GMMMG updates: November 2023

Following the November meetings of GMMMG and CEGC, the following actions have been published to the GMMMG website.

Updates to guidelines include:

  • New guidance: Safe Management of Medicines Within GP Practices

Formulary and RAG updates include:

  • Bempedoic acid – GREEN (previously green following specialist advice)
  • Betamethasone, dexamethasone, prednisolone and fluorometholone eye drops – GREEN (following specialist initiation)
  • Semaglutide for obesity in 12-17 year olds – DNP

Links to NICE guidance and MHRA safety advice added as appropriate. For full details of formulary and RAG updates, see the formulary change log available on the formulary page.

Following approval by the GM ICB Executive, the following have also been published:

  • Rimegepant for prevention of migraine – GREEN (following specialist initiation)
  • Sodium chloride 5% eye drops for corneal oedema – GREEN (following specialist advice)
  • An updated pathway for wet AMD was also approved, and will be published shortly

More details of the published decisions are available from the decision summaries page.


Formulary and RAG updates – June 2023

Following approval by CRG, GMMMG, and the Greater Manchester ICS Clinical Effectiveness and Governance Committee, the following updates have been made to GMMMG guidelines, formulary, and RAG list.

  • Note added to entry for aspirin in chapter 2 : “do not routinely offer aspirin for primary prevention of CVD”, with link to NICE CG181.
  • Upadacitinib for non-radiographic axial spondyloarthritis added as RED as per NICE TA861
  • Somatrogon added as RED (pending shared care) as per NICE TA863
  • Vutisiran added as RED, as per NICE TA868
  • Ataluren added as RED, as per NICE HST22

The formulary has also been updated to reflect relevant safety alerts and NICE guidelines. For full details, see the GMMMG decision summary for June 2023, or the formulary change log available on the formulary page.


New and updated resources

Following approval by CRG, GMMMG, and the Greater Manchester ICS Clinical Effectiveness and Governance Committee, the following documents have been approved and published.

The GMMMG Inappropriate Polypharmacy Review and Treatment Optimisation: Resource Pack has been reviewed and updated. The updated resource pack is available on the Clinical Guidelines and Pathways page.

Terms of reference for the Workforce subgroup have also been approved, and are available on the Membership and Terms of Reference page.

The formulary and RAG list have been updated to remove fostamatinib from the RAG list and assign a RED RAG status, and to reflect updated NICE guidelines and MHRA advice. See formulary change log for more details.

Outstanding decisions

Outstanding decisions expected to have a financial impact for the ICS are pending financial approval from by GM Directors of Finance, and will be published once approved. These include:

  • Dexamethasone intravitreal implant for diabetic macular oedema
  • Avacopan to severe active granulomatosis with polyangitis or microscopic polyangitis
  • Ozanimod for moderately to severely active ulcerative colitis
  • Upadacitinib for active ankylosing spondylitis
  • Relugolix–estradiol–norethisterone acetate for treating moderate to severe symptoms of uterine fibroids
  • Implementation of NICE guidance on Continuous Blood Glucose Monitoring (CGM)
  • Dexcom ONE rtCGM device
  • GMMMG antimicrobial guidance

New guidelines and Terms of Reference

Following approval by CRG, GMMMG, and the Greater Manchester ICS Clinical Effectiveness and Governance Committee, two new GMMMG guidelines have been published;

  • HRT Guidance for Menopause Management
  • Hypersalivation and Sialorrhoea in Adult Patients

Both guidelines are available on the clinical guidance and pathways page.

The formulary and RAG list have been updated to reflect the recommendations in these guidelines. For details of the updates, see the GM formulary change log, available on the formulary page.

The Terms of Reference for GMMMG and its subgroups have also been approved, and are available here. These include:

  • Clinical reference group
  • Medicines safety group
  • Population health management and health inequalities group
  • Digital group

Formulary and subgroup decision updates

Following approval by CRG, GMMMG, and the Greater Manchester ICS Clinical Effectiveness and Governance Committee, the following decisions have been approved and published:

  • Ranibizumab biosimilar added to formulary as RED and made first choice anti-VEGF-A treatment for NICE-approved indications. An updated GM macular pathway is also expected.
  • Faricimab added to formulary as RED for diabetic macular oedema and wet age-related macular degeneration.
  • Adaflex tablets added to formulary as first choice option for melatonin.
  • Mexiletine capsules added to formulary as RED for life-threatening ventricular arrhythmias.
  • Filgotinib added to formulary as RED for moderately to severely active ulcerative colitis.
  • Diroximel fumarate added to formulary as RED for relapsing-remitting multiple sclerosis.
  • Teduglutide added to formulary as RED for short bowel syndrome.

The formulary has also been updated to reflect relevant NICE guidelines and safety alerts. For full details please see the formulary change log, which is available on the formulary page.

For more information on these and other decisions, please see GMMMG decision summaries.


Formulary and subgroup decision updates

Following approval by CRG, GMMMG, the Greater Manchester ICS Clinical Effectiveness and Governance Committee, and Greater Manchester Management Executive, the following decisions have been approved and published:

  • Dapagliflozin for chronic kidney disease added to formulary as a GREEN drug
  • Edoxaban approved as first-line DOAC in atrial fibrillation, and DOAC statement published.
  • Sitagliptin approved as first-choice DPP-4 inhibitor
  • Romosozumab for severe osteoporosis added to formulary as a RED drug, as an alternative first-choice option alongside teriparatide
  • Simple eye ointment assigned a Do Not Prescribe status

Decision summaries from the July, August, and September meetings of GMMMG are also available, with further details on these and other decisions from those meetings. The formulary and RAG list change log has been updated accordingly and is available on the formulary page.


Formulary and subgroup decision updates

Following the first meeting of the Greater Manchester ICS Clinical Effectiveness and Governance Committee on Thursday 22nd September, the website and formulary have been updated to reflect decisions made by GMMMG and the Clinical Reference Group (CRG). This includes:

  • Empagliflozin for heart failure added as GREEN (specialist advice)
  • Pitolisant and solriamfetol for obstructive sleep apnoea added to DNP list (criterion 1)
  • Nirmatrelvir / ritonavir (Paxlovid) added as RED
  • Micronised progesterone vaginal capsules for management of miscarriage added as GREEN (specialist initiation)
  • Emollient section of chapter 13 updated to align with primary care emollient ladder
  • Minoxidil foam added to DNP list (criterion 3). Formulary updated to clarify that other minoxidil preparations are included in the Drug Tariff part XVIIIA (the “black list”).
  • Anti-reflux milks added to paediatric DNP list (criterion 3)
  • Phenazone / lidocaine eardrops for acute otitis media added to paediatric RAG list as GREEN, for use only if an immediate oral antibiotic prescription is not given, and there is no eardrum perforation or otorrhoea
  • Pegcetacoplan for paroxysmal nocturnal haemoglobinuria added to RAG list as RED
  • Atidarsagene autotemce for metachromatic leukodystrophyl added to RAG list as RED
  • Selumetinib for inoperable plexiform neurofibromas associated with type 1 neurofibromatosis added to RAG list as RED
  • Lixisenatide removed from formulary for new patients following discontinuation of the 10 microgram pen and initiation pack. Patients who are clinically stable on lixisenatide may continue and should not be switched without clinical reason

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.

Outstanding decisions

Outstanding decisions expected to have a financial impact for the ICS are pending approval by GM Directors of Finance, and will be published once approved:

  • Dapagliflozin for chronic kidney disease
  • Sitagliptin formulary position following patent expiry
  • Romosozumab for severe osteoporosis
  • Simple eye ointment DNP status

GMMMG shared care consultation extended

Please note: the GMMMG consultation on the adoption of the suite of national shared care protocols has been extended.

The consultation will now run for 10 weeks, to facilitate gathering of feedback from across all sectors of the ICS. The consultation will now run until Monday 3rd October 2022. Please follow the link above for more information, and to submit comments.


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)