Transcript 10 top tips for safer prescribing and review of medicines

RCN Advanced Nurse Practitioner
Forum conference 2011
10 top tips for safer
prescribing and review of
medicines
Dr Duncan Petty
Lecturer Practitioner
School of Health Care, University of Leeds
10 top tips for safer prescribing and review of medicines
Dr Duncan Petty
Lecturer practitioner, University of Leeds
Director , Prescribing Support Services Ltd
Scale of the problem
• 5% of hospital unplanned admissions are
due to medicines
• 7 out of 10 care home residents will
experience a medicine error each year
• Around 7.5% of prescriptions in general
practice contain an error
Where do things go wrong?
• Poor prescribing decision
• Wrong drug, dose, route, frequency and quantity
• Poor patient communication leading to patients not taking
medicines as intended
• Lack of monitoring and follow up
• Interface communication (especially primary and
secondary care and visa versa).
Professor Tony Avery
Who is most at risk?
•
•
•
•
•
Very young and the very old
Those with multiple serious morbidities
Those on a range of hazardous medications
Those with serious acute medical problems
Those who are ambivalent about medication-taking or
who have difficulty understanding or remembering to take
medication
Professor Tony Avery
• 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.
Aim
To describe in detail 10 behaviours that will
improve the quality of your prescribing
decisions and therefore should improve
patient outcomes whilst minimising harm
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
prescribing
• identify the important elements of medicine
history taking and medication review
10 ideas for safer prescribing
1. Be familiar with your area of prescribing
2. Don't prescribe other peoples recommendations unless you are
competent and confident
3. Follow the evidence base
4. Know what your patient is taking
5. Involve the patient
6. Keep the treatment as simple as possible
7. Stop things that don't work or are no longer needed
8. Review and monitor
9. Beware drug-drug and drug condition interactions
10. Apply the Goldie locks rule to doses
1. Be familiar with your area of prescribing
Obviously ! But how
• Use only a few medicines
• Learn to use them well
• Keep up to date
• Only introduce new medicine when evidence is
compelling.
• Warfarin or dabigatrin for stroke reduction
in atrial fibrilliation?
2. Don't prescribe other peoples recommendations
unless you are competent and confident.
Obviously again. But need to consider
– When 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?
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?
Asthma death girl 'was let down'
BBC News 24th May 2005
A sheriff has hit out at the "complacency"
of health professionals and a drugs
manufacturer over the safety of an asthma
inhaler steroid .A fatal accident inquiry found
that the death in 2001 of Emma Frame, from
Strathaven, Lanarkshire, might have been
avoided if precautions were taken.
Emma, five, had been given five times the licensed dose of
fluticasone.
• Inhaled steroids in children
3. Follow the evidence base
• New drugs
– Use trustworthy and unbiased sources or
information
– Follow local and national protocols and
guidance
– Be certain drug improves Patient Orientated
Outcomes rather than surrogate markers.
• Patient Orientated Evidence That Matters
(POEMs)
– They address a question that practitioners
encounter
– They measure outcomes that practitioners
and their patients care about: symptoms,
morbidity, quality of life, and mortality
– They have the potential to change the way
practitioner practise
Shifting through the evidence
Journal of Family Practice 1994;38:505-513
Frequency common
Best
Patient orientated evidence Best source of evidence
Disease orientated
evidence
Frequency rare
Only if time
May not be relevant
Relevance 1
Relevance 2
Danger
Misleading
Worst
Read only if very interested
Relevance 4
Relevance 3
19
Effect of intensive glucose lowering treatment on all cause mortality,
cardiovascular death, and microvascular events in type 2 diabetes: metaanalysis of randomised controlled trials. BMJ 2011; 343 doi: 10.1136/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.”
This meta-analysis
• HBA1c at baseline range (7.5 to 9.5%)
• At study end (7.0 to 6.4%)
• QOF 2011 - 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
• Surrogate markers
– HbA1c
– Blood pressure
– Cholesterol
– Bone density
4. Know what your patient is taking
• Medicines history taking
• Medicines reconciliation
• 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.
• 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.”
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 medicinesrecord the information sources
 Check this list of medicines against the current prescription and
ensure that the medicines, formulation, route and doses are
appropriate
 Communicate any changes, omissions and discrepancies and
remember to document and date any changes
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 errors
AND
 Up to 20% of adverse drug events in hospitals
(IHI 2004 , www.ihi.org)
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 admission
Cornish PL et al. Archives of Internal Medicine 2005; 165 424-429
Gleason KM et al. Amer. J. of Health-System Pharmacy 2004; 61 1689-1695.
Where do errors occur?
• Errors occur at the following stages
during the admission process:
– Determining what patients are currently
taking
– Transcribing details into the hospital
records
– Prescribing medication for the patient after
admission
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 5074% of patients studied .
Lowe CJ et al. Br.J.Clin Pharmacol 2000;50:172-5 and Bikowski R et al.
JAGS 2001:49 (10) 1353-1357.
 70% of drug-related problems were only recognised through a
patient interview.
Jameson JP & Van Noord GR. Ann Pharmacother. 2001;35: 835-40.
Reconciliation is not enough
Involve the patient
5. Involve the patient or carer
• 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.
• 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.
•
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.
Compliance
• “The extent to which the patient’s
behaviour matches the prescriber’s
recommendations”
• Does not respect patient’s autonomy
• Widely used term in literature
HORNE, R., J. WEINMAN, N. BARBER, R. ELLIOTT, and M. MORGAN, 2005. Concordance, adherence
and compliance in medicine taking. http://www.sdo.nihr.ac.uk/files/project/76-final-report.pdf
Adherence
“The extent to which the patient’s
behaviour matches agreed
recommendations from the prescriber”
• Informed adherence
BOND, C., (ed.), 2004. Concordance. Pharmaceutical Press:
London. Selected chapters.
Task 1: Rates of nonCompliance
Condition
Rate of non-compliance (%)
Contraception
8
Asthma
20
Epilepsy
30-40
Hypertension
40
Diabetes
40-50
Arthritis
55-71
What level of adherence?2
Disease
Desired outcome
Adherence rate
needed
Hypertension
Normotension
80%
(50% not
sufficient)
MI
Survival at 1 year
>75% 3x as likely
HIV
Efficacy/resistance
>95%
Is there a typical non-adherent patient?
• Patient related risk factors
–
–
–
–
–
–
Mental illness
Physical disability
Cultural/language
Reading ability
Home circumstances
Perceptions/health beliefs
– Education?
– Social class?
– Age?
Unintentional vs. intentional
Non-adherence
• Intentional
– Conscious decision not to take medication
as prescribed
• Unintentional
– Patient wants to take medicine but is
unable to do so
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.
Is there a typical non-adherent patient?
• Medicine related factors
– Number of daily doses
– Number of medicines
– Non-oral dose forms
– Complex devices
– Tablet size
– Side effects
Current asthma treatment
Total (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)
0
10%
20%
30%
40%
50%
60%
70%
80%
A high % of patients change their own treatment
due to this asthma variability
Haughney J, Barnes G, Partridge M, et al. Prim Care Resp J 2004; 13: 26-35
A high % of patients who thought their asthma was under control were
experiencing regular symptoms
100%
80%
60%
40%
20%
0
Total (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 symptoms
Haughney J, Barnes G, Partridge M, et al. Prim Care Resp J 2004; 13: 26-35
% change
Profile of 425 severe exacerbations
100
Rescue b2
80
Morning PEF
Nighttime symptoms
60
(most specific indicator)
40
20
0
-15
-10
-5
0
5
10
Days (before and post-exacerbation)
15
Tattersfield: Am J Respir Crit Care Med 160:594–599, 1999
Self-Management vs. Usual Care
RR (95% CI)
Hospitalisations
ER Visits
Unscheduled Dr Visits
Days off Work
Nocturnal Asthma
0.1
1
10
Favours Self-Management
Gibson PG, Couglan J, Wilson AJ et al. Cochrane Library 2000
Abramson MJ, Bailey MJ, Couper FJ et al. Am J Respir Crit Care Med 2001
Statin efficacy in primary prevention
Primary outcome measures:
• All-cause mortality
• Fatal and non-fatal CHD events
• Fatal and non-fatal CVD events
• Fatal and non-fatal stroke events
• Combined endpoint
Outcome measure RR (95%CI)
0.83 (0.73 to 0.95)
0.72 (0.65 to 0.79)
0.74 (0.66 to 0.85)
0.78 (0.65 to 0.94)
0.70 (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.: CD004816. DOI: 10.1002/14651858.CD004816.pub4.
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 scenarios
– presents the absolute risk of events numerically
– uses appropriate diagrams and text.
20% 10 year CV risk
20 out of 100
people will have a
CV event in the next
10 year
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 statin
These people will have a CV event,
whether or not they take a statin
50% 10 year CV risk
http://www.npc.co.uk/patient_decision_aids/pda.php#CAR
6. Keep the treatment as simple as possible
• Once or twice daily if possible
• Stop medicines that are not needed.
Principles of Conservative Prescribing.
Arch Intern med 2011: Sep 12.
• Seek non drug alternatives
• Consider underlying treatable causes rather than treating
symptoms.
• Prevention rather than focusing on symptoms
• Use the test of time as a diagnostic and therapeutic trial.
• Avoid frequent switching to new drugs without clear, compelling
evidence-based reasons.
Principles of Conservative Prescribing.
Arch Intern med 2011: Sep 12
• Be skeptical about individualising therapy
• Whenever possible start treatment with only one medicine at a
time
• Have a high level of suspicion for ADRs
• Educate patients about possible ADRs
• Be alert to clues that you may be treating or risking withdrawal
symptoms.
7. Stop things that don’t work or are no
longer needed
• Why is this hard to do?
–
–
–
–
–
–
–
–
Evidence of benefit subjective
Fear that might cause harm
Placebo and placebo “by proxy” effect
Perception undermining a colleague
Admission of failure
Collusion of anonymity
Passive or active avoidance
Prescriber distracted by other issues
How to address these factors.
– Evidence of benefit subjective
– Fear that might cause harm
– Placebo and placebo “by
proxy” effect
– Perception undermining a
colleague
– Admission of failure
– Collusion of anonymity
– Passive or active avoidance
– Prescriber distracted by other
issues
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.
8. Review and monitor
• Medication 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 and
– reducing waste.
Aims of medication review
Optimising the treatment regimen
•
•
•
•
Is 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
Aims of medication review
Identifying problems
• Are 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?
Aims of medication review
Patient’s views and preferences
• Does 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?
Aims of medication review
Waste reduction
•
•
•
•
Branded to generic
Unwanted medicines
Unneeded medicines
Over ordering
Monitoring and review
• Monitoring 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.
Monitoring and review
• Review 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
Any untreated conditions or unaccounted for
medicines?
Medical conditions
• Type 2 diabetes
• Vascular dementia
• Rheumatoid arthritis
• Asthma
• Ischaemic heart
disease
Medicines
• Adalat La 30
• Doxazosin
• Fluvastatin
• Metformin
• Humulin Insulin
• Epilim
• Sertraline
9. Beware drug-drug and drug condition
interactions
•
It is not possible to remember all contraindications/cautions to drugs
Important examples include:
– NSAIDs and peptic ulcer
– Beta-blockers and asthma
– COCP and venous thrombosis
•
GP computer system warning are not helpful as to much non specific
information
•
Ensure you have access to full medical record(s)
Examples of STOPP drug criteria
•
NSAID with heart failure
•
Use of long-term powerful opiates, e.g. morphine or fentanyl as first-line therapy for
mild-moderate pain
•
TCA 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/day
•
Bladder antimuscarinic drugs with dementia
•
Long-term opiates in those with recurrent falls
•
Systemic corticosteroids instead of inhaled corticosteroids for maintenance therapy in moderate–
severe COPD
Decreasing the total number of prescriptions for these drugdrug combinations or drug-disease combinations would be
expected to reduce admissions due to adverse events
120
100
80
60
Agree
Disagree
40
Unsure
20
0
NSAID with a Aspirin with a NSAID in heart
history of
history of
failure
peptic ulcer
peptic ulcer
disease
disease
NSAID with
CKD 3 to 5
Co-prescribing Co-prescribing Co-prescribing
Tricyllic
of NSAID with of NSAID with of NSAID with antidepressant
warfarin
aspirin
SSRI
with dementia
STOPP (Screening Tool of Older Peoples Potentially
Inappropriate Prescriptions) criteria
• The STOPP have been applied to a hospital
older people population.
• Of 715 admissions
– 12% of admissions were due to medicines
– 90% of these were on STOPP criteria drugs
Drug interactions
• Ensure you know what the patient is
prescribed from all sources
• Ensure you know what they actually take
• Computerised prescribing systems are of
some help
• Beware home visits
10. Apply the Goldie locks rule to doses
Not too much and not to little.
•
•
•
•
•
Start low and go slow
Review regularly
Consider ideal body weight
Consider renal function
Beware interactions that might increase plasma
level or drug sensitivity
Female aged 20yrs, LBW 60kg, creatinine 90
CrCl (C&G)= 1 x (140-20) x 60
90
= 80ml/min
Female age 85yrs, LBW 60kg, creatinine 90
CrCl (C&G)= 1 x (140-85) x60
90
= 37ml/min
Female age 85yrs, LBW 50Kg, creatinine 90
CrCl (C&G) = 1 x (140-85) x 50
90
= 30ml/min
Male age 85yrs, LBW 50kg, creatinine 90
CrCl (C&G) = 1.23 x (140-85) x 50
90
= 38ml/min
• Male aged 87yr on simvastatin, 55kg, serum creatinine
121: eGFR reported as 52ml/min
• CrCl (C&G) = f x (140-age)xLBW
serum creatinine
f = 1 for females and 1.23 for males
CrCl (C&G)
= 29ml/min
• BNF app3: simvastatin in doses over 10mg should only be
used with caution if CrCl<30ml/min
• Using eGFR we would be happy to give simvastatin 40mg
but using C&G shows it would be preferable to use an
alternative.
10 ideas for safer prescribing
1. Be familiar with your area of prescribing
2. Don't prescribe other peoples recommendations unless you are
competent and confident
3. Follow the evidence base
4. Know what your patient is taking
5. Involve the patient
6. Keep the treatment as simple as possible
7. Stop things that don't work or are no longer needed
8. Review and monitor
9. Beware drug-drug and drug condition interactions
10. Apply the Goldie locks rule to doses