Prescribing UpdateCATHERINE ARMSTRONG – NOVEMBER 2014

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?

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

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

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

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

Tools for assessing risk

Risk Calculation

CHA2DS2-Vasc

= 0 Do not offer anticoagulation

= 1 & Female Do not offer anticoagulation

= 1 & Male Consider anticoagulation (calculate HAS-BLED score)

≥ 2 Calculate HAS-BLED score

HAS-BLED ≤ 2 Proceed with anticoagulation

= 3 Proceed with anticoagulation with CAUTION

≥ 4 Consider anticoagulation on individual patient basis

Consult secondary care for further advice

NOAC vs Warfarin

Approximate no. per 1000 patients with AF still predicted to have a stroke

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

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

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

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 28 20mg = £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

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

NICE Technology appraisals

TA318 Lubiprostone for treating chronic idiopathic constipation

TA315 Canagliflozin in combination therapy for treating type 2 diabetes

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.’

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

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”

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

Any questions?