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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?