If it is for the specific condition you are asked to continue treatment for and you are happy to prescribe in accordance with the guideline, then take over the agreed responsibilities including prescribing. Please ensure the document is scanned into the patient's electronic records.

Click here for the Shared Care Guideline Repository

If sufficient information has not been provided and if you do not feel happy to continue to prescribe, it is advisable to refer the patient back to the specialist clinic and complete and send as soon as possible an 'inappropriate prescribing request communication form' . 
 

Use in Type 1 Diabetes and Heart Failure

Dapagliflozin is  HOSPITAL INITIATION when prescribed for use in the following indications: 

with reduced ejection fraction - HOSPITAL INITIATION ONLY

Type 1 Diabetes - manufacturer has withdrawn license for use in Type 1 diabetes  and subsequently NICE TA 597 has been withdawn.

• For existing patients, Barts Health will liaise with GPs to continue treatment as "off-label"using existing transfer of care documents available on portal  and if GP refuses, this will be stopped.

• No new patients are expected to be initiated,  and if so, GPs would be contacted by specialist to discuss further whether prepared to prescribe if treatment started by hospital. Evidence base remains unchanged, and license withdrawal was due to commerical reasons - not due to any concerns around safety. 

Treatment of symptomatic chronic heart failure with reduced ejection fraction: 

following initiation by specialist and review from hospital, and can be prescribed in Primary care. The indication is in line with NICE TA 679.

Dapagliflozin is for HOSPITAL INITIATION when prescribed for use in the following indications: 

1. Type 1 Diabetes - manufacturer has withdrawn the licence for use in Type 1 diabetes and subsequently the NICE TA 597 has been withdrawn.

• For existing patients, Barts Health will liaise with GPs to continue treatment as "off-label" using existing transfer of care documents available on the portal and if GP refuses, the treatment will be stopped.
• No new patients are expected to be initiated.  If required, GPs would be contacted by the specialist to discuss and whether they are prepared to prescribe if the treatment is started by the hospital. Evidence base remains unchanged, and licence withdrawal was due to commerical reasons - not due to any concerns around safety. 

2. Treatment of symptomatic chronic heart failure with reduced ejection fraction:

Following initiation and review by Hospital specialist and in line with NICE TA 679, this can be prescribed for continuation in Primary Care. 

Dapagliflozin is amber on the formulary for use in heart failure and may be initated at the recommendation of a Specialist.

Use is in line with recommendations from the NICE TA (see links for further detail); supporting resources are available on Clarity.

• Dapagliflozin for treating chronic heart failure with reduced ejection fraction - NICE TA 679
  •  Supporting resources available on Clarity here

AMBER FOR COMBINATION THERAPY ONLY

Only continue dulaglutide if the person has had a beneficial metabolic response (a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body weight in 6 months), as per NICE recommendations.

Insulin for the treatment of hyperkalaemia is Hospital Only.

Fiasp® is recommended for the treatment of diabetes mellitus in adults who are suitable for NovoRapid^® and their diabetes cannot be adequately managed with alternative formulary choices and at least one of the following applies:

• Where the prescriber believes a faster onset of action would be beneficial to the patient.

• Where a patient requires ‘tight’ control of blood sugar levels.
• Where a patient has rapid post meal increase in blood sugar levels.

Fiasp® is AMBER (i.e. should be recommended by a Specialist) in cases where patients are switching from NovoRapid® to Fiasp®.

Please find attached an MHRA Direct Healthcare Professional Communication, discussing the risk of mix-ups between insulin Fiasp® (fast-acting insulin aspart) and Tresiba® (basal insulin degludec).

Summary

• Cases have been reported where patients have mistakenly administered the mealtime insulin Fiasp® (currently available as yellow pens) instead of the basal insulin Tresiba® (available as light green pens) or vice versa.
• Such mix-ups can have serious clinical consequences, specifically hypo- or hyperglycaemia.
• Advise patients using both products to be extra vigilant and always check the name of the insulin before each injection to make sure that they administer the correct insulin.
• To strengthen the differentiation between the products, from 01 June 2018 Fiasp® will be available as red and yellow cartridges, pre-filled pens and vials (see Figure 1 below).

• Fiasp Safety Message.pdf

Insulin degludec (Tresiba®) is available in strengths of 100 units/mL (allows 1-unit dose adjustment) and 200 units/mL (allows 2-unit dose adjustment)—ensure correct strength prescribed. 

The prefilled pen devices have a dose-counter window which shows the number of units of insulin degludec that will be injected, irrespective of strength. Therefore no dose conversion is needed when transferring a patient from one strength of Tresiba to a different strength.

The MHRA have produced a bulletin detailing the care needed to minimise the risk of error, including training for patients. This is available here. 

Patients should be trained on the correct use of the Tresiba products, in particular how to check the dose displayed on the prefilled pen device. Ensure that the strength is included on the prescription and dispensing label. Patients should be aware of the different strengths.The pens and packaging of Tresiba are different for the two strengths. A letter on the safe use of Tresiba, including pictures of the different products, was sent to healthcare professionals in January 2013.

Toujeo^® is AMBER on the Tower Hamlets CCG Formulary and requires Hospital Initiation, before continued prescribing in Primary Care.

Toujeo^® is a high strength insulin: Healthcare providers involved in prescribing, dispensing and administering of these insulins need to be aware of the possible risks of medication errors. Advice for Healthcare Professionals on Minimising the Risk of Medication Error with high strength insulins is available here.

Liraglutide (Saxenda) is for hospital only prescribing when used in the management of overweight and obesity, alongside a reduced-calorie diet and increased physical activity in adults. 

For further information please refer to the recommendations from NICE TA664 (liraglutide for managing overweight and obesity).

NOTE: Topical capsaicin may be considered as an adjunct to core treatments for knee or hand osteoarthritis in line with NICE CG177 

Parenteral formulation is for Hospital Prescribing Only.

Parenteral formulation is for Hospital Prescribing only.

Parenteral formulation is for Hospital Prescribing Only.

Parenteral formulation for the treatment of corticosteroid responsive conditions is for Hospital Prescribing Only.

Denosumab (Prolia) is Shared Care when used for the treatment of osteoporosis in post-menopausal women. 

All other indications for denosumab remain for Hospital Only Prescribing. 

Parenteral formulation is for Hospital Prescribing Only.

Noqdirna for the treatment of nocturia due to idiopathic nocturnal polyuria in adults, is AMBER on the Tower Hamlets CCG Formulary. 

Note: for Hospital Initiation: see the Nocturnal Polyuria Pathway for more details. 

Intranasal Desmopressin for Cranial Diabetes Insipidus for Adults is AMBER on the Tower Hamlets CCG formulary.

Parenteral formulation is for Hospital Prescribing Only.      

Parenteral formulation is for Hospital Prescribing Only.

Parenteral formulation is for Hospital Prescribing Only.

LIOTHYRONINE SODIUM

Goserelin is considered Hospital Only on the NEL HOL list for all indications except Prostate Cancer.

Leuprorelin is Hospital Only for all indications, except for treatment of prostate cancer.

Triptorelin is hospital only for all indications, except for the treatment of prostate cancer.

Precocious Puberty