1. NHS Specialist Pharmacy Service Medicine Use Reviews NSAIDs NHS Specialist Pharmacy Service Medicines Use & Safety

2. NHS Specialist Pharmacy Service Introduction and welcome Housekeeping –Fire drills –Facilities –Refreshments

3. NHS Specialist Pharmacy Service Programme Objectives and warm-up Expert presentation Activities NSAID MUR and audit project presentation Activities Action plan and close

4. NHS Specialist Pharmacy Service Objectives To revise and update your knowledge of NSAID efficacy and safety problems To develop communication and clinical skills to enhance the NSAID targeted MURs To understand how NSAID MURs have been used to improve NSAID safety To improve outcomes for patients taking NSAIDs To increase the number and efficacy of NSAID targeted MURs locally

5. NHS Specialist Pharmacy Service Warm-up Write down on a sticky note a number from 1-10 where 1 is not confident in doing MURs and 10 is very confident What is the biggest barrier for you doing MURs?

6. NHS Specialist Pharmacy Service Key facts quiz 10 questions 10-15 seconds to discuss each answer in your groups

7. NHS Specialist Pharmacy Service Question 1 Are COX-2 selective inhibitors more effective than traditional NSAIDs?

8. NHS Specialist Pharmacy Service Answer to question 1 Are COX-2 selective inhibitors more effective than traditional NSAIDs? NO Similar efficacy to traditional NSAIDs such as diclofenac and naproxen.

9. NHS Specialist Pharmacy Service Question 2 Does NICE guidance on osteoarthritis recommend use of topical NSAIDs?

10. NHS Specialist Pharmacy Service Answer to question 2 Does NICE guidance on osteoarthritis recommend use of topical NSAIDs? YES These should be considered before oral NSAIDs or opioids.

11. NHS Specialist Pharmacy Service Question 3 Can ranitidine be used to prevent NSAID-induced ulcers?

12. NHS Specialist Pharmacy Service Answer to question 3 Can ranitidine be used to prevent NSAID-induced ulcers? YES But standard doses are not effective and PPIs are preferred.

13. NHS Specialist Pharmacy Service Question 4 Can misoprostol be used to prevent NSAID-induced ulcers?

14. NHS Specialist Pharmacy Service Answer to question 4 Can misoprostol be used to prevent NSAID-induced ulcers? YES But misoprostol tends to be poorly tolerated.

15. NHS Specialist Pharmacy Service Question 5 Should OTC omeprazole be used to prevent NSAID-induced ulcers?

16. NHS Specialist Pharmacy Service Answer to question 5 Should OTC omeprazole be used to prevent NSAID-induced ulcers? NO OTC omeprazole is only licensed for heartburn and acid reflux.

17. NHS Specialist Pharmacy Service Question 6 Should exercise be a core treatment for people with osteoarthritis, regardless of age and pain severity?

18. NHS Specialist Pharmacy Service Answer to question 6 Should exercise be a core treatment for people with osteoarthritis, regardless of age and pain severity? YES NICE advises exercise for all (irrespective of age, co-morbidity, pain or disability) and weight loss if overweight or obese.

19. NHS Specialist Pharmacy Service Question 7 Does NICE recommend using glucosamine in treatment of osteoarthritis?

20. NHS Specialist Pharmacy Service Answer to question 7 Does NICE recommend using glucosamine in treatment of osteoarthritis? NO The use of glucosamine or chondroitin products is not recommended for the treatment of osteoarthritis. Rubefacients are not recommended either.

21. NHS Specialist Pharmacy Service Question 8 Has use of naproxen increased because it has fewer GI adverse effects than other NSAIDs (eg diclofenac)?

22. NHS Specialist Pharmacy Service Answer to question 8 Has use of naproxen increased because it has fewer GI adverse effects than other NSAIDs (eg diclofenac)? NO Use has increased but this is because it appears to have lower cardiovascular risk than other NSAIDs, not lower GI risk.

23. NHS Specialist Pharmacy Service Question 9 Can NSAIDs be taken with methotrexate?

24. NHS Specialist Pharmacy Service Answer to question 9 Can NSAIDs be taken with methotrexate? Yes But NSAIDs reduce excretion of methotrexate so increase the toxicity. The dose of methotrexate needs to be carefully monitored and OTC NSAIDs avoided.

25. NHS Specialist Pharmacy Service Question 10 Is oral diclofenac available over the counter?

26. NHS Specialist Pharmacy Service Answer to question 10 Is oral diclofenac available over the counter? NO In January 2015 the MHRA issued a Drug Safety Update which changed the legal status of diclofenac and it is now only available as a prescription only medicine.

27. NHS Specialist Pharmacy Service Expert presentation

28. NHS Specialist Pharmacy Service Activity one – your NSAID patients In your groups discuss pre-workshop task three. Did you manage to find three patients with regular NSAIDs? Any of these over 75? Any of these with no gastroprotection? Have you done an MUR on any of these patients?

29. NHS Specialist Pharmacy Service Activity two – consultation skills In your groups discuss the pre-workshop task two. Discuss the questions you wrote down that relate to MURs and the 4Es practice tool Explore Educate Empower Enable

30. NHS Specialist Pharmacy Service Presentation NSAID MUR and audit project

31. NHS Specialist Pharmacy Service Medicines-related hospital admissions 6% of admissions due to problems with medicines Mostly preventable Most commonly NSAIDs, diuretics, anticoagulants and antiplatelets Howard R L et al. Quality and Safety in Health Care 2003;12: 280-285.

32. NHS Specialist Pharmacy Service Principles for MUR high-risk drugs list ‘Type of harm could be prevented by an MUR and the pharmacist will have the skills, knowledge and information to deliver it.’ http://psnc.org.uk/services-commissioning/advanced- services/murs/national-target-groups-for-murs

33. NHS Specialist Pharmacy Service NSAIDs and preventable admissions LACK OF MONITORING –Renal necrosis PRESCRIBING ISSUES –GI bleed – 2+ risk factors no GI prophylaxis prescribed ADHERENCE ISSUES –GI bleed – not taking GI prophylaxis –GI bleed – self-medicating with OTC NSAIDs

34. NHS Specialist Pharmacy Service Isn’t NSAID safety fixed already? Survey of 100 MURs 2009-2010 NSAIDs patients aged over 55 – 36% no GI protection OA patient survey 2011 43% not offered GI prophylaxis Community pharmacy audit 2014 2,838 (27.5%) patients had used NSAIDs regularly for more than two months and had no gastrointestinal protection

35. NHS Specialist Pharmacy Service Business case Put together in summer 2010 Support from CCG, PCT, LPC Information to all local GPs and CPs Educational grant from Pfizer

36. NHS Specialist Pharmacy Service The NSAID MUR Regular prescription for NSAID Focus GI safety Two patient groups at particular risk of NSAID adverse events: 1.Inadequate GI prophylaxis 2.Over 55s

37. NHS Specialist Pharmacy Service Data collection Smart-survey.co.uk or paper copy Show NSAID MURs being done Demonstrate value, ie, preventing adverse events and admissions

38. NHS Specialist Pharmacy Service Results 17 pharmacies involved (all types) 15 months (Jan 11 – Mar 12) 142 patients (mean age 64) –1% prescribed two NSAIDs –8% patients taking OTC and prescribed NSAIDs –3% patients taking other GI risk drugs

39. NHS Specialist Pharmacy Service Inadequate GI prophylaxis 4 non-adherent to GI prophylaxis 82 no GI prophylaxis Collected follow-up data on 48 patients –23 (48%) GI prophylaxis started –7 (15%) NSAID stopped –4 (8%) reduced/less frequent NSAID dose –8 (17%) prescriber/patient active decision not to change –6 (12%) no change

40. NHS Specialist Pharmacy Service Examples 91-year-old lady prescribed two NSAIDs, low dose aspirin but no PPI Patient stopped taking lansoprazole because of upset stomach, prescriber was unaware 85-year-old lady on ibuprofen referred to GP regarding GI risk, prescribed omeprazole

41. NHS Specialist Pharmacy Service Overview of results NSAID MURS 63% had NSAID safety issue identified 7% improved safety during MUR (eg, OTC NSAIDs identified or non-adherence to prophylaxis) Post-MUR follow-up of GI safety 71% changed to improve safety Livingstone C, Patel C J, Sinha R and Greensmith S. Evaluation of targeted MURs in preventing avoidable harm from NSAIDs. IJPP 2012;20(2): 71.

42. NHS Specialist Pharmacy Service CPPE and ‘Just One Patient’ 2012-2013 – 1,298 who attended CPPE NSAID safety workshops recorded ‘just one’ NSAID patient on the Smart Survey 159 of these patients 82 aged over 55 with no GI protection 15 also self-medicating with NSAID 77 referred to GP for safety review

43. NHS Specialist Pharmacy Service 1,278 community pharmacies across England 16,366 patients prescribed NSAIDs 28% regular NSAIDs without GI protection More than 2,000 patients referred to GP

44. NHS Specialist Pharmacy Service 17 million NSAIDs prescriptions in England each year….

45. NHS Specialist Pharmacy Service Activity three – case studies In your groups discuss the three case studies. You only have about 3-4 minutes for each one. Feedback at the end.

46. NHS Specialist Pharmacy Service Activity four – engaging with prescribers In your groups discuss what you will now do to engage with GPs with regard to NSAID MURs Discuss how you might improve the feedback you get from GPs after you send MUR information. Share hints and tips about good ways of linking with GP surgeries.

47. NHS Specialist Pharmacy Service NSAID audit NSAID safety clinical audit templateNSAID safety clinical audit template Available to downloadAvailable to download Use it to meet the contract requirementsUse it to meet the contract requirements

48. NHS Specialist Pharmacy Service Action plan What are you going to do as a result of this learning? –Tomorrow or as soon as you return to work –Within a few weeks –Within a longer period (may involve further learning or accreditation)

49. NHS Specialist Pharmacy Service Reminder of objectives To revise and update your knowledge of NSAID efficacy and safety problems To develop communication and clinical skills to enhance the NSAID targeted MURs To understand how NSAID MURs have been used to improve NSAID safety To improve outcomes for patients taking NSAIDs To increase the number and efficacy of NSAID targeted MURs locally

50. NHS Specialist Pharmacy Service Confidence ladder Do you feel more confident? Have you climbed the confidence ladder?

51. NHS Specialist Pharmacy Service Thank you Safe journey home