| Formulary Chapter 8: Malignant disease and immunosuppression - Full Chapter
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| NICE NG122 : Lung cancer: diagnosis and management |
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| NICE NG47: Haematological cancers: improving outcomes |
| NICE NG52: Non-Hodgkin’s lymphoma: diagnosis and management |
| Details... |
| 08.02.02 |
Corticosteroids and other immunosuppressants |
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Avacopan (Tavneos ®)
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Formulary
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Hard Capsules, 10mg
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NICE TA825: Avacopan for treating severe active granulomatosis with polyangiitis or microscopic polyangiitis
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Ciclosporin (Neoral®)
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Formulary
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Capsules 25mg, 50mg, 100mg
Liquid 100mg/1mL
Concentrate for intravenous infusion 50mg/1mL
Prescribe by brand name for transplant patients.
For use in other indications see sections 01.05.03, 10.01.03, and 11.11.
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 LSCMMG: Ciclosporin shared care guideline
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Pegcetacoplan (Aspaveli®)
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Formulary
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Solution for infusion. Each 20 mL vial contains 1 080 mg of pegcetacoplan.
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NICE TA778: Pegcetacoplan for treating paroxysmal nocturnal haemoglobinuria
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Prednisolone
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Formulary
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Tablets 1mg, 5mg
e/c tablets 2.5mg
25mg tablets are classified as 
There is no evidence that e/c prednisolone reduces the risk of gastrointestinal side effects. Uncoated tablets should be prescribed first line together with a PPI if necessary.
Also see sections 10.01.02.02, 06.03.02, 01.05.02, 11.04.01.
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Ruxolitinib (Jakavi®)
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Formulary
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Treatment of acute graft versus host disease that responds inadequately to corticosteroids in people 12 years and over.
Ruxolitinib will be available via the Innovative Medicines Fund (IMF) from 21st March 2025 in line with these recommendations and according to a set of treatment criteria which translates the NICE recommendation into a clinical guide as to use in practice.
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NICE GID-TA11512: Ruxolitinib for treating acute graft versus host disease refractory to corticosteroids in people aged 12 and over
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Sirolimus (Rapamune®)
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Formulary
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Tablets 500micrograms, 1mg, 2mg
The 500 microgram tablet is not bioequivalent to the 1 mg and 2 mg tablets. Multiples of 500 microgram tablets should not be used as a substitute for other tablet strengths.
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MHRA: Sirolimus: different immunoassays for therapeutic drug monitoring—risk of incorrect dose adjustment
NICE TA481: Immunosuppressive therapy for kidney transplant in adults
NICE TA482: Immunosuppressive therapy for kidney transplant in children and young people
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Tacrolimus
(Always prescribe by brand name)
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Formulary
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Brand name prescribing essential
For prophylaxis of graft rejection
Dailiport modified release oral capsules are recommended for all patients who are newly prescribed modified release tacrolimus for transplant rejection – RAG status RED for new patients
Please note:
Dailiport modified release capsules are not bioequivalent to Adoport immediate release capsules and do not replace Adoport capsules.
Existing patients using Advagraf modified release capsules will remain on Advagraf and are not routinely switched to Dailiport. If a prescriber considers that switching a patient to a different brand of oral tacrolimus would be of benefit, the change requires careful supervision and therapeutic monitoring by an appropriate specialist.
See section 13.05.03 for use in dermatology.
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LSCMMG: Position Statement Prescribing of Oral Tacrolimus
MHRA: Oral tacrolimus products: reminder to prescribe and dispense by brand name only
NICE TA481: Immunosuppressive therapy for kidney transplant in adults
NICE TA482: Immunosuppressive therapy for kidney transplant in children and young people
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Voclosporin (Lupkynis®)
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Formulary
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Capsules 7.9mg
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NICE TA882: Voclosporin with mycophenolate mofetil for treating lupus nephritis
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Key |
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Restricted Drug |
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Unlicensed |
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Link to adult BNF
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Link to children's BNF
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Link to SPCs
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Scottish Medicines Consortium |
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Cytotoxic Drug |
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Controlled Drug |
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High Cost Medicine |
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Cancer Drugs Fund |
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NHS England |
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Homecare |
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ICB |
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Low carbon footprint |
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Medium carbon footprint |
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High carbon footprint |
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| Status |
Description |
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Green:
Appropriate for initiation and ongoing prescribing in both primary and secondary care.
Generally, little or no routine drug monitoring is required. |
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Green (Restricted):
Appropriate for initiation and ongoing prescribing in both primary and secondary care provided:
Additional criteria specific to the medicine or device are met, or
The medicine or device is used following the failure of other therapies as defined by the relevant LSCMMG pathway.
Generally, little or no routine drug monitoring is required.
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Red medicines:
Medicine is supplied by the hospital for the duration of the treatment course.
Primary care initiation or continuation of treatment is not recommended unless exceptional circumstances such as specialist GP.
Red medicines are those where primary care prescribing is not recommended. These treatments should be initiated by specialists only and prescribing retained within secondary care. They require specialist knowledge, intensive monitoring, specific dose adjustments or further evaluation in use. If however, a primary care prescriber has particular specialist knowledge or experience of prescribing a particular drug for a particular patient it would not always be appropriate for them to expect to transfer that prescribing responsibility back to secondary care. There should be a specific reason and a specific risk agreement, protocol and service set up to support this.
Primary care prescribers may prescribe RED medicines in exceptional circumstances to patients to ensure continuity of supply while arrangements are made to obtain ongoing supplies from secondary care. |
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Amber level 0:
Suitable for prescribing in primary care following recommendation or initiation by a specialist.
Little or no specific monitoring required.
Patient may need a regular review, but this would not exceed that required for other medicines routinely prescribed in primary care.
Brief prescribing document or information sheet may be required.
Primary care prescribers must be familiar with the drug to take on prescribing responsibility or must get the required information.
When recommending or handing over care, specialists should ask primary care prescribers to take over prescribing responsibility, and should give enough information about the indication, dose, monitoring requirements, use outside product licence and any necessary dose adjustments to allow them to confidently prescribe. |
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Amber level 1 (with shared care):
Suitable for prescribing in primary care following recommendation or initiation by a specialist.
Minimal monitoring required.
Patient may need a regular review, but this would not exceed that required for other medicines routinely prescribed in primary care.
Full prior agreement about patient’s on-going care must be reached under the shared care agreement.
Primary care prescribers are advised not to take on prescribing of these medicines unless they have been adequately informed by letter of their responsibilities with regards monitoring, side effects and interactions and are happy to take on the prescribing responsibility. A copy of locally approved shared care guidelines should accompany this letter which outlines these responsibilities. Primary care prescribers should then tell secondary care of their intentions as soon as possible by letter so that arrangements can be made for the transfer of care. |
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Amber level 2 (with shared care and enhanced service):
Initiated by specialist and transferred to primary care following a successful initiation period.
Significant monitoring required on an on-going basis.
Full prior agreement about patient’s on-going care must be reached under the shared care agreement.
Suitable for enhanced service.
These medicines are considered suitable for GP prescribing following specialist initiation of therapy, as per shared care document which will be sent out with the request to prescribe, with on-going communication between the primary care prescriber and specialist. Amber Level 2 medicines require significant monitoring for which an enhanced service may be suitable. (Subject to local commissioning agreements). |
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Do not prescribe: NOT recommended for use by the NHS in Lancashire and South Cumbria.
Includes medicines that NICE has not recommended for use and terminated technology appraisals, unless there is a local need. |
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Grey medicines:
Medicines which have not yet been reviewed or are under the review process.
GPs and specialists are recommended not to prescribe these drugs.
This category includes drugs where funding has not yet been agreed.
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Refer to local guidance. |
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