ANNUAL REPORT April 2008 to March 2009

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1 North of Tyne Area Prescribing Committee ANNUAL REPORT April 2008 to March 2009 Executive Summary The APC continued its work of facilitating clinical decision making across the North of Tyne. 97 non-cancer products were reviewed, a 29% increase on the previous year, and 77% of products reviewed were approved. The rest were either rejected or deferred. The North of Tyne Formulary was completed and available on the APC s website for public scrutiny along with minutes of meetings and decision summaries. The committee was cited as an example of good practice in a handbook published by the National Prescribing Centre and it continued to regularly look at NICE and SMC decisions as well as reviewing newly licensed drugs and formulations. Introduction *********** The North of Tyne Area Prescribing Committee (APC) was established in January 2007 with the aim of facilitating a cross-organisational approach to medicines management, clinical decision making and related commissioning issues which affect primary care, acute hospitals, mental health, learning disabilities and social care. This report has been compiled to inform participating organisations of the Committee s activities for the 12 months up to the end of March The report includes the outcomes of new drug requests, membership details, attendance figures and other relevant/significant developments, areas of interest and involvement. Membership The Area Prescribing Committee (APC) serves the following participating organisations: Newcastle Primary Care Trust (NPCT) Newcastle upon Tyne Hospitals NHS Foundation Trust (NUTH) North Tyneside Primary Care Trust (NTPCT) Northumberland Care Trust (NCT) Northumberland, Tyne and Wear NHS Trust (NTWT) Northumbria Health Care NHS Foundation Trust (NHCT) Page 1 of 14

2 Membership of the committee comes from a wide variety of professional, clinical, educational, management, commissioning and organisational backgrounds. Attendance figures Between April 2008 and March 2009 there have been 7 meetings of the APC. The table below describes the attendance figures for members of the Committee. However please note that, owing to various organisational changes during this period, membership has changed and some individuals have left the committee. Those marked with an asterisk are no longer members of the Committee. Name Job Title Organisation Attendance Sue Brent Director of Pharmacy RDTC 1/1 Jacqui Ballantine (for Prescribing Advisor NNTCH 1/1 Zahra Irannejad) David Campbell Chief Pharmacist/Clinical Director for Medicines NHCT 7/7 Management (Chair) Ian Campbell Assistant Director of Pharmacy NUTH 4/7 David Cook Lead Clinical Pharmacist Procurement and Formulary NHCT 7/7 Barry Corbett (for Chief Pharmacist and Associate Director of Medicines NTWT 2/2 Tim Donaldson) Management Tim Donaldson Head of Pharmacy Clinical Governance NTWT 2/7 Alexander Dyker Consultant Physician NUTH 3/7 * Tony Francis GP, Newcastle/Local Medical Committee 1/1 Rosie England Head of medicines Management NHS NoT 2/3 Sue Gordon Consultant in Public Health Medicine NCT 3/7 Matt Grove Consultant Rheumatologist, NTGH NHCT 5/7 Mike Guy Medical Director NHS NoT 5/7 Mike Hannon Community Pharmacist/North of Tyne PEC NHS NoT 3/7 Zahra Irannejad Head of Prescribing NNTCH 1/7 Janet Kelly Modern Matron/Non Medical Prescribing Lead NHS NoT 0/7 Kenny Li (for Zahra Prescribing Advisor NNTCH 2/2 Irannejad) Kirsty Macfarlane Principal Pharmacist, Medicines Management RDTC 5/7 Peter McEvedy GP, PBC representative for Northumberland Care NHS NoT 5/5 (joined the committee July 08) Trust Neil Morris Deputy Medical Director NHS NoT 1/7 Andy Reay (for Tim Prescribing Interface Lead Pharmacist NTWT 1/1 Donaldson) Jayanta Sarma Consultant Microbiologist, NTGH NHCT 2/7 Helen Seymour (for Medicines Management Advisor NHS NoT 3/3 Rosie England) Alison Smith (for Prescribing Advisor NNTCH 2/2 Zahra Irannejad) Caroline Sprake GP, PBC representative for North Tyneside NHS NoT 3/7 Simon Thomas Consultant Clinical Pharmacologist NUTH 6/7 Glyn Trueman Formulary Pharmacist NUTH 7/7 Mritunjay Varma Consultant Anaesthetist, NGH NUTH 3/7 * Maria Vincent Nurse Consultant/Non Medical Prescribing Lead NUTH 2/5 Neil Watson Clinical Director of Pharmacy and Medicines NUTH 5/7 Management Lindsay White (for Prescribing Advisor NNTCH 1/1 Zahra Irannejad) Trevor White GP, Chair of North of Tyne PBC Forum NHS NoT 1/7 Steve Williamson Consultant Pharmacist in Cancer services NECN 5/7 Hilary Wynne Consultant Physician/Chair of NUTH D&T Panel NUTH 6/7 NECN NHS NoT NNTCH RDTC Glossary for organisations not listed on page 1 North of England Cancer Network NHS North of Tyne Newcastle and North Tyneside Community Health Regional Drugs and Therapeutics Centre Page 2 of 14

3 Sub groups and committees Various sub groups/committees exist to carry out specific programmes of work for the main committee. These include: - Formulary Sub-Committee This considers new product applications and leads the development of the shared formulary. Recommendations to approve, defer or reject applications, with summaries of evidence, are presented to the APC. - Shared Care Group - This looks at the development of Shared Care Guidelines and associated issues. - Antimicrobial Chemotherapy Sub-group This looks at sharing good practice with regard to antimicrobial chemotherapy as well as develops, reviews and maintains antibiotic guidelines for use in both primary and secondary care settings. - Wound Care Sub-group - This considers new wound care products for inclusion in the shared formulary and looks at the development of Wound Care Guidelines and associated issues. At the March 2009 committee meeting it was decided that this subgroup should report through the Formulary Sub-committee. Committee Officers The following are officers to the committee and its main sub groups/committees: APC Chair APC Vice Chair 1 APC Vice Chair 2 APC Vice Chair 3 APC Professional Secretary Formulary sub-committee Chair Formulary sub-committee Vice Chair 1 Formulary sub-committee Vice Chair 2 Formulary sub-committee Professional Secretary Shared Care Group Chair Shared Care Group Vice Chair Shared Care Group Professional Secretary Shared Care Group Technical Officer David Campbell Simon Thomas Mike Guy (or deputy) Hilary Wynne David Cook Simon Thomas Alexander Dyker Zahra Irannejad Glyn Trueman Hilary Wynne Richard Copeland Tim Donaldson Glyn Trueman Committee s activities/achievements During the period from April 2008 to March 2009 the committee carried out the following key activities: Formulary o Work continued on the development of a North of Tyne Formulary. By March 2009 this had been completed and a North of Tyne Formulary document had Page 3 of 14

4 been published covering all sections of the BNF. Regular reviews of BNF sections will be undertaken to ensure the document remains up to date. New drug applications o Applications to have new drugs or formulations added to the formulary continued to be a large part of the committee s work. These were made on a specific application form. Details of these applications and the committee s decisions are noted in appendix 1 but in summary: 107 products were reviewed 82 (76.6%) of these were approved for use 23 (21.5%) were rejected for use 2 (1.9%) were deferred Also 10 were initially considered by the cancer network 5 appeals were made against decisions by the committee o There was a 29% increase in the number of non-cancer products reviewed over last year ( ). This illustrates the increased activity of the committee. Communication o The committee continued to publish details of its meetings and decisions, the North of Tyne Formulary, finalised Shared Care Guidelines and other statements and guidelines for both healthcare professionals and members of the public on its website: Shared Care o No new Shared Care Guidelines were ratified by the Shared Care Group during the year owing to ongoing commissioning issues. However the recent appointment of a project manager by NHS North of Tyne to look at shared care issues as a whole, and specifically those issues related to commissioning, should facilitate the development and ratification of further guidelines. To date officially agreed guidelines include: Atypical antipsychotics - February 06 Methylphenidate in the treatment of ADHD February 2006 Lithium therapy updated November 2008 The use of Donepezil, Galantamine and Rivastigmine in the treatment of dementia - May 2007 High dose Venlafaxine in the treatment of depression January 2008 Newly licensed drugs and formulations o At each meeting the committee continued to review a list of drugs and formulations which had been newly licensed since the previous meeting. This included any formulary drug which had received a license for a new indication. NICE and SMC o The committee regularly looked at both NICE appraisals/guidance and SMC decisions to ensure that its own decisions and work plans are robust. National recognition of good practice o The committee had been cited as an area of good practice in a handbook of good practice published by the National Prescribing Centre (NPC). Though the committee welcomed this, a working group is to review the way decision making about medicines is carried out North of Tyne and map out a whole system process, using the NPC s handbook and diagnostic toolkit. In this way any gaps in process and effectiveness can be identified. Page 4 of 14

5 North East Therapeutics Advisory Group (NETAG) o After some work undertaken by the committee last year, this group was set up by the SHA to specifically look at high cost or potentially controversial noncancer drugs where postcode prescribing may be a problem because of the varying ways that decisions are made across the SHA. The group held its first meetings in October 2008 and the committee look forward to working with NETAG in streamlining the clinical decision making process, where appropriate, to ensure equality of access to treatments for patients across NHS North East. Summary The North of Tyne Area Prescribing Committee continues to make good progress in bringing together clinical decision making across the North of Tyne health economy. It has had excellent primary and secondary care representation, has been well attended and delivers a significant improvement in governance associated with medicines use for all of the organisations involved. Recommendation The Boards/Professional Executive Committees (or other) of member organisations are requested to acknowledge the details of this report. Page 5 of 14

6 Summary of APC Decisions April 08 to March 09 APPENDIX 1 1 R = RED drugs for hospital use only, A = AMBER drugs suitable for use under Shared Care arrangements, B = BLUE drugs initiated in secondary care where an information sheet for GPs is recommended, T = drugs used in Tertiary Care only. Product Decision + date of decision Comments / notes i) Requests Reconsidered or Deferred from Entecavir Exenatide Telbivudine Tiotropium Respimat Inhaler ii) New Requests Ambrisentan (Volibris ) Atripla DC Beads Dutasteride (Avodart ) Etravirine Febuxostat A R T R T R T R T Approved for use in accordance with NICE guidance. Has a very limited role and is only approved for use within the framework of NICE guidance. Initiation of prescribing should be by Consultant Diabetologists only. Decision to be reviewed when updated NICE guidance is issued in Refused. Likely to be rejected by NICE. Tiotropium Respimat approved for use only in those patients who are unable to use a tiotropium Handihaler properly (despite training). Approved for second-line use in the treatment of pulmonary hypertension. The role of sitaxentan is to be clarified/ reviewed. Approved Approved for use with doxorubicin in the treatment of hepatocellular cancer. Refused. Approved for use in the treatment of HIV infection that is resistant to first-line therapy. It is classified as a Red (hospital) and Tertiary Care drug. Approved for use as a treatment option in patients where allopurinol is not tolerated or is contraindicated. Intolerance of allopurinol is defined as adverse effects that are sufficiently severe to warrant its discontinuation or prevent full dose escalation for optimal effectiveness. Approval is made on the conditions that the price, when launched, is not substantially more that that envisaged, and NICE guidance being similar to that in the Final Appraisal Determination. Page 6 of 14

7 Product Decision + date of decision Comments / notes Ferric Carboxymaltose (Ferinject ) Fesoterodine (Toviaz ) Flaminal Hydro & Flaminal Forte Fostair Glucosamine Icatibant acetate (Firazyr ) Lacosamide (Vimpat ) Lidocaine and Tetracaine Patches (Rapydan ) Liposomal Doxorubicin Maraviroc (Celsentri ) Meglumine Gadoterate (Dotarem ) NeilMed Sinus Rinse (NeilMed nasal douche) Personal Best Peak Flow Meter Phosphate Polyfusor Posaconazole (Noxafil ) R R R T R 22 May 08 Approved for use as an alternative parenteral iron preparation. Use to be limited to locally agreed situations where its use is clinically and financially sensible. Refused. Approved for use. Approved Refused Approved for use in symptomatic treatment of acute attacks of hereditary angioedema. To be reviewed in the light of further data and when Berinert P becomes licensed. Approved for use. Rapydan not approved for use and requests for evaluations refused. Approved for use as a treatment option in patients with recurrent ovarian cancer. Approved for use in the treatment of patients with HIV infections that are resistant to standard therapy in accordance with BHIVA and EACS guidelines. Meglumine gadoterate (Dotarem ) approved for use in children. Approved for use in symptomatic relief in chronic rhinosinusitis and as a postoperative nasal douche. Approved for use. Approved for use in the treatment of hypophosphataemia. Newcastle Hospitals Trust protocol for the treatment of hypophosphataemia to be updated. Approved for use in: The prevention of invasive fungal infection in immunocompromised patients in whom there is a specific risk of aspergillus infection or where fluconazole and itraconazole are not tolerated or are unlikely to be sufficiently effective. The treatment of patients with invasive fungal infections that are not responding to other treatments or where they are not tolerated (largely in place of liposomal amphotericin/ voriconazole). Page 7 of 14

8 Product Decision + date of decision Comments / notes Privigen Approved for use as a replacement for Sandoglobulin. Raltegravir (Isentress ) Rimonabant Rivaroxaban (Xarelto ) Ropivacaine Rotigotine transdermal patches (Neupro ) SMOF Lipid Sulthiame (Ospolot ) (unlicensed) Taurolock and Taurohep R T R R Tetraspan & Volulyte iii) New Formulations & Extensions to Use Adalimumab (Humira ) use in psoriasis Adenosine 130mg in 130ml infusion (unlicensed) Aripiprazole Injection R R See notes Approved for use in the treatment of patients with HIV infections that are resistant to standard therapy in accordance with BHIVA and EACS guidelines. Approved for use as an adjunct to diet and exercise for adults who are obese or overweight and who have had an inadequate response to, are intolerant of, or are contraindicated to, orlistat and sibutramine, in accordance with NICE guidance. Additional local information/guidance on its use should be provided. Approved for use in the prevention of venous thromboembolism in patients undergoing elective total hip or total knee replacement surgery. The decision to use it instead of dabigatran is not considered to be incompatible with NICE guidance which recommends dabigatran as a treatment option. Not approved. Rotigotine patches approved for use in the treatment of Parkinson s disease. To be initiated only by specialists. Approved for use in children for the prevention and treatment of nutrition associated liver disease. Decision deferred. Dr Devlin wishes to withdraw the application and request sulthiame on an individual patient basis. To be discussed with Dr Devlin. Use of Taurolock and Taurohep approved for the prevention of central intravenous line infections in: Haemodialysis patients Adult parenteral nutrition patients with recurrent line infections Immune deficiency unit patients Results of pilot studies in other areas are to be reported to the Formulary Subcommittee. Deferred pending further consultation with the key user groups, to determine if just one of these products could be used or not. Approved for use in the treatment of psoriasis in accordance with BAD/NICE guidance. Application withdrawn. Page 8 of 14

9 Product Decision + date of decision Comments / notes Atazanavir (300mg R T capsules) Bleomycin (unlicensed use) Buprenorphine Transdermal Patches (BuTrans ) Buprenorphine Transdermal Patches (Transtec ) Caffeine Injection (Caffeine Citrate Injection) Chlorhexidine 2% oral gel Dasatinib 100mg tablets (Sprycel ) Clopidogrel 300mg tablets Diclofenac (Dyloject ) Injection Diloxanide Furoate Fentanyl and Levobupivacaine epidural infusions (unlicensed) R R 22 May 08 Approved for intralesional sclerotherapy in the treatment of low-flow vascular malformations affecting the head and neck and other parts of the body. This is on the understanding that patients and/or their parents are fully informed about the procedure and its risks. Refused. Refused. Approved for use for both oral and intravenous administration instead of the unlicensed injection. Approved for use in the prevention of ventilator-associated pneumonia in adult patients who are ventilated (for >48 hrs) as requested. Use will be reviewed if a cheaper 75mg generic clopidogrel becomes available. Approved for use in line with North of Tyne Primary Care Antimicrobial Guidelines. Gabapentin Liquid (Unlicensed) Grazax (unlicensed use) Insulin Glargine in Solo Star Pens Kaletra 100/25 tablets (lopinavir 100mg + ritonavir 25mg) Kwikpen Lilly insulins R Approved for use in those patients who are unable to swallow gabapentin capsules/tablets. The product made by Rosemont Pharmaceuticals should be used in preference to a product imported via IDIS UK manufactured and lower cost. Approved for use as sublingual immunotherapy in children who are ineligible for subcutaneous immunotherapy. All treatment to be provided by secondary care. To be added to the formulary. Approved for addition to the Formulary. Page 9 of 14

10 Product Decision + date of decision Comments / notes Magnesium Approved for use. Aspartate 6.5g sachets Melatonin 2mg controlled release tablets Metformin sustained release tablets Metformin SR 1000mg tablets Miconazole Buccal Tablets (Loramyc ) Miniversol sodium chloride Naltrexone Nicotine 16 hour patches (Nicorette Invisi ) Nicotine Nasal Spray Omalizumab See Notes R A R This licensed formulation of melatonin should be used instead of the unlicensed product where clinically appropriate. The uses of melatonin will be reviewed by the Formulary Sub-committee at its September meeting. Should be considered for very occasional use in patients who have to discontinue conventional metformin because of persistent intolerable gastrointestinal side effects, in spite of appropriate measures to avoid these, and where its successful use may avoid the need for other less suitable/more expensive anti-diabetic therapy. Approved for use, with the same restrictions as those applied to other strengths of modified release metformin. Approved for limited second line use in the treatment of severe oropharyngeal candidiasis in patients where agents such as nystatin and fluconazole are unsuitable for use and on approval of microbiologists. Approved for use subject to identifying that there are no costs implications to its introduction. Approved for use to reduce agitation and/or self injurious behaviour in patients with autism or learning disabilities. Prescribing should be initiated by specialists, and GPs should only be asked to prescribe it in accordance with a shared care arrangement after a positive response is shown. There should be explicit guidelines on identifying an appropriate response and monitoring. Approved for use. The range of smoking cessation products in use, to be reviewed with a view to rationalising the range of products in the Formulary. Approved, including use in combination with long-acting forms of NRT. Listed in the Formulary for use in tertiary care. Request for this restriction to be removed so use can be extended to secondary care. Oxybutynin Transdermal Patches (Kentera ) Decision Use extended to secondary care. Remains as a Red hospital only drug. Refused. Page 10 of 14

11 Rituximab (Mabthera ) Product Decision + date of decision Comments / notes Ropinirole Controlled release Sodium Bicarbonate 1mmol/ml oral solution (unlicensed) Sodium valproate M.R. granules (Epilim Chronosphere Granules) Solifenacin (Change of status from 3 rd to 2 nd line use) Stalevo 200 TachoSil Tacrolimus Prolonged Release (Advagraf ) Tadalafil 2.5mg & 5mg tablets Tenofovir Testosterone gel (Tostran ) Testosterone Patches (Intrinsa ) Valproate semisodium Vardenafil for first line use Vitamin A Injection (Unlicensed formulation) R T 22 May 08 R T A 22 May 08 Approved for use in children with Wegener s granulom-atosis who have failed conventional therapy with cyclophosphamide and/ or mycophenolate mofetil. Approval is subject to satisfactory information being provided regarding information to be given to the patient/carer and on how informed consent would be obtained and documented. Approved for use in patients with proven compliance problems - neurologists to be consulted about details. Not approved. Approved for second-line use along with tolterodine after oxybutynin tablets/liquid. May need to review when patent on tolterodine expires in TachoSil approved for use in renal surgery. Refused. Consideration should be given to using the conventional formulation once daily. Tadalafil formulations for daily use not approved. Approved for use as a first line treatment in patients with Hepatitis B infection. Consultation to take place on the possibility of it replacing Testogel. Refused. Testosterone patches (Intrinsa ) not approved for use in the treatment of hypoactive sexual desire disorder. Vardenafil remains a second-line drug. Approved for use. Page 11 of 14

12 Product Decision + date of decision Comments / notes Vitamin D (Cholecalciferol) 0.5mg 20,000 unit tablets (Dekristol ) (Unlicensed) Approved for use whilst a suitable licensed formulation is unavailable. Zoledronic acid - use in metastatic breast cancer R iv) Products Considered by Cancer Network Cisplatin and 5- fluorouracil for head and neck cancers Dasatinib (Sprycel ) Docetaxel (Taxotere ) with Carboplatin Lenalidomide (Revlimid ) Nilotinib Oral Topotecan (Hyamtin ) Pemetrexed with Carboplatin Pemetrexed Sorafinib (Nexavar ) R R R R R R R R R Approved for inclusion in the North of Tyne Formulary for this indication although it was recognised that not all Trusts may choose to use it. Approved for use for nasopharynx, and larynx preservation for larynx and hypopharyngeal locally advanced tumours. Protein kinase inhibitor approved for use as an alternative to nilotinib in patients with chronic myeloid leukaemia with resistance or intolerance to prior therapy including imatinib (in line with inclusion/exclusion criteria defined in the chemotherapy protocol). Approved for use in ovarian cancer: specifically for use in patients that have demonstrated an allergic reaction to paclitaxel (CTC grade 3 or above hypersensitivity) and for whom therapy with a taxane represents a significant treatment option. Requested for use in relapsed/refractory multiple myeloma. The cancer network was unable to approve at this time as the economic case had not been demonstrated, but noted that NICE was due to review the treatment. Approved treatment of Chronic Myeloid Leukaemia in patients with resistance or intolerance to prior therapy including imatinib. Approved for use in relapsed Small Cell Lung Cancer (SCLC) in patients for whom retreatment with the first-line regime is not considered appropriate. Approved for use instead of Gemcitabine- Carboplatin in patients with Non-Squamous Histology (Large Cell and Adenocarcinoma). This adds around 2 months to median survival. For large cell patients alone, the survival advantage may be as large as 6 months. Note Patients with non specified histology should continue to receive Gemcitabine /Carboplatin. Approved for second-line use in patients who have received first-line chemotherapy for Non- Squamous Non Small Cell Lung Cancer prior to 3 rd December This allows equity of access. Requested for treatment of hepatocellular cancer. The cancer network was unable to approve as the economic case had not been demonstrated. Page 12 of 14

13 Product Decision + date of decision Comments / notes TIP (Paclitaxel, Ifosfamide and Cisplatin) for germ cell cancers R v) Appeals against earlier decisions by the APC Abatacept Dabigatran (Pradaxa ) Approved for use as 2 nd line (post-bep) salvage chemotherapy for patients with metastatic germ cell cancer. This was initially refused by the APC at its meeting on 29 th November Not approved. The appeal for abatacept was rejected on the grounds of its lack of cost effectiveness and the fact that there was no clinical evidence strong enough to support its use as proposed. This correlated with the decision by NICE. This was initially refused by the APC at its meeting on 25 th November An appeal against this decision was heard on 29 th January 2009 which resulted in the original decision remaining unchanged. The Formulary Subcommittee subsequently reviewed data on this product and made a new recommendation to the APC. Desflurane (extension to use) Sitagliptin (Januvia ) 22 May 08 Approved for use as an alternative to rivaroxaban in patients undergoing elective total hip and knee replacement surgery. This was initially refused by the APC at its meeting on 10 th April Not approved. After reviewing the data presented for the appeal and the original evidence submitted, the APC felt that its original decision not to approve the use of Desflurane for general use as an inhalational general anaesthetic should stand. This was initially refused by the APC at its meeting on 18 th September Approved for use with the following conditions: Initiation of prescribing should be by Consultant Diabetologists only. Use restricted to particular patient groups with major risks associated with hypoglycaemia Usage would be less than 50 patients per year Page 13 of 14

14 Product Decision + date of decision Comments / notes Tacrolimus Prolonged Release (Advagraf ) vi) Miscellaneous decisions by the APC Adalimumab (Humira ) Pre-filled pens Buprenorphine onceweekly transdermal patches (BuTrans ) Dihydrocodeine Ethosuximide Fentanyl matrix patches Fentanyl lozenges / lollipops (Actiq ) Ketorolac injection Goserelin and Leuprorelin Melatonin 2mg Controlled release tablets Thalidomide R See notes See notes B See notes See notes See notes This was initially refused by the APC at its meeting on 29 th July Not approved. After reviewing the data presented for the appeal and the original evidence submitted, the APC felt that its original decision not to approve the use of Tacrolimus Prolonged Release (Advagraf ) should stand. However it was recognised that exceptional cases, where there are compliance issues with twice daily tacrolimus, might arise, which could be dealt with by existing non-formulary processes within each organisation. Pre-filled pens added to the Formulary Reviewed by an analgesics working group. Not approved. Reviewed by an analgesics working group. Recommendation to remove dihydrocodeine from the Formulary accepted (implementation to be agreed). Approved for use in absence seizures. Reviewed by an analgesics working group. It was acknowledged that, although it affected the licensed status of the product, the practice of cutting fentanyl matrix patches in half, was accepted on clinical grounds, as a means of providing the lower dose of analgesic necessary for some patients. Reviewed by an analgesics working group. Approved for use on the advice pain/palliative care specialists in the treatment of very severe incident pain. Reviewed by an analgesics working group. Recommendation to remove ketorolac injection from the Formulary accepted (implementation to be agreed). To have equal status in the Formulary. The traffic light status of this newly licensed product changed from RED to BLUE. Used for a number of years in the treatment of multiple myeloma, but not listed in the Formulary. To be listed in the Formulary. Page 14 of 14

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