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 Formulary Chapter 8: Malignant disease and immunosuppression - Full Chapter
Notes:

THIS CHAPTER IS CURRENTLY UNDER REVIEW. FOR FURTHER ADVICE PLEASE CONTACT YOUR LEAD PHARMACIST OR CCG MEDICINES OPTIMISATION TEAM (PRIMARY CARE ENQUIRIES ONLY)

Formulary and commissioned oncology and haematology regimens

From April 2013 cancer treatments listed on the National Cancer Drug Fund list are funded through the NHS England as outlined on their dedicated website.

Treatments recommended in a NICE Technology Appraisal will be added to Formulary but may not always be provided at all centres (Some centres may not see the cohort of patients the NICE Technology Appraisal covers)

For patient information about chemotherapy and chemotherapy regimens, please see the Macmillan cancer support website: 

Royal Papworth Hospital NHS Foundation Trust does not routinely administer chemotherapy and does not have facilities for the preparation of injectable cytotoxic medication. If a patient requires treatment, usual practice is to transfer to an alternative hospital able to provide this service. The Trust accepts that an occasion may arise where transfer of the patient gives cause for concern. In this situation the Consultant wishing to prescribe cytotoxic medication must discuss the case directly with the Chief Pharmacist.

Chapter Links...
 Details...
08.02.02  Expand sub section  Corticosteroids and other immunosuppressants
Antithymocyte immunoglobulin (rabbit)  (Thymoglobuline®)
(Injection)
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Restricted Drug Restricted
Red Hospital
High Cost Medicine

  • Transplant only – treatment of steroid resistant rejection.

  • Prophylaxis in kidney/pancreas and paediatric liver transplant. (Non-formulary at RPH for this indication)

 
Link  Guidance from the BCSH Aplastic Anaemia
   
Basiliximab (Simulect®)
(Injection )
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Restricted Drug Restricted
Red Hospital
High Cost Medicine

  • CUHFT:

    • For renal transplants to reduce incidence of acute rejection in line with NICE.

    • Maintenance of immunosuppression following intestinal transplant: Off-label use of basiliximab is approved for this indication in a small cohort of patients being treated by Dr Massey.

    • Otherwise not approved for other transplants or for use as maintenance therapy.



  • RPH: Formulary for use in transplant patients

 
Link  NICE TA481: Immunosuppressive therapy for kidney transplant in adults
Link  NICE TA482: Immunosuppressive therapy for kidney transplant in children and young people
   
Belatacept (Nulojix®)
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Restricted Drug Restricted
Red Hospital
High Cost Medicine
Clinically approved for organ transplant recipients who are:
• EBV seropositive AND
• Intolerant of first-line immunosuppressive therapy (for example thrombotic microangiopathy with tacrolimus/ciclosporin, acute tubular necrosis with tacrolimus/ciclosporin, ymphocele with sirolimus) AND
• In whom maintenance immunosuppression with an anti-proliferative agent (mycophenolate mofetil or mycophenolate sodium) and steroids alone is insufficient.
  • NOT ROUTINELY FUNDED. NEW PATIENTS REQUIRE FUNDING APPROVAL BEFORE INITIATING.  
  • Link  MHRA Letters sent to healthcare professionals in March 2019: Nulojix (belatacept) - Update on the temporary restriction in supply (initiated in March 2017)
       
    Ciclosporin (Neoral® and Sandimmun®)
    (transplants, Capsules, Oral Solution, Injection )
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    Formulary
    Amber SCG
    High Cost Medicine

     

    • Capsules25mg, 50mg, 100mg, Oral Solution(Neoral®), Injection (Sandimmun®)
    • MHRA specify that ciclosporin must be prescribed and dispensed by brand as bioavailability differences exist between brands. Neoral is the preferred brand in Cambridgeshire for transplant indications.Neoral liquid is equivalent to Neoral capsules. If changing from any other preparation contact Medicines Information for assistance.
    • RPH: Shared Care Guideline in place and also supply can be made via Homecare.

    FEBRUARY 2020 - DO NOT REPATRIATE EXISTING PATIENTS, SHARED CARE GUIDELINES ARE CURRENTLY UNDER REVIEW.

     

     
    Link  RPH SCG: Ciclosporin for transplant patients.
       
    Modigraf®
    (Tacrolimus (Granules))
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    Restricted Drug Restricted
    Red Hospital

    Granules (Prescribe by brand).
    TWICE DAILY TACROLIMUS

    • Caution, narrow therapeutic index drug, several brands and formulations available. Must be prescribed, dispensed and administered by brand, switching between brands only to be undertaken under specialist supervision with blood level monitoring.
    • RPH: Supply can be made via homecare.
    • Non-formulary at all other Trusts.
    • Tacrolimus is NHS England commissioned for immunosuppression associated with transplantation.

     

     
       
    Prednisolone
    (Post- transplant)
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    Formulary
    Green

    • RPH: Available via Homecare

     
       
    Prednisolone
    (Immunosuppressant)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Formulary
    Green
  • Available as tablets and soluble tablets
  • EC tablets are 1.5x the price of plain tablets without any substantial evidence that they confer any GI benefits and in some cases have worsened disease control.
  • 25mg tablets are 4x (GP) to 25x (hospital) more expensive per mg than 5mg tablets.
  • Soluble tablets are 35x(!) more expensive than normal tablets (which can be crushed & dispersed (unlicensed)).
  • Potential for adverse reactions to drug withdrawal. 
  • Link  UKMI: Prednisolone - Use plain, Not EC Tablets
    Link  UKMI: Prednisolone - Use plain, Not Soluble Tablets
       
    Sirolimus (Rapamune®)
    (Tablet, Oral Solution)
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    Restricted Drug Restricted
    Amber SCG
    High Cost Medicine

     

    • Restricted to transplant teams
    • RPH: Supply can be via homecare

    FEBRUARY 2020 - DO NOT REPATRIATE EXISTING PATIENTS, SHARED CARE GUIDELINES ARE CURRENTLY UNDER REVIEW.

     
    Link  RPH SCG: Sirolimus for transplant patients
    Link  SCG: Sirolimus (Rapamune„¥) for Maintenance of Immunosuppression after Kidney Transplantation in Adults
       
    Advagraf®
    (Tacrolimus Modified Release)
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    Restricted Drug Restricted
    Red Hospital

    Capsule MR (Prescribe by brand)
    ONCE DAILY TACROLIMUS

    • Nephrologists - transplantation programme.

     

    • Must be prescribed, dispensed and administered by brand, switching between brands only to be undertaken under specialist supervision with blood level monitoring.

     

    • RPH: Non-formulary

     

    • Tacrolimus is NHS England commissioned for immunosuppression associated with transplantation.

    FEBRUARY 2020 - DO NOT REPATRIATE EXISTING PATIENTS, SHARED CARE GUIDELINES ARE CURRENTLY UNDER REVIEW.

     

     
    Link  CAS letter: Oral tacrolimus products should be prescribed and dispensed by brand name to avoid the risk of medication errors
       
    AdoPORT®
    (Tacrolimus)
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    Restricted Drug Restricted
    Red Hospital

    Capsule (Prescribe by brand)
    TWICE DAILY TACROLIMUS



    • Restricted to use within new patients only in accordance with a phased implementation plan in the following patient groups: Adult renal, Paediatric renal, Ophthalmology (adults), Gastroenterology (adults) and Haematology (adults).

    • Caution, narrow therapeutic index drug, several brands and formulations available. Must be prescribed, dispensed and administered by brand, switching between brands only to be undertaken under specialist supervision with blood level monitoring.

    • RPH: Available via homecare.

    • Tacrolimus is NHS England commissioned for immunosuppression associated with transplantation.

     
       
    Prograf®
    (Tacrolimus)
    View adult BNF View SPC online View childrens BNF  Track Changes
    Restricted Drug Restricted
    Amber SCG

    Capsule (Prescribe by brand).
    TWICE DAILY TACROLIMUS

    • Caution, narrow therapeutic index drug, several brands and formulations available. Must be prescribed, dispensed and administered by brand, switching between brands only to be undertaken under specialist supervision with blood level monitoring.
    • RPH: Shared care guideline available or alternatively supply can be made via homecare.
    • Tacrolimus is NHS England commissioned for immunosuppression associated with transplantation. 

    FEBRUARY 2020 - DO NOT REPATRIATE EXISTING PATIENTS, SHARED CARE GUIDELINES ARE CURRENTLY UNDER REVIEW.

     
    Link  RPH SCG: Tacrolimus (Prograf) for transplant patients
       
     ....
     Non Formulary Items
    Cytotoxic Drug  Everolimus  (Certican®)
    (Transplant)

    View adult BNF View SPC online View childrens BNF Track Changes
    Non Formulary
    Black
    High Cost Medicine
    • This is not recommended for preventing organ rejection in liver transplantation.
    • See other formulary entries for different indication
    • Caution with Brand prescribed - Afinitor® is on formulary as per restrictions.

     
      
    Key
    note Notes
    Section Title Section Title (top level)
    Section Title Section Title (sub level)
    First Choice Item First Choice item
    Non Formulary Item Non Formulary section
    Restricted Drug
    Restricted Drug
    Unlicensed Drug
    Unlicensed
    Track Changes
    Display tracking information
    click to search medicines.org.uk
    Link to adult BNF
    click to search medicines.org.uk
    Link to children's BNF
    click to search medicines.org.uk
    Link to SPCs
    SMC
    Scottish Medicines Consortium
    Cytotoxic Drug
    Cytotoxic Drug
    CD
    Controlled Drug
    High Cost Medicine
    High Cost Medicine
    Cancer Drugs Fund
    Cancer Drugs Fund
    NHSE
    NHS England
    Homecare
    Homecare
    CCG
    CCG

    Traffic Light Status Information

    Status Description

    OTC

    Available Over the Counter. Consider Self Care   

    Green

    Formulary - Can be prescribed in both secondary and primary care.   

    Advice

    Formulary - Specialist Advice, secondary care advice provided for primary care initiation.  

    Amber No SCG

    Formulary - Specialist initiation without shared care guidance.  

    Amber SCG

    Formulary - Specialist initiation with shared care guidance.  

    Red Hospital

    Restricted - Hospital only, not to be prescribed in primary care.  

    Switch

    Not recommended for prescribing. Switch to alternative cost-effective option.   

    Black

    Not recommended for prescribing in primary or secondary care.  

    Grey

    Not recommended as no formal application made for addition to the formulary. Contact relevant pharmacy team for further information.   

    Non Formulary

    Non-Formulary (category under review).  

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