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For the latest updates and advice on coronavirus (COVID-19), please visit the NHS website.
This page provides a summary of Formulary updates specific to the COVID-19 pandemic.
For Clinical Referral Guideline (CRG) updates specific to the COVID-19 pandemic, please click here. The NHS Devon CCG Medicines Optimisation Team have produced a COVID-19 Information and Guidance page, which features a frequently asked questions section, please click here.
In order to minimise the need for patients to attend NHS facilities for face-to-face contact, the frequency of drug safety monitoring has been temporarily extended in certain clinical circumstances. Thresholds for action remain unchanged.
The guidelines for each drug have been amended, showing clearly in a blue font in the monitoring section of each guideline the changes introduced to apply during the COVID-19 pandemic.
A very brief summary of changes can be found by clicking here. Prescribers should refer to the relevant individual guidelines for details, these can be found on the NHS Devon CCG website and via the relevant drug entries in the formulary.
Template letters are available to support practices in writing to their patients who are affected by these temporary changes to advise them of the revised monitoring arrangements and what this means for them. These can be found by clicking here.
Please note: These recommendations only apply to patients being treated in accordance with the Devon Specialised Medicines Service/ shared care guidelines; they do not apply to other clinical situations e.g. transplant patients or ad hoc individual arrangements between GPs and specialists – Prescribers should seek specialist advice for these patients.
***UPDATE 03/06/2021*** The relatively low prevalence of COVID-19 in Devon and established infection control measures in primary care have reduced the risk of exposure to infection for patients who need drug safety monitoring. A return to usual monitoring is therefore preferred, however it is acknowledged that the pandemic is resulting in ongoing capacity restraints in primary care. GPs should aim to undertake monitoring at the usual frequency wherever possible. GPs who are experiencing capacity challenges as a result of the pandemic may continue to institute the minimum monitoring requirements detailed in the individual guidelines if necessary.
GPs are recommended to prioritise patients prescribed DMARDs, particularly the following groups, for usual monitoring:
In addition, following any dose increase, patients should have the standard short-term increase in monitoring schedule (see individual guidelines for details)
GPs should continue to seek specialist advice if they have any specific concerns about individual patients.
IMPORTANT: WEST DEVON GASTROENTEROLOGY. Specialists have requested that usual frequency monitoring is undertaken for all patients. Any GP with patients prescribed these medicines under a “shared care” arrangement with the gastroenterology department at UHP should seek specialist advice if they are unable to provide the routine monitoring required.
National guidance: Guidance has been issued for end of life symptom control for when a patient is dying of infection with COVID-19, please see here.
Prescribing for end of life symptom control: Local prescribing guidance and prescribing and medication administration records (PMAR) have been developed to support patients with COVID-19 infection who require end of life symptom control, please see here.
Prescribing information for symptom management via syringe driver: Local concise prescribing guidance has been produced to support practitioners in the care of patients in the community who require medicines for symptom management of COVID-19 via syringe drivers as they approach the end of life. Please see here.
End of life care resource for GPs: A resource page for GPs providing guidance for end of life care of patients with COVID-19 is available here. The page includes symptom management and links to the formulary palliative care section 16.17 End of life symptom control for patients dying of COVID-19 where the national and local guidance shown above is also available. Other topics covered include: the conversation, treatment escalation plans/do not resuscitate orders, care at the time of death, bereavement advice and support, care for carers and care for yourself.
Supply of medication for palliative care: please see here for a list of community pharmacies in Devon which maintain a minimum level of stock of more specialised medicines, including injectable medicines most likely to be used in the management of patients with COVID-19.
NICE has issued a COVID-19 rapid guideline (NG165): managing suspected or confirmed pneumonia in adults in the community (03 April 2020). The previous recommendations for severity assessment and management of community-acquired pneumonia have been revised for use during the COVID-19 pandemic. The antibiotics recommended in this guideline differ from the previous recommendations for treatment of community-acquired pneumonia. This decision was taken for clinical reasons and to support the supply chain. Points covered by the new guideline include:
NICE will review and update their guidance as knowledge and practice develops. Please remember to ensure you are using the current guidance.
NICE has issued a COVID-19 rapid guideline (NG173): antibiotics for pneumonia for adults in hospital (01 May 2020). The guideline includes patients presenting to hospital with community-acquired pneumonia and patients who develop pneumonia in hospital. Please also refer to your local acute trust's antibiotic guidelines.
The British Society of Haematology (BSH) has issued advice on the management of patients requiring vitamin B12 supplements during the COVID-19 pandemic (found under the "General Haematology" header). This guidance covers patients who receive vitamin B12 for diet-related conditions and for conditions which are not thought to be diet-related (e.g. pernicious anaemia, history of total/partial gastrectomy or achlorhydria, inflammatory bowel diseases).
In patients who have vitamin B12 deficiency which is not thought to be diet-related and who have received regular maintenance parenteral vitamin B12, liver stores of vitamin B12 will be adequate to allow for the omission of one or two three monthly injections to minimise the risk of transmission of COVID-19 from face to face interaction with a healthcare professional. As an alternative, oral cyanocobalamin can be offered at a dose of 1mg per day until regular IM hydroxocobalamin can be resumed, i.e. once GP surgeries are able to do so safely, aiming to have a shortest possible break from regular injections. If oral cyanocobalamin is necessary, the local preferred brand is Orobalin 1mg tablets, this is recommended to ensure a licensed product is dispensed (SPC available here) and helps support cost-efficient use of local NHS resources.
If a patient is intending to attend a healthcare facility for a vitamin B12 injection, they should be informed of the increase in risk of transmission of COVID-19.
Guidance has been issued from the Faculty of Sexual & Reproductive Healthcare of the Royal College of Obstetricians & Gynaecologists regarding contraception during the COVID-19 pandemic, please see here.
NICE has issued a COVID-19 rapid guideline (NG167): rheumatological autoimmune, inflammatory and metabolic bone disorders (03 April 2020). The following has been highlighted in the formulary to aid prescribers with patients having treatment with denosumab and zoledronic acid:
Issued by the Together Drugs and Alcohol Service: Exeter, East and Mid Devon, North Devon and South Devon (not Torbay)
The Together Drugs and Alcohol Service has issued advice for GPs who may be contacted by patients presenting in opiate or alcohol withdrawal during the COVID-19 pandemic. This advice can be found here. The prescribers at Together are continuing to assess and start new patients onto opioid substitution therapy; referral is via phone, email or letter (see contact details). Guidance is provided on adjunctive treatment and symptomatic relief for patients withdrawing from opiates.
GPs should not initiate a medically assisted withdrawal from alcohol. Guidance is provided for GPs who are contacted by patients for advice regarding alcohol detoxification. For urgent medical advice, see contact details.
The MHRA has issued temporary guidance for specialists for initiation of valproate in female patients, and for annual review and pregnancy testing to support adherence to pregnancy prevention requirements during the pandemic. Annual reviews should not be delayed. Please see here
Specific information regarding the Prevention and Treatment Protocol for Mask Associated Dermatitis (MAD) and Skin Damage beneath PPE (from Royal Devon and Exeter NHS Foundation Trust) during the Coronavirus (COVID-19) pandemic can be found here (RD&E Intranet)
For further support or advice please contact:
Specific information regarding maintaining immunisation programmes (from NHS England (NHSE)) during the Coronavirus (COVID-19) pandemic can be found here.
Where possible, the routine immunisation programmes should be maintained and offered in a timely manner and non-scheduled vaccinations should still be given. Anyone with an appointment cancelled as part of COVID-19 response should be invited for vaccination as soon as possible.
Information contained in the document includes:
From 3rd July 2020, an interim clinical commissioning policy has been put in place to define routine access to remdesivir in the treatment of COVID-19 across the UK.
Remdesivir is recommended to be available as a treatment option for patients hospitalised with COVID-19 (adults and children aged 12 years and older) in accordance with the criteria set out in the updated policy document (14 June 2021) (see UK interim clinical commissioning policy for more details). The commissioning policy has been updated to allow an extended treatment duration and other exemptions for immunocompromised patients, clarify when a further treatment course might be given following readmission, and reflect exceptions in the eligibility criteria for patients with end-stage renal disease on haemodialysis. The formulary entry for remdesivir can be found here.
For guidance which covers the management of patients with musculoskeletal and rheumatic conditions who are receiving corticosteroids, or require initiation of oral or intravenous corticosteroids, or require a corticosteroid injection during the pandemic, please click here.
The guidance is supported by the British Society of Rheumatology, the Royal College of General Practitioners and other professional bodies. It supersedes guidance issued by NHS England at an earlier stage in the pandemic. The guidance covers:
Clinical guidance for dexamethasone and hydrocortisone in the treatment of patients with COVID-19 has been issued by the DHSC and NHSE. For more information, please see the CAS alert (issued 03 September 2020) which can also be found under the entries for dexamethasone and hydrocortisone in section 6.3.2. Glucocorticoid therapy
NHS England guidance on management of anticoagulant services during the COVID-19 pandemic. Please see here
NICE COVID-19 rapid guideline (NG186): reducing the risk of venous thromboembolism in over 16s with COVID-19. This guideline covers pharmacological venous thromboembolism prophylaxis for all patients being treated for COVID-19 pneumonia. It includes patients receiving treatment in hospital or in a community setting with input from hospital clinicians such as a 'hospital at home' service or COVID-19 'virtual ward'. Specific guidance is referenced for women who are pregnant or have given birth within the last 6 weeks. Please see here
MHRA advice (October 2020): Warfarin and other anticoagulants – monitoring of patients during the COVID-19 pandemic
There have been concerns over an apparent increase in the number of patients taking warfarin found to have elevated international normalised ratio (INR) values. Continued INR monitoring is important in patients taking warfarin or other vitamin K antagonists (VKA) if they have suspected or confirmed COVID-19 infection.
Some patients taking warfarin may have been switched to DOACs during the pandemic to avoid regular blood tests for INR monitoring.
Patients with COVID-19 may be treated with antibiotics in line with NICE guidance and may also be treated with antivirals.
Healthcare professionals are therefore reminded:
Further information regarding the monitoring of patients taking warfarin and other anticoagulants (from the MHRA) during the Coronavirus (COVID-19) pandemic can be found here; including advice to give to patients.
NICE has issued a rapid COVID-19 guideline (NG187): vitamin D in collaboration with PHE and the Scientific Advisory Committee on Nutrition (SACN). The guideline states do not offer a vitamin D supplement to people solely to prevent or treat COVID-19, except as part of a clinical trial. For more information, see the guideline here.
The NICE guideline recognises that people may have spent more time indoors over the spring and summer due to the coronavirus restrictions and therefore might not have made enough vitamin D from sunlight. The NICE guideline highlights that it is more important than usual to take vitamin D supplements to prevent deficiency this winter; the recommended dose of vitamin D is 10 micrograms (400 IU) per day. There are a range of products available to purchase at supermarkets, pharmacies and other retailers (see here for more information).
In addition, the UK government has announced that adults in England who are at high risk (clinically extremely vulnerable) from coronavirus (COVID-19) are eligible to receive free vitamin D supplements this winter. This is because there may be a higher risk of vitamin D deficiency as these groups have spent more time indoors this year. Eligible patients will receive a letter from the NHS or the Department of Health and Social Care (DHSC) inviting them to apply for four months' supply of vitamin D. Anyone who is able to purchase a vitamin D supplement and start taking them now is advised to do so, even if they are eligible for a delivery later in the year (See here and here for further information).
Women and children who qualify for the Healthy Start scheme can get free supplements containing the recommended amounts of vitamin D. See the Healthy Start website for more information.
Vitamin D should not be routinely prescribed in primary care unless there is a medically diagnosed deficiency, or when using calcium and vitamin D for osteoporosis, or for treating malnutrition including alcoholism (refer to management of Vitamin D deficiency).
NICE has issued the COVID-19 rapid guideline NG188: Managing the long-term effects of COVID-19 in collaboration with the RCGP and the Scottish Intercollegiate Guidelines Network. The guideline covers identifying, assessing and managing the long-term effects of COVID-19, often described as 'long COVID'. It makes recommendations about care in all healthcare settings for adults, children and young people who have new or ongoing symptoms 4 weeks or more after the start of acute COVID-19.
The guideline does not include recommendations for specific medicines. The following recommendation is included for over-the-counter vitamins and supplements: “Explain to people that it is not known if over-the-counter vitamins and supplements are helpful, harmful or have no effect in the treatment of new or ongoing symptoms of COVID-19”.
From 01 February 2021, interim commissioning policies have been put in place to define routine access to sarilumab and tocilizumab for the treatment of COVID-19 across the UK.
***UPDATE 17/02/2021***: The commissioning policy for tocilizumab has been updated to cover a wider group of hospitalised COVID-19 positive patients. Sarilumab continues to be recommended as a treatment option for critically ill adult patients, in line with the policy criteria, who have not already received tocilizumab (or other interleukin-6 inhibitor).
For further details, see section 10.1.3 Drugs that suppress the rheumatic process.
Inhaled budesonide is not currently being recommended as standard of care but can be considered (off-label) on a case-by-case basis for symptomatic COVID-19 positive patients aged 65 years or over, or aged 50-64 years with co-morbidities, in line with the national Interim Position Statement (issued 12 April 2021). The position statement includes eligibility criteria for treatment, circumstances in which budesonide should not be administered, dose and duration of treatment. The position statement can also be found under the entry for budesonide in section 3.2 Corticosteroids
The MHRA has published temporary advice for specialists and patients about oral isotretinoin, alitretinoin and acitretin and the use of remote consultations for monitoring safety requirements during the COVID-19 pandemic (22nd June 2021). This guidance can be found here, and covers:
When prescription of an oral retinoid is under consideration, the initial consultation should be face to face wherever possible. If this is not feasible, for example due to the patient being in a high-risk group for COVID-19 complications, a remote consultation can be considered. The requirements of the Pregnancy Prevention Programme, blood testing and monitoring for psychiatric symptoms still apply, but may be adapted for remote consultation. For more information please see the full guidance.
NICE has issued the COVID-19 rapid guideline NG200: vaccine-induced immune thrombocytopenia and thrombosis (VITT). The guideline covers VITT, a syndrome which has been reported in rare cases after COVID-19 vaccination.
This is an evolving area, check the NICE website for the latest guidance.
Treatment is on the recommendation of a specialist involving a clinical haematologist.Last updated: 29-07-2021