Medicines information

• Blood Glucose and Ketones Self-Monitoring Formulary and Guidance 30.11.23
• Commissioning Statement on Blood Glucose and Ketones Self-Monitoring 30.11.23

The resources below are under review following the publication of NHS England and NHS Wales implementation plans for Hybrid Closed Loop in December 2023. NHS West Yorkshire Integrated Care Board (ICB) is committed to enabling access to life changing technology for eligible people living with diabetes. We will work with people living with diabetes to understand if technology is right for them and where possible to help them gain access where this is required. Our West Yorkshire Commissioning Policy for Continuous Glucose Monitoring (CGM) and our Formulary for CGM are currently being updated to reflect the recommendations in the NICE Hybrid Closed Loop (HCL) Technology Appraisal (see below under Hybrid Closed Loop) and the HCL technology available via the NHS supply chain. We hope to publish here before the end of August 2024.

Continuous Glucose Monitoring (CGM)

CGM gives people living with diabetes the opportunity to review their blood glucose as a complete picture over time, rather than at one point in time. It also allows for better shared decision-making with healthcare professionals.
The new commissioning policy below replaces the commissioning policy for Flash Glucose Monitoring.

• Patient information about the WYICB Commissioning Policy for Continuous Glucose Monitoring 02.11.23
• WYICB Commissioning Policy for CGM 21.04.23
• WYICB Formulary for CGM 21.04.23
• WYICB Supporting Guidance and Evidence Base for CGM Position 21.04.23
• Making a decision about managing type 1 diabetes leaflet

Hybrid closed loop (HCL)

Following the recent publication of the NICE Technology Appraisal for hybrid closed loop, NHS England have now published a national HCL five year implementation strategy. We are currently in the process of planning a West Yorkshire implementation strategy and more information will be posted here when available. As HCL technology will be made more widely available in England and Wales, the Juvenile Diabetes Research Foundation (JDRF) has put together these frequently asked questions about eligibility of HCL to help you understand what this may mean for you.

Further information:

• The NHS England HCL webpage includes information about the benefits of HCL, who is eligible and how it will be made available across the NHS in England.
• The NHS Health A-Z provides information about the treatment for type 1 diabetes which also has information about HCL, who it is suitable for and the phased rollout.

Frequently asked questions (for people with diabetes on GLP-1 therapy)

There are supply problems with a few medications used in the treatment of type 2 diabetes also known as type 2 diabetes mellitus (T2DM). These medicines are called GLP-1 receptor agonists. We will speak about them as GLP-1 RAs in this document. The medicines affected are:

My healthcare professional has stopped prescribing my GLP-1 RA, why is this?
There are two reasons why you might have been asked to stop your GLP-1 RA:

1. Your healthcare professional has reviewed the medication you are taking and the GLP-1 RA is no longer benefiting you. It is appropriate to expect your healthcare professional to discuss this with you before stopping the medication to ensure you understand and are involved in the decision making. If this conversation did not happen, speak to the healthcare professional.
2. There may be supply issues for the medication, meaning you may not be able to obtain this medication. There is a national shortage of these medications. Healthcare professionals will review people who are currently on these medications, to see if different medications can be taken instead.  

Is it safe to stop my GLP-1 RA?
This depends on how much your medication has reduced your average blood glucose level. For some people using a GLP-1 RAs, stopping will make little difference to the levels of glucose in your blood. In these cases, it is safe to stop. For other people, GLP-1 RA medication will be having a much bigger effect on blood glucose levels; for others blood glucose levels are high even though they are taking a GLP-1 RA medication. In these cases, where GLP-1 RAs are not available, different medications should be used to avoid health risks linked to high blood glucose levels.

Self-monitoring your blood glucose can be useful in those who do self-monitoring. For those who don’t self-monitor, going for your blood tests is important.   

I still have supply of my GLP-1 RA in the fridge, do I keep taking/using those for now?
Continue taking/using your medication as it has been prescribed unless you are told to stop by your healthcare professional. If you have run out and it is not possible to get a repeat supply, contact your healthcare professional.

I can’t obtain supply of my GLP-1 RA, what do I do now?
If you can’t get your GLP-1 RA medication as you usually would, contact your healthcare professional for advice.

I have heard there is a shortage of one of my medications, a GLP-1 RA. I have not had any problem getting this medicine for myself so far, when will this happen to me? 
If you are already on a GLP-1RA there is a chance, there will be some supply of certain types of this medicine. This means, for some people, they will not be affected by the national shortage. You should keep taking/using your medication as usual.  Contact your healthcare professional if you have problems getting your medication on prescription. Remember, order your repeat prescription at least 7 days before you run out.

If you cannot get my GLP-1 RA, can I be prescribed a lower strength and I could double the dose?
No, this is not allowed. These medications are not licenced in England be used in this way. Doing so may risk your health and will also cause remaining supplies to run out for those who are taking lower doses.

Can I be switched onto a different GLP-1 receptor agonist?
No, there are supply issues with ALL the GLP-1 RAs. It is advised not to switch products at this time. Healthcare professionals are aware of this advice.

I was told that I would potentially need to start a GLP-1 RA at my next appointment, will that still happen?
No. No new patients in England will be started on GLP-1 RAs until the current national shortage is over. The shortage may continue until the middle of 2024. Throughout this time your healthcare professional will arrange reviews with you to monitor your health and may discuss other medications.

My child takes/uses a GLP-1 RA, what do I do?
Please get in contact with the healthcare team that usually looks after your child’s diabetes care for more specific information and advice.

While I am able to get my medicine from my local pharmacy, should I ask for a larger supply so that I do not run out?
This is not recommended as it will use up the remaining supplies in England much faster. Do still try to order your repeat prescription 7 days before you need it. If the medicine is not available, your healthcare professional has time to review you and your treatment if needed.

I know someone who is managing to get their GLP-1 RA, why can I not get mine?
Different GLP-1 RAs are having different types of shortage. Some GLP-1 RA manufacturers are managing, for now, to maintain supply to people already on these medicines. There is no guarantee though of continued supply with any of these medicines and you should not switch between GLP- 1 RAs. 

If I get a GLP-1 RA on private prescription, am I likely to also have problems or is this just a problem for NHS supply?
There is a national shortage of these medications and there is no guarantee of a private supply or NHS supply. Healthcare professionals in the NHS can only give information about NHS prescriptions. Contact your private provider if you want further information.

I am on a GLP-1 RA, I cannot get my supply. My healthcare professional has said they will review me, but I cannot get an appointment for a few weeks, is that OK?
Due to the number of people affected by this shortage, those people who are most at risk will be prioritised by healthcare professionals for a review. This may mean that people who are not at risk may need to wait a little longer to be reviewed.

If I stop my GLP-1 RA, will I be able to restart it when supply increases again?
Everyone with diabetes should have a review with their healthcare professional – this should happen at least once a year. When the medication is available again, your healthcare professional may discuss with you the benefit of you going back on your GLP-1 RA therapy. If you had a good response to this treatment before the shortage, you should be reviewed to restart this medication.  Not everyone experiences benefits from this medication and so your healthcare professional might advise something different for you.

Am I better having it when I can get hold of it, even if that is every now and again, rather than stopping?
There is a chance that not taking your medication regularly may increase the risk of you experiencing side effects, for example this could lead to lots of changes in your blood glucose levels which may increase the likelihood of problems with your health. This is of most worrying in people on insulin or sulfonylurea therapy e.g., gliclazide, glimepiride etc. medications.

Will l gain weight when I stop the GLP-1 RA?
This will depend on whether you lost weight when you started this medication. If people have lost weight, stopping the medication increases the chance that weight will be regained. There are other options available to you to avoid weight regain. Speak to your healthcare professional for lifestyle advice.

Since stopping my GLP-1 receptor agonist I feel tired, thirsty and I am going to the toilet a lot, what should I do?
Please seek medical advice from your GP or 111 as soon as possible.

What are the alternatives?
Healthcare professionals will be reviewing people and will discuss treatment options with you. Treatment options will be different for different people which may include other medications and options including changes to diet, exercise etc. 

Before I went on the GLP-1 RA I was told that I might have to go onto insulin, does that mean I will need to go onto insulin sooner?
Healthcare professionals will be reviewing people and will discuss with you your treatment options. Treatment options will be different for different people and may involve options including changes to diet, exercise etc.  This may be in addition to review for other medications.

I drive for a living and have been trying to avoid going on medications that cause hypoglycaemia, does this mean I am going to have to go onto something that will affect my driving licence?
Healthcare professionals will be prioritising people for review and will discuss with you your alternative treatment options. You can drive even if you have a group 2 licence if taking both insulin and sulfonylureas e.g. gliclazide and glimepiride medications. People with a group 2 licence having insulin treatment can drive group 2 vehicles with DVLA approval. For some driver groups you may be asked to wear a capillary blood glucose monitor. Healthcare professionals will be reviewing people and will discuss treatment options with you. Treatment options will be different for different people which may include other medications and options including changes to diet, exercise etc. 

Should I buy GLP-1 RAs privately?
The NHS does not advise this. There is no guarantee of continued supply privately either and there is also some concern that products being sold privately are not what they say they are.

When do you expect the shortages to come to an end?
Stock shortages are expected until at least the middle of 2024. The Department of Health and Social care and NHS England teams are keeping the wider NHS regularly updated about the shortages.

My family member/friend is taking this drug but for weight loss, they don’t have diabetes, will they not be able to get any either?
Further guidance around these medications for weight loss is expected to come in the next few weeks. It is likely that supply will also be affected for these.

What can I do that is not adding in another new medication?
People with type 2 diabetes can get support with the NHS digital weight management programme (NHS England » The NHS Digital Weight Management Programme), the NHS Healthy Living programme for people with type 2 diabetes  Healthy Living or a remission programme, where you may be able to manage your diabetes without medications, such as the NHS Type 2 Path to Remission programme. Some of these programmes you can self-refer to and others you may need to be assessed to see if it is the right thing for you and then will need a referral from a healthcare professional.

Support to join may be available for those who do not have easy access to devices like computers, laptops, or smartphones. Please see the digital access pages on the Healthier Together website to find the nearest services that offer digital devices, or refer to your local social prescriber service who can find local support.

Eligible people with T2DM who would like support with weight management should be signposted to available weight management programmes. Nationally available options, include:

• Adult weight management: short conversations with patients
• The NHS Digital Weight Management Programme
• Lose weight - Better Health - NHS (www.nhs.uk)

Why is my medicine not in stock at the pharmacy?
Medicine supply issues can be caused by lots of things. It could be problems at the manufacturing stage, problems with safety or problems with the medications being available and delivered to pharmacies. Problems can develop quickly and can be shared nationally or can be more of a local issue.

There are recognised national shortages for GLP-1 RAs.  Information provided by the Department of Health and Social Care (DHSC) and NHS England Medicines Supply Teams is that supplies will continue to remain intermittent throughout 2023.  

What can I do if my usual community pharmacy is unable to obtain supplies of my GLP-1 RA?
If your usual pharmacy is not able to get stock of your GLP-1 RA, you may want to contact other local pharmacies to see if they have your medicine.  Please note that there is no guarantee that other pharmacies will have your GLP-1 RA in stock.  However, a different pharmacy may have GLP-1 RA stock remaining or use a different supplier or wholesaler who currently has stock.  Supply levels can change quickly and an item that was not available one day may become available the next.

Where you are unable to obtain your medicine from community pharmacy you will need to contact your healthcare professional as you will need to be reviewed and, where appropriate, switched to an alternative.

Your community pharmacy team are working hard to try to get GLP-1 RA medicines. Please be patient with them if they are having difficulty getting the medicines for you.

Community Pharmacy England have produced a patient factsheet regarding medicines supply: Medicines Supply Factsheet

Update 31 January 2024 - Changes to the commissioning policy for gluten-free prescribing
The ICB Transformation Committee will meet in February 2024 to review new information and decide whether to continue providing gluten-free products on prescription. Please see the full update on this page Treatments paid for by the NHS.

Read our full statement about gluten-free prescribing, published 19 December 2023, on the news section

The NHS began funding gluten-free products for people with coeliac disease and people with other gluten-sensitive conditions in the late 1960s when availability of gluten-free products was very limited. Once a wide variety of gluten-free products became available in supermarkets, many areas in England stopped providing them on prescription.

Gluten-free prescribing was stopped in Bradford District and Craven in 2016, and in Kirklees and Wakefield District in 2017. However, in Calderdale and Leeds limited gluten-free products were still prescribed.

At its meeting on 31 October 2023, the NHS West Yorkshire Integrated Care Board (ICB) Transformation Committee agreed that gluten-free prescribing would be stopped in Calderdale and Leeds to bring them in line with the other West Yorkshire places (Bradford District and Craven, Kirklees and Wakefield District). This does not apply to patients who require low protein gluten-free foods. 

It may be helpful to note please that we work alongside our colleagues as part of the clinical and care professional forum, which includes doctors, and that no decision is taken lightly.

All gluten-free prescriptions will be stopped from 1 April 2024 so patients will have an adjustment period of around five months to find ways to adapt their diets. Gluten-free prescriptions are not available for those newly diagnosed with coeliac disease from 1 November 2023.

• Hydroxychloroquine and chloroquine retinopathy monitoring - clinical pathway and commissioning policy for adults and children (06.23)
• Patient information leaflet - Eye monitoring for patients taking hydroxychloroquine or chloroquine (06.23)
• Referral form for hydroxychloroquine and chloroquine retinopathy monitoring
• Hydroxychloroquine and chloroquine amber guidance (03.24)

Guidance: Prescribing Specialist Infant Formula in Primary Care - January 2024

Guidance for use in: Bradford District and Craven Health and Care Partnership, Calderdale Cares Partnership, Kirklees Health and Care Partnership, Leeds Health and Care Partnership, Wakefield District Health and Care Partnership.

Breast milk is the optimal milk for infants. Breastfeeding should be promoted and encouraged where possible. This guidance aims to assist GPs and Health Care Professionals with information on the indications and appropriate prescribing of infant formula.
Prescription infant formula is recommended only when there is a medical need and the formula required is not widely available from retailers.

This document is for use within the NHS and is not for commercial or marketing purposes.

6 November 2024

Acute management of potential adverse treatment effects of Lecanemab

Alzheimer’s Disease, the most common cause of dementia, is in part caused by an abnormal build-up of proteins within the brain.

Lecanemab is a medication that targets these abnormal proteins and is now licensed for use in Great Britain. However, in line with the current draft NICE recommendation, Lecanemab will not be available in the NHS in England, but may be available through independent sector providers.

This information note on the Acute Management of Potential Adverse Treatment Effects of Lecanemab provides a short briefing for clinical teams who may be asked to support referrals for private treatment or otherwise assess, advise and possibly treat a small number of patients who could present with potential adverse treatment effects, including symptomatic Amyloid-Related Imaging Abnormalities (ARIA).

• WY Commissioning Policy for Lidocaine Patches - Paediatrics (December 2021)
• Lidocaine Plasters/Patches in Paediatrics - specialist initiation additional guidance

• Liothyronine commissioning policy
• Information about liothyronine

Lipids are types of fat that are transported in the bloodstream. They have several functions, including energy storage. Examples of lipids include cholesterol and triglycerides.
 
Having high levels of ‘bad cholesterol’ (LDL-cholesterol) and triglycerides can increase the risk of developing cardiovascular disease, as can having low levels of ‘good cholesterol’ (HDL-cholesterol). 
 
Lipid management for patients who already have cardiovascular disease, and for those who are at risk of developing cardiovascular disease, is very important. Your GP or other health professional may treat your high cholesterol or high blood pressure in line with treatment guidance, depending on what’s right for you.

This summary of national guidance for lipid management for primary and secondary prevention of CVD has been developed to support clinicians, along with this treatment guidance for uncomplicated hypertension (high blood pressure) which has been developed following extensive consultation with clinicians and other stakeholders including Public Health England, British Heart Foundation and our local pharmacy committees.
 
The West Yorkshire and Harrogate Healthy Hearts website also holds a number of other clinical resources developed to support clinicians in preventing cardiovascular disease. 

27 January 2023

Work is ongoing on classification and transfer of care document.

• Melatonin commissioning policy
• Melatonin crushing leaflet

23 August 2024

Mounjaro is the brand name for the drug tirzepatide. It lowers blood sugar levels and is used as a treatment for type 2 diabetes.
The ICB is awaiting the NICE guidance on the use of Mounjaro for weight loss so currently it is not prescribable for that purpose.
Access to Mounjaro for weight loss (once it is prescribable) would be via a referral from a healthcare professional (usually a patient’s GP) to an NHS specialist weight management service.

20 December 2024

National patient safety alert

The Department of Health and Social Care (DHSC) and NHS England have issued an updated national patient safety alert covering the shortage of Pancreatic Enzyme Replacement Therapy (PERT). NatPSA/2024/013/DHSC.

Further information for healthcare professionals: PERT Information Healthcare

The Government introduced emergency restrictions on 29 May 2024 on the use of a group of medicines called GnRH analogues where they are used to suppress puberty as part of treating gender incongruence or gender dysphoria in children and young people under 18 years of age. Some of these restrictions took effect from 3 June 2024. The Government’s announcement is published here: https://www.gov.uk/government/news/new-restrictions-on-puberty-blockers.

The new arrangements apply to medicines that consist of or contain:

• buserelin
• gonadorelin
• goserelin
• leuprorelin acetate
• nafarelin
• triptorelin

This includes, but is not limited to, medicines sold under these brand names:

• Decapeptyl®
• Gonapeptyl Depot®
• Salvacyl®
• Prostap®
• Staladex®
• Zoladex®
• Synarel.

As a result of the new Government policy, from 3 June 2024 it became a criminal offence for a pharmacist, doctor or any other individual in Great Britain to sell or supply these drugs to patients under the age of 18 except in the following circumstances:

• The child or young person is using an NHS prescription (for example, from the NHS Children and Young People’s Gender Service or from an NHS GP).
• The child or young person is using a private prescription from a clinician registered in the United Kingdom that fulfils the following criteria:
• If the prescription was dated prior to 3 June 2024, whether as a one off prescription or a repeat prescription, it can still be dispensed, whether the treatment is for gender incongruence/dysphoria or some other purpose. In practice, unless it is a repeat prescription, it will need to have been issued within the previous six months to still be valid.
• If the prescription is written on or after 3 June 2024, it can only be dispensed if it is written by a UK-registered doctor, nurse or pharmacist, whatever its purpose. It must be either for a purpose other than treatment for gender incongruence or, if it is for gender dysphoria/incongruence, the patient must have started treatment before 3 June 2024. In addition to those patients who have actually started treatment, patients are treated as having started treatment, whether or not they have actually taken a GnRH analogue, if they were prescribed with a GnRH analogue on or after 3 December 2023.

It will also be a criminal offence to possess these medicines, where the individual had reasonable cause to know that the medicine had been sold or supplied in breach of the ban.

Additionally, from 26 June 2024 NHS prescribers in GP practices in primary care will only be able to supply – or continue to supply - prescriptions for GnRH analogues in the following circumstances:

• the patient is aged 18 years or over or
• the patient is 17 years or under and has started treatment with these medicines (they will be treated as having started treatment if they have been issued with a Copyright © NHS England 2024 3 prescription for these medicines since 3 December 2023, even if they have not yet started to take the medicine) or
• the patient is 17 years or under and is being treated with GnRH analogues for gender incongruence or gender dysphoria by the NHS as part of a future clinical trial overseen by the National Institute for Health and Care Research or
• the patient is 17 years or under and the purpose of the prescription is for a medical condition other than gender incongruence or gender dysphoria.

From 3rd June, private prescriptions of GnRH analogues from a prescriber registered in the European Economic Area (EEA) or Switzerland are banned from being supplied in Great Britain in all circumstances for patients aged under 18.

NHS England sent this letter to everyone who is on the waiting list for the NHS Children and Young People’s Gender Service in May 2024.

Sativex® is a medicine that can be used to treat symptoms of moderate to severe spasticity (muscles feeling stiff, heavy and difficult to move) in patients with MS. The ICB is having discussions with local clinical specialists on how we can use Sativex® alongside existing treatment options for MS as per NICE guidance (NG144). Until these discussions have taken place, Sativex® is still classified as ‘do not prescribe’ which means it cannot be prescribed by healthcare professionals working across West Yorkshire.

NHS West Yorkshire Integrated Care Board (ICB) commissions the following use of VEGF inhibitors

1. All patients stabilised on Ranibizumab (Lucentis®) should be transferred to biosimilar ranibizumab (Ongavia®). Patient consent and consultation should be undertaken as per local trust policies.
2. Treatment naïve patients can be started on faricimab (Vabysmo®)
3. Patients already on facricimab (Vabysmo®), including those exiting a trial. should continue to receive faricimab (Vabysmo®).
4. Patients where it has not been possible to stabilise on injections of ranibizumab every eight weeks can be considered for treatment with faricimab (Vabysmo®).
5. Patients where it has not been possible to stabilise on injections of aflibercept (Eylea®) every eight weeks can be considered for treatment with faricimab (Vabysmo®).
6. Patients not stable on brolucizumab (Beovu®) can be considered for a switch to treatment with faricimab (Vabysmo®)
7. Patients currently using bevacizumab (Avastin®) may continue treatment if stable.

• VEGF inhibitors in ophthalmology - commissioning policy
• Medical retina - new medicines pathway

Wednesday 6 November 2024

Please see this information Access to weight loss drugs in West Yorkshire for the latest information about semaglutide (Wegovy),

Thursday 7 September 2023

On 4 September, the news reported that some NHS patients could be prescribed the Wegovy weight-loss drug after limited stock arrived in the UK. We are awaiting national guidance for when Wegovy will be available and for which patients, though it is anticipated that this will only be available to patients who are already under a Tier 3 weight management service and as part of a national pilot. Tier 3 weight management services provide non-surgical intensive treatment and support for the management of obesity.

Over the coming weeks we hope to receive clarity from NHS England on which West Yorkshire weight management services may have access to appropriate supplies to commence mobilisation and delivery as part of this national pilot safely.

At this time Wegovy is not available through your GP or any West Yorkshire weight management services.

We will update as we know more.

Wednesday 7 June 2023

NHS West Yorkshire Integrated Care Board (ICB) welcomes the news that considerations are being given on how to expand weight management offers to people in England. Wegovy is not currently available for prescribing. This is likely to be rolled out as an initial pilot project and at this time we do not know which areas will be pilot sites. We greatly appreciate that demand for these medications is likely to be high and will work in the coming weeks to gain clarity of what is likely to be the offer.

As supplies of Wegovy have not yet been made available in the UK by the manufacturer, there has been an increase in demand for off label use of Ozempic and Rybelsus, which has led to shortages of these drugs to treat people with type 2 diabetes. Ozempic and Rybelsus are only licensed for type 2 diabetes and as such must only be used for patients with type 2 diabetes.

West Yorkshire ICB does not support the off-label use of Ozempic or Rybelsus for weight loss treatment.

We know that obesity is particularly prevalent in low Index of Multiple Deprivation (IMD) areas and those most in need may not be able to afford to self-fund such a medication, so we want to ensure our commissioning policy reflects this. We will work to keep you updated on timescales and more detailed plans as they develop.

Please see the contact details below for any enquiries:
Email: Westyorkshire.ICS@nhs.net
Telephone: 01924 317659