Lanarkshire Area Drugs & Therapeutics Committee

LANARKSHIRE AREA DRUG & THERAPEUTICS COMMITTEE

Minute of the meeting held on Wednesday 24 May 2017 at 10am in the Board Room, Kirklands

PRESENT: Dr Mehrdad Malekian [Chair] Miss Katrina Mackie Dr Stephanie Dundas Mrs Karen Patterson Mrs Gail Richardson Miss Linda Johnstone Dr Vijay Sonthalia Mr Bill Angus Mr George Lindsay Mr John Milne Mrs Christine Gilmour

2017/069 Apologies Dr AAW Majumdar, Mrs Anne Mile, Mrs Jean Donaldson, Miss Anne Auld, Mrs Mary Gilfillan

2017/070 Declaration of interest Everyone was reminded of the importance of returning their Declaration of Interest to Dr Malekian as soon as practical.

2017/071 Matters Arising not covered elsewhere on the agenda

(a) Ratification of Minutes of 22 March 2017 The revised Minute of 22 March was reviewed and agreed as a true record of the meeting. This can now be published on the Website. MM

(b) The Minute of 19 April should be modified to note Dr Vijay Sonthalia’s apologies. It was also suggested that the wording for the optimised ADTC processes should be changed to “Dr Malekian and Mr Lindsay met with Eileen McGinlay and agreed that they would separate out the process for ADTCMM Guidance”.

(c) Use of Mobile Apps Mrs Gilmour indicated that she had discussed mobile apps with a number of other Health Boards in Scotland. It remains an ongoing issue and it is possible that the development of the Scottish National Formulary will be a catalyst to general guidance about how we use apps for governance and communication and support with medicines.

(d) Familial Hyperlipidaemia and Entresto Guidelines - Update Dr Malekian indicated that he was in discussion with the clinician experts and anticipated a guideline would be with the committee for its June Meeting. It was indicated that treatment issues across the Primary and Secondary care interface be clarified in this guideline.

(e) Terms of Reference for ADTC (i) Dr Malekian introduced the proposed Terms of Reference which were well received. The following changes were suggested:

 That the Committee recommend a Chair which would subsequently be ratified by the Medical Director.

ADTC\mins\240517_Final 1  There was also discussion about the best way of encouraging consultants to join the Committee although it was agreed that the Terms of Reference need not be changed in this regard.  The Antimicrobial Management Team should be described as a sub group of the Committee consistent with other groups.

Members are requested to make any further comments to Dr Malekian by e- mail. The document will then be ‘tidied up’ and ratified - probably at the next meeting.

(ii) Guidance on Production of Guidelines Again this document was well received. The suggested changes were:

 The phrase “ensure compliance with the Guidelines” on page one, be changed to “encourage compliance with the Guidelines”.  It was also suggested that a further bullet point be added which would indicate that the ADTC will quality assure the Guidelines are fit for purpose.  Under principle number 3 the wording should be that “Pharmacy should be consulted on all Guidelines” rather than “a Pharmacist be included in all Guidelines”.

Ms Johnstone gave an example of a guideline currently being developed at the Hospice and asked if this should be considered as ADTC work or not? Ms Johnstone will share this with Dr Malekian who will make a decision when he sees the detail. LJ

Again final comments are invited to Dr Malekian before this document is finalised. ALL (f) MHRA Advice on Illicit Drugs Mrs Richardson talked about this issue and some of the practical issues in knowing whether patients are or are not on illicit drugs. No further action is required and this monologue will be an Agenda item

2017/072 SMC NEW Submissions – Confidential until Monday 12th June 2017

FULL SUBMISSIONS Obeticholic acid (Ocaliva ® ) (No 1232/17) This was noted and feedback will come from Gastroenterology specialists.

Cabozantinib (Cabometyx ® ) (No 1234/17) This was noted and feedback will come from the West of Scotland Cancer Network.

Aprepitant (Emend ® ) (No 1241/17) This was noted and feedback will come from the West of Scotland Cancer Network.

ADTC\mins\240517_Final 2 RESUBMISSIONS Pertuzumab (Perjeta ® ) (No 897/13) This was noted.

Nivolumab (Opdivo ® ) (No 1188/16) This was noted and feedback will come from the West of Scotland Cancer Network.

ABBREVIATED SUBMISSIONS Adalimumab (Humira ® ) (No 1243/17) This was noted and feedback will come from Dermatology specialists.

Budesonide/Formoterol (Symbicort SMART ® ) (No 1244/17) This was noted and feedback will come from Respiratory specialists in Paediatrics.

Buprenorphine oral lyophilisate (Espranor ® ) (No 1245/17) This was noted and feedback will come from addiction services specialists.

Deferasirox (Exjade ® ) (No 1246/17) This was noted and feedback will come from Haematology specialists.

NON SUBMISSIONS Safinamide (Xadago ® ) (No 1259/17) This was noted.

Ibrutinib (Imbruvica ® ) (No 1258/17) This was noted.

2017/073 SMC follow-up

Miss Mackie talked the committee through the SMC follow-up which had been previously circulated. Advice on Idebenone was received after the paper had been sent to members. Treatment with Idebenone is not expected in Lanarkshire as patients attend a regional service in Glasgow. KM

2017/074 Lanarkshire formulary

a. Miss Mackie discussed the formulary amendment submitted by the Diabetes MCN. The request to add both Humalog 200units/ml and Toujeo 300units/ml was accepted by the committee, on the condition that both high strength insulins are specialist initiation/recommendation only.

b. The Toujeo guidance prepared by the Diabetes MCN was acceptable to the ADTC.

ADTC\mins\240517_Final 3 c. The Humalog guidance prepared by the Diabetes MCN was acceptable to the ADTC.

d. ADTC bulletin duplication. Also noted under minute point 2017/076.

e. Miss Mackie described the formulary review process undertaken to produce the Wound Management Primary Care Formulary. This finalised document was ratified by the committee. KM

2017/075 Clinical Protocols

(a) The ADHD Protocol was agreed subject to:  A link being added to the NHSL Formulary which has recently been updated for ADHD and  the update date being added to the front of the document.  In addition, on pages 10-11 the phrase ‘The SPC for Intuniv® provides evidence for the use of guanfacine in combination with stimulants but the studies did not look at the combination of guanfacine and atomoxetine’ needs expanded to highlight the SMC advice on Guanfacine does not support the combination of Guanfacine and a stimulant. The SMC advise that Guanfacine should be used when stimulants are not suitable, not tolerated or have been shown to be ineffective. GL Mr Lindsay will discuss the matter with Mrs Dewar.

(b) Updated Vancomycin Policy Subject to the addition of a bar code on the document this was agreed.

Mrs Richardson to liaise with Tricia Kent to arrange the bar code GR

(c) Updated Anticoagulant Guidance Dr Malekian introduced this document which was well received by the Committee. It was thought that it would provide a very useful template for a structured discussion with patients in coming to a conclusion about the best anticoagulant that suits their needs. It was approved by the Committee subject to clarification about potential food interactions with the DOACs.

Dr Malekian indicated that that he is awaiting further feedback from Dr Wallace about this. We should say that it was approved

(d) GP Adult Empirical Treatment of Infection Guidelines This was agreed subject to clarification of the need for stool samples to be sent with GI infections. Dr Dundas will check out HPA and other sources of this advice. SD Fosfomycin Paediatric Policies (e) All of these Policies were approved.

2017/076 ADTC Bulletin This was noted

ADTC\mins\240517_Final 4 2017/077 Unlicensed Medicines There was nil to note at this meeting.

2017/078 NICE/HIS Guidance There was nil to note at this meeting.

2017/079 Medication and Clinical Risk in Lanarkshire

The update on Valproate was noted. Mrs Gilmour indicated that she would contact Mrs Laura McIvor, Chief Pharmacist, Health Improvement Scotland to find if a Scottish version of the Valproate document was due to be circulated in Scotland, and in anticipation that this would be a case, a small Working Group to work through the practicalities of the requirements would be established. CG 2017/080 Regional Cancer Advisory Network Mr Milne talked through a very interesting document about potential side effects of Immunosuppressant therapy. Mr Milne indicated that he is in discussion with Dr John Murphy about how this important information will be disseminated throughout NHS Lanarkshire. Mr Milne will feed back at the next ADTC in June JM

2017/081 Patient Safety Alerts

There was nil to note at this meeting

2017/082 Lay Member Related Items

There was nil to note at this meeting except that Mr Angus requested information about the use of Sativex in NHS Lanarkshire and Mrs Gilmour was able to confirm that it was not approved by the SMC.

2017/083 Correspondence

(i) Effective Prescribing Programme on Melatonin Miss Mackie indicated that she was doing some work with a range of relevant stakeholders on this matter. She will feed back in due course. KM (ii) Acetylcysteine in Paracetamol Overdose Mrs Patterson talked the issues through and indicated that this is in line with the national recommendations in the Toxbase Database.

With that context, even although it is off-licence indication, it is our local recommendation and Mrs Patterson will complete the requisite form to go to Dr Malekian to sign off on behalf of the Committee. KP/MM

2017/084 ADTC Collaborative

(i) Launch of SPSP Medicines New Monthly WebEx Mr Lindsay indicated that he dialled into the first WebEx. It was an interesting

ADTC\mins\240517_Final 5 scene setting exercise and the June WebEx will focus on medicines reconciliation. GL (ii) What’s the right Medicine for Me Mr Lindsay will contact Communications for distribution of the video. GL

(iii) Early Access Scheme of Dupilumab This was noted

(iv) Consensus Guidance on Management of Pipracillin/Tazobactam Dr Dundas indicated that the AMT had taken this forward.

(v) Single National Formulary Meeting Mrs Gilmour and Miss Mackie talked through their attendance at this meeting and the fact that there was general acceptance of that a Scottish National Formulary will happen in due course. The challenges may not be the development of a Formulary as such but pragmatic and practical solutions to a Formulary Prescribing and Governance, ongoing ownership and responsiveness of the Formulary.

(vi) Research into Views of Public Partners This was discussed and Mr Angus will get back in touch with Dr Malekian should he wish to take part in the interviews.

2017/085 Any Other Business Dr Malekian indicated that he was in touch with Dr Majumdar and with the Nurse Director about further GP and Nurse representation on the Committee.

2017/086 Date of Next Meeting The next scheduled meeting is on Wednesday 21 June 2017 at 10am in the Board Room, Kirklands Hospital.

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