Cannock Chase Clinical Commissioning Group
South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group
Stafford and Surrounds Clinical Commissioning Group
East Staffordshire Clinical Commissioning Group
PRESCRIBING COMMISSIONING POLICY
JULY 2016
Policy number
Version number
Responsible individual
Author(s)
Date approved by Human Resources and
Organisational Development Group
Date approved by Finance and Performance
or Quality Committee
Date ratified by Governing Body
Date issued
Review date
Target audience
HISTORY OF CHANGES
Old version number
Significant changes
New version number
Contents
Section
Section title
Page number
1.
Purpose and Introduction
1
2.
Scope
1
3.
Definitions
1
4.
Roles and responsibilities
1
5.
Drugs of low clinical value
2
6.
Training
4
7.
References
4
8.
Monitoring and evaluation
6
9.
Review
6
10.
Appendices
6
1. PURPOSE AND INTRODUCTION
1.1. PURPOSE
The purpose of this Commissioning Policy is to clarify the commissioning intentions for prescribing
medications in the Clinical Commissioning Groups of NHS Cannock Chase, NHS Stafford & Surrounds,
NHS South East Staffs & Seisdon Peninsula and NHS East Staffordshire.
1.2. INTRODUCTION
NHS Commissioners receive funding to commission health services for their resident population and
make decisions within the context of statutes, statutory instruments, regulations and guidance. NHS
Commissioners have a responsibility to seek the greatest health advantage possible for local
populations using the resources allocated to them. It is necessary to make decisions regarding the
investment of resources in interventions which achieve the greatest health gain for the population.
This Policy is designed to help the CCGs to meet their obligation in providing equitable access to
health care. It aims to achieve this by ensuring prescribing locally is evidence-based and offers the
NHS value for money.
2. SCOPE
The Policy covers all patients, prescribers and prescribing within the CCG.
The Policy is applicable to prescribing for all CCG patients in primary care and also within all CCG
commissioned services.
3. DEFINITIONS
3.1. Abbreviations
CCG
Clinical Commissioning Group
NICE
National Institute for Clinical Excellence
NICE CG
NICE Clinical Guidance
NICE TAG
NICE Technology Appraisal
POM
Prescription only medication
ACBS
Advisory Committee on Borderline Substances
4. ROLES AND RESPONSIBILITIES
1
CCG Chair of Membership Board
•
In accordance with the Policy for the Development and Management of CCG Policies the
Policy will be approved by the CCG Membership Board.
•
The Policy will be signed by the Chair of the Membership board (or delegated deputy).
CCG Governing Body/ Joint Quality Committee
•
In accordance with the Policy for the Development and Management of CCG Policies the
Policy will be ratified by the CCG Governing Body or Joint Quality Committee.
GP and non-medical prescribers responsibilities:
•
Prescribers should use this policy, together with clinical judgement, to support clinicallyeffective decision making for prescribing
Medicine Optimisation Team Responsibilities:
•
Submit the Policy to the Assistant to the Chief Executive for the consistency check before
submission for ratification with the necessary Impact Assessment forms.
•
Support for prescribers will be provided by the CCG medicines optimisation teams.
•
Ensure availability of patient information to support the Policy.
5. DRUGS OF LOW CLINICAL VALUE
5.1. PrescQiPP Drugs to Review for Optimised prescribing (DROP-List)
The South Staffordshire CCG’s subscribe to PrescQiPP an organisation which provides evidence-based
medicines optimisation support to CCG medicines optimisation teams. Their aim is to support NHS
organisations to improve medicines-related care to patients, through the provision of robust,
accessible and evidence-based resources.
One role of PrescQiPP is to review drugs which have limited clinical value and offer guidance to NHS
organisations on prescribing recommendations for these. Their original document, DRugs Of low
Priority1 was first published in 2012 and was an accumulation of medicines that PCTs within the East
of England considered as low priority, poor value for money or for which there were safer
alternatives. The DROP-List is now rebranded as Drugs to Review to Optimise Prescribing2 and has
been updated to include drugs prescribed across the NHS that are considered low priority and poor
value for money and also some of the NICE do not do items. It also incorporates drugs which can be
provided as self-care, with advice and support from the community pharmacists, and discusses the
potential to support medicines optimisation for the drugs listed.
The PrescQiPP evidenced-based resources are produced predominantly by medicines information
pharmacists currently working within NHS Trusts. This provides a comprehensive literature search
approach to their guidance based on national guidance, including NICE, and other clinical evidence.
This evidence and guidance is reviewed to produce the DROP-List, for drugs which have limited
clinical evidence for their use on the NHS.
2
Medicines optimisation is key to achieving the best outcomes for patients. The Royal Pharmaceutical
Society good practice guide on medicines optimisation suggests the following principles are key to
help patients get the most out of their medicines.3 These principles would apply when reviewing
drugs in the DROP-List.
•
Treatments of limited clinical value are not used and medicines no longer required are
stopped.
•
Optimal patient outcomes are obtained from choosing a medicine using best evidence (for
example, following NICE guidance, local formularies etc.) and these outcomes are measured.
•
Medicines wastage is reduced.
•
The NHS achieves greater value for money invested in medicines.
•
Patients are more engaged, understand more about their medicines and are able to make
choices, including choices about prevention and healthy living.
•
It becomes routine practice to signpost patients to further help with their medicines and to
local patient support groups.
•
Incidents of avoidable harm from medicines are reduced.
The PrescQiPP DROP-list recommendations have been combined with existing South Staffordshire
prescribing recommendations to establish this policy which details the position of the CCGs in the
prescribing of included drugs. The Clinical Prioritisation Group within South Staffordshire review
treatments and procedures to assess their effectiveness and suitability for commissioning by CCG’s.
For drugs which are prescribed within primary care, those which have been reviewed and are not
considered a priority for commissioning are now included within this policy.
The drugs list within the policy is divided into 2 sections:
List A: Drugs not commissioned for prescribing within South Staffordshire (Appendix 1)
These drugs are not suitable for prescribing locally due to recommendations from NICE to ‘not
prescribe’ or are drugs which have been reviewed within South Staffordshire through the Clinical
Prioritisation Group and are not recommended for prescribing.
List B: Drugs which are only recommended for prescribing in certain circumstances (Appendix 2)
These drugs should not routinely be prescribed unless clinically indicated for the individual patient in
certain circumstances (as detailed in the appendix).
5.2. Implementation
This policy relates to prescribing within primary care and therefore will be implemented by GPs and
primary care health professionals when considering the treatment options for patients. Prescribing
decision software will be used to support the implementation of the Policy.
This Policy applies to all future prescribing of drugs included in this Policy. Patients currently
prescribed these medications will be reviewed to ensure prescribing is in accordance with this Policy.
3
PrescQiPP have additional resources for the drugs included in this Policy which are included in their
DROP-List – for each drug there is a full evidence-based summary of the clinical evidence which is
available for the Medicines Optimisation teams to share with prescribers.
The CCG Medicines Optimisation teams will produce patient information resources and ensure these
are available to support prescribers.
5.3. Managing Expectations
In their dealings with patients and the public, prescribers should, if necessary, make it clear that the
decision by NHS Commissioners to consider drugs to be of low priority under this policy is a
considered decision made against their responsibility to seek the greatest health advantage possible
for local populations using the resources allocated to them. It is necessary for the NHS
Commissioners to make decisions regarding the investment of resources in interventions which
achieve the greatest health gain for the local population.
6. TRAINING
It is not expected that any additional training will be required to implement this Policy.
7. REFERENCES
1. Homan K. PrescQiPP DROP-List, February 2012. Available at www.prescqipp.info
2. Dowell G. The PrescQiPP DROP-List 2015 (Drugs to Review for Optimised Prescribing) July 2015.
Available at www.prescqipp.info
3. Royal Pharmaceutical Society of Great Britain. Medicines Optimisation: Helping patients to get
the most of their medicines. May 2013.
4. South Staffordshire ‘Grey List’ Drugs that should not be prescribed in the South Staffordshire
Health Economy. Available at
http://www.southstaffordshirejointformulary.nhs.uk/docs/misc/GreyList.pdf
5. National Institute for Health and Care Excellence (NICE). CG127: Hypertension-full guideline the
clinical management of primary hypertension in adults. August 2011. Available at
http://www.nice.org.uk/guidance/cg127
6. National Institute for Health and Care Excellence (NICE). Clinical Guideline 186. Multiple Sclerosis
– management of multiple sclerosis in primary and secondary care. October 2014. Available at
http://www.nice.org.uk/guidance/cg186
7. National Institute for Health and Care Excellence (NICE). Do not do recommendations. September
2012.
8. MHRA Media Centre: European Medicines Agency (EMEA) recommends withdrawal of
dextropropoxyphene-containing medicines (including co-proxamol). June 2009. Accessed 18/02/2016
http://webarchive.nationalarchives.gov.uk/20141205150130/http://www.mhra.gov.uk/NewsCentre/
CON049300
4
9. MTRAC (Midlands Therapeutics Review and Advisory Committee). Verdict and Summary–
eflornithine. January 2006. Available at
http://centreformedicinesoptimisation.co.uk/download/642c6f9432641505d3cb0e8e8f58e79f/Eflor
nithine-Verdict-Jan-06.pdf
10.MHRA. Drug Safety Update. Serious and fatal overdose of fentanyl patches. September 2008.
Available at https://www.gov.uk/drug-safety-update/serious-and-fatal-overdose-of-fentanyl-patches
11.National Institute for Health and Care Excellence (NICE). Clinical guideline 177. Osteoarthritis.
Available at http://www.nice.org.uk/guidance/cg177
12.National Institute for Health and Care Excellence (NICE). Clinical guideline 173. Neuropathic Pain –
pharmacological management. Available at http://www.nice.org.uk/guidance/cg173
13.AMD Guidelines Group. The Royal College of Ophthalmologists. Age Related Macular
Degeneration. Guidelines for Management. (Chapter 6). September 2013.
14.National Institute for Health and Care Excellence. Clinical Guideline 172. Myocardial Infarction –
Secondary prevention in primary and secondary care. November 2013. Available at
http://guidance.nice.org.uk/CG172
15.National Institute for Health and Care Excellence. Clinical Guideline 170. Autism- management of
autism in children and young people. August 2013. Available at http://guidance.nice.org.uk/CG170
16.National Institute for Health and Care Excellence. Clinical Guideline 107. Hypertension in
pregnancy. August 2010. Available at https://www.nice.org.uk/guidance/cg107
17.National Institute for Health and Care Excellence. Clinical Guideline 71. Identification and
management of familial hypercholesterolemia. August 2008. Available at
https://www.nice.org.uk/guidance/cg71
18.National Prescribing Centre. Pain Overview Data Focused Commentary: Use of Opioids. 2010.
19.Advisory Council on the Misuse of Drugs (ACMD) consideration of tramadol. February 2013.
Accessed 11/02/2014
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/144116/advicetramadol.pdf
20.Hughes DA, Ferner RE. New drugs for old: disinvestment and NICE. BMJ 2010;340:C572.
21.Roflumilast for the management of severe chronic obstructive pulmonary disease NICE
technology appraisal guidance [TA244] Published date: January 2012
http://www.nice.org.uk/guidance/TA244?UNLID=7812238412016218193745
22.NHS Choices. Travel Vaccinations. November 2013. Available at
http://www.nhs.uk/conditions/Travel-immunisation/Pages/Introduction.aspx
23.National Institute for health and Care Excellence (NICE). Clinical guideline 180. Atrial fibrillation:
the management of atrial fibrillation. June 2014. Available at
https://www.nice.org.uk/guidance/cg180
24.National Institute for Health and Care Excellence (NICE). Clinical Guideline 90. Depression in
Adults. October 2009. Available at http://www.nice.org.uk/guidance/cg90
25.Okosieme et al. Management of primary hypothyroidism: statement by the British Thyroid
Association Executive Committee Clinical Endocrinology (2015), 0, 1–10. Accessed via
http://www.british-thyroid-association.org/news/BTA_Hypothyroidism_Statement.pdf
5
8. MONITORING AND EVALUATION
NHS Commissioners will monitor the adherence to this policy through prescribing data and audits
undertaken by the Medicines Optimisation teams.
The CCG Medicines Optimisation teams will provide periodic reports to the relevant CCG Boards
reporting the prescribing of drugs included within this policy, by provider and by drug/treatment.
Where there are defined criteria for drugs, the compliance with the criteria will be subject to regular
clinical audits carried out or organised by the CCG Medicines Optimisation teams.
9. REVIEW
The Policy review period will be 2 years from the date of issue.
10. APPENDICES
6
Appendix 1: List A - Drugs not commissioned for prescribing within South Staffordshire
These drugs are not suitable for prescribing locally due to recommendations from NICE to ‘not prescribe’ or are drugs which have been reviewed within
South Staffordshire through the Clinical Prioritisation Group and should not be prescribed locally.
Drug or Treatment
Aliskiren (Rasilez®)
Rationale for inclusion in the Policy
Not commissioned for prescribing.
NICE state there is insufficient evidence of its effectiveness to determine its
suitability for use in resistant hypertension.5
Suggested alternative(s)
For hypertension, a generic ACE inhibitor.
For resistant hypertension, follow the
NICE CG127.5
Not commissioned for prescribing.
Cannabis Sativa
For multiple sclerosis, the cost effectiveness evidence did not support its use.6
Not licensed for other indications in UK.
Reviewed by the South Staffordshire Clinical Prioritisation Group and not
recommended for prescribing.
Complementary
Therapies
There is a limited evidence base and a lack of robust randomised controlled trials
directly comparing them with standard treatments. Some are also associated
with severe adverse effects, they may significantly interact with other medicines
and can delay accurate diagnosis of underlying pathology. None reviewed by
NICE recommend their use.7
Alternatives as per NICE Clinical Guideline 186:
Multiple Sclerosis – management of multiple sclerosis
in primary and secondary care.6
Purchase as over-the-counter products.
Many products are not prescribable on NHS prescriptions as set out in Part XVIIIA
of the Drug Tariff
Not commissioned for prescribing.
Co-proxamol
Markedly more toxic in overdose than paracetamol. Withdrawn from the market
in 2005 due to safety concerns and marketing authorisations cancelled at end of
7
Alternative analgesics e.g. paracetamol and codeine or
co-codamol tablets.
2007.8
Previously included within the South Staffordshire Grey List - Drugs that should
not be prescribed in the South Staffordshire Health Economy.
Limited clinical value for these treatments – cough mixtures, aromatic
inhalations, decongestants, sore throat lozenges etc. Over the counter products
Cough and cold remedies are suitable for most patients’ in-line with their product licenses.
Purchase as over-the-counter products.
Many products are not prescribable on NHS prescriptions as set out in Part XVIIIA
of the Drug Tariff
Not commissioned for prescribing.
Dental products and
fluoride supplements
Products recommended by dentists (or other specialists) e.g. fluoride tablets,
toothpastes and mouthwashes should be purchased OTC or prescribed by the
dentist/specialist. It is inappropriate to ask a GP to take clinical responsibility for
this prescribing.
Dental Pain and Infections prescribing commissioning statement available via
http://www.southstaffordshirejointformulary.nhs.uk/.
Purchase as over-the-counter or prescribed by
dentist/specialist recommending treatment.
Not commissioned for prescribing.
Doxazosin ModifiedRelease (MR)
Eflornithine cream
(Vaniqua®) for hirsutism
No good evidence of additional benefit over immediate release doxazosin. Both
formulations provide effective blood pressure control (doxazosin is
recommended only as a fourth-line antihypertensive) and are effective at
controlling the symptoms of BPH and improving maximum urinary flow rate. The
long half-life of immediate release doxazosin allows once daily dosing.
Doxazoxin normal-release preparations.
Not commissioned for prescribing.
Patient to use alternative hair removal options.
There is no evidence of its efficacy in comparison to other hirsutism treatments.
It needs to be used indefinitely but the long-term benefits and safety have not
Dianette (co-cyprindiol) is licensed for moderate to
severe hirsutism.
8
9
been established (past 24 weeks). In-line with the local Procedures of Limited
Clinical Value, cosmetic treatments are not routinely funded.
Reviewed by the South Staffordshire Clinical Prioritisation Group and not
recommended for prescribing.
The prescribing of eflornithine cream for cosmetic reasons is not supported for
prescribing on the NHS within South Staffordshire for any patient. The Specialised
Services Circular: Primary Care Responsibilities in Prescribing and Monitoring
Hormone Therapy for Transgender and Non-Binary Adults (updated) – April 2016,
requests that GP’s should prescribe medication advised by Gender Identity Clinics
however eflornithine is not supported for prescribing on the NHS locally.
Not commissioned for prescribing.
Fentanyl immediate
release formulations
Morphine is the most valuable opioid for severe pain. Fentanyl is significantly
more expensive and there are potential safety problems presented by these
products, which provide relatively high doses of a potent opioid and are
associated with complicated titration and maintenance instructions.10
Alternative formulary immediate-release opioids.
No immediate-release fentanyl products are included within the South
Staffordshire Formulary.
Not commissioned for prescribing.
Glucosamine/
Glucosamine &
Chondroitin
Lidocaine plasters
Do not do recommendation in NICE CG177.11
“Do not offer glucosamine or chondroitin products for the management of
osteoarthritis.”
Glucosamine +/- chondroitin are available as over-thecounter products to patients to purchase.
Reviewed by the South Staffordshire Clinical Prioritisation Group and not
recommended for prescribing.
Not commissioned for prescribing.
Alternatives as per NICE Clinical Guideline 173:
9
NICE CG173 on neuropathic pain does not recommend the use of lidocaine
patches as a treatment option due to limited clinical evidence supporting its
use.12
Neuropathic Pain12
Previously reviewed by South Staffordshire Formulary Working Group and was
NOT included on to the local formulary.
Not commissioned for prescribing.
Lutein and antioxidant
vitamins for age-related
macular degeneration
Evidence base does not show that lutein and other eye vitamins are beneficial for
age-related macular degeneration.13
Products are food supplements and not licenced medicines.
Lutein and antioxidant vitamins are available as overthe-counter products for patients to purchase.
Reviewed by the South Staffordshire Clinical Prioritisation Group and not
recommended for prescribing.
Not commissioned for prescribing.
Minocycline for acne
Not considered first line tetracycline for acne. Increased risk of side effects,
including greater risk of lupus erythematosus-like syndrome and irreversible
pigmentation.
Not included in the South Staffordshire antimicrobial guidelines for primary care.
Oxytetracycline (500mg twice daily)
Please refer to the local Primary Care Antimicrobial
Prescribing Guidelines for further information.
Previously included within the South Staffordshire Grey List - Drugs that should
not be prescribed in the South Staffordshire Health Economy.
Omega-3 and other fish
oils
Not commissioned for prescribing.
• For secondary prevention of myocardial infarction NICE CG172 states:
“Do not offer or advise people use omega-3 fatty acid capsules or omega 3 fatty
10
NICE recommendation is that patients should eat a
Mediterranean style diet (more bread, fruit,
vegetables and fish; less meat; and replace butter and
cheese with products based on plant oils).
acid supplemented foods to prevent another MI.”
“Advise people to eat a Mediterranean-style diet (more bread, fruit, vegetables
and fish; less meat; and replace butter and cheese with products based on plant
oils)”.14
Omega-3 and other fish oils are available as over-thecounter products to patients to purchase.
• NICE CG170 states “Do not use omega-3 fatty acids to manage sleep problems
15
in children and young people with autism”.
• NICE do not recommend fish or algal oils solely with the aim of preventing
hypertensive disorders in pregnancy16 or omega-3 fatty acid supplements for
familial hypercholesterolaemia.17
Not commissioned for prescribing.
Oxycodone/Naloxone
(Targinact®)
Randomised controlled trials have only compared with standard-release
oxycodone, NOT with other strong opioids such as morphine, together with
regular laxatives.
Naloxone element has no effect on risk of overdose as it is not absorbed – it just
acts on the GI tract. There is also no data showing that combined oxycodone and
naloxone reduce the need for laxatives in the long-term.
Alternative opioid analgesics with regular laxatives e.g.
morphine and lactulose.
Poor cost-effectiveness. Previously reviewed by South Staffordshire Formulary
Working Group and was NOT included on to the local formulary.
Previously included within the South Staffordshire Grey List - Drugs that should
not be prescribed in the South Staffordshire Health Economy.
Not commissioned for prescribing.
Paracetamol/Tramadol
(Tramacet®)
Fixed dose combination of 37.5mg tramadol plus 325mg paracetamol per tablet.
No more effective than established analgesics in acute or chronic pain,18 contains
a sub-therapeutic amount of paracetamol and is more expensive than
alternatives.
11
Alternative formulary analgesics (paracetamol,
codeine, co-codamol or tramadol).
There are safety concerns with tramadol (harms and misuse) as well as an
increased number of deaths.19
Previously reviewed by South Staffordshire Formulary Working Group and was
NOT included on to the local formulary.
Not commissioned for prescribing.
Perindopril arginine
(Coversyl® Arginine and
Coversyl® Arginine Plus)
No benefit over generic perindopril erbumine and it is more costly.20
Perindopril erbumine.
Coversyl® prescribed by brand name will be dispensed as Coversyl® arginine.
Not commissioned for prescribing.
Roflumilast
NICE TA244 recommends roflumilast for people with severe COPD only if they are
COPD management in accordance with local guidance.
taking part in a research study (clinical trial) that is investigating using roflumilast
21
at the same time as a bronchodilator (a type of inhaled drug).
If roflumilast is appropriate it should be prescribed as
part of the clinical trial not within primary care.
Previously included within the South Staffordshire Grey List - Drugs that should
not be prescribed in the South Staffordshire Health Economy.
Rubefacients (excluding capsaicin and topical NSAIDs) - not commissioned for
prescribing.
Rubefacients (excluding
capsaicin and
topical NSAIDs)
Topical rubefacient preparations may contain nicotinate and salicylate
compounds, essential oils, capsicum, and camphor which are all irritants. There is
no clinical evidence for improvement in symptoms.
The BNF states there is a lack of evidence for the use of rubefacients in both
acute and chronic pain.
NICE do not recommend the use of rubefacients for the management of
12
Rubefacients are available as over-the-counter
products to patients to purchase or use alternative
topical NSAID products.
osteoarthritis.11
Not commissioned for prescribing.
Hepatitis B, Japanese encephalitis, tick-borne encephalitis, meningococcal
meningitis, rabies, tuberculosis and yellow fever are not available on the NHS for
the purposes of travel.22
Travel vaccine not
prescribable on the NHS
Hepatitis B is not available free of charge on the NHS for travel. Therefore the
combined hepatitis A and B vaccination should not routinely be given for travel
as travellers should be asked to pay for the hepatitis B component.
The combined hepatitis A and B vaccine may however be an option for children
under 3 years of age if clinically appropriate.
Vaccinations available on the NHS for travel are diphtheria, polio and tetanus
(combined booster), typhoid, hepatitis A and cholera. This is because these
diseases are thought to pose the greatest risk to public health if brought back
into the UK.
13
Patients should be charged privately for all travel
vaccines not prescribable on the NHS.
14
Appendix 2: List B - Drugs which are only recommended for prescribing in certain circumstances
The following drugs should not routinely be prescribed unless clinically indicated for the individual patient in certain circumstances (as detailed below).
Drug or Treatment
Rationale for inclusion in the Policy
Not commissioned for prescribing for new patients for long-term rate control prescribing only appropriate for existing patients if clinically appropriate.
Suggested alternative(s)
Amiodarone is no longer recommended by NICE for long-term rate control due to
its potentially fatal, long-term side effects. Digoxin is equally as effective.23
Amiodarone
Amiodarone is a treatment option:23
• for rhythm control in people with left ventricular impairment or heart
failure
• Pre (4 weeks) and post (up to 12 months) electrical cardioversion
• Pharmacological cardioversion in new onset AF
• People undergoing cardiothoracic surgery to reduce risk of post-op AF
Digoxin is first-line treatment option for long term
rate control.
Not commissioned for prescribing for new patients - prescribing only
appropriate for existing patients. Patients should be reviewed for alternative
treatments when appropriate.
Dosulepin
NICE CG90 for depression in adults states:
“Do not switch to, or start, dosulepin because evidence supporting its tolerability
relative to other antidepressants is outweighed by the increased cardiac risk and
toxicity in overdose.”24
Selective Serotonin Receptor Inhibitors (SSRIs) are
first-line.
Where non-SSRI antidepressants are
required, prescribers should follow the NICE
CG90.24
Previously included within the South Staffordshire Grey List - Drugs that should
not be prescribed in the South Staffordshire Health Economy.
Liothyronine
Only to be prescribed for clinically appropriate patients after specialist
initiation when levothyroxine not clinically effective.
15
Levothyroxine.
There is no robust clinical evidence on the use of liothyronine either alone or in
combination with levothyroxine and it is not licensed for long-term use.
There are some patients who can only achieve thyroid control with liothyronine
however these patients need to have been clinically assessed by a specialist.
The British Thyroid Association (BTA) has considered the evidence around L-T3
therapy, both alone and in combination with L-T4. The BTA advise that some
patients, who have unambiguously not benefited from L-T4, may benefit from a
trial of L-T4/L-T3 combination therapy. These patients should be supervised by
accredited endocrinologists with documentation of agreement after being fully
informed and have understood discussion of the uncertain benefits of treatment,
likely risks of over-replacements, potential adverse consequences and lack of
safety data.25
The BTA do not recommend the use of L-T3 (liothyronine) therapy alone as there
are no longer-term controlled clinical trials available which provide evidence to
support this treatment.
VSL#3 prescribable only accordance with ACBS for the specified conditions:
• For use under the supervision of a specialist/consultant for the
maintenance of remission of ileoanal pouchitis only in adults as induced
by antibiotics.
Probiotics
Capsaicin cream
(Rubefacients)
All other probiotics are classed as food supplements and are therefore
unlicensed products with no clinical evidence of effectiveness. They should
therefore be purchased as over-the-counter products and not prescribed on the
NHS.
Capsaicin cream – prescribe only in accordance with NICE guidance:
NICE states that capsaicin cream should be considered for people with localised
neuropathic pain who wish to avoid, or who cannot tolerate, oral treatments and
16
Purchase probiotics as over-the-counter products.
Purchase alternative over-the-counter products
or use topical NSAID products.
patches for neuropathic pain. It should only be used on the advice of a
specialist.12
The NICE Clinical Guideline (CG) for osteoarthritis states that topical capsaicin
should be considered as an adjunct to core treatments for knee or hand
osteoarthritis.11
17