April 2008

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					For agenda items contact Ann Howell, JAPC Administrator, Derbyshire County PCT
Tel: 01246 514302
Fax: 01246 514158


                     MINUTES OF MEETING HELD 8 APRIL 2008

Summary Points

Traffic light changes

    •   Vildagliptin and Eucreas – BROWN
    •   Ionsys patch – RED
    •   Tramadol – GREEN (neuropathic pain only)
    •   Suboxone – BROWN
    •   Mircera - RED


The following were ratified:
   • Updated naltrexone shared care
   • Updated methadone shared care
   • Updated buprenorphine shared care
   • Updated lofexidine shared care
   • Updated antimicrobial treatment guidelines
   • COPD drug treatment algorithm
   • Updated choice of antidepressant guidance
   • Emollient prescribing guide for adults
   • Pharmacological management of OA (attached)

Virulite CS cold sore machine

Not recommended for prescribing

E:\Website\JAPC Minutes\2008\April 2008.doc                                      1
    For agenda items contact Ann Howell, JAPC Administrator, Derbyshire County PCT
    Tel: 01246 514302
    Fax: 01246 514158

                  MINUTES OF MEETING HELD ON 8 APRIL 2008

    PRESENT                                                                              ACTION

    Derbyshire County PCT
    Mr P Barrett, Assistant Director of Finance (Commissioning)
    Mr P Burrill, Specialist Pharmaceutical Adviser for Public Health
    Dr A Collier, GP (High Peak & Dales)
    Mr S Hulme, Assistant Director of Medicines Management
    Dr S Tyler, GP (NED & Chesterfield)
    Dr A Mott, GP (Amber Valley)
    Dr A Meakin, Medical Director (Chair)

    Derby City PCT
    Mr G Distefano, Senior Commissioning Manager
    Mr S Dhadli, Lead Medicines Management Pharmacist
    Dr R Elkheir, Consultant in Public Health

    Derby Hospitals NHS Foundation Trust
    Mr D Anderton, Senior Pharmacist

    Derbyshire Mental Health Trust
    Dr D Branford, Chief Pharmacist

    Chesterfield Royal Hospital NHS Foundation Trust
    Mr M Shepherd, Chief Pharmacist

    Mr M Bond, Research Manager, Derbyshire County PCT
    Mrs A Howell (minute taker)
    Dr T Hudsen, FY2 doctor, Derbyshire County PCT
    Ms L Salmon, Pre-reg Pharmacist, Derby City PCT


    Dr A Austin
    Mr P Carney
    Mr I Gibbard
    Dr G Jackson
    Mr J McDonnell
    Dr R Richards
    Ms S Simms
    Mr M Steward

    There were no declarations of potential conflicts of interest.

3   MINUTES OF JAPC MEETING – 11 March 2008
    The minutes of the meeting held on 11 March 2008 were agreed as a true and
    accurate record.

    E:\Website\JAPC Minutes\2008\April 2008.doc                                      2
        For agenda items contact Ann Howell, JAPC Administrator, Derbyshire County PCT
        Tel: 01246 514302
        Fax: 01246 514158
    4   MATTERS ARISING                                                                          ACTION

        (a) Emollient guidance

        The Committee discussed the Emollient Prescribing Guide for adults, from Sue
        Jordan, and the CKS Emollients Patient Information Leaflet. It was agreed that
        barrier creams and Dermol 500 should not be included in the prescribing guide. In
        addition, it should be clearly stated that aqueous cream was only to be used as a
        soap substitute and the costs updated. It was also agreed that topical steroids
        should be applied before emollient.
        The PIL was supported for sharing with health professionals.

        Agreed: JAPC approved the emollient prescribing guide for primary care use,
        subject to the agreed amendments and addition of the PCT logos.
        Action: Peter Burrill to update.                                                          PB
        The guide to be included in the skin section of the formulary.

        (b) Use of biologics in RA

        Dr Elkheir explained the background to the audit template for anti-TNF and
        rituximab use in RA. Its aim was to be able to monitor the algorithm for use of
        biologics in RA agreed at the March meeting and was supported by Dr O’Reilly at
        Derby. Chesterfield rheumatologists had not yet commented
        Agreed: audit to be shared with Dr Fairburn at Chesterfield Royal Hospital for
        Action: Dr Elkheir to arrange.                                                            RE

        (c) Antidepressant algorithm

        Dr Branford confirmed that the comments from JAPC on the antidepressant
        algorithm had been discussed by the Mental Health Trust D&T Committee. It was
        agreed that the bleeding risk with SSRIs required further elaboration.

        Agreed: JAPC ratified the algorithm subject to the appropriate amendments
        regarding risk of bleeding.
        Action: Dr D Branford to update and send final copy to Peter Burrill.                     DB


        Mick Bond, Research Manager, Derbyshire County PCT, gave a presentation
        entitled “The interface between MREC decision making on commercial drug trials,
        local prescribing policy and management approval”. The Chair thanked Mr Bond
        for his interesting presentation and asked the committee to raise any questions.

        Steve Hulme pointed out that it would be useful to know about on-going drug trials
        in primary care, in order to anticipate any potential changes to prescribing. Mr
        Bond confirmed that he produces a quarterly update on research governance and
        trials in County PCT but the drug names are removed. He agreed to check
        whether a version including drug names could be sent to Peter Burrill, and whether
        Derby City PCT information could be included.
        Action: Mick Bond                                                                         MB

        How pharmaceutical input into research governance is now achieved was
        discussed. Mr Anderton confirmed that pharmaceutical input to research

        E:\Website\JAPC Minutes\2008\April 2008.doc                                          3
    For agenda items contact Ann Howell, JAPC Administrator, Derbyshire County PCT
    Tel: 01246 514302
    Fax: 01246 514158
    governance is provided.                                                                      ACTION
    Action: Peter Burrill to contact Kirsteen Farrar for further information.                      PB

    A question was asked if it is possible to put a stipulation into local trials that the
    patient is not guaranteed to receive the drug once the trial is completed. Mr Bond
    agreed to find out.
    Action: Mick Bond                                                                             MB

         • INSPIRE study
    Peter Burrill presented a critical appraisal of the study, set up by GSK to compare
    Seretide with tiotropium on exacerbation rates. There was no difference between
    these two options. Seretide (fluticasone component) increased the risk of
    pneumonia. The bottom line was that Seretide was not more effective than
    tiotropium and appeared to be less safe.
    The committee agreed with this conclusion.
    Action: Peter Burrill to include an article in the PACE Newsletter.                           PB


    Peter Burrill presented the treatment algorithm ratified at the CEPPaC meeting of
    10/4/07. It was agreed that INSPIRE did not necessitate any change to this
    Peter Burrill explained the progress in amalgamating and updating the old COPD
    guidelines by the Strategic Respiratory Group. An impasse had been reached on
    the content of the treatment algorithm. Dr Will Elston, Respiratory Consultant at
    Derby Hospitals, wanted the option of triple therapy with tiotropium, LABA and
    ICS, despite the lack of robust evidence to support this combination. The
    respiratory group asked JAPC for a decision on the content of the treatment
    After discussion of the relevant evidence base it was agreed not to support the
    triple therapy option as it does not meet the requirements of effective, cost-
    effective and affordable. The algorithm agreed on 10/4/07 was approved once
    Action: Peter Burrill to inform the Strategic Respiratory Group.                              PB
    Acute trust members of JAPC to take the COPD treatment algorithm to their
    respective DTCs for support and to influence the relevant consultants.                       DA/MS


    Peter Burrill presented paper G, information on the Virulite CS cold sore machine
    that is now available in the Drug Tariff for prescribing on the NHS.

    Agreed: JAPC advised that GPs should not prescribe the cold sore machine,
    because of insufficient evidence of effectiveness.
    Action: Peter Burrill to publish an article in the PACE newsletter.                           PB


    Peter Burrill presented the updated and combined antimicrobial guidelines for
    primary care use across Derbyshire. He identified the changes that had been
    made, with particular reference to acute exacerbation of COPD.
    He had received an e-mail from Amanda Rawlings, antibiotic pharmacist,
    concerned that ciprofloxacin was being used by GPs in Derby City as a second-

    E:\Website\JAPC Minutes\2008\April 2008.doc                                              4
      For agenda items contact Ann Howell, JAPC Administrator, Derbyshire County PCT
      Tel: 01246 514302
      Fax: 01246 514158
      line option in LRTI. She asked that an option for acute bronchitis be added to the           ACTION
      guideline to deter prescribing of ciprofloxacin. After discussion it was agreed that
      antibiotics for acute bronchitis should not be added. Some minor amendments
      were requested.

      Agreed: JAPC ratified the guideline, subject to the agreed amendments being
      made.                                                                                  PB
      Action: Peter Burrill to publish an article in the PACE Newsletter to highlight the
      new guideline and reinforce that ciprofloxacin has no indication for primary care
      use.                                                                                   PB
      Medicines Management to arrange for the guideline to be laminated and circulated
      to all GP practices, community pharmacies, etc.                                     Meds Man


      Peter Burrill highlighted changes to the traffic lights classification, which had been
      made following the first meeting of the traffic light group. There is now only a
      single BROWN section. This had resulted in the some light brown drugs moving to
      GREEN, with restrictions on use. All GREEN and BROWN drugs were agreed
      and finalised at the meeting. Classification of some red and amber drugs still
      needed to be decided and this would be discussed at the next meeting of the
      group. Dr Richards to arrange. A paper resulting from the first meeting was still
      awaited from Dr Richards.
      Action: Dr Richards                                                                            RR
      Agreed: JAPC ratified the updated version.

      The following changes were agreed:
      tramadol - GREEN (neuropathic pain only)
      Ionsys patch - RED
      vildagliptin - BROWN
      Eucreas - BROWN
      inhaled insulin to be removed from the RED category as no longer available.
      Action: Peter Burrill                                                                         PB

      (i) Triptorelin shared care
      JAPC agreed that a Triptorelin Shared Care Agreement was no longer required
      due to classification of GRH analogues as GREEN by the traffic light group.

      (ii) Mircera
      David Anderton presented paper K for information. This had been agreed by the
      Derby Hospitals D&TC.
      Agreed: JAPC approved classification of Mircera as a RED drug.
      Action: Peter Burrill                                                                         PB

      (iii) Irbesartan
      Dr Meakin presented paper L, a letter from the Department of Diabetes and
      Endocrinology, Derbyshire Royal Infirmary, requesting that irbesartan be
      recommended as ARB of choice for patients with diabetes combined with
      hypertension and diabetic nephropathy.
      Agreed: JAPC agreed to defer a decision until completion of the cardiovascular
      formulary review.
      Action: Dr Meakin to reply to the Department of Diabetes & Endocrinology at
      Derbyshire Royal Infirmary.                                                                   AM

      E:\Website\JAPC Minutes\2008\April 2008.doc                                              5
     For agenda items contact Ann Howell, JAPC Administrator, Derbyshire County PCT
     Tel: 01246 514302
     Fax: 01246 514158
12   ITEMS FROM CHESTERFIELD ROYAL HOSPITAL                                                     ACTION

     (i) Anaemia management in CKD
     Martin Shepherd informed the group that the NICE guideline on this would require
     more nephrology services. Unmet need had been identified and there was a lack
     of clarity at Chesterfield Royal Hospital on what to do. He asked for clarification
     about commissioning arrangements on how it will be provided. Is it possible to
     have a local service in Chesterfield?

     Agreed: JAPC requested this be referred to the Planned Care Programme Board.
     Action: Martin Shepherd to discuss with Prem Singh, Chair of the Planned Care
     Programme Board, and to involve Dr Richard Richards in these discussions.                  MS/RR


     (i) Suboxone
     Dr Branford presented a new drug assessment of Suboxone. He asked that this be
     classified as a BROWN drug due to lack of evidence that widespread use results
     in less diversion.

     Agreed: JAPC approved classification of Suboxone as a BROWN.
     Action: Peter Burrill                                                                       PB

     (ii) Naltrexone shared care/ Methadone shared care/ Buprenorphine shared care/
     Lofexidine shared care

     Dr Branford informed the group that these shared care agreements had now
     reached their review dates and had been updated. It was agreed that it should be
     made clear that they only applied to GPs in the Locally Enhanced Service and
     GPwSI service for drug misuse. A 3-year review date was agreed.

     Agreed: JAPC approved the shared care agreements, subject to the agreed
     Action: Dr Branford to amend the shared care agreements and forward to Peter                DB


     (i) NICE Clinical Guideline 59 – Osteoarthritis

     Peter Burrill presented papers S(i) (ii) and (iii), which had been referred to JAPC
     by the NOG because of significant drug use in the guideline. He described the
     development of the ‘pharmacological management of osteoarthritis’ algorithm
     S(iii), and highlighted key differences in the draft and final NICE guideline. JAPC
     were requested to decide on the place of glucosamine, topical salicylates, coxibs
     and PPIs in the treatment algorithm.

     After discussion, there was strong agreement not to follow some of the
     recommendations in the NICE guideline and to ratify the algorithm S(iii) in order to
     achieve the key objective of reducing NSAID and coxib use.

     Agreed: JAPC ratified the guidance as presented in paper S(iii) {appendix 1}.
     Action: Peter Burrill to publish an article in the PACE newsletter.                         PB

     E:\Website\JAPC Minutes\2008\April 2008.doc                                            6
     For agenda items contact Ann Howell, JAPC Administrator, Derbyshire County PCT
     Tel: 01246 514302
     Fax: 01246 514158
15   ACTION SUMMARY                                                                        ACTION
     The action summary was discussed and updated.
     Action: Peter Burrill                                                                  PB


        •   Sheffield Hospitals DTC 15 2 08
        •   S. Staffs APC 8 2 08
        •   Derby Hospitals DTC 26 2 08
        •   STAMP 20 2 08
        •   Notts APC 21 2 08
        •   Sheffield APC 26 2 08
        •   Mental Health Trust DTC 28 2 08
        •   Chesterfield Royal Hospital DTC 18 3 08

     Martin Shepherd reported that Chesterfield Royal Hospital had started to manage
     patients with pulmonary embolism on an out-patient basis as anew service.

     Action: An article to be published in the Chesterfield/NED locality newsletter.
     Steve Hulme to arrange.

     The next meeting to be held on Tuesday 13 May 2008, 1.30 pm in the Parkhouse
     Room, Coney Green, Clay Cross.

     E:\Website\JAPC Minutes\2008\April 2008.doc                                       7
             For agenda items contact Ann Howell, JAPC Administrator, Derbyshire County PCT
             Tel: 01246 514302
             Fax: 01246 514158

              Appendix 1                          Pharmacological management of osteoarthritis

             The evidence advocating the use of glucosamine and topicals remains weak and
             unchanged. However, recent evidence has identified that many oral NSAIDs,
             particularly diclofenac, cause additional CV events. With this in mind and the effect of
             placebo in managing pain, oral NSAIDs should be used with caution, only once the
             other options have been tried first.

             First-line:       Paracetamol 1g 3-4 times daily.
                               Add codeine 15-30mg if necessary for flare-ups.

             Second-line: add either
                          • Glucosamine sulphate 1500mg daily (suggested brands: Lifespan,
                             Natrahealth, Valupak) – knee OA only.
                             Three month trial necessary to assess effectiveness.
                          • Topical salicylate (e.g. Algesal, Transvasin) or topical NSAID (e.g.
                             ibuprofen gel, ketoprofen gel).
                             Two week trial to assess effectiveness.
                          • Use both if necessary.

             Third-line:       Consider an oral NSAID - ibuprofen 1200mg daily is first-line and
                               naproxen 1000mg daily second-line.
                               Add omeprazole 20mg or lansoprazole 15mg daily if high risk for
                               serious GI adverse events. This will not reduce the risk of CV or renal
                               adverse events.
                               Use of coxibs is not recommended.

                                                  Paracetamol 1g 3-4 times daily
First-line                                                +/- codeine

                                        ADD                                                   ADD

                           Glucosamine sulphate 1500mg od            or /            Topical salicylate/NSAID
Second-line                   3 month trial (knee OA only)           and                   2 week trial

                                                             Oral NSAID
Third-line                            Ibuprofen 400mg tds or naproxen 1000mg od/500mg bd
                                      Add PPI if high-risk for serious GI adverse events

             E:\Website\JAPC Minutes\2008\April 2008.doc                                                8

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