We are pleased to have been able to now extend our free pain workshops for people living in Lincolnshire, following a successful pilot earlier this year.
These workshops are part of Lincolnshire’s NHS work to provide alternatives to medications for people living with chronic non-cancer pain.
There is substantial evidence that non-pharmacological support for non-cancer chronic pain is safer and often more effective for managing symptoms and should be explored as a first step before prescribing.
Empowered Relief™ is an evidence-based, 2-hour virtual workshop on pain that rapidly equips people with the skills to effectively manage their pain. The session covers:
- How pain is processed in the brain and how to best manage it
- Simple skills that people can use everyday
- Creating a personalised plan for long-term relief
Our next round of workshops are being held on Friday 24 November 2023 and Friday 19 January 2024 between 10am and 12noon. The sessions are virtual and take place over Microsoft Teams. Patients can attend either workshop, which will be delivered by Dr Graham Dunthorne a Specialist Pain Management GP in the county, from the comfort of their own home.
We would like as many patients as possible to join, so would appreciate primary care colleagues sharing this opportunity widely, particularly considering any patients who may find this beneficial.
Patients should register their interest by using the following link http://bit.ly/Empowered-Relief
World Antimicrobial Awareness Week
World AMR Awareness Week (18th – 24th November 2023) is a global annual campaign aimed at improving awareness and understanding of antimicrobial resistance. Antimicrobial resistance (AMR) occurs when bacteria, viruses, fungi and parasites change over time and no longer respond to medicines, making infections harder to treat and increasing the risk of disease spread, severe illness and death. As a result of drug resistance, antibiotics and other antimicrobial medicines become ineffective and infections become increasingly difficult or impossible to treat.
The theme for WAAW 2023 is "Preventing antimicrobial resistance together". AMR is a threat to humans, animals, plants, and the environment. It affects us all.
The infographic below shows the number of predicted deaths caused by antimicrobial resistance in 2050 if we are unable to change the current trajectory. Experts predict that in just under 30 years, antimicrobial resistance will kill more people worldwide than cancer and diabetes combined. People will be dying of infections that were previously treatable.
Antimicrobial resistance currently adds over £1 billion to hospital treatment and societal costs in the EU, this is a continually increasing figure, and with an ageing population we will continue to use an increasing volume of antimicrobials, driving the problem further. From the 1930s to the 1960s, 14 classes of antimicrobial were introduced, but since 1968 there have been only five new drug classes developed. Since 1984, no new registered classes of antimicrobials for human treatment have been developed, so it is even more important that we protect the antibiotics that we do have, to ensure that they remain effective.
Antibiotics are wonderful life saving treatments, but we must only use them when we really need them, and it is everyone’s responsibility to protect them for the future.
Antibiotics in Lincolnshire
Unfortunately, in Lincolnshire we use more antibiotics than average, and we know that high use of antibiotics drives resistance. The good news is that this means that we are all capable of helping to improve the current situation and protect the world from future infections.
The graph below shows all ICB’s prescribing of antibacterial items per STAR-PU. The orange line depicts the national target. Lincolnshire ICB is in red at the right-hand side of the graph. We are the worst ICB in the country on this measure and prescribe more antibacterial items than anywhere else.
Optimising Antibiotic Course Length – Shorter is Better
We all need to work together on improving our use of antibiotics, and one of the areas that Lincolnshire ICB is going to focus on over the next twelve months is optimising antibiotic course length. Antibiotics should be prescribed for the shortest duration needed, and often, although seven-day courses have been historically prescribed, this is a longer course than is necessary for some conditions.
Unnecessarily long courses of antimicrobials are one of the factors driving antimicrobial resistance and an increased risk of C.Difficile infection in at-risk populations. Reducing course length is not only a good thing in terms of antimicrobial resistance, but also is potentially safer for the patient, as it reduces the incidence of adverse effects. Each additional day of antibiotic therapy is associated with a 4% increase in risk of side effects and a 3% increase in risk of resistance.
Looking purely at amoxicillin courses, we know that Lincolnshire prescribes roughly 32% of amoxicillin as 5-day courses and 63% of this as 7-day courses (the remainder is made up of other miscellaneous course lengths). The national average is 45% of 5-day courses, but some ICBs have reached up to 75% of amoxicillin being prescribed as 5 day courses, so we know there are massive gains which can be made on this in Lincolnshire. Data on this is free to access right down to practice level here: Optimising Antimicrobial Use Dashboard | PrescQIPP C.I.C
Antibiotic Research UK
Antibiotic Research UK (ANTRUK) is charity, founded in 2014, which aims to tackle antibiotic resistance by raising sufficient funds over the next five years to bring at least one new antibiotic treatment to market by the early 2020’s. The charity also aims to provide public and professional education and information for patients. It has lots of good information and support networks for patients who have been affected by antimicrobial resistance and provides a place for GPs to signpost these patients to. Support Antibiotic Research | Fight Antibiotic Resistance | ANTRUK
- Become an antibiotic guardian
- Check out your surgery’s 5 day vs 7 day prescribing of amoxicillin
- Run your own WAAW event.
- Review the resources available through the TARGET toolkit to see if they can help in your practice.
- Promote WAAW in your surgery through displays and posters.
- Keep an eye on upcoming comms from LICB for more information closer to WAAW itself.
- The Maxwell Finland Lecture: for the duration-rational antibiotic administration in an era of antimicrobial resistance and clostridium difficile - PubMed (nih.gov)
- The New Antibiotic Mantra — “Shorter Is Better” - PMC (nih.gov)
- Antibiotic resistance as big a threat as climate change – chief medic | Antibiotics | The Guardian
- Antimicrobial resistance: a global threat | UNEP - UN Environment Programme
- Antibiotic Guardian – Pledge to be an Antibiotic Guardian
- World AMR Awareness Week 2023 (who.int)
- Antibiotic Research UK | Fighting Antibiotic Resistance
- Course: TARGET antibiotics toolkit hub (rcgp.org.uk)
- World Antimicrobial Resistance Awareness Week (WAAW) and European Antibiotic Awareness Day (EAAD) - GOV.UK (www.gov.uk)
- O'Neill Review into Antibiotic Resistance (parliament.uk)
Guidance for the management of the National Patient Safety Alert Methylphenidate, Lisdexamfetamine & Guanfacine
6th October 2023
Here is the ICS guidance on how to manage the recent NatPSA alert regarding the shortage of methylphenidate prolonged-release capsules and tablets, lisdexamfetamine capsules, and guanfacine prolonged-release tablets.
Lincolnshire Blood Glucose and Ketone test strips Formulary
5th October 2023
This guidance is an updated formulary for blood glucose and ketone test strips. It was produced by the Lincolnshire Diabetes Specialist Clinicians and Lincolnshire ICB Medicines Optimisation Team, and approved at PACEF September 2023. It is based on the NHS England Commissioning National Recommendations produced April 2023.
It provides guidance on appropriate, cost effective blood glucose meters, test strips and ketone test strips.
NHS England have announced Changes to their Commissioning recommendations for blood glucose and ketone meters, testing strips (BGKT) and lancets Version 2, 12 October 2023.
• It has removed the AgaMatrix Agile and On Call Extra Mobile for first line treatment of gestational diabetes requiring a GDm-Health™ application due to technical issues with the software. (Page 7)
• They have also corrected their recommendation for type 2 diabetes - paediatrics to “On Call Extra” and not “On Call Extra Mobile”. (page 7)
• They have also advised that the launch date the Aga-Matrix Agile has now been delayed until December 2023. ( pages 6 & 9)
We have now updated our Lincolnshire joint formulary in line with the changes. The formulary and PACEF websites will be updated accordingly.
5th September 2023
Wegovy® (Semaglutide) has been launched in the UK on 4th September 2023. It is available to patients on the NHS only via NHS specialist weight management services. To obtain Wegovy® on the NHS those patients eligible for treatment under NICE TA 875 will need to be referred to/or currently under the care of NHS specialist tier 3 or 4 weight management services.
Novo Nordisk have confirmed that supplies will be sent direct to those centres providing this treatment. Wegovy® is licensed as an adjunct to a reduced-calorie diet and increased physical activity for weight management and should not be prescribed within primary care.
Medicines Supply Issues & Shortages
To support the management of supply shortages, The Medicines Optimisation team recommends to access the Medicine Supply tool available on the Specialist Pharmacy Service website. Registering via NHS email is required through https://www.sps.nhs.uk.
Please see our Medicines Supply Issues and Shortages document to support you with the increasing number of reported stock issues.
PrescQIPP - Clinical Masterclass - Pharmacogenomics
Please see the following from PrescQIPP:
Tuesday 14th November 13.00 - 14.00
On 14th November we welcome Professor Sir Munir Pirmohamed to talk about Pharmacogenetics.
Munir is David Weatherall Chair of Medicine at the University of Liverpool, and a Consultant Physician at the Liverpool University Hospital Foundation NHS Trust.
He is Director of the Centre for Drug Safety Sciences, Director of the Wolfson Centre for Personalised Medicine and Director of HDR North.
Medication Safety Week
6th to 12th November 2023
This year’s campaign will focus on WHO CAN REPORT.
All healthcare professionals have a key role to play in the cycle of medicines safety. The MHRA want to explore the different perspectives that come from the various healthcare professional groups and how the information that they can provide will help make medicines safer.
How can you open the lines of communication around reporting adverse reactions to medicines and vaccines via the Yellow Card Reporting?
Have you used the Yellow Card Reporting?
What methods can you use to promote the use of the reporting tool within your work area?
Please support the campaign and talk to your patients and colleagues about side effects and how they can report suspected problems to the MHRA Yellow Card Scheme. https://yellowcard.mhra.gov.uk/
If using social media follow the hashtag #MedSafetyWeek and #MHRAYellowCard to help extend and magnify the message.
There are various promotional tools on the Yellow Card website - https://yellowcard.mhra.gov.uk/MedSafetyWeek
You can view case studies to see where yellow card reporting has made a difference - https://yellowcard.mhra.gov.uk/casestudies
If you fancy completing some CPD there are e-learning modules which can be found here - https://yellowcard.mhra.gov.uk/resources/elearning
Upcoming PrescQIPP Webinars
11th October 2023
Please see the below message from PrescQIPP regarding their upcoming webinars later this month:
Clinical Masterclass - Stoma management in primary care
Tuesday 17th October 13.00 - 14.00
In our Clinical Masterclass on 17th October 2023 1-2pm, we welcome Heather Ilett who will talk about Stoma management in primary care.
Heather has been a registered nurse for over 30 years, specialising in stoma care. Having worked in an Acute NHS Trust for 15 years and run a busy stoma community service, she has taken her experience in a different direction, working as Lead Stoma Nurse for Hertfordshire and West Essex Integrated Care Board (ICB).
Heather works with GPs and Pharmacists (ICB, practice and primary care network) as well as other health care professionals, providing stoma education sessions and supporting practices with reviewing their stoma prescribing. She is also integral in local stoma formulary and guideline development, as well as being an active interface between primary and secondary stoma care.
Practice Plus Monthly Webinar
Wednesday 18th October 12.45 - 13.45
Medication Safety Research into Primary Care Practice
Dr Richard Keers ,Senior Clinical Lecturer in Pharmacy at the University of Manchester will bring us all up to date about medication safety research relevant to general practice , in particular the future of clinical decision support systems such as PINCER and improving the safety of mental health prescribing.
Lincolnshire Prescribing Forums
Your next Lincolnshire prescribing forum is Wednesday 18th October 2023.
For more information please click here.
Diabetes Continuous Glucose Monitoring (CGM)
The Lincolnshire Integrated Care Board Interim Position Statement on CGM can be found here.
TARGET - Train The Trainer Session
What is the TARGET antibiotics toolkit?
TARGET stands for “Treat Antibiotics Responsibly; Guidance, Education and Tools”. Developed by the UK Health Security Agency (UKHSA), the Royal College of General Practitioners (RCGP) and the Antimicrobial Stewardship in Primary Care (ASPIC) Group, TARGET is the central resource to help primary care healthcare professionals and commissioning organisations improve antibiotic prescribing. Using the TARGET Antibiotics Toolkit resources will also enable primary care organisations to demonstrate compliance with the Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance.
Lincolnshire ICB will be hosting a virtual TARGET train-the-trainer session with the aim being to improve antimicrobial prescribing across the system. This half-day event will be run in collaboration with our regional antimicrobial stewardship lead and the national TARGET team. We will also have one of our consultant microbiologists Dr Reena Rambani attending to help deliver the material and present it from a Lincolnshire perspective.
This training will not only upskill your personal knowledge on infections and AMR but will also train you to deliver TARGET antibiotic workshops locally, so that you can cascade training to others.
There will be two clinical scenarios covered in the session, as well as the training on how to be a trainer. This training should help to reduce inappropriate antibiotic prescribing within Lincolnshire and make a big difference to the quality of care for our patients; it is an excellent opportunity to proactively help improve prescribing and reduce antimicrobial resistance.
This training session is open to all healthcare professionals who work with primary care prescribers and who could deliver training sessions to their colleagues (GPs, practice nurses, pharmacists, paramedics, care home nurses, ICB or PCN staff etc). The session is also free and will count towards your CPD (you will need to complete the pre- and post-event survey to be accredited as a trainer and get your CPD certificate).
We would like it if we could get at least one member of staff from each PCN, so that they can then cascade this training down, but we would love to see as many people as possible. The training will be via Teams and will run from 09:30 – 13:00 on 27th September. Further information about the event will be sent out to those who register.
GLP-1 receptor agonist supply disruption
There is an ongoing national shortage of glucagon like peptide-1 receptor agonists (GLP-1 RAs) licensed in the management of Type 2 Diabetes Mellitus (T2DM). Information available indicates that there are very limited, intermittent supplies of all GLP-1 RAs. The supply issues have been caused by an increase in demand for these products for licensed and off-label indications and is not expected to return to normal until at least mid-2024.
This guidance aims to support clinicians in choosing suitable alternative glucose lowering therapies to GLP-1 RAs during this period of national shortage.
Clinicians are recommended to refer to the SPS Tool for Medicines Shortages for an up-to-date supply stock situation and clinical guidance on alternative treatment options; see links below:
Shortage of GLP-1 receptor agonists used in the management of type 2 diabetes (semaglutide, dulaglutide, liraglutide, exenatide) – SPS - Specialist Pharmacy Service – The first stop for professional medicines advice
Approach to weight loss management for obesity is multifactorial and should include dietary advice, weight loss targets, physical activity programmes, behavioural interventions and psychological support and pharmacological therapy such as semaglutide, a GLP-1 receptor agonists.
The National Institute for Health and Care Excellence (NICE) Technology appraisal guidance [TA875] Published: 08 March 2023 recommended the use of semaglutide (Wegovy®) alongside a reduced-calorie diet and increased physical activity to adults who have at least one weight-related comorbidity and a body mass index (BMI) of at least 30kg/m2 and over for managing overweight and obesity in an NHS specialist weight management service.
At present the product semaglutide (Wegovy®) has not been launched in the UK and currently there is no information regarding the product such as price or who will be able to prescribe. No date has been confirmed by the company Novo Nordisk as to when the product or information will be available. Semaglutide (Wegovy®) for weight loss will only be available to patients that meet the eligibility criteria outlined by NICE through a specialist weight management service. semaglutide (Wegovy®) was added to the formulary as a NICE TA875, but not given a traffic light classification until it becomes available in the UK and there is clarification how it will be used.
However, given the ongoing national shortage of GLP-1 receptor agonists caused by an increase in demand for these products for licensed and off-label indications, a National Patient Safety Alert – DHSC issued on 18-Jul-2023 requests that the off-label use of these agents for the management of obesity is strongly discouraged. All existing stock must be conserved for use in patients with diabetes because of the serious clinical implications in the management of patients with type 2 diabetes that these shortages pose.
The ICB DOES NOT support the use of GLP-1 receptor agonists for weight loss until there is clear guidance from NHS England and we are over the supply issue. In addition, we will put in place a clinically led pathway BEFORE this is authorised for use. Eligible people with T2DM who would like support with weight management should be signposted to available locally and nationally available weight management programmes.
NICE Technology Appraisal Guidance [TA875] https://www.nice.org.uk/guidance/ta875
MHRA Central Alerting System: National Patient Safety Alert (NatPSA)
Primary Care Diabetes Society PCDS_ABCD-GLP-1-RA-shortage_20230628.pdf (diabetesonthenet.com)
Healthier You. NHS Diabetes Prevention Programme – clinicians to complete the referral form embedded in your clinical system and send via email to firstname.lastname@example.org
Other useful resources to support clinicians in choosing suitable alternative glucose lowering therapies to GLP-1 RAs during this period of national shortage
Patient useful resource/information
World Sepsis Day - 13th September 2023
There are up to fifty million cases of sepsis annually and it causes at least eleven million deaths per year. One in five deaths worldwide is associated with sepsis.
What is Sepsis?
Sepsis is a life-threatening condition that arises when the body’s response to an infection injures its own tissues and organs. It occurs when the body’s immune system (which normally helps to protect us and fight infection) goes into overdrive. It can lead to shock, multiple organ failure and sometimes death, especially if not caught early and treated promptly.
Sepsis mainly affects very young children and the elderly, and it is also more common in people with underlying health conditions or a weakened immune system; however, it can happen to anyone, including those who are otherwise fit and healthy.
Sepsis always starts with an infection, but no-one knows why sepsis goes on to occur in some patients but not others. Five people an hour die of sepsis in the UK, and it can be triggered by any infection, such as chest infections and UTIs. The infographic below shows common causes of sepsis.