Minutes from the Medway and Swale Drugs & Therapeutics Committee
Postgraduate Centre Seminar Room 2
Medway Hospital, Gillingham, Kent, ME7 5NY
Wednesday 17th September 2014 12:00pm - 2:00pm
1. Members
Richard Patey (RP)
Oni Odelade (OO)
Louise Dark (LD)
Bal Minhas (BM)
Bukky Francis (BF)
Dr Las Ayathurai (LA)
Korede Ibitoye (KI)
Dr Maam Mamun (MM)
In attendance
Asankha Ranasinghe (AR)
Lisa Price (LP)
Shikohe Masood (SM)
Shirley Chan (SC)
Rella Workman (RM)
Laura Musson (LM)
Stephanie Gorman (SG)
Sarah Christie (SCh)
Chair; Consultant Paediatrician, Medway Foundation Trust
(MFT)
Prescribing Advisor, Medway Clinical Commissioning Group
(CCG)
Chief Pharmacist, MFT
Prescribing Advisor, Swale Clinical Commissioning Group
Formulary Pharmacist, MFT
GP, Swale CCG
Pharmacist, MCH
Consultant Elderly Care, MFT
Consultant Paediatrician, MFT
Senior Sister – The Birth Place, MFT
Urology Consultant, MFT
Consultant Surgery, MFT
Microbiology Consultant, MFT
Anti-microbial Pharmacist, MFT
Cardiac Nurse Specialist, MFT
Pharmacy Secretary
2. Apologies for absence
Yvette Bartlett
Zika Petrovic
Manpreet Pujara
3. Matters Arising
4. Minutes of the last meeting held and action points
All agreed as accurate.
Action Log Review
The action log was reviewed – refer to log for updates.
5. Conflict of Interests
None
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6. New Drug Applications / Changes to Current Formulary Status
Intradermal Sterile Water Injections
LP presented the application. Sterile water is used in women who are in labour suffering
with lumber pain often associated with occopito-posterior fetal position in labour. Just under
0.8ml is injected just under the skin at 4 points and is to be administered by 2 Midwives
simultaneously. LP explained that it is considered safe with no recorded side effects to both
mothers or babies just a stinging sensation whilst being administered. It is being used in
Scarborough & NE Yorkshire NHS Trust and Birth Centre at Maidstone Hospital. A guideline
and a PGD have been produced and it was confirmed that necessary documentation has
been approved by PALS and Governance committee. Training will be provided for midwives
and this will be on a monthly basis. The cost for each patient was estimated to be about
18p.
Decision: APPROVED
Action:
 Audit looking at outcomes and patient satisfaction should be carried out.
 Result from audit should be brought back to committee in a year’s time
_______________________________________________________________________
10% Metronidazole Ointment
Application was discussed in full at last meeting (July) but concerns were raised as the
product was unlicensed and does not have marketing authorisation in the UK. Some of the
questions raised were:
SC answered some of the questions raised:
 Surgery will be offered if treatment does not work
 GP’s would not need to prescribe as the ointment lasts for 6 weeks.
 There are no recorded side effects.
SC further explained the drug is still in trials. Patients who have had surgery with non-healed
wounds would be suitable for the ointment and the number of patients off trial will be low.
SC highlighted that 12 other Trusts already have it on their formularies. LD advised that she
was happy to speak to Pharmacists from the other Trusts to see how they got this onto the
formulary with the drug still in trials.
Decision: NOT APPROVED
The committee was supportive but decided it cannot be added to the formulary whilst the
trial is taking place due to patient safety. The committee felt that the application needed to
go to the Ethics Committee as the product is still in trials.
_________________________________________________________________________
Avanafil
SM presented the application. Avanafil is for the treatment of erectile dysfunction in adult
men. The aim is to use Avanafil when generic sildenafil has failed. SM explained that it has
been noted that around 30% to 40% of men fail on their first PDE-5 inhibitor so Avanafil will
be an alternative treatment and it is cost effective. The committee asked if Avanafil was to
replace one of the other PDE-5 inhibitors (Tadalafil and Vardenafil) already on the formulary
but SM explained that it will be best to have all on the formulary as Tadalafil tends to be
more suitable for younger patients.
Decision: APPROVED but Sildenafil (generic) to remain on 1st line and pathway to be
updated with changes
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_________________________________________________________________________
Dapagliflozin
Dr Gough submitted an application for Dapagliflozin. He wanted GPs to be able to initiate
treatment with Dapagliflozin. The committee felt that Dapagliflozin should be initiated by
specialist only. The committee felt that guideline should be produced for the management of
type 2 diabetes and with the recent NICE TA for Canagliflozin the preferred SGLT2 inhibitor
should be clearly stated.
Decision: Dapagliflozin to remain as Specialist Initiation only and GPs will continue to
prescribe after specialist initiation.
_________________________________________________________________________
Fultium D3 caps
Fultium D3 800units capsules already on formulary, but there is now a new strength of
3200units capsules. This means that patients will only need to take one capsule a day
instead of four capsules of the lower strength to treat vitamin D deficiency.
Decision: APPROVED
Action: Policy to be updated with new preparation
_________________________________________________________________________
InVita D3 Oral Solution
This is also a new strength and formulation of vitamin D preparation. Only need to take
contents of one ampoule weekly instead of daily.
Decision: APPROVED
Action: Policy to be updated for new preparation
_________________________________________________________________________
Sumatriptan/Naratriptan
Sumatriptan – Already on the formulary
Decision: APPROVED as generic
Naratriptan – This is a non formulary drug and therefore a full submission will be needed
before it can be considered
Decision: NOT APPROVED
_________________________________________________________________________
Botox for Achalasia
LD explained that the application was made to the DTC as there was a request for Botox for
Achalasia, an indication that is not commissioned by Medway CCG. For this particular
patient, it was agreed that the cost will come out of Medicine division budget. OO explained
that all the indications for Botox is currently being reviewed by HCIAG and once a policy has
been produced then this will be brought back to the committee.
7. Guidelines/Pathways
Botox for OAB (gynae) pathway
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Points raised:
 Needs a title
 OO highlighted that the dose for the treatment of OAB should be 100units as per
SPC
 Pathway states dose as 200units and references NICE CG 171 (but
recommendation by NICE was before Botox was licensed for OAB)
Action: This needs to be fed back to Miss Basu and dose also to be clarified. (BF to action)
________________________________________________________________________
Rivaroxaban for DCCV
SG presented the updated guideline for DCCV. The committee
Points raised regarding the guideline were:
 Patient consent form has been produced, however was not brought to the meeting.
 A review date should be added to the guideline.
 Patient letter
SG explained that the consent form is not pre-printed and once the patient has gone through
all the questions then page 7 of the guideline will be printed off and patient will have to sign
and then put in their medical notes. She further explained that the PIL will go through PALS
(Sarah Bush producing this) and the pathway will go through the governance committee. SG
asked the committee that if patients are on Apixaban what will be the procedure for CV for
such patients and the committee agreed that a line should be added to the guideline for
alternative NOACs.
Decision: APPROVED and to be rolled out in November
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Pain pathway
Points raised were:
 Changes to title to indicate use in secondary non-specialist settings.
 Fentanyl patch to change on JF to specialist initiation (orange).
 Buprenorphine patch to change to black on JF.
 Zomorph listed as generic Morphine sulphate and adding the preferred brand as
Zomorph (make green to highlight as first line use).
 Add Nortriptyline to JF
Decision: APPROVED
_______________________________________________________________________
Erectile dysfunction prescribing policy
Policy was discussed along with the application for Avanafil.
Decision: APPROVED and to be updated with new approved PDE-5 inhibitor.
_________________________________________________________________________
COPD guideline – This was not discussed as there is going to be applications for new
inhalers.
_________________________________________________________________________
Teicoplanin
RW presented the updated guideline which is specifically for bone, joint and prosthetic joint
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infections. She explained that the guideline had been updated to include the recent changes
to the SPC and to reflect the doses and monitoring required in patients with impaired renal
function. KI felt that section 7.2 should be reworded from 2 weekly to fortnightly to avoid
confusion on how often the follow up is done.
Decision: APPROVED
_________________________________________________________________________
Community Cellulitis Pathway
RW explained that there are currently a number of in patients being treated for cellulitis that
could in fact be treated as outpatients. Alaisdair Stewart has seen the pathway produced for
management of the cellulitis; he feels there are too many patients being treated as
inpatients and highlights that more support is needed out in the community. Points raised
regarding the pathway below:
 Class 1 – Doses need to be reviewed
 Class 3 – Ceftriaxone dose written as 2g without frequency
 Duration of all treatment to be made clearer on table
 There is already a pathway for cellulitis used by MEDOCC and not very clear if this
supersedes it or just another duplication of pathway.
RW explained that the guideline is still being reviewed by the antimicrobial pharmacists and
the doses will be adjusted as appropriate. RW is not aware of the pathway used by
MEDOCC but she will liaise with Dr Simon Collins, Medical Director of MCH to clarify this.
Decision: APPROVED subject to changes as stated above.
_________________________________________________________________
CAP guidelines
Dr Vincent-Smith should be working on this in line with the Enhancing Quality programme.
_________________________________________________________________
Intralipid
LD brought to DTC as she felt it needed clinical engagement.
Part of the introduction (section 1) in the guideline needs to be reworded and also not clear
in terms of immediate management of local anaesthetic toxicity if section 3 (immediate
management) should be carried out before section 5 (treatment of cardiac arrest with lipid
emulsion). Some of the committee members felt that the guideline is for hospital use only
and they had little or no contribution to it.
Decision: Committee felt that the guideline is okay but maybe should go to the MMC.
_________________________________________________________________
Stroke Pathway
This was circulated via email and all members agreed.
Decision: APPROVED
_________________________________________________________________
Rifaximin shared-care guideline
This has not been done by the Gastroenterology team and all doctors leading on it have
now left the Trust.
Decision: NOT APPROVED. The committee agreed that a letter should be sent to the
Gastroenterology team stating that a new submission for Rifaximin will have to be made to
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the DTC if the team still plans to use the drug as it has been well over 6 months since the
initial application was made.
8. Formulary Adherence
9. MHRA Safety Alerts
Drug safety update – July
 Drugs and driving: limits to be set for certain controlled drugs
 IV dantrolene: risk of skin and injection site reactions – use a filter needle.
 Fentanyl patches: potential for life-threatening harm from accidental exposure
(especially children)
 Administration errors with drug infusion: checking procedures should be in place.
Drug safety update – August
 Levonorgestrel and ulipristal acetate: suitable for all women regardless of weight or
BMI
 Ofatumumab: risk of serious and fatal infusion reactions.
11. NICE
 NICE TA 303 – Teriflunomide for treating relapsing-remitting multiple sclerosis. LD
explained that MFT is registered as a specialist centre for minimal conditions and still
not decided about MS so we can still treat at MFT. APPROVED.

NICE TA 312 - Alemtuzumab for treating relapsing – remitting multiple sclerosis.
As above for MS, MFT can treat. APPROVED.

NICE TA 315 – Canagliflozin in combination therapy for treating type 2 diabetes.
APPROVED.

NICE TA 316 – Enzalutamide for metastatic hormone-relapsed prostate cancer
previously treated with a docetaxel-containing regimen. APPROVED.

NICE TA 317 – Prasugrel with percutaneous coronary intervention for treating acute
coronary syndromes. APPROVED for specialist initiation only.

NICE TA 318 – Lubiprostone for treating chronic idiopathic constipation. APPROVED
for specialist initiation only. (Gastroenterologist to complete NICE review form).

NICE TA 319 – Ipilimumab for previously untreated advanced (unresectable or
metastatic) melanoma. APPROVED.
For the treatment of MS, the committee felt that there should be a protocol/guideline for the
different therapies. It was therefore agreed that Dr Memon should be invited to the next DTC
meeting to discuss this.
It was also decided that the current NICE TA forms are sufficient audit trails and application
forms do not need to be submitted.
12. Any Other Business
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Nebulised Colomycin
Response received from Lisa Vincent-Smith. Guidelines were being worked on by the
Community Respiratory Team. Jane Kindred, Lead Respiratory Nurse can be contacted.
Specialist Centre
MFT is registered as a specialist centre for minimal conditions; the main areas are Gynae,
Neonatal and Inherited cardiac disorders. This in turn means if MFT is not registered as a
specialist centre for other conditions we are not able to treat (unless there is a shared care
arrangement). It is still not decided about MS; therefore we are still able to treat at MFT.
Date of next meeting
Wednesday 15th October, 2014 (PG Centre Trust Boardroom)
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