Recommendations
This section contains a list of the policy recommendations of the Pan Mersey Area Prescribing Committee.
Reviews of the new medicines have been conducted by our pharmacists using a number of resources including National Institute for Health and Clinical Excellence (NICE) which is a Special health Authority (SHA) set up in 1999. It is used to give advice to the NHS on best clinical practice including the clinical and cost effectiveness of drugs and other treatments.
Definitions and Criteria for Categorisation of Medicines
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.
Documents
The Pan Mersey Area Prescribing Committee recommends the prescribing of abatacept infusion and subcutaneous injection (Orencia ®) for rheumatoid arthritis and infusion for polyarticular juvenile idiopathic arthritis as described below.
The Pan Mersey Area Prescribing Committee recommends the prescribing of adalimumab injection (Humira®) for rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, non-radiographic axial spondyloarthritis, polyarticular juvenile idiopathic arthritis and in patients fitting other criteria commissioned by Pan Mersey CCGs, as described.
The Pan Mersey Area Prescribing Committee recommends the prescribing of adalimumab, etanercept and infliximab, by specialists only, for the treatment of moderate rheumatoid arthritis after conventional DMARDs have failed and in accordance with NICE TA715.
The Pan Mersey Area Prescribing Committee recommends the prescribing of ANDEXANET ALFA infusion (Ondexxya®▼), by specialists only, for reversing anticoagulation from apixaban, edoxaban or rivaroxaban, when used in accordance with the criteria in NICE TA697.
The Pan Mersey Area Prescribing Committee recommends the prescribing of AVATROMBOPAG tablets (Doptelet®▼), by specialists only, for treating severe thrombocytopenia in adults with chronic liver disease having planned invasive procedures in accordance with NICE TA626.
The Pan Mersey Area Prescribing Committee recommends the prescribing of azithromycin tablets in selected high risk patients, when recommended by a respiratory specialist, for the prevention of exacerbations in COPD and bronchiectasis.
The Pan Mersey Area Prescribing Committee recommends the prescribing of BEMPEDOIC ACID tablets (Nilemdo®▼) and BEMPEDOIC ACID-EZETIMIBE tablets (Nustendi®▼) for primary hypercholesterolaemia or mixed dyslipidaemia in accordance with NICE TA694.
The Pan Mersey Area Prescribing Committee recommends the prescribing of BIMEKIZUMAB solution for injection (Bimzelx®▼), by specialists only, for the treatment of moderate to severe plaque psoriasis in accordance with NICE TA723.
The Pan Mersey Area Prescribing Committee recommends no more than TWO TREATMENT SESSIONS per YEAR of Botulinum Toxin Type A Injection (Botox®) by specialists for the treatment of severe axillary hyperhidrosis that has not responded to treatment with topical antiperspirants or other antihidrotic treatment, as a potential alternative to surgery.
The Pan Mersey Area Prescribing Committee recommends Botulinum Toxin Type A injection by specialists for the treatment of achalasia, non-specific gastric motility disorder and functional or post-operative gastroparesis in adults.
The Pan Mersey Area Prescribing Committee recommends prescribing a maximum of TWO COURSES of botulinum toxin type A injection in the treatment of chronic anal fissure which has not healed despite a minimum course of at least 8 weeks of topical management.
The Pan Mersey Area Prescribing Committee recommends the prescribing of BRIVARACETAM tablets/oral solution (Briviact®▼) for adjunctive treatment of focal seizures following initiation by a consultant neurologist.
AMBER patient retained by specialist NHS Wirral CCG
The Pan Mersey Area Prescribing Committee recommends the prescribing of BUDESONIDE orodispersible tablets (Jorveza®▼), by specialists only, as a treatment option for inducing remission eosinophilic oesophagitis in adults (older than 18 years of age) in accordance with NICE TA708.
NHS England specialised commissining resources: the clinical reference group responsible for allergy and immunology has published a commissioning policy that defines access to a particular service for a cohort of patients.
The Pan Mersey Area Prescribing Committee recommends the prescribing of CANAGLIFLOZIN, DAPAGLIFLOZIN, EMPAGLIFLOZIN and ERTUGLIFLOZIN as COMBINATION THERAPIES as options for treating type 2 diabetes in adults in accordance with NICE guidance.
The Pan Mersey Area Prescribing Committee recommends the prescribing ofCANAGLIFLOZIN, DAPAGLIFLOZIN, EMPAGLIFLOZIN and ERTUGLIFLOZIN as
MONOTHERAPIES as options for treating type 2 diabetes in adults in accordance with NICE TA390 and TA572.
The Pan Mersey Area Prescribing Committee recommends the prescribing of CARIPRAZINE hard capsules (Reagila®▼), following specialist initiation, as a non-first line treatment option for adult patients with predominant negative symptoms of schizophrenia.
The Pan Mersey Area Prescribing Committee recommends the prescribing of CENOBAMATE tablets (Ontozry®▼), following specialist initiation, for treating focal onset seizures in adults with epilepsy in accordance with NICE TA753.
The Pan Mersey Area Prescribing Committee recommends the prescribing of certolizumab injection (Cimzia®) for rheumatoid arthritis, ankylosing spondylitis, non-radiographic axial spondyloarthritis and psoriatic arthritis, as well as in patients fitting other criteria commissioned by Pan Mersey CCGs, as listed below.
The Pan Mersey Area Prescribing Committee recommends the prescribing of CICLOSPORIN 1mg/mL eye drops (Verkazia®), by specialists only, for the treatment of severe vernal keratoconjunctivitis (VKC) in children from 4 years of age and adolescents.
The Pan Mersey Area Prescribing Committee recommends the prescribing of COLESEVELAM HYDROCHLORIDE (Cholestagel®), following specialist initiation, for adult patients with bile acid malabsorption-associated diarrhoea who do not tolerate, or fail to respond to, 1st line treatments.
NHS England specialised commissining resources: the clinical reference group responsible for allergy and immunology has published a commissioning policy that defines access to a particular service for a cohort of patients.
The Pan Mersey Area Prescribing Committee recommends the prescribing of DAPAGLIFLOZIN tablets (Forxiga®) for symptomatic chronic heart failure with reduced ejection fraction, following specialist recommendation in accordance with NICE TA679.
- GP letter: GP communication letter: Dapagliflozin in Heart Failure with Reduced Ejection Fraction (HFrEF)
- Treatment Pathway: Pathway for the use of Dapagliflozin in Heart Failure with Reduced Ejection Fraction (HFrEF)
- Patient information leaflet: SGLT 2 Inhibitors: Information for patients with heart failure
- Patient medical alert card: Dapagliflozin Heart Failure DKA Medical Alert Card
The Pan Mersey Area Prescribing Committee recommends the prescribing ofCANAGLIFLOZIN, DAPAGLIFLOZIN, EMPAGLIFLOZIN and ERTUGLIFLOZIN as
MONOTHERAPIES as options for treating type 2 diabetes in adults in accordance with NICE TA390 and TA572.
The Pan Mersey Area Prescribing Committee recommends the prescribing of CANAGLIFLOZIN, DAPAGLIFLOZIN, EMPAGLIFLOZIN and ERTUGLIFLOZIN as COMBINATION THERAPIES as options for treating type 2 diabetes in adults in accordance with NICE guidance.
The Pan Mersey Area Prescribing Committee recommends the prescribing of DAPOXETINE tablets (Priligy®) for the treatment of premature ejaculation when recommended by a psychosexual service or a specialist clinician with experience of treating psychosexual disorders. Treatment is restricted to three doses per month.
The Pan Mersey Area Prescribing Committee recommends the prescribing of DEGARELIX SC injection (Firmagon®) following specialist initiation for treating advanced hormone-dependent prostate cancer in people with spinal metastases in accordance with NICE TA404.
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of DENOSUMAB solution for injection (Prolia®) for the treatment of bone loss associated with long-term systemic glucocorticoid therapy.
The Pan Mersey Area Prescribing Committee recommends the prescribing of Direct Oral Anticoagulants (DOACs) for the treatment and prevention of Deep Vein Thrombosis (DVT) and/or Pulmonary Embolism (PE)
GREEN for NHS Wirral CCG
Oral Anticoagulants (VKA and DOAC). Guidelines for prescribing, monitoring and management.
The Pan Mersey Area Prescribing Committee recommends the prescribing of ELUXADOLINE Tablets (Truberzi®▼) following specialist initiation for irritable bowel syndrome with diarrhoea in adults in accordance with NICE TA471.
Red NHS West Lancashire CCG
The Pan Mersey Area Prescribing Committee recommends the prescribing of EMPAGLIFLOZIN tablets (Jardiance®) for symptomatic chronic heart failure with reduced ejection fraction, following specialist recommendation in accordance with NICE TA773.
Patient information leaflet: SGLT 2 Inhibitors: Information for patients with heart failure
The Pan Mersey Area Prescribing Committee recommends the prescribing ofCANAGLIFLOZIN, DAPAGLIFLOZIN, EMPAGLIFLOZIN and ERTUGLIFLOZIN as
MONOTHERAPIES as options for treating type 2 diabetes in adults in accordance with NICE TA390 and TA572.
The Pan Mersey Area Prescribing Committee recommends the prescribing of CANAGLIFLOZIN, DAPAGLIFLOZIN, EMPAGLIFLOZIN and ERTUGLIFLOZIN as COMBINATION THERAPIES as options for treating type 2 diabetes in adults in accordance with NICE guidance.
The Pan Mersey Area Prescribing Committee recommends the prescribing of CANAGLIFLOZIN, DAPAGLIFLOZIN, EMPAGLIFLOZIN and ERTUGLIFLOZIN as COMBINATION THERAPIES as options for treating type 2 diabetes in adults in accordance with NICE guidance.
The Pan Mersey Area Prescribing Committee recommends the prescribing ofCANAGLIFLOZIN, DAPAGLIFLOZIN, EMPAGLIFLOZIN and ERTUGLIFLOZIN as
MONOTHERAPIES as options for treating type 2 diabetes in adults in accordance with NICE TA390 and TA572.
The Pan Mersey Area Prescribing Committee recommends the prescribing of etanercept injection for rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, non-radiographic axial spondyloarthritis, polyarticular juvenile idiopathic arthritis and adult-onset Still’s disease, as well as in patients fitting other criteria commissioned by Pan Mersey CCGs, as listed.
The Pan Mersey Area Prescribing Committee does not recommend the prescribing of EVOLOCUMAB injection (Repatha SureClick®) for reduction of cardiovascular risk in adults with established atherosclerotic cardiovascular disease.
The Pan Mersey Area Prescribing Committee recommends the prescribing of FERRIC MALTOL (Feraccru®) following specialist initiation for the treatment of iron deficiency anaemia in adult patients with inflammatory bowel disease.
The Pan Mersey Area Prescribing Committee recommends the prescribing on the NHS of flash glucose monitor sensors (FreeStyle Libre®) only within the criteria outlined.
These templates should be used by Pan Mersey organisations for incorporation into their specialist diabetes service clinic documentation that informs primary care prescriber that Freestyle Libre prescribing has been initiated in an individual patient according to the agreed criteria in the Pan Mersey statement, when confirming to primary care prescriber whether the patient has met continuation criteria after review, and into patient information/ contract documentation given to each patient on commencement of prescribing. There is also a template for use by a specialist when informing primary care prescribers that an individual has been switched to Freestyle Libre 2.
Background information is provided to support primary care prescribers in switching existing Freestyle Libre users to Freestyle Libre 2.
The Pan Mersey Area Prescribing Committee does not recommend the prescribing of FLUOCINOLONE intravitreal implant (Iluvien®) for treating chronic diabetic macular oedema in phakic eyes after an inadequate response to previous therapy, in accordance with NICE TA613
The Pan Mersey Area Prescribing Committee recommends the prescribing of FreeStyle Optium® blood glucose and FreeStyle Optium® ß-ketone test strips only for use with FreeStyle Libre® specifically in patients who are using carbohydrate counting/ bolus advice.
The Pan Mersey Area Prescribing Committee recommends the prescribing of GLP-1 mimetics in combination with insulin for type 2 diabetes, only with specialist care advice and ongoing support from a consultant-led MDT.
The Pan Mersey Area Prescribing Committee recommends the prescribing of golimumab injection (Simponi®) for rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, non-radiographic axial spondyloarthritis, and in patients fitting other criteria commissioned by Pan Mersey CCGs, as listed.
NHS England specialised commissining resources: the clinical reference group responsible for allergy and immunology has published a commissioning policy that defines access to a particular service for a cohort of patients.
The Pan Mersey Area Prescribing Committee recommends the prescribing of infliximab infusion for rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, non-radiographic axial spondyloarthritis and adult-onset Still’s disease, as well as in patients fitting other criteria commissioned by Pan Mersey CCGs, as listed.
The Pan Mersey Area Prescribing Committee recommends the prescribing of INSULIN DEGLUDEC 100units/mL and 200 units/mL solution for subcutaneous injection (Tresiba®), initiated by specialists only, for type 1 and type 2 diabetes for specific patient groups, taking into account NICE guidance
Ivabradine has been approved by NICE (TA 267)1 as an option for treating chronic heart failure following specialist initiation in patients with chronic, stable heart failure (NYHA class II-IV), left ventricular systolic dysfunction (LVEF 35% or less) and who are in sinus rhythm with a heart rate of 75 beats per minute or more.
NHS England specialised commissining resources: the clinical reference group responsible for cystic fibrosis has published a commissioning policy that defines access to a particular service for a cohort of patients.
The Pan Mersey Area Prescribing Committee recommends the prescribing of LIRAGLUTIDE injection (Saxenda®), by specialists only, for managing overweight and obesity within a Tier 3 secondary care weight management service, in accordance with NICE TA664.
The Pan Mersey Area Prescribing Committee recommends the prescribing of LUSUTROMBOPAG tablets (Mulpleo®▼), by specialists only, for treating severe thrombocytopenia in adults with chronic liver disease having planned invasive procedures in accordance with NICE TA617
The Pan Mersey Area Prescribing Committee recommends the prescribing of melatonin prolonged release tablets (Circadin® and Slenyto®) for the treatment of persistent chronic sleep disorders in the circumstances where sleep hygiene measures have been insufficient.
Management of sleep disorders in children and adults - flowchart
The Pan Mersey Area Prescribing Committee recommends the prescribing of Mesalazine oral formulations by brand name following specialist initiation for inflammatory bowel disease. Octasa® brand is considered to be equivalent to Asacol® brand and currently represents a more cost effective choice.
The Pan Mersey Area Prescribing Committee recommends the prescribing of methadone tablets (Physeptone®) in adults following initiation by a consultant in pain medicine in a tertiary centre.
Red NHS Halton CCG
The Pan Mersey Area Prescribing Committee recommends the prescribing of NALMEFENE (Selincro®) within its marketing authorisation, as an option for reducing alcohol consumption in adults with alcohol dependence, in line with NICE TA325.
Refer to Pan Mersey formulary for RAG status for each individual CCG.
The Pan Mersey Area Prescribing Committee recommends the prescribing of NALOXEGOL Tablets (Moventig®▼) as an option for treating opioid induced constipation in adults in accordance with NICE TA345 (22nd July 2015).
The Pan Mersey Area Prescribing Committee does not recommend the prescribing of CONJUGATED OESTROGENS and BAZEDOXIFENE 0.45mg/20mg modified release tablets (Duavive®) for the treatment of oestrogen deficiency in postmenopausal women with a uterus.
The Pan Mersey Area Prescribing Committee recommends the prescribing of OPICAPONE (Ongentys®▼) following specialist recommendation as add-on therapy in adult patients with Parkinson’s disease.
BLACK NHS West Lancashire CCG
The Pan Mersey Area Prescribing Committee recommends the prescribing of PATIROMER powder for oral suspension (Veltassa®▼) for emergency treatment of life-threatening hyperkalaemia in adults in accordance with NICE TA623.
The Pan Mersey Area Prescribing Committee recommends the prescribing of PATIROMER powder for oral suspension (Veltassa®▼) for persistent hyperkalaemia in adults following initiation by a specialist in accordance with NICE TA623.
The Pan Mersey Area Prescribing Committee does not recommend the prescribing of PITOLISANT HYDROCHLORIDE film-coated tablets (Ozawade®) for treating excessive daytime sleepiness caused by obstructive sleep apnoea, in accordance with NICE TA776.
The Pan Mersey Area Prescribing Committee recommends the prescribing of PITOLISANT tablets (Wakix®▼), by specialists working in a regional and national tertiary commissioned sleep service only, for the treatment of narcolepsy with or without cataplexy in adult patients in accordance with the Aintree University Hospital Sleep Service Pathway for Narcolepsy.
Black NHS West Lancashire CCG
The Pan Mersey Area Prescribing Committee does not currently recommend the prescribing of PRASTERONE pessaries (Intrarosa®▼) for the treatment of vulvar and vaginal atrophy in postmenopausal women having moderate to severe symptoms.
The Pan Mersey Area Prescribing Committee does not recommend the prescribing of PREDNISOLONE ENTERIC COATED 2.5 mg and 5 mg tablets.
The Pan Mersey Area Prescribing Committee recommends that IMMEDIATE RELEASE QUETIAPINE is the preferred formulation of quetiapine for prescribing across the Pan Mersey Area.
AMBER RETAINED NHS Southport and Formby, NHS South Sefton CCG
The Pan Mersey Area Prescribing Committee recommends the prescribing of RANIBIZUMAB intravitreal injection (Lucentis®), by ophthalmologists only, for the treatment of visual impairment secondary to choroidal neovascularisation (CNV) in conditions not covered by NICE technology appraisals.
The Pan Mersey Area Prescribing Committee does not recommend the prescribing of Rasburicase powder and solvent for concentrate for solution for infusion (Fasturtec®▼) for the “off label” treatment of severe, refractory, tophaceous gout resistant to xanthine oxidase inhibitors (allopurinol & febuxostat) and uricosuric agents (benzbromarone) or for whom these drugs are contraindicated.
The Pan Mersey Area Prescribing Committee recommends RIFAXIMIN 550mg tablets (Targaxan®), following specialist initiation, as an option for reducing the recurrence of overt hepatic encephalopathy in people aged 18 years or older in accordance with NICE TA 337.
NHS England specialised commissining resources: the clinical reference group responsible for specialised rheumatology has published a commissioning policy that defines access to a particular service for a cohort of patients.
NHS England specialised commissining resources: the clinical reference group responsible for specialised rheumatology has published a commissioning policy that defines access to a particular service for a cohort of patients.
RITUXIMAB (Truxima®▼, Rixathon®▼)The Pan Mersey Area Prescribing Committee recommends the prescribing of rituximab by specialists only, for immune (idiopathic) thrombocytopenic purpura before romiplostin and eltrombopag.
The Pan Mersey Area Prescribing Committee recommends the prescribing of rituximab infusion for rheumatoid arthritis in accordance with NICE TA195 and in accordance with the Mersey Rheumatoid Arthritis Biologics Pathway. Treatment should be initiated and supervised by a rheumatologist.
The Pan Mersey Area Prescribing Committee recommends the prescribing of Rivaroxaban 2.5mg tablets (Xarelto®▼) following specialist initiation for preventing adverse outcomes after acute management of acute coronary syndrome in accordance with NICE TA335.
The Pan Mersey Area Prescribing Committee recommends the prescribing of RIVAROXABAN 2.5mg tablets (Xarelto®▼) plus aspirin, for the prevention of atherothrombotic events in adult patients with coronary artery disease (CAD) or symptomatic peripheral artery disease (PAD) at high risk of ischaemic events, in accordance with NICE TA607.
The Pan Mersey Area Prescribing Committee recommends the prescribing of ROFLUMILAST tablets (Daxas®▼) following specialist recommendation as an add-on to bronchodilator therapy, for treating severe chronic obstructive pulmonary disease in adults with chronic bronchitis (in accordance with NICE TA461).
The Pan Mersey Area Prescribing Committee recommends the prescribing of ROMIPLOSTIM SC injection (Nplate®), by Haematologists only, for chronic immune (idiopathic) thrombocytopenic purpura (ITP) in accordance with NICE TA221.
The Pan Mersey Area Prescribing Committee recommends the prescribing of SACUBITRIL/VALSARTAN film-coated tablets (Entresto®▼) for treating symptomatic chronic heart failure following specialist initiation and in accordance with NICE TA388.
North West Strategic Clinical Network and Senate
The Pan Mersey Area Prescribing Committee recommends the prescribing of SAFINAMIDE (Xadago®▼) following specialist recommendation in the management of mid to late stage Parkinson’s disease.
BLACK NHS West Lancashire CCG
The Pan Mersey Area Prescribing Committee recommends the prescribing of SECUKINUMAB solution for injection (Cosentyx®), by specialists only, for the treatment of non-radiographic axial spondyloarthritis in accordance with NICE TA719.
Pan Mersey Area Prescribing Committee recommends the prescribing of SODIUM OXYBATE oral solution, by specialists working in a regional and national tertiary commissioned sleep service only, for the treatment of narcolepsy with cataplexy in adult patients in accordance with the Aintree University Hospital Sleep Service Pathway for Narcolepsy.
The Pan Mersey Area Prescribing Committee recommends the prescribing of SODIUM ZIRCONIUM CYCLOSILICATE powder for oral suspension (Lokelma®▼) for emergency treatment of life-threatening hyperkalaemia in adults in accordance with NICE TA599.
The Pan Mersey Area Prescribing Committee recommends the prescribing of SODIUM ZIRCONIUM CYCLOSILICATE powder for oral suspension (Lokelma®▼) for persistent hyperkalaemia in adults following initiation by a specialist in accordance with NICE TA599.
NHS England specialised commissining resources: the clinical reference group responsible for infectious disease has published a commissioning policy that defines access to a particular service for a cohort of patients.
The Pan Mersey Area Prescribing Committee does not recommend the prescribing of SOLIRAMFETOL tablets (Sunosi®▼), for treating excessive daytime sleepiness caused by obstructive sleep apnoea in accordance with NICE TA777.
The Pan Mersey Area Prescribing Committee recommends the prescribing of solriamfetol tablets (Sunosi®▼), by specialists only, for treating excessive daytime sleepiness caused by narcolepsy in accordance with NICE TA758.
The Pan Mersey Area Prescribing Committee recommends the prescribing of TAPENTADOL prolonged release tablets (Palexia® SR) for severe chronic pain in adults only when initiated by chronic pain specialists or palliative care specialists
The Pan Mersey Area Prescribing Committee recommends the prescribing of TICAGRELOR tablets (Brilique®), following specialist initiation, for the management of acute coronary syndromes in adults in accordance with NICE TA236 and for preventing atherothrombotic events after myocardial infarction in accordance with NICE TA420.
The Pan Mersey Area Prescribing Committee recommends the prescribing of TIOTROPIUM inhaler (Spiriva® Respimat®) as an option for patients with poorly controlled asthma who are already on a maintenance dose of inhaled corticosteroid plus a long-acting beta2 agonist inhaler.
The Pan Mersey Area Prescribing Committee recommends the prescribing of tocilizumab infusion and subcutaneous injection (RoActemra®) for the treatment of rheumatoid arthritis and adult-onset Still’s disease, and the infusion for juvenile idiopathic arthritis, as described.
The Pan Mersey Area Prescribing Committee recommends that TRIPTORELIN (Decapeptyl® SR 3mg, 11.25mg and 22.5mg) INTRAMUSCULAR INJECTION is first choice gonadorelin analogue for prostate cancer following specialist urologist / oncologist initiation under applicable local arrangement.
The Pan Mersey Area Prescribing Committee recommends the prescribing of UPADACITINIB prolonged-release tablets (RINVOQ®▼), by specialists only, for treating severe rheumatoid arthritis in accordance with NICE TA665.
The Pan Mersey Area Prescribing Committee recommends the prescribing of UPADACITINIB prolonged-release tablets (RINVOQ®▼), by specialists only, for treating moderate rheumatoid arthritis in accordance with NICE TA744.
The Pan Mersey Area Prescribing Committee recommends the prescribing of USTEKINUMAB solution for injection (Stelara®), by specialists only, for moderately to severely active ulcerative colitis in accordance with NICE TA633.