Committee Decisions

The Surrey Heartland Integrated Care System Area Prescribing Committee agree implementation of NICE TA878 Casirivimab plus imdevimab, nirmatrelvir plus ritonavir, sotrovimab and tocilizumab for treating COVID-19.

Casirivimab plus imdevimab is agreed as NON-FORMULARY – Not recommended by NICE 
 

The Surrey Heartland Integrated Care System Area Prescribing Committee agree implementation of NICE TA878 Casirivimab plus imdevimab, nirmatrelvir plus ritonavir, sotrovimab and tocilizumab for treating COVID-19.

Tocilizumab is agreed as  RED only for administration in the hospital setting
 

The Surrey Heartland Integrated Care System Area Prescribing Committee agree implementation of NICE TA878 Casirivimab plus imdevimab, nirmatrelvir plus ritonavir, sotrovimab and tocilizumab for treating COVID-19.

Sotrovimab is agreed as RED for prescription only by the commissioned CMDU service (not for prescribing through A&E / hospital clinics)

*if a patient who falls into one of the high risk cohorts is in hospital and gets COVID-19 (not admitted due to COVID) then these individuals should be treated with Paxlovid / Sotrovimab in line with NICE TA878 whilst they are an inpatient.

The Surrey Heartland Integrated Care System Area Prescribing Committee agree implementation of NICE TA878 Casirivimab plus imdevimab, nirmatrelvir plus ritonavir, sotrovimab and tocilizumab for treating COVID-19.

Nirmatrelvir with ritonavir *(Paxlovid) is agreed as RED for prescription only by the commissioned CMDU service (not for prescribing through A&E / hospital clinics)

*if a patient who falls into one of the high risk cohorts is in hospital and gets COVID-19 (not admitted due to COVID) then these individuals should be treated with Paxlovid / Sotrovimab in line with NICE TA878 whilst they are an inpatient.

The Surrey Heartland Integrated Care System Area Prescribing Committee agree that finerenone should be a treatment option as recommended line with NICE TA877 Finerenone for treating chronic kidney disease in type 2 diabetes. 

Finerenone for this indication will be considered as RED on the traffic light system (treatment should be initiated and continued by specialist clinicians). 

Primary care prescribers should be aware that their patient is receiving this medicine and ensure that this is recorded on the patient's medication screen as a hospital-only drug in line with guidance on the PAD. This will also alert the prescriber to potential side effects and interactions with other medicines prescribed in primary care. It will also ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication

The Surrey Heartlands Area Prescribing Committee (APC) approves the use of fostamatinib as recommended by NICE TA835 as an option for treating refractory chronic immune thrombocytopenia (ITP) in adults, only if:

• they have previously had a thrombopoietin receptor agonist (TPO-RA), or a TPO-RA is unsuitable,
• the company provides fostamatinib according to the commercial arrangement.

Fostamatinib for this indication will be considered as RED on the traffic light system (treatment should be initiated and continued by specialist clinicians).
Primary care clinicians should be aware that their patient is receiving this medicine and ensure that this is recorded on the patient's medication screen as a hospital-only drug in line with guidance on the PAD. This will also alert the prescriber to potential side effects and interactions with other medicines prescribed in primary care. It will also ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication.

The Surrey Heartlands integrated care system Area Prescribing Committee (APC) approves ozanimod as recommended by NICE TA828 as an option for treating moderately to severely active ulcerative colitis in adults, only if:
•    conventional treatment cannot be tolerated or is not working well enough, and infliximab is not suitable, or
•    biological treatment cannot be tolerated or is not working well enough, and
•    the company provides it according to the commercial arrangement.

Ozanimod for this indication will be considered as RED on the traffic light system (treatment should be initiated and continued by specialist clinicians).
Primary care prescribers should be aware that their patient is receiving this medicine and ensure that this is recorded on the patient’s medication screen as a hospital-only drug in line with guidance on the PAD. This will also alert the prescriber to potential side effects and interactions with other medicines prescribed in primary care. It will also ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient’s medication

Where the patient (or their carer) requires gloves for self-care, and the use of the gloves has been recommended by a healthcare professional, then the gloves can be prescribed on an FP10. 

Where gloves are used by health and social care professionals as part as their service, any protective equipment (including gloves) should be provided by the service and therefore not prescribed. In this situation they are NON-Formulary

The Surrey Heartlands Integrated Care System Area Prescribing Committee (APC) has agreed the National Shared Care Protocol (with local adaptations) for sulfasalazine for patients within adult services

The Surrey Heartlands Integrated Care System Area Prescribing Committee (APC) has agreed the National Shared Care Protocol (with local adaptations) for sulfasalazine for patients within adult services

The Surrey Heartlands Integrated Care System Area Prescribing Committee (APC) has agreed the National Shared Care Protocol (with local adaptations) for mycophenolate mofetil and mycophenolic acid for patients within adult services (non-transplant indications)

The Surrey Heartlands Integrated Care System Area Prescribing Committee (APC) has agreed the National Shared Care Protocol (with local adaptations) for mycophenolate mofetil and mycophenolic acid for patients within adult services (non-transplant indications)

The Surrey Heartlands Integrated Care System Area Prescribing Committee (APC) has agreed the National Shared Care Protocol (with local adaptations) for mycophenolate mofetil and mycophenolic acid for patients within adult services (non-transplant indications)

The Surrey Heartlands Integrated Care System Area Prescribing Committee (APC) has agreed the National Shared Care Protocol (with local adaptations) for mycophenolate mofetil and mycophenolic acid for patients within adult services (non-transplant indications)

The Surrey Heartlands Integrated Care System Area Prescribing Committee (APC) has agreed the National Shared Care Protocol (with local adaptations) for mycophenolate mofetil and mycophenolic acid for patients within adult services (non-transplant indications)

The Surrey Heartlands Integrated Care System Area Prescribing Committee (APC) has agreed the National Shared Care Protocol (with local adaptations) for mycophenolate mofetil and mycophenolic acid for patients within adult services (non-transplant indications)

The Surrey Heartlands Integrated Care System Area Prescribing Committee (APC) has agreed the National Shared Care Protocol (with local adaptations) for mycophenolate mofetil and mycophenolic acid for patients within adult services (non-transplant indications)

The Surrey Heartlands Integrated Care System Area Prescribing Committee (APC) has agreed the National Shared Care Protocol (with local adaptations) for mycophenolate mofetil and mycophenolic acid for patients within adult services (non-transplant indications)

The Surrey Heartlands Integrated Care System Area Prescribing Committee (APC) has agreed the National Shared Care Protocol (with local adaptations) for mycophenolate mofetil and mycophenolic acid for patients within adult services (non-transplant indications)

The Surrey Heartlands Integrated Care System Area Prescribing Committee (APC) has agreed the National Shared Care Protocol (with local adaptations) for mycophenolate mofetil and mycophenolic acid for patients within adult services (non-transplant indications)

The Surrey Heartlands Integrated Care System Area Prescribing Committee (APC) has agreed the use of faricimab as a treatment option for treating Diabetic Macular Oedema in line with NICE TA799.

Faricimab will be given a RED traffic light status. Prescribing will be by hospital specialists only, in line with NICE TA799.

Primary care prescribers should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication.

The Surrey Heartlands Integrated Care System Area Prescribing Committee (APC) has agreed the use of faricimab as a treatment option for treating wet age-related macular degeneration in line with NICE TA800.

Faricimab will be given a RED traffic light status. Prescribing will be by hospital specialists only, in line with NICE TA800.

Primary care prescribers should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication.

The Surrey Heartlands Integrated Care System Area Prescribing Committee (APC) has agreed the use of romosozumab for treating severe osteoporosis in people after menopause in line with NICE TA791.

Romosozumab will be given a RED traffic light status. Prescribing will be by hospital specialists only using Blueteq forms for initiation.

The romosozumab treatment course is 12 months ONLY.  

Patients should be started on anti-resorptive treatment by the specialist team after the romosozumab treatment course is complete.

Primary care prescribers should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication.

The Surrey Heartlands Integrated Care System Area Prescribing Committee has agreed the use of filgotinib for treating moderately to severely active ulcerative colitis in line with NICE TA792.

Filgotinib will be given a RED traffic light status. Prescribing will be by hospital specialists only using Blueteq forms for initiation & continuation

Primary care prescribers should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication.

The Surrey Heartlands Integrated Care System Area Prescribing Committee recommends Palforzia for treating peanut allergy in children and young people in line with NICE TA 769.

Palforzia will be considered RED on the traffic light system. Prescribing will be by hospital specialists only, in line with NICE TA769.

Primary care prescribers should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication

The Surrey Heartlands Integrated Care System Area Prescribing Committee does not recommend the use of Glycopyrronium for iontophoresis and a non-formulary traffic light status was agreed to be applied.

This  NICE guideline (NG215 - April 2022) covers general principles for prescribing and managing withdrawal from opioids, benzodiazepines, gabapentinoids, Z-drugs and antidepressants in primary and secondary care.

The Surrey Heartlands Integrated Care System Area Prescribing Committee recommends upadacitinib as a treatment option for the treatment of Psoriatic Arthritis in line with NICE TA768.

Upadacitinib will be considered RED on the traffic light system. Prescribing will be by hospital specialists only, in line with NICE TA768.

Primary care prescribers should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication.

The Surrey Heartlands Integrated Care System Area Prescribing Committee agreed the reviewed and updated Rheumatology Immunomodulator pathways (axial spondyloarthritis, psoriatic arthritis and rheumatoid arthritis (moderate and severe).

The Surrey Heartlands Integrated Care System Area Prescribing Committee recommends fremanezumab as a treatment option for preventing migraine in line with NICE TA764

Fremanezumab will be considered RED on the traffic light system. Prescribing will be by hospital specialists only, in line with NICE TA764.

Primary care prescribers should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication.

The APC recommends both presentations of alirocumab: 150mg fortnightly (see previous recommendation) AND 300mg monthly (new recommendation).

The monthly 300mg presentation maybe more conveniant for patients.  It was not covered in the evidence base underpinning NICE TA393 but the PAS price is the same monthly cost as 150mg fortnightly.  

Prescribing of either product should be in line with NICE TA393 under the conditions agreed in October 2016
 

This drug is currently not on the APC workplan. The APC will consider recommending prescribing of this treatment upon submission of a formal request with its associated evidence. Please contact your local CCG Medicines Management team OR formulary pharmacist at your acute trust, if you wish to make a submission. 
This drug has not yet been evaluated by NICE or the Surrey Heartlands Area Prescribing Committee (APC). As such, advice regarding safety, effectiveness (including cost-effectiveness) and its place in therapy is yet to be determined. It is recommended that clinicians contact their medicines management team for further information and advice before prescribing this drug.

The Kelhale MDI device is not locally recommended. It is equivalent to the preferred Qvar MDI (fine particles).

Inhaler devices should be prescribed by BRAND

See Asthma guidelines and other resources below

The Soprobec MDI device is not locally recommended. It is equivalent to the preferred Clenil Modulite MDI.

Inhaler devices should be prescribed by BRAND

See Asthma guidelines and other resources below

The Qvar Autohaler is not a locally preferred device and should not be initiated in new patients.
Consider Qvar Easi-Breathe in patients requiring a Qvar breath activated device.

Clenil Modulite® (beclometasone) MDI plus spacer (Volumatic, Able Spacer, Optichamber) or Qvar (beclometasone) MDI plus spacer (Aerochamber plus, Able Spacer, Optichamber) are the locally preferred ICS devices.

Other locally recommended devices are:
Easyhaler® Beclometasone (DPI) - not licensed in under 18 years
Easyhaler® Budesonide may be considered as an additional alternative in patients aged 12-17 if these other preferred, licensed devices are not suitable

Prescribe inhaler devices by BRAND

Flixotide Evohaler and Flixotide Accuhaler are not locally recommended. They are less cost effective and carry the risk of excess steroid dosing due to dose equivalence / potency compared to beclometasone
(500microgram of fluticasone propionate is equivalent to 1000micrograms beclometasone dipropionate)

Inhaler devices should be presrcibed by BRAND

See asthma guidelines and other resources below

Budesonide Easyhaler may be considered in patients aged 12-17 if these other preferred, licensed devices are not suitable:

Clenil Modulite (beclometasone MDI) plus spacer (Volumatic, Able Spacer, Optichamber) or Qvar (beclometasone MDI) plus spacer (Aerochamber plus, Able Spacer, Optichamber) are the locally agreed preferred ICS devices.

If a breath activated device is necessary, consider:
Easyhaler Beclometasone (breath activated) DPI
Qvar Easi-Breathe (breath activated) MDI

Prescribe inhaler devices by BRAND to ensure consistency and avoid confusion

The guidelines for asthma can be found below

Airomir Autohaler is not a locally preferred device.

Salamol MDI is the locally preferred salbutamol MDI device and should be used with a spacer device.
It has a lower carbon footprint than the large volume MDIs such as Ventolin.

Salbutamol Easyhaler is the locally preferred dry powder device

Branded prescribing of inhaler devices is recommended.

See Asthma local guidelines below

Bricanyl Turbohaler is not a locally preferred device.

The locally preferred SABA devices are as follows:

Low carbon:

• Salbutamol Easyhaler (dry powder inhaler)
• Ventolin Accuhaler (dry powder inhaler)

Alternative devices:

• Salamol (MDI) is the locally preferred salbutamol metered dose inhaler device and should be used with a spacer device. It has a lower carbon footprint than the large volume MDIs such as Ventolin.
• Ventolin Evohaler (MDI) 

Branded prescribing of inhaler devices is recommended.

See COPD local guidelines for more information

Bricanyl Turbohaler is not a locally preferred device.

Salamol MDI is the locally preferred SABA MDI device and should be used with a spacer device.
It has a lower carbon footprint than the large volume MDIs such as Ventolin.

Salbutamol Easyhaler is the locally preferred SABA dry powder device. If an alternative dry powder is required, Bricanyl Turbohaler may be considered.

Branded prescribing of inhaler devices is recommended.

See Asthma local guidelines below

Single device LABA is not recommended in Asthma or COPD.
Combined LAMA/LABA is the bronchodilator treatment of choice for patients with COPD who are breathless or having exacerbations following treatment with SABA.

Existing LABA patients, whose symptoms are under control, can continue with their current treatment until both they and their NHS healthcare professional agree it is appropriate to change.

Inhaler devices should be prescribed by BRAND.

See COPD guidelines for more information

Single device LABA is not recommended in Asthma or COPD.
Combined LAMA/LABA is the bronchodilator treatment of choice for patients with COPD who are breathless or having exacerbations following treatment with SABA.

Existing LABA patients, whose symptoms are under control, can continue with their current treatment until both they and their NHS healthcare professional agree it is appropriate to change.

Inhaler devices should be prescribed by BRAND.

See COPD guidelines for more information

Single device LABA is not recommended in Asthma or COPD.
Combined LAMA/LABA is the bronchodilator treatment of choice for patients with COPD who are breathless or having exacerbations following treatment with SABA.

Existing LABA patients, whose symptoms are under control, can continue with their current treatment until both they and their NHS healthcare professional agree it is appropriate to change.

Inhaler devices should be prescribed by BRAND.

See COPD guidelines for more information

Single device LABA is not recommended in Asthma or COPD.
Combined LAMA/LABA is the bronchodilator treatment of choice for patients with COPD who are breathless or having exacerbations following treatment with SABA.

Existing LABA patients, whose symptoms are under control, can continue with their current treatment until both they and their NHS healthcare professional agree it is appropriate to change.

Inhaler devices should be prescribed by BRAND.

See COPD guidelines below

Imipramine is no longer included in local guidelines for use in neuropathic pain.

Imipramine should not be initiated in any new patients for this indication.

Amitriptyline is the only tricyclic recommended by NICE.  It recommends a switch to another class of drug if amitriptyline is not tolerated or contra-indicated.

See guidelines below.

The Area Prescribing Committee recommends that nortriptyline for use in neuropathic pain should remain as unsuitable for prescribing and agreed to assign it a NON-FORMULARY status for this indication

There appears to be no evidence available to recommend this off label treatment. It is not recommended in NICE guidance (CG173) "Neuropathic pain in adults: pharmacological management in non-specialist settings ".
Amitriptyline is the only tricyclic recommended by NICE. It recommends a switch to another class of drug if amitriptyline is not tolerated or contra-indicated

See guidelines below

Capsaicin cream 0.075% (Axsain) is recommended at step 1 of the neuropathic pain guidelines for patients with localised neuropathic pain who cannot tolerate / wish to avoid oral treatments (amitriptyline or duloxetine).

See guidelines below

NOTE - capsaicin patches (Qutenza) are not recommended and have a non-formulary traffic light status.

Amitriptyline or duloxetine are recommended as a teatment option at step 1 of the local neuropathic pain guidelines.
See guidelines below.

Duloxetine 60mg once daily or amitriptyline are recommended as treatment options at step 1 of the local neuropathic pain guidelines..
Duloxetine is licensed only for diabetic peripheral neuropathic pain but is also recommended by NICE as a treatment option in neuropathic pain.
See guidelines below.

Gabapentinoids are recommended as a teatment option at step 2 of the local neuropathic pain guidelines. 
Gabapentin is preferential to pregabalin due to its lower potential for misuse.
Pregabalin may be used if gabapentin is effective but not well tolerated OR if gabapentin is ineffective.

Gabapentinoids are Controlled Drugs and a maximum supply of 30 days should be prescribed at any time.

See guidelines and other resources relating to the use of gabapentinoids below

Lidocaine 5% plasters are only recommended in local neuropathic pain guidelines for post-herpetic neuralgia with localised allodynia.

Lidocaine plasters are recommended at step 3 of the local neuropathic pain guidelines but may be considered 1st line where:
- the painful area is less than 5cm2
- the patient is unable to take oral medication
- there is a risk of drug-drug interaction with treatments in steps 2 and 3
- there is an increased risk of falls

see guidelines below for further information

Tramadol may be considered for patients awaiting referral to pain specialist, after initial treatments have failed. See neuropathic pain guidelines below.

Prescribe a short course (2-4 weeks on an acute script) and review at least every 3 months.

PLEASE NOTE:
Standard/Immediate release capsules should be prescribed GENERICALLY
Modified release tablets should be prescribed by BRAND with Marol® being locally preferred

Tramadol may be considered for patients awaiting referral to pain specialist, after initial treatments have failed. See neuropathic pain guidelines below.

Prescribe a short course (2-4 weeks on an acute script) and review at least every 3 months.

PLEASE NOTE:
Standard/Immediate release capsules should be prescribed GENERICALLY
Modified release tablets should be prescribed by BRAND with Marol® being locally preferred

The Area Prescribing Committee recommends avatrombopag for treating thrombocytopenia in people with chronic liver disease needing a planned invasive procedure in line with NICE guidance (NICE TA 626)

Avatrombopag is a payment by results excluded medicine and will be considered RED on the traffic light system. Prescribers will be required to complete a blueteq form at initiation

Primary care prescribers should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication

  The Area Prescribing Committee recommends the use of oral isotretinoin for the treatment of severe acne resistant to adequate courses of standard therapy with systemic antibacterials and topical therapy.

Isotretinoin will be considered RED with prescribing limited to or under the supervision of physicians with expertise in the use of systemic retinoids for severe acne and a full understanding of the risks and monitoring requirements.

For important information and resources related to Pregnancy Prevention Programme and neuropsychiatric disorders please see the Further Supporting Information document below.

This drug is currently not on the APC workplan. The APC will consider recommending prescribing of this treatment upon submission of a formal request with its associated evidence. Please contact your local CCG Medicines Management team OR formulary pharmacist at your acute trust, if you wish to make a submission.

The Surrey & North West Sussex Area Prescribing Committee does not recommend Vitamin B Compound Strong for use in alcohol dependence in line with the RMOC position statement for oral Vitamin B supplementation (see RMOC position statement document below).

Vitamin B Compound Strong for alcohol dependence is NON FORMULARY.

NOTE: Vitamin B compound strong may be prescribed for patients at high risk of refeeding syndrome – see Profile : Vitamin B Compound strong - Refeeding syndrome (res-systems.net) for further information

Where indicated and appropriate to prescribe, vitamin B compound strong are more cost effective than vitamin B compound tablets.

The Surrey & North West Sussex Area Prescribing Committee recommends the use of Aminolaevulinic acid (Ameluz® 78mg/g gel) for Actinic Keratosis, as an option for the treatment of actinic keratosis of mild to moderate intensity on the face & scalp (Olsen grade 1 to 2) when photodynamic therapy is considered appropriate.

Aminolaevulinic acid (Ameluz® 78mg/g gel) for this indication will be considered RED on the traffic light system

The UK marketing authorisation for Retigabine (Trobalt) was withdrawn by the MHRA in June 2017. This product was discontinued because of limited and declining use. 

The Surrey and North West Sussex Area Prescribing Committee does not recommend the use of vitamin B compound tablets and they will be considered Non Fomulary on the traffic light system
Current prescribing of vitamin B compound tablets should be reviewed (in line with the RMOC position statement document below). Patients should be checked for ongoing medical indication for prescribing and if there is a need to continue treatment, the patient should be switched to vitamin B compound strong tablets.

Note: vitamin B compound strong tablets are non-formulary for use in alcohol dependence (Profile : Vitamin B Compound strong - Alcohol dependence (res-systems.net)) but may be appropriate in refeeding syndrome (Profile : Vitamin B Compound strong - Refeeding syndrome (res-systems.net))

The Surrey & North West Sussex Area Prescribing Committee recommends Patiromer as a treatment option for the treatment of Hyperkalaemia in adults in line with NICE TA623 in emergency care for acute life threatening hyperkalaemia or for patients with persistent hyperkalaemia (in line with NICE thresholds).

Patiromer will be considered RED on the traffic light system in all cases.

Primary care prescribers should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient’s medication.

The Surrey & North West Sussex APC recommends the use of tacrolimus and pimecrolimus in atopic eczema as BLUE (with no information sheet) on the traffic light system and as per NICE TA82:

Topical tacrolimus and pimecrolimus are not recommended for the treatment of mild atopic eczema or as first-line treatments for atopic eczema of any severity.

Tacrolimus:

Topical tacrolimus is recommended, within its licensed indications, as an option for the second-line treatment of moderate to severe atopic eczema in adults and children aged 2 years and older that has not been controlled by topical corticosteroids, where there is a serious risk of important adverse effects from further topical corticosteroid use, particularly irreversible skin atrophy.

For the purposes of this guidance, atopic eczema that has not been controlled by topical corticosteroids refers to disease that has not shown a satisfactory clinical response to adequate use of the maximum strength and potency that is appropriate for the patient's age and the area being treated.

It is recommended that treatment with tacrolimus or pimecrolimus be initiated only by physicians (including general practitioners) with a special interest and experience in dermatology, and only after careful discussion with the patient about the potential risks and benefits of all appropriate second-line treatment options.

In addition it has been decided locally that the transfer of prescribing from the specialist to primary care may be considered following the first prescription from the specialist.

The Surrey & North West Sussex APC recommends the use of tacrolimus and pimecrolimus in atopic eczema as BLUE (with no information sheet) on the traffic light system and as per NICE TA82:

Topical tacrolimus and pimecrolimus are not recommended for the treatment of mild atopic eczema or as first-line treatments for atopic eczema of any severity.

Pimecrolimus:

Pimecrolimus is recommended, within its licensed indications, as an option for the second-line treatment of moderate atopic eczema on the face and neck in children that has not been controlled by topical corticosteroids, where there is a serious risk of important adverse effects from further topical corticosteroid use, particularly irreversible skin atrophy.

For the purposes of this guidance, atopic eczema that has not been controlled by topical corticosteroids refers to disease that has not shown a satisfactory clinical response to adequate use of the maximum strength and potency that is appropriate for the patient's age and the area being treated.

It is recommended that treatment with tacrolimus or pimecrolimus be initiated only by physicians (including general practitioners) with a special interest and experience in dermatology, and only after careful discussion with the patient about the potential risks and benefits of all appropriate second-line treatment options.

In addition it has been decided locally that the transfer of prescribing from the specialist to primary care may be considered following the first prescription from the specialist.

The Surrey & North West Sussex APC recognises the off-label use of tacrolimus and pimecrolimus (topical use) for short-term treatment of facial, flexural, or genital psoriasis in patients unresponsive to, or intolerant of other topical therapy as per the NICE clinical guidance (CG153) Psoriasis: assessment and management.

This is considered as BLUE (with no information sheet), with the following taken from the guidance:

• Calcineurin inhibitors should be initiated by healthcare professionals with expertise in treating psoriasis
• The prescriber should follow relevant professional guidance, taking full responsibility for the decision 
• The patient (or their parent or carer) should provide informed consent, which should be documented
• See the General Medical Council's Good practice in prescribing medicines – guidance for doctors for further information.

In addition, it has been decided locally that the transfer of prescribing from the specialist to primary care may be considered following the first prescription from the specialist.

The Surrey & North West Sussex APC recognises the off-label use of tacrolimus and pimecrolimus (topical use) for short-term treatment of facial, flexural, or genital psoriasis in patients unresponsive to, or intolerant of other topical therapy as per the NICE clinical guidance (CG153) Psoriasis: assessment and management.

This is considered as BLUE (with no information sheet), with the following taken from the guidance:

• Calcineurin inhibitors should be initiated by healthcare professionals with expertise in treating psoriasis
• The prescriber should follow relevant professional guidance, taking full responsibility for the decision 
• The patient (or their parent or carer) should provide informed consent, which should be documented
• See the General Medical Council's Good practice in prescribing medicines – guidance for doctors for further information.

In addition, it has been decided locally that the transfer of prescribing from the specialist to primary care may be considered following the first prescription from the specialist.

ULCERATIVE COLITIS

The Surrey & North West Sussex Area Prescribing Committee recommends ustekinumab for treating moderately to severely active ulcerative colitis in line with NICE TA633. 

The Area Prescribing Committee also agreed an update of treatment pathway 4 (high cost immunomodulator) for use in Inflammatory Bowel Disease. The Crohn's Disease Pathway and the Ulcerative Colitis Pathway are now incorporated into one document 

The Surrey & North West Sussex Area Prescribing Committee recommends the use of vedolizumab subcutaneous injection or vedolizumab intravenous infusion. Clinicians & patients will be able to choose the most appropriate product for them at the point of prescribing.

Please note: Dose escalation with vedolizumab is not commissioned for either presentation, by the APC collaborative organisations.

The Surrey & North West Sussex Area Prescribing Committee recommends the following 

Calcitriol (as Silkis®) is GREEN for use in adults. The safety and efficacy of Silkis® in children less than 18 years have not been established. This is the preferred vitamin D analogue for use in adults.

Calcipotriol is GREEN for adults and for treating children 6 years of age and upwards. The preferred, most cost-effective calcipotriol product is *Dovonex®. https://surreyccg.res-systems.net/PAD/Search/DrugConditionProfile/6381

Tacalcitol (as Curatoderm®) is BLACK https://surreyccg.res-systems.net/PAD/Search/DrugConditionProfile/6380

Follow link below to Clinical Knowledge summary for Psoriasis management.

The Surrey & North West Sussex Area Prescribing Committee recommends the following 

Calcitriol (as Silkis®) is GREEN for use in adults. The safety and efficacy of Silkis® in children less than 18 years have not been established. This is the preferred vitamin D analogue for use in adults. https://surreyccg.res-systems.net/PAD/Search/DrugConditionProfile/4223

Calcipotriol is GREEN for adults and for treating children 6 years of age and upwards. The preferred, most cost-effective calcipotriol product is *Dovonex®. 

Tacalcitol (as Curatoderm®) is BLACK https://surreyccg.res-systems.net/PAD/Search/DrugConditionProfile/6380

Follow link below to Clinical Knowledge summary for Psoriasis management.

The Surrey & North West Sussex Area Prescribing Committee recommends the following 

Calcitriol (as Silkis®) is GREEN for use in adults. The safety and efficacy of Silkis® in children less than 18 years have not been established. This is the preferred vitamin D analogue for use in adults.https://surreyccg.res-systems.net/PAD/Search/DrugConditionProfile/4223

Calcipotriol is GREEN for adults and for treating children 6 years of age and upwards. The preferred, most cost-effective calcipotriol product is *Dovonex®. https://surreyccg.res-systems.net/PAD/Search/DrugConditionProfile/6381

Tacalcitol (as Curatoderm®) is BLACK 

Follow link below to Clinical Knowledge summary for Psoriasis management.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

This drug is currently not on the APC work plan. The APC will consider recommending prescribing of this treatment upon submission of a formal request with its associated evidence. Prescribing should remain with the specialist team looking after the patient and GPs should not prescribe if asked to do so.

Specialists should contact the formulary pharmacist at your acute trust, if you wish to make a submission to APC.

This drug / device falls under the responsibility of NHS England Specialised Commissioning and should therefore not be prescribed in Primary Care

The use of tamoxifen for prevention of gynaecomastia in men undergoing treatment for prostate cancer is an off-label indication and traffic light status has yet to be considered by the APC.

NICE guidance is clear that patients should have been offered prophylactic radiotherapy to both breast buds within the first month of treatment with bicalutamide. Weekly tamoxifen (20mg) could then be considered if radiotherapy does not prevent gynaecomastia

Primary care prescribers should have confirmation that the patient has been treated in line with NICE guidance (NG131) before agreeing to prescribe. https://www.nice.org.uk/guidance/ng131/resources/prostate-cancer-diagnosis-and-management-pdf-66141714312133

Picato is no longer authorised in the EU as the marketing authorisation was withdrawn on 11 February 2020 at the request of LEO Laboratories Ltd, the company that marketed the medicine. 

The Actinic Keratosis guidelines have been updated and are attached below which reflect this change in status.

The Surrey & North West Sussex Area Prescribing Committee (APC) recommend the prescribing o betahistine for the treatment of Meniere's Disease in line with NICE Clinical Knowledge Summaries (CKS) https://cks.nice.org.uk/menieres-disease  

NOTE - the branded product, Serc, was considered BLACK at the PCN in May 2017. https://surreyccg.res-systems.net/PAD/Search/DrugConditionProfile/5580

The Surrey & North West Sussex Area Prescribing Committee (APC) do not recommend the use of betahistine for Tinnitus. This is in line with recommendations made by NICE (NG155) Tinnitus: assessment and management (NG155) NICE states:

'Do not offer' betahistine for tinnitus

The use of oral nutritional supplements (ONS) containing <1.5kcal per ml are of limited value to patients and have been assigned a BLACK traffic light status.

Please refer to your CCG's Preferred ONS Guidance (Surrey Heartlands or Surrey Heath) that can be found here: https://surreyccg.res-systems.net/PAD/Guidelines/Detail/4404

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

The Surrey & North West Sussex Area Prescribing Committee updated their recommendations in line with NICE guidance NG23 Menopause diagnosis and management in May 2020.

Tibolone is not recommended for prescribing for low libido in women and a NON FORMULARY light status has been agreed. Please refer to the Menopause -NG23 briefing paper attached below for further information (Page 17). 

The Surrey & North West Sussex Area Prescribing Committee updated their recommendations in line with NICE guidance NG23 Menopause diagnosis and management in May 2020.

Duavive has been withdrawn from the UK market. Any patient taking Duavive should be reviewed and switched to an alternative preparation.

The Surrey & North West Sussex Area Prescribing Committee updated their recommendations in line with NICE guidance NG23 Menopause diagnosis and management in May 2020.

Mirena is recommended for menopausal symptoms and a GREEN traffic light status has been agreed. Please refer to the Menopause -NG23 briefing paper attached below for further information (Page 11/12).  The Mirena® IUS (52 mg LNG) is the only intrauterine system licensed as part of HRT and needs to be
changed every 5 years (licensed for 4 years; recommended by the Faculty of Sexual and Reproductive Healthcare (FRSH) and licensed in other EU countries for 5 years)

The Surrey & North West Sussex Area Prescribing Committee updated their recommendations in line with NICE guidance NG23 Menopause diagnosis and management in May 2020.

Paroxetine is recommended for menopausal symptoms and a BLUE (with no information sheet) traffic light status has been agreed. Please refer to the Menopause -NG23 briefing paper attached below for further information (Page 13/14). Paroxetine should not be routinely offered as a first line treatment for vasomotor symptoms. 
 

The Surrey & North West Sussex Area Prescribing Committee updated their recommendations in line with NICE guidance NG23 Menopause diagnosis and management in May 2020.

Venlafaxine is recommended for menopausal symptoms and a BLUE (with no information sheet) traffic light status has been agreed. Please refer to the Menopause -NG23 briefing paper attached below for further information (Page 13/14). SNRIs should not be routinely offered as a first line treatment for vasomotor symptoms. 
 

The Surrey & North West Sussex Area Prescribing Committee updated their recommendations in line with NICE guidance NG23 Menopause diagnosis and management in May 2020.

Clonidine is recommended for menopausal symptoms and a BLUE (with no information sheet) traffic light status has been agreed. Please refer to the Menopause -NG23 briefing paper attached below for further information (Page 13/14). SNRIs should not be routinely offered as a first line treatment for vasomotor symptoms. Clonidine is the only non-hormonal drug with a licenced indication for control of hot flushes in the UK. 

The Surrey & North West Sussex Area Prescribing Committee updated their recommendations in line with NICE guidance NG23 Menopause diagnosis and management in May 2020.

Gabapentinoids are recommended for menopausal symptoms and a BLUE (with no information sheet) traffic light status has been agreed. Please refer to the Menopause -NG23 briefing paper attached below for further information (Page 13/14). Gabapentenoids should not be routinely offered as a first line treatment for vasomotor symptoms.

The Surrey & North West Sussex Area Prescribing Committee updated their recommendations in line with NICE guidance NG23 Menopause diagnosis and management in May 2020.

St Johns Wort is not recommended for menopausal symptoms and a NON FORMULARY traffic light status has been agreed. Please refer to the Menopause -NG23 briefing paper attached below for further information (Page 14). 

The Surrey & North West Sussex Area Prescribing Committee updated their recommendations in line with NICE guidance NG23 Menopause diagnosis and management in May 2020.

Non-hormonal lubricants are not recommended for menopausal symptoms and a NON FORMULARY traffic light status has been agreed. Please refer to the Menopause -NG23 briefing paper attached below for further information (Page 16).  Non hormonal moisturisers and lubicants can be used as an alternative where HRT is not  clinically appopropriate but these are not as effective as oestrogen therapy. These products are available Over the Counter (OTC)

The Surrey & North West Sussex Area Prescribing Committee recommends Lusutrombopag for treating thrombocytopenia in people with chronic liver disease needing a planned invasive procedure in line with NICE guidance (NICE TA 617)

Lusutrombopag is a payment by results excluded medicine and will be considered RED on the traffic light system. Prescribers will be required to complete a blueteq form at initiation 

Primary care prescribers should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication

The Surrey & North West Sussex Area Prescribing Committee have agreed the updated guidance on calculating creatinine clearance for DOACs. See below. The DOAC selection tool updated in October 2019, remains unchanged.

The Surrey & North West Sussex Area Prescribing Committee have agreed the updated guidance on calculating creatinine clearance for DOACs. See below. The DOAC selection tool updated in October 2019, remains unchanged.

The Surrey & North West Sussex Area Prescribing Committee have agreed the updated guidance on calculating creatinine clearance for DOACs. See below. The DOAC selection tool updated in October 2019, remains unchanged.

The Surrey & North West Sussex Area Prescribing Committee have agreed the updated guidance on calculating creatinine clearance for DOACs. See below. The DOAC selection tool updated in October 2019, remains unchanged.

The Surrey & North West Sussex Area Prescribing Committee will not move to implement this guidance until this product has been launched in the UK. Please see the statement from NICE in relation to implementation timeframes for this guidance:

Section 7(6) of the National Institute for Health and Care Excellence (Constitution and Functions) and the Health and Social Care Information Centre (Functions) Regulations 2013 requires clinical commissioning groups, NHS England and, with respect to their public health functions, local authorities to comply with the recommendations in this appraisal within 3 months of its date of publication. However, the company has informed NICE that sotagliflozin is not yet available in the NHS. Therefore, the period during which the NHS in England has to comply with the recommendations has been extended to within 3 months of the commercial launch of sotogliflozin in England. This extension is made under section 7(5b) of the regulations

The Voke Inhaler should only be used as part of a smoking cessation programme.

Primary Care Prescribers should not prescribe if asked to do so by a patient. 

The Primary Care Prescriber is advised to refer the patient to One You Surrey stop smoking service, where appropriate advice and support can be tailored to the patient’s needs.  

Refer your patient to One You Surrey:
• ONE YOU Surrey https://oneyousurrey.org.uk/
• EMIS referral form template available.  Email to: s.smoking@nhs.net

The Surrey & North West Sussex Area Prescribing Committee have agreed the updated guidance on calculating creatinine clearance for DOACs. See below. The DOAC selection tool updated in October 2019, remains unchanged.

The Surrey & North West Sussex Area Prescribing Committee recommends the use of domperidone for the treatment of nausea and vomiting as follows:

• GREEN - For relief of the symptoms of nausea and vomiting only in adults and adolescents 12 years of age or older and weighing 35kg or more. Domperidone should be used at the lowest effective dose for the shortest possible duration and maximum treatment duration should not usually exceed 1 week

• RED - For any indications in children younger than 12 years or those weighing less than 35kg, only when prescribed within a secondary care setting and treatment duration should not exceed one week.

These changes are in line with the MHRA advice published in December 2019. Domperidone is no longer licensed for use in patients under 12 or those patients weighing less than 35kg. 

Prescribers should ensure that the patient/carer/legal guardian understands the risks and consents to using domperidone off-label noting the MHRA alert (updated 2019)

 MHRA Drug Safety Update, December 2019: https://www.gov.uk/drug-safety-update/domperidone-for-nausea-and-vomiting-lack-of-efficacy-in-children-reminder-of-contraindications-in-adults-and-adolescents

Primary care prescribers should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication  

Airomir Autohaler is not a locally preferred device.

The locally preferred salbutamol devices are as follows:

Low carbon:

• Salbutamol Easyhaler (dry powder inhaler)
• Ventolin Accuhaler (dry powder inhaler)

Alternative devices:

• Salamol (MDI) is the locally preferred salbutamol metered dose inhaler device and should be used with a spacer device. It has a lower carbon footprint than the large volume MDIs such as Ventolin.
• Ventolin Evohaler (MDI) 

Branded prescribing of inhaler devices is recommended.

See COPD local guidelines below

Atrovent (Ipratropium MDI) should be reserved for patients who cannot tolerate salbutamol (Salamol MDI is the locally preferred salbutamol MDI device).

A spacer device should be used with MDI devices.

Branded prescribing of inhaler devices is recommended.

See COPD local guidelines below

The locally preferred LAMA devices are as follows:

• Spiriva Respimat (tiotropium soft mist inhaler). Re-usable device.
• Incruse Ellipta (Umeclidinium DPI)
• Seebri Breezhaler (Glycopyrronium DPI)
• Eklira Genuair (Aclidinium DPI)

Devices should be prescribed by BRAND

See full COPD guidelines for more information

The locally preferred LAMA devices are as follows:

• Spiriva Respimat (tiotropium soft mist inhaler). Re-usable device.
• Incruse Ellipta (Umeclidinium DPI)
• Seebri Breezhaler (Glycopyrronium DPI)
• Eklira Genuair (Aclidinium DPI)

Devices should be prescribed by BRAND

See full COPD guidelines for more information

The locally preferred LAMA devices are as follows:

• Spiriva Respimat (tiotropium soft mist inhaler). Re-usable device.
• Incruse Ellipta (Umeclidinium DPI)
• Seebri Breezhaler (Glycopyrronium DPI)
• Eklira Genuair (Aclidinium DPI)

Devices should be prescribed by BRAND

See full COPD guidelines for more information

The locally preferred LAMA devices are as follows:

• Spiriva Respimat (tiotropium soft mist inhaler). Re-usable device.
• Incruse Ellipta (Umeclidinium DPI)
• Seebri Breezhaler (Glycopyrronium DPI)
• Eklira Genuair (Aclidinium DPI)

Devices should be prescribed by BRAND

See full COPD guidelines for more information

The tiotropium Braltus device is NOT a locally preferred option. See below for preferred devices.

The locally preferred LAMA devices are as follows:

• Spiriva Respimat (tiotropium soft mist inhaler). Re-usable device.
• Incruse Ellipta (Umeclidinium DPI)
• Seebri Breezhaler (Glycopyrronium DPI)
• Eklira Genuair (Aclidinium DPI)

Devices should be prescribed by BRAND

See full COPD guidelines for more information

The Spiriva Handihaler device is NOT a locally preferred option.

The locally preferred LAMA devices are as follows:

• Spiriva Respimat (tiotropium soft mist inhaler). Re-usable device.
• Incruse Ellipta (Umeclidinium DPI)
• Seebri Breezhaler (Glycopyrronium DPI)
• Eklira Genuair (Aclidinium DPI)

Devices should be prescribed by BRAND

See full COPD guidelines for more information

The locally preferred LAMA/LABA devices are as follows:

• Spiolto Respimat (tiotropium / olodaterol soft mist inhaler). Re-usable device.
• Anoro Ellipta (Umeclidinium / vilanterol DPI)
• Ultibro Breezhaler (Glycopyrronium / indacaterol DPI)
• Duaklir Genuair (Aclidinium / formoterol DPI)

Devices should be prescribed by BRAND

See full COPD guidelines for more information

The locally preferred LAMA/LABA devices are as follows:

• Spiolto Respimat (tiotropium / olodaterol soft mist inhaler). Re-usable device.
• Anoro Ellipta (Umeclidinium / vilanterol DPI)
• Ultibro Breezhaler (Glycopyrronium / indacaterol DPI)
• Duaklir Genuair (Aclidinium / formoterol DPI)

Devices should be prescribed by BRAND

See full COPD guidelines for more information

The locally preferred LAMA/LABA devices are as follows:

• Spiolto Respimat (tiotropium / olodaterol soft mist inhaler). Re-usable device.
• Anoro Ellipta (Umeclidinium / vilanterol DPI)
• Ultibro Breezhaler (Glycopyrronium / indacaterol DPI)
• Duaklir Genuair (Aclidinium / formoterol DPI)

Devices should be prescribed by BRAND

See full COPD guidelines for more information

The locally preferred LAMA/LABA devices are as follows:

• Spiolto Respimat (tiotropium / olodaterol soft mist inhaler). Re-usable device.
• Anoro Ellipta (Umeclidinium / vilanterol DPI)
• Ultibro Breezhaler (Glycopyrronium / indacaterol DPI)
• Duaklir Genuair (Aclidinium / formoterol DPI)

Devices should be prescribed by BRAND

See full COPD guidelines for more information

The locally preferred ICS/LABA devices are as follows:

• Low carbon:

• Fostair Nexthaler (beclometasone / formoterol DPI)
• Fobumix Easyhaler (budesonide / formoterol DPI)
• Relvar Ellipta (Fluticasone / vilanterol DPI)
• Symbicort Turbohaler (budesonide / formoterol DPI)

• Alternative devices:

• Fostair (beclometasone / formoterol MDI)
• Symbicort (budesonide / formoterol MDI)

Devices should be prescribed by BRAND

A spacer device should be used with MDI devices.

See full COPD guidelines below

The locally preferred ICS/LABA devices are as follows:

Low carbon:

• Fostair Nexthaler (beclometasone / formoterol DPI)
• Fobumix Easyhaler (budesonide / formoterol DPI)
• Relvar Ellipta (Fluticasone / vilanterol DPI)
• Symbicort Turbohaler (budesonide / formoterol DPI)

Alternative devices:

• Fostair (beclometasone / formoterol MDI)
• Symbicort (budesonide / formoterol MDI)

Devices should be prescribed by BRAND

A spacer device should be used with MDI devices.

See full COPD guidelines below

The locally preferred ICS/LABA devices are as follows:

Low carbon:

• Fostair Nexthaler (beclometasone / formoterol DPI)
• Fobumix Easyhaler (budesonide / formoterol DPI)
• Relvar Ellipta (Fluticasone / vilanterol DPI)
• Symbicort Turbohaler (budesonide / formoterol DPI)

Alternative devices:

• Fostair (beclometasone / formoterol MDI)
• Symbicort (budesonide / formoterol MDI)

Devices should be prescribed by BRAND

A spacer device should be used with MDI devices.

See full COPD guidelines below

The locally preferred ICS/LABA devices are as follows:

Low carbon:

• Fostair Nexthaler (beclometasone / formoterol DPI)
• Fobumix Easyhaler (budesonide / formoterol DPI)
• Relvar Ellipta (Fluticasone / vilanterol DPI)
• Symbicort Turbohaler (budesonide / formoterol DPI)

Alternative devices:

• Fostair (beclometasone / formoterol MDI)
• Symbicort (budesonide / formoterol MDI)

Devices should be prescribed by BRAND

A spacer device should be used with MDI devices.

See full COPD guidelines below

The locally preferred ICS/LABA devices are as follows:

Low carbon:

• Fostair Nexthaler (beclometasone / formoterol DPI)
• Fobumix Easyhaler (budesonide / formoterol DPI)
• Relvar Ellipta (Fluticasone / vilanterol DPI)
• Symbicort Turbohaler (budesonide / formoterol DPI)

Alternative devices:

• Fostair (beclometasone / formoterol MDI)
• Symbicort (budesonide / formoterol MDI)

Devices should be prescribed by BRAND

A spacer device should be used with MDI devices.

See full COPD guidelines below

The locally preferred ICS/LABA devices are as follows:

Low carbon:

• Fostair Nexthaler (beclometasone / formoterol DPI)
• Fobumix Easyhaler (budesonide / formoterol DPI)
• Relvar Ellipta (Fluticasone / vilanterol DPI)
• Symbicort Turbohaler (budesonide / formoterol DPI)

Alternative devices:

• Fostair (beclometasone / formoterol MDI)
• Symbicort (budesonide / formoterol MDI)

Devices should be prescribed by BRAND

A spacer device should be used with MDI devices.

See full COPD guidelines below

Duoresp Spiromax (budesonide / formoterol DPI) is NOT a locally preferred device although there is no expectation for existing stable patients to change drug or device unless agreed as a clinically appropriate course of action.

The locally preferred ICS/LABA devices are as follows:

Low carbon:

• Fostair Nexthaler (beclometasone / formoterol DPI)
• Fobumix Easyhaler (budesonide / formoterol DPI)
• Relvar Ellipta (Fluticasone / vilanterol DPI)
• Symbicort Turbohaler (budesonide / formoterol DPI)

Alternative devices:

• Fostair (beclometasone / formoterol MDI)
• Symbicort (budesonide / formoterol MDI)

Devices should be prescribed by BRAND

A spacer device should be used with MDI devices.

See full COPD guidelines below

Seretide Accuhaler (and other fluticasone containing ICS/LABAs) is NOT a locally preferred device although there is no expectation for existing stable patients to change drug or device unless agreed as a clinically appropriate course of action.

The locally preferred ICS/LABA devices are as follows:

Low carbon:

• Fostair Nexthaler (beclometasone / formoterol DPI)
• Fobumix Easyhaler (budesonide / formoterol DPI)
• Relvar Ellipta (Fluticasone / vilanterol DPI)
• Symbicort Turbohaler (budesonide / formoterol DPI)

Alternative devices:

• Fostair (beclometasone / formoterol MDI)
• Symbicort (budesonide / formoterol MDI)

Devices should be prescribed by BRAND

A spacer device should be used with MDI devices.

See full COPD guidelines below

Aerivio Spiromax (and other fluticasone containing ICS/LABAs) is NOT a locally preferred device although there is no expectation for existing stable patients to change drug or device unless agreed as a clinically appropriate course of action.

The locally preferred ICS/LABA devices are as follows:

Low carbon:

• Fostair Nexthaler (beclometasone / formoterol DPI)
• Fobumix Easyhaler (budesonide / formoterol DPI)
• Relvar Ellipta (Fluticasone / vilanterol DPI)
• Symbicort Turbohaler (budesonide / formoterol DPI)

Alternative devices:

• Fostair (beclometasone / formoterol pMDI)
• Symbicort (budesonide / formoterol pMDI)

Devices should be prescribed by BRAND

A spacer device should be used with MDI devices.

See full COPD guidelines below

Airflusal (and other fluticasone containing ICS/LABAs) is NOT a locally preferred device although there is no expectation for existing stable patients to change drug or device unless agreed as a clinically appropriate course of action.

The locally preferred ICS/LABA devices are as follows:

Low carbon:

• Fostair Nexthaler (beclometasone / formoterol DPI)
• Fobumix Easyhaler (budesonide / formoterol DPI)
• Relvar Ellipta (Fluticasone / vilanterol DPI)
• Symbicort Turbohaler (budesonide / formoterol DPI)

Alternative devices:

• Fostair (beclometasone / formoterol MDI)
• Symbicort (budesonide / formoterol MDI)

Devices should be prescribed by BRAND

A spacer device should be used with MDI devices.

See full COPD guidelines below

Airflusal Forspiro (and other fluticasone containing ICS/LABAs) is NOT a locally preferred device although there is no expectation for existing stable patients to change drug or device unless agreed as a clinically appropriate course of action.

The locally preferred ICS/LABA devices are as follows:

Low carbon:

• Fostair Nexthaler (beclometasone / formoterol DPI)
• Fobumix Easyhaler (budesonide / formoterol DPI)
• Relvar Ellipta (Fluticasone / vilanterol DPI)
• Symbicort Turbohaler (budesonide / formoterol DPI)

Alternative devices:

• Fostair (beclometasone / formoterol MDI)
• Symbicort (budesonide / formoterol MDI)

Devices should be prescribed by BRAND

A spacer device should be used with MDI devices.

See full COPD guidelines below

Aloflute (and other fluticasone containing ICS/LABAs) is NOT a locally preferred device although there is no expectation for existing stable patients to change drug or device unless agreed as a clinically appropriate course of action.

The locally preferred ICS/LABA devices are as follows:

Low carbon:

• Fostair Nexthaler (beclometasone / formoterol DPI)
• Fobumix Easyhaler (budesonide / formoterol DPI)
• Relvar Ellipta (Fluticasone / vilanterol DPI)
• Symbicort Turbohaler (budesonide / formoterol DPI)

Alternative devices:

• Fostair (beclometasone / formoterol MDI)
• Symbicort (budesonide / formoterol MDI)

Devices should be prescribed by BRAND

A spacer device should be used with MDI devices.

See full COPD guidelines below

Flutiform (and other fluticasone containing ICS/LABAs) is NOT a locally preferred device although there is no expectation for existing stable patients to change drug or device unless agreed as a clinically appropriate course of action.

The locally preferred ICS/LABA devices are as follows:

Low carbon:

• Fostair Nexthaler (beclometasone / formoterol DPI)
• Fobumix Easyhaler (budesonide / formoterol DPI)
• Relvar Ellipta (Fluticasone / vilanterol DPI)
• Symbicort Turbohaler (budesonide / formoterol DPI)

Alternative devices:

• Fostair (beclometasone / formoterol MDI)
• Symbicort (budesonide / formoterol MDI)

Devices should be prescribed by BRAND

A spacer device should be used with MDI devices.

See full COPD guidelines below

Flutiform K-haler (and other fluticasone containing ICS/LABAs) is NOT a locally preferred device although there is no expectation for existing stable patients to change drug or device unless agreed as a clinically appropriate course of action.

The locally preferred ICS/LABA devices are as follows:

Low carbon:

• Fostair Nexthaler (beclometasone / formoterol DPI)
• Fobumix Easyhaler (budesonide / formoterol DPI)
• Relvar Ellipta (Fluticasone / vilanterol DPI)
• Symbicort Turbohaler (budesonide / formoterol DPI)

Alternative devices:

• Fostair (beclometasone / formoterol MDI)
• Symbicort (budesonide / formoterol MDI)

Devices should be prescribed by BRAND

A spacer device should be used with MDI devices.

See full COPD guidelines below

Fusacomb Easyhaler (and other fluticasone containing ICS/LABAs) is NOT a locally preferred device although there is no expectation for existing stable patients to change drug or device unless agreed as a clinically appropriate course of action.

The locally preferred ICS/LABA devices are as follows:

Low carbon:

• Fostair Nexthaler (beclometasone / formoterol DPI)
• Fobumix Easyhaler (budesonide / formoterol DPI)
• Relvar Ellipta (Fluticasone / vilanterol DPI)
• Symbicort Turbohaler (budesonide / formoterol DPI)

Alternative devices:

• Fostair (beclometasone / formoterol MDI)
• Symbicort (budesonide / formoterol MDI)

Devices should be prescribed by BRAND

A spacer device should be used with MDI devices.

See full COPD guidelines below

Sereflo (and other fluticasone containing ICS/LABAs) is NOT a locally preferred device although there is no expectation for existing stable patients to change drug or device unless agreed as a clinically appropriate course of action.

The locally preferred ICS/LABA devices are as follows:

Low carbon:

• Fostair Nexthaler (beclometasone / formoterol DPI)
• Fobumix Easyhaler (budesonide / formoterol DPI)
• Relvar Ellipta (Fluticasone / vilanterol DPI)
• Symbicort Turbohaler (budesonide / formoterol DPI)

Alternative devices:

• Fostair (beclometasone / formoterol MDI)
• Symbicort (budesonide / formoterol MDI)

Devices should be prescribed by BRAND

A spacer device should be used with MDI devices.

See full COPD guidelines below

Seretide Evohaler (and other fluticasone containing ICS/LABAs) is NOT a locally preferred device although there is no expectation for existing stable patients to change drug or device unless agreed as a clinically appropriate course of action.

The locally preferred ICS/LABA devices are as follows:

Low carbon:

• Fostair Nexthaler (beclometasone / formoterol DPI)
• Fobumix Easyhaler (budesonide / formoterol DPI)
• Relvar Ellipta (Fluticasone / vilanterol DPI)
• Symbicort Turbohaler (budesonide / formoterol DPI)

Alternative devices:

• Fostair (beclometasone / formoterol MDI)
• Symbicort (budesonide / formoterol MDI)

Devices should be prescribed by BRAND

A spacer device should be used with MDI devices.

See full COPD guidelines below

Sirdupla (and other fluticasone containing ICS/LABAs) is NOT a locally preferred device although there is no expectation for existing stable patients to change drug or device unless agreed as a clinically appropriate course of action.

The locally preferred ICS/LABA devices are as follows:

Low carbon:

• Fostair Nexthaler (beclometasone / formoterol DPI)
• Fobumix Easyhaler (budesonide / formoterol DPI)
• Relvar Ellipta (Fluticasone / vilanterol DPI)
• Symbicort Turbohaler (budesonide / formoterol DPI)

Alternative devices:

• Fostair (beclometasone / formoterol MDI)
• Symbicort (budesonide / formoterol MDI)

Devices should be prescribed by BRAND

A spacer device should be used with MDI devices.

See full COPD guidelines below

The Area Prescribing Committee recommends the use of domperidone for the treatment of gastro-oesophageal reflux disease (GORD) in adults only when prescribed within a secondary care setting.

Domperidone will be considered RED on the traffic light system for this indication.

Prescribers should ensure that the patient understands the risks and consents to using domperidone off-label noting the MHRA alert (updated 2019) - https://www.gov.uk/drug-safety-update/domperidone-risks-of-cardiac-side-effects 

Primary care prescribers should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication

The Area Prescribing Committee recommends the use of domperidone for the treatment of dyspepsia in adults only when prescribed within a secondary care setting.

Domperidone will be considered RED on the traffic light system for this indication.

Prescribers should ensure that the patient understands the risks and consents to using domperidone off-label noting the MHRA alert (updated 2019) - https://www.gov.uk/drug-safety-update/domperidone-risks-of-cardiac-side-effects

Primary care prescribers should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication

The Area Prescribing Committee recommends the use of domperidone for the treatment of gastroparesis in adults only when prescribed within a secondary care setting.

Domperidone will be considered RED on the traffic light system for this indication.

Prescribers should ensure that the patient understands the risks and consents to using domperidone off-label noting the MHRA alert (updated 2019) - https://www.gov.uk/drug-safety-update/domperidone-risks-of-cardiac-side-effects 

Primary care prescribers should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication

The Area Prescribing Committee recommends Pentosan Polysulfate Sodium as a treatment option for bladder pain syndrome in line with NICE guidance (NICE TA 610)

Pentosan Polysulfate Sodium for this indication will be considered RED on the traffic light system. Pentosan is recommended by NICE for use in secondary care only

Primary care prescribers should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication

Propantheline bromide is not recommended for treating overactive bladder in line with NICE NG123 - guidance can be found below

Imipramine is not recommended for treating overactive bladder in line with NICE NG123 - guidance can be found below

Oxybutinin transdermal patches may be used in patients who are unable to take oral medication

The 1st line oral medications are Solifenacin or tolterodine immediate release (alternative 1st line option where the patient has pre-existing hepatic or renal impairment (GFR <30mls/min)) & can be commenced at lower doses.)

The Surrey & North West Sussex Area Prescribing Committee (APC) recommends Nabilone for chemotherapy induced nausea & vomiting in adult patients and it will be considered RED on the traffic light system. 

Providers (NHS and non-NHS) will be solely liable for clinical governance, prescribing responsibility and costs of all prescriptions of nabilone when it is used off-label i.e. outside of its marketing authorisation. Shared care will not be supported for an off-label use of nabilone.

Primary care prescribers should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient’s medication.

The Surrey & North West Sussex Area Prescribing Committee (APC) notes that NHS England routinely commissions cannabidiol for epilepsy in line with NICE TAs 614 and 615.

When cannabidiol is not being used in combination with clobazam, funding is via individual funding request (IFR) through NHS England.

Cannabidiol for epilepsy other than Lennox-Gastaut syndrome / Dravet syndrome: The APC confirmed that this would currently be an off-label / unlicensed use of a product with limited evidence for clinical efficacy or cost effectiveness. Clinicians who fulfil the legal criteria for the prescription of cannabidiol and who wish to prescribe it should check the responsible commissioner's Individual Funding Request (IFR) policy for more details.

PLEASE NOTE: only those centres commissioned to provide adult specialist neuroscience services or specialist neuroscience services for children should be prescribing cannabidiol for epilepsy. (See the specialised service letter SSC2111 (23rd December 2019) for further information and for lise of commissioned specialist centres).

Primary care prescribers should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient’s medication.

The Surrey & North West Sussex Area Prescribing Committee (APC) recommends that Cannabis based medicinal products (CBMP) for chronic pain are given a BLACK traffic light status in line with NICE NG144, which states that these products (nabilone, dronabinol, Tetrahydrocannabinol (THC) & the combination of THC & cannabidiol (Sativex) should not be offered to manage chronic pain in adult patients unless as part of a clinical trial.

The APC concurred that there is likely to be even less evidence available for children and young people, so the recommendation should apply to all ages. 

Providers (NHS and non-NHS) will be solely liable for clinical governance, prescribing responsibility and costs of all prescriptions of cannabis-based medicinal products when it is used off-label i.e. outside of its marketing authorisation. Shared care will not be supported for an off-label uses.

Primary care prescribers should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient’s medication.

The Area Prescribing Committee recommends the use of low weight molecular heparins (LWMH) for the treatment of VTE in those patients who are unable to take oral anticoagulants (excluding obstetric patients and those on current cancer chemotherapy).

LMWH will be considered BLUE (no information sheet) on the traffic light system for the above indications (see below for exclusions).

The specialist should prescribe the initial 1st month of drug treatment. Primary care can take over prescribing upon receipt of an agreed treatment plan from the specialist, which must include details of drug dosage, possible side-effects, and action to take if problems arise, as per local guidance.

LMWH will be considered RED for obstetric use and in patients on current cancer chemotherapy.

Primary care prescriber should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication

The Area Prescribing Committee recommends the use of low weight molecular heparins (LWMH) for the treatment of VTE in those patients who are unable to take oral anticoagulants (excluding obstetric patients and those on current cancer chemotherapy).

LMWH will be considered BLUE (no information sheet) on the traffic light system for the above indications (see below for exclusions).

The specialist should prescribe the initial 1st month of drug treatment. Primary care can take over prescribing upon receipt of an agreed treatment plan from the specialist, which must include details of drug dosage, possible side-effects, and action to take if problems arise, as per local guidance.

LMWH will be considered RED for obstetric use and in patients on current cancer chemotherapy.

Primary care prescriber should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication

The Area Prescribing Committee recommends the use of low weight molecular heparins (LWMH) for the treatment of VTE in those patients who are unable to take oral anticoagulants (excluding obstetric patients and those on current cancer chemotherapy).

LMWH will be considered BLUE (no information sheet) on the traffic light system for the above indications (see below for exclusions).

The specialist should prescribe the initial 1st month of drug treatment. Primary care can take over prescribing upon receipt of an agreed treatment plan from the specialist, which must include details of drug dosage, possible side-effects, and action to take if problems arise, as per local guidance.

LMWH will be considered RED for obstetric use and in patients on current cancer chemotherapy.

Primary care prescriber should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication

The APC noted this advisory statement from the RMOC and agreed that the current commissioning policy with regards to this drug should be amended to reflect these recommendations.

The Area Prescribing Committee recommends sodium zirconium cyclosilicate as a treatment option for the treatment of hyperkalaemia in line with NICE TA599

Sodium zirconium cyclosilicate will be considered RED on the traffic light system

Primary care prescribers should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient’s medication.

The Surrey & North West Sussex Area Prescribing Committee recommends the off label use of domperidone for the treatment of gastric reflux in neonates and children only when prescribed within a secondary care setting. Treatment duration is restricted to a maximum of one week in all patients*.

Prescribers should ensure that the patient understands the risks and consents to using domperidone off-label noting the MHRA alert (updated 2019)

Primary care prescribers should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication

Domperidone will be considered RED on the traffic light system for this indication.

MHRA drug safety update (December 2019) https://www.gov.uk/drug-safety-update/domperidone-for-nausea-and-vomiting-lack-of-efficacy-in-children-reminder-of-contraindications-in-adults-and-adolescents

The Surrey & North West Sussex Area Prescribing Committee recommends the off label use of domperidone for the stimulation of lactation only when prescribed within a secondary care setting. Treatment duration is restricted to a maximum of one week in all patients*.

Prescribers should ensure that the patient understands the risks and consents to using domperidone off-label noting the MHRA alert (updated 2019)

Primary care prescribers should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication

Domperidone will be considered RED on the traffic light system for this indication.

*MHRA drug safety update (December 2019) https://www.gov.uk/drug-safety-update/domperidone-for-nausea-and-vomiting-lack-of-efficacy-in-children-reminder-of-contraindications-in-adults-and-adolescents

The Surrey & North West Sussex Area Prescribing Committee recommends the off label use of domperidone for the treatment of nausea & vomiting  when used in conjunction with apomorphine in Parkinson's Disease patients, only when prescribed within a secondary care setting. Treatment duration is restricted to a maximum of one week in all patients*.

Prescribers should ensure that the patient understands the risks and consents to using domperidone off-label, noting the updated MHRA alert (December 2019) and the MHRA drug safety update (April 2016) in relation to this treatment combination.

Primary care prescribers should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication

Domperidone will be considered RED on the traffic light system for this indication.

*MHRA drug safety update (December 2019) https://www.gov.uk/drug-safety-update/domperidone-for-nausea-and-vomiting-lack-of-efficacy-in-children-reminder-of-contraindications-in-adults-and-adolescents

MHRA drug safety update (April 2016) : Apomorphine with domperidone: minimising risk of cardiac side effects https://www.gov.uk/drug-safety-update/apomorphine-with-domperidone-minimising-risk-of-cardiac-side-effects

The Surrey & North West Sussex Area Prescribing Committee recommends the off label use of domperidone for the treatment of nausea & vomiting  when used in Parkinson's Disease patients, as recommended within NICE Clinical Knowledge Summaries (CKS) https://cks.nice.org.uk/parkinsons-disease 

Treatment duration is restricted to a maximum of one week in all patients*.

Prescribers should ensure that the patient understands the risks and consents to using domperidone off-label noting the MHRA drug safety alert (updated December 2019)

Domperidone will be considered GREEN on the traffic light system for this indication.

*MHRA drug safety update (December 2019) https://www.gov.uk/drug-safety-update/domperidone-for-nausea-and-vomiting-lack-of-efficacy-in-children-reminder-of-contraindications-in-adults-and-adolescents

The Area Prescribing Committee recommends fluocinolone acetonide as a treatment option in recurrent non-infectious uveitis in line with NICE TA590

Fluocinolone acetonide intravitreal implant will be considered RED on the traffic light system

Prescribing would be by hospital specialists only, in line with NICE TA596 using the Blueteq initiation and continuation forms.

Primary care prescribers should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient’s medication.

The APC recommends the use of biosimilar teriparatide in all new patients for all CCG-commissioned indications.

Teriparatide is considered as RED on the traffic light system.

Prescribing would be by hospital specialists only, in line with NICE and using the Blueteq initiation and repeat treatment forms.

Primary care prescribers should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient’s medication.

Please note: the Medicines Healthcare Products Regulatory Agency (MHRA) recommends that biological products are prescribed by brand name to ensure that substitution of a biosimilar product does not occur when the medicine is dispensed by the pharmacist.

https://www/gov/uk/drug-safety-update/biosimilar-products 

Tthe NHS England guidance ‘Items which should not routinely be prescribed in primary care: Guidance for CCGs’ Version 2, June 2019 states that amiodarone is only to be initiated by specialists in exceptional circumstances where other treatments cannot be used or have failed: 

1) in line with NICE Guidance CG180 https://www.nice.org.uk/guidance/CG180 in patients: 
- prior and post electrocardioversion / ablation; OR 
- who have heart failure or left ventricular impairment; OR 
- requiring pharmacological cardioversion; OR 
- undergoing cardiothoracic surgery 

2) in patients with ventricular tachycardia / ventricular fibrillation and tachyarrhythmias associated with Wolff-Parkinson-White syndrome.

 In these circumstances amiodarone must be initiated by a specialist and only continued in primary care under a shared care arrangement. Amiodarone should always be initiated with a treatment plan including dose schedule and when amiodarone is intended to be stopped. As such amiodarone will be considered AMBER on the traffic light system for the above indications.

Fluorouracil 5% cream (Efudix) has been agreed as an appropriate treatment option for aktinic keratosis and may be initiated in Primary Care.

The APC has made recommendations for the primary care treatment choices for actinic keratosis - see treatment guidelines below.

Diclofenac 3% gel has been agreed as an appropriate treatment option for aktinic keratosis and may be initiated in Primary Care.

The APC has made recommendations for the primary care treatment choices for actinic keratosis - see treatment guidelines below.

Imiquimod 5% should only be initiated on specialist advice.

The APC has made recommendations for the primary care treatment choices for actinic keratosis - see treatment guidelines below.

Fluorouracil/Salicylic Acid (Actikerall) should only be initiated on specialist advice.

The APC has made recommendations for the primary care treatment choices for actinic keratosis - see treatment guidelines below.
 

The APC does not support the routine use of Imiquimod 3.75% cream (Zyclara®) and it should be considered as BLACK on the traffic light system. 

The APC has made recommendations for the primary care treatment choices for actinic keratosis - see treatment guidelines below.

This drug / device falls under the responsibility of NHS England Specialised Commissioning and should therefore not be prescribed in Primary Care.
Treatment should remain with the specialist (RED) hospital only drug.

GPs should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient’s medication.

This drug / device falls under the responsibility of NHS England Specialised Commissioning and should therefore not be prescribed in Primary Care.
Treatment should remain with the specialist (RED) hospital only drug.

GPs should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient’s medication.

This drug is currently not on the APC workplan.

The APC will consider recommending prescribing of this treatment upon submission of a formal request with its associated evidence. Please contact your local CCG Medicines Management team OR formulary pharmacist at your acute trust, if you wish to make a submission.

This drug for this indiication has not yet been evaluated by NICE or the Surrey and North West Sussex Area Prescribing Committee (APC). As such, advice regarding safety, effectiveness (including cost-effectiveness) and its place in therapy is yet to be determined. It is recommended that clinicians contact their medicines management team for further information and advice before prescribing.

The Surrey & North West Sussex Area Prescribing Committee have agreed a Creatinine Clearance calculator for reference by prescribers. Please see below

The Surrey & North West Sussex Area Prescribing Committee have agreed a Creatinine Clearance calculator for reference by prescribers. Please see below

The Surrey & North West Sussex Area Prescribing Committee have agreed a Creatinine Clearance calculator for reference by prescribers. Please see below

The Surrey and North West Sussex Area Prescribing Committee (APC) does not recommend the use of melatonin (Slenyto) for the treatment of insomnia in children and adolescents (aged 2 – 18).

Melatonin (Slenyto) prolonged release tablets for this indication will be given a BLACK status (for all indications including the licensed status), on the traffic light system and is not recommended for use in any health setting across Surrey & North West Sussex health economy.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process

The Surrey & North West Sussex Area Prescribing Committee have agreed a guide to contraceptive prescribing in primary care (see attached below), which is a quick reference guidance to be used in conjunction with CKS.

Depo- provera (medroxyprogesterone) - Patient Specific Directions (PSDs) are often used to enable non-medical practitioners (practice nurses, health care assistants) to administer specific medicines for specific conditions. A PSD tempate for EMIS system users has been developed by a local GP practice to improve the consistency and content of their Depo-provera PSDs.
This PSD template (among others) is available from your local Medicines Management Team should your practice wish to adopt / adapt it.

Please contact your local Medicines Management Team for assistance

The Surrey & North West Sussex Area Prescribing Committee have agreed a guide to contraceptive prescribing in primary care (see attached below), which is a quick reference guidance to be used in conjunction with CKS.

Prescribe generically as desogestrel, levonorgestrel or norethisterone 

The Surrey & North West Sussex Area Prescribing Committee have agreed a guide to contraceptive prescribing in primary care (see attached below), which is a quick reference guidance to be used in conjunction with CKS.

Livest and Rigevidon (ethinylestradiol/levonorgestrel) are considered 1st line options where a combined hormonal contraception is indicated.

The APC have made  recommendations for alternative brands of contraception in the past . Prescribers are requested to consider cost effectiveness where alternatives are clinically indicated.

If there are compliance issues with ORAL combined hormonal contraception, consider using combined transdermal patch (Evra®) or combined vaginal ring (Nuvaring®) as alternative options

Please follow links here to NHS advice: 

https://www.nhs.uk/conditions/contraception/combined-contraceptive-pill/

https://cks.nice.org.uk/contraception-combined-hormonal-methods#!scenario

The Surrey and North West Sussex Area Prescribing Committee (APC) does not recommend the use of melatonin for use in the treatment of jet lag in adults.

Melatonin for this indication will be given a BLACK status on the traffic light system and is not recommended for use in any health setting across Surrey & North West Sussex health economy.

See policy statement below for further information

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

A clinical trial has shown an increased risk of recurrent thrombotic events associated with rivaroxaban compared with warfarin, in patients with antiphospholipid syndrome and a history of thrombosis. Other direct-acting oral anticoagulants (DOACs) may be associated with a similarly increased risk.
Please see Thrombosis risk safety alert information below

The September APC also agreed the use of a DOAC patient information leaflet and a counselling checklist for use by healthcare professionals when patients commence DOAC therapy - see documents below

A clinical trial has shown an increased risk of recurrent thrombotic events associated with rivaroxaban compared with warfarin, in patients with antiphospholipid syndrome and a history of thrombosis. Other direct-acting oral anticoagulants (DOACs) may be associated with a similarly increased risk.
Please see Thrombosis risk safety alert information below

The September APC also agreed the use of a DOAC patient information leaflet and a counselling checklist for use by healthcare professionals when patients commence DOAC therapy - see documents below

A clinical trial has shown an increased risk of recurrent thrombotic events associated with rivaroxaban compared with warfarin, in patients with antiphospholipid syndrome and a history of thrombosis. Other direct-acting oral anticoagulants (DOACs) may be associated with a similarly increased risk.
Please see Thrombosis risk safety alert information below

The September APC also agreed the use of a DOAC patient information leaflet and a counselling checklist for use by healthcare professionals when patients commence DOAC therapy - see documents below

A clinical trial has shown an increased risk of recurrent thrombotic events associated with rivaroxaban compared with warfarin, in patients with antiphospholipid syndrome and a history of thrombosis. Other direct-acting oral anticoagulants (DOACs) may be associated with a similarly increased risk.
Please see Thrombosis risk safety alert information below

The September APC also agreed the use of a DOAC patient information leaflet and a counselling checklist for use by healthcare professionals when patients commence DOAC therapy - see documents below

The Surrey and North West Sussex Area Prescribing Committee (APC) recommends ertugliflozin as an option for the treating type 2 diabetes in line with NICE TA583
Ertugluiflozin (in combination) will be considered GREEN on the traffic light system

The Surrey & North West Sussex Area Prescribing Committee (APC) does not recommend the use of oro-dispersible risperidone tablets (all indications) as there are more cost effective alternatives available

Risperidone oro-dispersible tablets will be considered BLACK on the traffic light system. Not recommended for use in any health setting across Surrey & North West Sussex health economy.

The Surrey & North West Sussex Area Prescribing Committee (APC) recommends risankizumab as a treatment option in adult patients with moderate to severe plaque psoriasis in line with NICE TA 596 (August 2019)

Risankizumab is a payment by results excluded medicine and initiation and subsequent monitoring of response will be by the dermatology specialist service. Blueteq forms for initiation and continuation will be available for completion by specialist teams.

Risankizumab will be considered as RED on the traffic light system

Primary care prescribers should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient’s medication.

Zomorph® is the locally preferred brand of morphine sulfate modified release (12-hourly formulation). 

Branded prescribing is recommended for morphine sulfate MR preparations by UKMi (see branded prescribing guidance below). Prescribers should identify patients currently prescribed generic preparations and change to the preferred branded product – Zomorph®.

Key points for consideration:
- Prescribers should be aware that there is no 5mg Zomorph® available so may wish to initiate MST® as the preferred brand if 5mg presentation is required.
- Switching MST® to Zomorph® is an option as they are bioequivalent.
- MXL is the only brand available for 24 hour preparations
- Zomorph® capsules can be opened and administered orally or via a tube – granules / capsules should not to be crushed

The locally preferred triple-therapy devices for COPD are as follows:

Low carbon:

• Trimbow NEXThaler (dry powder)
• Trelegy Ellipta (dry powder)

Alternative devices:

• Trimbow (pMDI). To be used with a spacer.

Triple therapy combination inhalers are recommended as a treatment option in COPD, where clinically appropriate, in line with NICE guidance (NG115 –updated July 2019) as follows:
Before starting LAMA+LABA+ICS, conduct a clinical review to ensure that:

• the person's non-pharmacological COPD management is optimised and they have used or been offered treatment for tobacco dependence if they smoke
• acute episodes of worsening symptoms are caused by COPD exacerbations and not by another physical or mental health condition
• the person's day-to-day symptoms that are adversely impacting their quality of life are caused by COPD and not by another physical or mental health condition.

For people with COPD who are taking LABA+ICS, offer LAMA+LABA+ICS if:

• their day-to-day symptoms continue to adversely impact their quality of life or
• they have a severe exacerbation (requiring hospitalisation) or
• they have 2 moderate exacerbations within a year.

For people with COPD who are taking LAMA+LABA, consider LAMA+LABA+ICS if:

• they have a severe exacerbation (requiring hospitalisation)

OR

• they have 2 moderate exacerbations within a year.

For people with COPD who are taking LAMA+LABA and whose day-to-day symptoms adversely impact their quality of life:

• consider a trial of LAMA+LABA+ICS, lasting for 3 months only
• after 3 months, conduct a clinical review to establish whether or not LAMA+LABA+ICS has improved their symptoms:
  • if symptoms have not improved, stop LAMA+LABA+ICS and switch back to LAMA+LABA and consider referral to a specialist respiratory team
  • if symptoms have improved, continue with LAMA+LABA+ICS.

The Area Prescribing Committee recommends that dronedarone must only be initiated for the maintenance of sinus rhythm after successful cardioversion in adult clinically stable patients with paroxysmal or persistent atrial fibrillation (AF) in exceptional circumstances when there is a clinical need for dronedarone to be prescribed:

• Where other treatments cannot be used or have failed

OR

• In line with NICE Guidance CG180 https://www.nice.org.uk/guidance/CG180

In these circumstances dronedarone must be initiated by a specialist and will be considered as RED on the traffic light system for the above indications.
Patients currently being prescribed dronedarone in primary care should be reviewed and referred back to specialist care if appropriate.

The APC recommends a RED status for the use of liothyronine monotherapy in oncology – thyroid and parathyroid disease.

Prescribing in thyroid and parathyroid cancer should only be addressed by specialists in secondary/tertiary care. Thyroid cancer patients who have completed their treatment usually need to take levothyroxine for life and should be managed in the same way as patients with hypothyroidism.

The NHS England and NHS Clinical Commissioners’ guidance: ‘Items which should not routinely be prescribed in primary care: Guidance for CCGs’ states:
? ‘Liothyronine is used for patients with thyroid cancer, in preparation for radioiodine ablation, iodine scanning, or stimulated thyroglobulin test. In these situations it is appropriate for patients to obtain their prescriptions from the centre undertaking the treatment and not be routinely obtained from primary care prescribers.’

The Area Prescribing Committee does not recommend the use of bath and shower preparations for dry and pruritic skin conditions in line with NHS England guidance.

Bath and shower preparations will be considered BLACK on the traffic light system.  Prescribers should:
• NOT initiate bath and shower preparations for any new patient AND
• Switch patients using bath and shower preparations to an alternative “leave-on” emollient in line with the Surrey & North West Sussex APC emollient guideline.

See also the NHS England guidance ‘Items which should not routinely be prescribed in primary care: Guidance for CCGs’ Version 2, June 2019

Emollient guidelines were approved at the APC in July 2019. Follow this link for further information; https://surreyccg.res-systems.net/PAD/Guidelines/Detail/5088

The Surrey & North West Sussex Area Prescribing Committee (APC) recommends risperidone for the treatment of moderate to severe Alzheimers dementia who have persistent aggression that is unresponsive to non-pharmacological approaches which must be tried as first line AND where there is a risk of harm to self or others.

Risperidone for this indication will be considered GREEN on the traffic light system for up to 6 weeks. The primary care prescriber should refer the patient to a specialist on initiation so that when the patient is seen by the specialist the response to risperidone can be reviewed.

A stepped approach to pain management is recommended. Paracetamol is considered a 1st line option for the treatment of pain. Consider initiation of an oral NSAID as an adjunct to paracetamol if required. See the guidelines attached for further information.

PLEASE NOTE: Oro-dispersible tablets should only be used when a patient has swallowing difficulties.

A stepped approach to pain management is recommended. Paracetamol is considered a 1st line option for the treatment of pain. Consider initiation of an oral NSAID as an adjunct to paracetamol if required. See the guidelines attached for further information.

PLEASE NOTE: Ibuprofen capsules (including modified release) are considered BLACK on the traffic light system  ( not recommended in any healthcare setting across Surrey & North West Sussex health economy..

A stepped approach to pain management is recommended. Paracetamol is considered a 1st line option for the treatment of pain. Consider initiation of an oral NSAID as an adjunct to paracetamol if required. See the guidelines attached for further information.

PLEASE NOTE: Naproxen effervescent tablets or naproxen oral suspension, should only be used where a patient with swallowing difficulties caanot tolerate ibuprofen suspension or ibuprofen suspension is ineffective.

A stepped approach to pain management is recommended. Paracetamol is considered a 1st line option for the treatment of pain. Consider initiation of an oral NSAID as an adjunct to paracetamol if required. See the guidelines attached for further information.

PLEASE NOTE: Naproxen gastro-resistant tablets offer no additional gastro-protective effect than standard naproxen tablets and are considered BLACK on the traffic light system  (not recommended in any healthcare setting across Surrey & North West Sussex health economy.

A stepped approach to pain management is recommended. Paracetamol is considered a 1st line option for the treatment of pain. Consider initiation of  oral NSAID (ibuprofen or naproxen) as an adjunct to paracetamol if required.  Diclofenac or celecoxib (first line COX 2) may be considered as alternatives when ibuprofen and naproxen are ineffective / not tolerated. See the guidelines attached for further information

A stepped approach to pain management is recommended. Paracetamol is considered a 1st line option for the treatment of pain. Consider initiation of  oral NSAID (ibuprofen or naproxen) as an adjunct to paracetamol if required.  Diclofenac or celecoxib (first line COX 2) may be considered as alternatives when ibuprofen and naproxen are ineffective / not tolerated. See the guidelines attached for further information

PLEASE NOTE: Diclofenac with misoprostil is considered BLACK on the traffic light system and is not recommended for use in any healthcare setting across the Surrey & North West Sussex health economy.

The Surrey & North West Sussex Area Prescribing Committee recommends latanoprost/timolol preservative free eye drops as the first-line combination prostaglandin/beta-blocker eye drop where a preservative-free formulation is required, for the reduction of intraocular pressure in patients with Glaucoma and they will be considered BLUE (with no information sheet) on the traffic light system and  at least 1 month supply should be supplied at initiation.

NB: Patients switching from separate components to the combination product can be switched by the primary care prescriber without the need to refer into an ophthalmologist for review. Primary care prescribers should be mindful of the strength of the timolol during rationalisation.

Primary care prescribers do not have the necessary equipment or skills to perform ocular pressure readings to make a diagnosis. The APC recomments that this product, when used for treatment of glaucoma, should be considered as BLUE.

Primary care prescribers do not have the necessary equipment or skills to perform ocular pressure readings to make a diagnosis. The APC recomments that this product, when used for treatment of glaucoma, should be considered as BLUE.

Note; the branded product (Alphagan) was considered BLACK at the PCN in May 2017.

Primary care prescribers do not have the necessary equipment or skills to perform ocular pressure readings to make a diagnosis. The APC recomments that this product, when used for treatment of glaucoma, should be considered as BLUE.

Note; the branded product (Azopt) was considered as BLACK at the PCN in May 2017.

Primary care prescribers do not have the necessary equipment or skills to perform ocular pressure readings to make a diagnosis. The APC recomments that this product, when used for treatment of glaucoma, should be considered as BLUE.

Note; the branded product (Trusopt) was considered BLACK at the PCN in May 2017.

Primary care prescribers do not have the necessary equipment or skills to perform ocular pressure readings to make a diagnosis. The APC recomments that this product, when used for treatment of glaucoma, should be considered as BLUE.

Note; the branded product (Cosopt) was considered as BLACK at the PCN in May 2017.

Primary care prescribers do not have the necessary equipment or skills to perform ocular pressure readings to make a diagnosis. The APC recomments that this product, when used for treatment of glaucoma, should be considered as BLUE.

Note; the branded product (Xalatan) was considered as BLACK at the PCN in May 2017.

Primary care prescribers do not have the necessary equipment or skills to perform ocular pressure readings to make a diagnosis. The APC recomments that this product, when used for treatment of glaucoma, should be considered as BLUE.

Note; the branded product (Xalacom) was considered BLACK at the PCN in May 2017.

The Surrey & North West Sussex Area Prescribing Committee (APC) agreed the BLUE information sheet for lithium.

The Surrey & North West Sussex Area Prescribing Committee agreed the BLUE information sheet for lithium.

The Surrey & North West Sussex Area Prescribing Committee agreed the BLUE information sheet for lithium.

The Surrey & North West Sussex Area Prescribing Committee recommends Diltiazem 2% ointment as a 2nd line treatment option in the following circumstances:

• If a patient has had an adverse event or intolerance to 1st line glyceryl trinitrate (GTN) 0.4% ointment (Diltiazem 2% ointment will be considered GREEN on the traffic light system in this situation)

OR

• If an anal fissure has not managed to heal after 6 weeks of treatment with GTN 0.4% ointment (1st line), then the patient should then be referred to a specialist for investigation of the underlying cause of non-healing.

Patients initially prescribed GTN 0.4% ointment may be switched to diltiazem ointment by the primary care prescriber whilst waiting to be assessed by the specialist. Diltiazem 2% ointment will be considered GREEN on the traffic light system in this situation.

Note - Diltiazem 2% cream is not the preferred formulation but will remain a treatment option in case of supply problems with the 2% ointment.

See policy statement below for further information and links to associated guidance

The Surrey and North West Sussex Area Prescribing Committee recommends pitolisant (Wakix®) monotherapy for the management of narcolepsy with or without cataplexy.

The APC recommend a RED traffic light status for the use of pitolisant monotherapy for this indication.

Combination treatment will not be routinely funded and if combination treatment is considered clinically appropriate, an individual funding request (IFR) will need to be completed by the specialist for consideration of commissioner funding.

Primary care prescribers should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient’s medication.

The Area Prescribing Committee does not recommend the use of aliskiren in line with NHS England guidance.

Aliskiren will be considered BLACK on the traffic light system.  Prescribers should:

• NOT initiate aliskiren for any new patient

AND

• Change patients taking aliskiren to an alternative antihypertensive in line with NICE on the diagnosis and management of hypertension in adults noting that it is important that blood pressure is monitored closely and to consider treatments that may not have previously been used OR
• Patients should be referred into a specialist for consideration of de-prescribing if appropriate

The Area Prescribing Committee does not recommend the use of silk garments.

Silk garments will be considered BLACK on the traffic light system.  Prescribers should:

•  NOT initiate silk garments for any new patient AND
•  Stop prescribing silk garments for existing patients and ensure that their eczema / dermatitis is being managed in line with NICE guidance 

The Medicines and Healthcare Products Regulatory Agency (MHRA) recommends to prescribe biological products by brand name to ensure that substitution of a biosimilar product does not occur when the medicine is dispensed by the pharmacist. Https://www/gov/uk/drug-safety-update/biosimilar-products

Primary care prescriber should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication.

The Medicines and Healthcare Products Regulatory Agency (MHRA) recommends to prescribe biological products by brand name to ensure that substitution of a biosimilar product does not occur when the medicine is dispensed by the pharmacist. Https://www/gov/uk/drug-safety-update/biosimilar-products

Primary care prescriber should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication.

The Medicines and Healthcare Products Regulatory Agency (MHRA) recommends to prescribe biological products by brand name to ensure that substitution of a biosimilar product does not occur when the medicine is dispensed by the pharmacist. Https://www/gov/uk/drug-safety-update/biosimilar-products

Primary care prescriber should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication.

The Medicines and Healthcare Products Regulatory Agency (MHRA) recommends to prescribe biological products by brand name to ensure that substitution of a biosimilar product does not occur when the medicine is dispensed by the pharmacist. Https://www/gov/uk/drug-safety-update/biosimilar-products

Primary care prescriber should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication.

The Medicines and Healthcare Products Regulatory Agency (MHRA) recommends to prescribe biological products by brand name to ensure that substitution of a biosimilar product does not occur when the medicine is dispensed by the pharmacist. Https://www/gov/uk/drug-safety-update/biosimilar-products

Primary care prescriber should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication.

The Medicines and Healthcare Products Regulatory Agency (MHRA) recommends to prescribe biological products by brand name to ensure that substitution of a biosimilar product does not occur when the medicine is dispensed by the pharmacist. Https://www/gov/uk/drug-safety-update/biosimilar-products

Primary care prescriber should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication.

The Medicines and Healthcare Products Regulatory Agency (MHRA) recommends to prescribe biological products by brand name to ensure that substitution of a biosimilar product does not occur when the medicine is dispensed by the pharmacist. Https://www/gov/uk/drug-safety-update/biosimilar-products

Primary care prescriber should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication.

The Medicines and Healthcare Products Regulatory Agency (MHRA) recommends to prescribe biological products by brand name to ensure that substitution of a biosimilar product does not occur when the medicine is dispensed by the pharmacist. Https://www/gov/uk/drug-safety-update/biosimilar-products

Primary care prescriber should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication.

The Medicines and Healthcare Products Regulatory Agency (MHRA) recommends to prescribe biological products by brand name to ensure that substitution of a biosimilar product does not occur when the medicine is dispensed by the pharmacist. Https://www/gov/uk/drug-safety-update/biosimilar-products

Primary care prescriber should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication.

The Medicines and Healthcare Products Regulatory Agency (MHRA) recommends to prescribe biological products by brand name to ensure that substitution of a biosimilar product does not occur when the medicine is dispensed by the pharmacist. Https://www/gov/uk/drug-safety-update/biosimilar-products

Primary care prescriber should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication.

The Medicines and Healthcare Products Regulatory Agency (MHRA) recommends to prescribe biological products by brand name to ensure that substitution of a biosimilar product does not occur when the medicine is dispensed by the pharmacist. Https://www/gov/uk/drug-safety-update/biosimilar-products

Primary care prescriber should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication.

The Medicines and Healthcare Products Regulatory Agency (MHRA) recommends to prescribe biological products by brand name to ensure that substitution of a biosimilar product does not occur when the medicine is dispensed by the pharmacist. Https://www/gov/uk/drug-safety-update/biosimilar-products

Primary care prescriber should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication.

The Medicines and Healthcare Products Regulatory Agency (MHRA) recommends to prescribe biological products by brand name to ensure that substitution of a biosimilar product does not occur when the medicine is dispensed by the pharmacist. Https://www/gov/uk/drug-safety-update/biosimilar-products

Primary care prescriber should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication.

The Medicines and Healthcare Products Regulatory Agency (MHRA) recommends to prescribe biological products by brand name to ensure that substitution of a biosimilar product does not occur when the medicine is dispensed by the pharmacist. Https://www/gov/uk/drug-safety-update/biosimilar-products

Primary care prescriber should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication.

The Medicines and Healthcare Products Regulatory Agency (MHRA) recommends to prescribe biological products by brand name to ensure that substitution of a biosimilar product does not occur when the medicine is dispensed by the pharmacist. Https://www/gov/uk/drug-safety-update/biosimilar-products

Primary care prescriber should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication.

The Medicines and Healthcare Products Regulatory Agency (MHRA) recommends to prescribe biological products by brand name to ensure that substitution of a biosimilar product does not occur when the medicine is dispensed by the pharmacist. Https://www/gov/uk/drug-safety-update/biosimilar-products

Primary care prescriber should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication.

The Medicines and Healthcare Products Regulatory Agency (MHRA) recommends to prescribe biological products by brand name to ensure that substitution of a biosimilar product does not occur when the medicine is dispensed by the pharmacist. Https://www/gov/uk/drug-safety-update/biosimilar-products

Primary care prescriber should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication.

The Medicines and Healthcare Products Regulatory Agency (MHRA) recommends to prescribe biological products by brand name to ensure that substitution of a biosimilar product does not occur when the medicine is dispensed by the pharmacist. Https://www/gov/uk/drug-safety-update/biosimilar-products

Primary care prescriber should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication.

The Medicines and Healthcare Products Regulatory Agency (MHRA) recommends to prescribe biological products by brand name to ensure that substitution of a biosimilar product does not occur when the medicine is dispensed by the pharmacist. Https://www/gov/uk/drug-safety-update/biosimilar-products

Primary care prescriber should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication.

The Medicines and Healthcare Products Regulatory Agency (MHRA) recommends to prescribe biological products by brand name to ensure that substitution of a biosimilar product does not occur when the medicine is dispensed by the pharmacist. Https://www/gov/uk/drug-safety-update/biosimilar-products

Primary care prescriber should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient's medication.

The Surrey & North West Sussex Area Prescribing Committee recommends etoricoxib as a treatment option for the treatment of pain and inflammation in line with the product licence*.

Etoricoxib will be considered as GREEN on the traffic light system as a 2nd line COX-2 inhibitor (after celecoxib) for use where a COX-2 inhibitor is indicated.

If etoricoxib is indicated for the treatment of gouty arthritis then etoricoxib should be considered before celecoxib as it is licensed for this indication.

*Licenced for: Osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, acute gouty arthritis

The branded product, Arcoxia, is considered BLACK. Please prescribe generically for this indication.

The Surrey & North West Sussex Area Prescribing Committee recommends celecoxib as a treatment option for the treatment of pain and inflammation in line with the product licence*.

Celecoxib will be considered as GREEN on the traffic light system and is the preferred COX II inhibitor for use where a COX II inhibitor is indicated.

*Licenced for: Osteoarthritis, Rheumatoid Arthritis & Ankylosing Spondylitis

The branded product, Celebrex, is considered BLACK. Prescribe generically for this indication.

The Surrey & North West Sussex Area Prescribing Committee does not recommend the use of skin camouflages and they will be considered BLACK on the traffic light system.

Not recommended for use in any health setting across Surrey and North West Sussex health economy

Aqueous cream is NOT recommended due to its use being associated with a higher risk of skin irritation.
Existing use should be reviewed in line with the guidelines.

Please refer to the Emollient Prescribing Guidelines and the Emollient Summary guidance below for further information and recommended alternatives

The APC supports the use of tapentadol SR as a treatment option for the management of severe persistent non-malignant pain in adults after assessment and recommendation by a pain specialist for patients not responding to / not tolerating morphine OR oxycodone.

Due to the similar mode of action and relative efficacy of tapentadol compared with tramadol, it would be appropriate to have tried tramadol before initiating tapentadol.

Tapentadol SR will be considered as BLUE (no information sheet) on the traffic light system.

Please be aware of the MHRA drug safety update (January 2019- attached below) in relation to potential increase in seizure risk in patients taking other medicines 

The Surrey and North West Sussex Area Prescribing Committee recommends minocycline for non-acne related dermatological indications, noting that there is limited supporting evidence data available and there are concerns about serious side effects for minocycline. (February 2019 APC).

Minocycline for non-acne related dermatology indications will be considered RED on the traffic light system.

The Surrey & North West Sussex Area Prescribing Committee (APC) recommends tildrakizumab as a treatment option in adult patients with moderate to severe plaque psoriasis in line with NICE TA 575 (April 2019)

Tildrakizumab is a payment by results excluded medicine and initiation and subsequent monitoring of response will be by the dermatology specialist service. Blueteq forms for initiation and continuation will be available for completion by specialist teams.

Tildrakizumab will be considered as RED on the traffic light system

Primary care prescribers should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient’s medication.

The Surrey & North West Sussex Area Prescribing Committee (APC) recommends certolizumab pegol as a treatment option in adult patients with moderate to severe plaque psoriasis in line with NICE TA 574 (April 2019)

Certolizumab pegol is a payment by results excluded medicine and initiation and subsequent monitoring of response will be by the dermatology specialist service. Blueteq forms for initiation and continuation will be available for completion by specialist teams.

Certolizumab pegol will be considered as RED on the traffic light system

Dose escalation to 400mg every 2 weeks is supported by APC whilst the manufacturer has the same Patient Access Scheme (PAS) in place noted by APC in June 2019.

Primary care prescribers should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient’s medication.

The Surrey and North West Sussex Area APC does not support the routine use of unlicensed liothyronine and thyroid extract products in the management of adults with hypothyroidism and they will be considered as BLACK on the traffic light system.

Thyroid extracts (e.g. Armour thyroid, ERFA Thyroid), compounded thyroid hormones, iodine containing preparations, and dietary supplementation are not recommended. The prescribing of unlicensed liothyronine and thyroid extract products are not supported as the safety, quality and efficacy of these products cannot be assured.

In very rare situations where patients experience continuing symptoms with levothyroxine (that have a material impact upon normal day to day function), and other potential causes have been investigated and eliminated, a 3 month trial with additional liothyronine may occasionally be appropriate.
This is only to be initiated by a consultant NHS endocrinologist. Following this trial the consultant NHS endocrinologist will advise on the need for ongoing liothyronine.
Liothyronine for this indication will be considered AMBER on the traffic light system.

Many endocrinologists may not agree that a trial of levothyroxine / liothyronine combination therapy is warranted in these circumstances and their clinical judgement is valid given the current understanding of the science and evidence of the treatment.

Patients taking liothyronine (monotherapy or in combination) prior to NHS England guidance ‘Items that should not routinely be prescribed in primary care’ (Nov 2017) should have been reviewed by an NHS consultant endocrinologist.

For further advice and information please refer to the Policy Statement below

The Surrey and North West Sussex APC recommends the use of liothyronine (T3) monotherapy initiated only by consultant endocrinologists in an NHS consultation for patients with an intolerance to levothyroxine (T4).
Transfer of prescribing to primary care is supported for those patients that have had a satisfactory response for at least 3 months prior to transfer to primary care.
Liothyronine for this indication will be considered as AMBER on the traffic light system. Shared-care documentation is available below.

Patients taking liothyronine (monotherapy or in combination) prior to NHS England guidance ‘Items that should not routinely be prescribed in primary care’ (Nov 2017) should have been reviewed by an NHS consultant endocrinologist.

This drug is currently not on the APC workplan. The APC will consider recommending prescribing of this treatment upon submission of a formal request with its associated evidence. Please contact your local CCG Medicines Management team formulary pharmacist or chief pharmacist at your acute trust, if you wish to make a submission.

This drug is currently not on the APC workplan. The APC will consider recommending prescribing of this treatment upon submission of a formal request with its associated evidence. Please contact your local CCG Medicines Management team formulary pharmacist or chief pharmacist at your acute trust, if you wish to make a submission.

This drug / device falls under the responsibility of NHS England Specialised Commissioning and should therefore not be prescribed in Primary Care. 
Treatment should remain with the specialist (RED) hospital only drug. 

GPs should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient’s medication.

 This drug / device falls under the responsibility of NHS England Specialised Commissioning and should therefore not be prescribed in Primary Care

The Surrey and North West Sussex Area Prescribing Committee recommends ertugliflozin as monotherapy or with metformin as a treatment option in patients with type 2 diabetes in line with NICE TA572 (27 March 2019)

Ertugliflozin for this indication will be considered GREEN on the traffic light system.

Please note: There is currently no cardiovascular or renal outcome data available

See the Blood Glucose control treatment algorithm below for SGLT2 place in therapy

Glyceryl Trinitrate (GTN) 0.4% ointment is a 1st line treatment option for the treatment of anal fissure
GTN 0.4% ointment will be considered GREEN on the traffic light system for this indication

NOTE - other GTN strengths and preparations (2%, 0.2% ointment and creams) are NOT licensed and have been assigned a BLACK traffic light status - see https://surreyccg.res-systems.net/pad/Search/DrugConditionProfile/6250

Glyceryl Trinitrate (GTN) 0.4% ointment is the licensed preparation and should be used in preference to unlicensed alternatives (0.2%, 2%, creams).

These unlicensed glyceryl trinitrate preparations have been assigned a BLACK traffic light status.

GTN 0.4% ointment will be considered GREEN on the traffic light system - see https://surreyccg.res-systems.net/pad/Search/DrugConditionProfile/5182

The Surrey and North West Sussex Area Prescribing Committee (APC) recommends desmopressin (Noqdirna) as a treatment option for idiopathic noturnal polyuria.

Desmopressin (Noqdirna) is a licensed product and should be prescibed as an alternative to other, off label desmopressin preparations.

Desmopressin (Noqdirna) will be assigned a BLUE (no information sheet) traffic light status and specialists in secondary care will be required to prescribe at least 1 month of desmopressin prior to requesting transfer of care with the patients primary care provider.

The attached nocturia treatment pathway has been developed in conjunction with colleagues at Ashford & St Peters Hospitals NHS Foundation Trust and is expected to assist primary care prescribers in the management of patients with nocturia. See below for further information 

The Surrey and North West Sussex Area Prescribing Committee (APC) has agreed the attached pathway for use in adult patients with bothersome nocturia.

The pathway has been developed in conjunction with colleagues at Ashford & St Peters Hospitals NHS Foundation Trust and is expected to compliment the information already available.

The Surrey and North West Sussex Area Prescribing Committee recommends vitamin B compound strong tablets for patients at high risk of developing re-feeding syndrome in line with NICE guidance CG32.
Patients at high risk will require treatment with vitamin B, immediately before and during the first 10 days (NICE guidance) of the introduction of food after a period of starvation.
Vitamin B compound strong tablets will be considered RED on the traffic light system for the 10 day treatment course.
Patients that are being prescribed vitamin B compound strong for longer periods should be reviewed and treatment should be stopped.

Fostair® (beclometasone / formoterol) metered dose inhaler is the locally preferred ICS/LABA.
Fostair Nexthaler ® breath-actuated inhaler is the preferred dry powder ICS/LABA device.

If patient cannot tolerate formoterol, a salmeterol / fluticasone combination may be indicated.
Combisal® (fluticasone / salmeterol) metered dose inhaler is the locally preferred device.
Seretide Accuhaler® is the locally preferred futicasone/salmeterol breath-actuated device.

Relvar Ellipta® is supported in a small group of asthmatics where ALL of the following criteria apply:

• a medium or high dose ICS/LABA is indicated
• the patient has already trialled one or more twice daily ICS/LABA devices and the prescriber has confirmed that the patient is unable to comply with the dosing regimen
• the patient requires a once daily social package of care

NOTE - due to the high potency of fluticasone furoate compared to other available inhaled corticosteroids, and no low dose availability (as per BTS classification), Relver Ellipta® should not be considered as standard therapy in asthma patients unless these criteria are fulfilled.

Relvar Ellipta® is not recommended outside of these circumstances because of concerns of inappropriate use of high dose ICS

Consider the use of an ICS Steroid Card 

Please refer to the Relvar Ellipta® Policy Statement below for further information.

(NOTE - this recommendation supersedes the previous PCN recommendations (March 2014 and July 2014) where Relvar Ellipta® was assigned a black traffic light status)

Prescribe inhaler devices by BRAND to ensure consistency and avoid confusion.

See Asthma Guidelines below.

Clenil Modulite® (beclometasone) MDI plus spacer (Volumatic, Able Spacer, Optichamber) or Qvar (beclometasone) MDI plus spacer (Aerochamber plus, Able Spacer, Optichamber) are the locally preferred ICS devices.

If an alternative device is necessary, consider:
Easyhaler® Beclometasone (DPI) - not licensed in under 18 years
Qvar Easi-Breathe® (breath activated) - not licensed in under 12 years
Easyhaler® Budesonide may be considered as an additional alternative in patients aged 12-17 if these other preferred, licensed devices are not suitable

Prescribe inhaler devices by BRAND to ensure consistency and avoid confusion.

See Asthma Guidelines below.

Clenil Modulite® (beclometasone) MDI plus spacer (Volumatic, Able Spacer, Optichamber) or Qvar (beclometasone) MDI plus spacer (Aerochamber plus, Able Spacer, Optichamber) are the locally preferred ICS devices.

If an alternative device is necessary, consider:
Easyhaler® Beclometasone (DPI) - not licensed in under 18 years
Qvar Easi-Breathe® (breath activated) - not licensed in under 12 years
Easyhaler® Budesonide may be considered as an additional alternative in patients aged 12-17 if these other preferred, licensed devices are not suitable

Prescribe inhaler devices by BRAND to ensure consistency and avoid confusion.

See Asthma Guidelines below.

Clenil Modulite® (beclometasone) MDI plus spacer (Volumatic, Able Spacer, Optichamber) or Qvar (beclometasone) MDI plus spacer (Aerochamber plus, Able Spacer, Optichamber) are the locally preferred ICS devices.

If an alternative device is necessary, consider:
Easyhaler® Beclometasone (DPI) - not licensed in under 18 years
Qvar Easi-Breathe® (breath activated) - not licensed in under 12 years
Easyhaler® Budesonide may be considered as an additional alternative in patients aged 12-17 if these other preferred, licensed devices are not suitable

Prescribe inhaler devices by BRAND to ensure consistency and avoid confusion.

See Asthma Guidelines below.
 

Clenil Modulite® (beclometasone) MDI plus spacer (Volumatic, Able Spacer, Optichamber) or Qvar (beclometasone) MDI plus spacer (Aerochamber plus, Able Spacer, Optichamber) are the locally preferred ICS devices.

If an alternative device is necessary, consider:
Easyhaler® Beclometasone (DPI) - not licensed in under 18 years
Qvar Easi-Breathe® (breath activated) - not licensed in under 12 years
Easyhaler® Budesonide may be considered as an additional alternative in patients aged 12-17 if these other preferred, licensed devices are not suitable

Prescribe inhaler devices by BRAND to ensure consistency and avoid confusion.

See Asthma Guidelines below.

Montelukast may be an appropriate first-line addition to ICS (particularly if atopy or allergic component).

Prescribe generically (the brand Singulair was assigned a BLACK traffic light status by the PCN in May 2017)

The guidelines for Asthma can be found below

Generic donepezil is the 1st-line acetylcholinesterase inhibitor for mild to moderate Alzheimer's disease.  It is also a treatment option for dementia with Lewy bodies, vascular dementia and Parkinson's dementia.
See below for the local treatment pathways

Donepezil has been recommended as BLUE (with information sheet) for those patients who are stable and suitable for discharge from specialist care.

AMBER shared care  will apply for the patients that are not suitable for discharge and who will continue to receive follow up by SABPT

Note - the donepezil brand, Aricept, is BLACK and should not be prescribed.

Generic donepezil is the 1st-line acetylcholinesterase inhibitor for mild to moderate Alzheimer's disease.  Galantamine or rivastigmine are alternative AChE inhibitors. Galantamine is also a treatment option for dementia with Lewy bodies, vascular dementia and Parkinson's dementia.
See below for the local treatment pathways

Galantamine has been recommended as BLUE (with information sheet) for those patients who are stable and suitable for discharge from specialist care.  

AMBER shared care  will apply for the patients that are not suitable for discharge and who will continue to receive follow up by SABPT

Generic donepezil is the 1st-line acetylcholinesterase inhibitor for mild to moderate Alzheimer's disease.  Galantamine or rivastigmine are alternative AChE inhibitors. Rivastigmine is also a treatment option for dementia with Lewy bodies, vascular dementia and Parkinson's dementia.
See below for the local treatment pathways

Rivastigmine has been recommended as BLUE (with information sheet) for those patients who are stable and suitable for discharge from specialist care.

AMBER shared care  will apply for the patients that are not suitable for discharge and who will continue to receive follow up by SABPT

Note - the branded rivastigmine, Exelon, has been assigned a BLACK traffic light status and should not be prescribed

Acetylcholinesterase inhibitors are 1st-line treatment option for mild to moderate Alzheimer's disease. Memantine is licensed for the treatment of patients with moderate to severe Alzheimer's disease and is also a treatment option for dementia with Lewy bodies, vascular dementia and Parkinson's dementia.
See below for the local treatment pathways.

The local pathways advise that memantine MONOTHERAPY should be initiated or recommended by a specialist and:
- should be offered to patients with severe Alzheimer's disease
- may be used in moderate disease where an AChE inhibitor is not tolerated or contraindicated
- may be used in dementia with Lewy bodies if AChE inhibitors are not tolerated or contraindicated (unlicensed)
- may be used in Vascular dementia ONLY  if co-morbid Alzheimer’s disease, or dementia with Lewy Bodies (unlicensed)
Memantine MONOTHERAPY has been recommended as BLUE (with information sheet) for those patients who are stable and suitable for discharge from specialist care.  

AMBER shared care  will apply for the patients that are not suitable for discharge and who will continue to receive follow up by SABPT

COMBINATION THERAPY - Memantine is appropriate for Primary Care initiation (GREEN status) when being added to existing AChE inhibitor therapy (i.e. combination therapy) in patients with worsening cognitive function or other markers of deterioration. See separate PAD page for further information https://surreyccg.res-systems.net/pad/Search/DrugConditionProfile/5204

Note - the branded memantine, Ebixa, has been assigned a BLACK traffic light status and should not be prescribed

COMBINATION THERAPY - Memantine is appropriate for Primary Care initiation (GREEN status) when being added to existing AChE inhibitor therapy (i.e. combination therapy) in patients with worsening cognitive function or other markers of deterioration. 
See locally agreed pathway below.
(This recommendation replaces the agreement made by the APC in September 2017 where memantine in combination therapy was assigned a blue traffic light status)

Note - the branded memantine, Ebixa, has been assigned a BLACK traffic light status and should not be prescribed

Memantine as MONOTHERAPY should only be initiated by a specilaist (BLUE status) - See separate PAD page for further information https://surreyccg.res-systems.net/pad/Search/DrugConditionProfile/4492

The Surrey and North West Sussex Area Prescribing Committee (APC) does not recommend AChE inhibitors* or memantine for people with frontotemporal dementia, in line with NICE guideline (NG97)

* AChE inhibitors - donepezil, galantamine amd rivastigmine

The Surrey and North West Sussex Area Prescribing Committee (APC) does not recommend AChE inhibitors* or memantine for people with frontotemporal dementia, in line with NICE guideline (NG97)

* AChE inhibitors - donepezil, galantamine amd rivastigmine

The Surrey and North West Sussex Area Prescribing Committee (APC) does not recommend AChE inhibitors* or memantine for people with frontotemporal dementia, in line with NICE guideline (NG97)

* AChE inhibitors - donepezil, galantamine amd rivastigmine

The Surrey and North West Sussex Area Prescribing Committee (APC) does not recommend AChE inhibitors* or memantine for people with frontotemporal dementia, in line with NICE guideline (NG97)

* AChE inhibitors - donepezil, galantamine amd rivastigmine

The Surrey and North West Sussex Area Prescribing Committee (APC) does not recommend AChE inhibitors* or memantine for people with cognitive impairment caused by multiple sclerosis, in line with NICE guideline (NG97)

* AChE inhibitors - donepezil, galantamine amd rivastigmine

The Surrey and North West Sussex Area Prescribing Committee (APC) does not recommend AChE inhibitors* or memantine for people with cognitive impairment caused by multiple sclerosis, in line with NICE guideline (NG97)

* AChE inhibitors - donepezil, galantamine amd rivastigmine

The Surrey and North West Sussex Area Prescribing Committee (APC) does not recommend AChE inhibitors* or memantine for people with cognitive impairment caused by multiple sclerosis, in line with NICE guideline (NG97)

* AChE inhibitors - donepezil, galantamine amd rivastigmine

The Surrey and North West Sussex Area Prescribing Committee (APC) does not recommend AChE inhibitors* or memantine for people with cognitive impairment caused by multiple sclerosis, in line with NICE guideline (NG97)

* AChE inhibitors - donepezil, galantamine amd rivastigmine

The Surrey and North West Sussex Area Prescribing Committee (APC) does not recommend valproate to manage agitation or aggression in people living with dementia (unless it is indicated for another condition), in line with NICE guidance (NG97)

The Surrey and North West Sussex Area Prescribing Committee (APC) does not recommend melatonin to manage insomnia in people living with Alzheimer’s disease, in line with NICE guidance (NG97)

The Surrey and North West Sussex Area Prescribing Committee (APC) recommends desmopressin (Noqdirna) as a treatment option for idiopathic noturnal polyuria.

Desmopressin (Noqdirna) is a licensed product and should be prescibed as an alternative to other, off label desmopressin preparations.

Desmopressin (Noqdirna) will be assigned a BLUE (no information sheet) traffic light status and specialists in secondary care will be required to prescribe at least 1 month of desmopressin prior to requesting transfer of care with the patients primary care provider.

The attached nocturia treatment pathway has been developed in conjunction with colleagues at Ashford & St Peters Hospitals NHS Foundation Trust and is expected to compliment the information all ready available for prescribers on this page. See below for further information 

Fostair® (beclometasone / formoterol) metered dose inhaler is the locally preferred ICS/LABA.
Fostair Nexthaler ® breath-actuated inhaler is the preferred dry powder ICS/LABA device.

If patient cannot tolerate formoterol, a salmeterol / fluticasone combination may be indicated.
Combisal (fluticasone / salmeterol) metered dose inhaler is the locally preferred device

NOTE: 
- Aloflute is not one of the locally preferred devices
- Aloflute is not available in a low dose device
- Aloflute is not licensed for maintenance and reliever therapy (MART)

Prescribe inhaler devices by BRAND to ensure consistency and avoid confusion.

See Asthma Guidelines below.

Fostair® (beclometasone / formoterol) metered dose inhaler is the locally preferred ICS/LABA.
Fostair Nexthaler ® breath-actuated inhaler is the preferred dry powder ICS/LABA device.

If patient cannot tolerate formoterol, a salmeterol / fluticasone combination may be indicated.
Combisal (fluticasone / salmeterol) metered dose inhaler is the locally preferred device

NOTE: 
- Airflusal is not one of the locally preferred devices
- Airflusal is not licensed for maintenance and reliever therapy (MART)

Prescribe inhaler devices by BRAND to ensure consistency and avoid confusion.

See Asthma Guidelines below.

Fostair® (beclometasone / formoterol) metered dose inhaler is the locally preferred ICS/LABA.
Fostair Nexthaler ® breath-actuated inhaler is the preferred dry powder ICS/LABA device.

If patient cannot tolerate formoterol, a salmeterol / fluticasone combination may be indicated.
Combisal (fluticasone / salmeterol) metered dose inhaler is the locally preferred device

NOTE: 
- Sereflo is not one of the locally preferred devices
- Sereflo is not available in a low dose device
- Sereflo is not licensed for maintenance and reliever therapy (MART)

Prescribe inhaler devices by BRAND to ensure consistency and avoid confusion.

See Asthma Guidelines below.

Fostair® (beclometasone / formoterol) metered dose inhaler is the locally preferred ICS/LABA.
Fostair Nexthaler ® breath-actuated inhaler is the preferred dry powder ICS/LABA device.

If patient cannot tolerate formoterol, a salmeterol / fluticasone combination may be indicated.
Combisal (fluticasone / salmeterol) metered dose inhaler is the locally preferred device

NOTE: 
- Seretide Evohaler is not one of the locally preferred devices
- Seretide Evohaler is not licensed for maintenance and reliever therapy (MART)

Prescribe inhaler devices by BRAND to ensure consistency and avoid confusion.

See Asthma Guidelines below.

Fostair® (beclometasone / formoterol) metered dose inhaler is the locally preferred ICS/LABA.
Fostair Nexthaler ® breath-actuated inhaler is the preferred dry powder ICS/LABA device.

If patient cannot tolerate formoterol, a salmeterol / fluticasone combination may be indicated.
Combisal (fluticasone / salmeterol) metered dose inhaler is the locally preferred device

NOTE: 
- Sirdupla is not one of the locally preferred devices
- Sirdupla is not available in a low dose device
- Sirdupla is not licensed for maintenance and reliever therapy (MART)

Prescribe inhaler devices by BRAND to ensure consistency and avoid confusion.

See Asthma Guidelines below.

Fostair® (beclometasone / formoterol) metered dose inhaler is the locally preferred ICS/LABA.
It is licensed for Maintenance and Reliever Therapy (MART) and is available in a full range of doses. 

See MART action plan document below

Fostair Nexthaler ® breath-actuated inhaler is the preferred dry powder ICS/LABA device.

Fostair devices are not licensed in under 18's. 

Prescribe inhaler devices by BRAND to ensure consistency and avoid confusion.

See Asthma Guidelines below.

Fostair® (beclometasone / formoterol) metered dose inhaler is the locally preferred ICS/LABA.
Fostair Nexthaler ® breath-actuated inhaler is the preferred dry powder ICS/LABA device.

If patient cannot tolerate formoterol, a salmeterol / fluticasone combination may be indicated.
Combisal® (fluticasone / salmeterol) metered dose inhaler is the locally preferred device.

NOTE: 
- Flutiform® is not one of the locally preferred devices
- Flutiform® is not licensed for maintenance and reliever therapy (MART)

Prescribe inhaler devices by BRAND to ensure consistency and avoid confusion.

See Asthma Guidelines below.

Fostair® (beclometasone / formoterol) metered dose inhaler is the locally preferred ICS/LABA.
Fostair Nexthale ® breath-actuated inhaler is the preferred dry powder ICS/LABA device.

If patient cannot tolerate formoterol, a salmeterol / fluticasone combination may be indicated.
Combisal® (fluticasone / salmeterol) metered dose inhaler is the locally preferred device

NOTE: 
- The Flutiform K-haler® device is not recommended for use in any health setting across Surrey and NW Sussex health economy.
- Flutiform K-haler® is not licensed for maintenance and reliever therapy (MART)
- Flutiform K-haler® is not available in a high dose device

Prescribe inhaler devices by BRAND to ensure consistency and avoid confusion.

See Asthma Guidelines below.

Fostair® (beclometasone / formoterol) metered dose inhaler is the locally preferred ICS/LABA.
Fostair Nexthaler ® breath-actuated inhaler is the preferred dry powder ICS/LABA device.

If patient cannot tolerate formoterol, a salmeterol / fluticasone combination may be indicated.
Combisal® (fluticasone / salmeterol) metered dose inhaler is the locally preferred device.
Seretide Accuhaler® is the locally preferred futicasone/salmeterol breath-actuated device (for use when patient cannot tolerate formoterol (Fostair Nexthaler)

NOTE: 
- The Aerivio Spiroma®x device is not recommended for use in any health setting across Surrey and NW Sussex health economy.
- Aerivio Spiromax® is ONLY available in a high dose device
- Aerivio Spiromax® is not licensed for maintenance and reliever therapy (MART)

Prescribe inhaler devices by BRAND to ensure consistency and avoid confusion.

See Asthma Guidelines below.

Fostair® (beclometasone / formoterol) metered dose inhaler is the locally preferred ICS/LABA.
Fostair Nexthaler ® breath-actuated inhaler is the preferred dry powder ICS/LABA device.

If patient cannot tolerate formoterol, a salmeterol / fluticasone combination may be indicated.
Combisal® (fluticasone / salmeterol) metered dose inhaler is the locally preferred device.
Seretide Accuhaler® is the locally preferred futicasone/salmeterol breath-actuated device (for use when patient cannot tolerate formoterol (Fostair Nexthaler)

NOTE: 
- The Airflusal Forspiro device is not recommended for use in any health setting across Surrey and NW Sussex health economy.
- Airflusal Forspiro is not licensed for maintenance and reliever therapy (MART)

Prescribe inhaler devices by BRAND to ensure consistency and avoid confusion.

See Asthma Guidelines below.

Fostair® (beclometasone / formoterol) metered dose inhaler is the locally preferred ICS/LABA.
Fostair Nexthaler ® breath-actuated inhaler is the preferred dry powder ICS/LABA device.

If patient cannot tolerate formoterol, a salmeterol / fluticasone combination may be indicated.
Combisal® (fluticasone / salmeterol) metered dose inhaler is the locally preferred device.
Seretide Accuhaler® is the locally preferred futicasone/salmeterol breath-actuated device 

NOTE: 
- The Fusacomb Easyhaler® device is not one of the locally preferred devices
- Fusacomb Easyhaler® is not available in a low dose device
- Fusacomb Easyhaler® is not licensed for maintenance and reliever therapy (MART)

Prescribe inhaler devices by BRAND to ensure consistency and avoid confusion.

See Asthma Guidelines below.

Fostair® (beclometasone / formoterol) metered dose inhaler is the locally preferred ICS/LABA.
Fostair Nexthaler ® breath-actuated inhaler is the preferred dry powder ICS/LABA device.

If patient cannot tolerate formoterol, a salmeterol / fluticasone combination may be indicated.
Combisal® (fluticasone / salmeterol) metered dose inhaler is the locally preferred device.
Seretide Accuhaler® is the locally preferred futicasone/salmeterol breath-actuated device.

NOTE: 
- Seretide Accuhaler® is not licensed for maintenance and reliever therapy (MART)

Prescribe inhaler devices by BRAND to ensure consistency and avoid confusion.

See Asthma Guidelines below.

Fostair® (beclometasone / formoterol) metered dose inhaler is the locally preferred ICS/LABA.
Fostair Nexthaler ® breath-actuated inhaler is the preferred dry powder ICS/LABA device.

It is licensed for Maintenance and Reliever Therapy (MART) and is available in a full range of doses. See MART action plan document below.

Fostair devices are not licensed in under 18's.

Prescribe inhaler devices by BRAND to ensure consistency and avoid confusion.

See Asthma Guidelines below.

Fostair® (beclometasone / formoterol) metered dose inhaler is the locally preferred ICS/LABA.
Fostair Nexthaler ® breath-actuated inhaler is the preferred dry powder ICS/LABA device.

If patient cannot tolerate formoterol, a salmeterol / fluticasone combination may be indicated.
Combisal® (fluticasone / salmeterol) metered dose inhaler is the locally preferred device.
Seretide Accuhaler® is the locally preferred futicasone/salmeterol breath-actuated device.

NOTE: 
- Symbicort Turbohaler® is not one of the locally preferred devices
- Symbicort Turbohaler® is less cost effective than Fostair at low and high doses

- A MART action plan is available for patients to use with this device - see MART action plan document below

Prescribe inhaler devices by BRAND to ensure consistency and avoid confusion.

See Asthma Guidelines below.

Symbicort as Reliever therapy for mild asthma - has not yet been evaluated by NICE or the Surrey Heartlands ICS Area Prescribing Committee (APC). As such, advice regarding safety, effectiveness (including cost-effectiveness) and its place in therapy is yet to be determined. It is recommended that clinicians contact their medicines management team for further information and advice before prescribing. 
This will be considered when guidance is published by NICE (publication expected July 2024)

Fostair® (beclometasone / formoterol) metered dose inhaler is the locally preferred ICS/LABA.
Fostair Nexthaler ® breath-actuated inhaler is the preferred dry powder ICS/LABA device.

If patient cannot tolerate formoterol, a salmeterol / fluticasone combination may be indicated.
Combisal® (fluticasone / salmeterol) metered dose inhaler is the locally preferred device.
Seretide Accuhaler® is the locally preferred futicasone/salmeterol breath-actuated device.

NOTE: 
- DuoResp Spiromax® is not one of the locally preferred devices
- DuoResp Spiromax® is less cost effective than Fostair at low and high doses

- A MART action plan is available for patients to use with this device - see MART action plan document below

Prescribe inhaler devices by BRAND to ensure consistency and avoid confusion.

See Asthma Guidelines below.

NOTE DuoResp Spiromax as Reliever therapy for mild asthma - has not yet been evaluated by NICE or the Surrey Heartlands ICS Area Prescribing Committee (APC). As such, advice regarding safety, effectiveness (including cost-effectiveness) and its place in therapy is yet to be determined. It is recommended that clinicians contact their medicines management team for further information and advice before prescribing. 
This will be considered when guidance is published by NICE (publication expected Oct 2024)

Fostair® (beclometasone / formoterol) metered dose inhaler is the locally preferred ICS/LABA.
Fostair Nexthaler ® breath-actuated inhaler is the preferred dry powder ICS/LABA device.

If patient cannot tolerate formoterol, a salmeterol / fluticasone combination may be indicated.
Combisal® (fluticasone / salmeterol) metered dose inhaler is the locally preferred device.
Seretide Accuhaler® is the locally preferred futicasone/salmeterol breath-actuated device.

NOTE: 
- Fobumix Easyhaler® is not one of the locally preferred devices

- A MART action plan is available for patients to use with this device - see MART action plan document below

Prescribe inhaler devices by BRAND to ensure consistency and avoid confusion.

See Asthma Guidelines below.

The Surrey and North West Sussex Area Prescribing Committee (APC) does not recommend valproate to manage agitation or aggression in people living with dementia (unless it is indicated for another condition), in line with NICE guidance (NG97)

Fostair® (beclometasone / formoterol) metered dose inhaler is the locally preferred ICS/LABA.
Fostair Nexthaler ® breath-actuated inhaler is the preferred dry powder ICS/LABA device.

If patient cannot tolerate formoterol, a salmeterol / fluticasone combination may be indicated.
Combisal (fluticasone / salmeterol) metered dose inhaler is the locally preferred device

Prescribe inhaler devices by BRAND to ensure consistency and avoid confusion.

See Asthma Guidelines below.

The Surrey and North West Sussex Area Prescribing Committee does not recommend the use of probiotics.

Probiotics will be considered BLACK on the traffic light system.

The Surrey & North West Sussex Area Prescribing Committee (APC) does not recommend minocycline as a treatment option for acne and a BLACK traffic light status is recommended. (NB: Not recommended for use in any health setting across Surrey and NW Sussex health economy)

See policy statement below for more information and key references.

The Surrey & North West Sussex Area Prescribing Committee (APC) recommends tofacitinib as a treatment option in adult patients with moderately to severely active ulcerative colitis in line with NICE TA 547 (November 2018)

Tofacitinib is a payment by results excluded medicine and initiation and subsequent monitoring of response will be by the gastroenterology specialist service. Blueteq forms for initiation and continuation will be available for completion by specialist teams.

Tofacitinib will be considered as RED on the traffic light system

Primary care prescribers should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient’s medication.

The Surrey & North West Sussex Area Prescribing Committee (APC) recommends tofacitinib as a treatment option in adult patients with active psoriatic arthritis after inadequate response to DMARDs in line with NICE TA 543 (October 2018)

Tofacitinib is a payment by results excluded medicine and initiation and subsequent monitoring of response will be by the rheumatology specialist service. Blueteq forms for initiation and continuation will be available for completion by specialist teams.

Tofacitinib will be considered as RED on the traffic light system

Primary care prescribers should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient’s medication.

The Prescribing Clinical Network recommends the use of tizanidine for the treatment of spasticity.

Tizanidine will be considered BLUE (no information sheet) on the traffic light system.

Prescribing should be retained by the specialist until the patient has been stabilised on the optimal dose which must be a minimum of 4 months.

The Prescribing Clinical Network recommends bevacizumab 1.25mg intravitreal injection as a cost-effective treatment option, alongside ranibizumab or aflibercept, for patients with Wet Age Related macular Degeneration (wet AMD).

Bevacizumab can be offered after discussion of treatment options with individual patients meeting NICE criteria for ranibizumab or aflibercept.

Bevacizumab can also be offered to individuals, after discussion of treatment options, for those patients with visual acuity outside of NICE

The PCN recommends the sequential use of TNF alpha inhibitors (adalimumab, infliximab or golimumab) in patients with moderately to severely active ulcerative colitis prior to a switch to vedolizumab.

Adalimumab, Infliximab and Golimumab are payment by results excluded drugs and will be considered RED on the traffic light system.

Gastroenterology specialists will be required to complete blueteq initiation and continuation forms for the commissioners.

The manufacture of sucralfate tablets and suspension have been discontinued in the UK.

The PCN and gastroenterology colleagues agree that the prescribing and supply of sucralfate should remain with the hospital / specilaist.
As such, sucralfate preparations are RED on the tarffic light system.

See policy statement below for details

The PCN does not recommend the routine use of Souvenaid as a dietary supplement in patients with Alzheimer's Disease and awarded it a BLACK traffic light status.

There is no further evidence published since the last evidence review that demonstrates that Souvenaid has any effect in decreasing the rate of cognitive decline or delaying Alzheimer’s Disease progression.

The Prescribing Clinical Network advises clinicians that finasteride is not prescribable in NHS primary care for the treatment of androgenetic alopecia.

Finasteride for androgenetic alopecia (male pattern hair loss) is not indicated for use in women, children and adolescents.

Patients should be advised to consult their private clinicians for further information and/or supply.

GPs should ensure that patient medication records include any medicine for which prescribing remains the responsibility of other care providers. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient’s medication.

Finasteride for the treatment of male pattern baldness (androgenetic alopecia) is considered BLACK (not recommended for use in any health setting across Surrey & North West facing Sussex health economy) on the traffic light system.

MHRA/CHM advice: rare reports of depression and suicidal thoughts (May 2017)

The MHRA has received reports of depression and, in rare cases, suicidal thoughts in men taking finasteride (Propecia®) for male pattern hair loss; depression is also associated with Proscar® for benign prostatic hyperplasia. Patients should be advised to stop finasteride immediately and inform a healthcare professional if they develop depression.

The Prescribing Clinical Network (PCN) recommends ixekizumab (Taltz®) as a treatment option in active Psoriatic Arthritis after inadequate response to disease-modifying antirheumatic drugs (DMARDs) in line with NICE TA537 (August 2018)

Ixekizumab for this indication will be considered as RED on the traffic light system and treatment should be initiated and continued by specialist rheumatology clinicians.

Gabapentin is recommended as a FIRST line option for the treatment of Restless Leg Syndrome, as per CKS guidance.

Link to CKS page - https://cks.nice.org.uk/restless-legs-syndrome   Please note; this is an off-label indication of a licensed medicine.

Pregabalin is recommended as a FIRST line option for the treatment of Restless Leg Syndrome, as per CKS guidance.

Link to CKS page - https://cks.nice.org.uk/restless-legs-syndrome  

Please note; this is an off-label indication of a licensed medicine.

Rotigotine is recommended as a FIRST line option for the treatment of Restless Leg Syndrome, as per CKS guidance.

Link to CKS page - https://cks.nice.org.uk/restless-legs-syndrome

Ropinirole is recommended as a FIRST line option for the treatment of Restless Leg Syndrome, as per CKS guidance.

Link to CKS page - https://cks.nice.org.uk/restless-legs-syndrome

Pramipexole is recommended as a FIRST line option for the treatment of Restless Leg Syndrome, as per CKS guidance.

Link to CKS page - https://cks.nice.org.uk/restless-legs-syndrome

The Prescribing Clinical Network recommends the use of ocriplasmin in line with NICE TA 297, as an option for treating vitreomacular traction in adults.

Ocriplasmin should be used only by specialists and as such is considered as RED on the traffic light system.

Ocriplasmin is excluded from the National Tariff when administered for its licensed indication. It should only be administered within a hospital setting by suitably trained specialists, and will not be transferred to primary care. Providers should apply for funding using the Blueteq system.

The Prescribing Clinical Network recommends the use of ranibizumab as an option for treating visual impairment due to choroidal neovascularisation secondary to pathological myopia in patients in line with NICE TA 298 criteria.

Ranibizumab should be used only by specialists and as such is considered as RED on the traffic light system.

Ranibizumab is excluded from the National Tariff when administered for its licensed indication. It should only be administered within a hospital setting by suitably trained specialists, and will not be transferred to primary care. Providers should apply for funding using the Blueteq system.

The Prescribing Clinical Network recommends the use of Atropine for the treatment of licensed hospital indications ( including Iritis and Uveitis)

Atropine will be considered to be RED on the traffic light system.

New patients:

·         Should be initiated on Atropine 1% minims® by their consultant ophthalmologist 

·         Patients with manual dexterity issues can be initiated on Atropine 1% eye drop (bottles)

Switching patients from Atropine 1% eye drops (bottles):

Patients currently using Atropine 1% eye drops for licensed indications who do not have manual dexterity issues, should be switched to Atropine 1% minims® at their next medication review.

The Prescribing Clinical Network recommends the use of Atropine for the treatment of licensed hospital indications ( including Iritis and Uveitis)

Atropine will be considered to be RED on the traffic light system.

New patients:

·         Should be initiated on Atropine 1% minims® by their consultant ophthalmologist 

·         Patients with manual dexterity issues can be initiated on Atropine 1% eye drop (bottles)

Switching patients from Atropine 1% eye drops (bottles):

Patients currently using Atropine 1% eye drops for licensed indications who do not have manual dexterity issues, should be switched to Atropine 1% minims® at their next medication review.

The Prescribing Clinical Network recommends the use of cyclopentolate eye drops (0.5% & 1%) for the treatment licensed hospital indications ( including Iritis and Uveitis)

Cyclopentolate eye drops will be considered to be RED on the traffic light system.

New patients should be initiated on cyclopentolate eye drops by their consultant ophthalmologist.

The Prescribing Clinical Network recommends the use of cyclopentolate eye drops (0.5% & 1%) for the treatment licensed hospital indications ( including Iritis and Uveitis)

Cyclopentolate eye drops will be considered to be RED on the traffic light system.

New patients should be initiated on cyclopentolate eye drops by their consultant ophthalmologist.

The Prescribing Clinical Network recommends the use of Atropine for the treatment of painful ciliary spasm in blind eyes

Atropine will be considered to be BLUE (no information sheet) on the traffic light system.

Initiation will be by consultant ophthalmologists and transfer of care can be considered after a minimum of 2 months prescribing by the consultant and once the patient has shown to be benefiting from treatment.

New patients:

·         Should be initiated on Atropine 1% minims® by their consultant ophthalmologist 

·         Patients with manual dexterity issues can be initiated on Atropine 1% eye drop (bottles)

Switching patients from Atropine 1% eye drops:

Patients currently using Atropine 1% eye drops for this indication who do not have manual dexterity issues, should be switched to Atropine 1% minims® at their next medication review.

The Prescribing Clinical Network recommends the use of cyclopentolate eye drops (0.5% & 1%) for the treatment of painful ciliary spasm in blind eyes

Cyclopentolate eye drops will be considered to be BLUE (no information sheet) on the traffic light system.

Initiation will be by consultant ophthalmologists and transfer of care can be considered after a minimum of 2 months prescribing by the consultant and once the patient has shown to be benefiting from treatment.

The Prescribing Clinical Network recommends dupilumab as a treatment option for treating moderate to severe atopic dermatitis in line with NICE TA534 (August 2018).

Dupilumab for this indication will be considered as RED on the traffic light status (treatment should be initiated and continued by specialist clinicians)

Dupilumab is a payment by results excluded drug and specialists will be required to notify commissioners of initiation and response to treatment using the tick box proformas available on the blueteq system.

The Prescribing Clinical Network recommends the use of febuxostat in line with NICE TA 164, for the management of chronic hyperuricaemia in gout only for people who are intolerant of allopurinol (as defined in TA) or for whom allopurinol is contraindicated.
Febuxostat is considered to have a GREEN status on the traffic light system

The Prescribing Clinical Network considers the prescribing of penicillamine in rheumatoid arthritis in NEW patients to be RED – specialist ONLY drugs - treatment initiated and continued by specialist clinicians.

Please note:

• Penicillamine is no longer used routinely (see guidelines from BSR and BHPR below).
• For any new patients initiated on penicillamine, prescribing should be retained by the specialist. 
• For the small number of patients currently taking penicillamine in primary care, monitoring requirements should be as described in the current BNF and SPC. 

Primary care monitoring requirements for people on penicillamine are available from CKS at: https://cks.nice.org.uk/dmards#!scenario:12 

The Prescribing Clinical Network considers the prescribing of sodium aurothiomalate in rheumatoid arthritis in NEW patients to be RED - specialist ONLY drugs - treatment initiated and continued by specialist clinicians.

Please note:

• For any new patients initiated on sodium aurothiomalate, prescribing should be retained by the specialist.
• For any patients currently taking sodium aurothiomalate in primary care, monitoring should be retained in primary care and requirements should be as described in the current BNF and SPC.

Primary care monitoring requirements for people on sodium aurothiomalate are available from CKS at: https://cks.nice.org.uk/dmards#!scenario:7

Racecadotril is not recommended by the PCN for the treatment of acute diarrhoea in adults and children.

See the Racecadotril Policy statement below for further details

The Prescribing Clinical Network does not recommend the use of pegloticase for treating severe debilitating chronic tophaceous gout, as its marketing authorisation has been withdrawn in the UK/EU.

See Pegloticase policy statement below for further details

The Prescribing Clinical Network recommends guselkumab as a treatment option for treating moderate to severe plaque psoriasis in line with NICE TA521 (June 2018).

Guselkumab for this indication will be considered as RED on the traffic light status (treatment should be initiated and continued by specialist clinicians)

Guselkumab is a payment by results excluded drug and specialists will be required to notify commissioners of initiation and response to treatment using the tick box proformas available on the blueteq system.

Vacuum pumps are now approved for prescribing in primary care. They are most useful in patients with nerve damage, whether by surgery or for medical reasons.

The brand has not been specified but must be selected from the options available in the drug tariff and the prescriber must be able to provide appropriate training.

Training is available from some of the agents marketing these products but GPs must have patient consent before transferring any details.

This can be initiated in primary care and is considered GREEN on the traffic light system

Combination treatments (oral & non oral)
These treatments should not be used in combination with other treatments for erectile dysfunction due to the limited evidence available to support their use. See here for further information: https://surreyccg.res-systems.net/pad/Search/DrugConditionProfile/6169

The PCN does not support the routine use of mistletoe extract for the treatment of cancer or palliative care.
Mistletoe extract will be considered as BLACK on the traffic light system.

The PCN does not support the routine use of mistletoe extract for the treatment of cancer or palliative care.
Mistletoe extract will be considered as BLACK on the traffic light system

Alprostadil cream (Vitaros) is restricted by SLS criteria as identified in the Health Service Circular (HSC) 1999/148 at a maximum frequency of dosing of four times per month.

Alprostadil cream (Vitaros®) is now available as a treatment option in primary care for patients who do not respond to PDE-5 inhibitors. This can be initiated in primary care and is considered GREEN on the traffic light system

Combination treatments (oral & non oral)
These treatments should not be used in combination with other treatments for erectile dysfunction due to the limited evidence available to support their use. See here for further information https://surreyccg.res-systems.net/pad/Search/DrugConditionProfile/6168

The Prescribing Clinical Network recommends the use of riluzole in line with NICE TA20, for the treatment of individuals with the amyotrophic lateral sclerosis (ALS) form of Motor Neurone Disease.

Riluzole should be only be initiated by a neurological specialist with expertise in the management of MND, but can be managed in primary care via a shared care agreement with general practitioners, and as such is considered as AMBER on the traffic light system.

PLEASE NOTE: In May 2017, the Prescribing Clinical Network recommended that the branded product Rilutek would be considered BLACK on the traffic light system. 

The PCN recommends guanfacine as a treatment option in line with NICE guidance below (NG87 - March 2018).

Offer atomoxetine or guanfacine to children aged 5 years and over if

• they cannot tolerate methylphenidate or lisdexamfetamine

or

• their symptoms have not responded to separate 6-week trials of lisdexamfetamine and methylphenidate, having considered alternative preparations and adequate doses.

Guanfacine will be considered AMBER on the traffic light system with initiation by specialists in secondary care only.

The PCN does not recommend Alimemazine for the treatment of Urticaria in children (over the age of 2 years) and adults

Alimemazine will be considered BLACK, for new patients, on the traffic light system

Patients whose treatment with Alimemazine was initiated by the NHS before this recommendation was made, must be reviewed by their prescriber within 6-12 months, but should be able to continue treatment until, the patient and their NHS consultant consider it appropriate to stop.

The Prescribing Clinical Network (PCN) does not recommend the use of RESPeRATE® as a non-pharmacological approach to the treatment of hypertension.

RESPeRATE® is considered as BLACK status on the Traffic Light System and is not recommended for use in any health setting across Surrey & North West facing Sussex health economy

The Prescribing Clinical Network does not recommend the prescribing of Potassium Hydroxide 5% products (MolluDab® and Molutrex®) either in primary or secondary care.

These products will be considered BLACK on the traffic light system and is not recommended for use in any health setting across Surrey & North West facing Sussex health economy.

If patients request these treatments, they can be advised that they are available for purchase from a community pharmacy.

The Prescribing Clinical Network does not recommend the prescribing of Potassium Hydroxide 5% products (MolluDab® and Molutrex®) either in primary or secondary care.

These products will be considered BLACK on the traffic light system and is not recommended for use in any health setting across Surrey & North West facing Sussex health economy.

If patients request these treatments, they can be advised that they are available for purchase from a community pharmacy.

The Prescribing Clinical Network recommends Brodalumab as a treatment option for moderate to severe plaque psoriasis in line with NICE TA511 (March 2018).

Brodalumab for this indication will be considered as RED on the traffic light status (treatment should be initiated and continued by specialist clinicians)

Brodalumab is a payment by results excluded drug and specialists will be required to notify commissioners of initiation and response to treatment using the tick box proformas available on the blueteq system.

Paracetamol is considered a 1st line option for the treatment option for pain (except diabetic neuropathy), see guidelines below for further information. Please see narrative below for information on paracetamol products:

• Paracetamol Tablets 500mg: GREEN (1st line treatment option)
• Paracetamol oral suspension 120mg/5ml, 250mg/5ml - GREEN (1st line treatment option IF suspension is indicated)

Effervescent or soluble formulations: 
There is no advantage in patient who can swallow tablets, these products contain high concentrations of sodium and are expensive. Avoid use unless patient has difficulty swallowing

• Paracetamol dispersible tablets 500mg - GREEN 

When oral preparations are not appropriate:

• Paracetamol suppository 60mg, 125mg, 250mg, 500mg - GREEN 

Not recommended for use in any healthcare setting across Surrey CCGs

• Paracetamol oral suspension 500mg in 5ml -  https://surreyccg.res-systems.net/pad/Search/DrugConditionProfile/6194

Paracetamol combination products: 

• Paracetamol & Tramadol: https://surreyccg.res-systems.net/pad/Search/DrugConditionProfile/5748
• Paracetamol & Codeine: Follow link here 

Persistent Non-Malignant Pain Guidelines
A stepped approach to pain management is recommended. Paracetamol is considered a 1st line option for the treatment of persistent non-malignant pain. A trial of codeine should be initiated where a weak opioid is indicated. Please see narrative below regarding specific  products. Refer to specific pages on PAD for products containing codeine phosphate (including combination products) and refer to persistent non-maligant pain guidelines attached: 

• Dihydrocodeine (standard release) 30mg tablets - GREEN
• Dihydrocodeine oral solution - GREEN (treatment option if oral solution is indicated)
• Dihydrocodeine sustained release tablets - GREEN  (use if standard release tablets are not tolerated or compliance is an issue. Initiate at a low dose).

Consider a patient agreement is completed by the patient (see below) prior to a trial of Dihydrocodeine

NICE does not recommend the use of anticholinergics in Parkinson's disease for patients who have developed dyskinesia and / or motor fluctuations.

NICE does not recommend the use of anticholinergics in Parkinson's disease for patients who have developed dyskinesia and / or motor fluctuations.

NICE does not recommend the use of anticholinergics in Parkinson's disease for patients who have developed dyskinesia and / or motor fluctuations.

Clonazepam or melatonin (generic 2mg MR tablets) may be considered to treat rapid eye movement sleep behaviour disorder (RBD) in people with Parkinson's Disease and sleep disturbance (unlicensed use).

A medicines review should first be undertaken to address any possible pharmacological causes.

Clonazepam or melatonin for this condition should only be initiated on request from a Parkinson's specialist

Rotigotine patches may be considered if levodopa and / or oral dopamine agonists are not effective in treating nocturnal akinesia

Midodrine may be considered (2nd line after fludrocortisone) for the treatment of orthostatic hypotension
- due to autonomic dysfunction;  OR
- in patients with Parkinson's Disease
See the Midodrine SPC for details of contraindications and monitoring requirements and information sheet

Midorine should only be initiated on request from a Parkinson's specialist and only after a review of existing medicines to address any potential pharmalogical causes for the hypotension (including antihypertensives, dopaminergics, anticholinergics, antidepressants).

Fludrocortisone, although unlicensed for this use, should be used in preference to midodrine . Again, refer to the SPC for clinical particulars including contraindications and interactions with other medicines

Fludrocortisone, although unlicensed for this use, is recommended for the treament of postural hypotension in Parkinson's Disease. Refer to the SPC for clinical particulars including contraindications and interactions with other medicines.

Fludrocortisone should only be continued or initiated on request from a Parkinson's specialist and only after a review of existing medicines to address any potential pharmalogical causes for the hypotension (including antihypertensives, dopaminergics, anticholinergics, antidepressants).

Midodrine may be considered (2nd line after fludrocortisone) for the treatment of orthostatic hypotension in patients with Parkinson's Disease.
Again, see the Midodrine SPC for details of contraindications and monitoring requirements.

Quetiapine can be used to treat hallucinations and delusions in Parkinson's Disease (unlicensed use) in patients with no cognitive impairment.

Quetiapine for this condition should only be initiated on request from a Parkinson's specialist.
Advice must be sought from a specialist in Parkinson's Disease before modifying therapy.

Clozapine may be used to treat hallucinations and delusions in Parkinson's Disease (unlicensed use) in patients with no cognitive impairment if quetiapine has not been effective.

Clozapine requires long-term monitoring of toxicity with the patient, prescriber and dispenser being registered with the clozapine monitoring service. As such, prescribing responsibility should remain with the Parkinson's specialist.

NICE does not recommend the use of olanzapine to treat hallucinations and delusions in Parkinson's disease

NICE does not recommend the use of vitamin E supplementation for neuroprotective therapy in Parkinson's disease

NICE does not recommend the use of Co-enzyme Q10 supplementation for neuroprotective therapy in Parkinson's disease

NICE does not recommend the use of creatine supplementation for Parkinson's disease

• Levodopa is recommended as a first-line treatment in the early stages of Parkinson's disease where motor symptoms are impacting on quality of life.
• Levodopa may also be a treatment choice in the early stages of Parkinson's disease where motor symptoms do not impact quality of life.
• Levodopa may be considered in the treatment of nocturnal akinesia in Parkinson's disease.

Initiation may be carried out in Primary Care but only after recommendation by a specialist.

Patients in whom Parkinson's is suspected should be referred quickly and untreated to a specialist.

NICE issued a Do Not Do Recommendation in June 2006 (updated July 2017) which states:

"Acute levodopa and apomorphine challenge tests should not be used in the differential diagnosis of parkinsonian syndromes."

NICE issued a Do Not Do Recommendation in June 2006 (updated July 2017) which states:

"Acute levodopa and apomorphine challenge tests should not be used in the differential diagnosis of parkinsonian syndromes."

• Levodopa is recommended as a first-line treatment in the early stages of Parkinson's disease where motor symptoms are impacting on quality of life.
• Levodopa may also be a treatment choice in the early stages of Parkinson's disease where motor symptoms do not impact quality of life.
• Levodopa may be considered in the treatment of nocturnal akinesia in Parkinson's disease.

Initiation may be carried out in Primary Care but only after recommendation by a specialist.

Patients in whom Parkinson's is suspected should be referred quickly and untreated to a specialist.

Levodopa-carbidopa (Duodopa®) intestinal gel is not for primary care prescribing.
Its specialist use is commissioned through NHS England.

• Non-ergot derived Dopamine agonists (or levodopa or monoamine oxidase B inhibitors) are a first-line treatment option in the early stages of Parkinson's disease where motor symptoms do not impact quality of life.
• Non-ergot derived Dopamine agonists are a choice of adjuvant treatment in patients who have developed dyskinesia or motor fluctuations despite optimal levodopa therapy
• Non-ergot derived Dopamine agonists may be considered in the treatment of nocturnal akinesia in Parkinson's disease.

Initiation may be carried out in Primary Care but only after recommendation by a specialist.

Modifications to therapy should only be carried out on specialist advice.

Prescribers are reminded to prescribe generically and not by brand.

• Non-ergot derived Dopamine agonists (or levodopa or monoamine oxidase B inhibitors) are a first-line treatment option in the early stages of Parkinson's disease where motor symptoms do not impact quality of life.
• Non-ergot derived Dopamine agonists are a choice of adjuvant treatment in patients who have developed dyskinesia or motor fluctuations despite optimal levodopa therapy
•  Non-ergot derived Dopamine agonists may be considered in the treatment of nocturnal akinesia in Parkinson's disease.

Initiation may be carried out in Primary Care but only after recommendation by a specialist.

Modifications to therapy should only be carried out on specialist advice.

Prescribers are reminded to prescribe generically and not by brand.

Dopamine agonists are not recommended as a neuroprotective therapy except in the context of a clinical trial

Dopamine agonists are not recommended as a neuroprotective therapy except in the context of a clinical trial

Dopamine agonists are not recommended as a neuroprotective therapy except in the context of a clinical trial

Dopamine agonists are not recommended as a neuroprotective therapy except in the context of a clinical trial

Dopamine agonists are not recommended as a neuroprotective therapy except in the context of a clinical trial

Ergot-derived Dopamine agonists (bromocriptine, pergolide, cabergoline) are NOT recommended as a first-line treatment option for Parkinson's disease and should be considered BLACK.

Ergot-derived Dopamine agonists (bromocriptine, pergolide, cabergoline) should only be considered as an adjunct to levodopa in Parkinson's disease patients:

• who have developed dyskinesia or motor fluctuations despite optimal levodopa therapy AND
• whose symptoms are not adequately controlled with a non-ergot derived dopamine agonist (pramipexole, ropinirole).

NOT for primary care prescribing, although all RED drug prescribing should be recorded on the patient's practice records. On-going toxicity monitoring is required.

Ergot-derived Dopamine agonists (bromocriptine, pergolide, cabergoline) are NOT recommended as a first-line treatment option for Parkinson's disease and should be considered BLACK.

Ergot-derived Dopamine agonists (bromocriptine, pergolide, cabergoline) should only be considered as an adjunct to levodopa in Parkinson's disease patients:

• who have developed dyskinesia or motor fluctuations despite optimal levodopa therapy AND
• whose symptoms are not adequately controlled with a non-ergot derived dopamine agonist (pramipexole, ropinirole).

NOT for primary care prescribing, although all RED drug prescribing should be recorded on the patient's practice records. On-going toxicity monitoring is required.

Ergot-derived Dopamine agonists (bromocriptine, pergolide, cabergoline) are NOT recommended as a first-line treatment option for Parkinson's disease and should be considered BLACK.

Ergot-derived Dopamine agonists (bromocriptine, pergolide, cabergoline) should only be considered as an adjunct to levodopa in Parkinson's disease patients:

• who have developed dyskinesia or motor fluctuations despite optimal levodopa therapy AND
• whose symptoms are not adequately controlled with a non-ergot derived dopamine agonist (pramipexole, ropinirole).

NOT for primary care prescribing, although all RED drug prescribing should be recorded on the patient's practice records. On-going toxicity monitoring is required

• Monoamine-oxidase-B inhibitors (rasagiline, selegiline), (or levodopa or dopamine agonists) are a first-line treatment option in the early stages of Parkinson's disease where motor symptoms do not impact quality of life.
• Monoamine-oxidase-B inhibitors are a choice of adjuvant treatment in patients who have developed dyskinesia or motor fluctuations despite optimal levodopa therapy.

Patients in whom Parkinson's is suspected should be referred quickly and untreated to a specialist.

Initiation may be carried out in Primary Care but only after recommendation by a specialist.
Modifications to therapy should only be carried out on specialist advice.

Prescribers are reminded to prescribe generically and not by brand.

•  Monoamine-oxidase-B inhibitors (rasagiline, selegiline), (or levodopa or dopamine agonists) are a first-line treatment option in the early stages of Parkinson's disease where motor symptoms do not impact quality of life.
• Monoamine-oxidase-B inhibitors are a choice of adjuvant treatment in patients who have developed dyskinesia or motor fluctuations despite optimal levodopa therapy.

Patients in whom Parkinson's is suspected should be referred quickly and untreated to a specialist.

Initiation may be carried out in Primary Care but only after recommendation by a specialist.
Modifications to therapy should only be carried out on specilaist advice.

Prescribers are reminded to prescribe generically and not by brand.

Monoamine-oxidase-B inhibitors (rasagiline, selegiline) are not recommended as a neuroprotective therapy except in the context of a clinical trial.

Monoamine-oxidase-B inhibitors (rasagiline, selegiline) are not recommended as a neuroprotective therapy except in the context of a clinical trial.

COMT inhibitors are a choice of adjuvant treatment in patients who have developed dyskinesia or motor fluctuations despite optimal levodopa therapy.

• Entacapone is the locally agreed 1st-choice COMT inhibitor (BLUE no information sheet)
• Opicapone is the locally agreed 2nd-choice COMT inhibitor (BLUE no information sheet)
• Tolcapone is the locally agreed 3rd-choice COMT inhiitor (AMBER shared care)

Initiation is to be carried out in in secondary care and prescribed by a specialist for a minimum of 2 months, doses stabilised and response to treatment reviewed prior to any transfer request to primary care.

Modifications to therapy should only be carried out on specialist advice.
Prescribers are reminded to prescribe generically and not by brand.

Amantadine may be considered as an adjuvant where dyskinesia is not adequately managed by modifying existing therapy.

Initiation may be carried out in Primary Care but only after recommendation by a specialist.

Modifications to therapy should only be carried out on specialist advice.

NICE issued a Do Not Do Recommendation in June 2006 (updated July 2017) which states:

"Acute levodopa and apomorphine challenge tests should not be used in the differential diagnosis of parkinsonian syndromes."

COMT inhibitors are a choice of adjuvant treatment in patients who have developed dyskinesia or motor fluctuations despite optimal levodopa therapy.

• Entacapone is the locally agreed 1st-choice COMT inhibitor (BLUE no information sheet)
• Opicapone is the locally agreed 2nd-choice COMT inhibitor (BLUE no information sheet)
• Tolcapone is the locally agreed 3rd-choice COMT inhiitor (AMBER shared care)

Initiation is to be carried out in in secondary care and prescribed by a specialist for a minimum of 2 months, doses stabilised and response to treatment reviewed prior to any transfer request to primary care.

Modifications to therapy should only be carried out on specialist advice.
Prescribers are reminded to prescribe generically and not by brand.

Paracetamol is considered a 1st line option for the treatment option for pain (except diabetic neuropathy), see guidelines below for further information.

Paracetamol oral suspension is not recommended for use in healthcare setting. Please follow the link here for information about other paracetamol products. https://surreyccg.res-systems.net/pad/Search/DrugConditionProfile/6159

Persistent Non-Malignant Pain Guidelines
A stepped approach to pain management is recommended. Paracetamol is considered a 1st line option for the treatment of persistent non-malignant pain. A trial of codeine should be initiated where a weak opioid is indicated. Please see narrative below regarding specific products and refer to persistent non-maligant pain guidelines attached: 

• Codeine tablets (30mg - 60mg): GREEN
• Codeine oral solution - GREEN (treatment option if oral solution is indicated)
• Dihydrocodeine (standard release) 30mg tablets - GREEN
• Dihydrocodeine oral solution - GREEN (treatment option if oral solution is indicated)
• Dihydrocodeine sustained release tablets -  Use if standard release tablets are not tolerated or compliance is an issue. Initiate at a low dose.

Combination products (not preferred)

• Co-codamol 30/500mg:  Limited role as this product does not allow titration to most effective analgesic dose.
• Co-codamol 8/500mg:  May lead to opioid adverse effects and no evidence to show low dose combination products are more effective than paracetamol alone.
• Co-dydramol 10/500mg -  May lead to opioid adverse effects and no evidence to show low dose combination products are more effective than paracetamol alone.

Effervescent or soluble combination formulations

• There is no advantage in using this product in patients who can swallow tablets, these products contain high concentrations of sodium and are expensive. Avoid use unless patient has difficulty swallowing

Branded prescribing (Kapake, Solpadol,Tylex):

• Please prescribe generically, the branded products are considered BLACK on the traffic light system

Consider a patient agreement is completed by the patient (see below) prior to a trial of Codeine

A stepped approach to pain management is recommended. Paracetamol is considered a 1st line option for the treatment of pain. A trial of tramadol (patient agreement) may be considered if maximum tolerated doses of codeine /dihydrocodeine are ineffective. Consider whether all measures have been taken to control side effects. Please refer to the guidelines attached: 

Ensure a patient agreement is completed by the patient (see below) prior to a trial of tramadol.

PLEASE NOTE:

• Standard/Immediate release capsules should be prescribed GENERICALLY
• Modified release tablets should be prescribed by BRAND with Marol® being locally preferred (See below)

A stepped approach to pain management is recommended. Paracetamol is considered a 1st line option for the treatment of pain. Consider buprenorphine patches (low dose) for use in the limited number of patients who are unable to tolerate oral medications or if morphine is contra-indicated. 

Higher dose buprenorphine patches are not included in the pathway within this guideline and have a limited place in therapy for persistent non-malignant pain. Please refer to the guidelines attached.

Consider a patient agreement is completed by the patient (see below) prior to a trial of Buprenorphine.

A stepped approach to pain management is recommended. Paracetamol is considered a 1st line option for the treatment of pain. Consider buprenorphine in this formulation for use in patients who are unable to tolerate standard codeine/ dihydrocodeine tablets or capsules or if morphine is contra-indicated.  Please refer to the guidelines attached: 

Buprenorphine buccal or sublingual tablets are recommended as BLUE (no infomation sheet) on the traffic light system. If this formulation is indicated, prescribing may be initiated and stabilised by a specialist service but has the potential to transfer to primary care WITHOUT a formal shared care agreement. In some circumstances a specialist may recommend that prescribing can be started in primary care 

Consider a patient agreement is completed by the patient (see below) prior to a trial of Buprenorphine.

A stepped approach to pain management is recommended. Morphine is the 1st line  treatment option where a strong opioid is indicated. Please refer to the guidelines attached.

It is recommended  that morphine oral modified release (MR) preparations are prescribed by BRAND - see UKMI Branded Prescribing Recommendations document below. Patients currently receiving generically written prescriptions for morphine MR preparations should be reviewed with a view to changing the prescribing to a more cost-effective brand.
Please note that Zomorph® capsules can be opened up for patients who are unable to swallow.

Ensure a patient agreement is completed by the patient (see below) prior to a trial of Morphine

A stepped approach to pain management is recommended.  A trial of oxycodone may be appropriate if the patient is intolerant to morphine. (Take into consideration dose equivalence - oxycodone is twice as potent as morphine so dose should be adjusted accordingly). See guidelines below for further information.

Ensure a patient agreement is completed by the patient (see below) prior to a trial of Oxycodone

Note the recommendations made at the Prescribing Clinical Network in December 2016 (below) in relation to brand prescribing.

Patients currently receiving generically written prescriptions should be reviewed with a view to change the prescribing to a cost-effective brand.

Fentanyl patches have a very limited place in therapy in persistent non-malignant pain and should only be prescribed on advice of a relevant specialist (e.g. renal physician).

Brand name prescribing is recommended to reduce the risk of confusion and error in dispensing and administration. Please refer to recommendation made by the MCG (below) in November 2015.

Fentanyl patches should not be prescribed under any circumstances for opioid naïve patients. Take care with the calculation of dose equivalents.

Please refer to the Persistent non-malignant pain guidelines and supporting resources below for further information

Pregabalin is not recommended as a treatment option for persistent non-malignant pain (including low back pain) and will be considered BLACK on the traffic light system. Please see the persistent non- malignant guidelines attached below for information on prescribing for this indication.

Pregabalin is not recommended as a treatment option for persistent non-malignant pain (including low back pain) and will be considered BLACK on the traffic light system. Please see the persistent non- malignant guidelines attached below for information on prescribing for this indication.

The branded product LYRICA is considered BLACK on the traffic light system for all indications 

Gabapentin is not recommended as a treatment option for persistent non-malignant pain (including low back pain) and will be considered BLACK on the traffic light system. Please see the persistent non- malignant guidelines attached below for information on prescribing for this indication.

The Prescribing Clinical Network (PCN), during the update of the persistant non-malignant pain guidelines, does not recommend intra-articular hyaluronic acid injection in line with NICE guidance CG177. 

It may be suitable for individual patients for whom other pharmacological options have been intolerable or ineffective and who are unable to undergo surgery. Hyaluronic acid for these patients should be made available on an individual basis at the Acute Trust (this is not a Payment by Results Excluded drug and in individual cases GPs should not be asked to prescribe). (Discussed and agreed by PCN in January 2011)

The Prescribing Clinical Network recommends Tiotropium (Spiriva Respimat®) as a treatment option for adult patients with asthma as an add-on maintenance bronchodilator treatment in patients who are currently treated with:

• Maintenance combination of inhaled corticosteroids (≥ 800micrograms budesonide daily or equivalent) AND
• Long acting beta2-agonists (LABA) AND
• Have experienced one or more severe exacerbations in the previous year AND
• If suitable have had a trial of MART (maintenance & reliever therapy).

Successful treatment would be no further exacerbations in the previous 12 months.
Stop treatment if success criteria not met OR if an increase in steroids is required.

Tiotropium (Spiriva Respimat®) will be considered GREEN on the traffic light system for this indication.

The Surrey and North West Sussex Area Prescribing Committee (APC) during the update of the persistant non-malignant pain guidelines, recommends topical capsaicin (Zacin) as an adjunct to core treatment for knee or hand osteoarthritis in line with NICE guidance CG177. 

Please note that the Axsain brand is not licensed for use in osteoarthritis.

Topical capsaicin (Zacin) will be considered GREEN on the traffic light system for this indication

The PCN supported the principles of switching from brand to generic medications (not recommended in the elderly) as per national guidelines in September 2013 and the proposed place in therapy of the anti-epileptic drugs which is based on NICE guidance was also discussed at that time. Transfer of care documents will be considered at a future PCN. Please note the MHRA categorisations for each drug in the attached guidance (updated January 2014) and in the link below.

The PCN supported the principles of switching from brand to generic medications (not recommended in the elderly) as per national guidelines in September 2013 and the proposed place in therapy of the anti-epileptic drugs which is based on NICE guidance was also discussed at that time. Transfer of care documents will be considered at a future PCN. Please note the MHRA categorisations for each drug in the attached guidance (updated January 2014) and in the link below.

The PCN supported the principles of switching from brand to generic medications (not recommended in the elderly) as per national guidelines in September 2013 and the proposed place in therapy of the anti-epileptic drugs which is based on NICE guidance was also discussed at that time. Transfer of care documents will be considered at a future PCN. Please note the MHRA categorisations for each drug in the attached guidance (updated January 2014) and in the link below

he PCN supported the principles of switching from brand to generic medications (not recommended in the elderly) as per national guidelines in September 2013 and the proposed place in therapy of the anti-epileptic drugs which is based on NICE guidance was also discussed at that time. Transfer of care documents will be considered at a future PCN. Please note the MHRA categorisations for each drug in the attached guidance (updated January 2014) and in the link below.

The PCN supported the principles of switching from brand to generic medications (not recommended in the elderly) as per national guidelines in September 2013 and the proposed place in therapy of the anti-epileptic drugs which is based on NICE guidance was also discussed at that time. Transfer of care documents supported in March 2015 are attached below. Please note the MHRA categorisations for each drug in the attached guidance (updated January 2014) and in the link below.

The PCN supported the principles of switching from brand to generic medications (not recommended in the elderly) as per national guidelines in September 2013 and the proposed place in therapy of the anti-epileptic drugs which is based on NICE guidance was also discussed at that time. Transfer of care documents will be considered at a future PCN. Please note the MHRA categorisations for each drug in the attached guidance (updated January 2014) and in the link below.

he PCN supported the principles of switching from brand to generic medications (not recommended in the elderly) as per national guidelines in September 2013 and the proposed place in therapy of the anti-epileptic drugs which is based on NICE guidance was also discussed at that time. Transfer of care documents will be considered at a future PCN. Please note the MHRA categorisations for each drug in the attached guidance (updated January 2014) and in the link below.

The PCN supported the principles of switching from brand to generic medications (not recommended in the elderly) as per national guidelines in September 2013 and the proposed place in therapy of the anti-epileptic drugs which is based on NICE guidance was also discussed at that time. Transfer of care documents will be considered at a future PCN. Please note the MHRA categorisations for each drug in the attached guidance (updated January 2014) and in the link below Prescribers are reminded to undertake a proportionate risk benefit assessment prior to prescribing Pregabalin or Gabapentin for patients with a known or suspected propensity to misuse.

The PCN supported the principles of switching from brand to generic medications (not recommended in the elderly) as per national guidelines in September 2013 and the proposed place in therapy of the anti-epileptic drugs which is based on NICE guidance was also discussed at that time. Transfer of care documents will be considered at a future PCN. Please note the MHRA categorisations for each drug in the attached guidance (updated January 2014) and in the link below.

The PCN supported the principles of switching from brand to generic medications (not recommended in the elderly) as per national guidelines in September 2013 and the proposed place in therapy of the anti-epileptic drugs which is based on NICE guidance was also discussed at that time. Transfer of care documents will be considered at a future PCN. Please note the MHRA categorisations for each drug in the attached guidance (updated January 2014) and in the link below. Prescribers are reminded to undertake a proportionate risk benefit assessment prior to prescribing Pregabalin or Gabapentin for patients with a known or suspected propensity to misuse.

he PCN supported the principles of switching from brand to generic medications (not recommended in the elderly) as per national guidelines in September 2013 and the proposed place in therapy of the anti-epileptic drugs which is based on NICE guidance was also discussed at that time. Transfer of care documents will be considered at a future PCN. Please note the MHRA categorisations for each drug in the attached guidance (updated January 2014) and in the link below.

The PCN supported the principles of switching from brand to generic medications (not recommended in the elderly) as per national guidelines in September 2013 and the proposed place in therapy of the anti-epileptic drugs which is based on NICE guidance was also discussed at that time. Transfer of care documents will be considered at a future PCN. Please note the MHRA categorisations for each drug in the attached guidance (updated January 2014) and in the link below.

The PCN supported the principles of switching from brand to generic medications (not recommended in the elderly) as per national guidelines in September 2013 and the proposed place in therapy of the anti-epileptic drugs which is based on NICE guidance was also discussed at that time. Transfer of care documents will be considered at a future PCN. Please note the MHRA categorisations for each drug in the attached guidance (updated January 2014) and in the link below

The PCN supported the principles of switching from brand to generic medications (not recommended in the elderly) as per national guidelines in September 2013 and the proposed place in therapy of the anti-epileptic drugs which is based on NICE guidance was also discussed at that time. Transfer of care documents will be considered at a future PCN. Please note the MHRA categorisations for each drug in the attached guidance (updated January 2014) and in the link below.

he PCN supported the principles of switching from brand to generic medications (not recommended in the elderly) as per national guidelines in September 2013 and the proposed place in therapy of the anti-epileptic drugs which is based on NICE guidance was also discussed at that time. Transfer of care documents will be considered at a future PCN. Please note the MHRA categorisations for each drug in the attached guidance (updated January 2014) and in the link below.

The PCN supported the principles of switching from brand to generic medications (not recommended in the elderly) as per national guidelines in September 2013 and the proposed place in therapy of the anti-epileptic drugs which is based on NICE guidance was also discussed at that time. Shared Care supported in November 2014 are attached below. Please note the MHRA categorisations for each drug in the attached guidance (updated January 2014) and in the link below.

This drug / device falls under the responsibility of NHS England Specialised Commissioning and should therefore not be prescribed in Primary Care. Treatment should remain with the specialist (RED) hospital only drug.

GPs should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient’s medication.

This drug / device falls under the responsibility of NHS England Specialised Commissioning and should therefore not be prescribed in Primary Care. Treatment should remain with the specialist (RED) hospital only drug. GPs should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient’s medication.

This drug / device falls under the responsibility of NHS England Specialised Commissioning and should therefore not be prescribed in Primary Care. Treatment should remain with the specialist (RED) hospital only drug.

GPs should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient’s medication.

A PREFERRED GLP-1 RECEPTOR AGONIST: Widely used, dose adjustment not required in severe renal impairment and has randomised controlled trial data to show improved cardiovascular outcomes Treatment should be reviewed at 6 months. If there is no beneficial metabolic response (defined in NICE guidance), then stop treatment, and consider alternative treatment (usually insulin initiation) in line with NICE guidance

The Prescribing Clinical Network working in conjunction with local specialists has agreed the treatment pathways below. The pathways have been developed to provide advice to primary care prescribers management of adult patients with inflammatory bowel disease.

Please see the attached pathway which has been developed in conjunction with local specialists for the GP management of adult patients with known ulcerative colitis . 

Please see the attached pathway which has been developed in conjunction with local specialists for the GP management of adult patients with known ulcerative colitis . 

Not a preferred treatment option in type 2 diabetes

See guidelines below and associated documentation for further information

The PCN noted that Dapagliflozin is a treatment option in NICE TA 288 & TA390

Enoxaparin is a biological medicine and must be prescribed by brand in line with MHRA guidance. Note; differences in the mechanisms for operation in needle guard between presentations of enoxaparin.

The Prescribing Clinical Network does not recommend the use of perindopril arginine Perindopril arginine will be considered BLACK on the traffic light system and prescribers should: - NOT initiate perindopril arginine in any new patients AND - Switch any patients taking perindopril arginine to perindopril erbumine in line with NHS England guidance.

The Prescribing Clinical Network does not recommend the use of oxycodone and naloxone combination product Oxycodone and Naloxone Combination Product will be considered BLACK on the traffic light system, prescribers should: o NOT initiate oxycodone and naloxone combination product for any new patient AND o De-prescribe oxycodone and naloxone combination product, with specialist support if appropriate, in all patients In exceptional circumstances where there is a clinical need for oxycodone and naloxone combination product to be prescribed in primary care this should be undertaken in a cooperation arrangement with a multidisciplinary team and / or other healthcare professional

The Prescribing Clinical Network does not recommend the use of lidocaine plasters for any indications (except symptomatic relief of neuropathic pain associated with previous herpes zoster infection). Lidocaine plasters will be considered BLACK on the traffic light system for all indications (except symptomatic relief of neuropathic pain associated with previous herpes zoster infection), primary care prescribers should

• NOT initiate lidocaine plasters for any new patient;

AND

• De-prescribe lidocaine plasters in all patients with specialist support if appropriate, in line with NHS England guidance.

In exceptional clinical circumstances (expect symptomatic relief of neuropathic pain associated with previous herpes zoster infection), where a patient has trialled all other treatments and the specialist pain or palliative care team consider there is a clinical need for lidocaine plasters to be prescribed in primary care, there should be an informed discussion between the specialists and the primary care prescriber about prescribing for individual patients.

The Prescribing Clinical Network does not recommend Safinamide as add on therapy to Levodopa, alone or in combination to other treatments in adult patients with idiopathic Parkinson’s Disease Safinamide will be considered BLACK on the traffic light status for all new patients as there are more cost effective treatment options available. Patients whose treatment with safinamide was initiated by the NHS before this recommendation was made, must be reviewed by their NHS consultant but should be able to continue treatment until, the patient and their NHS consultant consider it appropriate to stop.

The Prescribing Clinical Network does not recommend the use of paracetamol and tramadol combination product Paracetamol and tramadol combination product will be considered BLACK on the traffic light system prescribers should o NOT initiate paracetamol and tramadol combination product for any new patient AND o De-prescribe paracetamol and tramadol combination product with specialist support if appropriate, in all patients

Please follow the link here for information about other paracetamol products. https://surreyccg.res-systems.net/pad/Search/DrugConditionProfile/6159

The Prescribing Clinical Network does not recommend the use of rubefacients (excluding topical NSAIDs and capsaicin cream). Following link here to advice regarding capsaicin (Zacin) cream https://surreyccg.res-systems.net/pad/Search/DrugConditionProfile/6252

Rubefacients will be considered BLACK on the traffic light system prescribers should: o NOT initiate rubefacients for any new patient AND o De-prescribe rubefacients in all patients in line with NHS England guidance

The Prescribing Clinical Network does not recommend the use of Naltrexone-bupropion for managing overweight and obesity. This is in line with NICE TA494. Naltrexone-bupropion will be considered BLACK on the traffic light status for all new patients. This recommendation is not intended to affect treatment with naltrexone–bupropion that was started in the NHS before this guidance was published. Adults having treatment outside this recommendation may continue without change to the funding arrangements in place for them before this guidance was published, until they and their NHS clinician consider it appropriate to stop.

The Prescribing Clinical Network agreed a RED traffic light status for the use of omega-3 fatty acid compounds in Bipolar disorder (adolescents)

The Prescribing Clinical Network agreed a RED traffic light status for the use of omega-3 fatty acid compounds in treatment resistant psychosis

The Prescribing Clinical Network does not recommend the use of omega-3 fatty acid compounds for any indication other than:

• Patients with raised triglycerides for the treatment of hypertriglyceridemia as an option when triglycerides are not controlled by statins or fibrates – considered RED on the traffic light system (see separate entry for raised triglycerides)

• Bipolar disorder (adolescents) – considered RED on the traffic light system

• Treatment resistant psychosis – considered RED on the traffic light system

Omega-3 Fatty Acid Compounds are NON-FORMULARY for all other indications and prescribers should NOT initiate Omega 3 fatty acids compounds in any new patients

The PCN recommends the following medicines as treatment options for the management of benign prostatic hyperplasia and has assigned the following traffic light status to each treatment option as follows -

• Finasteride – GREEN (1st line)
• Dutasteride – GREEN (2nd line)

The branded product, Lyrica, is considered BLACK. Prescribe generically Pregabalin (prescribed generically) is considered GREEN (4th line).  Follow link here for more information:

https://surreyccg.res-systems.net/pad/Search/DrugConditionProfile/5035

The PCN does not recommend alimemazine (trimeprazine) for the unlicensed treatment of sleep disorders in children and adolescents. Alimemazine (trimeprazine) will be considered BLACK on the traffic light system for new patients Patients whose treatment with alimemazine was initiated by the NHS before this recommendation was made must be reviewed by their NHS consultant within 12 months but, should be able to continue treatment until the patient and their NHS consultant consider it appropriate to stop.

At the Surrey and North-West Sussex Area Prescribing Committee (APC) held in June 2020, it was decided that all BLACK status drugs would have their review dates extended for 5 years without the need for a review.

If a clinician or provider wishes to change the traffic light status of any BLACK drug then they will need to submit a paper for change as per usual APC process.

Where an alpha blocker is indicated, the PCN recommend one of the following as a 1st-line treatment option:

• Tamsulosin (modified release) – GREEN (NOTE - prescribe as generic capsules)
• Doxazosin (immediate release) – GREEN (NOTE - XL / modified release preparations are considered BLACK)

Alfuzosin is more costly and is therefore not recommended as a 1st-line option.

Terazosin is reserved for patients with hepatic or renal failure since no dose adjustment is required in these patient groups.

Where an alpha blocker is indicated, the PCN recommend one of the following as a 1st-line treatment option

• Tamsulosin (modified release) – GREEN (NOTE - prescribe as generic capsules)
• Doxazosin (immediate release) – GREEN (NOTE - XL / modified release preparations are considered BLACK)

Alfuzosin is more costly and is therefore not recommended as a 1st-line option. (NOTE - prescribe generically).

Terazosin is reserved for patients with hepatic or renal failure since no dose adjustment is required in these patient groups

The PCN recommends baricitinib as a treatment option for the treatment of severe Rheumatoid Arthritis in line with NICE TA466 Prescribing will be by hospital specialists only, in line with NICE TA466 using Blueteq initiation and continuation forms. Baricitinib will be considered RED on the traffic light system

The Prescribing Clinical Network recommends the use of memantine in combination with acetylcholinesterase inhibitors for adults with Behavioural and Psychological Symptoms of Dementia (BPSD). Memantine in combination with acetylcholinesterase inhibitors should be initiated by specialists within Surrey and Borders Partnership NHS Foundation Trust and will be considered as BLUE (with information sheet) on the traffic light system with a minimum of 3 months prescribed in secondary care. Please note; Memantine and the acetylcholinesterase inhibitor will be prescribed as their respective products and not as a combination product.

Tranexamic acid has been considered by the PCN and has been assigned a GREEN traffic light status, within its LICENSED indication(s).

NOTE

• the branded product (Cyklokapron) was considered BLACK at the PCN in May 2017.
• capsules were agreed as non-formulary at the APC in Sep 2024

The branded product, Levonelle One Step, is considered BLACK Prescribe generically

FOR NEW PATIENTS: The prescribing of tacrolimus is considered a RED drug, post-transplant only and is funded via NHS England for this indication. GPs should not accept any new request to start prescribing tacrolimus post-transplant. RED drugs are for specialist use in secondary / tertiary care – prescribing is to be initiated and continued by the specialist. GPs should ensure that patient medication records include any medicine for which prescribing remains the responsibility of secondary or tertiary care. This will ensure that GP records, which are accessed by other healthcare providers, are a true and accurate reflection of the patient’s medication.

GENERIC Sumatriptan has been considered by the PCN and has been assigned a GREEN traffic light status. NOTE - the branded product, Imigran, was considered BLACK at the PCN in May 2017.

Please prescribe these products GENERICALLY, the branded products (Kapake, Solpadol & Tylex) are considered BLACK on the traffic light system.

Please follow the link here for information generic prescribing https://surreyccg.res-systems.net/pad/Guidelines/Detail/5045

Please follow the link here for information about other paracetamol products. https://surreyccg.res-systems.net/pad/Search/DrugConditionProfile/6159

GENERIC doxazosin (immediate release) has been considered by the PCN and has been assigned a GREEN traffic light status.

NOTE - the branded product, Cardura, was considered BLACK at the PCN in May 2017.

GENERIC Spironolactone has been considered by the PCN and has been assigned a GREEN traffic light status.

NOTE - the branded product, Aldactone, was considered BLACK at the PCN in May 2017.

SAFETY NOTICE: In Feb 2016 the MHRA highlighted the risk of potentially fatal hyperkalaemia when spironolactone is used in combination with a renin-angiotensin drug in heart failure. The MCG approved the content of a guide which clarifies the monitoring requirements for patients on this combination - see guide below

GENERIC Alendronic acid tablets have been considered by the PCN and have been assigned a GREEN traffic light status. NOTE - the branded product, Fosamax, was considered BLACK at the PCN in May 2017.

GENERIC Risedonate sodium has been considered by the PCN and has been assigned a GREEN traffic light status. NOTE - the branded product, Actonel, was considered BLACK at the PCN in May 2017.