Transcript HYPNOTICS - NHS Networks

Medicine Optimisation
HYPNOTICS – Reducing & Stopping
The slides have been adapted from the NPC slide set available at
http://www.npc.nhs.uk/qipp/qipp_elearning/hypnotics_elearning.php
Options for local implementation
NPC. Key therapeutic topics – Medicines management options for
local implementation. Second update July 2011
 Practices to review and, where appropriate, revise
prescribing of hypnotics to ensure that it is in line with
national guidance
Key questions
 What are the recommendations on hypnotics?
 What are the risks and benefits of hypnotics?
 Do Z-drugs have advantages over benzodiazepine
hypnotics?
 How are we doing with prescribing?
 How can people who want to withdraw from hypnotics be
supported?
Problems associated with the long-term
use of benzodiazepines
Adverse effects
 Drowsiness and falls
 Impairment in judgement and dexterity
 Increased risk of experiencing a road traffic accident
 Forgetfulness, confusion, irritability, aggression and paradoxical
disinhibition
Complications related to long-term use
 Depression
 Reduction in coping skills
 Tolerance and dependence
Dependence (one or more of following)








Patients gradually ‘need’ benzodiazepines to carry out normal day-to-day
activities
Patients continue to take benzodiazepines although the original indication
for the prescription is no longer relevant
Patients have difficulty stopping treatment or reducing dosage due to
withdrawal symptoms
Short acting benzodiazepines may cause patients to develop anxiety
symptoms between doses
Patients contact their doctor regularly to obtain repeat prescriptions
Patients become anxious if the next prescription is not readily available
Patients may increase the dosage stated in the original prescription
Despite benzodiazepine therapy, patients may present with recurring
anxiety symptoms, panic, agoraphobia, insomnia, depression and an
increase in physical symptoms of anxiety
Insomnia

A common disorder characterised by unsatisfactory sleep
(sleep onset, sleep maintenance, early waking)
 Predominantly a long-term disorder
 Before treatment rule out any potential causes of insomnia









External factors (light, noise, room temperature)
Change in sleep environment (e.g. hotel)
Physiological disturbance (e.g. shift work, daytime napping)
Jet lag
Acute illness
Psychological factors (e.g. anxiety, depression, stressful life events)
Substance misuse and drug withdrawal
Stimulant use (e.g. caffeine, nicotine, OTC or prescribed medicines)
Perform sleep assessment (& anxiety rating)
Non-drug approaches
Clinical Knowledge Summaries. Last revised July 2009
 CBT (Cognitive Behaviour Therapy)
 Good sleep hygiene
 Regular exercise
 Relaxation
MHRA advice on benzodiazepines in
insomnia
(CSM. Curr Problems Pharmacovigilance. January 1988, No. 21)

Should be used only if insomnia is severe, disabling or subjecting
the patient to extreme distress

Use lowest dose, for maximum of four weeks

Use intermittently, if possible, for insomnia

Taper off gradually
NICE guidance: newer hypnotics
(Z-drugs)
NICE technology appraisal 77, April 2004

No compelling evidence of a clinically useful difference between the Z-drugs and
shorter-acting benzodiazepines from the point of view of their effectiveness,
adverse effects, or potential for dependence or abuse

The drug with the lowest purchase cost should be prescribed

Switching from one of these hypnotics to another should only occur if a patient
experiences adverse effects considered to be directly related to a specific agent.
These are the only circumstances in which the drugs with the higher acquisition
costs are recommended

Patients who have not responded to one of these hypnotic drugs should not be
prescribed any of the others.
Hypnotics for insomnia
SPCs for zopiclone, zolpidem, zaleplon;
www.medicines.org.uk
 Zopiclone, Zolpidem
 Short–term treatment of insomnia…in situations where the
insomnia is debilitating or is causing severe distress for the
patient
 Long–term continuous use is not recommended
 The duration of treatment should be limited to 4 weeks,
including any tapering off

Zaleplon
 A single course of treatment should not continue for longer
than 2 weeks
What would happen to 13 people like you who
take sleeping tablets for more than a week
Glass J, et al. BMJ 2005;331:1169

The hypnotic makes no difference to
what happens to these 12 people.
Their sleep improves, or doesn’t
improve, just as if they had taken
placebo.
This person finds his/her sleep
improves, who would not have
done had he or she taken the
placebo

The hypnotic makes no difference to
what happens to these 11 people.
They have adverse events, or don’t
have adverse events, just as if they
had taken placebo.
These 2 people have an
adverse event, who would not
have done had they taken the
placebo.
Increased risk of road traffic accidents
Gustavsen I, et al. Sleep Med 2008;9:818–22
www.npc.nhs.uk/rapidreview/?p=249

Cohort study of Norwegian drivers, aged 18 to 69 years

People prescribed zopiclone or zolpidem had double the risk of road traffic
accidents (RTAs), compared with people not prescribed hypnotics

Standardised incidence ratio (SIR) of hypnotic use in previous 7 days,
compared with no use:
 Zopiclone or zolpidem — SIR 2.3 (95%CI 2.0 to 2.7)
 Nitrazepam — SIR 2.7 (95%CI 1.8 to 3.9)
 Flunitrazepam — SIR 4.0 (95%CI 2.4 to 6.4)

Absolute rates (per exposed 1000 person-years) of RTAs were:
 about 5 to 9 accidents in groups treated with hypnotics
 about 2 accidents in the group not exposed to hypnotics
Hip fractures and benzodiazepines
Wagner AK, et al. Arch Intern Med 2004;164:1567–72

Incident relative risk of hip fracture with benzodiazepine (BZD) vs. no BZD
use based on US claims data (194,071 person years of data, 1988-90):
 Any BZD exposure: 1.24 (95%CI 1.06 to 1.44)
 Long half-life BZD only: 1.13 (0.82 to 1.55) NS
 Short half-life high potency: 1.27 (1.01 to 1.59)
 Short half-life low potency: 1.22 (0.89 to 1.67) NS
 >1 BZD type: 1.53 (0.92 to 2.53) NS
 New BZD <16 days: 2.05 (1.28 to 3.28)
 New BZD 16–30 days: 1.88 (1.15 to 3.07)
 Continued BZD: 1.18 (1.03 to 1.35)
NS – No significant difference

Authors conclude: incidence of hip fracture appears to be associated with
benzodiazepine use
Note: Different doses were not considered
Hypnotic QIPP data Q4 2012 -13
(Cumbria, Northumbria, Tyne & Wear)
Select Indicator:
Hypnotics ADQ/STAR PU
QIPP Prescribing Profile
January to March 2013
Hypnotics ADQ/STAR PU, Cumbria,Northumb,Tyne & Wear Area Team
Period: January to March 2013
Lower the Better
1.40
1.20
1.00
0.80
0.60
0.40
Newcastle North
And East CCG
Newcastle West
CCG
Northumberland
CCG
0.56
1.01
1.04
0.94
North Tyneside
CCG
0.79
Cumbria CCG
0.77
Sunderland
CCG
0.87
South Tyneside
CCG
0.72
Gateshead CCG
0.20
0.00
Upper Quartile Target
England average
0.00
Total number of average daily quantities (ADQs) for benzodiazepines (indicated for use as hypnotics) & “Z” drugs per Star-PU*.
QIPP Comparator Description
Hypnotics ADQ/STAR PU, Practice: A82077-Liverpool House Surgery
Grosvenor Hse (Frost)
Peninsula
Kirkoswald
St. Mary's
Seascale
Beechwood
Stoneleigh
Bank St
Castlegate
Askam
Windermere
Abbey Rd
Ambleside
Upper Quartile Target
Appleby
Upper Eden
Arnside
Bentham
Shap
James St
Dalston
Liverpool Hse
Ulverston (Graham)
Sedbergh
Cartmel
Fellview
Captain French
Stanwix
Selected Locality
Birbeck
Risedale
St Pauls
Norwod
Longtown
Waterloo Hse
Glenridding
Hartington St
Station Hse
The James Cochrane
Atkinson
Park View
Derwent Hse
Court Thorn
Selected Practice
Haverthwaite
Silloth
Brampton
Duddon Valley
Ulverston (Murray)
Temple Sowerby
Distington
Burnett Edgar
The Lakes
Alston
Solway
Queen St
Other Localities
Grosvenor Hse (Wigmore)
Lunesdale
Castlehead
Caldbeck
Lower the Better
Bridgegate
Dalton
Nelson St
Maryport
Nutwood
Duke St
Spencer St
The Croft
Wigton
Orchard Hse
Brunswick Hse
Mansion Hse
Catherine St
Wraysdale
Trinity Hse
The Family
Warwick Rd
Fusehill
Westcroft Hse
Lowther
Eden
Hawkshead
Aspatria
Grosvenor Hse (Ward)
Hypnotic QIPP data Q4 2012 -13
(Cumbria Practices)
QIPP Prescribing Profile
January to March 2013
Hypnotics ADQ/STAR PU, Practice: A82077-Liverpool House Surgery
Period : January to March 2013
4.00
England Average
3.50
3.00
2.50
2.00
1.50
1.00
0.50
Period : January to March 2013
How can people who want to withdraw from
hypnotics be supported?

Older people are not always being given appropriate safety
warnings about taking these drugs
Iliffe S, et al. Aging Ment Health 2004;8:242–8

It is difficult to withdraw from hypnotic drugs
 A letter from the GP can be effective in helping some to stop
Cormack MA, et al. Br J Gen Pract 1994;44:5–8
 CBT can be helpful
Morgan K, et al. HTA 2004:8(8)
 See CKS guidance for further information

Published criteria for clinical audit are available
NICE TA77, April 2004; Shaw E, Baker R. J Clin Governance 2001;9:45–50
Key messages







Non-drug treatments should be considered and used routinely in all
patients
1988 CSM advice re benzodiazepines still stands and is also
applicable to Z-drugs
NICE guidance confirms that Z-drugs offer little or no advantage
over benzodiazepines
However, overall prescribing of hypnotics is not decreasing
Hypnotics should be used at lowest dose for max 4 weeks for
severe insomnia only
Consider auditing hypnotic use and changing practice
Resources exist for managing withdrawal
Suggested Practice Actions(1)




All prescribers must agree to be engaged and involved with the project
Circulate to all prescribers the Welsh information pack, which containers
sample letters, sleep guides, reduction schedules etc.
- email to all prescribers
- electronic copy on surgery information folder
- hard copy to be kept by medicine manager- easily accessible for reference
- decide which parts are useful – print off?
Identify patients who receive hypnotics on repeat and acute
- Medicine Mangers to search for last 12 months
Establish the demographics of patients
- who to look at first?
Younger patients? (may be diverting supplies. If don’t stop now, may have many years
of benzo use ahead of them)
Elderly patients? (at greater risks of falls, maybe on older medicines e.g. nitrazepam)
Patients on high doses?
Middle aged group?
Suggested Practice Actions(2)




Patient selection
- For each prescriber, a list of patients to be produced, based on which GP has seen
the patient last or is most familiar with a patient. GPs can do ‘swaps’, if they wish!
Need to make sure the numbers are divided fairly equally.
- GP to go through the list, and eliminate anyone who has a genuine reason for being
on the drug, or feel would be too difficult a challenge to start with.
- GPs to identify one or two patients to call in for a medication review to discuss the
issue, and start reducing the dose. (method to be decided)
Each month, one or two more patients selected. This is a gradual process - the
numbers will build up slowly but steadily, depending on the workload created by
withdrawing patients.
Some patients may be deemed too difficult to stop completely but even a reduction in
dose or a switch to a shorter acting drug is preferable to doing nothing.
The reduction method should be discussed and tailored to each individual patients
needs
 converting to equivalent diazepam dose, and reducing slowly
 reducing the dose of the drug gradually
 reducing the number of tablets supplied for a set time period i.e. having drug
free nights e.g. 25 tablets lasting 28 days etc.
The patient needs to see the same GP during the reduction schedule, especially if
the patient is requesting the dose to be increased back up.
Suggested Practice Actions(3)





New Patients prescribed hypnotics
- only prescribe if absolutely clinically essential
- seven days supply only, as an acute script (Good Practice)
- label as ‘ one at night, if required’
- zopiclone = Lothian Joint Formulary 2nd choice (1st choice = no treatment)
- give patient ‘Good sleep guide/Good relaxation guide’
- no repeat prescriptions for new patients
At prescribing meetings within the practice, suggest analysing prescribing of
hypnotics within the last 3 months to determine if any patients have been
commenced and continued on hypnotics, and the reasons why.
Transferred patients
- Any new patients registering with the practice from another surgery on
hypnotics will have their medication discussed and reviewed at their initial
consultation.
The message that the patient needs to reduce, and eventually stop, their
use of these drugs should be re-enforced at every opportunity.
Involvement of the drug and alcohol service should be considered.
Support Material

Cumbria GP Practice guide

Welsh Education Pack

Presentation

Hypnotic Academic Detailing Aid

The Good Sleep Guide

The Good Relaxation Guide

Patient letters

Reduction Protocols

Community Pharmacy support
Prepared by
Fiona Gunston, Lynne Palmer, Judi Matthews & Jim Loudon
Medicines Optimisation Pharmacists for NHS Cumbria Clinical Commissioning Group
North of England Commissioning Support (NECS)
Using slides and notes provided by NPC (National Prescribing Centre)