Pan Mersey
Area Prescribing Committee
 
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8 Malignant disease and immunosuppression

Coronavirus guidance

Guidance to support primary care prescribers and pharmacists is available from the MLCSU Coronavirus guidance resource page. Links are provided to national resources and regional documents produced by MLCSU, RDTC, and SPS for use by Pan Mersey APC, LSCMMG, and GMMMG.

The list of resources will be updated as new material becomes available so please check back regularly for updates.

The Pan Mersey APC supports the use of COVID-specific guidance issued by NICE, and NHS England and NHS Improvement. During the COVID pandemic this will supersede any APC advice.

Malignant disease and immunosuppression

Review date: January 2022

Non-formulary drugs: Any drug or formulation not listed in the formulary is deemed to be non-formulary.

Off-label use: Drugs are included in the formulary for their licensed indications – where inclusion of off-label use is considered to be included in the formulary this is specifically stated in the formulary entry for the drug N.B. also see Paediatrics note below.

Paediatrics: Drugs are included in the formulary for paediatric use for their BNF for Children recommended indications (indicated by symbol View childrens BNF) which may be off-label, unless otherwise stated. All drugs are deemed to have the same RAG status as they have for adults unless stated otherwise.

NHS England Specialised Commissioning
Drugs carrying the NHS England logo are commissioned by them. Links to key documents, national programmes of care, and clinical reference groups are found below.

NHSE NHS England Specialised Commissioning: Key documents

NHSE NHS England Specialised Commissioning: National programmes of care and clinical reference groups

Medications which are indicated for medically assisted reproduction, including ovulation induction (e.g. clomifene, letrozole and tamoxifen) and assisted reproduction, such as In Vitro Fertilisation or Ex Vitro Fertilisation (e.g. gonadotrophins) are restricted to use by specialist secondary care physicians, and are categorised as RED drugs for these purposes.

08-02-01 Antiproliferative immunosuppressants

Azathioprine is RED for transplant rejection. Please note that this RAG rating refers to use in transplant rejection. Please see other relevant chapters of this formulary for use in other indications.

Thiopurine methyltransferase

The enzyme thiopurine methyltransferase (TPMT) metabolises thiopurine drugs (azathioprine, mercaptopurine, tioguanine): the risk of myelosuppression is increased in patients with reduced activity of the enzyme, particularly for the few individuals in whom TPMT activity is undetectable. Consider measuring TPMT activity before starting azathioprine, mercaptopurine or tioguanine therapy. Patients with absent TPMT activity should not receive thiopurine drugs; those with reduced TPMT activity may be treated under specialist supervision.

Mycophenolate / Mycophenolic acid are RED for transplant rejection.  Please see other relevant chapters of this formulary for use in other indications.

Mycophenolic acid 720mg is approximately equivalent to mycophenolate mofetil 1g but avoid unnecessary switching because of pharmacokinetic differences.


Azathioprine
Formulary

Tablets 25mg,50mg;

Oral suspension 10mg/mL (Special)

Injection 50mg vial

NHS NHSE commissioned drug - see Specialised Commissioning: Key documents Transplant immunosuppression only


Red View adult BNF  View SPC online  View childrens BNF
Mercaptopurine
Formulary
Red Triangle Take care when prescribing and dispensing
Oral suspension and tablets are not bioequivalent with respect to peak plasma concentration; intensified haematological monitoring is advised when switching formulations [SPS (2018)]
Tablets 50 mg, 10 mg (unlicensed special for paediatric use)
Oral supension 100 mg/5 ml (licensed for paediatric use - expensive)

 

NHS NHSE commissioned drug - see Specialised Commissioning: Key documents
Transplant immunosuppression only


Red View adult BNF  View SPC online  View childrens BNF
Mycophenolate Mofetil
Formulary

Capsules 250mg; Tablets 500mg; Oral suspension 1g/5mL when reconstituted with water

Injection 500mg vial powder for reconstitution for IV infusion

Expert opinion locally is that mycophenolate does not require brand prescribing – significant cost savings are available with generic prescribing.

NHS NHSE commissioned drug - see Specialised Commissioning: Key documents
Transplant immunosuppression only


Red View adult BNF  View SPC online  View childrens BNF
Mycophenolic acid
Formulary
Mycophenolic acid (as mycophenolate sodium)
e/c tablets 180mg, 360mg

NHS NHSE commissioned drug - see Specialised Commissioning: Key documents
Transplant immunosuppression only

Red View adult BNF  View SPC online  View childrens BNF