Specials Webkit

This page will bring together all the PrescQIPP specials resources and suggests good practice and how to optimise the use of licensed medicines, alternatives and reviews to be done to support the reduced use of specials. Each set resource makes recommendations, as well as supportive documentation where applicable and alternative resources from other providers.

B159: Specials Prescribing Optimisation Tool (SPOT) List

The Specials Prescribing Optimisation Tool (SPOT) is based on the national specials prescribing data. This list includes specials that appear regularly in the top ten specials prescribed list, those where there has been a significant growth in prescribing and those that may not appear very often but when they do pose significant cost pressure due to their expense.

The SPOT resource (and supporting bulletins) provide information on specials versus licensed medication.  Support tools include advice on hierarchy of risk, on alternatives, and areas for cost saving.


PrescQIPP Bulletins to Support the SPOT-List

The bulletins linked below are the more in depth reviews of items on the spot list designed to support implementation of change for specific treatments. 

B108: Melatonin

 The Melatonin SPOT list support document reviews the place in therapy for melatonin and recommends reviewing patients regularly to assess for continued need.  A shared care template document is available so support appropriate prescribing.

Melatonin (SPOT-List)

B120: Vitamin D

 The vitamin D resource provides information on licensed preparations, pathways for adults and children as well as guidance around licensed alternatives. 

 Vitamin D

B165: Glycopyrronium

This bulletin focuses on the use of glycopyrronium in hypersalivation (both off label and unlicenced special usage). It also covers use in other conditions in both adults and children.

 Glycopyrronium (SPOT-List)

Other Glycopyrronium Resources

B123: Omeprazole

The omeprazole resource provides recommendations on licensed alternatives where appropriate for patients on unlicensed preparations.

 Omeprazole (SPOT-List)

B133: Topical Diltiazem

The topical diltiazem resource discusses the evidence available and alternative treatments. A pathway to treat anal fissure is also available as a supporting tool. 

 Topical diltiazem (SPOT-List)

B147: Buccal Midazolam

This bulletin reviews the place in therapy of unlicensed buccal midazolam and switching to a licences product where appropriate. Safety issues and savings are also discussed.

 Buccal midazolam (SPOT-List)

B186: Sodium Chloride

This bulletin reviews the use of sodium chloride specials products and suggests alternative treatments for both oral and eye preparations. A data pack is available to support local planning and review.

 Sodium chloride (SPOT-List)

Video Specials Prescribing Optimisation Tool Webinar - February 2015 - Rakhi Aggarwal

In this webinar Rakhi Aggarwal, PrescQIPP’s Pharmacist Project Manager for Specials introduces the SPOT List (Specials Prescribing Optimisation Tool) and providing an overview of plans for future delivery around Specials in 2015. Subscibers can now view this webinar below:

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Other Resources

The Specials Tariff Watch

The quarterly Specials Tariff Watch is designed to help prescribers navigate the changes in Part VIIIB of the drug tariff to facilitate cost-effective prescribing. It also includes the top ten list of potential highest savings. The document is based on, and replaces, work by Anne Fowler of NHS Lancashire (with thanks!). 

    Specials Tariff Watch

Royal Pharmaceutical Society Specials Guidance

In April 2016, the Royal Pharmaceutical Society produced professional guidance for prescribers of specials which is an update of a resource produced by the National Prescribing Centre in 2011.

Bulletin 48 - Liquid Formulation Requirements in Bariatric Surgery patients

The number of weight-loss bariatric procedures has been on the increase, especially since the publication of NICE guidelines on obesity in which bariatric surgery was recommended as a treatment option for some patients. Following bariatric surgery patients are restricted to a liquid diet and their medications are usually changed from solid dosage forms to unlicensed liquid formulations. This switch may not be necessary or may continue for longer than the clinical need and can have significant implications for the drug budget. This bulletin provides information for prescribers on the appropriate prescribing of liquid formulations for patients that have undergone bariatric surgery.

 Liquid formulation requirements in bariatric surgery patients 

B168: British Association of Dermatologists Revised Guidelines

This bulletin reviews the prescribing of dermatology specials to try and ensure that any prescribing of dermatology specials is appropriate and in line with the British Association of dermatologists guidelines.

 Dermatology specials (SPOT-List)

Other Products on the SPOT-List and Best Practice 

The products below have appeared in the SPOT-List, however as there are useful supporting resources and information already available, we have signposted to these rather than produce new resources.

Magnesium Glycerophosphate/Magnesium Oxide Resources

A licenced magnesium Glycerophosphate 4mmol chewable tablet product is now available priced at £22.77 for 50 tablets. See link below for SPC

Midodrine Resources

Midodrine tablets appear in the top 20 SPOT list. In March 2015 a licensed preparation of midodrine tablets became available as Bramox 2.5mg and 5mg tablets.  

Sodium Bicarbonate

Sodium bicarbonate 1mmol/ml oral solution was granted a UK license in September 2014. It is licensed for the treatment of hyperacidity, dyspepsia and provide symptomatic relief heartburn and peptic ulceration for patients 12 years and above. Specialist Pharmacist Services have produced a document as the licensed product was subject to some labelling safety concerns and use of unlicensed preparations is currently known to continue. The table in the link below summarises details of currently known products. 

Sodium Bicarbonate Oral Liquids - October 2016

NICE Evidence Summaries: Unlicensed/Off-Label Medicines

NHS has recently started producing evidence reviews for unlicensed or off-label medicines. It has already published two reviews. The first covers the off-label use of tranexamic acid for the treatment of significant haemorrhage following trauma, and the second reviews the use of unlicensed melatonin preparations for the treatment of sleep disorders in children and young adults with attention deficit hyperactivity disorder. There are plans to publish more reviews in the coming months and a list of those proposed can be found on the NICE website along with the published reviews at the following link:


NICE has produced a statement to describe what the evidence summaries on unlicensed or off-label medicines cover:

“Evidence summaries: unlicensed or off-label medicines' summarise the published evidence for selected unlicensed or off-label medicines that are considered to be of significance to the NHS, where there are no clinically appropriate licensed alternatives. The summaries provide information for clinicians and patients to inform their decision-making and support the construction and updating of local formularies.

The summaries support decision-making on the use of an unlicensed or off-label medicine for an individual patient, where there are good clinical reasons for its use, usually when there is no licensed medicine for the condition requiring treatment, or the licensed medicine is not appropriate for that individual.

The strengths and weaknesses of the relevant evidence are critically reviewed within this summary, but this summary is not NICE guidance.”

Guidance on Prescribing Unlicensed Eye Preparations Has Been Published - May 2014

The Royal College of Ophthalmologists and the UK Ophthalmic Pharmacy Group have published Ophthalmic Specials Guidance. It has been written in response to the high number of prescriptions for unlicensed eye preparations with an aim to promoting more cost-effective prescribing and more efficient use of NHS resources. The guidance will also assist prescribers in determining the appropriateness and suitability of eye preparations to achieve the best clinical outcomes for their patients. Reviewed every six months, the guidance is available to download on the websites of The Royal College of Ophthalmologists here https://www.rcophth.ac.uk/wp-content/uploads/2015/05/2015_PROF_319_Ophthalmic-Special-Order-Products-updated-June-2015.pdf