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HELD ON 3RD DECEMBER 2010
AT THE HOLIDAY INN RUNCORN
Jo Bateman, Countess of Chester Hospital (JB)
Sarah Roden, Western Cheshire PCT (SR)
Danny Forrest, Liverpool Heart and Chest Hospital (DF)
Victoria Birchall, NHS CL WL Locality (VB)
Diane Hornsby Western Cheshire PCT (DH)
Dave Thornton, Aintree Hospital (DT)
Michael Lloyd, Whiston Hospital (ML)
Michelle Wong, Arrowe Park Hospital (MW)
Catherine Lee, Royal Liverpool University Hospital (RLUH) (CL) Apologies
Jenny Lunn, Warrington PCT
Erica Baker, NHS Halton and St Helens
1. The Way Forward
JB told the group that she was the new Chair. She recapped on the fact that CMCSN are now stepping back from the Pharmacy Forum both financially and organisationally. Future meetings would still be hopefully arranged by the Cardiac Network. JB asked the group if they would be happy for future meetings to be sponsored by Pharmaceutical Companies and there were no objections to this proposal, providing the Company Representatives did not sit in on the meeting. The Holiday Inn at Runcorn was approved of as the venue for future meetings and it was agreed that these should be held on Friday afternoons, with a start time of 2.00pm. JB asked the group what should be covered in future meetings. It was agreed that the following areas should be covered:
discussions to ensure smooth transitions between primary, secondary and tertiary
sharing of clinical guidelines to prevent duplication of work educational presentations from group members ensuring pharmacist input into the CMCSN workstreams
On the last point it was felt that the Pharmacy Forum had lost contact with the Cardiac
Workstreams. DT suggested that a formal letter be written to the Director of CMCSN (Margaret
Lead) highlighting the importance of pharmacy representation on the Cardiac Workstreams. ACTION: JB to draft letter to send to Director of CMCSN and to circulate for comments.
DH highlighted the fact that some of the PCT pharmacists who were absent from the meeting may
also have some thoughts on what should be covered at subsequent Pharmacy Forum meetings ACTION: All Pharmacy Forum members who did not attend meeting to forward suggestions
re how to structure future meetings to JB
Note: the views expressed in the meeting and minuted below are representative of general
discussions around the subject in question and do not necessarily reflect specific or ratified
protocols in place
2. Fondaparinux – sharing guidelines
JB showed the group guidelines drawn up at the Countess of Chester (COCH) for fondaparinux in
the treatment of NSTEMI/UA and asked the other secondary care pharmacists how they were
using this drug in their hospitals. MW stated that at Arrowe Park (AP) they had switched from
enoxaparin to fondaparinux in November and the transition had gone smoothly so far. She stated
that there had been some confusion over the fact that it was for prophylactic use only and had
made an educational poster to help deal with this. JB said that there had been similar issues at
COCH. There was discussion around when to stop fondaparinux prior to angiogram and when to
restart it. MW said that at AP it is stopped on the day of the angiogram, although some
cardiologists have said to still give a night-time dose, and she wondered if there were any
guidelines on this. Nothing was available from the Company she said. DT suggested that a query
be placed on the UKCPA message board to see if any guidance was available ACTION: JB to put message on message board.
JB said that at COCH fondaparinux is also stopped on the day of the angiogram and the
Cardiologists wait until the next day to restart, as fondaparinux may not be required in any case,
depending on the results of the angiogram. CL queried if the drug needed to be stopped 24 hours
prior to the procedure and JB confirmed that this was the recommended action. DF stated that
Liverpool Heart and Chest Hospital (LHCH) had not seen any fondaparinux as it is stopped before
the patient arrives there. DT said that at Aintree the Cardiologists were reticent to switch to
fondaparinux before seeing guidelines from CMCSN. JB stated that at COCH, enoxaparin is still
being used in renal patients, although data shows fondaparinux is safer, and CL stated that at
Royal Liverpool University Hospital (RLUH), renal patients were also still receiving enoxaparin. CL
stated that she would ask Dr Saltissi where CMCSN is up to with ACS guidance. ACTION: CL to ask Dr Saltissi where CMCSN up to with ACS guidance
JB asked the group when to give fondaparinux if a patient had been receiving prophylactic
tinzaparin, then had ACS. DF said that there was no black and white answer. Give fondaparinux
12-24 hours after a treatment dose or any time after a prophylactic dose of tinzaparin. CL queried
what to do if a patient had ACS and existing AF. JB said that at COCH, if a patient had
UA/NSTEMI and new AF then they would be given enoxaparin 1mg/kg twice daily. MW added that
if the patient was on aspirin, not warfarin, then the patient should have fondaparinux. DT said that
for acute ACS the full dose of enoxaparin was 1mg/kg and this dose was supported by 2 trials. 3. Dronedarone
This item had been added to the agenda by Erica Baker, who unfortunately was not at the meeting.
Informally the group discussed where dronedarone was being used (COCH, LHCH, Aintree). VB
stated that it was about to go to Sefton and North Lancs MMC. DF said that dronedarone had been
taken to North Mersey MMC prior to the recent NICE TAG being published and prescribing for
some patients had been refused as it was believed that dronedarone was 3rd line after amiodarone.
DT said that this highlighted the fact that Pharmacist input to various committees was required. ML
stated that at Whiston, 4MB locality have proposed that the NICE audit tool be used to determine
whether a patient fits the eligibility criteria for dronedarone, before the Consultant prescribes it. MW
said that dronedarone is not on the AP Formulary. ML queried the group’s opinion on switching
patients who can’t tolerate amiodarone, to dronedarone. DT said that this had happened at Aintree.
ML said that potentially the patients might need a washout period between the two drugs, but JB
stated that in the ADONIS and EURIDIS trials, patients were switched within 48 hours, whereas in
ATHENA, the washout period was 4 weeks. DT said that he hadn’t used a washout period at all
and there had been no problems so far. 4. Losartan – a suitable alternative to candesartan?
JB asked the group if anybody was thinking of switching from candesartan to losartan, as losartan
was now available generically and at much lower cost. CL stated that in the HEAAL study 150mg
losartan had better clinical outcomes in HF than 50mg losartan. However, losartan is not licensed
at this dose. DT and ML said that losartan had been licensed for HF on the basis of the ELITE II
and LIFE studies which used 50mg losartan. The fact that losartan is not licensed for use in
combination with an A2RA and has been associated with increased mortality when used in
combination with a beta-blocker was also noted. 5. Updated NICE Chronic HF guidelines
CL took the group through the main changes to the recently updated NICE chronic HF guidelines.
DT and ML pointed out that the evidence base for using hydralazine and a nitrate is in Afro-
Caribbean patients. The fact that ivabradine is being used in some HF patient who also have
angina was also touched on. 6. Prasugrel Audit
DF presented an audit looking at whether the use of prasugrel at LHCH fitted within NICE
guidance. In addition, the group heard that a letter had come from NW QUIPP (??) asking if the
use of prasugrel could be reconsidered. NICE states that it is an ‘option’ and the cost analysis
within the NICE guidance was based on the cost of Plavix, rather than generic clopidogrel. There
was some thought that PCTs were cherry picking how to use the wording in NICE. Current NICE
guidance for prasugrel is not due to be reviewed until January 2012. It is likely that at that point the
cost-effectiveness argument will go, but until then the guidance should be followed.
JB asked if LHCH had a test for clopidogrel resistance. DF said that LHCH did have a reliable
machine to do this, although not being used in all patients at the moment, and that he thought
bedside platelet testing was on the near horizon Any other business
DF stated that LHCH had seen ACS patients from COCH and AP coming through on atorvastatin 40mg. MW stated that the evidence was not good for atorvastatin 80mg. DT also stated that a Cardiologist at Aintree didn’t like using atorvastatin 80mg either. JB said that at COCH, Lipid Management Guidelines had just been signed off and that in these ACS patients should be receiving atorvastatin 80mg. DF stated that all ACS patients were switched back to atorvastatin 80mg at LHCH.
MW asked what the rest of the group was doing re this potential interaction and the continuing and conflicting data being published. The group all agreed that for now the advice from the MHRA should be followed, i.e. avoid clopidogrel in combination with omeprazole or esomeprazole.
DT highlighted the fact that the CMCSN website was still not up and running and as such no
guidelines could be accessed. He asked if this could be flagged up to CMCSN WE NEED SOMEBODY TO TAKE THIS ACTION ON – ANY TAKERS?
Date to be confirmed. JB said that she would ask Company Representatives for dabigatran and rivaroxaban to sponsor the meeting and to give an overview of each drug. CL said that she would ask Richard Reed, who has set up Liverpool Anti-coagulant Clinic, to come along and talk to the group. Vernakalant was proposed for discussion at the end of the next meeting so that anybody not primarily interested in this can leave.
Date and Time of Next Meeting to be confirmed
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