10 top tips for safer prescribing and review of medicines

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10 top tips for safer prescribing and review of medicines

Dr Duncan PettyLecturer PractitionerSchool of Health Care, University of Leeds

RCN Advanced Nurse Practitioner

Forum conference 2011

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

Be familiar with your area of prescribing

Don't prescribe other peoples recommendations unless you are competent and confident

Follow the evidence base

Know what your patient is taking

Involve the patient

Keep the treatment as simple as possible

Stop things that don't work or are no longer needed

Review and monitor

Beware drug-drug and drug condition interactions

Apply the Goldie locks rule to doses

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

Atypical antipsychotics may worsen cognition in Alzheimer’s

Shifting through the evidenceJournal of Family Practice 1994;38:505-513

Frequency commonFrequency rarePatient orientated evidenceBestBest source of evidenceRelevance 1Only if timeMay not be relevantRelevance 2Disease orientated evidenceDangerMisleadingRelevance 3WorstRead only if very interestedRelevance 4

19

Effect of intensive glucose lowering treatment on all cause mortality, cardiovascular death, and microvascular events in type 2 diabetes: meta-analysis 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 takingMedicines history takingMedicines 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 medicines- record 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 50-74% 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 non-Compliance

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 factorsMental illnessPhysical disabilityCultural/languageReading abilityHome circumstancesPerceptions/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

A high % of patients change their own treatment

due to this asthma variability

Total (n=517)

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)

Reliever once a day, no

other medication (n=169)

Current asthma treatment

0

20%

30%

60%

50%

80%

10%

40%

70%

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

Percentage of respondents who thought that their asthma was under control, related to the frequency of asthma symptoms

Total (n=517)

Every day –

both day and

night

(n=120)

2-3 timesa week(n=127)

Every day –either duringthe dayor during the night(n=92)

Oncea week(n=86)

Oncea month(n=50)

Less thanonce a month(n=42)

100%80%60%40%20%0

Haughney J, Barnes G, Partridge M, et al. Prim Care Resp J 2004; 13: 26-35

100

80

60

40

20

0

-15

-5

-10

5

0

10

15

% change

Days (before and post-exacerbation)

Rescue

b

2

Morning PEF

Nighttime

symptoms

(most specific indicator)

Profile of 425 severe exacerbations

Tattersfield: Am J Respir Crit Care Med 160:594–599, 1999

Hospitalisations

ER Visits

Unscheduled Dr VisitsDays off WorkNocturnal Asthma

RR (95% CI)

Self-Management vs. Usual Care

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:

Outcome measure RR (95%CI)

All-cause mortality 0.83 (0.73 to 0.95)

Fatal and non-fatal CHD events 0.72 (0.65 to 0.79)

Fatal and non-fatal CVD events 0.74 (0.66 to 0.85)

Fatal and non-fatal stroke events 0.78 (0.65 to 0.94)

Combined endpoint 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 have a CV event, whether or not they take a statin

These people will be saved from having a CV event because 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 subjectiveFear that might cause harmPlacebo and placebo “by proxy” effectPerception undermining a colleague Admission of failureCollusion of anonymity Passive or active avoidancePrescriber 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

un

treated 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 reductionBranded to genericUnwanted medicinesUnneeded medicinesOver 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 conditionsType 2 diabetesVascular dementiaRheumatoid arthritisAsthmaIschaemic 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)

 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  

Examples of STOPP drug criteria

Decreasing the total number of prescriptions for these drug-drug combinations or drug-disease combinations would be expected to reduce admissions due to adverse events

The STOPP have been applied to a hospital older people population.Of 715 admissions12% of admissions were due to medicines90% of these were on STOPP criteria drugs

STOPP (Screening Tool of Older Peoples Potentially Inappropriate Prescriptions) criteria

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

= 80ml/min

90

Female age 85yrs, LBW 60kg, creatinine 90

CrCl (C&G)= 1 x

(140-85) x60

= 37ml/min

90

Female age 85yrs, LBW 50Kg, creatinine 90

CrCl (C&G) = 1 x

(140-85) x 50

= 30ml/min

90

Male age 85yrs, LBW 50kg, creatinine 90

CrCl (C&G) = 1.23 x

(140-85) x 50

= 38ml/min

90

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

Be familiar with your area of prescribing

Don't prescribe other peoples recommendations unless you are competent and confident

Follow the evidence base

Know what your patient is taking

Involve the patient

Keep the treatment as simple as possible

Stop things that don't work or are no longer needed

Review and monitor

Beware drug-drug and drug condition interactions

Apply the Goldie locks rule to doses