taken forward as drugs
for more detailed work (see below)
o Morphine was removed but the amended formulary will state the same
doses for SC as IV
Reviews and deciding next  It was emphasised that the scope of the work of the Master Formulary
steps (real time case
steering group is not primary research but may include systematic reviews,
reporting/ Delphi/
prospective and retrospective audits and consensus building. Larger scale
retrospective audit(s)
research projects are likely to arise from the work of the Master Formulary
but these will require separate funding and steering groups as well as links
into the Master Formulary itself.
 Equivalent starting doses of strong opioids administered PO, SC or IV in
babies and young children. This will be explored further through circulation
of the dosage chart (see above)
 Ketamine. Agreed as priority for further work. Suggested multicentre and
potentially international audit. This may be followed by a real time multiple
“n of 1” type study or prospective audit. Need to separate out “burst
ketamine” from adjuvant ketamine use. Need more information on oral,
buccal and subcutaneous use
 Buccal or intranasal fentanyl. AK has been approached by a
pharmaceutical company to pull together single centre experience of
buccal/ intranasal fentanyl. ideally this would be extended to a broader
multicentre audit. Financial support from the pharmaceutical industry may
not be inappropriate as long as the intellectual property/ publication rights
remain with AK/ APPM, the protocol is unbiased and the financial support
is declared.
 Methadone. It was suggested that in the UK methadone is mainly used as
an adjuvant rather than a complete switch from another strong opioid.
4
Identify experts in this
area and pull together a
steering group for the
audit. Draft protocol
LB with AA Oct/
Nov 2011
Liaise with
pharmaceutical company
regarding extending to a
multicentre study. Seek
independent advise
regarding working with a
pharmaceutical company
Contact Craig Gannon
AK Oct/Nov
2011
EH Oct 2011
Agenda item
Key discussion points

Funding
Areas of controversy include whether there is a need for inpatient care
when commencing methadone, dose and route of administration, maximal
doses and whether methadone or an alternative opioid should be used for
breakthrough pain/ titration. Craig Gannon is an adult palliative care
specialist who has a specific interest in methadone. It was suggested that
although the Master Formulary Steering group did not have capacity to
commence a detailed study of methadone at this stage contact with Craig
may yield a collaborative approach and appropriate way forward. One
possibility might be to set up a Delphi conference to debate different
approaches to using methadone.
Dexamethasone doses for different indications. Emily has pre-existing
work on dexamethasone doses. Lynda has also undertaken a small
qualitative study with Prof Chris Eiser into parents perspectives of benefits
and adverse effects of corticosteroids in palliation of brain tumours. It was
suggested that as a first step this information together with Anita’s
systematic review could be pulled together as a paper. Additional
information from oncologists in particular will be invaluable

Ongoing funding is essential to support the Master Formulary updating and
publication. It is anticipated that this will require around £10,000 per year
at current prices. Additional funding will be required for “spin off” research
or high level audit/ consensus building studies
 Aim to generate £10,000 - £15,000 per year for ongoing Master Formulary
updating and development. It is hoped that this will be achieved through a
combination of
o Sponsorship/ grant funding from ACT/CH-UK
o Drug company sponsorship
o APPM subscriptions
o An annual training day focussing on symptom management and
pharmacology: The first of these will be held in March 2012 in
Loughborough. Target audience will be through clinical networks including
both medical and nursing staff. Content will be based on Rainbows
Symptom Guidance and Master Formulary. Methadone Delphi conference
could form part of this meeting.
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Actions
Owner/
timescale
Pull together work on
dexamethasone. Involve
Julie Myhill and an
appropriate neurooncologist
EH, LB JM
Oct/Nov 2011
Discuss funding with key
players:
 Myra Bluebond
Langner
 William Vand-hoff
(MRC)
 Imti Choonara
 ACT/CH-UK
 Kianee Shar (did
medicines
management work
with CHUK)
Start work on training
day
Sat and Suzie
Oct/Nov 2011
Agenda item
Any other business
Date and time of next
meeting
Key discussion points
Actions
Owner/
timescale
Additional project funding will be generated through other routes. Specific
academic partners will be required for these e.g.
o Specific research grants from relevant bodies
o Health lottery
o RfPB
 Issues with APPM membership subscriptions not being collected from
some members and some members not receiving mailings were identified
 The issues of mixing drugs in syringe drivers were also discussed noting
that paediatric doses are often smaller and combinations maybe different.
Administration of drugs via central lines was also raised as this route does
not cause local reactions and phlebitis even with very irritant drugs at high
concentration. Suggested that these items are carried over for more
detailed discussion at next steering group meeting.
 Rainbows Hospice, Loughborough, 6th December
 Time 11am to 2pm
Discuss potential grant
applications with Alder
Hey Research and
Development team
LB Oct 2011
Discuss with ACT
LB/SJ Oct 2011
Put on agenda for next
meeting
SJ Dec 2011
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