Chester Clinic

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North Manchester CCG Board Meeting – 11 February 2015
Dr Martin Whiting Paper prepared by: Dr Martin Whiting Dr Martin Whiting Sub-Committee consideration Chief Clinical Officer's Report
Background papers and links to priorities/objectives: To provide an update to the board on strategic Purpose of the paper: developments within Greater Manchester. Relevance of the paper to delivery of North Manchester Strategic or Operational Plans Does the report take into account the Equality, Diversity and human rights impact on health inequalities? How does the report cover the impact on health inequalities? Does the paper evidence effective use of resources? If so, how? How does this paper contribute to NHS Operating and Outcomes How does this paper link to the CCG's assurance framework? To ratify the decision made by the Association of Greater Manchester CCGs to approve GMMMG New Action/decision required: Therapies recommendations as per the attached paper.

Issue under Consideration GMMMG New Therapies recommendations Brief Paragraph Summary These have been approved by the Greater Manchester Medicines Commissioning implications Low, unless CCGS are commissioning community treatment of venous thromboembolism {VTE] in which case an additional drug option is available. Financial implications A small number of these recommendations have financial implications – these have been highlighted. These are particularly the antidiabetic drugs and long-acting injectable antipsychotics. Regarding the antidiabetic drugs, these recommendations are in line with existing NICE guidance, both Technology Appraisals for certain individual drugs and the more general Clinical Guideline [CG87]. Therefore they represent the most rational approach to managing Regarding the antipsychotic injections, these do cost around £300 per patient per month but the number of patients receiving these is relatively small. The ability for patients to receive their injections in the community would be more convenient, as well as possibly releasing some capacity within Trusts. The positive recommendation for the use of Fostair® in COPD could release savings within the respiratory area. Author of Paper and contact Andrew Martin Strategic Medicines Optimisation Pharmacist, details GMCSU [email protected] 0161 212 6218 The item has been approved Approved by GMMMG at meetings between March and September at this meeting GM Heads of Commissioning / Directors of Finance received this by email 9.12.14 AGG are recommended to approve this paper and adopt as policy GMMMG summary paper of recommendations made by the New Therapies subgroup for
consideration by the Heads of Commissioning and Directors of Finance. These have been approved
at GMMMG between the time period April 2014 – September 2014. Some recommendations have a
modest financial implication and one offers significant scope for savings. Consideration: Approval at
the HoC and DoF meeting

Drug & published
IPNTS recommendation
Financial implications
The group does not recommend None. Will not be added No financial risk treatment of obesity the use of liraglutide for the above indication. Gliptins (DPP-4 The group recommends that Diabetes drugs growing
inhibitors) for the DPP-4 Inhibitors may be at £37,000 per 100,000 treatment of type 2 considered as a treatment option population per year diabetes mellitus as add on therapy, in those patients who fail to achieve glycaemic control despite an adequate trial of current antidiabetic therapy as per NICE Clinical Guideline CG87 The group recommends that (Invokana®▼) for canagliflozin may be considered the treatment of as a treatment option as add on adults with type 2 therapy, in those patients who fail to achieve glycaemic control mellitus(T2DM) to despite an adequate trial of improve glycaemic current antidiabetic therapy as per the NICE TA on <superseded by generic SGLT-2 recommendation, July 2014> The group does not recommend None. Will not be added No financial risk (Valdoxan®▼) for the use of agomelatine the treatment of (Valdoxan®▼) for the above major depressive episodes in adults
May 2014
Paliperidone Depot
The group recommends There could be reduced While oral forms of Injection (Xeplion®) paliperidone depot injection outpatient attendance risperidone are now for Schizophrenia (Xeplion®) as an option for costs or use of CPN available generically at schizophrenia in those patients nurse time as the significant discount to where a long acting atypical injection is administered branded, the availability of injectable is deemed appropriate 4-weekly instead of 2- a similar saving in weekly. Due to the injectables is difficult to potential for reduced predict but highly unlikely. wastage of risperidone This preparation is
depot injection, [these likely to receive an
injections are stored in "amber" Interface status
the fridge and must be i.e. prescribing may be
allowed to come to room transferred to GPs
temperature before use
under a shared care
but if not then used, protocol. Prescribing of
storage time is limited depot injections within
and they are discarded if MH Trusts is a
they have been
significant financial
pressure [annually
particular patient who £540k MMHSC, £355k
does not attend], P.Care] and transfer of
commissioners are prescribing could have
advised not to provide significant impact for
extra funding for this CCGs although it is an
inefficient use of
resources to have
patient attend MH
Trusts solely to receive
depot injections.
Newer Products for The group recommends use of By increasing GP Average item value is in Topical Treatment the above products in confidence, the pathway excess of £40 so a small of Actinic Keratoses accordance with the Primary may reduce referrals. increase in patients Care Dermatology Society identified for treatment (PCDS) AK treatment pathway increase in prescribing could have a moderate May 2014, slightly costs should be off-set impact on prescribing revised June 2014 by a reduction in outpatient costs. The condition is not a significant disease burden in Greater Manchester and so no major changes in prescribing costs nor patient attendances are expected. It is likely that two-week wait referrals may reduce appropriately due to the guidance contained within this pathway although this should be audited. Ulipristal acetate Ellaone® is recommended as a Already in formulary: No financial risk (Ellaone®) 30mg treatment option for those Recommended where patients that present between 72 unprotected intercourse and 120 hours of unprotected contraception within sexual intercourse or between 72 and 120 120 hours (5 days) contraceptive failure sexual intercourse <No change> or contraceptive failure May 2014 [re-review] Lidocaine 5% The group does not recommend None. Will not be added No financial risk plaster (Versatis®) the use of lidocaine plasters for for the treatment of the above indication. <No change> May 2014 [re-review] Aripiprazole The group recommends Similarly to paliperidone A budget impact model prolonged release aripiprazole prolonged release [see May 2014], there injection (Abilify injection as an option for could be reduced manufacturer predicts a Maintena®) for the schizophrenia in those patients outpatient attendance move to this depot already established on oral costs or use of CPN injection by 4% of patients aripiprazole and where a second- nurse time as the on depot therapy each generation long acting injectable injection is administered year, resulting in overall antipsychotic is deemed 4-weekly instead of 2- cost savings of £61k in the first year, £133k in the second year and £208k in the third year. While overall drug spend would increase slightly, these savings arise from reduced administration costs due to monthly administration as opposed to fortnightly for risperidone, the current market leader. See also comments under paliperidone The group does not recommend None. Will not be added No financial risk modified release the use of hydrocortisone tablet (Plenadren®) modified release tablets for the for the treatment of above indication adrenal insufficiency June 2014 Lurasidone The group does not recommend None. Will not be added Very small place in the use of lurasidone over more therapy; no significant established therapies. Schizophrenia June 2014 Insulin Degludec & The group does not recommend None. Will not be added No financial risk the use of the combination of (IDegLira®▼, name Insulin degludec and liraglutide for the above indication. changed to Xultophy®) for the treatment of adults with type 2 diabetes inadequately controlled on a basal insulin analogue. July 2014 Insulin Degludec The group does not recommend Diabetes drugs growing
(Tresiba®▼) for the the use of insulin degludec over at £37,000 per 100,000 other more established insulins population per year Diabetes Mellitus for the above indications (Type 1 and Type 2) where insulin is required July 2014 Sodium Glucose The group recommends that the Diabetes drugs growing
Co-transporter 2 above class of drugs may be at £37,000 per 100,000 (SGLT2) Inhibitors considered as a treatment option population per year as add on therapy, in those canagliflozin and patients who fail to achieve empagliflozin▼) for glycaemic control despite an the treatment of adequate trial of current adults with type 2 antidiabetic therapy as per the diabetes mellitus NICE TA on dapagliflozin. (T2DM) to improve glycaemic control July 2014 Brimonidine The group recommends that Could save some costs Providing monitoring of (Mirvaso®) gel for brimonidine be limited for use in through prevention of the effectiveness of any the treatment of patients with severe erythema, if referral and use of laser prescribing is carried out all other formulary treatment although these may be options have failed and unlikely to be routinely recommendation, overall immediately prior to referring for funded and may have financial impact is likely to generated Individual be relatively very small. Funding Request applications. Dabigatran for the The group does not recommend Unlikely to have the routine use of dabigatran for significant impact unless a the above indication; however it pathway for treatment of recurrent Deep Vein may be suitable for use in treatment / prophylaxis VTE in the community is Thrombosis (DVT) patients who are not suitable for and has significantly LMWH plus warfarin or for higher spend per head Embolism (PE) in adults. August 2014 Fostair® The group recommends that Offers a more cost- Fostair® should be considered effective option for dipropionate and as an option for the above treatment of patients with formoterol fumarate indication and particularly for COPD requiring inhaled dehydrate) metered those patients that would prefer a corticosteroids. pressurized metered dose Significant potential for
combination inhaler [MDI]. savings through
changing or stepping
down therapy in COPD
patients able to use an
MDI.
Cystistat® (sodium The group recommends that None: already in use None as Interface group Cystistat® bladder instillations has proposed a "Red" solution for the may be considered for initiation status i.e. no transfer of and prescribing by specialists, prescribing to primary when other treatment options interstitial cystitis have failed and prior to consideration for surgery. September 2014 Use of Melatonin in The group recommends the The recommendation sleep disorders in restricted use of melatonin in should lead to more children and young children for the above indication. rational use of this drug people with ADHD Any prescribing should be in and yield some cost keeping with the updated shared savings by eliminating use neurodevelopmental care protocols on melatonin which has little or no developed by the CAMHS team. clinical effect. The Financial Forward Planning Steering Group has already sent out recommendations to CCGs about cost-effective use of melatonin based on this recommendation. The group does not recommend None. Will not be added No financial risk (Clindamycin 1% + the routine use of Treclin® gel for to Formulary. 0.025% tretinoin) the above indication. gel for the treatment of acne vulgaris September 2014

North Manchester CCG Board Meeting – 11 February 2015
Dr Martin Whiting Paper prepared by: Dr Martin Whiting Dr Martin Whiting Sub-Committee consideration Chief Clinical Officer's Report
Background papers and links to priorities/objectives: To provide an update to the board on strategic Purpose of the paper: developments within Greater Manchester. Relevance of the paper to delivery of North Manchester Strategic or Operational Plans Does the report take into account the Equality, Diversity and human rights impact on health inequalities? How does the report cover the impact on health inequalities? Does the paper evidence effective use of resources? If so, how? How does this paper contribute to NHS Operating and Outcomes How does this paper link to the CCG's assurance framework? To ratify the decision made by the Association of Greater Manchester CCGs to approve GMMMG New Action/decision required: Therapies recommendations as per the attached paper.

Issue under Consideration GMMMG New Therapies recommendations Brief Paragraph Summary These have been approved by the Greater Manchester Medicines Commissioning implications Low, unless CCGS are commissioning community treatment of venous thromboembolism {VTE] in which case an additional drug option is available. Financial implications A small number of these recommendations have financial implications – these have been highlighted. These are particularly the antidiabetic drugs and long-acting injectable antipsychotics. Regarding the antidiabetic drugs, these recommendations are in line with existing NICE guidance, both Technology Appraisals for certain individual drugs and the more general Clinical Guideline [CG87]. Therefore they represent the most rational approach to managing Regarding the antipsychotic injections, these do cost around £300 per patient per month but the number of patients receiving these is relatively small. The ability for patients to receive their injections in the community would be more convenient, as well as possibly releasing some capacity within Trusts. The positive recommendation for the use of Fostair® in COPD could release savings within the respiratory area. Author of Paper and contact Andrew Martin Strategic Medicines Optimisation Pharmacist, details GMCSU [email protected] 0161 212 6218 The item has been approved Approved by GMMMG at meetings between March and September at this meeting GM Heads of Commissioning / Directors of Finance received this by email 9.12.14 AGG are recommended to approve this paper and adopt as policy GMMMG summary paper of recommendations made by the New Therapies subgroup for
consideration by the Heads of Commissioning and Directors of Finance. These have been approved
at GMMMG between the time period April 2014 – September 2014. Some recommendations have a
modest financial implication and one offers significant scope for savings. Consideration: Approval at
the HoC and DoF meeting

Drug & published
IPNTS recommendation
Financial implications
The group does not recommend None. Will not be added No financial risk treatment of obesity the use of liraglutide for the above indication. Gliptins (DPP-4 The group recommends that Diabetes drugs growing
inhibitors) for the DPP-4 Inhibitors may be at £37,000 per 100,000 treatment of type 2 considered as a treatment option population per year diabetes mellitus as add on therapy, in those patients who fail to achieve glycaemic control despite an adequate trial of current antidiabetic therapy as per NICE Clinical Guideline CG87 The group recommends that (Invokana®▼) for canagliflozin may be considered the treatment of as a treatment option as add on adults with type 2 therapy, in those patients who fail to achieve glycaemic control mellitus(T2DM) to despite an adequate trial of improve glycaemic current antidiabetic therapy as per the NICE TA on <superseded by generic SGLT-2 recommendation, July 2014> The group does not recommend None. Will not be added No financial risk (Valdoxan®▼) for the use of agomelatine the treatment of (Valdoxan®▼) for the above major depressive episodes in adults
May 2014
Paliperidone Depot
The group recommends There could be reduced While oral forms of Injection (Xeplion®) paliperidone depot injection outpatient attendance risperidone are now for Schizophrenia (Xeplion®) as an option for costs or use of CPN available generically at schizophrenia in those patients nurse time as the significant discount to where a long acting atypical injection is administered branded, the availability of injectable is deemed appropriate 4-weekly instead of 2- a similar saving in weekly. Due to the injectables is difficult to potential for reduced predict but highly unlikely. wastage of risperidone This preparation is
depot injection, [these likely to receive an
injections are stored in "amber" Interface status
the fridge and must be i.e. prescribing may be
allowed to come to room transferred to GPs
temperature before use
under a shared care
but if not then used, protocol. Prescribing of
storage time is limited depot injections within
and they are discarded if MH Trusts is a
they have been
significant financial
pressure [annually
particular patient who £540k MMHSC, £355k
does not attend], P.Care] and transfer of
commissioners are prescribing could have
advised not to provide significant impact for
extra funding for this CCGs although it is an
inefficient use of
resources to have
patient attend MH
Trusts solely to receive
depot injections.
Newer Products for The group recommends use of By increasing GP Average item value is in Topical Treatment the above products in confidence, the pathway excess of £40 so a small of Actinic Keratoses accordance with the Primary may reduce referrals. increase in patients Care Dermatology Society identified for treatment (PCDS) AK treatment pathway increase in prescribing could have a moderate May 2014, slightly costs should be off-set impact on prescribing revised June 2014 by a reduction in outpatient costs. The condition is not a significant disease burden in Greater Manchester and so no major changes in prescribing costs nor patient attendances are expected. It is likely that two-week wait referrals may reduce appropriately due to the guidance contained within this pathway although this should be audited. Ulipristal acetate Ellaone® is recommended as a Already in formulary: No financial risk (Ellaone®) 30mg treatment option for those Recommended where patients that present between 72 unprotected intercourse and 120 hours of unprotected contraception within sexual intercourse or between 72 and 120 120 hours (5 days) contraceptive failure sexual intercourse <No change> or contraceptive failure May 2014 [re-review] Lidocaine 5% The group does not recommend None. Will not be added No financial risk plaster (Versatis®) the use of lidocaine plasters for for the treatment of the above indication. <No change> May 2014 [re-review] Aripiprazole The group recommends Similarly to paliperidone A budget impact model prolonged release aripiprazole prolonged release [see May 2014], there injection (Abilify injection as an option for could be reduced manufacturer predicts a Maintena®) for the schizophrenia in those patients outpatient attendance move to this depot already established on oral costs or use of CPN injection by 4% of patients aripiprazole and where a second- nurse time as the on depot therapy each generation long acting injectable injection is administered year, resulting in overall antipsychotic is deemed 4-weekly instead of 2- cost savings of £61k in the first year, £133k in the second year and £208k in the third year. While overall drug spend would increase slightly, these savings arise from reduced administration costs due to monthly administration as opposed to fortnightly for risperidone, the current market leader. See also comments under paliperidone The group does not recommend None. Will not be added No financial risk modified release the use of hydrocortisone tablet (Plenadren®) modified release tablets for the for the treatment of above indication adrenal insufficiency June 2014 Lurasidone The group does not recommend None. Will not be added Very small place in the use of lurasidone over more therapy; no significant established therapies. Schizophrenia June 2014 Insulin Degludec & The group does not recommend None. Will not be added No financial risk the use of the combination of (IDegLira®▼, name Insulin degludec and liraglutide for the above indication. changed to Xultophy®) for the treatment of adults with type 2 diabetes inadequately controlled on a basal insulin analogue. July 2014 Insulin Degludec The group does not recommend Diabetes drugs growing
(Tresiba®▼) for the the use of insulin degludec over at £37,000 per 100,000 other more established insulins population per year Diabetes Mellitus for the above indications (Type 1 and Type 2) where insulin is required July 2014 Sodium Glucose The group recommends that the Diabetes drugs growing
Co-transporter 2 above class of drugs may be at £37,000 per 100,000 (SGLT2) Inhibitors considered as a treatment option population per year as add on therapy, in those canagliflozin and patients who fail to achieve empagliflozin▼) for glycaemic control despite an the treatment of adequate trial of current adults with type 2 antidiabetic therapy as per the diabetes mellitus NICE TA on dapagliflozin. (T2DM) to improve glycaemic control July 2014 Brimonidine The group recommends that Could save some costs Providing monitoring of (Mirvaso®) gel for brimonidine be limited for use in through prevention of the effectiveness of any the treatment of patients with severe erythema, if referral and use of laser prescribing is carried out all other formulary treatment although these may be options have failed and unlikely to be routinely recommendation, overall immediately prior to referring for funded and may have financial impact is likely to generated Individual be relatively very small. Funding Request applications. Dabigatran for the The group does not recommend Unlikely to have the routine use of dabigatran for significant impact unless a the above indication; however it pathway for treatment of recurrent Deep Vein may be suitable for use in treatment / prophylaxis VTE in the community is Thrombosis (DVT) patients who are not suitable for and has significantly LMWH plus warfarin or for higher spend per head Embolism (PE) in adults. August 2014 Fostair® The group recommends that Offers a more cost- Fostair® should be considered effective option for dipropionate and as an option for the above treatment of patients with formoterol fumarate indication and particularly for COPD requiring inhaled dehydrate) metered those patients that would prefer a corticosteroids. pressurized metered dose Significant potential for
combination inhaler [MDI]. savings through
changing or stepping
down therapy in COPD
patients able to use an
MDI.
Cystistat® (sodium The group recommends that None: already in use None as Interface group Cystistat® bladder instillations has proposed a "Red" solution for the may be considered for initiation status i.e. no transfer of and prescribing by specialists, prescribing to primary when other treatment options interstitial cystitis have failed and prior to consideration for surgery. September 2014 Use of Melatonin in The group recommends the The recommendation sleep disorders in restricted use of melatonin in should lead to more children and young children for the above indication. rational use of this drug people with ADHD Any prescribing should be in and yield some cost keeping with the updated shared savings by eliminating use neurodevelopmental care protocols on melatonin which has little or no developed by the CAMHS team. clinical effect. The Financial Forward Planning Steering Group has already sent out recommendations to CCGs about cost-effective use of melatonin based on this recommendation. The group does not recommend None. Will not be added No financial risk (Clindamycin 1% + the routine use of Treclin® gel for to Formulary. 0.025% tretinoin) the above indication. gel for the treatment of acne vulgaris September 2014

North Manchester CCG Board Meeting – 11 February 2015
Dr Martin Whiting Paper prepared by: Dr Martin Whiting Dr Martin Whiting Sub-Committee consideration Chief Clinical Officer's Report
Background papers and links to priorities/objectives: To provide an update to the board on strategic Purpose of the paper: developments within Greater Manchester. Relevance of the paper to delivery of North Manchester Strategic or Operational Plans Does the report take into account the Equality, Diversity and human rights impact on health inequalities? How does the report cover the impact on health inequalities? Does the paper evidence effective use of resources? If so, how? How does this paper contribute to NHS Operating and Outcomes How does this paper link to the CCG's assurance framework? To ratify the decision made by the Association of Greater Manchester CCGs to approve GMMMG New Action/decision required: Therapies recommendations as per the attached paper.

Issue under Consideration GMMMG New Therapies recommendations Brief Paragraph Summary These have been approved by the Greater Manchester Medicines Commissioning implications Low, unless CCGS are commissioning community treatment of venous thromboembolism {VTE] in which case an additional drug option is available. Financial implications A small number of these recommendations have financial implications – these have been highlighted. These are particularly the antidiabetic drugs and long-acting injectable antipsychotics. Regarding the antidiabetic drugs, these recommendations are in line with existing NICE guidance, both Technology Appraisals for certain individual drugs and the more general Clinical Guideline [CG87]. Therefore they represent the most rational approach to managing Regarding the antipsychotic injections, these do cost around £300 per patient per month but the number of patients receiving these is relatively small. The ability for patients to receive their injections in the community would be more convenient, as well as possibly releasing some capacity within Trusts. The positive recommendation for the use of Fostair® in COPD could release savings within the respiratory area. Author of Paper and contact Andrew Martin Strategic Medicines Optimisation Pharmacist, details GMCSU [email protected] 0161 212 6218 The item has been approved Approved by GMMMG at meetings between March and September at this meeting GM Heads of Commissioning / Directors of Finance received this by email 9.12.14 AGG are recommended to approve this paper and adopt as policy GMMMG summary paper of recommendations made by the New Therapies subgroup for
consideration by the Heads of Commissioning and Directors of Finance. These have been approved
at GMMMG between the time period April 2014 – September 2014. Some recommendations have a
modest financial implication and one offers significant scope for savings. Consideration: Approval at
the HoC and DoF meeting

Drug & published
IPNTS recommendation
Financial implications
The group does not recommend None. Will not be added No financial risk treatment of obesity the use of liraglutide for the above indication. Gliptins (DPP-4 The group recommends that Diabetes drugs growing
inhibitors) for the DPP-4 Inhibitors may be at £37,000 per 100,000 treatment of type 2 considered as a treatment option population per year diabetes mellitus as add on therapy, in those patients who fail to achieve glycaemic control despite an adequate trial of current antidiabetic therapy as per NICE Clinical Guideline CG87 The group recommends that (Invokana®▼) for canagliflozin may be considered the treatment of as a treatment option as add on adults with type 2 therapy, in those patients who fail to achieve glycaemic control mellitus(T2DM) to despite an adequate trial of improve glycaemic current antidiabetic therapy as per the NICE TA on <superseded by generic SGLT-2 recommendation, July 2014> The group does not recommend None. Will not be added No financial risk (Valdoxan®▼) for the use of agomelatine the treatment of (Valdoxan®▼) for the above major depressive episodes in adults
May 2014
Paliperidone Depot
The group recommends There could be reduced While oral forms of Injection (Xeplion®) paliperidone depot injection outpatient attendance risperidone are now for Schizophrenia (Xeplion®) as an option for costs or use of CPN available generically at schizophrenia in those patients nurse time as the significant discount to where a long acting atypical injection is administered branded, the availability of injectable is deemed appropriate 4-weekly instead of 2- a similar saving in weekly. Due to the injectables is difficult to potential for reduced predict but highly unlikely. wastage of risperidone This preparation is
depot injection, [these likely to receive an
injections are stored in "amber" Interface status
the fridge and must be i.e. prescribing may be
allowed to come to room transferred to GPs
temperature before use
under a shared care
but if not then used, protocol. Prescribing of
storage time is limited depot injections within
and they are discarded if MH Trusts is a
they have been
significant financial
pressure [annually
particular patient who £540k MMHSC, £355k
does not attend], P.Care] and transfer of
commissioners are prescribing could have
advised not to provide significant impact for
extra funding for this CCGs although it is an
inefficient use of
resources to have
patient attend MH
Trusts solely to receive
depot injections.
Newer Products for The group recommends use of By increasing GP Average item value is in Topical Treatment the above products in confidence, the pathway excess of £40 so a small of Actinic Keratoses accordance with the Primary may reduce referrals. increase in patients Care Dermatology Society identified for treatment (PCDS) AK treatment pathway increase in prescribing could have a moderate May 2014, slightly costs should be off-set impact on prescribing revised June 2014 by a reduction in outpatient costs. The condition is not a significant disease burden in Greater Manchester and so no major changes in prescribing costs nor patient attendances are expected. It is likely that two-week wait referrals may reduce appropriately due to the guidance contained within this pathway although this should be audited. Ulipristal acetate Ellaone® is recommended as a Already in formulary: No financial risk (Ellaone®) 30mg treatment option for those Recommended where patients that present between 72 unprotected intercourse and 120 hours of unprotected contraception within sexual intercourse or between 72 and 120 120 hours (5 days) contraceptive failure sexual intercourse <No change> or contraceptive failure May 2014 [re-review] Lidocaine 5% The group does not recommend None. Will not be added No financial risk plaster (Versatis®) the use of lidocaine plasters for for the treatment of the above indication. <No change> May 2014 [re-review] Aripiprazole The group recommends Similarly to paliperidone A budget impact model prolonged release aripiprazole prolonged release [see May 2014], there injection (Abilify injection as an option for could be reduced manufacturer predicts a Maintena®) for the schizophrenia in those patients outpatient attendance move to this depot already established on oral costs or use of CPN injection by 4% of patients aripiprazole and where a second- nurse time as the on depot therapy each generation long acting injectable injection is administered year, resulting in overall antipsychotic is deemed 4-weekly instead of 2- cost savings of £61k in the first year, £133k in the second year and £208k in the third year. While overall drug spend would increase slightly, these savings arise from reduced administration costs due to monthly administration as opposed to fortnightly for risperidone, the current market leader. See also comments under paliperidone The group does not recommend None. Will not be added No financial risk modified release the use of hydrocortisone tablet (Plenadren®) modified release tablets for the for the treatment of above indication adrenal insufficiency June 2014 Lurasidone The group does not recommend None. Will not be added Very small place in the use of lurasidone over more therapy; no significant established therapies. Schizophrenia June 2014 Insulin Degludec & The group does not recommend None. Will not be added No financial risk the use of the combination of (IDegLira®▼, name Insulin degludec and liraglutide for the above indication. changed to Xultophy®) for the treatment of adults with type 2 diabetes inadequately controlled on a basal insulin analogue. July 2014 Insulin Degludec The group does not recommend Diabetes drugs growing
(Tresiba®▼) for the the use of insulin degludec over at £37,000 per 100,000 other more established insulins population per year Diabetes Mellitus for the above indications (Type 1 and Type 2) where insulin is required July 2014 Sodium Glucose The group recommends that the Diabetes drugs growing
Co-transporter 2 above class of drugs may be at £37,000 per 100,000 (SGLT2) Inhibitors considered as a treatment option population per year as add on therapy, in those canagliflozin and patients who fail to achieve empagliflozin▼) for glycaemic control despite an the treatment of adequate trial of current adults with type 2 antidiabetic therapy as per the diabetes mellitus NICE TA on dapagliflozin. (T2DM) to improve glycaemic control July 2014 Brimonidine The group recommends that Could save some costs Providing monitoring of (Mirvaso®) gel for brimonidine be limited for use in through prevention of the effectiveness of any the treatment of patients with severe erythema, if referral and use of laser prescribing is carried out all other formulary treatment although these may be options have failed and unlikely to be routinely recommendation, overall immediately prior to referring for funded and may have financial impact is likely to generated Individual be relatively very small. Funding Request applications. Dabigatran for the The group does not recommend Unlikely to have the routine use of dabigatran for significant impact unless a the above indication; however it pathway for treatment of recurrent Deep Vein may be suitable for use in treatment / prophylaxis VTE in the community is Thrombosis (DVT) patients who are not suitable for and has significantly LMWH plus warfarin or for higher spend per head Embolism (PE) in adults. August 2014 Fostair® The group recommends that Offers a more cost- Fostair® should be considered effective option for dipropionate and as an option for the above treatment of patients with formoterol fumarate indication and particularly for COPD requiring inhaled dehydrate) metered those patients that would prefer a corticosteroids. pressurized metered dose Significant potential for
combination inhaler [MDI]. savings through
changing or stepping
down therapy in COPD
patients able to use an
MDI.
Cystistat® (sodium The group recommends that None: already in use None as Interface group Cystistat® bladder instillations has proposed a "Red" solution for the may be considered for initiation status i.e. no transfer of and prescribing by specialists, prescribing to primary when other treatment options interstitial cystitis have failed and prior to consideration for surgery. September 2014 Use of Melatonin in The group recommends the The recommendation sleep disorders in restricted use of melatonin in should lead to more children and young children for the above indication. rational use of this drug people with ADHD Any prescribing should be in and yield some cost keeping with the updated shared savings by eliminating use neurodevelopmental care protocols on melatonin which has little or no developed by the CAMHS team. clinical effect. The Financial Forward Planning Steering Group has already sent out recommendations to CCGs about cost-effective use of melatonin based on this recommendation. The group does not recommend None. Will not be added No financial risk (Clindamycin 1% + the routine use of Treclin® gel for to Formulary. 0.025% tretinoin) the above indication. gel for the treatment of acne vulgaris September 2014

North Manchester CCG Board Meeting – 11 February 2015
Dr Martin Whiting Paper prepared by: Dr Martin Whiting Dr Martin Whiting Sub-Committee consideration Chief Clinical Officer's Report
Background papers and links to priorities/objectives: To provide an update to the board on strategic Purpose of the paper: developments within Greater Manchester. Relevance of the paper to delivery of North Manchester Strategic or Operational Plans Does the report take into account the Equality, Diversity and human rights impact on health inequalities? How does the report cover the impact on health inequalities? Does the paper evidence effective use of resources? If so, how? How does this paper contribute to NHS Operating and Outcomes How does this paper link to the CCG's assurance framework? To ratify the decision made by the Association of Greater Manchester CCGs to approve GMMMG New Action/decision required: Therapies recommendations as per the attached paper.

Issue under Consideration GMMMG New Therapies recommendations Brief Paragraph Summary These have been approved by the Greater Manchester Medicines Commissioning implications Low, unless CCGS are commissioning community treatment of venous thromboembolism {VTE] in which case an additional drug option is available. Financial implications A small number of these recommendations have financial implications – these have been highlighted. These are particularly the antidiabetic drugs and long-acting injectable antipsychotics. Regarding the antidiabetic drugs, these recommendations are in line with existing NICE guidance, both Technology Appraisals for certain individual drugs and the more general Clinical Guideline [CG87]. Therefore they represent the most rational approach to managing Regarding the antipsychotic injections, these do cost around £300 per patient per month but the number of patients receiving these is relatively small. The ability for patients to receive their injections in the community would be more convenient, as well as possibly releasing some capacity within Trusts. The positive recommendation for the use of Fostair® in COPD could release savings within the respiratory area. Author of Paper and contact Andrew Martin Strategic Medicines Optimisation Pharmacist, details GMCSU [email protected] 0161 212 6218 The item has been approved Approved by GMMMG at meetings between March and September at this meeting GM Heads of Commissioning / Directors of Finance received this by email 9.12.14 AGG are recommended to approve this paper and adopt as policy GMMMG summary paper of recommendations made by the New Therapies subgroup for
consideration by the Heads of Commissioning and Directors of Finance. These have been approved
at GMMMG between the time period April 2014 – September 2014. Some recommendations have a
modest financial implication and one offers significant scope for savings. Consideration: Approval at
the HoC and DoF meeting

Drug & published
IPNTS recommendation
Financial implications
The group does not recommend None. Will not be added No financial risk treatment of obesity the use of liraglutide for the above indication. Gliptins (DPP-4 The group recommends that Diabetes drugs growing
inhibitors) for the DPP-4 Inhibitors may be at £37,000 per 100,000 treatment of type 2 considered as a treatment option population per year diabetes mellitus as add on therapy, in those patients who fail to achieve glycaemic control despite an adequate trial of current antidiabetic therapy as per NICE Clinical Guideline CG87 The group recommends that (Invokana®▼) for canagliflozin may be considered the treatment of as a treatment option as add on adults with type 2 therapy, in those patients who fail to achieve glycaemic control mellitus(T2DM) to despite an adequate trial of improve glycaemic current antidiabetic therapy as per the NICE TA on <superseded by generic SGLT-2 recommendation, July 2014> The group does not recommend None. Will not be added No financial risk (Valdoxan®▼) for the use of agomelatine the treatment of (Valdoxan®▼) for the above major depressive episodes in adults
May 2014
Paliperidone Depot
The group recommends There could be reduced While oral forms of Injection (Xeplion®) paliperidone depot injection outpatient attendance risperidone are now for Schizophrenia (Xeplion®) as an option for costs or use of CPN available generically at schizophrenia in those patients nurse time as the significant discount to where a long acting atypical injection is administered branded, the availability of injectable is deemed appropriate 4-weekly instead of 2- a similar saving in weekly. Due to the injectables is difficult to potential for reduced predict but highly unlikely. wastage of risperidone This preparation is
depot injection, [these likely to receive an
injections are stored in "amber" Interface status
the fridge and must be i.e. prescribing may be
allowed to come to room transferred to GPs
temperature before use
under a shared care
but if not then used, protocol. Prescribing of
storage time is limited depot injections within
and they are discarded if MH Trusts is a
they have been
significant financial
pressure [annually
particular patient who £540k MMHSC, £355k
does not attend], P.Care] and transfer of
commissioners are prescribing could have
advised not to provide significant impact for
extra funding for this CCGs although it is an
inefficient use of
resources to have
patient attend MH
Trusts solely to receive
depot injections.
Newer Products for The group recommends use of By increasing GP Average item value is in Topical Treatment the above products in confidence, the pathway excess of £40 so a small of Actinic Keratoses accordance with the Primary may reduce referrals. increase in patients Care Dermatology Society identified for treatment (PCDS) AK treatment pathway increase in prescribing could have a moderate May 2014, slightly costs should be off-set impact on prescribing revised June 2014 by a reduction in outpatient costs. The condition is not a significant disease burden in Greater Manchester and so no major changes in prescribing costs nor patient attendances are expected. It is likely that two-week wait referrals may reduce appropriately due to the guidance contained within this pathway although this should be audited. Ulipristal acetate Ellaone® is recommended as a Already in formulary: No financial risk (Ellaone®) 30mg treatment option for those Recommended where patients that present between 72 unprotected intercourse and 120 hours of unprotected contraception within sexual intercourse or between 72 and 120 120 hours (5 days) contraceptive failure sexual intercourse <No change> or contraceptive failure May 2014 [re-review] Lidocaine 5% The group does not recommend None. Will not be added No financial risk plaster (Versatis®) the use of lidocaine plasters for for the treatment of the above indication. <No change> May 2014 [re-review] Aripiprazole The group recommends Similarly to paliperidone A budget impact model prolonged release aripiprazole prolonged release [see May 2014], there injection (Abilify injection as an option for could be reduced manufacturer predicts a Maintena®) for the schizophrenia in those patients outpatient attendance move to this depot already established on oral costs or use of CPN injection by 4% of patients aripiprazole and where a second- nurse time as the on depot therapy each generation long acting injectable injection is administered year, resulting in overall antipsychotic is deemed 4-weekly instead of 2- cost savings of £61k in the first year, £133k in the second year and £208k in the third year. While overall drug spend would increase slightly, these savings arise from reduced administration costs due to monthly administration as opposed to fortnightly for risperidone, the current market leader. See also comments under paliperidone The group does not recommend None. Will not be added No financial risk modified release the use of hydrocortisone tablet (Plenadren®) modified release tablets for the for the treatment of above indication adrenal insufficiency June 2014 Lurasidone The group does not recommend None. Will not be added Very small place in the use of lurasidone over more therapy; no significant established therapies. Schizophrenia June 2014 Insulin Degludec & The group does not recommend None. Will not be added No financial risk the use of the combination of (IDegLira®▼, name Insulin degludec and liraglutide for the above indication. changed to Xultophy®) for the treatment of adults with type 2 diabetes inadequately controlled on a basal insulin analogue. July 2014 Insulin Degludec The group does not recommend Diabetes drugs growing
(Tresiba®▼) for the the use of insulin degludec over at £37,000 per 100,000 other more established insulins population per year Diabetes Mellitus for the above indications (Type 1 and Type 2) where insulin is required July 2014 Sodium Glucose The group recommends that the Diabetes drugs growing
Co-transporter 2 above class of drugs may be at £37,000 per 100,000 (SGLT2) Inhibitors considered as a treatment option population per year as add on therapy, in those canagliflozin and patients who fail to achieve empagliflozin▼) for glycaemic control despite an the treatment of adequate trial of current adults with type 2 antidiabetic therapy as per the diabetes mellitus NICE TA on dapagliflozin. (T2DM) to improve glycaemic control July 2014 Brimonidine The group recommends that Could save some costs Providing monitoring of (Mirvaso®) gel for brimonidine be limited for use in through prevention of the effectiveness of any the treatment of patients with severe erythema, if referral and use of laser prescribing is carried out all other formulary treatment although these may be options have failed and unlikely to be routinely recommendation, overall immediately prior to referring for funded and may have financial impact is likely to generated Individual be relatively very small. Funding Request applications. Dabigatran for the The group does not recommend Unlikely to have the routine use of dabigatran for significant impact unless a the above indication; however it pathway for treatment of recurrent Deep Vein may be suitable for use in treatment / prophylaxis VTE in the community is Thrombosis (DVT) patients who are not suitable for and has significantly LMWH plus warfarin or for higher spend per head Embolism (PE) in adults. August 2014 Fostair® The group recommends that Offers a more cost- Fostair® should be considered effective option for dipropionate and as an option for the above treatment of patients with formoterol fumarate indication and particularly for COPD requiring inhaled dehydrate) metered those patients that would prefer a corticosteroids. pressurized metered dose Significant potential for
combination inhaler [MDI]. savings through
changing or stepping
down therapy in COPD
patients able to use an
MDI.
Cystistat® (sodium The group recommends that None: already in use None as Interface group Cystistat® bladder instillations has proposed a "Red" solution for the may be considered for initiation status i.e. no transfer of and prescribing by specialists, prescribing to primary when other treatment options interstitial cystitis have failed and prior to consideration for surgery. September 2014 Use of Melatonin in The group recommends the The recommendation sleep disorders in restricted use of melatonin in should lead to more children and young children for the above indication. rational use of this drug people with ADHD Any prescribing should be in and yield some cost keeping with the updated shared savings by eliminating use neurodevelopmental care protocols on melatonin which has little or no developed by the CAMHS team. clinical effect. The Financial Forward Planning Steering Group has already sent out recommendations to CCGs about cost-effective use of melatonin based on this recommendation. The group does not recommend None. Will not be added No financial risk (Clindamycin 1% + the routine use of Treclin® gel for to Formulary. 0.025% tretinoin) the above indication. gel for the treatment of acne vulgaris September 2014 North Manchester CCG Board Meeting – 11 February 2015
Dr Martin Whiting Paper prepared by: Dr Martin Whiting Dr Martin Whiting Sub-Committee consideration Chief Clinical Officer's Report
Background papers and links to priorities/objectives: To provide an update to the board on strategic Purpose of the paper: developments within Greater Manchester. Relevance of the paper to delivery of North Manchester Strategic or Operational Plans Does the report take into account the Equality, Diversity and human rights impact on health inequalities? How does the report cover the impact on health inequalities? Does the paper evidence effective use of resources? If so, how? How does this paper contribute to NHS Operating and Outcomes How does this paper link to the CCG's assurance framework? To ratify the decision made by the Association of Greater Manchester CCGs to approve GMMMG New Action/decision required: Therapies recommendations as per the attached paper. Issue under Consideration GMMMG New Therapies recommendations Brief Paragraph Summary These have been approved by the Greater Manchester Medicines Commissioning implications Low, unless CCGS are commissioning community treatment of venous thromboembolism {VTE] in which case an additional drug option is available. Financial implications A small number of these recommendations have financial implications – these have been highlighted. These are particularly the antidiabetic drugs and long-acting injectable antipsychotics. Regarding the antidiabetic drugs, these recommendations are in line with existing NICE guidance, both Technology Appraisals for certain individual drugs and the more general Clinical Guideline [CG87]. Therefore they represent the most rational approach to managing Regarding the antipsychotic injections, these do cost around £300 per patient per month but the number of patients receiving these is relatively small. The ability for patients to receive their injections in the community would be more convenient, as well as possibly releasing some capacity within Trusts. The positive recommendation for the use of Fostair® in COPD could release savings within the respiratory area. Author of Paper and contact Andrew Martin Strategic Medicines Optimisation Pharmacist, details GMCSU [email protected] 0161 212 6218 The item has been approved Approved by GMMMG at meetings between March and September at this meeting GM Heads of Commissioning / Directors of Finance received this by email 9.12.14 AGG are recommended to approve this paper and adopt as policy GMMMG summary paper of recommendations made by the New Therapies subgroup for
consideration by the Heads of Commissioning and Directors of Finance. These have been approved
at GMMMG between the time period April 2014 – September 2014. Some recommendations have a
modest financial implication and one offers significant scope for savings. Consideration: Approval at
the HoC and DoF meeting

Drug & published
IPNTS recommendation
Financial implications
The group does not recommend None. Will not be added No financial risk treatment of obesity the use of liraglutide for the above indication. Gliptins (DPP-4 The group recommends that Diabetes drugs growing
inhibitors) for the DPP-4 Inhibitors may be at £37,000 per 100,000 treatment of type 2 considered as a treatment option population per year diabetes mellitus as add on therapy, in those patients who fail to achieve glycaemic control despite an adequate trial of current antidiabetic therapy as per NICE Clinical Guideline CG87 The group recommends that (Invokana®▼) for canagliflozin may be considered the treatment of as a treatment option as add on adults with type 2 therapy, in those patients who fail to achieve glycaemic control mellitus(T2DM) to despite an adequate trial of improve glycaemic current antidiabetic therapy as per the NICE TA on <superseded by generic SGLT-2 recommendation, July 2014> The group does not recommend None. Will not be added No financial risk (Valdoxan®▼) for the use of agomelatine the treatment of (Valdoxan®▼) for the above major depressive episodes in adults
May 2014
Paliperidone Depot
The group recommends There could be reduced While oral forms of Injection (Xeplion®) paliperidone depot injection outpatient attendance risperidone are now for Schizophrenia (Xeplion®) as an option for costs or use of CPN available generically at schizophrenia in those patients nurse time as the significant discount to where a long acting atypical injection is administered branded, the availability of injectable is deemed appropriate 4-weekly instead of 2- a similar saving in weekly. Due to the injectables is difficult to potential for reduced predict but highly unlikely. wastage of risperidone This preparation is
depot injection, [these likely to receive an
injections are stored in "amber" Interface status
the fridge and must be i.e. prescribing may be
allowed to come to room transferred to GPs
temperature before use
under a shared care
but if not then used, protocol. Prescribing of
storage time is limited depot injections within
and they are discarded if MH Trusts is a
they have been
significant financial
pressure [annually
particular patient who £540k MMHSC, £355k
does not attend], P.Care] and transfer of
commissioners are prescribing could have
advised not to provide significant impact for
extra funding for this CCGs although it is an
inefficient use of
resources to have
patient attend MH
Trusts solely to receive
depot injections.
Newer Products for The group recommends use of By increasing GP Average item value is in Topical Treatment the above products in confidence, the pathway excess of £40 so a small of Actinic Keratoses accordance with the Primary may reduce referrals. increase in patients Care Dermatology Society identified for treatment (PCDS) AK treatment pathway increase in prescribing could have a moderate May 2014, slightly costs should be off-set impact on prescribing revised June 2014 by a reduction in outpatient costs. The condition is not a significant disease burden in Greater Manchester and so no major changes in prescribing costs nor patient attendances are expected. It is likely that two-week wait referrals may reduce appropriately due to the guidance contained within this pathway although this should be audited. Ulipristal acetate Ellaone® is recommended as a Already in formulary: No financial risk (Ellaone®) 30mg treatment option for those Recommended where patients that present between 72 unprotected intercourse and 120 hours of unprotected contraception within sexual intercourse or between 72 and 120 120 hours (5 days) contraceptive failure sexual intercourse <No change> or contraceptive failure May 2014 [re-review] Lidocaine 5% The group does not recommend None. Will not be added No financial risk plaster (Versatis®) the use of lidocaine plasters for for the treatment of the above indication. <No change> May 2014 [re-review] Aripiprazole The group recommends Similarly to paliperidone A budget impact model prolonged release aripiprazole prolonged release [see May 2014], there injection (Abilify injection as an option for could be reduced manufacturer predicts a Maintena®) for the schizophrenia in those patients outpatient attendance move to this depot already established on oral costs or use of CPN injection by 4% of patients aripiprazole and where a second- nurse time as the on depot therapy each generation long acting injectable injection is administered year, resulting in overall antipsychotic is deemed 4-weekly instead of 2- cost savings of £61k in the first year, £133k in the second year and £208k in the third year. While overall drug spend would increase slightly, these savings arise from reduced administration costs due to monthly administration as opposed to fortnightly for risperidone, the current market leader. See also comments under paliperidone The group does not recommend None. Will not be added No financial risk modified release the use of hydrocortisone tablet (Plenadren®) modified release tablets for the for the treatment of above indication adrenal insufficiency June 2014 Lurasidone The group does not recommend None. Will not be added Very small place in the use of lurasidone over more therapy; no significant established therapies. Schizophrenia June 2014 Insulin Degludec & The group does not recommend None. Will not be added No financial risk the use of the combination of (IDegLira®▼, name Insulin degludec and liraglutide for the above indication. changed to Xultophy®) for the treatment of adults with type 2 diabetes inadequately controlled on a basal insulin analogue. July 2014 Insulin Degludec The group does not recommend Diabetes drugs growing
(Tresiba®▼) for the the use of insulin degludec over at £37,000 per 100,000 other more established insulins population per year Diabetes Mellitus for the above indications (Type 1 and Type 2) where insulin is required July 2014 Sodium Glucose The group recommends that the Diabetes drugs growing
Co-transporter 2 above class of drugs may be at £37,000 per 100,000 (SGLT2) Inhibitors considered as a treatment option population per year as add on therapy, in those canagliflozin and patients who fail to achieve empagliflozin▼) for glycaemic control despite an the treatment of adequate trial of current adults with type 2 antidiabetic therapy as per the diabetes mellitus NICE TA on dapagliflozin. (T2DM) to improve glycaemic control July 2014 Brimonidine The group recommends that Could save some costs Providing monitoring of (Mirvaso®) gel for brimonidine be limited for use in through prevention of the effectiveness of any the treatment of patients with severe erythema, if referral and use of laser prescribing is carried out all other formulary treatment although these may be options have failed and unlikely to be routinely recommendation, overall immediately prior to referring for funded and may have financial impact is likely to generated Individual be relatively very small. Funding Request applications. Dabigatran for the The group does not recommend Unlikely to have the routine use of dabigatran for significant impact unless a the above indication; however it pathway for treatment of recurrent Deep Vein may be suitable for use in treatment / prophylaxis VTE in the community is Thrombosis (DVT) patients who are not suitable for and has significantly LMWH plus warfarin or for higher spend per head Embolism (PE) in adults. August 2014 Fostair® The group recommends that Offers a more cost- Fostair® should be considered effective option for dipropionate and as an option for the above treatment of patients with formoterol fumarate indication and particularly for COPD requiring inhaled dehydrate) metered those patients that would prefer a corticosteroids. pressurized metered dose Significant potential for
combination inhaler [MDI]. savings through
changing or stepping
down therapy in COPD
patients able to use an
MDI.
Cystistat® (sodium The group recommends that None: already in use None as Interface group Cystistat® bladder instillations has proposed a "Red" solution for the may be considered for initiation status i.e. no transfer of and prescribing by specialists, prescribing to primary when other treatment options interstitial cystitis have failed and prior to consideration for surgery. September 2014 Use of Melatonin in The group recommends the The recommendation sleep disorders in restricted use of melatonin in should lead to more children and young children for the above indication. rational use of this drug people with ADHD Any prescribing should be in and yield some cost keeping with the updated shared savings by eliminating use neurodevelopmental care protocols on melatonin which has little or no developed by the CAMHS team. clinical effect. The Financial Forward Planning Steering Group has already sent out recommendations to CCGs about cost-effective use of melatonin based on this recommendation. The group does not recommend None. Will not be added No financial risk (Clindamycin 1% + the routine use of Treclin® gel for to Formulary. 0.025% tretinoin) the above indication. gel for the treatment of acne vulgaris September 2014

Source: https://www.northmanchesterccg.nhs.uk/download.cfm?doc=docm93jijm4n1775.pdf&ver=2142