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 19th September 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/.


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.