February 2025

Drug changes and additions

Oseltamivir 30mg, 45mg, 75mg capsules and 6mg/ml oral suspension sugar free and zanamivir 5mg inhalation powder blisters with device for the treatment and post-exposure prophylaxis of influenza have been reclassified as green (first line). The drug entries have been updated with dosing and additional information, and links to UKHSA resources have been added.

The DHSC provides annual notification, usually through the CMO, of the start and end of the season when influenza is circulating in the community. GPs may prescribe antivirals for the treatment of influenza during this time period. 

Antiviral treatment outside of the flu season, and prophylaxis (at any time), is provided through a commissioned service and should not be routinely prescribed by GPs.

See here for the formulary entry.

Ivermectin 3mg oral tablets have been added as a blue (second line) option for the treatment of scabies if topical therapy is contraindicated or unsuitable.

See here for the formulary entry.

Co-trimoxazole tablets and oral suspension have been added as blue (second line) options for the prophylaxis and treatment of human and animal bites for those aged 12 years and above.

Co-trimoxazole solution for infusion ampoules have been added as a red (hospital only) option.

See here for the formulary entry.

Dienogest 2mg tablets have been added as an amber (specialist input) option for use in the management of endometriosis when initial hormonal therapy (for example, the combined oral contraceptive pill or a progestogen) is ineffective or not tolerated or contraindicated.

Treatment with dienogest may be started in primary care on the advice of a specialist.

See here for the formulary entry.

Ferric maltol 30mg hard capsules have been added to the formulary as an amber (specialist input) option for the treatment of iron deficiency anaemia (IDA) in patients with inflammatory bowel disease (IBD) in whom two standard oral iron preparations have been ineffective or not tolerated.

Gastroenterology specialists will prescribe the first 4-weeks of treatment and assess haematological response. If an adequate haematological response is observed following 4-weeks of treatment, primary care may be asked to continue prescribing for a further 12-weeks.

See here for the formulary entry.

Fluticasone propionate and azelastine hydrochloride nasal spray (50micrograms / 137micrograms) has been added to the formulary as an amber (specialist input) option for moderate to severe symptoms of allergic rhinitis in adults and children aged ≥12 years, following failure of combination therapy (antihistamine and nasal corticosteroid) which has been optimised by a secondary care allergy specialist (adult immunology services or specialists in paediatric allergy management).

Initiation of treatment by other specialist services is not supported.

Allergy specialists will prescribe and assess treatment response; if the product results in a sustained reduction in symptoms primary care may be asked to continue prescribing.

See here for the formulary entry.

The formulary recommendations and supporting guidance for thickened fluids have been updated in consultation with local Speech and Language Therapists (SLT) and dieticians. Thickened fluids are one of several dysphagia management tools, and should be considered only after comprehensive assessment by SLT.

All thickened fluids (including thickeners, pre-thickened drinks, and semi-solid desserts) are now classified
as amber (specialist input), however, it is accepted that GPs may occasionally initiate thickened fluids for individual patients without the need for SLT assessment, i.e. end-of-life care or infants/babies with reflux.

• Instant Carobel powder has been added as clear gum-based option for patients from birth to 3 years.
• Thixo-D Original powder has been added as starch-based option for children aged 1 year and over.

For patients already using thickened fluids without SLT involvement, there is no need to seek retrospective specialist input; if the patient’s clinical requirements have changed, and/or it is thought that thickened fluids may no longer be required, GPs can seek advice from / refer to SLT.

See here for the formulary guidance.

The formulary continence chapter product recommendations have been reviewed with Bladder and Bowel Care and Urology Specialists from the three acute NHS Trusts across Devon, to create cohesive Devon-wide continence care recommendations.

See here for Chapter 18: Continence care.

Formulary guidance

Human and animal bites

Updates include:

• Antibiotic course durations have been reduced to 3 days for prophylaxis and 5 days for treatment
• Advice to seek specialist advice for those who are pregnant
• Prophylaxis and treatment recommendations for those under 18 years of age have been added, these include:
  • Co-amoxiclav as a green (first line) option
  • Doxycycline plus metronidazole as a blue (second line) option for those aged 12 years and above
  • Co-trimoxazole as a blue (second line) option for those aged 12 years and above
• Updated advice on when to offer antibiotic prophylaxis
• Reassessment and referral advice.

See here for the formulary guidance.

Management of scabies

Updates include:

• definition and transmission of scabies
• single case / contact / closed setting management
• hygiene and prevention advice
• addition of ivermectin 3mg oral tablets
• follow up and post-treatment advice.

See here for the formulary guidance.

NICE Technology Appraisals (TAs)

NICE TA1015: Teclistamab solution for injection vials have been added to the Devon Formulary as a red (hospital only) option for treating relapsed and refractory multiple myeloma after 3 or more treatments in line with the technology appraisal guidance.

See here for the formulary entry.

NICE TA1016: Elafibranor tablets have been added to the Devon Formulary as a red (hospital only) option for previously treated primary biliary cholangitis, in line with the technology appraisal guidance.

See here for the formulary entry.

Commissioning Policies

The routine commissioning of ferric maltol is accepted in Devon for the treatment of IDA in patients with IBD in whom two standard oral iron preparations have been ineffective or not tolerated (see Commissioning Policy for more details).

See here for the formulary entry.

The routine commissioning of fluticasone propionate and azelastine combination nasal spray is accepted in Devon for the treatment of allergic rhinitis when allergy specialists have optimised treatment with standard combination therapies (see Commissioning Policy for more details).

See here for the formulary entry.

January 2025

Drug changes and additions

Sulfasalazine tablets, gastro-resistant tablets, and oral suspension are now recommended Devon-wide as amber (specialist input) options for use in line with relevant “Shared Care” / SMS guidelines.

See here for the formulary entry.

Penicillamine tablets are now classified as a red (hospital only) option Devon-wide.

See here for the formulary entry.

Commissioning policies

The formulary entry for opicapone has been updated to reflect the updated Commissioning Policy for opicapone for the treatment of patients with Parkinson's disease (see Commissioning Policy for more details).

• The updated policy was agreed by NHS Devon following discussion and recommendation by the Clinical Policy Recommendation Committee and supports the use of opicapone as an option, alongside entacapone, for the management of end of dose motor fluctuations in Parkinson’s disease.

See here for the formulary entry.

Revised formulary guidance

Management of seborrhoeic dermatitis

Updates include:

• Advice on treatment for those aged from birth to 18 years
• Updates to treatment options, including:
  • the addition of topical calcineurin inhibitors as amber (specialist input) options
  • the removal of combination steroid and antimicrobial product recommendations
• Supporting information on treatment durations and licensed age ranges
• Advice on reassessment and referral, including links to local Clinical Referral Guidelines (CRGs).

See here for the formulary guidance.

NICE Technology Appraisals

NICE TA1009: Latanoprost / netarsudil 50 microgram/ml / 200 microgram/ml eye drops have been added to the Devon Formulary as an amber (specialist input) option for reducing intraocular pressure (IOP) in adults with primary open-angle glaucoma or ocular hypertension in line with the technology appraisal guidance.

See here for the formulary entry.

NICE TA1010: Danicopan 50mg and 100mg tablets have been added to the Devon Formulary as a red (hospital only) option for treating paroxysmal nocturnal haemoglobinuria alongside ravulizumab or eculizumab.

See here for the formulary entry.

NICE TA1012: Avapritinib 25mg, 50mg, 100mg, and 200mg tablets have been added to the Devon Formulary as a red (hospital only) option for treating advanced systemic mastocytosis.

See here for the formulary entry.

NICE TA1013: Quizartinib 17.7mg and 26.5mg tablets have been added to the Devon Formulary as a red (hospital only) option for induction, consolidation, and maintenance treatment of newly diagnosed FLT3-ITD-positive acute myeloid leukaemia.

See here for the formulary entry.

"Shared Care" / Specialised Medicines Service (SMS) guidelines

Sulfasalazine (gastroenterology) shared care guideline (North & East Devon) has been amended to remove reference to prescribing by brand.

See here for the formulary entry.

Penicillamine (rheumatology) shared care guideline (North & East Devon) has been withdrawn.

• Penicillamine is no longer routinely used as a DMARD in contemporary practice, it has therefore been reclassified to hospital only.
• There should be no new requests for shared care.
• Existing rheumatology patients may continue to receive treatment in primary care under historic shared care agreements.

See here for the formulary entry.

December 2024

Drug changes and additions

Xonvea (doxylamine/pyridoxine) 10mg/10mg gastro-resistant tablets are recommended as a second-line option for the treatment of nausea and vomiting of pregnancy (NVP) in pregnant women ≥ 18 years who do not respond to conservative management (i.e., lifestyle and diet change) and first line anti-emetics.

• Doxylamine/pyridoxine is considerably more expensive than other antiemetics that have long been used off-label for NVP, but there are currently no other licensed pharmacological treatments available in the UK.
• Doxylamine/pyridoxine should be administered on an empty stomach with a glass of water.

See here for the formulary entry.

Glycopyrronium bromide 1mg and 2mg tablets are recommended for the treatment of severe sialorrhoea (chronic pathological drooling) in patients with chronic neurological disorders.

Treatment may be started in primary care on the advice of a specialist.

The NHS Devon Medicines Optimisation Team recommends prescribing of glycopyrronium bromide tablets as Assicco brand to help ensure cost-efficient use of local NHS resources (see here).

See here for the formulary entry.

Kay-Cee-L syrup has been discontinued and removed from the Devon Formulary.

Revised formulary guidance

Management of Chronic Obstructive Pulmonary Disease (COPD): updated guidance based on the GOLD 2024 report with additional information from NICE Guideline NG115 (2019). Non inhaled prevention and maintenance strategies (smoking cessation, vaccinations, self-management plans, pulmonary rehabilitation [where available]) remain essential in the management of COPD. Rescue short-acting bronchodilators should continue to be prescribed to all patients for immediate symptom relief.

Key updates to the formulary guidance include:

• Eosinophil count to be taken into account when considering the use of ICS (this recommendation features more prominently than in previous guidance).
• Updated recommendations for initial pharmacological treatment:
  • LAMA monotherapy is recommended for all patients in group A (if unsuitable, LABA may be considered)
  • LABA + LAMA combination therapy is recommended for all patients in group B
  • Groups C and D have been combined into new group E, which includes all patients with ≥ 2 moderate exacerbations or ≥ 1 exacerbation leading to hospitalisation in the last year, regardless of symptom score
    • These patients are now recommended LABA + LAMA combination therapy as initial treatment, with triple therapy (ICS + LABA + LAMA) considered for those with blood eosinophils ≥ 0.3x10⁹/L
  • ICS + LABA is not encouraged (GOLD suggests triple therapy with ICS + LABA + LAMA is superior).
• Updated recommendations for follow up pharmacological treatment. Consider the predominant treatable trait to target: dyspnoea or exacerbations. Use exacerbation pathway if both exacerbations and dyspnoea need to be targeted.
• GOLD no longer refers to asthma and COPD overlap, instead emphasizing that these are different disorders, which may co-exist in an individual patient. If a concurrent diagnosis of asthma is suspected, pharmacotherapy should primarily follow asthma guidelines. The formulary information on Asthma - COPD Overlap Syndrome (ACOS) has been withdrawn.

See here for the formulary guidance.

Management of nausea and vomiting in pregnancy (NVP) and hyperemesis gravidarum (HG)

Updates include:

• Small amendments to self-care measures.
• Cyclizine reclassified as a first line option alongside promethazine.
• Inclusion of doxylamine/pyridoxine as a second line option alongside metoclopramide and prochlorperazine.
• Addition of oral prednisolone as a third line specialist input (amber) option.
• Updated timescales for review.
• Consider combinations of drugs from different classes in women who do not respond to a single anti-emetic.

See here for formulary guidance.

NICE Technology Appraisals

NICE TA995: Relugolix 120mg tablets have been added to the Devon Formulary as an amber (specialist input) option for treating hormone sensitive prostate cancer in line with the technology appraisal guidance.

See here for the formulary entry.

NICE TA996: Linzagolix 100mg and 200mg tablets have been added to the Devon Formulary as a red (hospital only) option for treating moderate to severe symptoms of uterine fibroids in line with the technology appraisal guidance.

See here for the formulary entry.

NICE TA1011: Belzutifan 40mg tablets have been added to the Devon Formulary as a red (hospital only) option for treating with von Hippel-Lindau disease in line with the technology appraisal guidance.

See here for the formulary entry.

NICE TA1019: Crovalimab 240mg/2ml solution for injection vials have been added to the Devon Formulary as a red (hospital only) option for treating paroxysmal nocturnal haemoglobinuria in line with the technology appraisal guidance.

See here for the formulary entry.

NICE TA1020: Eplontersen 45mg/0.8ml solution for injection pre-filled devices have been added to the Devon Formulary as a red (hospital only) option for treating hereditary transthyretin-related amyloidosis in line with the technology appraisal guidance.

See here for the formulary entry.

NICE TA1022: Bevacizumab gamma 25mg/ml solution for injection vials have been added to the Devon Formulary as a red (hospital only) option for treating wet age-related macular degeneration in line with the technology appraisal guidance.

See here for the formulary entry.

NICE TA1025: Ublituximab 150mg/6ml concentrate for solution for infusion has been added to the Devon Formulary as a red (hospital only) option for treating relapsing multiple sclerosis in line with the technology appraisal guidance.

See here for the formulary entry.