Updated shared care protocol: melatonin for children and adolescents

Following approval by CRG and GMMMG, and the first meeting of the Greater Manchester ICS Clinical Effectiveness and Governance Committee on Thursday 22nd September, a shared care protocol for melatonin in children adolescents has been updated.

All of the currently active shared care protocols in Greater Manchester are available on the shared care page.


GMMMG charter

Following the first meeting of the Greater Manchester ICS Clinical Effectiveness and Governance Committee on Thursday 22nd September, the GMMMG charter has been approved and published.

The charter is available on the website by clicking here.


Updated shared care protocols

Following approval by CRG and GMMMG, and the first meeting of the Greater Manchester ICS Clinical Effectiveness and Governance Committee on Thursday 22nd September, the following shared care protocols have been updated:

  • GnRH analogues for breast cancer – now includes both goeserelin and leuprorelin, and applies to all adult patients
  • Somatropin for paediatric patients – updated to reflect the available products
  • DMARDs in dermatology, including azathioprine, hydroxychloroquine, oral methotrexate and mycophenolate – updated to reflect current contact details for dermatology clinic at MFT.

All of the currently active shared care protocols are available on the shared care 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
  • 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.


Consultation: actions from August meeting of CRG

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

Actions in this consultation include:

  • Famotidine added to formulary as GREEN, replacing ranitidine as first choice H2-receptor antagonist for adults
  • Risankizumab for active psoriatic arthritis added to chapter 10 as RED
  • Icosapent ethyl added to chapter 2 as GREEN (specialist advice)
  • Roxadustat added to chapter 9 as RED
  • Fenfluramine added to chapter 4 as RED
  • Imlifidase added to chapter 8 as RED
  • Setmelanotide added to RAG list only as RED

All links to MHRA drug safety updates will be added to formulary as appropriate.

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


Consultations: GMMMG shared care protocols for Lokelma and Veltassa

On behalf of the GMMMG Clinical Reference Group, two GMMMG shared care protocols have been drafted for:

  • sodium zirconium cyclosilicate (Lokelma) for refractory hyperkalaemia
  • patiromer (Veltassa) for refractory hyperkalemia

We now seek comments on these drafts, which are available from the GMMMG consultations page. The consultation period is open until 5pm on Monday 12th September.


Consultation: actions from July meeting of CRG

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

Actions in this consultation include:

  • Ranibizumab biosimilar to be added to formulary as RED, and ranibizumab to be first choice anti-VEGF therapy for NICE-approved indications.
  • Melatonin (Adaflex) to be added to formulary as AMBER (children) and GREEN (specialist advice) for adults with REM sleep behaviour disorder in Parkinson’s disease.
  • Mexiletine – RED for life-threatening ventricular arrhythmias
  • Filgotinib – RED for moderately to severely active ulcerative colitis
  • Faricimab – RED for diabetic macular oedema and wet age-related macular degeneration
  • Diroximel fumarate – RED for relapsing-remitting multiple sclerosis
  • Teduglutide – RED for short bowel syndrome
  • NICE clinical guideline for gout, NG219, to add to formulary.

All links to MHRA drug safety updates will be added to formulary as appropriate.

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


GMMMG Consultation on the Adoption of the National Shared Care Protocols

On 8th July 2022 NHS England published a suite of 18 shared care protocols: https://www.england.nhs.uk/medicines-2/regional-medicines-optimisation-committees-advice/shared-care-protocols/.

These have been developed by the Regional Medicines Optimisation Committee (RMOC) North in conjunction with the Shared Care Working Group and the Regional Drug and Therapeutics Centre.

Before being published they underwent a national consultation and approval process by RMOC North and ultimately by the relevant NHSE National Clinical Directors and the Chief Pharmaceutical Officer. Further information on this process can be found on the NHSE website using the link above.

The GMMMG Clinical Reference Group (CRG) are now seeking comments from stakeholders on the potential barriers to implementation of these 18 shared care protocols. The clinical content has been approved nationally with representation from all regions including Greater Manchester, with input during the development, and via the consultation process undertaken by RMOC.

For this reason CRG are not seeking comments on the clinical content of the documents but are looking to the GM Integrated Care System to provide feedback on how these should now be used to replace the current shared care protocols.

GMMMG are keen to understand what barriers, if any, may prevent all GM localities from being able to adopt these national shared care protocols. These could include, but may not be limited to:

  • Specialist service design and capacity
  • Resource implications in both primary care and specialist clinics
  • Compatibility with current digital communication methods
  • Appropriateness of the listed indications for use of the medicine

Therefore CRG on behalf of GMMMG invite all GM stakeholders to submit comments using the link below before the closing date of 3rd October 2022. A downloadable copy of this text is also available via the link.

Comments submitted on clinical content of the documents are unlikely to be addressed at a GM level unless GMMMG agree that there are significant safety concerns. Any other comments will be collated and submitted to the NHSE Medicines Policy Team to inform future work to manage and update the documents.

Consultation comments can be submitted via the feedback form at https://gmmmg.nhs.uk/consultations/136-consultation-national-shared-care/.

* Please note: this news item was updated on 17th August 2022 to reflect the new closing date for this consultation. The consultation period has been extended from 8 to 10 weeks, and will now close on Monday 3rd October 2022.


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