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STANDARD OPERATING PROCEDURE

TO ENSURE PRESCRIBING IS COMPLIANT WITH NHS STOCKPORT CLINICAL COMMISSIONING GROUP POLICIES

(including black and grey lists)

NHS Stockport Clinical Commissioning Group will allow people to access health services that empower them to

live healthier, longer and more independent lives.

NHS Stockport Clinical Commissioning Group7th FloorRegent HouseHeaton LaneStockportSK4 1BS

Tel: 0161 426 9900 Fax: 0161 426 5999Text Relay: 18001 + 0161 426 9900 Website: www.stockportccg.org

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STANDARD OPERATING PROCEDURE TOENSURE PRESCRIBING IS COMPLIANT WITH NHS STOCKPORT CLINICAL

COMMISSIONING GROUP POLICIES

SUMMARYThe key objective of this SOP is to support Practices to comply with NHS Stockport Clinical Commissioning Group (CCG) & GMMMG policies which restrict the prescribing of some products in primary care. Such items should not be initiated without prior approval.

The SOP will also enable practices ; To ensure that the patient is provided with an adequate explanation for any change, that they

are supplied with an alternative product, if necessary, and that their confidentiality is respected. To make any necessary change successfully, in consultation with the patient, with as little

disruption as possible for both the patient and the practice. To ensure no unfunded drug or device is continued on without the approval of NHS Stockport

CCG.

SCOPE The work will cover all patients identified as taking or using products that are considered by NHS

Stockport CCG as unsuitable for prescribing at NHS expense (under a CCG policy e.g. treatment list or black list) or which the CCG allows to be prescribed under limited circumstances (grey list).

RESPONSIBILITIES The overall responsibility for completion of the necessary work lies with the GP Practice and

prescribing of unfunded or restricted products is subject to regular audit by practice based staff and/ or the Medicines Optimisation Team.

Medicines Co-ordinators are responsible for identifying patients taking/using such products and completing an authorisation sheet following receipt of relevant e-pact data. Once the patients have been reviewed and authorised by a prescriber, the co-ordinator may be responsible for carrying out the computer changes and for sending out appropriate letters informing patients that they will no longer receive the item or to invite patients for review. They will also annotate the patient record to ensure the drug is not re-started without CCG approval having been given.

A designated clinician or prescriber is responsible for making an assessment of the potential impact on the patient, whether any alternative product is required and ensuring the message is communicated in the best way possible to each patient.

The Lead GP is responsible for ensuring compliance with the policy and for ensuring that, where a patient is considered unsuitable for change, for ensuring an approval request to continue prescribing is submitted to Medicines Optimisation.

The Lead GP is also responsible for ensuring all prescribers are aware of policy restrictions including medical students, registrars and locums.

The Senior Partner/Practice Manager is responsible for highlighting inappropriate prescribing of items to relevant practice staff and for taking steps to ensure compliance with NHS Stockport CCG policy going forward. This is particularly important where Optimise Rx is in place and the message alerting to a breach in policy has been ignored by a prescriber.

Deliberate and continued breach of policy may be considered as excessive or inappropriate prescribing under the GP contract and will be raised with the Neighbourhood Leadership Team for consideration and action may be taken against the practice to re-coup the cost of unfunded items.

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RISK ASSESSMENTThere is no significant clinical risk associated with this program as all items have been considered by NHS Stockport CCG and are not considered suitable for prescribing either due to safety concerns, lack of evidence of clinical effectiveness or as there are more effective alternatives. Each item will be reviewed by a prescriber and clinically appropriate alternatives provided if necessary.Patients may be unhappy about the medication being stopped or changed and should be supported through this process. Patients with exceptional needs, different from the general population with the same condition, can be granted funding via the approval process. (See guidance section for details)

GUIDANCEThere are a number of Greater Manchester Effective Use of Resource (EUR) and NHS Stockport CCG policies that affect prescribing. The policies either restrict prescribing to limited circumstances or indicate that products should not be used in any situation. Examples of these policies include;

GMMMG Do not prescribe and grey lists NHS Stockport CCG black and grey lists NHS Stockport Treatment lists

Examples of items restricted under the last item would include Cosmetic treatment policies for both GM and NHS Stockport Erectile dysfunction treatments Homeopathic and herbal medicines

Separate SOPS are still in place for certain guidance to ensure compliance e.g. gluten free foods and nutritional supplement prescribing.

Products this SOP applies to are listed in Appendix 2 in 2 separate categories. Category 1 - Items which can be discontinued without and alternative product. Category 2 - Items where an alternative may be needed or some other action taken.

Applies to all grey listed medication where Protocol 2 should be applied.

Suggested alternatives and actions are provided for guidance but the reviewing clinician must use their own clinical judgement on the most appropriate action needed for an individual patient. All changes must be authorised by a prescriber.It is recognised that prescribing outside of policy does occasionally occur, even in the best practices. This may be inadvertent, due to lack of familiarity with a policy or because a new or revised policy now affects a product. Whatever the cause it is important to ensure such prescribing stops at the earliest opportunity after discovery, unless the clinician believes the patient has an exceptional need such that they would benefit far more than the general patient population with the same condition. If the patient is considered by the prescriber to be exceptional, approval must be sought from the CCG to continue the treatment. Please note that exceptionality cannot be evidenced until all clinically appropriate alternatives have been tried without success. It is vital that any request is supported by comprehensive information to evidence exceptionality and that all information requested in the request form is provided in full detail.

See CCG guidance on approvals for further details. Click here

The approval request form can also be found on the website Click hereApproval for a GP to prescribe any medication or device outside of policy must be submitted to the CCG in this way. Approval for procedures or non-drug therapies (click here) continues to be administered by the Effective Use of Resource Team at the shared service. Click here for further information. If in doubt as to whom approval should be sought from, please contact Medicines Optimisation at the CCG. [email protected]

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http://www.stockportccg.nhs.uk/about-us/treatment-available-on-the-nhs/

http://www.stockportccg.nhs.uk/download/1698/

http://stockportccg.org/gp-members-area/medicines-management/black-grey-list/

http://stockportccg.org/gp-members-area/medicines-management/black-grey-list/

THE PROCESS STAGESThe Practice Authorisation Form must be completed. The practice should identify the Lead GP for the SOP and details and who is responsible for each

step of the audit must be added to the form. The authorisation can remain in place until a new full version of the SOP is issued and does not

have to be re-authorised after each update of Appendix 2 (category lists) The Lead GP must be given the form to agree and must sign on behalf of the Practice. The practice medicines Co-ordinator (where one is available) or Medicines Optimisation Support

staff should sign the form if working under this SOP.

Protocols Patient medication changes can be managed by a standard letter process or by invitation to a

consultation as detailed in the SOP or as determined by the Lead GP. If a practice chooses an alternative process for making changes then a practice specific protocol

must be written and agreed with Medicines Optimisation Pharmacist supporting the practice.

Document Preparation Templates should be prepared for any letters that may be required and agreed by the Lead GP. A

generic change letter is provided plus a suite of template letters to support practices with appropriate communication for the most common changes. ( Appendix 1)

Practices should maintain a list of patients where approval to prescribed an unfunded item has been given and those who are taking a grey listed item within the specified criteria.

Informing staff involved All practice staff and contractors should be aware of NHS Stockport CCG policies and be familiar

with the products listed if they are responsible for initiating, authorising or issuing prescriptions. Local pharmacies have been made aware of the policy restrictions and have access to the

treatment, black and grey lists via the CCG website.

Searches for patients taking any highlighted unfunded item must be run Medicines Co-ordinators will be supplied with e-pact data on a regular basis. The data will identify

individual drugs prescribed by the practice Medicines co-ordinators should search on the clinical system to identify the patient receiving the

unfunded medication or device as acute or repeat prescription initially within current drugs. If the drug is not found in current drugs a search including prescribing of past drugs issued in the previous year may be used to trace the prescription. Deducted patients may also have to be considered to find the prescribed item.

Any items not found should be flagged to the Medicines Optimisation Team for further investigation. The searches run must contain all preparations listed on the e-pact searches provided though

individual drug searches may be run at different times. The search results should be printed off and saved for 2 years future reference in case of a query.

Authorisation sheets These sheets should be prepared by a Medicines Co-ordinator (either Practice based or provided

by the Medicines Optimisation Team). Sheets should identify the type of e-pact data that has highlighted prescribing e.g. Red Drug. Black

list or grey list, and list all patients receiving these items The reviewing clinician reviews each patient and indicates whether any alternative medication is

required, the template letter to be used or the need for a patient consultation. A prescriber must authorise the changes as per the Practice Agreement

Keeping a record.

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The printed list of patients identified from the computer search must be marked to show those patients that have been changed

Documentation containing patient information must not be removed from the practice Any documentation produced must be placed in a designated file held within the practice for a

minimum of 2 years

Safety. Should there be any doubt regarding patient records, please refer to the lead GP or a prescriber.

EXCLUSION CRITERIA Patients taking grey listed medications within the criteria specified can be subsequently excluded. Any patient, who has received authorisation to continue receiving an unfunded item on the grounds of

exceptionality, Any patient with a pending approval request awaiting a decision on exceptionality.

PROTOCOLS FOR CHANGESCategory 1- discontinuation – no alternative

A For Drugs in past medication list If the item has already been discontinued or has expired, i.e. is in past medication, it is

essential to ensure that it is not re-started. The drug should be re-instated and then deleted. Enter the reason for discontinuation as “NHS Stockport Unfunded item- DO NOT RESTART WITHOUT PRIOR CCG APPROVAL”

A read code of 66R7 (repeat medication stopped) must be added to the patient’s notes. A free text message of “Item previously discontinued and is an NHS Stockport Unfunded item - DO NOT RESTART WITHOUT CCG PRIOR APPROVAL” must be added along with details of the item removed.

There is no need to send a letter and the process stops here for items in past medication.

B Removing the old medication from current drugs Delete the unfunded product from current medication and enter the reason as “NHS

Stockport Unfunded item- DO NOT RESTART WITHOUT CCG APPROVAL” A read code of 66R7 (repeat medication stopped) must be added to the patient’s notes. A

free text message of “NHS Stockport Unfunded item discontinued- DO NOT RESTART WITHOUT CCG APPROVAL” must be added along with details of the item removed.

C Preparing the letter. A letter should be prepared with the practice’s details from the appropriate template.

( Numbered letters). Use letter 1 unless otherwise stated The patient’s name and address must be taken from the patient’s computer record when

preparing the letter. Add the date to the letter. An updated repeat medication slip should be included with the letter if possible. The letter

must be completed and placed in the addressed envelope or mailed to the patient electronically before moving on to the next patient.

Repeat the process A - C for each patient where necessary. Letters, if needed, must be produced on the same day as the computer record is changed.

Category 2 – Items for discontinuation with alternative or consultation to

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determine if any alternative medication is appropriateIf the medication is in past medication follow the process for Category 1.If in current medication an alternative may be needed. The reviewer may choose to offer an alternative by telephone or letter (Protocol 1) or the patient may be invited in for a routine consultation to discuss the way forward (Protocol 2)

For Either ProtocolBefore making any medication changes ensure you are familiar with the warning that may appear when adding the new medication. This warning is triggered by having the same class of medication on a drug list twice.This warning and ONLY this warning can be ignored. If any other warnings appear, it is not safe to continue making the change. If in any doubt, consult a prescriber.

Protocol 1 – changing a patient’s medication by letterA. Adding new medication

Make a note of any unexpected warning messages which appear and discuss with GP or prescribing advisor. Do not continue to add a medication until the warning has been assessed and you are advised it is safe to proceed.

The new medication must be added to the patient medication screen making sure that the correct strength from the signed authorisation sheets has been selected

The directions should be added as given on the authorisation sheet The number of repeats, where used, must be altered to match the number of repeats that

remain of the old medication, or to cover the period until the next medication review.

B. Removing the old medication When the new medication has been verified as correct and there is no alteration needed

then the old medication can be deleted. The reason for the medication being deleted should be added where possible; this must be

“NHS Stockport Unfunded item - DO NOT RE-INSTATE WITHOUT CCG APPROVAL” A read code of 66R5 (repeat medication changed) must be added to the patient’s notes. A

free text message of “NHS Stockport Unfunded Item - DO NOT RE-INSTATE WITHOUT CCG APPROVAL” must be added.

C. Preparing the letter A letter must be prepared using the appropriate template, letter B, using the practice’s

usual heading The patient’s name and address must be taken from the patient’s computer record when

preparing the letter. Add the date to the letter. The names of the old medication and the new medication must be stated on the letter. An updated repeat medication slip should be included with the letter if possible. The letter must be completed and placed in the addressed envelope or sent electronically,

before moving on to the next patient.

Repeat the process A-C for each patient where necessary. Letters must be produced on the same day as the computer record is changed.

Protocol 2 – Changing medication through consultation

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Telephone Consultations The reviewing clinician should contact the patient by telephone if possible to discuss and agree any

changes. Appropriate consultation notes should be added to record the content and outcome of the consultation. Changes should be managed and confirmed by letter as per Protocol 1 Using template Letter B if necessary.

Face to Face consultationWhere the reviewing clinician or authorising prescriber feels a face to face consultation is necessary, they should arrange for a routine appointment request to be sent to the patient.

Preparing the invitation letter The appropriate letter, Letter C, should be prepared requesting that the patient make an

appointment with the consulting clinician. The patient’s name and address must be taken from the patient’s computer record and the letter

must be printed and placed in the addressed envelope or mailed electronically before moving on to the next patient.

Log the date the letter is sent on Form A and the date changes will be made if the patient does not respond to the letter.

If the patient does not make an appointment by this date send the follow up letter prepared as above.

If the patient attends ensure the unfunded medication has been stopped and the appropriate reason added to the record. If it hasn’t reinstate and add the standard message as per Category 1.

If the patient attended but the medication was not stopped, alert the Lead GP and/ or prescribing adviser so action can be taken to resolve this situation.

Repeat this process for each patient as necessary.First Consultation The aim of the consultation is to engage the patient in the change process and gain concordance

and adherence. The patient’s concerns should be heard and addressed. Give the patient a prescription for a replacement product if needed. Agree what actions need to be taken if the patient has any concerns regarding the change. Determine if the patient needs to be seen again and if so book the necessary appointments.

If an agreement cannot be reached and the clinician believes the patient has an exceptional need and gains greater benefit than other patients with the same condition do, then an approval request should be submitted by the consulting clinician.

Patient DissentEvery patient should have their concerns listened to and addressed with clear statements of the reasons why their medication should not be prescribed at NHS expense. An approval request can only be submitted by a clinician where, in their clinical opinion, the patient is exceptional. This ensures that any approval request has the GPs full support and assures the CCG that the GP is happy to accept the responsibility for providing the medication long term if needed.If any patient approaches NHS Stockport CCG, seeking approval to have their GP continue prescribing medication, they will be referred back to their GP or to the Medicines Optimisation Pharmacist responsible for the patient’s practice.

Private prescriptions should not be provided by the patient’s NHS practice outside of the contractual framework permitted by the national GP contract, but the patient can seek to obtain the medication by a private consultation with another practice or private provider.

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For all PatientsIt is recognised that under any policy some patients may have exceptional circumstances making them different from the general population; examples of exceptionality would include situations where the individual would gain much higher benefit than that of a member of the average population, with the same condition.

Where a GP feels a patient is exceptional, an approval request should be submitted to the CCG via the Medicines Optimisation department. It should not be started without prior approval.

Where a medication has already been given by the GP for some time it may continue to be prescribed during the interval between submission of the approval request and a decision being communicated to the practice.

If the decision is that exceptionality has been demonstrated then prescribing may continue and the decision letter should be included in the clinical record as evidence of this. Where exceptionality has not been demonstrated the panel will inform the prescriber and prescribing of the medication for that patient should cease.

Failure to discontinue at this point may be deemed inappropriate prescribing by the NHS Stockport Clinical Commissioning Group and action may be taken to recoup the cost of the medication.

Prepared by: Liz BaileyDesignation: Medicines Optimisation Lead

Approved by: Dr Ranjit Gill Date: November 2016Designation: Clinical Lead

Full Review Date: November 2019

This will be within 3 years of last full approval. Amendments to this version, made as a result of changes to policies, agreed by STAMP and/or GMMMG will be made in Appendix 2 (Category lists) without a new version of the SOP being issued.

Updates

Version 1.1 April 17 2017 – Blacklist additions.GMMMG

Varsion 1.2 October 2017 - blacklist additions. GMMMG & Brands

Version 1.3 January 2018- Low priority for funding & brands blacklist changes

Version 1.4 April 2018 – Brands and GMMMG Changes

Version 1.5 May 2018 – Brands and GMMMG changes including Vaccines for travel

Version 1.6 Sept 2018 – Dicycloverine and Caprizine

Version 1.7 – Bath Emollients, Gluten free foods and longer Insulin needles

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Practice Authorisation Record of agreement for discontinuation of prescribed items not funded by NHS Stockport CCG without prior approval

Practice

I / We agree for a medicines Co-ordinator to identify patients receiving unfunded prescribed items and to implement authorised actions as detailed on the authorisation sheet.

I/ We agree that all identified products will be reviewed by (delete as appropriate)o A GP oro An Independent Non-Medical Prescribero A nominated member of practice or Medicine Optimisation staff

I/ We agree that all changes will be authorised by a prescriber which may be o A GP oro An Independent Non-Medical Prescriber

I / We agree that the practice will commit to complying with the CCG policies and guidance on prescribing

I / We agree that:Category 1 medicines are suitable for discontinuation with no alternative:Category 2 medicines will be discontinued and the patient provided with an alternative or contacted to determine the need for an alternative medication.

Frequency of review- Monthly following e-pact data being supplied by the CCG.

Lead GP on behalf of the practice

Name____________________ Signature___________________ Date_________

Medicines Co-ordinators (Practice based or CCG provided)

Name_____________________ Signature________________________ Date______

Name_____________________ Signature________________________ Date______

Medicines Optimisation Support Staff

Name__________________ Signature___________________ Date_________



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Data Collection Form for Practice

Date Data CollectedPatient’s name

& numberCategory

1/ 2 current or

past

Item to discontinue (inc form, strength & qty) or device and

date started

Dose Prescriber Authorised

Alternative item (inc form,

strength & qty)

Approval to be

requested

Protocol2 phone2 apt or

1

Date stopped &

initials

Letter sent

Monthly savings

£

e.g. John Smith 963258

Cat 2Current

Vitamin B Co Forte15.6.2015

Apply bd

None No 2 phone 1.6.16 LB LB

Shaded columns to be completed by GP or Prescribing Adviser

Recommendations made by (print name)……………………………….………………Signature………………………………………Date.….……….

Authorised by (print name & designation)…………………………………….………....Signature………………………………………Date……………

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Appendix 1

Sample letters to patients for adoption by practices

Changes to the letters in this appendix do not require re-authorisation of the SOP, only approval by the Lead GP and Medicines Optimisation Team

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Letter 1Category 1- Sample letter to Patients

Prescribers NamePractice Name

Street NameStockportPostcode

DatePrivate and ConfidentialPatient NameHouse Number and street nameTownPostcode

CHANGES TO YOUR MEDICATIONWe have been checking that all our prescribing is in line with guidance from NHS Stockport Clinical Commissioning Group (CCG) which advise on the range of medications and treatments it is able to support within current funding, guidance and safety information. NHS Stockport CCG along with other CCGs in Greater Manchester has a limited number of items it is unable to permit on NHS prescriptions and takes such decisions to ensure that high quality treatments which have a strong evidence base can be made available for the whole of Stockport’s population.

The medication we were prescribing for you was ………………………………………….. (add details of unfunded item).

We will not issue any further prescriptions for this medication and we do not consider that an alternative is needed.

The practice believes in providing the best medical care and advice for our patients according to the latest available evidence with regard to safety and benefit. The Doctors would like to thank you for your understanding and support of this decision.

Please do not hesitate to contact us and arrange to speak to the practice prescribing adviser or ………………………………….….if you have any queries.

Yours sincerely

Dr X and Partners

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Letter 2 Category 1- Sample letter to Patients Bath additives





The medication we were prescribing for you was ………………………………………….. (add details bath emollient).

In line with current guidance, we will not issue any further prescriptions for this product. Recent studies have shown that moisturising bath and shower products aren’t very effective, with very low quantities of emollient/ moisturiser being left on the skin. Using your standard emollient………………………………………….. (add details) instead of soap and rinsing it off during bathing works much better in adding moisture. If you require a larger quantity of your standard emollient to achieve this, please inform us so we can amend your prescription accordingly.

Our practice believes in providing the best medical care and advice for our patients according to the latest available evidence with regard to safety and benefit. The doctors would like to thank you for your understanding and support of this decision.


Yours sincerely

Dr X and Partner(s)

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Letter 3Category 1- Sample letter to Patients Bath additives





The medication we were prescribing for you was ………………………………………….. (add details bath emollient). This product contains an antimicrobial to kill off bacteria. Products like this are best used for a short time when your skin has an infection and not all the time. This si to help ensure that the antimicrobials we have keep working and so the bacteria do not develop resistance.

In line with current guidance, we will not issue any further prescriptions for this product. Recent studies have shown that moisturising bath and shower products aren’t very effective, with very low quantities of emollient/ moisturiser being left on the skin. Using your standard emollient………………………………………….. (add details) instead of soap and rinsing it off during bathing works much better in adding moisture. If you require a larger quantity of your standard emollient to achieve this, please inform us so we can amend your prescription accordingly.

Our practice believes in providing the best medical care and advice for our patients according to the latest available evidence with regard to safety and benefit. The doctors would like to thank you for your understanding and support of this decision.


Yours sincerely

Dr X and Partner(s)

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Letter 4:- On Gluten Free Products other than bread or flour.



DatePrivate & ConfidentialPatient NameHouse Number and street nameTownPostcode

CHANGES TO YOUR MEDICATION

We have been reviewing our prescribing of gluten free foods in preparation for reduced availability of gluten free foods at a national level. The Department of Health is making these changes very soon and we wanted you to be aware this is happening.

You are currently collecting

… ……… (please add a list of gluten free food(s) to stop).

This/ these (delete as appropriate) product/s has/have been removed from your prescription as they will no longer be available on prescription from the NHS.

Following a national consultation GPs can only prescribe a limited range and quantity of gluten free food to patients who have a specific diagnosis of gluten enteropathy (coeliac disease) or a related skin condition dermatitis herpetiformis. The available products will be limited to bread and flour. In future we can supply up to 8 loaves of bread every 2 months plus flour for you to make other foods, to supplement a diet that is naturally free of gluten or those gluten free foods you buy yourself. Loaves of bread will only be supplied with a single prescription for eight loaves every eight weeks if needed. An updated prescription request slip is enclosed so you can see what we can continue to prescribe for you. You should use this slip when you next request any prescription items.

Our practice believes in providing the best medical care and advice for our patients within the national framework. The doctors would like to thank you for your understanding in our making the required changes to your prescription.

If you have any queries regarding this change, please contact the surgery and arrange to speak to …………………………………. (a named person should be given)

Yours sincerely

On behalf of (Dr X and Partners)

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Form A for Category 2 itemsPractice

Patient’s name & number

Item (inc form, strength, dose & qty)

Offer alternative by letter (inc drug, form, strength, dose & qty)

Date Apt letter sent

Date for change to be made

Apt (date)Attended

Y / N

Item stopped

Monthly Savings

£E.g. Michael Mouse 22436

Co-codamol 15/500mg tablets 1-2 qds prn 150

Zapain 30/500mg tablets 1-2 QDS PRN 100

1.6.16 15.6.16 13.6.1Yes

Yes £10.37

Review completed by _________________________________ Designation_________________________________ Date_____________

Changes authorised by (print name) _________________________________________________________________ Date____________

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Letter BCategory 2 Protocol 1- Sample generic letter to Patients




Dear Ttl/ initial/name

CHANGES TO YOUR MEDICATIONWe have been checking that all our prescribing is in line with guidance from NHS Stockport which advise on the range of medications and treatments it is able to fund within the current funding, guidance and safety advice. NHS Stockport takes decisions to ensure that high quality treatments which have a good evidence base can be made available for the whole of Stockport’s population.

You are currently prescribed _____________ (add details of the unfunded item from the authorisation sheet) at a dose of ____________as detailed on the authorisation sheet)

We will prescribe this alternative for you in the future______________________ (add details of the alternative item from the authorisation sheet) at a dose of ____________________ (as detailed on the authorisation sheet)

Although this is different to your previous medicine, please do not worry, we have checked your records and selected this particular replacement for you in line with our usual prescribing practice.


Yours sincerely

Lead GPOn behalf of (Dr X and Partners)

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Letter CCategory 2 Protocol 2 - Sample letter to Patients





CHANGES TO YOUR MEDICATIONWe have been checking that all our prescribing is in line with guidance from NHS Stockport which advise us on the range of medications and treatments it is able to fund, taking account of current guidance, best practice and safety information. This advice is given to ensure that high quality treatments which have good evidence of improving outcomes are available for the whole of Stockport’s population. As a result of our most recent checks we are writing to inform you that we will not be able to continue to prescribe the item below and have removed it from your list of repeat prescription items.

The medication currently prescribed for you is…………………………………………… (add details of blacklisted medication)

We ask that you make a telephone appointment /routine non-urgent appointment with …………………………, (specify a person or role) so we can provide advice and discuss whether any possible alternatives to replace this medication are appropriate. Please attend this appointment before you have finished using all of the old medication.

The practice believes in providing the best medical care and advice for our patients according to the latest available evidence with regard to safety and efficacy. The Doctors would like to thank you for your understanding. Please do not hesitate to contact us and arrange to speak to the practice pharmacist or ………………………………..………….if you have any queries.

Yours sincerely

Dr X and Partners

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Letter DSample Letter to consultant



DatePrivate and ConfidentialConsultant NameTrust detailsRoadTownPostcode


Re: Patient name, DOB, Address etc.

We have been checking that all our prescribing is in line with local and regional policies and it has come to light that we have been prescribing ______________________________________ ( detail the medication and whether black/ grey listed) for the above patient outside of policy. ( give details of policy e.g. on the do not prescribe or grey lists or if NHSE funded)

We have been advised that we cannot continue to provide this medication in the long term and would be grateful if you could advise on and appropriate alternative medication/ action to meet the needs of this patient.

We propose to __________________ (give details of proposed action/ alternative)

If in your professional opinion there is no alternative we can request approval to continue to supply the medication on the grounds of exceptionality. If exceptionality is applicable in your view, we would appreciate it if you could support such an application by providing details of why this patient differs from the rest of the population who have the same condition, or why they would gain exceptional benefit compared to others.

We will of course continue to supply the medication in the interim and would appreciate a prompt response. If we have not heard from you within 28 days we will presume that you are in agreement with the proposed action/ medication alternative(delete as appropriate) and will proceed with the necessary changes.

Yours sincerely

Dr X and Partners

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Letter ESample letter to Patients – alendronate and vitamin D




Dear Ttl/ initial/nameCHANGES TO YOUR MEDICATION

We have been checking that all our prescribing is in line with guidance from NHS Stockport CCG which does not fund the use of branded Fosavance® tablets (also called alendronic acid 70mg + colecalciferol 70mcg). There is no evidence that Fosavance® is better than using alendronic acid 70mg alone, this is the reason for the change.

Our records show that you are a patient who uses this medicine.

When you take this type of medication you need to make sure you take enough calcium as well as Vitamin D to reduce the risk of osteoporotic fractures.

If you don’t feel you could do this by eating foods high in calcium (see information on foods high in calcium) please ask your doctor to prescribe a combined calcium and vitamin D supplement or you may wish to buy a supplement that you find more pleasant to take.

You are currently taking ………………………………………..

At a dose of ………………………………..

If this is not the case please let us know.

We would like you to start taking…………………………………………………

At a dose of………………………………………………..

Please remember to take this medicine 30 minutes before breakfast or any other medicines.

Please finish taking any old medication you currently have at home before ordering any of the new medication. If you have any problems when using this medication please contact us so we can look at adjusting your medication.

Please do not hesitate to contact us and arrange to speak to the practice pharmacist ……………………….or ……………………….if you have any queries.

Yours sincerely

Dr x and partners

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Letter FSample letter to Patients Calcium and vitamin D (incorrect proportions)





We have been checking that all our prescribing is in line with guidance from NHS Stockport which advise on the range of medications and treatments it is able to fund within the current funding, guidance and safety advice. NHS Stockport takes decisions to ensure that high quality treatments which have a good evidence base can be made available for the whole of Stockport’s. NHS Stockport do not recommend the use of Calcichew D3( delete or amend as appropriate or the equivalent Calcium carbonate 1.25g/colecalciferol 5mcg as it does not contain an adequate level of Vitamin D3 to reduce your risk of breaking a bone.

You are currently taking Calcichew D3 at a dose of 1 twice a day or 1 a day (delete or amend as appropriate)

We would instead like you to start taking Accrete D3 tablets/ Adcal D3 Caplets/ Calfovit D3 sachet (Delete as appropriate) at a dose of one tablet or two caplets caplets twice a day/ one sachet in the morning (delete as appropriate).

This new medication has a large amount of evidence to show that it reduces your risk of a bone fracture and maintaining bone health.

For you to get the most benefit from either your old medication or this new one it is important that you take it regularly, as missing doses can reduce its effectiveness.

Please finish taking any old tablets/capsules you have at home before starting the new tablets/sachets (delete as appropriate).


Yours sincerely

Dr x and partners

21

Letter GProtocol 1- Sample letter to Patients





We have been checking that all our prescribing is in line with guidance from NHS Stockport which advise on the range of medications and treatments it is able to fund within the current funding, guidance and safety advice. NHS Stockport takes decisions to ensure that high quality treatments which have a good evidence base can be made available for the whole of Stockport’s population.

You are currently taking Co-codamol 15/500mg tablets or Kapake 15/500mg tablets or Codipar 15/500mg caplets (delete as appropriate) at a dose of please add.

We would instead like you to start taking Paracetamol 500mg tablets at a dose of ……………… (give new directions).

Delete if not required Plus, Codeine Phosphate 15mg tablets at a dose ………. ( give direction from data collection sheet ). OR Co-codamol 8/500mg (delete as appropriate) at a dose of ……………….

This/These medication/s (delete as appropriate) has/have a large amount of evidence to show that it gives the same benefits as your current medication but offers greater flexibility in dose adjustment. There is a large body of evidence to show that your new medication is safe and as effective as your old medication.

For you to get the most benefit from either your old medication or this new one it is important that you take it regularly if you have chronic pain, other users may find it appropriate to use when required.

Please finish taking any old tablets/ capsules you have at home before starting the new tablets/ capsules.


Yours sincerely


22

Letter HProtocol 1- Sample letter to Patients - co-codaprin






We have been checking that all our prescribing is in line with guidance from NHS Stockport which advise on the range of medications and treatments it is able to fund within the current funding, guidance and safety advice. NHS Stockport takes decisions to ensure that high quality treatments which have a good evidence base can be made available for the whole of Stockport’s population

You are currently taking Co-codaprin (Codeine phosphate 8mg & Aspirin 400mg) tablets at a dose of…………….. (please add current dose from records).

We would instead like you to start taking ( Please add medication choice from data collection sheet ) ……………………….tablet/ capsules at a dose of (add from data collection sheet)……………… (give new directions).

This/These medication(s) has/have a large amount of evidence to show that it gives the same benefits as your current medication but offers greater flexibility in dose adjustment. There is a large body of evidence to show that your new medication is safe and as effective as your old medication.

For you to get the most benefit from either your old medication or this new one it is important that you take it regularly if you have chronic pain, other users may find they can take pain relief when required.



Yours sincerely


23

Letter ISample letter to Patients for alternative – ear wax removal products






We have been reviewing your medication in line with guidance from Stockport CCG which does not fund the use of certain products for the removal of ear wax. As a result of this the doctors are changing your medication to an alternative which will have similar benefits. These alternative drops will soften ear wax to aid its removal and have a large amount of evidence to show that they are equally effective when used as suggested.

You have previously been prescribed (add in name of product).................................. with the instructions to (add directions).............................................................

Should you need help with ear wax removal again we would like you to request (Insert name of product as chosen by GP from formulary)…………….drops. These have been added to your medication list and should be used (insert direction)..........for………….days.

To get the best effect from each application of your ear drops you should instil a generous amount of the drops into the affected ear and after application lie with the treated ear uppermost for 5 to 10 minutes to allow the drops to penetrate. Repeat this process with the other ear if necessary.

Please finish using any old medication you currently have at home before ordering any of the new medication. We are confident this medication will be equally effective but if this is not your experience please let us know so we can consider alternatives to help you with this problem.

The Doctors at the practice believe in providing the best medical care and advice for their patients based on the latest available evidence relating to safety and effectiveness. The Doctors would like to thank you for your understanding. Please do not hesitate to contact us and arrange to speak to the practice pharmacist ……………………….or ……………………….if you have any queries.

Yours sincerely

Dr x and partners

24

Questions often asked about ear wax- A leaflet for patientsWhat is ear wax?

Ear wax is a perfectly natural secretion of fats and oils produced in the outer ear. Its scientific name is cerumen. The wax in your ear also contains dead skin, hair and dust and debris from the world outside, which may sound unpleasant, but is perfectly healthy and normal.

Why is it there?

Ear wax keeps the lining of the ear canal moist and helps to keep the ear clean. It is continually being moved outwards by lots of little hairs acting like a conveyor belt and is removed by normal washing. You probably won’t even know it’s there. It is only when a hard plug forms and starts causing you discomfort that you need to do anything about it.

What does it do?

Sometimes excessive wax is produced and this can gradually form a plug in the outer ear canal outside the eardrum. That’s why deafness and a blocked feeling in the ear are the most common symptoms. Sometimes earache develops as well and occasionally tinnitus – a ringing in the ears.

Who suffers from excessive ear wax?

Anyone can suffer from a build-up of wax in the ear – young or old people from most ethnic groups, people who live in the country or the town. However, it’s more likely to occur the older you get. And men tend to suffer more often than women.

How common is this problem?

Impacted wax is a common problem seen in the doctor’s surgery. It’s been with us as long as we’ve been on the planet. The ancient Egyptians used a mixture of olive oil, frankincense and salt to alleviate it. All sorts of other concoctions have been used over the centuries. Today, this common problem is easily treated.

How do you treat it?

Removal of wax can often be achieved by simply softening the wax with olive oil. You can buy a “dropper” bottle of olive oil from your chemist;

Lie with your head on a pillow, affected ear uppermost Drop 2 or 3 drops of warm olive oil (room temperature) into the ear canal Stay lying down for at least 5 minutes - the longer the better Get up and wipe away excess oil DO NOT leave cotton wool at the entrance to the ear, this will absorb the olive oil and reduce its effect Repeat the procedure with the opposite ear if necessary Repeat the procedure for at least 7 days prior to irrigation. By using the drops up to 3 times a day for up to 3 weeks the wax can sometimes be softened sufficiently

for irrigation not to be necessary.

How to take care of your earsNever insert anything into your ear. Objects like matchsticks, hairpins, paperclips or even cotton buds can

do serious damageCover your ears if you are working in a dusty environmentKeep your ear canals dry. Use ear plugs when you are washing your hair, putting your head under water, showering or swimming

To prevent an unnecessary build-up of ear wax you are advised to use olive oil once a weekSee your GP, Practice Nurse, District Nurse or Treatment Room Nurse if the problem persistsTell your GP, Practice Nurse, District Nurse or Treatment Room Nurse if there is a previous history of the problem or if you have had an ear operation or perforated ear drum

See your GP if you are worried about any problems with your hearing

Letter J -Sample letter to Patients -Vitamin B12

25



DatePrivate and ConfidentialPatient NameHouse Number and Street NameTownPostcode



We have been checking our prescribing is in line with advice from NHS Stockport and the National Institute for Clinical Excellence who recommends the use of Hydroxocobalamin for Vitamin B12 deficiency and/or anaemia (low numbers of red blood cells in the blood).

You are currently prescribed Cyanocobalamin 50mcg tablets/ liquid 35mcg/5ml / injection 1mg/1ml at a dose of (Please specify dose on repeat prescription)

We would instead like you to start having Hydroxocobalamin 1mg/1ml injection at a dose of One ampoule to be injected every (add directions indicated by GP from data collection sheet).

This drug has a large amount of evidence to show that it will have the same benefits at the dose prescribed but needs to be given less often. Cyanocobalamin can no longer be prescribed within NHS Stockport.

We would like you to make an appointment at the surgery for a blood test 8 weeks after changing.


Yours sincerely


Letter L

26

Doxazosin MR 8 or 4mg tablets template change letter Prescribers Name

Practice NameStreet Name

StockportPostcode

DatePrivate and confidentialPatient NameHouse Number and street nameTownPostcode



You are currently taking ……………………………………….. (add drug name as it appears on current prescription) at a dose of ……………………………….. (add dose as it appears on).


We would like you to start taking……………………………………… (add drug name as it appears on authorisation sheet) at a dose of................................. (add dose as it appears on authorisation sheet).

For the standard release version of the tablet, 1mg is equivalent to a 2mg dose of the slow release tablets. So change in the amount you take should still give the same benefits.


If taken for hypertension add the following paragraphAs this is a change to your blood pressure medication, we would like to check your blood pressure a few days after you start the new medication, this is to make sure that the dose is correct for you and that the medication is working as we expect.

Please do not hesitate to contact us and arrange to speak to ……………………….if you have any queries.

Yours sincerely

Lead GP on behalf ofDr x and partnersLetter M

27

Gliclazide MR 30mg tablets template change letter Prescribers Name


StockportPostcode




You are currently taking ………………………………………..

at a dose of ………………………………..


We would like you to start taking…………………………………………………

at a dose of………………………………………………..

In the standard release version of the tablet, 80mg is equivalent to a 30mg dose of the slow release gliclazide. So this is NOT an increase in your dosage, it should give the same control of your blood sugar.


As this is a change to your diabetic medication, we would like you to make an appointment for an HbA1c blood test about 8-12 weeks after you start the new medication, just to ensure the new medication is working as we expect.

Please do not hesitate to contact us and arrange to speak to ……………………….if you have any queries.

Yours sincerely

Dr X and partners

Prescribers NameLetter N Protocol 1- Sample letter to Patients – MR iron

28


StockportPostcode

Date

Private and ConfidentialPatient NameHouse Number and street nameTownPostcode



We have been reviewing medication following advice from NHS Stockport which recommends the use of Ferrous Fumarate for low iron levels.

You are currently taking … ………mg tablets/capsules. at a dose of…………………. (add dose).

We would instead like you to start taking Ferrous Fumarate at a dose of ……………… (give new directions).

This drug has a large amount of evidence to show that it restores iron levels as effectively, if not more, as your current treatment, with no additional side effects.

For you to get the most benefit from either your old medication or this new one it is important that you take it regularly, as missing doses can mean your iron levels will not adjust as quickly and you will need to take the medication for longer.



Yours sincerely


29

Letter O Sample letter to Patients - Cetirizine Prescribers Name


StockportPostcode

Date




We have been reviewing your medication in line with new guidance from NHS Stockport which recommends the use of Cetirizine for all patients currently taking the antihistamine Levocetirizine (Xyzal®). This alternative drug has a large amount of evidence to show that it is equally effective at the dose prescribed and we have more evidence of safety in a large variety of patient groups as Cetirizine has been available for a greater length of time. Levocetirizine (Xyzal®) should not be prescribed within NHS Stockport.

In order to maintain our NHS services in Stockport we need to work together to make the most of the resources we have. The NHS needs your help and support to make changes now. By changing to this different but equally effective medication you can help your local health service to release money to maintain other services in the current difficult financial situation we all face.

You are currently taking Levocetirizine (Xyzal®) 5mg tablets/solution at a dose of ………………… ( add dose )

We would like you to start taking Cetirizine 10mg tablets/syrup, at the equivalent dose of ………………… (add dose)

Please finish taking any old medication you have at home as required before ordering any of the new medication.

The Doctors at the practice believe in providing the best medical care and advice for their patients based on the latest available evidence relating to safety and effectiveness. The Doctors would like to thank you for your understanding. Please do not hesitate to contact us and arrange to speak to the practice pharmacist …………………………………. (a named person should be given).

Yours sincerely


30

Letter P Sample letter to Patients - Midrid Prescribers Name


StockportPostcode




We have been reviewing your medication in line with guidance from NHS Stockport which do not fund Midrid® capsules or its generic equivalent.

You are currently taking Midrid® Capsules at a dose of ………………………………………….

Instead, we would like you to start taking……………………. (insert name of new medication)

at a dose of …………………………………………..insert dose as given on authorization sheet,.

We are confident this medication will be equally effective but if this is not your experience please let us know so we can review your current symptoms and new medication to ensure you have satisfactory pain relief.

Please finish taking any old tablets/ capsules you have at home before starting the new tablets/ capsules (amend as necessary).

Should you wish to continue taking Midrid® capsules in preference to the alternatives the GPs can prescribe you may choose to buy them from your local pharmacy.

If you have any queries regarding this change, please contact the surgery and arrange to speak to …………………………………. (Practice pharmacist) or ……………………………….. (GP Prescribing lead)

Yours sincerely


31

Letter Q - Sample letter to Patients taking Migraleve Yellow






We have been reviewing medication following advice from NHS Stockport which recommends the use of Co-Codamol 8/500mg for migraine.

You are currently taking Migraleve Yellow at a dose of…………………. (add dose from patient records).

We would instead like you to start taking Co-Codamol 8/500mg tablets at a dose of two tablets up to four times a day when required. In common with all tablets containing paracetamol there is a maximum dose of 8 tablets in 24 hours.

This active medication is the same as that contained in Migraleve Yellow tablets. It should be just as effective as your current treatment.

Please finish taking your current supply of tablets you have at home before starting or ordering the new tablets.

If you have any queries regarding this change, please contact the practice and arrange to speak to …………………………………. (a named person should be given).

Yours sincerely


32

Letter R - Sample letter to Patients taking Migraleve Pink Prescribers Name


StockportPostcode



We have been reviewing a number of medications following advice from NHS Stockport which recommends the use of Co-Codamol 8/500mg for migraines, if the more usual treatments recommended by NICE have not been effective.

You are currently taking Migraleve Pink tablets at a dose of…………………. (add dose from patient records).

We would instead like you to start taking Co-Codamol 8/500mg tablets at a dose of two tablets up to four times a day when required. In common with many tablets containing paracetamol there is a maximum dose of 8 tablets in 24 hours.

This pain relief medication is the same as that contained in Migraleve Pink tablets. It should be as effective as your current treatment.

Add following if anti-emetic is prescribed

Migraleve Pink also contain a medicine to reduce the nausea/vomiting you experience due a migraine attack. We would also like you to start taking a medication called (add anti-emetic indicated on data collection sheet) at a dose of (add dose specified on data collection sheet). This medication will help to reduce the nausea you experience during a migraine attack.

Please finish taking your current supply of tablets you have at home before starting or ordering the new tablets.


Yours sincerely


33

Letter S - Orlistat- Sample letter to Patients Prescribers Name


StockportPostcode

Date



CHANGES TO YOUR MEDICATIONWe have been reviewing medication in line with guidance from NHS Stockport and the National Institute for Health and Clinical Excellence (NICE). In Stockport the recommendations are that a range of methods are tried to help people manage their weight and that medication is only alongside other measures as a last resort.

The medication used is called Orlistat. It has a number of side effects and is of limited benefit in helping people change their food and exercise habits and so is only used on the advice of the Stockport Weight Management Service. They also advise us that if Orlistat treatment appears to be ineffective i.e. less than initial 5% of body weight lost in first 12 weeks and weight loss not noted at every monthly review, then the medication should be stopped as it hasn’t worked.

Following a review of your medical records we have decided to discontinue your prescription for Orlistat with immediate effect. Please finish your current supply then continue to follow lifestyle advice in order to increase or maintain your weight loss.

The Doctors at the practice believe in providing the best medical care and advice for their patients based on the latest available evidence relating to safety and effectiveness.


Yours sincerely


34

Letter T -Sample letter to Patients Tramacet Prescribers Name


StockportPostcode

Date

Private and ConfidentialPatient NameHouse Number and Street NameTownPostcode


CHANGES TO YOUR MEDICATIONHere at the practice we have been reviewing medication following advice from NHS Stockport which recommends the use of Paracetamol 500mg tablets and Tramadol 50mg capsules when required (delete if not required) in place of Tramacet® (Tramadol 37.5/Paracetamol 325mg) tablets.

You are currently taking Tramacet® (Tramadol 37.5mg/Paracetamol 325mg) tablets at a dose of…………….(add dose).

We would instead like you to start taking Paracetamol 500mg at a dose of two tablets up to FOUR times a day (amend if new directions differ on data collection sheet).

Add if additional analgesia indicated on data collection sheet

We would like you to take Tramadol 50mg capsules at a dose of one capsule up to four times a day when required. The maximum recommended dose is a limit of four in 24 hours.

This medicine has a large amount of evidence and is the preferred analgesia pain killer across Stockport. It is also well tolerated and safe to use.

For you to get the most benefit from either your old medication or this new one it is important that you take it regularly.

Please finish taking any old tablets/capsules you have at home before starting the new tablets/ capsules.


Yours sincerely

Lead GP

On behalf of (Dr X and Partners)

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Letter V -Sample letter to Patients on 5mg or 2.5mg e/c tablets to plain Prescribers Name


DatePrivate and ConfidentialPatient NameHouse Number and street namePostcode


CHANGES TO YOUR MEDICATIONWe have been reviewing medication following advice from NHS Stockport Clinical Commissioning Group who recommends the use of plain prednisolone tablets. As a result of this we have changed your future prescriptions to the plain uncoated prednisolone 5mg or 2.5mg tablets. The tablets are white so may look different to your existing ones which are usually red or brown, however the strength and dose remain the same and you should not notice any difference in effect. If you do notice any difference in benefit or develop new side effects contact the surgery to discuss with your usual doctor.

You are currently taking (add current medication name here as per authorization sheet include e/c (enteric coated or gastro resistant)… (add strength here) mg tablets) at a dose of (add dose/ directions).

We would instead like you to start taking Plain prednisolone (add new strength) tablets at a dose of. (Add dose /directions as per authorization sheet).

ADD THE TEXT BELOW FOR PATIENTS WHO NEED TO HAVE A PPI ADDED AND CHECK WORDING OF EACH LETTER FOR EACH PATIENT WITH YOUR LEAD GP or PRESCRIBING ADVISER TO ENSURE THE CORRECT REASON FOR ADDING A PPI IS CORRECTLY INDICATED. If no PPI is added omit this section.

We also note –add one or more of the following as appropriate; –1. that you are currently receiving a type of medication which can irritate the stomach and/or

2. that you have been taking prednisolone regularly for more than 30 days and/or

3. that you are aged 65 years or above (the risk of developing gastro intestinal side effects to medication is higher in this group of patients) and/or

4. that you have a history of peptic ulcer disease/gastro intestinal bleed

and would therefore like to offer you a medication which protects your stomach. We have added omeprazole 20mg capsules or lansoprazole 15mg capsules (delete as appropriate) to your list of repeat medicines; you should take one capsule each morning. Please also order these when you next order your repeat medications.

This change is in line with practice prescribing policy, if you have any queries please feel free to contact the surgery to discuss them.

Yours sincerely


36

Letter WProtocol 1- Sample letter to Patients






We are reviewing all our patients who take Spatone® following advice from NHS Stockport. Spatone® has very little evidence to show any benefit from using and the content of iron it provides is far below the current recommended levels.

You are currently taking Spatone® at a dose of…………………. (add dose).

We would instead like you to start taking ………… (please add drug and dose indicated on data collection sheet) at a dose of ……………… (give new directions).

This drug has a large amount of evidence to show that it works well. It usually can be taken without problems but occasionally may cause gastrointestinal irritation.

For you to get the most benefit from either your old medication or this new one it is important that you take it regularly, as missing doses will increase the length of time that you have to remain on iron supplements.

Include for those patients who require a follow up blood test

We would like you to make an appointment to have a blood test in 8- 10 weeks’ time following the medication change. This will allow us to decide how long you have to remain on iron supplements.


Yours sincerely


37

Letter X Sample letter to Patients – Nail Paints Prescribers Name


StockportPostcode




We have been reviewing medication following advice from NHS Stockport Clinical Commissioning Group which have reviewed current guidance and no longer recommends the general prescribing of topical nail paints for fungal nail infections.

You are currently using … ………nail paint/lacquer.

These nail paints are not very effective compared to oral treatments. The paints can be inconvenient to use and have to be used regularly for many months. They can now only be prescribed in limited circumstances e.g. patients with diabetes or peripheral vascular disease.

For these reasons we have decided to stop prescribing … ………nail paint/lacquer.

These products can be purchased at local pharmacies. If you wish to continue using them we suggest that you speak to the pharmacy staff which will be happy to help.

If you have any queries regarding this change, or your condition has worsened, please contact the surgery and arrange to speak to your usual GP or _____________.

Please find enclosed a leaflet on the management of nail infections that you may find useful.


Yours sincerely


38

Fungal Nail InfectionsFungal infection of nails is common. The infection causes thickened and unsightly nails which sometimes become painful. Medication often works well to clear the infection, but you need to take medication for several weeks.

Who gets fungal nail infections?Between 3 and 8 out of 100 people in the UK will have a fungal nail infection at some stage of their lives. Toenails are more commonly affected than fingernails. It is more common in people aged over 55, and in younger people who share communal showers, such as swimmers or athletes.

How do you get a fungal nail infection? Spread from a fungal skin infection. For example, athlete's foot is a fungal skin infection of the toes. This

may spread to the toenails if the skin infection is not treated early. Fingernail infection may occur after a toenail infection has become established. The fungus may spread

to a finger if you scratch your itchy toes and toenail. Fingernail infections are also more likely to occur if you wash your hands frequently, or have them in

water a lot. For example, if you are a cook or a cleaner. Constant washing may damage the protective skin at the base of the nail. This may allow fungi to enter.

A nail that has recently been damaged is also more likely to become infected. You have an increased risk of developing a fungal nail infection if you have various other conditions. For

example: diabetes, psoriasis, poor circulation, a poor immune system (for example, if you have AIDS or are on chemotherapy), or a general poor state of health.

Nail infections are more common in people who live in hot or humid climates. Smoking also increases the risk of developing a nail infection. In some cases there is no apparent reason. Fungus germs (fungi) are common and an infection can

occur 'out of the blue'.

What are the symptoms of a fungal nail infection?Often the infection is just in one nail, but several may be affected. At first the infection is usually painless. The nail may look thickened and discoloured (often a greeny-yellow colour). Commonly, this is all that occurs and it often causes no other symptoms. However, it can look unsightly.

Sometimes the infection becomes worse. White or yellow patches may appear where the nail has come away from the skin under the nail (the nailed). Sometimes the whole nail comes away. The nail may become soft and crumble. Bits of nail may fall off. The skin next to the nail may be inflamed or scaly. If left untreated, the infection may eventually destroy the nail and the nailed, and may become painful. Walking may become uncomfortable if a toenail is affected.

The website www.dermnetnz.org/fungal/onychomycosis.html has pictures of fungal nail infections.

Do I need any tests?Other nail conditions can sometimes look like a fungal infection. Therefore, to confirm the diagnosis, a doctor will usually take a nail clipping and send it to the laboratory for testing.

What is the treatment for a fungal nail infection?Not treating

This is an option if the infection is mild or causing no symptoms. For example, a single small toenail may be infected and remain painless and of little concern. Some people may prefer not to take treatment because: Treatment does not always cure the infection. Cure rates are about 60-80%. Treatment that clears the infection does not always restore the nail's appearance to normal. The antifungal medicines used for treatment need to be taken for several months - sometimes longer. Although rare, unpleasant side-effects sometimes occur with antifungal medicines.

39

The option to treat can be reviewed at a later date if the infection becomes worse or if you change your mind.

However, treatment is usually advised if: Symptoms are troublesome. For example, if walking is uncomfortable due to an affected nail. You have diabetes, vascular disease or a connective tissue disorder (because of a higher risk for

secondary bacterial infections and cellulitis). The nail infection is thought to be the source of a fungal skin infection on your body. You have, or are likely to develop, severe problems with your immune system. For example, if you are to

have certain types of cancer treatment.

MedicationAntifungal tablets will often clear a fungal nail infection. The medication will also clear any associated fungal skin infection, such as athlete's foot. Your doctor will usually recommend one of the following two medicines. The one chosen may depend on the type of fungus causing the infection. Both of these medicines cause side-effects in a small number of people, so read the packet that comes with the medicine for a full list of cautions and possible side-effects.

Terbinafine tablets. The usual adult dose is 250 mg once a day; for between 6 weeks and 3 months for fingernails, and for 3–6 months for toenails. Visible improvement can be expected after the end of two months of treatment for fingernails and three months of treatment for toenails.

Itraconazole tablets. This is usually given as pulsed treatment. That is, for an adult: 200 mg twice a day for one week, with subsequent courses repeated after a further 21 days. Fingernail infections require two pulsed courses and toenail infections require at least three pulsed courses.

Studies suggest that in about 5 in 10 cases the nail will look fully normal again after treatment. In about a further 2 in 10 cases the fungus will be cleared from the nail after treatment, but the nail does not look fully normal again. Fingernails tend to respond better to treatment than toenails do. One reason for treatment to fail is because some people stop their medication too early.

Antifungal nail paint (nail lacquer)A nail lacquer that contains the antifungal medicine amorolfine is an alternative for most (but not all) types of fungi that infect nails. You can buy amorolfine nail lacquer from pharmacies as well as getting it on prescription. However, this tends not to work as well as medication taken by mouth. Your doctor will advise if it is a suitable option for your type of infection. For example, it may be useful if the infection is just towards the end of the nail. This treatment does not tend to work so well if the infection is near the skin, or involves the skin around the nail.

The nail lacquer has to be put on exactly as prescribed for the best chance of success. You may need six months of nail lacquer treatment for fingernails, and up to a year for toenails.

Tioconazole is another solution that can be applied to the nail. It can also be bought from a pharmacy, although research trials suggest it does not work as well as amorolfine.

Nail removalIf other treatments have failed, an option is to have the nail removed by a small operation done under local anaesthetic. This is combined with treatment with antifungal medication.

Newer optionsResearch is looking at newer methods of treating fungal nail infections. These include laser treatment and ultrasound. Initial results are positive but more evidence is needed about the long-term results of the treatments.

What to look out for with treatmentThe fungi that are killed with treatment remain in the nail until the nail grows out. Fresh, healthy nail growing from the base of the nail is a sign that treatment is working. After you finish a course of treatment, it will take several months for the old infected part of the nail to grow out and be clipped off. The non-infected fresh new nail continues growing forward. When it reaches the end of the finger or toe, the nail will often look normal again.

40

Fingernails grow faster than toenails, so it may appear they are quicker to get back to normal. It may take up to a year after starting treatment before toenails look completely normal again and six months for fingernails to look completely normal.

Consult a doctor if there does not seem to be any healthy new nail beginning to grow after a few weeks of treatment. However, the infection can still respond to treatment even after you finish a course of medication. This is because the antifungal medication stays in the nail for about nine months after you stop taking medication.

What can I do to help?

Take medication as directed, and do not give up without discussing this with a doctor.

Side-effects are uncommon with modern medication, but tell a doctor if you notice any problems with treatment.

Tips on nail care if you have a nail infection, with or without taking medication, include the following:

Keep your nails cut short, and file down any thickened nail. Use a separate pair of scissors to cut the infected nail(s) to prevent contaminating the other nails. Do not

share nail scissors with anyone else (for the same reason). Avoid injury and irritants to your nails. For example, if fingers are affected, use cotton and vinyl gloves

for wet work. Use heavy cotton gloves for dry work. If toenails are affected, wear properly fitted shoes with a wide toe box. Keep your feet cool and dry as much as possible.

Preventing fungal nail infectionsStudies suggest that in about 1 in 4 cases where the infection has been cleared from the nail, the infection returns within three years. One way to help prevent a further bout of nail infection is to treat athlete's foot as early as possible to stop the infection spreading to the nail. Athlete's foot is common and may recur from time to time. It is easy to treat with an antifungal cream which you can buy from pharmacies, or get on prescription. The first sign of athlete's foot is itchy and scaling skin between the toes. See separate leaflet called Athlete's Foot (Tinea Pedis) for further detail. Also:

Try to avoid injury to nails, which may increase the risk of developing a nail infection. Wear footwear such as flip-flops in public places, such as communal bathing/shower places, locker

rooms, etc. Avoid towel sharing. Consider replacing old footwear, as this could be contaminated with fungal spores.

This leaflet is provided by Patient UK & has been copied from the NHS choices website

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Category 1It is recommended that the following items, as brand or generic (unless otherwise stated) can be discontinued without an alternative preparation being offered. Use template letter 1 unless otherwise indicated belowAll Herbal productsAll Homeopathic productsAloe Vera GelAnhydrol forte (unless prior to botulinum therapy as per EUR policy)Arnica Cream or GelBath emollients e.g. Oilatum (Letter 2)Bath emollients with antimicrobials e.g Dermol (Letter 3)Benzyl benzoate preparationsBCG Vaccine for TravelBioXtra® toothpaste & mouth rinse – advice to seek dental practitioner advice if needed.Bimatoprost 0.03%)eye drops (Latisse® only this strength as for cosmetic purposes)Blepharitis relief products –advice on lid hygiene See NHS advice on lid hygiene Click hereCalamine preparations including specially manufactured productsCo-enzyme Q 10 preparations (unless for mitochondrial disorders under the care of a specialist)Cod Liver Oil preparationsCough preparations ( for suppression, expectoration or as a demulcent) including codeine and simple linctus, pholcodine, dextromethorphan and diamorphineDietary supplements for eye health – can be bought OTCDriclor® productsEflorithine Cream (Vaniqa®) – any approval request requires supporting photographs showing growth after 48 hours without shaving- seek advice from medicines optimisation and mange via protocol 2)Evening primrose oil preparationsFinasteride 1mg preparationsFlexitol® Hand Balm and Skin BalmFluoride mouthwashes e.g., Fluoriguard®

Gamolenic acid preparationsGlucosamine (all salts and combination products)Gluten Free Foods other than Bread and Flour (Letter 4)Hepatitis B vaccines for travel purposesIcaps® ( all preparations)Idoxuridine in dimethyl sulfoxideInosine PanobexInsecticidal cream shampoos and cream rinses (not lotions)Inositol preparationsJapanese Encephalitis vaccination for travelKaolin PreparationsLactase Drops ( Colief ®)Lanolin Cream (Lansinoh ® HPA)Lid care preparations – provide hygiene advice See NHS advice on lid hygiene Click hereMacule® EH preparationsMacushields ® preparationsMeningitis ACWY vaccination for travelMinoxidil lotionsMolludab® (potassium hydroxide 5% solution)Moxisylyte

Appendix 2Category ListsLast updated November 2016 to align with the current black and grey list

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http://www.nhs.uk/Conditions/Blepharitis/Pages/Treatment.aspx

http://www.nhs.uk/Conditions/Blepharitis/Pages/Treatment.aspx

Category 1Occuvite® PreservisionOcuvite® luteinOral atropine preparationsOscillating positive expiratory pressure devicesPentoxifyllinePollinex® preparations – review symptom reliefPotassium aminobenzoatePreservision® luteinRabies vaccination for travelRESPeRATE® deviceRowacholRowatinexRutosides (Paroven®)Rubefacients (topical)Rybarvin® InhalantSilicone keloid dressings and gels including

Advasil® Conform BAP scar Care® all preps Cica-Care® products Ciltech® products Dermatrix® products Kelo cote® products Mepiform® products New-Gel® + products Scar Fix products Silgel ® app preparations

Silk Garments for adults or childrenStarflower oil preparationsStoma Deorourant productsSunscreen products (only ACBS approved products for an ACBS approved indication)Tempe® SprayTherabiteTick-borne encephalitis vaccination for travelTopical antihistamine productsVaniqa ®

Visionace® productsVitamin B Compound Forte (unless on dietetic advice to prevent re-feeding syndrome)Vitamin B compound (unless on dietetic advice to prevent re-feeding syndrome) Vitamin B compound (unless on dietetic advice to prevent re-feeding syndromeViteyes ® original plus luteinVitalux ® -plusYellow Fever vaccination for travel

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Category 2Unfunded item Possible Alternative- use letters B or C unless

otherwise suggested

Alendronate with Vitamin D preparations (Fosavance®)

Separate alendronate with or without vitamin D 800iu – Letter E

Alere® INRatio test strips* None outside the grey list criteria- Approval required

Alimemazine (Trimeprazine) Alternative antihistamine e.g. hydroxyzine

Aliskiren Review therapy for hypertension if no consultant recommended and under regular review,

Almotriptan as branded preparations* Use generic – Brand to generic SOP can be applied

Alprostadil cream (Vitaros®)* Use outside of the ED policy requires approval

Anastrazole as branded preparations Use generic – Brand to generic SOP can be applied

Apixaban ( outside grey list criteria) Warfarin or acenocoumarol- Seek advice from anticoagulant service to manage changeover.

Armour Thyroid Preparations Seek consultant advice- Letter D

Atorvastatin tablets as branded preparations Use generic – Brand to generic SOP can be applied

Atorvastating 30mg or 60mg Review target achievement and use combinations of 10, 20 or 40mg as necessary to provide a clinically appropriate dose

Azapropazone products Formulary NSAID

BD Micro-Fine +, Microfine Ultra and Autoshield Duo pen needles

Use insulin Pen needle SOP

Bio-Oil ® products Formulary emollients

Brimonidine Gel (Mirvaso®) Consider topical antibiotics if indicated. May require consultation – Use Protocol 2.

Brinzolamide eye drops as branded preparation (Azopt®)

Use generic – Brand to generic SOP can be applied

Camouflage Preparations Covermark® Classic Foundation Covermark® Finishing Powder Dermacolor® Camouflage Cream Dermacolor ® Fixing Powder Keromask® Finishing Powder Keromask® Masking Cream Veil ® Cover Cream Veil ® Finishing Powder Vichy Dermablend® Foundation

Listed preps are blacklisted locally any other camouflage products not listed here are not funded nationally-

No alternative item prescribed without prior approval

Suggest manage by protocol 2

Calcium 500mg with colecalciferol 200i.u Accrete or Adcal D3 caplets – letter F

Candesartan, as branded preparations (Amias®*)

Generic candesartan or any and all alternate ARBs if an ACE inhibitor is not tolerated.

Cannabis extract preparations or any Refer back to consultant – letter D

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product containing THC or cannabinoids

Cariprazine Preparations Refer back to consultant- No shared care.

Celecoxib as branded preparations (Celebrex®*)


Chlorpropamide preparations Gliclazide or tolbutamide

Ciclesonide Inhaler Review treatment regime

Cilostazol preparations Naftidrofuryl

Circadin® M/R tablets 2mg* Use alternative hypnotic or refer back to consultant. This includes adults

Citalopram as branded preparations (Cipramil®)*

Use generic or alternative SSRI

Clonidine products (unless used for resistant hypertension under the care of a specialist)

Dependent on indication

Clopidogrel as branded preparation (Plavix®)*

Ensure still clinically appropriate and use generic if it is

CoaguCheck Test strips ( unless patient self manages their INR)

None outside the grey list criteria- Approval required

Co-careldopa Intestinal Gel Refer to consultant (NHSE funded)

Co-codamol 15/500 products Zapain or separate paracetamol & codeine

Co-codaprin Separate codeine and aspirin – Letter H

Co-flumactone (only for hyper-aldosteronism under the supervision of a specialist)

Separate spironolactone and a loop diuretic

Colesevelam ( Patients on this treatment before 2013 till gaining benefit may continue)

Cholestyramine

Compound preparations for the removal of ear wax

Sodium bicarbonate ear drops - Letter I plus leaflet

Co-proxamol products Paracetamol plus separate opiate at a dose to control pain. DOH is withdrawing funding for this drug and will blacklist it in 2018

Crestor® ( branded rosuvastatin) Use generic – Brand to generic SOP can be applied

Cyanocobalamin oral preparations ( unless patient has severe needle phobia)

Dietary advice or Hydroxycobalamin injections – Letter J

Cymbalta® Capsules Use generic – Brand to generic SOP can be applied

Dabigatran ( unless within a NICE TA approved condition)

Warfarin or acenocoumarol- Seek advice from anticoagulant service to manage changeover.

Dapoxetine (Priligy®) Sildenafil

Dermatonics ® (outside grey list criteria) Alternative oily emollient

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Diclofenac as branded preparations (e.g.Voltarol®)

Use generic

Dicycloverine preparations Use alternative antispasmodic such as mebeverine, alverine, hyoscine or peppermint oil.

Diuretics with Potassium Diuretic plus separate potassium

Donepezil as branded preparations (e.g. Aricept® )


Dosulepin Preparations Alternative tricyclic or SSRI

Doxazosin MR preparations Doxazosin standard release at a clinically appropriate dose– letter L

Duraphat® Toothpaste (only appropriate for prescribing by dental practitioners)

Refer to dental practitioner

Edoxaban preparations ( unless for use within a NICE TA approved indication)

Warfarin or acenocoumarol- Seek advice from anticoagulant service to manage changeover.

Eicosapentaenoic acid preparations (e.g.Omacor®/Maxepa®or Prestylon®)

Approval request required for continuation on the basis of exceptionality only. Seek advice from Practice pharmacist support.

Efexor® all branded products Use generic – Brand to generic SOP can be appliedEletriptan as branded preparations*


Ergotamine preparations Dependent upon indication

Esomeprazole tablets as branded preparations (e.g. Nexium®)*


Etoricoxib as branded preparations (e.g. Arcoxia®)*

Use generic or an alternative NSAID or cox 2 inhibitor

Evoke® e-cigarettes Alternative NRT

Fentanyl nasal sprays and lozenges Alternative formulary opiate

Fentanyl tablets (unless on the recommendation of a palliative care specialist)

Alternative formulary opiate

Fidaxomicin (Dificlir ® unless on the advice of a icrobiologist)

Seek advice from microbiology

Flexitol® heel balm (outside grey list criteria) Alternative greasy emollient

Fluoride supplements (only for prescribing by dental practitioners)

Refer to dental practitioner

Freestyle Libre sensors ( unless prior approval or supported by the specialist service)

Blood glucose testing until an approval request is submitted and accepted

Frovatriptan as branded preparations* Use generic or an alternative triptan

Fulvestrant (Faslodex® unless initiated prior to 30/11/2011)

Refer to oncologist

Glibenclamide products (unless for diabetes Gliclazide or tolbutamide

46

on specialist advice)

Gliclazide MR tablets Gliclazide standard release- Letter M

GLP1 inhibitors – Albiglutide, Dulaglutide, Liraglutide, Exenatide,Lixisenatide (unless within NICE criteria)

Optimise other diabetes therapies and refer to GLP1 SOP

Gluten Free bread Ensure patient has a confirmed diagnosis and that the issued quantity averages, in a year, not more than 8 loaves every 2 months.

Gluten Free Flour Ensure patient has a confirmed diagnosis of gluten enteropathy

Grass Pollen extract (Grazax®) Refer to immunologist in severe cases or manage symptoms appropriately.

Hyaluronan injections (for osteoarthritis) Optimise anti-inflammatory therapy and pain relief

IME- FINE® insulin pen needles Use insulin pen needle SOP

Insulin Degludec (except on specialist advice)

Alternative insulin

Insulin Degludec & Liraglutide (IdegLira®) Alternative insulin plus GLP1 Inhibitor

Insulin pen needles costing more than £6 per 100 needles or longer than 6mm

Use insulin pen needle SOP

Irbesartan as branded preparations e.g. (Aprovel®)*


Iron tablets/ capsules with added vitamins ( unless folic acid in pregnancy)

Ferrous fumarate

Iron Modified release products Ferrous fumarate – Letter N

Ketoconazole oral preparations Seek advice from microbiology.

Latanoprost as a single ingredient in eye drops as branded preparations

Generic latanoprost eye drops or unit dose vials if sensitive to preservatives (Monoprost)– Use brand to generic SOP

Lesinurad preparations Refer back to speiclist services for advice

Letrozole as a branded preparation (Femara®)*


Levocetirizine preparations Cetirizine – Letter O

Lidocaine patches/ plasters Alternative pain relief

Linaclotide ( unless initiated by a specialist) Alternative laxatives

Liothyronine Preparations including armour thyroid

Use the CCG liothyronine switch guidance available here to manage a transition to levothyroxine. Seek specialist advice if necessary

Loperamide as a branded preparation (Imodium®)*

Prescribe generic

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http://www.stockportccg.nhs.uk/practicehub/medicines-optimisation-guidance/endocrine-system/

Losartan as branded preparations

Lubiprostone (unless initiated by a specialist)

Alternative laxatives

Melatonin unlicensed preparations (use Circadin® as per grey list but only within shared care)

Circadin® as brand or generic

Methenamine Refer back to consultant

Methocarbamol Consider Dantrolene or baclofen

Meprobamate Consider benzodiazepine or buspironeMethenamine hippurate Seek advice from MicrobiologyMicrodot Verifine® safety pen needles Use insulin pen needle SOP

Midrid® Paracetamol and/ or aspirin –Letter P

Migraleve® preparations (all formulations) Paracetamol & codeine with/ without antimemetic Letter Q- Yellow tabsLetter R – Pink tabs

Mometasone nasal sprays-as branded preparations (e.g.Nasonex®)*

Generic mometasone nasal sprays

Montelukast tablets as branded preparations

Generic Montelukast– Use brand to generic SOP

Monoamine oxidase inhibitors ( only under specialist psychiatric supervision)

Dependent on indication

Mylife Clickfine AutoProtect® insulin pen needles

Use insulin pen needle SOP

Nalmefene (except as part of the approved pathway with psychosocial support provided)

Refer to alcohol service

Naltrexone / Bupropion (Mysimba®) Refer to weight management service

Nanopass® insulin pen needles Use insulin pen needle SOP

Naproxen with esomeprazole Separate agents

Naratriptan as branded preparations (e.g. Naramig®)*


Nedocromil Sodium preparations Sodium cromoglycate if appropriate

NeedleBay® Fine insulin pen needles Use insulin pen needle SOP

Nefopam tablets (outside grey list criteria) Alternative pain reliefNovofine® insulin pen needles inc. Autocover & Twist Use insulin pen needle SOP

Olmesartan as branded preparations (Olmetec®)* Use generic

Olodaterol (outside grey list criteria) Tiotropium respimat or alternative LABA

Omeprazole tablets/ capsules/ dispersible Use generic – Brand to generic SOP can be applied

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tablets as branded products

Ondansetron (unless for chronic emesis on specialist advice)

Formulary anti-emetic depending on cause

Orlistat (unless within the criteria specified and the recipient is losing weight every month)

Refer to separate SOP

Oxycodone with Naloxone Oxycodone

Paracetamol / isometheptene mucate* (Midrid®)*

Paracetamol and/ or aspirin – Letter P

Pentosan preparations (oral) Tolterodine or seek advice from urology

Perampanel ( unless in line with the NTS statement)

Seek advice from neurology

Perindopril arginine* Switch to Perindopril erbumine

Piroxicam (oral) (outside grey list criteria) Alternative NSAID

ProTime 3® cuvettes®* None outside the grey list criteria- Approval required

Prednisolone EC tablets Prednisolone tablets – Letter V

Prednisolone MR preparations Prednisolone tablets

Pregabalin as branded Lyrica® Generic pregabalin or a low cost brand

Prilocaine/lidociane Spray (Tempe®) Formulary ED treatment

Ranitidine 75mg tablets Ranitidine 150mg tablets or syrup 7.5mg/5ml.

Retapumulin® Seek advice from microbiology

Rifaximin (outside grey list criteria) Seek advice from microbiology

Rivaroxaban (outside grey list criteria) Warfarin or acenocoumarol- Seek advice from anticoagulant service to manage changeover.

Rizatriptan as branded preparations* Use generic – Brand to generic SOP can be applied

Roflumilast (outside grey list criteria) Seek specialist advice – Letter D to transfer back to initiating specialist.

Sacubitril/ Valsartan ( Entresto®)(outside grey list criteria)

Seek specialist advice – Letter D to transfer back to initiating specialist.

Salbutamol 2mg and 4mg standard release tablets*

Salbutamol inhaler

Sertraline as branded preparation (eg Lustral®)*


Sildenafil as branded preparations* Generic Sildenafil with a max qty of 12 per month– Use brand to generic SOP

Sildenafil generic preparations (unless for SLS treatment of erectile dysfunction – max 12 per month)

Align quantity to be within policy

Simvastatin with ezetimibe tablets (e.g.Inegy®)

Simvastatin or atorvastatin with separate ezetimibe if necessary

49

Silk Garments* Optimise other therapy

Slow K® tablets Soluble/ effervescent potassium

Sodium hyaluronate injections for osteoarthritis (SportVis®)

Optimise anti-inflammatory therapy and pain relief

Sodium oxybate preparations Seek consultant advice Letter D

SpaTone® Products Sytron ot Nifrex – Letter W

Sumatriptan as branded preparations (e.g. Imigran®)*


Tadalafil as branded preparations (e.g Cialis®)*


Tadalafil 2.5mg or 5mg Use 10mg or 20mg on prn basis within policy. If treating for BPH use clinically appropriate alternative.

Tadalafil 10mg or 20mg (unless under SLS treatment of erectile dysfunction - maximum of 4 treatments per month)

Sildenafil up to a maximum of 12 per month.Please note this is on the DOH list of items the NHS should not fund and should be deprescribed

Tamsulosin with Dutasteride ( only where patient cannot tolerate finasteride with tamsulosin)

Tamsulosin plus finasteride

Tapentadol tablets ( only where pain cannot be controlled by any other opiate)

Any other opiate which has not been tried.

Testosterone patches ( Intrinsa®) Testosterone gel

Thyroid extracts See Liothyronine.

Topical antifungal treatments (outside grey list criteria)

Oral terbinafine if appropriateLetter X

Topical Gabapentin Appropriate alternative pain relief

Topiramate capsules* Seek specialist advice and consider Topiramate tablets

Tramadol in fixed dose combination with paracetamol (e.g. Tramacet®)

Separate agents

Trandolopril/ verapamil capsules (Tarka®) Separate agents

Trimipramine Alternative tricyclic antidepressants

Triptans as branded preparations (e.g. Imigran®, Maxalt®, Naramig® and Zomig®)*


Ulipristal Tablets 5mg ( Esmya®) (outside grey list criteria)

Seek specialist advice.

Unifine Pentips ®

(not pentips plus)Use insulin pen needle SOP

Yohimbine preparations Sildenafil

Zolmitriptan as branded preparations (e.g. Zomig®)*

Use generic

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