1. Prescribing Update CATHERINE ARMSTRONG – NOVEMBER 2014

2. Quiz  What does Medicines Optimisation mean?  Which of these are Red drugs: linezolid, tobramycin or cyclophosphamide?  What is a NOAC?  Which inhaler device is preferred?  Which has the greater street value: diazepam, temazepam, pregabalin or codeine?

3. Medicines Optimisation Medicines Management  Focus on systems, processes and infrastructure  For the NHS first  Driven by professionals  Practices based on custom/tradition  Hospitals at the centre of service delivery Medicines Optimisation  Focus on outcomes that matter to patients  For the patient first  Driven by customers and end users  Practices based on evidence  Services delivered closer to home

4. Medicines Optimisation - Principles 4 Guiding Principles:  Aim to understand the patient experience  Evidence based choice of medicines  Ensure medicines use is as safe as possible  Make medicines optimisation part of routine practice  Patient-orientated outcomes  System-orientated outcomes

5. Red Drugs  Prescribed by primary or secondary care specialist prescriber only  A drug may be classified as red due to toxicity, monitoring or preparation requirements, license status or requirement for efficacy monitoring  Examples include antivirals used in the treatment of HIV, drugs used as part of a clinical trial, cytotoxics for cancer treatment  GP should refuse any request to prescribe  Red drugs should be recorded on the patients medication records  Many are centrally-funded by NHS England

6. Newer Oral AntiCoagulants (NOAC)  Apixaban, Dabigatran and Rivaroxaban  NICE CG180 – Atrial Fibrillation (June 2014)  CHA2DS2-Vasc and HAS-BLED tools for risk assessment  Do not offer antiplatelets as sole treatment for the prevention of stroke in people with atrial fibrillation.  Where anticoagulation is not indicated antiplatelets should be stopped.  In cases where an individual has a stent or is post ACS and would normally be treated with dual antiplatelet therapy - discuss with Cardiology

7. Tools for assessing risk

8. Risk Calculation  CHA 2 DS 2 -Vasc  = 0 Do not offer anticoagulation  = 1& Female Do not offer anticoagulation  = 1& MaleConsider anticoagulation (calculate HAS-BLED score)  ≥ 2Calculate HAS-BLED score  HAS-BLED  ≤ 2Proceed with anticoagulation  = 3Proceed with anticoagulation with CAUTION  ≥ 4Consider anticoagulation on individual patient basis  Consult secondary care for further advice

9. NOAC vs Warfarin Approximate no. per 1000 patients with AF still predicted to have a stroke

10. NOAC or warfarin  Target newer agents to patients likely to derive greatest benefit  Key groups in which to consider NOAC:  Those who cannot take vitamin K antagonists or who have declined warfarin  Those who cannot be stabilised on warfarin (TTR <65% despite adherence)  Those taking aspirin for stroke prevention where warfarin is not suitable but anticoagulation is not excluded  Should be an informed decision between patient and prescriber  Consider risks and benefits, including no treatment option

11. NOAC – final points  Check dosage in renal function  Rivaroxaban must be taken with food  Rivaroxaban can be put into a compliance aid or feeding tube  Can start NOAC on first day after last antiplatelet dose  No need to change stable warfarin patients  If changing from warfarin, involve the relevant anticoagulation monitoring service

12. Inhalers  Multiple new devices and combinations recently launched  Best inhaler device = one that a patient uses  Aim to have least number of different devices  Placebos for all devices can be obtained

13. Drugs that can cause concern  Pregabalin is most widely abused drug  Care – patients presenting with exact symptoms of neuropathic pain  Temazepam is very high (NHS) cost  10mg = £19.77 per 2820mg = £18.99 per 28  NICE TA77 (April 2004)……”doctors should prescribe the cheapest drug, taking into account the daily dose required and the cost for each dose.”  Zopiclone and Zolpidem are < £2 per 28 tablets

14. NICE Clinical guidance  CG187 Acute heart failure  CG185 Bipolar disorder  CG184 Dyspepsia and gastro ‑ oesophageal reflux disease  CG183 Drug allergy  CG182 Chronic kidney disease  CG181 Lipid modification  CG180 Atrial fibrillation

15. NICE Technology appraisals  TA318 Lubiprostone for treating chronic idiopathic constipation  TA315 Canagliflozin in combination therapy for treating type 2 diabetes

16. Sildenafil – legislation changes  If generic – no restrictions  All should be on NHS not on private prescription  If Viagra®– still restricted  DH guidance (1999)  ‘one treatment per week is considered appropriate for most patients being treated for erectile dysfunction. If a GP in exercising his clinical judgement considers that more than one treatment a week is appropriate he should prescribe that amount on the NHS.’

17. Safety alerts (1)  Adrenaline auto-injectors  Ambulance after every use, even if improving  Lie down with legs raised (ideally not alone)  Need to carry 2 devices at all times  Combination of renin-angiotensin system drugs  Risk of hypokalaemia, hypotension and impaired renal function  Combination of ACE-inhibitor, ARB or aliskiren NOT RECOMMENDED  Avoid ACEi+ ARB in diabetic nephropathy  Combinations should be under specialist supervision with MONTHLY bloods

18. Safety alerts (2)  Ivabradine  Starting dose = 5mg daily  Maintenance dose = 7.5mg twice daily  Monitor for bradycardia  Drugs & Driving  New blood concentration limits for some CDs  Advise “against the law to drive if driving ability is impaired by this medicine”

19. Safety alerts (3)  Emergency contraceptives in obese patients  Levonorgestrel and ulipristal both remain suitable  Domperidone  No longer available without prescription  Dexamethasone 4mg/ml injection  Changing to 3.8mg/ml strength – CARE re dose to give

20. Any questions?