Committees : Surrey & North West Sussex Area Prescribing Committee (formerly Prescribing Clinical Network)

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.

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

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 ICS Area Prescribing Committee (APC) has agreed an additional lines of treatment process and principles in conjunction with the local Rheumatology, Gastroenterology and Dermatology Clinical Networks.

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.

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 Heartlands Area Prescribing Committee (APC) agreed an updated Inflammaory Bowel Disease (IBD) pathway for use.

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

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 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 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 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 (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 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

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 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 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 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
 

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

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

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 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

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

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

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

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.

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

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

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.

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

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 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 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.

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.

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

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.

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

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

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 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.

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.

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 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 Surrey & North West Sussex Area Prescribing Committee have agreed the updated guidance on calculating creatinine clearance for DOACs. 

The Surrey & North West Sussex Area Prescribing Committee have agreed the updated guidance on calculating creatinine clearance for DOACs. 

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 Surrey & North West Sussex Area Prescribing Committee have agree the updated guidance on calculating creatinine clearance for DOACs. 

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 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 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

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

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  

The Surrey & North West Sussex Area Prescribing Committee have agreed the updated guidance on calculating creatinine clearance for DOACs. 

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

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

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 Surrey & North West Sussex Area Prescribing Committee have agreed the updated guidance on calculating creatinine clearance for DOACs. 

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 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 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 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 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 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

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

Flavoxate 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

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 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 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 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 & Sussex Area Prescribing Committee have made recommendations in relation to paracetamol dosing in frail elderly patients. 

There have been some case reports of liver failure associated with therapeutic doses of paracetamol in some patients. Frail elderly patients with a body-weight < 50kg and those with risk factors for hepatotoxicity such as cardiac, pulmonary and renal insufficiency in conjunction with old age, co-administration of medicines that induce liver enzymes, hepatitis and chronic alcohol consumption.  
 
The BNF recommends that clinical judgement should be used to adjust the dose of oral paracetamol in such patients. The clinicians may choose to either reduce the dosage or the frequency of administration of paracetamol. Co-administration of enzyme-inducing medications may also increase toxicity; paracetamol doses should be reviewed and reduced.

NOTE: Patients having IV paracetamol will already have had adjustments made based on body weight so no further adjustment should be required.

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 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 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 

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.

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.

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.

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 & 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 NICE Clinical Knwoledge Summaries

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

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) 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.

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 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 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.

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

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.

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 added January 2025 - this drug should be prescribed on recommendation from a specialist.

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 (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 (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 (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.

Preservative free eye drops:

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.

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 agreed the BLUE information sheet for lithium.

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. 

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 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 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. 

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. 

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 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 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 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 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 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 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 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. Note added January 2025 - this drug should be prescribed on recommendation from a specialist.

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 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.

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.

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 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.

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

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 are non-formulary

CROHN'S DISEASE

The Surrey and North West Sussex Area Prescribing Committee recommends that ustekinumab in patients with moderately to severely active Crohn’s Disease, may be dose optimised to 8 weekly when a patient starts to lose response to standard (12 weekly) dosing.  Dose optimisation will be for a 16 week treatment course to recapture response.

Patients must return to standard dosing (ustekinumab 12 weekly) after the 16 week course has been completed. 

If the patient loses response to the standard dosing within a short time period (12 weeks) then the provider can apply for maintenance funding to return to the escalated dose (8 weekly).

Gastroenterologists can repeat the 16 week course if the patient starts to lose response after returning to 12 weeks of standard dosing.

Ustekinumab is a payment by results excluded drug 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.

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 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.

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

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

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

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

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.

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) 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 

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

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.
 

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 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 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 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 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 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. 

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 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 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 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 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 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 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.

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 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.

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)

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

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.

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.

• 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.

• 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.

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

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)

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."

• 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

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."

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

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. Note added January 2025 - this drug should be prescribed on initiated by a specialist.

Advice must be sought from a specialist in Parkinson's Disease before modifying therapy.

NICE does not recommend the use of olanzapine to treat hallucinations and delusions in Parkinson's disease

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 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

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

A stepped approach to pain management is recommended. Paracetamol is considered a 1st line option for the treatment of pain.

Sub-lingual / buccal - consider for use patients who are unable to tolerate standard codeine/ dihydrocodeine tablets or capsules or if morphine is contra-indicated. Note added Jnauary 2025 - 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.

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.

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

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.

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 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. 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.

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 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.

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.

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

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

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 . 

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 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 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

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 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 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. (NOTE - prescribe generically).

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.

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

CROHN'S DISEASE

The PCN recommends Ustekinumab as a treatment option for treating moderately to severely active Crohn’s Disease in line with NICE and the associated treatment pathway. Prescribing will be by hospital specialists only, in line with NICE TA456 using Blueteq initiation and continuation forms. Ustekinumab will be considered RED on the traffic light system

GENERIC Bicalutamide has been considered by the PCN and has been assigned a BLUE traffic light status. Note added January 2025 - this drug should be prescribed on recommendation from a specialist.

NOTE - the branded product, Casodex, was considered BLACK at the PCN in May 2017.

GENERIC Eplerenone has been considered by the PCN and has been assigned a BLUE traffic light status. Transfer to primary care only after initiation and at least the first month supply from the specialist.

NOTE - the branded product, Inspra, was considered BLACK at the PCN in May 2017.

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 Zolmitriptan has been considered by the PCN and has been assigned a GREEN 1st line traffic light status. NOTE - the branded product, Zomig, was considered BLACK at the PCN in May 2017.

Zolmitriptan/ Rizatriptan orodispersible tablets should be considered as a suitable first line treatment for patients when there are difficulties in swallowing the solid dose formulations or the patient has difficulties with nausea and vomiting.

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 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.

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

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 Orlistat has been considered by the PCN and has been assigned a GREEN traffic light status. NOTE - the branded product, Xenical, was considered BLACK at the PCN in May 2017.

The PCN recommends Alendronate (Alendronic acid) 70mg/100ml Oral Solution as a treatment option for patients with post-menopausal osteoporosis who are:
- unable to swallow tablets; AND
- can meet the practical requirements needed to facilitate delivery to the stomach and permit adequate absorption (see SPC)

Alendronate (Alendronic acid) 70mg/100ml Oral Solution will be considered GREEN on the traffic light system

The PCN recommends the use of fibrates for lipid modification as follows:

Familial hypercholesterolaemia - as per NICE CG71 (updated July 2016) in patients with familial hypercholesterolaemia (FH) with intolerance or contraindications to statins or ezetimibe. Patients should be offered a referral to a specialist with expertise in FH for consideration for treatment with either a bile acid sequestrant (resin), nicotinic acid or a fibrate to reduce their LDL-C concentration. For these patients, fibrates should be considered BLUE (no information sheet) on the traffic light system. Specialists to initiate treatment or make a recommendation for the primary care prescriber to initiate treatment.

Hypertriglyceridaemia - as a treatment option for patients with hypertriglyceridaemia (>10mmol/L).
BLUE traffic light status - Specialists to initiate treatment or make a recommendation for the primary care prescriber to initiate treatment.

Policy statements and further information below.

The PCN recommends the use of fibrates for lipid modification as follows:

Familial hypercholesterolaemia - as per NICE CG71 (updated July 2016) in patients with familial hypercholesterolaemia (FH) with intolerance or contraindications to statins or ezetimibe. Patients should be offered a referral to a specialist with expertise in FH for consideration for treatment with either a bile acid sequestrant (resin), nicotinic acid or a fibrate to reduce their LDL-C concentration. For these patients, fibrates should be considered BLUE (no information sheet) on the traffic light system. Specialists to initiate treatment or make a recommendation for the primary care prescriber to initiate treatment.

Hypertriglyceridaemia - as a treatment option for patients with hypertriglyceridaemia (>10mmol/L).
BLUE traffic light status - Specialists to initiate treatment or make a recommendation for the primary care prescriber to initiate treatment.

Policy statements and further information below.

The PCN recommends the use of fibrates for lipid modification as follows:

Familial hypercholesterolaemia - as per NICE CG71 (updated July 2016) in patients with familial hypercholesterolaemia (FH) with intolerance or contraindications to statins or ezetimibe. Patients should be offered a referral to a specialist with expertise in FH for consideration for treatment with either a bile acid sequestrant (resin), nicotinic acid or a fibrate to reduce their LDL-C concentration. For these patients, fibrates should be considered BLUE (no information sheet) on the traffic light system. Specialists to initiate treatment or make a recommendation for the primary care prescriber to initiate treatment.

Hypertriglyceridaemia - as a treatment option for patients with hypertriglyceridaemia (>10mmol/L).
BLUE traffic light status - Specialists to initiate treatment or make a recommendation for the primary care prescriber to initiate treatment.

Policy statements and further information below.

The PCN recommends the use of fibrates for lipid modification as follows:

Familial hypercholesterolaemia - as per NICE CG71 (updated July 2016) in patients with familial hypercholesterolaemia (FH) with intolerance or contraindications to statins or ezetimibe. Patients should be offered a referral to a specialist with expertise in FH for consideration for treatment with either a bile acid sequestrant (resin), nicotinic acid or a fibrate to reduce their LDL-C concentration. For these patients, fibrates should be considered BLUE (no information sheet) on the traffic light system. Specialists to initiate treatment or make a recommendation for the primary care prescriber to initiate treatment.

Hypertriglyceridaemia - as a treatment option for patients with hypertriglyceridaemia (>10mmol/L).
BLUE traffic light status - Specialists to initiate treatment or make a recommendation for the primary care prescriber to initiate treatment.

Policy statements and further information below.

The PCN recommends, as per NICE CG71 (updated July 2016), that patients with Familial Hyperchosterolaemia (FH) with intolerance or contraindications to statins or ezetimibe, should be offered a referral to a specialist with expertise in FH for consideration for treatment with either a bile acid sequestrant (resin), nicotinic acid or a fibrate to reduce their LDL-C concentration. For those patients, bile acid sequestrants should be considered BLUE (without an information sheet) on the traffic light system Specialists to initiate treatment or make a recommendation for the primary care prescriber to initiate treatment.

See below for policy statement and further information

The PCN recommends, as per NICE CG71 (updated July 2016), that patients with Familial Hyperchosterolaemia (FH) with intolerance or contraindications to statins or ezetimibe, should be offered a referral to a specialist with expertise in FH for consideration for treatment with either a bile acid sequestrant (resin), nicotinic acid or a fibrate to reduce their LDL-C concentration. For those patients, bile acid sequestrants should be considered BLUE (without an information sheet) on the traffic light system Specialists to initiate treatment or make a recommendation for the primary care prescriber to initiate treatment.

See below for policy statement and further information

This product or device has not been included within the locally agreed list of preferred treatment options for Asthma. Please see Asthma Guidelines below.

There is no expectation for existing, stable patients to change drug or device unless this is agreed as a clinically appropriate course of action.

Prescribe inhaler devices by BRAND to ensure consistency and avoid confusion

The PCN recommends Aflibercept as a treatment option for treating visual impairment caused by macular oedema after branch retinal vein occlusion in line with NICE TA409 (28th September 2016). Aflibercept is a payment by results excluded drug which will be considered RED on the traffic light system.

The PCN recommends the branded prescribing of oxycodone in line with advice from the Care Quality Commission (CQC). Care Quality Commission link to guidance below. The current (February 2017), most cost effective brands of oxycodone are:

• Modified release: Longtec & Reltebon
• Immediate release: Shortec & Lynlor

CCGs to implement guidance, if considered appropriate, in collaboration with local stakeholders. See individual CCG recommendation documents (at the bottom of the page) where local agreements have been reached. Oxycodone is recommended as GREEN (not 1st line), strong opioid, after morphine, on the traffic light system.

The PCN recommends the use of Insulin Degludec (Tresiba®) in line with the policy statements below - see separate policy statements for Type I and Type II below.

Insulin Degludec (Tresiba®) will be considered as BLUE (without an information sheet) on the traffic light system.

Note added January 2025 - Prescribe on specialist recommendation only

Important - Insulin degludec is available in strengths of 100units/mL and 200units/mL - ensure correct strength is prescribed and dispensed - see MHRA Safety Update (below) for key points and practical information.

Rizatriptan oral lyophilisates (Maxalt Melt) should not be prescribed. Please see the policy statement below for further information

UPDATED: The PCN recommends that sumatriptan, zolmitriptan, rizatriptan and naratriptan should be considered as first line triptans where clinically appropriate and should be prescribed generically.

Zolmitriptan/ Rizatriptan orodispersible tablets should be considered as a suitable first line treatment for patients when there are difficulties in swallowing the solid dose formulations or the patient has difficulties with nausea and vomiting.

The PCN support the use of Secukinumab as a treatment option for treating moderate to severe plaque psoriasis in line NICE TA 350

NICE TA342 - Vedolizumab for the treatment of Ulcerative Colitis was published by NICE in June 2015. PCN members recommend the use of Vedolizumab as a treatment option in line with NICE guidance and a treatment pathway has been developed with local gastroenterologists. 

The PCN recommends Ustekinumab as a treatment option for treating active Psoriatic Arthritis in adults in line with NICE TA340.

Thiazide-like diuretics such as Indapamide or chlorthalidone are the preferred option for patients requiring a diuretic for hypertension as per NICE Clinical Guideline 127.

However for people who are already having treatment with bendroflumethiazide and whose blood pressure is stable and well controlled, continue treatment with the bendroflumethiazide.

Note: 2.5mg produces a maximal blood pressure lowering effect, with very little biochemical disturbance

Lisinopril or ramipril are the prefered ACE inhibitors as per locally agreed guidelines (see below).

However, this drug has been agreed as appropriate for initiation in Primary Care and/or continued in Primary Care following a recommendation from specialists in other health care sectors. Following consideration by the PCN, it has been assigned a GREEN traffic light status.

NOTE Perindopril should be prescribed generically as perindopril or perindopril erbumine and is available as 2mg, 4mg and 8mg tablets. Do not confuse this with perindopril arginine (2.5mg, 5mg and 10mg tablets) that are not available generically and are considerably more expensive

This drug has been agreed as appropriate for initiation in Primary Care and/or continued in Primary Care following a recommendation from specialists in other health care sectors. Following consideration by the PCN, it has been assigned a GREEN traffic light status.

Insulins should be prescribed by BRAND

This drug has been agreed as appropriate for initiation in Primary Care and/or continued in Primary Care following a recommendation from specialists in other health care sectors. Following consideration by the PCN, it has been assigned a GREEN traffic light status.

Insulins should be prescribed by BRAND

This drug has been agreed as appropriate for initiation in Primary Care and/or continued in Primary Care following a recommendation from specialists in other health care sectors. Following consideration by the PCN, it has been assigned a GREEN traffic light status.

Insulins should be prescribed by BRAND

This drug has been agreed as appropriate for initiation in Primary Care and/or continued in Primary Care following a recommendation from specialists in other health care sectors. Following consideration by the PCN, it has been assigned a GREEN traffic light status.

Insulins should be prescribed by BRAND

This drug has been agreed as appropriate for initiation in Primary Care and/or continued in Primary Care following a recommendation from specialists in other health care sectors. Following consideration by the PCN, it has been assigned a GREEN traffic light status.

Insulins should be prescribed by BRAND

Rosuvastatin is not a cost-effective treatment option for most patients and should be reserved for a small number of individual patients where high-intensity statin therapy is appropriate but the alternatives are not tolerated or are contraindicated.

Rosuvastatin should ONLY be considered as GREEN on the traffic light system for these individual patients.

NICE published CG 181 in July 2014 to update and replace NICE CG 67 and NICE TA 94 (statins for the prevention of cardiovascular events). This new NICE guidance does not mention rosuvastatin so the PCN sought clarification from NICE - see update following clarification from NICE below.

If statin therapy is considered appropriate the guidelines recommend using atorvastatin 20mg for primary prevention and atorvastatin 80mg for secondary prevention.

NICE published CG 181 in July 2014 to update and replace NICE CG 67 and NICE TA 94 (statins for the prevention of cardiovascular events).

This latest guidance replaces all former Surrey guidance for lipid modification - see NICE CG 181 below.

If statin therapy is considered appropriate the guidelines recommend using atorvastin 20mg for primary prevention and atorvastatin 80mg for secondary prevention.

Modafinil is not licensed for this indication. The PCN advised a RED traffic light status. There are a number of neurologists who may decide that modafinil is appropriate in a small cohort of patients in whom other treatments have been unsuccessful. In these circumstances, prescribing should remain with the specilaist.

Prescribe generically

Modafinil is not licensed for this indication. The PCN advised a RED traffic light status. There are a number of neurologists who may decide that modafinil is appropriate in a small cohort of patients in whom other treatments have been unsuccessful. In these circumstances, prescribing should remain with the specilaist.

Prescribe generically

Modafinil is not licensed for fatigue in MS. The PCN advised a RED traffic light status. There are a number of neurologists who may decide that modafinil is appropriate in a small cohort of patients in whom other treatments have been unsuccessful. In these circumstances, prescribing should remain with the specilaist.

Prescribe generically

NICE guidance discussed at the PCN. Denosumab is not a payment by results excluded drugs and should be funded from within tariff by the oncology department within the acute trusts. See Surrey West Sussex & Hampshire cancer network protocol at the link below for more information St Luke's SACT Protocols and Policies | Royal Surrey NHS Foundation Trust

Use of both oral and non-oral combination treatments for erectile dysfunction in patients who had not responded or had a sub-optimal response to monotherapy was considered.The network members concurred that based on the limited available evidence, noting the feedback from clinicians, that combination treatments should not be supported and a BLACK status should be given on the PAD.Please see policy statement from June 2012

Use of both oral and non-oral combination treatments for erectile dysfunction in patients who had not responded or had a sub-optimal response to monotherapy was considered.The network members concurred that based on the limited available evidence, noting the feedback from clinicians, that combination treatments should not be supported and a BLACK status should be given on the PAD.Please see policy statement from June 2012

Use of both oral and non-oral combination treatments for erectile dysfunction in patients who had not responded or had a sub-optimal response to monotherapy was considered.The network members concurred that based on the limited available evidence, noting the feedback from clinicians, that combination treatments should not be supported and a BLACK status should be given on the PAD.Please see policy statement from June 2012

Use of both oral and non-oral combination treatments for erectile dysfunction in patients who had not responded or had a sub-optimal response to monotherapy was considered.The network members concurred that based on the limited available evidence, noting the feedback from clinicians, that combination treatments should not be supported and a BLACK status should be given on the PAD.Please see policy statement from June 2012

Pending the imminent patent expiry of Xalatan, generic latanoprost will be the most cost effective prostaglandin analogue in primary and secondary care. Acute trust colleagues are requested to initiate patients on generic latanoprost as the first line prostaglandin analogue. Xalatan prescribing in primary care should be changed to generic.