Lincolnshire Prescribing and Clinical Effectiveness Forum (PACEF) was founded in 2007. It is the current strategic advisory network to NHS Lincolnshire Integrated Care Board (ICB). PACEF has the responsibility for ensuring the cost-effective use of medicines and other healthcare interventions and their functional integration into healthcare delivery across Lincolnshire.

Representation on the group is comprised of leading professionals from NHS Lincolnshire Integrated Care Board, primary care, the local acute trust United Lincolnshire Hospitals NHS Trust, Lincolnshire Partnership NHS Trust, Lincolnshire Community Health Services NHS Trust, Lincolnshire LMC and Community Pharmacy Lincolnshire.

PLEASE NOTE: The publication of PACEF bulletins is currently suspended. We will provide a brief update of formulary decisions and updates following PACEF meetings in the LICB Medicines Optimisation Newsletter and also listed below. 

Please allow time for the Lincolnshire Joint Formulary to be updated.

PACEF and Formulary Meeting Updates

PACEF November 2024

Freestyle Libre 2 Plus approved in line with current guidance and classified as amber 2. Freestyle Libre 3 has been classified as Red Red.

NICE TA958 Ritlecitinib for treating severe alopecia areata in people 12 years and older - This was approved and given a Red classification on the formulary, with treatment and monitoring responsibilities to lie with specialist secondary care teams, as Ritlecitinib is a high-cost drug requiring Blueteq. Primary care’s role would be limited to referring patients who meet the criteria to the specialist team. For initiation, patients must have failed topical treatments, and many opt against steroidal scalp injections due to pain. Ritlecitinib is the first oral treatment available for this condition.

NICE TA996 Linzagolix for treating moderate to severe symptoms of uterine fibroids - Classified as Red on the formulary.

NICE TA 999 Vibegron for treating symptoms of overactive bladder - Classified as Green on the formulary.

NICE TA 1009 Latanoprost–netarsudil for previously treated primary open-angle glaucoma or ocular hypertension – Classified as Amber 2 on the formulary.

Ivermectin - Reclassified from Red Red to Amber 2.

Trifarotene - Reclassified from Red Red to Green.

Sodium Chloride Oral Solutions - Reclassified to Amber 2.

Mefylnate XL (Methylphenidate) – Reclassified to Amber 1 with the shared care agreement being updated to reflect this.

Kay-Cee-L alternatives -ULTH has agreed to use these three alternatives Potassium Chloride (Nova), Potassiuum Chloride (Rokshaw) and Potassium Chloride (Smartway).

Medi-derma barrier products are now green and first line choice for primary care, for moisture associated skin damage. A pathway for stepping up and stepping down treatment, produced by LCHS, is now available on the formulary.

Cavilon barrier products remain green, second line choice for primary care, for moisture associated skin damage, but first line choice for secondary care. A pathway for stepping up and stepping down treatment, produced by ULTH, is now available on the formulary.

Dressit sterile dressing packs have been changed from redred to green and are the first line choice for primary care, where procurement through NHSSC (supply chain) is unavailable.

Softdrape remains green, first line choice for secondary care and Trusts where procurement through NHSSC (supply chain) is available.

Liquid paraffin – Is now classified as Amber 2 and It was reiterated that liquid paraffin would only be initiated and recommended by the specialist gastro-paediatric teams.

Human Milk Fortifier – Has been added onto the formulary as Amber 2. The monitoring responsibility would lie with the neonatal team, including decisions on when it is appropriate to stop the treatment. However, it is expected that the specialist team may request GPs to continue prescribing in primary care after discharge. Guidance has also been uploaded onto the formulary.

Visutrax (Travoprost) P/F eye drops – Added to the formulary as Amber 2.

Guidance/Position statements/Shared care:

Diabetes Continuous Glucose Monitoring - The NHS Lincolnshire position statement has been uploaded onto the PACE website and recently updated to include an additional statement advising consideration of CGM to be provided to all pregnant women with gestational diabetes who use intensive insulin therapy, but only if they experience problematic glucose levels or severe hypoglycaemia.

Asthma guidelines for use in children has been approved by ULTH and respiratory group. 

MicroGuide - All links to the Microguide, including QR codes, have been removed from the PACE website and guidance. This decision was made due to concerns that the app could be corrupted, and removing the links was considered the safest course of action.

Mycophenolate shared care agreement amended to include respiratory indication - Shared care is already in place for renal conditions but has now been expanded to include respiratory conditions (not to be used for Idiopathic pulmonary fibrosis). This expansion will specifically cover its use in treating interstitial lung disease, as previously outlined in a national shared care protocol.

Lincolnshire Guidance for the use of Anticoagulants in the management of Non-Valvular Atrial Fibrillation (NVAF) has now been approved. 

Formulary meetings October and December

Alfacalcidol capsules - Alfacaless and One-Alpha are the two lowest-cost brands that prescribers should be selecting.

Dexamethasone sodium phosphate and 0.1% eye drops preservative-free 0.4ml unit dose and Dropadex 0.1% eye drops 0.4ml - Swap to Dexafree 1mg/ml eye drops 0.4ml unit dose vials as the most cost-effective brand..

Cinacalcet - There are significant cost savings if swapping to multiple 30mg tablets rather than using the 60mg or 90mg tablets.

Levomepromazine - 25mg tablets are scored for doses of 12.5mg and can be quartered for doses of 6.25mg. 6mg and 6.25mg tablets are very expensive and the halving or quartering of tablets reflects current ULTH practice.

Buprenorphine once weekly patches - The lowest cost brands are Rebrikel  5mcg, 10mcg and 20mcg patches as first line choice for those strengths, Reletrans 15mcg, 25mcg, 30mcg and 40mcg patches as first line choice for those strengths (only brand that makes patches in 25mcg, 30mcg and 40mcg strength) and Sevodyne as second line choice. It is not recommended to change brands of Buprenorphine for patients, so only change brands for patients that are increasing/decreasing strength or for new patients.

Fentanyl transdermal matrix patches – Opiodur brand is now the first line choice and Matrifen as second line choice.

Oxycodone modified release tablets - Oxylan brand is now first line choice and Ixyldone as second line choice.

Discontinuations

Labetalol tablets - 400mg tablets were discontinued in Dec 24. The 50mg tablets were discontinued a few months ago, but 100mg and 200mg tablets remain available.

Capsaicin cream 0.025% and 0.075% - Following the long-term shortage of these, both licensed strengths have been discontinued and are now only available as unlicensed products.

Coal Tar 2% shampoo (T/Gel) - Will be discontinued Feb 25.

Hydrocortisone 0.1% Cream - Discontinued June 24.

Levobunolol 0.5% udv PF - Discontinued Dec 24.

Caverject (Alprostadil) powder for solution for injection - Pfizer will commence the supply of Alprostadil, a generic version of Caverject powder for solution for injection from February 2025. They will continue to offer both the branded and generic presentation, for a short period of transition, after which the brand will no longer be routinely available.

PACEF September 2024

Stiripentol - PACEF approved the change of formulary classification to Amber 2, restricting it’s use for the treatment of epilepsy, within its licensed indication, only at the request of an epilepsy specialist from a tertiary centre. In these circumstances Stiripentol is approved for ongoing prescribing in primary care, following approval of a named patient requests. Stiripentol remains as RED/RED for all other uses.

Phytomenadione (unlicensed) – PACEF approved this due to the shortage of Menadiol tablets, which may necessitate the use of unlicensed Phytomenadione. This has been added onto the formulary as a second-line treatment option and will state unlicensed on the formulary too.

Tadalafil (Daily dose) – Following the change in NHSE advice PACEF has approved tadalafil once daily, 5mg and 2.5mg, as a treatment option for those where use of a daily dose is considered clinically appropriate. 2.5mg strength are significantly more expensive than the 5mg strengths and should only be used when 5mg dose is not suitable. Cialis brand should not be used as significantly more expensive than the generic equivalent. Tadalafil remains as second line treatment for erectile dysfunction after sildenafil for patients that meet the SLS criteria.

Formulary meeting August 2024

• Doxazocin is more cost effective to prescribe 2 x 4mg tablets rather than 1 x 8mg tablet. This reflects what is issued at ULHT.
• Removal of Eloquis brand from Apixaban formulary entry as no longer the most cost-effective brand. Removal of Xarelto brand from Rivaroxaban as no longer the most cost-effective brand. Formulary section clarifies to ensure clarity over full course supply issued on discharge from ULHT.
• Nitrofurantoin 50mg/5ml discontinued. 25mg/5ml remains available.