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.
PACEF Bulletins
| Title | |
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| PACE Bulletin Vol 6 No 19 Dec12 | |
DescriptionPrescribing depot antipsychotic medication. Updated guidance on the use of prostaglandin analogues in the treatment of chronic open angle glaucoma and ocular hypertension. Rapid Review: Oxycodone/Naloxone prolonged release tablets (Targinact). Rapid Drug Assessment: Oxycodone prolonged release tablets (Longtec). Rapid Drug Assessment: Colecalciferol 20,000IU capsules (Bio-Vitamin D3). Summary Algorithm: Diagnosis and Management of Vitamin D Deficiency in Primary Care. Rapid Drug Assessment: Linagliptin 2.5mg/ metformin 850mg/1g tablets (Jentadueto). New Indication Assessment: Rifaximin tablets 200mg (Xifaxanta). NICE Technology Appraisal 236: Ticagrelor for the treatment of acute coronary syndromes (October 2011). New Trial Assessment: Ivabradine and heart failure. Review of NICE Technology Appraisal 182: Prasugrel for the treatment of acute coronary syndromes with percutaneous coronary intervention (October 2009). Withdrawal of mesalazine modified release 400mg tablets (Mesren MR). |
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| PACE Bulletin Vol 6 No 18 Oct12 | |
DescriptionGuidance on the prescribing of phenytoin sodium capsules. Innovation, Health and Wealth: Accelerating Adoption and Diffusion in the NHS (December 2011): Implications for Joint Formulary development in Lincolnshire. NICE Technology Appraisal 251: Dasatinib, Nilotinib and standard-dose Imatinib for the first-line treatment of chronic myeloid leukaemia (April 2012). NICE Technology Appraisal 252: Telaprevir for the treatment of genotype 1 chronic hepatitis C (April 2012). NICE Technology Appraisal 255: Cabazitaxel for hormone-refractory metastatic prostate cancer previously treated with a docetaxel-containing regimen (May 2012). NICE Technology Appraisal 253: Boceprevir for the treatment of genotype 1 chronic hepatitis C (April 2012). |
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| PACE Bulletin Vol 6 No 16 Oct12 | |
DescriptionGuidance on the prescribing of generic pioglitazone. Rapid Drug Assessment: Alfentanil sublingual spray 5mg in 5ml (140 micrograms per spray. Rapid Drug Assessment: Adrenaline tartrate auto-injector device (Jext). Updated New Drug Assessment: Ulipristal 30mg tablet (Ellaone). New Low Cost Generics: Drug Tariff (October 2012). MHRA Drug Safety Update (August 2012): Calcitonin (Miacalcic): increased risk of cancer with long-term use; Ondansetron (Zofran): risk of QTc prolongation; Doripenem (Doribax): current dosing regimen is insufficient in some patients. |
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| PACE Bulletin Vol 6 No 15 Oct12 | |
DescriptionSimvastatin: Updated advice on drug interactions and contraindications. |
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| PACE Bulletin Vol 6 No 13 Aug12 | |
DescriptionGuidance on the prescribing of warfarin, dabigatran or rivaroxaban for the prevention of stroke and systemic embolism in atrial fibrillation. |
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| PACE Bulletin Vol 6 No 12 Aug12 | |
DescriptionRisk to patients of inappropriate use of zuclopenthixol acetate injection (Clopixol Acuphase) where zuclopenthixol decanoate injection (Clopixol) was intended. Generic atorvastatin price reductions. New Indication Assessment: Ivabradine (Procoralan) for the treatment of chronic heart failure. New Indication Assessment: Exenatide (Byetta) injection in combination with insulin in type 2 diabetes mellitus. Commission on Human Medicines: Oral tacrolimus products should be prescribed and dispensed by brand name to avoid the risk of medication errors (May 2012). MHRA Drug Safety Update (May 2012): Fingolimod and the risk of cardiovascular adverse reactions; Domperidone –small risk of serious ventricular arrhythmia and sudden cardiac death; Strontium ranelate - risk of venous thromboembolism. |
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| PACE Bulletin Vol 6 No 10 Jul12 | |
DescriptionNew Trials in Brief: Omega 3 fatty acid supplementation (Omacor) in the secondary prevention of cardiovascular disease; Antipsychotics in dementia; Aspirin and cancer prevention. Rapid Drug Assessment: Varicella zoster virus vaccine (Zostavax). NICE Technology Appraisal 250: Eribulin for the treatment of locally advanced or metastatic breast cancer (April 2012). NICE Clinical Guideline 137: The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care (January 2012). National Patient Safety Agency: Prevention of harm with buccal midazolam (February 2012). MHRA Drug Safety Update (April 2012): Proton pump inhibitors in long-term use – hypomagnesaemia and increased risk of bone fracture. |
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| PACE Bulletin Vol 6 No 8 May12 | |
DescriptionAtorvastatin patent expiry and the future role of rosuvastatin. Supply problems with orlistat (Xenical). New Drug Assessment: Actikerall (5-fluorouracil 0.5% and salicylic acid 10%) cutaneous solution for hyperkeratotic actinic keratoses. New Drug Assessment: Asenapine sublingual tablets 5mg and 10mg (Sycrest). Rapid Drug Assessment: Optive eye drops for dry eye syndrome. New Drug Assessment: Tolvaptan 15mg and 30mg tablets (Samsca). New Device Assessment: RESPeRATE. New Device Assessment: InsuJet needle free insulin delivery system. NICE Technology Appraisal 246: Pharmalgen for the treatment of bee and wasp venom allergy (February 2012). NICE Technology Appraisal 247: Tocilizumab for the treatment of rheumatoid arthritis (February 2012). MHRA Drug Safety Update (March 2012): Aliskiren (Rasilez) risk of cardiovascular and renal adverse reactions; Teva levothyroxine 100 microgram tablets – suspension of marketing authorisation; Unlicensed imported vitamin D (colecalciferol) capsules - potential peanut oil and soya oil allergens. NICE Technology Appraisal 248: Exenatide prolonged release suspension for injection in combination with oral antidiabetic therapy for the treatment of type 2 diabetes mellitus (February 2012). |
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| PACE Bulletin Vol 6 No 7 May12 | |
DescriptionNew Drug Assessment: Rifaximin 200mg tablets (Xifaxanta) for travellers’ diarrhoea. Rapid Drug Assessment: Tacrolimus ointment 0.03% and 0.1% (Protopic) for maintenance treatment of moderate to severe atopic dermatitis. NICE Technology Appraisal 241: Dasatinib, high-dose imatinib and nilotinib for the treatment of imatinib-resistant chronic myeloid leukaemia (CML) and dasatinib and nilotinib for people with CML for whom treatment with imatinib has failed because of intolerance (January 2012). NICE Technology Appraisal 242: Cetuximab, bevacizumab and panitumumab for the treatment of metastatic colorectal cancer after first-line chemotherapy (January 2012). NICE Technology Appraisal 243: Rituximab for the first-line treatment of stage III-IV follicular lymphoma (January 2012). NICE Technology Appraisal 244: Roflumilast for the management of severe chronic obstructive pulmonary disease (January 2012). NICE Technology Appraisal 245: Apixaban for the prevention of venous thromboembolism after total hip or knee replacement in adults (January 2012). Policy and Formulary Update: Wound Management Formulary; Policy Relating to the Prescribing, Supply, Storage and Disposal of Controlled Drugs in Primary Care. |
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| PACE Bulletin Vol 6 No 5 Mar12 | |
DescriptionReview: Indapamide 2.5mg tablets vs Indapamide 1.5mg sustained release (Natrilix SR). Review: Use of hypnotics in Lincolnshire. New Drug Assessment: Midazolam 5mg in 1ml oromucosal solution (Buccolam). Rapid Drug Assessment: Olopatadine 0.1% eye drops (Opatanol). License extension: Sitagliptin tablets (Januvia). Guidelines for the treatment of commonly occurring infections in Lincolnshire primary care: Winter 2011/12. Emerging safety concerns around the use of aliskiren (Rasilez). |
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| PACE Bulletin Vol 6 No 4 Feb12 | |
DescriptionNew Drug Assessment: Tapentadol immediate release tablets (Palexia) and tapentadol prolonged release tablets (Palexia SR). New Formulation Assessment: Atorvastatin chewable tablets (Lipitor). Review: Topical Non-Steroidal Anti-Inflammatory Drugs. NICE Technology Appraisal 237: Ranibizumab for the treatment of diabetic macular oedema (November 2011). NICE Technology Appraisal 240: Panitumumab in combination with chemotherapy for the treatment of metastatic colorectal cancer (December 2011). Key Patent Expiries 2012/13. Atorvastatin patent expiry and the future role of rosuvastatin. MHRA: Drug Safety Update (2011): Dabigatran (Pradaxa): risk of serious haemorrhage; Angiotensin II receptor antagonists; evidence does not suggest any link with cancer. |
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| PACE Bulletin Vol 6 No 3 Jan12 | |
DescriptionReview: Dipeptidyl peptidase-4 (DPP-4) inhibitors (or gliptins). New Drug Assessments: Aprepitant capsules (Emend) and fosaprepitant injection (Ivemend). Rapid Drug Assessment: Bromfenac eye drops 900microgram/ml (Yellox). Rapid Drug Assessment: Eflornithine 11.5% cream (Vaniqa). MHRA: Drug Safety Update (November 2011): Lenalidomide (Revlimid): risk of second primary malignancy; High-dose rosuvastatin and rhabdomyolysis; Paracetamol - reminder of updated dosing recommendations for children Domperidone and possible increased cardiac risk. Supply Update: Trifluoperazine tablets (Stelazine). |
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| PACE Bulletin Vol 6 No 2 Jan12 | |
DescriptionRapid Drug Assessment: Fentanyl patches (Fencino). Rapid Drug Assessment: Azithromycin 15mg/g eye drops (Azyter). Review: Naproxen/Esomeprazole 500mg/20mg (Vimovo). New Drug Assessment: Risperidone injection ( Risperdal Consta). NICE Technology Appraisal 231: Agomelatine for the treatment of major depressive episodes (terminated appraisal) (July 2011). NICE Technology Appraisal 232: Retigabine for the adjunctive treatment of partial onset seizures in epilepsy (July 2011). NICE Technology Appraisal 235: Mifamurtide for the treatment of osteosarcoma (October 2011). New Trials in Brief: Tailored letters to patients can help to reduce benzodiazepine use; Topical antibiotics for acute infective conjunctivitis. Shared Care Guidelines: Dronedarone for the treatment of patients with non-permanent atrial fibrillation after other anti-arrhythmic medicines have been considered (November 2011). MHRA Drug Safety Update (December 2011): Citalopram and escitalopram associated with dose-dependent QT interval prolongation. MHRA Drug Safety Update (October 2011): Buccal midazolam (Buccolam); Calcium and vitamin D - studies of cardiovascular risk. |
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The current form to request a non-formulary medicine can be viewed here:
Are you a member of our PACEF committee?
If so, please see the forthcoming dates for 2025:
2025 Meeting Dates
Wednesday 22nd January 2025 - 1.15pm start
Wednesday 19th March 2025 - 1.15pm start
Wednesday 21st May 2025 - 1.15pm start
Wednesday 16th July 2025 - 1.15pm start
Wednesday 17th September 2025 - 1.15pm start
Wednesday 19th November 2025 - 1.15pm start
