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Recent Formulary Updates

First Line
Second Line
Specialist
Hospital Only

July 2024

Drug changes and additions

  • Fresubin PRO COMPACT ready to drink milkshake-style drink has been added as an amber (specialist input) oral nutritional supplement (ONS).

    • This has replaced Fortisip Compact Protein ready to drink milkshake-style ONS which have been removed from the formulary.

    • See here for the formulary entry.
  • Zeyzelf (rivastigmine) twice-weekly transdermal patches 4.6mg/24hours and 9.5mg/24hours have been added as an amber (specialist input) option for the symptomatic treatment of mild to moderately severe Alzheimer’s dementia.
    • They are reserved for patients where there is a clear clinical benefit i.e., administration of transdermal patches causes significant distress to the patient.
    • See here for the formulary entry.
  • The Emollients drug page has been updated after the MHRA published a Field Safety Notice linking cetostearyl alcohol (an excipient of some Epimax products and a number of other formulary recommended emollients) to eye-related toxicity and corneal epithelial loss.
Formulary guidance
  • Guidance providing key considerations for deprescribing hypnotic drugs has been added to the formulary including information in the following scenarios: treatment initiated whilst a patient was receiving in-patient care, deprescribing of benzodiazepines and z-drugs, deprescribing melatonin in adults, and deprescribing melatonin in children.
Revised sections
  • Following a review of the effectiveness of current measures to reduce the risk of potentially long-term or irreversible side effects associated with fluoroquinolone antibiotics, the MHRA introduced further restrictions to limit fluoroquinolone use. The MHRA announced that fluoroquinolone antibiotics given systemically (by mouth, injection, or inhalation) must only be administered when no other antibiotics are appropriate for use.
    • The Devon Formulary has been updated to include the strengthened regulations from the MHRA and fluoroquinolones are now only to be used when other recommended antibiotics have failed, will not work due to resistance, or are unsafe to use in an individual patient.
    • See here for the drug page.

June 2024

Drug changes and additions
  • Liothyronine 5micrograms and 10micrograms hard capsules have been added as an amber (specialist input) option for hypothyroidism that has not responded adequately to levothyroxine therapy or patients who have persistent symptoms felt to be secondary to thyroid hormone deficiency despite seemingly adequate replacement therapy with levothyroxine.
  • Ceyesto (melatonin) 1mg/ml oral solution has been added as an amber (specialist input) option for insomnia in children and adolescents aged 6-17 years with attention deficit hyperactivity disorder (ADHD), where sleep hygiene measures have been insufficient.
Revised formulary guidance
  • Infected eczema: formulary guidance has been revised and updated. The updated guidance provides more detail including specific antibiotic recommendations depending on the patient’s age and presenting symptoms, adverse effects and concomitant use of emollients and topical corticosteroids, and reassessment and referral advice.
  • COVID-19 treatments for patients who do not require hospitalisation: NICE has recommended a phased implementation of new recommendations for nirmatrelvir plus ritonavir (Paxlovid) to expand its use (TA878). Further patient groups have been added to the formulary guidance. An overview of the new recommendations is provided (see below). There will be a further expansion of the patient groups eligible for Paxlovid during the course of 2024.
Revised sections
  • Reference to Sleepio, a six-week digital course of cognitive behavioural therapy for insomnia (CBTi) that is available free for all NHS patients in England aged 18 and over, has been added to the formulary guidance on the management of insomnia in adults.
  • Rapid eye movement behaviour disorder in Parkinson’s disease has been added to the indications for melatonin. Treatment will be initiated and supervised by a specialist. Further information is provided in the formulary entry.
NICE Technology Appraisals
  • NICE TA878 (update): Phased implementation of new patient groups for nirmatrelvir plus ritonavir (Paxlovid). See above for update to formulary guidance.
  • NICE TA971: Remdesivir is recommended for treating patients with COVID-19 in hospital. Tixagevimab plus cilgavimab (Evushield) is not recommended for treating COVID-19.
Specialised Medicines Service (SMS) prescribing guidelines
  • NHS Devon has commissioned a hydroxychloroquine (HCQ) retinopathy monitoring service from an external provider (InHealth). HCQ does not require routine laboratory blood monitoring or physical health monitoring by the GP and therefore no longer fits the local definition of formal “Shared Care”.
    • The five existing shared care guidelines for HCQ in Devon (three for rheumatology patients (North & East Devon, South Devon & Torbay, and West Devon) and two for dermatology patients (South Devon & Torbay, and West Devon only)) have been withdrawn and replaced by an enhanced Devon Formulary entry.
    • The patient’s specialist will be responsible for referring the patient to InHealth. The service will offer annual monitoring for patients who have been on HCQ for five or more years, and one or more years if additional risk factors identified.
    • See here for the formulary entry.
    • See here for further information regarding the retinopathy monitoring service.
Formulary Interface Group (FIG) Governance

April 2024

Drug changes and additions
  • Epimax Oatmeal Cream has been added to the Devon Formulary as a blue (second line) option for patients who may prefer an emollient cram containing colloidal oatmeal when treating dermatological conditions. This has replaced Zeroveen Oatmeal Cream which has been removed from the Devon Formulary.
  • LimbO Waterproof Protectors (Adult Half Leg, Adult Elbow, and Adult Foot) have been added to the Devon Formulary as a green (first line) option to protect dressings on adults with long-term conditions such as leg ulcers caused by diabetes or those undergoing IV treatment through a PICC Line or Midline. Seal-Tight limb protectors have been removed from the formulary.
  • Desitrend (levetiracetam) granules: 250mg, 500mg, 1g. Levetiracetam granules are included in the Devon Formulary for use in paediatric patients who cannot take the tablets and cannot tolerate the oral solution. Prescribe by brand. Desitrend granules are licensed to be administered via a feeding tube. Generic levetiracetam granules are not licensed to be given via this route.
Revised formulary guidance
  • Guidance on the Management of insomnia in adults has been updated in line with the British Association of Psychopharmacology consensus statement (2019) and NICE CKS for insomnia (updated 2022). Updated guidance includes advice on sleep hygiene, management of short-term insomnia (<3 months) and long-term insomnia (>3 months) and incorporates the recent NICE TA for daridorexant for long-term insomnia.
  • Management of eczema guidance has been updated in line with NICE CG57: Atopic eczema in under 12s: diagnosis and management but applies to all ages unlike the NICE Clinical Guideline. Topical calcineurin inhibitors (TCIs) have been reclassified from amber (specialist input) to blue (second line) in South & West.
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