Presentation on theme: "10 top tips for safer prescribing and review of medicines"— Presentation transcript:
1 10 top tips for safer prescribing and review of medicines RCN Advanced Nurse PractitionerForum conference 201110 top tips for safer prescribing and review of medicinesDr Duncan PettyLecturer PractitionerSchool of Health Care, University of Leeds
2 10 top tips for safer prescribing and review of medicines Dr Duncan PettyLecturer practitioner, University of LeedsDirector , Prescribing Support Services Ltd
3 Scale of the problem5% of hospital unplanned admissions are due to medicines7 out of 10 care home residents will experience a medicine error each yearAround 7.5% of prescriptions in general practice contain an error
4 Where do things go wrong? Poor prescribing decisionWrong drug, dose, route, frequency and quantityPoor patient communication leading to patients not taking medicines as intendedLack of monitoring and follow upInterface communication (especially primary and secondary care and visa versa).Professor Tony Avery
6 Who is most at risk? Very young and the very old Those with multiple serious morbiditiesThose on a range of hazardous medicationsThose with serious acute medical problemsThose who are ambivalent about medication-taking or who have difficulty understanding or remembering to take medicationProfessor Tony Avery
7 A 85 year old lady is prescribed diclofenac 50mg three times a day for osteoarthritis. She takes it regularly. She also has cardiovascular disease. She is admitted with a GI bleed.
8 AimTo describe in detail 10 behaviours that will improve the quality of your prescribing decisions and therefore should improve patient outcomes whilst minimising harm
9 By the end of this session you will be able to: describe how prescribing and poor review can lead to patient harm.describe ways in which you can improve your prescribingidentify the important elements of medicine history taking and medication review
10 10 ideas for safer prescribing Be familiar with your area of prescribingDon't prescribe other peoples recommendations unless you are competent and confidentFollow the evidence baseKnow what your patient is takingInvolve the patientKeep the treatment as simple as possibleStop things that don't work or are no longer neededReview and monitorBeware drug-drug and drug condition interactionsApply the Goldie locks rule to doses
11 Be familiar with your area of prescribing Obviously ! But howUse only a few medicinesLearn to use them wellKeep up to dateOnly introduce new medicine when evidence is compelling.
12 Warfarin or dabigatrin for stroke reduction in atrial fibrilliation?
13 2. Don't prescribe other peoples recommendations unless you are competent and confident. Obviously again. But need to considerWhen will you continue a medicine initiated by another prescriber ?What information do you need to continue the prescribing ?What ongoing arrangements do you need in place to continue the prescribing?
14 Discharge letter from cardiologists says to change atenolol to bisoprolol. The letter states he is also on verapamil. Would you be happy to continue this prescription?
15 Asthma death girl 'was let down' BBC News 24th May 2005A sheriff has hit out at the "complacency"of health professionals and a drugsmanufacturer over the safety of an asthmainhaler steroid .A fatal accident inquiry foundthat the death in 2001 of Emma Frame, fromStrathaven, Lanarkshire, might have beenavoided if precautions were taken.Emma, five, had been given five times the licensed dose of fluticasone.
17 3. Follow the evidence base New drugs Use trustworthy and unbiased sources or informationFollow local and national protocols and guidanceBe certain drug improves Patient Orientated Outcomes rather than surrogate markers.
18 Atypical antipsychotics may worsen cognition in Alzheimer’s Patient Orientated Evidence That Matters (POEMs)They address a question that practitioners encounterThey measure outcomes that practitioners and their patients care about: symptoms, morbidity, quality of life, and mortalityThey have the potential to change the way practitioner practiseAtypical antipsychotics may worsen cognition in Alzheimer’s
19 Shifting through the evidence Journal of Family Practice 1994;38:505-513 Frequency commonFrequency rarePatient orientated evidenceBestBest source of evidenceRelevance 1Only if timeMay not be relevantRelevance 2Disease orientated evidenceDangerMisleadingRelevance 3WorstRead only if very interestedRelevance 4
20 Effect of intensive glucose lowering treatment on all cause mortality, cardiovascular death, and microvascular events in type 2 diabetes: meta-analysis of randomised controlled trials. BMJ 2011; 343 doi: /bmj.d4169“This meta-analysis of data from 13 randomised controlled trials showed no benefit of intensive glucose lowering treatment on all cause mortality or death from cardiovascular causes in adults with type 2 diabetes. ““Overall, the absolute benefit of treatment for five years was modest; 117 to 150 people would need to be treated to avoid one myocardial infarction, 32 to 142 to avoid one episode of microalbuminuria,”“The absence of benefits from intensive glucose lowering treatment further illustrates why relying on surrogate end points for treating people is a fallacy.”
21 This meta-analysisHBA1c at baseline range (7.5 to 9.5%)At study end (7.0 to 6.4%)QOF The percentage of patients with diabetes in whom the last IFCC-HbA1c is 59 mmol/mol (equivalent to HbA1c of 7.5% in DCCT values) or less (or equivalent test/reference range depending on local laboratory) in the preceding 15 months
23 Surrogate markersHbA1cBlood pressureCholesterolBone density
24 4. Know what your patient is taking Medicines history takingMedicines reconciliation
25 A patient with Ulcerative Colitis comes to see you A patient with Ulcerative Colitis comes to see you. She says she takes azathioprine and mesalazine. When you look back through the specialists letters there is no mention if mesalazine yet the practice has prescribed it for the last 5 years.
26 Medicines reconciliation “a technical process to ensure that the prescribed and non-prescribed medicines (drug, dose/strength, form, route, frequency) that a patient reports to be taking before a transition in care across a health care or social care boundary corresponds with those prescribed afterwards by identifying and resolving discrepancies and communicating these to the patient and the patient’s health care providers.”
27 The NPC 3C’s of medicines reconciliation Collect an accurate medication history using the most recent sources of information to create a full list of current medicines- record the information sourcesCheck this list of medicines against the current prescription and ensure that the medicines, formulation, route and doses are appropriateCommunicate any changes, omissions and discrepancies and remember to document and date any changes
28 Problems associated with transfer of care The Institute for Healthcare Improvement showed that poor communication of information at transition points was responsible for up to 50% of all medication errorsANDUp to 20% of adverse drug events in hospitals(IHI 2004 ,
29 Problems associated with transfer of care Two literature reviews reported unintentional variances of 30-70% between the medications patients were taking before admission and their prescriptions on admissionCornish PL et al. Archives of Internal Medicine 2005;Gleason KM et al. Amer. J. of Health-System Pharmacy 2004;Reference the literature reviewsCornish, P. L., Knowles, S. R., Marchesano, R., Tam, V., Shadowitz, S., Juurlink, D. N.,and Etchells, E. E. Unintended Medication Discrepancies at the Time of HospitalAdmission. Archives of Internal Medicine 2005;Gleason, K. M., Groszek, J. M., Sullivan, C., Rooney, D., Barnard, C., and Noskin, G. A.Reconciliation of discrepancies in medication histories and admission orders of newlyhospitalized patients. American Journal of Health-System Pharmacy 2004;1695.
30 Where do errors occur?Errors occur at the following stages during the admission process:Determining what patients are currently takingTranscribing details into the hospital recordsPrescribing medication for the patient after admission
31 How accurate are the information sources? Studies in elderly patients showed that what the patients were taking and what the GP thought they were taking differed in 50-74% of patients studied .Lowe CJ et al. Br.J.Clin Pharmacol 2000;50:172-5 and Bikowski R et al. JAGS 2001:49 (10)70% of drug-related problems were only recognised through a patient interview.Jameson JP & Van Noord GR. Ann Pharmacother. 2001;35:
33 Involve the patient 5. Involve the patient or carer
34 Mr B is an 87 year old gentleman who has lived in a care home Mr B is an 87 year old gentleman who has lived in a care home. He suffers from dementia. Following a mechanical fall he is prescribe Ibandronic acid 150 mg once monthly by the GP.
35 After two grand mal seizures he was started on levetiracetam After two grand mal seizures he was started on levetiracetam. As levetiracetam is known to cause drowsiness and thrombocytopenia, careful titration of the dose and monitoring of FBC was advised.Five days after discharge he developed sore gums. He was seen by a nurse practitioner, who recommended Bonjela. The cause of the sore gums was thought to be Fixodent®, a denture adhesive product used to keep dentures in place. He previously used a different adhesive product without any problems.
36 One day later, the whole mouth was very sore and the patient experienced difficulties swallowing. The inflammation appeared to have spread over the mucosa of the inner cheeks, the upper palate and the pharynx. The prescription was changed to Nystatin based on the diagnosis of oral thrush. A current course of antibiotics was considered as the cause.Another day later, the condition deteriorated, blisters had spread over the whole mucosa of the mouth, including the upper palate and the pharynx. He also started to develop blisters on the lips.
37 Does not respect patient’s autonomy Widely used term in literature Compliance“The extent to which the patient’s behaviour matches the prescriber’s recommendations”Does not respect patient’s autonomyWidely used term in literatureHORNE, R., J. WEINMAN, N. BARBER, R. ELLIOTT, and M. MORGAN, Concordance, adherence and compliance in medicine taking.
38 Adherence“The extent to which the patient’s behaviour matches agreed recommendations from the prescriber”Informed adherenceBOND, C., (ed.), Concordance. Pharmaceutical Press: London. Selected chapters.
39 Task 1: Rates of non-Compliance ConditionRate of non-compliance (%)Contraception8Asthma20Epilepsy30-40Hypertension40Diabetes40-50Arthritis55-718; 20; 30-50; 40; 40-50; 55-71
40 What level of adherence?2 DiseaseDesired outcomeAdherence rate neededHypertensionNormotension80%(50% not sufficient)MISurvival at 1 year>75% 3x as likelyHIVEfficacy/resistance>95%
41 Is there a typical non-adherent patient? Patient related risk factorsMental illnessPhysical disabilityCultural/languageReading abilityHome circumstancesPerceptions/health beliefsEducation?Social class?Age?
42 Unintentional vs. intentional Non-adherence Conscious decision not to take medication as prescribedUnintentionalPatient wants to take medicine but is unable to do so
43 Concordance – a solution? “An agreement reached after a negotiation between a patient and a healthcare professional that respects the beliefs and wishes of the patient in determining whether, and how, medicines are taken”Patients view takes precedence if can’t reach agreement.
44 Is there a typical non-adherent patient? Medicine related factorsNumber of daily dosesNumber of medicinesNon-oral dose formsComplex devicesTablet sizeSide effects
45 A high % of patients change their own treatment Current asthma treatmentTotal (n=517)Reliever once a day, no other medication (n=169)Reliever once/twice a day, no other medication (n=85)Reliever and preventer, once/twice a day, no other medication (n=196)Reliever and preventer, once/twice a day, plus other medication (n=67)When a patient’s asthma does vary, a large % of patients change their own asthma treatment in response to this change.References:The Living and Breathing Survey. Haughney J, Barnes G,Partridge MR, Cleland J. Primary Care Respiratory Journal March 200410%20%30%40%50%60%70%80%A high % of patients change their own treatmentdue to this asthma variabilityHaughney J, Barnes G, Partridge M, et al. Prim Care Resp J 2004; 13: 26-35
46 A high % of patients who thought their asthma was under control were experiencing regular symptoms 100%80%60%40%20%It is commonly thought by both patients and clinicians that asthma is under control. However, when questioned, patients were experiencing symptoms despite being under the impression that their asthma was actually under control.References:The Living and Breathing Survey. Haughney J, Barnes G,Partridge MR, Cleland J. Primary Care Respiratory Journal March 2004Total (n=517)Every day – both day and night (n=120)Every day – either during the day or during the night (n=92)2-3 times a week (n=127)Once a week (n=86)Once a month (n=50)Less than once a month (n=42)Percentage of respondents who thought that their asthma was under control, related to the frequency of asthma symptomsHaughney J, Barnes G, Partridge M, et al. Prim Care Resp J 2004; 13: 26-35
47 Profile of 425 severe exacerbations % change100Rescue b280Morning PEFNighttime symptoms (most specific indicator)6040The FACET study gives us a chance to examine events leading up to exacerbation in a large cohort.A 20% increase in rescue beta-agonist use can be noted more than a day earlier than 20% change in PEF and almost 5 days earlier than a change in nighttime symptoms – a frequently used indicator of worsening. Although the rate of change was statistically similar, differences can be seen in onset.This helps us to identify an opportunity to intervene with therapy to stop the exacerbation before it takes hold.References:Tattersfield: Am J Respir Crit Care Med 160:594–599, 199920-15-10-551015Days (before and post-exacerbation)Tattersfield: Am J Respir Crit Care Med 160:594–599, 1999
48 Self-Management vs. Usual Care RR (95% CI) HospitalisationsER VisitsUnscheduled Dr VisitsDays off WorkNocturnal AsthmaBy giving patients robust asthma action plans, a number of benefits were evident; these included fewer hospitalisations, ER visits, unscheduled GP visits, days off work and nocturnal asthma.Favours Self-ManagementGibson PG, Couglan J, Wilson AJ et al. Cochrane Library 2000Abramson MJ, Bailey MJ, Couper FJ et al. Am J Respir Crit Care Med 2001
50 Statin efficacy in primary prevention Primary outcome measures: Outcome measure RR (95%CI)All-cause mortality (0.73 to 0.95)Fatal and non-fatal CHD events 0.72 (0.65 to 0.79)Fatal and non-fatal CVD events 0.74 (0.66 to 0.85)Fatal and non-fatal stroke events 0.78 (0.65 to 0.94)Combined endpoint (0.61 to 0.79) Taylor F, et al. Statins for the primary prevention of cardiovascular disease. Cochrane Database of Systematic Reviews 2011, Issue 1. Art. No.: CD DOI: / CD pub4.
51 Involving patients in treatment decisions NICE recommends that people should be offered information about their absolute risk of CVD and about the absolute benefits and harms of an intervention over a 10-year period. This information should be in a form that:presents individualised risk and benefit scenariospresents the absolute risk of events numericallyuses appropriate diagrams and text.
52 20% 10 year CV risk20 out of 100 people will have a CV event in the next 10 year
53 If 100 people take a statin for 10 years 5 will be saved from having a CV event (NNT = 20) These people will be saved from having a CV event because they take a statinThese people will have a CV event, whether or not they take a statin
55 6. Keep the treatment as simple as possible Once or twice daily if possibleStop medicines that are not needed.
56 Principles of Conservative Prescribing. Arch Intern med 2011: Sep 12. Seek non drug alternativesConsider underlying treatable causes rather than treating symptoms.Prevention rather than focusing on symptomsUse the test of time as a diagnostic and therapeutic trial.Avoid frequent switching to new drugs without clear, compelling evidence-based reasons.
57 Principles of Conservative Prescribing. Arch Intern med 2011: Sep 12 Be skeptical about individualising therapyWhenever possible start treatment with only one medicine at a timeHave a high level of suspicion for ADRsEducate patients about possible ADRsBe alert to clues that you may be treating or risking withdrawal symptoms.
58 7. Stop things that don’t work or are no longer needed Why is this hard to do?Evidence of benefit subjectiveFear that might cause harmPlacebo and placebo “by proxy” effectPerception undermining a colleagueAdmission of failureCollusion of anonymityPassive or active avoidancePrescriber distracted by other issues
59 How to address these factors. Evidence of benefit subjectiveFear that might cause harmPlacebo and placebo “by proxy” effectPerception undermining a colleagueAdmission of failureCollusion of anonymityPassive or active avoidancePrescriber distracted by other issues
60 Long term antidepressant prescribing is common Petty D, et al. Prevalence, duration and indications for prescribing of antidepressants in primary care. Age and Ageing 2006.
61 8. Review and monitorMedication review is a structured, critical examination of a patient's medicines with the objective of :reaching an agreement with the patient about treatment,optimising the impact of medicines,minimising the number of medication-related problems andreducing waste.
62 Aims of medication review Optimising the treatment regimenIs the medicine needed?Is it working?Is the dosage evidence based?Does the patient have any under-treated conditions?Does the patient have any untreated problems
63 Aims of medication review Identifying problemsAre the medicines being ordered?Is the patient able to take it?Is the medicine interacting with other medicines?Is the medicine contraindicated?Are there any adverse drug reactions (ADRs), either reported by the patient or evident from tests?
64 Aims of medication review Patient’s views and preferencesDoes the patient want to take the medicine?Does the patient have any information needs about their condition and its treatment?Does the patient understand the purpose of the medicine?Are the prescription directions clear and practical?
65 Aims of medication review Waste reductionBranded to genericUnwanted medicinesUnneeded medicinesOver ordering
66 Monitoring and reviewMonitoring is a watching brief, and only involves intervention in response to pre-set criteria.It is generally uni-modal, looking at one dimension of the disease or its management.It is essentially technical and is prescriptive, following a clear protocol.It does not involve making value judgements.
67 Monitoring and reviewReview is a judgement about the success or otherwise of the treatment.It consists essentially of a professional assessment.It should be holistic, encompassing the patient and the illnesses as well the diseases and drugs.Its outcome will consist of decisions about the patient’s progress prognosis and management
68 Any untreated conditions or unaccounted for medicines? Medical conditionsType 2 diabetesVascular dementiaRheumatoid arthritisAsthmaIschaemic heart diseaseMedicinesAdalat La 30DoxazosinFluvastatinMetforminHumulin InsulinEpilimSertraline
69 9. Beware drug-drug and drug condition interactions It is not possible to remember all contraindications/cautions to drugsImportant examples include:NSAIDs and peptic ulcerBeta-blockers and asthmaCOCP and venous thrombosisGP computer system warning are not helpful as to much non specific informationEnsure you have access to full medical record(s)
70 Examples of STOPP drug criteria NSAID with heart failureUse of long-term powerful opiates, e.g. morphine or fentanyl as first-line therapy formild-moderate painTCA with dementia (delirium, fall and fractured femur)Digoxin >125 μg per day with impaired renal function (digoxin toxicity)Aspirin with history of PUD without histamine H2 antagonist or PPI (PUD)Aspirin ≥150 mg/dayBladder antimuscarinic drugs with dementiaLong-term opiates in those with recurrent fallsSystemic corticosteroids instead of inhaled corticosteroids for maintenance therapy in moderate–severe COPD
71 Decreasing the total number of prescriptions for these drug-drug combinations or drug-disease combinations would be expected to reduce admissions due to adverse events
72 The STOPP have been applied to a hospital older people population. STOPP (Screening Tool of Older Peoples Potentially Inappropriate Prescriptions) criteriaThe STOPP have been applied to a hospital older people population.Of 715 admissions12% of admissions were due to medicines90% of these were on STOPP criteria drugs
73 Drug interactionsEnsure you know what the patient is prescribed from all sourcesEnsure you know what they actually takeComputerised prescribing systems are of some helpBeware home visits
74 10. Apply the Goldie locks rule to doses Not too much and not to little.Start low and go slowReview regularlyConsider ideal body weightConsider renal functionBeware interactions that might increase plasma level or drug sensitivity
76 Female aged 20yrs, LBW 60kg, creatinine 90 CrCl (C&G)= 1 x (140-20) x = 80ml/min90Female age 85yrs, LBW 60kg, creatinine 90CrCl (C&G)= 1 x (140-85) x60 = 37ml/minFemale age 85yrs, LBW 50Kg, creatinine 90CrCl (C&G) = 1 x (140-85) x = 30ml/minMale age 85yrs, LBW 50kg, creatinine 90CrCl (C&G) = 1.23 x (140-85) x 50 = 38ml/min
77 Male aged 87yr on simvastatin, 55kg, serum creatinine 121: eGFR reported as 52ml/min CrCl (C&G) = f x (140-age)xLBWserum creatininef = 1 for females and 1.23 for malesCrCl (C&G) = 29ml/minBNF app3: simvastatin in doses over 10mg should only be used with caution if CrCl<30ml/minUsing eGFR we would be happy to give simvastatin 40mg but using C&G shows it would be preferable to use an alternative.
78 10 ideas for safer prescribing Be familiar with your area of prescribingDon't prescribe other peoples recommendations unless you are competent and confidentFollow the evidence baseKnow what your patient is takingInvolve the patientKeep the treatment as simple as possibleStop things that don't work or are no longer neededReview and monitorBeware drug-drug and drug condition interactionsApply the Goldie locks rule to doses