Transcript PowerPoint Slides for South East England Specialist
East & South East England Specialist Pharmacy Services East of England, London, South Central & South East Coast
Medicine Use Reviews NSAIDs
NHS Specialist Pharmacy Services Medicines Use & Safety
East & South East England Specialist Pharmacy Services
Introduction and welcome
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Housekeeping
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Fire drills
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Facilities
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Refreshments
East & South East England Specialist Pharmacy Services
Programme
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Objectives and warm-up Expert presentation Activities NSAID MUR project presentation Activities Action plan and close
East & South East England Specialist Pharmacy Services
Objectives
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To revise and update your knowledge of NSAID efficacy and safety problems To develop communication and clinical skills to enhance the NSAID targeted MURs To understand how NSAID MURs have been used to improve NSAID safety To improve outcomes for patients taking NSAIDs To increase the number and efficacy of NSAID targeted MURs locally
East & South East England Specialist Pharmacy Services
Warm-up
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Write down on a sticky note a number from 1-10 where 1 is not confident in doing MURs and 10 is very confident
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What is the biggest barrier for you doing MURs?
East & South East England Specialist Pharmacy Services
Key facts quiz
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10 questions 10-15 seconds to discuss each answer in your groups
East & South East England Specialist Pharmacy Services
Question 1
Are COX-2 selective inhibitors more effective than traditional NSAIDs?
East & South East England Specialist Pharmacy Services
Answer to question 1
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Are COX-2 selective inhibitors more effective than traditional NSAIDs?
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NO
Similar efficacy to traditional NSAIDs such as diclofenac and naproxen.
East & South East England Specialist Pharmacy Services
Question 2
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Does NICE guidance on osteoarthritis recommend use of topical NSAIDs?
East & South East England Specialist Pharmacy Services
Answer to question 2
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Does NICE guidance on osteoarthritis recommend use of topical NSAIDs?
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YES
Like paracetamol, these should be considered before oral NSAIDs.
East & South East England Specialist Pharmacy Services
Question 3
Can ranitidine be used to prevent NSAID-induced ulcers?
East & South East England Specialist Pharmacy Services
Answer to question 3
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Can ranitidine be used to prevent NSAID-induced ulcers?
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YES
But standard doses are not effective and PPIs are preferred.
East & South East England Specialist Pharmacy Services
Question 4
Can misoprostol be used to prevent NSAID-induced ulcers?
East & South East England Specialist Pharmacy Services
Answer to question 4
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Can misoprostol be used to prevent NSAID-induced ulcers?
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YES
But misoprostol tends to be poorly tolerated.
East & South East England Specialist Pharmacy Services
Question 5
Should OTC omeprazole be used to prevent NSAID-induced ulcers?
East & South East England Specialist Pharmacy Services
Answer to question 5
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Should OTC omeprazole be used to prevent NSAID-induced ulcers?
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NO
OTC omeprazole is only licensed for heartburn and acid reflux.
East & South East England Specialist Pharmacy Services
Question 6
Should exercise be a core treatment for people with osteoarthritis, regardless of age and pain severity?
East & South East England Specialist Pharmacy Services
Answer to question 6
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Should exercise be a core treatment for people with osteoarthritis, regardless of age and pain severity?
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YES
NICE advises exercise for all (irrespective of age, co-morbidity, pain or disability) and weight loss if overweight or obese.
East & South East England Specialist Pharmacy Services
Question 7
Does NICE recommend using glucosamine in treatment of osteoarthritis?
East & South East England Specialist Pharmacy Services
Answer to question 7
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Does NICE recommend using glucosamine in treatment of osteoarthritis?
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NO
The use of glucosamine or chondroitin products is not recommended for the treatment of osteoarthritis. Rubefacients are not recommended either.
East & South East England Specialist Pharmacy Services
Question 8
Has use of naproxen increased because it has fewer GI adverse effects than other NSAIDs (eg diclofenac)?
East & South East England Specialist Pharmacy Services
Answer to question 8
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Has use of naproxen increased because it has fewer GI adverse effects than other NSAIDs (eg diclofenac)?
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NO
Use has increased but this is because it appears to have lower cardiovascular risk than other NSAIDs, not lower GI risk.
East & South East England Specialist Pharmacy Services
Question 9
Can NSAIDs be taken with methotrexate?
East & South East England Specialist Pharmacy Services
Answer to question 9
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Can NSAIDs be taken with methotrexate?
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Yes
But NSAIDs reduce excretion of methotrexate so increase the toxicity. The dose of methotrexate needs to be carefully monitored and OTC NSAIDs avoided.
East & South East England Specialist Pharmacy Services
Question 10
Is OTC diclofenac 12.5mg a useful product?
East & South East England Specialist Pharmacy Services
Answer to question 10
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Is OTC diclofenac 12.5mg a useful product?
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?
The MHRA is consulting on whether to make POM again!
East & South East England Specialist Pharmacy Services
Expert presentation
East & South East England Specialist Pharmacy Services
Activity One - patients
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In your groups discuss the following:
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What would make you feel more confident to do MURs?
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What systems do you have in place to sign up people for MURs?
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Share the ways you recruit reluctant patients (pre-workshop activity).
East & South East England Specialist Pharmacy Services
Activity two - prescribers
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In your groups, discuss whether or not you get feedback from GPs after doing MURs.
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If not, think about how you might get this.
Share hints and tips about good ways of linking with GP surgeries.
East & South East England Specialist Pharmacy Services East of England, London, South Central & South East Coast
Presentation NSAID MUR project
East & South East England Specialist Pharmacy Services
Medicines-related hospital admissions
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6% of admissions due to problems with medicines Mostly preventable Most commonly NSAIDs, diuretics, anticoagulants and antiplatelets Howard R L et al. Quality and Safety in Health Care 2003;12: 280-285.
East & South East England Specialist Pharmacy Services
Principles for MUR high-risk drugs list ‘Type of harm could
be prevented by an MUR and the pharmacist will have the skills, knowledge and information to deliver it.’
http://psnc.org.uk/services-commissioning/advanced services/murs/national-target-groups-for-murs
East & South East England Specialist Pharmacy Services
NSAIDs and preventable admissions
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LACK OF MONITORING
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Renal necrosis
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PRESCRIBING ISSUES
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GI bleed – 2+ risk factors no GI prophylaxis prescribed
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ADHERENCE ISSUES
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GI bleed - not taking GI prophylaxis
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GI bleed - self-medicating with OTC NSAIDs
East & South East England Specialist Pharmacy Services
Isn’t NSAID safety fixed already?
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Survey of 100 MURs 2009-2010 11 patients on NSAIDS 4 regular NSAID patients aged over 55 with no GI protection
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Local pharmacy snapshot December 2010 25 patients on regular NSAIDs 5 aged over 55 with no GI protection 4 not regularly collecting PPI
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OA patient survey 2011 43% not offered GI prophylaxis
East & South East England Specialist Pharmacy Services
Business case
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Put together in summer 2010 Support from CCG, PCT, LPC Information to all local GPs and CPs Educational grant from Pfizer
East & South East England Specialist Pharmacy Services
The NSAID MUR
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Regular prescription for NSAID Focus GI safety Two patient groups at particular risk of NSAID adverse events: 1. Inadequate GI prophylaxis 2. Over 55s
East & South East England Specialist Pharmacy Services
Data collection Smart-survey.co.uk or paper copy Show NSAID MURs being done Demonstrate value i.e. preventing adverse events and admissions
East & South East England Specialist Pharmacy Services
Results
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17 pharmacies involved (all types) 15 months (Jan 11 – Mar 12) 142 patients (mean age 64)
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1% prescribed two NSAIDs
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8% patients taking OTC and prescribed NSAIDs 3% patients taking other GI risk drugs
East & South East England Specialist Pharmacy Services
Inadequate GI prophylaxis
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4 non-adherent to GI prophylaxis 82 no GI prophylaxis Collected follow-up data on 48 patients
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23 (48%) GI prophylaxis started 7 (15%) NSAID stopped 4 (8%) reduced/less frequent NSAID dose 8 (17%) prescriber/patient active decision not to change
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6 (12%) no change
East & South East England Specialist Pharmacy Services
Examples
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91-year-old lady prescribed two NSAIDs, low dose aspirin but no PPI.
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Patient stopped taking lansoprazole because of upset stomach, prescriber was unaware.
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85-year-old lady on ibuprofen referred to GP regarding GI risk, prescribed omeprazole.
East & South East England Specialist Pharmacy Services
Overview of results
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NSAID MURS 63% had NSAID safety issue identified 7% improved safety during MUR (eg, OTC NSAIDs identified or non-adherence to prophylaxis)
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Post MUR follow-up of GI safety 71% changed to improve safety Livingstone C, Patel C J, Sinha R and Greensmith S. Evaluation of targeted MURs in preventing avoidable harm from NSAIDs. IJPP 2012;20(2): 71.
East & South East England Specialist Pharmacy Services
17 million NSAIDs prescriptions in England each year….
East & South East England Specialist Pharmacy Services
Activity three – your NSAID patients
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In your groups discuss your pre-workshop activity.
Did you manage to find three patients with regular NSAIDs?
Any of these over 75?
Any of these with no gastro-protection?
Have you done an MUR on any of these patients?
East & South East England Specialist Pharmacy Services
Activity four – case studies
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In your groups discuss the three vignettes.
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You only have about 3-4 minutes for each one.
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Feedback at the end.
East & South East England Specialist Pharmacy Services
NSAID audit
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NSAID safety clinical audit template
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Available to download
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Use it to meet the contract requirements
East & South East England Specialist Pharmacy Services
Action plan
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Do you feel more confident?
What are you going to do as a result of this learning?
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Tomorrow or as soon as you return to work Within a few weeks Within a longer period (may involve further learning or accreditation) *
East & South East England Specialist Pharmacy Services
Reminder of Objectives
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To revise and update your knowledge of NSAID efficacy and safety problems To develop communication and clinical skills to enhance the NSAID targeted MURs To understand how NSAID MURs have been used to improve NSAID safety To improve outcomes for patients taking NSAIDs To increase the number and efficacy of NSAID targeted MURs locally
East & South East England Specialist Pharmacy Services
Thank you