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.

"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Penicillamine (rheumatology) shared care guideline (North & East Devon) has been withdrawn.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.
• A visual summary which incorporates local treatment choices is in development.
• 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.

November 2024

Drug changes and additions

Direct-acting oral anticoagulants (DOACs) have been updated to reflect updated commissioning recommendations from NHS England. 

For patients commencing treatment for atrial fibrillation, subject to the criteria specified in the relevant NICE TAs, clinicians should use the best value DOAC that is clinically appropriate for the patient. 

The ranking for best value DOACs is as follows: generic apixaban (twice a day) or generic rivaroxaban (once a day), followed by edoxaban, then Xarelto (branded rivaroxaban), then dabigatran, then Eliquis (branded apixaban).

See here for the formulary guidance.

An additional (higher) strength Epiduo (adapalene 0.3% / benzoyl peroxide 2.5%) gel has been added as a green (first line) option for the initial treatment for acne (as monotherapy or in combination with oral lymecycline or doxycycline) (for 12 weeks) and for the maintenance treatment for acne (as monotherapy).

An additional (lower) strength Benzoyl peroxide plus clindamycin (3% / 1%) gel has been added as a green (first line) option for the initial treatment for mild to moderate acne (for 12 weeks).

Trifarotene 50micrograms/g cream (a topical retinoid) has been added as a blue (second line) option for the maintenance treatment of acne where Epiduo is contraindicated or not suitable.

See here for the formulary entry.

Kay-Cee-L syrup will be discontinued from late November 2024; refer to the National Patient Safety Alert for guidance.

Primary and secondary care providers MUST:

1. not initiate new patients on Kay-Cee-L syrup
2. proactively review all patients currently prescribed Kay-Cee-L syrup to establish if potassium supplementation is still required, and switch to an alternative treatment, if considered necessary, ensuring no intolerance of excipients.

See here for the formulary entry.

Revised formulary guidance

Management of acne: updated guidance based on NICE guideline (NG198) Acne vulgaris: management.

For initial treatment, the Devon Formulary now recommends a 12-week course of one of the following first-line treatment options:

• Mild to moderate acne:
  • Benzoyl peroxide plus clindamycin gel once daily in the evening, or
  • Epiduo (adapalene plus benzoyl peroxide) gel once daily in the evening, or
  • Treclin (clindamycin plus tretinoin) gel once daily in the evening.
• Moderate to severe acne:
  • Epiduo or Treclin (as above), or
  • Epiduo (as above) or azelaic acid (15% gel or 20% cream) twice daily, PLUS oral antibiotic (lymecycline or doxycycline) (refer to formulary guidance for second line oral antibiotic options and information regarding combined oral contraceptives).
• Benzoyl peroxide 5% gel (monotherapy) applied once or twice daily can be considered as an alternative treatment to any of the options above, if these treatments are contraindicated, or the person wishes to avoid using a topical retinoid, or an antibiotic (topical or oral).

Where maintenance treatment is indicated:

• Epiduo (adapalene plus benzoyl peroxide) gel once daily in the evening is first line.
• If this is contraindicated or not tolerated alternative maintenance options include topical adapalene, azelaic acid, benzoyl peroxide or trifarotene.

See here for the formulary guidance.

Management of blood lipids: updated guidance based on NICE guidance NG238

A summary of the updates:

• Baseline measurements and monitoring: HbA1c no longer required at baseline. Check patient’s diabetes status.
• Primary prevention: risk assessment:
  • QRISK3 is the current version of the calculator. QRISK2 can be used if QRISK3 is not available. QRISK3 has been updated with indicators for certain patient groups to incorporate disease or medication specific risks of cardiovascular disease (CVD). QRISK3 (on-line version if necessary) should be used for the following patient groups:
    • people taking corticosteroids or atypical antipsychotics or people with systemic lupus erythematosus, migraine, severe mental illness (schizophrenia, bipolar disorder or other psychoses), or erectile dysfunction.
  • Consider using QRISK3-lifetime to inform discussions on CVD risk and to motivate lifestyle changes particularly for people with a 10-year QRISK3 score less than 10%, and people under 40 who have CVD risk factors.
• Secondary prevention:
  • New target lipid level: LDL-C 2.0 mmol/L or less, or non-HDL-C 2.6 mmol/L or less.
  • Consider ezetimibe in addition to maximum tolerated intensity and dose of statin to reduce CVD risk further, even if the lipid target for secondary prevention of CVD is met.

See here for the formulary guidance.