Consultations: DOAC statement and hypersalivation pathway

Two new consultations have been opened on the GMMMG site; see details below. Both consultations will run until 5pm on Monday 1st August 2022. Comments can be submitted using the feedback forms on the GMMMG consultations page, and comments are invited from all stakeholders.

DOAC statement

CRG seek comments from Greater Manchester on this position statement regarding the prescribing of best value direct oral anticoagulants (DOACs) for stroke prevention in atrial fibrillation. When developing the statement CRG carefully considered, amongst other things:

  • The financial savings associated with increased edoxaban use,
  • A clinician’s freedom to prescribe the treatment they think is most appropriate for their patient
  • The available evidence base to support (or not) the use of one medicine over another.
  • The Investment and Impact Fund indicators
  • The high court ruling that has invalidated the patent for apixaban, and may yet be subject to appeal.

CRG want edoxaban to be the first choice DOAC for use in non-valvular AF, and an alternative used where edoxaban would not be safe or appropriate. This position is still current at the time of publication of the draft statement, despite the legal issues surrounding apixaban.

GMMMG therefore seek feedback from a wide range of stakeholders regarding this statement.

Hypersalivation pathway

CRG seek comments from Greater Manchester on this draft pathway for the management of hypersalivation. It has been developed and approved by MFT and CRG are seeking to adapt it for use across GM, particularly in primary care.

It looks to provide evidence-based, cost-effective recommendations on the management of hypersalivation in a number of conditions.

GMMMG therefore seek feedback from a wide range of stakeholders regarding this pathway

Updated antimicrobial guidance

Following routine quarterly review, the GMMMG antimicrobial guidelines have been updated and is now available on the Clinical Guidance and Pathways page.

Updated headache pathway

Following review and Greater Manchester-wide consultation, the GMMMG headache pathway has been updated and is now available on the Clinical Guidance and Pathways page. The formulary and RAG list have also been updated to reflect the guidance, including:

  • Additional options for simple analgesia and antiemetics
  • Clearer guidance on choice of triptan
  • Additional options for migraine prophylaxis in primary care, including metoprolol, amitriptyline, nortytipyline, candesartan. Zonisamide has also been added, for use following specialist advice
  • Flunarazine added as a RED drug
  • Additional options for acute treatment of cluster headache: zolmitriptan nasal spray, and oxygen.
  • Additional option for cluster headache prophylaxis: verapamil (following specialist advice)

Formulary and subgroup decision updates

Following approval by GMMMG, the website and formulary have been updated to reflect decisions made by GMMMG and the Clinical Reference Group (CRG). This includes:

  • Restriction to macrogol 3350 removed, and statement added directing prescribers to choose the most cost-effective macrogol
  • Moxonidine: GREEN (following specialist initiation). Clarification of previous position.
  • Palforzia for peanut allergy: RED, and GREY, only for use in adults if treatment was started between the ages of 4 & 17.
  • Ponesimod for multiple sclerosis: RED.
  • Brand name & formulation for calcipotriol/betamethasone removed and replaced with advice to choose the most cost-effective option.
  • Strength of Epiduo gel removed, to align with primary care acne pathway.
  • Odevixibat (RAG list only): RED,

The formulary has also been updated to reflect relevant NICE guidelines and safety alerts. For full details of the changes, please see the Formulary Change Log and GMMMG decision summaries.

Consultation: actions from June meeting of CRG

On behalf of the GMMMG Clinical Reference Group, we now seek comments on the actions proposed at the June 2022 CRG meeting.

Actions in this consultation include:

  • Minoxidil foam to be DNP, and formulary updated to clarify that other topical minoxidil preparations are not prescribable
  • Lixisenatide to be removed from formulary following discontinuation of initiation packs
  • Romosozumab for severe osteoporosis to be RED, and added to formulary as a first line anabolic treatment alongside teriparatide
  • Selumetinib for symptomatic and inoperable plexiform neurofibromas to be RED
  • Links to NICE clinical guidance on baricitinib for COVID-19 to be added to formulary in chapters 10 & 13.

For information:

  • Epiduo gel: strength to be removed from formulary, to align with primary care dermatology acne pathway
  • Brand name and formulation for topical calcipotriol / betamethasone to be removed from formulary, and replaced with a statement that prescribers should choose the most cost-effective option.
  • Formulary restriction to macrogol 3350 to be removed, replaced with a statement that prescribers should choose the most cost-effective macrogol formulations.

To take part in this consultation, visit the consultations page. The consultation period is open until 5pm on Thursday 28th July 2022

Neuropathic pain guidance updated

Following technical review and Greater Manchester-wide consultation, the GMMMG neuropathic pain guidance has been updated and is now available on the Clinical Guidance and Pathways page. The formulary has also been updated to reflect the guidance.

Formulary and subgroup decision updates

Following the May meeting of GMMMG, the website and formulary have been updated to reflect decisions made by GMMMG and the Clinical Reference Group (CRG). This includes:

  • Bempedoic acid: GREEN following specialist advice (previously specialist initiation)
  • Sotrovimab for COVID-19: RED
  • Liraglutide for obesity in people aged 12-17: Do Not Prescribe
  • Dupilumab for severe asthma: RED
  • Belimumab for SLE: RED
  • Cenobamate for epilepsy: GREEN following specialist initiation (by a tertiary epilepsy service)
  • Risdiplam for spinal muscular atrophy: RED
  • Solriamfetol for narcolepsy: RED
  • Fostamatinib for chronic ITP: Do Not Prescribe

The formulary has also been updated to reflect relevant NICE guidelines and safety alerts. For full details of the changes, please see the Formulary Change Log and GMMMG decision summaries.

Consultation: actions from May meeting of CRG

On behalf of the GMMMG Clinical Reference Group, we now seek comments on the actions proposed at the May 2022 CRG meeting.

Actions in this consultation include:

  • Sitagliptin to replace alogliptin as first choice DPP4 inhibitor
  • Anti-reflux formula milks to be DNP
  • Nirmatrelvir & ritonavir (Paxlovid) to be added to formulary as RED
  • Links to NICE clinical guidance to be added to formulary: NG215 (medicines associated with dependence or withdrawal symptoms) and NG217 (epilepsies in children, young people and adults).
  • Links to MHRA safety advice to be added to formulary: pregabalin: findings of safety study on risks during pregnancy

To take part in this consultation, visit the consultations page. The consultation period is open until 5pm on Thursday 30th June 2022.

Updated asthma pathway published

Following GM-wide consultation and approval by chief finance officers and directors of commissioning, an updated GMMMG asthma guideline is now available on the Clinical Guidance and Pathways page.

The guideline has been updated in response to a request from GMHSCP to produce an updated asthma management plan to support the move to lower carbon inhalers. This includes consciously reducing the propellants contained in metered-dose inhalers which is a significant contributor to enabling the Greater Manchester Combined Authority’s and Greater Manchester Joint Commissioning Board’s commitment to sustainability.

An updated inhaler guide to support the pathway is in production, and will be available in due course.

Consultations: CRG actions and draft shared care protocol

Two new consultations have been opened on the GMMMG consultations page

CRG actions

On behalf of the GMMMG Clinical Reference Group, we now seek comments on the actions proposed at the April 2022 CRG meeting. Actions in this consultation include:

  • Simple eye ointment – DNP
  • Goserelin and leuprorelin for male early or advanced breast cancer – AMBER (see also consultation on updated draft shared care protocol)
  • Empagliflozin for chronic heart failure – GREEN following specialist advice
  • Dapagliflozin for chronic kidney disease – GREEN
  • Phenazone/lidocaine eardrops – add to formulary for treatment of otitis media
  • Pitolisant for excessive daytime sleepiness caused by obstructive sleep apnoea – DNP
  • Solriamfetol for excessive daytime sleepiness caused by obstructive sleep apnoea – DNP
  • Pegcetacoplan for paroxysmal nocturnal haemoglobinuria – RED
  • Atidarsagene autotemcel for metachromatic leukodystrophy – RED

Shared care protocol: GnRH analogues for breast cancer

CRG seek comments on this updated shared care protocol for the treatment of breast cancer.

The main changes are:

  • The addition of leuprorelin within the indications listed in the SCP
  • The SCP now includes the treatment of male breast cancer within the indications detailed in the SCP
  • A move to the new approved GM shared care protocol format.

Both consultations will run until 5pm on Wednesday 25th May 2022. Comments can be submitted using the feedback forms on the GMMMG consultations page, and comments are invited from all stakeholders.