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Palliative Care Formulary migration to MedicinesComplete - January 2019

11th December 2018

As you will now be aware, we are making some important changes to the way you access the current on-line Palliative Care Formulary. If you are an on-line formulary subscriber you will shortly receive details about how to access your updated formulary account on MedicinesComplete in January 2019.

Please note that only access to the Palliative Care Formulary will be moving over to the MedicinesComplete platform.

The Bulletin board, Document Library, News, Surveys and the Syringe Driver Survey Database (SDSD) will continue to be available at www.palliativedrugs.com. The site will also contain a link to the Palliative Care Formulary on the MedicinesComplete platform.

Once you have received your updated login instructions you will need to complete migration to your updated account on MedicinesComplete by 1st February 2019 when access via the palliativedrugs.com site will be switched off.

If you have any questions regarding the migration then please contact hq@palliativedrugs.com

Supplementary information on cannabis-based products for medicinal use

22nd November 2018

Supplementary information has been published to clarify the status of the recent NHS England guidance to clinicians that was published on 31 October 2018 (see our news item) and provide clarification surrounding synthetic cannabinoids for medicinal use, e.g. dronabinol and nabilone.

NHS England Supplementary information

NICE consultation on cannabis-based products for medicinal use

20th November 2018

Comments are now being sought on the draft scope for the NICE guidance on cannabis-based products for medicinal use. The consultation closes on 4 December 2018.

Guidance and information on prescribing and supply of cannabis-based products for medicinal use

6th November 2018

Guidance is now available to help health professionals with the prescribing and supply of cannabis-based products for medicinal use, which were rescheduled in England, Wales and Scotland on the 1 November 2018 from Schedule 1 to Schedule 2 (see our previous news item).

Cannabis-based products for medicinal use: Guidance to clinicians (NHS England)

Guidance on the supply, manufacture, importation and distribution of unlicensed cannabis-based products for medicinal use in ‘specials’ (MHRA)

Interim clinical guidelines have also been produced by the Royal College of Physicians (RCP) and the British Paediatric neurology Association (BPNA), to support prescribing decisions.

RCP interim guidance

BPNA interim guidance

Finally, information for patients and the public is available on the NHS website.

Editor’s notes

Also see the recently updated PCF Cannabinoids, which reflects and was used to help inform the RCP guidance for use in palliative care.

The legislative changes do not apply to;

  • synthetic versions of naturally occurring cannabinoids e.g. dronabinol (not UK)
  • chemically synthesized derivatives e.g. nabilone
  • Sativex® (an authorized product in Schedule 4).

Instanyl (fentanyl) multidose nasal sprays discontinued

6th November 2018

Takeda UK is discontinuing all strengths of Instanyl® (fentanyl citrate) multidose nasal sprays on the 14th December 2018 for commercial reasons.

The single dose Instanyl® products (50micorgram/mL, 100microgram/mL and 200micorgram/mL) will remain available.

Alternative transmucosal fentanyl citrate products are available including, sublingual (Abstral®) and buccal (Effentora®) tablets, a lozenge with oromucosal applicator (Actiq®) and a nasal spray (Pecfent®). However, these products are not interchangeable on a microgram per microgram basis from one product to another and patients must undergo full titration if switching to a new product.

See the PCF Fentanyl (transmucosal) monograph and individual SPCs for details.

Letter to healthcare professionals

Gabapentin and pregabalin to be controlled as class C drugs

17th October 2018

The UK government has announced that gabapentin and pregabalin will be reclassified as class C controlled substances, under the Misuse of Drugs Act 1971, from April 2019. This follows increasing concerns over misuse and illegal diversion and rising numbers of fatalities linked to the drugs.

From April 2019, it will be illegal to possess gabapentin or pregabalin without a prescription. Further, prescribers will need to physically sign prescriptions, and pharmacists must dispense drugs within 28 days of the prescription being written.

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TD fentanyl patches: MHRA alert

17th October 2018

The MHRA has produced another Drug Safety Update, again highlighting the risks of life-threatening and fatal opioid toxicity from accidental exposure to fentanyl from transdermal patches, particularly in children. This follows continued reports of unintentional opioid toxicity, despite previous alerts in 2008, 2014 and updated advice on minimising accidental exposure in the SPC and PILs since 2014.

Both unused and used fentanyl patches should be stored out of sight and reach of children. After use, patches should be folded so that the adhesive side of the patch adheres to itself and then placed back into the original sachet. Care should be taken not to touch the adhesive.

Health professionals are reminded to:

  • always fully inform patients and their caregivers about directions for safe use for fentanyl patches, including the importance of:
    • not exceeding the prescribed dose
    • following the correct frequency of patch application, avoiding touching the adhesive side of patches, and washing hands after application
    • not cutting patches and avoiding exposure of patches to heat including via hot water (bath, shower)
    • ensuring that old patches are removed before applying a new one
    • following instructions for safe storage and properly disposing of used patches or those which are not needed
  • ensure that patients and caregivers are aware of the signs and symptoms of fentanyl overdose to seek urgent medical attention immediately (by dialling 999 and requesting an ambulance) if overdose is suspected
  • in patients who experience serious adverse events, remove patches immediately and monitor for up to 24 hours after patch removal
  • report any cases of accidental exposure where harm has occurred or suspected side effects via the Yellow Card Scheme

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Rescheduling of cannabis-based products for medicinal use

17th October 2018

The government in England, Wales and Scotland has announced that cannabis-based products for medicinal use will be rescheduled as from the 1 November 2018 from Schedule 1 to Schedule 2. Northern Ireland is expected to mirror these changes shortly.

This change follows the government review (see our previous news item) and is the legislative step needed to enable cannabis-based medicinal products to be prescribed and supplied for human use.

The new regulations define a cannabis-based medicinal product as satisfying all the following criteria:

  • a preparation or product which contains cannabis, cannabis resin, cannabinol or a cannabinol derivative and
  • it is produced for medicinal use in humans and
  • it is a medicinal product, or a substance or preparation for use as an ingredient of, or in the production of an ingredient of, a medicinal product.

Any product which does not satisfy this definition will remain a Schedule 1 drug and only be available under a Home Office licence.

The existing medicines framework allows three access routes for the order, supply and use of these products by patients:

  • a medicinal product with a marketing authorisation or
  • an investigational medicinal product without marketing authorisation for use in a clinical trial or
  • an unauthorized (unlicensed) “special” for a specific patient, which can only be manufactured in, or imported into, the UK by a manufacturer or wholesale dealer that has a licence from the MHRA to do so and meets standards of good manufacturing practice (GMP).

In the case of cannabis-based medicinal products, a further restriction on specials has been included and the prescribing doctor (or direction from a doctor who has made the decision to prescribe) must be on the Specialist Register of the General Medical Council.

The 2018 Regulations continue to prohibit smoking of cannabis, including of cannabis-based products for medicinal use in humans.

Editor’s notes

This announcement is unlikely to affect palliative care specialists initiating cannabinoids for symptom management. Because trials examining cannabinoids for symptom relief generally use Δ9-THC, or a synthetic analogue, clinicians are likely to continue to prescribe either Sativex® or nabilone (see the recently updated PCF Cannabinoids monograph).

Specials manufacturers could now produce other cannabis-based medicinal products for human use, e.g. cannabidiol alone. However, to date, no RCT has confirmed a role for cannabidiol alone in palliating the symptoms of advanced life limiting illness. Thus, neither cannabidiol ‘specials’, nor Epidiolex® (a cannabidiol oral solution, marketing authorization pending; see our previous news item) are likely to be used by palliative care specialists at present.

We believe that the cannabidiol oils that patients have previously obtained via on-line suppliers (which generally retain traces of cannabis-based products) will not meet the criteria above for prescribing as a special unless they are produced and obtained within the existing framework for unlicensed specials (see above) and prescribed by a doctor on the specialist register of the GMC.

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Cochrane review: olanzapine for the prevention and treatment of cancer-related nausea and vomiting in adults

26th September 2018

In this review, the authors concluded that oral olanzapine probably increases the likelihood of not being nauseous or vomiting during chemotherapy from 25% to 50% in adults with solid tumours, in addition to standard therapy, compared to placebo or no treatment.

There is uncertainty whether it increases serious undesirable effects. It may increase the likelihood of other undesirable effects, e.g. somnolence and fatigue. There is uncertainty about relative benefits and harms of 5mg versus 10mg.

Only RCTs describing oral administration were found. The authors noted that the findings of this review cannot be extrapolated to provide evidence about the efficacy and safety of any injectable form (intravenous, intramuscular or subcutaneous) of olanzapine.

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Lorazepam 4mg/mL injection shortage

18th September 2018

Pfizer is currently experiencing supply problems with lorazepam (Ativan) 4mg/mL injection in the UK. It is anticipated that there may be limited supply and stock restrictions until late October 2018. There is no other alternative authorized UK supplier.

Diamorphine 5mg and 10mg injection

18th September 2018

Diamorphine 5mg and 10mg injection are now available again to order from UK wholesalers. The supply shortage that has existed since May 2018 has now been resolved. However, to prevent a recurrence, units have been asked not to stockpile.

Cannabis-derived medicinal products: update

18th September 2018

Following the Chief Medical Officer for England’s report (see our news item 11 July 2018), the Advisory Council on the Misuse of Drugs (ACMD) was commissioned by the Home Secretary to consider the appropriate scheduling of cannabis-derived medicinal products. Their response was published on 19 July 2018 and forms part of the government review.

ACMD recommendations 

In the interim, an expert panel has been established to consider licence applications for the use of cannabis and cannabis-based medicinal products, in exceptional cases, where there is unmet clinical need.

Government review

Note. The PCF cannabinoids monograph has been updated on-line this month and summarizes the current evidence in palliative care and reflects the current supply situation.