Hospital medicines list news 6
Prescribing from 1 July 2013 - information for hospitals and health professionals
6 August 2013
DHB hospitals started prescribing from a nationally consistent pharmaceutical list on 1 July 2013. The Hospital Medicines List (HML) – Part II of Section H of the Pharmaceutical Schedule – has been developed by clinicians, pharmacists and PHARMAC over the past two-and-a half years. It means New Zealanders get access to the same hospital medicines, wherever in New Zealand they are being treated.
In this issue:
Printed copies of the August HML Update have been delivered to DHB Pharmacies and should now be available in your hospital. The July HML Update can be discarded when you receive the August Update.
The Update is a compilation of the July HML Update, two ‘interim’ website updates made during July, and changes effective from 1 August. It should be read alongside the 1 July HML first edition and is available on our website as a PDF.
We’ve had a number of NPPA Rapid Assessment requests from DHB prescribers over the HML’s first month in action.
Rapid Hospital Assessment is a process for DHB clinicians to request the urgent use of a non-HML medicine when a patient is expected, within five working days, to ‘experience either significant deterioration or miss the opportunity for a significant improvement in clinical outcomes (length or quality of life)’ if not treated with the requested medicine.
Clinicians should use their own DHB’s Rapid Assessment processes where these are in place. If for some reason an assessment can’t be done at the DHB, the PHARMAC process is available.
DHBs need to be aware that internal DHB approvals to make the application should be done before sending us the completed Rapid Assessment form.
The application steps to work through are included in a short guide we’ve recently put together on Rapid Assessments. We’ve sent this through to DHB Pharmacies and it’s also on our website.
Some items listed in the HML have restrictions or rules applied to them. Restrictions can be by prescriber type or by indication. They can apply either at the chemical level or to presentations of that chemical. Some restrictions apply to all presentations of a chemical listed in the HML, and some apply only to specific presentations.
Each presentation that has a restriction applied to it is identified in the HML with the arrow symbol (). If a presentation does not have this symbol beside it, then no restriction applies to the prescribing or dispensing of that presentation.
What happens if there are multiple HML restrictions?
Sometimes HML medicines have multiple indication restrictions. An indication restriction is a limitation placed by PHARMAC on the use of a pharmaceutical restricting it to the treatment in particular clinical circumstances.
Where there is only one indication restriction, only patients meeting this indication restriction may receive this treatment.
There has been some confusion on how to interpret restrictions where multiple indication restrictions are listed. Where there are two or more indication restrictions listed, a patient meeting any one of these indication restrictions may receive treatment.
Example of multiple indication restriction
An example of a multiple indication restriction is ursodeoxycholic acid 250 mg capsules. Ursodeocycholic acid has two indication restrictions. These are pregnancy/cirrhosis or haematological transplant. The patient only needs to meet ONE of these indication restrictions, so pregnancy/cirrhosis or haematological transplant. Below is a screen shot of the HML listing for ursodeoxycholic acid.
Example of restrictions applying to only one presentation
An example of this is captopril – screen shot below. The indication restriction applies only to the oral liquid presentation, and not to the tablets. The restriction symbol () is only against the oral liquid presentation.
If you want further advice on interpreting the restricted listings, please call our HML advice line on the 0800 number at the end of this newsletter.
Starship Hospital has protocols for certain sub-specialty uses of antimicrobials that are unlikely to exist in other centres, particularly in children with complex medical conditions. The Starship Clinical guidelines are available online at: https://www.starship.org.nz/for-health-professionals/starship-clinical-guidelines(external link)
These have been approved by the Starship paediatric ID team and include several protocols for subspecialist management of paediatric problems. PHARMAC encourages other DHBs to take advantage of that resource.
We have received a few questions regarding the use of pre-thickened drinks and food/fluid thickeners in DHB hospitals. We have clarified the situation with DHB pharmacies. However, for your general information, as from 1 July, while pre-thickened drinks and supplements have not been included in Section H, DHB hospitals may continue to use such products for patients with dysphagia, provided that:
- use was established prior to 1 July 2013; and
- the product has not been specifically considered and excluded by PHARMAC; and
- use of the product conforms to any applicable indication restrictions for similar products that are listed in Section H (for example, use of thickened high protein products should be in line with the restriction for high protein oral feed in Section H).
So what does this mean?
1. If the use of pre-thickened drinks and pre-thickened supplements was established in the DHB hospital prior to 1 July 2013, then the DHB hospital may continue to use them in both new and existing patients (NOTE: any new patients would not be able to use products that have been specifically excluded from the HML – see below).
2. Certain products have been considered and specifically excluded from the HML at this time. The list of these products can be found on PHARMAC’s website at www.pharmac.health.nz/assets/notification-2013-05-16-hospital-a-z-list.pdf – the excluded products are in red. If your hospital wishes to use one of the excluded products either a NPPA application would need to be submitted if it relates to an individual, or you could submit a clinician’s application form for it to be further considered for inclusion on the HML. A meeting of the Special Foods Subcommittee is scheduled for later this year, so should you wish to have a product considered for inclusion on the HML, please provide a clinician’s application form before the end of September.
3. Please remember that any individual patients who were receiving treatment with these products prior to 1 July 2013 may continue to access them. This usage is covered by the HML rules (rule 13).
4. If anything changes then we will let hospitals know.
We have received a number of queries regarding the listing for magnesium hydroxide. The only product listed on the HML was the 311mg (130 mg elemental) Milk of Magnesia product, which is section 29 and requires an extra level of record keeping.
Following requests for an alternate product, there is now a new listing of magnesium oxide cap 663 mg (400 mg elemental) “Twinlab Magnesium Caps”, 200 capsules, manufactured by ISI Brands Inc, Utah, USA in Part II of Section H of the Pharmaceutical Schedule, which was effective from 1 August 2013.
The United Kingdom’s Medicines and Healthcare Products Regulatory Agency (MHRA) has issued a recall for hydroxyethyl starch (HES) products in the UK. This is following results from large randomised clinical trials which reported an increased risk of renal dysfunction and mortality in critically ill or septic patients who received HES compared with crystalloids (simple salt solutions).
There are currently two brands of HES solutions listed on the Hospital Medicines List (HML) - Volulyte 6% and Voluven. Medsafe has issued a safety alert on these HES solutions (http://www.medsafe.govt.nz/Projects/B2/monitoring-communications.asp#8-July-2013(external link)) and the relevant datasheets will be updated with new safety-related information (contraindications etc).
Medsafe is continuing to review this safety concern and will provide further information once this review is complete. Until Medsafe completes its review of HES, Volulyte 6% and Voluven will remain listed on the HML. Clinicians will continue to have the discretion to use these products in the treatment of patients if considered clinically appropriate.
After today we plan to start sending you HML News monthly. We think this will be often enough to keep you up-to-date with what’s happening generally with the HML transition. You can also keep an eye on the HML pages on our website.
We are continuing to provide more regular detailed updates to DHB Pharmacies. So as well as contacting our advice lines with any specific HML queries, you can also talk to your pharmacy about what is happening.
If you have a question, comment or concern please email HML@pharmac.govt.nz, phone 0800 66 00 50 or fax 64 4 974 7819.
Last updated: 2 November 2015