April 2025

Drug changes and additions

The use of ICS + LABA combination inhalers is no longer encouraged in patients with COPD. The formulary entries have been updated with the following advice on how to manage patients with COPD and no features of asthma who are currently prescribed ICS + LABA (see here for the formulary entry):

If a patient with COPD and no features of asthma is well controlled on ICS + LABA, continuation is an option. However, if the patient has:

• Controlled symptoms and has never had raised eosinophils ≥ 0.3x10⁹/L: 
  • consider switching to LABA + LAMA combination therapy at next review.
• Persistent breathlessness or exercise limitation: 
  • consider switching treatment to LABA + LAMA combination therapy.
• Further exacerbations:
  • switch to LABA + LAMA combination therapy, unless triple therapy is indicated (see below)
  • step up treatment to ICS + LABA + LAMA triple combination therapy if:
    • blood eosinophils ≥ 0.3x10⁹/L, or
    • ≥ 1 severe exacerbation (requiring hospitalisation) or
    • ≥ 2 moderate exacerbations in the last year.

Bijuve capsules (estradiol 1mg / micronised progesterone 100mg) have been added as a blue (second line) option for the management of menopausal symptoms in patients experiencing troublesome progestogenic side effects with first line options.

See here for the formulary entry.

Roflumilast 500microgram tablets have been reclassified to amber (specialist input) for maintenance treatment of severe COPD in adults with chronic bronchitis in line with NICE TA461.

Treatment should be started by a specialist in respiratory medicine. Specialist prescribing should continue until the patient is established on the maintenance dose, after which GPs may be asked to continue prescribing.

The 250microgram tablets remain hospital only (this is a sub-therapeutic dose used to reduce adverse effects and discontinuation during initiation).

See here for the formulary entry.

Formulary guidance

Cellulitis and erysipelas

Updates include:

• Guidance has been expanded to include erysipelas (recommendations and treatment options are the same as for cellulitis).
• Additional information has been added to support assessment, re-assessment, and referral.
• Treatment recommendations for adults aged 18 years and over have been amended, these include:
  • Antibiotic course durations have been reduced to 5-7 days
  • Two additional blue (second line) options have been added:
    • erythromycin (for use in pregnancy)
    • doxycycline
  • Clindamycin has been removed as a treatment option (previously S&W only)
  • Recommendations for “facial cellulitis” have been amended to “infection near the eyes or nose”, and dual therapy with clarithromycin plus metronidazole has been added as a blue (second line) option for those patients.
• Treatment recommendations for those under 18 years of age have been added, these include:
  • Flucloxacillin as a green (first line) treatment option
  • Three blue (second line) options:
    • co-amoxiclav
    • clarithromycin
    • erythromycin (for use in pregnancy)
  • For infection near the eyes or nose:
    • Co-amoxiclav as a green (first line) option
    • Clarithromycin plus metronidazole (if anaerobes suspected) as a blue (second line) option.

See here for the formulary guidance.

Formulary recommendations guidance on vitamin and mineral supplements following bariatric surgery has been updated in consultation with local specialists.

All bariatric surgery patients should be given a long-term management plan by their specialist team, including guidance on life-long nutritional supplementation. The updated formulary guidance signposts to additional resources for GPs from the British Obesity and Metabolic Surgery Society (BOMSS), relevant formulary products, and highlights additional considerations for preconception and pregnancy.

Some patients post bariatric surgery may require non-formulary products and/or off-label doses.

See here for the formulary guidance.

Visual summaries

A visual summary of inhaled therapy for COPD has been produced; it is intended to supplement the formulary pages and act as a quick reference / aide-mémoire for local clinicians.

NICE Technology Appraisals (TAs)

Vamorolone 40mg/ml oral suspension has been added to the formulary as a red (hospital only) option for treating Duchenne muscular dystrophy in people 4 years and over.

"Shared Care" / Specialised Medicines Service (SMS) guidelines

Mycophenolate mofetil and mycophenolic acid for patients within adult dermatology, ophthalmology and neurology services (Devon Wide)

The existing mycophenolate mofetil guideline has been reviewed and updated:

• The guideline now covers the use of mycophenolic acid,
• use has been extended to cover the whole of Devon,
• ophthalmology and neurology indications have been added.

The guideline will be remunerated at Tier 2.

The guideline can be found on the NHS Devon ICB website, or via the individual drug entry.

March 2025

Drug changes and additions

Hydrofilm Plus dressings have been renamed to Cosmopor Transparent.

See here for the formulary entry.

Offmate adhesive remover spray has been renamed to Offmore.

See here for the formulary entry.

Dexamethasone 1mg tablets have been added to the Devon Formulary as a blue (second line) option.

See here for the formulary entry.

Acetazolamide 250mg modified-release capsules have been discontinued and removed from the Devon Formulary.

Buserelin 150micrograms/dose nasal spray has been discontinued and removed from the Devon Formulary.

Hydrocortisone 0.1% cream has been discontinued and removed from the Devon Formulary.

Magnesium trisilicate oral suspension has been discontinued and removed from the Devon Formulary.

NICE Technology Appraisals (TAs)

NICE TA1027: Tebentafusp solution for infusion vials have been added to the Devon Formulary as a red (hospital only) option for treating advanced uveal melanoma (in line with the technology appraisal guidance).

See here for the formulary entry.

Formulary Interface Group (FIG) Governance

The Devon Formulary Interface Group (FIG) Annual Report (1^st April 2023 to 31^st March 2024) has been published.

See here for an account of the activity and governance processes of the NHS Devon FIG.

February 2025

Drug changes and additions

Oseltamivir 30mg, 45mg, 75mg capsules and 6mg/ml oral suspension sugar free and zanamivir 5mg inhalation powder blisters with device for the treatment and post-exposure prophylaxis of influenza have been reclassified as green (first line). The drug entries have been updated with dosing and additional information, and links to UKHSA resources have been added.

The DHSC provides annual notification, usually through the CMO, of the start and end of the season when influenza is circulating in the community. GPs may prescribe antivirals for the treatment of influenza during this time period. 

Antiviral treatment outside of the flu season, and prophylaxis (at any time), is provided through a commissioned service and should not be routinely prescribed by GPs.

See here for the formulary entry.

Ivermectin 3mg oral tablets have been added as a blue (second line) option for the treatment of scabies if topical therapy is contraindicated or unsuitable.

See here for the formulary entry.

Co-trimoxazole tablets and oral suspension have been reclassified as blue (second line) options for the prophylaxis and treatment of human and animal bites for those aged 12 years and above.

See here for the formulary entry.

Dienogest 2mg tablets have been added as an amber (specialist input) option for use in the management of endometriosis when initial hormonal therapy (for example, the combined oral contraceptive pill or a progestogen) is ineffective or not tolerated or contraindicated.

Treatment with dienogest may be started in primary care on the advice of a specialist.

See here for the formulary entry.

Ferric maltol 30mg hard capsules have been added to the formulary as an amber (specialist input) option for the treatment of iron deficiency anaemia (IDA) in patients with inflammatory bowel disease (IBD) in whom two standard oral iron preparations have been ineffective or not tolerated.

Gastroenterology specialists will prescribe the first 4-weeks of treatment and assess haematological response. If an adequate haematological response is observed following 4-weeks of treatment, primary care may be asked to continue prescribing for a further 12-weeks.

See here for the formulary entry.

Fluticasone propionate and azelastine hydrochloride nasal spray (50micrograms / 137micrograms) has been added to the formulary as an amber (specialist input) option for moderate to severe symptoms of allergic rhinitis in adults and children aged ≥12 years, following failure of combination therapy (antihistamine and nasal corticosteroid) which has been optimised by a secondary care allergy specialist (adult immunology services or specialists in paediatric allergy management).

Initiation of treatment by other specialist services is not supported.

Allergy specialists will prescribe and assess treatment response; if the product results in a sustained reduction in symptoms primary care may be asked to continue prescribing.

See here for the formulary entry.

The formulary recommendations and supporting guidance for thickened fluids have been updated in consultation with local Speech and Language Therapists (SLT) and dieticians. Thickened fluids are one of several dysphagia management tools, and should be considered only after comprehensive assessment by SLT.

All thickened fluids (including thickeners, pre-thickened drinks, and semi-solid desserts) are now classified
as amber (specialist input), however, it is accepted that GPs may occasionally initiate thickened fluids for individual patients without the need for SLT assessment, i.e. end-of-life care or infants/babies with reflux.

• Instant Carobel powder has been added as clear gum-based option for patients from birth to 3 years.
• Thixo-D Original powder has been added as starch-based option for children aged 1 year and over.

For patients already using thickened fluids without SLT involvement, there is no need to seek retrospective specialist input; if the patient’s clinical requirements have changed, and/or it is thought that thickened fluids may no longer be required, GPs can seek advice from / refer to SLT.

See here for the formulary guidance.

The formulary continence chapter product recommendations have been reviewed with Bladder and Bowel Care and Urology Specialists from the three acute NHS Trusts across Devon, to create cohesive Devon-wide continence care recommendations.

See here for Chapter 18: Continence care.

Formulary guidance

Human and animal bites

Updates include:

• Antibiotic course durations have been reduced to 3 days for prophylaxis and 5 days for treatment
• Advice to seek specialist advice for those who are pregnant
• Prophylaxis and treatment recommendations for those under 18 years of age have been added, these include:
  • Co-amoxiclav as a green (first line) option
  • Doxycycline plus metronidazole as a blue (second line) option for those aged 12 years and above
  • Co-trimoxazole as a blue (second line) option for those aged 12 years and above
• Updated advice on when to offer antibiotic prophylaxis
• Reassessment and referral advice.

See here for the formulary guidance.

Management of scabies

Updates include:

• definition and transmission of scabies
• single case / contact / closed setting management
• hygiene and prevention advice
• addition of ivermectin 3mg oral tablets
• follow up and post-treatment advice.

See here for the formulary guidance.

NICE Technology Appraisals (TAs)

NICE TA1015: Teclistamab solution for injection vials have been added to the Devon Formulary as a red (hospital only) option for treating relapsed and refractory multiple myeloma after 3 or more treatments (in line with the technology appraisal guidance).

See here for the formulary entry.

NICE TA1016: Elafibranor tablets have been added to the Devon Formulary as a red (hospital only) option for previously treated primary biliary cholangitis,(in line with the technology appraisal guidance).

See here for the formulary entry.

NICE TA1023: Elranatamab solution for injection vials have been added to the Devon Formulary as a red (hospital only) option for treating relapsed and refractory multiple myeloma after 3 or more treatments (in line with the technology appraisal guidance).

See here for the formulary entry.

NICE TA1026: Tirzepatide solution for injection pre-filled disposable devices have been added to the Devon Formulary section ‘4.5 Drugs used in the treatment of obesity’ as a red (hospital only) option for use in the specialist weight management services for the purposes of weight management in line with NICE TA1026.

Implementation of TA1026 is determined by NICE and NHS England (see here). The national plan for the future is for a phased delivery to patient cohorts in other settings, including primary care-based services, based on NHS England prioritisation criteria.

Until further communication, use of tirzepatide for weight management purposes remains with the specialist weight management service. The formulary entry and traffic light classification for tirzepatide for weight management will be reviewed in the future when more information is available.

See here for the formulary entry for tirzepatide for weight management.

Note: Tirzepatide remains blue (second line) for use in type 2 diabetes in line with NICE TA924.

• See here for the tirzepatide formulary entry for type 2 diabetes and formulary guidance for type 2 diabetes.

Commissioning Policies

The routine commissioning of ferric maltol is accepted in Devon for the treatment of IDA in patients with IBD in whom two standard oral iron preparations have been ineffective or not tolerated (see Commissioning Policy for more details).

See here for the formulary entry.

The routine commissioning of fluticasone propionate and azelastine combination nasal spray is accepted in Devon for the treatment of allergic rhinitis when allergy specialists have optimised treatment with standard combination therapies (see Commissioning Policy for more details).

See here for the formulary entry.