North of Tyne Area Prescribing Committee Update July 2015

Recent Approvals

Levonorgestrel 13.5mg IUS (Jaydess®) has been approved as a long acting reversible contraceptive (LARC) that differs from Mirena® in that the levonorgestrel dose is lower. It is licensed for nulliparous women but there is not sufficient evidence to support its first line use in this group. Jaydess® can only be used for 3 years compared to 5 years for Mirena® therefore it is marginally more expensive overall however the device is narrower, potentially making insertion easier. Due to the lower progesterone dose users are less likely to experience ovarian cysts.

Ivermectin 1% cream (Soolantra®) has been approved, as second line for people who had failed topical metronidazole,  for the treatment of papulopustular rosacea. It has dual anti-inflammatory and anti-parasitic properties and has been compared with placebo and topical metronidazole. Some weaknesses were noted in the studies but compared with metronidazole it is marginally more effective in terms of reduction in lesion counts and it is well tolerated. Whilst the evidence of efficacy was not overwhelming it was felt that it could reduce the likelihood of some patients requiring systemic antibiotics, therefore the committee agreed it should be supported. as second line for people who had failed topical metronidazole.

Ulipristal 5mg tablets were added to the formulary in 2013, as a hospital only drug, for pre-op treatment of moderate to severe uterine fibroids in women of reproductive age. The formulary status is now to be changed from red to “s”(specialist initiation) to make it more convenient for patients to receive treatment after the initial three month course but this should only be for up to 2 x 3 month treatment courses prior to surgery. Clear communication between secondary and primary care should be provided to indicate this intended treatment duration. Use for up to 4 courses, or use in any non-surgical indication, has not yet been approved locally, despite a change in the licence to allow this.

Practices should ensure that patients are not inadvertently  left on multiple repeat courses in primary care without appropriate specialist review.

Mebeverine MR will be added to the formulary as it currently offers cost savings over mebeverine IR.  NICE CG61 (Irritable Bowel Syndrome) showed there was little difference between the two formulations.

Viridal® Duo  There is currently a supply problem with Caverject® Dual Chamber injections. Alprostadil vials are still available, however the ancillary items are difficult to obtain and there may be increased risks from poor technique .

Viridal® Duo starter pack is now available to prescribe in primary care.  It was agreed that new patients would therefore be prescribed Viridal® Duo.  Specialist nurses will be asked  to identify which patients already receiving Caverject® will require re-training to use Viridal® Duo prior to switch. Practices may wish to identify their exisiting patients and ensure steps are in place to facilitate ongoing appropriate treatment.

Plain emollient (Epimax®) cream will be added to the formulary as it is currently lower cost than some of the alternatives. It was agreed that it could be added to the formulary in addition to current options allowing prescriber choice.

Magnesium aspartate dihydrate sachets are now licensed for the treatment of prevention of magnesium deficiency  and will therefore be added as the 1st line formulary agent over the unlicensed magnesium glycerophosphate.

Guidelines

Diabetes – a Type 2 diabetes guideline was approved. Stepped Approach to Type 2 Diabetes 2015